DIVINE MERCY HOSPITAL

# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan

Tel # 075-568-5563 / 075 -656-2103

POLICY AND PROCEDURES ON HOW SOILED LINEN

ARE COLLECTED, DISINFECTED AND WASHED

A. All soiled linen should be first exposed to UV light for initial sterilization for
at least 1 hour then allow 30 minutes to simmer in the room just vacated by
the patient prior to each collection. The utility men should use (at least Level
2) PPE’s when collecting linens especially used by patients with infectious
diseases (such as Covid -19 disease, Hepa B, HIV, etc.).

B. The linens will be carried via a trolley cart and be sent to an area in the
LAUNDRY Section solely for contaminated linens. The same should be
soaked with a Sodium Hypochlorite (CHLOROX) & detergent soap laden
water for another 1-2 hours.

C. The linen will then be washed via a washing machine with the usual
detergents till its eventual drying via sunlight exposure or air-drying.

D. The following are the PPE’s: plastic/rubber apron, mask, hairnet, rubber
gloves, rubber Boots, and plastic eyeglass, (Level 2).

E. The following are the chemical disinfectants / whiteners: Sodium

Hypochlorite, detergent soaps, fabric conditioners.

F. The linens are then sort out by the CSR personnel to determine its worthiness
and cleanliness for its eventual stocking and storage at the supply room.

G. OR/DR linens, gowns and OR sheets are packed accordingly for autoclaving /
sterilization prior to storage.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

July 2, 2022

MEMORANDUM ORDER
No. 1

SUBJECT: Creation of Quality Improvement (QI) Team

_____________________________________________________________________

The following personnel are hereby designated to comprise the Team for Quality
Improvement (QI):

CHAIRMAN: Priscilla R. Baun, RN, MAN, PhD

MEMBERS: Katrina Asumio, RN
Lili Andrea Flor Mercado, RMT
Ma. Socorro Mendoza, RPh

ANITA C. TARECTECAN, M.D.

Medical Director

Conforme:

___________________________
Priscilla R. Baun, RN, MAN, PhD - CHAIRMAN, Quality Improvement
July 2, 2022ent

_________________
Katrina Asumio, RN - MEMBER, Quality Improvement
July 2, 2022

___________________________
Lily Andrea Flor Mercado, RMT - MEMBER, Quality Improvement
July 2, 2022

_______________________________
MA. SOCORRO MENDOZA, RPh - MEMBER, Quality Improvement
July 2, 2022
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

July 20, 2022

MEMORANDUM ORDER
No. 2

SUBJECT: Monitoring of CPG Use

PERSONNEL CONCERNED : All Admitting Physicians and Consultants

_____________________________________________________________________

You are hereby directed to follow the updated Clinical Practice Guidelines
( CPG ) of the 10 Most Common Diseases in your management of patients, namely
:

1. Jjj
2. M
3. M
4. M
5. C
6. C
7. C
8. C
9. C
10.

Please take time to read the CPG Compilations available at the ER Station and at the
Ward Stations.

For your guidance and compliance.

ANITA C. TARECTECAN, M.D.

Medical Director
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

HOSPITAL PLAN FOR CONTINOUS QUALITY

IMPROVEMENT (CQI)

The hospital abides by the DOH – required training of personnel for

Continuous Quality Improvement

 FOR NURSES
 Basic Life Support (BLS)
 Advanced Cardiovascular Life Support
 Operating Room Training for OR Nurses
 Delivery Room Training for DR Nurses
 Emergency and Trauma Care for ER Nurses
 Future Plans Include:
1. ICU Care Training
2. Hemodialysis

 FOR MEDICAL TECHNOLOGISTS

 Blood Banking
 Biosafety
 Blood Chemistry
 HIV Proficiency Training

The hospital stall allot an annual budget of ₱50,000.00 for its personnel trainings
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY ON HOW CLIENT SATISFACTION SURVEY

IS PROCESSED

1. Hospital Survey Forms should be available at the front desk for OPD patients
with drop box

2. Survey form is provided to all admitted patients and / or watchers and

submitted thru drop box or collected by the cashier or head nurse upon
clearance of bill.

