Circular No. 18/2009/TT-BYT guides the organization and implementation of infection control work in medical examination and treatment facilities.

CIRCULAR

Guidelines for organizing the implementation of infection control work

in medical examination and treatment facilities

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Pursuant to the Law on Health Care for the People dated June 11, 1989;

Pursuant to the Law on Prevention and Control of Infectious Diseases dated November 21, 2007;

Pursuant to Decree No. 188/2007/NĐ-CP dated December 27, 2007 of the Government on the functions, tasks, powers, and organizational structure of the Ministry of Health;

Pursuant to Decision No. 153/2006/QĐ-TTg dated June 30, 2006 approving the Master Plan for the Development of the Healthcare System in Vietnam until 2010 with a vision to 2020.

The Ministry of Health guides the organization of the implementation of infection control work (controlling pathogenic microorganisms) in state and private medical examination and treatment facilities as follows:

PART I

SPECIAL TECHNIQUES FOR INFECTION CONTROL

Article 1. Hand hygiene

Clause 1. Medical personnel, healthcare staff, students undergoing internships at medical examination and treatment facilities must comply with hand washing instructions and techniques as directed by the Ministry of Health.

Clause 2. Patients, patient relatives, and visitors must wash their hands according to regulations and guidance provided by the medical examination and treatment facility.

Article 2. Implementation of aseptic technique regulations

Clause 1. When performing surgery, procedures, and other invasive techniques, conditions, equipment, and aseptic techniques must be ensured in accordance with the technical procedures of the Ministry of Health.

Clause 2. Reusable medical instruments must be disinfected and sterilized centrally at the sterilization unit and must ensure asepsis from the sterilization process, storage, transportation, to the point of use on patients.

Clause 3. Gloves should not be shared among patients; gloves must be changed when moving from contaminated areas to clean areas on the same patient, and sterile gloves must be worn when performing aseptic techniques.

Clause 4. Healthcare staff must strictly adhere to aseptic technique regulations, standard precautions, and isolation precautions when entering and working in sterile areas.

Article 3. Cleaning, disinfection, and sterilization of equipment and treatment devices

Clause 1. Equipment, materials, and tools used in surgery, procedures, and other invasive techniques must be disinfected, sterilized, and have their sterilization quality controlled before use, following the guidelines of the Ministry of Health.

Clause 2. Equipment, devices, and treatment tools used for each patient and reused must be processed according to appropriate procedures.

Clause 3. Contaminated equipment must be initially treated (decontaminated) in departments before being transferred to the centralized disinfection and sterilization unit.

Clause 4. At the centralized disinfection and sterilization unit, all equipment must be cleaned, disinfected, packaged, sterilized, and stored according to the prescribed procedures of the Ministry of Health.

Clause 5. The centralized disinfection and sterilization unit must have necessary cleaning, disinfection, and sterilization equipment; dedicated transport vehicles and containers for receiving contaminated equipment and delivering sterile equipment to specialized departments.

Clause 6. Specialized departments must have sufficient means, soap, and disinfectants for initial treatment of contaminated equipment and cabinets for storing sterile equipment.

Clause 7. Equipment contained in packaging, boxes that have exceeded their expiration date, packaging that is not intact, or opened for daily use but not yet finished cannot be used for patients and must be sterilized again.

Article 4. Implementation of preventive isolation measures

1. Medical examination and treatment facilities must disseminate information and train medical staff, healthcare workers, patients, patient relatives, and visitors to implement appropriate preventive isolation measures.

2. Healthcare workers must apply standard precautions when coming into contact with blood and biological fluids while caring for and treating all patients regardless of their diagnosed condition, and apply additional precautions according to the mode of transmission.

3. Medical examination and treatment facilities must establish a management system for monitoring, detecting, handling, and reporting occupational accidents and risks to healthcare workers. They must closely coordinate with the same-level preventive healthcare system to promptly report and handle outbreaks.

