Fortis Infection Prevention and Control Manual

FORTIS HEALTHCARE LIMITED Page1of
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Standard Operating Procedure for
Infection Prevention and Control
FORTIS
INFECTION PREVENTION AND
CONTROL MANUAL
SOP No. FCIPCM–P-2021-1.0

Version 1.0 Effective 1st April Supersedes FCIPCM– Next 31st
Number: Date: 2021 Version: P-2020- Review March
1.0 Date: 2022
Prepared Working Reviewed CIPACC Approved Dr Murali Chakravarthy
By: group By: By: Dr Bishnu Panigrahi
This document contains proprietary information of FORTIS HEALTHCARE LTD

For internal circulation only
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Table of Contents
S. No. Section Page
I Change Control Information 5
II Functional Organizational Structure 6
III Objectives 7
IV Common Abbreviations 8
V Glossary 9
VI Involved Personnel (Roles & Responsibilities) 14
VII Flowchart 14
1 Risk Categorization of Hospital Areas 15
2 Surveillance Mapping to Risk Categorization 18
3 Hand Hygiene 23
4 Standard Precautions 35
5 Isolation Precautions 42
6 Occupational Exposure to Blood and Body Fluids 52
7 Recommendations for Cleaning and Disinfection 64
A General Recommendations 64
B Recommendations for Cleaning & Disinfection of instruments, 65

equipment and similar articles: ICU and High risk areas
C Recommendations for Cleaning & Disinfection of area, 68
instruments, equipment and similar articles: OT
D Recommendations for Cleaning & Disinfection of area, 70
instruments, equipment and similar articles: Cath Lab

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E Recommendations for Floor and Wall Cleaning 70
F Recommendations for Cleaning & Disinfection of Scopes 71
G Recommendations for Cleaning & Disinfection in Dialysis units 73
H Miscellaneous 73
I Recommendations for Environmental Surveillance Including 74

Critical and Non-critical Areas
8 Surveillance Definitions 77
9 Vaccination Policy 98
10 Policy on Infection Prevention Practices in Transplant Patients 105
11 Policy on Solid Organ Transplant 110
12 Guidelines for Preventing Infectious Complications among 115

Hematopoietic Cell Transplant Recipients
13 Handling and processing of linen 137
14 Investigation and prevention of an outbreak in hospital 139
Annexure 1 Risk Categorization Tool (Example) 144
Annexure 2 Hand Hygiene Tool 146
Annexure 3 Hand Hygiene Poster 147
Annexure 4 Bio Medical Waste Audit Sheet 148
Annexure 5 General Infection Control Audit Sheet 160
Annexure 6 Disease Specific Precautions 163
Annexure 7 Blood and Body Fluid Exposure Report 176
Annexure 8 Needle stick and Sharp Object Injury Report 178

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Annexure 9 Post exposure Follow-up 180
Annexure 10 CLABSI Event Form 182
Annexure 11 CAUTI Event Form 184
Annexure 12 VAP Event Form 186
Annexure 13 SSI event form 188
Annexure 14 ICRA form 191
Annexure 15 Terms of Reference of CIPACC 192
Annexure 16 Indicative Checklist for Outsourced Laundry Visit 194
Annexure 17 Specific Site Algorithms for Pneumonia 195
Annexure 18 Disease Specific Isolation Recommendations 199

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I. Change Control Information

Version 1.0 Effective 01-Apr- Supersedes FCIPCM–P- Next 31-Mar-
Number: Date: 2021 Version: 2020-1.0 Review 2022
Date:
Changes Reason for Revision
Made: change:

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II. Functional Organizational Structure (Organogram)

(TO BE DEVELOPED BY FACILITY)

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III. Objectives
A. To standardize infection prevention and control practices across Fortis hospitals

B. To standardize infection prevention and control related forms/formats/documents
C. To provide a framework for infection risk identification and mitigation

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IV. Common Abbreviations
Sl. Abbreviation Full Form

No.
1 AFB Acid Fast Bacilli
2 AIDS Acquired Immunodeficiency Syndrome
3 AIIR Airborne Infection Isolation Room
4 BF Body Fluid
5 CIPACC Central Infection Prevention and Control Committee
6 CSSD Central Sterile Supplies Department
7 CVP Central Venous Pressure
8 EPINET Exposure Prevention Information Network
9 ESBL Extended Spectrum Beta Lactamase
10 ETO Ethylene oxide
11 HBIG Hepatitis B Immunoglobulin
12 HBsAg Hepatitis B surface Antigen
13 HBV Hepatitis B Virus
14 HCV Hepatitis C Virus
15 HEPA High Efficiency Particulate Air filter
16 HIV Human Immunodeficiency Virus
17 HSCT Haematopoietic Stem Cell Transplant
18 LFT Liver Function Tests
19 MDRO Multidrug Resistant Organism
20 MPN Most Probable Number
21 MRSA Methicillin Resistant Staphylococcus Aureus
22 N95 NIOSH 95
23 PEP Post Exposure Prophylaxis
24 PPE Personal Protective Equipment
25 PPM Parts Per Million
26 QAC Quaternary Ammonium Compounds
27 SGPT Serum Glutamic Pyruvic Transaminase
28 VRE Vancomycin Resistant Enterococci
29 WHO World Health Organisation

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V. Glossary
Sl. Term Definition

No.
1 Aerosol-generating Procedures that promote the generation of aerosols / any
procedures activity that can induce the production of aerosols of various
sizes, including droplet nuclei.
2 Airborne Precautions Precautions intended to protect against airborne transmission

of infectious agents.
3 Antisepsis Prevention of infection by inhibiting or arresting the growth

and multiplication of germs (infectious agents).
4 Autoclave It is a pressure chamber used to sterilize equipment and

supplies by subjecting them to high pressure saturated steam
for the recommended time, temperature and pressure in
accordance with the manufacturer recommendations. The
cycle is chosen depending on the item to be sterilized.
5 Blood borne pathogens Means pathogenic microorganisms that are present in human
blood and can cause disease in humans. These pathogens
include, but are not limited to, hepatitis B virus (HBV),
hepatitis C virus (HCV) and human immunodeficiency virus
(HIV).
6 Chemoprophylaxis Administration of a medication for the purpose of preventing

disease or infection.
7 Cohort The practice of grouping patients infected or colonized with

the same infectious agent together to confine their care to one
area and prevent contact with susceptible patients (cohorting
patients).
8 Colonization The presence of microorganisms on skin, on mucous

membranes, in open wounds, or in excretions or secretions
but are not causing adverse clinical signs or symptoms

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9 Contact Precautions Procedures that reduce the risk of spread of infections through
direct or indirect contact.
10 Decontamination The use of physical or chemical means to remove, inactivate,

or destroy blood-borne pathogens on a surface or item to the
point where they are no longer capable of transmitting
infectious particles and the surface or item is rendered safe
for handling, use, or disposal. In health-care facilities, the
term generally refers to all pathogenic organisms.
11 Dialysate The fluid and solutes in a dialysis process that flow through
the dialyzer, do not pass through the membrane, and are
discarded along with removed toxic substances after leaving
the dialyzer.
12 Disinfection Means the use of a chemical or physical procedure that

eliminates virtually all recognized pathogenic
microorganisms but not necessarily all microbial forms (e.g.,
bacterial endospores) on inanimate objects.
13 Droplet Precautions Precautions intended to prevent transmission of pathogens

spread through close respiratory or mucous membrane
contact with respiratory secretions.
14 Drug naïve Someone who has never been on medication for that illness.
15 Endotoxin A toxic heat-stable lipopolysaccharide substance present in

the outer membrane of gram-negative bacteria that is released
from the cell upon lysis.
16 Hand hygiene Any method that removes or destroys microorganisms on

hands. It is well-documented that this is the most important
measure for preventing the spread of pathogens.
17 High level disinfection Complete elimination of all microorganisms in or on an

instrument, except for small numbers of bacterial spores. The
FDA definition of high-level disinfection is a sterilant used

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for a shorter contact time to achieve a 6-log10 kill of an

appropriate Mycobacterium species.
18 Immunocompromised Patients whose immune mechanisms are deficient because of

immunologic disorders (e.g., human immunodeficiency virus
[HIV] infection or congenital immune deficiency syndrome),
chronic diseases (e.g., diabetes, cancer, emphysema, or
cardiac failure), or immunosuppressive therapy (e.g.,
radiation, cytotoxic chemotherapy, anti-rejection medication,
or steroids).
19 Intermediate level Disinfection of semi-critical and noncritical items such as

Disinfection stethoscopes, x-ray machines and bed side rails.
20 Low level Disinfection Disinfection of noncritical items that come in contact with
skin, such as stethoscopes, blood pressure and tourniquet
cuffs, EKG leads, bedside equipment, and environmental
surfaces.
21 Non-responder A "vaccine non-responder" is a person who does not

develop protective surface antibodies after completing two
full series of the hepatitis B vaccine and for whom acute or
chronic hepatitis B infection has been ruled out
OR
A non-responder is defined as a person with anti-HBs <10

mIU/mL after ≥6 doses of Hepatitis B vaccine.
22 Nosocomial infection A localized or systemic condition resulting from an adverse

reaction to the presence of an infectious agent(s) or its
toxin(s). There must be no evidence that the infection was
present or incubating at the time of admission to the acute care
setting.
23 Outbreak Disease outbreak is the occurrence of cases of disease in

excess of what would normally be expected in a defined
community, geographical area or season.

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24 Personal Protective Specialized clothing or equipment worn by employees for

Equipment protection against health and safety hazards.
25 Plasma sterilization Low temperature sterilization alternative, suitable for many

heat and moisture sensitive medical devices. This method
disperses a hydrogen peroxide solution in a vacuum chamber,
creating a plasma cloud; reactive species are generated from
the hydrogen peroxide that is reactive with microorganisms.
26 Post exposure Is any preventive medical treatment started immediately after

prophylaxis exposure to a pathogen (such as a disease-causing virus), in
order to prevent infection by the pathogen and the
development of disease.
27 Pre-filters A filter placed before the main filter(s). A pre-filter is coarser

and is used to remove larger particles.
28 Respiratory Hygiene Respiratory hygiene and cough etiquette are terms used to
describe infection prevention measures to decrease the
transmission of respiratory illness (e.g., influenza and cold
viruses).
29 Safe Injection Practices Are a part of Standard Precautions and are aimed at
maintaining basic levels of patient safety and provider
protections.
30 Slit air sampler It is one of several sampling methods used for quantitation of
biological aerosols. In this method, particles from the air are
impinged directly on a rotating agar plate, the plate is
incubated, and the colonies that develop from the bacteria-
laden particles are counted.
31 Standard Precautions Are a set of infection control practices used to prevent

transmission of diseases that can be acquired by contact with
blood, body fluids, non-intact skin (including rashes), and
mucous membranes.
32 Sterilization A validated process used to render a product free of all forms

of viable microorganisms. In a sterilization process, the

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presence of microorganisms on any individual item can be

expressed in terms of probability. Although this probability
can be reduced to a very low number, it can never be reduced
to zero.
33 Surveillance The ongoing, systematic collection, analysis, and

interpretation of health data essential to the planning,
implementation, and evaluation of public health practice,
closely integrated with the timely dissemination of these data
to those who need to know.
34 Terminal disinfection A procedure required to ensure that an area has been

cleaned/decontaminated following discharge/shift out of a
patient with an infection in order to ensure a safe environment
for the next patient.
35 Thermo-hygrometer It is an electronic instrument that can measure and display the

current temperature and relative humidity. It is small enough
to be portable or hand-held, and it typically uses batteries for
power.
36 Vector-borne Indirect transmission of an infectious agent that occurs when

transmission a vector bites or touches a person.

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VI. Involved Personnel (Roles & Responsibilities)
Sl. Role Name/Title Belong To Role in Process

No. Function
1 Listed in each process
VII. Flowchart– NA

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SOP No. 01
Risk Categorization of Hospital Areas
1. Purpose: A tool to help categorize hospital areas into high, medium or low risk based on defined
criteria.
2. Scope: Hospital wide.
Irrespective of the Risk Categorization score* (see below, and Annexure 1), following areas have
been defined as high risk areas by Central Infection Prevention and Control Committee [CIPACC]
a. Operation Theater(s)
b. Intensive Care Unit(s)
c. Procedure Labs (Cath Lab, DSA Lab, etc.)
d. Dialysis
e. Isolation Room
f. Central Sterile Supply Department (CSSD)*
3. Roles and responsibilities:
4. Procedure
The Risk Categorization tool is in the following table. Criteria to be used for risk evaluation are:
- Compromised Immune Status (Likely)

- Compromised Immune Status (Possible)
- Long Stay (10 days or longer) or Complex Cases
- Handling of internal anatomy/organs
- Prone to cross contamination/ infection

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- Vulnerable patient cohort (e.g. Dialysis)

- Employee Safety
- Patients with devices
- Handling of Infectious Waste/Instruments
Each criteria has been assigned a Risk Multiplier based on the risk potential.
Risk categorization of any area shall be done using this Risk Categorization tool. Refer Annexure
1.
Compromised Compromised Long Handling of Prone to cross

Immune Status Immune Status Stay/Complex internal contamination/
Criteria (Likely) (Possible) Cases anatomy/organs infection
Type Essential Additional Additional Essential Essential

Risk Multiplier X2 X1 X1 X2 X2
OT
Dialysis
ICU
Isolation Room
Procedure Labs
ER
CSSD*
Blood Bank
BMW Storage
Day care (Chemo)
HDU
Lab
LDR
Wards
OPD Area
Admin Area

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Vulnerable Employee Patients Handling of

patient Safety with Infectious TOTAL RISK
Criteria cohort devices Waste/Instruments SCORE CATEGORY
Type Essential Essential Additional Essential

Risk Multiplier X2 X2 X1 X2
OT
Dialysis
ICU
Isolation Room
Procedure Labs
ER
CSSD
Blood Bank
BMW Storage
Day care
(Chemo)
HDU
Lab
LDR
Wards
OPD Area
Admin Area
High Risk:- 20 and above Scoring Criteria:-Yes= 3,

Possible= 1,
Medium Risk:- 10-19 No= 0,
Low Risk:- 0-9 NA= 0

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SOP No. 02
Surveillance Mapping to Risk Categorization
 Operation Theater(s)
 Intensive Care Unit(s)
 Procedure Labs (e.g. Cath Lab, DSA Lab)
 Dialysis
 Isolation Room
 CSSD
A. OPERATION THEATER:
Type Audit Frequency Sample Recording Tool

Hand Hygiene One OT per week Total 30 moments in Hand Hygiene Tool (Annexure
a month (at the 2)
minimum)
Bio Medical Waste As per BMW DU, Common Area, BMW Audit Sheet (Annexure
Audit Sheet 1 Operating Room 4)
(Annexure 4)
SSI MOS Process NA 25 per month MOS
Compliance
Instrument Washing Monthly 1 observation Audit General IC Audit Sheet
(Annexure 5)
Temperature Monthly At least one OT per General IC Audit Sheet
Monitoring month
Humidity Monthly At least one OT per General IC Audit Sheet
Monitoring month

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Air Pressure Monthly At least one OT per General IC Audit Sheet

Monitoring month
Air Changes Monthly At least one OT per Engineering Log of the week
month
Environmental As per CIPACC NA NA
Surveillance Recommendation
Audit Frequency is separate from Monitoring Frequency – which is mentioned in CIPACC

recommendations
B. INTENSIVE CARE UNIT:

Hand Hygiene One ICU per week Total 30 moments in Annexure 2
a month (at the
minimum)
Bio Medical Waste As per BMW Audit NA BMW Audit Sheet
Sheet
Device Related NA 25 per month As per MOS
Infection (MOS
Process Compliance)
Temperature Monthly At least one ICU per General IC Audit Sheet
Monitoring month
Humidity Monitoring Monthly At least one ICU per General IC Audit Sheet
month

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C. PROCEDURE LABS:

Hand Hygiene One Procedure lab Total 30 moments in Hand Hygiene (Annexure 2)
per week a month (at the
minimum)
Bio Medical Waste As per BMW NA BMW Audit Sheet
Audit Sheet
Instrument Washing Monthly 1 observation Audit General IC Audit Sheet
Temperature Monthly At least one General IC Audit Sheet
Monitoring procedure lab per
month
Humidity Monthly At least one General IC Audit Sheet
Monitoring procedure lab per
month
D. DIALYSIS UNIT:

Hand Hygiene Once a week Total 20 moments in Annexure 2
a month (at the
minimum)
Audit Sheet
Machine cleaning & Monthly 1 observation Audit General IC Audit Sheet
disinfection

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Temperature Monthly Dialysis unit General IC Audit Sheet

Monitoring
Humidity Monthly Dialysis unit General IC Audit Sheet
Monitoring
E. ISOLATION ROOM (If Occupied):

Hand Hygiene When occupied Total 10 moments in Annexure 2
a month (at the
minimum when
occupied)
Audit Sheet
Air Pressure Monthly At least two General IC Audit Sheet
Monitoring (For Isolation rooms in a
isolation rooms month, on a
maintained at either rotational basis so as
negative or positive to cover all annually.
pressure)

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F. CSSD:

Indicators (Process, Monthly NA General IC Audit
Chemical, Biological) Sheet
Bio Medical Waste As per BMW Audit NA BMW Audit Sheet
Sheet
Instrument Washing (if Monthly 1 observation Audit General IC Audit
Sheet
done in CSSD)
Temperature Monitoring Monthly NA General IC Audit
Sheet
Humidity Monitoring Monthly NA General IC Audit
Sheet
Pressure Monitoring Monthly NA General IC
(ETO only) Audit Sheet
Audit Sheet OT ICU Procedure Dialysis Isolation CSSD

Labs Rooms
Hand Hygiene Tool     
(Annexure 2)
BMW Audit Sheet      
(Annexure 4)
GIC Checklist (Annexure      
5)

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SOP No. 03
Hand Hygiene
1. Purpose: To define guidelines on when and how to perform hand hygiene, in order to prevent the
transmission of bacteria, germs and infections.
2. Scope: Applicable to all staff of the hospital that is in contact with patients.
3. Rationale:
The major concern of any infection control program is the prevention of healthcare associated
infection. Handwashing is considered the single most important procedure in preventing the spread
of infection. The term hand hygiene refers to all of the processes, including hand washing & hand
decontamination achieved using other solutions e.g. alcohol based hand rub.
4. Indications of hand hygiene:

a. Wash hands with soap and water when visibly dirty or visibly soiled with blood, body fluids
or after using the toilet.
b. If exposure to potential spore forming pathogens is suspected or proven (e.g. outbreaks of

Clostridium difficile), hand washing with soap and water is preferred.
c. Use an alcohol based hand rub as the preferred means for routine hand antisepsis in all other
clinical situations in items d (i) to d (vi) listed below, if hands are not visibly soiled.

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d. Perform hand hygiene:
i. Before and after touching the patient.
ii. Before handling an invasive device for patient care, regardless of whether or not
gloves are used.
iii. After contact with body fluids or excretions, mucous membranes, non-intact skin, or
wound dressings.
iv. If moving from a contaminated body site to another body site during care of the same
patient.
v. After contact with inanimate surfaces and objects (including medical equipment) in
the immediate vicinity of the patient.
vi. After removing sterile or non-sterile gloves.
e. Before handling medication or preparing food perform hand hygiene using an alcohol based
hand rub or wash hands with either plain or antimicrobial soap and water
f. Before eating and after using a restroom

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5. WHO has defined Your FIVE moments of hand hygiene:
Key moments Representative situations when moment applies
1. Before patient contact  Before shaking hands
 Before assisting a patient in personal care activities: e.g. to move,

to take bath, to eat, to get dressed

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 Before delivering care and other non-invasive treatment: e.g.

applying oxygen mask.
 Before performing a physical non-invasive examination: e.g.

taking pulse, BP, Chest auscultation, recording ECG
2. Before clean/aseptic  Before brushing the patient teeth, instilling eye drops, examining
procedure mouth, nose, ear with or without an instrument, inserting a
suppository/pessary, suctioning mucus.
 Before dressing a wound with or without instrument, applying

ointment on vesicle, making a percutaneous injection/puncture.
 Before inserting an invasive medical device (nasal cannula,

naso-gastric tube, endotracheal tube, urinary probe,
percutaneous catheter, drainage), disrupting/opening any circuit
of an invasive medical device (for food, medication, draining,
suctioning, monitoring purposes).
 Before preparing food, medications, pharmaceutical products,

sterile material.
3. After Body fluid  When the contact with a mucous membrane and with non intact
exposure risk skin ends
 After a percutaneous injection or puncture, after inserting an

invasive medical device (vascular access, catheter, tube, drain
etc.), after disrupting and opening an invasive circuit.
 After removing an invasive medical device

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 After removing any form of material offering protection (napkin,

dressing, gauze, sanitary towel etc.)
 After handling a sample containing organic matter, after cleaning

excreta and any other body fluid, after cleaning any
contaminated surface and soiled material (soiled bed linen,
dentures, instruments, urinal, bedpan, lavatories etc.)
4. After touching a patient  After shaking hands, stroking a child’s forehead
 After you have assisted the patient in personal care activities: to

move, to bath, to eat, to dress
 After delivering care and other non-invasive treatment: e.g.

changing bed linen as patient is in bed, applying oxygen mask,
giving a massage
 After performing a physical non-invasive examination: e.g.

taking pulse or BP, chest auscultation, recording ECG.
5. After touching patients  After an activity involving physical contact with patients
surroundings immediate environment, changing bed linen with the patient out
of bed, holding a bed rail, clearing a bedside table
 After a care activity: adjusting perfusion speed, clearing a

monitoring alarm
 After other contacts with surfaces or inanimate objects: leaning

against a bed/night table/bedside table.

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6. Procedure:
6.1 Steps of hand washing:
a) Keep clothing away from sink and splashes.
b) Remove jewelry.
c) Turn on water.
d) Wet hands and apply approximately 2ml of liquid soap to hands. Lather well (soap reduces
surface tension enabling the removal of bacteria).
e) Wash hands thoroughly, using the following steps to facilitate eradication of all bacteria
(about five strokes/step)
 Palm to palm
 Palm over dorsum
 Palm to palm, fingers interlaced
 Back of fingers to opposing palms
 Rotate thumbs in palm
 Rotate fingers in palm
f) Rinse hands and wrists under running water.
g) Thoroughly dry hands with a clean paper towel.
h) Taps should be turned off using a dry paper towel ensuring hands are not re-contaminated. If
elbow operator tap available open and close with elbow.
i) Repeat hand washing technique whenever necessary (to prevent recontamination of hands).

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j) Preferred duration for the entire procedure is 40-60 sec.