3. The cashier who collected the survey forms compile and submit to hospital
management.

4. Adverse comments or unsatisfactory ratings noted by the Cashier or Head

Nurse should call the attention of the hospital manangement immediately for
prompt resolutions and appropriate actions.

5. Written and signed complaints should be reported to the Complaints and

Grievance Committee

( Please see POLICY ON HANDLING COMPLAINTS, GRIEVANCES AND

ADVERSE COMMENTS IN THE CLIENT SATISFACTION SURVEY )
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY ON HANDLING COMPLAINTS,

GRIEVANCES AND ADVERSE COMMENTS IN THE
CLIENT SATISFACTION SURVEY

A Complaint and Grievance Committee shall be composed of the following

personnelm :

Chaiman - Hospital Administrator ( Dr. Leo Tarectecan )

Vice Chairman _ Medical Director ( Dr. Anita C. Tarectecan
Members : All Section Heads
Nursing – Ms Katrina Asumio
Laboratory – Ms. Lili Mercado
X-ray – Mr. Michael Gamboa
Pharmacy – Mrs. Socorro Mendoza
Maintenance – Mr Rodolfo De Guzman

POLICY :

1. Survey forms should be made available to all patients and watchers for
comments or complaints

2. Only signed written complaints are entertained by the grievance committee.

3. The concerned personnel or staff shall make an Incident Report (logbook and
a file copy) and an Explanation Letter attached to the written report to be
submitted to its section head or hospital management (Hospital Admnistrator /
Medical Director)

4. Concerned staff shall be interviewed by the committee or any of its members.

5. Adverse comments or unsatisfactory ratings noted by the cashier or head nurse

should call the attention of the hospital management (Hospital Admnistrator /
Medical Director). The hospital management may call the concerned staff of
the particular area with the adverse comments or unsatisfactory rating.
Solutions and recommendations for improvements are advised and
implemented.

6. Written complaints of patients and / or watcher shall be settled first at the level
of the head nurse. If unresolved, elevated to the grievance committee then to
the hospital management.

7. Meeting of grievance committee shall be called for and discuss the matter to
come up with solutions and or recommendations.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

8. The committee or its members shall call the complaint and further inquire
about its complaints and try clear the matter and present the possible solutions
or recommendations by the committee.

9. All possible measures should be exerted by the committee and / or hospital

managements to settle or clear the issue and prevent litigations in court,
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY ON HOW NEWBORN RECEIVES

BCG AND HEPATITIS B VACCINES

A. HEPATITIS B VACCINATION

1. All newborn infants delivered in our institution will be given a

first dose of Hepa B Vaccine 10 mcg IM on either thigh prior to
discharge.

2. Vaccine vial sticker should be attached to patient’s chart for proper

documentation and recordings.

3. Subsequent doses with 1 month and 2 months interval (2 nd and 3rd

doses) after the 1st dose are given options to mother and / or
parents to have it completed in our institution or to their nearest
health centers

4. Hepa B Vaccines and boosters are made available at the hospital

pharmacy

B. BCG

1. BCG vaccines are available on multiple dose vials. Unless at least

10 babies for vaccination are available at a given time / schedule,
vaccine spoilage is very likely. Until a single dose vial vaccine is
made available by the vaccine companies, the hospital does not
want vaccine spoilage and profit loss. Hence BCG vaccine
acquisition is directed to Pediatrician in-charge

2. Detailed information is given to the mother or parents regarding the

importance of BCG vaccination. Hence, they are advised to ensure
that the vaccine is given to their babies at their Pediatrician clinic
or avail a free vaccination at their nearest health centers.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

MISSION
To provide a Healthy Atmosphere that will ensure the best comfort for both
Health Workers and Patients that will complement health programs of the
Government tailored fit to the needs of clients in congruent of what we can provide
with hospital charges significantly lower and with utmost priority for the
underserved.

