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OMEGA HOSPITALS

MLA COLONY,

BANJARA HILLS, HYDERABAD

HIC MANUAL

Manual Con!ol In"o!#a$on%

Manual T$l& HOSPITAL INFECTION CONTROL MANUAL

Manual Co'& OH()AD(HIC*MNL

+&!$on Nu#-&! 1.0

Manual Sau Approved

Iu& Da& 10th March 2014

E""&.$/& Da& 11th March 2014

Da& o" N& R&/$& Annually

R&"&!&n.& NABH 3rd edition

Manual R&/$&%

+&!$on A#&n'#&n

0.1 & 0.2 • e! "ocu#entation & Procedure$ changed.

• Header and ooter changed.

1.0 inal approved copy

Con!oll&' Co3 D$!$-u$on R&.o!'%Sl*

No*

Con!oll&' Co3

Do.u#&n No*

No* o"

Co$&

Iu&' o R&.&$/&! S$4n*

PREPARED BY: CHECKED & REVIEWED

BY:

APPROVED BY:

Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)

Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)

Dr. W.I. KIRAN(MEDICALDIRECTOR)

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.

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1 01(02 01 HIC D&a!#&n

2 01%02 01 Nu!$n4 D&a!#&n


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RELEASE AUTHORISATION

hi$ update H'( Manual i$ relea$ed under the authority of

D!* *I* 7$!an

)#ega Ho$pital$* Hydera+ad and i$ the property of

OMEGA HOSPITALS

MLA COLONY, BANJARA HILLS, HYDERABAD

ANDHRA PRADESH, INDIA

CONTENTS


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Page 8 of 260

,'-NA/ %

NAM % DR* *I* 7IRAN

",'-NA')N % MEDICAL DIRECTOR

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Sl* No* TITLE Pa4& No*1 'N/)"(')N

2 'N(')N ()N/) P/)-/AM 10

3 'N(')N ()N/) ()MM' 12

3.1 H'/A/(H 13

3.2 N(')N 14

3.3 /N( ) M'N- 14

4 'N(')N ()N/) AM 15

4.1 N(')N 15

5 /P)/'N- ) ()MMN' A('/" 'N(')N, ) -)6

HAH AH)/'',

27

5.1 /P)/'N- MH)"))- 27

5.2 N)''AB "',A,, 28

7 6A/'), H'(( ,/6'AN( 29

8 N),)()M'A 'N(')N 31

8.1 ("( -'"'N, 31

8.2 'N(')N P/6N')N MH)"))- 34

9 ,AN"A/" P/(A')N, 44

9.1 ,AN"A/" P/(A')N, 'N ('N'(A AB)/A)/

/AN,,')N ,/6'(,

49

/()MMN"A')N, )/ PA'N, :N);N ) HA/B)/ B))"

B)/N PAH)-N,

53

.1 'N,/(')N )/ ;A/", 53

.1.1 HAN" H-'N & -)6'N- 54


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.2 (A/ ) ,,M, AN" 'N";'N- "6'(, 7410 ',)A')N P)'(', & P/)("/, 81

11 6',')/, P)'( 8

12 'N(')N ()N/) 'N ,P('A (A/ N',%H'-H /',: A/A, 90

12.1 'N(')N ()N/) P/A('( 'N ) 91

12.2 'NN,'6 (A/ N', 99

13 ()(')N AN" /AN,P)/A')N ) ,P('MN, 4

14 ,A 'N AB)/A)/ 8

15 'N(" )/ ,)'" 'NN MANA-MN 9

17 HAN"'N- ) H'6 P),''6, PA'N, 100

17.1 N/,'N- (A/ 101

17.2 H),:P'N- ;'H H'6 PA'N, 103

18 (,," /(A P)'( 105

19 N-'N/'N- ()N/) 108

1 MP) HAH 111

20 P/))() ) ,(H" )/ A('6 ,/6'AN( ,;AB 117

21 'N(')N ()N/) P/A('(, 'N AMBAN( 119

22 ,HA/P "',P),A 121

23 M"'(A')N 'N

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28.2 'N/M"'A /',: (A-)/ 15028.3 ); /',: (A-)/ 151

29 )B/A: MANA-MN 153

2 /N( )/ P"A'N- 'N(')N ()N/) MANA 158

30 A' 'N"'(A)/ 159

31 /()/", H'( "PA/MN 15


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1* INTRODUCTION

'nfection control include$ the prevention and #anage#ent of infection through the application

of re$earch +a$ed >no!ledge to practice$ that include? $tandard precaution$* deconta#ination*

!a$te #anage#ent* $urveillance and audit.

he overall ai# of thi$ docu#ent i$ to provide evidence +a$ed infor#ation in the prevention and

control of infection in thi$ ho$pital. o fulfill thi$ ai# the ho$pital infection control co##ittee

ha$ +een for#ed that !ill loo> after the infection control need$ of the ho$pital.

't i$ relevant to all $taff including doctor$* nur$e$* other clinical profe$$ional$ and #anager$

!or>ing at )#ega Ho$pital* Hydera+ad to help fulfill their legal and profe$$ional o+ligation$

!ith regard to +oth co##unica+le di$ea$e$ and infection control.

The manual identifies the high risk areas of the hospital.

It outlines the methods of surveillance in the identified high risk areas.

• It focuses on adherence to standard precautions and isolation policies & procedures.

"i$infection and $terili@ation practice$.

:itchen $anitation and food handling i$$ue$.

ngineering control$ to prevent infection.

Pu!o&

1* o #aintain $tandard$ in infection control #ea$ure$ and #ini#i@e ho$pital acuired

infection$ in patient$ and $taff.

2* o define policy and procedure regarding no$oco#ial infection$ at )#ega Ho$pital*

Hydera+ad.

5* o fra#e anti+iotic policy and #onitor it$ adherence +y the pre$cri+ing authoritie$.


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S.o&

All inpatient and outpatient area$ including diagno$tic facilitie$

R&on$-$l$$&

Ho$pital ;ide

2* INFECTION CONTROL PROGRAM

he infection (ontrol Progra# i$ a #ethod of preventing ho$pital=acuired infection$.

OBJECTI+ES

i. o develop !ritten policie$ and procedure$ for a$eptic practice$ in the ho$pital

ii. o i#ple#ent the$e procedure$ in $pecific $ituation$ and area$.

iii. o provide $urveillance for no$oco#ial infection.

iv. o revie! and analy$e the infection$ that occur in order to ta>e corrective $tep$.

v. o develop corrective #ea$ure$ to control* prevent or #ini#i@e the ri$> of no$oco#ial

infection$.

vi. ,tatutory provi$ion$ !ith regard to +io=#edical !a$te #anage#ent are co#plied !ith.

vii. o train the $taff and $upport e#ployee health.

Pu!o&

i. o provide #ai#u# protection* again$t infection* for patient$* per$onnel* and vi$itor$


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!hile in health care $etting.

ii. o en$ure co#pliance !ith $tandard$ for infection control.

iii. o en$ure continuou$ feed+ac> of infor#ation related to the prevention and control of

infection* e$pecially co##unica+le infection$* to phy$ician$* denti$t$ and other

healthcare provider$.

iv. o reco##end ri$> reduction practice$ +y integrating infection control principle$ into

all $tandard$ of practice.

Pol$.$&

i. here $hall +e an active infection control progra#.

ii. ,taff $hall +e #ade a!are of infection control policie$ and procedure$ and their role in

$urveillance* prevention and control.

iii. here $hall +e $pecific depart#ental infection control policie$ and procedure$ !ritten

for all ho$pital depart#ent$.

iv. he prevention and control #ethod$ and $urveillance $trategie$ $hall +e evaluated for

effectivene$$ throughout Ho$pital.

5* INFECTION CONTROL COMMITTEE

O!4an$=a$on o" $n"&.$on .on!ol .o##$&&


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he '(( i$ re$pon$i+le for day=to=day infection control activitie$ !ithin the ho$pital. 't ha$ the

follo!ing #e#+er$

()%NABH ())/"'NA)/%

M"'(A "irector%(HA'/MAN H'((

(on$ultant Micro+iologi$t & H'()=H'(( ())/"'NA)/

(linician fro# different $pecialtie$ CH)" ,urgical oncology and H)" Medical

oncologyD.

(on$ultant Anae$theti$t

uality #anager.

Nur$ing 'n=charge

:itchen 'n=charge %"ietician

(,,"'n=charge

Hou$e>eepingManager

'nfection (ontrol Nur$e

5*1 O!4ano4!a# o! H&$!a!.>3 "o! HICC%


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() % NABH (oordinator

(hairper$on H'(( %Medical "irector

uality H)"

Micro+iologi$t % H'(( (oordinator

Nur$ing ,uperintendant

H'(N

'nput$ fro# all !ard$* inpatient$ and hou$e >eeping & >itchen dept$.*etc.

5*2 FUNCTIONS

he H'(( carrie$ out the follo!ing function$?