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6.2 Hand rub:
When decontaminating with alcohol based hand rub, apply adequate volume of the product as
recommended by the manufacturer to palm of one hand & rub hands together covering all surfaces
of hands & fingers following the same six steps of hand washing until the hands are dry.
Preferred duration for the entire procedure is 20-30 seconds.

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6.3 Surgical hand washing:
6.3.1 It should be performed:
 Prior to all surgical procedures.
 Prior to other invasive or diagnostic procedures, e.g. insertion of a central venous catheter
or lumbar puncture.
6.3.2 Procedure:
a) Remove rings, watches, and jewelry before beginning the surgical hand scrub.
b) It is recommended to remove debris from underneath fingernails using a nail cleaner under
running water.
c) Surgical hand antisepsis using either an antimicrobial soap or an alcohol based hand rub with
persistent activity is recommended before donning sterile gloves when performing surgical
procedure.
d) When using a hospital approved antimicrobial agent (e.g. 4% chlorhexidine or 7.5%

povidone-iodine) scrub hands and forearms for the length of time recommended by the
manufacturer, usually 2 -5 minutes.
e) Keep arms level and well away from body and hands up above elbows for duration of scrub
f) Wet hands and forearms.
g) Apply hospital approved antimicrobial agent.
h) Lather hands and forearms from fingertips to three (3) inches above elbows starting with
hands to forearm, forearm to elbow and then hands and forearm again.
i) Rinse off.
j) Pay attention to all areas of hands and forearms.

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k) Rinse hands and forearms under running water; keep hands higher than the elbows at all times.
l) Using a sterile towel, dry each arm from fingertips to elbow, using a different side of towel
on each arm.
m) Turn off the water, using foot or elbow operated controls.
n) Proceed to OR, keeping hands above the elbows and out from scrub clothes
o) When using an alcohol based surgical hand rub product with sustained activity, follow the
manufacturer’s instructions for application times. Apply the product to dry hands only. Use
sufficient alcohol based hand rub to keep hands and forearms wet with it throughout the
surgical hand preparation procedure and allow it to dry before donning sterile gloves.
7. General Aspects of Hand Hygiene:

 Do not wear artificial nails when in contact with patients at high risk e.g. ICU or OT.
 Keep nails trimmed
 Wear gloves when contact with blood, body fluids, mucous membranes and non-intact
skin could occur
 Remove gloves after care of a patient. Do not wash gloves in between uses with different
patients. Do not wear the same pair of gloves for the care of more than one patient.
8. Promotion of hand hygiene and monitoring:
a) Keep the hand rub solution at a convenient location preferably at the bedside and replace as
soon as empty – do not refill empty containers.

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b) Educate health care workers about need and method of hand hygiene.
c) Monitor the adherence to hand hygiene on a periodic basis and give the feedback to healthcare
workers regularly. Monitoring is based on the WHO model of five moments of hand hygiene
(Annexure 3).
d) It is also required to monitor the consumption of alcohol based hand rub solutions from the
stores.

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SOP No. 04
Standard Precautions
1. Purpose:
To define Standard Precautions which have to be practiced while taking care of patients receiving
care in hospitals, regardless of their diagnosis or presumed infection status.
3. General points:
 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; and 4)
mucous membranes.
 Standard Precautions are designed to reduce the risk of transmission of microorganisms from
both recognized and unrecognized sources of infection in hospitals.
 Standard Precautions assume that every person is potentially infected or colonized with an
organism that could be transmitted in the healthcare setting and apply the following infection
control practices during the delivery of health care.
4. Key components:
 Hand hygiene
 Personal Protective equipment
 Respiratory Hygiene
 Patient placement
 Patient-care equipment and instruments/devices
 Care of environment
 Care of textiles/laundry

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 Safe Injection practices

 Handling needles and sharps
4.1 Hand Hygiene: Refer to the Hand hygiene policy.
4.2 Personal protective equipment (PPE):
PPE is specialized clothing or equipment worn by an employee for protection against infectious
materials.
Principles of use:
o Wear PPE when the nature of the anticipated patient interaction indicates that contact with
blood or body fluids may occur
o Prevent contamination of clothing and skin during the process of removing PPE
o Before leaving the patient’s room or cubicle, remove and discard PPE
o Do not share PPE
Components: Personal protective equipment includes:
 gloves
 gown/apron
 protective eye wear (goggles)

 masks and respirators
 boots/shoe covers and
 cap/hair cover

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Selection of PPE is determined by the type of anticipated exposure, such as touch, splashes or sprays,
or large volumes of blood or body fluids that might penetrate the clothing.
Gloves: -
 Wear gloves when it can be reasonably anticipated that contact with blood or other potentially
infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact
skin (e.g., of a patient incontinent of stool or urine) could occur.
 Wear gloves with fit and durability appropriate to the task
 Wear disposable medical examination gloves for providing direct patient care.
 Wear disposable medical examination gloves or reusable utility gloves for cleaning the
environment or medical equipment.
 Remove gloves after contact with a patient and/or the surrounding environment (including
medical equipment) using proper technique to prevent hand contamination
 Do not wear the same pair of gloves for the care of more than one patient.
 Change gloves during patient care if the hands will move from a contaminated body-site (e.g.,
perineal area) to a clean body-site (e.g., face), or if the gloves are damaged.
Gowns: -
 Wear a gown, to protect skin and prevent soiling or contamination of clothing during
procedures and patient-care activities when contact with blood, body fluids secretions, or
excretions is anticipated.
 Wear a gown for direct patient contact if the patient has uncontained secretions or excretions
 Remove gown and perform hand hygiene before leaving the patient’s environment
 Do not wear the same gown for the care of more than one patient

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Mouth, nose, eye protection: -

 Use PPE to protect the mucous membranes of the eyes, nose and mouth during procedures
and patient-care activities that are likely to generate splashes or sprays of blood, body fluids,
secretions and excretions. Select masks, goggles, face shields, and combinations of each
according to the need anticipated by the task performed.
 During aerosol-generating procedures (e.g., bronchoscopy, suctioning of the respiratory tract,
endotracheal intubation) in patients who are not suspected of being infected with an agent for
which respiratory protection is otherwise recommended (e.g., M. tuberculosis), wear one of
the following: a face shield that fully covers the front and sides of the face, a mask with
attached shield, or a mask and goggles (in addition to gloves and gown).
 It is recommended to wear N95-or higher respirators for potential exposure to infectious
agents transmitted via the airborne route (e.g., M. tuberculosis).
Caps: -
 In aseptic units, operating rooms, or performing selected invasive procedures, staff must wear
caps which completely cover the hair.
4.3 Respiratory Hygiene:
 Respiratory hygiene is important in source containment of infectious respiratory secretions in

symptomatic patients, beginning at initial point of encounter e.g., triage and reception areas
in emergency departments and physician offices.
 Instruct symptomatic persons to cover mouth / nose when sneezing /coughing or sneeze into
the crook of elbow;
 use tissues and dispose
 observe hand hygiene after soiling of hands with respiratory secretions;

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4.4 Patient placement:
 Place patients who pose a risk for transmission to others (e.g., uncontained secretions,
excretions or wound drainage; infants with suspected viral respiratory or gastrointestinal
infections) in a single-patient room when available or patients infected or colonized by the
same organism can be cohorted (sharing of room/s).
 Determine patient placement based on the following principles:
a) Route(s) of transmission of the known or suspected infectious agent
b) Risk factors for transmission in the infected patient
c) Risk factors for adverse outcomes resulting from an HAI in other patients
d) Availability of single-patient rooms
e) Patient options for room-sharing (e.g. cohorting patients with the same infection)
4.5 Patient-care equipment and instruments/devices:
 Handle in a manner that prevents transfer of microorganisms to others and to the environment;
wear gloves if visibly contaminated; perform hand hygiene.
 Remove organic material from critical and semi-critical instrument/devices, using
recommended cleaning agents before high level disinfection and sterilization to enable
effective disinfection and sterilization processes.
4.6 Care of environment:
 Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those
that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-
touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding
toilets in patients’ rooms) on a more frequent schedule compared to that for other surfaces.
 Use hospital approved disinfectants. Use in accordance with manufacturer’s instructions.
4.7 Care of textiles/laundry:

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 Handle used textiles and fabrics with minimum agitation to avoid contamination of air,
surfaces and persons.
4.8 Safe Injection practices:
The following recommendations apply to the use of needles, cannulas that replace needles, and,
where applicable intravenous delivery systems.
 Use aseptic technique to avoid contamination of sterile injection equipment.

 Do not administer medications from a syringe to multiple patients, even if the needle or
cannula on the syringe is changed. Needles, cannulas and syringes are sterile, single-use items;
they should neither be reused for another patient nor to access a medication or solution that
might be used for a subsequent patient. Use fluid infusion and administration sets (i.e.,
intravenous bags, tubing and connectors) for one patient only and dispose appropriately after
use. Consider a syringe or needle/cannula contaminated once it has been used to enter or
connect to a patient’s intravenous infusion bag or administration set.
 Use single-dose vials for parenteral medications whenever possible.
 Do not administer medications from single-dose vials or ampules to multiple patients or
combine leftover contents for later use.
 If multi-dose vials must be used, both the needle or cannula and syringe used to access the
multi-dose vial must be sterile.
 Do not keep multi-dose vials in the immediate patient treatment area and store in accordance
with the manufacturer’s recommendations; discard if sterility is compromised or questionable.
4.9 Handling needles and sharps:

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 Handle needles and other sharp devices in a manner that will prevent injury to the user and to
others who may encounter the device during or after a procedure.
 Do not recap, bend, break, or hand-manipulate used needles.
 If recapping is required, use a one-handed scoop technique only.
 Place used sharps in puncture proof container as per the hospital policy.
4.10 Worker safety
Adhere to hospital policy for protection of healthcare personnel from exposure to blood borne
pathogens.

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SOP No. 05
Isolation Precautions
1. Purpose:
To define various categories of isolation and indications and requirements for each category of
isolation.
3. Routes of Transmission:
Microorganisms are transmitted by various routes, and the same microorganisms may be transmitted
by more than one route. There are five main routes of transmission - contact, droplet, airborne,
common vehicle, and vector borne.
A. Contact transmission
This is the most important and frequent means of transmission of nosocomial infections and can
be divided into two sub-groups: direct contact and indirect contact.
I. Direct Contact - Involves direct physical transfer between a susceptible host and an
infected or colonized person, such as occurs when hospital personnel turn patients, give
baths, change dressings, or perform other procedures requiring direct personal contact.
Direct contact can also occur between two patients, one serving as the source of
infection and the other as a susceptible host.
II. Indirect Contact - Involves personal contact of the susceptible host with a contaminated

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intermediate object, usually inanimate, such as bed linen, clothing, instruments,

dressings, contaminated hands not washed and gloves that are not changed.
B. Droplet Transmission
Droplets (more than 5µ) are generated from the source patient mainly through coughing, sneezing
and talking as well as aerosolizing procedures as suctioning. Transmission occurs when droplets
containing the infective agent come in contact with the conjunctivae or the mucous membranes of
the nose or mouth of a susceptible person. Droplets do not remain suspended in the air and
generally travel only short distances (usually 3 feet or less), thus special air handling and
ventilation is not necessary.
C. Airborne transmission
Occurs by dissemination of either droplet nuclei (less than 5µ in size, residue of evaporated
droplets that may remain suspended in the air for long periods of time) or dust particles in the air
containing the infectious agent. Organisms carried in this manner can be widely dispersed by air
currents before being inhaled by or deposited on the susceptible host. Special air handling (6-12
air changes/hour, monitored HEPA filters, discharge of air outdoors) is needed to prevent this
transmission.
D. Common vehicle route

Applies to diseases transmitted through contaminated items such as:
1. Food, (salmonellosis)
2. Water, (legionellosis)
3. Drugs, (bacteremia resulting from infusion of a contaminated infusion product)
4. Blood (Hepatitis B, Hepatitis C, HIV)
E. Vector-borne transmission
Occurs when vectors such as flies, mosquitoes transmit disease.

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Isolation precautions are designed to prevent the spread of microorganisms among patients,
personnel, and visitors. Since agent and host factors are more difficult to control, interruption of the
chain of infection in the hospital is directed primarily at transmission.
Recommendations for isolation precautions:
These recommendations are designed to prevent transmission of infectious agents among patients and
healthcare personnel in all settings where healthcare is delivered.
I. Standard Precautions
It is an integral component of isolation precautions.
For details, refer to document on Standard Precautions.
II. Transmission-Based Precautions/Isolation precautions
A. Contact Precautions
 Use Contact Precautions for patients with known or suspected infections or evidence of
syndromes that represent an increased risk for contact transmission e.g. patients with wound
infections (major), Staphylococcal scalded skin syndrome, poliomyelitis, scabies.
 Patient placement-
Place patients who require Contact Precautions in a single-patient room when available. When
single-patient rooms are in short supply, apply the following principles for making decisions
on patient placement:
- Prioritize patients with conditions that may facilitate transmission (e.g., uncontained
drainage, stool incontinence) for single-patient room placement.
- Place together in the same room (cohort) patients who are infected or colonized with
the same pathogen and are suitable roommates

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- If it becomes necessary to place a patient who requires Contact Precautions in a room

with a patient who is not infected or colonized with the same infectious agent:
1) Ensure that patients are physically separated (i.e., >3 feet apart) from each other.
Draw the privacy curtain between beds to minimize opportunities for direct
contact.
2) Change protective attire and perform hand hygiene between contacts with patients
in the same room, regardless of whether one or both patients are on contact
precautions.
 Use of personal protective equipment

1) Gloves-
Wear gloves whenever touching the patient’s intact skin or surfaces and articles in close
proximity to the patient (e.g., medical equipment, bed rails). Don gloves upon entry into
the room or cubicle.
2) Gowns-
Wear a gown whenever anticipating that clothing will have direct contact with the patient
or potentially contaminated environmental surfaces or equipment in close proximity to
the patient. Don gown upon entry into the room or cubicle. Remove gown and observe
hand hygiene before leaving the patient-care environment.
After gown removal, ensure that clothing and skin do not contact potentially contaminated
environmental surfaces that could result in possible transfer of microorganism to other
patients or environmental surfaces.
 Patient transport
- Limit transport and movement of patients outside of the room to medically-necessary
purposes.

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- When transport or movement in any healthcare setting is necessary, ensure that

infected or colonized areas of the patient’s body are contained and covered.
- Remove and dispose of contaminated PPE and perform hand hygiene prior to
transporting patients on Contact Precautions.
- Don clean PPE to handle the patient at the transport destination.
 Patient-care equipment and instruments/devices
- Handle patient-care equipment and instruments/devices according to Standard
Precautions
- Implement patient-dedicated use of equipment like blood pressure cuff. If common
use of equipment for multiple patients is unavoidable, clean and disinfect such
equipment before use on another patient
 Environmental measures
Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and
disinfection with a focus on frequently-touched surfaces (e.g., bed rails, over-bed table,
bedside commode, lavatory surfaces in patient bathrooms, doorknobs) and equipment in the
immediate vicinity of the patient
 Discontinue Contact Precautions after signs and symptoms of the infection have resolved.
B. Droplet Precautions
 Use Droplet Precautions for patients known or suspected to be infected with pathogens
transmitted by respiratory droplets (i.e., large-particle droplets >5µ in size) that are generated
by a patient who is coughing, sneezing or talking e.g. pneumonia due to Streptococcus group
A, Mycoplasma (primary atypical pneumonia), Pertussis.
Place patients who require Droplet Precautions in a single-patient room when available. When
single-patient rooms are in short supply, apply the following principles for making decisions
on patient placement:

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a) Prioritize patients who have excessive cough and sputum production for single-patient
room placement.
b) Place together in the same room (cohort) patients who are infected the same pathogen
and are suitable roommates.
c) If it becomes necessary to place patients who require Droplet Precautions in a room
with a patient who does not have the same infection:
- Ensure that patients are physically separated (i.e., >3 feet apart) from each other.
Draw the privacy curtain between beds to minimize opportunities for close contact
- Change protective attire and perform hand hygiene between contact with patients
in the same room, regardless of whether one patient or both patients are on Droplet
Precautions
 Use of personal protective equipment
Don a mask upon entry into the patient room or cubicle
a) Limit transport and movement of patients outside of the room to medically-necessary
purposes.
b) If transport or movement in any healthcare setting is necessary, instruct patient to wear
a mask and follow Respiratory Hygiene
c) No mask is required for persons transporting patients on Droplet Precautions.
 Discontinue Droplet Precautions after signs and symptoms have resolved.
C. Airborne Precautions
 Use Airborne Precautions for patients known or suspected to be infected with infectious agents
transmitted person-to-person by the airborne route (e.g., M tuberculosis, measles, chickenpox,
disseminated herpes zoster).

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1) If possible, place patients who require Airborne Precautions in an AIIR (Airborne
infection isolation room) that has the following features.
- Negative air pressure
- Provides at least six (existing facility) or 12 (new construction/renovation) air changes
per hour.
- Direct exhaust of air to the outside. If it is not possible to exhaust air from an AIIR
directly to the outside, the air may be returned to the air-handling system or adjacent
spaces if all air is directed through HEPA filters.
2) Keep the AIIR door closed when not required for entry and exit.
3) In the event of an outbreak or exposure involving large numbers of patients who require
Airborne Precautions:
- Consult infection control professionals before patient placement to determine the
safety of alternative room that do not meet engineering requirements for an AIIR.
- Place together (cohort) patients who are presumed to have the same infection (based
on clinical presentation and diagnosis when known) in areas of the facility that are
away from other patients, especially patients who are at increased risk for infection
(e.g., immunocompromised patients).
- Use temporary portable solutions (e.g., exhaust fan) to create a negative pressure
environment in the converted area of the facility. Discharge air directly to the outside,
away from people and air intakes, or direct all the air through HEPA filters before it
is introduced to other air spaces
 Instruct patients with a known or suspected airborne infection to wear a surgical mask and
observe Respiratory Hygiene. Once in an AIIR, the mask may be removed; the mask should
remain on if the patient is not in an AIIR.
 Personnel restrictions

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Restrict susceptible healthcare personnel from entering the rooms of patients known or
suspected to have measles (rubeola), varicella (chickenpox), disseminated zoster, if other
immune healthcare personnel are available.
 Use of PPE
It is recommended to wear a fit-tested N95 or higher level respirator for respiratory protection
when entering the room of a patient when the following diseases are suspected or confirmed:
- Infectious pulmonary or laryngeal tuberculosis or when infectious tuberculosis skin

lesions are present and procedures that would aerosolize viable organisms (e.g.
irrigation, incision and drainage) are performed.
- No recommendation is made regarding the use of PPE by healthcare personnel who
are presumed to be immune to measles (rubeola) or varicella-zoster based on history
of disease, vaccine, or serologic testing when caring for an individual with known or
suspected measles, chickenpox or disseminated zoster, due to difficulties in
establishing definite immunity.
- Limit transport and movement of patients outside of the room to medically-necessary
purposes.
- If transport or movement outside an AIIR is necessary, instruct patients to wear a
surgical mask, if possible, and observe Respiratory Hygiene.
- For patients with skin lesions associated with varicella or smallpox or draining skin
lesions caused by M. tuberculosis, cover the affected areas to prevent aerosolization
or contact with the infectious agent in skin lesions.
- Healthcare personnel transporting patients who are on Airborne Precautions do not
need to wear a mask or respirator during transport if the patient is wearing a mask and
infectious skin lesions are covered.
 Exposure management

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Advise immunization or appropriate immune globulin administration to susceptible persons

as soon as possible following unprotected contact (i.e., exposed) to a patient with measles or
varicella.
- Advise measles vaccine to exposed susceptible persons within 72 hours after the
exposure or administer immune globulin within six days of the exposure event for
high-risk persons in whom vaccine is contraindicated.
- Advise varicella vaccine to exposed susceptible persons within 120 hours after the
exposure or advise varicella immune globulin, when available, within 96 hours for
high-risk persons in whom vaccine is contraindicated (e.g., immunocompromised
patients, pregnant women, newborns whose mother’s varicella onset was <5 days
before or within 48 hours after delivery).
- Discontinue Airborne Precautions according to pathogen specific recommendations in
Annexure 6.
Protective Environment:
 Place allogeneic hematopoietic stem cell transplant (HSCT) patients in a Protective

Environment.
 No recommendation for placing patients with other medical conditions that are associated
with increased risk for environmental fungal infections (e.g., aspergillosis) in a Protective
Environment
Recommendations for prevention of transmission of Multidrug Resistant Organisms (MDRO)
MDRO definition:

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MDROs are defined as microorganisms, predominantly bacteria, that are resistant to one or more
classes of antimicrobial agents e.g. MRSA, VRE, ESBL producing gram negative bacilli GNB.
Organisms such as Stenotrophomonas maltophilia, Burkholderia cepacia, and Ralstonia pickettii that
are intrinsically resistant to the broadest-spectrum antimicrobial agents are also considered as MDRO.
I. Infection control precautions to prevent transmission of MDROs

 Follow Standard Precautions and contact precautions.
 Use masks according to Standard Precautions when performing splash generating procedures
(e.g., wound irrigation, oral suctioning, intubation); when caring for patients with open
tracheostomies and the potential for projectile secretions; and in circumstances where there is
evidence of transmission from heavily colonized sources (e.g., burn wounds).
Masks are not otherwise recommended for prevention of MDRO transmission from patients to
healthcare personnel during routine care (e.g., upon room entry).
II. Environmental measures

 Clean and disinfect surfaces and equipment that may be contaminated with pathogens,
including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and
frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and
surrounding toilets in patients’ rooms) on a more frequent schedule compared to that for
minimal touch surfaces (e.g., horizontal surfaces in waiting rooms).
 If possible, dedicate noncritical medical items to use on individual patients known to be
infected or colonized with MDROs.
Refer to Annexure 6 for suggested type and duration of precautions recommended for selected
infections and conditions.

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SOP No. 06
Occupational Exposure to Blood and Body Fluids
1. Purpose:
This Procedure provides guidance on prevention and management of occupational exposures to blood
or other potentially infectious materials. Each hospital is expected to develop and implement a detailed
SOP based on this policy.
2. Scope:
This section applies to all occupational exposure to blood or other potentially infectious materials:
 Injuries from all sharps or instruments contaminated with blood or body substances.
 Splashes to mucous membranes/non intact skin from blood and body substances.
Body fluids that are potentially infectious include blood, semen, vaginal secretions, CSF, synovial,
pleural, peritoneal, pericardial, amniotic fluid or other body fluids contaminated with visible blood.
Exposure to tear, sweat, saliva, urine and feces is not considered infectious unless these secretions are
contaminated with blood).
3. Roles and responsibilities:
 All HCWs in hospital: Report all blood and BF exposure events immediately to the designated
person.