VISION
We envision the DIVINE MERCY FOUNDATION OF URDANETA
HOSPITAL to be the premier Center for Health in the Eastern front of Pangasinan in
the next 10 years with compassionate and highly skilled Health Workers who work in
an upgraded and safe facilities under a progressive and dynamic leadership.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

CHECK LIST OF ORIENTATION FOR

NEW PERSONNEL

1. Introduction

A. Hospital Management, Personnel and Staff

B. Hospital Mission and Vision
C. Hospital Policies
i. Attendance, Tardiness and Leave of Absence
ii. Medical, Nursing, and Administrative Section
iii. Timely Referral and Reporting of highly
transmissible and notifiable infectious disease
iv. Waste Disposal Management
v. NO Smoking
vi. NO Alcohol Drinks
vii. Ambulance Breakdown
viii. Cadaver Disposal
ix. Issuance of Certificate of Employment
x. Hiring, Credentialing, and Privileging of Staff
xi. Infection, Prevention and Control
xii. Data Privacy Act
xiii. Accidents and/ Injuries inside the Hospital
Premises
xiv. Contact Tracing
xv. Isolation

2. Standard Operating Procedure (SOP’s) at ER, OPD and Ward

3. Charts and Forms

a. OPD, Admission
b. Request form for X-ray, Ultrasound, ECG, Laboratory
c. Referral Form with Return Slip

4. Tour of Different Hospital Areas

New Employee: Chief Nurse/ Head Nurse

________________________ ___________________________
Signature Over Printed Name Signature Over Printed Name
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

Date Signed : Date Signed :

DOCUMENTATION ON HOW CQI ACTIVITIES

CONTRIBURE TO BETTER PATIENT OUTCOME

1. FIRE AND EARTHQUAKE DRILL

 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

For information, education, Training of Staffs,

personnel, patients, watchers and expectators
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY AND PROCEDURES ON

RECORD STORAGE, SAFEKEEPING AND
MAINTENANCE, RETENTION AND DISPOSAL

Law and Usage dictate the retention of medical records under Republic Act
No. 4226, otherwise known as the Hospital Licensure Act which requires hospitals to
maintain medical records from ten to twenty – five years.

Until such time, all Medical Records and charts are kept in the Records
Section.
Containing cabinets and room are kept locked and can only be accessed by duly
authorized personnel on duty.

RECORDS DISPOSAL

Disposal of records should always be with authority from the Records

Management and Archives Office.

1. Conducts inventory of records for disposal.

2. Accomplishes Request for Authority to dispose records in a

quadruplicate.

3. Upon receipt of the Request for Authority by the Records

Management and Archives Office, representative is sent to
inspect and evaluate the disposable records after which they
submit a Records Analysis Report

4. A few days later, the RMAO sends the Approved Authority to

Dispose

5. Scheduling for the disposal is done

 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY AND PROCEDURES ON HANDLING CASES

OF PATIENTS FOR DISCHARGE BUT WITH
UNPAID BILLS

INFORMED CONSENT UPON ADMISSION

Patient and patient's relatives are to be advised by the Hospital Office clerk on
the financial capability of the client where they could save most, either to stay in a
private room or in the ward. Should they choose the private room, whether air-
conditioned or with an electric fan. The room rates will be provided for their
assessment of budget.

Then they will be advised as to whether their attending physician will be a

house - case or a visiting consultant providing them with the list and their respective
charges till apparent recovery. This again could offer them a glimpsed of the extent of
their financial capability.

OTHER SOURCES OF FINANCIAL SUPPORT

Clients are advised remedies for financial support like membership in

PHILHEALTH which Provide Case-Rate to most common diseases and SSS, which
they can apply to avail of sickness benefits. Senior citizen membership for 60 years
old and above wherein they could secure their I.D. at the Municipal/City Social Work
Office. A 20% discount to their total bill can be deducted provided they can present
their I.D.
They are also advised to seek help of the PCSO and the hospital shall
provide them of the necessary papers and the documents for their early morning filing
at the PCSO Office. The PCSO provides a Guarantee Letter to the Hospital stating
therein the amount they would pay. All these are mitigation to lessen the out-of-
pocket expenses of the patients admitted in the Hospital.

IN CASES OF FINANCIAL INCAPABILITY OF CLIENTS

All hospital bill balances should be accompanied by a Promissory Note duly

prepared and notarized by a competent lawyer. Notarial fees are shouldered by the
patient or relatives.