• "evelop$ infection control policie$ and procedure$ in ho$pital


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•

he '(( act$ a$ a $ource of eperti$e on #atter$ relating to infection control? n$ure that corrective action and control #ea$ure$ are ta>en in the event of out+rea>$ of

infection.

Monitor$ functional co#pliance !ith infection control policie$ and procedure$.

"evelop$ educational progra# a+out infection control policie$ and practice$ for ho$pital

$taff.

/evie!$ ho$pital infection control policie$ and procedure$ every t!o year$.

"e$ign$ and deter#ine$ the type of $urveillance and reporting progra#$.

A$$ign$ re$pon$i+ility to an individual or a depart#ent to carry out action$ or

reco##endation$.

Advi$e$ on $pecific area$ of hygiene and infection control li>e '(* (,,"* ventilation*

operating theatre$* etc in High ri$> !ard$ and >itchen food $afety policy etc.

'nvolve$ the H'(( tea# for any H'( progra##e i#ple#entation.

;or> after e#ployee health policy and vaccination progra##e.

5*5 FRE)UENCY OF MEETING

he infection control co##ittee #eet$ regularly Conce in A #onthD.

he head operation appoint$ the chairper$on* infection control co##ittee* and the

#e#+er$ of the infection control co##ittee and their alternate$.

Head of the depart#ent notifie$ the infection control co##ittee* of any change of

repre$entative$ or alternate$.


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8* HIC TEAM

't i$ a $u+co##ittee of the infection control co##ittee #eant for field i#ple#entation of the

variou$ H'( activitie$ and for corrective action$ i#ple#entation$.

't ta>e$ care of ho$pital environ#ental engineering and #aintenance engineering and pu+lic

health #ea$ure$ and al$o high ri$> !ard care and vi$itorE$ policy care etc and BM;

#anage#ent* $afe !ater $upply* !ater tan> cleaning* A%c cleaning* /)/ plant #aintenance$ etc.

't$ #e#+er$ co#pri$e $o#e of the #e#+er$ of H'(( along !ith BM; 'n=charge* +io#edical

engineer* ) incharge* (,," incharge* High ri$> !ard$ in=charge* aundry in=charge* uality

depart#ent* Nur$ing $uperintendant* Hou$e>eeping in=charge and $upervi$or$* ,ecurity* ront

office incharge in )P"* /adiology and a+ depart#ent in=charge$* Medical record$ incharge*

,tore$ and purcha$e #anager*:itchen incharge* food $afety co##ittee #e#+er or dietician*

Phy$iotherapi$t* etc.etc.

H'(( (o##ittee$E function$ and /e$pon$i+ilitie$?

8*1 HICC FUNCTIONS%?$* CEO ( NABH .oo!'$nao!(

Approve$ the no#inated chairper$on and other #e#+er of H'(( co##ittee and tea#.

He repre$ent$ the #anage#ent.

Authori$e$ H'(( for corrective action$ to +e ta>en for control and prevention of HA'

infection$.

He $anction$ infection control +udget and #onitor variou$ activitie$ and acade#ic

progra##e$.

He per$onally #onitor$ the $urveillance activitie$ thro uality depart#ent and M" etc.


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And advi$e$ accordingly.

$$* C>a$!#an, HICC ( M&'$.al D$!&.o!(

(onven$ #eeting of the infection control co##ittee not le$$ than once in t!o #onthlyF

#ore often if nece$$ary.

'f an urgent #atter ari$e$* a$$e#+le$ a$ #any #e#+er$ of infection control co##ittee a$

po$$i+le* +ut not le$$ than the follo!ing?

Hi# % her$elf* Here vie$ reco##endation$ fro# preventive and control #e#+er$.

he chief of the concerned depart#ent $ervice and di$cu$$ !ith H'() and other

depart#ent and H'(( tea# to $olve any H'( related pro+le#.

,erve$ a$ a per#anent core #e#+er of the infection control co##ittee.

(oordinate$ the field=!ide i#ple#entation of the Ho$pital infection control progra#.

,upervi$e$ the accurate collection of infection control data and participation in the

analy$i$ of the dataF prepare$ $u##ary report for the infection control co##ittee.

'nfor#$ Ho$pital $taff of ne! develop#ent$ in infection control and act$ a$ a

profe$$ional re$ource regarding $tate=of=the=art develop#ent.

(onduct$ pro$pective prevalence $tudie$ periodically to evaluate the effectivene$$ of the

$urveillance $y$te# to >eep all H'( rate$ !ithin +ench#ar> level$. ,erve$ on or con$ult !ith co##ittee in=charge of evaluating procedure$ or euip#ent*

!hich ha$ an i#pact on infection control activitie$.

(oordinate$ and a$$i$t$ !ith e#ployee orientation and in=$ervice education progra#

related to infection control

(olla+orate$ !ith all depart#ent$ in the develop#ent* revie! and revi$ion of infection

control #anual.

Act$ a$ a con$ultant regarding infection control i$$ue$.

$$$* HICC Co?o!'$nao! (Conulan M$.!o-$olo4$(HICO


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(onvene$ #eeting of the infection control co##ittee and H'( tea# al$o?

"oe$ detailed trac>ing analy$i$ report for any out+rea> % HA' !ithin ho$pital and di$cu$$e$

in H'(( #eeting for corrective action and i#ple#entation.

a>e$ active part in $urveillance activitie$ and H'( progra##e i#ple#entation along !ith

H'(N.

Advi$e$ and report$ to the head operation on all #atter$ relating to infection control.

,upervi$e$ the infection control nur$e and N, for infection control activitie$ fir H'((.

"evelop$ and i#prove infection control policie$ and procedure$ for Ho$pital.

)rgani@e the infection control co##ittee #eeting$ during any out+rea> or e#ergency.

'#ple#ent $urveillance activitie$ and audit the >itchen* (,," etc.

Provide adeuate infection control training for the $taff a$ part of (N and (M

progra##e.

Monitor$ all the function$ of H'(N and help$ her !ith valua+le advice$ red. H'( topic$

and #onitor$ high ri$> !ard$ function$ and i$olation care etc.

'#ple#ent$ all corrective action$ thro H'( tea# for control of HA'G, in ho$pital.

$/* )ual$3 Mana4&! ( HOD

hey !ill +e ta>ing active part in pa$$ive and active $urveillance progra# #eat for H'((in order to prevent and control of HA'.

hey !ill +e collecting data and #onitoring the activitie$ of the depart#ent and >eeping

the record$.

hey !ill +e reporting the updation and develop#ent$ a+out the H'(( activitie$ to the

()%M".

hey !ill +e coordinating H'(( activitie$ along !ith other depart#ent activitie$.

Monitoring the (N % (M teaching progra#$ and al$o !ard training progra##e to

hou$e>eeping $taff and !ard nur$e$ +y H'(N and nur$ing depart#ent* etc.

a>e active role in induction training HB6 vaccination progra##e$ and e#ployee health

policy* food $afety protocol$ i#ple#entation etc.


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/* In"&.$on Con!ol Nu!& @ICN

he '(N prove$ a$$i$tance to the Micro+iologi$t for the prevention and control of infection

in the ho$pital.

"etect$ and inve$tigate$ $u$pected no$oco#ial infection$ on a $y$te#atic and current +a$i$*

and collect$ relevant infor#ation fro# !ard$ and $taff and hou$e>eeping $taff.

'nve$tigate$ all $ignificant infection control pro+le#$* i#ple#ent$ all H'((

reco#endation$ and +ring$ all H'( related $!a+$ and $a#ple$ to la+.

Pro#pt$ the initiation to infor# for Notification of infectiou$ "i$ea$e$* !hen indicated and

di$tri+ute$ #inute$ to all !ard$.

'nitiate$ follo!=up culture$ on patient$ and contact$ !hen indicated* and reco##end$

other $tudie$ to confir# or rule out a $u$pected infection and ta>e part proactively in H'((

$urveillance progra##e

A$$i$t$ in the develop#ent and the annual revie! and revi$ion of infection control policie$

and procedure$ and #onitor their i#ple#entation and #aintain$ all H'( related record$

and infor#$ uality depart#ent % Nur$ing $uperindant etc.

'n$pect the environ#ent and o+$erve$ per$onnel activitie$ for the purpo$e of detecting

po$$i+le infection ha@ard$ and evaluating co#pliance !ith $tandard$ $et +y the infection

control co##ittee* doe$ daily and !ee>ly round$ and report$ to #icro+iologi$t and hicc

coordinator and in$truct$* the hou$e>eeping $taff al$o.

/outinely #onitor$ co#pliance !ith Ho$pital policy on i$olation of patient$ !ith

co##unity=acuired or no$oco#ial infection$* !hich reuire $pecial care and #onitor$

+undle care and fu#igation in high ri$> area$.

Al$o #onitor$ >itchen hygiene and food handler$ $creening* N,' victi#$ care* i$olation

care* All high ri$> !ard$* BM; central collection area* infected linen policy and vi$it$ -<

#ulticlave co#pany and laundry al$o periodically.

a>e$ part activity in internal audit activitie$ and reive! #eeting$ $u+#it$ #onthly report$


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loo> after Ho$pital e#ployee health progra##e* #aintain food and !ater analy$i$ report$.