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 Infection Control staff:
- To educate staff on action following exposure.
- Coordinating exposure action identified in this procedure and related documents.
- Document and assess all reported accidents/incidents using the EPINET form (Annexure
7, 8, 9).
4. Types of exposure:
 Percutaneous injury (e.g. a needle stick or cut with a sharp object)
 Mucus membrane exposure
 Non-intact skin (e.g. when the exposed skin is chapped, abraded or afflicted with dermatitis).
5. Action by health care worker following blood borne injury/exposure:
Sharps Injury:
 Do not squeeze or suck the injury site.
 Wash liberally with soap and water.
 Report and give the details of injury to infection control staff or any other designated
person.
Other Exposures (e.g. mouth, eyes, fresh abrasions):
 Eyes: Should the eyes become contaminated, rinse the eyes gently but thoroughly with
water or normal saline.

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 Mouth: Should blood or BF spray into the mouth, spit out the blood and then rinse the
mouth with water several times.
6. Management Protocol:
a) If Source HBV/HCV and HIV status is unknown, then send the source blood samples for
estimation of HIV/HCV/HBV.
b) Exposed HCW is also tested for HBV, HCV and HIV.
c) If the Source is negative, then no further action is taken
Testing of source patients and health care personnel potentially exposed to hepatitis C virus
Source-patient testing
 Testing of the source patient may follow option A (preferred), which is testing with a nucleic
acid test (NAT) for hepatitis C virus (HCV) RNA, or option B, which is testing for anti-HCV
with reflex to a NAT if positive.
 If a source patient is known or suspected to have recent behaviors that increase risk for HCV
acquisition (e.g., injection drug use within the previous 4 months) or if risk cannot be reliably
assessed, initial testing should include a NAT.
 Follow-up testing of health care personnel (HCP) is recommended if the source patient is
HCV RNA positive, anti-HCV positive with RNA status unknown, or cannot be tested.
HCP testing*
 Baseline testing of HCP for anti-HCV with reflex to a NAT if positive should be conducted
as soon as possible (preferably within 48 hours) after the exposure and may be simultaneous
with source-patient testing.

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 If follow-up testing of HCP is recommended based on the source-patient’s status, test with a
NAT at 3–6 weeks post-exposure.
 If the HCP is NAT negative at 3–6 weeks post-exposure, a final test for anti-HCV at 4–6
months post-exposure is recommended.
 A source patient or HCP who is positive for HCV RNA should be referred to care.
* Follow-up testing of HCP is also warranted when concerns exist about specimen integrity,
including handling and storage conditions that might have compromised source-patient test results,
or if they exhibit any clinical signs of HCV infection.
d) If the source is HBV positive / unknown:
Appropriate and timely prophylaxis can prevent HBV infection and subsequent development
of chronic infection or liver disease. The mainstay of post exposure prophylaxis (PEP) is
Hepatitis B vaccine, but, in certain circumstances, Hepatitis B immune globulin is
recommended in addition to vaccine for added protection.

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* A nonresponder is defined as a person with anti-HBs <10 mIU/mL after ≥6 doses of HepB vaccine.
Persons who do not have a protective concentration of anti-HBs after revaccination should be tested
for HBsAg. If positive, the person should be referred to physician for appropriate management.

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 When a source patient is unknown, the exposed HCP should be managed as if the source patient
were HBsAg positive.
 When indicated, immunoprophylaxis should be initiated as soon as possible, preferably within 24

hours.
Post exposure management of health-care personnel after occupational percutaneous and

mucosal exposure to blood and body fluids, by health-care personnel HepB vaccination and
response status
Post-exposure testing Post-exposure Post-

Health-care Personnel status prophylaxis vaccination
Source HCP testing HBIG* Vaccination serologic
patient (anti-HBs) †
testing
(HbsAg)
Documented Responder § after

No action needed
complete series (≥3 doses)
Documented Non-responder Positive/ HBIG x 2 No
after 6 doses ¶ Unknown __** separated _____

by 1 month
Negative No action needed
Response Unknown after 3 Positive/ <10 mIU/ml HBIG x 1 Initiate re- Yes
doses Unknown ** vaccination
Negative <10 mIU/ml None
Any result ≥10 mIU/ml No action needed
Unvaccinated/ Incompletely Positive/ HBIG x 1 Complete Yes
__**
vaccinated or vaccine refusers Unknown vaccination
Negative None Complete Yes
____
vaccination

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* HBIG should be administered intramuscularly as soon as possible after exposure when indicated.
The effectiveness of HBIG when administered >7 days after percutaneous, mucosal, or non-intact skin
exposures is unknown. HBIG dosage is 0.06 mL/kg.
HBIG can be administered simultaneously with HepB vaccine but at a different injection site
† Should be performed 1–2 months after the last dose of the HepB vaccine series (and 4–6 months
after administration of HBIG to avoid detection of passively administered anti-HBs) using a
quantitative method that allows detection of the protective concentration of anti-HBs (≥10 mIU/mL).
§ A responder is defined as a person with anti-HBs ≥10 mIU/mL after ≥3 doses of HepB vaccine.
¶ A nonresponder is defined as a person with anti-HBs <10 mIU/mL after ≥6 doses of HepB vaccine.
** HCP who have anti-HBs <10mIU/mL, or who are unvaccinated or incompletely vaccinated, and
sustain an exposure to a source patient who is HBsAg-positive or has unknown HBsAg status, should
undergo baseline testing for HBV infection as soon as possible after exposure, and follow-up testing
approximately 6 months later. Initial baseline tests consist of total anti-HBc; testing at approximately
6 months consists of HBsAg and total anti-HBc. If positive, the person should be referred to physician
for appropriate management.
e) If the source is unknown:
 Evaluation for HIV: Perform baseline testing for exposed person for Antibodies to HIV. If
chances of sharp belonging to HIV positive patient are high, preferably start PEP as given
in the following section (g). Repeat HIV antibody testing at 6 months.
 Evaluation for HCV: proceed as given in the previous section (d).
 Evaluation for HBV: proceed as given in the previous section (e).

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f) Management and follow-up of exposures for HIV:
Determine the Nature of exposure and the HIV status of source of exposure as described
in the tables below:
Assessing the nature of exposure

Category Definition and example
Mucus membrane/non-intact skin with small volume, e.g., a superficial
wound (erosion of the epidermis) with a plain or low calibre needle;
Mild Exposure
contact with the eyes or mucous membranes; subcutaneous injections
following small bore needles.
Mucus membrane/non-intact skin with large volumes or percutaneous
Moderate Exposure superficial exposure with solid needle (e.g., a cut or needle stick injury
penetrating gloves).
Percutaneous with large volume, e.g., an accident with wide bore needle
(>18G) visibly contaminated with blood; a deep wound (haemorrhagic
Severe Exposure wound and/or very painful); transmission of a significant volume of
blood; an accidental injury with material, which has previously been
used intravenously or intra-arterially.
Assessing the HIV status of the source of exposure

HIV status of source Definition of risk in source
HIV negative Source is not HIV infected (but consider HBV and HCV)
Low risk HIV positive and clinically asymptomatic

High risk HIV positive and clinically symptomatic
Status of the patient is unknown and neither the patient nor his/her
Unknown
blood is available for testing

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Assessing the need for PEP:
1. If the HIV status of the source person is known and confirmed as negative, PEP is not required.
2. If the status of the patient is unknown and neither the patient nor his/her blood is available for
testing, then the choice of whether to use PEP and what regimen will depend upon the severity
of the wound and how much is known about the individual’s HIV risk history.
3. If the status of the patient is unknown, and the patient is available, he is to be counselled and
consent obtained for testing.
4. If the patient refuses testing but a sample of blood is available, it is the right of the exposed
person that the blood sample be tested but the source patient may decline to be informed of the
result.
5. If the patient has refused counselling and testing, and there is no blood sample available, it is
the right of the exposed person to ask that blood be taken for testing and the source patient may
decline to be informed of the result. Under no circumstances should the source patient be
charged for the test.
6. If the patient is known to be HIV positive, evaluation of risk is in order. The two key factors to
consider are:
 Whether the patient is antiretroviral drug naive
 Whether he/ she is on ARTs and whether the patient is likely to have a high viral load, as
determined by testing, if available, or by clinical signs and symptoms.
Low risk: Asymptomatic, or viral load< 400 copies /ml

High risk: Symptomatic with OI or AIDS, acute seroconversion, high viral load.
In the case of a high-risk exposure from a source patient on ARTs, consult an expert to choose
the appropriate PEP regimen if drug resistance is high.
Informed Consent and Counselling:

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Exposed persons should receive appropriate information about the risks and benefits of PEP
medications. It should be clear that PEP is not mandatory. Exposed persons should, however, be made
to understand that a few cases of transmission have been seen in cases given prophylaxis.
For prophylactic treatment the exposed person must sign a consent form. Informed consent also means
that if exposed, the person has been advised on PEP. If the individual refuse to initiate PEP, it should
be documented.
Decision on PEP Medications/Regimen:

Ideally, therapy should be started within 2 hours and definitely within 72 hours of exposure. Never
delay starting therapy due to uncertainty. Re-evaluation of the exposed person should be considered
within 72 hours post exposure, especially if additional information about the exposure or source person
becomes available. If the risk is insignificant, PEP could be discontinued, if already started.
Exposed individuals who are known or discovered to be HIV positive should not receive PEP.
Seek an expert opinion in case of:

 Delay in reporting exposure (> 72 hours)
 Unknown source
 Known or suspected pregnancy, but initiate PEP
 Breastfeeding mothers, but initiate PEP
 Source patient is on ARTs
 Major toxicity of PEP
While the Source Patient is on ART:
The physician should consider, the comparative risk represented by the exposure, taking into account
the source’s history of and response to ARTs (based on clinical response), CD4 cell count, viral load
measurements (if available), and current disease stage.

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If the source person’s virus is known or suspected to be resistant to one or more drugs considered for
PEP regimen, then the exposed person needs to be given alternate PEP drug regimen and referred for
expert opinion.
Pregnancy and PEP:
If the concerned HCP is pregnant at the time of occupational exposure to HIV, she should get the
regimen for primary management of the exposure, like non-pregnant persons. Pregnant women, who
sustain occupational exposure, should also be offered antiretroviral chemoprophylaxis, if required. The
designated authority/physician must be consulted about the use of ARTs for post-exposure
management.
For a female HCP considering PEP, a pregnancy test is recommended in case of a doubt.
Dosages of the Drugs for PEP for adults and adolescents-

FDC of Tenofovir (TDF) 300 mg plus
Lamivudine (3TC) 300 mg plus
Efavirenz (EFV) 600 mg once daily for 4 weeks.
If the source is already on ART, start the exposed person the above mentioned regimen at the earliest
with proper counselling and then refer for an expert opinion.
Side effects and Adherence to PEP:

Side effects occur mainly at the beginning of the treatment and include nausea, diarrhoea, muscular
pain and headache. The person taking the treatment should be informed that these may occur and
should be dissuaded from stopping the treatment as most side effects are mild and transient, though
possibly uncomfortable.
Anaemia and/or leukopenia, and/or thrombocytopenia may occur during the month of treatment.

196
Adherence information and psychological support are essential. Adherence is important to maximise
the efficacy of the medication in PEP. Side effects can be reduced through medications.
A complete blood count and liver function test (transaminases) may be performed at the beginning of
treatment (as baseline) and after 4 weeks.
Follow-up testing for exposure to HIV positive source:

The first sample for HIV testing is collected immediately after exposure, the 2nd at 6 weeks, the 3rd
at 12 weeks, and the last at 6 months after exposure.
During the follow up period, especially the first 6-12 weeks, the following measures are to be adopted
by the HCP: refraining from blood, semen, organ donation and abstinence from sexual intercourse. In
case, sexual intercourse is undertaken, a latex condom must be used to reduce the risk of HIV
transmission. Women should not breast feed their infants. The exposed person is advised to seek
medical evaluation for any febrile illness that occurs within 12 weeks of exposure.
7. Promotion and Monitoring:

a) Incidence of needle stick injuries are monitored monthly.
= Number of sharp exposures/ number of in patient days x 100
b) Incidence of blood/body fluid exposures are monitored monthly.
= Number of blood and body fluid exposures exposures/ number of in patient days X100
c) All the incidents are filled in the EPINET format (Annexure 7, 8, 9- as applicable) and report
is generated as required.
Educate the staff on prevention of needle stick injuries and blood and body fluid exposures.

196
SOP No. 07
Recommendations for Cleaning and Disinfections
1. Purpose:
To define protocol for cleaning / disinfection / sterilization of various instruments, equipment and
surfaces.
2. Scope: Hospital wide
3. Recommendations: The recommendations are listed below along with the preferred agent and
frequency.
A. General Recommendations:
S. No ACTIVITY RECOMMENDATIONS
1 Hand Hygiene Hand Rub [2.5% Chlorhexidine v/v + 70% Ethyl Alcohol v/v (or
Isopropyl alcohol 70%) + Emollients] / Soap & water
2 Surgical scrub Chlorhexidine 4% w/v or 7.5% povidone-iodine
2 Skin Antisepsis Povidone Iodine 10% w/v OR Tincture Chlorhexidine 2.5% v/v
(0.5% w/v)
3 Surface disinfection (Low Fourth generation (or higher) Quaternary Ammonium compound
Level disinfection) (QAC) OR Hydrogen Peroxide based product
4 CVP Line insertion > 2 months: > 2.5% v/v (> 0.5% w/v) Tincture Chlorhexidine, <
2 months: 70% Alcohol / Tincture iodine

196
5 Peripheral vein 70% Ethyl/Isopropyl alcohol swabs of appropriate size
6 High Level Disinfection Glutaraldehyde (= or >2.4%) OR Hydrogen Peroxide (7.5%

stabilized) OR ortho-phthalaldehyde OR Peracetic Acid with
Hydrogen Peroxide
High Risk Areas: OT, ICU, Cath Lab and Procedure Labs, Dialysis, Isolation Room, CSSD.
B. Recommendations for Cleaning & Disinfection of Instruments, Equipment and Similar

Articles: ICU and High risk areas
ARTICLES/ TECHNIQUE/
S. No RECOMMENDATION FREQUENCY
INSTRUMENTS CHEMICAL
1 Telephones, Screen of Surface disinfection (Low 4th generation (or higher) Once daily/if soiled
monitors/equipment Level disinfection) QAC (with lint free cloth with blood or body
or Wipes) OR Hydrogen fluid whichever is
peroxide based product earlier, weekly once
scrubbing
2 Defibrillators, SpO2 Surface disinfection 4th generation (or higher) Once daily/if soiled
probes, Syringe pump, QAC (with lint free cloth with blood or body
Transducer stand, or Wipes) OR Hydrogen fluid whichever is
peroxide based product earlier, weekly once
scrubbing
3 Common Stethoscope, Surface disinfection (Low 4th generation (or higher) Once daily/if soiled
BP cuff, E.C.G cables, Level disinfection) BP QAC (with lint free cloth with blood or body
leads, pacing cables, Cuff - Launder when or Wipes) OR Hydrogen fluid whichever is
Transducer cables soiled peroxide based product earlier, weekly once
scrubbing. Common
stethoscope: in
between patients
4 External parts of Surface disinfection (Low 4th generation (or higher) Once daily/if soiled
ventilator, Echo Level disinfection) QAC (with lint free cloth with blood or body
machine, X-ray or Wipes) OR Hydrogen fluid whichever is
machine peroxide based product earlier, weekly once
scrubbing
5 Laryngoscope HLD/ ETO sterilization Clean with soapy water, After each use
whenever possible Immerse in Multi-enzyme
agent (duration as per
manufacturer's

196
recommendation),
Followed by High Level
disinfection / ETO
sterilization
6 Hemodialysis/CRRT Surface disinfection (Low 4th generation (or higher) After each dialysis
machine Level disinfection) QAC (with lint free cloth session
or Wipes) OR Hydrogen
peroxide based product
7 Internal parts of As per manufacturer's ETO Between patients.
ventilator - Flow recommendation
Sensor
8 Internal parts of As per manufacturer's - -
ventilator - Cassettes recommendation
9 Tongue depressor Clean with soapy water, Autoclaving After each use
(non-disposable), Immerse in Multi-enzyme
Magills forceps agent (time as per
manufacturer's
recommendation);Rinse
with water, air dry, send
for sterilization
10 Ambu Bag Clean with soap water, dry ETO sterilization After each use As
and send for ETO mentioned in IPCM
sterilization (needs to be changed
to: ETO in between
patients)
11 Ambu connector, Clean with soap water, ETO sterilization After each use (needs
Ambu mask, Airway Immerse in Multi-enzyme to be changed to: HLD
agent (time as per after each use, ETO in
manufacturer's between patients)
recommendation) and
send for ETO sterilization
12 ET CO2 adapter Clean mechanically with ETO sterilization/High After each use
soapy water, air dry. Send level disinfection
for ETO sterilization, OR
high level disinfection
13 Oxygen Jars Clean mechanically with ETO sterilization/High In between successive
(humidifiers), Suction soapy water, air dry. Send level disinfection patients
Jars for ETO sterilization, OR
high level disinfection
14 ICD bottles Clean mechanically with ETO sterilization (Non After each use
soap water, Send for ETO Glass), Autoclave (Glass)
sterilization OR High level OR High level
disinfection disinfection

196
15 Connector tubing from Discard - After each use

patient to suction jar
16 Connector tubing from Clean and then ETO Clean mechanically with After each use
suction jar to suction soapy water, air dry. Send
apparatus for ETO sterilization
/HLD
17 Surgical instruments Clean with soapy water, Autoclave After each use
immerse in enzymatic
cleaner (time as per
manufacturer's
recommendation), rinse,
dry, send to CSSD for
autoclaving
18 Temperature probe Clean with soapy water, ETO sterilization After each use
rinse, dry. Send for high
level disinfection
19 Crash Cart Surface disinfection (Low 4th generation (or higher) Weekly and after each
Level disinfection) QAC (with lint free cloth use
20 Miscellaneous items Surface disinfection (Low 4th generation (or higher) Once daily/if soiled
(e.g. patient bed, Level disinfection) QAC (with lint free cloth with blood or body
cabinets, cardiac table or Wipes) OR Hydrogen fluid whichever is
etc.) peroxide based product earlier, weekly once
scrubbing
21 Wall mounted oxygen Surface disinfection (Low 4th generation (or higher) Between patients/when
and suction fixtures Level disinfection) QAC (with lint free cloth soiled
22 Transport equipment - Surface disinfection (Low 4th generation (or higher) After each use/Daily
Walker, wheelchair Level disinfection) QAC (with lint free cloth
23 Storage cupboards / Surface disinfection (Low 4th Generation (or higher) Weekly (frequency as
Sterile stores Level disinfection) QAC mentioned in IPCM
needs to be amended as
wet cleaning at this
frequency is not
doable)
24 Blood / body fluid Small spills: (i.e. drops of Hypochlorite solution (1% -
spills blood) on noncritical solution equivalent to
surfaces, disinfect with 10000 PPM)
1% Sodium hypochlorite
solution

196
Large spills: Wipe with

absorbent material like
paper towels. Cover area
with Sodium hypochlorite
solution (1% solution
equivalent to 10000 PPM),
leave for 20 min and wipe
off.
Spill with sharps:

Decontaminate, then clean
and disinfect with Sodium
hypochlorite solution as
above.
25 Curtains Sent to Laundry - Weekly basis or earlier
if visibly soiled
26 Blankets Send to Laundry - Between patients
27 Soiled / contaminated Send to Laundry in yellow - After each use

Linen & towels (or appropriate colored)
bags
28 Dirty Linen & towels Send to Laundry - After each use
29 Bedpans, Urinals Bedpan washer; Manual - After each use

cleaning with soap and
water if bedpan washer is
not available
C. Recommendations for Cleaning & Disinfection of Area, Instruments, Equipment and

Similar Articles: OT
S. ARTICLES/ FREQUENCY (At the

RECOMMENDATIONS TECHNIQUE/CHEMICAL
N. INSTRUMENTS Minimum)
1 OT Table / Anesthesia Surface disinfection 4th generation (or higher) QAC (with After each case and
Machine / OT Lights / lint free cloth or Wipes) OR Hydrogen weekly once scrubbing
C-ARM peroxide based product
2 OT Surgeon / Surface disinfection (Low 4th generation (or higher) QAC (with Once daily/if soiled with
Anesthesia Pendant / Level disinfection) lint free cloth or Wipes) OR Hydrogen blood or body fluid
Electro Surgical Unit peroxide based product whichever is earlier,
weekly once scrubbing.

196
3 Anaesthetic Gas Surface disinfection (Low 4th generation (or higher) QAC (with After each use
Monitoring Device / Level disinfection) lint free cloth or Wipes) OR Hydrogen
Laparoscopy Camera peroxide based product
4 Baby Warmer / Surface disinfection (Low 4th generation (or higher) QAC (with After each use and
Incubator Level disinfection) lint free cloth or Wipes) OR Hydrogen weekly once scrubbing
/Microscope / Suction peroxide based product
Machine
5 CS 100 IABP Surface disinfection 4th generation (or higher) QAC (with Once daily/after each use
(Datascope) / Cautery lint free cloth or Wipes) OR Hydrogen /when soiled with blood
machine / Bair peroxide based product or body fluid whichever
Hugger / HP is earlier, weekly once
Recording System / scrubbing.
Helmet battery
Charger
6 ArthroCare Wand Surface disinfection (Low 4th generation (or higher) QAC (with Once daily/after each use
Machine Level disinfection) lint free cloth or Wipes) OR Hydrogen /if soiled with blood or
peroxide based product body fluid whichever is
earlier, weekly once
scrubbing. Probe changed
after each case
7 Camera Image Hub / Surface disinfection (Low 4th generation (or higher) QAC (with Once daily/if soiled with
Tourniquet System / Level disinfection) lint free cloth or Wipes) OR Hydrogen blood or body fluid
LIGHT SOURCE peroxide based product whichever is earlier,
XENON / LASER weekly once scrubbing.
(DIODE) / Holmium
(Laser) / Electronic
Endoflator
8 OT Floors (Operating Surface disinfection (Low 4th Generation (or higher) QAC After each case and
Room Floors) Level disinfection) weekly once scrubbing
9 Operating Rooms Fogging (if done) Peroxide based product Weekly
10 OT corridors Surface disinfection (Low 4th Generation (or higher) QAC cleaned twice a day and
(Common areas and Level disinfection) weekly scrubbed
corridors)
11 Scrub sinks-stainless Surface disinfection (Low 4th Generation (or higher) QAC cleaned twice a day and
steel Level disinfection) weekly scrubbed
12 OT sluice room/utility Surface disinfection (Low 4th Generation (or higher) QAC once daily and weekly
room Level disinfection) scrubbed
*High Level Disinfection = As per CDC - High-level disinfection kills all organisms, except high levels
of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by
the Food and Drug Administration. Glutaraldehyde, hydrogen peroxide, ortho-phthalaldehyde, and
peracetic acid with hydrogen peroxide are cleared by the Food and Drug Administration (FDA) and
are dependable high-level disinfectants.

