Circulars and Regulations
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Infection control regulation in bed-care facilities Resmi Gazete: 11 Ağustos 2005 - 25903 Part One Purpose, Scope, Basis and Definitions The Purpose Madde 1 — The purpose of this Regulation is to regulate the methods and principles for preventing and controlling infectious diseases arising in connection with health services in bed-care institutions, identifying problems related to the subject, organizing and carrying out activities for its resolution and communicating to the necessary stakeholders the decisions to be taken at the level of bed-care institutions, organising the infection control committee and its working methods, duties, powers and responsibilities. Kapsam Madde 2 — This Regulation covers all public and private-sector bed-care institutions and staff working in these bed-care institutions. Dayanak Madde 3 — This Regulation was prepared on the basis of Article 3 of the Basic Law on Health Services No. 3359 of 7/5/1987 and Article 9 (c) and Article 43 of the Resolution on Organizations and Tasks of the Ministry of Health No. 181 of 13/12/1983. Definitions Madde 4 — The provisions of this Regulation; Ministry: Ministry of Health, Bed-care institution: all bed-care institutions belonging to the private sector and providing observation, examination, diagnosis and treatment services and falling within the scope of this Regulation, excluding day-care institutions, Management: dean or chief physician in charge of management in university hospitals, and chief physician in other hospital beds, Administrators: In university hospitals, the dean or chief medical officer responsible for administration, and in other bed-care institutions, the chief medical officer, Hospital Infections: all infections that develop in bed-care settings, related to health care, Infection Control Committee: the committee responsible for carrying out the activities specified in this Regulation in bed-care facilities, Infectious Diseases and Clinical Microbiology Clinic or Branch Representative: an expert in the field of infectious diseases and clinical microbiology to be appointed as head or deputy head of the department of infectious diseases and clinical microbiology in university hospitals, as head of clinic or chief coordinator in training hospitals, or as an expert to be appointed by the chief medical officer in other bed-care institutions, Representative of the Laboratory of Microbiology and Clinical Microbiology: Head of or to replace the Department of Microbiology and Clinical Microbiology, which has a laboratory of routine microbiology within university hospitals, or responsible for the microbiology of the relevant laboratory in university hospitals, which has a central laboratory; head or coordinator of the microbiology laboratory in training hospitals, or head or to replace the specialist of the microbiology laboratory in other bed-care institutions, who is appointed by the chief medical officer; Infection control physician: specialist in infectious diseases and clinical microbiology who is responsible for establishing and implementing hospital infection control programmes in bed-care settings, in accordance with the decisions of the infection control committee, Infection Control Nurse: nurse who is responsible for the implementation of hospital infection control programs in bed-care facilities, in accordance with the decisions of the infection control committee, Infection Control Team: Infection disease and clinical microbiology clinic or anabiology branch representative, microbiology and clinical microbiology laboratory representative, infection control doctor and infection control nurse team, Pharmacy: A pharmacy established in accordance with the legislation of a bed-care facility. That's what it means.
Part two The structure of the Infection Control Committee, the way it works, Duties, powers, responsibilities and areas of activity Organization of the Infection Control Committee Madde 5 — The infection control committee consists of the following members: (a) an assistant surgeon general or assistant dean to be appointed by the Director, (b) a representative of the clinic of infectious diseases and clinical microbiology or a representative of the clinical branch of anabiology, a pediatric infectious disease specialist in children's hospitals, a pediatric infectious disease specialist in children's hospitals if not a pediatric health and disease specialist, a specialist in university hospitals who shall be appointed as head or head of the clinical branch of anabiology or science, a specialist who shall be appointed as head or coordinator of clinical hospitals, or a specialist who shall be appointed by the administrator in other bed-care institutions, (c) a specialist in internal diseases, preferably from the branches of internal medicine; a specialist to be appointed as head or deputy head of the department of anaesthesia in university hospitals; a specialist to be appointed as head of clinic or coordinator or deputy head in training hospitals; and in other bed-care institutions, a specialist to be appointed by the administrator; (d) a general surgeon, preferably from the branches of the sciences of surgical medicine; a specialist to be appointed as head or deputy head of the department of medicine in university hospitals; a specialist to be appointed as head of clinic or coordinator or deputy head in training hospitals; and a specialist to be appointed by the administrator in other bed-care institutions; (e) the representative of the Laboratory of Microbiology and Clinical Microbiology, (f) Head nurse or director of nursing services, (g) Infection control physician, (h) Infection control nurse, (i) the person responsible for the pharmacy, (i) the director of the hospital, (b) and (g) The duties specified in paragraphs (b) and (g) may be performed by the same person. Depending on the conditions of the bed-care facility and the problems encountered, other clinical heads or heads of the anabiology branch, unit officials and representatives of the administrative unit may also be appointed to the infection control committee by the management, on the recommendation of the infection control committee. These members shall be selected from staff who