(oordinate$ and a$$i$t$ !ith e#ployee orientation and in=$ervice education and al$o

ta>e$up progra#$ related to infection control training to +y !ard cleaner$* to nur$e$ and

hou$e>eeping $taff cla$$roo# and !ard$ training$ al$o to the#..

ollo!=up of all infection$ in Ho$pital per$onnel and a$$i$t$ in the develop#ent of the

Ho$pital #ployee Health progra# and HB6 vaccinatic progra#$ and M/,A carrier$

$creenigprogra##e etc.

(olla+orate$ !ith the clinician and nur$e$ a+out the routine #onitoring of the unit$* !hich

are particularly vulnera+le to infection pro+le#$.

;or>$ !ith the Micro+iologi$t$ and nur$ing $uperindant and uality depart#ent etc* to

identify* analy$i$ and deter#ination of H'( indicator$ and it$ report di$$e#ination to !ard$

and a$$i$t$ in out+rea> inve$tigation$ ,),.

/$* Nu!$n4 Sa"" an' Nu!$n4 In?.>a!4&

Adhere to the infection control policie$ and procedure$ and #aintain !ard hygeine.

:no!$ the nur$ing function$ e$$ential to the prevention* recognition and #anage#ent of

infection and #onitor hou$e>eeping $taff function$ in !ard. Adhere to #ea$ure$ of infection control* including hand !a$hing and i$olation techniue$

and u$e of PP and i#ple#ent a$eptic precaution$ in +arrier nur$ing.

/eport any $ign$ of infection to the attending phy$ician%$urgeon and record the finding$ in

the nur$eG$ note$ and the# alert$ any cro$$ infection$.

Alert infection control nur$e of $u$pected or confir#ed infection$ or N,' or out+rea>$ etc.

'n$titute i$olation or precautionary #ea$ure$ !hen an infectiou$ di$ea$e i$ $u$pected F

infor# the attending phy$ician%$urgeon a$ $oon a$ po$$i+le.

Participate* in orientation and continuing education progra# for infection control.

Adhere to the Ho$pital #ployee Health progra# and HB6 vaccination progra##e.

Nur$ing in=chargecoordinate$ !ith uality depart#ent and H'() and H'(N and M" etc.


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/$$* M$.!o-$olo43 La-o!ao!3 an' En/$!on#&n H&al> '&a!#&n

Provide la+oratory $upport for infection control activitie$ e$pecially in #icro+iologi$t la+

and perfor# $erology HA6* H(6* HB6 $creening$ etc.

Proce$$e$ all $urveillance $!a+$ and report$ to concerned depart#ent a$ per protocol$ and

$chedule$.

:itchen $!a+$ and $a#ple$ and M/,A $creening i$ al$o done for $taff.

Maintenance$ depart#ent loo>$ after A%c* plu#+ing $anitation !or>$* $e!age plant* !ater

plant* /)/ plant* $afe !ater $upplie$ and other environ#ental engineering control$ and

food $afety rule$ etc.

/$$$* Hou&&&$n4 '&a!#&n%

o carry out la+ inve$tigation$ of H'(( $urveillance and develop guideline$for tran$fer

and handling of la+ $a#ple$.

o revie! anti+iogra# and provide $u##ary report of prevalence of re$i$tance* to detect

carrier a#ong $taff doe$ environ#ental $urveillance !hen needful.

,pecial a+out for M/,A* 6/ etc.

o coordinate !ith '() % 'nfection (ontrol nur$e.

o provide input$ to develop policie$ for appropriate cleaning techniue$

o provide input$ to procedure* freuency* agent$ u$ed* etc.* for each type

of roo#* fro# highly conta#inated to the #o$t clean* and en$uring that the$e practice$

are follo!ed


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o provide input$ develop policie$ for collection* tran$port and di$po$al ofdifferent type$

of !a$te Ce.g. container$* freuencyD.

o en$ure that liuid $oap and paper to!el di$pen$er$ are repleni$hed regularly

o infor# the #aintenance $ervice of any +uilding pro+le#$ reuiring repair?(rac>$*

defect$ in the $anitary or electrical euip#ent* etc.

o care for flo!er$ and plant$ !ith in ho$pital pre#i$e$.

o carryout pe$t control Cin$ect$* rodent$D activitie$.

o provide input$ to develop policie$ for the collection and tran$port of dirty linen.

o provide input$ to develop criteria for $election of $ite of laundary $ervice$ for

en$uring appropriate flo! of linen* $eparation of cleanI and dirtyI area$ and

reco##ending !a$hing condition$Ce.g. te#perature* durationD

o provide input$ to en$uring $afety of laundary conta#inated !ith potential pathogen$.

$* Rol& o" Cl$n$.$an

a>ing all a$eptic precaution$ in patient care* try to #ini#i@e no$oco#ial infection rate.

ollo!ing procedure$ of freuent hand !a$h* $upporting and i#ple#enting all policie$

of H'(( tea#.

Protecting their patient fro# infection$* co#plying !ith anti+iotic and di$infection policy

and notify co##unica+le di$ea$e$.

Advi$ing patient$* vi$itor$ & $taff on techniue$ and preventive care infection$ and other

tran$#i$$ion of infection$.


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* Rol& o" CSSD

T>& !&on$-$l$$& o" >& .&n!al &!$l$=a$on &!/$.& a!&%

o clean* deconta#inate* te$t* prepare for u$e* $terili@e* and $tore a$eptically all $terile

ho$pital uip#ent & linen.

o !or> in colla+oration !ith the 'nfection (ontrol (o##ittee and other ho$pital progra#$

to develop and #onitor policie$ on cleaning and deconta#ination of?

/eu$a+le euip#ent.

(onta#inated euip#ent including

o over$ee the u$e of different #ethod$ J (he#ical and +acteriological indicator$ to #onitor the $terili@ation proce$$ of autoclave and ) $terili@ation .reproce$$ing of $ingle u$e

di$po$a+le ite#$ are $terili@ed in ) $terili@er$e$p. the pla$tic and ru++er #aterial tu+e$

and catheter$ etc

o en$ure technical #aintenance of the euip#ent according to #anufacturer$G

reco##endation$ the ite#$ $upplied +y (,," aredre$$ing $et$ and pad$and pac>$*

&in$tru#ent$ $et$. ;e have to chec> for integrity or tear$ or +rea>age$ in pac>age$

o report any defect to ad#ini$tration* #aintenance* infection control and other appropriate

per$onnel. ;henever HB6 )/ H(6 )/ H'6 po$itive pt$. u$edin$tru#ent$ are $ent it i$

handled !ith $pl. (are and $oa>ed in cide for 1 hr and rin$ed in hypochlorite al$o.

o #aintain co#plete record$ of each autoclave run* and en$ure long=ter# availa+ility of

record$ ite#$ are received and after cleaning they are pac>ed and $terili@ed .the recall

regi$ter i$ al$o #aintained !henever there i$ +rea>do!n or !henever control$ are not

!or>ing .in ca$e of in$tallation of ne! autoclave 3 con$ecutive $pore te$t$ are o+tained !hen

running an load and it i$ not u$ed till all are negative.

o collect or have collected* at regular interval$* all outdated $terile unit the $terile $torage

roo# i$ al$o cleaned !ith +acillocid and po$tfu#igation $!a+$ are al$o $ent* in order to

#aintain $terile at#o$phere there.


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o co##unicate* a$ needed* !ith the 'nfection (ontrol (o##ittee*the nur$ing $ervice* the

operation theatre .recall policy i$applied for inappropriate pac>ing &loading* poor$tea#*

in$ufficient ti#e $terili@er #alfunction$* +iological indicator$ not $ho!ing correct re$ult$*if

pac>$ are open or +lood $tained +ecau$e of i#proper cleaning etc.