196
Lumens:- To be filled & flushed with multi-enzyme agent wherever applicable.
D. Recommendations for Cleaning & Disinfection of area, instruments, equipment and similar
articles: Cath Lab
S. ARTICLES/
RECOMMENDATIONS TECHNIQUE/CHEMICAL FREQUENCY
No INSTRUMENTS
4th generation (or higher)
After each case
Surface disinfection (Low QAC (with lint free cloth or
1 Cath lab table and weekly once
Level disinfection) Wipes) OR Hydrogen
scrubbing
4th generation (or higher)
Surface disinfection (Low QAC (with lint free cloth or After each case
2 Lead Aprons
Level disinfection) Wipes) OR Hydrogen and when soiled
After each case
Surface disinfection (Low 4th Generation (or higher)
3 Cath lab Floors and weekly once
Level disinfection) QAC
scrubbing
4 Cath lab Fogging (if done) Peroxide based product Weekly
Cath lab corridors Cleaned twice a

Surface disinfection (Low 4th Generation (or higher)
5 (Common areas day and weekly
Level disinfection) QAC
and corridors) scrubbed
Cleaned twice a
Scrub sinks- Surface disinfection (Low 4th Generation (or higher)
6 day and weekly
stainless steel Level disinfection) QAC
scrubbed
E. Recommendations for Floor and Wall Cleaning:
S. ARTICLES/ TECHNIQUE/
RECOMMENDATIONS FREQUENCY
No INSTRUMENTS CHEMICAL
Surface disinfection
Floor cleaning 4th Generation (or higher) Every shift/whenever
1 (Low Level
(Critical areas) QAC required
disinfection)

196
Floor cleaning ( Surface disinfection

4th Generation (or higher) Daily/whenever
2 Non critical (Low Level
QAC required
areas) disinfection)
Floor-
Administrative
Daily/whenever
3 areas/Non - Detergents
required
patient care
areas
Surface disinfection
4th Generation (or higher)
4 Walls/Blinds (Low Level When visibly soiled
QAC
disinfection)
Beginning of the day
Housekeeping and as required and
5 cleaning mop Detergents after cleaning of spills.
washing After washing, allow
to dry before reuse.
*High Level Disinfection = As per CDC - High-level disinfection kills all organisms, except high levels
of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by
the Food and Drug Administration. Glutaraldehyde, hydrogen peroxide, ortho-phthalaldehyde, and
peracetic acid with hydrogen peroxide are cleared by the Food and Drug Administration (FDA) and
are dependable high-level disinfectants.
F. Recommendations for Cleaning & Disinfection of Scopes:
S. ARTICLES/ TECHNIQUE
RECOMMENDATIONS FREQUENCY
No INSTRUMENTS /CHEMICAL
1 Rigid Scopes Sterilization/HLD Autoclave/ LTSF After every use
2 Flexible Scopes High level disinfection/ LTSF For HLD, use After every use
chemicals
compatible with the
scope, as per
manufacturer's
recommendations.
3 Water bottle Cleaned & HLD/ Sterilized Ideally b/w each
patient or at least end
of each day
4 Valves Cleaned & HLD/ Sterilized After each use

196
5 Air/water suction Cleaned & HLD/ Sterilized After each use

valve
6 Biopsy port cover Cleaned & HLD/ Sterilized As per
manufacturer's
instructions
7 Channel cleaning Cleaned & HLD/ Sterilized After each use. As
adapters, cleaning per manufacturer's
brushes instructions
8 Biopsy forceps Sterilized After each use.
9 Video scopes Sterile sheaths with After each use.
Intermediate level disinfection
(70 % alcohol wipe) provided
no breach in sheath. Else HLD
10 Flexible Video ETO/ HLD After each use.
Endoscopes
11 Trocars/Cannulas/ Autoclave/ ETO/ Plasma/ After each use.
Sheaths/Obturator HLD
s/Laryngoscopes
12 Fiber optic light Autoclave/ ETO/ Plasma After each use.
cables /HLD
13 Bronchoscope/La Autoclave/ ETO/ HLD After each use.
ryngoscope
Suction Tubes
High level Disinfectants

Agents – HLD Olympus Pentax Fujinon Contact time Max days Reactivation
of use required
Glutaraldehyde; 3.4 % C C C 20 min at 25 degree 28 D Yes
C
12 min at 20 degree 14 D No
0.55% Ortho- C
C C C
phthalaldehyde 5 min at 25 degree 14 D No
C
0.2% Peracetic Acid NC C C 5 min at 30 degree Single use No
C
7.5% Hydrogen NC NC NC 30 min at 20 degree 21 No
peroxide C
C = Compatible
NC= Not compatible

196
Note: Automated endoscope reprocessor (AER) - Disinfectant should be used as per the
Manufacturer’s recommendation.
G. Recommendations for Cleaning & Disinfection in Dialysis units:
ARTICLES/
S. No RECOMMENDATIONS TECHNIQUE/CHEMICAL FREQUENCY
INSTRUMENTS
1 Floors Surface disinfection (Low 4th Generation (or Every shift/ whenever
Level disinfection) higher) QAC required
2 Dialysis chairs Surface disinfection (Low 4th generation (or higher) After each dialysis
/ Dialysis Level disinfection) QAC (with lint free cloth session
Machines / or Wipes) OR Hydrogen
Bed, trolleys peroxide based product
and other
surfaces
3 Isolation room Decontamination 1% hypochlorite Daily
H. Miscellaneous:
S. ARTICLES/
RECOMMENDATIONS TECHNIQUE/CHEMICAL FREQUENCY
No INSTRUMENTS
1 US Probe - Clean with QAC wipes After every use
2 Echo Probe - Clean with QAC wipes After every use
Clean after every use
Sputum Mugs High level disinfection
Clean with soap water, and high level
3 (Preferably with hospital approved
dry. disinfection in
disposable) disinfectant.
between patients.

196
I. Recommendations for Environmental Surveillance:
S. FREQUENCY (At the

Area RECOMMENDATIONS TECHNIQUE
N. Minimum)
OT, Units fitted

Air sampling for Slit Air Sampler/Settle
1 with/without HEPA Quarterly
Microbiological surveillance plate method
filters
OT, Units fitted Engineering &Maintenance
Digital thermo-
2 with/without HEPA Dept. to check Temperature Daily
hygrometer
filters & Humidity
OT, Units fitted Engineering & Maintenance Annually
By External Agency/
3 with/without HEPA Dept. to check Air particulate
Company
filters count
OT, Units fitted Engineering. & Annually
By External Agency/
4 with/without HEPA Maintenance: Air change
Company
filters rate circulation
Engineering. Annually
OT, Units fitted
&Maintenance: Air velocity By External Agency/
5 with/without HEPA
at outlet of terminal filtration Company
filters
unit
Engineering. Annually
OT, Units fitted
&Maintenance: Pressure By External Agency/
6 with/without HEPA
differential levels of OT w.r.t Company
filters
adjacent areas
Engineering. &Maintenance:
OT, Units fitted with By External Agency/
7 HEPA Filter report (DOP test Semi annually
HEPA filters Company
etc.)
Engineering. &
OT, Units fitted
Maintenance: Relevant By External Agency/
8 with/without HEPA Semi annually
preventive maintenance Company
filters
report (e.g. Pre-filters)
Laminar Air Flow & By External Agency/
9 HEPA filter check Annually
Bio-Safety Cabinets Company
Weekly for autoclave
Rapid method/ indicators, & Daily for
Biological indicators of
10 CSSD, Microbiology Conventional incubation ETO indicators and in
autoclaves, ETO etc.
at 37 C/ 56 C every load with an
implant
Source Water Microbiological surveillance
11 Conventional methods Monthly
(Municipal Supply) (culture)
Microbiological surveillance Most probable Monthly (Random
12 Drinking water
(culture) number(MPN) method Selection)

196
If required (e.g.
Microbiological surveillance Most probable
13 Tap Water suspected or confirmed
(culture) number(MPN) method
outbreak)
Culture (& AFB stain if
needed as per situation)
1) Swab from outer surfaces-
distal end, valve ports, bridge Monthly (Rotation basis
Scopes (Endoscopes, elevator to ensure that each
14 Conventional methods
Bronchoscopes etc.) 2) Suction/biopsy, water endoscope is sampled at
channel, air channel, Elevator least once yearly)
channel on duodenoscopes
3) Water bottle-liquid sample
4) Final rinse water
Microbiological Testing of
cooked food (preferably all
If required (e.g.
types), salads, homogenate Conventional culture
15 Food suspected or confirmed
feeds(daily sample to be methods
outbreak)
labeled and stored for
minimum 48 hrs)
In case of outbreaks/
sudden rise in
nosocomial infection
Surface swab sampling (bed
rates/ routine cleaning &
Isolation Rooms / and other relevant surfaces of
16 Swab rinse method disinfection methods or
ICU / Wards equipment etc. depending on
procedures are
the situation/ need)
unsatisfactory - in
consultation with the
infection control team
A) Culture--Water used for
Dialysate, Dialysate,
Culture by conventional
Bicarbonate concentrate,
17 Dialysis methods, endotoxin levels Monthly
Water used for dialyzer
by external agency
reprocessing
B) Endotoxin Testing
Nail clipping/
Nailbed swabs, nasal In case of outbreaks/
swabs & other sudden rise in
samples like stool etc. Microbiological surveillance nosocomial infection
18 Conventional methods
(as per the situation) (culture) rates - after consultation
of staff in direct with the infection control
patient care/ food team
handlers

196
* Note: Environmental report of the hospital should be tabled by the Engineering and maintenance
department in each hospital infection control committee meeting.
N.B. Sodium hypochlorite solution 1% solution is equivalent to 10000 PPM

196
SOP No. 08
Surveillance Definitions
1. Purpose: To collect and analyze the data for timely and appropriate action.
2. Scope: CLABSI/CAUTI/VAP - All ICUs (please note that PICU & NICU are not covered in this
document. Hospitals are expected to collect, analyse and discuss at hospital level)
SSI- Adult and pediatric surgeries
3. Definitions:
Surveillance involves a continuous and systematic process of collecting, analyzing, interpreting, and
disseminating descriptive information to monitor health problems.
HealthCare Associated Infection (CDC/NHSN)
 A healthcare-associated infection (HAI) is a localized or systemic condition resulting from an

adverse reaction to the presence of an infectious agent(s) or its toxin(s) that was not present on
admission to the acute care facility.
 An infection is considered an HAI if all elements of a CDC/NHSN site-specific infection
criterion were first present together on or after the 3rd calendar day of admission to the facility
(the day of hospital admission is day 1).
 HAIs may be caused by infectious agents from endogenous or exogenous sources:

- Endogenous sources are body sites, such as the skin, nose, mouth, gastrointestinal (GI) tract,
or vagina that are normally inhabited by microorganisms.
- Exogenous sources are those external to the patient, such as patient care personnel, visitors,
patient care equipment, medical devices, or the healthcare environment.

196
The following infections are not considered healthcare associated:

- Infections associated with complications or extensions of infections already present on
admission, unless a change in pathogen or symptoms strongly suggests the acquisition of a new
infection.
- Infections in infants that have been acquired transplacentally (e.g., herpes simplex,
toxoplasmosis, rubella, cytomegalovirus, or syphilis) and become evident on the day of birth
or the next day.
- Reactivation of a latent infection (e.g., herpes zoster [shingles], herpes simplex, syphilis, or
tuberculosis).
4. Definitions of Infections:
4.1 Central Line Associated Blood Stream Infections (CLABSI):
 DEFINITIONS:
Central Line: An intravascular catheter that terminates at or close to heart OR in one of the great
vessels that is used for infusion, withdrawal of blood or hemodynamic monitoring. Following
great vessels are considered for CLABSI:
- Aorta
- Pulmonary artery
- Superior vena cava
- Inferior vena cava
- Brachiocephalic veins
- Internal jugular vein
- Subclavian vein
- External iliac veins
- Common iliac veins
- Femoral veins

196
Eligible Central Line: A CL that has been in place for more than two consecutive calendar
days (on or after CL day 3), following the first access of the central line, in an inpatient location,
during the current admission. Such lines are eligible for CLABSI events and remain eligible for
CLABSI events until the day after removal from the body or patient discharge, whichever comes
first.
Eligible BSI Organism: An organism that is not an excluded pathogen for use in meeting LCBI
criteria.
Devices Not Considered CLs:
- Arterial catheters
- Arteriovenous fistula
- Arteriovenous graft
- Atrial catheters (also known as transthoracic intra-cardiac catheters, those catheters inserted
- directly into the right or left atrium via the heart wall)
- Extracorporeal membrane oxygenation (ECMO)
- Hemodialysis reliable outflow (HERO) dialysis catheter
- Intra-aortic balloon pump (IABP) devices
- Non-accessed central line (not accessed nor inserted during the hospitalization)
- Peripheral IV or Midlines
- Ventricular Assist Device (VAD)
Central Line Associated Blood Stream Infection (CLABSI):

A laboratory-confirmed bloodstream infection (LCBI) where central line (CL) was in place for
>2 consecutive calendar days on the date of event, with day of device placement being Day 1,
AND
a CL was in place on the date of event or the day before. If a CL was in place for >2 calendar
days and then removed, the date of event of the LCBI must be the day of discontinuation or the
next day.

196
As per latest (January 2018) guidelines of Centre for Disease Control National Healthcare Safety
Network (CDC-NHSN), criteria for Laboratory-Confirmed Blood Stream Infection (LCBI) are
as follows:
LCBI 1 Patient of any age has a recognized pathogen cultured from one or more blood
samples obtained by a culture or non-culture based microbiologic testing method
And
Organism cultured from blood is not related to an infection at another site.
LCBI 2 Patient of any age has at least one of the following signs or symptoms:
Fever (>38oC), chills, or hypotension
and
positive laboratory results are not related to an infection at another site
and
the same common commensal (i.e., diphtheroids [Corynebacterium spp. [not C.

diphtheriae], Bacillus spp. [not B. anthracis], Propionibacterium spp., coagulase-
negative staphylococci [including S. epidermidis], viridans group Streptococci,
Aerococcus spp., and Micrococcus spp., Rhodococcus species) is identified by a
culture or non-culture based microbiologic testing method, from two or more blood
samples drawn on separate occasions.
Criterion elements must occur within the Infection Window Period (the seven-day
time period which includes the date the positive blood culture was collected, the 3
calendar days before and the 3 calendar days after).

196
NOTE: The matching common commensals represent a single element; therefore,

the collection date of the first common commensal is the date of the element used to
determine the Date of Event (CLABSI).
Pathogens exclusions:
The term “recognized pathogen” in LCBI 1 criteria refers to any organism that is not included
on the NHSN common commensal list (see NHSN Master Organism) Exceptions:
a. Organisms belonging to the following genera are excluded as LCBI pathogens:
Campylobacter, Salmonella, Shigella, Listeria, Vibrio and Yersinia as well as C. difficile,
Enterohemorrhagic coli, and Enteropathogenic E. coli.
b. Organisms belonging to the following genera cannot be used to meet any NHSN definition:
Blastomyces, Histoplasma, Coccidioides, Paracoccidioides, Cryptococcus and
Pneumocystis. These organisms are excluded because they typically cause community-
associated infections and are rarely known to cause healthcare-associated infections.
Note: For further microbiological criteria, refer CDC-NHSN guidelines Jan 2018
4.2 Catheter Associated Urinary Tract Infection (CAUTI):

 DEFINITIONS: (As per CDC-NHSN January 2018)
Indwelling Catheter: A drainage tube that is inserted into the urinary bladder through the urethra,
is left in place, and is connected to a drainage bag (including leg bags). These devices are also
called Foley catheters. Condom or straight in-and-out catheters are not included nor are
nephrostomy tubes, ileoconduits, or suprapubic catheters unless a Foley catheter is also present
Catheter Associated Urinary Tract Infection (CAUTI): A laboratory-confirmed urinary tract
infection (UTI) as per either criteria listed below:

196
Criterion A Criterion A includes 1,2 and 3 below:

1. Patient has an indwelling urinary catheter in place for >2 calendar days,
on the date of event and was either present for any portion of the calendar
day on the date of event or removed the day before the event.
2. Patient has at least one of the following signs or symptoms:
• Fever (>38.0°C): To use fever in a patient > 65 years of age, the

indwelling urinary catheter needs to be in place > 2 calendar days on date
of event.
• Suprapubic tenderness*
• Costovertebral angle pain or tenderness*
• Urinary urgency
•Urinary frequency
• Dysuria
3. Patient has a urine culture with no more than two species of organisms,
at least one of which is a bacteria of ≥105 CFU/ml.
Symptoms (Urgency, Frequency, Dysuria) cannot be used when catheter is

in place.
Pathogen exclusions:
a. Mixed flora (> 2 species of microorganisms)
b. Candida species or yeast not otherwise specified
c. Mold
d. Dimorphic fungi
e. Parasites

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4.3 Ventilator Associated Pneumonia (VAP):
Ventilator:
Any device used to support, assist or control respiration (inclusive of the weaning period) through
the application of positive pressure to the airway when delivered via an artificial airway,
specifically an oral/nasal endotracheal or tracheostomy tube.
Note: Ventilation and lung expansion devices that deliver positive pressure to the airway (for
example: CPAP, Bipap, bi-level, IPPB and PEEP) via non-invasive means (for example: nasal
prongs, nasal mask, full face mask, total mask, etc.) are not considered ventilators unless positive
pressure is delivered via an artificial airway (oral/nasal endotracheal or tracheostomy tube).
Pneumonia (PNEU) is identified by using a combination of imaging, clinical and laboratory

criteria. The following pages detail the various criteria that may be used for meeting the
surveillance definition of healthcare-associated pneumonia, general comments applicable to all
site-specific criteria, and reporting instructions.
Ventilator Associated Pneumonia (VAP):
A pneumonia where the patient is on mechanical ventilation for >2 calendar days on the date of
event, with day of ventilator placement being Day 1,*
AND
the ventilator was in place on the date of event or the day before.
*If the ventilator was in place prior to inpatient admission, the ventilator day count begins with
the admission date to the first inpatient location.
Pathogen exclusions:
Excluded organisms that cannot be used to meet the PNEU/VAP definition are as follows:

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a. “Normal respiratory flora,” “normal oral flora,” “mixed respiratory flora,” “mixed oral flora,”
“altered oral flora” or other similar results indicating isolation of commensal flora of the oral
cavity or upper respiratory tract.
b. The following organisms unless identified from lung tissue or pleural fluid (where specimen
was obtained during thoracentesis or initial placement of chest tube and NOT from an indwelling
chest tube):
i. Any Candida species as well as a report of “yeast” that is not otherwise specified
ii. Any coagulase-negative Staphylococcus species
i. Any Enterococcus species

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Fig: Pneumonia Flow Diagram

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 How to calculate the Device days:
Total number of days of exposure to the device (central line, ventilator, or urinary catheter) by all of
the patients in the selected population during the selected time period at the same time each day. (One
or more central lines in a patient are to be taken as one)
Device days for a particular area can be calculated as follows:
No. of patients with No. of patients with No. of patients on
Date Indwelling urinary catheter Central line(s) Ventilator
1 _______________ ______________ ______________
2 _______________ ______________ ______________
3 _______________ ______________ ______________
4 _______________ ______________ ______________
5 _______________ ______________ ______________
6 _______________ ______________ ______________
7 _______________ ______________ ______________
8 _______________ ______________ ______________
9 _______________ ______________ ______________
10 _______________ ______________ ______________
11 _______________ ______________ ______________
12 _______________ ______________ ______________
13 _______________ ______________ ______________
14 _______________ ______________ ______________
15 _______________ ______________ ______________

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16 _______________ ______________ ______________
17 _______________ ______________ ______________
18 _______________ ______________ ______________
19 _______________ ______________ ______________
20 _______________ ______________ ______________
21 _______________ ______________ ______________
22 _______________ ______________ ______________
23 _______________ ______________ ______________
24 _______________ ______________ ______________
25 _______________ ______________ ______________
26 _______________ ______________ ______________
27 _______________ ______________ ______________
28 _______________ ______________ ______________
29 _______________ ______________ ______________
30 _______________ ______________ ______________
31 _______________ ______________ ______________
TOTAL _______________ ______________ ______________
4.4 Surgical Site Infection (SSI):
 DEFINITION:
I. Superficial SSI: Infection occurs within 30 days after the operative procedure & involves skin
& subcutaneous tissue of the incision; and meets the following criterion:

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CRITERIA Patient has at least one of the following:
 Infection occurs within 30 days after any operative procedure (where day 1 =
the procedure date),
AND
 involves only skin and subcutaneous tissue of the incision
AND
 patient has at least one of the following:

a. purulent drainage from the superficial incision.
b. organisms isolated from an aseptically-obtained culture from the
superficial incision or subcutaneous tissue.
c. superficial incision that is deliberately opened by a surgeon and culture or
non culture based testing is not performed
AND patient has at least one of the following signs or symptoms: pain or
tenderness; localized swelling; erythema; or heat.
d. diagnosis of a superficial incisional SSI by the surgeon
II. Deep SSI – 30 day surveillance: Infection occurs within 30 days after any operative procedure
listed in Table 1 (where day 1 = the procedure date) and involves deep soft tissues of the incision
(e.g., fascial and muscle layers).
Criteria Infection occurs within 30 days after the operative procedure (where day 1 =
the
procedure date)
AND
involves deep soft tissues of the incision (e.g., fascial and muscle layers)
AND
patient has at least one of the following:

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(a) purulent drainage from the deep incision.