4. Patients suspected or confirmed to be infected with infectious diseases must immediately apply appropriate preventive isolation measures in accordance with the laws on prevention and control of infectious diseases.

5. Doctors and healthcare workers working in medical examination and treatment facilities shall be vaccinated against infectious diseases such as hepatitis B, influenza, and other dangerous infectious diseases.

6. Patients infected with multi-drug resistant bacteria must have appropriate isolation measures applied based on the mode of disease transmission.

Article 5. Surveillance and detection of hospital-acquired infections and infectious diseases in healthcare facilities

1. Medical examination and treatment facilities must organize, monitor, detect, and report cases of suspected highly dangerous infectious diseases in accordance with the laws on prevention and control of infectious diseases.

2. Establish surveillance, detection, reporting, and data retention systems for hospital-acquired infections in each medical examination and treatment facility, and take timely intervention measures to reduce healthcare-associated infections.

Article 6. Environmental hygiene and waste management

1. Medical examination and treatment facilities must:

a) Equip with appropriate and specialized environmental hygiene equipment such as mops, cloths, brooms, cleaning chemicals, and dedicated transport vehicles.

b) Develop schedules and procedures for environmental hygiene suitable for each area in accordance with regulations and guidelines issued by the Ministry of Health.

c) Conduct microbial monitoring at least every six months regarding air quality in high-risk areas, water sources used for treatment and daily activities, in compliance with national technical standards.

d) Implement medical waste management in accordance with regulations.

e) Have regulations and implement thorough cleaning and disinfection of patient rooms and related care equipment immediately after transferring patients with infectious diseases that could cause outbreaks to another department, hospital, discharge, or death.

f) Ensure ward hygiene, outdoor environment hygiene, and regular pest control to maintain a green, clean, beautiful, and safe environment.

2. Attendants and personnel engaged in hygiene work at medical examination and treatment facilities must be trained in hygiene practices in healthcare settings according to training programs issued by the Ministry of Health.

Article 7. Hygiene for patients and patient relatives

1. Patients and patient relatives (when visiting and participating in patient care) must wear hospital clothing in accordance with medical dress code regulations and use personal items.

2. Before surgery, patients must undergo body hygiene in accordance with the technical procedure guidelines issued by the Ministry of Health.

Article 8. Food Safety and Hygiene

1. The infection control department (team) shall be responsible for supervising the implementation of laws and regulations on food safety and hygiene at dining areas, food preparation sites within medical facilities.

2. Direct food processing and distribution units within medical facilities must have certificates confirming compliance with food safety and hygiene standards, and staff working directly in these units must undergo regular health checks and comply with relevant laws and regulations on food safety and hygiene.

Article 9. Management and Use of Linens

1. Medical facilities must strictly adhere to medical uniform regulations for patients, their families, and healthcare personnel; establish a schedule for changing linens daily and when necessary for patients.

2. Linens from medical facilities must be centrally laundered and disinfected. Contaminated linens, those stained with blood, and biological fluids must be collected, transported, and processed separately to ensure safety.

3. Clean linens must be stored in clean cabinets, and specialized linens must meet specifications, quality standards, and sterile requirements.

4. Medical facilities must provide dedicated carts and bins for receiving contaminated linens and transporting laundered and sterilized linens to departments and specialized rooms.

Article 10. Sanitation in the Preservation, Embalming, Burial, and Transport of Deceased Bodies

Preservation, embalming, burial, and transport of corpses must be carried out in accordance with the guidelines set forth by the Ministry of Health in Circular No. 02/2009/TT-BYT dated May 26, 2009, regarding sanitation in funeral and cremation activities.

Chapter II

CONDITIONS TO ENSURE INFECTIOUS DISEASE CONTROL WORK

Article 11. Infrastructure

Medical facilities must:

1. Be designed and equipped to meet infection control requirements. When constructing new buildings or undergoing renovations, they must involve consultation from the infection control department or personnel.

2. Have a centralized disinfection-sterilization unit meeting standards: one-way design; clear separation of three zones: contaminated, clean, and sterile; equipment for handling tools based on treatment levels such as washing-disinfecting machines, wet steam sterilizers, low-temperature sterilizers, drying machines, packaging tools; cleaning agents, chemical tests for sterilization quality; cabinets, shelves for storing sterilized tools.

3. Have a one-way laundry facility equipped with washing machines, dryers, ironing equipment, dirty linen transport vehicles, clean linen storage tanks, chemical soaking tanks for contaminated linens, linen storage cabinets, laundry soap, disinfectants. Medical facilities may contract with companies specializing in laundry and disinfection services to ensure the provision of linens that meet patient and professional needs.

4. Have infrastructure to safely process liquid, solid, and gaseous medical waste according to regulations on medical waste management.

5. Departments must have sufficient shower rooms, restrooms, clean water, and washing facilities for patients, their families, and healthcare workers.

6. Each department must have at least one room for dirty items and the processing of medical instruments.

7. Operating rooms and intensive care units must be equipped with appropriate ventilation and air filtration systems to meet sterile requirements.

8. Clinical departments must have at least one isolation room equipped with isolation devices as directed by the Ministry of Health to isolate patients who pose a risk of spreading dangerous infectious agents.

9. Clinical departments must have at least one procedure room fully equipped and designed to meet infection control requirements: handwashing sink, faucet, clean water, soap or hand sanitizer, hand towels, scrub brushes, procedure table, sterile instrument cabinet, waste bin.

10. Laboratories must meet biosafety conditions appropriate to each level and only conduct tests within their designated scope as stipulated by the Law on Prevention and Control of Infectious Diseases.

11. Infection departments must have adequate preventive measures against disease transmission and maintain safe distances from other departments and residential areas as required by laws on prevention and control of infectious diseases.

12. Food processing and distribution facilities in hospitals must be constructed and designed in accordance with legal regulations on food hygiene and safety.

Article 12. Equipment and Means

Medical examination and treatment facilities must be equipped with sufficient equipment and means to ensure the requirements for infection control:

1. Ensure adequate and appropriate environmental hygiene means:

a) Hand washing facilities: hand washing basins, hand sanitizing means, single-use clean towels, and hand washing chemicals.

b) Sufficient specialized hygiene means to ensure effective hygiene work for medical examination and treatment facilities.

c) In cases where medical examination and treatment facilities contract with Industrial Cleaning Service Companies, the contract must clearly define the requirements for equipment, chemicals, hygiene standards, cleaning procedures, training of cleaning staff according to the Ministry of Health's training materials, and quality inspection.

d) Adequate means for collecting, transporting, and storing waste. Waste storage containers and bags must ensure sufficient quantity, quality, and comply with specified colors.

2. The infection control department must be equipped with office means to serve monitoring and training tasks such as computers and printers; other means to serve environmental quality testing and infection control.

3. Food processing and distribution units within hospitals must have complete equipment and means in accordance with food safety regulations.

Article 13. Dedicated Human Resources for Infection Control

Medical examination and treatment facilities must ensure human resources for the Infection Control Department (unit) to operate. In addition to personnel for decontamination, sterilization, laundry departments, and infection surveillance departments, there must be at least one trained infection control personnel per 150 beds.

Article 14. Training to Enhance Knowledge and Practical Skills in Infection Control for Healthcare Staff

1. Doctors and staff of the Infection Control Department (unit) must be trained in specialized fields and regularly update their knowledge and practical skills in infection control.

2. Doctors and staff of medical examination and treatment facilities must be trained in technical procedures related to infection control, proper and proficient use of personal protective equipment.

Chapter III

ORGANIZATIONAL SYSTEM, TASKS AND LIMITATIONS

Article 15: Organizational System for Infection Control at Medical Examination and Treatment Facilities

1. Hospitals must establish an organizational system for infection control, including:

a) Infection Control Council (Board)

b) Infection Control Department (Unit)

c) An infection control network.

