UNIT 1 HOSPITAL ACQUIRED

INFECTION
I

Structure

1.3 Epidemiology
1.4 Routcs of Spread
1.5 Control ;u~dl'reve~ition
1.5.1 I-lausc Keeping

L.5.4 (Icntral StcriIe Supply Dcpnrtment (CSSD)

1.5.9 Antit~ioticPolicy
1.B FIospilal Infecliol~Control Committee .-
1.6.1 Composition
1.6.2 Rold and Functions
1.7 ~u;veilltu~ce
1.7.1 Proce4in.g of ~ n f o ~ ~ n n t Cgllected
ion
1.7.2 Mode of Trnnslnission
1.7.3 Intenuption of Transmission
1.7.4 I ligh Iiisk Pl~ocedures
1 .X Training :md Educalion . .

1 .!IUniversal l'recaulions for Healtli Care Workers

1.10 Legal Aspccls
. .

1.12 Answers to Chek Your Progress

7 ,

..
1.0 OBJECTIVES I

N'ler studying tl~isunit, t l ~ student

e shall be able to:
. . b

e describe t l ~ cil~plicationsand impact of Hospital Acquired Infection (HAI);

e discuss the epidemiology of HAI;
e discuss Lhe routes Af spread gf HAI;.
e discuss the tnell~odsof controllii~gHAI; . .
e discuss h e cumposition of I-Iospital Infection Control cdmm'ittee; and
:-
3
e describe tllc inettiod of active and passive sutveillance.
. a
Safely n l ~ dRisk M:~asgeraent
1.~1INTRODUCTION

I-Iospital infection occurs in every liospitd bcyond doubt, but on many occasions it is
.overlooked. It becomes glaring only wlien damage has been dorie out of proportion in
magnitude to a relatively minor tllernpeutic procedure c i ~ i e dout,on the patient.
Johnbell, in 1801, remarkcd that hospital infection cxists in cvcry type o i liospital. Louis
Pasleur in his celebrated leclure to academic De Medicine on 30 April, 1873 said "If I had
tlle honour of being a Surgeo~i.,lot only would I use absolutely clcxi instt.umeiits, but
after clea~iingmy hands with greatest care would still liave Lo fear g e r m suspended iu air
and surrounding Ule bed of Ule patient."
Ilospital Infection is perhaps tlie single most important factor tllat adversely affects tl~e
performance and image of the hospitals. Besiclcs morbidity and mortality, it prolongs the
hospital stay of patients, increase bed occuplvicy rate xid Ll~erebyputs undue pressure on
already slrained resources of the hospital, piltients, community and tllc couiitry.
The magnitude of the problem is dil'licult to assess in our liospitals tluc lo paucity of
available literature and data on the subject. I-Iowever, ovcr;lll reportcil iiicidence ol' post
operiitive wound infection i11 various hospitals in India range from 10-25%.
Florence Nightingle, more than 100 yexs ago, said "No slrongcr condernnatioii of any
hospital or w i ~ could
d be pronounced thaul the sin$le fact that zymotic (infectious)
disease has originated in it, or tliat such a disease has attacked other paticiits thzul tliose
biought in with thein."
No hospik~lcan conlinue to perpetuate such co~idemndtion,liowcver, liospitill acquired
infections remains a problem world over. In a rccent survey conducted by WIIO 011
28,861 patients in 47 hospitds of 14 countries located in 4 continents, the prevaleiice ratc
of HA1 of different hospitals varied from 3-21% with inem ol 8.4%. 'l'lie results of the
survey reported in 1988 indicated that the HA1 is a considera~ldeprobkein, even in
liosplhis with meals and interest in co11trol of I-IAI. Furtiler it is possible to rcduce tlle
incidence of infection. Tlie authors co~icludedthat there is :I need mid opporturiity for .
intenlational cooperation in finding aid applying effective ~nc:u~s of prcventlon iuld
control.
The problem of hospital infcction has received the attention of Government of India and
two high powered committees, one in 1968 Ileaded by Dr. K.N. Rao, tlie tl~criDirector
General of Health Services and other in 1976 headed by Dr. Slialrad Kuinnr, Deputy
Director General of Health Services, investigated in detail tile problem of 1iospit;ll
inkction in Delhi hospitals. Dr,Rao Committee suggested a multiprongecl attack for
cotltrol of l~ospitalacquired infections occurring not i~ifrecluenllyi ~ l dc~npliasizcdthat I

"?he reservoirs of infections in the hospitals must be attacked, r:uricrs must be dealt
with, and rigorous asepsis in the wards and theaters introduced. Clca~lllair, elem beddings
and liygieilic methods of dust removal lnust be recognized as basic requirelnents, and the
use of hospitals must be strictly co~~trolled;uid dictated by essential nccds." Sliiuad
Kum;u Committee in 1976 reco~nmeridedformulation of I-Iospital Infcction Conrrol
Committee, maintenance of proper medical records, and rnedicd audit (death committee),
training of staff, control of overcrowding, irnprovein~tof sanitation, kitchen .and laundry
services.
It is necessary to streiigtlienlintroducethe following activities in each hospital with bed
strength of more than 250:
- Management of HAI co~~trol
activities.
- Surveillance of IIAI.
- . Operational manuals for differenl high risk procedurcs,
- Sterilization and disinfection procedures.
- Disciucling 'and disposal procedures.
- Manpower development ul service training.
- Publication of informalion. I
 1.2 DEFINITION

Hospital infection cxi be 'liospital associated' or 'liospital acquired'. I-Iospital associated

.
infectioiis are those, I.liat are acquired during liospit;~lizatioiias well as tliose that are
present upon admission, having been acquired prior to hospitalization.

The present topic is restricted in scope to 'liospital acquired' infection which is also
know11 as 'Nosocomial infection' and cim be dciii~edas "liifeclion acquired by the person
in the hospital, manifestation of wliicll may occur during hospitalization or after disc1i;ugc
from hospilal." The persoil may be n'pilient, ~nelnbersof the liosl~italstaff ?uld/or'
visilors.

EPIDEMIOLOGY . . '

Like my oll~erdisease process hospilal acquired infeclion has also got "cpideiniological
d the agenl, host :uid environmenl. Soundrze,rs of ,fsuiveilla~zcemzd control
~ i a i.e.
pmgmtnme depends on solind epiclcwzinlogicul knowledge.

a) ?'he Agent
V I Agent
~ possibly ilicludcs enlire spcclru~nof lnicrobcs e.g. su~phylococci,gruk~-ve
bacilli, occasloiial streptococci, viral, rickel~sial,fungal ;1nd prolozoal infe'eclions. It is
staled tllat: ...
- Large nuinber of ill1 liospital ilifections are due lo gram -ve orgauiisms.
- Some of infections are ctlntribulcd by sliipliylococci (coagu1;lse +vc phi1ge typeable).
- Roteus, E, coli, Sahnonella, Shingclla, Klebsielli~,Ps, aenlgillosa are increasiiig in
their involvernenl as causalivc: agent of liospital :~ctluiredinfeclion.
- Carrier stale of orgimisin xid their coloxiizalion n~itlincrc:lsed resistiulce of
xitimicrobial ageiits are iinportant i'aclors of considcralion.

