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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$4n*
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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OMEGA HOSPITALS
MLA COLONY,
BANJARA HILLS, HYDERABAD
HIC MANUAL
1 01(02 01 HIC D&a!#&n
2 01%02 01 Nu!$n4 D&a!#&n
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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OMEGA HOSPITALS
MLA COLONY,
BANJARA HILLS, HYDERABAD
HIC MANUAL
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
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.
Page 8 of 260
,'-NA/ %
NAM % DR* *I* 7IRAN
",'-NA')N % MEDICAL DIRECTOR
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BANJARA HILLS, HYDERABAD
HIC MANUAL
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
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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BANJARA HILLS, HYDERABAD
HIC MANUAL
.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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HIC MANUAL
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
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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BANJARA HILLS, HYDERABAD
HIC MANUAL
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$$ue$.
ngineering control$ to prevent infection.
Pu!o&
1* o #aintain $tandard$ in infection control #ea$ure$ and #ini#i@e ho$pital acuired
infection$ in patient$ and $taff.
2* o define policy and procedure regarding no$oco#ial infection$ at )#ega Ho$pital*
Hydera+ad.
5* o fra#e anti+iotic policy and #onitor it$ adherence +y the pre$cri+ing authoritie$.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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HIC MANUAL
S.o&
All inpatient and outpatient area$ including diagno$tic facilitie$
R&on$-$l$$&
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$itor$
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.
Page
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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##$&&
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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MLA COLONY,
BANJARA HILLS, HYDERABAD
HIC MANUAL
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%
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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BANJARA HILLS, HYDERABAD
HIC MANUAL
() % 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
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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HIC MANUAL
•
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$.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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HIC MANUAL
8* HIC TEAM
't i$ 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.
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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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
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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(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.
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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/* 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$$i+le infection ha@ard$ and evaluating co#pliance !ith $tandard$ $et +y the infection
control co##ittee* doe$ daily and !ee>ly round$ and report$ to #icro+iologi$t and hicc
coordinator and in$truct$* the hou$e>eeping $taff al$o.
/outinely #onitor$ co#pliance !ith Ho$pital policy on i$olation of patient$ !ith
co##unity=acuired or no$oco#ial infection$* !hich reuire $pecial care and #onitor$
+undle care and fu#igation in high ri$> area$.
Al$o #onitor$ >itchen hygiene and food handler$ $creening* N,' victi#$ care* i$olation
care* All high ri$> !ard$* BM; central collection area* infected linen policy and vi$it$ -<
#ulticlave co#pany and laundry al$o periodically.
a>e$ part activity in internal audit activitie$ and reive! #eeting$ $u+#it$ #onthly report$
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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loo> after Ho$pital e#ployee health progra##e* #aintain food and !ater analy$i$ report$.
(oordinate$ and a$$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$$i+le.
Participate* in orientation and continuing education progra# for infection control.
Adhere to the Ho$pital #ployee Health progra# and HB6 vaccination progra##e.
Nur$ing in=chargecoordinate$ !ith uality depart#ent and H'() and H'(N and M" etc.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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/$$* 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
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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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$$ion of infection$.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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* Rol& o" CSSD
T>& !&on$-$l$$& 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.
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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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$$ for ne! $taff. )ur organi@ation are al$o encourage our la+ doctor$ and $taff to attend
once in year at lea$tcertificate training progra# for H'(NE,* "octor$ and con$ultant$ and in
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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charge$ etc* +y their training $chedule hi$ i$ the #anage#ent thi$ i$ done a$ part of uality
i#ple#ent progra#$.
he $tandard$ are #aintained and #onitored in variou$ depart#ent$ and regular #eeting are
al$o here +y #anage#ent in uality co##ittee* $afety co##ittee* and H'( co##ittee.
he feed+ac> data i$ analy@ed and di$cu$$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$e$.
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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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$.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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9* REPORTING OF NOTIFIABLE DISEASES AND ANY EPIDEMICS, CASES TO
GO+T HEALTH AUTHORITIES% @AT GHMC
Ho$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$i$.
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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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
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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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;',.
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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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$$ing roo# are
al$o $ent periodically for culture and ,en$itivity. H u$e of $avlon in ho$pital i$ di$couraged
H H'(N vi$it$ BM; co#pany $ite t!ice or thrice in year and laundry and linen out$ourcing
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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area once in uarterly or $o to note do!n their $tandard protocol$ and their i#prove#ent.
All the High ri$> !ard$ including i$olation roo# etc Po$t fu#igation ,!a+$ are al$o
proce$$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
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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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$$ing trolleyE$*
patientE$ +ed* floor$ and
euip#ent$* ta+le$ &
A%(. filter$
Aero+ic +acteria
2 (entral ,terile
,upply depart#ent.C(,,"D
;ee>ly onceCpo$t
fu#igationD
(he#ical chec> tu+e*
Biological indicator$fro# each cycle. ,ettle
Aero+ic +acteria
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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plate count & ,!a+$fro# (,," every !ee>
3 )peration heatre?
