DAFTAR ISI

DAFTAR ISI ………………………………………………………………... ii

A. KEBIJAKAN UMUM..................................................................................................... 1
B. KEBIJAKAN KHUSUS.................................................................................................. 1
1. ORGANISASI PPI................................................................................................. 2
2. KEWASPADAAN ISOLASI................................................................................
2
a) Kewaspadaan standar......................................................................................
1) Kebersihan Tangan................................................................................
2
2) Alat Pelindung Diri (APD)....................................................................
2
3) Pengelolaan Limbah Dan Benda Tajam................................................ 2
4) Pengendalian Lingkungan..................................................................... 2
5) Penatalaksanaan Linen.......................................................................... 2
6) Kesehatan Karyawan............................................................................. 3
7) Penempatan Pasien................................................................................ 3
8) Kebersihan Pernafasan/Etika Batuk...................................................... 3
9) Penyuntikan Yang Aman....................................................................... 3
10) Peralatan Perawatan Pasien................................................................... 3
11) Praktik Lumbal Punksi.......................................................................... 3
b) Kewaspadaan Berdasarkan Transmisi............................................................
4
4
1) Transmisi Kontak..................................................................................
4
2) Transmisi Droplet..................................................................................
4
3) Transmisi Udara/Airborne.....................................................................
4
3. SURVEILANS INFEKSI RS................................................................................
4. PENDIDIKAN DAN PELATIHAN PPIRS.......................................................... 4
5. PENGENDALIAN RESISTENSI ANTIBIOTIK................................................. 4
6. PENCEGAHAN INFEKSI................................................................................... 5
7. PENGAWASAN PERALATAN KADALUARSA.............................................. 5
8. PEMAKAIAN ULANG (RE-USE) PERALATAN DAN MATERIAL............... 5
9. PENGELOLAAN SAMPAH INFEKSIUS DAN CAIRAN TUBUH.................. 5
10. PENGELOLAAN DARAH DAN KOMPONEN DARAH...................................
11. PELAYANAN PPI DI KAMAR JENAZAH........................................................
5
12. PENYELENGGARAAN PERSIAPAN MAKANAN.......................................... 5
13. PENGONTROLAN FASILITAS.......................................................................... 5
14. KRITERIA RISIKO AKIBAT DAMPAK RENOVASI ATAU PEKERJAAN 6
PEMBANGUNAN (KONSTRUKSI) BARU....................................................... 6
15. PERAWATAN PASIEN PENYAKIT MENULAR.............................................
16. AREA YANG MENGGUNAKAN APD............................................................. 6
17. PENANGANAN KEJADIAN LUAR BIASA (KLB)..........................................
6
18. PENGGUNAAN ANTIBIOTIKA YANG RASIONAL.....................................
19. PENEMPATAN PASIEN YANG IMMUNOSUPPRESSED............................... 6
20. PENEMPTAN PASIEN PENYAKIT AIRBORNE DESEASE BILA RUANG 6
TEKANAN NEGATIF TIDAK ADA................................................................... 6
21. PENDIDIKAN PPI DIBERIKAN UNTUK SETIAP PASIEN.......................... 7
22. PPI UNTUK PASIEN, KELUARGA DAN PENGUNJUNG.............................
23. STERILISASI ALAT/INSTRUMEN KESEHATAN PASKA PAKAI.............. 7
24. PEMERIKSAAN KULTUR DAN SWAB MIKROBIOLOGI DI 7
LINGKUNGAN RUMAH SAKIT........................................................................ 7
25. PERSIAPAN PEMAKAIAN RUANGAN BARU PASKA
7
KONSTRUKSI/RENOVASI RS...........................................................................
7

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DAFTAR ISI

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DAFTAR ISI ………………………………………………………………......................... ii
A. Pendahuluan ................................................................................................................... 1
B. Sasaran............................................................................................................................. 1
C. Dasar Hukum Kebijakan PPI di RS Muhammadiyah Gresik.......................................... 1
D. Ruang Lingkup................................................................................................................ 2
1. Kebijakan Manajemen........................................................................................... 2
2. Kebijakan Berfokus pada program........................................................................ 2
1. Organisasi PPI .................................................................................................. 2
2. Kewaspadaan Isolasi......................................................................................... 2
a) Kewaspadaan Standar................................................................................ 2
1. Kebersihan Tangan................................................................................ 2
2. Alat Pelindung Diri (APD).................................................................... 3
3. Pengelolaan Limbah dan Benda Tajam................................................ 3
4. Pengendalian Lingkungan..................................................................... 3
5. Penatalaksanaan Linen.......................................................................... 3
6. Kesehatan Karyawan............................................................................. 3
7. Penempatan Pasien................................................................................ 4
8. Kebersihan Pernafasan/Etika Batuk...................................................... 4
9. Penyuntikan Yang Aman....................................................................... 4
10. Peralatan Perawatan Pasien................................................................... 4
11. Praktik Lumbal Punksi.......................................................................... 4
b) Kewaspadaan Berdasarkan Transmisi............................................................ 5
4) Transmisi Kontak.................................................................................. 5
5) Transmisi Droplet.................................................................................. 5
6) Transmisi Udara/Airborne..................................................................... 5
3. Surveilans Infeksi RS............................................................................................. 5
4. Pendidikan dan Pelatihan PPIRS........................................................................... 5
5. Pengendalian Resistensi Antibiotik....................................................................... 6
6. Pencegahan Infeksi................................................................................................ 6
7. Pengawasan Peralatan Kadaluarsa......................................................................... 6
8. Pemakaian Ulang (Re-Use) Peralatan dan Material.............................................. 6
9. Pengelolaan Sampah Infeksius dan Cairan Tubuh................................................. 6
10. Pengelolaan Darah dan Komponen Darah............................................................. 7
11. Pelayanan PPI di Kamar Jenazah........................................................................... 7
12. Penyelenggaraan Persiapan Makanan.................................................................... 7
13. Pengontrolan Fasilitas............................................................................................ 7
14. Kriteria Risiko Akibat Dampak Renovasi atau Pekerjaan Pembangunan
(Konstruksi) Baru................................................................................................... 7
15. Perawatan Pasien Penyakit Menular...................................................................... 8
16. Area Yang Menggunakan APD............................................................................. 8
17. Penanganan Kejadian Luar Biasa (KLB)............................................................... 8
18. Penggunaan Antibiotika yang Rasional................................................................. 8
19. Penempatan Pasien yang Immunosuppressed.................................. 8
20. Penempatan Pasien Penyakit Airborne Desease bila Ruang Tekanan Negatif 8
tidak ada................................................................................................................ 8
21. Pendidikan PPI Diberikan untuk Setiap Pasien..................................................... 8
22. PPI untuk Pasien, Keluarga dan Pengunjung........................................................ 8
23. Sterilisasi Alat/Instrumen Kesehatan Paska Pakai................................................. 9
24. Pemeriksaan Kultur dan Swab Mikrobiologi di Lingkungan Rumah
Sakit....................................................................................................................... 9
25. Persiapan Pemakaian Ruangan Baru Paska Konstruksi/Renovasi
RS........................................................................................................................... 9
26. Perbandingan Data Dasar Infeksi (Benchmarking)............................................... 9
27. Risk Management PPI / ICRA HAI’S................................................................... 10
28. Pengadaan bahan dan alat yang melibatkan PPI.................................................... 10

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