Decreased resistaicc of patients cluc to uudcr mentioned filclor contribute Lo u great

lenglli 011 susccplibilities to h ~ ~ p i t iacquired
ll iiifcclion. The Iactors we:
- Extreines of ayes
- Primary ailments with concomitant disease like diabetes mellilus, cl~roliicnepl~rilis
and malignancies,
- Tlle therapculic p actices c.g. wholc body irradiation, use of cytotoxic ~tndimmuilo-
suppressive dl-t~gs,iiidiscrilninate usc of u~libiotics[uid steroids etc.
- Cornplicaled diagilostic procedures c.g. vetiepullclure, types of aspiratio~is,ctudiac
caLlleterization and Ienglh oi' opertltivc procedures.
- Endogenous infections.

c) . The Environnrent
Everything that surround a palieill in the hospital is his environment. l'llese infection can,
be acquired froin:

0 Other patients, llospital staff [uid visitors, food, water, dust iuid otlicr contiul~inated
inanimate articles;
0 Durg resistance microorganism and cl~:u~gc
from non-patliogenic slrain to pathogenic
are found commonly.
FIospital acquired in fe'rtioiis can be derived from:

r
 Sul'cly ant1 Risk Mulmge~nent 1) Tlle patient's own flora: Self infection (:~uto-infection): The micro-organism
concenled is not pathogenic under nor~niilconditions, but underlying disease.
invasive diagnoslic aid therapeutic procedures including irnll~unosuppressiveeven
iultiobiotic therapy uld the like, may enable it to reproducc, spread and implant itself
at a site where it may produce an infection.
. .
2) The flora of another patient: Cross-infection: 111such cases, the micro-organism
concerned is transmitted:

a) By direct corrtrrct betweell patients (saliva droplets, patient's hands);

.. . ' b) By air (dust fmm fabrics carrying a patient's flora);

C) B-v the st@

. - who collect the micro-orgamisrns directly on their hands or clotl~esand .
tramsinit t l ~ c ~ton anoll~erpatient.
- who harbour the micro-org;u~isms011 the lnucosa of their own respiratory
and intestiilal tracts, where Ulcy reproducc auld are transmitted rarely by air,
more often by contact (micro-organism carriers),
3) Environmental sources: Environniental Infection

a) Hospital air usually l~nrboursInore bacteria which ilre more often pathogenic
tmd multi-drug rcsistwt.

b) Surfaces contaminated by patient's secretions, excretions, blood md body I

fluids, amimals and insects.

c) Incmimateobjects:
- contmninnted by Ule patients - hospilal ecluipinent (sanitary installation,,
lights; tables, beds etc.), nledical equipment (endoscopes, catheters, vesccal
probes, needles, lancets, spatula and oher instruments used for invasive
i ~ non-invnsive
~ d procedure, aerosols etc.)
- conmni~~ated by tlle'hrmds of tuly hospital staff ill any part of the hospital
(kitchen, laundry, treatment room, etc.)
- conthinated by visitors
- conLminated by staff who are ill or are carriers of micro-organisms
- col~taminatedby food or infected water
- col~tamjnatedby animals imd insects.
In general, most of the iilfcctions caused by e~~terococci :uld other non-haemolytic
streptococci, anaerobic cocci, gas gamgrene producing clostridia and bacteroides are self
infectious; that by S. aureus, grbup B streptococci, cnterobacteria (Xi. coli, Klebsiella,
proteus etc.) may be acquired either from person to person (dross infection). Infections
will1 Clostriclum tetani, Flavobacterium, aeruginosa iuld Klebsiella-Serratin-
Enterobacter groups are often acquired from environmental sources. I-IJV and FNB in .
health c x e settings lnay be acquired from blood of the I-IIV and HBV positive patients by
direct inoculation or through contact will1 broken slch or mucous membrane.
Man thereforq occupies a cerltral position:
1) as reservoir iuld source of micro-organisms;
2) as disseminator (communica~ionroutes);

3) as recipient or target, thus becoming a new reservoir,

ROUTES OF SPREAD

The organisms are translnitted by the Ibllowillg routes:

 aj Direct route: Perso11Lo perso11carrier. Iiospilal s~;II'J' ; I I I ~visitors. air hornc rpulc
which ~licludcspallenl.

b) Iudirect route: Througli co~itnm~nnled

rnanlll~alearl~clcsc.p. food and drink, dust,
bed linen and equipment.

Ilnporlani cons~derationsIn lhc ~nodc01' transmission ol' 11oai7ilalacq~~irecl

~nkclionsI'or
instilul~ngel'l'cclive conlrol measure :we:
- Grealer exposure ol' palicnts lo i~ilccliousagenls in Iioslli~alcnvironmenl.
- vcnlila~ion,Salllty dcsigli 01' wards ancl dcporlmcnts.
Inadcq~~ale
- Non-~~v;~ilahilily
of isolu~ionroonis, dilly and clcan ~~lilily
room and janitor's closcls
in nia~iywards.
- Over crowding in hospital wards.
- Spread of ~nfectionhorn undiagnosed inl'cclious I)nllcnts nL ~ l i ctime of atlmission.
- Ilili~nalecontact hctwccn paticn~sand staff nncl visitors.
- Inadequate and subs~andar\Iaseptic proccdurcs, including carelcssncss in hantl
wnslring.

- Poor kitchen scrvicc. luuncl~.ylhcilities iuid inaclcqu:~tcslerili/alion stanclards.

- Faully Ilouse keeping.

Check Your Progress 1 . ,

I) Hospital Acquired Inl'cction can be derived from :

..................................................................................................................................

...................................................................................................................................
2) The organisnis arc ~runsmitlerlhy the I'ollowing roulcs :

1.5 CONTROL AND PREVENTION

1.5.1 House Keeping

i) Personal hygiene and environ~nenlalsani~ationkepl ill high lcvcl in llic liospi~alol'
:Iny kind, is mantlalory require~ncnttowards control ol' 11osl)ital infection.

ii) Ell'icicnt house keeping inclucliug clcan supply ol' I)ccl linens ancl pulients dress;'
pt-opcr bcd ilrrangemcot:

I I ~ ) Frequent mopping anrl periodic wnsliinp 01' Ilospi~alw n ~ ~ant1

l s tlcparlmcnts floors;

IV) Each ward Inlist bc provitlcd with isolation facilities in scparnlc rooms for infectious
pnlicnts over ancl above lie isol~~lion
wards.
 --

1.5.2 Dietary Services

Orderin:, procurement, prepi~rat.ion:lud tlist.rihl.~tionInusL be :lrr:lngetl tl~rou;;husganised
kitchen service. Minimu111ol'h:fi~dl.ingInusr bc cosuretf. .Aclcclu;ltc w:.ltt's supply a i d .
wasliing f;lcililies of h o d ite~ils:uld ulensils to he made av;lil:iblc. Wllc.rc possible in
larger hospitals ~ n e c l ~ i ~ l ~cnolcil~g
i c a l riuigc :)lid olher l':~cili~ics
bc l~rovidcd.Sanitatioll ol'
coolc house zmd distribution centre, provision ol' Sood trollies etc. will Ilelp ill rctlucing
infection clue to cout:unin:ltion by h o d . I'crioilic: mctlical cxi~mi~~ation ~ J I coolts
' iuitl food
li;*l~dlersmust be donc.

1.5.3 Linen arlcl Laundry

The wasliiag of li11e11cim he rn;uiu:ll b y 'dliohics' (11. rnecl~;n~ic;~l
hy \ \ 7 ; ~ s l ~machi~~c.
~ng
S~iecialcare is Ilcccssmy when washing it; dnl~cby 'dliohics'. 'I'hl: li~rcn11scdhy the
patic~lts,doctors iuid p;u-amedlcal stal'l'm;ry l ~ e'clcan colil;unirr;l~c~l'ol 'conta~niniitxl'
when soilcd with blo(7d/pus/l1rine/l:1ccesor :Iriy otllcr hotly I'luids.

'rile cont,unin;ired lincn must he clisi~~i'ectccl bct'orc giving to 'clhohies' lor wi~sl~ing. Tlie.
disinfection ciu~be done hy c1ie:iiical c1isinfc~:tiultor by boiling or : ~ i ~ l o c l : l \ i;it~ ~low
g
pressure of s t e m . 1-Icnce tile ti.:rlcilitiesfor disiiifectin~~
of ccinl~ni-ri11alec1
soiled line11
should be ;rvail;ible in tile I~ospilalnear the tlisca~.cli~~g ol' coou~ii1in:rtctllinc~i.
Both the 'clcicr~col~tamio:tW'iu~tl'cont;in~i~~a~c.d' lincn slloulrl bc ~ran!;porlcilto laundry
separalely in thick p o l y l b r ~ ~bags
e ol' d~fi'erci~t
colours. 'I'll? 1,lcan cnntainin;~lerllinen c;ui
he 1r;uisported in thick cottoll bags also.
II;hldling, separating :uid counting of even clcan cunt:.~min;~tcil
linen is Jlazardous, hence,
tliere should bc minimull1 11:uidling.
Drying of Llie linen in rlie su11after w:ishing sl~oultl11c discoura~ctl:IS it is usually spread
on road side or other cont;uninatecl x c a .
Dscunt;imination :incl Wasl~ingof Blankets
The cotton a i d acrylic:lsyiitl~eticblaul<etsare prcfcrreil lo woolen h1:ml;cls sllice tliey c;nl
be easily tlccol~larnillatedwhen soilcd and w:ishilig is alsu cheap ;uicl c::~sy. 'l'l~cyc;ul be
huuidled like linen.. Conauninatcd soiled cvaolcn bl:ull<ets can be tlccc,~~tamin:ltcd either
by &q-msin6 lo formultlehyde v q ~ o u r or
s :lutocla\ring. Liquitl clismli:cl:i~ltmay tliunage
woolen blankets. 'rbe only mclliod of' clcanlng is by dry c l c a ~ ~ i n\~v'iiicli
g tlocs 1101
' inactivate/kill HIV.