$* ROLE OF PHARMACIST

o #aintain all drug record$ including for anti+iotic$*high ri$> #edicine$ & narcotic

drug$** ) $tore and di$pen$e vaccine$ *di$infectant$ *anti$eptic$ and di$tilled !ater and

'6 fluid$ etc .

he $torage condition$ are to +e #onitored .vi@. te#perature* light*hu#idity etc and to

#aintain phar#acopeia of drug$

o re$trict high end anti+iotic u$age$ and it$ $ale at counter.they are proactive #e#+er$

of anti+iotic u$age and drug$ co##ittee and al$o H'(( co##ittee.H are the #o$t

proactive #e#+er$ of phar#aceutical and drug$ co##ittee .

$$* MANAGEMENT ROLE IN HIC PROGRAMME%

he #anage#ent #a>e$ availa+le all re$ource$ !hich are needful for conductivity H'(

progra#* and H'( $urveillance at ho$pital. hey allot $eparate +udget for H'( co##ittee

progra# i#ple#entation$. All the $upplie$ for PP and $pillage >it $upply and phar#acy

and drug $upplie$ are adeuate.

he organi@ation ta>e proactive role in adeuate training of $taff ho#e >eeping $taff and

doctor$ C"M)E$D +y periodically cleaned. )ur H/ depart#ent (onduct$ induction training

cla$$ for ne! $taff. )ur organi@ation are al$o encourage our la+ doctor$ and $taff to attend

once in year at lea$tcertificate training progra# for H'(NE,* "octor$ and con$ultant$ and in


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charge$ etc* +y their training $chedule hi$ i$ the #anage#ent thi$ i$ done a$ part of uality

i#ple#ent progra#$.

he $tandard$ are #aintained and #onitored in variou$ depart#ent$ and regular #eeting are

al$o here +y #anage#ent in uality co##ittee* $afety co##ittee* and H'( co##ittee.

he feed+ac> data i$ analy@ed and di$cu$$ed for further i#portant !hich ha$ to +e

$u$tained. he uality progra# of $ervice $hould +e integrated into organi@ational uality

plan.

he organi@ation defen$e$ it$ $anctioned event$. And #onitor$ all progra##e

i#ple#entation$ .thy are the ulti#ate $upervi$ory +ody for thi$ H'( progra##e

$$$* ROLE OF HOSPITAL MANAGEMENT IN HICC ACTI+ITIES%

$ta+li$h #ultidi$ciplinary infection control co##ittee and coordinate activitie$ of

H'(( and infection control tea# and the clinician$ and nur$ing or H: $taff etc

'dentify and allocate adeuate re$ource$ fro# annual +udget for i#ple#entation of

variou$ H'(( progra#$ and policie$.

o en$ure all (M* (N activitie$ for it$ $taff* H: $taff etc

o revie! uality indicator$ of H'(( and encourage $urveillance activitie$.

o i#ple#ent induction training for all ne! e#ployee and eplain ai#* o+Kective$ and

#i$$ion of the ho$pital through H/ dept.

o en$ure adeuate $upplie$ of glove$* #a$>$* di$infectant$ etc

o en$ure e#ployee health progra#$ and policie$* and to #onitor the correct $pending of H'( +udget for it$ purpo$e$.


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o en$ure pre=and po$t epo$ure prophylai$ progra#$. to notify the reporta+le di$ea$e$

a$ per given li$t to the -HM( pu+lic health authoritie$.

o di$cu$$ and i#ple#ent corrective #ea$ure$ during H'(( #eeting$. And do trac>ing

analy$i$ in ca$e of any out+rea>$. hey $hould al$o encourage the $taff and dr$ to attend

any acade#ic $u##it$ to update the#$elve$.

hey $hould allocate $eparate +udgetary provi$ion$ to H'( dept and $ee that it i$ $pent

properly for active and pa$$ive $urveillance$ and $ua$tainance$ and #onitoring of

variou$ H'(( activitie$.


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9* REPORTING OF NOTIFIABLE DISEASES AND ANY EPIDEMICS, CASES TO

GO+T HEALTH AUTHORITIES% @AT GHMC

Ho$pital $hould have the policy to reporta+le di$ea$e$ to the local health authoritie$. or certain

infection$* even one ca$e #ay +e of etraordinary i#portance in the contet of pre$ent day

epide#iology. very $uch ca$e ha$ to +e con$idered $ignificant +y the pu+lic health authoritie$

and i##ediate $tep$ ta>en to find further ca$e$ and to prevent further infection.

"engue and cholera are ea#ple$.

(hildhood vaccine preventa+le di$ea$e$ are reporta+le $ince a ca$e i$ evidence for

inadeuate.i##uni@ation in the area of re$idence of children !ith $uch di$ea$e. or the a+ove

rea$on$* reporta+le di$ea$e $hould +e infor#ed !ithout delay and !ith co#plete re$idential

addre$$ to the health authoritie$.

Acuired i##une deficiency $yndro#e and hu#an i##unodeficiency 6iru$ infection HB6 %

H(6 infection$ have recently +een included in the li$t of reporta+le di$ea$e +y govern#ent

directive. Ho!ever reporting i$ only for $tati$tical purpo$e$ of deter#ining the ti#e=trend of

prevalence. Moreover* $trict confidentiality of the identity of the per$on i$ to +e #aintained*hence the report !ill not contain the identity of the individual.

9*1 REPORTING METHODOLOGY

Although the #edical $upt. i$ ulti#ately re$pon$i+le for reporting* the reporting proce$$ +egin$

fro# the ti#e of diagno$i$* either at the +ed$ide or in the la+oratory. hu$ the flo! of

infor#ation !ill +e fro# the clinician$ and #icro+iologi$t$* to infection (ontrol Nur$e* to the

M/" depart#ent and Medical "irector to pu+lic health authoritie$. C-HM(D. )#ega ho$pital$

$ent the notifia+le di$ea$e$ to the -HM( on #onthly +a$i$.


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No$"$a-l& '$&a&

(holera

(ere+ro=$pinal fever

"iphtheria

"enguefever

nteric ever

-a$tro=enteriti$ and cholera

Hepatiti$

epto$piro$i$

Mea$le$

Plague

Paralytic Polio#yeliti$

/a+ie$

,carlet ever

u+erculo$i$

epro$y

yphu$

6iral encephaliti$

'nfective Hepatiti$ CA*B*(D

yphoid

;henever $putu# AB po$itive open ca$e of B i$ detected at our ho$pital or if any pt!ith $!ine or +ird flu $y#pto#$ are co#ing acro$$ at our ho$pital 'P%)P then


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i##ediately they are referred to che$t ho$pital%)-H%-H etc for further #anage#ent and

do#iciliary treat#ent a$ our$ i$ +a$ically only an $uper$peciality oncology ho$pital !ith

$carecely vi$iting phy$ician $ervice$ here .N) 'N('), AN" ()MMN'(AB

"',A," P, A/ A"M'" H/ .

In .a& o" an &$'$.%

1. Acute ga$troenteriti$

2. 6iral hepatiti$

Ho$pital $taff infor#$ the infection control tea# i##ediately !hen the follo!ing

)rgani$#%condition$ are confir#ed

• M/,A= P),''6 $ite of coloni@ation%infection

• Beta= Hae#olytic ,treptococcu$ -roup B

• P$eudo#ona$ aerugino$aJM"/ $train

•

Acineto+acter $pp.

• nterococci Jvanco#ycin re$i$tant

• Any other unco##on or unu$ual organi$#$

• Hepatiti$ B and (

• Hu#an i##unodeficiency 6iru$ CH'6D

• A$ our$ ho$pital i$ an +a$ically oncology ho$pital !e do not ad#it a+ove $aid

co##unica+le di$ea$e$ ca$e$ and !e refer the# to )-H%-H%/)P'(A M"''N

6/ ho$pital . he only notifia+le di$ea$e$ !hich !e inti#ate to -HM( authoritie$ i$

a+out HB6* H(6* H'6 (A,, )N M)NH;',.


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6* +ARIOUS HICC SUR+EILLANCE @BOTH PASSI+E AND ACTI+E TYPES

ACTI+ITIES UNDER TA7EN AT OMEGA HOSPITALS HYDERABAD

;e do ) nviron#ent ,urveillance +y po$t fu#igation ,!a+$ and )pen $ettle plate

#ethod$.P,'('" ,P/A 'N H),P'A ', M)N')/" /-A/ and $pillageincidence$ are recorded and docu#ented.

(,," ,terile $torage roo# po$t fu#igation $!a+$ are done periodically .BM;

policy *'N(" 'NN P)'( AN" ', "',P),A and BM; $egregation i$

#onitored daily and $harp$ policy and $afe inKection practice$ are al$o #onitored clo$ely and

advice$ given to $taff,), .

) ,terili@ed ite#$ $!a+$ ta>en for each lot for #icro+ial gro!th if any AN" B'))-'(A

()N/), )/ A)(A6 AN" ) ,/'',/ A/ A,) ,"

P/')"'(A and /(A P)'( M)N')/".

All device tip$ are al$o $ent routinely for culture and $en$itivity for ,urveillance purpo$e. &)/

()N'/MA')N ) ()MM)N N),)()M'A 'N(')N,. ;e al$o #onitor !hether all

nur$e$ and H: $taff are follo!ing all univer$al $tandard precaution$ for +arrier nur$ing and

a$eptic care of pt$ to prevent cro$$ infection$ and no$oco#ial infection$ etc 'N ;A/", and

H'-H /',: A/A,.

"i$infectant fro# ) and (a$ualty J)P or ,urgical ;ard$ & #inor ) and dre$$ing roo# are

al$o $ent periodically for culture and ,en$itivity. H u$e of $avlon in ho$pital i$ di$couraged

H H'(N vi$it$ BM; co#pany $ite t!ice or thrice in year and laundry and linen out$ourcing


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area once in uarterly or $o to note do!n their $tandard protocol$ and their i#prove#ent.