2. Other medical examination and treatment facilities must establish an organizational system for infection control as stipulated in point a and point c of Clause 1 of this Article and have officers responsible for infection control.

Article 16. Organization and Tasks of the Infection Control Council (Board)

1. Organization:

a) The Infection Control Council (Board) is established by the Director (Head) of the medical examination and treatment facility. The Council includes a Chairman, one Vice-Chairman, one Standing Member, and other members.

b) The Chairman of the Infection Control Council is a leader of the medical examination and treatment facility. The Vice-Chairman or Standing Member is the Head of the Infection Control Department or Unit Leader or a leader from a department or room with experience in infection control.

c) Members of the Infection Control Council are representatives from clinical and paraclinical departments; Planning and General Affairs Office, Nursing Office, Administrative Management Office, Financial Accounting Office, Personnel Organization Office, Medical Equipment Supply Office, and other relevant departments.

2. Tasks:

a) Review, propose, and advise the Director (Head) of the unit on building, revising, and supplementing technical regulations on infection control in accordance with the Ministry of Health's regulations.

b) Advise the Director (Head) of the unit on plans for developing infection control work, preventing infections related to healthcare, epidemics; advise on repairs, designs, and new constructions of medical facilities in the unit in compliance with infection control principles.

c) Organize training, scientific research, line guidance, and propaganda related to infection control within the management scope.

Article 17. Organization and Tasks of the Infection Control Department (Team)

1. Organization:

a) Medical facilities with 150 beds or more or hospitals classified as Class II or higher must establish an Infection Control Department; if they have fewer than 150 beds, they must establish an Infection Control Team; outpatient clinics and health stations need to have staff responsible for infection control work.

b) The Infection Control Department, depending on the scale of the hospital, shall have the following units: administrative-supervision; disinfection-sterilization; laundry, and other units as decided by the Director.

c) Leadership of the department (team): There shall be a Head of the Department (Team Leader), Deputy Heads of the Department, and a Chief Nursing Officer of the Department. The Head of the Department (Team Leader) must have a university degree or higher in medicine, nursing, or pharmacy and have been trained in infection control.

2. Tasks:

a) Develop periodic and annual infection control plans to submit to the Infection Control Council (Board) for review before approval by the Director (Head) and organize their implementation.

b) Be responsible for drafting regulations and procedures for infection control based on general guidelines issued by the Ministry of Health and submit them to the Director (Head) of the unit for approval and organization of implementation.

c) Coordinate with related departments to monitor infection control activities, including:

- Detecting, monitoring, and reporting infectious diseases according to laws on prevention and control of infectious diseases.

- Identifying and receiving reports of healthcare-associated infections from clinical departments and bacterial culture results from the Microbiology (Laboratory) Department, and proposing timely intervention measures.

- Monitoring and reporting antibiotic-resistant bacteria.

d) Inspect and urge medical and auxiliary staff, contractual workers, teachers, students, patients, patient relatives, and visitors to comply with infection control regulations during medical examination and treatment activities.

đ) Conduct public awareness campaigns, training, scientific research, international cooperation, and direct lower-level units on infection control.

e) Manage and supervise disinfection, sterilization, laundry, provision of sterile equipment, antiseptic chemicals, laundry, and consumables for infection control activities throughout the unit.

g) Monitor, evaluate, and report occupational exposure and accidents related to microbial agents for physicians and healthcare personnel.

h) Participate with the Microbiology Department, Pharmacy Department, and clinical departments in monitoring antibiotic-resistant bacteria and rational antibiotic use.

i) Collaborate with departments, sections, and members of the infection control network to identify and resolve issues related to infection control work.

