Policy Template1

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DOCUMENT No./ REV. No.
CAMIGUIN GENERAL HOSPITAL

POLICY ON SAFETY
HPTLY-MER-P01-5 REVISION DATE
PAGE No.
PURPOSE: To provide a safe and healthy workplace for all patients, visitors and employees. SCOPE: Hospital wide.
POLICY: 1. The hospital shall protect all individuals from preventable occupational injuries and illnesses. The Hospital will undertake a program of education and enforcement in safety directed at employees. 2. The primary responsibility for supervision and coordination of the hospital Safety Program rests with the Hospital Safety Officer. The Hospital Safety Officer has the authority to deal immediately and directly with any situation that may be hazardous or potentially hazardous to the environmental health or safety of the Hospital. 3. The Hospital Safety Officer will issue and maintain safety policies and procedures which shall be the primary formal medium for communicating information and instructions to the Hospital as well as through staff training . These publications will contain rules and regulations and technical information relating to safety , and is to be enforce by Environmental Health and safety (EH&S). The Hospital Safety Program is not limited to passive defense against physical injury , but shall be an active program to prevent injuries and illnesses by reducing risk and exposure.
LIBRADO E. BAGAS, JR. Engineer II
ARVIN F. SAMPILO, M.D. Medical Specialist II- OIC
POLICY ON MANAGEMENT
PAGE No.
Purpose: The purpose of this is to describe the safety management structure at Camiguin General Hospital. Has established a multidisciplinary safety management team consisting of representative from key departments . This management team is committed to promote safety awareness and practices to evaluate the safety programs effectiveness. Policy Statements: It is the policy of Camiguin General Hospital care of Free of recognized hazards. Application : This structure is administered through a variety of committees . As applicable , the safety programs at Camiguin General Hospital apply to patients , visitors , employees, staff, students, vendor And contractors. Exception: No exceptions Procedure:
1.
to provide
and environment of
Safety policies , plans, procedures , and programs designs to maintain a safe healthful environment of care have been develop through the Health and safety , various departments , and the safety committee . Safety policies are available , paper copies of emergency preparedness plans are also available at the command and control are Engineering and Maintenance Section.
2. The safety committee meets monthly to review safety management and environment of Care activity and to analyze identified safety management issues and recommended appropriate action.

POLICY ON SAFETY MANAGEMENT
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3. The safety Committee activity will be communicated quarterly to the trustee
patient care committee . An annual report will be also presented based on calendar year.
4.
The safety committee will review all issues involving safety including safety ,fire safety , hazardous materials & waste , security , emergency preparedness , medical equipments , utilities safety education , infection control quality assurance and risk management , and committee will discuss the implementation of the various management plans. The committee implements and monitors the performance improvement indicators and revises the management plans as necessary.
5. The safety member present the technical aspects of their respective disciplines as they arise . Safety committee members assists in the development of resolutions to safety issues and evaluate their effectiveness . In order majority of the members must be present.
6. The community health center develop , implement and evaluate their own
policies and procedures . Camiguin General Hospital environment care team member are available for assistance in the development and maintenance of management plans policies.
DOCUMENT No./ REV. No. HPTLY-MER-P01-5

POLICY ON SECURITY MANAGEMENT PROGRAM
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Responsibility A collaborative effect between management and staff is needed to maintain the security program and to efficient manner .Its is the responsibility of the Chief of Hospital ensure that the program functions in an effective and efficient manner It is the responsibility of the chief Executive Officer of the facility to ensure that the security program meets the needs of the facility.
SECURITY MANAGEMENT PROGRAM INCLUDES : 1. Addressing security issues concerning patients , visitors , personnel ,and property implementation. a. Monitoring and patrolling designated perimeter , areas , structures and activities in the hospital. b. Checking designated areas and building during other when normal working hours that determine that they are property locked or are otherwise in order.
c. Responding to protective signal or other hazard indicators.
d. Acting as necessary in the event of situation affecting the safety and security of the facility including responding to fire and emergency orders. e. Providing staff information on responding to violence in the work place.
ARVIN F. No./ REV. No. DOCUMENT SAMPILO, M.D. Medical Specialist II- OIC HPTLY-MER-P01-5
REVISION DATE
POLICY ON HOSPITAL FIRE PLAN

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PURPOSE: To provide a plan for Hospital staff to follow in case of fire , outlining roles and responsibilities. SCOPE: HOSPITAL only. I. General The term Emergency Evacuation has different meanings according to vulnerability of the building in question. When a building such as the Camiguin General Hospital affords protection because of its construction and fire suppression system , evacuation will mean removal of patients , to areas deemed fire safe for as long it may be necessary to decide further action . The plan of action for the Hospital is horizontal evacuation to an adjacent fire-safe area protected by fire \ smoke barriers until the area is deemed safe by fire department officials and Environmental Health and (EH&S) staff , or until further evacuation is necessary. II. Discovery of fire follow R.A.C.E. Procedures: RRemove endangered persons AAlarm by activating fire alarm and dialing 321 CConfine fire by closing door EExtinguish or evacuate A. The code phrase Code Red shall be used under the following condition: 1. When an Individual discovers a fire and immediately goes to the aid of any endangered persons , they shall call out Code Red. When someone hears this phrase, they will activated the nearest fire alarm pull station. 2. During a malfunction of the building fire alarm system 3. During an actual fire and \or smoke condition to alert building staff of the emergency.
HPTLY-MER-P01-5
LIBRADO E. BAGAS, JR. M.D.
ARVIN F. SAMPILO, Medical Specialist II- OIC DOCUMENT No./ REV. No. HPTLY-MER-P01-5
Engineer II
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B.
Remove all people from immediate danger. In patient care areas , the room that has the fire , the adjacent rooms and the rooms directly across the hall should be evacuated first. Visitors to inpatients will be told to stay in the room with the person they are visiting, door closed , and await further instruction. If the fire alarm has not activated automatically, the person discovering a fire shall either follow Paragraph A.1 above ,or pull the nearest fire alarm pull station. Dial 321 and announce a Code Red , giving information on the location, and fire\smoke condition present.
C.
NOTE: A fire alarms can be activated by the following mechanism: 1. Manual pull station 2. Fire suppressions system 3. Heat and\or smoke detection devices D. E. Contain the fire by closing the door the fire room. All the patients room shall be closed to keep smoke out. If the fire is being fed by piped oxygen , the Fire Warden charge nurse, or respiratory therapists shall direct the oxygen control valve for that room be shut off. Prior to this , it must be assured that other patients on that oxygen zone are not dependent on the flow of oxygen . As part of the E.D. Full Capacity Protocol ,patients awaiting in-house acute care bed assignments are allowed to be admitted to acute care unit hall beds. These patients are most exposed to fire and smoke conditions and need immediate relocating to either the nearest patient room if ambulatory, or the adjacent area of refuge if non-ambulatory. All equipment associated with this patient shall be cleared from the hall.
F.
ARVIN F. SAMPILO, M.D. Medical Specialist II- OIC DOCUMENT No./ REV. No. HPTLY-MER-P01-5
REVISION DATE
POLICY ON HOSPITAL PLAN
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G.
Corridors shall be cleared of all obstructions. Do not place items in the patient rooms which could to obstruct the removal of the patients. If all obstructions cannot be removed, they will be place on one side of the corridor only. Any individual trained to used an extinguisher shall attempt to extinguish the fire if they can do so without injuring themselves. However, do not delay turning in the alarm or starting an evacuation simply to extinguish the fire. If the fire cannot be immediately extinguish or contained, and\or conditions warrant relocation rather than stay-in-room protection, the Fire Warden or charge nurse shall direct that all patients be moved horizontally to an adjacent fire compartment and area of refuge. All available persons on the unit to include nurse, doctors, and volunteers will be made available to Fire Warden as necessary to assist in clearing the corridors, closing doors, and patients relocation . Use any means of transport available to evacuate patients. Ambulatory patients shall be led to the adjacent smoke compartment. On network levels all visitors and non- critical staff will evacuate the alarm are to the outside or an adjoining fire safe area located past a set of fire doors. Areas other than alarm floor or area, no action is required other than checking the fire alarm annunciator to determine the alarm location, and being aware of a possible fire situation in another area, being evacuees from that area or to evacuate based on input from the commander. Preparedness includes clearing corridors. Fire Wardens or charge nurses will direct activities until Fire Marshals, University Police or Setauket Fire Department arrive.
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ARVIN F. SAMPILO,
Engineer II
Medical Specialist II- OIC

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III.
Fire Notification System
A. The police will immediately notify the Mambajao Fire Department and Hospital\ Fire Marshals of the alarm. Annunciator panels are located on all floors of the hospital in the areas listed. The annunciator panels graphically display the fire alarm zone. This specific display will only show on the fire floors itself; All other floors will just display the floor in alarm. B. Bell: Bells sound on the fire floor or area of alarm origin. This indicates that evacuation, whether actual or preparing for 30 such in that area will necessary. The bell will alarm initially for 30 seconds . After 30 sec the bell will resume on the fire floor, and remain on for 2 minutes. The sequence will begin again if second alarm is activated.
C. Chimes: Chimes indicate that a fire alarm has activated on some other floor
or area . Chime will also sound on the floor. The chimes will sound for 30 seconds. On those floors where chimes sound, follow instructions listed in paragraph II.M above. D. Strobe Lights: Strobe lights will activate on the area where a fire condition exist . They will remain on until manually reset at the fire alarm panel. E. Public Address System: The Telephone Operators will broadcast a message over the public address system, notifying where the is located preceded by the phrase, Code Red . The phrase Code Green over the P A signifies all clear.
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IV.
Responsibilities
A. ADN During an active code red situation, ADN shall proceed to the fire area and come in contact with the Fire Warden, Fire Marshal, and other on site command personal. The ADN shall active the Hospital Emergency Incident Command System (HEICS) as necessary to support the relocation and evacuation efforts as well as assure continuity of hospital operation. B. Environmental Health and Safety
1. The Fire Safety Manager acts as
campus emergency response forces Incident Commander (IC) and coordinate activities with local fire departments and hospital command structure.
2. Fire Marshals will immediately response to all alarms. They will take action as appropriate. C. Hospital Staff 1. Fire Wardens are specially trained staff members , tasked with taking charge of their areas during fire and fire alarms situations. They will investigate all fire alarms within their area of the Hospital by first inspecting the annunciator panel located closest to their area. Fire Wardens take the lead in coordinating an evacuation for their area, directing where patients will be evacuated to, keeping account of who has moved. Nurses take lead role under the direction of the Fire Warden or charge nurse in the evacuation and accountability of patients,. Doctors will assist the nursing staff and be under the direction of the Fire Warden or in-charge nurse, clearing halls, closing doors, and evacuating patients. They will then remain in the evacuation area , providing care as appropriate to the evacuated patients.
3.
2.
LIBRADO E. BAGAS, JR.
ARVIN F. SAMPILO, M.D.
Engineer II
Medical Specialist II- OIC DOCUMENT No./ REV. No. HPTLY-MER-P01-5

REVISION DATE
PAGE No.
4.
Volunteers will assist the nursing staff and be under the direction of the Fire Warden or charge nurse, clearing halls, closing doors, and evacuating patients. If at the time fire alarm activation they are responsible for the volunteer will stay with those patients and assist in their evacuation under the guidance of the Fire Warden. All other hospital staff present on the unit will remove any of their items such as housekeeping, food, and linen carts from the corridors. They will assist in patient evacuation if necessary, or evacuate the floor or area if not necessary. Nurses will evacuate the area unless they are specifically tasked by the Fire Warden or in-charge nurse to assist in patient evacuation.
5.
6.
D. Hospital SSAs
1. Respond to all fires and fire alarm events in the hospital. During
Fires, assist with evacuation as appropriate, as well as keep unauthorized personnel out of the fire zone. 2. Meet responding fire department personnel at the Fires Command Room directing them to the fire location. 3. Assist Fire Marshals in finding cause of alarm as well as keeping unauthorized personnel out of the fire alarm z.
ARVIN F. SAMPILO,
Engineer II
Medical Specialist II- OIC DOCUMENT No./ REV. No.

HPTLY-MER-P01-5
REVISION DATE
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V.
Operating Room \ICU \ Recovery
A. OR Policy, Fire Emergency Guidelines for the OR, Code F:1 , shall be referenced for full guidance.
B. The Fire Wardens of
PACU and OR, OR Nursing and Anesthesia Coordinators, Nurse Manager of OR and PACU are responsible for coordination of activities in the event of a fire.
C. No cases will be started after the fire alarm has activated or a fire announced. Surgeons and Anesthesiologist with cases in progress will be informed of the situation and advised to complete procedures as quickly as possible and report the minimum length of time before evacuation of the can takes place. D. The surgical team will stay with their patient in the room until instructed to evacuate. E. If evacuation becomes necessary (ie: extreme smoke and fire) from the OR, the patient will be Stabilized surgically and moved as quickly as possible to the adjacent OR suites which are separated by fire barriers. Reference posted the fire evacuation plans for location of barriers and direction of travel to areas of refuge. F. For fires in the PACU, patients will be moved to the ORs, or adjacent fire evacuation zones, per the evacuation plan. G. For fires in the OR trailer suite, move patients on the adjacent smoke compartment which is Radiology, and into the main surgical area, per the evacuation plan. H. The decision to shut off oxygen flow to the affected OR will depended on the circumstances of the fire , Emergency shut off valves are located and clearly marked in the corridor outside each OR. The surgical team will decide if this measure is necessary immediately, and shut off the supply valve themselves.
LIBRADO E. BAGAS, JR. M.D. Engineer II

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PAGE No.
VI.
Vertical Evacuation
The Hospital fire response plans primary method of evacuation is horizontally to adjacent areas of refuge, protected by fire rated smoke barriers and/or horizontal exits. Patients and staff are to remain, evacuation in place while the combination of the facilities fire suppression system and local fire department extinguish the fire. Should there be a need to conduct an evacuation of an entire floor, or complete evacuation of the facility due to a fire not being held to a fire compartment, the fallowing evacuation procedures will be fallowed. This plan is companion plan to the hospitals Emergency Management P&P Manual Total Evacuation Plan which must be reference for complete emergency planning details.
A. Patients in imminent danger should be immediately evacuation, with ambulatory patients moving first. Ambulatory patients should be instructed to line up outside their rooms, and form a chain by holding hands. An employee should be at the beginning and end of the chain to guide the patient to safety. As ambulatory patients are being guided to a safe area, all available staff should begin assisting non-ambulatory patients with the evacuation. Due to the extreme effort required to move the amount of bedridden patients, the hospital IC will, when acting in unison under the Unified Command with the local fire department, have firefighters provide manpower for carrying patients down. B. Stretchers, wheelchairs and Paraslyde evacuation sleds can be used to move non- ambulatory patients. Never use an elevator unless it is under the control of the fire Department personnel or Fire Marshals. The Emergency Management Total Evacuation Plan details evacuation equipment and methods to include Respiratory Cares portable vents. Alternate care sites and transportation methods are also outline in the same plan.

POLICY ON DISPOSAL AND CONTROL OF HAZARDOUS MATERIALS/BIOLOGICAL WASTE
REVISION DATE
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Management Plan which includes policies, procedure and programs, assessment hazard surveillance among others that address the following:
risk
How the risk is determined In the estimation of the risks, three or steps are involved, requiring the inputs of different discipline:
1. Hazard Identification, aims to determine the qualitative nature of the
potential adverse consequences of the contaminant (chemical, radiation, noise, etc.) and the strength of the evidence it can have that effect. This is done, for chemical hazards, by drawing from the result of the sciences of TOXICOLOGY and epidemiology. For other kinds of hazards, engineering or other disciplines are involved.
2. Dose-Response Analysis, is determining the relationship between dose
and the probability or the incidence of effect (dose- response assessment). The complexity of this step in many contexts derives mainly from the need to exportable results from experimental animals (e.g. mouse, rat) to humans, and\or from high to lower doses. In addition, the differences between individuals due to genetics or other factors mean that the hazard may be higher from particular groups, called susceptible populations. An alternative to dose-response estimation is to determine an effect unlikely to yield observable effects, that is a no effect concentration. In developing such a dose, to account for the largely unknown effects of an animal to human extrapolations, increase variability in humans, or missing data, a prudent approach is often adopted by including safely factor in the estimate of the safe dose, typically a factor 10 of each unknown step.