All the High ri$> !ard$ including i$olation roo# etc Po$t fu#igation ,!a+$ are al$o

proce$$ed.After N,' $erology te$ting i$ done for victi# and pt$al$o and HB6 6accination

progra##e a#ong $taff i$ al$o #onitored #onthly!i$e . N,' inKury file i$ al$o #aintained

.A H'( indicator rate$ data are docu#ented and di$$e#inated to all !ard$ and uality dept

.H'(( #inute$ of #onthly #eeting are prepared and corrective action$ !ill + di$cu$$ed for it$

effective i#ple#entation$a>e.

After Hand ;a$h or Hand /u+ ,!a+$ are ta>en fro# Hand to a$$e$$ the effective

i#ple#entation of it$ procedural $tep$. Hand !a$h audit$ are regularly conducted #onthly +y

$tudying it$ co#pliance a#ong (on$ultant$* "M)$ and Nur$e$ and Hou$e>eeping $taff etc

A%( ilter$ ,!a+$ are $ent periodically fro# high ri$> !ard$ and ) to $ee any #old or aero+ic

$pore +earer$E conta#ination$. Bed $ore$ healing a#ong inpatient$ i$ recorded & alpha +ed$ u$e

i$ noted.

(M* (N* and Health education raining and induction training etcprogra##e$ are regularly

conducted for "uty doctor$ Nur$e$ and H: ,taff and ,trict (o#pliance i$ advi$ed for their

attendance purpo$e$. H /egular cla$$roo# training and daily !ard !i$e inten$ive training i$

al$o given.

,!a+$ fro# No$e and hroat and Hand$ are periodically ta>en for all ,taff e$pecially fro# High

/i$> !ard$ and food handler$ for M/,A carrier$E detection. "aily round$ are done for

#onitoring of H'( $urveillance activitie$ .Notifia+le di$ea$e$ are reported to -HM( authoritie$E

#onthly !i$e through M/" dept.

;ater ,a#ple$ & food $a#ple$ are te$ted every #onth in NAB Accreditated la+ fro# all

$ource$ and /)/ !ater plant function$ are #onitored.

"uring rac>ing Analy$i$ report $tudy variou$ $a#ple$ are te$ted to detect the po$$i+ility of


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No$oco#ial infection$. And to detect any out+rea>$ etc corrective action$ !ill + underta>en to

prevent any $uch recurrence$ .(H)/HL'"'N anti$eptic i$ u$ed for '6 $ite preparation for

preventing Peripheral thro#+ophle+iti$ and (AB,' infection$ .,i#ilarly Bundle care and

preventive care #ethod$ are advi$ed to all $taff to prevent 6AP%HAP%,'%,,'%(AB,' etc

No$oco#ial infection$ .

H H'-H end anti+iotic audit i$ done every #onth and it$ u$e #onitored and culture $a#ple$

$ending i$ encouraged to Ku$tify our anti+iotic pre$cription$ etc "e$calation of anti+iotic$ to

lo!er level after $eeing anti+iogra# report$ or $topping of $uch anti+iotic$ after clinical

i#prove#ent i$ advi$ed after it$ u$e for 5 to 8 day$ for critical care pt$ e$pecially in order to

control and prevent gro!ing Bacterial /e$i$tance in Ho$pital.

:itchen !or>er$ are $creened $erologically and they are periodically te$ted for any carrier $tate

and they revi$ited daily for a$$e$$ing area hygiene and per$onal hygiene of food

handler$.!or>ing $urface area$ are te$ted +y $!a+$ !ee>ly to a$$e$$ any +acterial

conta#ination$ etc . Micro+iologi$t i$ a regular #e#+er of food $afety co##ittee al$o.

6*1 PROTOCOL OF SCHEDULE FOR ACTI+E SUR+IELLANCE SAB

1. ,'(* M'( very

#onthCAccording to

patient$ occupancyD

,!a+ fro# variou$ du$t

$ettling area$. ,!a+ fro#

dre$$ing trolleyE$*

patientE$ +ed* floor$ and

euip#ent$* ta+le$ &

A%(. filter$

Aero+ic +acteria

2 (entral ,terile

,upply depart#ent.C(,,"D

;ee>ly onceCpo$t

fu#igationD

(he#ical chec> tu+e*

Biological indicator$fro# each cycle. ,ettle

Aero+ic +acteria


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plate count & ,!a+$fro# (,," every !ee>

3 )peration heatre?

' & ''

After every

fu#igation

!ice a #onth

,!a+$ fro# operating

a+le$* light$* rolley$*

,uction #achine* A%(

filter$ & anae$the$iatrolly

& floor etc.

,!a+ fro#

variou$ du$t

$etting areaE$ a$

a+ove. or

Bacteria Ca$

a+oveD

4. )peration theatre$

3 &4

After every

fu#igation

,ettle plate count #ethod

& $!a+$ are ta>en fro#

different article$ & $ite$ n

A/)B'(

)/-AN',M,

5. "i$infectant$ 'f tur+id %every

#onth

,!a+$ ta>en fro# the

di$infectant

P$eudo#ona$

7. Nur$ing $taff A// )/

H'-H /',: ;A/"

,A

,!a+$ are ta>en fro#

hand$ of nur$ing $taff and

no$tril$ rando#ly.

M/,A*

,!a+$ ta>en ta+le top$ at

all nur$ing $tation

$*

M/,A

8. "rin>ing !ater &

/)/ !ater $ent

periodically to

NAB accreditated

la+

very #onth (ooler$ and $upplier$ Pre$ence of coli

for# and 6(

Cotal via+le

countD


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9 -eneral !ard uarterly ,!a+$ are $entor aero+ic )rgani$#$

:* NOSOCOMIAL INFECTIONS

• A no$oco#ial infection i$ one that i$ acuired in a ho$pital or health care facility and !a$

notincu+ating at the t=i#e of ad#i$$ion. or #o$t +acterial infection$ the on$et of $y#pto#$

#ore than 49=82 hr$ after ad#i$$ion and !ithin 10day$ after ho$pital di$charge are defined

a$ no$oco#ial or ho$pital acuired. ,urgical $ite infection$ are con$idered no$oco#ial if the

infection occur$ !ithin 30day$ after the operative procedure or !ithin 1year if a device or

foreign #aterial i$ i#planted.

he ho$pital ta>e$ action to prevent or reduce the ri$>$ of ho$pital a$$ociated infection$ CHA'D

he organi@ation #onitor$ urinary tract infection$ of all indoor patient$.

he organi@ation #onitor$ re$piratory tract infection$

he organi@ation #onitor$ intra va$cular device infection$

he organi@ation #onitor$ $urgical $ite infection$

:*1 CDC Gu$'&l$n&%

Center for Disease Control has given case definitions for various nosocomial infections

I* Su!4$.al $& oun' In"&.$on

a* Su&!"$.$al In.$$on u!4$.al $& $n"&.$on%

Infection occurs within 30 days after operation and involves skin or

Sucutaneous tissues of incision site.


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$* Purulent drainage fro# $uperficial inci$ion !ith or !ithout la+oratory confir#ation.

$$* )rgani$#$ i$olated fro# a$eptically collected fluid or ti$$ue fro# $uperficial

inci$ion.

$$$* At lea$t one of the $ign$ and $y#pto#$ of infection=paint%tenderne$$* locali@ed

$!elling and redne$$.

-* '&& $n.$$on u!4$.al $& $n"&.$on%

'nfection occur$ !ithin 30day$ after the operation if no i#plant i$ left in place or !ithin one year

if i#plant i$ in place and infection appear$ to +e related to the operation. 'nfection involve$ deep

$oft ti$$ue$ Ceg? facial and #u$cle layer$D of the inci$ion.

1. Purulent drainage fro# deep inci$ion +ut not fro# organ%$pace co#ponent of the $urgical

$ite.

2. A deep inci$ion $pontaneou$ly dehi$ce$ or i$ deli+erately opened +y a $urgeon !hen the

patient ha$ at lea$t one of the follo!ing $ign$ and $y#pto#$=fever39 deg (el$iu$*

locali@ed pain or tenderne$$ unle$$ culture of the inci$ion i$ negative.

3. An a+$ce$$ or other evidence of infection involving the deep inci$ion i$ found on direct

ea#ination* during re=operation or +y hi$topathologic or radiologic ea#ination.

.* O!4an ( a.& u!4$.al $& $n"&.$on%

i. Purulent drainage fro# a drain placed through a $ta+ !ound into the organ or $pace.

ii. )rgani$#$ i$olated fro# an a$eptically o+tained culture of fluid or ti$$ue in the organ

or $pace. ;ithin one #onth period after operation .

iii. An a+$ce$$ or other evidence of infection involving organ or $pace on direct

ea#ination* during re operation or +y hi$topathologic or radiologic ea#ination.for

ca$e$ of pro$thetic $urgerie$ it i$ one year cutoff period it i$ confir#ed +y pu$ c%$ or

+y $urgeon$ opinion . )/ P, ;'H P/),H,', )/ 'MPAN, the ti#e li#it


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for ,,' ta>en i$ one year period

II* I+ Ca>&&! R&la&' Bloo' S!&a# In"&.$on

i. ,y$te#ic $ign$ of infection

ii. (oloni@ation of #ore than 102c fu in uantitative or 15 colonie$ in ualitative

culture of the catheter.

iii. '$olation of $a#e organi$# fro# catheter and fro# a concurrent +lood culture of a

patient !ith $ep$i$ $yndro#e. **along !ith $%$ of infla##ation at the $ite of central

cannula !ih di$charge .