Article 18. Organization and Tasks of Members of the Infection Control Network

1. Organization: Comprising representatives from clinical and paraclinical departments; each department shall appoint at least one doctor or nurse/midwife to participate in the infection control network under the professional guidance of the Infection Control Department (Team). Members regularly receive updates on infection control through training.

2. Tasks:

a) Participate and coordinate in implementing infection control activities within the unit.

b) Participate in inspections, supervision, and urging medical personnel within the unit to comply with relevant professional regulations and procedures related to infection control.

Article 19. Duties and Authorities of the Head of the Infection Control Department (Unit).

1. Duties: Shall be responsible to the Director (Head) of the medical examination and treatment facility for infection control work within the unit:

a) Organize the full implementation of the tasks of the infection control department.

b) Develop plans for infection control work, submit them to the Director for approval, and organize their implementation.

c) Direct monitoring, detection, and propose timely intervention measures to control healthcare-associated infections and diseases with the potential to spread epidemically.

d) Participate in establishing regulations and procedures for infection control and direct inspections and supervision of their implementation.

đ) Propose procurement plans, standards, and technical specifications for equipment, consumables, and chemicals serving infection control throughout the unit.

e) Participate in disseminating information, guiding, and training healthcare workers, medical students, patients, patient relatives, and visitors on infection control knowledge and skills.

g) Organize scientific research, training, and direct line work related to infection control.

h) Coordinate with relevant departments to evaluate the effectiveness of specialized infection control techniques.

i) Summarize, report on activities and results of infection control work throughout the unit.

2. Authorities:

a) Exercise general authority of the Department Head.

b) Inspect and require departments, rooms, and individuals to comply with regulations on infection control work.

c) Propose to the Director (Head) rewards and disciplinary actions for individuals and groups with achievements or violations of the specialized infection control techniques stipulated in this Circular.

d) Be a permanent member of the Infection Control Council, Quality Management Council (if any), and the Pharmacy and Treatment Council.

Article 20. Duties and Authorities of the Head Nurse of the Infection Control Department.

1. Duties:

a) Perform the general duties of a head nurse of a department.

b) Assist the Head of the Department in performing the duties of the Infection Control Department.

c) Assist the Head of the Department in developing plans for managing equipment, using consumables, and chemicals for professional activities at the department.

d) Participate in establishing regulations and procedures for infection control and inspecting and supervising their implementation.

e) Carry out other tasks assigned by the Head of the Infection Control Department.

2. Authorities:

Have the same authorities as other head nurses and have the right to inspect and supervise infection control activities in departments and rooms within the medical examination and treatment facility.

Article 21. Duties and Authorities of Physicians and Professional Staff of the Infection Control Department (Unit):

1. Duties:

a) Comply with regulations on infection control.

b) Participate in establishing regulations and procedures for infection control and inspecting and supervising their implementation.

c) Monitor, detect, follow up, and compile information on healthcare-associated infections in departments and rooms.

d) Manage equipment, supplies, and chemicals for professional activities when assigned.

đ) Carry out other tasks assigned by the Head of the Department.

2. Authorities:

Inspect and supervise the implementation of this Circular on organizing infection control work for individuals and departments as assigned by the Head of the Infection Control Department.

Chapter IV

RESPONSIBILITIES FOR IMPLEMENTATION

Article 22. Responsibilities of the Director (Head) of Medical Examination and Treatment Facilities.

1. Direct and organize the implementation of the Circular guiding the organization and implementation of infection control activities in medical examination and treatment facilities. Develop and promulgate specific regulations on specialized techniques for infection control that are suitable to the actual conditions of the unit in accordance with the guidance of this Circular.

2. Invest sufficient annual operating funds for infection control activities.

3. Ensure adequate human resources, equipment, devices, chemicals, and materials for the practice of specialized techniques, infection control, waste management, and hygiene, ensuring that medical examination and treatment facilities are clean, green, and beautiful.

4. Direct the organization of training, research, inspection, and supervision of infection control activities.

5. Ensure safety and prevent the transmission of infectious diseases to healthcare workers and patients, especially during epidemic situations.

