This departmental manual is

released under the authority of

Managing Director
&
Is the property of

S P MULTI SPECIALITY HOSPITALS, PARASSALA.

Copying of this manual in any form will be done under the permission
of
Managing Director

Signature :

Name & Designation :

Document : Hospital Infection Control Manual

Designation: General Manager

Issued By : Name : Mr. Vijaya Krishnan G V

Signature :

Designation: Managing Director

Approved By : Name : Dr. Robert Raj, MD

Signature :

Designation: Deputy Medical Superintendent

Reviewed By : Name : Dr. Mrityunjay C Modi

Signature :

Designation: Quality Manager (NABH Coordinator)

Prepared By: Name : Ms. Chithra S R

Signature :
 INDEX
Section No Contents Page No
Contents 2
1 Introduction 4

2 Scope and Objectives 6

3 Staffing 8
4. Organogram 13

5. Job responsibilities 14

6. Infection Control Protocols and Practices 21

6.1 Infection control practices in high risk areas 21

6.1.1 Infection Control Practices In Haemodialysis 21
6.1.2 Operation Theatre 23

6.1.3 Central Sterile Supply Department 43

6.2 Equipment Cleaning Protocols in User Areas 44

6.2.1 Equipment cleaning protocol in ICU 44

6.2.2 Equipment cleaning protocol in wards 46

6.2.3 Protocol for using disinfectants in 47
wards, critical care area & CSSD

6.2.4 Protocol for monitoring housekeeping activities 47

6.3 Infection Surveillance Programme 48

6.4 Infection Control Practices For CAUTI, RTI, SSI & CRBSI 51

6.5 Infection control protocol in obstetrics and labor room 55

6.6 Antibiotic Policy 56

6.7 HIC Policy for Casualty 74

6.8 Infection Control Protocols & Practices for Other (Non High-Risk) 76
Areas
6.8.1 Protocol for laundry & linen 76

6.8.2 HIC protocol for Kitchen 78

6.8.3 Engineering controls 80

6.8.4 Handling of cadavers 82

6.9 Notifiable Diseases 82

 6.10 Policy on isolation and barrier nursing 84
6.11 Standard Precautions 127

6.12 Employee Health Program 134

6.13 Management of Outbreak 138

6.14 Biomedical waste Disposal 140

6.15 Training on HIC 144

6.16 Policy for Ambulance services 147

6.17 Safe Injection Practices 148

7 Management of Information 150

8 Coordination with other departments 152

9 Policy for single use devices 153

10 Endoscope reprocessing protocol 158

1.1 INTRODUCTION TO INFECTION CONTROL IN HOSPITALS

Nosocomial infection — also called “hospital acquired infection” can be defined as: an infection acquired in hospital by
a patient who was admitted for a reason other than that of infection. An infection occurring in a patient in a hospital or
other health care facility in whom the infection was not present or incubating at the time of admission. This includes
infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the
facility (WHO).

• Hospital-acquired infections add to functional disability and emotional stress of the patient and in some cases,
lead to disabling conditions that reduce the quality of life. Nosocomial infections are also one of the leading
causes of death.
• The economic costs are considerable. The increased length of stay for infected patients is the greatest contributor
to cost. Prolonged stay not only increases direct costs to patients or payers but also indirect costs due to lost
work.
• The increased use of drugs, the need for isolation, and the use of additional laboratory and other diagnostic
studies also contribute to costs.
• Hospital-acquired infections add to the imbalance between resource allocation for primary and secondary health
care by diverting scarce funds to the management of potentially preventable conditions.

1.2 INTRODUCTION TO INFECTION CONTROL DEPARTMENT

Infection control department works to help prevent Hospital acquired Infections by

• Providing an advice service for the staffs to help and prevent and manage infections
• Providing advice about decontamination of equipment and environment and the best practice in the prevention of
the infections associated with any area of the health care
• Conduct the programme of audit (Environment and practice) and surveillance
• Produce guidelines on the prevention and management of infections
• Providing inputs to all educational programmes.
• Liaising with the staff involved in purchasing and planning to ensure infections control issues are given high
priority in their activities
 • Liaising with the staff of other depts. To provide infection control inputs

2. SCOPE AND OBJECTIVES

2.1 Scope

The scope of the standards will include Infection control related practices and policies used by S P Multi Speciality
Hospitals, including all the concerned departments like hospital management, the hospital pharmacy, the nursing staff,
the central sterilization service, the food service, the laundry service, the housekeeping service and the infection control
team. The Hospital Infection Control Manual is reviewed once a year.

2.2 Objectives
• To develop written policies, procedures and standards for cleanliness, sanitation and asepsis in the hospital.
• To interpret, uphold and implement hospital infection control policies and procedures in specific situation.
• To provide surveillance for nosocomial infection.

Target rates for Medical ICU:

• To keep Ventilator Associated Pneumonia (VAP) incidence less than 5 per 1000 ventilator days.
• To keep Central Line Associated Blood Stream Infection (CLABSI) less than 5 per 1000 line days.
• To keep Catheter Associated Urinary Tract Infection (CAUTI) rate less than 5 per 1000 Foley’s days

Target rates for Surgical ICU:

• To keep VAP incidence less than 5 per 1000 ventilator days.
• To keep CLABSI less than 5 per 1000 central line days.

• To keep CAUTI rate less than 5 per 1000 Foley’s days.

3. Staffing
Hospital Infection Control Committee [HICC]
3.1 Committee members
1. Chairman
Deputy Medical Superintendent

2. Infection Control Officer

3. General Manager

4. Quality Manager
(NABH Coordinator)

5. Anesthesiology Dept

6. Consultant Surgeon
 8. Nursing Superintendent

9. Infection Control Nurse

10. CSSD I/C

11. House Keeping I/C

3.2 Infection control team Members

• Chairman - 1

• Infection Control Officer – 1

• Microbiologist - 1
• Infection Control Nurse – 1

3.3 The Nature of Authority of HIC

1. The hospital infection control program is an activity of the Consultant Microbiologist and is responsible for the
implementation of the program. The HICC is advisory to the Consultant Microbiologist and shall make its
recommendations to him. Chief Executive Officer is the chairman concerned with infection control and related
activities will be authorized by the HICC to make recommendations in emergency situations.

3.4 Terms of reference of HIC

The HICC will supervise the implementation of the hospital infection control program, specifically committee shall:

Maintain surveillance over hospital acquired infections.

Develop a system for identifying, reporting, analyzing investigating and controlling hospital acquired infections.

Develop and implement preventive and corrective programs in specific situations where infection hazards exist.

Advice the chairman of the hospital on matters related to the proper use of antibiotics, to develop antibiotic
policies and to recommend remedial measures when antibiotic resistant strains are detected.
Review and update hospital infection control policies and procedures from time to time.
Help provide employee health education regarding matters related to hospital acquired infections.
Shall meet regularly not less than once in 2 months or as often required.

The minutes of the meeting will be regularly conveyed to all the members of the committee The agenda for the next
meeting would be served in advance to all the committee members.

3.5 Responsibilities of HICC

Define nosocomial infections for surveillance purposes; to establish the modus operandi for early identification
and reporting of HAI and to determine the prevalence rates of defined infections.
 measures and to ensure follow up action.
To establish the ongoing evaluation and review of all aseptic, isolation, and sanitation techniques employed in the
hospital. Such techniques shall be defined in written policies and procedures.
To develop written policies defining the specific indications for patient isolation requirements.
To ensure the proper conduct of sterilization and disinfection practices and to ensure that the, central services,
housekeeping, laundry, engineering and maintenance, food sanitation, and waste management are in conformity
with the hospital infection control policies. The necessary procedures shall be evaluated and revised periodically.
To guide the scope and content of the Employee health program.
To help in the education and the orientation of all new employees as to the importance of infection control and the
relevant policies and procedures.
To act upon recommendations related to infection control, received from the administration departments, services
and other hospital committees.
To provide appropriate feedback regarding HAI rates on regular basis to medical and nursing staff.
To provide statistics related to Infection Rate and Infection Control activities to Chairman, Medical
Superintendent, Clinical Staff, Intensivist, and Nursing Staff on monthly basis.

3.6 The various High risk areas identified by the HICC are:

Operation Theatres
Intensive Care Units
CSSD
Labor room
Lab

3.7 The various High risk procedures

These can classified into surgical and non surgical interventional
Surgical Procedure
1. Urosurgeries
2. General surgeries

Non surgical procedure

1. Endoscopies
2. All the line (Peripheral, central & arterial) insertions.
3. All intubations and extubations
4. Urinary catheterization, Suprapubic puncture
5. Tracheostomy
6. Suctioning of tracheal secretions
7. Lumbar puncture
8. Tapping of Effusions

3.8 The following are the activities which are aimed to prevent and reduce the risk of infections

1. All patients undergoing surgeries are given antibiotic prophylaxis.

2. Surveillance activities like water cultures , air cultures are done periodically in the hospital
3. Chlorination of water supplied to all the locations in the hospital is ensured by checking the levels daily
4. Fumigation of the OT is done once in a week and the sterility is ensured by sending the environmental swabs
once in 15 days.
5. Hand washing is carried out and monitored on daily basis by taking 10 observations every day.
 7. Infection control protocols and practices for non high risk areas like Kitchen , laundry and linen are
implemented.

3. ORGANOGRAM
HOSPITAL INFECTION CONTROL COMMITTEE (HICC)
4. Job Responsibilities
4.1. Chairman – Hospital Infection Control Committee
Responsibility/Authority
Reports to MD.
Supervises surveillance of hospital acquired infection (HAI)
Assists the administrators in identifying, reporting, analyzing, investigating and controlling hospital-acquired
infections.
Supervises preventive and corrective programs.
Prepares the monthly analysis reports of the infection control data collected.
Presides over the infection control meeting and presents the analysis of the past three months.
To regularly update the infection control committee about the current status of patients and allied departments
under surveillance.
To provide updates to members of Infection control committee regarding new developments worldwide as per the
studies conducted in the field of Infection control.
To coordinate with allied departments like Maintenance and Engineering, Housekeeping, Dietary department, etc
regarding infection control.
Visits the laundry once in four months and conducts an audit
Takes care of all the infection control activities.
Involved in formulating & modifying infection control policies.
Conducts regular rounds of all the areas in the Hospital.
Conducts training regarding infection control practices.
Monitors waste management and disposal.

5.1 Infection Control Officer

Responsibility/Authority

Reports to Chairman, Infection Control Committee.

In absence of the chairman, Infection Control Officer will preside over the meetings.
Assume all the responsibilities of Infection Control Chairman in his absence.
Supervises all the infection control activities
Responsible for the surveillance of hospital-acquired infection (HAI)
Involved in formulating & modifying infection control
Conducts regular rounds of all the areas.
Assist the Chairman in identifying, reporting, analyzing, investigating, and controlling hospital-acquired infections
Supervises preventive and corrective programs
To regularly update the Medical Superintendent about patients under surveillance as and when required.
Conducts training for nursing staff, Physiotherapists & other staff regarding infection control practices.
Monitors waste management and disposal
Supervise the Microbiology and Serology department.
To do medical checkup for new canteen staff every six months & deworm them on employment and every six
months and to conduct canteen audits every month.
5.2 Job Responsibility for Infection control nurse in Infectious diseases department (For all Wards,
Radiology, Specimen collection area, out patient departments & Casualty)

Reports to the Infection Control Officer.

Filling up the Infection Control Check list of all the culture positives cases in the wards and analyzing and
Identifying the possible source of infection in consultation with the consultant Microbiologists
Supervision of Infection Control practices in all wards Radiology, Specimen collection area, Out patient
departments & Casualty (Noting of the culture positive cases, serology positive, communicable diseases,
Readmission )
Reporting the incidences related to the Infection Control Activities on a daily basis to Infection Control officer in
her Respective area
Conduct surveillance and maintain of daily records and statistics
Participate in Infection Control team meetings for discussion & analysis of any problems in their areas.
To inform the Infection control nurse of any notifiable diseases.
To send the water for bacteriological analysis once in a month in respective area.
To check the chlorine levels in respective area everyday and inform regarding the same.
Ensure linen checking once in a month and maintaining the record for the same
Counseling all the patients with Hepatitis B and Hepatitis C infections.
Monitoring the chronic wounds for dressings.
Reporting occupational exposure to blood/ body fluids in staff working in her respective area to the Infection
Control Officer/ HICC Chairman and to follow up the cases wherever necessary.
Weekly checklist for waste transportation
To collect clinical samples for culture.

Supervision of Infection Control practices

Reporting the incidences related to the Infection Control Activities on a daily basis to Infection Control Officer.
Conduct surveillance and maintain daily records and statistics.
Participate in Infection Control team meetings for discussion & analysis of any problems in their areas.
To inform the Infection control officer of any Notifiable diseases. And send the duly filled form with photocopy of
the report to MRD.
To send water for bacteriological culture once in a month.
To monitor the chlorine levels on daily basis and inform the Infection Control Officer regarding the same.
To monitor hand washing every day. Collecting 10 observations every day and recording the same.
To monitor waste management on daily basis.
To conduct audit for Linen collection, segregation & transportation once in a week.
To monitor changing of lines, ventilator tubing’s.
To maintain a record of culture positives.
To conduct a orientation class for new nursing staff
To conduct bedside training for the nurses regarding infection control on daily basis
To collects samples for culture.
To monitor cot cleaning, Oxygen hood cleaning and ET Mask cleaning once in a week.
Maintaining the ICU temp in the range of 18 –22
Arranging the solutions and items (CSSD items etc) pertaining to infection control in their respective area.
Ensuring all the cleaning protocol to be followed after the discharge of the MRSA and Multi drug resistant
patients.
To give weekly statistics to Infection Control Officer.
To monitor weekly unit cleaning & record it.
 To educate nursing staff regarding Blood borne infections like HIV, Hepatitis B & HCV. Reporting occupational
exposure to blood/ body fluids in staff working in her respective area to the Infection Control Officer/ HICC
Chairman and to follow up the cases wherever necessary.

6. INFECTION CONTROL PROTOCOLS AND PRACTICES

6.1 INFECTION CONTROL IN HIGH-RISK AREAS
6.1.OperationTheatre
6.1.1 Fumigation

RESPONSIBILITY
OT nursing staff and technician

PURPOSE
To kill pathogenic microorganism on inanimate objects or surfaces that cannot be sterilized

EQUIPMENT
Fogger machine, FUMIFLOOR

PROCEDURE
• Clean the OT thoroughly as per the protocol.
• Pour 20 ml of FUMIFLOOR in Fogging machine and add 80 ml of distilled water.
• Place the machine in OT to be fumigated on a stool.
• The AC should be switched off.
• The exhaust should be sealed with tape and thick brown paper.
• Switch on the machine with the head kept at an angle of 45 degrees to give a jet into the air.
• Close the OT door for 1 hour.
• Switch off the machine after one hour and keep the OT closed for half an hour.
• OT is ready to be used now. Microbiologists will regularly check the area to ascertain that fumigation is
effective.

DOCUMENTATION
• Date and time.
• Which areas are fumigated
• Time the area was under fumigation.
• Signature of person who fumigated the OT

6.1.2.2 Operation Room Environmental Sanitation

RESPONSIBILITY
All OT / CSSD and Intensive Care personnel / House keeping staff.

PURPOSE:
• To provide a safe clean environment for surgical patients.
• A basic concept is that all the patients are considered potentially infectious.

EQUIPMENT
Lint free dusters, Infection Committee Approved Disinfectant.
Beginning of the day/ In-between case cleaning:
After patient leaves the OT all the team assist in clean – up. The areas considered contaminated during and after an
operation are:
• All furniture, equipment and floors within and around the parameter of the sterile fields. If accidental spillage occurs in
other parts of the room, these areas are considered contaminated also.
• Stretchers devices to be cleaned daily with FUMIFLOOR 1%. Clean but not sterile gloves must be worn.
The following must be documented:

a. Furniture and floors

Clean the OT table & Gauze stand including mattress with Bacillol spray with dry lint free cloth and then the floor
mopped with a FUMIFLOOR 1% any spillages taken care of before mopping.

b. Overhead lights
The light reflectors are wiped using a clean cloth wet with Bacillol spray. Lights and overhead tracks become
contaminated quickly, presenting a hazard from fall out into the wounds of each operation. Therefore for every case they
must be cleaned.

c. Anesthetic equipment:
All reusable equipment must be cleaned and sterilized before reuse. Disposable equipment is put into plastic bags, sealed
and sent for incineration.

Sl No Equipment Cleaning method Frequency

Before
1. Anesthesia machine
induction
2. Monitor with accessories Every case
3. Drug trolley Every day
4. OT table Every case
5. Defibrillator & Fibrillator Every day
6. Suction machine Every day
7. Suction bottles 1 % Sodium Hypochlorite. Every case
8. Intubation trolley Every case
9. Dash monitor & ECHO machine Every day

d. Linen:
All OT linen is considered infected. It should be placed the double blue colored bag and tied. It is sealed with an infected
linen sticker and sent directly to the laundry without counting the contents. Disposable drapes are discarded in yellow dust
bin and sent.

e. Walls
It is cleaned thoroughly with cloth soaked with Sodium Hypochlorite 1% once a day.
If walls are splashed with blood or organic matter during surgery, these areas should be spot cleaned with 2 % Sodium
Hypochlorite.
Note: The maximum time taken for in-between case clean up is 20 minutes with a well-organized team.

f. Trash or infected waste:

All mentioned waste is collected in appropriate colored double bags and clearly labeled with infected sticker and sealed
and sent for incineration.
eg. X- Ray film reader mounted on the wall is cleaned with Sodium Hypochlorite 1% everyday.
6.1.2.3 Daily Cleaning After the Completion of OT List

Inside OT:
• Furniture is thoroughly scrubbed with friction and disinfection.

• Caster and wheels: All suture material ends and debris is cleaned.
• Equipment: All equipment must be cleaned with care, no water or moisture must enter into mechanisms causing
malfunction.
• Wall mounted fixtures: These are cleaned on all surfaces.
• Kick buckets, linen hamper frames and outer waste receptacles: These items are cleaned and disinfected.
• Doors: Special attention to be taken to the push plates of the doors where contamination build up is likely to occur.
• Trolleys are washed with soap and water everyday

Outside OT:
Counter tops and scrubs sinks:
All should undergo a though cleaning especially the taps where there tends to be a build up of microorganisms with each
use. Scrub sinks must not be used for any other purpose than hand washing.
Walls around the scrub sink:
They must receive daily attention as spray and splash from hand washing builds up around the sink and must be
removed.
Patient trolleys:
Need to be cleaned with specific attention to mattress, wheels and attachments.
Counter tops & floors in Surgeons’ rooms and change rooms must be cleaned as thoroughly as in the OT.

Weekly Cleaning:
The weekly cleaning routine is performed in addition to the daily schedule. Areas to be considered are:
• Walls: Washing wall throughout the OT, Surgeons rest rooms and change rooms is done once a week.
• Ceilings: Require special cleaning techniques because of the tracks and light fixtures. Excessive moisture must not
enter the electric circuits, as it may cause defects in equipment.
• Floor: Must be thoroughly mechanically scrubbed to remove the accumulated deposits and films floor must never be
waxed.
• Air conditioning grills: The exterior of A/C units should be vacuumed every week.
• Storage shelves: Should be emptied and cleaned and dried thoroughly every week, especially in the sterile storage
areas.
• Exchange and support areas: Walls, ceilings, furniture, air-conditioning grills. Lockers cupboards, furniture etc.
should be thoroughly cleaned with disinfectant solution.