It is advisable to cover nll Inattresses wilh wiuer 1,roof synli~eric ~nalcri:rllilcc rcsine or
plastic. This makcs ~l1cdisil1fectioii of the mnttrcsscs easier. Big a ~ ~ t o r ~ l aare
v c s:~\r;~ilablc
of matresscs. One of LIIC I.)elhi 11ospit:rls has such aulocI;~vcs. Waslling
for disi~ifectio~l
is not easy zuid a u i bc dolie mimually.

1.5.4 Central Sterile Supply DeparlnlenC (CSSD)

Facilities 01' stilndard slerilizatio~iof all hospital supplics c.g. syrinsc, nccdles, sulgical
insLrumails, OT linen, sets or trilys for diagnostic ;uld thcraipclrtic purposc, ruhhcr good
a~dother recluriement will cilsu$ Cconolny :uld higl~eslsuu~cl:lrdof nsel>sis :~ntl
steri1iz;ltloa in the Iiospitnl ;uid tllorby reduce the I~ospitnl;lccluircd inkction. In sniallw
11ospil;lls ophnmn sterilizaticm of cquip~iie~it, lllstrtunellt :mtl li~icliL C ) hi' c ~ i s ~ r throu$l~
ed
auloclave and stcam slerilizcr. 1;requenl clicck to ensure sta~itl;u'dto I)c ciirncd out.

Slcrilization is a process of frecing all ilrti~leii.0111 ; ~ l 1iivi~lyorg:ulis~i~s

n ~ c l u d i nbalctcrial
~~
auld fungal sports a i d vinises.
All ski11ant1 ~nucousn~cmbnulcpiercing n~stlumcnts(r~ccdlcs,1:lnccts. sc:rlpcls, scissors
clc.) otller iiistru~nents~uidecluip~nmteotl~ing111 c.o~it;~ct
with orgiu~s;air1 t i s s u ~during
I surgical prcxechlres ~ilustbc sterilized before use. c
Sterilizltinn can be achievetl by Ilc:ll (dry :uld o~oist)lonizinyr ~ t l i a t i o n( ~ m m u a
 ra(]ialioii. Illtr;l\liolet) cliem~cal(fo~'li~alrlrI~yclc,
ethylene oxide) iuld liltratinn.

IJo~vevcr,thc only p~.ilcticaltuitl ilepeiit,l:.ll~lc~nelhodof sterilizntioa in I-Ieilltll Ct~rt'

Settings is rnoisl hc;ll sle;uii under ~ S C S S ~tltilizi~~g
I I . ~ ? different types (si~nplc,slcam
jacketed etc.) 01- :~r~loclu\~es. It is ini~lorts.ililo IioLe that lelnpcralure :~cliicvctLin ~ul
all[r)clavc dcpcnds on ~)~-csst~re ol' llic stc.;ui~:lnrl 1101 pressure of h e stc:un and ail.; 15 Ibs.
prcssurc 01' st.c:lrn will cnrrctsl~c~ntl to 121°C' \vlicrc;ls if .C;Of%,t~iris present, tlie Lcmpcrature
;1cllie\7eclwill 111: o~lly1 1 YC1.

i o n be i~cliiewda1 15 II~sIst~
Satisl';iclo~:ys t o r ~ l i ~ i ~ lciul illell prcssure (15 p.s.1,) equivil1cnt
to one at~nospIie~'ic pressurr a ~ ~;I ttclnperalu~c
l of 11,I0Cin 15-20 111i11utcs(Iioldi~~g time).
I-[ous(:holtl prrssurc cooli~rccall ac.l~ie\j~~ :I pr'cssure of 15 p.s.i. ol' steiuil ant1 c:ui be used
\vrtli c;luIion f'or slcnli~alion.
An clecrric (11'g:~sOVL'II C:III111: IISCCI 101' ~ l c ~ ' i l i . i : ~01'l i i~~~~i ~ t r u m c(blli~il
~ l t s iiisli-UI~CIIIS,
;111
glass syringes? :!lass\\:are L.I.L..j i111t1 ~ni~tcri:~l (wi~x,oils, puwdcrs clc.) wliicll i 1 1 ~
i111penne:tble li:) st.c:un alltl c:lll n'iLll~Li~ld ::I 1~IITlpeI':lIUrC01' 170°C. 1-IoUselloltlovcll clul be
used l i ~ tl~is
r plrrpos~~. '1'11~' Iiol~li~i:;l111lr;:l~i;!c:s li.011160 I ~ ~ I ~ U I C111: S120 ~ l ~ i ~ i i ~ t c s
depcllclir~gOII illc cnot;unin:~lic111 (11' Illc: 1l1;lIcri;lllo bc !;lerilizetl ar~rli ~ ~ i i p c ~ . achieved.i~ll~c

Testing for Stcbriliairag 1Sftir:ucy of',.hi~tot.ll;avc.

In hospital s c l ~ i ~ wllcrc
~ p s stc~'iliziltionis rlonc ci:~it.rt~lly((:'SSI)), it is ncccssivy to rr~onilor
if eacll load Iias bce11~,~r.opcrly sturilij.ccl. 'I'llcrc: arc 11u1u1-wol'\~;~~.i:~l~lcs ill stcriliz:~lionby
autocl:nie lilx prcssura iliilicatctl I I :II.I~OC~;I\'C
~ I I I ; L 11('1t
~ he ( . I I I ~til'
~ slei~~ii
~ I I C1.0 i1lit~l~t1u;~t~
rc~nc~v;ll of i ~ i rcsrilling
r ill :~cllicvili!,!lu~vcl'~c:llll)c~'ill~~~'c :11 1l1cs:~mctprcs!iulc, o\rerlo:lcli~~g
of;l~iautoclave lllris illl~ilrilii~y 01' SLIYIIII ISL'IWCL~I~ Il~e.;lrtirIcs, I)I'c;~<(~o\vII of
f1.c~I?;ISS:I;:!:C
electricity i111ri11gthe pix)c(:.ss 01' ;III~OC.~;IYIII;; ~~):~rti~:~iIi~rly dt~riligI I I C liolili~~g t i ~ ~~~I'tcr
i c 111c
m a x i m ~ mtclnpcsaturc 11;~s hccn :~thicvctl. [I ll.lay hc notctl rll:~t autoclil\lc r:tl,cs ~ I paclis I
merely pro\riclc i l . 1 ~ 1i~~ilic.;~liontIi;~llllc 11roct.s~Ii:ls bccn carricil (.)111 at or inore
temperarurc al, wliicli color~r01' llle 1:1l,c cllallgcs I,ut IIOL Illat lllc corllc~ttsare sl.crilizcil.

It is, I.llcrclhre, Ilcccssary 1.0 c:ir'l'y 01.1t pcrioilicillly I,iologic:~ltcsl. by ptrtli~igdisc or slrips
containing at Icasl. I06 spo~.cs( ~ 1 U ' ,slc:~roIl~cni~opliilus (NCYI'C' 10003. or IYI'CC' 7 0 5 7 ) in
OIlc IllOl'c llilcI~-sill cb(l i ~ l c i.11ld
~ t I p i l ~ L:II:C.CSS~~~~C
jX11.1 (I(' 1111' illltO~'Iil\'~
~ I 1 ; ~ l l l ~ c ' l.%l'tcr
'.
;lulocla\~!l.lg, ~~llccli
it' all lllc sports 11;~vcI~ccritlcs~myctlhy c : ~ ~ [ I Ii lIl .:;l~il:~I>Ic
~ I I ~ liq~.~icl
I 1nedi11111( ' r r y ~ i soy:~I~r~~l.li~
)~~ at 56"(? ['or 5 (I;Ivs,
j
. 1.5.5, Security
Large n u ~ ~ ~crl'
b c\ ris~to~':,
ilrc t'ou11~1visilin;! p:it~i~lls ill IIIC I1osl)it;~l: I I I ~solneti~i~es ill
prol~ibtcdaucils lil.rc lC'lJ, I'o~l-opc~ari\lc alc;lj clc. 'I'llcy bring along w~Llitllcll~tl~ll'crc~il
hotly Klura iuid Icavii~gs o ~ u c01' 11in und ; I I O I I I I ~llle
~ I ) ; I ~ I ~ Iwliicli
I~ L'IIIILLCI. 11i;ly C ~ I L I S C
hospitul ac-qui~cclinli'clio~~.licstr~ctnig111cvisilors will1 cllicicnt scculity services
dccrc:ises liospital a c q t ctl
~ ~i ~~l l ' t ' c l ~ o ~ ~ .