(b) a deep incision that spontaneously dehisces, or is deliberately opened or
aspirated by a surgeon and is culture positive or not cultured AND patient has at
least one of the following signs or symptoms: fever (>38°C); localized pain or
tenderness. A culture negative finding does not meet this criterion.
(c) an abscess or other evidence of infection involving the deep incision that is
detected on gross anatomical or histopathologic exam, or imaging test.
TABLE 1:
LIST OF OPERATIVE PROCEDURES FOR 30 DAY SURVEILLANCE

Abdominal aortic aneurysm repair Laminectomy
Limb amputation Liver transplant
Appendix surgery Neck surgery
Shunt for dialysis Kidney surgery
Bile duct, liver or pancreatic surgery Ovarian surgery
Carotid endarterectomy Prostate surgery
Gallbladder surgery Rectal surgery
Colon surgery Small bowel surgery
Cesarean section Spleen surgery
Gastric surgery Thoracic surgery
Heart transplant Thyroid and/or parathyroid surgery
Abdominal hysterectomy Vaginal hysterectomy
Kidney transplant Exploratory Laparotomy

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III. Deep SSI – 90 day surveillance: Infection occurs within 90 days after any operative procedure
listed in Table 2 (where day 1 = the procedure date) and involves deep soft tissues of the incision
(e.g., fascial and muscle layers).
Criteria Infection occurs within 90 days after the operative procedure (where day 1 =
the procedure date)
AND
involves deep soft tissues of the incision (e.g., fascial and muscle layers)
AND
(a) purulent drainage from the deep incision.
(b) a deep incision that spontaneously dehisces, or is deliberately opened or

aspirated by a surgeon and is culture positive or not cultured AND patient has at
least one of the following signs or symptoms: fever (>38°C); localized pain or
tenderness. A culture negative finding does not meet this criterion.
(c) an abscess or other evidence of infection involving the deep incision that is
detected
on gross anatomical or histopathologic exam, or imaging test.
TABLE 2:
LIST OF OPERATIVE PROCEDURES FOR 90 DAY SURVEILLANCE
Breast surgery
Cardiac surgery

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Coronary artery bypass graft with both chest and donor site incisions
Coronary artery bypass graft with chest incision only
Craniotomy
Spinal fusion
Open reduction of fracture
Hernioplasty
Hip prosthesis
Knee prosthesis
Pacemaker surgery
Peripheral vascular bypass surgery
Ventricular shunt
TABLE 3:
Code Site Code Site

BONE Osteomyelitis LUNG Other infections of the lower
respiratory tract
BRST Breast abscess or mastitis MED Mediastinitis
CARD Myocarditis or pericarditis MEN Meningitis or ventriculitis
DISC Disc space ORAL Oral cavity (mouth, tongue, or
gums)
EAR Ear, mastoid OREP Other infections of the male or
female reproductive tract
EMET Endometritis PJI Periprosthetic Joint Infection
ENDO Endocarditis SA Spinal abscess without meningitis

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SINU Sinusitis UR Upper respiratory tract

GIT GI tract USI Urinary System Infection
IAB Intra-abdominal, not specified VASC Arterial or venous infection
IC Intracranial, brain abscess or dura VCUF Vaginal cuff
JNT Joint or bursa
IV. Organ/Space SSI:
Criteria Infection occurs within 30-90 days after the operative procedure (where day 1 =
the procedure date)
AND
infection involves any part of the body deeper than the fascial/muscle layers, that
is opened or manipulated during the operative procedure
AND
(a) purulent drainage from a drain that is placed into the organ/space (e.g., closed
suction drainage system, open drain, T-tube drain, CT guided drainage)
(b) organisms isolated from an aseptically-obtained culture of fluid or tissue in

the organ/space by a culture or nonculture based method
(c) an abscess or other evidence of infection involving the organ/space that is

detected on gross anatomical or histopathologic exam, or imaging test
AND
meets at least one criterion for a specific organ/space infection site listed in Table
3.

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5. Monitoring of device associated infections: (Event forms: Annexure 10-12)
5.1 DEVICE ASSOCIATED INFECTION RATES: These are calculated monthly and expressed
per 1000 device-days.
Number of ventilator-associated pneumonias

 VAP = X 1000
Number of ventilator-days
Number of central line-associated BSIs
 CLABSI = X 1000
Number of central line-days
Number of urinary foley catheter-associated UTIs

 CAUTI = X 1000
Number of urinary catheter-days
5.2 DEVICE UTILIZATION RATIOS: It is advisable to calculate the utilization ratio of devices.
Number of ventilator days

 Ventilator Utilization Ratio = Number of patient days
Number of central line days

 Central line Utilization Ratio = Number of patient days
Number of foley's catheter days

 Urinary Catheter Utilization Ratio = Number of patient days
5.3 SURGICAL SITE INFECTION RATE:

It is calculated monthly and expressed per 100 procedures performed.
Number of superficial surgical site infections

 Superficial incision SSI = X 100
Number of surgeries performed

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Number of infections (deep SSI)

 Deep SSI (30 day surveillance) = Number of surgeries (as per table 1) X 100
Number of infections (deep SSI)

 Deep SSI (90 day surveillance)= No. of surgeries in month of initial surgery (as per table 2) X 100

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SOP No. 09
Vaccination Policy
1. Overview:
To ensure safety of all patient care givers in the Company, Vaccination policy provides an
understanding of process for vaccination administration to various employees. Strict compliance to the
same shall ensure good safety practice and enable superior patient care.
2. Objective:
The objective of this document is to define vaccination requirement for our employees/empaneled
consultants/retainers and contractual staff.
3. Eligibility:
This policy document is applicable to all employees/empaneled consultants/Retainers/contractual staff
of Fortis Healthcare Ltd. and its hospitals/ Regions / Offices in India including the corporate office.
4. General policy:
4.1 All new joiners to undergo an assessment to determine their vaccination and screening
requirement(s)
4.2 The assessment will be carried out as part of joining formalities by HR in conjunction with Infection
Control and Medical Administration.
4.3 All empaneled consultants, retainers, employees and contractual staff are considered hospital staff
for vaccination and screening purposes.
5. Guidelines:
Risk Categorization - The following categorization of risk is offered as a guide to determine the risk
status of patient care providers. The categorization is detailed below:
 Category A — Direct contact with blood or body substances

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This category includes all persons who have physical contact with or potential exposure to blood or
body substances. Examples include dentists, medical practitioners, nurses, allied health practitioners,
health care students, health care assistants, emergency personnel (fire, ambulance and volunteer first
aid workers), Nuclear Medicine Technicians, Radiology Technicians, Blood Bank Staff, Lab
Technicians, OT Technicians, Perfusionists, Biomedical Engineers, CSSD Staff, Cath Lab
Technicians, maintenance engineers who service health equipment, mortuary technicians, Sample
carriers, central sterile supply staff, and cleaning staff responsible for decontamination and disposal of
soiled/contaminated materials. Fortis Healthcare Ltd Vaccination Policy
 Category B — Indirect contact with blood or body substances
This category includes workers in patient areas who rarely have direct contact with blood or body
substances. These employees may be exposed to infections spread by droplets, such as measles, rubella
and influenza, but are unlikely to be at risk from blood-borne diseases. Examples include catering staff
and ward clerks.
 Category C — Laboratory staff
Laboratories pose special risks because of the equipment used (centrifuges), and the possibility of
exposure to high concentrations of micro-organisms generated by culture procedures. An additional
risk to laboratory staff occurs in the handling of human blood and tissues.
 Category D — Minimal patient contact
Other occupational groups employed, such as gardening and clerical staff, and volunteers, that have
no patient contact have no greater exposure to infectious diseases than do the general public.
6. Hepatitis B vaccine program:
A. HBV Vaccine offered/Potential exposure

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I. All employees whose jobs involve tasks with potential exposure to blood borne pathogens shall
be offered the HBV vaccination (Category A and C).
II. Any person, who, at the time of recruitment claims to be fully vaccinated against HBV, shall be
required to submit the proof regarding the same. If the employee does not have documentary
proof, s/he shall get anti HBs titers done and submit report of the same as proof at the time of
recruitment. Report of titers done anytime earlier is also acceptable. A written
declaration/undertaking shall be obtained by the employees not being vaccinated by the hospital
(Annexure 2).
III. The first dose of Hep B vaccine shall be administered preferably on the day of joining or
maximum within 7 days of joining.
IV. Based on the categorization of the employee HR fixes a day for vaccination in conjunction with
infection control as part of joining formalities.
V. Details of vaccination are to be sent to HR for filing in the personal file of staff.
VI. Contractual Staff: all contract workers falling in risk categories A and C shall be vaccinated
against HBV as mentioned in point II above. A list of all such workers working anywhere in the
hospital at a given time shall be available with the HR department.
VII. Administration of vaccination to contractual employees will be as per the contractual agreement
with the contractor.
B. HBV Awareness to employees
I. Information on the risk of occupational Hepatitis B, as well as other blood borne pathogens, will
be provided to all employees at risk.

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C. Post-vaccination screening
I. Post-vaccination screening (anti-HBs levels for assessing seroconversion at 1-2 months after last
dose) is required for all healthcare workers with direct patient contact including but not restricted
to all doctors, nurses, OT staff, Lab staff, Blood Bank staff and Dialysis staff.
II. If the test is negative (i.e. < 10 IU/mL), repeat the 3 dose series and follow with anti-HBs
screening 1-2 months after the last dose.
III. If repeat screening is negative, person should be tested for HBsAg to determine their HBV
infection status.
7. Chicken pox vaccination

Chicken pox vaccination is not offered as part of joining protocol.
HR Department shall incorporate in the personal medical data, the history of Chicken pox disease or
vaccination, which will be part of pre joining medical examination.
8. Tetanus immunization
All healthcare workers and others who are involved in handling of biomedical waste need to be
immunized for Tetanus.
9. COVID vaccination
It is recommended that HCWs receive COVID vaccination as per Government of India COVID-19
Vaccination Policy.
10. Vaccination for BMT Staff
Varicella and Influenza vaccines to be provided in addition to Hepatitis B, Tetanus and COVID
vaccine.

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9. Screening of food handlers (Staff involved in handling cooked/raw food)

9.1 All staff, to be recruited directly or on contract basis, as food handler in the F& B department shall
be screened for ova/ cyst and carriage of pathogenic bacteria in their stool samples, and allowed to join
if the result is negative. Screening may be done in the hospital lab or a report from a list of labs
approved by the hospital (unit to include this list as Annexure) should be provided.
9.2 In case of positive test results, the tests are to be repeated after the person undergoes appropriate
therapy at his/her own cost and the subsequent test result is negative.
9.3 Typhoid vaccine and Hepatitis A vaccine are not offered by the hospital to the food handlers.
9.4 Appropriate report stating the above has been provided by the contractor and submitted to HR
before the contract worker is engaged.
9.5 Frequency of vaccination - Typhoid every two years and Hepatitis A every ten years.
10. Maintenance of vaccination record

10.1 The HR Department shall keep a copy of all records related to vaccination, serology and screening
in the personal files of staff. The Infection Control Nurse will have an oversight on the vaccination
status of the employees. Fortis Healthcare Ltd Vaccination Policy.
11. Vaccination schedule completion

11.1 List of persons eligible for second or third dose of Hepatitis B vaccination shall be generated by
HR department on a weekly basis.
11.2 List will be sent to the Infection Control Nurse, Chief of Nursing, Head Admin and Medical
Superintendent.
11.3 Information will be sent to all persons on the list by email.
11.4 In case of staff not reporting for their vaccination dose within 7 days of the due date, a reminder
email shall be sent by HR Department with copy to supervisor and chief of that function.

FORTIS HEALTHCARE LIMITED Page100o
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12. Emergency vaccination

Employees may need extra vaccination at the time of joining or within the course of their work due to
unexpected circumstances like influenza outbreaks etc. In such cases, recommendation made by the
Hospital Infection Control Committee/Officer shall be considered and appropriate steps taken.
13. The Vaccination Matrix:

Employees Timelines Responsibility Administration of Custodian
Vaccination
Hep B Assessment at HR to send new Infection HR – To file report of
Vaccination the time of joiners to Control/Preventive administration in the
Nurses / Joining Infection control Health personal file.
Technicians / Administration Infection Control Check/OPD or Copy with Infection
Paramedical / of Vaccine / Injection Room Nurse Control
Doctors (A within 7 days of Medical (Also see page 3 - Hep
and C Joining Administration B vaccination program
category) a ii)
Hep B Not to join HR and HR and Department
Vaccination without being Respective A) Administered by Heads to maintain all
Contractual vaccinated OR Department unit (as above) and relevant documents
Employees Administration Heads cost debited to regarding vaccination of
(GDAs of Vaccine contractor contractual staff.
/ Nurse Aids / within 7 days of B) Contractor Copy with Infection
Nursing Joining produces documentary Control
GDAs/ evidence of complete
Housekeeping vaccination (3 doses)
) A and C C) Contractor
category produces anti-HBS
titre reports done
within last 6 months.
Hep B Not to join HR and A) Produces document HR and Department

Vaccination without being Respective of complete Heads to maintain all
Trainees / vaccinated OR Department vaccination relevant documents
Interns in A Administration Heads (or Anti HBS titer regarding vaccination
and C category of Vaccine report within last 6 trainees/interns.
within 7 days of months) and signs a Copy with Infection
Joining self-declaration Control
B) Administered by
unit at the cost of
employee

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14. ANNEXURE – List of Laboratories approved for screening tests done for food handlers (to
be developed and maintained by individual unit)

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SOP No. 10
Policy on Infection Prevention Practices in Transplant Patients
Aim
The patients undergoing transplant might be at an additional risk to acquire infections because of the
immunocompromised status. Additionally, they can also acquire health care associated infections and
hence require additional precautions. This policy aims to protect the transplant recipients, donors and
the staff attending them.
Scope
 Transplant evaluation for appropriate patients

 Transplant unit
Risk of infections in transplant recipients
A) Infections in peri-operative period:
a. Various Hospital Acquired Infections like central line infections, catheter related infections,
ventilator related infections, surgical site infections etc.
b. Bacterial pathogens spreading by contact (MRSA, VRE, Gram negative MDROs, clostridium
difficile etc.)
B) Infections later on due to immunosuppression
a. Viral infection (example- Herpes, CMV, EBV, influenza, varicella)

b. Bacterial infections- like streptococcus pneumoniae
c. Fungal infections- aspergillus, mucormycosis and other molds, cryptococcus
d. Reactivation of previous infections (Herpes, HIV, HBV, HCV, TB, varicella, toxoplasmosis)
e. Specific travel associated infections (eg. - parasitic infections)

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Pre-transplant evaluation
1. Tests required in all transplant recipient candidates before clearance for undergoing
transplant:
i. HIV antibody, HBsAg, anti HCV antibody- all to be done at least within last 3 months of
evaluation
ii. Anti HbS Antibody Titre
iii. Anti HBcore Total Antibody
iv. Anti HAV IgG (for liver transplant)
v. Varicella IgG (can be omitted if history of chickenpox)
vi. CMV IgG
vii. Toxoplasma IgG (for cardiac transplant)
viii. TPHA/ VDRL
ix. Interferon gamma release assay (IGRA) i.e. Quantiferon TB gold
x. Chest X- ray PA view
2.Tests to be done on transplant donor:
i. HIV antibody, HBsAg, anti HCV antibody- all to be done at least within last 3 months of
evaluation
ii. Anti HBcore total antibody (for liver transplant)
iii. Varicella IgG (can be omitted if h/o chickenpox or if varicella IgG positive for recipient)
iv. CMV IgG
v. Toxoplasma IgG (for cardiac transplant)
vi. TPHA/ VDRL
3.Vaccination in transplant candidates:
i. All the patients planned for solid organ transplant should be vaccinated with influenza,
pneumococcal (both PCV- 13 and PPSV-23), DaPT vaccines.
ii. Also, vaccination against other vaccine preventable infections (eg. HBV, HAV, varicella) can
be done if there is no evidence of immunity.
iii. Deworming of all candidates with Tab. IVERMECTIN 12 mg once daily for 2 days should be
done.

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Post-transplant care
1.Responsibility:
Nursing: Monitoring of compliance to all precautions
Engineering: To ensure engineering controls as described in the policy below
Infection Control Team: Scheduled supervision of all processes
2.Policy to be followed by staff while attending transplant recipients:
1. Only well trained staff would be posted in transplant units

2. Adherence to standard precautions would be followed at all times (hand hygiene and
appropriate use of PPE).
3. The personal protective equipment (PPE-) would be kept outside the patients room, all staff
entering the room would perform hand hygiene , wear the appropriate PPE ( clean scrubs, in
case of handling of patient- gloves , scrubs, mask and cap and if anticipated splash, then mask
and face shield) and after exiting the room would discard the PPE inside the patients room
only.
4. Adherence to standard hospital protocols regarding equipment cleaning and disinfection would
be followed.
5. Hepatitis B vaccination for all susceptible transplant patients and staff will be provided.
6. Patient skin care, oral and dental care would be as per defined protocols-
i. Use chlorhexidine gluconate (0.2%) for oral rinse once in every shift
ii. For dental care brushing to be done twice daily
iii. Sponging with chlorhexidine wipes to be done once daily
iv. All transplant patients need to have preoperative at least 1 bath with octenidine or
chlorhexidine 4% for staphylococcus aureus decolonization
7. The existing care bundles for prevention of device related infections would be followed.
8. The staff having upper respiratory infections, or any other known contagious infections would
refrain from duty
9. There would be a regular, documented education program for all staff on patient care.
10. I/V lines will be managed as per hospital defined protocol.

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3.Environment
i. The room would be a positive pressure with a PD of >=2.5 PA, well sealed with smooth
ceilings free of fissures , open joints or crevices
ii. If any leakage is detected immediately source would be located and repaired
iii. There would be self closing doors on all room exits
iv. In addition, all Haematopoietic stem cell transplant (HSCT) patients would be kept in a
room with >= 12 air changes per hour.
v. No carpenting is allowed
vi. No real flowers are allowed to be kept in /around the patient care areas.
vii. Any construction/ renovation would be avoided, if at all it is unavoidable, construction site
would be completely sealed, workers will wear plastic shoes while going inside the site ,
wet mopping twice a day of all surfaces in patient care areas would be done , negative
pressure would be created at construction site, fumigation would be done post construction
of the patient care areas and environmental cultures would be taken cultures during and
post construction, IC team would ensure that the ICRA forms are filled regularly as per
protocol during the construction.
viii. Overcrowding in transplant unit will be avoided.
4. Food and drink
i. Hospital food is normally very safe. Immunocompromised individuals are advised to avoid
certain high-risk foods, for example soft cheeses and foods made with raw egg, such as
mayonnaise
ii. All drinking water for immunocompromised patients should be bottled drinking water.
4.Patient movement
Patient movement would be restricted and done only if required
Any patient if severely immunocompromised would be provided with a respirator (example N 95) if
being moved out of the room.

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5.Surface cleaning
1. Daily wet dusting of all surfaces would be done with a hospital approved disinfectant in each
shift and necessary logs be maintained
2. Avoid dusting methods which disperse dust. Prohibit exposures of patients to such activities
as vacuuming or other floor or carpet vacuuming that could cause aerosolization of fungal
spores (e.g. Aspergillus species)
3. Exhaust vents, window sills and all horizontal surfaces should be cleaned with cloths and
mop heads that have been premoistened with disinfectant
6.Visitors
Visitors would be restricted as far as possible. Visitors with communicable disease – upper respiratory
infections, varicella, history of taking OPV within 3-6 weeks prior etc. will not be allowed to visit.
All visitors would be taught on the usage of hand hygiene /PPE and the compliance ensured by the
nursing staff. All the close contacts of the transplant patient (family members or any frequent visitors)
need influenza vaccine. Other vaccines are not required.
Note: standard precautions would be taken while attending to transplant donors and deceased donors.

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SOP No. 11
Policy on Solid Organ Transplant
There are no published guidelines of isolation precautions for solid organ transplant.
The current SOP is based on the best practices in some of the solid organ transplant centers.
Following guidelines needs to be followed after the surgery till the patient is discharged.
General guidelines:
a) Any staff/visitors with infection which has potential spread should not enter the room.
b) Outside footwear is not allowed. (To avoid the contamination of patient surrounding)
c) Before entering the ICU, everyone must disinfect their hands with an alcohol-based hand rub.
d) Before entering patient cubicle and examination, the staff should wear a surgical mask, cap,
shoes, sterile gown and gloves
e) Use patient designated/ disposable articles e.g. Stethoscope, B.P. Apparatus, and glucometer in
the patient’s room.
f) Critical & Non-critical equipment (e.g. Ventilator, monitors, IV stand) must be disinfected
before use and as far as possible it should not be shared with any other departments. Thorough
disinfection of equipment to be used on transplant patients must be mandatory.
g) Restrict entry of staff (Doctor, nurse, other paramedical staff), visitors to a maximum of 5. The
exact number can be decided at unit level.
Reference: Standard of Care: Cardiac Transplant; 2009 The Brigham and Women's Hospital, Inc.,
Department of Rehabilitation Services.
Patient placement:
No published reports support the benefit of placing solid organ transplants or other
immunocompromised patients in a Protective Environment.
Patient can be placed in single room.

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Use of PPE:
As per the CDC guidelines standard precautions are enough.
In view of patient’s immunosuppressed status and different invasive interventions PPEs like Gown,
gloves, cap and mask are recommended before touching the patient or patient surroundings.
CLEANING & DISINFECTION
a) The floors are cleaned with Hospital approved Disinfectant once in a day and as and when
required in every patient cubicle, window panes and walls are cleaned once in a week or as
part of terminal cleaning whichever is earlier. Ceilings are cleaned as part of terminal cleaning.
The disinfectant is changed after each cubicle and as and when required.
b) Curtains in all patient care areas are changed every week and after patient discharge whichever
is earlier.
c) It is to be ensured that a dry mop is used for a new cleaning session. Mop should be changed
if it is visibly soiled or worn out. It is desirable to have dedicated mops for transplant units.
d) Sterile bed linen/ bedsheets/ blanket/ patient uniform/ towel to be availed from CSSD and
should be changed every day and as and when required.
CLABSI Bundle:
CLABSI Bundle to be followed as part of monitoring adherence to protocol as follows:
a) Surgical handwash performed before inserting catheter
b) Maximum barrier precautions taken (sterile gloves, gowns, cap, mask)
c) Sterile drape (covering full body) used
d) Prior to insertion, alcohol chlorhexidine solution used to disinfect skin
e) Two operators for insertion

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f) One operator for hub care
g) Two operators for dressing
i. Daily review of line necessity undertaken and documented (look for frequency of
line change as per protocol)
ii. Entry site covered with transparent dressing and checked daily for
leakage/inflammation
iii. Ports accessed using a clean technique (70% alcohol swabs for 30 secs followed by
drying)
iv. Hand hygiene performed before touching the line
g) Use pre-filled syringes for flushing the peripheral and central lines.
Reference: CDC Guidelines on CLABSI, 2011.
CAUTI Bundle:
CAUTI Bundle to be followed as part of monitoring adherence to protocol as follows:
a) Justification for UC insertion documented

b) Strict asepsis during insertion
c) Daily assessment of need for maintaining UC documented in clinical notes
d) Close system to be maintained
e) Collecting bag kept below level of bladder (not on floor)
f) No kinks in catheter and collecting tube
g) Securing device used to prevent movement of catheter
h) Meatal cleaning (with luke warm water) done in present shift (ask patient if possible)
i) Urinary bag is less than 2/3rd full.
j) Assigned nurse is aware of method of collecting small volume specimen.
Reference: CDC Guidelines for CAUTI, 2009.

