kebijakan ppi8

8/18/2019 KEBIJAKAN PPI8

1/22


2/22

MEMUTUSKAN

Menetap&an 5

Ke4at$ 5 Kep$t$4an Di'e&t$' R$mah Sa&it Pa'$ Re4pi'a Yo!%a&a'ta tentan! &ebi7a&an pela%anan pen


3/22

Kep$t$4an Di'e&t$' RS Pa'$ Re4pi'a

Nomo' 5

Tan!!al 5

KEBIJAKAN PELAYANAN

PENCEGAHAN DAN PENGENDALIAN INFEKSI

RUMAH SAKIT PARU RESPIRA YOGYAKARTA

A. KEBIJAKAN UMUM

1. Pelayanan ruma !a"#$ %# !eluru un#$ &elayanan aru! !elalu %#lan%a!#

%en'an (#n$a "a!#) $#%a" mem*e%a"an !u"u) ra!) a'ama) '+l+n'an) %an

mem&era$#"an mere"a yan' lema %an "uran' men%a&a$ &era$#an ,option

for the poor).

2. Pelayanan ruma !a"#$ %# !eluru un#$ &elayanan aru! !elalu *er+r#en$a!#

&a%a mu$u layanan) "e!elama$an &a!#en) %an "e!elama$an %an "e!ea$an

"er-a ,K/ *a'# &a!#en) "eluar'a %an ma!yara"a$ !er$a "arya0an !e!ua#

%en'an 1#!#) M#!#) %an Tu-uan Ruma Sa"#$ Paru Re!ra Y+'ya"ar$a.

3. Pelayanan ruma !a"#$ %# !eluru un#$ &elayanan aru! !elalu *er2+"u! &a%a

&a!#en , patient centeredness) %en'an mela"!ana"an a"!e! "e &elayanan %an

"+n$#nu#$a! &elayanan) memenu# a" &a!#en %an "eluar'a) a!e!men &a!#en)

&em*er#an &elayanan &a!#en) !er$a mem*er#"an e%u"a!# "e&a%a &a!#en)

"eluar'a %an ma!yara"a$.

4. Pelayanan ruma !a"#$ %#la"!ana"an !elama 34 -am !e$#a& ar#) "e(ual#

*e*era&a un#$ &elayanan $er$en$u.

5. Se$#a& un#$ &elayanan aru! men-alan"an u&aya &en#n'"a$an mu$u melalu#

"e'#a$an Plan-Do-Check-Action (PDCA).

6. Se$#a& un#$ &elayanan aru! men-alan"an "e0a!&a%aan un#5er!al melalu#

"e'#a$an &en(e'aan %an &en'en%al#an #n2e"!# yan' men-an'"au !e$#a&

&elayanan %# ruma !a"#$ %an mel#*a$"an *er*a'a# #n%#5#%u.

7. Ruma !a"#$ mem*er#"an &elayanan $erle*# %aulu $an&a memun'u$ uan'

mu"a.

. Se$#a& mnan un#$ &elayanan aru! mam&u mem*er#"an araan)

men'en%al#"an) men'el+la) %an mem#mn un#$ &elayanan ma!#n'6ma!#n'

un$u" men(a&a# 5#!#6m#!# un#$ &elayanan mau&un 5#!#6m#!# ruma !a"#$.

!. Dalam mela"!ana"an $u'a!nya !e$#a& &e$u'a! ruma !a"#$ 0a-#* mema$u#

"e$en$uan Ke!elama$an %an Ke!ea$an Ker-a ,K/ %en'an mela"u"an u&aya

un$u" men'uran'# %an men'en%al#"an *aaya) re!#"+) men(e'a "e(ela"aan

%an (e%era) %an memel#ara "+n%#!# l#n'"un'an %an "eamanan) $erma!u"

%alam &en''unaan ala$ &el#n%un' %#r# ,APD/.


4/22

1". Semua #n%#5#%u yan' $erl#*a$ %alam &elayanan ruma !a"#$ 0a-#* mela"u"an 7

,enam/ !a!aran Ke!elama$an Pa!#en.

11. Perala$an %# un#$ &elayanan aru! !elalu %#la"u"an &emel#araan %an "al#*ra!#

!e(ara $era$ur !e!ua# "e$en$uan yan' *erla"u %an !elalu %alam "+n%#!# !#a&

&a"a#.

12. Semua &e$u'a! ruma !a"#$ 0a-#* mem#l#"# #-#n8 l#!en!#8 !er$#2#"a!# !e!ua#

%en'an &r+2e!# %an "e$en$uan yan' *erla"u.

13. Se$#a& &e$u'a! ruma !a"#$ aru! *e"er-a !e!ua# !$an%ar &r+2e!#) !$an%ar

"+m&e$en!#) !$an%ar &r+!e%ur +&era!#+nal) e$#"a &r+2e!#) "+%e e$#" ruma !a"#$

%an !emua &era$uran ruma !a"#$ yan' *erla"u.

14. Se$#a& un#$ &elayanan aru! mam&u men'el+la %a$a yan' %a&a$ %#-a%#"an

!e*a'a# !um*er #n2+rma!# %an &en'am*#lan "e&u$u!an *a'# "e&en$#n'an

mana-emen %an &elayanan "e&a%a ma!yara"a$.

15. Se$#a& un#$ &elayanan aru! *eru&aya mem&er+le) men'+la %an

men''una"an #n2+rma!# !e(ara $er#n$e'ra!# yan' %#"+mun#"a!#"an !e(ara

*enar un$u" men#n'"a$"an "e!ea$an &a!#en !er$a "#ner-a ruma !a"#$ *a#"

!e(ara "e!eluruan mau&un #n%#5#%u.

16. Semua un#$ &elayanan 0a-#* mem*ua$ la&+ran ar#an) *ulanan) !eme!$er %an

$aunan "e&a%a mana-emen ruma !a"#$.17. Ruma !a"#$ men-alan"an &r+'ram "e!elama$an &a!#en melalu# 9 ,$u-u/

!$an%ar "e!elama$an &a!#en) %an 9 ,$u-u/ lan'"a menu-u "e!elama$an

&a!#en ruma !a"#$.