1.5.6 Etlgincerirmg Aspects

IIospilal dcs~;ns ;ultl c111:tlily01 ro~~slruc*tio~i
;!oca a long \\lay in ~.cducinghospilal
:~cquircdinl'ccrion hy prov~tli~li:hetlcr veulil:ltiou i~ndlipl~l.

Air Conditioning
..
Positive pressure liltcrc~li~irin linspiral ac.quircd iuScctio11 pronc ;lre;ls rc*Juccs hospital
a ~ ~ ~ l l i ilit'cclio!i
fctl collsldcrilbl y ilnd slior~lilbe inlroduccd ill :mas viz. C).'I', Colnplcx.
IC[J. Nursrrics, I,ahot~rI<oo~i~s ct~.,Ciooltl m:ii~i(e~~:ulccol'k)uiltiing :md 24 Iiours wtltcr
supply Su!Ll:~.r dcerc;lscs cli:~nccsof liospi~;~l i~cquirctli ~ ~ l ' c ~ l i o ~ ~ .

1.5.7 Nursing Care

A septic nursing cilrc pro\~iilctlalso I . ~ ( I I I ~I C ~ i ~ l il~l'ectioll. 'lllis is ~ilorcS O
i ~S ~ p i;icqui~'ed
in palients \vho arc either very young or very old or suffering l i o ~ nchrouic i1isc:lses lilte
diebctics malilis, cbrclnic ncpl~ritisor mi~liyliu~cies of ~Iiosewllo alsc gcl1111gradiothcra~y
we imrnuno yccilic dnlgs. Special nursing 1~1edica1 C:ITC is nccded wl~e~icvcr

".
S~ahtyr ~ r dRisk M~lnuge~llcl~l complicated diagnostic iuld therapeutic procedures are cmied out by the bed side. A ~ O V L
all, nursing staff inust ensure strict, personal hyegene and l i i ~ ~washing,
d use of mauk, due
care for preparation of Seeds, sterilizatioil of bottles auld olher accessories need Lo be
Laken care of.

1.5.8 Waste Disposal

There is liltle awareness aboul Ihe discardi~lgand dispos;il of llospilal wasle in this
country. More oofleil ha111101 all the hospital waste, i.e., botl~the household type and tl~e
'infecled' liospita~lwaste are treated in h e same manner. In inmy of the hospilals tiley
are dumped at a place 'Garbage Collection Cellwe' Srom whcre Lhis total waste is tidceten
away by the Municipal Corporatio~z'sgarbage collection viuls. However, behre it is
collecled by the van, a number of scavei~gerssort out this waste and take oul everything
of aiy value without knowing the harmfulness of tile malerial.
The waste from a llospital should be dividcd into Lhree parls:

a) Hor~selloldnon-infective waste: To be collected in Uiick polythene bags or plaslic

cans and discarded like household wastc.

b) 'Infected' sharp, liospital waste: 'Iiospital waste' which is sharp arid is lilcely to cut
or pierce skin sllould be collected separately in puliclurc proof plaslic conlainer
which car1 be closed or sealed.
. c) 'Infected hospital' waste otlier than 'sharp' liospital waste: To be collected in
thick polytllene bags or plastic containers.

RoUl (b) uld (c) above, i.c. 'infected' hospital waste should be incinerated. I-Iowcver, till
incineration facililies are avail&le, il is importu~tto emphasise on the hospital1 authorities
to take great care in discarding and final disposal of the 'hospital waste'
The only altcrnative to incineralion is deep burial in controlled land fill sites. Needles aud
syringes must be destroyed ~nccl~atnici~llybefore burial. The conlrollcd till must be
fenced off, and scavengers slrictly prohibited.

or deep burial are available, all the 'infected' hospital

Till the facilities for i~lciileratio~~
waste Inust be disiilfccted bcfore disposal. Thus, tllc authoritics should give top priority
to inslallalioi~01' incjilerators in all tl~ehospitals. Also, it n~ustbe e~lsuredLhal these
incinerators :Ire in warking order.
The plilstic bags should be made freely availitble auld each area must put all its waste in
the plastic bags before transporting il for ii)ciiierathi or disposal.

Discardingand Disposal of Disposable Material

The awareness of the danger of acquirit~gI-IIV infectio~~ (the causative agent of AIDS)
while liandling blood ;uld blood contaminated lnatcrial llats resulled in sudden increase in
the use of presterilized disposable material. Tlle use oS disposable material has reached a I

stage when in a teaching liospjtal in Dellii, all tlle needles auld syringes used for giving
i~!jectio~ls or collectil~gblood are pre-sterilized disposable, whereas in some other 1
hospitals, only autoclaved needles and syringes. The hospitals in between thesc ~ w o
extremes use a coinbination of presterilized dis~osableneedles iuld ilutoclaved syringes in I

dil'fcrent situations, 111inost of the hospilals, disposable needles ;re reused alter boiling.
This practice must be discontinued immediately.

In tliis couutry, the plastic or Ule material will1 wllicll these presterilized disposable
equipments are made has got some value :md are mostly removed by the scavengers suld
others between discarding and iinal disposal. Further, lhcre is a high J ssibility Ulat
unscrupulous persons may starl,cycling the disposed disposable matcr ,l resulting in their
reuse witl~outeven proper ster~lizntion.
Therefore, tlle I~ullowi~l'g
procedure 1s recommenilcd:

a) All the disposal materitil after use has lo be accounted for like ahyother ~.eusable
material, !
!
!
L
 This c m be achievcd by discarding the disposable m;ilerial in a plasliclmelal
contiliner and sealing this in tllc presence of a respo~isibleperson. 'Ille plastic
container for piercing itistrurnents like needles etc, shoultl be pUWhUe resismit.
Plastic bread boxes are suitable for this purpose. Other lion-piercing material can be ,
discarded in plastic bags.

b) The sealed or tied plastic containers containing Lhe disposiible lnalerial should be
transported in closed wheel barrows to the incincrator.

c) The incineration arca must be out of hounds rbr everyone except tllose working
there.

111efollowing proceclure is rccoir~lnelldcdfor disinfectlcln of liecdles iuld syringes ifler

use and before disposal, till the facility of iiicineralor or hot :dr oven bccolnes available:

- Do no1 detach the needles from tllc syringcs alter use.

" - Aspirate disinfccttuil fluid into tllc syringe
- Immerse tlle syringe with attilched nccdles in Ihc disinfectant fluid horizontally in
flat lnetal/glass tray or puncturc proof plaslic contamer.
- Keep Uiem i~n~nerscd fluid l'or :it least 30 minutes.
in disinl'ect~u~l
- l'he needles and syringes cam bc rcinovcd from the disi~il'ectmtI'luid :uld destroyed
'mechanicdly bcfbre disposal.
.I- Alternatively all Uic disposable lnateriill cm be put in the liot idr oven at a
tempen~ture01' 160°C for 30-60 minutes. 'This will ensure tllilt ncitllcr disposable
inaterial after use cam go in the 11;uicIs 01'scavengers i~orBlerc will be iuiy possibility
qf its reuse.

1.5.9 Antibiotic Policy

Each l~ospik~l lnusl havc in anliblolic usc policy so h a t indiscr~min:ucuse of antibiotics
can be checked as i~~discriinate usc of tuitil~iolicsis know11 Lo c:kuse tlrug rcsistrlll
bacterias. Hospital ilcquircd infection tloe to this tlmg rcsistclll bactcriils arc very difficult
. to treat and are major cause of scplisc1ni:l.