III* Noo.o#$al Pn&u#on$a(+AP(HAP

i. Ne! or progre$$ing pul#onary infiltrate* fever* leucocyto$i$ and purulent tracheal

$ecretion$. **for ventilated pt$ only after 2 to 3 day$ of devicie in$ertion .

ii. (linical evaluation plu$ po$itive uantitative culture$ of endotracheal

a$pirate%P,B%BA and #icro$copic ea#ination of recovered cell$ fro# fluid.

iii. HAP i$ de$cri+ed for pt$ !ih na$o or oroga$tric intu+ation$ !ith a$piration

pneu#onia develop#ent after 2 to 3 day$ of ad#i$$ion .

I+* Bloo' S!&a# In"&.$on(&$

$* Blood culture po$itive for a +acteriu#%fungu$ that i$ o+tained in a patient #ore

than 49 hr$ after +eing ad#itted to the ho$pital.

$$* (linical $ep$i$* fever39 deg ( hyperten$ion and oliguria.focu$ of infection #ay

or #ay not +e pre$ent at the ti#e of ad#i$$ion .


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+* Ca>&&! ao.$a&' U!$na!3 T!a. In"&.$on

a. (linical $ing$ and $y#pto#$ of ' !ith a po$itive urine culture !ith $ignificant

+acteriuria and #icro$copy after 2 day$ of catheteri@ation for tho$e !o develop $%$ of

' .

+. A count #ore than 105 cfu%#l can indicate a clinically $ignificant +acteriuria in

catheteri@ed patient$.

:*2 INFECTION PRE+ENTION METHODOLOGY% /a!$ou -un'l& .a!& !&/&n$/&

.o#on&n !a&4$& a!& .$!.ula&' o all a"" &&.$all3 "!o# SICU (MICU &. o

>a $" "ollo&' >&!& .an -& lo&!&' $n.$'&n.& o" u.> .o##on noo.o#$al $n"&.$on

alo4&>&! *#o!&o/&! an .>&.l$ $ alo !&a!&' "o! /a!$ou noo.o#$al $n"&.$on a

an #on$o!$n4 !o.& *>& o>&! noo.o#$al $n"&.$on >$.> o..u! on /&!3 #all

.al& a!& -&' o!& '&/&lo#&n 'u!$n4 $na$&n a3 a >o$al ,I+ l$n& >&!a3

.o#l$.a$on , &. >$.> a!& oo !a!& $n $n.$'&n.& *#o o" >&& $n"&.$on .an -&

!&/&n&' -3 "ollo$n4 >an' a> an' -3 u& o" PPE ETC BARREIR NURSING

TECHNI)UES ETC

P!&/&n$on an' #on$o!$n4 o" CAUTI

'. Appropriate rinary (atheter $e

A. 'n$ert catheter$ only for appropriate indication$* and leave in place only a$ long a$

needed.1. Mini#i@e urinary catheter u$e and duration of u$e in all patient$* particularly tho$e at


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higher ri$> for (A' or #ortality fro# catheteri@ation.

2. $e urinary catheter$ in operative patient$ only a$ nece$$ary* rather than routinely.

3. or operative patient$ !ho have an indication for an ind!elling catheter* re#ove the

catheter a$ $oon a$ po$$i+le po$toperatively* prefera+ly !ithin 24hour$* unle$$ there

are appropriate indication$ for continued u$e.

B. (on$ider u$ing alternative$ to ind!elling urethral catheteri@ation in $elected patient$

!hen appropriate.

1. (on$ider u$ing eternal catheter$ a$ an alternative to ind!elling urethral catheter$ in

cooperative #ale patient$ !ithout urinary retention or +ladder outlet o+$truction.

2. (on$ider alternative$ to chronic ind!elling catheter$* $uch a$ inter#ittent

catheteri@ation* in $pinal cord inKury patient$.

3. 'nter#ittent catheteri@ation i$ prefera+le to ind!elling urethral or $uprapu+ic

catheter$ in patient$ !ith +ladder e#ptying dy$function.

''. Proper echniue$ for rinary (atheter 'n$ertion

a. Perfor# hand hygiene i##ediately +efore and after in$ertion or any #anipulation of the

catheter device or $ite.

+. n$ure that only properly trained per$on$ !ho >no! the correct techniue of a$eptic

catheter in$ertion and #aintenance are given thi$ re$pon$i+ility.

c. 'n the acute care ho$pital $etting* in$ert urinary catheter$ u$ing a$eptic techniue and

$terile euip#ent.

1. $e $terile glove$* drape* $ponge$* an appropriate anti$eptic or $terile $olution for


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periurethral cleaning* and a $ingle=u$e pac>et of lu+ricant Kelly for in$ertion.

2. /outine u$e of anti$eptic lu+ricant$ i$ not nece$$ary.

d. 'n the non=acute care $etting* clean Ci.e.* non=$terileD techniue for inter#ittent

catheteri@ation i$ an accepta+le and #ore practical alternative to $terile techniue for

patient$ reuiring chronic inter#ittent catheteri@ation.

e. Properly $ecure ind!elling catheter$ after in$ertion to prevent #ove#ent and urethral

raction

:*5 A!o!$a& $n"!a!u.u!& "o! !&/&n$n4 CAUTI

Proper echniue$ for rinary (atheter Maintenance

A. ollo!ing a$eptic in$ertion of the urinary catheter* #aintain a clo$ed drainage $y$te#

1. 'f +rea>$ in a$eptic techniue* di$connection* or lea>age occur* replace the catheter

and collecting $y$te# u$ing a$eptic techniue and $terile euip#ent.

2. (on$ider u$ing urinary catheter $y$te#$ !ith preconnected* $ealed catheteru+ing

Kunction$.

B. Maintain uno+$tructed urine flo!.

:eep the catheter and collecting tu+e free fro# >in>ing.

:eep the collecting +ag +elo! the level of the +ladder at all ti#e$. "o not re$t the

+ag on the floor.

#pty the collecting +ag regularly u$ing a $eparate* clean collecting container for

each patientF avoid $pla$hing* and prevent contact of the drainage $pigot !ith thenon$terile collecting container.


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(. $e ,tandard Precaution$* including the u$e of glove$ and go!n a$ appropriate* during

any #anipulation of the catheter or collecting $y$te#.

". (o#ple urinary drainage $y$te#$ Cutili@aingD #echani$#$ for reducing +acterial entry

$uch a$ anti$eptic=relea$e cartridge$ in the drain portD are not nece$$ary for routine u$e.

. (hanging ind!elling catheter$ or drainage +ag$ at routine* fied interval$ i$ not

reco##ended. /ather* it i$ $ugge$ted to change catheter$ and drainage +ag$ +a$ed on

clinical indication$ $uch a$ infection* o+$truction* or !hen the clo$ed $y$te# i$

co#pro#i$ed.

. nle$$ clinical indication$ ei$t don not u$e $y$te#ic anti#icro+ial$ routinely to prevent

(A' in patient$ reuiring either $hort or long=ter# catheteri@ation.

Ca>&&! Ma&!$al

A. 'f the (A' rate i$ not decrea$ing after i#ple#enting a co#prehen$ive $trategy to reduce

rate$ of (A'* con$ider u$ing anti#icro+ial% anti$eptic= i#pregnated catheter$.

he co#prehen$ive $trategy $hould include* at a #ini#u#* the high priority

reco##endation$ for urinary catheter u$e* a$eptic in$ertion* and #aintenance.

B. Hydrophilic catheter #ight +e prefera+le to $tandard catheter$ for patient$ reuiring

inter#ittent $ catheteri@ation.

(. ,ilicone #ight +e prefera+le to other catheter #aterial$ to reduce the ri$> of encru$tation

in long ter# catheteri@ed patient$ !ho have freuent o+$truction.

:*8 STRATEGIES TO PRE+ENT SSI

1. 'nfra$tructure reuire#ent$

a. rained per$onnel


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i. 'nfection prevention and control per$onnel #u$t +e $pecifically trained in

#ethod$ of ,,' $urveillance and +e adept at providing feed+ac> and

education to healthcare per$onnel !hen appropriate.