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VAP Bundle:
VAP Bundle to be followed as part of monitoring adherence to protocol as follows:
a) Patient intubation and ventilation justified by clinical care team

b) Standard aseptic precautions followed
c) Endotracheal tube with dorsal lumen above ET cuff used (ventilation >24hrs)
d) Daily Weaning plan
e) Sedation free period of 2 hours given to assess readiness to wean or extubate
f) Patient is in semi-recumbent position of 30-45 degrees (unless contraindicated) (24 hrs)
g) Cuff pressure maintained between 20-25 cms H2O
h) DVT prevention measures (pharma &/or mechanical) and ulcer prevention measures
(Sucralfate, H2 blockers) undertaken
i) Blood sugar maintained between 140-180 mg%
j) Sterile fluid used for nebulization
k) Mouth care with Chlorhexidine (per shift)
l) Orotracheal suction performed before deflating ET cuff.
Reference: SHEA Guidelines, 2008.
Hand Hygiene:
Indications for Hand washing / Hand hygiene -
a. Indications for hand washing with non-antimicrobial soap and water (Routine hand wash):
When hands are visibly dirty or contaminated with proteinaceous material or visibly soiled
with blood & body fluids.
b. Before eating and after using a restroom

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c. If exposure to potential spore-forming pathogens is strongly suspected or proven, including

outbreaks of Clostridium difficile, hand washing with soap and water is the preferred means.
Indications for hand washing with antimicrobial soap and water -
Prior to putting on sterile gloves for insertion of a central venous catheter, urinary catheter, peripheral
vascular catheter or any other non-surgical invasive procedure done in wards, ICU, OR.

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SOP No. 12
Infection prevention and control guidelines in Hematopoietic Cell Transplant (HCT)

Recipients
Based on Recommendations of the Center for International Blood and Marrow Transplant Research
(CIBMTR®), the National Marrow Donor Program (NMDP), the European Blood and Marrow
Transplant Group (EBMT), the American Society of Blood and Marrow Transplantation (ASBMT),
the Canadian Blood and Marrow Transplant Group (CBMTG), the Infectious Disease Society of
America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), the Association of
Medical Microbiology and Infectious Diseases, Canada (AMMI), and the Centers for Disease Control
and Prevention (CDC):2009
Background
HCT is defined as any transplantation of blood or marrow-derived hematopoietic stem cells, regardless
of transplant type (i.e., allogeneic or autologous) or cell source (i.e., bone marrow, peripheral blood,
or umbilical cord blood).
The definition of immune competence following transplant is defined by the ability of the HCT
recipient to receive live vaccine following recovery from transplant. Conventionally, this is thought to
occur at approximately 24 months following HCT in patients who are not receiving
immunosuppressive therapy and do not have active graft-versus-host disease (GVHD).
For patients with on-going GVHD or continued use of immunosuppressive therapy, it is recommended
to consider the patient as immune deficient and still at risk for significant infectious complications.
These guidelines address the need of stringent infection prevention and control strategies both in adult
and pediatric transplant recipients.

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Components of infection prevention and control strategies
A. Ventilation settings of BMT room
HCT recipients should be placed in Protective Environment rooms that incorporate the following
features:
a. ≥12 air exchanges/hour

b. Central or point-of-use HEPA filters with 99.97% efficiency for removing particles ≥0.3 μm in
diameter. This is particularly critical in HCT centers with ongoing construction and renovation.
c. Filters should be replaced regularly based on manufacturers’ recommendations, and, when
there is ongoing construction, filtration efficiency should be monitored frequently to best
determine appropriate time for replacement.
d. Directed airflow so that air intake occurs at one side of the room and air exhaust occurs at the
opposite side.
e. Consistent positive air pressure differential between the patient’s room and the hallway ≥ 2.5
Pa.
f. Well-sealed rooms (e.g., filling the gaps between walls and windows, outlets, floor, and ceiling)
should always be used for HCT patients to prevent infiltration of air from outside the room that
could allow entry of spores and hinder maintenance of proper pressure differential.
g. Continuous pressure monitoring, especially while rooms are occupied.
h. Consideration should be given to using monitoring systems that alarm when the pressure
differential between any Protective Environment room and adjacent hallway or anteroom falls
to less than 2.5 Pa, to alert staff to possible engineering failures.
i. Self-closing doors to maintain constant pressure differentials. To enable the nursing staff to
observe the HCT recipient even when the doors are closed, windows can be installed in either
the door or the wall of the HCT recipient’s room.
When a shortage of Protective Environment rooms to accommodate all HCT patients exists, the
allocation of these rooms should be prioritized for those at highest risk of invasive mold infection (e.g.,
expected prolonged neutropenia, receiving treatment for GVHD).
Portable, industrial-grade HEPA filters may be used in non–Protective Environment rooms to

accommodate other vulnerable patients. These should be placed centrally in-patient rooms so that
space is available around all surfaces to allow free air circulation.

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Laminar air flow (LAF) room
LAF room contains HEPA-filtered air that moves in parallel, unidirectional flow (the air enters the
room from one wall and exits the room on the opposite wall). Some studies have shown that LAF may
protect patients from infection during Aspergillosis outbreaks related to hospital construction.
HCT center maintenance personnel should prevent birds from nesting near hospital air-intake ducts.
HCT centers should have provisions for backup emergency power and redundant air-handling and
pressurization systems to maintain a constant number of air exchanges and room pressurization when
the central ventilation system is shut off for maintenance and repair.
Additionally, an Infection Control Risk Assessment (ICRA) should be created by infection control
personnel and maintenance personnel to develop protocols to protect HCT patients at all times from
bursts of mold spores that might occur when air-handling systems are restarted after routine
maintenance shut-downs. Because of this risk, air-handling systems should never be shut off in HCT
units for energy conservation purposes.
Anterooms for HCT center rooms though ideal scenario but optional, except in the case of HCT
recipients requiring airborne precautions for certain infections. If a Protective Environment airborne
infection isolation room with an anteroom is not available, the patient should be placed in a standard
airborne infection isolation room and a portable, industrial-grade HEPA filter used to enhance removal
of spores in the room.
B. Construction, Renovation, and Building Cleaning
Construction and Renovation
Hospital construction and renovation may result in an increased risk for healthcare-associated invasive
mold infection, particularly aspergillosis, among HCT recipients.
When construction or renovation is undertaken, plans should include intensified mold-control

measures. An ICRA should be planned prior to construction. Construction and renovation infection
control planning committees should include engineers, architects, housekeeping staff, infection control
personnel, the director of the HCT center, the administration and construction project managers.
During outdoor construction and demolition, the intake air should be sealed, if possible; if not, filters
should be checked frequently to verify that they are well-seated and replaced when necessary.

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False ceilings should be avoided whenever possible. If use of false ceilings cannot be avoided, the area
above false ceilings should be vacuumed routinely to minimize dust and fungal exposure to patients.
Measures to minimize the impact of construction on HCT recipients
a. Construct rigid, dust-proof barriers with airtight seals between patient care and construction or
renovation areas to prevent dust from entering patient care areas. These barriers should be
impermeable to Aspergillus spores.
b. Construction and renovation areas should have negative air pressure relative HCT patient care
areas to ensure that air flows from patient care areas toward construction areas.
c. If impervious barriers cannot be created around the construction area, patients should be moved
from the area until renovation is complete and the area has been cleaned appropriately.
d. Direct pedestrian traffic occurring near construction or renovation areas away from patient care
areas, to limit the opening and closing of doors or other barriers that might cause dust
dispersion, entry of contaminated air, or tracking of dust into patient areas.
e. Tacky floor mats should be placed at the threshold of construction areas in order to minimize
tracking of dust. Visible dust and debris tracked out of the construction zone should be vacuum
cleaned.
f. Construction workers, whose clothing might be contaminated with mold spores, should use the
construction elevator and avoid contact with patients, patient care areas, other elevators, and
non-construction areas.
g. A portable, industrial-grade HEPA filter should be used between a construction zone and the
HCT unit if a large area is under construction and negative pressure differential cannot be
guaranteed.
h. Monitoring of Air Handling Unit (AHU) air quality during construction may include daily
particle counts, environmental air sampling, and more frequent measurements of ventilation
pressure differentials.
Also, HCT center staff should avoid transporting equipment and supplies used by HCT recipients
through construction or renovation areas.
Newly constructed or renovated areas should be cleaned and disinfected before patients are allowed to
enter them.
Areas above dropped ceilings in rooms located under or adjacent to construction areas should be
vacuumed. Additionally, the ventilation, direction of airflow, and room pressurization should be tested
and correctly adjusted before patients are allowed to enter.

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Cleaning
a. HCT centers should be cleaned at least daily with special attention to dust control. Wet-dusting
should be performed; dusting techniques that aerosolize dust should be avoided.
b. Exhaust vents, window sills, and all horizontal surfaces should be cleaned with cloths and mop
heads that have been premoistened with an approved hospital disinfectant.
c. Thorough cleaning during and after any construction activity, including minor renovation
projects, is critical.
Floor surfaces and finishes should be smooth, nonporous, and for scrubbing to minimize dust levels.
Carpeting should not be installed in HCT center hallways outside of patient rooms or inside the rooms.
HCT recipients should not be exposed to vacuuming that could cause aerosolization of fungal spores.
All vacuum cleaners used in the HCT center should be fitted with HEPA filters.
Water leaks should be cleaned up and repaired as soon as possible but within 72 hours to prevent mold
proliferation in floor and wall coverings.
If cleanup and repair are delayed ≥72 hours after the water leak, the involved materials should be
assumed to contain fungi and handled accordingly (discarded preferably).
Design and selection of furnishings should focus on creating and maintaining a dust-free environment.
Upholstery should be smooth, nonporous, and easily disinfected to minimize contamination with
potential nosocomial pathogens.
Finishes (i.e., wall coverings, window shades, and countertops) used in HCT centers should also be
scrubbable, nonporous, and amenable to easy disinfection to minimize dust accumulation.
C. Isolation and Barrier Precautions
HCT recipients should be placed in single-patient rooms, if possible.
If the availability of single-patient rooms is limited, their use should be prioritized for the most severely
immunosuppressed patients (e.g. HCT recipients during their initial transplant admission, particularly

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allogeneic HCT recipients, or patients who are receiving immunosuppressive therapy for GVHD
during readmissions).
Allogeneic HCT recipients are more likely to benefit from protective isolation measures. The efficacy
of protective isolation measures for autologous HCT recipients is not well established.
Individual circumstances should guide the prioritization of protective environment rooms in settings
where the number of these rooms is limited (e.g. some patients who receive tandem autologous HCT
may be more immunosuppressed than those who receive non-myeloablative allogeneic HCT).
At a minimum, standard precautions, including hand hygiene and wearing of appropriate personal
protective equipment, should be followed for all patient contacts.
Centers may use additional protective precautions (use of mask, either during respiratory season or
year-round) in an attempt to further reduce the risk of transmission of respiratory viruses from health
care workers and visitors to patients. However, there are insufficient data to provide recommendations
regarding the use of additional protective precautions.
When indicated on the basis of co-existing conditions, HCT recipients should also be placed on
airborne, droplet, or contact precautions in addition to standard precautions. Adherence to isolation
precautions is critical in preventing transmission of infectious agents among HCT recipients, HCWs,
and visitors.
HCT recipients with illnesses due to respiratory or gastrointestinal viruses can have prolonged or
episodic excretion of organisms (e.g., RSV, adenovirus, rotavirus). Guidance regarding the duration of
isolation precautions for specific pathogens is provided in the following section.
Surveillance and monitoring of infections
Monitoring for clinical cases of aspergillosis and other invasive mold infections should be performed,
with enhanced surveillance of microbiological, pathological, and radiological data to identify trends
suggesting an environmental mold source.
Routine microbiological air sampling for fungal spores in HCT units is not recommended, however,
during a suspected outbreak, there may be a role for microbiological air sampling in patient care areas.
If microbiological air sampling is performed as part of an outbreak investigation, sample volumes of
at least 1000 L may achieve a higher degree of sensitivity than smaller samples.

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Whenever possible, HCT recipients, especially allogenic HCT recipients, should avoid construction or
renovation areas. HCT recipients may benefit from wearing N95 respirators while outside of HEPA
filtered areas, especially during periods of healthcare facility construction and renovation. Standard
surgical masks provide negligible protection against mold spores.
D. Equipment
Equipment and devices should be cleaned, disinfected or sterilized, and maintained as per
recommendations.
Opened and unopened wound-dressing supplies (e.g., adhesive bandages, surgical and elastic adhesive
tape should be examined for factors that could result in mold contamination and possible subsequent
cutaneous transmission to patients. This should consist of discarding all bandages and wound dressings
that are out of date, have damaged packaging, or are visually contaminated by construction debris or
moisture.
When arm boards are used to provide support for intravenous lines, only sterile dressing materials
should be used, and arm boards should be changed daily.
Additionally, non-sterile tongue depressors inserted into a piece of foam tubing should not be used as
splints for intravenous and arterial catheter sites because these have been associated with an outbreak
of fatal invasive nosocomial Rhizopus infection among preterm, very-low-birthweight infants.
Infection control guidelines in terms of usage of general items
Plants and flowers:
Plants and dried or fresh flowers should not be allowed in hospital rooms during conditioning or after
HCT (phases I–III of immune system recovery) because Aspergillus species have been isolated from
the soil of potted ornamental plants (e.g., cacti), the surface of dried flower arrangements, and fresh
flowers.
High counts of gram-negative bacteria have been found in vase water of cut flowers, with
Pseudomonas species most frequently isolated.

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In order to minimize the risk of mold infection, HCT recipients and candidates should avoid contact
with soil-based materials.
Toys:
Toys are commonly colonized with bacteria and viruses associated with respiratory and gastrointestinal
illnesses. Water-retaining bath toys should not be used by immunocompromised HCT recipients and
candidates as they have been associated with an outbreak of Pseudomonas aeruginosa.
Published recommendations for washing and disinfecting toys should be followed.
Cloth toys should be washed in a hot cycle of a washing machine at least once weekly and more often
as needed (contact precautions). Alternatively, machine washing in a cold cycle is acceptable if laundry
chemicals for cold water washing are used.
Hard plastic toys should be scrubbed with warm soapy water using a brush to clean crevices, rinsed in
clean water, immersed in a 1% sodium hypochlorite which should be made fresh daily for 10–20
minutes, rinsed again, and allowed to air dry. Alternatively, they can be washed in hot cycle of a
washing machine.
Infants, toddlers, and children who put toys in their mouths should not share toys.
Toys that cannot be washed or disinfected after use should be avoided.
Play areas should be cleaned and disinfected daily.
Toys, games, and videos should be allowed in playrooms in HCT centers only if they can be kept clean
and disinfected.
Children on contact precautions:
Disposable play items should be offered whenever possible to children on contact precautions. If a
child on contact precautions has used a toy, game, or video, the item should be thoroughly cleaned and
disinfected before being used by other children.
When a child no longer requires contact precautions, any toys, games, and videos used during the
period of isolation should be thoroughly cleaned and disinfected. All cloth or plush toys used by a child

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on contact precautions should be washed in a washing machine before the toy is given to another child
or placed in a play area.
Toys that have been used in an isolation room and that cannot be thoroughly disinfected should be
discarded.
E. Healthcare Personnel
Immunization of all HCT unit HCWs with all recommended vaccines, Hepatitis B, Tetanus, Varicella
and Influenza vaccines at a minimum, is critical to prevent transmission of vaccine-preventable
diseases to HCT recipients and candidates undergoing conditioning therapy.
HCWs caring for HCT recipients should preferentially receive inactivated vaccines rather than live
vaccines in order to minimize the theoretical risks of transmission of vaccine virus to HCT recipients.
Every effort should be made to restrict from direct patient care activities all HCWs with infections that
are potentially transmissible to HCT recipients or candidates. The extent of work restrictions (e.g.,
leave from work versus temporary reassignment to non-patient care duties) will depend on the specific
infection.
HCWs with draining skin and soft tissue infections or other skin or mucous membrane lesions (e.g.,
HSV lip lesions) that cannot be completely covered should also be restricted from patient contact.
HCT center HCWs with blood-borne viral infections (i.e., HIV or hepatitis B or C viruses) should not
be restricted from patient contact.
F. Hand Hygiene
Hand hygiene is the mainstay of infection prevention in the hospital and is an essential element of
Standard Precautions for all patients.
HCT center policies should encourage visitors to perform hand hygiene before and after each patient
visit.

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HCT recipients and candidates and their household contacts should be educated about the importance
of hand hygiene during the HCT hospitalization and after hospital discharge.
G. HCT Center Visitors
Signs should be posted to inform the public about visitation restrictions.
Trained personnel (e.g., administrative or nursing personnel) should perform active screening of all
visitors for communicable infections, at key entry points to HCT units, particularly during the
respiratory virus season.
Ideally, staff should actively screen visitors daily. Visitors with signs or symptoms suggestive of
communicable infections (e.g., fever, URI or flu-like symptoms, diarrhea, vomiting) or recent known
exposure to communicable infections (e.g., chickenpox, mumps, measles, pertussis) should be
excluded from direct contact with HCT recipients or candidates undergoing conditioning therapy.
This is particularly important during periods of widespread community-acquired respiratory virus

(CRV) activity in the surrounding community or suspected nosocomial CRV outbreaks.
Affected visitors are denied entry until signs and symptoms of infection have resolved or, for recent
exposures to communicable infections, until the incubation period for that infection has passed without
the appearance of signs or symptoms suggestive of active infection.
Visitors should also be screened for recent receipt of live vaccines and excluded.
The screening process should include all visitors who stay overnight in the rooms of HCT recipients
or candidates.
No absolute minimum age requirement for HCT center visitors exists; however, all visitors must be
able to follow appropriate hand hygiene and isolation precautions.
Number of HCT center visitors at any one time should be limited to a number that permits the nursing
staff to perform appropriate infection screening and adequate instruction and supervision of hand
hygiene and glove and mask use, as appropriate.

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H. Patient Skin and Oral Care
Skin Care:
HCT recipients should take daily showers or baths using a mild soap during and after transplantation.
For patients with GVHD, regular lubrication of dry, intact skin with emollients may decrease pruritus
and maintain skin integrity.
Routine inspection of skin sites likely to be portals of infection (e.g., perineum, intravascular access
sites) is recommended during neutropenia.
HCT recipients and candidates undergoing conditioning therapy should maintain good perineal
hygiene to minimize loss of skin integrity and risk for infection.
Recommendations to be provided for gentle but thorough perineal cleaning after each bowel movement
and thorough drying of the perineum after each episode of urination.
After using the toilet, females should always wipe the perineum from front to back to prevent fecal
contamination of the urethra and urinary tract infections.
To prevent vaginal irritation and to avoid the risk for cervical and vaginal abrasions that can serve as
portals of entry for infection, menstruating HCT recipients should not use tampons.
The use of rectal thermometers, enemas, or suppositories; internal rectal exams are contraindicated
among HCT recipients to avoid skin or mucosal breakdown, which can introduce pathogens.
Oral Care:
To reduce the risk of oral and dental infections, all HCT candidates and their caregivers should be
educated regarding the importance of maintaining good oral and dental hygiene for at least the first
year after HCT.
HCT candidates should be informed that establishment of the best possible periodontal health before
HCT is of substantial benefit in avoiding short- and long-term oral infections and that maintenance of
oral hygiene after HCT can minimize the severity of infections and facilitate healing of mucositis,
particularly before engraftment.

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If time permits, all HCT candidates should undergo a dental evaluation and relevant treatment before
the start of conditioning therapy.
Dentists should eliminate likely sources of dental infection, for example by restoring teeth with
moderate to severe caries and repairing ill-fitting dental prostheses. Dentists should extract teeth
compromised by moderate to severe periodontal disease, non-restorable carious teeth, and partially
impacted teeth.
Ideally, at least 10–14 days should elapse between the completion of tissue-invasive oral procedures
and onset of conditioning therapy, to enable adequate healing and monitoring for postsurgical
complications.
Elective dentistry should be postponed until the patient has demonstrated substantial immune recovery.
HCT recipients with mucositis and HCT candidates undergoing conditioning therapy should maintain
oral hygiene by performing oral rinses 4–6 times/day. HCT recipients and candidates should brush
their teeth 2 to 3 times/day with a soft regular toothbrush that is replaced regularly.
HCT recipients and candidates undergoing conditioning therapy who are skilled at dental flossing
should floss daily if this can be done without trauma. Routine dental supervision to monitor and guide
the patient’s maintenance of oral and dental hygiene should be provided.
To decrease the risk for mechanical trauma and infection of oral mucosa, HCT patients should not
wear fixed orthodontic appliances or space maintainers from the start of conditioning therapy until pre-
engraftment mucositis resolves or during any subsequent periods of mucositis.
Patients should minimize the use of removable dentures during conditioning and the early post-
transplantation period in order to reduce the potential for mucosal injury. HCT recipients at risk for
mucositis should wear dentures only while eating, clean them twice daily with a soft toothbrush, and,
when not wearing them, soak dentures in antimicrobial denture soaking solution that is changed daily.
Patients with GVHD of the oral cavity should undergo frequent dental evaluation because of the
accelerated pace of dental caries in these patients.
Dental caries, gingivitis, and periodontal disease must be managed promptly in order to avoid
infectious sequelae, including periodontitis and dental abscesses.

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I. Care of indwelling devices
Line related infection prevention strategies
Catheter-associated infections are a leading cause of bloodstream infections in HCT recipients,

particularly during the pre-engraftment phase and in patients with GVHD. These infections often result
in catheter removal and, much less commonly, in death.
All central venous catheters (CVCs), should be inserted using the CLABSI prevention bundle, which
consists of hand hygiene, full barrier precautions, cleaning the insertion site with chlorhexidine,
avoiding femoral sites for insertion, and removing unnecessary catheters.
For HCT centers with high CLABSI rates (more than 1 per 1,000 catheter days) despite effective
implementation of the CLABSI bundle elements, use of additional interventions, such as
minocycline/rifampin antimicrobial-impregnated catheters, to prevent CLABSIs should be considered.
Chlorhexidine-impregnated sponges have been shown to decrease the rates of catheter related
infections in non-HCT patients.
Topical antimicrobials should be avoided because of the risk of antimicrobial resistance or increased
fungal colonization in immunosuppressed HCT patients.
Use of vancomycin-containing locks is not recommended, because of the increased risk of selecting
for staphylococci with reduced vancomycin susceptibility.
Patients or parents and caretakers should be trained in the care of intravascular devices. Contact with
tap water at the central venous catheter skin site should be avoided, and patients should cover and
protect the catheter tip or end cap during bathing or showering to avoid contamination from tap water.
J. Prevention and Control of Specific Healthcare-Associated Infections
i) Recommendations for prevention of nosocomial Legionellosis:
Use only sterile water to fill reservoirs of nebulization devices and to rinse nebulization devices and
other semi-critical respiratory-care equipment after cleaning or disinfection.

