Lecture Notes in Medical Technology: Administrative Order No. 27 s. 1994

March 24, 1994

ADMINISTRATIVE ORDER

No. 27 series 1994

GUIDELINES ON OPD CONSULTATION AND/OR HOSPITALIZATION OF HIV/AIDS PATIENTS

The HIV/AIDS pandemic has been declared a worldwide emergency by the World Health Organization. This situation has serious health, social, economic and political implications for all countries. The Philippines is not spares of the problems brought about by this pandemic as evidenced by the current national statistics on AIDS.

All sectors of our society have to come together to help in the prevention and control of HIV /AIDS, and these includes hospitals.

In this regard, the Hospital Operations and Management Service Technical Working (TWG) on the Management of HIV/AIDS Patients in Hospitals composed of representatives from Hospital Operations and Management Service (HOMS), STD/AIDS unit, San Lazaro Hospital and Research Institute for Tropical Medicine (RITM) created by virtue of Department Order No. 67–K series 1994 has formulated this initial guidelines in the OPD Consultation and/or hospitalization of HIV/AIDS patients.

I. HIV/AIDS CORE TEAM (HACT)

A. Composition:

The HACT shall be composed of a doctor(s), nurse(s), medical social worker(s) and medical technologist(s) who have undergone specified training on HIV/AIDS.

B. Functions of the HACT members:

1. Doctor

a. OPD

(1) Assessment

(2) Physical examination and history taking

(3) Request for laboratory work–up

(4) Counseling

(5) Follow–up of patient every 3 months

b. Admission

(1) Criteria: (+) ELISA (+) Western Blot

(2) Interview of patient and further assessment

(3) Patient Care:

(a) History taking and physical examination

(b) Code name of patient

(d) Daily round

(e) Request for laboratory work – up

(f) Request for dental check – up

(g) Treatment of opportunistic infection (PTB), PCP)

(h) Prevention of iatrogenic infection

(i) Counseling

c. Other Activities

(1) Case presentation once a week with Core Team Members

(2) Training

(a) Lectures on HIV/AIDS for health care workers

(b) Proper clinical care management

(d) Program management

(3) Research

(a) Retrospective and prospective research by resident physician.

(b) Clinical research on HIV/AIDS in collaboration with core team members and other hospitals and clinics

d. Strict observation of hospital infection control, policies and guidelines

2. Nurse

a. Nursing care and responsibilities

(1) Patient care

(a) Use of nursing process

· Assessment

· Interview

· Observation

· Data interpretation

· Plan of care

· Implementation of the Nursing Care Plan

· Evaluation

(b) Physical care

(d) Emotional care

(e) Provision of comfort and support

(2) Strict observation of the established ethico–moral standards formulated by the agency:

(a) Privacy of patient

(b) Accuracy/confidentiality of records and reports

b. Other Activities

(1) Strict observation of the Hospital Infection Control Policies and Guidelines:

(a) Universal Precautions

(b) Barrier Precaution

(d) Related policies of the departments

(2) Provision of technical assistance to the other member of the health team

(a) Doctor

(b) Medical Social Worker

(d) Pharmacist

(e) Dietitian

(f) Co–nurses

(g) Others

c. Promotion of health education through the following approaches:

(1) Information

(2) Education

(3) Communication

3. Medical Social Worker

a. HIV/AIDS counseling shall be incorporated in social casework activities with special consideration on the following:

(1) Establishing rapport for a continuous, professional relationship with team members, patients and relatives

(2) Interviewing and data gathering of psycho social/sexual history, family background, behavioral history, support system and economic concerns.

(3) Strengthening of emotional, moral and spiritual values

(4) Mobilization of materials and medical resources

(5) Counseling family members/ significant other in the impact, implications and consequences of the disease.

b. HIV/AIDS prevention and control program shall be included in social group work activity.