• Ceiling/ wall mounted fixtures and tracks: These are cleaned on all surfaces.
• Fumigation: is done with FUMIFLOOR every week and whenever a serology positive /infected case is done.
• Traffic Patterns in the Surgical Suite

RESPONSIBILITY
OT personnel/ CSSD personnel

PURPOSE

Planned controlled movement of equipments, patients and personnel are a basic component of infection control.

PROCEDURE
• Environmental and dress codes increase, as progression is made from the unrestricted to restricted area, and these
 areas should be clearly demarcated. The traffic and dress codes restricted are to be strictly followed by all personnel.
• Operating room air is filtered, and with strict as progress is made from unrestricted to restricted area of the OT itself.
• Patients entering the surgical suite are changed into clean OT patient gowns and their hair completely covered by a
cap.
• During the operative procedure, movement of personnel should be kept at an absolute minimum the team should be
self sufficient, having all equipment and materials required for the operation in position before the patient and surgeon
enter the operating room.
• Doors of the operating room should be closed, except for essential movement of personnel and patient. This decreases
the mixing of operating room air and the corridor air, which has a higher microbial count.
• The number of people within the operating room and amount of conversation is to be minimized during surgery.
• Soiled supplies, instruments and equipments for reprocessing, linen, and OT waste for incineration, should be sealed in
impervious plastic bags in the operation room, and double bagged and sealed at the door of the OT room, without
contamination of the outer wrapper. Sticker for infected materials should identify all such bags.
• Movement of clean and sterile supplies must be separated from soiled and infected equipment and material. Planned
movement separated by time and/or space does this.

6.1.2.4 Gowning and Gloving

RESPONSIBILITY

Scrub nurse and surgeons and OT technologists.

PURPOSE
• To exclude skin contaminants
• To create a barrier between the sterile and unsterile area.

GENERAL CONSIDERATIONS
• The scrub nurse gowns and gloves self, then gowns and gloves the surgeon and assistants.
• Gown packages and glove packs are opened on a separate table from the other packages to avoid any contamination
from dripping water.

DRYING HANDS AND ARMS

Hands and arms must be thoroughly dry before donning the sterile gown. The gown pack for scrub nurse contains a
sterile gown, folded inside out, and a towel for hand drying and a pair of gloves of appropriate size.

The hands are dried as follows:

• Reach down and open package, take towel (avoiding water splash) and ensure no one is within arms reach.
• Open towel full length, taking one end, dry the hand and arm, using an oscillating motion from fingertips to the elbow
only.
• Reversing the towel, repeat step2.

Gowning and Glowing Technique:

Sterile gloves may be put on in two ways: Closed glove technique, or open glove technique. The closed glove technique
is preferred for the scrub nurse. The method of gloving determines how the gown is put on.

Closed glove technique:

• Reach for the sterile gown and lift directly upwards.
• Step away from table, hold the gown carefully and locate the neckband.
• Hold the inside front of the gown, allow it to unfold.

Slip the hands in the armholes simultaneously. The circulating nurse brings the gown over the shoulders, leaving
 is not touched until gloving is complete.
Using the left hand, inside the sleeve, pick up the right glove by grasping the folded cuff. Extend the right forearm
with palm upward; place the palm of the glove against the palm of the right hand, grasping the right hand top of the
cuff above the palm. Grasp the back of the cuff in the left hand and turn over end of the right sleeve and hand, the
cuff of the glove is now over the cuff of the gown, with the hand sill inside the sleeve. Grasp the top of the right
glove and sleeve. Pull the glove over the extended fingers until it completely covers the cuff.
Repeat for the left hand. Use the right hand to pull on the left glove. Fasten the waistband.

Open glove technique:

• Reach down and lift the folded gown directly upwards. Holding the gown carefully locate the neckband.
• Hold the inside front of the gown and let it unfold. Slip the hand simultaneously into the armholes.
• The circulating nurse pulls the sleeves over the hands and fastens the back securely. Do not fasten the waistband until
gloved.
• The first glove is put on with the skin-to-skin technique, and the second glove is put on glove- to glove technique.
• With the left hand grasp the cuff of the right glove on the fold, insert right hand into glove and pull it on leaving the
cuff turned well down over the hand.
• With the fingers of the gloved right hand under the averted cuff of the left glove. Pick up the glove and pull it on,
leaving the cuff turned down over the hand.
• With the fingers of the right hand pull the cuff. Avoid touching the bare wrist.
• Fasten the waist belt.

Note: The gloving technique used in the OT is subject to the clinician’s preference.

Gowning another person:

A scrub nurse gowned and gloved assists other than members.
• Open the hand towel and lay it on the surgeon’s hand.
• Unfold the gown carefully, holding at neckline.
• Keeping hand on outside of the gown, protected by a cuff of the neck and shoulder area, offer the inside of the gown
to the surgeon, who slips his arm into the sleeves.
• The circulating nurse fastens the gown touching the inside of the gown and the tapes only.
Gloving another person:
• Pick up the right glove, grasp firmly with fingers in averted cuff. HOLD THE PALM TOWARDS THE
SURGEON.
• Stretch the cuff sufficiently for the surgeon to introduce the hand, void touching the surgeon’s hand by holding your
thumbs outward.
• Exert upward pressure as the surgeon plunges his hand into the gloves.
• Unfold the averted cuff over the cuff of the surgeon’s gown.
• Repeat for left hand.
• The surgeon fastens his waistband.

6.1.2.5 Basic Aseptic Techniques in OT

Responsibility: In charge OT staff nurse.

Purpose
• To maintain a safe environment in OT for a patient.
• To establish and maintain a sterile field.
• To minimize surgical wound infection.
Procedure:
A scrubbed person scrub hands according to recommended practice.
 In front from chin to sterile field.
2” above elbow to above stockinet cuff.
Stockinet cuff is considered unsterile and should be covered with the cuff of sterile surgical gloves at all times.
The neckline, shoulders, under the arms, and the back of the gown (also wrap around gowns) are considered unsterile.
Self gowning and gloving of the scrub nurse should be performed from separate surface. Gloves must be put on by
closed method.

Sterile drapes should be used to establish a sterile field:

Sterile drapes are placed on patient, furniture and equipment to be included in the sterile.
Drapes should be handled as little as possible.
The drapes are held above the waist level in a compact position. Draping is performed from operation site to
periphery.
While placing drapes, cuff your gloves in the draping material to prevent contaminating them.
Once placed in position, a sterile drape is not moved around or shifted.
All items introduced onto the sterile field should be dispensed by methods that maintain sterility of the item and
integrity of the sterile field.
Sterile packs should be opened from the far side first and near side last.
All wrapper tails must be secured by hand when supplies are presented to the sterile field, to avoid contamination.
Sterile items should be presented to the scrubbed nurse, or place securely on the sterile fieldstrip or heavy instruments
are opened on a separate surface.
When dispensing liquid on the sterile field. The whole content should be used. And the remains discarded. The
receptacle to receive the liquid is placed near the edge of the table, or held by the scrub nurse.
Solutions are poured to avoid splashing the sterile field.
A sterile field should be constantly monitored and maintained.
Sterile tables should be prepared as near the time of surgery as possible.
An unguarded sterile field is to be considered unsterile.
Every team member should observe the sterile field. Any events or action that may compromise its sterility, corrective
action should be taken immediately. A sterile drape to protect it, as it is impossible to remove the drape without
contaminating the whole table.
Conversation should be kept to a minimum in the operating room during surgery.
All cables and tubing should be secured on the sterile field with non-perforating devices.
Non-sterile items brought into the sterile field must be draped with sterile material.
Items of doubtful sterility moving in, or around the sterile field must do so in a manner to maintain the integrity of the
field: distance from the sterile field.
Scrubbed persons move from sterile to sterile areas only. If they must change position, they move face-to-face or
back-to-back keeping a safe distance between each other.
Scrubbed persons must never leave the operating room.
Scrubbed persons should avoid changing working levels at the table.
Un-scrubbed persons move from unsterile to unsterile areas only, maintaining a safe

Un-scrubbed people approach the sterile field facing it; they never walk between 2 sterile surfaces.
Sterile wound dressings should be applied before drapes are removed.

Operation Room Attire

RESPONSIBILITY
PURPOSE
• To provides a barrier to contamination that may pass from personnel to patient.
• To promote high-level cleanliness and hygiene within the surgical environment.
• To protect cross contamination from outside to the OT suite.

EQUIPMENT:
OT dress and pyjama or pyjama set, Cap, Mask, Chappals, A cupboard for personnel items.

GENERAL INFORMATION:
The OT suite is divided into 3 disinfect zones.

a. Unrestricted Zone: Entrance of OT suite, toilet A/C rooms and change rooms. Street
cloths are permitted in these areas.
b. Semi –Restricted zone: Surgeon rest rooms, ICU areas, recovery area and patient trolley
exchange area. OT attire is required in these areas.
c. Restricted area: CSSD sterile supply storeroom, Hand scrub sinks, and corridor and
operation rooms themselves. OT attire plus masks are required in these areas.

Procedure:
• All personnel entering the semi-restricted and restricted zones of the OT suite should be surgical attire intended for
the use only.
• OT dress in put on the change rooms. The first item to be worn is the cap, which should contain all hair in females,
and facial hair in males, this prevents contamination of scrub dress with microorganism from the hair, then the dress
and pyjamas paints, chappals are worn in the Doctors rest room. Separate chappals are kept in the unrestricted area for
toilet use.
• OT attire must be change when visibly soiled or wet. Laundry of these cloths should not be done at home, due to the
risk of spread of potential contamination in the home.
Scrub cloths should not be worn outside the OT complex. In dire emergencies, a cover –all may be put on, but on
return, both scrub suit and coverall must be changed and sent for laundry.
All personnel entering the restricted area must wear mask at all times in operating rooms and in the CSSD sterile
supply room. The mask should cover both mouth and nose, and be secured to prevent venting.
Mask should be removed and discarded after each after each case, or when they become wet, they are not to be
saved for further use in the pocket or hanging around the neck. When removing a mask, untie and remove by
touching only the tapes and dispose in plastic bag provided for infected items which will be sealed and incinerated.
All persons entering the change rooms should remove their jewelry, or totally confine it within their dress.
Fingernails must be free of the nail polish, this may crack, chip and peel harboring microorganism
Gloves should be worn depending on the task performed. Gloves should be worn between patients contacts/or
handling contaminated items. Hands must be washed after removing gloves.
Additional protective attire, such as fluid resistant aprons should be worn when contact with blood or other body
fluids are not avoidable

6.1.2.6 Management of Serology Positive Case

Procedure:
Take prior information about the positive case.
Confirm about the case from the ward sister and patient’s serology report.
Take the case at the weekend or as the last case of the day.
Use disposable drape kits for the patients as well as the trolley.
The surgical team should wear plastic apron, eye wear and use double gloves.
 Handle sharp instrument carefully.
There should be and circulating nurse. One should be with gloved hand to handle contaminated things and another
for clean things
Clean all the instruments with wet swab to remove blood clots if any.
The instruments need to be sent to CSSD with appropriate color code.
Scrub the OR properly, do through cleaning of all equipments and fumigate the OR before taking the next care.
All the linen should be sent to the laundry separately in double bag with proper colour code.

6.1.2.7 OT cleaning

Equipment:
Brush, Bucket, cup, cloth, mop stick, solutions: -Fumifloor, Hypochlorite , Colin, Lysol.

Procedure:
Instruct the housekeeping staff regarding the OT cleaning and the OT staff supervises this.
Make sure that the cleaning solution is diluted in adequate concentration.
After the surgeries are over, OT should be thoroughly scrubbed including floors, walls, window glasses and
equipments.
The nurse should check in the morning whether the OT is mopped properly and should see that the corners of the
windows, glasses, doors and walls are cleaned properly.
Before starting cleaning, all the equipments should be kept out and specific care should be given to clean the wheels
before taking them inside.
Before starting surgery patient table and instrument trolleys should be cleaned with isopropyl alcohol.
Separate mop cloth should be used for each section such as sterile, clean and dirty area and the mop should be changed
every day.
The items used for infected cases should be discarded after single use.
The maintenance staff should open AC duct, and clean the AC at end of the week.
Clean the racks, which are used to keep the steam and ETO items, every day.
Every staff should be thorough with the OT cleaning protocol.

6.1.2.8 OT Equipments Setting

Equipment:
OT table, Boyle’s apparatus, diathermy machine, fibrillation, defibrillation, suction apparatus, light source, head light,
top light, anesthesia trolley, suture trolley, instrument trolley, leg trolley, Mayo trolley, basin stand, ACT machine, IV
stand, sponge stand, sitting stool, chairs, foot steps, waste buckets, x-ray viewer, saline warmers, clock.

Procedure:
All OR equipments should be grounded by wheels, easily accessible, placed in appropriate places, properly connected
and checked.
Ensure the safety of all equipments
Monitor ventilator, and make sure that the light source and heart lung machine are connected to UPS
All the wheeled equipments should be locked and kept.
Separate bins should be kept for linen, plastic paper and sharps.

Hand Scrubbing Technique followed in the OT -Purpose

To remove transient flora from the hands and forearms.
To reduce resident microbial flora to an absolute minimum.
Reagent
Povidone Iodine scrub/ Chlorhexidine scrub, elbow operated taps, water. No Cake soaps are to be used for hand washing
or hand scrubbing.

Procedure
All jewelry should be removed from the hands and forearms.
Fingernails should be cut short and free of polish; cuticles must be in good condition.
Hands and arm should be free of the open lesions and breaks in skin integrity.
All persons should be appropriately dressed in OT attire.
The procedure for a surgical scrub procedure should include but not limited.
Hands and forearms should be washed to remove gross soil and transient microbes.
Nails and cuticles washed.
Hands and arm are held up and away from your dress. Splashing of dress or footwear should be avoided.
An antimicrobial soap should be applied with friction to hands and forearms.
Hands and forearms thoroughly rinsed in clean water.
There are two methods of performing a surgical scrub.
The anatomically timed scrub.
The counted stroke method.

I. Timed stroke scrub method (5 minutes scrub):

Open the tap with elbow and wet hands and forearms.
Apply 6 drops of antiseptic agent on to hands.
Wash hands and arms several times upwards, allowing water to drip from flexed elbows.
Apply antimicrobial agent. Scrub nails and hand, half a minute for each hand.
Clean under fingernails and cuticles.
Again scrub hand for half a minute each hand, maintaining later.
Rinse the hands.
Reapply antimicrobial detergent and wash hands and arms with friction to the elbows for these minutes. Interface the
fingers to cleanse between them.
Rinse hands and arms as before.
Close tap with elbow.

II. Counted Stroke Method:

Open tap with elbows, wet hands and arm.

Wash hands and arms thoroughly to above the elbows with antiseptic agent.
Clean under fingernails and cuticles.
Rinse hands and arms under running water, keeping hands raised, allowing water to drip from elbows, avoid
splashing dress and footwear.
Apply antiseptic agent.
Scrub left hand as follows.
o The nails of one hand 10 strokes.
o All sides of the each finger 20 strokes.
o The back of the hand 20 strokes.
o The arm 20 strokes for each third of the arm, to 2 inches above the elbow.

NOTE:
Special attention to webs between fingers and creases on knuckles and elbows).
• Repeat step for the right hand and arm.
• Turn off tap with elbows.
• During and after scrubbing keep the hand higher than elbows to allow after flowing from the cleanest area, the hands
to the marginal area of the upper arms.
• If policy dictates a ten minutes scrub initially, and a five minutes scrub may be used for subsequent operations. Once
gloves are removed the hands become contaminated from contact with inanimate objects.
• Avoid splashing on your scrub dress; as moisture penetrates, contaminating a sterile gown.
• All personnel entering the OT complex should perform a 10 minutes scrub before entering the operation rooms.
• The technique of the surgical scrub is subjected to the surgeons’ preference.

6.1.3 CENTRAL STERILE SUPPLY DEPARTMENT

The process for sterilization activities has been duly documented in the departmental SOP for CSSD

The transport of Unsterile packs, trays, from operation theatres to CSSD through the sterile dumbwaiters situated
next to the decontamination zone of the CSSD.
Collection of the unsterile items from wards and ICUs to be done regularly. The items need to be washed and
packed and sent to CSSD for sterilization.
Transport the unsterile items in covered trolleys to avoid accidental spilling and reduce the possibility of injury to
transporting and receiving personnel.
In CSSD proper sterilization protocols to be followed. The sterile supplies are provided with adequate racks and
storage bins to ensure the proper storage of the sterile packs.
All needle stick injury / sharp injury to be reported.

6.2 EQUIPMENT CLEANING PROTOCOLS IN USER AREAS

6.2.1 Equipment Cleaning Protocol in ICU

Elastic bandages are changed when soakage occurs or after 8 days with a fresh bandage.
Thermometers are for individual patient use. It is cleaned with isopropyl alcohol before and after measuring the
temperature. Stethoscope is for individual patients in ICU. It should be cleaned with alcohol after use.
Suction apparatus to be cleaned with hot water and detergent, disinfected with Hypochlorite2 % for 30 mins, rinsed
with water, dried and used.
Ambu Bags washed every 48 hours or after each patient with soap and water and disinfected with Cidex OPA 10
mins and rinsed with water and packed.
NIBP cuff & Alpha beds are cleaned with isopropyl alcohol before & after use.
Dishes & Cutlery to be cleaned with warm water and detergent and to be kept dry.
Kidney Trays wash with soap and water. Disinfect with Hypochlorite2 % for 30 mins, rinsed with water, dried and
used.
Urine cans wash with soap and water, dried properly and then given to the patient. They are dedicated to each
patient.
Bed pans are washed with soap and water.
Cots, cardiac tables, base of ventilators, wheel chairs, patient trolleys are cleaned with Hypochlorite solution daily
basis. Washing with soap and water & disinfection is done whenever there is gross soiling.
Humidifiers are cleaned with Isopropyl alcohol and sterilized by ETO or washed with soap and water and sterilized
by steam once in 24 hrs for adult cases and 72 hours for pediatrics cases.
Other areas are cleaned with alcohol before each case.
Flow sensor surface cleaned everyday with Hypochlorite
 Oxygen masks & hoods are washed with soap & water, dried every shift/SOS.
Spiro meters are for individual patients- to be cleaned with alcohol swab before use.
Warmer bed cleaned with and side rails are washed with soap and water everyday
Ventilators & monitors are cleaned every day with Hypochlorite
Ventilator tubings to be changed after every 72 hours and sent to CSSD for cleaning and sterilization.
Syringe pumps Surface cleaning with Bacillol every day.
Parental nutrition fluids Hang time not more than 24 hours.
IV Fluids stand to be cleaned with Bacillol everyday.
Side rails to be cleaned with Bacillol before using.
Mattresses to be cleaned after each patient – wipe with Bacillol.
Laryngeal blades are washed with soap and water and cleaned with Isopropyl alcohol for 5-10 minutes and keep it
dry in a box.
Crash cart is to be cleaned with Bacillol everyday.
Dressing trolley is to be cleaned with Bacillol every 24 hours.
Telephones & Computer key boards are to be cleaned with Isopropyl alcohol every day.
Endoscopes are to be washed with sterile distilled water and disinfected with Cidex OPA for 12 minutes.