have been trained in hospital infections, preferably on the basis of the views of the relevant departments. An infection control committee must be set up in all hospital beds. In the absence of infectious diseases and clinical microbiology specialists in two bed-restricted treatment facilities, an infection control committee of other existing members shall be established upon appointment of an infection control nurse to work full-time. For infection control medicine, the consultation service is provided by an occupational infection control doctor in a bed-care facility located within the same county boundaries. A specialist physician with the conditions set out in Article 11 may provide infection control services in a maximum of two different bed-care settings. The needs of the infection control committee, such as physical space, computers, technical equipment, tools, consumables and personnel, are met by the Management, to the extent of the facilities of the bed-care facility. How to work Madde 6 — The infection control committee acts as the highest decision-making body in infection control and meets regularly at least three times a year. Members of the Infection Control Committee shall be appointed for a term of three years. The infection control committee is chaired by the infectious diseases and clinical microbiology clinic or an anabiology branch representative. In meetings not attended by the representative of the clinic of infectious diseases and clinical microbiology or the branch of anabiology, the office of chairperson shall be held by the deputy chief medical officer or the deputy dean of the committee. Members of the infection control committee meet to discuss the agenda prepared by the infection control team and presented to them in advance. The meeting invitation shall be communicated to the members at least two days before the meeting, together with the meeting place, date, time and agenda. In exceptional cases, the infection control committee may meet at the invitation of the president or upon the application of one of the members to the presidency and at the discretion of the president. Members who, for any reason whatsoever, are unable to attend ordinary or extraordinary meetings are obliged to give a written excuse to the President. The infection control committee meets by a simple majority of the full number of members and decides by a majority of the participants. If there is a tie in the vote, the president's opinion is settled. The decisions of the committee shall be entered in the decision book and signed by the members who attend the meeting. Those who oppose the decision sign the decision in writing stating the reason for the opposition. The annual working report of the infection control committee is prepared by the infection control team and submitted to the Management after consultation with the Committee. The duties, powers and responsibilities of the Infection Control Committee Madde 7 — The duties, powers and responsibilities of the Infection Control Committee are: (a) To implement, within the framework of scientific principles, an infection control programme in accordance with the specifications and conditions of the bed-care facility, and to make recommendations to the Management and relevant departments in this regard; (b) In accordance with current national and international guidelines, write down and, where appropriate, update the infection control standards to be applied in a bed-care facility; (c) Ensure continuing in-service training and monitoring of practices for personnel employed in bed-care facilities to be able to apply these standards; (d) To develop a monitoring programme appropriate to the needs and conditions of the bed-care facility and to ensure continuity of its work; (e) Establishing targets for the hospital infection control programme in terms of hospital infection, identifying priority areas and acting on the findings, assessing the extent to which the targets have been achieved at the end of each year and including those assessments in the annual work report; (f) Report to the relevant commissions on the procurement of antibiotics, disinfection, antiseptics, sterilization tools and equipment, other ironhead and infection control-related consumables; and, where appropriate, to the Management on matters relating to the area of assignment, on decisions on the construction and renovation of a bed-care facility; (g) In the event of detection of an infection risk that poses a threat to patients or hospital staff, to conduct necessary examinations, identify, monitor and determine the presence of such risk, and to decide whether to restrict or, if necessary, stop the admission of patients to the relevant section; (h) To determine, monitor and guide policies for the use of antibiotics, taking into account surveillance data and pharmaceutical consumption data, (i) laying down the principles of sterilization, antiseptic and disinfection procedures and standards for the selection of disinfectants, monitoring their use in accordance with standards; (i) To prepare and notify the Management, at least every three months, of a surveillance report containing the speeds, factors and resistance patterns of hospital infection for transmission to the relevant departments; (j) submit to the Management the results of the annual activity evaluation prepared by the infection control team; (k) Deciding on issues and suggestions for solutions communicated by the infection control team and communicating them to the Management The Infection Control Committee may set up working groups where it considers it necessary in relation to its area of responsibility. Activity areas Madde 8 — These are the areas of activity of the Infection Control Committee: (a) Surveillance and recording, (b) control of the use of antibiotics, (c) disinfection, antiseptic treatment, sterilization, (d) occupational infections of health workers, (e) Control of hospital infections in support services such as hospital cleaning, laundry, kitchen, waste management. Decisions of the Infection Control Committee Madde 9 — The decisions taken by the infection control committee shall be communicated to the Management for enforcement. These decisions shall be binding on the Management and all staff of the bed-care institution.