1 . HOSPITAL INFECTION CONTROL COMMITTEE

b

To conibat I~ospitalinfection, it is esselltial thal liospikls according to its :lv;lil:lhlc

' . resources md requriemcnt est;ihlisli :I I-Iospikil Infection Colllrol Coinlniltee (I-IICOM)
il.ld invest witll il~thorityto pursue:
- Iilvestigalio~~
of all hospitill infeclions.
. - Establish surveilltmcc prowun~ne.
- Provide guidance iuld leadership in tllc prevenlio~laid control of liospilal inrection.
C

1.6.1 Composition
MCOM in an institutional hospital or referral hospital should be broad based ill
composition with rcpresentatives of ail1 major specialities as ineinbers i.c. Surgeon,
Physician, Aiaeslhetist, Pedialriciiui, Microbiologisl/Bilcteriologisl and,Gynecologist,
Nursing Matron, 'I-Iouse Keepjng st:lt'i, Engineer Service rcprescntative and Dietitiiu~.
Microbiologist/Bxctcriologistto be detailcd as IIospilal Inl'cclia~Control Oflicer arid
should work is Meinher Secretary. Hospital Superintendent or llis represenlative should
be Ch&man.
In a district hospilal set up, the orgiulisation should bc coii~poscdof:
- Amilable pro~essionalspecialists.
- Matron of the hospital or iuiy other specialist ofticel' as hlfection Control Ofticer
- Medical Superii~tendei~t
of 1iosl)ital as Chainna~i.

In a still smaller hospital situation the respc-rnsiblity aui be given to one Medical Ofticer
only.

1.6.2 Role and Functions

I-Inspita1Infection Co~iuolCom~nillcewith Ll~ellelp of Survcill;u~cestaff cnsures slnooU~
surveillauice iuid co~~h-ol
of110spit;~linl'ection by:
- Eslablisliiilg reporling system through:
a) Nursing Unit report tiailylweekly.
' , b) Individual patient report.
c) Review ol' bacteriological sergicc record of hospital
d) ~ u t o Report.
~ s ~
- Meet periodically to take decision.
- Lay daw~istandards of ascptic procedures ill l~ospitals.
- To disti~iguisl~
betweell infection acquired in the hospital iuid tllose acquired outsidc
- To prcpaue inanual for control or infection :uld lay down training progriunme of
perso~u~~el.
- 'rake all decisions based on reports received llirougl~hospital infection co~ltrolol'ticer
reganling investigation ant1 control lneasures in Lllc cvent of sudden rise of 11ospital
infection rate.

1.7 SURVEILLANCE

Tile aim (11' lIle surveillance is tb dctect uid record ii~etllodicalIyall FIospit:ll Acquired
I~ifections(IUI). Hence tlie surveillaice of I-IM is indispeus:~bleinhospitalls for
irli'ection control. Co~itinuoussurveillance allo~vsd ~ early
e dclcction of outbreaks. 11is
necessary to find out incidence and trends of I-IAI, causative organisms iuid tllcir
antimicrobial sensitivity, according to site of infection, speciality and wardlkloor. This
inKonnation can also be uscd for evaluating control measures zuid policies iiltroduced
iioln time to tune.
Paticlits in hospiliils are Inore susccpliblc to ii~l'ectionsh i m tllosc in Lhe com~nu~iity
(ycl~ernlpoylation). This is often rel:lted lo pre-existing discase, such as diabetes,.
medical auld surgical procedures ra~diotberapyor immuno-suppressive trei~trne~~t. Patients
at exuelnes of age iue especially susceptible to h~lection.

i) Cominunily or non-l~ospitalinfection with which the patie111 ciiters the hospital,

ii) Hospital (nosocomral)acquired infection, which is acquired in ~Iiehospital and

inakes its appegirnce eilher during l~ospitaliziltionor :iAcr tlle patient is discharged.
T11ere are predo~ninmtlyfour types of 11ospit;ll acquircd infec[ioiis. 'Tl~eycan be recorded
cm Ihe basis of cli~licalimdlor microbiological data,
1) Urinary Tract Infections
Tllc urinary ilzfectinns may be symptolniltic (fever, dysuria, lumbar pain) or
asy~nptomaic.Their recording depends partly on h e microbiologica~ltests pcrhnned
(over 100,000 micro-orgat~ismsimlinidstrean urine samples).

2) Infections of' the Lower Respiratory 'fiact

T11e clil~icalsigns of infection (coughit~g,pleural pain, fever and exppctoratioii) we
e~~ougli for these infections to be recorded, cveii if no chest X-ray or bacteriological tests
llave been performed,
 3 ) Post-operative Infections HospituI Acquired Illl'ecllon
1
h y surgical wouiid which resulls in a purulenl discliarge must be regarded as a l~ospital
acquired infection.
4) Systemic Pi~fections

A positive blood culture revealing a known pathogen, or a1 least two blood cultures
revealilig a micro-orgzu~isnzrcputcd to bc non-pathogenic or opportunistic, must be take11
illto account and listed as hospital infection.

1.7.1 Processing of Information Collected

The informatioli collected i ~this i way is processed by the Infection Cogtrol Sister. A
weekly, monUily mil ycwly report, makes i l possible to conlpile statistics on iufeclions by
speci:llity or floor and I'or tlic hospital ;IS u whole, for each type of infection.
Incidence rates :~ndperiod prcvalcnce rates sliould be worked out as follows:

- Tlic incidence rate corresponds Lo the numbex ol'ilew p;llicnls developing HA1 in a
given period in rclalion to llie number of patients discharged during the same period.
- Tlie period prevalcrlcc rate corrcspund,~to the nulnbcr of new m d old paliet~ts
developing I-IAt tlurine a give11 period in rclatio~ito the ~iuunberof paticnts
discharged during the s;unc pcrioo

Analysis of these various rates by llie I-Iospihl Infection Team will reveal the true
dimeqsions of the hospital infection aud make it possible lo dircct conrrol operations aid
to develop t l ~ crnost efkctivc possible strategies of action.
In order to contain specific outbreaks of infections, it is necessary,to fuid out source/
rescrvoir of infection by delecLing c:u.riers, sampling the inanimate objects (equipment
'and material) used for palient ccarc :u~dair a i d likely node of wa~smission,

1.7.2 Mode of 'Ikansmission

There are four main routes of inl'ection that have to be watchcd in liospitds: (1) h e aerial
route, (2) the oral route, (3) the c01lt;lct mute, especially tlie "liat~dborne" route, and (4)
the parenteral roule.
In the sequcnce of t~u~smission the following faclurs must be taken into account; (1) the
pathogell; (ii) tlic reservoir or source for the pathogen; (iii) the exit point; (iv) t l ~ e
transmission route; (v) the point of entry into the host; (vi) the susceptibility of the host.

1,7,3 Interruption of Tkansmission

Efforts ~ n u sbe
l made to brc:rk this scquence a1 its most vulnerable point, which differs
from one case lo :uiolher.
It is possible therefore to:

i) destroy h e pathogenic agents of tl~ecarricr staff or source patient by specific

antibiotic :uld antiseptic therapy;
ii) control tlie source or reservoir by isolallon of infectious patients atid by freeing
inanimate reservoir of micro-orgmis~nsby sterilizalion or disinfection;
iii) control the exist point by disinfection of excreta 'and infected malerial;

iv) control the tra~slsmissionroute by washing of hatlds, disinfection of equipment,

chmge of working clothes;

v) protect the susceptible host by protective vaccination, e.g,, tetanus, gas gangrene,
etc. I
Surety and Risk Mnlhganent 1.7.4' 'High Risk Proced~~res
Certai~~ activities/procedures cai be said to be high risk procedurcs/activitics. Special
c u e is reco~nmcndedfor practising lliese procedureslactivities. The followhg procedures
need special attentio11:

- Injections
- Surgical procedures
- Dressing of wounds
- ~ h a g e m e nof
t Delivery (child birth)
- lilvestigative procedures
- Laboratory investigations
- Dialysis

One of the coininonest procedure in any hospital is to give i~~jcctions to tlie patients for
treatmelit ant1prophylaxis, I11 inost of Ule hospitals, here is a coillinon area for giving
injectiolls to all OPD patients.
It must be reineinbered that intact skin iuid mucous mcmbra~~e provide maximum
protection to infection and barrier to invading organisms. Any type of injection breaks
this continuity of Ule skill harrier, iillroduces matei-ial directly into tlic body whicb, if
contaminated by micro-~r~au~isin, will result in severe ini'cctions. Great ciue is necessary
for thc deconttmination ol' skin area wlarc thc in.jection is to be given :uld cnsuring
sterility of the needle, syringe and injecting material. Needles uld syringes get
contuninatcd with the p:*.lientlr'sblood which inay be infective and cause serious diseases
like Hepatitis and AILIS. Thus, it is necessary to ensure h e proper disini'ection of the
needles and syringes after use. It should be eilsured that no one gets a needle stick .
(piercing by the neerlles) eihcr as part of their duties or i~cidentally.