This Hospital does not accept Guarantors as a warranty to their balances in the
Hospital. We accept Valid Original LAND TITLE in the name of the patient or
patient's
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

relatives to be deposited in the Hospital vault with an attach promissory note as when
will they shall redeem their title duly Notarized by a Lawyer and with corresponding
witnesses. Failure to redeem their T.C.T. on the designated date, then an interest is
computed based on the prevailing bank interest rate and added to the balances.
Attorney's Fees are for the client’s expenses.

The hospital may also t accept valuable movable assets like automobiles and
motorcycles with complete legal documents and proof of ownership; and further
provided that any damage to their vehicle is not a liability of the Hospital as the
hospital has no impounding area. Promissory notes are prepared and notarized by a
lawyer and the notarial fees should be shouldered by the patient or his relatives.

In extreme cases, the Hospital may accept electrical appliances like electric
fan, refrigerators, and other appliances but the same are to be tested for their
functionality. Failure to redeem these appliances within the specified date of
redemption, the same will be imputed as a payment to their balances and becomes a
property of the hospital. Again,these are covered by a notarized promissory notes.

The Hospital does not accept jewelries as a collateral as the management does
not have the capability to detect and evaluate the value of jewelries. In cases wherein
the client cannot provide any of the above-mentioned assets and documents, as long
as the patient stayed in the NBB / charity ward, the Hospital Social Worker will assess
the indigency of the client. If he / she passes the criteria, then patient will be sent
home with the balances written-off without further ado ( may be included in the No
Balance Billing ).

But for those clients who stayed in the private room, they are given 5 days to
remedy their hospital balances and the management will be sending a team which will
do a background check of the client. If determined capable, then they have to make a
Promissory note in front of the Hospital Lawyer and witnessed by the Barangay
Captain where the client resides. In case the client is incapable to pay all the bills,
then they would be asked to pay the drugs and the medicines used and the laboratory
fees and the other fees can be remedied via a PROMISSORY NOTE. Failure to
comply with what was promised in the promissory note, the Hospital Lawyer will be
notified of their neglect, and he will write and notify them of their balances. Failure to
answer or appear to the Lawyer, then judicial remedy will be the last resort.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

ANNUAL TRAINING PLAN WITH ALLOCATION OF

BUDGET

Trainings build the nurse's and personnel’s confidence, improves overall

performance and encourages cooperation, as well as creativity to bring new ideas into
the workplace. Aside from this, training also includes information about personal and
patient safety practices.

 Training of proper handwashing, donning, and doffing

 Proper use of Personal Protective Equipment ( donning and doffing )
 Training of Breast feeding with E-05 prohibiting use of bottled milk
 Training on Advance Life Support and Basic Life Support
 Training on Operating Room Nurses and Delivery Room Nurses
 Training on TRAUMA NURSES for 35 days
 Med. Tech trainings

An annual allocated budget of ₱ 50,000.00 is set for training of personnel.

 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY ON RATIONAL USE OF ANTIBIOTICS

 The hospital shall purchase medicines like antibiotics based on the commonly
used drugs in the CPG’s ( Clinical Practice Guidelines ) and recommendations
of the Therapeutic Committee accordingly to the updated or latest national or
international guidelines ( Evidence – based guidelines ).

 The Infection Prevention and Control Committee with its Subcommittee on

Antibiotic Stewardship shall monitor the rational use of high – end antibiotics

 First – lines of antibiotics are given to uncomplicated infections. Completion

of therapy should be encouraged and guided by empiric clinical
improvements or outcomes

 Upgrading of antibiotic generations or level should be guided by an

ANTIBIOGRAM results or Culture and Sensitivity tests results.

 In the absence of an Antibiogram results, the IPCC may be consulted and

approval sought in the interest of a worsening infection and clinical status of a
patient needing high – end antibiotics.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY ON RECYCLING AND REUSE

OF ITEMS FOR COVID – 19 CASES

 Only disposable items as much as possible should be used for Covid – 19

patients and eventually disposed accordingly

 All disposable items such as masks, gloves, oxygen cannulas, ambubags,

underpads, gauze, etc, should be collected and placed in a YELLOW BAGS
( containers for infectious, pathologic, pharmaceutical and genotoxic wastes )

 Recycling of items used by Covid – 19 patients are discouraged and not

allowed.