1. Ruma !a"#$ Paru Re!ra *u"an Ruma Sa"#$ yan' %#$un-u" un$u" mela"u"an

&elayanan &a!#en %en'an HI18AIDS) !e#n''a &elayanan yan'

%#!elen''ara"an Ruma Sa"#$ Paru Re!ra mel#&u$# &elayanan 1+lun$ary

C+n(el#n' an% Te!$#n' ,1CT/) &elayanan ru-u"an HI1 "e ruma !a"#$ la#n yan'

%# $un-u" melayan# HI18AIDS) %an &enera&an Un#5er!al Pre(au$#+n.

1!. Ruma !a"#$ mela"u"an &enan''ulan'an Tu*er"ul+!a ,TB/ !e!ua# %en'an

&e%+man !$a$e'# DOTS.

2". J#"a &elayanan yan' %#*u$u"an &a!#en $#%a" Ter!e%#a %# ruma !a"#$) ma"a

&a!#en aru! %#ru-u" "e ruma !a"#$ la#n yan' *#!a melayan# !e$ela men%a&a$

&er!e$u-uan &a!#en8 "eluar'a.

21. Ruma !a"#$ men'ar'a# %an memenu# a" &a!#en yan' %#layan#.

22. Seluru "arya0an ruma !a"#$ *er"e0a-#*an men-a'a %an mel#n%un'# raa!#a

me%#! &a!#en yan' %#layan#.

23. Ruma !a"#$ mela"u"an &en'um&ulan) 5al#%a!# %an anal#!#! %a$a *a#" #n$ernal

a$au&un e"!$ernal un$u" &en'em*an'an &elayanan ruma !a"#$.

B. KEBIJAKAN KHUSUS :

1. ORGANISASI PENCEGAHAN dan PENGENDALIAN INFEKSI


5/22

a/ Dalam ran'"a mel#n%un'# &a!#en) &en'un-un' %an &e$u'a! $era%a&

&enularan #n2e"!# %# Ruma Sa"#$) ma"a Ruma Sa"#$ Paru Re!ra

mela"!ana"an Pen(e'aan %an Pen'en%al#an In2e"!# ,PPI/.

*/ A'ar &ela"!anaan PPI $er"++r%#na!# %en'an *a#") D#re"$ur mem*en$u"

K+m#$e Pen(e'aan %an Pen'en%al#an In2e"!# ,KPPI/ !er$a T#m Pen(e'aan

%an Pen'en%al#an In2e"!# ,TPPI/. K+m#$e PPI Ruma Sa"#$ Paru Re!ra

*er$an''un' -a0a* lan'!un' "e&a%a D#re"$ur. T#m PPI *er$an''un' -a0a*

lan'!un' "e&a%a K+m#$e PPI.

(/ K+m#$e %an T#m PPI mem&unya# $u'a!) 2un'!# %an "e0enan'an yan' -ela!

!e!ua# %en'an Pe%+man Mana-er#al Pen(e'aan %an Pen'en%al#an In2e"!#

%# Ruma Sa"#$ %an 2a!#l#$a! "e!ea$an la#nnya yan' %#"eluar"an +le

Kemen$er#an Ke!ea$an Re&u*l#" In%+ne!#a Taun 3:;;.

%/ Pela"!anaan PPI %#"el+la %an %##n$e'ra!#"an an$ara !$ru"$ural %an 2un'!#+nal

%#!emua un#$ %an men-a%# $an''un' -a0a* !eluru !$a2 %an "arya0an.

e/ A'ar "e'#a$an Pen(e'aan %an Pen'en%al#an In2e"!# *er-alan lan(ar) ma"a

Ruma Sa"#$ Paru Re!ra mem#l#"# IPCN ,In2e($#+n Pre5en$#+n an% C+n$r+l

Nur!e/ &urna 0a"$u yan' *er$u'a! men'a0a!# !eluru "e'#a$an &en(e'aan

&en'en%al#an #n2e"!# yan' mel#&u$# 'u'u! $u'a! &era0a$an) IPSRS) Farma!#)

G#


6/22

Mema"a# !arun' $an'an !e*elum &emer#"!aan "l#n#! %an $#n%a"an

#n5a!#2

Menye%#a"an8 mem&er!#a&"an +*a$6+*a$an

Mem&er!#a&"an ma"anan

Mem*er# ma"an &a!#en

Men#n''al"an ruma !a"#$

D#an$ara = &r+!e%ur $er$en$u &a%a &a!#en yan' !ama %#mana $an'an

$er"+n$am#na!# un$u" men'#n%ar# "+n$am#na!# !#lan'

Se$ela =

K+n$a" %en'an &a!#en

Mele&a! !arun' $an'an

Mele&a! ala$ &el#n%un' %#r#

K+n$a" %en'an %ara) (a#ran $u*u) !e"re!#) lu%a) %aa") mun$aan)

ur#ne) "er#n'a$ %an &erala$an yan' %#"e$au# a$au "emun'"#nan

$er"+n$am#na!# %en'an %ara) (a#ran $u*u) !&+$) ur#nal *a#"

men''una"an a$au $#%a" men''una"an !arun' $an'an

Men''una"an $+#le$) menyen$u 8 mela& #%un' %en'an $an'an ,*a$u"8

*er!#n/

Menyen$u l#n'"un'an %# !e"#$ar &a!#en

(. 4 Jen#! "e*er!#an $an'an

Ke*er!#an $an'an !ur'#(al

Ke*er!#an $an'an A!e&$#"

Ke*er!#an $an'an al"++l an%ru*

Ke*er!#an $an'an S+!#al

%. Ke*er!#an $an'an %#la"u"an menuru$ > M+men Ke*er!#an Tan'an ,?HO/=

M+men ; = !e*elum "+n$a" %en'an &a!#en

M+men 3 = !e*elum $#n%a"an a!e&!#!