Di&.fection of the Skin

Before giving ii~jection,the skin area should he cletuied imd disinfcctcd, The ideal skin
disinfection is Tincture or iodine, provided Ule path11 is 1101 allergic to iodi~iemid does
not mind the colour; alternatively 70% alcoliol, cidea, savlon or au~yotllcr deperldable
disinfectant in proper concentration can be usetl.

Use of Needles and Syringes

The iiljection shouid only be give11 by autoclaivcd or prestcrilised disposable needle and
syringe. Before givjng i~ljection,Ihc needle must not be touched with spirit cotton wool
swab, hand or,aiiy othcr materid.
The needles and sjringes should bc discarded in dependable disinfectant fluid. A
common practice seen in almost all the hospitals in Delhi, is h e use of plastic buckets
- without dishilectant fluid lor discarding dispostil~lei~eedlcsand syringes i.lfter use. This
practice is dangerous md is likely to cause :imn to Ulose who subsequently handle the
used needles and syringes.. Suitilhlc disinlecta~itshould be aspirated in the syringe.
Disposable aid reusableneedles and syringcs containing disiuCectmt lluid sllould be kcpt
in separate puncture-proof container (plastic or metal) by immersing Ihein in disinfectant
fluid i11 tithese containers. "Tlile reusable ueedles and syringes must be cleaned and washed
after taking out of disinfectant fluid.

Disposal of Di.vposnhle Needles nlzd ,S.vring.cs

It is necessary to treat disposal~leneedlcs ;uld syringes like rreusal~lematerial of value. It

is also necessary that under the supcrvision of a pei-son nominated by the Medical
..
Superintendent, all the disposable needles ;md syriliges slrould be destroyed by meltini
 t:lc plastic malerial. ~ h best
; method of disposal of disposable material IS by
i~icincc~.ation,Disposable needles and syringes are great lia~cu-dssince they are likely to
be re-used and misused. The hospital policy 5hould be to exchange ncedles and syringes
and dispose them off centrally, prcl'crably by incinccration or clcep land fill. .

Surgical Procedilres
All the surgical procedures including denlal procedures are invasive proceclures and
involve use of instr~~mcnts. cq~~illn.reritand material. The duration of surgical procedures
like operations is important. Tlie longer the duration of' an ol~cration,the greater arc tlie
chances of infection. There is lot of liandlit~gof blood, tiss~lcs,organs nud body fluids
during these procedures. The rnic1.o-organisms get directly inocl~lutcdinto the body and
may enter tlie blood cir'culation if' there is a lapse in aseptic ~~~.ccautions.

Thcrdbl-e, it is absolutely csscnt~alto ensure Chat :dl the i~islr~~mcnts, cquiplncnl ant1
matu~alused during surgc1.y [u'c S ~ I - i l cSpecial
. atten1lon 1s ncetled regarding [lie
I>osilivepressure of Ilic opcratlng area, enviro~~mcnt of the operation theatre (low
microbial counts), prcscncc of number of persons i n tlic tlicat~'c,anaesthesia and other
activities.
Ally s~1r1':icewhich might have bccn contn~iiinatetlwill1 tlic blood or body tluitl must hc
disinfected I'irst by covering it with :thsorbcnt matcrinl. L)islnli.clanl l'luid should I'irst be
poured arouncl the co111:rminatcdarea ant1 then over the absorbc~itmnterial and left for
Inore [han I0 minutcb. The disinfccti~ntusc~lslioultl he ol'tllc concentration which is
I-ccommcndcd l'or ~ i s cin contaminatccl situations.
Tissue, organs nncl uny 1)arl 01' tlic hody r c ~ ~ ~ o vduring
c d surgery slio~~ld
be incinerated1
buwl or huricd dccp w~tlihlcakli or lime. 13lood and body I'luicls re~iiovcdduring
opcrr"tlon ~iiustbe disi~~li.c~cclbcI'c11.ctlis1losnl.

Dressing of Wounds

Wounds ciln bc SLII-gical after opclSatlnns,accitlcn~;~l after III.~LII.Y01.d i ~ cto ]~u~'ule~lt

infections (boils. ahscess. c;rrbunclcs ctc.) or clue to ~~nclcrlying disease likc fistula, piles
elc.

The wo~intlscan be diviclcd into l i ) ~ ~I.OLIJ)S:

~r (a) clcari, (11) clean conlamina~ed,
(c) co~ital~ii~ii~tcd,
;~nd(d) dirty. 'I'lic tlrcssing ol'tlicsc wo~~nils sliol~lclbe clone in two
separate areas; on? for clcan wounds ;lnd clcan cont:unina~cdand (lie other Sol.
colita~ninate~l
and dirty wountls. Tlius. extrcmc cart is ncccssiuy to use only sterile
instruments, matcrial (cotton wool and o ~ h c rtlrcssinz rnatcrit~l),lotions, anti-septic and
anti-bacter~alcreams ctc.

The disposal of drcssing malcrial, disl>osablc material and leusable instruments weds
spcc~alattcntio~i.All material ant1 in\lrunicnts 1.1scd nntl ~.cmovcdduring tlic. dressing
should be take11as contaminated. 'T'licrcf'orc, :111 the niatcr~~il slioultl he disinfected,
reusnhlc instruments hcl'orc stcrili~atio~i and clispo~i~l inslrumcnts and contaminated
dressing etc. bcforc disposal, if' incine~.ationis 1101 ~wssible. Itlcally, all the material
should be discarcled in three sepamc containers. Twn of the containers should bc
puncture proof and should contain disinfectant Iluid for s1i;u.l) ~nst~.u~iiznw like needles,
scissors, scalpel, hladcs ctc. C)nc for reusable ~nstrurncntsand otlics for tlisposablc
inslrumcnts including ~yringesand ncctllcs, Both the reusahlc mid disposable inslrum~nts
should be discarded in separate containers in wliicli llic used tnstrumcnls could be put
, horizontally and im~iier~cd in the disinfcclant fluid. The tliirtl containa can be a
polytlienc bag in the buckot. Tlie polytliene bag containing drcssing ~iialcriallike used
cotlon, bandngcs ctc. should be sealed or tied. All tlic material other than reusablc
nii~terialslinuld he incinerated or burnt or disinl'cctcd hcforc rlisposal. l'hc'rcusilblc
matcrial aflcr disinl'cotion should he cleaned and s t c r ~ l l ~ chy
d :lutoclovinp.

of Deliver-y (Child Birth)

Mallage~l~ellt

The delivery of a child is molt or Icss crisis man:lgemcnt. The s h a ~ pinstruments are ? .

around and cvcry one including the expectant noth her in the delivery room is tense, Tlius,
at this time [lie persons conducting (lie delivery may get splashes of potentially infected
hlood ant1 amniotic illlid and even cuts. 111view 01' the short time availahlc for delivcry
 iuld related Rroceuures, thc cllances of exposure to HIV and other blood borne infections
are much higller during deliveries tl1x1 my other situation. In view of this, following
guidelines may be useiul:

- l?le delivcry ol'known or suspected case of I-IIV positive patient should be c a ~ ~ i e d

out in ;.UI xea near Ule inail1 iUCa but s e p i ~ ~ t from
e d the main area.
- A I3IV positive patient is more prone to infection, hence, she ileeds greater
protection froni inl'ection from other patients.
- A:I irlstru~nents,equipment and material used for the delivery must be sterile and
nlusl be deconta~~iuatedafter use.
- The surfaces illcluding table tops ald floors which have been conkuninated by blood
or amniotic fluid nlust be deco~~l~minated.
- During the delivery, the tetm of Health Care Workers including Pcdiatridan :uld
olllers must be exclusively involved with the delivery of I-IIV positive womiu1.
I~n~nediately aflcr care of IiIV positive woman and llcr newboi~l;(bey should cllange
lo aloLher set of footwear, gown etc, bclbre handling tllc olller palients, lo avoid
person to pcrson inkction to olher patients.
- J~nlnedialelyaflcr cauc of HIVpositive woman iuid her newborn, h e y sliould change
to ariolller set of footwear, gown etc. before h~u~lling
the other patients, to avoid
person inlkction to other palicnls.
- The placenta inusl be incinerated, burnt or buried deep with blenching powder all
auu-oui~dplacenta. The bleaching powder should be first sprcad in thc pi1 inade for
burial ~uldthen on Llle placenta.