+. ducation

i. /egularly provide education to $urgeon$ and preoperative per$onnel through

continuing education activitie$ directed at #ini#i@ing preoperative ,,' ri$>

through i#ple#entation of reco##ended proce$$ #ea$ure$.

ii. Provide education regarding the outco#e$ a$$ociated !ith ,,'* ri$>$ for ,,'*

and #ethod$ to reduce ri$> to all patient$* patient$E fa#ilie$* $urgeon$* and

preoperative per$onnel.

iii. ducation for patient$ and patient$E fa#ilie$ i$ an effective #ethod to reduce

ri$> a$$ociated !ith intrin$ic

c. ducation

a. ducate $urgeon$ and perioperative per$onnel a+out ,,' prevention Aand

infor# $trictly our )P" nur$e$ to !rite hi$tory of operation$ and $ite of pu$

$!a+ +efore $ending the $!a+ $a#ple to la+ for po$t op pt$ .

2. ducate patient$ and their fa#ilie$ a+out ,,' prevention* a$ appropriate

a. Provide in$truction$ and infor#ation to patient$ +efore $urgery* de$cri+ing $trategie$

for reducing ,,' ri$>. ,pecifically provide pre printed #aterial$ to patient$.

S&.$al a!oa.>& "o! >& !&/&n$on o" SSI

Perfor# an ,,' ri$> a$$e$$#ent. he$e $pecial approache$ are reco##ended for u$e in location$

and% or population !ithin the ho$pital that have unaccepta+ly high ,,' rate$ de$pite


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i#ple#entation of the +a$ic ,,' prevention $trategie$ li$ted a+ove.

1. Perfor# epanded ,,' $urveillance to deter#ine the $ource and etent of the pro+le# and

to identify po$$i+le target$ for intervention.

A!oa.>& >a >oul' no -& .on$'&!&' a !ou$n& a! o" SSI !&/&n$on

1* "o not routinely u$e vanco#ycin for anti#icro+ial prophylai$

a. 6anco#ycin $hould not routinely +e u$ed for anti#icro+ial prophylai$* +ut it can +e an

appropriate agent for $pecific $cenario$. /e$erve vanco#ycin for $pecific clinical

circu#$tance$* $uch a$ a proven out+rea> of ,,' due to M/,A* high ende#ic rate$ of ,,'

due to M/,A* targeted high=ri$> patient$ !ho are at increa$ed ri$> for ,,' due to M/,A.

:*9 SRATEGIES TO PRE+ENT +AP

he core reco##endation$ are de$igned to interrupt the 3#o$t co##on #echani$#$ +y !hich

6AP develop?

i. A$piration of $ecretion$ii. (oloni@ation of the aero dige$tive tract

iii. $e of conta#inated euip#ent

2* -eneral $trategie$ that have +een found to influence the ri$> of 6AP

a. -eneral $trategie$

i. (onduct active $urveillance for 6AP

ii. Adhere to hand=hygiene guideline$

iii. $e noninva$ive ventilation !henever po$$i+le.


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iv. Mini#i@e the duration of ventilation.

v. Perfor# daily a$$e$$#ent$

vi. ducate healthcare per$onnel !ho care for patient$

+. ,trategie$ to prevent a$piration

i. Maintain patient$ in a $e#irecu#+ent po$ition

c. ,trategie$ to #ini#i@e conta#ination of euip#ent u$ed to care for patient$ receiving

#echanical

d. ,trategie$ to #ini#i@e conta#ination of euip#ent u$ed to care for patient$ receiving

#echanical ventilation

i. $e $terile !ater to rin$e reu$a+le re$piratory euip#ent.

ii. /e#ove conden$ate fro# ventilatory circuit$. :eep the ventilatory circuit

clo$ed during conden$ate re#oval.

iii. (hange the ventilatory circuit only !hen vi$i+ly $oiled or #alfunctioning.

iv. ,tore and di$infect re$piratory therapy euip#ent properly

Ba$. !a.$.& "o! !&/&n$on an' #on$o!$n4 o" +AP

A. ducation

1. ducate healthcare per$onnel !ho care for patient$ undergoing ventilation a+out 6AP*

including infor#ation a+out the follo!ing.

a. ocal epide#iology

+. /i$> factor$

c. Patient outco#e$

2. ducate clinician$ !ho care for patient$ undergoing ventilation a+out noninva$ive

ventilatory $trategie$


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3. HAP i$ an infection #o$tly $een in ad#itted pt$ due to a$piration pneu#onia in pt$ !ith

oro or na$o ga$tric feeding tu+e$ . actually they !ill not have any $%$ of pneu#onia at all

at the ti#e of ad#i$$ion or +efore operation +ut after 3 day$ of ad#i$$ion he #ay

develop all $%$ of pneu#onia !hich i$ iatrogenic due to faulty or negligent procedure of

feeding +y the concerned nur$e .it$ incidence i$ very rare at our ho$pital .

:*6 STRATEGIES TO PRE+ENT CLABSI

1* 'nfra$tructure reuire#ent$

a* An adeuately $taffed infection prevention and control progra# re$pon$i+le for

identifying patient$ !ith (AB,'

-* 'nfor#ation technology to collect and calculate catheter= day$ a$ a deno#inator

for co#puting rate$ of (AB,' and patient=day$ to allo! calculation of (6(

utili@ationF catheter day$ fro# infor#ation $y$te#$ $hould +e validated again$t

a #anual #ethod.

.* /e$ource$ to provide appropriate education and training

'* Adeuate la+oratory $upport for ti#ely proce$$ing of $peci#en$ and reporting

of re$ult$

2* Practical i#ple#entation

a* ducate phy$ician$* nur$e$* and other healthcare per$onnel a+out guideline$ to

prevent (AB'. he$e guideline$ $hould +e ea$ily acce$$i+le.

-* "evelop and i#ple#ent a catheter in$ertion chec>li$t. ducate nur$e$*


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phy$ician$* and other healthcare per$onnel involved in catheter in$ertion*

regarding the u$e of the catheter in$ertion chec>li$t.

.* ducate healthcare per$onnel a+out the in$ertion and #aintenance of catheter$.

'* $ta+li$h catheter in$ertion >it$%cart$ containing all nece$$ary ite#$ for

in$ertion.

Ba$. !a.$.& "o! !&/&n$on an' #on$o!$n4 o" CLABSI

A* Before in$ertion

1. ducate healthcare per$onnel involved in the in$ertion* care* and #aintenance of (6($

a+out (AB,' prevention

a. 'nclude the indication$ for catheter u$e* appropriate in$ertion and #aintenance*

the ri$> of (AB,'* and general infection prevention $trategie$.

+. n$ure that all healthcare per$onnel involved in catheter in$ertion and

#aintenance co#plete an educational progra# regarding +a$ic practice$ to

prevent (AB,' +efore perfor#ing the$e dutie$.

c. Periodically a$$e$$ healthcare per$onnel >no!ledge of and adherence to

preventive #ea$ure$.

d. n$ure that any healthcare profe$$ional !ho in$ert$ a (6( undergoe$ a

credentialing proce$$

B* At in$ertion

1. $e a catheter chec>li$t to en$ure adherence to infection prevention practice$ at the ti#e of

(6( in$ertion


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a. $e a chec>li$t to en$ure and docu#ent co#pliance !ith a$eptic techniue.

+. he$e healthcare per$onnel $hould +e e#po!ered to $top the procedure if

+reache$ in a$eptic techniue are o+$erved.

2. Perfor# hand hygiene +efore catheter in$ertion or #anipulation

a. $e an alcohol=+a$ed !aterle$$ product or anti$eptic $oap and !ater.

3. Avoid u$ing the fe#oral vein for central venou$ acce$$ in adult patient$

4. $e #ai#al $terile +arrier precaution$ during (6( in$ertion P///AB ,

BA"'N )/ (H)/HL'"'N )/ P/PA/A')N ) iv ,' A/A

C* After in$ertion

1. "i$infect catheter hu+$* needlele$$ connector$* and inKection port$ +efore acce$$ing

the catheter

2. /e#ove none$$ential catheter$

3. /eplace ad#ini$tration $et$ not u$ed for +lood* +lood product$* or lipid$ at interval$

not longer than 7 hour$

4. Perfor# $urveillance for (AB,'

S&.$al a!oa.>& "o! >& !&/&n$on o" CLABSI

Perfor# a (AB,' ri$> a$$e$$#ent. he$e $pecial approache$ are reco##ended for u$e in

location$ and%or population$ !ithin the ho$pital that have unaccepta+ly high (AB,' rate$.

:*: SUR+EILLANCE OF NOSOCOMIAL INFECTIONS


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,urveillance of no$oco#ial infection i$ the foundation for organi@ing and #aintaining an

infection control progra##e. 'nfor#ation o+tained fro# $urveillance data i$ a u$eful tool in

identifying area$ of priority and allocating re$ource$ accordingly. 6ariou$ $!a+$ are ta>en for

$urveillance$ and for trac>ing analy$i$ report $a>e and root cau$e i$ >no!n and thereafter

corrective action i$ i#ple#ented and for $a>e of further prevention (M & (N cla$$e$$ are

al$o conduced for $taff to prevent any $uch rcurrance$ .

O-&.$/& o" Su!/&$llan.&

• /educing the infection rate$ !ithin health care facilitie$.