6.2.2 Equipment Cleaning Protocol in Wards

Syringe pumps, IV line stand, Stethoscope, BP apparatus, Thermometers, suction apparatus and 02 flow meter-
Outer surface should be cleaned with Bacillol.
Drug trolley if any should be washed with detergent and dried.
General Items:
Wooden Cots, Sofa, cupboards, Doors, Cardiac table and electrical switches should be dry mopped.

Iron Handles of doors and cupboards and Cot key should be cleaned with soap and water and dried.
Curtains, bed sheets, blankets, pillow covers should be sent immediately to the laundry for washing.
Water resistant top of the Mattress should be cleaned with soap and water, subsequently wipe with 70% isopropyl
alcohol. Soggy pillows should be replaced with new once otherwise wash it and dry thoroughly.
Canteen Utensils should be sent immediately to the canteen for washing.

Phone instrument along with the receiver should be cleaned with Bacillol.
Steam Inhalers should be cleaned with soap and water.
Washbasin handles and taps should be cleaned with soap and water.
The plastic covering of the remote control of the television set has to be replaced with a new plastic cover.
Floor and the wall should be cleaned with detergent and 0.025% Lizol.
Window glasses should be cleaned with Colin spray.
Bedpans and urinals should be emptied, cleaned with soap and water and dried.
All the above precautions should be taken immediately after the patient is discharged.

6.2.3. Protocol for using disinfectants in wards, critical care area & CSSD

1. The hospital Infection control committee has approved the following disinfectants for the usage in the hospital:
a. Benzalkonium chloride (0.025 % Lizol)
b. Cidex OPA
d. Hypochlorite 1% cleaning floor and surfaces.
e. Hypochlorite 2% for Disinfection of suction bottles and kidney trays.
f. Bacillol
 2 The disinfectants will be used in rotation to avoid the resistance of the resident
Organism
3 The disinfectants will be used in the following concentration
a. Non-critical areas - 0.025% Lizol.
b. Critical areas - 1% Hypochlorite

4 Before the usage of the disinfectants the liquid soap is used in the following
concentration: 50 ml of liquid soap must be mixed in 10 liters of water in all the areas.

6.2.4 Protocol for monitoring house keeping activities

1. The house keeping activities are monitored on day to day basis by the supervisors with a check list. The infection
control personnel monitors once in month.
2. The house keeping activity inside the room is monitored randomly [not documented] by the infection control
personnel in respective area.
3. Capacity testing is done on a randomly collected in use disinfectant once a month
4. Biomedical waste disposal is monitored and recorded once in a week.
5. Transportation of biomedical waste done by the housekeeping dept is monitored and recorded once a week.

6.3 INFECTION SURVEILLANCE PROGRAMME

Surveillance encompasses the collection, collation analysis, interpretation and dissemination of the relevant data
related to actual HAI or the risk for the same. Under the hospital infection control program “surveillance” shall cover
clinical conditions of infection, microbiological causes of such infections and the microbiological surveillance of the
hospital environment.

The surveillance for clinical infections acquired in the hospital may be passive or active. Passive surveillance
consists of the reporting of any occurrence of suspected HAI by the clinicians. Active surveillance, on the other hand is
the systematic collection of data by a designated surveillance team.

6.3.1 Active surveillance:

• Whenever clinicians suspect the occurrence of HAI it shall be reported to the Chairperson of the HICC. Details
regarding the patients, all procedures, medications with details of duration dates etc. should be communicated.
• No single standardized protocol is recommended for the investigation of an outbreak of HAI.
• Passive clinical surveillance will be correlated to relevant microbiological information by investigator and action
taken.
• The Microbiology department shall be responsible for reporting any information about infections suspected to have
been acquired in the hospital.

6.3.2 Passive Surveillance of HAI

• A hospital infection surveillance team will be necessary to establish and maintain ongoing active surveillance of HAI.
The recommended team shall consist of the HICO assisted by infection control nurses.
• The suggested clinical units for active surveillance include surgical wards, Adult ICU, Pediatric ICU, and CCU. The
clinical surveillance data shall be correlated with relevant microbiological data.

6.3.3 Passive Surveillance activities carried out by HICC:

OT swabs are taken every week after fumigation.
 ICU swabs are taken randomly.
Water from the critical care areas are taken for culture every month
Validation of alcoholic hand rub solution is done once every quarter.
Air sampling in the OT is done once in a month by settle plate method.
Swabs of the health care workers are taken randomly when ever suspected.
All the cultures taken from the patients are correlated with the surveillance
swabs cultures.
Hand scrubbing compliance in OT and hand hygiene compliance in ICU’s &
ward are monitored on a daily basis (10 observations/ day).
Infection risks determined by the surveillance cultures are eliminated by taking
appropriate measures like disinfecting the area or removing the source of
infection.
Infection control team members collect surveillance data on a day-to-day basis, compile and communicate the same
to Infection Control Officer.

Data communicated by infection control team is verified by E.g., Examining a particular patient or a group of patients
infected and assessing the cause or route of infection, Random checking for chlorine levels and waste management.

6.3.4 Microbiological Surveillance of The Hospital Environment

Studies have shown that this is a wasteful exercise when carried out in the absence of specific infections
transmissible through the environment. A well-run housekeeping department with regular, methodical cleaning practices
of the environment should be able to keep environment-transmitted infections under control.

6.3.4.1 Protocols for Water Sampling

• The task will be carried out by one of the members of the infection control team.
• The sampling will be done once in once a month

6.4 INFECTION CONTROL PRACTICES

6.4.1 Catheter Associated Urinary Tract Infections

Foleys catheters to be inserted aseptically.
Foley’s catheters are to be changed every 15 days ICU . In chronic patients change of catheter is done if necessary.
Outer surface of the catheter is to be cleaned with a Betadine swab every 8 hours.
Urobags are to be emptied once in 8 hours or as and when required by the staff with gloves on.
Urobags are to be changed every 7th day.
Any case of fever/urinary tract irritation, mid stream urine sample or catheters sample should be sent for culture in a
sterile container
Record of UTI is made in surveillance register. UTI infection rates are calculated on monthly basis.

Strategies for Urinary Tract Infection Prevention

Indwelling urinary catheters should be inserted using aseptic technique and sterile equipment.
Only hospital personnel who know the correct technique of aseptic insertion and maintenance of the catheter should
handle catheters.
Indwelling urinary catheters should be inserted only when necessary and left in place only for as long as necessary.
Other methods of urinary drainage such as condom catheter drainage, suprapubic catheterization, and intermittent
urethral catheterization should be considered as alternatives to indwelling urethral catheterization.
Hand washing should be done immediately before and after any manipulation of the indwelling urinary catheter site
or apparatus.
 A sterile, continuously closed drainage system should be maintained.
The catheter and drainage tube should not be disconnected unless the catheter must be irrigated, and irrigation
should be used only for suspected obstruction.
If breaks in aseptic technique, disconnection, or leakage occur, the collecting system should be replaced using
aseptic technique after disinfecting the catheter-tubing junction.

Specimen collections should be obtained from the distal end of the catheter, preferably from the sampling port after
cleansing with a disinfectant and then the urine specimen aspirated with a sterile needle and syringe. Clean the outer
surface of the catheter, collect 1 ml of urine using a thin gauge needle and 1 cc syringe.

6.4.2 Respiratory Tract Infections

Patients on ventilators, long standing endotracheal intubation and tracheostomies are subjected to.
i. Suctioning using sterile disposable suction catheters as per suction protocol given by Intensivist.
ii. Monitoring signs of lung infections using X-Rays on daily basis along with other clinical and laboratory
parameters.
iii. ET secretions/BAL /Tracheal aspirates are cultured when indicated.
iv. Preventive measures:
Humidifier are changed every 24 hrs in ICU.
Ambu bags are changed 48 hrs.
Humidivent & Catheter mount are changed everyday or SOS in ICU.
Tracheostomy tubes are changed 15 days/ SOS
Surface cleaning of ventilators every day using Bacillol.
Changing ventilator tubings every 72 hrs.
Suction apparatus is emptied washed and disinfected as and when required as per the protocol.
Changing expiratory valve every 72 hours or once the patient is extubated.
Oxygen mask/hood cleaned every day.
Kidney trays used for suction is changed every 24 hrs.
Diaphragm of the expiratory valve is cleaned with Bacillol for every case.
A record of RTI is maintained in surveillance register, and RTI rates are calculated every month. vi. Ventilator
bundles checklists are filled for all patients on ventilator for more than 48 hrs.

Guidelines for Prevention and Management of Hospital-Associated Pneumonia

Hand hygiene as an essential component of hospital-associated pneumonia reduction.
Respiratory care with encouragement of deep-breathing exercises.
Head-of-bed elevation to between 30 and 45 degrees.
Daily assessment of readiness for extubation.
Control of oral-tracheal secretions and oral care to minimize colonization and aspiration of biofilm.

6.4.3 Catheter Related Blood Stream Infection

• Peripheral line set is changed every 72 hours
• Jugular vein should be preferred over subclavian and femoral for less chances of infection
• Arterial line site is changed after 7th day in adults / 10th day in pediatrics.
• CVP lines site is changed after 7th day in adults / 10th day in pediatrics.
• Aseptic precautions is taken to put any lines
• Swelling , redness, oozing at the site of insertion is addressed immediately
• Soiling at the site of insertion is cleaned with spirit swab
• Blood & CVP/Arterial tip Cultures is sent in case of suspicion of infection
• Cultures are correlated with the environmental swab culture results and source of infection is eliminated.
 Strategies for Central Line Infection Prevention
• Education and training should be provided for staff that insert and maintain intravenous lines.
• Maximal sterile barriers should be used during catheter insertion (cap, mask, sterile gown and gloves, and a large
sterile drape).
• A 2% chlorhexidine preparation is the preferred skin antiseptic, to be applied prior to insertion.
• Replace peripheral intravenous sites in the adult patient population at least every 96 hours but no more frequently than
every 72 hours. Peripheral venous catheters in children should be left in until the intravenous therapy is completed,
unless complications such as phlebitis or infiltration occur.
• Replace intravenous tubing at least every 96 hours but no more frequently than every 72 hours.
• Replace central line dressings whenever damp, loose, or soiled or at a frequency of every day for fix pore dressings.
• Avoid use of antibiotic ointment at insertion sites because it can promote fungal infections and antibiotic resistance.
• Include daily review of line necessity.

6.4.4 Surgical Site Infections

The personnel involved in preparing the surgical area are trained at the time of employment about infection
control practices in the hospital. They are provided with disposable razors for each patient. The used sharps are disposed
according to the prevailing local biomedical waste management rules into puncture proof sharps containers. The
appropriate personal protective wears have to be worn while preparing the parts and care to be taken while disposing
sharps. Separate shaving sets are maintained for serology positive cases.

Surveillance is done regarding patients with oozing, pus discharge, swelling at chest wound site, graft site, CVP site,
drainage tube site, arterial site. Cases with oozing, pus discharge, swelling are subjected to C/S of appropriate sample
and treated accordingly. Infected cases are isolated and treated.
Separate dressing trolley/ tray, stethoscope; BP apparatus is used for such cases. Dressing of wounds has to be done
aseptically every day using sterile dressing, spirit and Betadine solutions. Hand rub containing isopropyl alcohol
surgical spirit and glycerin is used before and after doing dressing.
A record is maintained in surveillance register. Statistics are done every month regarding infection rate, organisms
isolated and their sensitivity pattern. The results are communicated to the doctors and nursing staff for appropriate
action. Surgical site infection prevention bundle checklist is adopted for surgical cases.
6.5 Infection control protocol in obstetrics and labor room
Policies regarding admission of pregnant women with infection
1. Pregnant women suffering from infections

Not in labor – Admitting In ward/ isolation, just as one would admit a non pregnant women with similar illness.

In labor – Admit to isolation side of the labor room.

2. Indications for admission to isolation side in labor room

Pregnant women with at least 22 weeks of gestation and in labor with:
Hepatitis A, E or unknown
Diarrhea (severe, watery, with blood and mucus)
Known infection with a blood borne pathogen
Suspected or confirmed communicable disease requiring isolation.

Labor room

House keeping has to be meticulous

Clean the floor at least 4 times in 24 hours. One of this should be detergent and disinfectant and copious amount of
water
 Any spill of the blood or fluids should be immediately disinfected with sodium Hypochlorite 1%, mop dry and then
clean thoroughly with detergent and water

Strip the bed and wipe clean with detergent and water after each patient and then with isopropyl alcohol. Wear gloves
for this procedure

Use fresh linen for each patient.

6.6 ANTIBIOTIC POLICY:

Antimicrobials are handy tools in curing and preventing the spread of infections. The irrational usage of antimicrobials
(antibiotics) has however led to development of large-scale resistance to many frequently used drugs. Many
antibiotics are available as ‘over the counter’ drugs, which has further accentuated the problem. The lack of a stringent
law in this regard can be attributed as an important cause for this situation.

6.6.1. Respiratory tract infections:

Condition Pathogens Antibiotics

Acute pharyngitis Group A ß-hemolytic 1. AmoxycillinClavulanic acid
Streptococci 2. In penicillin allergic patients,
Azithromycin
Acute epiglotitis H.influenzae Ceftriaxone
Ludwig’s angina Polymicrobial 1. Penicillin +/- Metronidazole
2. Clindamycin/Metronidazole/Amoxycillin
clavulanate
Acute bacterial S.pneumoniae 1. Amoxycillin Clavulanate
rhinosinusitis H.influenzae 2. Doxycycline
M.catarrhalis
Acute bacterial S.pneumoniae 1. Amoxycillin Clavulanate
exacerbation of COPD H.influenzae 2. Doxycycline
M.catarrhalis 3. Azithromycin
4. Levofloxacin
Pneumocystis carinii P.jeroveci Co-trimoxazole
pneumonia in AIDS

6.6.2.Community acquired pneumonia (IDSA guideline 2008 )

Condition Pathogens Antibiotics

Community S.pneumoniae No comorbidities/risk 1. Azithromycin/

acquired Enterobacteriaceae factors Clarithromycin
pneumonia H.influenzae 2. Doxycycline

Comorbidities * 1.Fluroquinolones
(levofloxacin /Moxifloxacin)
Based on CURB -65 criteria 2. Amoxycillin clavulanate+
Azithromycin / Clarithromycin

Inpatient Non ICU 1. Fluroquinolones

 2. Ampicillin + Azithromycin /
Clarithromycin

Patient in ICU 1. Ampicillin sulbactum +

Levofloxacin / Azithromycin
Penicillin allergic patients –
Aztreonam + Levofloxacin
2. Pseudomonas – Cefipime +
Levofloxacin / moxifloxacin
3. MRSA – Vancomycin
Linezolid

Comorbid conditions:
7.2.1.1 Chronic heart/ lung/ liver / renal disease
7.2.1.2 Diabetes mellitus
7.2.1.3 Alcoholism
7.2.1.4 Malignancy
7.2.1.5 Asplenism
7.2.1.6 Immunosuppressant
7.2.1.7 Antimicrobials in last 3 months

Note:
Antibiotics to be given within 1 hr of admission
Duration of therapy – Minimum of 5 days

6.6.3.Ventilator associated pneumonia / Hospital acquired pneumonia/ Health care associated pneumonia (IDSA
guideline 2008)

Condition Pathogens Antibiotic

Early onset VAP  . Streptococcus 1. Ampicillin-sulbactum
( < 4 days & No risk pneumoniae Or
factors for MDR  H. influenzae 2. Levofloxacin
pathogens )  MSSA Or
 Antibiotic sensitive, 3. Ertapenem
aerobic GNB( E.coli,
Klebsiella, Proteus,
Enterobacter )
Late onset VAP MDR pathogens Antipseudomonal cephalosporin
( > 4 days or with (Ceftazidime/ Cefipime)
risk factors* for  Pseudomonas, or
MDR pathogens) Acinetobacter Antipseudomonal carbapenem
 ESBL Klebsiella ( Imipenem/ Meropenem )
 MRSA +
Antipseudomonal quinolone
(Levofloxacin)
or
Antipseudomonal aminoglycosides
 (Amikacin/Gentamycin / Tobramycin )
Vancomycin / Linezolid

Risk factors:
Antimicrobial therapy in last 90 days.
Hospitalization for 5 days or more
High frequency of antibiotic resistance in community/ hospital
Immunosuppressive disease or therapy
Presence of risk factors for HCAP like home infusion therapy, chronic dialysis in last 30 days, home wound
car, residence in nursing home or extended care facilities, hospitalization for 2 days or more in preceding
90 days and family members with MDR pathogens

Note:
Antibiotics to be given within 1 hr of admission
Duration of therapy – minimum of 5 days
For Pseudomonas & Acinetobacter spp – antibiotics given for minimum of 14 days

6.6.4.Sepsis:
Condition Pathogens Antibiotics
Community acquired ( Ecoli, Klebsiella, 1. Ceftriaxone + Metronidazole
no specific pathogen) S.pneumoniae, 2. Ceftriaxone + Metronidazole +
1. Non life threatening N.meningitidis Amikacin
2. Life threatening 1. Cefipime + Vancomycin + Amikacin
2. Meropenem/Imipenem +
Vancomycin
Hospital acquired Follow VAP/HCAP therapy guide
sepsis Follow pyelonephritis therapy guide
1. Due to 1. Vancomycin/Teicoplanin/Linezolid +
pneumonia Cefoperazone sulbactum +/-
2. Due to UTI antifungals
3. Line 2. Vancomycin/Teicoplanin/Linezolid +
associated Cefipime +/- Antifungals

6.6.5.Cardio vascular system:

Condition Pathogens Antibiotics

Infective endocarditis Penicillin sensitive CP x 4 wks or
(native valve ) Strep.viridans Ceftriaxone x 4 wks or
CP + Gentamycin x 2 wks
Enterococcus CP or
Penicillin intermediate Ampicillin + Gentamycin x 4-6 wks
Strep.viridans
Culture negative Ampicillin + Gentamycin x 4 wks
Infective endocarditis MSSA Cloxacillin +
 Gentamycin x 6 wks
MRSA Vancomycin +
Rifampicin+
Gentamycin x 6 wks

6.6.6. Infective endocarditis –Prophylaxis

Dental procedures

Oral antibiotics Parenteral antibiotics

Amoxycillin 2 g 1 hr before procedure Ampicillin 2 g iv/im 30 min before procedure

Allergic to penicillins Allergic to penicillins

Cephalexin 2 g 1 hr before procedure or Cefazolin 1 g iv/im 30 min before procedure

Clindamycin 600 mg 1 hr before procedure or or
Azithromycin 500mg 1 hr before procedure Clindamycin 600mg iv/im 30 min before
procedure

Gastrointestinal & Genitourinary procedures

High-risk patients

Ampicillin 2 g + Gentamicin 1.5 mg/kg iv with in 30 min of procedure

6 hrs later : Ampicillin 1 g iv/im or

Amoxycillin 1 g orally

Allergic to penicillin :
Vancomycin 1 g iv over 1 to 2 hrs before the procedure +
Gentamicin 1.5 mg/kg iv
Moderate risk patients