Protective barriers are recommended for all deliveries.

It~vestigativeProcedures
The j~lvestigaliveprocedures can be broadly divided into two categories: (a) invasive
procedures, and (b) non-invasive procedures.
/'

a) blvnsirje Procedures

Thcsc include lumbar puncture, cut downs, tappings, aspirc~lions,biopsy, laproscopy,

endoscopy, cardiac-catlielerisi1tio11,bronchoscopy :u~dsimilar other proced~ires.During
these procedures, Ulc continuity of the skin or illucous mernbranc is lilcely to be broke11
and micro-og'misms can gain h e cntry. Ilcnce, all nrccautioils recomineilded (or
surgical procedures sllould be followed for iilvasivc procedures.

b) Noir-invnsiw Procediires
'6
'Ihese include vaginal, anal and rectal exaniilations, proslalic massage, rneasurenient of
intra-oculiu pressure, ENT examinations; and dil'lerenl imaging processes like echo-
cardiography, ultra-sound, X-ray and CAT scan. It is highly possible that during SOIIIC of
.
these non-iilvasive procedures, break in the continuity of the mucous membrane may be
encountered which may result in contamillation of iiistnlinetlts used for the exanination.
Tlle vaginal and reclal examinations are particularly hazardous. Since I-IIV and other
c)rganisins including Ulose causing sexually transmiltcd diseases may be present in lllese
situations. Thelafore, only sterile insttu~nents,equipment or material shc3uld be used for
such &n-invasive procedures. After use they must be rqgauded as 'contiu~~iiinated' ilnd
must not bc used on olller palicnts without proper disi~llkctioi~
uld sterilizaLion.

Disinfection of lke Instruments usedfor Non-invasive Procedures

Immediately afler use tl~einstruments (like vaginal speculum, proctoscope etc. should be
immersed in suitable disinfectant fluid for at least 20 ~ninutcs.A f e r disinfection, they
preferably be autoclaved or boiled for 20 ininutes and then reused.
 Laboratory Investigations
The clinical speciine~lsare collected I'or different laboratory investigations. Most ol' these
specimens are highly infective and on occasions, caul cause diseases includillg I-Iepatitis
suld AIDS, Hence, great carc inust be taltcn in handling tllese spccimens. These
specimens pritnarily fidl in threc categories:

a) Blood, tissue and blood contaminated material like pus and body fluids etc.

b) Body fluicls like CSF, pleural ant1 pcricauadialfluid, semen,.v;kginal lluid and other
such specimen.

c) Urine, sputum, bronchial washings and swabs from nlucous membr:u~culd skin. ,

The following recornmendations will bc useful for li;u~dlinglhesc clinical spccimens:

a) Blood, Tissrre and Blood Corttanrincrtcd Material

Use ollly autoclavetlJpresterilizedclispos:lblc needles auld syringes I'or cnllcctioil ol'blood.

All precautions described for giving injections should be followed strictly f ~collection
r
of blood including disinfectio11of skin.
Use only autoclavcd or preslerilizetl tlisposablc inslrumenls lo remove Ulc tissue or blood
contiiinated ~nilteriallike pus and body Lluids.

b) Body Fluids like Pleurcrl, Pc.ricnr.dic11nr~dCerebro-sl~irtnlFlrrid, Rrgincrl Sacr~tiorrs

and Senieri etc.
Only autoclaved or presterilized clisposable inslnnnalts should be uscd for collectiilg
these matesial.

I
I
c) Urine, S')nhcmn, Brorlchinl Secretiorrs arrd Sjvabs frnrrr Mrrcorr.~Mernbra~~s
I
Most of tliese specimens arc excrelio~ls(IS thc body and do not rcquirc use of w y
equipxnenl or instrumcilt for rheir collcct~on,cxcepl bronchial secretions : u ~ rarely
l urine.
Only autoclaved Tor presterilizetl disposnblc inslrun~cntsor mutcrial shoulcl be uscd il' the
material to bc collected is not available as cxcrction.

All clinical specimens should bc rcgardcd as inlcction risk ant1 slloultl bc Iramsfcrrcd to
.tile laboratory in spill prool' screw capped botllcs. Spcci:ll precautions shoultl be tiikcil for
the blood suspected to be l i o ~ nljalients of 1 lepalilis or AIDS, which sliould bc transported
in leak proof polylhenc bags.
Any accident, contamination or spill fro~nthe collectiol~to disposal lnusl bc repclrlcd :nd
proper disinfection should bc carried out.

Tlle blood, blood cont;uninaled specimals and tissue tnusl not spill on llle table tops,
floor, requisition tbrms, reparl, t'ollns or any other suriilces. In case of any such spilling,
the surfaces must be disint'ectetl.
Under no circu~nslanccs,mouth pipelti~lgsl~ouldbe pe~mitlcdfor carrying out my test.

Discardirzg

All clinical speci~neilsafter cimyillg out ~~eccssarylest must be discmtled in discarding jar
containing suitable disinfecliut, I-Iaziudous spcciincns like microbial culture must be
I autoclaved before disposal.

I
Disposal

All clinical specimens must bc disposcd ocf by inci~leralingor fluslringtheln. It must be

Sul'cty nntl Risk Muauge~~ie~rt e~isuredh a t no one shoultl come in contilct wilh ;my cli11ic;ll specimen w~lllout
disinfection otlicr Illiu~those who have to be ;~ssociiitcdas part of their duties.

Dialysis
Dialysis is a coinlnon proccdurc c;lrried out in 1n:uiy 1lospit:lls. It is of two typcs -
Peritoneal dialysis and I-laemo tl1;ilysis. lnl'ections ofit.11co~nplicatehcmo dialysis iuid
persontic1 working in a (1i:llysis unit may :lcquire inkctions during work if prc;per
precautio~~s are not t;~ken,Ihc comlno~lcslI)cing I-lcpatit~sB.
Attetnpts at comnplete segrcgatioil of I ll3sAg positive pillients :ultl tlieir dialysis equipment
and antisepsis, liavc subsl:uitjally rci1uca.i thc incidence ol' tliis
proper disinl'ectio~~
ini'cction. Seronegative to IIT3sr\g stall'slioulll br lully immunize with 1lep;~titisB
vaccine.
The requiremen1 fur acccss to a patient's blood supply lwice ill e:~clit1i;lIysis ~,roccilurcs
makes the dialysis'unil sirni1;u to a surgic:il iinit. 'I'l~etl;:llysis unit is cri~.\~dcd,
with,a lot
ofqachines, wires, tubcs, Iloses ;uid the i1e;uiing is Inore diflicult. Special instructions
iuld training iuc ncccssauy for the stall, especially rcg:trding the cleaning o1'1ni~chinc;md
ecluipment. Wastes iiorn the nnit sliould i~lwaysbe classilicd iw 'infectious' I~ccauseof
the high incidence of hepatitis anong patients.

Clieck Your Progress 2

Tlie high risk procedure wliicli nceds spccial attentio~~:

TRAINING AND EDUCATION

It. is vcry esseiidal that knowledge, skills and I-rehaviout 01' ill1 cii~cgorics01' 1iospit;tl
staff is tuned to cc>nU.oland prevention 01' I-I(~spiu~l
Acq11ircd Infection. 'I'llis ciui be
achieved by holding lectures iulcl dcnlonstt-;llionscssio~rw~thrlicm, Apitrt I'soal it,
mining of few grcjups of functionaries spc:ially scctjon heads viz. Sisler Incliatr2c, OT
Colnplex~ICUs, Lilbo~rrooms, post opclntivc wartls, s;uliI:u.y in~pcctors,1nch:irgc CSST).
Security, dietetics will go a long way in rc&eng I[lospit:ll Accluirccl Inl'cctic-a i~!111c
hospital.