(1) Group activity in the ward

(2) OPD orientation and health education

(3) Mothers/parents/watchers class

(4) Group Therapy

c. Community Organization activities shall involve:

(1) Referral and networking

(2) Coordination and linkages with GO and NGO

(3) Community Outreach Program

(4) House visit/Follow up

(5) Volunteerism

d. Assist in identifying and encouraging individuals with high risk behavior for HIV infection to undergo HIV antibody test

(1) Pre–test counseling

(2) Post–test counseling

e. Confidentiality shall be observed on all information gathered and on personal behavior manifested by patients, family members and significant persons.

f. Livelihood Program for HIV/AIDS patients in coordination with AIDS Core Team, AIDS Ward staff and personnel, GO and NGO and volunteers shall be undertaken.

g. Other activities

(1) Participation in Consultative and Advisory Function involving :

(a) Policies

(b) Programs

(d) Needs of HIV/AIDS patients

h. Social Research shall be undertaken on

(1) Psychosexual and economic data

(2) Psychosexual data

(3) Socio–economic concerns

i. Orientation training and continuing education program on HIV/AIDS

(1) Conduct echo seminar

(2) Staff Development

(3) In–service training

(4) MSW as resource speaker

j. Systematic documentation of all activities on HIV/AIDS shall be observed for the purpose of evaluation, training and research

(1) Record of case studies

(2) Record of group activities

(3) Record of C.O. activities

(4) Record on policies, programs, rules and regulations

4. Laboratory Staff

Specimen collection and transport:

a. All patients for laboratory testing shall have pre–test counseling

b. Only authorized, laboratory personnel are allowed to extract blood samples from these patients.

c. All cases referred by the doctor of HACT for blood screening of possible HIV infection will have their blood extracted at the Blood Chemistry Section by the Med. Tech HACT member during office hours.

d. At least 10 cc of blood will be extracted to allow repeated examinations.

e. HIV Screening test will be the main screening procedure. Both negative and positive tests will be repeated. A “NEGATIVE” result will be signed out only if two successive test turn out to be positive, the blood sample will be referred to the Bureau of Research and Laboratories (BRL) or Research Institute for Tropical Medicine (RITM) for confirmatory testing.

f. Confidentiality will be maintained at all times by:

(1) Use of code number for patient identification

(2) Results will be forwarded to the AIDS CORE Team physician by the Laboratory Chief

(3) Results will be given to the patients directly or to any authorized individual

g. No blood samples will be discarded until all tests are completed.

h. Request for pre–employment AIDS testing will not be done. Concerned individuals will be directed to POEA–authorized diagnostic centers.

i. Specimen for transport will be placed in a vial with screw cap, then placed into a plastic bag and finally transported in a plastic box cover. All containers will be properly identified with code numbers. A “CAUTION” label will be stamped on all plastic boxes.

j. The transported specimen will only be handled by authorized laboratory personnel.

k. Prevention and control measures shall be strictly observed.

II. OUT–PATIENT DEPARTMENT (OPD)

A. Who may seek consultation/treatment at OPD?

1. All diagnosed HIV positive patients coming from the community

2. Any of high risk individual

B. Who may refer to OPD?

1. Relative of patient

2. Significant others (non–relative but close to patient)

3. Government (GO) and non–government (NGO) organization

4. OPD or Ward Staff

C. Who will attend to the patients/referrals?

1. HACT located in some hospitals shall attend to the screening, pertinent data–gathering, history taking, medical examinations and counseling (Pre–test and Post–test).

2. The OPD staff shall immediately refer to the HACT patients seeking consultation and referrals.

3. Hospitals without HACT may perform networking referral to the nearest hospital with HACT.

4. Laboratory examination for qualified patients shall be ordered by the doctor to determine if they are positive for ELISA and Western Blot.

D. Other Provisions

1. HACT members shall encourage HIV out–patients to have check–up every three (3) months in the hospital.

2. HIV out–patient shall be followed up at home by HACT members for a continuity of counseling, to determine their health condition, and monitor their activities in relation to control and prevention in the spread of the disease.

3. Community agencies and volunteers shall be tapped to assist HIV patients and their families in coping with problems emanating from their health condition.

E. Confidentiality

Patients seeking consultation and/or treatment for HIV/AIDS are entitled to absolute confidentiality on all information and pertinent data gathered from them, all medical and laboratory tests and results, and verbalized and/or demonstrated aspects of attitudes and behavior revealed to the counselor. Any revelation on their condition shall be determined by the patients.

III. ADMISSION

A. Patients found to be positive with both screening and confirmatory test.

B. For asymptomatic individuals, they shall be admitted for 3 days for further work up.

C. For symptomatic individuals, they shall be admitted for treatment of different opportunistic infections and shall be confined for 2–3 weeks or several months as per recommendation of the AIDS Core Team.

D. On admission, the AIDS Core Team physician shall perform complete history taking and physical examination with the assistance of the AIDS Core Team Nurse.