Amoxicillin 2 g orally 1 hr before procedure or

Ampicillin 2 g im/iv 30 min before procedure

Allergic to penicillins :
Vancomycin 1 g iv complete infusion with in 30 min of procedure

6.6.7.Febrile illnesses:

Condition Pathogens Antibiotics

Typhoid fever S.typhi 1. Ceftriaxone
 S.paratyphi A & B 2. Ofloxacin
3. Chloramphenicol
4. Cotrimoxazole
Leptospirosis Leptospira interrogans 1.Crytalline penicillin
2. Ceftriaxone
3. Doxycycline
Scrub typhus Doxycycline
Spotted fever Doxycycline

6.6.8.Gastro intestinal and intraabdominal infections:

Condition Pathogens Antibiotics
Amoebic dysentry E.histolytica Metronidazole x 10 days
Bacillary dysentry Shigella species Ciprofloxacin x 3 days only in patients with
severe symptoms and imuunocompromised
patients
Acute cholecystitis Enterobacteriaceae 1. Ceftriaxone + Amikacin +
and Cholangitis Anaerobes Metronidazole
2. Clindamycin + Amikacin
3. Imipenem /Meropenem
Cholera Vibrio cholerae Doxycycline
Spontaneous bacterial Enterobacteriaceae 1. Ceftriaxone / Cefotaxime
peritonitis (mainly E.coli ) 2. Piperacillin – tazobactum
Anaerobes 3. Ertapenem

Intra-abdominal Enterobacteriaceae 1. Ceftriaxone + Amikacin +

abscess & Peritonitis Enterococcus Metronidazole
secondary to bowel Bacteriodes fragilis 2. Piperacillin –tazobactum
perforation 3. Ertapenem
Amoebic liver abscess E.histolytica Metronidazole x 10 days followed by
Diloxanide furoate x 10 days
C. difficile colitis C. difficile Metronidazole

6.6.9.Skin and soft tissue infections:

Condition Pathogens Antibiotics

Necrotizing fascitis Group A Streptococcus 1. Amoxycillin Clavulanate +
Polymicrobial Clindamycin + Ciprofloxacin
2. Clindamycin +
Amikacin/Netilmicin
3. Linezolid
Cellulitis Streptococcus pyogenes 1. Amoxycillin clavulanate +
Staphylococcus aureus Metronidazole /Clindamycin
2. Linezolid
Decubitus ulcers/ Staphylococcus aureus 1. Cloxacillin x 7 -10 days
 Diabetic foot Polymicrobial – S.aurues, Amoxyclav + Amikacin/Netilmicin +
(moderate to severe) Group A Streptococcus, Metronidazole/ Clindamycin
Gram negative bacilli and
anaerobes
Surgical site infections M.fortium Clarithromycin +
caused by atypical M.chelonei Ciprofloxacin +
mycobacteria M.abscessus Amikacin x 3 months

6.6.10.Central Nervous system infections:

Condition Pathogens Antibiotics –I line

Community acquired Strep. pneumoniae CP
acute bacterial N.meningitidis Penicillin intermediate susceptible –
meningitis Ceftriaxone
Penicillin resistant – Ceftriaxone +
Vancomycin
Brain abscess Enterobacteriaceae Ceftriaxone + Metronidazole
Anaerobes

Head & Neck injuries 1. Benzyl Penicillin + Metronidazole

+/- Amikacin
2. Ceftriaxone +/- Metronidazole
+/- Amikacin

6.6.11.Urinary tract infections:

Condition Pathogens Antibiotics

Acute uncomplicated E.coli 1. Ciprofloxacin / Ofloxacin
cystitis 2. Cefixime/ Cephalexin/ Cefuroxime
/ Cefadroxil
3. Co-trimoxazole
4. Nitrofurantoin
Uncomplicated E.coli 1. Cefipime
pyelonephritis Enterococcus 2. Piperacillin tazobactum
3. Amikacin /Netilmicin
Complicated UTI E.coli 1. Cephalosporins +
P.aeruginosa Amikacin/Netilmicin
Protues 2. Piperacillin tazobactum +
Klebsiella Amikacin/ Netilmicin
3. Meropenem +
Amikacin/Netilmicin
CAUTI Gram negative bacilli Treat according to antibiotic
sensitivity report, only when patient
has severe symptoms
6.6.12.Obstetrics and Gynecology

Condition Pathogens Antibiotic

1. Cefoxitin + Doxycycline
C.trachomatis 2. Gentamycin + Clindamycin
Pelvic inflammatory N.gonorrheae 3. Ampicillin sulbactum +
disease G.vaginalis Doxycycline
Anaerobes 4. Ceftriaxone + Doxycycline
with/without Metronidazole

Group A ßhemolytic
Respiratory tract Streptococci 1. Amoxycillin
infections S.pneumoniae 2. Ampicillin
M.catarrhalis

1. Amoxicillin
2. Ampicillin
Urinary tract infections Enterobacteriaceae
3. Nitrofurantion
4. Oral cephalosporins

6.6.13.Bone and joint infections:

Condition Pathogens Antibiotics
Acute osteomyelitis Staph.aureus Selected depending on culture report

Septic arthritis Staph.aureus 1.Cloxacillin

2. Vancomycin/ Linezolid

Prosthetic joint Selected depending on culture report

infections

6.6.14.GUIDELINES FOR THE USE OF ANTIMICROBIALS IN SURGICAL PROPHYLAXIS

6.6.`4.1.Abdominal surgeries
Condition
Clean surgeries
Gastric surgeries
Biliary tract surgeries
Penetrating trauma abdomen
Abdominal surgeries - if intra-
operative decision in Tuberculosis
Antibiotic
Single dose of Cefuroxime
Cefuroxime
1. Cefuroxime
2. Amikacin + Cefuroxime (in biliary spillage )
Ceftriaxone + Amikacin + Metronidazole
Ofloxacin + Streptomycin

6.6.14.2.Orthopedics surgery

Condition Antibiotic Duration

 Elective surgeries Cefipime 1gm, at the time of induction, thereafter
12th hourly for next 72 hours.
Joint replacement Cefipime 1gm, at the time of induction, thereafter
surgeries 12th hourly for next 72 hours.
Short procedures Ceftriaxone Single intra-operative dose
Open cases involving Cefipime + Metrogyl If wound soakage present, antibiotics
head and neck given for 5 days
Antibiotic given for 3 days if there is no
wound soakage

6.6.14.3.Obstetrics & Gynecology

Condition Antibiotic Duration

Obstetrics 1. Amoxycillin 5 – 7 days
(vaginal delivery) 2. Ampicillin
3. Amoxicillin clavulanate
Premature rupture of 1. CP 5 days
membranes (PROM) 2. Allergic to penicillins,
Gentamicin or
Ceftriaxone
Caesarean section 1. Amoxicillin cloxacillin 5 days
2. Amoxicllin clavulanate
3. Ceftriaxone
4. CP + Metronidazole
Gynecology 1. Amoxicillin cloxacillin 5 days
(Minor and major 2. Ceftriaxone
surgeries ) 3. Amoxycillin clavulanate

6.6.15 RESTRICTED ANTIBIOTICS

Empiric therapy of the following antimicrobial agents will be avoided: These agents may be called
Restricted Usage Antimicrobials.
1. Meropenem
2. Imipenem-Cilastatin
3. Teicoplanin
4. Rifampicin (other than for Mycobacterium)
5. Chloramphenicol
6. Polymixin – B.
7. Vancomycin
8. Linezolid
9. Amphotericin – B
10. Voriconazole
11. Caspofungin

Any other drugs passed by HICC to be on this list or may be struck off from the list. Such drugs are to be used
only under extraordinary life threatening conditions for empirical therapy.

An antimicrobial escalation form will be filled by the treating doctor clearly mentioning the details of the patients
and reasons for escalation and get the same approved by the Infection Control Team. Infection Control Team would be
notified by the Pharmacy within 48 hours of such drugs being dispensed.

6.6.16: Surveillance of the Antibiotic Policy –

• HICC Chairman / Infection Control Officer Checks for antibiotics used prophylactically for various
surgeries.
• If higher antibiotics are started for any patient from day 1 of surgery- it will be discussed with Intensivist and
surgeon.
Request form for antibiotic escalation is used giving the details of the patient and reasons for escalation.
• De-escalation of antibiotics done if the clinical condition of the patient improves

6.7 HIC POLICY FOR CASUALTY

I] Patients coming to Casualty need to be taken care of using standard precautions for
prevention of blood borne viral infections.

2] Patients referred from other hospitals need to be assessed clinically and to be isolated if any infection is suspected
.Appropriate cultures need to be sent and isolation continued till the culture results are available for further action.

3] Patients referred from other hospitals with lines & catheters: Lines & catheters need to be changed once the patient’s
condition is stabilized.

4] Patients received from other hospitals on ventilation: ET secretions need to be sent for culture to rule out the presence
of MDR bacterial colonization

5] Hand washing needs to be done as per the protocol and at required instances-after entering the CCU , before and after
touching the patient or doing any procedure , in between examining two patients , in between touching clean and unclean
parts of a patient , before leaving the CCU, gross soiling of hands.

6] Alcohol based hand rubs can be used in the said circumstances as for hand washing.

7] Equipment: Stethoscope, syringe pumps, BP apparatus, IV fluids stand, Ventilators, monitors, bed railings need to be
cleaned with Bacilloll every shift.

8] The crash cart, dressing trolley, Intubation’s Trolley & CVP tray needs to be cleaned every shift with Bacillol
avoiding the electrical points.

9] Computer key board needs to be cleaned with spirit swab. The other parts of the computer need to be dry mopped with
a clean cloth.

10] ECHO machine needs to be cleaned using clean dry cloth everyday.

11].Suction bottles, kidney trays need to be handled with gloved hands, washed with soap
and water, disinfected with 2% Sodium Hypochlorite for 30 mins, rinsed with water and used. Urine cans are washed
with soap and water.

12] Cots, base of cardiac tables and ventilators are to be cleaned with Bacillol every shift and after shifting the patient.

13] Patients trolley, wheel chairs are to be cleaned with Bacillol.

 15] Biomedical waste disposal is to be done as per the protocol.

16] Triage area needs to be cleaned thoroughly as and when possible /after shifting the patient.

17] Medicine trolley needs to be cleaned everyday with Bacillol after every patient.

18] ECG machine and cables are to be cleaned with Isopropyl alcohol everyday.

19] Mobile suction apparatus has to be cleaned with Isopropyl alcohol on outer surface and the bottle with the liquid
waste as per the protocol.

20] Oxygen cylinder and trolley need to be cleaned with Bacillol on daily basis.

21] NIPPI machine and mask need to be cleaned everyday with Bacillol and after using for a patient.

6.8 INFECTION CONTROL PROTOCOLS & PRACTICES FOR OTHER (NON HIGH-RISK) AREAS

6.8.1 Protocols for Laundry and Linen

A. Collection: -
1) Removal of used/contaminated linen from OT, ICU wards, laboratories: sisters who are changing bed
sheets and pillow covers, patient apparels should wear cap, mask and gloves.
2) Bed sheets should be stripped from the bed with care taken not to shake the linen during this action.
3) Bed sheets should be rolled away and folded in the ward into a bundle.
4) Handle other linen like blankets; towel patient clothing, personal clothing, and uniforms, scrub suits
gowns, drapes with minimal agitation.
B. Place the contaminated linen in containment area. (In appropriate hampers) Leak resistant
plastic bags to be used for wet linen.

C. Segregation:
1) Segregation has to be done in containment area.
2) People segregating the linen should wear cap, mask & gloves.
3) The infected linen should be segregated, double bagged (MDR, HIV, HBSAG + HCV +) separately
and labeled with appropriate colour code, area, date, description and number of linen.
D. Transportation: -
1) Transport these bags in dedicated trolleys to dispatch area.
2) Contaminated linen will be transported in a vehicle, having a facility to
keep infected and non infected linen separately.

E. Treatment:

Linen cleaning is in the laundry.

F. Clean Linen is transported in hospital premises in dedicated trolleys to the store /area and distributed.

Process in S P Multispeciality Hospital:

Handling of Clean Linen.

1. Clean linen: Clean linen received from the laundry is transported in a dedicated trolley to the department and
stored in cupboards or racks for distribution.
2. Any damaged linen is identified, repaired and used or condemned.
3. Soiled linen: Collection, transportation of soiled linen is done using mask, gloves and apron if required. Used
disposable linen is discarded in double appropriate color code r bags other contaminated linen is segregated, counted,
put in double appropriate color code plastic bags, labeled with appropriate color code, date, area and description of
 type of linen and number, sent to dispatch area.
4. The hospital staff, housekeeping staff and laundry staff is trained for usage of PPE for clean, soiled and infected
linen.
5. Dedicated trolleys are used for clean and soiled linen.

Scrub Suites & aprons:

Clean linen is received by 7.30pm from the laundry, transported in dedicated trolley and stored in clean cupboards
or racks.

Soiled scrub suits and aprons are collected from different areas by linen and laundry staff between 8am to 9 am
.PPE used by the staff during this process. It is transported to the laundry at 9.15 am.

Linen from OPD areas is collected by housekeeping staff using PPE, transported to dispatch area in a dedicated
trolley, counted by Linen and laundry person and sent by 10 am to laundry.

Clean linen is delivered to all areas at 7.30 to 8.30pm. Record is maintained by Sister In
charge in respective area.

Soiled linen from the wards ,ICU ,OPD are collected by laundry boy between 7.30 to 8.30 am
floor wise , transported to dispatch area , counted using PPE and sent to laundry, counted and
transported using PPE to dispatch area and sent to the laundry.

Note: Infected linen will be handled in all the areas as per the policy.
6.8.2

Kitchen – The medical check and De-worming is done on employment and every 6 months
The persons working in dietary department should
Wear clean, neat, uniform and appropriate clothing for work
Wear shoes with closed toes, closed heels and safety soles.
Wear caps or hairnets.
Wear aprons and change them immediately when soiled.
Not wear jewelry on hands except wristwatch, wedding band and earrings.
Remove all jewelry on hands during hand washing and food contacting.
Practice good personal hygiene (trimming finger nails, not to use nail polish)
Follow strict hand washing procedures before, between and after handling food handling trays, equipments and
supplies.
Gum chewing, use of snuff and smoking are not permitted.
Injuries and suspected infections are reported immediately.
Food is held at proper temperature during storage and service.
Expired products immediately separated from general storage and returned for credit or destroyed.
Serve food is covered during transport
Left over food is discarded
Refrigerated items are stored in covered containers with labels and dates Floors and walls are cleaned periodically
Food and chemicals are stored separately

• Medical check-up is done once in 6 months and the staffs are de-wormed.

6.8.3 Engineering Controls

a. The engineering and the maintenance department always works in liaison with
the infection control department
 b. Any construction planned in the hospital is informed to the infection control
officer to make the requisite arrangements
c. The chlorine level of the water is checked every day in all critical care areas to
ensure the condition of the chlorine pump.
Monitoring of chlorine content in water is done by the infection control nurses using a Chloroscope- a colour
ladder comparator on a daily basis in the patient care areas and is maintained at 2 ppm. In case of a reduced
content of chlorine, the infection control nurses alert the Infection Control Chairman/ Infection Control
Officer and the Maintenance department to correct the same. A record of the daily monitoring is maintained
by the infection control nurses in their respective area.
Test procedure:
Rinse the test jar with sample water.
Add 5 drops of reagent OT-1 in the test jar.
Add to the test jar, sample water to make up to 10mL mark.
Wait for 2 minutes. A yellow colour will develop at this stage.
Transfer the water into the empty compartment of the chloroscope comparator.
Hold the chloroscope against light and match the colour of water with that of the chloroscope color ladder through
the observation window by sliding the comparator up and down.
Note the step number at which the colour matches.
Read the total chlorine residual content in ppm directly on the chloroscope.

d. Sinks used in the critical care area are checked for working condition.
e. The overhead tank is cleaned once in quarter and the underground tank once a
year, using the following protocol:
A circular has to be sent one day in advance for the same.
The walls and floor of the tank is scrubbed with a wire brush and then disinfected with bleaching powder, by
personnel wearing heavy duty gloves, masks, hair cove, goggles, gum boots and plastic apron.
The dirty water should be drained separately.
A final water wash has to be done and drained separately.
Fresh clean water should be supplied to the tank, chlorinated and released for use in the hospital.
A record of the same should be maintained in the department.
f. The temperature in the OTs is maintained at 20±20 C and humidity between 45-
55%.
g. Room temperature in the ICUs is maintained in the range of 22-240 C.

Protocol for cleaning the filters of the AHU, AC and HEPA filters:
1. AHU pre-filters should be cleaned with a blower once in 15 days. The persons cleaning the filters should use
appropriate PPE and transport the filters in a yellow coloured plastic cover to the area of cleaning.
2. The cleaning should be done preferably on Sunday.
3. Prior to cleaning kindly switch off the AHU, this should prevent the passage of unclean air into the hospital
environment.
4. Switch on the AHU once the whole process is complete.
5. A record for the same has to be maintained by the maintenance dept.
6. The pre-filters are to be changed as and when required or at least once a year.
7. AHU fine filters are cleaned once in a month with a blower.
8. AHU maintenance is done once quarterly in-house and the record will be with the maintenance department.
9. HEPA Filters in the OTs are changed on a regular basis and a record of the same is maintained by the AC
engineer.
10. Air changes for OTs and ICUneed to be done once in a year.
11. OTs also requires a particulate count to be done on a yearly basis.
 12. The AC ducts of critical care areas are cleaned with the vacuum cleaner once in a month/ during unit cleaning.

6.9. NOTIFIABLE DISEASES

Notifiable Diseases (Reportable Diseases): Diseases that must be reported to state or local
Health officials when diagnosed.
Infection Control Team members report the incidents of notifiable diseases to the Chairman/ Infection Control In
charge on a day-to-day basis. The Chairman / Infection Control In charge looks into the Serology and Microbiology
reports of such cases. The Serology department reports the total number of cases to the HICC Chairman.
The Chairman of HICC informs the Medical Records Department (MRD) once the disease is confirmed. The
Medical Records Department notifies to the appropriate Government authorities in a prescribed format.
Infected cases in the ICU and wards are identified and analyzed regarding cause and type of infection.
Any case needing isolation will be subjected to it and appropriate action taken to prevent the spread of infection.
Monthly, half yearly and yearly statistics are studied regarding rate of different infections and analyzed for trend in
infection and necessary changes that have to be done.

List of Diseases to be notified

•
Malaria

•
Leprosy

•
HIV

•
Infective Hepatitis (Hepatitis A)

•
Gastroenteritis

•
Dengue

•
Encephalitis

•
Tuberculosis

•
Cholera

•
Diphtheria

•
Tetanus

•
Mumps

•
H1N1
6.10. POLICY ON ISOLATION AND BARRIER NURSING
1. Purpose:

Nosocomial or hospital acquired infections are a major public health problem in hospitals throughout the world. At least
5% of patients entering hospitals will develop a nosocomial infection. Nosocomial infections represent a leading cause of
death. Nosocomial infections, such as bacteremia, surgical wound infection, pneumonia and urinary tract infection, are
also associated with major morbidity in hospitalized patients. These nosocomial infections add significantly to the
expected length of stay for patients.
The Study on the Efficacy of Nosocomial Infection Control project, conducted by The Centers for Disease Control, found
that up to one third of nosocomial infections can be prevented by an effective infection control program.