 Reusable materials such as stainless steel materials such as surgical

instruments and clamps, plastic box containers, metal trays, linens / bedsheets
are not mixed with other items used by non – Covid patients, and processed :

 First exposed to UV light sterilization on site for at least 1

hour.
 Then collected by the personnel / nurse in their proper PPE’s
for cleansing with soap and water and Lysol
 Instruments are soaked into a separate / designated container
with Glutaraldehyde ( Cidex, Metricide ) solutions for at least 1
hour, afterwhich, these are air - dried or packed separately for
autoclaving and to be reused again for another Covid – 19
patients only
DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

MISSION AND VISION

 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

2. BLS AND ACLS

To improve patient care management
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICIES AND PROCEDURES FOR DISASTERS AND

EMERGENCIES

Policies and procedures for disasters and emergencies are essential for every
organisation.

Policies and procedures provide:

 a framework for action

 decisions grounded in legitimate authority
 written documentation so the organization can keep track of what’s agreed.
 a starting point for building understanding for everyone in the organization

In relation to disasters and emergencies every organization needs policies that

cover all the elements in the Disaster Plan:

Step 1: Leadership

 Mandate & approach

 Objectives to be achieved
 Roles: staff and volunteers

Step 2: Building Networks

 Local Emergency Management Committee & Plan & Emergency

services
 Community organisations
 Identifying vulnerable clients

Step 3: Know Your Risks

 Past and possible future disasters and emergencies

 Risk register (resources)

Step 4: Manage Your Risks

 Prevention and Adaption

 Risk Register
 Business Continuity Plan
 Insurance
 Preparing for community recovery
 Disaster and emergency policies and procedures
 Triggers and key messages identified and communicated

Step 5: Preparing Others

 Staff and volunteer awareness and knowledge

 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

Step 6: Learning and improving

 Testing, monitoring and reviewing

 Learning and sharing

The Disaster Plan can itself be a starting point for organizational policies and
procedures. Further details may be needed in the organization’s policy and procedures
manuals. Useful polices can include:

 Organizational mandate for disaster resilience

 Objectives to be achieved in the face of disasters and emergencies
 Relationships with local emergency management and services and
associated processes (committee memberships).
 Identifying vulnerable clients - Processes and systems
 Staff and volunteer disaster and emergency training
 Client disaster preparedness

As these policies are developed further detail can be added, for example:

 emergency procedures, including: an effective response to an

emergency
 evacuation procedures
 notifying emergency service organizations at the earliest opportunity
 medical treatment and assistance, and
 effective communication between the person authorized to coordinate
the emergency response and all people at the workplace
 testing of the emergency procedures—including the frequency of
testing, and
 information, training and instruction to relevant workers in relation to
implementing the emergency procedures.

Emergency policies and procedures should include the following types of

practical information:

 emergency contact details for key personnel who have specific roles or
responsibilities under the emergency plan, for example fire wardens,
floor wardens and first aid officers
 contact details for local emergency services, for example police, fire
brigade and poison information center
 a description of the mechanisms for alerting people at the workplace to
an emergency or possible emergency, for example siren or bell alarm
 evacuation procedures including arrangements for assisting any
hearing, vision or mobility-impaired people
 a map of the workplace illustrating the location of fire protection
equipment, emergency exits, assembly points
 Procedures for testing the emergency plan including the frequency of
testing must be included.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

BLOOD TRANSFUSION POLICY

Blood transfusion is a potentially hazardous procedure which should only be
given when the clinical benefits to the patient outweigh the potential risks, the most
important of these being acute haemolytic reactions and transfusion-transmitted
infections. Stringent procedures must be followed to ensure that the correct blood is
given and that any adverse reactions are dealt with promptly and efficiently.

This policy on blood transfusion is supported by procedures on ordering,

prescribing, administration of blood and the management of any complications.
Procedures for the documentation of transfusions in nursing, medical and laboratory
records are also provided, including the procedure for the reporting of any adverse
incidents occurring in relation to transfusion.

It is the policy of the DIVINE MERCY HOSPITAL that blood transfusions

must be conducted according to procedures annexed to this policy and must only be
conducted by staff who are trained and competent in the procedures.

The purpose of this policy is to: ensure that the correct blood is given and that
any adverse reactions are dealt with promptly and efficiently. All staff involved in the
process must be appropriately trained and aware of their responsibilities in relation to
handling blood components and performing transfusion related tasks within their own
competence and in accordance with procedures which are in place to reduce the risks
to patients

The Blood Station is responsible for the following:

1. Compatibility testing and issuing of blood products are done correctly.

2. The ordering and management of blood product and component stocks

including liaison with NVBSP

3. Investigating adverse events and reporting them to Transfusion scheme

and the BLOOD TRANSFUSION COMMITTEE

4. Monitoring requests for products and usage

5. Training and competence of staff involved in laboratory processes

6. Regulatory compliance and the maintenance of a quality management

system including the traceability of blood components

Medical and nursing staff are responsible for:

1. Requesting blood, clearly indicating the reason for transfusion and

communicating the degree of urgency to the Blood Transfusion
Laboratory.

2. Providing full information on transfusion requests

3. Explaining to patients the risks, benefits and possible alternatives to blood

transfusion and providing written information where appropriate
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

4. Requesting collection of blood including arranging urgent transportation if

required

5. Obtaining red cells for transfusion via the electronic remote issue system,
ensuring that the right blood unit is correctly labelled for the intended
patient and that blood for only one patient is collected at each visit

6. Carrying out pre transfusion checks to ensure the right blood is transfused

7. Monitoring the patient during transfusion

8. Inclusion of medical staff in the 21.8. Inclusion of medical staff in the

management of the patient if a transfusion reaction should occur.

9. Reporting of transfusion reactions or other incidents to the Blood

Transfusion Laboratory

10. Documentation of indications for transfusion, number of units

administered and observations recorded in patients’ medical records

BLOOD TRANSFUSION PROCEDURES

1. All blood components are logged and recorded (electronically where possible)
throughout the process of transfusion to provide ‘vein to vein’ traceability
ensuring that each blood component is handled and stored correctly, given to
the right patient for the right reasons and that records are retrievable in
compliance with NVBSP rules.

2. The decision to transfuse and consent to transfusion should be made in

advance with the patient, parent or guardian as appropriate before any planned
transfusion. Patients receiving a transfusion should be informed of the
indication for the transfusion as well as the potential risks, benefits and
alternatives. A record of this discussion should be documented in the patient's
health records, which does not require the signature of the patient. In an
emergency, this information should be provided after the transfusion.

3. Patient information leaflets are available to assist clinical staff in obtaining

patient consent to transfusion..

4. If the patient or parent/guardian refuses to consent to a transfusion, the matter

should be referred firstly to a senior doctor, within that patients primary
treatment team. Where consent is not possible, for example in emergency
situations, where the patient has no capacity to consent, it is a matter of
clinical judgement of what is in the patient’s best interests and full
documentation of this decision must be made in the patient record.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

DOCUMENTING THE TRANSFUSION

Each transfusion must be documented in the patient’s medical records by the

medical team responsible for the patient including the following information:

 Consent to the transfusion

 Date and time of transfusion
 Clinical indication for the transfusion
 Type of blood component and the number of units transfused
 The unit numbers of each blood component transfused
 Transfusion reactions and their management
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

POLICY ON PATIENT SAFETY

1. The Hospital has employed security Guards and they should have previous
experience guarding public Institutions.

2. They serve the Hospital of a 8 hour shift Only as the management prohibit 12
hours duty as they Are no longer effective especially at night.

3. They have a 1 day off with a back-up Guard taking on their post.

4. Security Guard have a visitors logbook , when covid 19 pandemic came the
visitors were probihited.

5. They have a Logbook for incoming vehicles entering the premises noting the
plate number and The time of entry and time of departure.

6. They have a VISITOR'S LOGBOOK wherein all patient's visitors are required
to fill-up presenting Their valid I.D. and asked the full name of their patient.

7. Visitors are not allowed to enter the Hospital after 11p.m except for valid
reason and with the Consent of the patient and or patient's relatives.

8. Visitors under the influence of alcohol are not be allowed to enter the
Hospital.

9. Visitors with bulk baggage shall be inspected and or asked to declare the
contents of their Baggage.

10. The Hospital has a 24 hour CCTV Monitor. The cameras are located in the
most secretive Place and reviewed for any possible breach of security.
Suspected footages are compared with the other monitor, reviewed and
analyzed.

11. The Hospital Electrician maintains and manages the CCTV system.

12. The Hospital provided a Nurses Quarters wherein incoming or outgoing

nightshift employees May stay for the night.

13. A Quarters for Ambulance Drivers and Janitors are also provided for their
easy accessibility.

14. All employees are allowed to cook at the site as they are provided with a
kitchen and utensils.
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

15. This is to prevent them going out in the middle of the night to buy food.

REPORTS OF SURVEILLANCE OF INFECTOIN

PREVENTON AND CONTROL

A. COMMONLY ISOLATED PATHOGENS AS PER URINE

CULTURE AND SENSITIVITY RESULTS OF OUR PATIENTS
FROM JANUARY 2021 TO JULY 2022

PATHOGENS NUMBER
1. STAPHYLOCOCCUS AUREUS 11
2. ESCHERICHIA COLI 10
3. PSEUDOMONAS SPP 7
4. ENTEROCOCCUS SPP 5
5. KES GROUP 4
6. PROTEUS SPP 3
7. CANDIDA SPP 1
8. CANDIDA ALBICANS 1
9. STAPHYLOCOCCUS 1
HAEMOLYTICUS
10. KLEBSIELLA PNEUMONIAE 1
Table 1. COMMONLY ISOLATED PATHOGENS

B. ANTIBIOTIC RESPONSES

ANTIBIOTICS SENSITIVE RESISTANT

GENTAMICIN 21 2
PIPERACILLIN/TAZOBACTAM 21
AMIKACIN 20
AMOXICILLIN/CLAVULANIC ACIDS 20 1
CEFTAZIDIME 20 2
CIPROFLOXACIN 20 3
AMPICILLIN/SULBACTAM 19 3
CEFOTAXIME 19
TETRACYCLINE 19 1
TOBRAMYCIN 19
FOSFOMYCIN 18 1
CEFOPERAZONE 18 2
LEVOFLOXACIN 17 2
CO-TRIMOXAZOLE 17
TRIMETHOPRIM/SULFAMETHOXAZOLE 15
COLISTIN 3
CEFOXITIN 3
ERTAPENEM 3
 DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

IMIPINEM 3
MEROPENEM 3
CEFTRIAXONE 2 2
CEFUROXIME 2 2
CEFEPIME 1
QUINUPRISTIN/PALFOPRISTIN 1
RIFAMPICIN 1
TIGECYCLINE 1
VANCOMYCIN 1
AMPHOTERICIN 1
CASPOFUNGIN 1
FLUCYTOSINE 1
FLUCONAZOLE 1
MICAFUNGIN 1
VOMICONAZOLE 1
CLINDAMYCIN 1
ERYTHROMYCIN 1
NITROFURANTOIN 1
MOXIFLOXACIN 1
OXACILLIN 1
BENZYLPENICILLIN 1
Table 2. ANTIBIOTIC RESPONSES

SUMMARY:

In our hospital facility, 29 urine culture and sensitivity of

inpatients and outpatients were processed from January 2021 to July
2022. Among the 29, 18 were females and 11 were males.

The most frequently reported pathogens among the 29 patients were

STAPHYLOCOCCUS AUREUS (11) followed by ESCHERICHIA COLI (10) and
PSEUDOMONAS SPP (7) as shown in table 1 above.

The antibiotic responses were shown in table 2 above which indicates that the
most sensitive antibiotic to pathogens were Gentamicin and Piperacillin/Tazobactam
followed by Amikacin, Amoxicillin/Clavulanic acids, Ceftazidime and Ciprofloxacin.

Attached were sample results from three different hospitals (Dagupan Doctors
Memorial Hospital, Urdaneta Sacred Heart Hospital and Divine Mercy Foundation of
Urdaneta hospital).
DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

FAMILY PLANNING
DIVINE MERCY HOSPITAL
# 25 High School Drive, San Vicente West, Urdaneta City, Pangasinan
Tel # 075-568-5563 / 075 -656-2103

WASTE HOLDING AREA