• $ta+li$hing ende#ic infection rate$.

• 'dentifying out+rea>$.

• (onvincing #edical per$onnel to adopt reco##ended preventive practice$.

!valuating control measures.

argeted $urveillance ai#ed at high ri$> area$ i$ #ore effective and #anagea+le. 't can +e $ite

$pecific* unit $pecific* or out+rea> a$$ociated $urveillance. Both active and pa$$ive $urveillance#ea$ure$ are +eing conducted along !ith involve#ent of !hole H'(( and H'( tea# etc

.detailed trac>ing analy$i$ inve$tigation are done and root cau$e analy$i$ i$ al$o done in detail.

6ariou$ corrective #ea$ure$ are advi$ed and preventive $tep$ li>e health education i$ ta>en in

order to prevent any $uch recurrance$ in future at our ho$pital.


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;* STANDARD PRECAUTIONS

nder $tandard precaution$* all patient$ receiving care in ho$pital$* irre$pective of their

diagno$e$ or pre$u#ed infection$ $tatue$* $hould +e treated in $uch a #anner a$ to reduce the

ri$> of tran$#i$$ion of #icro=organi$#$ fro# health care !or>er to patient* patient to healthcare

!or>er* and fro# patient to healthcare !or>er to patient.

Ca!'$nal !ul& o" an'a!' !&.au$on

(on$ider all patient$ potentially infectiou$

A$$u#e all +lood and +ody fluid$ and ti$$ue covered +y $tandard precaution$ are

conta#inated !ith a +lood +orne pathogen.

A$$u#e all non $terile needle$ and other $harp$ are $i#ilarly conta#inated.

Pu!o&

o e$ta+li$h individual re$pon$i+ilitie$ in order to #ini#i@e the tran$#i$$ion of infection to*

fro#* and +et!een patient$ and all other people in facilitie$. he ai# i$ to reduce the ri$> of

tran$#i$$ion of #icro=organi$#$ fro# +oth >no!n and un>no!n $ource$ of infection in the

ho$pital.

D&"$n$$on

he #ea$ure$ de$igned to reduce the ri$> of tran$#i$$ion of +lood +orne pathogen$ and other

#icro=organi$#$ fro# +oth recogni@ed and unrecogni@ed $ource$ of infection.

Pol$.$&


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a. ,tandard precaution$ are to +e u$ed for all patient$* to #ini#i@e ri$> to $taff and patient$.

+. ,tandard precaution$ are to +e u$ed for contact !ith.

i. Blood* +ody fluid$* $ecretion and ecretion$ regardle$$ of !hether or not they

contain vi$i+le +lood.

ii. Non= intact $>in.

iii. Mucou$ #e#+rane.

c. Body fluid$ !hich #ay contain +lood +orne viru$e$ Ce.g. Hepatiti$ B* Hepatiti$ (* and

H'6 include? Blood* +lood= $tained +ody fluid$* (,* $e#en* ti$$ue$* vaginal $ecretion$*

pericardial* a#niotic* peritoneal and pleural fluid$.

d. Body fluid$ !hich #ay contain other pathogen$ includeF

i. aece$* urine.

ii. 6o#itu$* $putu#.

P!o.&'u!& "o! an'a!' $n"&.$on .on!ol !&.au$on

a Han' a>$n4

Hand !a$hing i$ the $ingle #o$t i#portant #ea$ure in infection control.

Hand !a$hing $hould +e done?

i. Before and after patient contact.

ii. After u$ing glove$

iii. Before & after any procedure.

iv. '##ediately after contact !ith +lood* +ody fluid$* $ecretion$* ecretion$* non intact

$>in or #ucou$ #e#+rane$* and conta#inated euip#ent.


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v. Al!ay$ !a$h hand +efore leaving the !ard.

vi. Before handling food.

vii. After contact !ith patient +ed$* loc>er$ etc.

- Ma!

$* No need to +e routinely !orn.

$$* Any ti#e the healthcare !or>er anticipate$ the po$$i+ility of +eing $pla$hed !ith

+lood* +ody fluid$* $ecretion$ or ecretion$.

$$$* or +arrier protection.

. P!o&.$/& E3& &a! An'(o! Fa.& S>$&l'

$* Any ti#e the health care !or>er anticipate$ the po$$i+ility of +eing $pla$hed

!ith +lood* +ody fluid$* $ecretion$ or ecretion$.

' Glo/& @Cl&an, non &!$l&

i. ;ear for contact !ith +lood* +ody fluid$* $ecretion$* ecretion$* #ucou$

#e#+rane$* non=intact $>in or $urface$ $oiled !ith vi$i+le +lood or +ody fluid$

and conta#inated euip#ent and article$.

ii. -love$ $hould +e changed +et!een patient$.

iii. -love$ $hould +e changed if they are torn* punctured & conta#inated.

& Pla$. A!on(G!on, .a, >o& .o/&!, -oo


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$* or contact !ith infective #aterial. o protect again$t tran$#i$$ion of highly

tran$#i$$i+le organi$#$ e.g. M/,A

$$* Any ti#e that clothing i$ li>ely to +e $oiled +y $plattering of +lood* +ody fluid$*

$ecretion and ecretion$.

" Han'l$n4 n&&'l& an' #all >a!

$* "o not recap needle$

$$* "i$po$e of u$ed needle$ and $#all $harp$ in puncture=re$i$tant container.*

;hich are located a$ clo$e a$ po$$i+le to the area of u$e

$$$* Needle$ $hould not +e recapped* +ent or +ro>en +y hand.

$/* 'f a needle ha$ to +e re#oved fro# a $yringe* u$e forcep$ or do it !ith ut#o$t care.

/* "o not overfill a $harp$ container. All $harp$ container$ to +e di$carded !hen 3%4th$

full.

/$* ,harp$ $hould not +e pa$$ed fro# one H(; CHealth (are ;or>erD to another. he

per$on u$ing the euip#ent $hould di$card it. 'f nece$$ary a tray +e u$ed to

tran$port $harp$

4 Cl&an$n4 S$ll

i. ;ear protective #ea$ure$ li>e go!n* #a$>* glove$ etc.

ii. ;et the area !ith ,odiu# hypo chloride and dry carefully u$ing di$po$a+le paper

to!el.

iii. (lean !ith detergent & >eep the area dry.


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> Pa$&n Pla.&n

i. Place a patient !ho conta#inate$ the environ#ent !ith highly tran$#i$$i+le

organi$#$ or !ho doe$ not a$$i$t in #aintaining appropriate hygiene in a $ingle

roo#.

ii. 'f a $ingle roo# i$ not availa+le* con$ult infection control tea# for other

alternative$.

;*1 San'a!' P!&.au$on $n Cl$n$.al La-o!ao!3 T!an"u$on S&!/$.&

A* P!$n.$l&

i. /eco##endation$ +y the (entre for di$ea$e control C("(D and regulation$ +y the

occupational $afety and health ad#ini$tration C),HAD have +een developed for $tandard

precaution$ for prevention of occupational epo$ure to +lood=+orne pathogen$.

ii. he$e reuire#ent$ apply to +lood and +ody fluid$ fro# all patient$ regardle$$ of

diagno$i$. No di$tinction i$ #ade +et!een patient$ !ho are >no!n to +e infected and all

other$. ,tandard precaution$ con$titute a $afe approach to prevent infection +ecau$e

e#ployee$ have a $ingle +ehavioral $tandard* and error$ in a$$e$$ing patient $tatu$ !ill

not endanger e#ployee $afety.

iii. he $tandard precaution$ do ac>no!ledge a difference +et!een ho$pital patient$ and

healthy donor$* in !ho# the prevalence of infectiou$ di$ea$e #ar>er$ i$ $ignificantly

lo!er.

B* G&n&!al !an"u$on &!/$.& 4u$'&l$n&*


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OMEGA HOSPITALS

MLA COLONY,


HIC MANUAL

$* Han' a>$n4

reuent* effective hand !a$hing i$ the fir$t line of defen$e in infection control. Blood=

+orne pathogen$ of concern generally do not penetrate intact $>in* $o i##ediate re#oval

reduce$ the li>elihood of tran$fer to a #ucou$ #e#+rane or +ro>en $>in area or of

tran$#i$$ion to other$.

Hand$ $hould al!ay$ +e !a$hed?

Before & after handling a patient.

Before & after touching the patient unit.

Before leaving a !or> area.

'##ediately after co#ing into contact !ith +lood or other +ody fluid$.

'##ediately after re#oving ru++er glove$.

After u$ing toilet.

$$* Glo/&

he u$e of glove$ +y all technician$ !hen cleaning up $pill$ or handling !a$te

#aterial$.

-love$ $hould +e !orn routinely !henever there i$ the po$$i+ility of epo$ure to a

patientE$ +lood or +ody fluid$ Ce.g. collecting a therapeutic unit on the !ard$D.

$e glove$ for any ta$> !here +lood or +ody fluid$ #ay +e encountered if your hand$

have any cut$* $c

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