6. Launch competitive movements and implement rewards and disciplinary actions related to infection control activities.

Article 23. Responsibilities of the Infection Control Committee.

1. Advise the Director (Head) of medical examination and treatment facilities on infection control activities.

2. Review proposals from the Department (unit) of infection control and members of the Infection Control Committee to provide advice to the Director (Head) of medical examination and treatment facilities regarding plans, supplements, and amendments to regulations, procedures, and issues related to infection control.

3. Propose opinions and recommendations related to infection control when requested by the Director (Head) of medical examination and treatment facilities.

Article 24. Responsibilities of functional departments.

The Nursing Department, Planning and Comprehensive Department, and relevant departments cooperate with the Department (unit) of infection control to develop infection control regulations and procedures and conduct inspections and supervision related to infection control activities.

Article 25. Responsibilities of Ward Chiefs in medical examination and treatment facilities.

1. Organize the implementation of infection control regulations and procedures.

2. Organize guidance for patients, patient relatives, and visitors to comply with infection control regulations for patients, patient relatives, and visitors.

3. Coordinate with the Department (unit) of infection control to organize training, supervision, and evaluation of infection control activities in the ward.

4. Timely identify and report cases of hospital-acquired infections in the ward to the Department (unit) of infection control and the Director (Head) of medical examination and treatment facilities. Coordinate with the Department (unit) of infection control to monitor and determine cases of epidemics, hospital-acquired infections, and antibiotic-resistant bacteria in the ward.

Article 26. Responsibilities of Ward Nursing Chiefs.

1. Supervise doctors, healthcare workers, patients, patient relatives, students, and healthcare staff coming for study to comply with infection control regulations in care and treatment.

2. Guide and inspect hand washing compliance by doctors, healthcare workers, patients, patient relatives, and visitors.

3. Manage, guide, and supervise the use of personal protective equipment to ensure appropriate purpose, target group, and effectiveness in infection control.

4. Assign nurses or midwives to participate in the infection control network.

Article 27. Responsibilities of the Microbiology Department (Laboratory)

1. Coordinate with the Infection Control Department (team) to conduct investigations and monitor hospital-acquired infections and the environment.

2. Timely notify the Infection Control Department (team) and clinical departments about the results of bacterial cultures and antibiotic resistance patterns of pathogenic bacteria as prescribed.

Article 28. Responsibilities of the Pharmacy Department

1. Provide information on disinfectants, antibiotics, and the rational and safe use of antibiotics at healthcare facilities to the Infection Control Department (team).

2. Collaborate with the Infection Control Department (team) to propose procurement, supply, and use of chemicals and consumables for infection control activities.

Article 29. Responsibilities of medical doctors, healthcare staff, teachers, students, and interns at healthcare facilities

1. Participate in training courses and continuing education on infection control.

2. Adhere to all procedures and regulations related to infection control.

Article 30. Responsibilities of patients, patient relatives, and visitors

1. Comply with visiting hours and isolation measures as stipulated and guided by healthcare facilities.

2. Follow personal hygiene and hospital sanitation rules, waste classification, and other regulations set by healthcare facilities.

3. Individuals diagnosed with or suspected of having infectious diseases in Group A and certain diseases in Group B as specified by the Minister of Health must comply with treatment, isolation, movement, or discharge regulations as prescribed by healthcare facilities.

Chapter V

IMPLEMENTING PROVISIONS

Article 31. Effective Date

Article 31. Effective Date of this Circular

1. This Circular takes effect from December 1, 2009.

2. Repeal the Infection Control Regulations, the Infection Control Department Operations Regulations, and the Infection Control Department Head Function and Responsibility Regulations in the Hospital Regulations issued together with Decision No. 1895/1997/QĐ-BYT dated September 19, 1997 of the Minister of Health.

Article 32. Responsibilities for Implementation