E. The AIDS Core Team medical social worker shall interview patient/ family members on the psychosocial and economic aspects and perform counseling activities which includes the Pre–test and Post–test.

F. Complete laboratory work–up shall be ordered by the Core Team physician on the following:

1. T4 and T8 cell count

Blood chemistry like CBC, blood typing, ESR determination, cholesterol determination, BUN, creatinine, Total Protein, Albumin, SGOT, SGPT, blood culture.

2. Routine urinalysis an culture

3. Examination and culture

4. Chest x–ray

5. CSF examination (when indicated)

6. Vaginal swab for gonococci, candida, trichomonas, herpes

7. Sputum exam for AFB and PCP

G. AIDS Core Team members shall perform specific functions as required, with utmost consideration on confidentiality, continuous consultation, collaboration and coordination.

H. HIV/AIDS patients shall be monitored every three (3) months upon their discharge.

I. Confidentiality

AIDS patients shall be entitled to the confidentiality of any medical test and treatment administered to them; all information gathered concerning their physical, psychosocial and economic status; any laboratory test and result carried out; and all aspects of personal behavior manifested by them.

IV. TRAINING

A. HOMS TWG in collaboration with Health Manpower Development and Training Service (HMDTS) shall conduct orientation seminar for all staff and personnel in hospitals and GO and NGO representatives in coordination with HACT members.

B. For HACT members:

1. Doctors, nurses and medical social workers shall undergo clinical management training on HIV/AIDS at San Lazaro Hospital

2. Medical technologists shall undergo clinical management training at BRL or RITM.

C. All HIV/AIDS, related training programs for hospital staff, shall be coordinated with HOMS TWG for acknowledgement and proper endorsement to HMDTS.

V. PREVENTION AND CONTROL OF HIV TRANSMISSION IN HOSPITALS

People who come into physical contact with human blood, body fluids or tissues at work are the only ones potentially at risk of acquiring HIV infection through occupational exposure. The risk is generally low and can be minimized if the infection control guidelines are followed.

A. HIV INFECTION AND THE WAY IT SPREADS

1. The term HIV infection is used when HIV, the cause of AIDS, is present in the body. People with HIV infection may not feel ill or look ill and may even be unaware of their infection.

Infection is usually indicated by a positive HIV antibody test. In a small number of cases, repeated or more sophisticated tests are necessary to detect the presence of HIV.

Extensive studies worldwide have identified only three ways of spreading HIV infection:

a. By having sexual intercourse with an infected person.

b. Through the transfer of infected human blood, body fluids or tissues.

c. From infected mother to infant before, during or after deliveries.

2. Repeated scientific studies have shown that the risk of HIV infection in the health care setting is low. The very few reported cases of workplace infection have been caused by the transfer of infected blood, body fluids or tissues.

a. Health care setting includes:

· Hospitals

· Laboratories

· OPD’s

· Clinics

· Homes/Community

b. Risk of HIV Transmission in Health Care setting

c. Major route of transmission

· Body and/or Body Fluids

· Cervical/Vaginal secretion

· Semen

· Breast milk (rare)

d. Transmission of HIV in:

(1) Patient to health care workers

(a) Parenteral contact

· Exposure to HIV infected blood

· Needle stick injury/cuts

(b) Mucous membrane contact

· Splash of infected blood/body fluids into open wounds, broken skin, abrasions, dermatitis

(2) Patient to patient

(a) Transfusion with HIV contaminated blood and blood products

(b) Sharing of HIV contaminated needles and sharp equipment (indirect route)

(3) Health Care Worker to Patient

(a) Unlikely; only possibility is when health care worker is HIV infected

B. HOW THE INFECTION DOESN’T SPREAD

HIV cannot be transmitted by person to person contact of a casual, non–sexual nature.

HIV cannot be transmitted by insects, food, water, sneezing, coughing, toilets, urine, swimming pools, sweat, tears, shared eating and drinking an utensils, clothing or telephones.

VI. GENERAL INFECTION CONTROL

A. HANDLING OF BLOOD AND BODY FLUIDS BY HEALTH CARE WORKERS

1. OBSERVE UNIVERSAL PRECAUTION

Treat all human body fluids and tissues as potentially infectious. Fluids or materials derived from human blood or tissue are similarly potentially infectious.

2. WASH HANDS THOROUGHLY between patients and after contact with human blood, body fluids or tissues. Wash hand after removing protective clothing or gloves potentially contaminated with HIV. Soap and water or antiseptic handwash are appropriate.

3. WEAR GLOVES when:

a. Touching blood, body fluids, mucous membranes and non–intact skin

b. Handling instruments or equipment contaminated with human blood, body fluids or tissues

c. Drawing blood or performing invasive procedure

d. Handling uncooperative patients

e. Handling linens or trash

f. Cleaning spills

4. Use plastic bags, forceps, towels or gauze as necessary when gloves are not available.

5. WEAR GOWNS or APRONS when:

a. Splashes of blood and body fluids are expected

b. Performing surgery, invasive procedures, vaginal delivery or wound drainage

6. WEAR MASKS AND EYE COVER OR GOGGLES when:

a. Droplets or splashes of blood and body fluids are expected as in procedures stated in 5b.

7. Cover open wounds or broken skin to prevent direct contact with human blood, body fluids or tissues.

8. Work on a clean surface and with clean instruments. Mop up and remove all human blood, body fluids or tissues. Clean instruments in cold water and then soak them in disinfectants. Surfaces should be cleaned with disinfectant. No visible contaminant should remain.

9. Use disposable instrument if at all possible. After use, they should be placed inside unbreakable plastic containers labeled “CAUTION”.

10. WASTE DISPOSAL

Dispose liquid wastes (body fluids) down or drain connected to a sewer. Incinerate, burn or autoclave soiled wastes before disposal.

11. Disinfect materials or areas contaminated with blood using ordinary bleach solution (chlorox) or phenolic agents.

DON’T manipulate specimen before disposal.

DON’T pipette specimen by mouth – do use rubber bulb or mechanical pipette

B. PREVENTION OF HIV TRANSMISSION BY NEEDLE–STICK OR OTHER SHARP INSTRUMENTS

1. Use disposable needles and syringes; use only once and destroy

2. Use only sterile needles and one sterile syringe per injection

3. Handle use needles and sharp instruments as infected materials

4. Wear gloves (double gloves or extra–heavy duty) in handling sharp instruments.

5. Dispose needles and other sharp instruments in puncture resistant containers near working area.

6. Reusable sharp instruments should be washed, sterilized and disinfected

DON’T manipulated, recap, break, bend or remove needles from syringes by hand before disposal.

DON’T use chemical disinfection for needles syringes and sharp instruments.

C. HANDLING/DISPOSAL OF INFECTED WASTES AND MATERIALS

1. Disinfect/Decontaminate materials or areas contaminated with blood.

a. Sterilization (complete destruction of all microorganisms, therefore inactivates HIV and HBV).

b. Boiling (for 20 minutes – start timing from start of boiling when sterilization is not possible).

c. Decontamination can also be done by using: 70% ethanol, 2% glutaraldehyde (cidex), 2% household bleach (chlorox), 10% formaldehyde and Lysol.

2. Spills should be covered with gauze soaked on household bleach (chlorox) and left for 30 minutes before cleaning.

3. Place wet wastes or used dressings to leak proof containers.

4. For solid waste, incinerate or burn or bury 7 feet deep, 30 feet away from water source.

5. For liquid waste, pour down a sink unto a working sewer.

6. Place needles, sharp instruments in puncture–proof containers immediately after use and preferably incinerated.

7. Disinfect materials or HIV infected area with ordinary bleach solution or phenolic detergent.

D. HOUSEKEEPING PRECAUTION

1. The greatest risk is via needle stick injury from trash which has not been properly packed for disposal. All sharp instruments and equipment, including needles and syringes, must be disposed of in puncture–resistant containers.

2. Carry waste in containers which are small enough to be easily held away from the body to avoid injuries.

3. Do not use disinfectant fogging following patient discharge or in any patient care area. Thorough cleaning with soap, water and chlorine compound is the most effective way to remove soils and microorganisms.

E. LAUNDRY PRECAUTIONS

1. Handle soiled linen as little as possible. Wear gloves when handling it.

2. Place wet linens into leak proof bags. If no leak proof containers are available, fold the linen with the wet part inside, and surround with dry linen for carrying.

3. Bag linen at the location where it is used. Do not sort linen in patient areas.

4. Soak soiled linen and clothing in cold water containing household chlorine bleach (chlorox, freshly diluted 1% solution) and then wash in hot or cold water with detergent.

F. LABORATORY PRECAUTION

1. Treat all specimens as potentially infectious.

2. GLOVES should be worn by all personnel engaged in activities that may involve skin contact with potentially infectious materials.

3. Wash hands after removal of gloves and immediately after contact with blood, body fluids and other specimens.

4. Do not pipette specimens by mouth. Use rubber bulb or mechanical pipettes.

5. Collect, transport and hold all specimens in leak proof containers.

6. All laboratory glassware, disposable materials and wastes or suspected or known to contain HIV must be decontaminated preferably in the autoclave before washing or discarding. Incineration of solid wastes may be used as an alternative method of disposal.

7. Work surfaces should be decontaminated at the end of each working day or when overtly contaminated.

G. POST MORTEM PROCEDURES

Precautions for handling dead bodies are the same as those for preventing the transmission of HIV in a health care delivery situation.

1. All persons should be considered to be HIV infected.

2. Precautions are not needed if there is no contact with blood, semen, vaginal secretions or other fluids. For example, moving a body from the hospital room to the mortuary or home does not require special precautions.

3. All persons performing autopsies or assisting in post–mortem procedures (e.g., embalming) which involve contact with blood, semen, vaginal secretions or tissues should take the following precautions:

a. Wear gloves for contact with body fluids

b. Wear gown, mask and eye protection (goggles or eye glasses) if splashes of these fluids is expected.

c. Disinfect contaminated instruments and surfaces after postmortem procedures.

4. Patients who dies of AIDS shall be buried unembalmed or be cremated within 24 hours.

VII. STERILIZATION AND DISINFECTION

A. STERILIZATION

All forms of sterilization will inactivate HIV and HBV

1. Steam under pressure

2. Dry Heat – 170^oC (340^oF) for 2 hours

3. Chemical – 2% Glutaraldehyde for at least 10 hours; 3% hydrogen peroxide for at least 2.5 hours.

B. DISINFECTION

1. Boiling for 20 minutes (start timing from beginning of boiling point) is an effective way to disinfect instruments and equipment when sterilization is not possible.

2. Chemical disinfection – do not use chemical disinfection for needles and syringes. Chemical disinfection for other invasive equipment should only be used as a last resort.

3. Chlorine compounds (bleach). HIV is rapidly killed by liquid chlorine (household bleach), making it ideal for decontaminating large surfaces. The following are guidelines for chlorine use:

For small spills or clean equipment:

Dilution: liquid – 1 part in 100 parts water

Powder – 1.5 grams per liter water

For large spills or grossly contaminated equipment:

Dilution: liquid – 1 part in 10 parts water

Powder – 7 grams per liter water

Chlorine compounds are very unstable. Prepare solutions daily or store in a covered brown bottle for up to 30 days. The bottle must be tightly capped between use.

C. OTHER DISINFECTANTS active against HIV:

1. 70% ethyl or isopropyl alcohol

2. 2% glutaraldehyde

3. 3% phenol (or Lysol)

4. 2.5% povidone iodine

5. 4% formaldehyde

6. 3% to 6% hydrogen peroxide

D. PRACTICES WHICH INCREASE THE RISK OF EXPOSURE TO HIV:

Accidents involving exposure to human blood, body fluids or tissues containing HIV have been recorded in the following situation:

1. During recapping or disposal of used needles and other sharp instruments.

2. When infection control procedures are not routinely applied to all blood, body fluids or tissues. This breakdown in safe procedures has been seen in clinical patient care situation and in laboratory environment.

VIII. ACCIDENTS

Accidents involving exposure to blood, body fluids or tissues need to be documented. The risk of HIV transmission for each accident should be assessed by a trained infection control officer. If transmission is possible, then testing, with informed consent, should be offered to the people who were exposed. The source of the material involved in exposure should also be tested. Once again, informed consent should be obtained if this involves testing a person.

The particular circumstances of the accident need to be investigated so that work practices can be changed to prevent a recurrence.

If potentially exposed person requests testing, then an HIV antibody test should be done immediately following the accident and repeated at least three months later. If concerns persist, or arise at a later date, further testing is appropriate. This testing should be STRICTLY CONFIDENTIAL and accompanied by skilled counseling by a trained counselor. COUNSELING IS NECESSARY BEFORE AND AFTER THE TEST.

JUAN M. FLAVIER, M.D., MPH

Secretary of Health

20 August 2017

Administrative Order No. 27 s. 1994

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