Part three . Infection control team, infection control doctor, infection control Choosing a Nurse, Responsibilities, Powers, and Responsibilities Infection control team Madde 10 — The duties, powers and responsibilities of the infection control team are: (a) Assess supervision data and identify problems by submitting proposed solutions to the infection control committee; (b) To monitor the risks associated with occupational infections of personnel, to make preventive medical recommendations, and to propose to the infection control committee, if necessary, the establishment and implementation of immunization and prevention programmes; (c) To monitor, guide and inform the infection control committee on the use of antibiotics in inpatient treatment facilities, using surveillance data and pharmacy-based antibiotic consumption data; (d) control of the sterilization, antiseptic and disinfection processes; (e) To establish and supervise, in coordination with the relevant administrative units, the principles of hospital cleaning, kitchen, laundry and waste management; (f) To prepare the preliminary annual work report and submit it to the infection control committee; (g) Establish the agenda of the Infection Control Committee and run its secretariat. The infection control doctor Madde 11 — An infection control physician is selected from among infectious diseases and clinical microbiology specialists, preferably those with a national or international certificate in hospital infections and epidemiology. In the absence of an infectious disease and clinical microbiology specialist within the boundaries of the municipality where the bed-treatment institution is located, the task of infection control medicine is carried out by an expert doctor from the internal branches, preferably an expert in internal diseases or an expert in child health and diseases. In bed-care facilities with more than 1,000 beds, multiple infection control doctors may be assigned, in which case the assignment of infection control doctors is done by the infection control committee. The duties of an infection control physician Madde 12 — The duties of an infection control physician are: (a) to meet with infection control nurses at least once a week to evaluate the work, and to give medical instructions and advice to the infection control nurse wherever necessary, (b) Overseeing the work of infection control nurses and the ministerial training program; (c) To provide hospital-acquired infections training to the staff of a bed-care facility within the framework of the programmes of the Infection Control Committee; (d) regularly review and interpret surveillance data, periodically inform the infection control team and present these data at the meetings of the infection control committee, (e) To be responsible for the development and implementation of infection control programmes; (f) To initiate and conduct work to identify the source of the suspected outbreak of hospital infection and to resolve the problem; (g) To communicate to those units the problems relating to the departments and to ensure their participation in the establishment, implementation and evaluation of control measures. Infection control nurse Madde 13 — The nurse general is chosen by the nursing profession, preferably from among nurses who have a high school diploma, know how to use computers, and are certified as infection control nurses by the Ministry and work under the infection control committee. An infection control nurse must be assigned for every 250 beds. Ministry-certified infection control nurses shall serve for at least five years unless a proposal to the contrary is made by the infection control committee. They cannot leave their assignments unless they are replaced by a qualified nurse. Infection control nurses cannot be assigned any additional duties other than infection control, including watch services. The duties of an infection control nurse Madde 14 — The duties of the infection control nurse are: (a) To monitor hospital infections, monitor culture outcomes from the laboratory of microbiology and clinical microbiology, evaluate patients with respect to daily clinical visits, coordinate with the physicians and nurses responsible, identify new cases where the hospital infection is developing or is likely to develop, and ensure that appropriate measures are taken by evaluating these patients in terms of risk of infection; (b) Keeping computer records of the supervisory data collected; (c) Identify increases in clinical infection rates or increases in infections involving specific microorganisms and report them to an infection control physician; (d) To participate in research into the source and solution of a suspected outbreak of hospital infection, (e) Meet with the infection control doctor at least once a week to evaluate the work; (f) To communicate with the infection control practitioner the problems relating to the departments and to ensure their participation in the development, implementation and evaluation of control measures; (g) To be responsible for the development and implementation of infection control programmes; (h) monitoring of infection control practices throughout the bed-care facility; (i) To train the staff of the bed-care facility on hospital infections and control.
Chapter four Various and Final Judgments The notifications Madde 15 — The management shall report the annual activity report, including hospital infection rates and surveillance results, to the Ministry by the end of February each year at the latest. Training and certification Madde 16 — Issues relating to the training and certification of the staff who will carry out the services of infection control nursing shall be regulated by the Ministry within six months of the date of publication of this Regulation. Guidelines for infection control Madde 17 — With regard to infection control services to be implemented in bed-care facilities, the guidelines containing the infection control standards referred to in subparagraph (b) of paragraph 1 of Article 7 of this Regulation shall be issued by the General Assembly within six months of the publication of this Regulation. Removing the doubts Madde 18 — The Ministry shall be empowered to remedy any doubts arising from the implementation of the provisions of this Regulation. Geçici Madde 1 — Until the completion of the training and certification of infection control nurses, the nurses shall carry out the duties specified in article 14 of this Regulation, at the proposal of the Directorate-General of Nursing or Directorate-General of Nursing Services, to be determined by the Administration. Walking Madde 19 — This Regulation shall enter into force on the date of its publication. Running Madde 20 — The provisions of this Regulation shall be implemented by the Minister of Health. 25 Haziran 2011 CUMARTESİ Resmî Gazete The number is: 27975 The controls From the Ministry of Health (Refik Saydam Hıfzıssıhha Center Presidency):
When bed-care facilities manage infection control MADDE 1 – The second sentence of the first sentence of Article 13 of the Infection Control Regulations of Bed Care Institutions, published in the Official Gazette dated 11/8/2005 and number 25903, is amended as follows: An infection control nurse must be assigned for every 150 beds, taking into account the average annual bed occupancy rate. MADDE 2 – Article 15 of the same Regulation is amended as follows: “MADDE 15 – Hospital infection surveillance data is collected and recorded daily. The notification tool is the web-based National Hospital Infection Surveillance Network (UHESA). Hospitals affiliated with the Ministry of Health are required to submit weekly reports. University hospitals, private hospitals and military hospitals report on a weekly or quarterly basis. MADDE 3 – This Regulation shall enter into force on the date of its publication. MADDE 4 – The provisions of these Regulations are implemented by the Minister, who is attached to the Refik Saydam Hıfzıssıhha Central Presidency. |