M+men = !e$ela $er"ena (a#ran $u*u &a!#en

M+men 4 = !e$ela "+n$a" %en'an &a!#en

M+men > = !e$ela "+n$a" %en'an l#n'"un'an !e"#$ar &a!#en

e. 7 lan'"a "e*er!#an $an'an

2. Jen#! "e*er!#an $an'an un$u" !eluru ruan'an8 *a'#an ,"l#n#! @ n+n6"l#n#!/ %# RSParu Re!ra) ya#$u =

Ke*er!#an $an'an %en'an a#r men'al#r %an !a*un ,!+!#al/

Ke*er!#an $an'an %en'an a#r men'al#r %an !a*un an$#!e&$#"

Ke*er!#an $an'an %en'an laru$an *er*aan %a!ar al"++l ,an%ru*/

'. Ke*er!#an $an'an e2e"$#2 =

T#%a" men'ena"an -a! len'an &an-an' !aa$ melayan# &a!#en.


7/22

Ba'# !emua &e$u'a! yan' *er"+n$a" lan'!un' %en'an &a!#en ,"l#n#!#/)

!emua &er#a!an yan' a%a ,m#!alnya= -am $an'an) (#n(#n) 'elan'/ aru!

%#le&a!"an !elama *er$u'a! %an &a%a !aa$ mela"u"an "e*er!#an $an'an.

Ku"u %#-a'a $e$a& &en%e" $#%a" mele*## ; mm) $#%a" men''una"an "u"u

&al!u %an (a$ "u"u.

J#"a $an'an a%a lu"a %#$u$u& %en'an &le!$er "e%a& a#r.

Tu$u&la "ran %en'an !#"u $an'an a$au &u$ar "ran men''una"an an%u"

!e"al# &a"a#8 $#!!u.

Mem*er!#"an $an'an %en'an !a*un (a#r %an a#r men'al#r a&a*#la $an'an

$erl#a$ "+$+r.

Mem*er!#"an $an'an %en'an laru$an *er*aan %a!ar al"++l ,an%ru*/ *#la

$an'an $#%a" $erl#a$ "+$+r %#an$ara $#n%a"an.

Ker#n'"an $an'an men''una"an an%u" !e"al# &a"a#8 $#!!u.

Pa!$#"an $an'an "er#n' !e*elum memula# "e'#a$an8 men'ena"an !arun'

$an'an.

Jan'an menam*a"an !a*un (a#r "e %alam $em&a$nya *#la ma!# a%a #!#nya.

D#!&en!er !a*un aru! %#*er!#"an $erle*# %aulu !e*elum &en'#!#an ulan'.

. Se%#a"an %# !e$#a& ruan'an8 *a'#an =

Area "l#n#! ,area &era0a$an8 &elayanan lan'!un' $era%a& &a!#en/ =

?a!$a2el %en'an a#r yan' men'al#r

Laru$an chlorhe#idine 3 ,#n%#"a!# "e*er!#an $an'an momen 2 dan 3/ =

&+l# ra0a$ -alan) UGD ,area n+n $#n%a"an/) ruan' "e&era0a$an) un#$

&enun-an' me%#" ,ra%#+l+'#) la*+ra$+r#um "l#n#") rea*#l#$a!# me%#"/

Laru$an chlorhe#idine 4 = UGD ,area $#n%a"an/) "amar *e%a) 1K

Sa*un *#a!a ,an%!+a&/ = "amar &a!#en) &+! &era0a$ ,#n%#"a!# "e*er!#an

$an'an momen 1,4,/) $+#le$) %a&ur

Laru$an *er*aan %a!ar al"++l ,an%ru*/ = !e$#a& $em&a$ $#%ur &a!#en %#

area "r#$#! ,UGD/) !e$#a& n$u ma!u" "amar &a!#en) me-a $r+lly $#n%a"an

Area n+n6"l#n#! ,area &elayanan $#%a" lan'!un' $era%a& &a!#en/ =

?a!$a2el %en'an a#r yan' men'al#r

Sa*un *#a!a ,an%!+a&/ = $+#le$) %a&ur) &er"an$+ran) "an$#n) aula

Laru$an chlorhe#idine 3 ,#n%#"a!# "e*er!#an $an'an momen 3/= !an#$a!#)

"amar (u(#) "amar -ena


8/22

#. Mela"u"an m+n#$+r#n' (+m&l#an(e "e*er!#an $an'an %en'an (ara =

Men'u"ur 8 men'+*!er5a!# "e&a$uan "e*er!#an $an'an =

Pe$u'a! "l#n#! !e$#a& 3 m#n''u !e"al# ,ruan' "e&era0a$an) UGD) re"am

me%#") ra%#+l+'#) la*+ra$+r#um) G#


9/22

e. Pr+!e%ur &enun-an' me%#" ,&en'am*#lan %ara) &em*er#an '#


10/22

k. Ruma !a"#$ men-am#n %#la"!ana"annya u&aya &erl#n%un'an %#r# yan' a%e"ua$

*a'# &e$u'a! "e!ea$an %an mere"a yan' *er$u'a! %# $em&a$ &elayanan.

%. ETIKA BAT"K #H&GIENE RESPIRASI$

Ba$u" a%ala me"an#!me &er$aanan $u*u %# !aluran &erna2a!an %an meru&a"an

'e-ala !ua$u &enya"#$ a$au rea"!# $u*u $era%a& #r#$a!# %# $en''+r+"an "arena

a%anya len%#r) ma"anan)%e*u) a!a& %an !e*a'a#nya.

E$#"a *a$u" a%ala (ara &en$#n' un$u" men'en%al#"an &enye*aran #n2e"!# %ar#

!um*ernya. Seluru &e$u'a! %# RS Paru Re!ra Y+'ya"ar$a %an &en'un-un'8

ma!yara"a$ !e"#$ar aru! men%a&a$"an !+!#al#!a!# %an mela"!ana"an &r+!e%ur

(ara *a$u" yan' aman , E$#"a *a$u" / !e!ua# SOP.

Semua &a!#en) &en'un-un') %an &e$u'a! "e!ea$an aru! %#an-ur"an un$u" !elalu

mema$u# e$#"a *a$u" %an "e*er!#an &erna&a!an un$u" men(e'a !e"re!#

&erna&a!an) ya#$u %en'an (ara=

6 Menu$u& #%un' %an mulu$ an%a %en'an men''una"an $#!!ue 8 !a&u $an'an

a$au len'an %alam *a-u.