POLICY ON DISPOSAL AND CONTROL OF HAZARDOUS MATERIALS/BIOLOGIC WASTE
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3. Exposure
Quantification, aims to determine the amount of a contaminant (dose) that individuals and population will receive. This is done by examining the results of the discipline of exposure assessment. As different location, lifestyle and other factors likely influence the amount of containment that received, a range or distribution of possible values is generated in this step. Particular care is taken to determine the exposure of the susceptible population (S).
Finally, the results of the steps above are then combined to procedure an estimate of risk. Because of the different susceptibilities and exposures, this risk will vary within a population.
Hazards Material and Hazards Wasted Management Program This program description provides information on requirements for the management of hazardous materials, including the disposal of hazardous waste, Camiguin General Hospital (CGH). Failure to comply with these requirements may subject CGH and\or individual to fines, and civil or criminal prosecution. In the additional, the management of hazardous materials is necessary to reduce disposal cost. While the disposal of all material as hazardous wasted is expensive, there are certain materials that require special attention to minimize the difficulty and expense of their disposal.

POLICY ON DISPOSAL AND CONTROL OF HAZARDOUS MASTERIALS/BIOLOGIC WASTE
HPTLY-MER-P01-5
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HAZAROUS WASTED INDENTIFICATION .Wasted Identification Classification . All wasted streams generated throughout the CGH must be identified and then classified as hazardous or non-hazardous according to EPA and state definition. If you need assistance in determining whether wasted is hazardous, you should contact the Environmental Health and Safety Office at CGH for assistance.
ARVIN F. SAMPILO, Medical Specialist II- OIC

POLICY ON FIRE SAFETY MANAGEMENT PLAN
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FIRE SAFETY MANAGEMENT PLAN Reasons for the plan This plan been written to ensure that school: . observes fire related legislation . has an effective Fire Safety Management System in place . identifies the roles and responsibilities of all who use the hospital.
How the plan was developed The plan was developed by the hospital after consultation with the Fire and Rescue Service and written in accordance with the hospital policies. Fire safety Specification The hospital consists of main single/double-storey building used for patients and administration purpose . All are covered by a common fire alarm system and served by 19 fire extinguishers strategically placed around the building. Risk assessment The risk assessment will be carried out by the Fire Safety Coordinator (FSC), using the county format. It should identify risks and controlling measures together with dates for controls measures to established plus identification of who responsible for bringing these into effect. These assessments will be monitored by doctors/nurses and reviewed annually or sooner if significant changes occur. Copies will be kept in the Fire Safety Manual stored in reception.
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An Evacuation Plan This will be produced by the FSC and should catalogue everything planned to happen during the evacuation plus pre-planned control measures and actions. This will include a Fire Brigade Reception Pack which will be kept in reception alongside the Fire Safety Manual. The plan which be monitored by the chief of hospital and reviewed annually or sooner if significant changes occur. A copy will be kept in the Fire Safety Manual. Tackling Fires In the event of a fire, the hospital will generally adopt a flight not fight policy. However dealing with small fires can prevent them developing into a more serious, larger fire. If a small fire is blocking an escape route then staff will be expected to use a fire extinguisher to put out the fire. Larger fires should only be tackled by staff that have undergone enhanced training on how to use fire extinguishers. Staff should always deal with such fires in twos and if visibility becomes a problem or the flames reach ceiling height then they should withdraw immediately. The safety of staff and patient is always the firsts priority. Effective Records. Records form an important part of fire management system. They should be kept in the fire Safety Manual and demonstrate the following: Fire alarms checks, tests and maintenance weekly tests by site supervisor, six monthly maintenance by approved contractors monitored by the site supervisor. Equipment connected to the fired alarms- checks, tests and maintenance; weekly by site supervisor, six monthly maintenance by approved contractors monitored by the site supervisor.
LIBRADO E. BAGAS, JR. Engineer II CAMIGUIN GENERAL HOSPITAL M.D.
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Emergency lighting checks, tests and maintenance- monthly tests by site supervisor, six monthly maintenance by approved contractors monitored by the site supervisor. Fire fighting equipment- monthly checks by site supervisor, annual maintenance by approved contractors monitored by site supervisor. Fire doors quarterly conditions checks by site supervisor of fire resisting doors and final exist to ensure effective operation and maintenance as necessary.
Management Structure: Roles and Responsibilities. The governing body has overall responsibilities to ensure that the hospital complies with fire safety regulations and has an adequate Fire Safety Management Plan. The Chief of Hospital is responsible for the day to day implementation of the management Plan.
The Fire Safety Coordinator (FSC) is responsible for: Complementing the Fire Risks Assessment Producing the Evacuation Plan. Organizing fire drills(FSC) is responsible for: Complementing the Fire Risks Assessment Producing the Evacuation Plan. Organizing fire drills.
ARVIN F. SAMPILO,
Engineer II


PAGE No.
Fire Drills A fire drill will be carried at least one each term. These will be organized and monitored by the FSC. A record sheet will be completed on each occasion and should include the narrative, problems noted, remedial actions undertaken together with completion dates and who had been tasked with the actions. These records should be field in relevant section of the Fire Safety Manual. Training The FSC will receive appropriate training. All staff will undertake basic training on safety to include: General Fire Safety Issues housekeeping and fire prevention measures and use of extinguishers. Issues specific to the evacuation plan. Issues arising from the risks assessment. Issues relating Fire Drills.
The general training will be provide for new staff as part of their induction and will be updated annually for all staff. This is the responsibility of the FSC. Staff will be updated on any issues regarding fire safety at staff briefing meetings. Records will be kept of who gave the training, what is related to and its duration. These will be kept in Fire Safety Manual. Housekeeping and Fire Prevention.
Waste bins will be emptied at least daily. External bins are housed in a locked compound and emptied weekly. The school will arrange for additional collections as required. All escape routes and Fire exists must be kept clear and classrooms and work areas kept tidy.

6.3.5 POLICY ON FIRE SAFETY MANAGEMENT PLAN
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Any flammable materials are stored in caretaker room which is kept locked. Matches and candles are only use when necessary and always in the presence of an adults. Fire prevention is include within the curriculum as part of the hospital. It is the responsibility of all the staff to give clear fire safety message including when using emergency lights.
Special Needs The hospital is mindful that staff and patient with special needs will need to have fire safety procedures explained them and if necessary provided with a Personal Emergency Evacuation Plan.
The Site Supervisor is responsible for: Carrying out safety checks Providing information for the risks assessment. Implementing arson prevention measures. Helping with fire drills
The Assistant Administration Officer is responsible for checking that:
All appropriate checks and procedures are completed as stated in the management plan. Any actions identified to improved fire safety are completed within the specified timescale.

6.3.5 POLICY ON FIRE SAFETY MANAGEMENT PLAN
All Staff has a legal Responsibility to:
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Report any concerns regarding fire safety to the FSC or supervisor. Implementing the aspects of this policy which refer to them. Undertake training as required.
Arson Prevention The hospital recognizes that hospital sites are particularly vulnerable to arson attacks. The following prevention measures will adhered to:
Daily checks of the hospital building, grounds and woodlands to detect any signs of intruders, vandalism and fire lighting. Any incident will be reported to the police. Care will be taken not to live, anywhere on the hospital site, easily combustible materials e.g. wood a paper that could be used to start a fire. Rubbish waiting for collection will be housed in the locked bin store. The hospital has no letter box and good outdoor lighting.
Monitoring and Review The Governing Body has delegated the responsibility for reviewing the Fire Safety Management Plan. The Plan will reviewed annually and the committee will received regular updates from the supervisor on any matters relating to Fire Safety. Staff who has specific responsibilities for implementing the Fire Safety Management Plan should inform the Chief of Hospital of any concerns relating to fire safety.

6.4.1 POLICY ON HEALTH AND SAFETY PROCEDURE
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The Management of Health and safety all to effective plan, organize, control, monitor and review their health and safety systems and procedures. For your health and safety policies and procedures to be effectively implemented, they need to be: up - to date relevant practical comprehensible.
We can draft health and safety policies and procedures from scratch or simply review and update existing material. Whichever route you choose, we work closely with you to ensure legal compliance and workable procedures. Benefits Efficient use of time our health and safety consultants know what legislation is relevant to your business and the best way to implement it Keep up to date we can let you know when policies need to reviewed due to new legislation or best practice. Dont reinvent the wheel model policies and procedures are available for you to adapt. Practical approach our policies and procedures are written to be used, not to be filed and forgotten.
Our approach
We can manage and deliver a full health and safety policy, plan and procedures
ARVIN F. SAMPILO, Medical Specialist II- OIC DOCUMENT No./ REV. No.

POLICY ON HEALTH AND SAFETY PROCEDURE
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Project stages often include:

review of current health and safety procedures.
Development of plans and policies for areas not already covered Recommendation for change and revision of existing policies Making the revisions Regular review of documents for this is legal requirement.
Engineer II


POLICY ON MERCURY SPILLAGE AND PROCEDURE
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Purpose : To ensure that staff have relevant information regarding the procedures to be followed when dealing with spillage of Metallic mercury. Policy Statement : IT is the policy of the Camiguin General Hospital To ensure the health and Safety of the Staff in relation to potential Exposure to metallic mercury and its vapours. Policy Application : Trust wide Author: Health and Safety Advisor MERCURY SPILLAGE POLICY AND PROCEDURES 1. Introduction 1.1. The aim of this policy is to provide information regarding health and safety issues when the spillage or mercury occurs,
1.2.
Mercury is the silver liquids metal contained in thermometers and sphygmomanometers. It is toxic. The principle hazard is by inhalation of vapour . Skin and eye absorption add to the danger. It may also be ingested. All staff should Therefore be familiar with basic safety precaution and the action to be taken in the event of a mercury spillage.
1.3. Mercury and its compounds are listed substances which must not be put down drains, Incinerated or and taken both trust and the individual liable to criminal prosecution. 2. Responsibilities / Accountabilities a. Responsibility for Spillage Clearance b. Department Wards the person in charge of the department of ward at the time the spillage is responsible for arrange the safe clearance of the spillage and for ensuring that the medical attention is sought for any injured person. An incident form via Trust internet must also be completed by the person in charge.
c. Public Areas - A mercury spillage must be reported immediately
to the person in charge.
Engineer II


POLICY ON DISASTER MANAGEMENT
HPTLY-MER-P01-5
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Refers to range of activities designated to maintain control over disaster and emergency situation and to provide a framework for helping persons at risks, to avoid or recover from the impact of disaster.
Policies : 1. Formulation of a Disaster Management Plan considering the following elements of disaster : . Identify threats ( hazards likely to occur ) . Determine their probability of occurrence
Engineer II


POLICY ON FIRE SAFETY
Policies : 1. Formulation of a fire Disaster Management Plan
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2. Conduct of Fire Drill at least once a year to be conducted By Bureau of Fire Protection. The following should be considered : 1. Building and equipment should be as close to fire resistant and fire proof as possible. 2. Written report of any deficiency. 3. All fire codes are observe and carried out 4. Fire regulation and signages are prominently posted (ex. No smoking). 5. Fire detection equipment should be checked every six months. 6. Fire Extinguisher installation should be checked annually. 7. ALL fire exits should not be locked 8. Driveways to building should be free for access by big fire trucks. PROCEDURE: Identify Exits: identify the different exits identify the different stairs identify the different evacuation areas identify the war and corresponding rooms
Plan an escape Route Make an escape route according to ward room number thru the
nearest exit into nearest stairs leading to the nearest evacuation area but which are safer and father from the fire and which are accessible in case of earthquake.
Engineer II


POLICY ON FIRE SAFETY
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Prepare a Directory
Make a ready Directory to emergency numbers t be called like: o Fire stations o Fire rescue units o Emergency light service provider
Designate Rule and Roles
Engineer II


POLICY AND PROCEDURE OF UTILITY SYSTEM
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Procedure Emergency Procedures for Utility System : Disruption

The power Plant Directive and its associated manuals manual provide specific procedures in the event of a utility system malfunction, identifies alternative sources of essential utilities, location and shut off procedures, emergency numbers and notification procedure , repair services and emergency clinical inventions when utility system fail.
Engineer II


POLICY ON ELECTRICAL SAFETY
INTRODUCTION
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This program established minimum standards to prevent hazardous electrical exposure to personnel and ensure compliance with regulatory requirements applicable to electrical systems. The program is intended to protect employees against electrical shock, burns and other shock, burns and other potential electrical safety hazards as well as comply regulatory requirements. ELECTRICAL HAZARDS Electrical related hazards include electrical shock and buns, arc- flash burns blast impacts, and falls.
Electric shock and burns. An electric shock occurs when electric current passes though the body. This can happen touching and energized part. If the electric current passes across the chest or head, death can result. At high voltage, severe burns can result.
PURPOSE This program has been established in order to:
Ensure the safety of employees who may work on or near electrical equipment. Ensure that employees understand and comply with safety standards related to electrical work. Ensure that campuses, agencies and employees follow uniform practice during progress of electrical work. Comply with Standards and procedures according to the following six points:
1. Provide and demonstrate a safety program with defined responsibilities. 2. Determine the degree of arc flash hazard by qualified personnel. 3. Affix warning labels on equipment. 4. Provide personal protective equipment (PPE) for workers.
5. Provide documented training to workers on Lockout. 6. Provide appropriate tools for safe work.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D.
Engineer II


SCOPE
6.5.1 POLICY ON ELECTRICAL SAFETY
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This is program applies to all State of Wisconsin properties and work performed by its employees regardless of job site location. ELECTRICAL SAFETY PRINCIPLES ENERGIZED CONDITION
De-energized whenever possible.
Plan every job. The approach and step by step procedures to complete the work at hand must be discussed and agreed upon between all involved employees before beginning. Write down first- time procedures. Discuss hazards and procedures in a job briefing with supervisors and other workers before starting any job. It is the employers responsibility to have or develop a checklist system for working on live circuits, if such a scenario arises. Identify the hazard .Conduct a job hazard analysis. Identify steps that could create electric shock or arc- flash hazards. Minimize the hazards. De energized any equipment, and insulate, or isolate exposed live parts so contact cannot be made. If this impossible, obtain and wear proper personal protective equipment (PPE) and tools. Anticipate problems. If it can go wrong, it might. Make sure the proper PPE and tools are immediately available for worst case scenario.
Obtain training. Make sure all involved employees are qualified electrical worker with appropriate training for the job.
RESPONSIBILITIES Each agency must determine the assignment of the following responsibilities based on staff expertise, resources and agency specific considerations:
Engineer II

REVISION DATE
PAGE No.
Safety Precaution Evaluate work being performed and determine compliance with this program. Provide or assist in the task of specific training for electrical work qualifications. Training recordkeeping. Periodically review and update this written program. Provide or coordinate general training for work units on the content of this program. Evaluate the overall effectiveness of the electrical safety program on a periodic basis. Assist work units in the implementation of this program.
Supervisors Promote electrical safety awareness to all employees. Ensure employees comply with ALL provisions of the electrical safety program. Ensure employees receive training appropriate to their assigned electrical tasks and maintain documentation of such training. Develop and maintain a listing of all qualified employees under their supervision.
Ensure employees are provided with and use appropriate protective equipment.
Engineer II


REVISION DATE
PAGE No.
Employees Follow the work practice describe in this document, including the use of appropriate protective equipment and tools. Attend all training required relative to this program. Immediately report any concerns related to electrical safety supervision.
DEFINATIONS
Authorized Maintenance personnel- A person who has completed the required hazardous energy control training and authorized to maintain specific machine or equipment to perform service maintenance. A Person must be certified as Authorized Technical Employee in order to apply her/his knowledge to control dangerous equipment. All Authorized Maintenance personnel must be trained in: Electrical Safety / Maintenance Equipment Equipment specific procedures in their individual works units
Confined space An enclosed space which has limited egress and access, and has an atmospheric hazard (e.g., electrical hazard). Damp location Particularly protected location subject to moderate degrees of moisture, such as some basements. De- energized electrical work- Electrical work that is performed on equipment that has been previously energized and is now free from any electrical connection to a source of potential difference and from electrical charges.
Disconnecting (or Isolating ) work- A device designed to close and / or open an electrical circuits. Dry location Locations not normally subject to dampness or wetness, as in the case of a building under contraction.
Engineer II


PAGE No.
Energized source Any source of electrical, mechanical, hydraulic, pneumatic, chemical, thermal, 2nd Generator. Exposed electrical parts Energized parts that can be inadvertently touched or approach nearer than a safe distance by person. Parts not suitably guarded, isolated, or insulated. Examples include terminal contacts or lugs, and bare wiring. Flash Protection Boundary- An approach limit distance from exposed live parts within which a person could receive a second degree burn if an electrical arc flash were to occur. Ground Fault Circuit Interrupt (GFCI)- A device whose function is to interrupt the electrical circuit to the load when a fault current to ground exceeds a predetermined value that is less than that required to operate the over- current protective device of the supply circuit. Ground A conducting connection, whether international or accidental, between an electrical circuit or equipment and the earth or to some conducting body that serves in place of the earth. Hazardous Location- An area in which an Toxic wasted, Laboratory wasted. Interlock- An electrical, mechanical, or key-locked device intended to prevent an undesired sequence of operations. Isolating Switch- A switch intended for isolating an electric circuit from source of the power. It has no interrupting rating, and intended to operate only after the circuit has been opened by some other means. Life Safety Equipment Equipment that provides critical protection for safety in the event of an emergency or other serious hazard. Life safety equipment, which is electrically energized, should be worked on using
Energized Electrical Equipment (EEW) procedures to ensure that the protection provided by the equipments is not lost.
Limited Approach Boundary An approach limit is a distance from an exposed live part within a shock hazards exists. Lockout The placement of a lock on an energy isolating device according to procedure, ensuring that the energy isolating device and equipment being controlled cannot be operated until the lockout device is removed.

PAGE No.
Lockout / tagout A standard that covers the servicing and maintenance of machines and equipment in which the unexpected re energization of the equipment or release of stored energy could cause injury to employees. It establishes performance requirements for the control of such hazardous energy. Prohibited Approach Boundary An approach limit distance from an exposed live part within which work is considered the same as making contact with the live part. Qualified Electrical Worker A qualified person trained and knowledgeable of construction and operation of equipment or specific work method and is trained to recognized and avoid the electrical hazards that might be present with respect to that equipment or work method.
Qualified electrical workers shall be familiar with the proper use of the
special precautionary techniques, personal protective equipment (PPE) , including arc, flash insulating and shielding materials, and insulated tools and tests equipment. A person can be considered qualified with respect to certain equipment and methods but is unqualified for others. An employee who is undergoing on-the-job-training, and who is the course of such training, has performed duties safety at his or her level training and who under the direct supervision of a qualified person shall be considered to be qualified.
Qualified electrical workers shall not be assigned to work alone, except
for replacing fuses, operating switches, or other operations that do not require the employee to contact energized high voltage conductors or energized parts of equipment, clearing trouble, or emergencies involving hazard to life or property.
Note One : Whether a person is considered to be qualified person will depend upon various circumstances in the workplace. It is possible and, in fact, likely for an individual to be considered qualified with regard to certain equipment in the workplace, but unqualified as to other equipment.
Engineer II


PAGE No.
Note Two : An employee who is undergoing on-the-job training and who, on the course of such training, has demonstrated an ability to perform duties safely at his/ her level of training and who is under the direct supervision of a qualified person is considered to be a qualified person of the performance of those duties.
Restricted Approach Boundary An approach limit distance from an exposed live part within which there is an increase risk of shock, due electrical arc-over combined with inadvertent movement, for personnel working in close proximity to the live part. though a relay on an equivalent device.
Remote- control Circuit- Any electric circuit that controls any other circuit
Service- The conductors and equipment for delivering energy from the
electricity supply system to the wiring system of the promises served.

Service Equipment The necessary equipment, usually consisting of a
circuit breaker or switch and fuses, and their accessories, located near the entrance of supply conductors to the building and intended to constitute the main control and means of cutoff the supply.
Setting Up Any work performed to prepare a machine or equipment to
perform its normal production operation.

Switching Devices Devices designed to close and / or open one more
electric circuits. Included in this category are circuit breakers, cutouts, disconnecting (or isolating) switches, disconnecting means, interrupter switches, and oil (field) cutouts.
Voltage (of a circuit ) The greatest root-mean square (effective)
difference of potential between any two conductors of the circuit concerned.

Voltage, high Circuits with a nominal voltage more than 50 volts. Voltage, low Circuits with nominal voltage less than or equal to 50 volts.
Voltage, nominal An approximate value assigned to a circuit or system
for the purpose of conveniently designating its voltage class, e.g., 120/ 240, 480/277, and 600.
Engineer II

CAMIGUIN GENERAL 1. PURPOSE and HOSPITAL APPLICABILITY

6.5.4 and
1.1
This policy is designed to ensure that all Hospital and institution activities operation involving the use of radioactive materials /x rays/ ct scan are PAGE No. performed in RADIATION SAFETY such a way as to protection users, staff patients and general POLICY ON public from exposure. The operating procedure is to main all radiation exposures as Low As Reasonably Achievable (ALARA). 1.2 This policy to all Hospital and institution Doctors and Nurses who receive, possess, use, transfer, own, or acquire any source of ionizing radiation or radioactive material. 2. DEFINATION and SCOPE 2.1 Radioactive materials include any material that spontaneously emits ionizing radiation. 2.2 Ionizing Radiation is electromagnetic radiation ( x ray and gamma ray photons ) or particulate radiation ( beta particles, electrons, positrons, neutrons, and alpha particles) capable of producing ions by secondary processes. 2.3 ALARA is an acronym for as low as reasonably achievable a level to which radiation protection aims to reduce occupational exposures. ALARA is achieved though good radiation protection planning and practice, backed by management commitment.
3. ROLES and RESPONSIBILITIES 3.1 The Radiation Safety Committee (RSC) is a committee responsible for development and administration of radiation safety program at the Hospital affiliated institutions. It establishes policies and enforce compliance with program.
3.2 The Radiation Safety Officer (RSO) is responsible for the daily implementation of the radiation safety program in accordance with directives from the RSC, license provisions, and regulatory requirements. As the authorized representative of the Radiation Safety Committee, the RSO supervises all radiation control activities. The RSO is responsible for ensuring the safe use of radiation and radioactive materials and for meeting ALARA levels.
REVISION DATE
PAGE No.
POLICY ON RADIATION SAFETY
3.3 The Office of Environmental Health and Radiation Safety (EHRS) is the lead office for radiation safety at the Hospital and affiliated institutions. Details of these duties and responsibilities are described I the appropriate radiation safety manuals (radioisotopes an x rays). 3.4 A License is an individual authorized in writing by the RSC to use radioactive materials in laboratory research or class instruction. The official document providing the defined scope of authorization is known as license. A licensee is responsible for the radiation control activities under his/her license. 3.5 A radiation Worker us an individual who works with ionizing radiation and receives radiation safety training She/he is responsible for following all applicable regulations pertaining to the use of x rays and / or radioactive materials as presented in the Radiation Safety Manual, in the license, and in notices issued by the RSO.
1. PROCEDURES License to Use Radioactive Material All individuals who wish to independently use radioactive material must apply to the RSC for a license. The license evacuation take into consideration the adequacy of facilities and equipment, training and experience of the user, and the operating of equipment.
Engineer
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
POLICY ON WATER SAFETY
Water safety is critically important and essential in the operation and services in the hospital. In fact, water is defined as LIFE.
POLICIES:
1. Water sample analysis should be done at least 2x a year. 2. Regular check of water lines, pipes and fitting and immediate replacement of defective faucets and other plumbing fixtures.
Engineer

6.5.9 POLICY ON FIRE PREPAREDNESS
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Make Hospital Fire Safe Smoke alarms save lives. Install a smoke outside each sleeping area and on each additional level of your hospital. If people sleep with doors closed, install smoke alarms inside sleeping area, too. Immediately Use the test button to check each smoke alarm once a month. When necessary, replace batteries immediately. Replace all batteries at least once a year. Vacuum away cobwebs and dust from your smoke alarms monthly. Smoke alarms become less sensitive overtime. Replace your smoke alarms every ten years. Consider having one or more working fire extinguisher at hospital. Get training from the fire department in how to use them. Consider installing an automatic fire sprinkler system in hospital.
Plan Your Escape Routes Determine at least two ways to escape from every room of the hospital Consider escape ladders for sleeping areas on the second or third floor. Learn how to use them and store them near the window. Select a location outside the hospital where everyone would meet after escaping.
Practice your escape plan at least twice a year.
Engineer
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
POLICY ON FIRE PREPAREDNESS
ESCAPE SAFELY
Once you are out, stay out! Call the fire department from a neighbors phone. If you see smoke or fire in your first escape route, use your second way out. If you must exit through smoke, crawl low under the smoke to your exit. If you are escaping through a closed door, feel the door be3fore opening it. If it is warm, use your second way out. If smoke, heat, or flames block your exit routes, stay in the room with the door closed. Signal for help using a bright-colored cloth at the window. If there is a telephone in the room, call the fire department and tell them where you are.
Be Smart, Be Responsible, Be Prepared. Get Ready Get involved, Volunteer, Bear Responsibility 10 ways YOU can be Disaster Prepared
1. Identify Your Risk. 2. Create a Family Disaster Plan 3. Practice Your Disaster Plan 4. Build a Disaster Supply Kit For Your Home and Car
5. Prepare Your Children 6. Dont Forget Those With Special Needs 7. Learn CPR and First Aide 8. Eliminate Hazards in Your Home and the Workplace 9. Understand Post 9/11 Risks 10. Get Involved, Volunteer, Bear Responsibility
HPTLY-MER-P01-5
REVISION DATE
POLICY ON SPECIAL PRECAUTION FOR CLEANING-UP SPILLAGE OF POTENTIALLY HAZARDOUS SUBSTANCE
PAGE No.
The place to be cleared must be secured and cordoned. Only authorized personnel or the pollution control officer should be allowed in the area. In clearing-up spillage of the body fluids or other potentially hazardous substances, particularly if there is a risk of splashing, eye protectors and face masks should be worn in addition to gloves and overalls. The need for respirators/gas mask is also necessary if an activity is particularly dangerous,, for example, if it involves toxic dust, chemical reagents, the clearance or incinerator residues, or the cleaning of contaminated equipment. It is especially important also to recover spilled droplets of metallic mercury, if leakage or spillage involves material; the floor should be cleaned and disinfected after most of the waste has been recovered.
RESPONSE TO INJURY AND EXPOSURE

All staff that handles health care waste must be trained to deal with injuries and exposures. Health care establishment should develop a program that would prescribe the actions taken in the event of injury or exposure to a hazardous substance. Essential elements of the program should include the following:
Immediate first aid measures, such as cleaning of wounds and skin, and irrigation (splashing) of eyes with clean water . An immediate report of the incident to designated responsible person. Retention, if possible, of the item involved in the incident, details of its source for identification of possible infection Additional medical attention in an accident and emergency or occupational health department, as soon as possible
HPTLY-MER-P01-5
REVISION DATE
POLICY ON SPECIAL PRECAUTION FOR CLEANING-UP SPILLAGE OF POTENTIALLY HAZARDOUS
PAGE No.
Medical surveillance Blood or other test if indicated Recording of the incident Investigation of the incident, and identification and implementation of remedial action to prevent similar incident in the future.
Engineer

The generating set is designed to be safe in correct manner.
CAMIGUIN GENERAL Responsibility for safe however rests with the personnel REVISIONthe set. who use DATE HOSPITAL
Policies:
HPTLY-MER-P01-5
POLICY ON GENERATOR SET
1. The generating set should only be operated by authorized and trained PAGE No. personnel. 2. A logbook on preventive maintenance should be maintained.
(sample of safety precaution contained in the generator manual) Warning: Read and understand al safety precaution and warning before operating the generating set. Never start the generating set unless it is safe to do so. Do not attempt to operate the generating set unless it is safe to do so. If the generating set unsafe, fit danger notices and disconnect the battery (-) lead so that it cannot be started until the condition is corrected. Disconnect the battery (-) lead prior to attempting any repairs or cleaning inside the ensure, if equipped.
Install only in full compliance with relevant national, local, or federal codes, standards or other requirements.
Fire and explosion: Ensure the generating set room is property ventilated. Keep the room, floor and generating set clean. When spills of fuel, oil, battery electrolyte or coolant occur, they should be cleaned up immediately.
CAMIGUIN GENERAL Never store flammable liquids near the engine. HOSPITAL Store oily rags in covered metal containers
or batteries. Fuel vapor are explosives.
REVISION DATE
6.10 not smoke or allow sparks, flames or other sources of ignition around fuel Do
PAGE No.
Avoid refilling the fuel tank while the engine is running. Do not attempt to operate the generating set with any known leaks in the fuel system.
Mechanical: The generating is design with guards for protection from moving parts. Warning: Do not attempt to operate the set with safety guards removed. While the generating set is running do not attempt to reach under or around the guards for any reason. Keep hands, arms, long hair, loose clothing and jewelry away from pulleys, belts and other moving parts.
Attention: Some moving parts ca not be seen clearly when the set is running. Keep access doors on enclosures, if equipped closed and locked when not required to be open. Avoid contact with hot oil, hot coolant, hot exhaust gases, hot surface and sharp edges and corner. Wear protective clothing including gloves and hat when working around.
ARVIN F. SAMPILO, M.D. Medical Specialist II OIC

HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Chemical Fuels, oils, coolants, lubricants and battery electrolyte used typically of the industry. Warning: Do not swallow or have skin contact with fuel, oil, coolant, lubricants or battery electrolyte, if swallowed, seek medical treatment immediately. Do not induce vomiting if fuel is swallowed. For skin contact wash with soap and water. Do not wear clothing that has been contaminated by fuel or lube oil.
Electrical Safety Safe and efficient operation of electrical equipment can be achieved only if the equipment is correctly operated and maintained.
Warning: Ensure that generating set effectively ground/earthed prior to operating. Do not touche electrically energized parts of the set or interconnecting cables or conductor with any part of the body or with any non insulated conductive object Use only class BC or class ABC extinguishers on electrical fires.
LIBRADO E. BAGAS, JR. Engineer II ARVIN F. SAMPILO, M.D. Medical Specialist II OIC

POLICY ON SPECIAL PRECAUTION FOR CLEARING UP SPILLAGE OF POTENTIAL HAZARDOUS

HPTLY-MER-P01-5
REVISION DATE
PAGE No.
The place to be cleared must be secured and cordoned. Only authorized personnel or the pollution control officer should be allowed in the area. In clearing- up spillage of body fluids or other potentially hazardous substance, particularly if there is a risk of splashing eye protectors and face masks should be worn in addition to gloves and overalls. The need for respirators / gas mask is also necessary if an activity is particularly dangerous, for example, if it involves toxic dust, chemical reagents, the clearance or incinerator residues, or the cleaning of contaminated equipment. It is especially important also to recover spilled droplets of metallic mercury, if leakage or spillage involves material; the floor should be cleaned and disinfected after most of the waste has been recovered.
RESPONSIBLE TO INJURY AND EXPOSURE All staff that handles health care waste must be trained to deal with injuries and exposures. Health care establish should develop a program that would prescribe the action taken in the event of injury or exposure to a hazardous substance. Essential elements of the program should include the following.
o
Immediate first aid measures, such as cleaning of wounds and skin, and irrigation (splashing) of eye with clean water
o An immediate report of the incident to designated responsible person. o Retention, if possible, of the item involved in the incident, details of its source for identification of possible infection.
o Additional medical attention in an accident and emergency or occupation health department, as soon as possible o Medical surveillance

POLICY ON SPECIAL PRECAUTION FOR CLEARING UP SPILLAGE OF POTENTIAL HAZARDOUS SUBSTANCE
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Blood or other test if indicated Recording of the incident Investigation of the incident, and identification and implementation of remedial action to prevent similar incident in the future.

POLICY PROCEDURES ON RISK IDENTIFICATION, ASSESSMENT AND CONTROL, SECURITY RISKS, USE OF PERSONAL EQUIPMENT
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Introduction Risk assessment is the process of quantifying of a harmful effect to individual or population from certain human activities, In most hospital the use of specific chemicals, or the operation of specific facilities is not allowed unless it can be shown that they do not increase the risk of death or illness above a specific threshold. The process of managing risk to identify potential risks. Are about events that, when triggered, cause problem. Hence, risk identification can start with the source of problems, or with the problem itself.
Policy
1. Camiguin General Hospital should identify, assess the risk and manage the risk before any harmful effects would come to the patients, family, and staff 2. If there is presence of security risk, control should be established immediately in order to prevent harm to the patients, family, and staff. 3. Risk is identified assessed and appropriately controlled. Where elimination or substitution is E. BAGAS, JR. adequate warningF.and protection devices are LIBRADO not possible, ARVIN SAMPILO, M.D. Engineer II Medical Specialist II OIC used.
4. A coordinated security arrangement in the organization assures protection of patients, staff, and visitors.

POLICY ON MEDICAL EQUIPMENT AND PROCEDURE
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
1.DOT NOT use the EQUIPMENT if there is an intermittent audio alarm. 2.DO NOT plug the unit if the power lines/ outlet is overloaded. 3.DO NOT plug MEDICAL EQUIPMENT if the voltage regular is under wattage. 4. ALWAYS USE voltage regular or UPS when using the MEDICAL EQUIPMENT. 5.ALWAYS USE power time delay when using the MEDICAL EQUIPMENT.

POLICY AND PROCEDURE ON MERCURY SPILLAGE
REVISION DATE
PAGE No.

Title: Purpose: Mercury Spillage and Procedures To ensure that staff have relevant information regarding the procedures to be followed when dealing with spillages of metallic mercury. It is the policy of the Camiguin General Hospital to ensure the Health and safety of staff in relation to potential exposure to metallic mercury and its vapours. Trust-wide Health and Safety Advisor
Policy Statement;
Policy Application: Author:
MERCURY SPILLAGE POLICY AND PROCEDURES
1. Introduction.
LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. Engineer II Medical Specialist II and 1.1 The aim of this policy is to provide information regarding healthOIC safety
issues when the spillage of mercury occurs.
1.2 Mercury
is the silver liquids metal contained in thermometers and sphygmomanometers. It is toxic. The principle hazard is by inhalation of vapour. Skin and eye absorption add to the danger. It may also be ingested. All staff should Therefore be familiar with basic safety precautions and the action to be taken in the event of s mercury spillage.
HPTLY-MER-P01-5
REVISION DATE
POLICY AND PROCEDURES ON MERCURY SPILLAGE:
PAGE No.
1.3 Mercury and its compounds are listed substance which must not be put down drains, Incinerated or put in general wasted. To do so would be illegal and taken both the trust and the individual liable to criminal prosecution. 2. Responsible for Spillage Clearance
i.
Department and Wards the person in charge of the department or ward at the time the spilla is responsible for arrange the safe clearance of the spillage and for ensuring that medical attention Is sought for any injured person. An incident form via Trust internet must also be complicated by the person in charge. Public Areas A mercury spillage must be reported immediately to the person in Charge of the nearest ward or department. The spillage area must be supervised.
ii.
3. Clearance Procedure 3.1 In the event of mercury spillage (e.g. a broken sphygnomameter), the spillage must be cleaned up Immediately by taking the following steps: v. Follow up the instruction supplied with the kit. I. vi. II. III. Open doors and window to improve ventilation Vacuum cleaners must not be used. Keep unnecessary personnel, patient and visitors away from the spillage area. Disposable gloves and aprons must be worn.
IV.
Contact Bleep Holder or out of hours Pharmacist on call for a mercury spillage kit, if one if one is not available in the Department or on the Ward.

6.10 POLICY AND PROCEDURES ON MERCURY SPILLAGE
PAGE No.
vii.
Wash hands when the procedure is complete Seek first aid/ medical attention for any injured persons, including individuals who have had skin contact with the spillage mercury and remove them from the contaminated atmosphere. Contact Engineering / Maintenance Department regarding disposal waste.
viii.
ix.
4. Equipment for Repair ( e.g. broken Sphygomomanometer )

4.1 Using gloves, broken equipment contaminated with mercury should be
sealed in two strong yellow Plastic sacks and declaration of contamination status label should be completed and fixed to the Bag stating Broken Equipment for Repair Contaminated with mercury and taken to the Engineering / Maintenance Department having first alerted Department by Telephone. 4.2 For disposal out of hours, the container should be stored in a safe place until removal to the Engineering / Maintenance Department. 4.3 The Engineering / Maintenance Department will recycle mercury and arrange for Associate contaminated waste to be sent to the hazardous Waste Management of the Government.
5. Equality and Diversity 5.1 The Camiguin General Hospital is committed to an environment that promotes equality and embraces diversity both within our workplace and in service delivery. This policy (procedure/ guideline) should be implemented with due regard to this commitment . 6. Review 6.1 This document will be review by safety & waste Management Committee every two years.
Performance of preventive maintenance procedure of each machine / HPTLY-MER-P01-5 equipment should be daily, weekly and monthly in accordance with the operators manual. Proper filing up of the form provided for, must be made. All authorized equipment users should know the basic limitations and precaution in handling every machine. All authorized equipment users must familiarize themselves with the PAGE No. POLICY ON PREVENTIVE mechanical, physical, and electrical safety features of each machine. Strictly follow manufactures equipment and instruments: instruction for installing / operating all
REVISION DATE
6.10

MAINTENANCE ON EQUIPMENT
Only those personnel who properly trained can operate the machine. Use only the prescribed input voltage of the equipment / instrument. Never remove ground plug. Never operate the instruments with their cover off. Do not attempt to make repairs or adjustments to the circuitry. Storage temperatures should be followed. Do not install any unspecified parts. Adequate clearance and ventilation should be provided as well as vibration free surfaces. Connection to main pumps with large pumps, compressors or refrigeration should be avoided. To enhance trouble free operation of all equipment, it is imperative to follow the maintenance schedule outline for individual equipment.
Perform maintenance procedure either on a time schedule or on an instrument cycle schedule. Keep a calendar marked with dates for maintenance and calibration schedule.

6.14 POLICY ON PREVENTIVE MAINTENANCE ON EQUIPMENT

PAGE No.
Keep a logbook of visits of technician or engineers for quick reference. Service reports on all equipment should be field and documented. Prior to running temperature controlled assays, and periodically while running temperature controlled assays, monitor the temperature on the display ( Block and Cell temperature for chemistry analyzers ) to assure that 37c is being properly maintained. Periodically check the calibration and linearity of the instrument against standard reference. Appropriate control should be run with each assay or indicated in the package inserts to check the performance of the equipment. Clearing should be done when necessary. Read instrument instruction manuals before performing testing. Keep them handy as reference.
Excessive humidity should be avoided and storage condition must be followed. Do not place, eat or drink foods and liquids near instrument / equipment to avoid accidental spillage. Do not smoke or allow sparks, flames or other sources of ignition around fuel or batteries. Fuel vapor are explosives. Judicious use of AVR and USP for all machines. Engineer II Medical Specialist II OIC

6.15 POLICY ON CORRECTIVE MAINTENANCE EQUIPMENT
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
To train a pool of medical equipment technician who will be responsible to do the corrective maintenance of hospital equipment.
CONTINGENCY PLAN ON EQUIPMENT BREAKDOWN Do not continue to operate malfunction equipment to avoid further damage to the equipment. Back up equipment should always be available in case of machine malfunction. Manual technical procedures and reagents must be available in case the automated bogs down. Inform the Supervisors immediately to facilitate arrangements with the technicians. If the appropriate trouble shooting procedures do not correct the observed errors, contact the authorized technician or the local distributor of the equipment.

6.27 POLICY ON EQUIPMENT MANAGEMENT PLAN
HPTLY-MER-P01-5
REVISION DATE
PAGE No.

Maintenance Section
EQUIPMENT MANAGEMENT PLAN 1. JOEL CUTAB Medical Equipment Technician - Electrician II Scope of Work a. Maintain all Medical Equipment b. Maintain all Electrical works at Hospital
2. ANACLITO INFATE - Air Condition Technician I Scope of Work

a. Maintenance all air condition unit at Hospital ARVIN F. SAMPILO, M.D. b. Quarterly cleaning of air condition
Medical Specialist II OIC
HPTLY-MER-P01-5
REVISION DATE
POLICY ON COMPOSITION OF IC 2. Infection Control Nurse TEAM

3. Microbiologist
1. Infection Control Doctor / Infection Disease Specialist
PAGE No.
The Infection Control Team; The Infection Control Team shall be responsible for the day to day infection control activities.
There shall be least 1 full time infection Control Nurse(ICN) who is registered nurse who has been trained or is receiving training in infection control provided by an accredited training organization like PHICS, PHICNA, PSMID. The ICN coordinates with the ICP as well as with other senior hospital staff.
There shall be sufficient number of trained ICNs to facilitate and ensure the effective implementation of infection control program in the health care facility. The ICN may be augmented by trained nurses (link nurses) in patient care areas or at least in high risk clinical areas.

6.29
HPTLY-MER-P01-5
REVISION DATE
POLICY ON ICC FUNCTION
PAGE No.
Mission We are the lead multidisciplinary group of concerned healthcare workers committed to promote quality care, though the prevention and control of healthcare associated infection. Vision The society aims to attain a promotive and preventive culture and be recognized as the known resource in the reduction of healthcare associated infection among patients, healthcare workers and significant others by: Training and development of competent and highly motivated infection control practitioners Implementing infection control standards ICC Function and Responsibilities Promoting sustainable infection control program 1. 2. Pioneering research in infection control Formulate / update infection control policies, guidelines and procedures Influencing policy and decision makers to support infection control program Ensure implementation of infection of control, guidelines and procedures.
3. Ensure availability of resources and contingencies for infection control program. 4. Defines the goal, objectives and priorities for all surveillance activities on healthcare associated infections, including time frame areas, patient population to be studied and surveillance method to be used.

POLICY ON ICC FUNCTION
PAGE No.
5. Prepare, review and evaluate the process the effectiveness of the infection control program. 6. Disseminate the necessary information and coordinate with medical, nursing, administration, other appropriate government agencies. 7. Oversees the performance of the ICT 8. Approves the infection control training modules. 9. Conduct IC meetings regularly at least quarterly and as needed.
Chairman or Infection Control Officer

Duties and responsibilities: Senior member of the hospital staff with experience and training in infection control, such as medical microbiologist, epidemiologist, or infectious disease physician. In the absence of these a surgeon, pediatrician or other appropriate physician with interest in the field could be appointed. Responsible to the hospital manger or medical director for infection control in the health care facilities.

POLICY PROGRAM ON INFECTION CONTROL
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
An Infection Control Program must have the following elements:
1. Definitions of Nosocomial Infections Infection for surveillance purpose, to provide for early identification and reporting and to determine infection rate.
1.1 Nosocomial Infection (NI) (hospital acquired)

-
Is one that develop during hospitalization 48 hours after admission and was not prevent on incubating at the time of the admission into the hospital.
1.2 Community Acquired Infection(CAI) Infection occurring within the first 48 hours of admission or incubating at the time of admission.
Measures Recommended A. Do prevalence studies - establish at a point or a period of the time the prevalence of NI & CAI in the hospital. You can do these studies on regular basis, and check the trend.
B. Do Nosocomial Infection Surveillance The most common HAI /NI are: pneumonias, bacteremias, wound infection, intravascular infection and urinary tract infection. In the absence of microbiologic facilities, the facilities, the diagnosis of infection can be made using data LIBRADO E. BAGAS, JR. ARVIN F. SAMPILO, M.D. from history, physical exam and simple laboratory exam.
Engineer II Medical Specialist II OIC

POLICY PROGRAM ON INFECTION CONTROL
PAGE No.
2. A record system for patient and personnel infections, resident and in service physicians must write the complete infectious disease diagnosis on the chart. A member of ICC may review this and compile in into a report. 3. Written policies on isolation requirements of infectious disease. 4. Provision of a good microbiology laboratory. Training of medical technician and doctors may be availed at RITM. 5. Regular review of the clinical use o f antibiotics as they relate to susceptibility and resistance trends seen from microbiology data. 6. Consultation relative to purchase of equipment and supplies for sterilization, disinfection, decontamination and cleaning agents.
PAGE No. POLICY ON ISOLATION PRECAUTION AND CODING GUIDELINES ON ISOLATION PRECAUTION IN PREVENTING HOSPITAL SYSTEM AND PROCEDURES ACQUIRED INFECTION
1. STANDARD PRECUATION(S) Assume that every person in potentially infected or colonized with an organism that could be transmitted in the healthcare setting and apply the following infection control practices during the delivery the health care. Practice Standard Precaution during care of all patients regardless of diagnosis. Apply the following infection control measures during delivery of healthcare.
1.1 Hand hygiene Recommendation: After touching blood, body fluids, secretions, excretions, contaminated items; Immediately after removing gloves; between patient contacts. Wash hands after touching blood, body fluids, secretion, excretions, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to other patient or environments. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross contamination of different body sites. 1.1.1 Use plain ( non antimicrobial ) soap or alcohol based hand rub for routine hand washing or hand hygiene. 1.1.2 Use an antimicrobial agent or waterless antiseptic agent alcohol based hand rub for specific circumstance ( e.g. control of outbreaks or hyperendemic infections), as defined by infection control program. 1.2 Respiratory Hygiene Cough Etiquette 1.2.1 Educated healthcare personnel on the importance of source control measures to contain respiratory secretion to prevent droplet and fomite transmission respiratory pathogens, especially during outbreaks of viral respiratory tract infections (e.g., influenza, RVS, adenorvirus, parainfluenza virus) in communities.

6.32 6.38
HPTLY-MER-P01-5
REVISION DATE
1.2.2 Post signs at entrances and in strategic places (e.g., elevators,
POLICY ON ISOLATION PRECAUTION AND CODING SYSTEM AND PROCEDURES
PAGE No.
cafeterias ) within ambulatory and in patient setting with instructions to patients and other person with symptoms of respiratory infection to cover their mouths/ noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands been contact with respiratory secretions. 1.2.3 Provide tissues and no touch receptacles ( e.g., Foot pedal operated lid or open, plastic lined waste basket ) for disposal of tissues 1.2.4 Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory and inpatient setting; provide conveniently located dispensers of alcohol based hand rubs and, where sinks are available, supplies for hand washing 1.2.5 During periods of increased prevalence of respiratory infection in the community ( e.g., as indicated by increased school absenteeism, increased number of patients seeking care for a respiratory infection ), offer masks to coughing patients and other symptomatic persons ( e.g., person who accompany ill patients ) upon entry into the facility or medal office and encourage them to maintain spatial separation, ideally a distance of at least 3 feet, other in common waiting areas.
1.3
Use of Personal Equipment (PPE) 1.3.1 Gloves Recommendation: For touching blood, body fluids, secretions, excretions, contaminated item; for touching mucous membranes and nonintact skin. Wear gloves (clean, nonsterile gloves are adequate ) when touching blood, body fluids, secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminateditems and environmental surface,
and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environments.

1.3.2 Mask, Eye Protection, Face Shield
PAGE No.
During procedures and patient care activities likely to generate splashes spays of blood. Body fluids, secretions, especially suctioning, edotracheal intubation Wear a mask and eye protection or a face shield to protect mucous membranes of the eye, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. 1.3.3 Gown During procedures and patient care activities when contact of clothing / exposed skin blood/body fluids, secretions, and excretions in anticipated. Wear a gown (a clean nonsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or spays of blood, body fluids, secretions or excretions. Select a gown that is appropriate for the activity and amount of 1.4fluid likely to be encountered. Remove a soiled gown as promptly as Patient Care Equipment possible, and wash hands to avoid transfer of microorganism to other Recommendation: patients or environments. Handle in a manner that prevents transfer of microorganisms to other and should to the environment; wear gloves if visibility contaminated; perform hand hygiene. Handle used patient care equipment soiled with blood, body fluids secretions and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, transfer of microorganisms to other patients and environments. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. Ensure that single use items are discarded property.

1.5 Environmental Control Recommendation:
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Develop procedures for routine care, cleaning and disinfection of environmental surface, especially frequent touched surface in patient care areas. Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces, bedrails, bedside equipment and other frequently touched surfaces, and ensure that these procedures are being followed.
1.6
Linen Recommendation: Handle in a manner that prevent transfer of microorganism to other and to the environment. Handle, transport, and process used linen soiled with body fluids, secretions and excretions in a manner that prevents skin mucous membrane exposure and contamination of clothing, and that avoids transfer of microorganisms to other patients and environments.
1.7
Occupation Health and safe Injection Practices Recommendation: Do not recap, bend, or hand manipulate used needless; If recapping is required, use one handed scoop technique only; use features when available; place used sharps in puncture resistant container.

6.32 6.38
HPTLY-MER-P01-5
REVISION DATE
POLICY ON ISOLATION PRECAUTION AND CODING 1.7.1 Take PROCEDURES SYSTEM AND care prevent injuries
PAGE No.
when using needles, scalpels, and other sharp instrument or devices, when handing sharp instruments after procedures; when cleaning and instrument; and when disposing of used needles. Never recap used needles or otherwise manipulate them using both hands, or use any other technique that involves directing to point of needle toward any part of the body; rather, use either a one handed scoop technique or a mechanical device designed for holding the needle sheath. Do not remove used needles from disposable syringe by hand, Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture resistant containers, which should be located as close as practical to the area in which items were used and place reusable syringes and needles in a puncture resistant containers for transport to reprocessing area.
1.7.2 Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth to mouth resuscitation methods in the where the need for resuscitation is predictable. Recommendation: Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions.
1.8
Patient Placement Recommendation: Prioritize for single patient room if a patient is at increased risks transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is increased risk of acquiring infection or developing adverse outcome following infection.

POLICY ON AIRBORNE PRECAUTIONS
VISITORS: Report to Nurse Before Entering Patient Placement
PAGE No.
o Use private room that has: Monitored negative air pressure 6 to 12 air exchanges per hour Discharge of air outdoors or HEPA filtration if recirculated Keep room door closed & patient in room
Respiratory Protection Wear an N95 respirator when entering the room of a patient with known or suspected infections pulmonary Tuberculosis . Susceptible persons should not enter the room of patients known or suspected to have measles (Rubeola) or varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter, they should wear an N95 respirator. (Respirator or surgical mask not required if immune to measles and varicella). Patient Transport Limit transport of patient from room to essential purpose only use surgical mask on patient during transport.

6.33
HPTLY-MER-P01-5
REVISION DATE
POLICY ON NATIONAL ANTIMICROBIAL USE BASED ON THE HOSPITAL ANTIBIOGRAM
PAGE No.
Antibiograms are often taken into account to define a rational selection of an empirical antimicrobial therapy for treating patients with hospital acquired infections. Hospital antibiogram is used to assist clinicians in the design of empirical therapies for suspected infections within hospital settings.
Policy: 1. A clinical microbiology laboratory is established and should do a timely and accurate reporting of microbiology susceptibility test results. 2. Then a regular Hospital antibiogram (monthly basis) is done and a periodic summary of antimicrobial susceptibilities of local bacterial isolates submitted to the hospital clinical microbiology laboratory is furnished. 3. Exclusion of clinical isolates from outpatient clinics will give a better sense of the true state of resistance. In addition, preparation of antibiograms specific to certain patient care areas, especially in intensive care units, may allow identification of local problems and focused antimicrobial stewardship and infection control efforts.
4. Antibiograms may be distributed as printed cards, as part of institutional
handbooks on antimicrobial therapy, or in the institutional intranet.
REVISION DATE
POLICY AND PROCEDURES ON WAITING TIME

Introduction:
PAGE No.
Camiguin General Hospital Aims to deliver prompt quality care to clients on each service areas. Camiguin General Hospital uses a wide range of equipments in the operation of its clinical activities and support functions. Camiguin General Hospital recognizes General Policy the risk arising from the use of medical devices by its staff and patients and has a moral and legal duty generally that this equipment doesimmediately danger to the 1. Clients are to ensure seen and entertained not present arised to any health and safety of the employees, staff and general public. service area. 2. A general 30 minutes waiting period on less than an hour waiting period given to each client. Policies: 3. If there is a delayed in the delivery of services an explanation is given to the client. 1. Medical devices and equipment are used everyday by most health care professionals to times the routinely monitored, evaluated and General 4. Patient waitingsupport are care treatment of patients. Camiguin imposed Hospital on standardsand procedure develop by Camiguinthat equipment is based recognizes and accepts its responsibility to General Hospital. managed in a way that safeguards the health and safety of the employees, patients and the general public. Procedure management must be undertaken to identify and document any hazards 2. Risk associated with medical devices and steps to mitigate these risks. 1. Patient upon arrival to service areas are entertained and are listed on first come basis. 3. Good management will involve assessment of medical devices from clinical use and support, staff training and equipment management. 2. Patient then will go the waiting area, where they wait for their turn. 3. Each waiting time are monitored, chart and are conducted. Patient then would give his/her evaluation on his/her waiting time on the survey form provided.
ARVIN F. SAMPILO, M.D. Medical Specialist II OIC ARVIN F. SAMPILO, M.D. Medical Specialist No./ REV. No. DOCUMENT II OIC HPTLY-MER-P01-5
REVISION DATE
POLICY AND PROCEDURE ON SAFE AND EFFICIENT USE OF MEDICAL EQUIPMENT
PAGE No.
Patients would come and visit Camiguin General Hospital with myriad of illness and sickness and with varying symptoms. Thus there is a need to identify clinical services that would cater to the patients clinical needs.
Policy: 1. Every patient coming to the ER / OPD must be thoroughly assessed / evaluated and correctly diagnosed. 2. Patients are referred to appropriate clinical services that would best address to the patients clinical needs.
Procedures: 1. Patients visit at the ER / OPD. 2. Physicians will examine the patients and identify their clinical needs. 3. Patients are then referred to appropriate clinical services.
LIBRADO E. GENERAL CAMIGUIN BAGAS, JR. Engineer II HOSPITAL
DOCUMENT No./ REV. No. ARVIN F. SAMPILO, M.D. HPTLY-MER-P01-5 Medical Specialist II OIC
REVISION DATE
POLICY AND PROCEDURE IN IDENTIFYING SERVICES THAT WILL BEST ADDRESS PATIENTS
PAGE No.
CAMIGUIN BAGAS, JR. LIBRADO E. GENERAL Engineer II HOSPITAL
HPTLY-MER-P01-5 ARVIN F. SAMPILO, M.D. Medical Specialist II OIC REVISION DATE
POLICY ON HOSPITAL THAT CONFORMS TO THE JOINT DOHDENR CIRCULAR ON WASTE
PAGE No.
Policy: 1. Camiguin General Hospital joins the DOH-DENR in controlling and managing the import, transport, treatment, and disposal of toxic substances and hazardous nuclear wastes in the country. 2. Camiguin General Hospital joins the DOPH-DENR in promoting public health and environmental protection and to employ environmentally sound methods to encourage resource conservation.
3. Encourages a greater private participation while retaining the primary
enforcement and responsibility with local government units.

4. Segregation and collection of solid waste shall be conducted at the
Barangay level specifically for biodegradable, compostable and reusable waste. At least 25% of LGUs solid waste are reused, recycled and compost.
CAMIGUIN GENERAL LIBRADO E. HOSPITAL BAGAS, JR. Engineer II
HPTLY-MER-P01-5
ARVIN F. SAMPILO, M.D. REVISION DATE Medical Specialist II OIC
POLICY AND PROCEDURES ON RISK IDENTIFICATION, ASSESSMENT AND CONTROL

Introduction
PAGE No.
Risk assessment is the process of quantifying the probability of a harmful effect to individuals or populations from certain human activities. In most Hospital-acquired (nosocomial) chemicals of the cross infections (infections that are countries, the use of specific infections and operations of specific facilities (e.g. transmitted between individuals plants) is not pathogens) shows can need of applying power plants, manufacturing with different allowed unless it the be shown that basic principles of medicalrisk of death or illness above aoutline the basic procedures they do not increase the asepsis. The following steps specific threshold. used in applying medical asepsis. The process of managing risk is to identify potential risks. Risks are about a. that, when triggered, cause Follow previous risk identification can care events Perform Patient Handwash. problems. Hence, instruction on patient start handwash. The patient care handwash is the most important step in with the source of problems, or with the problem itself. preventing and controlling infection. There may be times when you do not have the materials or the time to do a thorough handwash; however, always wash Policy your hands and clean your fingernails if time permits. b. Disinfect Materials Required. Disinfecting means cleaning objects to remove most organisms. Follow should identify, assess the risk and manage are 1. Camiguin General Hospital directions explicitly where chemicals agents the used. risk before any harmful effects would come to the patients, family, and staff. c. there Clean Patient Care security risk, 2. IfMaintainis a presence of Environment. control should be established immediately in order to prevent harm to the patients, family, and staff. 1. Concurrent cleaning. Disinfect and dispose of infectious matter. 3. Risk Immediately assessed and appropriately controlled.aWhere elimination or is identified during the course of a disease. This is constant task. substitution is not possible, adequate warningmaterials after a devices dies, 2. Terminal cleaning. Disinfect contaminated and protection patient are used. transfer, or is discharged.
4. A coordinated security arrangement in the organization assures protection
of patients, staff, and visitors.
CAMIGUIN GENERAL LIBRADO E. BAGAS, JR. Engineer II HOSPITAL
HPTLY-MER-P01-5 ARVIN F. SAMPILO, M.D. Medical Specialist II OIC
REVISION DATE
POLICY ON PROCEDURES FOR APPLYING MEDICAL ASEPSIS
PAGE No.
d. Use Clean and Dirty Utility Rooms. Clean and dirty articles are not stored in the same place in order to prevent contamination. Clean rooms are used to store clean, unused equipment. Dirty rooms are rooms used to store contaminated items such as used linen, trash, contaminated equipment, dirty dietary trays, and basic laboratory tests. 1) Clean linen. Store clean linen in a clean room marked for clean linen only. Prevent the contamination of clean linen by: a.) Limiting access to authorized personnel only.
a. Use freshly prepared germicidal detergent solution to wash furniture, mattress covers, grossly soiled areas of walls, and equipment not handled by central supply. b. Wet-vacuum or mop floors.
c. If an isolation room, read isolation technique sign for special
instruction.
DOCUMENT No./ REV. No. LIBRADO E. GENERAL CAMIGUIN BAGAS, JR. Engineer II HOSPITAL HPTLY-MER-P01-5 ARVIN F. SAMPILO, M.D. Medical Specialist II OIC REVISION DATE
POLICY ON PROCEDURES FOR APPLYING MEDICAL ASEPSIS
PAGE No.
1. The security guard of Camiguin General Hospital must assumed and aware of the responsibility of their duties, bringing with them the security fundamentals such as eleven general orders, code of ethics, code of conduct, safety of the establishment, properties and protect any individual inside the hospital from harm or peace and order in general the task include everything out of patient upon arrival of ambulance or vehicle bringing patient at the emergency room. 2. No security guard on duty shall leave his post even after the expiration of his shift of the one who will relieve him has not yet arrived. 3. Wearing of complete uniform shall be strictly observed while on tour of duty. 4. Clearance from discharge patients shall be presented to the guard on duty and patients bags should be inspected before they leave the hospital. 5. Roving within the hospital premises (inside and outside) should be done regularly while on duty and the guard should see to it that all necessary lights will be turned on at 5:30 PM and be turned off at 6:00 AM. 6. The guard must see to it that for every one patient, only one watcher is allowed to stay with the patient and that the proper visiting hours should be observed. 7. Implementation of visiting hours should be strictly observed. 8. Any vehicles of Camiguin General Hospital must prepare a trip[ ticket signed by chief of hospital or administrative department head. 9. Records in the logbook the incoming and outgoing of vehicles or vice versa of both inside and outside vehicles. 10. Monitoring all employees of Camiguin General Hospital going out of the hospital premises, present to the guard their pasd slip duly signed by the management. 11. Security Guard must prepare monthly schedule of duties and submit the DOCUMENT No./ REV. No. approved schedule to Human Resource Management Officer Five(5) days HPTLY-MER-P01-5 before the succeeding month.
CAMIGUIN GENERAL incoming guard. 12. Proper turn over of duties to the HOSPITAL
REVISION DATE
POLICY ON THE SECURITY GUARD ARVIN F. SAMPILO, M.D. LIBRADO E. BAGAS, JR. Engineer II Medical Specialist II OIC AT CAMIGUIN GENERAL HOSPITAL
PAGE No.
1.0
INTRUCTION
Patients with highly transmissible infection are admitted to healthcare facilities! Hospital and are taken cared by doctors, nurses and premedical staff. The housekeeping, linen, maintenance staff although not directly involved in patient care keep environment clean and sanitary for patients and staff. It is therefore important that important that hospital staff directly involved in the care of patients with highly transmissible infectious disease be informed or WARNED about the infection status of patients so they can apply the appropriate precaution to prevent acquiring and spreading of infection to health care personnel, patients and visitors. Since patients who admitted for non infectious conditions may also be infected with viruses (HIV, Hepatitis B and C) and bacteria (TB), all healthcare workers should routinely practice standard (routine) precaution regardless of patient diagnosis.
2.0
OBJECTIVES 2.1 General Objective
To establish documented policies and procedures on isolation Precaution and coding system/ 2.2 Specific Objectives 2.2.1 To prevent and control spread infectious agents in healthcare facilities/hospitals among patients and healthcare workers in all settings where healthcare is delivered. 2.2.2 To implement Isolation Precaution in healthcare facilities/hospitals. 2.2.3 To implement a confidential coding system of warning healthcare DOCUMENT workers (HCW) about infection status of patients. No./ REV. No. 3.0
CAMIGUIN GENERAL The procedures involves application of isolation precaution by healthcare workers HOSPITAL is seen at any healthcare facility to the time of discharge. from the time patient REVISION DATE
POLICY ON BAGAS, JR. LIBRADO E. ISOLATION AND Engineer CODINGII SYSTEM POLICIES AND PROCEDURES
ARVIN F. SAMPILO, M.D. PAGE OIC Medical Specialist II No.
SCOPE
HPTLY-MER-P01-5
4.0
POLICIES 4.1 Infection Control Isolation precaution shall be implemented in healthcare facilities/hospitals by ALL healthcare workers. (See Annex 1) 4.1.1 Standard Precaution shall be practiced during care of all patients regardless of diagnosis. 4.1.2 In addition to standard precaution, expanded or transmission based precaution shall be applied during care of patients with or suspected with infectious disease. 4.1.3 Patients diagnosed/suspected to have highly transmissible infectious disease shall preferably be admitted in single room. A fan exhausting air to the outside can be installed in rooms to attain negative pressure without endangering the public. 4.1.4 A standardized but confidential coding system of warning healthcare worker about the infection status of patients and the appropriate precaution to be observed shall be established and implemented in healthcare facilities/hospitals. 4.1.5 Before implementation of isolation Precaution policies, all healthcare workers shall undergo adequate orientation and training.
5.0
PRECEDURE 5.1 All HCWs shall observe Standard Precaution in handling patients regardless of the diagnosis while the precaution code is not yet known or written in the forms and while waiting for the final diagnosis. 5.2 When admitting patients, Attending Physicians ( from ER, OPD and HPTLY-MER-P01-5 Doctors Clinics) are required asses patients infection status and write chief complaint diagnosis and manner of transmission of patient infectious disease. HE/SHE shall inform healthcare workers (HCW) about the case by REVISION DATE drawing a rectangle sign with appropriate letter code* at the right upper corner face of any of these forms: ER Admission Form, Admitting Oder Sheet, Physician, Referral Form and Diagnostic Request Forms. The MDs can use combination of letter codes POLICY ON ISOLATION AND as indicated in Isolation Precaution PAGE No. Guidelines.
CODING SYSTEM
LIBRADO E. BAGAS, POLICIES AND II JR. PROCEDURES Engineer
5.3 When patient is admitted, Transmission based/ Expanded Isolation Precaution is ordered, coding system shall be implemented to warn the HCWs so that specific precaution are observed. (See Annex 2)
5.3.1 The Receiving or Charge Nurses shall place a yellow rectangle sticker sign on the right upper corner of the metal cover of the patients chart. The nurse on duty shall include in their shift endorsement the isolation precaution cade. 5.3.2 In private and Semi Private Rooms the yellow coded rectangle plastic sign shall be placed on the door of patient rooms. 5.3.3 In Multi Bed Rooms (Wards, ICU, NICU) the yellow coded rectangle sign shall be placed beside Patients Bed Number. 5.3.4 All request forms for diagnostic procedures shall be property marked with appropriate sign and code while precaution are enforced. 5.3.5 The Nurse shall remind the auxiliary service Staff to pay attention to the letter code in the yellow rectangle plastic sign and apply appropriate precautions. 5.3.6 HCWs shall routinely check doors sign, codes at the right upper corner of the ER Admission Sheet and other forms to know the patients infection status so that they can apply the appropriate precautions.
CAMIGUIN GENERAL HOSPITAL3) (See Annex
5.4 Isolation Precaution and coding system shall be terminated when no longer indicated.
REVISION DATE
5.4.1 The MD shall write the order of terminated of Isolation Precaution POLICY and coding after consulting the guideline on isolation Precaution ON ISOLATION AND ( re: duration of precaution ) or after coordination No. Infection PAGE with CODING SYSTEM Control Team or Infectious Disease Specialist.
POLICIES AND PROCEDURES LIBRADO E. BAGAS, JR.

Engineer II 6.0
The nurse will then cross out the rectangle and write the termination date: Plastic sign with corresponding letter code are then removed from patient and chart.
5.4.2
*Codes: A Airborne Precaution B Contract Precaution D Droplet Precaution PE Protective Environment

POLICY ON ISOLATION AND CODING SYSTEM
Engineer II POLICIES AND PROCEDURES LIBRADO E. BAGAS, JR.
HPTLY-MER-P01-5
REVISION DATE
PAGE No. ARVIN F. SAMPILO, M.D. Medical Specialist II OIC
In-Charge
Activity
DEMS Admission
Isolation Precaution Guidelines MD RN No MD Official Diagnostic Results
Isolation Precaution DOCUMENT No./ REV. No. Guidelines

No
HPTLY-MER-P01-5
REVISION DATE Isolation
Precaution Guidelines
PAGE No.
POLICY ON ISOLATION AND CODING SYSTEM POLICIES AND PROCEDURES

RN
Results
Isolation Diagnostic REFERENCES

Precaution Guidelines
MD
All HCW
Receive Admission
Form
Assess patient and determine Mode Of Transmission
Physician Order Sheet MD Order Form MD
Admission Referral
Write Order of Expanded Precaution
Apply Coding System
CODING LEGEND
LOCATION OF INDICATOR
For Diagnostic
Maintain Precautions
Yes MD RN
Mark Forms with Codes
HANG CODED TAG AT THE DOOR BESIDE BED NUMBER AND CRIB
Is precautio n still indicated?
Order Terminate Expanded Precaution & Coding System
6.0 RESPONSIBILITIES AND ACCOUNTATIBILITIES

6.1 Attending physician assesses patients infection status and indicates Maintain Precautions MD manner of transmission. DOCUMENT No./ REV. No.
CAMIGUIN GENERAL 6.3 Charge nurse places identifying stickers and signs to patient chart and HOSPITAL REVISION DATE door.
6.4 Other health care workers takes precautions as indicated in coded signs.
6.2 Resident physician (admitting or floor) identifies patients infectious HPTLY-MER-P01-5 disease and writes code in forms to inform nurse in floors.
POLICY ON ISOLATION AND 6.5 Administration provides, sends or memorandum resources for hospitalPAGE No. wide implementation. SYSTEM CODING POLICIES AND PROCEDURES 6.6 Infection Control Team facilitates and monitors implementation
5.6 Legend of Coding System
RECTANGLE WITH APPROPRIATE LETTER CODE LETTER CODED TAG A D CD C AC ACD
DRAW AT THE UPPER CORNER OF DEMS ADMISSION FORM, PHYSICIANS ORDER SHEET, REFERRAL FORM, DIAGNOSTIC REQUEST FORM, PATIENT DATA SHEET.
Asepsis and Aseptic Practices in the Operating Room

PE Preventing surgical site infection in the operating is the primary goal of the surgical team, and all activities performed by the team support this goal. Some of these activities include patient risk assessment, environmental cleaning, disinfection and sterilization of instrumentation, patient antibiotic prophylaxis, and use of standard precautions. However, operating room activities pertaining to asepsis and aseptic practices have the greatest direct impact upon surgical team in helping to reduce the patients risk to surgical site infection.
The goal of asepsis is to prevent the contamination of the open surgical wound by i isolating the operative site from the surrounding non environment. The surgical team accomplishes this by creating and maintaining the sterile field and by following aseptic principles aimed at preventing microorganisms from contaminating the surgical wound.
The standards and recommended practices, developed by the Association of preoperative Registered Nurses (AORN), are guidelines to be used by the surgical team to achieve the optimal level of technical and aseptic practice when caring for DOCUMENT No./ REV. No. their patients in the perioperative setting.
HPTLY-MER-P01-5 These guidelines are not to be considered policies. They should be used by institutions to provide direction and information on perioperative practice incorporate them into their own policies and procedures.
This principle of aseptic technique play a vital role in accomplishing the goal of asepsis in the operating room environment. It is the responsibility of each surgical staff member to understandSURGERY of these principles and to incorporate them POLICY ON the meaning into their everyday practice. The principle of aseptic technique include the following PAGE No. OPERATING ROOM principles.
REVISION DATE
Principle # 1
Scrubbed persons function within a sterile field.
The surgical team is made up of sterile and nonsterile members. Sterile members or scrubbed personnel work directly in the surgical field while the nonstrile members work in the periphery of the sterile surgical field. All surgical team members wear scrub attire. In addition to scrub attire, scrubbed person must wear a sterile surgical gown, mask, and gloves within the sterile field to establish bacterial barriers. These barriers protect the patient from the transmission of microorganisms from the surgical team. Once the scrubbed person dons the sterile surgical gown, the gowns sterility is limited to the gown portions directly viewed by the scrubbed person. These sterile areas include the gown front form chest to the sterile field level, and these sleeves from two inches above the elbow to the cuff. The scrubbed personnel always perform a surgical hand scrub prior to donning their sterile surgical gown and gloves.
Principle #2
Sterile drops are used to create a sterile field.
Sterile surgical drapes establish an aseptic barrier minimizing the passage of microorganisms from nonsterile to sterile areas. Sterile drapes should be placed on the patient, furniture, and equipment to include in the sterile field, leaving only the incisional site exposed. During the draping process, only scrubbed personnel should DOCUMENT No./ REV. No. handle sterile drapes. The drapes should be held higher than the operating room bed HPTLY-MER-P01-5 with the patient draped from the prepped incisional site out to the periphery. Once the sterile draped positioned, it should not be moved or rearrange. Keep in mind that after the patient and operating room tables are draped, only the top surface of the REVISION DATE draped area is considered sterile.
Principle #3 All items used within a sterile field must be sterile POLICY ON SURGERY
Under no circumstance should ROOM nonsterile items/areas be mixed since one OPERATING sterile and contaminates the other. Sterilization provides the highest level assurance that all instruments, sutures, fluids, supplies, and drapes are avoid of microorganisms. The sterility of a package is determined by events, not by time. To ensure sterility, all sterile items need to be inspected for package integrity and sterilization process indicators, such as indicator tape and internal chemical indicators, prior to introduction onto the sterile field. If a package has been compromised, it should be considered contaminated and not be used.
PAGE No.
Principle #4
All items introduced onto a sterile field should be opened, dispensed and transferred by methods that maintain and integrity.
All sterile items should be dispensed to the sterile field by methods that preserve the integrity of the items and sterile field. Nonsterile personnel, usually the circulating nurse, must use good judge when dispensing sterile items onto the sterile field either by presenting them directly to the scrubbed person or placing them securely on the sterile field. Sterile items that tossed onto the sterile field may displace other sterile items, penetrate the drape, or roll the sterile field causing contamination to occur. When opening wrapped supplies, the nonsterile person should open the top wrapper flap away from tem first, then open the flaps to each side. The last wrapper flap is pulled toward the nonsterile person opening the package. This technique of opening a wrapped package ensures that nonsterile person does not reach over the sterile item inside. All wrapper edges should be secured to prevent flipping the wrapper and contaminating the contents of the sterile package or field. After wrapper has been opened, the inside of the wrapper and its contents are considered sterile with the exception of the 1 inch outer edge of the wrapper. This 1 inch outer edge of the wrapper is considered the margin of policy between sterile and nonsterile. When a package is double wrapped, each institutions policies and procedures determine if DOCUMENT one or both wrapper are opened before presentation to sterile field. No./ REV. No.
Principle #5
CAMIGUIN GENERAL A sterile should be maintained and monitored constantly HOSPITAL REVISION DATE
HPTLY-MER-P01-5
It is the responsibility of the operating room staff to monitor and maintain the sterile field. Sterility can never be absolutely guaranteed, but surgical team members should make every reasonable effort to reduce the likelihood of contamination and be POLICY ON SURGERY vigilant to breaches in sterility. When a breach of sterility occurs,PAGE No. team member must OPERATING ROOM take immediate and appropriate action to correct the break in technique to reduce further risks of contamination. Remember, if there is doubt regarding an items consider it is not sterile.
The sterile field should be prepared as close as possible to the time of use. The sterility of supplies used during a surgical procedure can affected by the events taking place within the operating room, and the length of time the items have bewen exposed to the environment. Once set up the sterile field needs to be monitored constantly. When the sterile field is left unattended, personnel, airborne contaminants, insects, and liquids can contaminate the sterile field. Each facility should have policies and procedures that address these issues for the surgical team to follow.
Principle #6
All personnel moving within or around a sterile field do so in a manner to maintain the sterile field. Since the patient is the center of the sterile field, scrubbed personnel should remain close to this area without wandering around the room. This movement can result in contamination of the sterile field. Scrubbed personnel should move only from sterile areas to sterile areas. When scrubbed personnel change positions, they should maintain a safe distance from each other and always pass each other turning back to back or face to face. This movement reduces the risks of contamination by ensuring the scrub persons are passing either nonsterile or sterile to sterile. Scrubbed personnel should remain in the position in which they began the surgery. DOCUMENT No./ REV. No. For example, if the surgery begins with the scrubbed person sitting and is completed HPTLY-MER-P01-5 with the scrubbed with the person standing the portion of the grown that was considered sterile is uncertain. Scrubbed personnel should keep their arms and hands within the sterile field at all times to avoid any accidental contact with nonsterile REVISION DATE items or areas. Scrubbed personnel must maintain a safe distance when approaching nonsterile object and personnel. The safe distance or margin of safety is important in identifying safe boundaries between sterile and nonsterile areas.

POLICY ON SURGERY OPERATING ROOM
PAGE No.
Nonsterile personnel should always remain in nonstrile areas and contact only nonsterile items to prevent contamination of the sterile field. It is important that the nonstrile personnel always face the sterile field area is always being observed and accidental contact is avoided. Just as the sterile scrubbed person must maintain a safe distance contact is avoided. Just as the sterile fields and scrubbed personnel. And finally, when delivering sterile supplies to the sterile field, the nonsterile team member must always maintain a margin safety between themselves and the sterile field, never contacting or reaching over any portion of the sterile area. This margin safety is generally identified as minimum of 12 inches (30 cm) or more.
Principle #7
Policies and procedures for maintaining a sterile field should be written, reviewed annually, and readily available within the practice setting. These recommended practice for aseptic technique should be used as guidelines for developing policies and procedure within the practice setting. Introduction and review of policies and procedures should be included in the orientation and ongoing education of all perioperative personnel. Training of aseptic technique and practice requires experienced and skilled surgical DOCUMENT No./ REV. No. team members of demonstrate these skills to new and inexperienced personnel. New HPTLY-MER-P01-5 personnel should be assigned an experienced mentor who will be a good role model and teacher providing leadership and education in perioperative practice.
CAMIGUIN GENERAL Summary HOSPITAL
REVISION DATE
All surgical team members must practice these principle of aseptic technique to help prevent the transfer to microorganisms into the surgical wound during the POLICY is the responsibility perioperative period. ItON SURGERY of the surgical team members to develop PAGE No. a strong surgical conscience, adhering to the principles of asepsis and rectifying any OPERATING ROOM improper technique witnessed in the operating room. In addition to principles of asepsis, proper surgical attire plays an important role in the reduction of surgical site infections by reducing the amount of hair and skin contaminants reaching the sterile field.
The goal of asepsis and aseptic technique is to prevent the transfer of microorganisms into the surgical wound. Preventing surgical site contamination requires the efforts of all trained surgical team members to use their knowledge and experience in aseptic practice to provide their patients with optimal care resulting in positive surgical outcomes.

POLICY ON SURGERY OPERATING ROOM
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
1.Practice hand washing before and after every direct contact with patients. 2.Avoid hand to hand passing of needles during the venipuncture procedure. 3.Dont open or empty the safety box. It should be stored in a safe and secure place until it is ready for disposal. 4.Never recap used needles instead place them uncapped into the safety box. DOCUMENT No./ REV. No.
HPTLY-MER-P01-5 5.Make sure there is a puncture and liquid proof safety CAMIGUIN GENERAL box in the immediate area where you administer HOSPITAL venipuncture. Place this at eye level and arm reach. REVISION DATE
6.Never fill a box more than 3 quarters full.

POLICY ON SHARPS MOVES
7.Protect yourself with HB vaccination. PAGE No. ahead Think AGAINST and plan the safe handling and disposal of needles SHARP INJURY before using them. 8.Be proactive. Use passive safety engineered needle device available to protect yourself.
POLICY
All department/section handling sharps must be provided with a closeable, puncture resistant, leak proof container and clearly marked FOR SHARPS ONLY. Follow the color coding for sharps which is Red with biohazard symbol Employers must maintain a logbook of injuries for contaminated sharps to include all work related needlestick injuries and cuts from sharps objects that are contaminated with persons blood or other potentially infectious materials. Compliance to universal precaution must be strictly imposed to all staff. Hepatitis B vaccine must be made available to all employees
Procedures:
Evaluation and follow up of post exposure prophylaxis shall be done when HPTLY-MER-P01-5 appropriate.
REVISION DATE
1. Remove the needle from the syringe using a mechanical device or a forcep. 2. Drop used needles, sharps, razors, blades empty ampoules into leak proof & PAGE No. PROPER HANDLING AND SAFE puncture container with sodium hypochlorite solution (Following a dilution of 1 DISPOSAL OF SHARPS NEEDLES part sodium hypochlorite to 9 parts of water). 3. Discard contaminated sharps immediately or as soon as feasible into appropriate container. 4. Follow the protocol in handling needles Do not bend, break recap or remove contaminated needles from the syringe using bare hands and other sharps unless such act is required by a specific procedure or has no feasible alternative. 5. Use the One handed scoop technique when handling needles or use a mechanical device designed for holding needle such as forceps.
POLICY AND PROCEDURES ON
6. When sharps container becomes full (3/4 full is allowed ) it must be replaced
with a new container so that it do not over spill.

7. Do not require the employee to reach into container where used sharps or
needles have been placed.

8. Always do hand washing before and after any procedure.

POLICY AND PROCEDURES ON PROPER HANDLING AND SAFE DISPOSAL OF SHARPS NEEDLES
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Organizational Structure; ICC

Chief of Hospital

Nursing Services
HPTLY-MER-P01-5
REVISION DATE
POLICY AND PROGRAM ON Medical Services INFECTION CONTROL STRUCTURE
Administration PAGE No.
ICC- - - - - - - - - - - - - - - - - -
If the appropriate pieces of PPE are used correctly, they will protect health-care workers from being exposed to certain types of infectious diseases. In addition to hand hygiene which should always be performed healthcare workers should also wear personal protective equipment that is appropriate for the procedure they are performing and the level of contract with the patient that it will entail in order to avoid contract with blood and body fluids.
DOCUMENT No./ REV. No. PPE for Standard Precautions purposes comprises gloves, gowns, eye protection and
medical masks. Additional terms, such as caps to cover the HPTLY-MER-P01-5 hair, are not considered PPE, but can be used for the comfort of the health-care worker. Likewise, boots can also be used for practical purposes, for example when resistant closed foot wear is needed and to avoid accidents with sharp objects. When used correctly, PPE will REVISION DATE protect the health-care worker from being exposed to certain types of infectious diseases.
POLICIES AND PROCEDURES OF Choosing Items of PPE PERSONAL PROTECTIVE PAGE No. EQUIPMENT (PPE) ACCORDING It is not always essential to use all the items of PPE as part of Standard Precautions. TO which items of PRECAUTIONS In selectingSTANDARD PPE to use, the health-care worker should undertake an
assessment of the potential risk to exposure to an infectious diseases that might be associated with the intended procedure when providing routine care. In particular, the health-care worker should consider. The Procedure What procedure will be undertaken? What are the chances of contact with the patients blood or body fluids and wht type of fluids might be involved?
The Health-care worker Does the health-care worker have any skin abrasions?

POLICIES AND PROCEDURES OF PERSONAL PROTECTIVE EQUIPMENT (PPE) ACCORDING TO STANDARD PRECAUTIONS
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
The Equipment and Facilities Are all the items of PPE available to use? What facilities exist for putting on and taking off items of PPE? Is any external assistance required in putting on or taking off items of PPE? Where are the nearest hand-hygiene facilities located?
Does every item of PPE fit correctly? Where are the waste disposal facilities located?
General Principles when using PPE Whenever items of PPE are used, there are some general principles that apply to all and should always be taken into consideration.
Always perform hand hygiene before handling and putting on any item of PPE. Any damaged or broken pieces of re-usable PPE must be removed and replaced immediately. All items of PPE must be removed as soon as possible after completing the health-care procedure to avoid contaminating other surfaces.
ARVIN F. SAMPILO, M.D. Medical Specialist II - OIC

HPTLY-MER-P01-5
REVISION DATE
PAGE No.
All single-use items of PPE must be discarded immediately after use, using the appropriate waste management facilities. Always perform hand hygiene immediately after removing and discarding any item of PPE.
General PPE Guidelines o Hand Hygiene should always be performed despite PPE use. o Remove and replace if necessary any damaged or broken pieces of re-usable PPE as soon as you become aware that they are not in full working order.
o Remove all PPE as soon possible after completing the care and avoid contaminating.
The environment outside the isolation room; Any other patient or worker; and yourself
o Discard all items of PPE carefully and perform hand hygiene immediately afterwards

HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Hand Hygiene
Gloves
Gown
Medical Mask
Protective Eyewear

POLICY AND PROCEDURES IN RECYCLING & RE-USE OF EQUIPMENT
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Wash the piece of equipment with soap, detergent and water. Rinse Disinfect Rinse again if using chemicals to disinfect Dry Store
HPTLY-MER-P01-5
REVISION DATE
POLICY AND PROCEDURE ON STERILIZATION, DISINFECTION AND ANTISEPSIS
PAGE No.
Equipment should be cleaned regularly and stored where it will not become contaminated. Items must be cleaned manually with soap and water to remove organic debris autoclaving.
Steam autoclaving uses distilled water that must reach a temperature of 121 to 132 c. required time of exposure is 20 minutes for unwrapped instrument and 30 minutes for small packs. Unwrapped instruments should transferred to a sterile container. be used immediately or aseptically
Hot air oven sterilization is used for instruments having contact with mucous membranes.
Boiling instruments are placed in boiling water for at least 20 minutes. Chemical disinfection is accomplished with glutaraldehyde, hydrogen peroxide or bleach. After disinfection; instrument are rinsed with sterile water, dried and stored aseptically to avoid contamination.
Housekeeping department operation involving substantial risks of direct exposure to LIBRADO E. BAGAS, JR. ARVIN F. be taken while cleaning body fluids shall be addressed for proper precaution to SAMPILO, M.D. Engineer II Medical Specialist II - OIC rooms and blood spills.
FUNCTIONS: HPTLY-MER-P01-5 To develop and maintain clean, safe and sanitary environment for patients and hospital personnel.
CAMIGUIN GENERAL HOSPITAL RESPONSIBILITY
REVISION DATE
Provides clean, safe and sanitary environment for patients and hospital personnel. with
PAGE No. POLICY AND PROCEDURE OF Inspects building and grounds regularly to determine conformity sanitation and infection control requirements of the hospital. HOUSEKEEPING
POLICIES:
Directs repairs and replacement of furniture and other hospital fixtures. Formulates and recommends housekeeping policies and procedures.
Housekeeping personnel should be responsible for cleanliness and safety in the hospital. A housekeeping training program training program shall be established in each hospital to equip personnel with appropriate knowledge and skills in environmental sanitation. The housekeeping unit shall be provided with adequate personnel, equipment and facilities to perform their required functions effectively. A utility room shall be provided for safekeeping of cleaning materials and to prevent spread of contaminants.

Engineer II

Medical Specialist II - OIC
The housekeeping unit shall maintain and update aipment. There should be adequate hospital waste disposal system.
CAMIGUIN GENERAL There should be HOSPITAL adequate hospital waste disposal system. REVISION DATE

The housekeeping unit shall maintain and update HPTLY-MER-P01-5 adequate and accurate inventory of housekeeping supplies and equipment.
Inspections of hospital buildings and premises shall be done daily (before and after shift). Safety precaution signs such as NO SMOKING shall be posted in conspicuous PAGE No. POLICY AND PROCEDURE ON area on the hospital to prevent accidents. HOUSEKEEPING Fire drills and safety programs shall be organized and implemented at least once a year.
All places of employment, passageways, store rooms and service rooms shall be kept clean and orderly and in sanitary condition. The floor in every room shall be maintained in a clean and so far as possible, in a dry condition. Use soap, and water and rising of chorine disinfectant is most commonly used to clean the floor. Ensure that all hospital has adequate procedures for routine care, cleaning and disinfection of environmental surface, beds, bedside equipment and other frequently touched surface and ensures that these procedures are being followed. Room cleaning where body fluids are present: schedules shall be as frequent as necessary according to area in the institution. Toilet and bathroom facilities including walls and floors must be cleaned and scrubbed thoroughly with soap water and rinsed with a solution of 5.25% sodium hypochlorite (house bleach) diluted between 1:10 and 1:100 with water. A utility sink for washing and rinsing mops must be situated in every floor avoid transfer of microorganisms from one floor to another. Mops in the patients room must not be used in mopping hallways. A separate mop must also be used for toilet and bathrooms.
LIBRADO E. BAGAS, JR. Engineer II ARVIN F. SAMPILO, M.D. Medical Specialist II - OIC

POLICY AND PROCEDURE ON HOUSEKEEPING
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
PROCEDURES: BASIC TECHNIQUE IN CLEARING AREA: 1. DUSTING Is removing dirt surfaces; equipment, furniture, ledges, windows sills; though the use of a dry damp or treated cloth. Low dusting is used for easily reached surfaces and objectives. HIGH DUSTING is done though a handled tool or ladder.
2. MOPPING is wiping or rubbing a surface clean of dirt/soil though the use of a
wet collection of coarse yarn on a handle. Mopping may involve four steps.
1. Dump mopping is applied in slightly soiled areas using a yarn or mop
head that is wrung out after immersion in a cleaning solution.

2. Flood mopping is good for special areas for special areas where the
cleaning solution must penetrate deep into the floor and remain for a required period time.
3. Washing is simply mopping surface above the floor with a wet cloth.
4. Wet mopping is applied to grossly soiled areas with a mop head
partially wrung out after immersion in a cleaning solution.
3. STIPPING is the removal of wax from surfaces though the use of a stripper. 4. SWEEPING is removing soil or dirt from surfaces with a broom, brush, or
vacuum cleaner. Scrubbing is a form of sweeping where water and coarse brush are used.
5. WAXING is the application of wax and polishing materials on surfaces for
protection and clean beautiful shine.

LIBRADO E. BAGAS, JR. Engineer II ARVIN F. SAMPILO, M.D. Medical Specialist II - OIC
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
AREA OFR CLEANING Ward Cleaning and Sanitizing High dust ceiling and walls of ward including gadgets that maybe attached on the surface. Start at the upper most left corner of the door, generally working down in circular motion ending at the lowermost right corner. Damp mop using the same direction. Dust windows, window sills and jambs. Follow with damp mop. High dust bathroom, ceiling and walls. Scrub walls, sink, toilet bowl and floor, in that order, with cleaning solution. Let stand to dry. Dust cabinets, tables and other ward fixtures. Wax and buff. Empty wastebaskets. Sweep floor from the innermost going outstrip and wet mop. Let stand to dry. Inspect whole ward for quality control.
Corridor, Lobby Cleaning and Sanitizing High dust ceiling and walls follow with damp mop and let dry. Dust and wash windows, if any. Dust and polish furniture and fixtures. Polish and shine. Empty trash cans. Sweep the floor. Strip then wet mop. Allow to dry. Wax and polish.
LIBRADO E. BAGAS, JR. Engineer II ARVIN F. SAMPILO, M.D. Medical Specialist II - OIC DOCUMENT No./ REV. No.
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Compound Cleaning
High dust faade and outside walls in the same direction. Follow with damp mop Dust and scrubs screens. Sweep and removed debris from gutters. Weed plants of dirt and trash. Sweep ground starting from buildings/structures going towards gate. Hi jet drains and sewers. Inspect whole compound for quality control.
HPTLY-MER-P01-5
REVISION DATE
POLICY AND PROCEDURE ON REPORTING OF INFECTIONS TO PERSONNEL AND PUBLIC HEALTH AGENCIES
Policy:
PAGE No.
1. Personal who should make the reports are the Medical Doctors, Veterinarians, Registered Nurses, Nurse Midwives, Infection Control Practitioner, Dentists and Administrator of Health Facilities. 2. Any Health care provider having knowledge of any outbreak or unusual incidence of infection or parasitic Disease or infections shall immediately report the facts to local health department. 3. An outbreak means the occurrence of case of disease (illness) above the expected to baseline level. 4. An unusual disease means a rare disease or a newly apparent on emerging disease or syndrome of uncertain etiology. 5. The provincial Health Office is responsible investigation of the sources of circumstances on for conducting Public Health. special
6. Timely reporting of Communicable Disease is essential component of disease surveillance, prevention and control. Delay and failure to report has contributed to secondary transmission.

POLICY AND PROCEDURE OF PROCUREMENT PLAN
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Procurement Policy and Plan considers the following:
1) Intended use the procurement of medical supplies, drugs / medicines, equipments, materials, etc. should be procured according to needs of the hospital. 2) Cost Benefits prices of the medical supplies, drugs / medicines equipments, materials, etc. procured of the supplier offering the lowest price, effective and has good quality. 3) Infection Control Ensure hospital infection control by protecting medical equipment with paper protectors, and by thoroughly cleaning equipment with disinfecting wipes and spays. Before and after each storage, ensure medical infection control by scrubbing sanitizing nd antibacterial soaps. 4) Safety packing of medical supplies, drugs / medicines, equipments, materials, etc. must be safe to the user. Medicines and drugs must be checked their expiration dates. 5) Waste Creation and Disposal Exercise medical infection control by disposing of waste properly.
a. BLACK - Non biodegradable,
Non infectious
Dry
wastes
(General Waste ) Empty cans
Plastic bags / cellophane Biodegradable, Non infectious, Non DRY wastes Dry foods wrappers Paper

HPTLY-MER-P01-5
REVISION DATE
PAGE No.
b. GREEN -
Biodegradable, dietary, etc.)
Non infectious Wet waste (kitchen,
Peeling of fruits and vegetables Kitchen waste Egg shells Grasses and leaves Discard foods Used cooking oils - Infectious or pathological wastes
c. YELLOW
Placenta and other products Body tissues and specimen from laboratory Blood bags and Tubings Diapers Gloves Soiled dressing and swabs Rubber drains NGT and ET tubes

HPTLY-MER-P01-5
REVISION DATE
PAGE No.
d. RED
- Sharps and pressurized containers IV C annuals Disposable needles Surgical blades Glass vials and ampoules - Chemical and heavy Materials
e. YELLOW w/ BLACK BAND
Plastic dextrose bottles and plastic distilled water containers Macroset/ microset/ soluset Plastic medicine bottle
6) Storage medical supplies, drugs /medicines, equipments, materials, etc.
are stored in safe place, in safe place, in controlled temperature for drugs and medicines.
A. Temperature B. Humidity C. Avoid storing supplies near ventilation ducts or open windows D. Store like items together clean with clean and dirty with dirty; wet
separate from dry.

E. Sterile Supplies
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
1. Intended use 2. Cost benefits 3. Infection control 4. Safety 5. Waste creation and disposal 6. Storage POLICY 1. Planning of facilities and selection and acquisition of equipment and supplies involve input from staff and are undertaken by appropriately qualified personnel. 2. Appropriate equipment and supplies that support the organizations role and level of services provided. 3. To obtain in a costeffective safe and responsive manner the supplies, services and construction required by Camiguin General Hospital. 4. To provide safeguards for all maintenance of procurement system of quality and integrity. 5. Procurement practices shall comply with laws, regulation and guideline of the Provincial Government. 6. If is the policy of the Agency to procure all needed goods and services at the lowest total end-use cost, maintaining the highest
quality standard and in accordance with the Agencys procurement policy plan.
HPTLY-MER-P01-5
REVISION DATE
LIST OF SPECIALIZED EQUIPMENT
PAGE No.
1.) 2.) 3.) 4.) 5.) 6.) 7.) 8.) 9.)
ANESTHESIA INCUBATOR ELECTRO SURGICAL UNIT ( CAUTERY MACHINE) ENDOSECOPE PATIENT SMONITOR INFANT WARMER FETAL MONITOR PROCTOSECOPE INFUSION PUMP SYRINGE PUMP PULSE OXIMETER DOPPLER BILILIGHT SUCTION MACHINE 4 D UTRASOUND
10.) 11.) 12.) 13.) 14.) 15.)

POLICY AND PROCEDURE ON SAFE RE-USE ITEMS
Policy:
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Policy of single-use or disposable patient care items maybe permitted if the users either obtain written instructions from the manufacturer or provide documentation showing that the re-use will not compromise patient safety or device effectiveness and integrity or follow guidelines when using a third-party re-processor of medical devices. All expenses related to re-use must be thoroughly analyzed to ensure the cost-effectiveness of reprocessing the item. The process to prepare each item for re-use must be reviewed and approved by Hospital Epidemiology and Infection Control. Definitions: Material Risks to
-
Risks which a reasonable person would Know about an item or product before giving consent to undergo a procedure or treatment using that item or product.
Reprocessing
The cleaning, repacking, and sterilization (or disinfection) of an item that was either (a) used on a patient or (b) not used on a patient, but has had its packaging breached. The use of an item, labeled by the manufacturer as a single-use or disposable patient-care item, that has been cleaned and disinfected or sterilized after its original use on a patient. Reprocessing services provided by an outside company which may include resterilization of open but unused singleuse medical products (e.g. sultures),
Re-use
Third Party Re-processing
products whose sterility expiration dates have passed and reprocessing of singleuse items for re-use.
POLICY AND PROCEDURE ON SAFE RE- USE ITEMS

Procedures:
PAGE No.
1. Clinical Department Administrator, Functional Unit Administrator or Designee a. Prepare a cost analysis for reuse of the item. Include estimated one-time costs associated with item and process evaluation, as well as ongoing costs associated with personnel, repackaging materials, sterilization costs, data base management, etc. (Complete Form A). When a third party processor, obtain information regarding registration, business practices, other clients/products serviced, policies and procedures, insurance information, etc. (Form C). If cost analysis indicates that reprocessing of this item may be costeffective proceed to 1b. b. Submit in written format a method for completing each of the following components/steps to support the reuse of a disposable or single-use patient-care item. Each components/steps must be measurable or observable so that it may be consistently repeated. Each component/step must be accompanied by documentation to support the following item: 1) A method for cleaning, disinfecting, repackaging, and reprocessing the item as described by the manufacturer. If the manufacturer does not produce this information, consult Central Sterile Processing or Hospital Epidemiology and Infection Control for assistance in creating an appropriate method. Clinical Engineering Services should be consulted about the physical characteristics of the item and any special consideration that should be given. Included in this document must be a method for testing any electrical or movable components of the item prior to reprocessing. 2) Measurement data to indicate how much, if any, chemical residual (e.g. ethylene oxide) is expected to remain on the reprocessed item. Further documentation must compare these data with the acceptable residual levels described in federal and/or state regulations. This toxicology screen can be performed by an outside laboratory, but if so, the results must be reviewed and approved by Central Sterile Processing.
3) A data-base system to maintain a product inventory and also track
each reprocessed item during its useful life. The data base must contain information on how many times an individual item can be reprocessed and reused, and how many times each item actually has been reprocessed and reused. The data base also must provide documentation
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
of when the item was finally discarded and why (complete maximum cycles, failed testing procedures, etc.) 4) A surveillance strategy to monitor patients for adverse outcomes. 5) A statement regarding the material risks, if any, to the patient from the reuse of the item. If there is such a material risk, an appropriate consent document must also be provided. 6) A billing schedule to describe the method for patient billing throughout the useful life of the item. c. Provide supporting documentation for the written proposal 1. A document which attests that an item can be effectively cleaned and reprocessed. If written documentation cannot be obtained from the manufacturer, then provide a statement by Hospital Epidemiology and Infection Control and the Director of Central Sterile Processing. 2. A document from an outside laboratory or Hospital Epidemiology and Infection Control which approves the effectiveness of the cleaning and sterilization/disinfection procedure. If the item is evaluated at an outside laboratory, Hospital Epidemiology and Infection Control must review and approve the evaluation process. 3. A document from the manufacturer which attests that the item can withstand reprocessing and reuse without loss of structural, mechanical, of chemical integrity. If this document cannot be obtained from the manufacturer, then provide a statement by Clinical Engineering Services, the Applied Physics Laboratory, or similar facility.
4. A document from the manufacturer which describes the maximum
number of reuse cycles the item can safely tolerate. If the manufacturer cannot provide this information, then provide a statement from Clinical Engineering Services, the Applied Physics Laboratory, or the clinical department.
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
5. A document which outlines how the department will verify if reused instruments will be tracked.
6. If no scientific evidence or documentation is available to support any of
the steps in the proposed process, a document summarizing past experience that has resulted in this process being created, along with a proposal on how concurrent data will be collected, maybe acceptable. d. Submit the proposal to the Risk Management Committee 2. Risk Management Committee
1. Reviews
clinical department proposal or third party processor. Recommends approval or denial. The committee may convene a task force which may include representatives from Central Sterile Processing, Hospital Epidemiology and Infection Control, Clinical Engineering Services, and the involved clinical department. If approved, the department proposal or third party contract may be initiated by the requesting department, Medical Board approval is not required.
3. Central Sterile Supply a. Assign an item number for each item that is reprocessed. b. Visually inspect each item for soil and structural or physical damage which would make the item unsuitable for reuse. c. Clean and sterilize each item as per recommended method.
d. Maintain a pool of individuals specifically trained to process item for reuse.

POLICY AND PROCEDURE ON RE- USE ITEMS
HPTLY-MER-P01-5
REVISION DATE
PAGE No.
Policy: To re use some medical equipment or item especially when supplies are limited in Camiguin General Hospital. List of Item to be re-used 1. Gloves 2. Suction catheter 3. Straight catheter 4. Breathing circuits (mechanical ventilator tubings)
5. Asepto syringe and 02 inhalation cannula
Procedure: GLOVES 1. Wash gloves with soap and water. (back to back) 2. Rinse well with clean water. 3. Hang and let it dry. 4. Pack by pair according to size
5. Send to CSR for autoclaving. SUCTION CATHETER 1. Brush with soap and water 2. Flush with soap and water 3 times using syringe

POLICY AND PROCEDURE ON SAFE RE- USE ITEMS
3. Rinse thoroughly with water. 4. Flush with air, using syringe 3 times 5. Let it dry. 6. Soak with appropriate solution (ex. Cidex/benzol) 7. After soaking, rinse with sterile NSS or water. 8. Let it dry. 9. Store in sterile clothe and ready to use. STRAIGHT CATHETER
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REVISION DATE
PAGE No.
1. Wash with soap and water, flush with water and soap 3x using syringe. 2. Rinse with water and flush with air using syringe 3. Let it dry 4. Pack according to size 5. Send to CSR for autoclaving. BREATHING CIRCUITS 1. wash with soap and water 2. let it dry
3. soak with appropriate solution (zonrox 100:1000 solution or cidex) 4. rinse with sterile water 5. let it dry 6. store and pack according to size
HPTLY-MER-P01-5
REVISION DATE
POLICY AND PROCEDURE WHICH INVOLVES REUSE, REDUCTION AND RECYCLING

Waste Minimization
PAGE No.
The waste management hierarchy consists of source reduction, recycling, treatment and residuals disposal. In addressing waste management, waste minimization basically utilizes the first two elements that could help reduce the bulk of health care waste for disposal. Waste minimization is beneficial not just to the waste receiving environment but to the waste procedure also The cost for both the purchases of goods and waste treatment and disposal are reduce and liabilities associated with the disposal of health care waste is lessened. The extent to which a hazardous waste minimization program is implemented depends upon the health care establishments particular operation and procedures. If waste minimization is to be undertaken by healthcare facility, it is important to develop a good baseline data of the amount of waste generated prior to implementation of the waste minimization program. Health care waste generation data from the various units of the health care facility should be properly recorded on a chart with the amount of waste displayed in descending order. This method can be used easily to determine the highest waste generating areas in which the minimization strategies should be initiated. This information should be displayed and communicated throughout the facility. The waste minimization strategy should be formally approved in writing by the top management within the health care facility as a demonstration of their support and commitment to the program. Principle of Waste Minimization Identify baseline waste generation rates, current hazardous management strategies, and current waste management cost. waste
Health care establishment operators/owners must be committed to waste minimization for it to be successful and sustainable in the long run. Waste minimization programs should include a written policy with specific goals, objectives, and timeliness.
HPTLY-MER-P01-5
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POLICY AND PROCEDURE WHICH INVOLVES RE-USE, REDUCTION AND RECYCLING
PAGE No.
Train employees in hazardous waste handling and site specific waste minimization methods. Be aware of and keep undated on the hazardous materials regulations.
Health care waste minimization centered on the elimination or reduction of the health care waste stream. There are several measures that can be instituted to achieve waste minimization including the following: Reduction at source Some reduction involves measures that either completely eliminate of a material or generate less waste. Examples are: improving housekeeping practices to eliminate use of chemical air fresheners (which only serve to masks odors and release toxic compounds such as formaldehyde, petroleum distillates, p- dichlorobenzene, etc.) replacing mercury thermometers with digital electronic thermometers; working with suppliers or reduce packing of the products; and substituting a non biodegradable cleaner for a hazardous chemical cleaner.
HPTLY-MER-P01-5
REVISION DATE
POLICY ON SAFETY PROGRAMS OF WASTE MANAGEMENT
PAGE No.
Hospital Waste Management means the management of waste produced by hospitals using such techniques that will help to check the spread of diseases through it. The management of waste poses to be a major problem especially hospital waste. It is an ongoing problem for many hospitals. In recent years, medical waste disposal has posed even more difficulties with the appearance of disposable needles, syringes, and other similar items. This type of waste has a bad affect on the environment by contaminating the land, air and water resources. Different Types Hospital wastes constituents. are categorized according to their weight, density and
The World Health Organization (WHO) has classified medical waste into different categories, these are: Infectious: material-containing pathogens in sufficient concentrations or quantities that, if exposed, can cause diseases. This includes waste from surgery and autopsies on patients with infectious diseases; Sharps: disposable needles, syringes, saws, blades, broken glasses, nails or any other item that could cause a cut;
Pathological: tissues, organs, body parts, human flesh, fetuses, blood and body fluids; Pharmaceuticals: drugs and chemicals that are returned from wards, spilled, outdated, contaminated, or are no longer required; Radioactive: solids, liquids and gaseous waste contaminated with radioactive substances used in diagnosis and treatment of diseases like toxic goiter; and
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POLICY ON SAFETY PROGRAMS OF WASTE MANAGEMENT
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Others: waste from the offices, kitchens, rooms, including bed linen, utensils, paper, etc. Guidelines There are Guidelines for Hospital Waste Management in Camiguin General Hospital, giving a detailed information and covering all aspects of safe hospital waste management in Camiguin, including the risk associated with the waste, formation of a waste management team in hospitals, their responsibilities, plan, collection, segregation, transportation, storage, disposal methods, containers, and their color coding, waste minimization techniques, protective clothing, etc.
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POLICY ON SAFETY PROGRAMS ON MEDICAL DEVICE
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The medical devices in hospitals use are also an important part of the equation because they help to save lives and assist in curing disease. Here are the medical devices in hospital uses. 1. Autoclave for Sterilizing Objects Autoclave is specifically used for sterilizing objects and can be found in hospital. The autoclave includes a sterile dry cycle and a 10 inch chamber and features filtered close door drying, electronic temperature and time controls and preprogrammed sterilization. Another important feature is the automatic chamber, which preheats to maximize productivity by shortening the cycle times. A digital function display is also a key component because it allows for accurate and easy monitoring of the sterilization cycle. 2. Patient Monitor for Recording Blood Pressure The Data scope Passport Patient Monitor includes ECG, SPO2 and noninvasive blood pressure and recorder. The monitor features a large screen for viewing at any angle of the operating room, adult finger sensor, ECG cable, blood pressure hose, standard adult cuff and recorder paper. 3. Surgical Lights for a Precision Work The Skytron Stellar ST2323 is a popular brand of surgical lights that feature dual center-mounted light heads with focusable control and wallmounted intensity control box. The surgical lights also feature advanced multi-lamp optics with vertically segmented reflector designs, light
maneuverability, 360 degree movement of all points of rotation, intensity of up to 24,000 foot candles, 90 degree downward travel for low angle lighting and cool beam temperature.
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POLICY ON SAFETY PROGRAM OF CHEMICAL
PAGE No.
DoH to Ban Mercury Importation 6-point agenda to a mercury-free Philippines presented Manila Following movements to ban mercury globally, the Philippine Department of Health on Friday said that it will ask for the banning on importation of mercury products in the country. Health Secretary Esperanza Cabral in a meeting with environmental health group, Health Care Without Harm-Southeast Asia (HCWH-SEA) identified other measures to ensure that the public will be safe from mercury. No more mercury permits According to Cabral, since Administrative Order (AO) 21 was implemented in September 2008, the DoH is no longer giving permits to medical devices distributors to sell mercury thermometers. The program will be escalated to include mercury sphygmomanometers. Prior to AO 21, all hospitals have a one-is-to-one policy on mercurial thermometers. This means that every patient admitted or discharged in a hospital is entitled to one mercurial thermometer. In 2007, one 300 bed hospital distributed 10,000 mercurial thermometers in just a year. With the 98,463 hospital beds in the country, the health care sector alone gave out more than 3 million thermometers in just one year, said Faye Ferrer, HCWH-SEA Program Officer for Mercury in Health Care. This doesnt include yet purchases made by individuals, schools, laboratories small clinics.
AO 21 to reach local health units The DoH likewise said that they will promote and disseminate AO 21 to the local government units (LGUs) who are managing the barangay health units, rural health units, city heath and municipal, district and provincial hospitals.
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POLICY ON SAFETY PROGRAM OF CHEMICAL
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In the regional conferences organized by HCWH-SEA and DoH Center for Health Development (CHD), majority of LGU-run hospitals and health centers said that they are unaware of AO 21. In the conference for CALABARZON region, several health units raised the issue of involving the Department of Interior and Local Government (DILG) in the implementation of AO 21 citing that they are directly under the Department and that funding must also be supported by the LGUs. Mercury-free budget To further speed-up AO 21 implementation, Cabral said that they will look into the 2009 General Appropriations Act (GAA) 13.2 M allocation for 66 government-run hospitals to purchase non-mercurial devices and have it released at the soonest possible time. In 2008, HCWH-SEA together with Social Watchs Alternative Budget Initiative for health lobbied for additional environmental health allocations in the DoH budget. This however remains unreleased. Beyond health care Cabral likewise expressed that DoH will set-up a program to follow-up on the state of the more than 20 student victims of mercury poisoning in St. Andrews School in Paranaque in 2006. Earlier, one of the victims who is now suffering advanced stage of Parkinsonism and nerve damage filed a 6M civil case against the school.
While the other victims have stopped chelation therapy to remove mercury from their system, it is unclear whether they have been cleared by the hospital.
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POLICY ON SAFETY PROGRAM ON CHEMICAL
PAGE No.
More alternatives Cabral also pronounced that the DoH will continue the program to replace mercury devices in hospitals. To further strengthen this, Cabral signed the Green Health Covenant which calls for the health sector and other individuals to call on their candidates to support mercury phase-out in the country and other green health care agenda such as proper heath care waste management leading to zero waste, chemical safety in health care and a health care responsive to climate change.
The Green Health Covenant now has more than 900 signatures from health care facilities in Regions 1, 2, 4A and online signatories. Ban mercury importation The next logical step to mercury phase-out: ban mercury. DoH said they will ask for the banning of importation of mercury products. This will prevent entry of mercury devices in the Philippine market. Now that the DoH has taken a firmer stand to ban mercury, we are enjoining the health care sector, other government and non-government
agencies and organizations and the general public to support the banning of mercury importation in the country, Ferrer added.
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POLICY ON SAFETY PROGRAM On MECHANICAL
PAGE No.
A wide variety of mechanical hazards are associated with clinical instrumentation containing mechanical components. Therefore, safety considerations for clinical equipment must be extended to include mechanical safety standards, maintenance programs, and operating procedures. Mechanical risk classes have been developed from the study of mechanical-mode failures of medical devices. To facilitate the development of priorities for clinical engineering involvement in mechanical safety programs, most mechanical devices which are commonly used in clinical practice have been assigned an appropriate risk classification. General recommendations for the development of such programs are also presented.
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POLICY ON SAFETY PROGRAM ON COMBUSTIBLE MATERIALS
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Hospitals generate fluid, gaseous and solid waste, with solids accounting for the bulk of it. The average of Camiguin General Hospital produces about 9 kg of solid waste per patient-day, and even though most of the waste is innocuous office trash or cafeteria scraps, some is potentially hazardous (e.g., radionuclide tracers, neoplastic drugs and blood products). Compared with other industries, hospitals produce relatively small quantities of radioactive or hazardous chemical waste, but potentially infectious biomedical waste constitutes as much as 20% of a hospital's total waste output. However, much of the waste considered to be biomedical may, in fact, be misclassified. About 80% of the biomedical waste comprised items such as paper, cans, bottles and packaging that did not belong there. This misclassification is costly, since it is about 16 times more expensive to dispose of infectious waste than it is to get rid of regular waste. Hospital waste management: Incineration has been the main method for disposing of the wide range of combustible materials that constitute biomedical waste, because it can significantly reduce the volume of waste material and it can destroy organic matter. Typically, an incinerator has a 2-chambered, controlled-air system to maximize combustion. However, 3 types of medical waste material are difficult to incinerate. Materials with low heating values, such as full urine bags and dense body parts, may burn more slowly than the surrounding material and not be completely destroyed during incineration. Toxic metals, such as the lead, chromium and cadmium found in red plastic bags and vacutainer caps, vaporize during incineration and form fine fumes that enter the atmosphere with the flue gas. Plastics composed of polyvinyl chloride contain chlorine that converts to corrosive hydrochloric acid during incineration. Daily variations in the composition and volume of hospital waste, when combined with inadequately maintained equipment, can upset the stoichiometric balance
and cause toxic emissions. Polycyclic aromatics, such as the carcinogen benzopyrene, and respiratory irritants, such as the oxides of nitrogen and sulfur, are also recognized by-products of inefficient incineration that pose public health concerns. Over the past few years, incineration has become increasingly controversial because of growing concerns over the inability of the technology to process safely the current increased volumes of plastics, metals and pathogens in hospital waste. The program's success was attributed to the support and leadership of infectioncontrol personnel, a clearer definition of biomedical waste, hospital-wide awareness and education programs about biomedical waste, and regular audits and direct feedback to staff members.

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DOCUMENT No./ REV. No.

CAMIGUIN GENERAL HOSPITAL

HPTLY-MER-P01-5 REVISION DATE

LIBRADO E. BAGAS, JR. Engineer II

ARVIN F. SAMPILO, M.D. Medical Specialist II- OIC

DOCUMENT No./ REV. No.

CAMIGUIN GENERAL HOSPITAL

HPTLY-MER-P01-5 REVISION DATE

LIBRADO E. BAGAS, JR. Engineer II

ARVIN F. SAMPILO, M.D. Medical Specialist II- OIC

DOCUMENT No./ REV. No.

CAMIGUIN GENERAL HOSPITAL

HPTLY-MER-P01-5 REVISION DATE

3. The safety Committee activity will be communicated quarterly to the trustee

LIBRADO E. BAGAS, JR. Engineer II

ARVIN F. SAMPILO, M.D. Medical Specialist II- OIC

DOCUMENT No./ REV. No. HPTLY-MER-P01-5

CAMIGUIN GENERAL HOSPITAL

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. Engineer II

POLICY ON HOSPITAL FIRE PLAN

DOCUMENT No./ REV. No.

LIBRADO E. BAGAS, JR. M.D.

CAMIGUIN GENERAL HOSPITAL

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LIBRADO E. BAGAS, JR. Engineer II

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LIBRADO E. BAGAS, JR. M.D.

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CAMIGUIN GENERAL HOSPITAL

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Fire Notification System

LIBRADO E. BAGAS, JR. Engineer II

CAMIGUIN GENERAL HOSPITAL

POLICY ON HOSPITAL FIRE PLAN

LIBRADO E. BAGAS, JR.

ARVIN F. SAMPILO, M.D.

Medical Specialist II- OIC DOCUMENT No./ REV. No. HPTLY-MER-P01-5

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. M.D.

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Operating Room \ICU \ Recovery

LIBRADO E. BAGAS, JR. M.D. Engineer II

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. Engineer II

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. Engineer II

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. Engineer II

ARVIN F. SAMPILO, M.D. Medical Specialist II- OIC

DOCUMENT No./ REV. No.

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. M.D. Engineer II

ARVIN F. SAMPILO, Medical Specialist II- OIC

DOCUMENT No./ REV. No. HPTLY-MER-P01-5

CAMIGUIN GENERAL HOSPITAL

CAMIGUIN GENERAL HOSPITAL

LIBRADO E. BAGAS, JR. Engineer II

POLICY ON FIRE SAFETY MANAGEMENT PLAN

LIBRADO E. BAGAS, JR. Engineer II CAMIGUIN GENERAL HOSPITAL M.D.