' & ''
After every
fu#igation
!ice a #onth
,!a+$ fro# operating
a+le$* light$* rolley$*
,uction #achine* A%(
filter$ & anae$the$iatrolly
& floor etc.
,!a+ fro#
variou$ du$t
$etting areaE$ a$
a+ove. or
Bacteria Ca$
a+oveD
4. )peration theatre$
3 &4
After every
fu#igation
,ettle plate count #ethod
& $!a+$ are ta>en fro#
different article$ & $ite$ n
A/)B'(
)/-AN',M,
5. "i$infectant$ 'f tur+id %every
#onth
,!a+$ ta>en fro# the
di$infectant
P$eudo#ona$
7. Nur$ing $taff A// )/
H'-H /',: ;A/"
,A
,!a+$ are ta>en fro#
hand$ of nur$ing $taff and
no$tril$ rando#ly.
M/,A*
,!a+$ ta>en ta+le top$ at
all nur$ing $tation
$*
M/,A
8. "rin>ing !ater &
/)/ !ater $ent
periodically to
NAB accreditated
la+
very #onth (ooler$ and $upplier$ Pre$ence of coli
for# and 6(
Cotal via+le
countD
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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9 -eneral !ard uarterly ,!a+$ are $entor aero+ic )rgani$#$
:* NOSOCOMIAL INFECTIONS
• A no$oco#ial infection i$ one that i$ acuired in a ho$pital or health care facility and !a$
notincu+ating at the t=i#e of ad#i$$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.$$on u!4$.al $& $n"&.$on%
Infection occurs within 30 days after operation and involves skin or
Sucutaneous tissues of incision site.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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$* Purulent drainage fro# $uperficial inci$ion !ith or !ithout la+oratory confir#ation.
$$* )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$$ or other evidence of infection involving organ or $pace on direct
ea#ination* during re operation or +y hi$topathologic or radiologic ea#ination.for
ca$e$ of pro$thetic $urgerie$ it i$ one year cutoff period it i$ confir#ed +y pu$ c%$ or
+y $urgeon$ opinion . )/ P, ;'H P/),H,', )/ 'MPAN, the ti#e li#it
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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for ,,' ta>en i$ one year period
II* I+ Ca>&&! R&la&' Bloo' S!&a# In"&.$on
i. ,y$te#ic $ign$ of infection
ii. (oloni@ation of #ore than 102c fu in uantitative or 15 colonie$ in ualitative
culture of the catheter.
iii. '$olation of $a#e organi$# fro# catheter and fro# a concurrent +lood culture of a
patient !ith $ep$i$ $yndro#e. **along !ith $%$ of infla##ation at the $ite of central
cannula !ih di$charge .
III* Noo.o#$al Pn&u#on$a(+AP(HAP
i. Ne! or progre$$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$$ion .
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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+* Ca>&&! ao.$a&' U!$na!3 T!a. In"&.$on
a. (linical $ing$ and $y#pto#$ of ' !ith a po$itive urine culture !ith $ignificant
+acteriuria and #icro$copy after 2 day$ of catheteri@ation for tho$e !o develop $%$ of
' .
+. A count #ore than 105 cfu%#l can indicate a clinically $ignificant +acteriuria in
catheteri@ed patient$.
:*2 INFECTION PRE+ENTION METHODOLOGY% /a!$ou -un'l& .a!& !&/&n$/&
.o#on&n !a&4$& a!& .$!.ula&' o all a"" &&.$all3 "!o# SICU (MICU &. o
>a $" "ollo&' >&!& .an -& lo&!&' $n.$'&n.& o" u.> .o##on noo.o#$al $n"&.$on
alo4&>&! *#o!&o/&! an .>&.l$ $ alo !&a!&' "o! /a!$ou noo.o#$al $n"&.$on a
an #on$o!$n4 !o.& *>& o>&! noo.o#$al $n"&.$on >$.> o..u! on /&!3 #all
.al& a!& -&' o!& '&/&lo#&n 'u!$n4 $na$&n a3 a >o$al ,I+ l$n& >&!a3
.o#l$.a$on , &. >$.> a!& oo !a!& $n $n.$'&n.& *#o o" >&& $n"&.$on .an -&
!&/&n&' -3 "ollo$n4 >an' a> an' -3 u& o" PPE ETC BARREIR NURSING
TECHNI)UES ETC
P!&/&n$on an' #on$o!$n4 o" CAUTI
'. Appropriate rinary (atheter $e
A. 'n$ert catheter$ only for appropriate indication$* and leave in place only a$ long a$
needed.1. Mini#i@e urinary catheter u$e and duration of u$e in all patient$* particularly tho$e at
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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higher ri$> for (A' or #ortality fro# catheteri@ation.
2. $e urinary catheter$ in operative patient$ only a$ nece$$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
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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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$$ary.
d. 'n the non=acute care $etting* clean Ci.e.* non=$terileD techniue for inter#ittent
catheteri@ation i$ an accepta+le and #ore practical alternative to $terile techniue for
patient$ reuiring chronic inter#ittent catheteri@ation.
e. Properly $ecure ind!elling catheter$ after in$ertion to prevent #ove#ent and urethral
raction
:*5 A!o!$a& $n"!a!u.u!& "o! !&/&n$n4 CAUTI
Proper echniue$ for rinary (atheter Maintenance
A. ollo!ing a$eptic in$ertion of the urinary catheter* #aintain a clo$ed drainage $y$te#
1. 'f +rea>$ in a$eptic techniue* di$connection* or lea>age occur* replace the catheter
and collecting $y$te# u$ing a$eptic techniue and $terile euip#ent.
2. (on$ider u$ing urinary catheter $y$te#$ !ith preconnected* $ealed catheteru+ing
Kunction$.
B. Maintain uno+$tructed urine flo!.
:eep the catheter and collecting tu+e free fro# >in>ing.
:eep the collecting +ag +elo! the level of the +ladder at all ti#e$. "o not re$t the
+ag on the floor.
#pty the collecting +ag regularly u$ing a $eparate* clean collecting container for
each patientF avoid $pla$hing* and prevent contact of the drainage $pigot !ith thenon$terile collecting container.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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(. $e ,tandard Precaution$* including the u$e of glove$ and go!n a$ appropriate* during
any #anipulation of the catheter or collecting $y$te#.
". (o#ple urinary drainage $y$te#$ Cutili@aingD #echani$#$ for reducing +acterial entry
$uch a$ anti$eptic=relea$e cartridge$ in the drain portD are not nece$$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$$ clinical indication$ ei$t don not u$e $y$te#ic anti#icro+ial$ routinely to prevent
(A' in patient$ reuiring either $hort or long=ter# catheteri@ation.
Ca>&&! Ma&!$al
A. 'f the (A' rate i$ not decrea$ing after i#ple#enting a co#prehen$ive $trategy to reduce
rate$ of (A'* con$ider u$ing anti#icro+ial% anti$eptic= i#pregnated catheter$.
he co#prehen$ive $trategy $hould include* at a #ini#u#* the high priority
reco##endation$ for urinary catheter u$e* a$eptic in$ertion* and #aintenance.
B. Hydrophilic catheter #ight +e prefera+le to $tandard catheter$ for patient$ reuiring
inter#ittent $ catheteri@ation.
(. ,ilicone #ight +e prefera+le to other catheter #aterial$ to reduce the ri$> of encru$tation
in long ter# catheteri@ed patient$ !ho have freuent o+$truction.
:*8 STRATEGIES TO PRE+ENT SSI
1. 'nfra$tructure reuire#ent$
a. rained per$onnel
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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i. 'nfection prevention and control per$onnel #u$t +e $pecifically trained in
#ethod$ of ,,' $urveillance and +e adept at providing feed+ac> and
education to healthcare per$onnel !hen appropriate.
+. ducation
i. /egularly provide education to $urgeon$ and preoperative per$onnel through
continuing education activitie$ directed at #ini#i@ing preoperative ,,' ri$>
through i#ple#entation of reco##ended proce$$ #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$pite
PREPARED BY: CHECKED & REVIEWED
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APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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i#ple#entation of the +a$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.
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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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 $trategie$
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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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$e$*
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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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$$
B* At in$ertion
1. $e a catheter chec>li$t to en$ure adherence to infection prevention practice$ at the ti#e of
(6( in$ertion
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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a. $e a chec>li$t to en$ure and docu#ent co#pliance !ith a$eptic techniue.
+. he$e healthcare per$onnel $hould +e e#po!ered to $top the procedure if
+reache$ in a$eptic techniue are o+$erved.
2. Perfor# hand hygiene +efore catheter in$ertion or #anipulation
a. $e an alcohol=+a$ed !aterle$$ 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
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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,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.
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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;* 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$.$&
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
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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$* and conta#inated euip#ent.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
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v. Al!ay$ !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
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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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$a+le paper
to!el.
iii. (lean !ith detergent & >eep the area dry.
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN
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> Pa$&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$$ing patient $tatu$ !ill
not endanger e#ployee $afety.
iii. he $tandard precaution$ do ac>no!ledge a difference +et!een ho$pital patient$ and
healthy donor$* in !ho# the prevalence of infectiou$ di$ea$e #ar>er$ i$ $ignificantly
lo!er.
B* G&n&!al !an"u$on &!/$.& 4u$'&l$n&*
PREPARED BY: CHECKED & REVIEWED
BY:
APPROVED BY:
Mrs. RAMANJANAMMA(INFECTION CONTROLNURSE)
Dr. K. AMRUTH RAO(INFECTION CONTROLOFFICER)
Dr. W.I. KIRAN(MEDICALDIRECTOR)
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$* Han' a>$n4
reuent* effective hand !a$hing i$ the fir$t line of defen$e in infection control. Blood=
+orne pathogen$ of concern generally do not penetrate intact $>in* $o i##ediate re#oval
reduce$ the li>elihood of tran$fer to a #ucou$ #e#+rane or +ro>en $>in area or of
tran$#i$$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
top related