6 Se'era *uan' $#!!ue yan' !u%a %# &a"a# "e %alam $em&a$ !am&a.

6 Cu(# $an'an %en'an men''una"an a#r *er!# %an !a*un a$au &en(u(#

$an'an *er*a!#! al"++l !e!ua# &r+!e%ur.6 Guna"an !elalu ma!"er *e%a *#la an%a !e%an' *a$u".

6 T#n%a"an &en$#n' #n# aru! !elalu %# la"u"an un$u" men'en%al#"an !um*er

#n2e"!# &+$en!#al.

'. ALAT PELIND"NG DIRI #APD$

D#$a$a &eren(anaan) &enye%#aan) &en''unaan) %an e5alua!#nya +le K+m#$e PPI

RS *er!ama K RS) #n!$ala!# 2arma!# %an *a'#an l+'#!$#" RS.

a. APD %#'una"an *er%a!ar"an &r#n!#& "e0a!&a%aan !$an%ar %an #!+la!# %en'an

!elalu men'u"ur &+$en!# r#!#"+ !&e!#2#" &a%a !e$#a& a"$#5#$a! &elayanan8

$#n%a"an me%#" !e#n''a $e&a$) e2e"$#2 %an e2#!#en.

*. APD !e"al# &a"a# %#!e%#a"an melalu# #n!$ala!# 2arma!#.

(. A%anya (e"l#!$ $#n%a"an yan' men''una"an APD %an "e*er!#an $an'an.

%. APD yan' la#n %#!e%#a"an melalu# un#$ K RS.

e. Ma!"er un$u" ruan' "++r$ a#r *+rne %e!ea!e %en'an ma!"er *e%a ran'"a& 3.

2. T#m K RS mela"u"an m+n#$+r#n' %an au%#$ "e$e&a$an &en''unaan APD

!e*a'a# *aan %alam e5alua!# %an re"+men%a!# &en#n'"a$an e2e"$#5#$a!nya.

(. S"R)EILANS INFEKSI RS #IRS$

D#la"u"an !e(ara !#!$ema$#" a"$#2 +le IPCN ,In2e($#+n Pre5en$#+n C+n$r+l Nur!e

&era0a$ &en'en%al# #n2e"!# &urna 0a"$u/ %an IPCLN ,l#n" nur!e &era0a$

&en'u*un' &en'en%al# #n2e"!#/ un$u" men''am*ar"an $#n'"a$ "e-a%#an *er*a'a#


11/22

&enya"#$ #n2e"!# $ar'e$ !e!ua# Pe%+man Sur5e#lan! In2e"!# Ruma Sa"#$) Kemen"e!

%an &enya"#$ en%em#! %# ruma !a"#$.

a. Mela"u"an !ur5e#len! PPIRS

*. Mela"u"an Anal#!#!) e5alua!# %an re"+men%a!# $#n%a" lan-u$ %a$a #n2e"!#

%#la"u"an T#m PPI RS %# *a0a "++r%#na$+r. D+"$er Penan''un' -a0a* PPI

,IPCO/ un$u" $u-uan &en'en%al#an) mana-emen r#!#"+ %an "e0a!&a%aan

$era%a& "e-a%#an luar *#a!a,KLB/.

(. Pen'en%al#an an'"a IRS men''una"an $ar'e$ !a!aran !eua# &r+'ram PPI.

Sa!aran an'"a IRS %#e5alua!# !e$#a& $aun.

%. Ke-a%#an luar *#a!a IRS %#$e$a&"an +le %#re"$ur RS *er%a!ar"an &er$#m*an'an

T#m PPI RS &a%a a!#l e5alua!# e%em#+l+'#" "e(en%erun'an an'"a IRS

melalu# !ur5e#lan!. Ke(en%erun'an "e-a%#an IRS yan' $eru! meneru!

men#n'"a$ !#'n#2#"an !elama *ulan *er$uru$6$uru$ a$au &en#n'"a$an !#'n#2#"an

an'"a "e-a%#an &a%a !ua$u 0a"$u &en'ama$an $er$en$u %#0a!&a%a# !e*a'a#

KLB. Pen(e'aan %an &en'en%al#an r#!#"+ &enye*aran "e-a%#an yan'

*er&+$en!# men-a%# KLB %#la"u"an !e'era !e(ara !#ner'# melalu# "er-a!ama

l#n$a! un#$8!a$uan "er-a +le T#m PPI RS.

e. La&+ran In2e"!# RS %#!am&a#"an T#m PPI RS "e&a%a D#re"$ur Me%#" %an

Ke&era0a$an !e$#a& *ulan.

*. PENGENDALIAN RESISTENSI ANTIBIOTIKA

a. Pem#l#an $era an$#*#+$#" !e(ara ra!#+nal "e&a%a &a!#en %#%a!ar"an $u-uan %an

#n%#"a!# ,&r+2#la"!#! a$au $era/ !e!ua# a!#l &emer#"!aan "ul$ur %an re!#!$en!#

m#"r+*a) !e#n''a un$u" &en%er#$a &enya"#$ #n2e"!# &erlu %#la"u"an

&emer#"!aan m#"r+*#+l+'# $er!e*u$ *e"er-a !ama %en'an KFT.

*. Ke$e&a$an &em*er#an an$#*#+$#"a a'ar aman *a'# &a!#en mel#&u$# =

Te&a$ #n%#"a!#) +*a$ *enar6*enar %#*u$u"an

Te&a$ &em#l#an +*a$ %en'an &er*an%#n'an *#aya e2e"$#5#$a! yan' *a#"

Te&a$ &a!#en) $#%a" a%a "+n$ra #n%#"a!#) e2e" !amn'# m#n#mal

Te&a$ %+!#!) $e&a$ (ara &em*er#an) $e&a$ %ura!# &ema"a#an

Te&a$ #n2+rma!#) "e&a%a &a!#en %an "eluar'anya

(. Pa!#en 0a-#* %#*er# #n2+rma!# $en$an' &en'+*a$an yan' %#*er#"an %an e2e" yan'

%#$#m*ul"an.