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Do not use large-volume room air humidifiers that create aerosols unless these humidifiers are
sterilized or subjected to daily high-level disinfection and filled with sterile water only.
For new constructions, cooling towers should be placed so that the tower drift is directed away from
the hospital’s air-intake system, cooling towers should be designed so that the volume of aerosol drift
is minimized.
For operational hospital cooling towers, hospitals should install drift eliminators, regularly use an
effective biocide, maintain cooling towers according to the manufacturer’s recommendations, and keep
adequate maintenance records.
Decorative fountains should not be installed in HCT units or areas in a healthcare facility frequented
by HCT recipients.
Drinking water does not seem to pose a risk for Legionella exposure among HCT recipients in the
absence of an outbreak.
The goal should be to maintain water systems with no detectable organisms. If Legionella species are
detected in the water supplying an HCT center, the following measures should be performed until
Legionella species are no longer detected by culture:
 Decontaminate the water supply.

 Prevent patients from showering with LD-contaminated water. Instead, provide HCT recipients
with sponge baths using water that is not contaminated with Legionella species (e.g., use water
that is not from the HCT center’s potable water system).
 Do not use faucets containing LD-contaminated water in patient rooms or the HCT center or
ambulatory HCT clinics to avoid creating infectious aerosols.
 Provide HCT recipients with sterile water instead of tap water for drinking, brushing teeth, or
flushing nasogastric tubes during proven or suspected Legionellosis outbreaks.
ii) Recommendations Regarding Methicillin-Resistant S. aureus
To prevent MRSA transmission, adherence to the following infection control practices is

recommended:
 Perform hand hygiene before and after all patient contact or contact with the patients’
potentially contaminated equipment or environment;

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 Use contact precautions for patients colonized or infected with MRSA, including the use of
gloves and gowns;
 Ensure adherence to standard environmental cleaning with hospital approved disinfectant.
 Continue contact precautions until all antimicrobials active against the MRSA isolate are
discontinued and three consecutive screening cultures taken on separate days are negative.
Routine screening of all HCT recipients for MRSA or the use of topical or systemic antimicrobial
therapy for patients with asymptomatic MRSA colonization is not recommended.
If high rates of MRSA persist despite implementation of basic infection control practices, consider
implementing a program to obtain MRSA surveillance cultures on admission and serially (e.g., weekly)
with or without decolonization therapy; routine bathing of patients with chlorhexidine; cohorting of
MRSA patients in designated areas; or assigning care to dedicated staff.
For patients with recurrent MRSA infection, eradication of the carrier state can be attempted by
applying a 2% mupirocin calcium ointment to the nares, use of topical antiseptics such as chlorhexidine
for bathing, or administration of systemic antimicrobials.
Incorrect use or overuse of mupirocin can result in the emergence of mupirocin-resistant staphylococci.
Selection of systemic antimicrobials used to treat MRSA infection should be guided by susceptibility
patterns.
Recommendations Regarding VRE
VRE infection is associated with poor outcomes among HCT recipients. To reduce the risk of VRE
infection, HCT clinicians should minimize the use and duration of treatment with, vancomycin and
antimicrobial agents with anti-anaerobic coverage (e.g., metronidazole and third-generation
cephalosporins).
Although oral vancomycin promotes overgrowth of VRE in stool, the risk of acquiring VRE or
promoting VRE overgrowth should not be a defining consideration when selecting oral vancomycin
for treatment of severe or recurrent C. difficile infection.
Patients colonized with VRE typically remain colonized for long periods extending beyond the
hospitalization during which the initial VRE-positive culture result was obtained. VRE may “re-
emerge” after prior negative cultures when the patient is re-exposed to antimicrobials.

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Contact precautions for HCT recipients with past VRE colonization or infection should be continued
during hospital readmissions.
Discontinuation of contact precautions: three consecutive sets of screening cultures negative for VRE
obtained on separate days for a patient who is not receiving antimicrobial therapy active against the
VRE isolate.
To prevent VRE transmission, the following infection control measures are recommended:
 Perform hand hygiene before and after all patient contacts or contact with the patients’
 Use contact precautions for patients colonized or infected with VRE, including the use of
gloves and gowns.
 Ensure adherence to standard environmental cleaning with a hospital approved disinfectant.
Antimicrobial treatment of VRE carriers carries potential risks, including toxicity and the development
of drug-resistant organisms; therefore, it should be discouraged.
VRE rectal or stool active surveillance cultures to identify colonized patients can be considered if there
is evidence for ongoing transmission of VRE on a HCT unit.
iii) Recommendations Regarding Multidrug-Resistant Gram-Negative Bacilli (MDR-GNB)
Multidrug-resistant gram-negative bacilli (MDR-GNB)
are GNB that are resistant to one or more classes of antimicrobial agents, including those producing
ESBLs and carbapenemases, highly resistant strains of Acinetobacter baumannii and organisms such
as Stenotrophomonas maltophilia, Burkholderia cepacia, and Ralstonia pickettii with intrinsically
broad antimicrobial resistance.
Judicious use of antimicrobial agents is important for control of MDR-GNB.
As with other multiply–drug-resistant organisms, adherence to the following infection control

measures is important to prevent healthcare-associated transmission:
 Perform hand hygiene before and after all patient contacts or contact with the patients’

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 Use contact precautions, including gowns and gloves, for patients colonized or infected with
MDR-GNB that are of epidemiologic importance;
 Ensure adherence to standard environmental cleaning with a hospital approved disinfectant.
Units experiencing high rates of MDR-GNB infection can consider the use of active surveillance
cultures ASC as a component of their control and prevention program.
iv) Recommendations Regarding Clostridium difficile
Patients with CDI should be placed on contact precautions for the duration of illness.
All HCWs who anticipate contact with a C. difficile–infected patient or the patient’s environment
should don gloves and gowns before entering the patient’s room.
Contact precautions should be continued at least until the patient is asymptomatic.
If there is evidence of ongoing transmission of C. difficile despite implementation of the basic

prevention practices, consider maintaining contact precautions even after diarrhea has resolved and
until hospital discharge.
During nosocomial CDI outbreaks, ensure implementation of appropriate control measures.
In the setting of an outbreak or ongoing C. difficile transmission in a HCT center, consider instructing
visitors and HCWs to wash hands with soap and water instead of sanitizer after contact with patients
with CDI or their equipment or environment. Proper technique (i.e., a minimum 15 to 30 seconds of
hand washing) should be ensured. There should be facility for dedicated toilet.
The use of 1% freshly prepared sodium hypochlorite solution for 10 minutes for environmental
disinfection should be considered when there is evidence of ongoing C. difficile transmission.
v) Recommendations Regarding Community Respiratory Virus Infections
HCT recipients or candidates with URI or LRI symptoms due to suspected CRV infection should
empirically be placed on contact plus droplet precautions until a specific pathogen has been identified.
After identification, pathogen-specific CRV isolation precautions to be followed:
 Contact precautions for RSV and parainfluenza;

 Droplet precautions for influenza;

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 Droplet plus contact precautions for adenovirus; and

 Airborne plus contact precautions for primary or disseminated varicella infection.
Personal protective equipment (e.g., gown, gloves, surgical mask, and eye protection) should be
donned prior to entering and discarded upon exiting a patient’s room, ensure that personal protective
equipment is always changed between patients.
When caring for an HCT recipient or candidate undergoing conditioning therapy with URI or LRI,
HCWs and visitors should disinfect hands:
 Before and after each contact with a patient;

 After handling respiratory secretions or fomites potentially contaminated with patients’
secretions;
 Before donning and after removal of gloves.
Use of a mask without appropriate hand disinfection, glove-wearing, or facial protection is insufficient
to prevent transmission of CRV infections.
While performing aerosol-generating procedures (e.g., bronchoscopy, open suctioning of the

respiratory tract, endotracheal intubation), HCWs should wear a face shield that fully covers the front
and side of the face, a mask with an attached shield, or a mask and goggles, along with gloves and
gowns to avoid contamination from the patient’s respiratory secretions regardless of the presence or
absence of CRV symptoms.
HCT centers should consider daily screening of all persons who enter the center, including HCWs and
visitors, for URI symptoms, especially during nosocomial or community outbreaks of CRV infection.
HCT center HCWs with URI symptoms should be restricted from patient contact and reassigned to
nonpatient care duties until symptoms resolve.
Visitors with URI symptoms should be asked to defer their visit until their URI symptoms resolve.
HCWs and visitors with infectious conjunctivitis should be restricted from direct patient contact until
the drainage resolves.
Respiratory secretions of any hospitalized HCT candidate or recipient with signs or symptoms of CRV
infection should be tested promptly by viral culture or rapid diagnostic tests for CRV. Appropriate

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samples include nasopharyngeal washes, swabs, aspirates, (with or without throat swabs), and BAL
fluid.
This practice permits timely initiation of isolation precautions to prevent transmission to other patients
and HCWs as well as preemptive treatment of certain CRVs (e.g., influenza) that might prevent severe
disease and death among HCT recipients.
HCT centers should obtain nasopharyngeal swabs, throat swabs, or aspirates for culture, PCR, or rapid
antigen testing to help determine whether patients have stopped shedding virus.
To prevent nosocomial transmission of CRV, HCT recipients with CRV infection should be placed on
the appropriate precautions for at least the duration of illness; and precautions should be continued for
the duration of hospitalization or viral shedding in order to prevent transmission within the unit.
During periods of widespread RSV or influenza activity in the surrounding community or suspected
healthcare-associated CRV outbreaks, all HCT recipients and candidates with signs or symptoms of
respiratory infection should be tested for RSV and influenza infection.
During an outbreak of healthcare-associated RSV infection, managers should cohort healthcare

personnel as much as is practical (i.e., restrict personnel who care for RSV-infected patients from
giving care to uninfected patients).
No recommendation can be made for cohorting of personnel during an outbreak of other healthcare-
associated CRV infections.
HCWs and close contacts of HCT recipients should receive yearly influenza vaccine at the start of the
influenza season, preferably with inactivated influenza vaccine rather than live attenuated influenza
vaccine to avoid concerns about transmission of vaccine virus.
Healthcare personnel with influenza should be excluded from work for 5 days following the onset of
symptoms.
Preventing CRV exposure among HCT recipients after hospital discharge is more challenging because
of high CRV prevalence. Preventive measures should be individualized in accordance with the
immunologic status and tolerance of the patient. In outpatient waiting rooms, patients with CRV
infections should be separated to the extent possible from other patients and should be instructed to
use respiratory hygiene/cough etiquette (BIII).

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vi) Recommendations Regarding Adenovirus
Adenovirus can cause outbreaks of diarrheal illness among adult HCT recipients. Transmission can
occur via inhalation of aerosolized droplets; direct and indirect contact through contaminated surfaces;
fecal-oral spread; exposure to infected tissue or blood; and rarely contaminated water.
HCT recipients with adenoviral gastroenteritis should be placed on contact precautions for at least the
duration of illness, and precautions should be continued for the duration of hospitalization or viral
shedding in order to prevent transmission within the unit.
For cases of respiratory illness or disseminated infection associated with adenovirus, droplet and
contact precautions should be maintained for at least the duration of illness.
For cases of adenoviral conjunctivitis in immunosuppressed patients, contact precautions and droplet
precautions should be instituted for at least the duration of illness (usually 5–7 days).
Hand hygiene has been shown to be effective against adenovirus. Environmental disinfection of
surfaces with hospital-approved disinfectants is important to limit the spread of adenoviral infection.
vii) Recommendations Regarding Viral Gastroenteritis
Viral gastroenteritis is most commonly spread by the fecal-oral route. Common pathogens include
rotavirus, norovirus, astrovirus, and adenovirus.
In order to prevent the acquisition and spread of viral gastroenteritis, HCT centers should ensure
adherence to hand hygiene, appropriate isolation precautions, and environmental disinfection.
Appropriate precautions should be maintained for at least the duration of illness, or for the duration of
hospitalization.
viii) Rotavirus
Rotavirus is shed in high concentrations in stool and is transmitted primarily by the fecal-oral route,
through person-to-person contact and fomites. Healthcare-associated transmission due to rotavirus
infection has been linked to toys and contaminated hands.

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Contact precautions should be implemented for HCT recipients with suspected or confirmed rotavirus
gastroenteritis to prevent transmission in the healthcare setting. Alcohol-based hand gel is sufficient
for routine hand hygiene unless hands are visibly soiled.
Since prolonged shedding can occur in immunocompromised patients, HCT staff should ensure
consistent environmental cleaning and disinfection and removal of soiled diapers. If soiled diapers
need to be weighed outside of the patient room, it is important to ensure environmental disinfection of
items in contact with soiled diapers (e.g., cover the scale with paper, appropriately discard soiled
diapers and paper disinfect the scale after each use).
ix) Norovirus
Fecal-oral transmission is most common, although environmental and fomite contaminations are also
important sources of infection.
To reduce transmission, several strategies need to be employed including hand washing with soap and
water, contact precautions, wearing masks while cleaning areas contaminated by feces or vomitus, and
minimal handling of soiled linens and clothes.
Use of alcohol-based hand rubs may be inadequate for preventing norovirus transmission.
A hypochlorite-based cleaning agent is recommended for use on hard, nonporous environmental

surfaces. Environmental cleaning and disinfection with a hypochlorite-based cleaning agent should be
performed at minimum on patient discharge from the room (i.e., terminal cleaning).
x) Astroviruses
Astroviruses can be transmitted via the fecal-oral route, direct and indirect contact, and possibly via
contaminated water.
Contact precautions and environmental disinfection should be used to control the spread of astrovirus
infection among HCT recipients during known outbreaks.
Quaternary ammonium compounds and chlorine solutions can be effective in inactivating enteric
viruses provided a cleaning step to remove organic matter precedes terminal disinfection.

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K. Infection Control Surveillance
Routine surveillance should be performed for cases of invasive mold disease, including aspergillosis,
occurring among HCT recipients.
All cases of invasive mold infection should be tracked regardless of time to onset after admission.
Cases of invasive mold disease with onset of symptoms ≥ 7 days after hospital admission are more
likely to be hospital acquired.
An increase in the number of cases or in the incidence of invasive mold disease among HCT recipients
should trigger careful evaluation of the HCT center environment for sources of mold exposure. In
addition, the ventilation system should be evaluated to ensure adequate filtration, air flow, and air
pressure differentials.

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SOP No. 13
Handling and processing of linen
1. Purpose:
This document provides guidance on appropriate methods to handle and process used linen.
2. Scope:
Applies to all linen including staff uniforms and laboratory coats.
3. Categories of hospital linen

A. Clean linen:
Linen which is received from the Laundry after washing.
B. Dirty linen:
Includes all used linen which has been used but not classified as soiled / contaminated.
C. Soiled / Contaminated linen:
Linen, that is contaminated with blood, body fluids, other potentially infective materials, or is likely to
contain sharps. It also includes linen from patients on isolation precautions.
Contaminated linen can be a source of microbial contamination, which may cause infection in hospital
patients and personnel. All contaminated linen should be handled in the same manner regardless of the
patient's diagnosis. Although the risk of disease transmission from contaminated linen is minimal, the
following infection control guidelines apply to the management of such linen and laundry.
4. Recommendations:
1. Routine Handling of Contaminated Linen:
 All contaminated linen is considered potentially infectious.
 Protective barriers as appropriate (gloves, gown, eye shield etc.) should be worn for actual or
potential contact with contaminated linen.
 Hand washing should be performed after contact with contaminated linen.

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 Contaminated linen should be handled as little as possible and with minimum agitation to
prevent gross microbial contamination of the air, surfaces and of persons handling the linen.
 Do not sort or pre-rinse contaminated linen in patient-care areas.
 All contaminated linen should be collected in leak-resistant yellow bags with biohazard symbol
at the point of use.
 Contaminated linen is transported to the Laundry by separate linen-carrying trolleys.
 If laundry chutes are used, ensure that they are properly designed, maintained, and used in a
manner to minimize dispersion of aerosols from contaminated laundry. Ensure that laundry
bags are closed before tossing the filled bag into the chute.
 Masks should be worn if there is a potential for exposure to aerosolized blood or body
substances. This may occur if contaminated linen is extensively agitated (in the Laundry).
2. Washing of Contaminated Linen:

 Contaminated linen is washed with a detergent in water at least 71oC (160oF) for at least 25
minutes.
 Choose chemicals suitable for low-temperature washing at proper use concentration if low-
temperature (<160°F /<71°C) laundry cycles are used.
3. Washing of Dirty Linen:

Low temperature (<70o C) laundry cycles are used.
4. Transportation of Clean Linen:

Package, transport, and store clean linen by methods that will ensure their cleanliness and protect them
from dust and soil during loading, transport, and unloading.

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SOP No. 14
Investigation and prevention of an outbreak in hospital
1. Purpose:
To define a procedure for investigation of an outbreak within the hospital and prevent it from
spreading.
2. Scope: Hospital Wide
3. Identification of an “outbreak”
An outbreak or an epidemic is the occurrence of more cases of disease than expected in a given area
or among a specific group of people over a particular period of time. Usually, the cases are presumed
to have a common cause or to be related to one another in some way. Any outbreak needs investigation
to discover the route of transmission of infection, and possible sources of infection in order to apply
measures to prevent further spread.
 If the cases occur in steadily increasing numbers and are separated by an interval approximating
the incubation period, the spread of the disease is probably due to person-to-person spread.
 If a large number of cases occur following a shared exposure e.g. an operation, it is termed a
common source outbreak, implying a common source for the occurrence of the disease.
4. Epidemiological Methods
Formulation of a hypothesis regarding source and spread should be made before undertaking
microbiological investigations in order that the most appropriate specimens are collected.

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Steps to be taken to investigate an outbreak,
Step 1:
 Recognition of an outbreak: an increase in the number of cases of a particular infection or a rise

in the prevalence of an organism. This may be reported by Clinician, Microbiology lab or Infection
Control Nurse.
 Develop a case definition - a case definition is a standard set of criteria for deciding whether an
individual should be classified as having the health condition of interest. A case definition includes
clinical criteria and particularly in the setting of an outbreak investigation, restrictions by time,
place, and person. Identify the site, pathogen and affected population.
 Determine the magnitude of the problem. If immediate control measures are required, general
control measures such as isolation or cohorting of infected cases; strict hand washing and asepsis
should be immediately applied.
 Verify the diagnosis. Diagnoses may be uncertain, particularly early in an investigation. As a
result, different categories of a case definition may be used, such as confirmed, probable, and
possible or suspect, that allow for uncertainty. To be classified as confirmed, a case usually must
have laboratory verification. A case classified as probable usually has typical clinical features of
the disease without laboratory confirmation. A case classified as possible usually has fewer of the
typical clinical features. Each case should be reviewed to meet the definition.
 Confirm that an outbreak exists by comparing the present rate of occurrence with the endemic
rate.
Step 2:
 Notify appropriate departments and personnel and the hospital administration.
Step 3:
 Search for additional cases by examining the clinical and microbiological records.

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 Develop line listings for every case, patient details, place and time of occurrence and infection
details.
 Develop an epidemic curve based on place and time of occurrence, analyze the data, identify the
common features of the cases e.g. age, exposure to various risk factors, underlying disease etc.
Interpreting an epidemic curve:
An epidemic curve is interpreted considering its overall shape which is determined by the
epidemic pattern (for example, common source versus propagated), the period of time over which
susceptible persons are exposed, and the minimum, average, and maximum incubation periods for
the disease.
An epidemic curve that has a steep upslope and a more gradual downslope is characteristic of a
point-source epidemic in which persons are exposed to the same source over a relative brief period.
All the cases occur within one incubation period. If the duration of exposure is prolonged, the
epidemic is called a continuous common-source epidemic, and the epidemic curve has a plateau
instead of a peak. An intermittent common-source epidemic, in which exposure to the causative
agent is sporadic over time, usually produces an irregularly jagged epidemic curve reflecting the
intermittence and duration of exposure and the number of persons exposed. A propagated
epidemic, one spread from person-to-person with increasing numbers of cases in each generation,
has a series of progressively taller peaks one incubation period apart, but in reality few produce
this classic pattern.
 Formulate a hypothesis based on literature search and the features common to the case; to arrive
at a hypothesis about suspected causes of the outbreak. Depending on the outbreak, the hypotheses
may address the source of the agent, the mode (and vehicle or vector) of transmission, and the
exposures that caused the disease. The hypotheses should be testable.

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 Carry out microbiological investigations depending upon the suspected epidemiology of the
causative organism. This may include (a) microbial culture of cases, carriers and environment (b)
epidemiological typing of the isolates to identify clonal relatedness.
 Test the hypothesis by reviewing additional cases.
Step 4:
 Implement specific control measures as soon as the cause of outbreak is identified.

 Monitoring for further cases and effectiveness of control measures should be done. Prepare a
report for presentation to the Infection Control Committee, departments involved in the outbreak,
administration.
5. Immediate control measures:
Initial general infection control measures during the process of investigation. General measures
include:
 Strict hand washing;

 Intensification of environmental cleaning and hygiene;
 Adherence to aseptic protocols, and
 Strengthening of disinfection and sterilization.
6. Specific Control Measures:

Institute specific control measures on the basis of nature of agent and characteristics of the high-
risk group and the possible sources. These measures may include:
 Identification and elimination of the contaminated product;

 Modification of nursing procedure;
 Identification and treatment of carriers; and
 Rectification of lapse in technique or procedure.

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7. Evaluation of efficacy of control measures:

The efficacy of control measures should be evaluated by a continued follow-up of cases after the
outbreak clinically as well as microbiologically. Control measures are effective if cases cease to
occur or return to the endemic level.
8. Documentation of outbreak:
The outbreak should be documented.