2. Policy:

RATIONALE FOR ISOLATION PRECAUTIONS IN HOSPITALS

Transmission of infection within a hospital requires three elements: a source of infecting microorganisms, a susceptible
host, and a means of transmission for the microorganism.
Source
1. Human sources of the infecting microorganisms in hospitals may be patients, personnel, or, on occasion, visitors,
and may include persons with acute disease, persons in the incubation period of a disease, persons who are
colonized by an infectious agent but have no apparent disease, or persons who are chronic carriers of an infectious
agent.
2. Other sources of infecting microorganisms can be the patient's own endogenous flora, which may be difficult to
control, and inanimate environmental objects that have become contaminated, including equipment and
medications.

Host
1. Resistance among persons to pathogenic microorganisms varies greatly.
2. Some persons may be immune to infection or may be able to resist colonization by an infectious agent; others
exposed to the same agent may establish a commensal relationship with the infecting microorganism and become
asymptomatic carriers; still others may develop clinical disease.
3. Host factors such as age; underlying diseases; certain treatments with antimicrobials, corticosteroids, or other
immunosuppressive agents; irradiation; and breaks in the first line of defense mechanisms caused by such factors
as surgical operations, anesthesia, and indwelling catheters may render patients more susceptible to infection.

Different Routes of Transmission:

1. Contact transmission, the most important and frequent mode of transmission of nosocomial infections, is divided
into two subgroups: direct-contact transmission and indirect-contact transmission.

a. Direct-contact transmission involves a direct body surface-to-body surface contact and physical transfer of
microorganisms between a susceptible host and an infected or colonized person, such as when a person
turns a patient, gives patient a bath, or performs other patient-care activities that require direct personal
contact. Direct-contact transmission also can occur between two patients, with one serving as the source of
the infectious microorganisms and the other as a susceptible host.
b. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate
object, usually inanimate, such as contaminated instruments, needles, or dressings, or contaminated hands
that are not washed and gloves that are not changed between patients.
 2. Droplet transmission is a form of contact transmission. As the mechanism of transfer of the pathogen to the host is
quiet distinct from either direct- or indirect-contact transmission. Therefore, droplet transmission will be
considered as a separate route of transmission in this policy. Droplets are generated from the source person
primarily during coughing, sneezing, and talking, and during the performance of certain procedures such as
suctioning and bronchoscopy. Transmission occurs when droplets containing microorganisms generated from the
infected person are propelled a short distance through the air and deposited on the host’s conjunctivae, nasal
mucosa, or mouth. Because droplets do not remain suspended in the air, special air handling and ventilation is not
required to prevent droplet transmission; that is, droplet transmission must not be confused with airborne
transmission.
3. Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle residue [5 micron
or smaller in size] of evaporated droplets containing microorganisms that remain suspended in the air for long
periods of time) or dust particles containing the infectious agent. Microorganisms carried in this manner can be
dispersed widely by air currents and may become inhaled by a susceptible host within the same room or over a
longer distance from the source patient, depending on environmental factors; therefore special air handling and
ventilation are required to prevent airborne transmission. Microorganisms transmitted by airborne transmission
include Mycobacterium tuberculosis and the Rubella and Varicella viruses.
4. Common vehicle transmission applies to microorganisms transmitted by contaminated items such as food, water,
medications, devices, and equipment.
5. Vector borne transmission occurs when vectors such as mosquitoes, flies and rats transmit microorganisms.

Hospital Isolation Policy

Many diseases may be transmitted between patients and potentially between patients and members of staff. For
this reason, it is sometimes necessary to isolate infected patients, or to isolate patients who are particularly
vulnerable to infection.
Although patients should normally be isolated as laid down in this policy, it is accepted that in certain
circumstances it may not always be possible to do so. In such cases, ward staff should discuss the case with the
infection control team who will advise on alternative methods to those given in this policy.
Within existing facilities there should be two classes of isolation:

Source isolation: for patients who are sources of pathogenic micro-organisms which may spread from them and infect
other patients and / or members of staff;

Protective isolation: for patients who are rendered highly susceptible to infection by disease or therapy.

The hospital infection control team must be informed of any patient with a communicable disease on the ward
(whether isolated or otherwise) in order to ensure that the correct infection control procedures are being followed.
A member of the team is always available to give advice and help in the isolation of patients.

When informed about a patient with a communicable disease, the hospital infection control team will, where
necessary, inform the appropriate authorities. However, some infections are statutorily notifiable and the formal
notification must be made by the clinician in charge of the case (usually through MRD).
Source isolation can be divided into three categories:
 STANDARD For most other communicable diseases
RESPIRATORY For diseases where the main pathway of transmission is airborne,
including pulmonary tuberculosis

The policy contains two tiers of precautions:

1st Tier- Most important tier, which is implemented for care of all patients in the hospitals regardless of their diagnosis or
presumed infection status. Implementation of these “Standard Precautions” is the primary requirement for successful
Nosocomial infection control.

2nd Tier- These precautions are implemented and practiced only for the care of specific patients. These additional
“Transmission-based Precautions” are used for patients known or suspected to be infected or colonized with
epidemiologically important pathogens that can be transmitted by airborne or droplet transmission or by contact with dry
skin or contaminated surfaces.
Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and
unrecognized sources of infection. They contain the major features of:
1. Universal Precautions (Blood and Body fluids) Precautions designed to reduce the risk of transmission of blood
borne pathogens.
2. Body substance isolation designed to reduce the risk of transmission of pathogens from moist body substances.

Standard Precautions apply to:

1. Blood
2. All body fluids, secretions, and excretions, except sweat, regardless of whether or not they contain visible blood.
3. Non-intact skin.
4. Mucous membrane.

There are three types of Transmission-based Precautions:

1. Airborne Precautions.
2. Droplet Precautions.
3. Contact Precautions.

They may be combined for diseases that have multiple routes of transmission. When used either singularly or in
combination, they are to be used in addition to Standard Precautions.
Airborne Precautions
1. Designed to reduce the risk of airborne transmission of infectious agents.
2. Airborne Precautions apply to patients known or suspected to be infected with epidemiologically important
pathogens that can be transmitted by the airborne route.
Droplet Precautions
1. Designed to reduce the risk of droplet transmission of infectious agents.
2. Droplet Precautions apply to any patient known or suspected to be infected with epidemiologically important
pathogens that can be transmitted by infectious droplets.
Contact Precautions
1. Designed to reduce the risk of transmission of epidemiologically important microorganisms by direct or indirect
contact.
2. Contact Precautions apply to specified patients known or suspected to be infected or colonized (presence of
 important microorganisms than can be transmitted by direct or indirect contact.

EMPIRIC USE OF AIRBORNE, DROPLET OR CONTACT PRECAUTIONS:

1. In many instances, the risk of nosocomial transmission of infection may be highest before a definitive diagnosis
can be made and before precautions based on that diagnosis can be implemented.
2. The routine use of Standard Precautions for all patients should reduce greatly this risk for conditions other than
those requiring Airborne, Droplet, or Contact Precautions.
3. While it is not possible to prospectively identify all patients needing these enhanced precautions, certain clinical
syndromes and conditions carry a sufficiently high risk to warrant the empiric addition of enhanced precautions
while a more definitive diagnosis is pursued.
4. The organisms listed under the column "Potential Pathogens" are not intended to represent the complete or even
most likely diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard
Precautions until they can be ruled out.

IMMUNO COMPROMISED PATIENTS

1. Immuno-compromised patients vary in their susceptibility to nosocomial infections, depending on the severity and
duration of Immuno-suppression. They generally are at increased risk for bacterial, fungal, parasitic, and viral
infections from both endogenous and exogenous sources.
2. The use of Standard Precautions for all patients and Transmission-Based Precautions for specified patients, as
recommended in this policy, should reduce the acquisition by these patients of institutionally acquired bacteria
from other patients and environments.

Fundamentals of Isolation Precautions:

Standard Precautions:
Hand washing and Gloving

1. Hand washing is the single most important measure to reduce the risk of transmitting organisms from one person
to another or from one site to another on the same patient.
2. Washing hands as promptly and thoroughly as possible between contacts and after contact with blood, body fluids,
secretion, excretions and equipment or articles contaminated by them is an important component of infection
control and isolation precautions.
3. In addition to Hand washing, gloves play an important role in reducing the risk of transmission of microorganisms.
4. Gloves are to be worn to provide a protective barrier and to prevent gross contamination of the hands when
touching blood, body fluids, secretions, excretions, mucous membranes, and non intact skin.
5. Gloves are to be worn to reduce the likelihood that hands of personnel contaminated with microorganisms from a
patient or a fomite can transmit these microorganisms to another patient. In this situation, gloves must be changed
between patient contacts and hands washed after gloves are removed.
6. Wearing gloves does not replace the need for Hand washing, because gloves may have small, in apparent defects
or may be torn during use, and hands can become contaminated during removal of gloves.
7. Failure to change gloves between patients is an infection control hazard.
 1. Appropriate patient placement is a significant component of isolation precautions.
2. A private room is important to prevent direct- or indirect-contact transmission when the source patient has poor
hygienic habits, contaminates the environment, or cannot be expected to assist in maintaining infection control
precautions to limit transmission of microorganisms (i.e., infants, children, and patients with altered mental status).
3. When possible, a patient with highly transmissible or epidemiologically important microorganisms is placed in a
private room with Hand washing and toilet facilities, to reduce opportunities for transmission of microorganisms.
4. When a private room is not available, an infected patient is placed with an appropriate roommate.
5. Patients infected by the same microorganisms usually can share a room, provided they are not infected with other
potentially transmissible microorganisms and hands that are not washed and gloves that are not changed between
patients. Such sharing of rooms, also referred to as cohorting patients, is useful especially during outbreaks or
when there is a shortage of private rooms.
6. When a private room is not available and cohorting is not achievable or recommended, it is very important to
consider the epidemiology and mode of transmission of the infecting pathogen and the patient population being
served in determining patient placement.
7. Under these circumstances, consultation with infection control nurse is advised before patient placement.
8. Moreover, when an infected patient shares a room with a non infected patient, it also is important that patients,
personnel, and visitors take precautions to prevent the spread of infection and roommates are selected carefully.
9. A private room with appropriate air handling and ventilation is particularly important for reducing the risk of
transmission of microorganisms from a source patient to susceptible patients and other persons in hospitals when
the microorganism spreads by airborne transmission.
10. Ventilation recommendations for isolation rooms housing patients with pulmonary tuberculosis have been
delineated in other CDC guidelines.

Transport of Infected Patients

Limiting the movement and transport of patients infected with virulent or epidemiologically important microorganisms
and ensuring that such patients leave their rooms only for essential purposes reduces opportunities for transmission of
microorganisms in hospitals.
When patient transport is necessary, it is important that
1. Appropriate barriers (e.g., masks, impervious dressings) are to be worn or used by the patient to reduce the
opportunity for transmission of pertinent microorganisms to other patients, personnel, and visitors and to reduce
contamination of the environment;
2. Personnel in the area to which the patient is to be taken are to be notified of the impending arrival of the patient
and of the precautions to be used to reduce the risk of transmission of infectious microorganisms.
3. Patients are to be informed of ways by which they can assist in preventing the transmission of their infectious
microorganisms to others.

Masks, Respiratory Protection, Eye Protection, Face Shields

1. Masks that covers both the nose and the mouth, and goggles or a face shield by hospital personnel during
procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions,
or excretions provides protection to the mucous membranes of the eyes, nose, and mouth from contact
transmission of pathogens.
2. A surgical mask generally is to be worn by hospital personnel to provide protection against spread of infectious
large-particle droplets that are transmitted by close contact and generally travel only short distances (up to 3 ft)
from infected patients who are coughing or sneezing.
Gowns and Protective Apparel
1. To be worn to provide barrier protection and to reduce opportunities for transmission of microorganisms in
hospitals.
 2. Gowns are to worn to prevent contamination of clothing and to protect the skin of personnel from blood and body
fluid exposures.
3. Gowns are to be worn by personnel during the care of patients infected with epidemiologically important
microorganisms to reduce the opportunity for transmission of pathogens from patients or items in their
environment to other patients or environments; when gown are worn for this purpose, they are removed before
leaving the patient’s environment and the hands are washed.

Patient-Care Equipment and Articles

1. Contaminated, reusable critical medical devices or patient-care equipment (i.e., equipment that enters normally sterile
tissue or through which blood flows) or semi-critical medical devices or patient-care equipment (i.e., equipment that
touches mucous membranes) are to be sterilized or disinfected (reprocessed) after use to reduce the risk of transmission of
microorganisms to other patients; the type of reprocessing is determined by the article and its intended use, the
manufacturer's recommendations, hospital policy, and any applicable guidelines and regulations.
2. Noncritical equipment (i.e., equipment that touches intact skin) contaminated with blood, body fluids, secretions, or
excretions are to be cleaned and disinfected after use, according to hospital policy.

3. Contaminated disposable (single-use) patient-care equipment is to be handled and transported in a manner that reduces
the risk of transmission of microorganisms and decreases environmental contamination in the hospital; the equipment is to
be disposed off according to hospital policy and applicable regulations.

Dishes, Glasses, Cups, and Eating Utensils

1. No special precautions are needed for dishes, glasses, cups, or eating utensils.
2. Both disposable or reusable dishes and utensils can be used for patients on isolation precautions.
3. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes,
glasses, cups, and eating utensils.

Routine and Terminal Cleaning

1. The room, or cubicle, and bedside equipment of patients on Transmission-Based Precautions are cleaned using the
same procedures used for patients on Standard Precautions, unless the infecting microorganism(s) and the amount
of environmental contamination indicates special cleaning.
2. In addition to thorough cleaning, adequate disinfection of bedside equipment and environmental surfaces (e.g.,
bedrails, bedside tables, carts, commodes, doorknobs, faucet handles) is indicated for certain pathogens, especially
enterococci, which can survive in the inanimate environment for prolonged periods of time.
3. Patients admitted to hospital rooms that previously were occupied by patients infected or colonized with such
pathogens are at increased risk of infection from contaminated environmental surfaces and bedside equipment if
they have not been cleaned and disinfected adequately.
4. The methods, thoroughness, and frequency of cleaning and the products used are as per the hospital policy.
Environmental Control
Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection of environmental surfaces,
beds, bedrails, bedside equipment, and other frequently touched surfaces, and ensure that these procedures are being
followed.
Linen
Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretions in a manner that
prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms
Occupational Health and Blood borne Pathogens
1. Take care to prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling
sharp instruments after procedures; when cleaning used instruments; and when disposing of used needles.
2. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves
directing the point of a needle toward any part of the body; rather, use either a one-handed "scoop" technique or a
mechanical device designed for holding the needle sheath.
3. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate
used needles by hand.
4. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant
containers, which are located as close as practical to the area in which the items were used, and place reusable
syringes and needles in a puncture-resistant container for transport to the reprocessing area.
5. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation
methods in areas where the need for resuscitation is predictable.
Airborne Precautions
A. Patient Placement
Place the patient in a private room that has 1) monitored negative air pressure in relation to the surrounding areas, 2) 6
to 12 air changes per hour, and 3) appropriate discharge of air outdoors or monitored high-efficiency filtration of room
air before the air is circulated to other areas in the hospital. Keep the room door closed and the patient in the room.
When a private room is not available, place the patient in a room with a patient having active infection with the same
microorganism and not with other infection. When a private room is not available and cohorting is not desirable,
consultation with infection control professionals is advised before patient placement.
B. Respiratory Protection
Wear respiratory protection (N95 respirator) when entering the room of a patient with known or suspected infectious
pulmonary tuberculosis. Susceptible persons should not enter the room of patients known or suspected to have measles
(rubella) or Varicella (chickenpox) if other immune caregivers are available. If susceptible persons must enter the
room of a patient known or suspected to have measles (rubella) or Varicella, they should wear respiratory protection
(N95 respirator).Persons immune to measles (rubella) or Varicella need not wear respiratory protection.
C. Patient Transport
Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is
necessary, minimize patient dispersal of droplet nuclei by placing a surgical mask on the patient, if possible.
D. Additional Precautions to be taken for Preventing Transmission of Tuberculosis.
Droplet Precautions
A. Patient Placement
Place the patient in a private room. When a private room is not available, Place the patient in a room with a patient(s)
who has active infection with the same microorganism but with no other infection (cohorting). When a private room is
not available and cohorting is not achievable, maintain spatial separation of at least 3 ft between the infected patient
and other patients and visitors. Special air handling and ventilation are not necessary, and the door may remain open.
B. Mask
In addition to wearing a mask as outlined under Standard Precautions, wear a mask when working within 3 ft of the
patient.
 C. Patient Transport
Limit the movement and transport of the patient from the room to essential purposes only. If transport or movement is
necessary, minimize patient dispersal of droplets by masking the patient, if possible.
Contact Precautions
A. Patient Placement
Place the patient in a private room. When a private room is not available, Place the patient in a room with a patient(s) who
has active infection with the same microorganism but with no other infection (cohorting). When a private room is not
available and cohorting is not achievable, consider the epidemiology of the microorganism and the patient population
when determining patient placement. Consultation with infection control professionals is advised before patient
placement.
B. Gloves and Hand Washing
In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-sterile gloves are adequate)
when entering the room. During the course of providing care for a patient, change gloves after having contact with
infective material that may contain high concentrations of microorganisms (fecal material and wound drainage). Remove
gloves before leaving the patient's room and wash hands immediately with an antimicrobial agent or a waterless antiseptic
agent. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental
surfaces or items in the patient's room to avoid transfer of microorganisms to other patients or environments.
C. Gown
In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean, non-sterile gown is adequate)
when entering the room if you anticipate that your clothing will have substantial contact with the patient, environmental
surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or
wound drainage not contained by a dressing. Remove the gown before leaving the patient's environment. After gown
removal, ensure that clothing does not contact potentially contaminated environmental surfaces to avoid transfer of
microorganisms to other patients or environments.
D. Patient Transport
Limit the movement and transport of the patient from the room to essential purposes only. If the patient is transported out
of the room, ensure that precautions are maintained to minimize the risk of transmission of microorganisms to other
patients and contamination of environmental surfaces or equipment.
E. Patient-Care Equipment
When possible, dedicate the use of noncritical patient-care equipment to a single patient (or cohort of patients infected or
colonized with the pathogen requiring precautions) to avoid sharing between patients. If use of common equipment or
items is unavoidable, then adequately clean and disinfect them before use for another patient.
F. Additional Precautions for Preventing the Spread of Vancomycin Resistance are to be followed.
STANDARD OPERATING PROCEDURES:
Standard Operating Procedures- General Points
Hands Hand washing before and after contact with the patient in the single most
important measure in preventing spread of infection. It is recommended
that the hands and forearms are thoroughly washed with an antiseptic
detergent preparations followed by careful drying.
Sharps Extreme care must be taken to ensure that needles and other sharp
instruments are handled safely to prevent inoculation injury.
Room door Provided that the patient’s safety is not compromised, the isolation
cubicle door must remain closed
Visitors Everyone entering an isolation room must comply with the recommended
 procedures. The ultimate responsibility for deciding who may visit a
patient rests with the consultant in charge of the patient, but guidance is
given in this document, and additional advice can be obtained from the
infection control team.
Cleaning of Separate cleaning equipments should be reserved for each isolation room.
rooms Nursing staff are responsible for the standard of hygiene in isolation
rooms and for decontamination spillages of blood and body fluids.
Nursing staff must identify hazards and undertake a risk assessment
before allowing domestic staff to clean the room, and must advise the
domestic staff on any necessary precautionary measures.
Equipments Remove unnecessary items of furniture prior to occupying the room.
Limit the number of items taken into or stored in the room.

Finally, please remember that to a patient being placed in isolation can be a traumatic experience. To remain in isolation
for prolonged periods of time can be distressing to the patient, and every effort should be made to explain the reason for
isolation and (if possible) when it can be discontinued.
The three types of Transmission Based Precautions may be used alone, or in combination for diseases that have multiple
routes of transmission:
Contact Precautions
Droplet Precautions
Airborne Precautions
Patients with suspected or confirmed diseases listed on either table shall be placed on the appropriate Transmission Based
Precautions until the condition has been ruled out or the criteria for removal from isolation have been met.
When a condition is suspected enough to test for the causative agent, the appropriate PRECAUTIONS are to be
instituted.
HAND HYGIENE IS THE MOST IMPORTANT ACTIVITY TO PREVENT TRANSMISSION!
CLEAN HANDS with hospital supplied soap or alcohol-based hand rub before
caring for patient and after contact with ANYTHING in the room.
ALWAYS CLEAN HANDS AFTER REMOVING GLOVES

 Contact Precautions:
Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Patients in
Contact Precautions include those infected or colonized with Clostridium difficile ("C. diff"), rotavirus, or other
organisms deemed significant by Infection Control. Contact transmission can occur by directly touching the
patient, through contact with the patient's environment, or by using contaminated gloves or equipment.

Patients in Contact Precautions require:

Private Room
Dedicated, disposable equipment (e.g., stethoscope, blood pressure cuff,
thermometer, etc.).
Shared equipment is to be cleaned with hospital disinfectant
Dispose detergent disinfectant-impregnated wipes after each use
Healthcare workers caring for patients in Contact Precautions must:
Put on gloves before entering the room
 environment is anticipated.
Remove and discard gloves and gown and clean hands before leaving the patient's room or, in semi-private room
or multi-bed bay situation, before leaving the patient's immediate vicinity.
Discontinuing precautions:
Clostridium difficile: when patient's diarrhea is resolved
Other conditions/diseases: consult with Infection Control Team

 Droplet Precautions
Droplets are formed when a person coughs, sneezes, speaks, spits, sings, or undergoes oral or tracheal/bronchial
suctioning. Transmission occurs when droplets containing microorganisms generated from an infected person are
propelled a short distance (about 3 feet), and may come in contact with another person's conjunctivae or mucous
membranes (eyes, nose or mouth). Diseases transmitted by the droplet route include influenza, and meningococcal
meningitis.
Patients in Droplet Precautions require:
Private room, except when directed otherwise by Infection Control Team.
The caregiver wears a mask that covers the mouth and nose (regular surgical or paper mask), and eye protection
(safety goggles, fluid shield).
Patients are encouraged to remain in their room except for essential purposes, in which case, a regular mask
(surgical or paper) is worn.
Visitors
Visitors are educated regarding the transmission of droplet-borne diseases
Hand hygiene with alcohol based hand rub or soap and water should be performed regularly and always upon
leaving the patient's room.
Risk of acquisition of droplet-borne diseases is reduced through the use of personal protective equipment (i.e.,
surgical mask with eye shield or goggles). This equipment is available for visitors who choose to wear it.
Visitors with upper respiratory symptoms are restricted from visiting. Special consideration may be given to close
family members. Please consult with Infection Control.
Nursing staff must instruct family/visitors to clean hands after contact with patient secretions or contact with
immediate patient environment.
Discontinuing Precautions: Droplet precautions may be discontinued when symptoms resolve or when criteria for
discontinuing precautions (see Transmission-based precautions tables) have been met. Consult with Infection Control if
you have questions.

 Airborne Precautions:
When a person infected with Tuberculosis, Measles, and Chicken Pox coughs, sneezes, speaks, spits, sings, or
undergoes oral or tracheal/bronchial suctioning, droplet nuclei (particles sized 5 microns or smaller), which carry the
infectious organism may be released into the air and be carried via air currents. Negative pressure air handling
(ventilation) is required for isolating patients diagnosed or suspected of being infected with airborne-transmitted
organisms.
Patients in Airborne Precautions require:
Private Negative Pressure Isolation Room (NPIR)
All persons entering the room of a patient with suspected or confirmed tuberculosis MUST wear a fit-tested N-95
respirator
Healthcare workers or visitors susceptible to chickenpox or measles MAY NOT enter the patient's room;
healthcare workers immune to chickenpox or measles may enter the room without wearing a mask.
 by the patient at all times outside the negative pressure environment.
Visitors
For patients with suspected or confirmed tuberculosis
Visitors will wear a surgical mask that is secured and snugly fitted.
Symptomatic household or other contacts of patient may not visit until medically cleared. If symptomatic contact
must visit, a mask will be donned before entering the hospital and worn continuously while in the facility.
For other conditions to which airborne precautions apply
Visitors will be limited to those immune to the patient's disease.
For exceptional circumstances, please consult with Infection Control.
TABLE No.01

Types of Precautions to be taken and the patients requiring these Precautions*

Airborne Precautions
Contact
In addition to Standard Precautions, use Airborne Precautions for patients known or suspected to
have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include:
Measles
Varicella (including disseminated zoster)†
Tuberculosis‡
Droplet Precautions
In addition to Standard Precautions, use Droplet Precautions for patients known or suspected to
have serious illnesses transmitted by large particle droplets. Examples of such illnesses include:
Invasive Haemophilus influenza type b disease, including meningitis, pneumonia,
epiglottitis, and sepsis
Invasive Neisseria meningitidis disease, including meningitis, pneumonia, and sepsis
Other serious bacterial respiratory infections spread by droplet transmission, including:
Diphtheria (pharyngeal)
Mycoplasma pneumonia
Pertussis
Pneumonic plague
Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young
children
Serious viral infections spread by droplet transmission, including:
Adenovirus†
Influenza
Mumps
Parvovirus B19
Rubella
Viral hemorrhagic infections (Ebola, Lassa, or Marburg)*
In addition to Standard Precautions, use Contact Precautions for patients known or suspected to have serious illnesses
easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such
illnesses include:
Gastrointestinal, respiratory, skin, or wound infections or colonization with multidrug-resistant bacteria judged by
the infection control program, based on current state, regional, or national recommendations, to be of special
clinical and epidemiologic significance
Enteric infections with a low infectious dose or prolonged environmental survival, including:
 Clostridium difficile
 For diapered or incontinent patients: enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A,
or rotavirus
Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children
Skin infections that are highly contagious or that may occur on dry skin, including:
 Diphtheria (cutaneous)
 Herpes simplex virus (neonatal or mucocutaneous)
 Impetigo
 Major (noncontained) abscesses, cellulitis, or decubiti
 Pediculosis
 Scabies
 Staphylococcal furunculosis in infants and young children
 Zoster (disseminated or in the immunocompromised host)†
Viral/hemorrhagic conjunctivitis

Discontinuing Precautions:
Consult with Infection Control Team/ Nurse before discontinuing Airborne Precautions.

TABLE 2:

Clinical Syndromes or Conditions Warranting Additional Empiric Precautions to Prevent

Transmission of Epidemiologically Important Pathogens Pending Confirmation of
Diagnosis*

Clinical Syndrome or Potential Pathogens‡ Empiric

Condition† Precautions

Diarrhea
Acute diarrhea with a likely Enteric pathogens§ Contact
infectious cause in an
incontinent or diapered patient
Diarrhea in an adult with a Clostridium difficile Contact
history of recent antibiotic use
Meningitis Neisseria meningitidis Droplet

Rash or exanthems, generalized,

etiology unknown:
Petechial/ecchymotic with fever Neisseria meningitidis Droplet
Vesicular Varicella Airborne and
Contact
Maculopapular with coryza and Rubella (measles) Airborne
fever
 Respiratory infections
Cough/fever/upper lobe Mycobacterium Airborne
pulmonary infiltrate in an HIV- tuberculosis
negative patient or a
patient at low risk for HIV
infection
Cough/fever/pulmonary infiltrate Mycobacterium Airborne
in any lung location in a HIV- tuberculosis
infected patient or a
patient at high risk for HIV
infection

Paroxysmal or severe persistent Bordetella pertussis Droplet

cough during periods of pertussis
activity
Respiratory infections, Respiratory syncytial or Contact
particularly bronchiolitis parainfluenza virus
and croup, in infants and young
children

Risk of multidrug-resistant microorganisms

History of infection or Resistant bacteria|| Contact
colonization with multidrug-
resistant organisms||
Skin, wound, or urinary tract Resistant bacteria|| Contact
infection in a patient with a
recent hospital or nursing home
stay in a facility where
multidrug-resistant organisms
are prevalent
Skin or Wound Infection
Abscess or draining wound that Staphylococcus aureus, Contact
cannot be covered group A streptococcus

* Clinical departments at SPMSH are encouraged to modify or adapt this table according to local conditions. To ensure
that appropriate empiric precautions are implemented always, departments must have systems in place to evaluate
patients routinely according to these criteria as part of their preadmission and admission care.

† Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g., pertussis in
neonates and adults may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by
the prevalence of specific conditions in the community, as well as clinical judgment.

‡ The organisms listed under the column "Potential Pathogens" are not intended to represent the complete, or even
most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard
Precautions until they can be ruled out.

§ These pathogens include enterohemorrhagic Escherichia coli O157:H7, Shigella, hepatitis A, and rotavirus.

||Resistant bacteria judged by the infection control program, based on current state, regional, or national
recommendations, to be of special clinical or epidemiological significance.
 APPENDIX - 1

Type and Duration of Precautions Needed for Selected Infections and Conditions

Precaution/
Infection/ Condition
Type*
Abscess
Draining, major a C
Draining, minor or limited b S
Acquired immunodeficiency syndrome c S
Actinomycosis S
Adenovirus infection, in infants and young children D,C
Amebiasis S
Anthrax
Cutaneous S
Pulmonary S
Antibiotic-associated colitis (see Clostridium difficile)
Arthropodborne viral encephalitides (eastern, western, Venezuelan
Sd
equine encephalomyelitis; St Louis, California encephalitis)
Arthropodborne viral fevers (dengue, yellow fever, Colorado tick fever) Sd
Ascariasis S
Aspergillosis S
Babesiosis S
Blastomycosis, North American, cutaneous or pulmonary S
Botulism S
Bronchiolitis (see respiratory infections in infants and young children)
Brucellosis (undulant, Malta, Mediterranean fever) S
Campylobacter gastroenteritis (see gastroenteritis)
Candidiasis, all forms including mucocutaneous S
Cat-scratch fever (benign inoculation lymphoreticulosis) S

Cellulitis, uncontrolled drainage C

Chancroid (soft chancre) S
Chickenpox (varicella; see F e for varicella exposure) A,C
Chlamydia trachomatis
Conjunctivitis S
Genital S
Respiratory S
Cholera (see gastroenteritis)
Closed-cavity infection
Draining, limited or minor S
Not draining S
Clostridium
C botulinum S
C difficile C
C perfringens
 Gas gangrene S
Coccidioidomycosis (valley fever)
Draining lesions S
Pneumonia S
Colorado tick fever S
Congenital rubella C
Conjunctivitis
Acute bacterial S
Chlamydia S
Gonococcal S
Acute viral (acute hemorrhagic) C
Coxsackievirus disease (see enteroviral infection)
Creutzfeldt-Jakob disease Sg
Croup (see respiratory infections in infants and young children)
Cryptococcosis S
Cryptosporidiosis (see gastroenteritis)
Cysticercosis S
Cytomegalovirus infection, neonatal or immuno-suppressed S
Decubitus ulcer, infected
Major a C
Minor or limited b S
Dengue Sd
Diarrhea, acute-infective etiology suspected (see gastroenteritis)
Diphtheria
Cutaneous C
Pharyngeal D
Ebola viral hemorrhagic fever Ci
Echinococcosis (hydatidosis) S
Echovirus (see enteroviral infection)
Encephalitis or encephalomyelitis (see specific etiologic agents)
Endometritis S
Enterobiasis (pinworm disease, oxyuriasis) S
Enterococcus species (see multidrug-resistant organisms if
epidemiologically significant or vancomycin resistant)
Enterocolitis, Clostridium difficile C
Enteroviral infections
Adults S
Infants and young children C
Epiglottitis, due to Haemophilus influenzae D
Epstein-Barr virus infection, including infectious mononucleosis S
Erythema infectiosum (also see Parvovirus B19) S
Escherichia coli gastroenteritis (see gastroenteritis)
Food poisoning
Botulism S
Clostridium perfringens or welchii S
Furunculosis-staphylococcal
Infants and young children C
Gangrene (gas gangrene) S
Gastroenteritis
Campylobacter species Sj
Cholera Sj
Clostridium difficile C
Cryptosporidium species Sj
Escherichia coli
Enterohemorrhagic O157:H7 Sj
Diapered or incontinent C
Other species Sj
Giardia lamblia Sj
Rotavirus Sj
Diapered or incontinent C
Salmonella species (including S. typhi) Sj
Shigella species Sj

Diapered or incontinent C
Vibrio parahaemolyticus Sj
Viral (if not covered elsewhere) Sj
Yersinia enterocolitica Sj
German measles (see rubella)
Giardiasis (see gastroenteritis)
Gonococcal ophthalmia neonatorum (gonorrheal ophthalmia,
S
acute conjunctivitis of newborn)
Gonorrhea S
Granuloma inguinale (donovanosis, granuloma venereum) S
Guillain-Barré syndrome S
Hand, foot, and mouth disease (see enteroviral infection)
Hantavirus pulmonary syndrome S
Helicobacter pylori S
Hemorrhagic fevers (for example, Lassa and Ebola) Ci
Hepatitis, viral
Type A S
Diapered or incontinent patients C
Type B-HBs Ag positive S
Type C and other unspecified non-A, non-B S
Type E S
Herpangina (see enteroviral infection)
Herpes simplex (Herpesvirus hominis)
Encephalitis S
Neonatal l (see F l for neonatal exposure) C
Mucocutaneous, disseminated or primary, severe C
Herpes zoster (varicella-zoster)
Localized in immunocompromised patient, or disseminated A,C
Localized in normal patient Sm
Histoplasmosis S
HIV (see human immunodeficiency virus) S
Hookworm disease (ancylostomiasis, uncinariasis) S
Human immunodeficiency virus (HIV) infection c S
Impetigo C
Infectious mononucleosis S
Influenza Dn
Kawasaki syndrome S
Lassa fever Ci

Legionnaires' disease S
Leprosy S
Leptospirosis S
Lice (pediculosis) C
Listeriosis S
Lyme disease S
Lymphocytic choriomeningitis S
Lymphogranuloma venereum S
Malaria Sd
Marburg virus disease Ci
Measles (rubella), all presentations A
Melioidosis, all forms S
Meningitis
Aseptic (nonbacterial or viral meningitis; also see enteroviral
S
infections)
Bacterial, gram-negative enteric, in neonates S
Fungal S
Haemophilus influenza, known or suspected D
Listeria monocytogenes S
Neisseria meningitidis (meningococcal) known or suspected D
Pneumococcal S
Tuberculosis o S
Other diagnosed bacterial S
Meningococcal pneumonia D
Meningococcemia (meningococcal sepsis) D
Molluscum contagiosum S
Mucormycosis S
Multidrug-resistant organisms, infection or colonization p
Gastrointestinal C
Respiratory C
Pneumococcal S
Skin, wound, or burn C
Mycobacteria, nontuberculosis (atypical)
Pulmonary S
Wound S
Mycoplasma pneumonia D
Necrotizing enterocolitis S
Nocardiosis, draining lesions or other presentations S
Norwalk agent gastroenteritis (see viral gastroenteritis)

Orf S
Parainfluenza virus infection, respiratory in infants and young children C
Parvovirus B19 D
Pediculosis (lice) C
Pertussis (whooping cough) D
Pinworm infection S
Plague
Bubonic S
Pneumonic D
Pleurodynia (see enteroviral infection)
Pneumonia
Adenovirus D,C
Bacterial not listed elsewhere (including gram-negative bacteria) S
Burkholderia cepacia in cystic fibrosis (CF) patients,
St
including respiratory tract colonization
Chlamydia S
Fungal S
Haemophilus influenzae
Adults S
Infants and children (any age) D
Legionella S
Meningococcal D
Multidrug-resistant bacterial (see multidrug-resistant organisms)
Mycoplasma (primary atypical pneumonia) D
Pneumococcal S
Multidrug-resistant (see multidrug-resistant organisms)
Pneumocystis carinii Su
Pseudomonas cepacia (see Burkholderia cepacia) St
Staphylococcus aureus S
Streptococcus, group A
Adults S
Infants and young children D
Viral
Adults S
Infants and young children (see respiratory infectious disease,
acute)
Poliomyelitis S
Psittacosis (ornithosis) S
Q fever S
Rabies S
Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus
S
disease)
Relapsing fever S
Resistant bacterial infection or colonization (see multidrug-resistant
organisms)
Respiratory infectious disease, acute (if not covered elsewhere)
Adults S
Infants and young children c C
Respiratory syncytial virus infection, in infants and
C
young children, and immuno compromised adults
Reye's syndrome S
Rheumatic fever S
Rickettsial fevers, tick borne (Rocky Mountain spotted fever, tickborne
S
typhus fever)
Rickettsialpox (vesicular rickettsiosis) S
Ringworm (dermatophytosis, dermatomycosis, tinea) S
Ritter's disease (staphylococcal scalded skin syndrome) S
Rocky Mountain spotted fever S
Roseola infantum (exanthem subitum) S
Rotavirus infection (see gastroenteritis)
Rubella (German measles; also see congenital rubella) D
Salmonellosis (see gastroenteritis)
Scabies C
Scalded skin syndrome, staphylococcal (Ritter's disease) S
Schistosomiasis (bilharziasis) S
Shigellosis (see gastroenteritis)
Sporotrichosis S
Spirillum minus disease (rat-bite fever) S
Staphylococcal disease (S aureus)
Skin, wound, or burn
Major a C
Minor or limited b S
Enterocolitis Sj
Multidrug-resistant (see multidrug-resistant organisms)
Pneumonia S
Scalded skin syndrome S
Toxic shock syndrome S
Streptobacillus moniliformis disease (rat-bite fever) S
Streptococcal disease (group A streptococcus)
Skin, wound, or burn

Major a C
Minor or limited b S
Endometritis (puerperal sepsis) S
Pharyngitis in infants and young children D
 Pneumonia in infants and young children D
Scarlet fever in infants and young children D
Streptococcal disease (group B streptococcus), neonatal S
Streptococcal disease (not group A or B) unless covered elsewhere S
Multidrug-resistant (see multidrug-resistant organisms)
Strongyloidiasis S
Syphilis
Skin and mucous membrane, including congenital, primary, secondary S
Latent (tertiary) and seropositivity without lesions S
Tapeworm disease
Hymenolepis nana S
Taenia solium (pork) S
Other S
Tetanus S
Tinea (fungus infection dermatophytosis, dermatomycosis, ringworm) S
Toxoplasmosis S
Toxic shock syndrome (staphylococcal disease) S
Trachoma, acute S
Trench mouth (Vincent's angina) S
Trichinosis S
Trichomoniasis S
Trichuriasis (whipworm disease) S
Tuberculosis
Extrapulmonary, draining lesion (including scrofula) S
Extrapulmonary, meningitis o S
Pulmonary, confirmed or suspected or laryngeal disease A
Skin-test positive with no evidence of current pulmonary disease S
Tularemia
Draining lesion S
Pulmonary S
Typhoid (Salmonella typhi) fever (see gastroenteritis)
Typhus, endemic and epidemic S
Urinary tract infection (including pyelonephritis), with or without
S
urinary catheter
Varicella (chickenpox) A,C
Vibrio parahaemolyticus (see gastroenteritis)

Vincent's angina (trench mouth) S

Viral diseases
Respiratory (if not covered elsewhere)
Adults S
Infants and young children (see respiratory infectious disease,
acute)
Whooping cough (pertussis) D
Wound infections
Major a C
b
 Yersinia enterocolitica gastroenteritis (see gastroenteritis)
Zoster (varicella-zoster)
Localized in immunocompromised patient, disseminated A,C
Localized in normal patient Sm
Zygomycosis (phycomycosis, mucormycosis) S

Abbreviations:
* Type of Precautions: A, Airborne; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.
† Duration of precautions: CN, until off antibiotics and culture-negative; DI, duration of illness (with wound lesions, DI
means until they stop draining); U, until time specified in hours (hrs) after initiation of effective therapy; F, see footnote.
1. No dressing or dressing does not contain drainage adequately dressing covers and contains drainage adequately.
2. Also see syndromes or conditions listed in Table 2.
3. Install screens in windows and doors in endemic areas.
4. Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a
range of 10 to 21 days. After exposure, use varicella zoster immune globulin (VZIG) when appropriate, and discharge
susceptible patients if possible. Place exposed susceptible patients on Airborne 5.Precautions beginning 10 days after
exposure and continuing until 21 days after last exposure (up to 28 days if VZIG has been given). Susceptible persons
should not enter the room of patients on precautions if other immune caregivers are available.
6. Place infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine cultures are
negative for virus after age 3 months.
7. Additional special precautions are necessary for handling and decontamination of blood, body fluids and tissues, and
contaminated items from patients with confirmed or suspected disease.
8. Until two cultures taken at least 24 hours apart are negative.
9.Call state health department.
10. Use Contact Precautions for diapered or incontinent children <6 years of age for duration of illness

INFECTION CONTROL PROTOCOLS & PRACTICES FOR MULTI-DRUG RESISTANT ORGANISMS

The microbiology department shall send multi-drug resistant bacteria alert on diagnosis of an isolate to the
head of the concerned unit, and the Hospital Infection Control Officer.

Infection Control Measures for MRSA

• In situ isolation- Isolation in single rooms or as cohorts. The latter is ideal but may not be always possible. Patients
will have to be isolated, preferably in private rooms. (General ward patients requiring isolation will be charged
general ward bed rates when placed in private rooms) If this is not possible they will have to be accommodated in
beds at the far end of the wards. In all cases strict contact isolation practices will have to be followed.
• Hand washing- Using soap and water or alcohol hand rub before and after every patient contact. This is probably the
single most important factor with regard to controlling MRSA infection in the hospital. Efforts are being made to
change all taps to elbow operable taps and to provide more taps in all wards to make hand washing between patients
easy to practice.
• Mask & Gowns- are required in case of splashing or chances of coming in contact with drainage or secretions.
Gowns will have to be replaced at least 2 times a day.
• Gloves – Are to be worn for all contact with the patient especially when doing wound dressing or physical handling of
the patient such as when an immobilized patient requires position changes.
• Labels- Patients chart and bed will have to be labeled and contact isolation at the bedside, until the patient is cleared
of the infection.
• Terminal disinfection of the room- The room and all surfaces should be cleaned with a disinfectant solution so that
 The above precautions need to be taken immediately for the patient with MRSA infection or Infection with Multi-drug
resistant bacteria.

Medical items and equipments

• Syringe pumps, IV Line stand, Stethoscope, BP apparatus, thermometers, suction apparatus and 02 flow meter – Outer
surface should be cleaned with Bacillol.
• Drug trolley if any should be washed with detergent and dried

General Items
• Wooden Cots, Sofa, cupboards, Doors, Cardiac table and electrical switches should be dry mopped
• Iron Handles of doors and cupboards and Cot key should be cleaned with soap and water and dried
• Curtains, bed sheets, Blankets, Pillow covers should be sent immediately to the laundry for washing.
• Water resistant top of the Mattress should be cleaned with soap and water, subsequently wipe with 70% isopropyl
alcohol. Soggy pillows should be replaced with new ones, otherwise wash it and dry thoroughly.
• Canteen Utensils should be sent immediately to the canteen for washing.
• Phone instrument along with the receiver should be cleaned with 70% isopropyl alcohol.
• Steam Inhalers should be cleaned with soap and water.
• Washbasin handles and taps should be cleaned with soap and water.
• The plastic covering of the remote control of the television set ha s to be replaced with a new plastic cover
• Floor and the wall should be cleaned with Virex 0.4%
• Window glasses should be cleaned with Colin spray.
• Bed pans and urinals should be emptied, cleaned with soap and water and dried

The ward nurses and doctors concerned shall have the responsibility of informing the patients relatives of the measures
to be taken and the importance of restriction of visitors and hand washing after all contact with the patient will have to be
stressed.

6.11 STANDARD PRECAUTIONS

• Standard work precautions refer to the precautions consistently used on the presumption that all blood and
body fluids are potentially infectious for blood borne pathogens.
• Standard precautions must be taken by all health care workers coming into contact with blood and body fluids
• Similarly, all instruments and other equipment that come in contact with blood are assumed to be potentially
infectious and must be properly handled, cleaned, sterilized/ disinfected or safely disposed off.
Standard work precautions include:
• Hand washing with soap & water (Alcoholic hand rub can also be used)
• Barrier protection. For e.g., Effective use of Personal Protective Equipment (PPE)-Gloves, gowns, masks,
goggles, foot cover, etc.
• Safe handling of sharp items and prevention of accidents with sharps
• Safe handling of specimens (blood etc) during collection, processing and transport
 • Safe handling of spills of blood
• Safe waste disposal
• Immunization with hepatitis B vaccine
Key infection control measures:
• Take protective measures
• Ensure proper use of gloves
• Do not touch eyes, nose, mouth or any uncovered body parts, telephone receiver, door handles, tap with gloved
hands
• Dispose infectious waste in appropriate container
• Do not interchange equipment between laboratories Do not open laboratory doors
with gloved hands

• Gowns should be closed in front (neck to knees) and with cuffed sleeves
• Do not wear open shoes

Sequence for Removing PPE

2.
3.
4.
5.
6.
Remove in anteroom when possible 1. Gloves
Hand hygiene
. Gown (and apron, if worn)
Goggles
Mask
. Cap (if worn)
Hand hygiene
H

MANAGEMENT OF SMALL BLOOD & BODY FLUID SPILLS

• To wear gloves & gowns
• Wipe the area with 1% sodium hypochlorite solution using absorbent material
• Place the absorbent material in the biohazard bag meant for infectious waste (Yellow)
 • Thorough wash of the area with soap and water.
• Dry thoroughly with a clean wipe.

MANAGEMENT OF LARGE BLOOD & BODY FLUID SPILLS

• To wear gloves & gowns
• Put absorbent material (cotton) on spillage area
• Flood with 10% sodium hypochlorite solution upon & around the spill and leave for 30 minutes

• Place the absorbent material in the biohazard bag meant for infectious waste (Yellow)
• Reapply the disinfectant solution to all exposed surfaces
• Thorough wash of the area with soap and water.
• Dry thoroughly with a clean wipe.

PRINCIPLES – USE AND DISPOSAL OF SHARPS

1. It is the responsibility of the healthcare worker carrying out a procedure involving a sharp to ensure that the sharp is
disposed of correctly.
2. An approved sharps disposal container must be used.
3. Dispose of sharps immediately after use at the point of use. Small portable sharps containers are available and can
be taken to the bedside, using the near at point tray.
4. Sharps must not be passed directly from hand to hand and handling should be kept to a minimum.
5. Do not resheath needles. If inevitable, single handed technique of recapping to be done.
6. Needles and syringes should be separated carefully to prevent micro splashes on the fingers. Use alcohol hand rub
after removal.
7. Ensure sharps containers are assembled correctly. Inform house keeping supervisor, when sharps containers are
2/3rds full. 1% sodium hypochlorite to decontaminate the sharps will be added by the house keeping personnel.
8. Once the sharps box has been sealed it must be disposed of into the appropriate waste container.
9. All sharps boxes must be affixed with a BIOHAZARD sign.

10. Sharps boxes must be stored above floor level and out of direct heat and sunlight. All sharps boxes should be
positioned out of the reach of children at a height that enables safe disposal by all members of staff.
11. Damaged, overfilled or open containers should NOT be handled. These should be reported to the ward in charge and
house keeping supervisor whose responsibility will be to ensure that the sharps container is made safe.
12 .Spillage of sharps must be dealt with using the correct protective equipment which is available via the Housekeeping
Manager and Housekeeping supervisor. S Domestic staff during the normal course of their duties should not come into
contact with or handle sharps. They should be aware of the remote possibility that this hazard does exist and be instructed
in the procedure for reporting sharps accidents.

DON’T TOUCH SHARP ITEMS WITH HANDS

 RE-USEABLE USED SHARP INSTRUMENTS
• These should be safely returned to CSSD in the tray/box/bag provided.

• Theatre procedure trays must be checked and returned to CSSD.

• Disposable sharps must NOT be returned to CSSD on the trays. Blades and needles must be removed from handles
and holders before returning to CSSD. These sharps must be disposed of into a sharps container in the theatre or
department.
• Never place sharps including intravenous giving sets into plastic waste bags.
ACTION TO BE TAKEN IF A SHARPS/CONTAMINATION INJ.URY OCCURS
• Encourage bleeding.
• Wash the site immediately with soap and water, but do not scrub the skin or put the broken area of skin into the
mouth.
• If splashed, wash the area immediately.
• Keep a note of the name and location of the patient concerned, if known.
• Staff to report to the concerned Infection Control Nurse of the area immediately and get the risk assessment done by
the infection control department. If the infection control team members are not available, report immediately to
Emergency department.
• Report the accident to your Infection Control Nurse and complete an incident form.

FOR YOUR OWN PROTECTION- DO NOT DELAY, ACT IMMEDIATELY.

Standard precautions are simple infection control measures that reduce the risk of transmission of blood borne
pathogens through exposure to blood or body fluids among patients and health care workers. Under the “standard
precaution” principle, blood and body fluids from all persons should be considered as infected with HIV, regardless of
the known or supposed status of the person. Improving the safety of injections is an important component of standard
precautions.

6.11.1 Importance of Standard precautions

• Any percutaneous or permucosal exposure to blood or body fluids represent a potential source of HIV infection.
These include skin-piercing procedures with contaminated objects and exposures of broken skin, open wounds,
cuts and mucosal membranes (mouth or eyes) to the blood or body fluid of an infected person. Although they
account for a minority of HIV infections, health care procedures represent a highly preventable source of HIV
infection. Among health care associated sources of infection, unsafe Injections are of particular concern,
accounting for an estimated 3.9% to 7.0% of new infections worldwide. In addition, unsafe practices in
haemodialysis and plasmapheresis centers have been associated with HIV transmission.
Health care worker protection is an essential component of any strategy to prevent discrimination against HIV
infected patients by health care workers. If health care workers feel they can protect themselves from HIV
infection, they can provide better care.
6.11.2 Ensuring Standard precautions

Use of new, single-use disposable injection equipment for all injections is highly recommended. Sterilizable
injections should only be considered if single use equipment is not available and if the sterility can be documented
with Time, Steam and Temperature indicators.
Discard contaminated sharps immediately and without recapping in puncture and liquid proof containers that are
closed, sealed and destroyed before completely full.
Document the quality of the sterilization for all medical equipment used for percutaneous procedures.
Wash hands with soap and water before and after procedures; use of protective barriers such as gloves, gowns
aprons, masks, goggles for direct contact with blood and other body fluids.
Disinfect instruments and other contaminated equipment.
 should be used if necessary. Cleaning should occur outside patient areas, using detergent and hot water.)

6.11.3 Ensuring adherence to Standard precautions

Staff understanding of standard precautions. Health care workers should be educated about occupational risks and should
understand the need to use standard precautions with all patients, at all times, regardless of diagnosis. Regular in-service
training should be provided for all medical and non-medical personnel in health care settings. In addition, pre-service
training for all health care workers should address standard precautions.
Reduce unnecessary procedures. Reduce the supply of unnecessary procedures: Health
care workers need to be trained to avoid unnecessary blood transfusions (e.g., using volume replacement
solutions), injections (e.g., prescribing oral equivalents), suturing (e.g. episiotomies) and other invasive
procedures. Standard treatment guidelines should include the use of oral medications whenever possible.
Injectable medications should be removed from the national Essential Drug List where there is an appropriate oral
alternative. Reduce the demand for unnecessary procedures: Create consumer demand for new, disposable, single-
use injection equipment as well as increased demand for oral medications.
Make adequate supplies available. Adequate supplies should be made available to comply with basic infection control
standards, even in resource-constrained settings. Provision of single use, disposable injection equipment matching
deliveries of injectable substances, disinfectants and “sharps” containers should be the norm in all health care settings.
Attention should also be paid to protective equipment and water supplies. (While running water may not be
universally available, access to sufficient water supplies should be ensured.

6.12 EMPLOYEE HEALTH PROGRAMME

Employees who are in contact with patients have a risk of acquiring the infections in their work place. S P Multi
Speciality Hospitals is primarily responsible for staff health, and also handles potential occupational exposure to
infections. All services provided to individual by the hospital will be confidential.

Placement evaluation
When the staffs are appointed initially, a medical checkup is performed and baseline data on certain infections
are collected. A placement evaluation is made to ensure that persons with special health problems are not placed in the
job that could pose undue risk of infection to them. Anti-HBs titres will be done upon completion of Hepatitis B
vaccination schedule. Pre-employment screening is done for HBsAg, HCV, Anti-HBs titres; Chest X-ray done for
Tuberculosis and physical evaluation done by staff doctor. Persons found to be HBsAg and HCV positive will be
advised to work in areas not involving invasive procedures. At this time, the health service also confirms that
vaccinations required are complete. If the vaccination is not complete then hospital will advice completion of the vaccine
schedule.

Employee health and safety education

Safety education starts at the time of employment .On induction all the staffs are informed about the standard
safety precautions, biomedical waste management, Exposures to blood and body fluids. The staffs are informed of the
need to report exposure to blood and potentially infectious body fluids to the Infection control dept without any delay.
Annual health check –up will be organized by HR department for all the employees.

Health counseling
NH will conduct health counseling and offer prophylaxis when required (For e.g., Following accidental exposure
to blood or potentially infectious body fluids)

Work restriction for staff

It is the responsibility of the staff to report suspected illness to the infection control dept. The dept will arrange
duration found appropriate.

SPECIFIC PROPHYLAXIS Pre-employment

Immunization with hepatitis B vaccine is given to all the staffs who are directly involved in the patient care areas. It is
informed to all during orientation (on joining).
Any Uneventful exposure to blood and body fluids is immediately informed to infection control officer and the
documentation for the same is maintained. Subsequent prophylaxis is provided to the staff.

Needle stick injuries:

Post – Exposure Prophylaxis / Management Immediate Measures:

1. Do not panic.
2. Do not squeeze the injured area.
3. Do not put the injured area in the mouth.
4. Do not use alcohol based antiseptic or Betadine for needle stick injuries or exposure of skin.
5. Allow the site to bleed.
Wash with soap and water in percutaneous/ mucocutaneous exposures.
6. Promptly report to HIC Team member and should be subjected to counseling. Determine the status for HIV,
Hepatitis B and HCV [Antibodies & Antigens] of the patient and person exposed.
Post-exposure prophylaxis treatment should be started within two hours based on risk assessment done i.e., Type of
exposure, status of the patient] by HICC Chairman or Infection Control Officer.
Prophylaxis for HIV:
Basic Regimen: Tab Zidovudine [AZT] 300 mg BID X 4 weeks

Tab Lamivudine [3TC] 150 mg BID X 4 weeks.

Expanded Regimen: Basic regimen + tab Indinavir 800 mg TID X 4 weeks.
Note: If the patient is on antiretroviral therapy, duration and drug resistance to
be kept in mind before starting prophylaxis.
HIV testing for person exposed:
Baseline HIV testing on exposure.
Follow up testing at 6 weeks, 12 weeks, 6 months and 12 months.

Prophylaxis for Hepatitis B

Hepatitis B Immunoglobulin IM 5 ml in adults within 24 hours of exposure.
Start hepatitis B vaccination at another site 1ml IM within 7 days of exposure.
If the exposed individual has been vaccinated for Hepatitis B, determine the Hepatitis B surface antibody levels by
ELISA, which should be >10 units. In case values are less than ten, one needs to take a full course of the vaccine &
Hepatitis B Immunoglobulins.
Some individuals after second round of vaccination do not respond, which is indicated by absence of Hepatitis B
antibody levels. Such Individuals need to be given two doses of Hepatitis B Immunoglobulins with an interval of
one month.

Prophylaxis for HCV Exposure:

Test for anti-HCV for the source person.
For the person exposed to HCV positive source,
a. Perform baseline testing for anti-HCV.
b. Follow up testing at 6 weeks, 12 weeks

NOTE:
beneficial when started early in the course of infection.
b.Seroconversion rate after needle stick injury /exposure to contaminated sharp is
1.8% [Range 0 to 7 %].
c.HCV RNA detectable 1-2 weeks earliest.
d.Anti – HCV antibodies positive 5-6 weeks after infection

6.13. MANAGEMENT OF THE OUTBREAKS:

Any outbreak that occurs in the hospitals is informed immediately to Infection Control Chairman / Officer.
Outbreaks can be defined as infections with the same organisms in more than 2 patients
Upon receipt of the information of the outbreaks, cultures/ blood samples of the patients involved are taken.
Environmental swabs of the outbreak area are correlated with the cultures of the patients
Any etiopathogenesis of the infection is established and corrective action taken to prevent recurrence

Flow Chart for Epidemic Management

6.14 BIOMEDICAL WASTE DISPOSAL

The hospital has assigned the job of Bio Medical waste management to IMAGE, which has been authorized by Kerala State
Pollution Control Board to carry out the same.
 6.14.1 Biomedical Waste Disposal In OT Responsibility
OT staff nurse/ House keeping staff.

Purpose
• To destroy microorganisms as quickly as possible after operation.
• To prevent cross infection to personnel.
• To contain infection.

Procedure
Reusable materials and equipment:
As the patient is ready to be wheel out of the OT. The OT team prepares for clean up.
Linen: is checked by the scrub nurse (before un-gowning and un-gloving) for towel clips, instruments and other
items. Be sure nothing is discarded with the drapes. Roll the linen drapes off the patient to prevent sparks and air-
borne infection, and discard into large yellow double plastic bag kept for this purpose, and close the neck of bag,
label it with date, area, details of type of linen and number and send it to dispatch area. Put an appropriate color
code if the case was infected one.
Disposable drapes, gowns used during surgery need to be discarded in yellow double plastic cover, sealed, labeled
with area, date and sent to dispatch area.
All soiled instruments and reusable equipment should be placed in the instrument trays and by lifting the 4 corners
of the trolleys sheet, this bundle is inserted into a plastic bag and sealed and removed to CSSD for processing and
cleaning prior to sterilization.
Disposable waste and human parts.
All disposable waste and human parts are placed de are discarded in appropriate color coded dustbins which are
sealed, labeled with the details of area & date and taken by the housekeeping staff to waste storage area with
appropriate PPE. All sharp disposable items are placed in puncture and fluid resistant container and sent for
disposal.
The OT is now ready for cleaning.
6.14.2 Waste Disposal in the Other Departments
Plastic bin, plastic covers different colors and sizes, white plastic container, brown tape.

Procedure
All the waste should be disposed in assigned containers.
The entire house keeping staff should be instructed clearly regarding the waste disposal.
All the sharp items should be put in white plastic puncture proof container. Once the can is 3/4th full, it is filled with
1% sodium hypochlorite, sealed and sent to BMW storage area.
All the plastic items should be put in blue plastic covered bin.
All the non-infectious waste should be put in black plastic covered bin.
All the human tissue organs and other body parts , infected swabs, dressings bandages, heavily soiled linen , diapers
contaminated with faeces to be discarded in yellow colored dust bin.
Infected linen should be discarded in yellow colored double bag and in seropositive cases appropriate colour code
labels to be stuck on the bag for proper identification for disinfection and sterilization.
Histopathology specimens are discarded [after removing formalin] in yellow bag.
Once the care is over, all the covers should be sealed properly, labeled and sent to waste storage area. Waste storage
area has three rooms: One room is dedicated to infectious waste- yellow bags, one for blue, white bags and sharp
containers and third one for general waste.
The rooms are cleaned on everyday after the waste has been collected and cleaned with 1 % sodium hypochlorite.
Finally the things will be taken for disposal.
Cytotoxic drugs: Unused cytotoxic drugs, expired cytotoxic drugs need to be discarded in black covered dust bin
with cytotoxic hazard symbol. The equipment used for administration of these drugs need to be discarded in
 transportation to BMW storage area.

6.14.3 WASTE MANAGEMENT:

All the Biomedical waste collected in the hospital is outsourced to IMAGE Ltd. for safe disposal.
The Bio Medical waste is being treated as per the statutory provisions by the outsourced agency.
Appropriate personal protective equipments including masks, gloves and caps are provided to all categories of staff
handling Bio Medical waste.

6.14.4 LIQUID WASTE DISPOSAL –

The following are the Infectious liquid waste generated in the hospital
1. Blood
2. All Body fluids

Disposal of blood and Body fluids

1. The liquid waste is transported in a liquid waste trolley to the disposal area using
mask, unsterile gloves, plastic apron, eye protective glasses / visor.
Place a yellow cover with biohazard symbol in the trolley compartment.
Container with liquid waste from OT should be placed in the trolley compartment
with lid of the trolley closed.
2. The trolley should be transported to Liquid waste disposal area slowly.
3. All the infectious liquid waste should be decanted carefully in to the dedicated liquid waste wash basin. Then the
wash basin is flushed with water taking care to avoid splashes.
4. The container is washed with soap and water, disinfected with 1% Hypochlorite, rinsed with water and handed
over to the end user.
5. Remove the yellow cover from trolley and discard in blue dust bin.
6. Disinfect the trolley with 1% Hypochlorite
7. Wash your gloved hand, discard the apron, cap and mask; wash your hands well with soap and water.
8. The ICD bottles and suction bottles from the ICU can be carried with gloved hands to the liquid disposal area,
decanted carefully into the dedicated liquid waste wash basin. Then the wash basin is flushed with water taking
care to avoid splashes.
The suction bottles are washed with soap & water, disinfected with 1% Hypochlorite The ICD bottles are washed
with soap & water and then sent to CSSD for sterilization in yellow coloured plastic bags.
 6.15 TRAINING ON HOSPITAL INFECTION CONTROL
Training classes are conducted on a regular basis for all the staff that are in direct patient care and are associated with
Infection Control practices.
All the staffs recruited are oriented with infection control protocols pertaining to their departments at the time of
joining.
Regular in service training sessions are taken periodically.

6.15.1 Topics/ Areas for Training

A. Nurses and Physiotherapists –
Ubiquity of Organisms
Sterilization- Steam
Disinfection
Infection: Source, methods of transmission, types of Infectious diseases.
Normal flora skin, nose, nasopharynx, intestine
Hand Hygiene
Standard Precautions
Blood and body fluid precautions
Use of masks and gloves
Collection and transportation of samples like body fluids, blood, sputum, urine, tracheal secretions, BAL, stool,
skin swabs
Catheter related Blood Stream infections
CVP line Care, peripheral line care
Care of Tracheotomy
Care of Urinary catheter
Wound Infections and care
Perineal care and Hand Hygiene
Contact Precautions
Care of Patients with multi drug resistance
Needle stick injuries and post exposure prophylaxis
Label indicators
Use of Sterilium
Waste management
Ventilator associated pneumonia
MRSA
Tuberculosis
HIV
Hepatitis B Virus
HCV
Linen
B. X- Ray Technicians –
Hand Hygiene
Routes of Infection
Standard Precautions
Blood and Body Fluid Precautions
Use of masks and gloves
Contact precautions
Label Indicators
Waste management
 Care of patients with MDR infections

C. House Keeping Staff –

Hand Hygiene
Use of Hand rubs
Use of mask gloves
Waste management
Label indicators
Cleaning suction apparatus, urine cans etc.
Contact precautions
Emptying Urobags, Urine Cans
Hygiene of worker
Post exposure prophylaxis

6.16. INFECTION CONTROL POLICY FOR AMBULANCE SERVICES

Responsibility of Checking: In charge, Travel Desk is responsible to check the details and
report to medical Superintendent on a daily basis.

1. Ambulance needs to be cleaned on a daily basis.

2. Floor of the ambulance needs to be scrubbed with detergent and mopped with 1% Hypochlorite everyday.
3. Patient trolley, seats, fan need to be cleaned with a mop soaked in with 1% Hypochlorite on a daily basis and after
patient is shifted to casualty.
4. The wash basin needs to be cleaned with detergent and water on a daily basis and whenever soiled.
5. The medicine & consumables cupboard needs to be cleaned once in 3 days with with 1% Hypochlorite and
whenever there is soiling with blood and body fluids.
6. Adequate water and soap to be available in the ambulance for hand washing.
7. AC needs to be checked for functioning and maintenance done on regular basis.
8. Oxygen cylinder needs to be cleaned with 1% Hypochlorite and then kept in the ambulance.
9. Ambulance drivers & cleaning boy for ambulance need to be trained for standard precautions and are to be
vaccinated for Hepatitis B.
10. Spillage of blood and body fluid to be dealt as per spillage protocol.

Nursing responsibility:
1. Ventilator, monitor, BP apparatus, IV fluid stand, syringe pumps, stethoscope are to be cleaned with cotton soaked
with Bacillol on a daily basis and after the patient has been shifted from ambulance to Casualty.
2. Ambu bag needs to be disinfected after being used for a patient.
3. Laryngoscope blade needs to be washed with soap and water, dried, and disinfected with Bacillol and stored in a
plastic pouch.
4. Dispose the waste as per the Biomedical Waste Protocol.
5. Any spillage in the ambulance needs to be treated with 1% sodium hypochlorite as per the spill protocol.
6. A bottle of sterillium is required for adequate hand hygiene.
7. Adequate masks, gloves, cap and plastic apron are required in the ambulance. Any spillage in the ambulance needs
to be treated with 1% sodium hypochlorite as per the spill protocol.
8. Portable suction apparatus need to be cleaned on outer surface with Bacillol and the contents of the bottle to be
dealt as per the protocol.
9. The oxygen cylinder and its trolley has to be cleaned with 0.4% Virex everyday and after the patient has been
shifted from ambulance to Casualty

6.17. SAFE INJECTION PRACTICES

Standard Precautions
Use aseptic technique to avoid contamination of sterile injection equipment
Use single-dose vials for parenteral medications whenever possible
Needles, cannulae and syringes are sterile, single-use items; they should not be reused for another patient nor to
access a medication or solution that might be used for a subsequent patient
Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients
What is Aseptic Technique?
Handling, preparation, and storage of medications and all supplies used for injection and infusions—e.g., syringes, needles,
intravenous (IV) tubing—in a manner that prevents microbial contamination
Medications should be drawn up in a designated “clean” medication preparation area.
In general, any item that could have come in contact with blood or body fluids should be kept separate
Fact: Injection preparation on surfaces where contaminated substances are handled can lead to the spread of infections

Safe handling of parenteral medications

Always use a new sterile syringe and needle to draw up medications
Proper hand hygiene should be performed before handling medications
Parenteral medications and injection equipment should be accessed in an aseptic manner
Maintaining sterility of vials
A new sterile needle and syringe should be used for each injection.
Medications should be discarded upon expiration or any time there are concerns regarding the sterility of the medication
Leftover parenteral medications should never be pooled for later administration
A needle should never be left inserted into a medication vial septum for multiple uses
This provides a direct route for microorganisms to enter the vial and contaminate the fluid

Minimizing the use of shared medications reduces patient risk

Single-use medications vials should never be used for more than one patient Assign multi-dose vials to a single patient
whenever possible. Do not use bags or bottles of intravenous solution as a common source of supply for more than one
patient.

• Absolute adherence to proper infection control practices must be maintained during the preparation and administration of
injected medications.

7. Management of Information

FORMS

Sl. No TITLE
1. Hospital Infection Control Surveillance Data Sheet
2. HAI tracking sheet
3. Confirmed cases of HAI sheet
4. Waste Transportation Checklist
5. Laundry Visit Checklist
6. Overhead Tank Cleaning Checklist
7. Hand Hygiene Compliance Checklist
8. Infection Control Practices For Isolated Patients
9. Needle Stick Injury Checklist
 10. VAP, CAUTI & CLABSI Prevention Bundle Checklist
11. Surgical Site Infection Prevention Bundle Checklist

Files
1. Temperature and humidity register
2. Chlorination files
3. Linen checklist file
4. Waste management file
5. Pre & Post disinfection culture for ICU
6. Culture positive file
7. Cleaning file of ICU
8. Water culture file of ICU.
9. Hand hygiene compliance file
10. Needle stick injury file
11. Overhead tank cleaning file
12. VAP Bundle file- ICU
13. CLABSI Bundle file- ICU
14. SSI Bundle file

OT Files
1. Water culture file
2. Environmental culture file
3. Air culture file
4. Fumigation file
5. Waste transportation file
6. Chlorine level monitoring file

8. COORDINATION WITH OTHER DEPARTMENT

9.0. POLICY FOR SINGLE USE DEVICES AND RE-USE OF SINGLE USE DEVICES AND THEIR CLEANING/
DISCARDING PROTOCOL

PURPOSE: To define a set of guidelines for the reprocessing of single-use, or disposable medical devices (SUD).
Note: This policy does not address the reprocessing of devices that are marketed or labeled as reusable or multi-use
devices.

DEFINITIONS:
Single-Use or Disposable Device: A device that is marketed or labeled for single patient use or single procedure use. It is
not marketed or labeled with the intent of reusing the device on another patient. The labeling identifies the device as
single-use, or disposable and does not include instructions for reprocessing.
Note: Some SUDs are marketed and labeled as non-sterile and include appropriate pre-use sterilization or processing
instructions to make the device patient ready. This is not considered “reprocessing”.
Open but Unused: An “Open but Unused” product is a SUD whose sterility has been breached or whose sterile package
was opened but the device has not been used on a patient.
This also includes a device whose packaging has expired as identified by the label on the package.

Reuse: The repeated use or multiple use of any medical device on the same patient or different patients, with applicable
reprocessing (cleaning, functionality verification, and/or disinfecting /sterilization) between uses.

Reprocessing: Includes all operations performed to assure that a previously used

SUD is clean, sterile and will function as intended by the original equipment manufacturer (OEM). The process
includes, but is not limited to, disinfection, cleaning, functional verification, packaging and possibly sterilization.
Resterilization: The repeated application of a terminal process designed to remove or destroy all viable forms of
microbial life, including bacterial spores, to an acceptable sterility level.
POLICY: Narayana Hrudayalaya has adopted the following policy regarding the reprocessing of SUDs:
Narayana Hrudayalaya is committed to reprocess SUD’s in a manner so as to ensure patient safety and stringent quality
controls.
SUDs that may be reprocessed are those listed below. SUDs not listed cannot be reprocessed and should be discarded
after single use.

List of SUDs which are re-used:

 1 Fine suction OT 10
2 Transducer domes OT & ICU 3
3 Anchor suction OT 10
4 Nasal cannulae ICU 5
5 Oxygen tubing ICU 5
6 Oxygen mask ICU 5
7 Cautery cable OT 10
8 TUR set OT 10
9 Stimuplex Needle OT 10
10 Corrugated Drain OT 10
11 Skin Stappler OT 10
12 Ureteric Catheter OT 10
13 Guide wire OT 10
14 Airway guedal OT 10
15 Liga clip OT 10
16 Karman canula OT 10

AUTHORITY:
Authority for the program is vested with the Infection Control Committee. The Infection Control Committee is a multi
disciplinary group comprised of clinical, Central Sterile Processing, Materials Management, Risk Management,
Infection Control, Quality control and Clinicians with a commitment to patient safety and will follow the policies set
forth regarding the reprocessing of SUDs.

PROCEDURE: Sorting:

An initial sort of each SUD shall take place to eliminate obvious rejects or unapproved products. Any SUD for
reprocessing which has visible color change, change in handling properties, leaks, kinks, physical damage, fraying etc
will be immediately identified & discarded.
Cleaning:
The SUD shall be cleaned thoroughly to eliminate any blood or other body fluids. The SUD shall be cleaned with
heparin saline (hollow items) or plain water. Hollow instruments shall be cleaned with a brush. The SUD shall then be
placed in Multi-enzyme solution to dissolve all protein residues. These items are then cleaned with hydrogen peroxide
(3%) to remove blood residue. The items are then sent to CSSD where they undergo a cleaning cycle in the ultra-sonic
cleaner. The SUD shall then be thoroughly rinsed with water and left to dry or dried with air under pressure for hollow
tubings.

Testing:
Verifying that devices perform as intended shall be an integral component of the reprocessing cycle. This can involve
injection of water through the catheters, or other device-specific functional indicators.

Packaging:
All devices shall be packaged, sealed and labeled in Hospital approved pouches for EO purposes. Prior to packing, a dot
with a permanent marker shall be placed on the device, indicating the number of times it has been reused. Those SUD
used more than ten times are either sturdy or may get potentially damaged following marking. Hence such items shall
not be marked.

Sterilization:
Sterilization shall be performed in state-of-the-art Ethylene Oxide (EO) gas sterilizer.
Every load shall contain PCD & chemical indicators. Biological indicators shall be used once a week & shall be sent to
the Microbiology laboratory for testing. Final Inspection & Product Release: After undergoing sterilization cycle, the
sterilization indicators and integrator are inspected. If the cycles have passed, only then shall the devices be brought in
use.

Labeling requirements:
All reprocessed SUD shall be labeled with the number of times the device has been used, date of reprocessing, date of
expiry, EO machine number & Lot number. Lot number is a non-repeatable number that shall be allocated to the device
in order to facilitate recall of the device.

Incident reporting:
Any incident due to a reprocessed SUD shall be immediately reported on the “Patient Incident” Form. The data shall be
collated and analyzed by the HIC Team and report shall be made in the Quarterly Steering Committee. The Safety
Committee and Infection Control Committee shall also review the data.

SUD Recall:
Any SUD found to be unsafe due to repetitive incidents or due to a report by Microbiology or from manufacturers, shall
be immediately recalled and disposed of as per hospital policy for bio-medical waste.

Disposal:
All devices that have been reused the number of times as per policy, shall be mutilated and disposed off in the yellow
waste bags.

Inspection at the time of Reuse:

All SUDs that are re-sterilized would be inspected by the end-user at the time of re-use for integrity, damages, kinks,
frays or any such indication that the SUD may not fulfill the patient care necessity. Such SUDs that are found unsuitable
for use on patients would be discarded by the end user.

10. ENDOSCOPE REPROCESSING PROTOCOL

1. After withdrawal of the endoscope, using appropriate personal protective equipment (PPE) - Mask, gloves, plastic
aprons and eye cover, clean the outer surface of the endoscope with a lint free cloth to remove debris.
2. Perform suctioning of air/ water & biopsy channels with potable water for 2-3 minutes.
3. When transporting the endoscope by hand to the cleaning area, loop the universal cord, hold the endoscope
connector with the control section in one hand and hold the end of the insertion tube securely, but gently without
squeezing, in the other hand.
4. Clean the biopsy and air/water channels thoroughly with a channel cleaning brush.
5. Fix the injection tube to the channels and channel plug to air / water and suction ports.
6. Fill the lumens of the scope with the enzymatic solution- 3M Rapid Multi-Enzyme Cleaner (1:100). Immerse the
endoscopes along with the injection tube, cleaning brush, suction cleaning adaptor, mouth piece, washing tube,
biopsy valve and distal cover completely in a container filled with 20 litres of 3M Rapid Multi-Enzyme Cleaner
(1:100 dilution- 200 mL + 19.8 L of water) for 8-9 minutes.
7. Flush the endoscope with potable water.
8. Fill the lumens of the scope with 2% Lysoformin. Immerse the endoscope along with the injection tube, cleaning
brush, suction cleaning adaptor, mouth piece, washing tube, biopsy valve and distal cover completely in a container
filled with 20 litres of 2% Lysoformin (400 ml of Lysoformin 3000 + 19.6 L of water) for 20 minutes.
9. Flush and rinse the endoscope with potable water.
ANNEXURE

INTERVIEW FORM FOR SELECTION OF INFECTION CONTROL NURSE

Date:
1] Name:

2] Interview Number:

3] Present area of work:

4] Years of experience:

5] Marks for Interview: [Max. Marks: 25]

Basic training in nursing : ________
Knowledge about basic infection control measures: ________
Knowledge of infection control policies : ________
Communication skills : ________
Leadership quality & Attitude : ________

Total score obtained by the candidate : ________

6] Remarks:

Chairman, Infection Control Infection Control Officer

REFERENCES

WHO Infection Control Policies

Infection Control Protocols – CDC Guidelines 2004
Recommendations for Post Exposure Prophylaxis- MMWR – CDC guidelines –June 29, 2001/Vol-50/No. RR –11
Infection Control Protocols for Dietary Department – TAHSA
Centers for Disease Control [CDC] Guidelines for Preventing Transmission of Infectious Agents in health Care
Settings 2007.
 ISSUE
PREPARED BY REVIEWED BY APPROVED BY

Ms. Chithra S R, QM Dr. Dr. Mrityunjay C Modi, Dr. Robert Raj, MD Mr. Vijaya Krishnan
DMS