1+. STERILISASI ALAT INSTR"!EN KESEHATAN PASKA PAKAI

D# RS %#la"u"an %en'an 3 (ara ya#$u !e(ara 2#!#"a a$au "#m#a) melalu# $aa&an

&en(u(#an ,$erma!u" &eren%aman %an &em*#la!an/) &en'er#n'an) &en'ema!an)

la*el#n') #n%#"a$+r#!a!#) !$er#l#!a!#) &eny#m&anan) %#!$r#*u!# %##"u$# %en'an


12/22

&eman$auan %an e5alua# &r+!e! !er$a "ual#$a!8mu$u a!#l !$er#l#!a!# !e(ara $er&u!a$

melalu# In!$ala!# Pu!a$ Pelayanan S$er#l#!a!# ,CSSD/ yan' !aa$ #n# *era%a %# IKO.

a. Pemr+!e!an ala$8#n!$rumen &a!"a &a"a# %#l# *er%a!ar"an "r#$er#a ala$.

S$er#l#!a!# %#la"u"an un$u" ala$ "r#$#"al) !$er#l#!a!# a$au %#!#n2e"!# $#n'"a$ $#n''#

,DTT/ %#la"u"an un$u" ala$ !em# "r#$#"al) %#!#n2e"!# $#n'"a$ ren%a un$u" ala$ n+n

"r#$#"al.

*. Kr#$er#a &em#l#an %e!#n2e"$an %#%a!ar# $elaa !e(ara (erma$ $er"a#$ "r#$er#a

mem#l#"# !&e"$rum lua! %en'an %aya *unu "uman yan' $#n''# %en'an

$+"!#!#$a! ren%a) 0a"$u %#!#n2e"!# !#n'"a$) !$a*#l %alam &eny#m&anan) $#%a"

meru!a" *aan %an e2#!#en. Un#$ "er-a yan' *er$an''un' -a0a* $era%a&

&enye%#aan %e!#n2e"$an %an an$#!e&$#" %# RS !e!ua# re"+men%a!# K+m#$e PPI

RS Paru Re!ra Y+'ya"ar$a melalu# #n!$ala!# 2arma!#.

(. In!$ala!# Pu!a$ Pelayanan S$er#l#!a!# ,CSSD/ *er$an''un' -a0a* menyu!un

&an%uan %an &r+!e%ur $e$a&) men'"++r%#na!#"an !er$a mela"u"an m+n#$+r#n'

%an e5alua!# &r+!e! !er$a "ual#$a!8mu$u a!#l !$er#l#!a!# %en'an &er!e$u-uan

K+m#$e PPI RS.

%. Un#$ CSSD mem+n#$+r &ela"!anaan &r+!e! %e"+n$am#na!# %# !e$#a& un#$

men''una"an 2+rm.

1+. PE!AKAIAN "LANG PERALATAN - !ATERIAL SEKALI PAKAI #/n0e e

an0 d/e5e$

Da&a$ %#'una"an "em*al# !e!ua# %en'an re"+men%a!# 0an&fact&r 6nya. Ala$ Me%#!

Se"al# Pa"a# ,AMSP/ %a&a$ %#'una"an ulan' ,reu!e +2 !#n'le u!e %e5#(e!/ !e!ua#

"e*#-a"an RS.

a. AMSP %a&a$ %#&r+!e! !e(ara *enar8 $e&a$ ,ra!#+nal/ %an a!#l !$er#l#!a!# ma!#

e2e"$#2 %an e2#!#en *a#" !e(ara 2#!#" 82un'!#) "ual#$a! !er$a aman %#'una"an *a'#

&a!#en.

*. AMSP !an'a$ %#*u$u"an &en''unaannya) $e$a !ul#$ %#&er+le a$au !an'a$

maal ar'anya.

(. Pemr+!e!an AMSP yan' %#!$er#l"an %an %#'una"an "em*al# aru! melalu#

&r+!e! &en(a$a$an %an &en'a0a!an mu$u %# *a'#an CSSD.

%. AMSP yan' n+n !$er#l %#la"u"an &en'a0a!an mu$u %en'an mel#a$ !e(ara

5#!ual %an 2un'!# %ar# ala$ 8 *aan.

e. Da2$ar AMSP yan' a"an %#'una"an "em*al# %#$en$u"an +le RS.

2. A%anya 2+rm %a2$ar &erala$an ala$ !#n'le u!e yan' %# re6u!e.

'. A%anya 2+rm %a2$ar m+n#$+r#n' alar !#n'le u!e yan' %#re6u!e.

11. PENGENDALIAN LINGK"NGAN RS

Mel#&u$# &enyea$an a#r) &en'en%al#an !eran''a %an *#na$an' &en''an''u)

&enyea$an ruan' %an *an'unan) &eman$auan #'#ene !an#$a!# ma"anan)


13/22

&eman$auan &enyea$an l#nen) %#!#n2e"!# &ermu"aan8 u%ara8 lan$a#) &en'el+laan

l#m*a (a#r8 l#m*a B8 l#m*a &a%a$ me%#!8n+n me%#! %#"el+la +le In!$ala!#

San#$a!# L#n'"un'an RS ,ISLRS/ %an Su* Ba'#an Ruma Tan''a *e"er-a!ama

%en'an a" "e$#'a) *er"++r%#na!# %en'an T#m PPI RS) !e#n''a aman *a'#

l#n'"un'an.

a. Pen'el+laan l#m*a aru! mem&era$#"an &r#n!#& !e*a'a# *er#"u$ =

Semua l#m*a *ere!#"+ $#n''# aru! %#*er# la*el8 $an%a yan' -ela!.

?a%a8 (+n$a#ner %#*er# ala! "an$+n' &la!$#( %en'an 0arna = "un#n' un$u"

l#m*a #n2e"!#u! @ B) mera un$u" l#m*a ra%#+a"$#2) #$am un$u" l#m*a

n+n me%#!8 %+me!$#"a.

L#m*a $#%a" *+le %#*#ar"an a$au %#!#m&an 34 -am.

Kan$+n' &la!$#( $em&a$ l#m*a $#%a" %##!# $erlalu &enu , (u"u& 84/.

?a%a 8 (+n$a#ner aru! $er$u$u&) $aan *+(+r) $#%a" *er"ara$) mu%a

%#"+!+n'"an a$au %#an'"a$) mu%a %#*er!#"an %an *era%a %#$em&a$ yan'

$erl#n%un'# *#na$an' a$au !eran''a.

*. L#m*a *en%a $a-am aru! %#"um&ul"an %alam !a$u 0a%a an$# *+(+r %an

$aan $u!u"an ,!a2e$y *+/) $an&a mem&era$#"an $er"+n$am#na!# a$au $#%a".

(. Jarum %an !yr#n'e aru! %#ma!u""an "e %alam Sa2e$y *+ .

%. Pen'an'"u$an l#m*a aru! men''una"an $r+l# yan' $er$u$u&. Pen'an'"u$an

%#la"u"an 3 "al#. A&a*#la aru! men''una"an l#2$ aru! %en'an l#2$

$er!en%#r#8RAM.

e. Pem*uan'an a$au &emu!naan l#m*a me%#! &a%a$ aru! %#la"u"an %# $em&a$

&en'el+laan !am&a me%#! %alam al #n# Ruma Sa"#$ *e"er-a!ama %en'an

a" "e$#'a.

2. Pe$u'a! yan' menan'an# l#m*a aru! men'una"an APD !e&er$# !arun'

$an'an "u!u!) ma!"er) !e&a$u *++$) a&r+n) &el#n%un' ma$a) %an *#la &erlu

elm.

'. Pr#n!#& me$+%e &em*er!#an ruan' &era0a$an %an l#n'"un'an) &em#l#an

*aan %e!#n2e"$an) (ara &eny#a&an %an &en''unaannya %#la"!ana"an

*er%a!ar"an $elaa &an#$#a PPI RS un$u" men(a&a# e2e"$#5#$a! yan' $#n''#.

12. PENGELOLAAN LINEN

a. Jen#! l#nen %# RS Paru Re!ra %#"ual#2#"a!#"an men-a%# l#nen *er!#) l#nen "+$+r

#n2e"!#u!) l#nen "+$+r n+n #n2e"!#u!.

*. Un$u" men(e'a "+n$am#na!#) &en'an'"u$an l#nen men''una"an "an$+n' l#nen

yan' *er*e%a) l#nen "+$+r %en'an "an$+n' l#nen *er0arna #$am %an l#nen "+$+r

#n2e"!#u! %en'an "an$+n' l#nen "un#n'.

(. Pen(e'aan "+n$am#na!# l#n'"un'an mau&un &a%a &e$u'a! %#la"u"an %en'an

%e!#n2e"!# "ere$a l#nen) &en'e&elan8 %#!#n2e"!# lan$a#) #m&lemen$a!# &ra"$#"


14/22

"e*er!#an $an'an) &en''unaan ala$ &el#n%un' %#r# ,APD/ !e!ua# &+$en!# re!#"+

!elama *e"er-a.

13. PENGELOLAAN !AKANAN

Pen'el+laan ma"anan %# #n!$ala!# '#


15/22

(. Pemer#"!aan "e!ea$an *er"ala *a'# "arya0an8 &er!+nel Ruma Sa"#$

!e"uran'6"uran'nya ; ,!a$u/ $aun.

1. PENDIDIKAN dan PELATIHAN PENCEGAHAN dan PENGENDALIAN INFEKSI

RS

D#ren(ana"an %an %#la"!ana"an !e(ara &er#+%#" %an *er"e!#nam*un'an +le

*a'#an Pen%#%#"an %an Pela$#an ,DIKLAT/ *e"er-a!ama %en'an K+m#$e PPI RS

un$u" men-am#n !e$#a& &e$u'a! yan' *era%a %an *e"er-a %# RS memaam# %an

mam&u mela"!ana"an &r+'ram PPI RS ) "u!u!nya "e0a!&a%aan !$an%ar %an

"e0a!&a%aan *er*a!#! $ran!m#!#.

a. Seluru SDM *aru %# RS 0a-#* men'#"u$# &r+'ram +r#en$a!#) $erma!u" ma$er#

PPIRS.

*. Se$#a& a%a maa!#!0a yan' a"an &ra"$e" aru! %#*er#a"an ma$er# +r#en$a!#

PPIRS.

(. M+n#$+r#n' %an e5alua!# a!#l &en%#%#"an %an &ela$#an %#la"u"an +le *a'#an

SDM *er!ama K+m#$e PPI RS !e!ua# "e$en$uan yan' *erla"u !e*a'a# %a!ar

&eren(anaan &r+'ram !elan-u$nya.

%. Seluru !$a22 %#%#%#" $en$an' &en'el+laan #n2e"!#u!.

1%. PENDIDIKAN PENCEGAHAN dan PENGENDALIAN INFEKSI DIBERIKAN

"NT"K SETIAP PASIEN

Un$u" &a!#en ra0a$ #na& %#!am&a#"an +le &era0a$ !aa$ +r#en$a!# &a!#en *aru

ma!u") mel#&u$# "e*er!#an $an'an) e$#"a *a$u" %an "e$er$#*an mem*uan' !am&a.

1'. PENGKA6IAN RISIKO INFEKSI PADA KONSTR"KSI - RENO)ASI d/ RS

a. Se*elum mela"u"an "+n$ru"!# a$au ren+5a!# *an'unan %#la"u"an anal#!#!

$era%a& "ual#$a! u%ara) &er!yara$an u$#l#!a!#) "e*#!#n'an) 'e$aran %an &r+!e%ur emer'en!#.

*. Se$#a& "+n!$ru"!# mau&un ren+5a!# *an'unan yan' %#la"u"an %# RS aru!

men'u$ama"an "e!elama$an &a!#en) &en'un-un' %an &e$u'a! *er%a!ar"an

&r#n!#&6&r#n!#& &en(e'aan %an &en'en%al#an #n2e"!#.

(. Pen'"a-#an r#!#"+ #n2e"!# %#*ua$ *er%a!ar"an %ar# &an%uan In2e($#+n C+n$r+l R#!"