1.9 UNIVERSAL PRECAUTIONS FOR HEALTH CARE ,

WORKERS

. 1) - All health are workers should ror~tinelyusc approprialc \~;mierprecautions to

prevent skin arid mucous-me~nl~ru~e exposure wlle~lconl;lct with blood or olher body
fluids 01' any patient is x1ticip:lted. Gloves should be worn Ibr touchin;! blood :uid
body Iluids, inucous manbralcs, or non-intact skin of all p:ltients, for haldliug items
or surfaces soiled will1 blood or body fluids, allid lix pcrli,nning vcncpncture and
otlier vascular access proccldures. Gloves sl~ouldbc climigcd after contact with each
. patient. Masks and protcctive eyewcitr or i'licc sliielcls should bc worn [luring
procedures Illat iue likely to generate droplcts oT blood or oiher body Ilaids to
'
prevent exposurc ol' IP.UCOUS membriulcs of tlic; moucli, nrlsc al~deyes. Ciow~lsor
aprons sllould be worn durin: D I - o c ~ ~ tli:d
u ~ ~arc
s likely to gcncrutc splaslles of blood
or other body fluids.
. . .
P
 2) I-1;ulds ;uld other slcin surl'aces should be w;lshcd immediately and throughly if Hospital Acquirrrl Iilfcctlon
cont;uninated with blood or olher body fluids. Hiuids should be washed immediately
after gloves are reinovcd.

3) All health care workers should lake precaulions to prevent injuries caused by
needles, scalpels ;uid olher sharp instruments or devices during procedures; when
handling sharp instrunze~ltsalter procedures. ?'o prevent needlestick injuries, needles
sliould be recapped, while Ihe cap is placcd on my llal surface and no1 held in the
other hand. This prevc~llsaccidenlal needle stick in the lixicl holding Uze needle cap,
Also, needles sliould no1 be purposely bcnl or broken by hand, removed from
disposable syringes, or otherwise in:ulipulalcd by 1i;und. Afler they are used,
disposable syringes and nccdles, scalpel blades, and other sh;up items sliould be
placed in punclmc-resislalt conll-linersfor dispos~ll.

4) Although saliva has ilot been implicaletl 111 HIV Ir;msinission, lo lnirliinize the need
for eiizergency iizoulll to mouth resuscilation, mouth pieces, resuscitation bags, or
other veillilatio~idcbriccs sliould be availiiblc for use in arcas in which llie need for
resuscitation is predictable. Although lIlV h;ls been recovered from saliva, there is
no conclusive evidence Uial saliva is i~lvolvcdin I-I1V Uans~nission.Nevertheless, to
reduce occupational cxposurc lo HIV. iiioull~picces, scsuscilal~onbags, or othcr
vciltilalion devices should bc used il' available when rcsuscilalion is necessary.
Resuscitation equipment should be used oilcc only iuid discarded, or be thoroughly ;
cleansed a i d disinl'ected.

5 ) tIealtli care worlcers who 1i;lve exudalivc lcsions or weeping dennalitis sliould refrain
from all direct padicnl care ;md l'rom Iialldli~lgl):ltic111C:UC cquip~nciilulllil llle
condition resolved.

6) Pregnant health c;xc workers arc no1 Icnown lo bc a1 grcalcr risk of contracti!lg HIV
infection tli;ui health care worIccrs who ;we no1 prcgn:uit, however, if a healtli c;ue
, worker develops I-TIV inkclion during prcgntmcy, Ihc infant is at risk o l infection
resulting from perinatal Lr;ulsmissio~i.Prcgn:ull health care workers because of this
risk, shouId be cspeci:~llyl';u~liliilrwiUi and strictly adhere Lo precaulions to
minimize the risk of I-I1V tr;ulsinission.
1mplemenl;llion of \~nivcrs:llblood :uld body fluicl prccaulions l'or a11 palicnls climinaltx
the need for use of Ihe isolation c:ltcgory of "l3lood ; u ~Iloily
l Fluid Precaulions" for
I palienls known or suspected lo be inkcled will1 blood borne pafllogens. .Isolation
I
i precautions (c.g. cnleri~:, lubcrculosis) shoultl l?e used as ncccssary il' associaltcd
condilions, such :IS inkctious cliarrLloea or lubcrculosis, :uc diagnosed or suspended.

1 . 1 LEGAL ASPECTS

Hospital Acquired Infection will i~~crcase average le~lglhof stay. Assuming Ulat 10% of
tlle admitted patieills suffer from I-Iospilal Acquired lnfcction resulting inlo increafed
hospital stay, the country will lose on to major accounts, productivity xld llie treatlneilt
cost tlle palient and their relations will sullkr froin increased morbidity iuld may be
occasionally ~norlalityand looscn Uieir daily earning clue to Ihe i~icrcasedhospital stay.
Liligation on account of acquired hospilal inkclion due lo the negligence of hospital
authorilies including doctors can bc potential litigation under Consumer Protection Act, '

I1 is in.tlle interest of all ofys that Hospilal Acquired Infection will be eradicated,

1.11 LET US'SUM UP

Hospital Acquired Infeclions ;ue known Lo take place leading to large mount of
morbidity and mortzlily iuld loss oJ square liospitall resources. It also increases average
Ieilgth of stay iin the hospitals. It is csti~naledh a t cllicient liosp'ilal acquired infection
measures when adopted can reduce average length of stay by 20% which when converted
illto gain and productivity iuid saving in hospital rhsources, will account very large
volume, Tllerc is no way that y e can e1imin:lte hospital accluired infection altogether but
our knowledge about hospital acquired infeclion and inesures innulnuncrale to control it .
will cerlllillly go a long way in reducing hospital accluircd infeclions in our healtll care
centres.
S ~ ~ r cund
i y Risk M a ~ ~ u g c ~ n c l ~ t
1.12 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1

1 ) - The patien L own llora

- Auto infection
- Tile iloni of olher patient
- Cross Infection
- Environmental sources
- Environmental inkction
2) Direct route : Person to person canicr, hospi~alslafi', visilnr
Air born route which includcs palien1
Illdirect r a t e : Through coiir;uni~iatcdarticles viz. I'oot!, clrink, dusi, hr:d lincn iuld
equipment.

Check Your Progress 2

- I~ljection

- Surgical proccdurc
- Ikessing of wounds
- Mmagemciit of clelivery
- l~ivcstigativcprocctlurc
- Litbor;lto~-yiuvcsligalion
- I)i;~lysix
 DISASTER WIIANAGEMENT

Structure
2.0 Objectives'
2.1 I~ltroduction
2.2 Basic ConcepLs
2.2.1 General
2.2.2 Disilsler Classification
2.2.3 ~isi~stcr'Pr~)ce~s
2.2.4 Spectrum of Disaster Mnnagemcnl
2.2.5 . Special Ch:~racleristics
2.3 Disaster Management in India
2.3.1 N:~tiunalLevel
2.3.2 State Level
2.4 Principles of Disaster Planning
2.4.1 l'rinci[~les
2.4.2 Disaatcr ilnd I-Ifi~ltl~
Problems
2.4.3 Orp;~nisatiatih r Medical Relicf
2.4.1 IJrinciplcs of Mass C:ls~l;~ltyI\/lanagelnent
2.5 Objectives of Hospital Ilisaatcr I'lan
a 2.5.1. Need for 1-Itrspit:ll Dihastcr Plan
2.5.2 Objective and Purpnse
2.5.3 Plnnn~ngI3rocess and Dcvclopmcnl of Pkin
2.6 Disaster Committee
2.7 Org~uiisation,Role iu~dResponsihilitics
2.7.1 Oiyanisalion
2.7.2 Role :~ndRcsponsibilitirs
2.8 Orgiuiising Disaster Rlcililias

2.9.2 Alert ;lnll Kec;rll

. 2.9.3 L~q~loyniclil
2.9.4 Disaster A d l i ~ i l ~ i \ u a t l l ~ ~ ~
2.10 Disaster Manual
2.1 1 Disaster DrilI
2.12 Let Us Swn Up
2.13 Answers to Check Your Progress

2,O OBJECTIVES --- -

I

Afler going tl~rouglithis unit, ycm should be able to:

unclerstiuld llle co~icrplsof disasters imd its m:u~agemcnt;
e describe tile principles of clis:isler gla~~ning
ant1 Ulc oh,jectives tuld purpose or disiistcr

e describe Llic composition, h~nctionsand rcspo~isibiljtics of Disastcr Commirtce: