Annual Infection Prevention & Control Report

Dalkut Health Center

2021
INSTRUCTIONS:

This template details the minimal information required in an Annual Report. Sections can be
added to fit the needs of the Institutions. All sections within this template can be easily
modified or sized to facilitate customization.

Any important information that does not fit within the structure of this template can be
included at the end of the appropriate section. Inclusion of other supplementary material
(supporting documentation, relevant calculations, etc.) should be incorporated into the
Appendices.

This general instruction and the guidelines/examples that follow throughout the document
indicated by [blue text] should be deleted when this document is complete and submitted for
final review to your appropriate authorities.
 Table of Contents
Table of Contents....................................................................................................................1
Abbreviations..........................................................................................................................2
Introduction............................................................................................................................3
Executive summary..................................................................................................................4
Infection Prevention and Control Program...............................................................................6
Infection Prevention and Control & CSSD Team Members.......................................................6
Infection Control committee.....................................................................................................7
Antimicrobial Stewardship Program..........................................................................................8
Hand Hygiene..........................................................................................................................9
Hand Hygiene Compliance.........................................................................................................9
Healthcare Associated Infection Surveillance.........................................................................11
Healthcare Associated Infection reports (MDRO, SSI, CLABSI, VAP/VAE, CAUTI)...................11
Implementation of prevention bundles for HAIs:....................................................................12
Occupational Health..............................................................................................................13
Status of Vaccination for HCWs...............................................................................................13
Reporting of Accidental Exposure to Blood & Body Fluids......................................................14
Outbreak Management.........................................................................................................14
Education/Training................................................................................................................15
Competency of IPC training program......................................................................................16
Environmental Cleaning and Decontamination......................................................................17
Projects & Initiatives..............................................................................................................18
Incident /challenges..............................................................................................................19
Infection Prevention and Control Risk Assessment.................................................................20
Annual Plan of IPC Program...................................................................................................21
Appendices............................................................................................................................22

1
 Abbreviations

C.diff Clostridium difficile

CAUTI Catheter-Associated Urinary Tract Infections
CLABSI Central Line Associated Blood Stream Infections
CRE Carbapenem-resistant Enterobacteriaceae
DE Dialysis Event
ESBL Extended Spectrum Beta-Lactamase
HAI Healthcare Associated Infection
HCWs Healthcare Workers
HEPA High-Efficiency Particulate Air filter
HH Hand Hygiene
ICU Intensive Care Unit
IPC Infection Prevention and Control
MDRA Multidrug Resistant Acinetobacter
MDRO Multidrug-Resistant Organisms
MDRP Multidrug-Resistant Pseudomonas aeruginosa
MRSA Methicillin-Resistant Staphylococcus Aureus
NICU Neonatal Intensive Care Unit
No. Number
PAPR Powered Air Purifying Respirators
PPE Personal Protective Equipment
Qtr Quarter
SCBU Special Care Baby Unit
SSI Surgical Site Infection
VAE Ventilator-Associated Event
VAP Ventilator-Associated Pneumonia
VRE Vancomycin-Resistant Enterococci

2
 Introduction
Healthcare Facility Profile:
1. Governorate: DHOFAR

2. Name of the facility: DALKUT HEALTH CENTER

3. Level of care: ☑️Primary □Secondary □Tertiary

□Other, specify:
4. Total No. of Healthcare workers in the facility: 21
5. Hospital beds capacity / Number of PHC facilities*: 6
6. Total isolation room: 1
7. 7.a. No. of negative pressure room with 7.b. No. of negative pressure room without
HEPA filter: n/a HEPA filter: n/a
8. Bed capacity in intensive care: Ward/unit (e.g. ICU, NICU, SCBU, etc.) No. of beds

N/A

3
 Executive summary

(Approximately 1 page)

For the year 2021, we tried to limit the stay of the patients to less than 15mins to decrease the
risk of contraction of any diseases. If suspected case, we immediately keeping the patient in
isolation and stabilizing their condition and limiting contact with other patients on isolation as
well as the by-standers.

Based on this year’s report, the key priorities for next year will be:

Priority 1: Priority 2: Priority 3: Priority 4:

Maintain compliance Decrease cases of Decrease the cases

in hand hygiene for infection that is of defaulter in all
all healthcare transferrable by programs handled in
workers close contact the health center

4
 Infection Prevention and Control Program

Infection Prevention and Control & CSSD Team Members

S. Name Designation Staff No. Qualification Years of Contact no. email
No. Experienc
e

Ruby Joyce Aguilar Staff Nurse 72499 Focal point of IP&C 6 years under 93546234 clieojoyce@gmail.com
the MOH

Provide names (First, Last, Titles, contact number, email, etc.) of all members including:
Oncall/Office Number:

6
Infection Control committee
 (List of members, responsibilities, objectives, number of meetings conducted last year and highlighted activities and actions.)
Designation of Members Objective Role and Number of Highlighted
responsibilities meeting activities

 -Focal oint of IP&C  -Maintain the  -Keep the continuity  -at least once a  -Posting of
 - practice of IP&C in of maintaining the month parhernalias
 - the institution protocols of IP&C regarding IP&C
 -  -Update the staff  -Supervise the around the
 - about the news in correct practice institution
 - IP&C under the IP&C  -Disseminate
 - protocols information
 -  - about certain
 -  - communicable
 -  - diseases and
 - how to preven
it
 -Correct the
wrong
information by
giving health
teaching to the
members of
the
community
 -
 -
 -

7
Antimicrobial Stewardship Program
Designation of Objectives Role and Targeted Number of Highlighted
Members responsibilities ward/unit meeting activities

 -  -  -  -  -  -
 -  -  -  -  -
 -  -  -  -  -
 -  -  -  -
 -  -  -  -
 -  -  -  -

 (List of members, responsibilities, objectives, frequency of meeting (e.g. weekly..), targeted ward/unit and highlighted
activities and actions.)

8
 Hand Hygiene

Hand Hygiene Compliance

Target Actual
100% 90%

< by click on graph than right click, Edit data in excel

according your needs and compliance rate >

Your graph should show the trend. For example: If your graph compares annual results,
your trend will be based on the last four years. If your graph compares year quarters,
your trend will be based on the last four quarters.

Hand Hygiene Compliance

100%
90%
80%
70%
Compliance Rate

60%
50%
40%
30%
20%
10%
0%
ICU A/E Medical ward Surgical ward Overall

9
 Hand hygiene program interventions for the last year
 What initiatives contributed to increase HH compliance?
 What is the plan for the future?

The initiatives done by the institution is dissemination of correct information about hand
hygiene like posting posters, giving away of pamphlets and giving health teaching to patients
that are coming to the health center.

The plan for the future is to continue the actions that was done in the past year and be
consistent with it to totally change the thinking of the community.

10
 Healthcare Associated Infection Surveillance
Healthcare Associated Infection reports (MDRO, SSI, CLABSI,
VAP/VAE, CAUTI)
INSTRUCTIONS: Use this section to report all your Hospital Associated Infection (HAI) Indicators
by provide the numbers of each HAI; incident/event, patient days, device days by using below
formula
MDRO rate = (new positive culture of specific MDRO / No. of patients days) *1000
Surgical site Infection (SSI) = (No. of SSI / No. of specified surgical procedures
performed) *100.
Catheter Associated Urinary Tract Infection (CAUTI) = (No. of CAUTI / No. of urinary
catheter days) *1000
Ventilated Associated Event (VAE) = (No. of VAE/ No. of ventilators days) *1000
Central Line Associated Blood Stream Infection (CLABSI) = (No. of CLABSI/ No. of
Central line days) *1000
Dialysis Event (DE)= (No. of Dialysis event/Patient census)*100
Example of MDROs (MDRA, MDRP, CRE, MRSA, ESBL, VRE, Candida auris, C.diff)

Report of Multi-Drug Resistant Organisms

Edit data on the below excel sheet according your
needs [Double Click on below icon of Excel sheet or
right click mouse, click on worksheet object, click on
excel edit]

Report of Device/Procedure-Related Infections

Edit data on the below excel sheet according your
needs [Double Click on below icon of Excel sheet or
right click mouse, click on worksheet object, click on
excel edit]

11
 Prevention Bundles Location (Ward/units) Attach bundle form

CLABSI N/A

VAP N/A

CAUTI N/A

SSI N/A

DI N/A

Implementation of prevention bundles for HAIs:

(If you are implementing care bundle, attach your bundle form in below table)

12
 Occupational Health
Status of Vaccination for HCWs in DALKUT HEALTH CENTER
Number of Targeted staff Percent of Coverage

Hepatitis B Vaccine 12

Varicella Vaccine 3

MMR Vaccine 21

Influenza Vaccine 15

T-dap Vaccine 20

Meningococcal Vaccine (Lab) -

IPV (Lab) -

Others (e.g. COVID-19 21

vaccine)

13
Reporting of Accidental Exposure to Blood & Body Fluids
Months Number of incidents Status of exposed Intervention plan
persons

January  -
 -
February
 -
March  -
 -
April

May

June

July

August

September

October
November

December

14
 Outbreak Management
INSTRUCTIONS: Complete the table below according to your records.
Responsible Organism: What caused the outbreak? What kind of outbreak was it? Respiratory or Gastrointestinal?
No. of HCWs Affected: How many HCWs were affected by the outbreak?
No. of Patients Affected: How many patients were affected by the outbreak?
Dates/Length of Outbreak: What was the duration of the outbreak? Include relevant dates.
Ward/unit: Where did the outbreak occur? (i.e. ICU, NICU, etc.)

Causative Organism No. of No. of Patients Dates / Length Ward/ units Interventions significantly
HCWs Affected of Outbreak contributed to control
Affected

 -
 -
 -
 -

 -
 -
 -
 -
 -
 -

*Please share the final report of each outbreak mentioned above if available

14
 Education/Training
Describe your facility infection prevention and control educational initiatives for all HCWs in the table below.

Type: Workshops, presentations, conferences, seminar, orientation, training course, etc.

Content: list the contents and outline
Targeted Participants: Who participated? (Designations and working areas)
Number of participant: How many people attended?
Duration: What was the duration of the educational event?

Date Type of Objectives Targeted participants No. of Participants Duration of the activities
education/training

15
 Number of trained HCW Total Number of Targeted Percent of Coverage
HCWs
Education in IPC program
N95 Fit test 3M (1860) Pass
(Type and size)
3M (1860S) Pass
3M (9105) Pass
3M (9105S) Pass
Other N95 Pass
(Specify)
Not fit
Competency of PPE use

Competency of HH technique

Competency of PAPR use

Competency of IPC training program

16
 Environmental Cleaning and Decontamination

 Number of environmental cleaning audit done per year:

 Summary of the audit finding:

 Name and brand of fogging device:

Cartridge Hydrogen Peroxide 6% Hydrogen Peroxide 12%
Solution Solution

Annual Consumption

Balance

17
 Achievements
INSTRUCTIONS:
Discuss the IPC achievements in your institution and outcomes related to patient safety and
infection control.

18
 Projects & Initiatives
INSTRUCTIONS:
Use the first project/initiative outline as a guide to complete the other project boxes. Copy and
paste the box to add more projects or initiatives.

Project/Initiative Title

Provide a brief description of the project/initiative. What is the purpose of

Description:
the project/initiative? What are goals and objectives?

What is the current status of the project/initiative? (Completed, Delayed,

Status:
In-Progress etc.)

Activities What was achieved in the last year? What activities were completed?

What partnerships and collaborations were carried out? By who? What are
facility Impact: the outcomes and impact of this project/initiative (i.e. improved patient
care, reduce healthcare associated infections, etc.)?

19
 Incident /challenges
Discuss major incident/challenges that occurred in your institution.

Include details on causes, significant impacts on the institution(s), interventions, and results of
intervention. (How to overcome these challenges)

One big challenge that we faced in the last year is the compliance of protocols in the cases of
yemeni patients. We found a lot of instances that yemeni patients that has omani relatives are
the ones who is bypassing the rules and in the end the staff are suffering. We hope that in the
following hear we will have a better compliance from the citizens.

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21
22
 Infection Prevention and Control Risk Assessment
Risk assessment to determine priorities for infection control activities

Issue/Topic Current Status Desired Status Gap Action Plan Priority for IPC
(Measurable (Describe) and Evaluation Plan
Objective) (High, Mild, Low)

23
 Annual Plan of IPC Program

Goal Objective Action plan Responsibilities Time frame Outcome

24
 Appendices
Please insert any supporting documentation, calculations, photos, forms, etc. that expand on
the content within this report.

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