A!!e!men$ ,ICRA/.

%. T#m Pen(e'aan %an Pen'en%al#an In2e"!# Ruma Sa"#$ ,KPPI RS/ mela"u"an

&en'"a-#an r#!#"+ #n2e"!# %an $#n%a" lan-u$ *er"+la*+ra!# %en'an *a'#an

&emel#araan %an K RS.

1(. PENGG"NAAN CAIRAN DESINFEKTAN

a. Pr+!e! %e!#n2e"!# ala$ %a&a$ %#"a$e'+r#"an men-a%#=


16/22

Perala$an Kr#$#!8 r#!#"+ $#n''#= a%ala &erala$an me%#! yan' ma!u" "e%alam

-ar#n'an $u*u !$er#l a$au !#r"ula!# %ara. C+n$+ #!n$rumen *e%a) "a$e$er

#n$ra5ena) "a$e$er -an$un'. Pen'el+laannya %en'an (ara !$er#l#!a!#.

Perala$an !em#"r#$#!8 r#!#"+ !e%an'= a%ala &erala$an yan' "+n$a" %en'an

mem*rana mu"+!a $u*u. Pa%a &erala$an !em#"r#$#!) &r+!e! !$er#l#!a!#

%#!aran"an namun $#%a" mu$la") -a%# *#!a %#la"u"an %#!#n2e"!# $#n'"a$ $#n''#.

Perala$an N+n"r#$#!8 re!#"+ ren%a= a%ala &erala$an yan' "+n$a" %en'an

&ermu"aan "ul#$ u$u (+n$+= $en!#me$er) !$e$+!"+&) l#nen) ala$ ma"an)

lan$a#) &era*+$) $em&a$ $#%ur. Un$u" -en#! &erala$an #n# %a&a$ %#'una"an

%#!#n2e"!# $#n'"a$ !e%an' !am&a# $#n'"a$ ren%a.

*. D#!#n2e"!# l#n'"un'an ruma !a"#$

Permu"aan l#n'"un'an = lan$a#) %#n%#n') %an &ermu"aan me-a) $r+lly

%#%#!en2e"!# %en'an %e$er'en ne$ral.

L#n'"un'an yan' $er(emar %ara a$au (a#ran $u*u la#nnya %#*er!#"an

%en'an %e!#n2e"$an $#n'"a$ menen'a.

(. Pen''unaan %#!#n2e"$an %# ruan' #n2e"!# ,menular/ %an Area "r#$#!

Un$u" men'e&el8mem*er!#"an lan$a# %an 0( men''una"an (re+l#n

Un$u" area yan' !er#n' %#!en$u ,H#' $+u( area/ men''una"an

%#!#n2e"$an Ly!+l ;=;:: ,&ermu"aan l+'am/) Cl+r#ne :.:> ,&ermu"aan

*u"an l+'am/

Un$u" area yan' -aran' %#!en$u ,N+n H#' $+u( area/ men''una"an

!a*un PH ne$ral

%. Pen''unaan %#!#n2e"$an %# area *anya" $um&aan %ara8(a#ran $u*u

men''una"an %#!#n2e"$an Cl+r#ne :.>

Ca/an de/n7e89an an0 d/0na8an d/ RS Pa Re:/a &o0a8a9aN+. I!# Mer" Pen''unaan

;. I!+&r+&yl) e$#l al"++l Al"++l 9:) !+2$aman An$#!e&$#" "ul#$

3. Cl+re#%#ne 3 A(e$r+n An$#!e&$#" "e*er!#an

ruan' &era0a$an

Cl+re#%#ne 4 Cu$#!+2$ An$#!e&$#" "ul#$

"e*er!#an $an'an

%aera "r#$#!

Pr+5#%+ne I+%#n 9)> Be$a%#ne !+lu$#+n An$#!e&$#" "ul#$ %an lu"a

+&era!#

Cl+r#n By(l#ne De!#n2e"$an $um&aan

%ara %an (a#ran $u*u

la#nnya

Mul$# Dru' Re!#!$en

Or'an#!m

Glu$eral%ey%e )4 S$eran#+! 3 H#' le5el %e!#n2e"$an


17/22

S$a*#me%

Pr+&an+l) *#&en+l

3.:'

Pr#ma!e&$ An$#!e&$#" "ul#$ "amar

*e%a

E$an+l Ly!+l L+0 le5el %e!#n2e"$an

Cl+reu%#ne

%#'lu(+na$e !+lu$#+n

De!man+l an%ru* An$#!e&$#" "ul#$

;:. Ben


18/22

e. Pa!#en) "eluar'a) %an &en'un-un' yan' %#ra0a$ %# RS Paru Re!ra aru!

men$aa$# &era$uran yan' a%a %# RS Paru Re!ra !e!ua# %en'an &era$uran $a$a

$er$#* &a!#en.

2. Bu"u Pe%+man &en(e'aan %an &en'en%al#an #n2e"!# %# ruma !a"#$ %an

2a!#l#$a! la#nya $aun 3:;; = $en$an' "e*er!#an $an'an %an &en''unaan Ala$

Pel#n%un' D#r# , APD / %# 2a!#l#$a! "e!ea$an.

'. Pa!#en %a&a$ men'#n'a$"an &e$u'a! "e!ea$an ,D+"$er) Pera0a$) F#!#+$era)

Pe"arya) G#


19/22

Men(a$a$ !e$#a& "e-a%#an #n2e"!# %# ruan'an !e!ua# &r+!e%ur Sur5e#lan!

In2e"!# Ruma Sa"#$

Men(a$a$ !e$#a& "e-a%#an #n2e"!# %# ruan'an !e!ua# &r+!e%ur Sur5e#lan!

In2e"!# Ruma Sa"#$.

Ber"++r%#na!# %en'an IPCLN %an Ke&ala ruan'an !er$a %+"$er yan'

*er$an''un' -a0a* menan'an# &a!#en) un$u" mela"u"an 5er#2#"a!#

%#a'n+!#! #n2e"!# ruma !a"#$) &ene'a"an %#a'n+!#! IRS %an

men'"+n2#rma!# !e*a'a# "a!u! KLB. Sela#n #$u -u'a %#la"u"an #n5e!$#'a!#

$era%a& "emun'"#nan !um*er &enularan) (ara &enularan %an

"emun'"#nan &enye*arannya) !er$a a!&e" la#n yan' %#&erlu"an un$u"

&enan''ulan'an a$au memu$u!"an ran$a# &enularan.

Ber"++r%#na!# %en'an Ba'#an La*+ra$+r#um un$u" mela"u"an=

S0a* ruan'8ala$ yan' %#%u'a $er"+n$am#na!# *a"$er#.

Pen'am*#lan *aan %ar# *er*a'a# l+"a!# $er!an'"a !um*er #n2e"!#

un$u" %#*#a""an %an an$#*#+'ram.

Pema!an'an la*el %# $em&a$ &enam&un'an *aan &emer#"!aan

la*+ra$+r#um &a!#en &enya"#$ menular. La*el *er$ul#!"an A0a! Baan

Menular

Ber"++r%#na!# %en'an !eluru &er!+n#l %# *a'#an $er"a#$ un$u" mem*er#"an

"lar#2#"a!#6"lar#2#"a!# &er#al yan' $er"a#$ %en'an KLB) m#!alnya &ela"!anaan

Pr+!e%ur Te$a& !e(ara *enar.

'. A&a*#la a!#l #n5e!$#'a!# meny#m&ul"an $ela $er-a%# KLB) ma"a T#m PPIRS

mene$a&"an !$a$u! !#a'a *en(ana KLB %an mela&+r"an "e&a%a mnan RS.

. Un$u" menan''ulan'# KLB K+m#$e PPIRS *er"++r%#na!# %en'an Pelayanan

Me%#") Pan#$#a K RS) La*+ra$+r#um) Farma!#) San#$a!#) CSSD) G#


20/22

A&a*#la %#&erlu"an men'u!ul"an "e&a%a D#re"$ur U$ama un$u" men'#!+la!#

ruan'an a$au men'#!+la!# &a!#en *er!an'"u$an yan' %#an''a& $er(emar

+le #n2e"!#.

Men'a0a!# "e$a$ &enera&an Ke0a!&a%aan S$an%ar.

Ruan'an yan' $er-a%# KLB aru! %#%#!#n2e"!#.

". T#m PPIRS mela"u"an %+"umen$a!# $en$an' "e-a%#an %an $#n%a"an yan' $ela

%#am*#l $era%a& %a$a a$au #n2+rma!# KLB.

l. T#m PPIRS $eru! mela"u"an m+n#$+r#n' %an e5alua!# !am&a# KLB *era!#l

%#a$a!#.

m. S$a$u! KLB 0a-#* %#la&+r"an "e %#na! "e!ea$an !e$em&a$.

n. T#m PPI menya$a"an KLB !ele!a# -#"a %ua "al# ma!a #n"u*a!# $er&an-an' $#%a"

%#$emu"an "a!u! *aru.

22. PE!ERIKSAAN K"LT"R dan SWAB !IKROBIOLOGI DI LINGK"NGAN R"!AH

SAKIT

a. S0a* %#la"u"an 3 "al# !e$aun un$u" area "r#$#! ,


21/22

A!&e" *u%aya %an a'ama aru! %#&era$#"an. Keluar'a &a!#en yan' #n'#n

mel#a$ -ena


22/22

%. Mala"u"an !0a* ruan'an %an u-# "ual#$a! u%ara) "u!u!nya %# area *er#!#"+

$#n''# !e*elum ruan'an %#'una"an.

2%. PERBANDINGAN DATA DASAR INFEKSI #BENCH!ARKING$

a. Per*an%#n'an %a$a %a!ar #n2e"!# %#la"u"an !e(ara #n$ernal ,an$ar un#$/ mau&un

e"!$ernal ,%en'an Ruma Sa"#$ la#n yan' !e-en#! a$au %en'an &ra"$#" $er*a#" 8

*u"$# #lm#a yan' %#a"u#/.

*. Per*an%#n'an %a$a %a!ar #n2e"!# %#la"u"an +le $#m Pen(e'aan %an

Pen'en%al#an In2e"!# !e$#a& *ulan ,*en(mar"#n' #n$ernal/ %an !e$aun !e"al#

,*en(mar"#n' e"!$ernal/.

(. Ruma !a"#$ yan' men-a%# m#$ra %alam *en(mar"#n' e"!$ernal a%ala ruma

!a"#$ l+"al 8 na!#+nal yan' !e$ara mau&un +r'an#!a!# "e!ea$an #n$erna!#+nal

yan' $er*u"$# mem#l#"# &ra"$#" $er*a#" !e(ara #lm#a.

%. Ha!#l &er*an%#n'an %#anal#!a) %#$#n%a"lan-u$# %an %#la&+r"an "e&a%a D#re"!#

!e(ara $er$ul#! %alam *en$u" la&+ran *ulanan PPI ,*en(mar"#n' #n$ernal/ %an

la&+ran !ur5e#lan! $aunan ,*en(mar"#n' e"!$ernal/.

e. Ha!#l &er*an%#n'an %a$a %a!ar #n2e"!# #n$ernal mau&un e"!$ernal

%#"++r%#na!#"an %alam ra&a$ $#m &+"-a PPI !e$#a& *ulan !e"al#.

2'. RISK !ANAGE!ENT PPIa. Se$#a& 'u'u! $u'a! mela"u"an &en'"a-#an r#!" PPI %# ma!#n'6ma!#n' ruan'an.*. Pen'"a-#an %#%a!ar"an &a%a mana'emen$ r#!".(. D#la"u"an anal#!#! r#!" mana'emen$ PPI +le IPCN *er!ama T#m PPI.%. T#m PPI mene$a&"an a!#l anal#! un$u" %#-a%#"an &r+'ram "er-a PPIRS &an$#

raayu.e. R#!" PPI -u'a $er"a#$ "e-a%#an KLB.

Y+'ya"ar$a) 3:;7

Ke$ua T#m PPI

Ruma Sa"#$ Paru Re!ra

Y+'ya"ar$a

,/

kebijakan ppi8

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