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Annexure 1: Risk Categorization Tool (Sample Calculation)
Compromised Compromised Long Handling of Prone to cross

Criteria Immune Status Immune Status Stay/Complex internal contamination/
(Likely) (Possible) Cases anatomy/organs infection
Type Essential Additional Additional Essential Essential

Risk Multiplsier X2 X1 X1 X2 X2
Yes (3) NA(0) NA(0) Yes (3) Yes (3)
OT
Yes (3) NA(0) No (0) No (0) Yes (3)
Dialysis
NA(0) Yes (3) Yes (3) Possible(1) Yes (3)
ICU
Yes (3) NA(0) Possible(1) No (0) Yes (3)
Isolation Room
No (0) Possible(1) No (0) Yes (3) Yes (3)
Procedure Labs
No (0) No (0) Yes (3) Yes (3) Possible(1)
ER
NA(0) NA(0) NA(0) NA(0) Yes (3)
CSSD
NA(0) NA(0) NA(0) NA(0) Yes (3)
Blood Bank
NA(0) NA(0) NA(0) NA(0) Yes (3)
BMW Storage
Yes (3) No (0) NA(0) No (0) Possible(1)
Day care (Chemo)
No (0) Possible(1) Yes (3) No (0) No (0)
HDU
NA(0) NA(0) NA(0) NA(0) NA(0)
Lab
No (0) NA(0) Possible(1) Yes (3) No (0)
LDR
No (0) Possible(1) Possible(1) No (0) Possible(1)
Wards
NA(0) NA(0) NA(0) NA(0) NA(0)
OPD Area
NA(0) NA(0) NA(0) NA(0) NA(0)
Admin Area

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Vulnerable Employee Patients Handling of

patient Safety with Infectious TOTAL RISK
Criteria
cohort devices Waste/Instruments SCORE CATEGORY
Type Essential Essential Additional Essential

Risk Multiplier X2 X2 X1 X2
OT
NA(0) Possible(1) Yes (3) Yes (3) 29 High
Dialysis
Yes (3) Possible(1) Yes (3) Yes (3) 29 High
Yes (3) No (0) Yes (3) Possible(1) 25 High

ICU
Possible(1) Yes (3) Possible(1) Possible(1) 24 High
Isolation Room
Procedure Labs
No (0) Possible(1) Yes (3) Possible(1) 20 High
Possible(1) Possible(1) Possible(1) Possible(1) 18 Medium

ER
CSSD
NA(0) Yes (3) NA(0) Yes (3) 18 Medium
Blood Bank

BMW Storage
Day care Possible(1) No (0) Possible(1) Possible(1) 17 Medium
(Chemo)
Yes (3) No (0) Yes (3) Possible(1) 15 Medium
HDU
Lab
NA(0) Possible(1) No (0) Possible(1) 11 Medium

LDR
No (0) No (0) Possible(1) Possible(1) 7 Low
Wards
NA(0) NA(0) Possible(1) Possible(1) 3 Low
OPD Area
Admin Area
NA(0) NA(0) NA(0) NA(0) 0 Low
Scoring Criteria:-Yes= 3,
High Risk:- 20 and above
Possible=1,
Medium Risk:- 10-19 No= 0,
NA= 0
Low Risk:- 0-9

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Annexure 2: Hand Hygiene Tool

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Annexure 3: Hand Hygiene Poster

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Annexure 4: Bio Medical Waste Audit Sheet
BIOMEDICAL WASTE AUDIT SHEET
PART A: Bio Medical Waste Segregation & Disposal Audit
 Weekly audit to be done for at least one high risk area (OT, CSSD, ICU, Dialysis, Lab, Cath
Lab & Procedure rooms, Labour Room, ER, Chemo/Day Care, Central BMW storage room)
 Although the weekly audit will be for a single high risk area, the audits shall be planned in such
a manner that all high risk areas of the hospital are covered regularly.
 In addition to the weekly audits, a monthly audit covering the entire hospital to be carried out
preferably within first two weeks of each month.
 Audit to be conducted by team nominated by the Hospital Infection Control Committee (e.g.
ICN for wards, Microbiologist/MS for OT & ICU, AMS for CSSD, Cath Lab, Head Admin for
HK areas, Laundry & Linen room, etc.)
 After completion of audit, audit report to be submitted to Infection Control Officer with copy
to MS. Sheets must be retained for 5 years
 BMW Audit reports discussion to be a fixed agenda in HICC meetings
S. Audit Criteria for Weekly/Monthly Audit Yes/No Comments

No.
1. Waste segregation information is prominently
displayed near or on the waste bins
2. Staff (due for training) have attended a training session

on correct & safe disposal of clinical waste
3. Staff are aware of the waste segregation procedures.

Interview 5 Staff

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No.
4 Staff are aware of the appropriate action to be taken in
case of spill/exposure
5 Is the waste segregated correctly?
6 Sharp disposal is done in sharps containers
7 Sharps containers are free from protruding sharps from

the inlet
8 All sharp bins are labeled with date and time of starting
of usage
9 Sharp bins are not filled more than 3/4th level
10 Inappropriate re-sheathing of needles does not occur

(Observation/interview)
11 Needles and syringes are discarded appropriately (as

specified/okayed by the state PCB)
12 The waste storage area is clean & dry
13 There is no storage of waste in corridors or in other

inappropriate areas inside/outside the facilities where
waste is awaiting collection
14 All plastic bags are well fitted within the bin
15 All waste bins are lidded & in good working order
16 All waste bins are visibly clean, externally & internally
17 Waste bags are removed from clinical areas daily
18 There is no emptying of clinical waste from one bag to

another

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No.
19 Waste bags are not more than 3/4th full
20 Bags carrying waste are sealed/tied securely during

transportation
21 Bags are labelled with information regarding point of

generation
22 Bags carrying soiled linen is labelled as ‘Bio-hazard’
23 Staff wear industrial gloves during transport of waste
24 A separate closed trolley is used for waste

transportation
25 The utility lift is used by the staff during waste

transportation (if available)
26 Is the dedicated area (Central Storage Area) for the safe

storage of biomedical waste (inside compound) locked
& inaccessible to animals & public
27 Is the dedicated area (Central Storage Area) a safe,

ventilated and secured location for storage of
segregated biomedical waste in coloured bags or
containers in the manner as specified in Schedule I, to
ensure that there shall be no secondary handling,
pilferage of recyclables or inadvertent scattering or
spillage by animals.
28 Is the bio-medical waste from such place or premises
directly transported in the manner as prescribed in these
rules to the common bio-medical waste treatment
facility or for the appropriate treatment and disposal, as
the case may be, in the manner as prescribed in
Schedule I

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No.
29 The waste compound is kept clean & tidy and pest free
30 Has the Pre-treatment of Microbiology, Biotechnology

and other clinical laboratory waste been done on-site
The below mentioned points are to be only audited during the monthly audit covering the entire
hospital
31 Is the BMW Register maintained & updated on a day to

day basis
32 Has the BMW been collected by the Vendor on each

day (as agreed in the terms & conditions with the
vendor) including holidays
33 In case the vendor has not collected the BMW on a

given day (as agreed in the terms & conditions with the
vendor) including holidays, was the appropriate
authority informed of the same
34 Is the copy of the Copy of valid license/certificate

issued by the appropriate authority (State Pollution
Control Board) should be available with designated
person in the unit
35 Is a copy of the vendor’s authorization by state authority

(including list of authorized vehicles) available with the
designated person in the unit.
36 Is the list of vehicles authorized to collect BMW

prominently displayed at the Central storage area &
available at security gate
37 Has the State authorized biomedical waste treatment

facility visited at least once in last 6 months (by 2
persons nominated by the unit) to ascertain that BMW
disposal is done as per Biomedical Waste Management

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No.
Rules, 2016 and a formal report of the visit submitted to
the MS and Infection Control Team
38 Has the monthly record of BMW generated in terms of

category & colour coding as specified in Table 1
displayed on the Website
39 Has the Chemical Liquid Waste been pre-treated in the

on-site Effluent/Sewage treatment Plant before
discharge
40 Has BMW management been discussed in the Infection

Control Committee Meeting and minutes recorded (if
the meeting was scheduled to be held in the previous
month as per the prescribed frequency)
41 Has Induction training on BMW been provided to all

new joinees (Health care workers) who joined during
the previous month
42 Has yearly training on BMW been provided to all

Health care Workers due for the same during the
previous month
43 Has Health Check-up been done for all new joinees

(Health care workers) who joined during the previous
month
44 Has Immunization been done for all Health care

Workers due for the same during the previous month
45 In case of a major accident has the same been reported

along with the remedial actions within 24 hrs to the
appropriate authority
46 If applicable within the last month has the Annual

Report been submitted

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No.
47 If applicable within the last month has the application
for renewal of License been submitted
48 In case of any change in the bio-medical waste

generation, handling, treatment and disposal for which
authorisation was earlier granted, has the intimation
been sent to the prescribed authority about the change
or variation in the activity and shall submit a fresh
application in Form II for modification of the conditions
of authorisation.
Auditor’s Name and Signature:
Ward/Area audited:
Date:
Infection Control Officer Med Supdt.

MSOG/BMW-SACL/20160701/1.0

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PART B: AUDIT SHEET FOR WASTE TRANSPORT AND TREATMENT
 Audit to be done at least once in six months
Audit Criteria YES NO
BMW is transported to a pollution control board approved

common waste treatment facility
Waste is transported in a closed vehicle which conforms to the

Pollution control board specifications & bears the name of the
treatment agency
Proper documentation of the waste records is maintained
Category Type of Waste Type of Bag Treatment and Yes/No

or Container Disposal options
to be Used
(1) (2) (3) (4)
Yellow (a) Human Anatomical Yellow Incineration or

Waste: Human tissues, coloured non- Plasma Pyrolysis or
organs, body parts and chlorinated deep burial*
foetus below the viability plastic bags
period (as per the Medical
Termination of Pregnancy
Act 1971, amended from
time to time).
(b) Animal Anatomical

Waste : Experimental
animal carcasses, body
parts, organs, tissues,
including the waste
generated from animals
used in experiments or
testing in veterinary
hospitals or colleges or
animal houses.

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to be Used
(1) (2) (3) (4)
(c) Soiled Waste: Items Incineration or

contaminated with blood, Plasma Pyrolysis or
body fluids like dressings, deep burial*
plaster casts, cotton swabs
and bags containing In absence of above
residual or discarded facilities,
blood and blood autoclaving or
components. micro-waving/
hydroclaving
followed by
shredding or
mutilation or
combination of
sterilization and
shredding. Treated
waste to be sent for
energy recovery.
(d) Expired or Discarded Yellow Expired `cytotoxic

Medicines: coloured non- drugs and items
Pharmaceutical waste like chlorinated contaminated with
antibiotics, cytotoxic plastic bags cytotoxic drugs to be
drugs including all items or containers returned back to the
contaminated with manufacturer or
cytotoxic drugs along supplier for
with glass or plastic incineration at
ampoules, vials etc. temperature >1200
0C or to common
bio-medical waste
treatment facility or
hazardous waste
treatment, storage
and disposal facility
for incineration at
>12000C Or
Encapsulation or
Plasma Pyrolysis at
>12000C.
All other discarded

medicines shall be

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to be Used
(1) (2) (3) (4)
either sent back to

manufacturer or
disposed by
incineration.
(e) Chemical Waste: Yellow Disposed of by

Chemicals used in coloured incineration or
production of biological containers or Plasma Pyrolysis or
and used or discarded non- Encapsulation in
disinfectants chlorinated hazardous waste
plastic bags treatment, storage
and disposal facility.
(f) Chemical Liquid Waste: Separate After resource

Liquid waste generated collection recovery, the
due to use of chemicals in system chemical liquid
production of biological leading to waste shall be pre-
and used or discarded effluent treated before
disinfectants, Silver X-ray treatment mixing with other
film developing liquid, system wastewater. The
discarded Formalin, combined discharge
infected secretions, shall conform to the
aspirated body fluids, discharge norms
liquid from laboratories given in Schedule-
and floor washings, III.
cleaning, housekeeping
and disinfecting activities
etc.
(g) Discarded linen, Non- Non- chlorinated

mattresses, beddings chlorinated chemical disinfection
contaminated with blood yellow plastic followed by
or body fluid. bags or incineration or
suitable Plazma Pyrolysis or
packing for energy recovery.
material
In absence of above
facilities, shredding
or mutilation or
combination of

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to be Used
(1) (2) (3) (4)
sterilization and
shredding. Treated
waste to be sent for
energy recovery or
incineration or
Plasma Pyrolysis.
(h) Microbiology, Autoclave Pre-treat to sterilize

Biotechnology and other safe plastic with non-chlorinated
clinical laboratory bags or chemicals on-site as
waste: Blood bags, containers. per National AIDS
Laboratory cultures, Control Organisation
stocks or specimens of or World Health
microorganisms, live or Organisation
attenuated vaccines, guidelines thereafter
human and animal cell for Incineration.
cultures used in research,
industrial laboratories,
production of biological,
residual toxins, dishes and
devices used for cultures.
Red Contaminated Waste Red coloured Autoclaving or

(Recyclable) non- micro-waving/
chlorinated hydroclaving
Wastes generated from plastic bags followed by
disposable items such as or containers shredding or
tubing, bottles, intravenous mutilation or
tubes and sets, catheters, urine combination of
bags, syringes (without sterilization and
needles and fixed needle shredding. Treated
syringes) and vacutainers with waste to be sent to
their needles cut) and gloves. registered or
authorized recyclers
or for energy
recovery or plastics
to diesel or fuel oil
or for road making,

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to be Used
(1) (2) (3) (4)
whichever is
possible.
Plastic waste should

not be sent to landfill
sites.
White Waste sharps including Puncture Autoclaving or Dry
(Translucent) Metals: Needles, syringes proof, Leak Heat Sterilization
with fixed needles, needles proof, tamper followed by
from needle tip cutter or proof shredding or
burner, scalpels, blades, or containers mutilation or
any other contaminated sharp encapsulation in
object that may cause metal container or
puncture and cuts. This cement concrete;
includes both used, discarded combination of
and contaminated metal shredding cum
sharps autoclaving; and sent
for final disposal to
iron foundries
(having consent to
operate from the
State Pollution
Control Boards or
Pollution Control
Committees) or
sanitary landfill or
designated concrete
waste sharp pit.
Blue (a) Glassware: Broken or Cardboard Disinfection (by

discarded and boxes with soaking the washed
contaminated glass blue coloured glass waste after
including medicine vials marking cleaning with
and ampoules except detergent and
those contaminated with Sodium
cytotoxic wastes. Hypochlorite
(b) Metallic Body Implants Cardboard treatment) or through
boxes with autoclaving or
microwaving or
hydroclaving and

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to be Used
(1) (2) (3) (4)
blue coloured then sent for

marking recycling.
Observations:
Designation:
Date:
Infection Control Officer Med Supdt.
(In case of improper waste treatment &/or disposal by outsourced vendor, please send relevant
information to the State Pollution Control Board)
MSOG/BMWTT-ACL/20160701/1.0

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Annexure 5: General Infection Control Audit Sheet
GENERAL INFEECTION CONTROL AUDIT SHEET
 Audit of high risk areas (OT, ICU, Procedure Labs, Dialysis, Isolation Room, CSSD) to be
conducted (as per frequency defined in SOP 2) and observations to be documented on this sheet
 Hand Hygiene Audit and BMW Audit observations to be documented on respective sheets
(refer Annexure 2 and 4 respectively)
 After completion of audit, audit sheets to be submitted to Infection Control Officer with copy
to MS. Sheets must be retained for at least 6 months
 Audit reports discussion to be a fixed agenda in HICC meetings
S. Audit Criteria Yes/No Comments

No.
GENERAL CLEANLINESS
Area is visibly clean
Walls and Curtains/Blinds are visibly clean
Floor is visibly clean and non-chipped
Log/record of floor cleaning is available and

updated
Floor cleaning is done using CIPACC

approved cleaning agent (4th generation QAC
or higher) - see log/register
Floor cleaning is done in each shift - see

log/register
STERILITY ASSURANCE &

MAINTENANCE
Sterile and Unsterile/Soiled items are clearly

segregated

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No visible breach in sterility of items identified
CSSD – Indicators (Process, Chemical,

Biological) are used as per SOP
recommendations – check Log/Register and
check load if possible
OVERALL INFECTION CONTROL

PRACTICE
Appropriate PPE is used as applicable (e.g. in

Isolation Room, Barrier Nursing, etc.)
Infection Prevention practices are followed

(e.g. OR door opening kept to minimum,
Minimum traffic inside the OR, sterile zoning
is maintained, etc.)
EQUIPMENT CLEANING
Equipment cleaning is done using CIPACC

approved cleaning agent (4th generation QAC
or higher OR Peroxide based product) - see
log/register and observe if possible
Lint free cloth/Wipes are used for equipment

disinfection
Surface disinfection is done in each shift
(For DIALYSIS - after each session,

additional internal heat disinfection with Citric
Acid )
ENVIRONMENTAL SURVEILLANCE
Current Temperature reading is within range

(mention reading here _____________)

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Current Humidity reading is within range
Current Air Pressure reading is within range –

applicable to OT, Isolation Room, Transplant
ICU, BMT and ETO Room
Environmental Surveillance is as per CIPACC

recommendation and updated record is
available
INSTRUMENT WASHING (Where

applicable)
Instrument washing is done thoroughly
For instruments with Lumen – through flushing

of lumen is done
PPE is worn while cleaning/washing

instruments
Name of instrument/set observed -

Area audited:
Date:
Infection Control Officer MSOG/GICAS/2015/1.0

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Annexure 6: Disease Specific Isolation Precautions
S: Standard precautions C: Contact precautions

D: Droplet precautions A: Airborne precautions
DI: Duration of illness
TYPE AND DURATION OF PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND

CONDITIONS
Infection/Condition
Type Duration Comments
Precautions
Abscess
No dressing or containment of
Draining, major C DI drainage; until drainage stops or
can be contained by dressing
Draining, minor or Dressing covers and contains
S
limited drainage
Acquired human
Post-exposure chemoprophylaxis
immunodeficiency S
for some blood exposures
syndrome (HIV)
Not transmitted from person to
Actinomycosis S
person
Person to person transmission is

Amebiasis S rare. Use care when handling
diapered infants

Ascariasis S
person
Contact Precautions and Airborne

Precautions if massive soft tissue
Aspergillosis S
infection with copious drainage
and repeated irrigations required

Botulism S
person
Candidiasis, all forms
including S
mucocutaneous
Cellulitis S

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Chancroid (soft Transmitted sexually from person

S
chancre) (H. ducreyi) to person
Chlamydia trachomatis
Conjunctivitis/ Genital
(lymphogranuloma
S
venereum) /Pneumonia
(infants < 3 mos. of age)
Chlamydia Outbreaks in institutionalized
S
pneumonia populations reported, rarely
Clostridium
C. botulinum S
person
C. difficile (see
Gastroenteritis, C. C DI
difficile)
C. perfringens
Food poisoning S
person
Transmission from person to
person rare; Use Contact
Gas gangrene S
Precautions if wound drainage is
extensive.
Standard Precautions if
nasopharyngeal and urine cultures
Congenital rubella C Until 1 yr of age
repeatedly negative after 3 mos. of
age
Conjunctivitis
Acute bacterial/
S
Chlamydia/ Gonococcal
Adenovirus most common;
enterovirus 70, Coxsackie virus
A24 also associated with
community outbreaks. Highly
contagious; Eye clinics should
Acute viral (acute follow Standard Precautions when
C DI
hemorrhagic) handling patients with
conjunctivitis. Routine use of
infection control measures in the
handling of instruments and
equipment will prevent the
occurrence of outbreaks

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Cryptococcosis S person, except rarely via tissue and
corneal transplant
Cysticercosis S
person
Cytomegalovirus
infection, including in
No additional precautions for
neonates and S
pregnant HCWs
immunosuppressed
patients
Dengue fever S
person
Diphtheria
Until 2 cultures taken 24 hrs. apart
Cutaneous C CN
negative
Until 2 cultures taken 24 hrs. apart
Pharyngeal D CN
negative
Echinococcosis Not transmitted from person to
S
(hydatidosis) person
Enterobiasis
(pinworm disease, S
oxyuriasis)
Epiglottitis, due to
See specific disease agents for
Haemophilus D U 24 hrs
epiglottitis due to other etiologies
influenzae type b
Epstein-Barr virus
infection, including
S
infectious
mononucleosis
Botulism/ C. perfringens
Food poisoning or welchii/ S
person
Staphylococcal
Contact if drainage not controlled.
Furunculosis,
S Follow institutional policies if
staphylococcal
MRSA
Gangrene (gas gangrene) S
person
Gastroenteritis

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Adenovirus/campylobac
ter species/Cholera
(Vibrio
cholerae)/Cryptosporidi
um
species/Enteropathogeni
c O157:H7 and other
shiga toxin-producing
Use Contact Precautions for
strains/Other species of
diapered or incontinent persons for
E coli/ Giardia S
the duration of illness or to control
lamblia/Salmonella
institutional outbreaks
species (including S.
typhi)/Shigella species
(Bacillary dysentery)
/Vibrio
parahaemolyticus/Viral
(if not covered
elsewhere)/ Yersinia
enterocolitica
Discontinue antibiotics if
appropriate. Do not share
electronic thermometers; ensure
consistent environmental cleaning
and disinfection. Hypochlorite
C. difficile C DI solutions may be required for
cleaning if transmission continues
.Handwashing with soap and water
preferred because of the absence of
sporicidal activity of alcohol in
waterless antiseptic hand rubs
Ensure consistent environmental
cleaning and disinfection and
frequent removal of soiled diapers.
Rotavirus C DI Prolonged shedding may occur in
both immunocompetent and
immunocompromised children and
the elderly.
Gonococcalophthalm
ianeonatorum
(gonorrheal
S
ophthalmia, acute
conjunctivitis of
newborn)
Gonorrhea S
Helicobacter pylori S

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Hepatitis, viral
Provide hepatitis A vaccine post-
Type A S
exposure as recommended
Maintain Contact Precautions in
infants and children <3 years of
age for duration of hospitalization;
Diapered or incontinent
C for children 3-14 yrs. of age for 2
patients
weeks after onset of symptoms;
>14 yrs. of age for 1 week after
onset of symptoms.
Type B-HBsAg positive;
S
acute or chronic
Type C and other
unspecified non-A, non- S
B
Type D (seen only with
S
hepatitis B)
Type E S diapered or incontinent individuals
for the duration of illness
Type G S
Hookworm S
Herpes simplex (Herpes virus hominis)
Encephalitis/Mucocutan
eous, recurrent (skin, S
oral, genital)
Mucocutaneous,
Until lesions dry
disseminated or primary, C
and crusted
severe
Also, for asymptomatic, exposed
infants delivered vaginally or by C
section and if mother has active
Until lesions dry infection and membranes have
Neonatal C
and crusted been ruptured for more than 4 to 6
hrs until infant surface cultures
obtained at 24-36 hrs. of age
negative after 48 hrs incubation
Herpes zoster (varicella-zoster) (shingles)
Disseminated disease in Susceptible HCWs should not
any patient enter room if immune caregivers
A,C DI
Localized disease in are available; no recommendation
immunocompromised for protection of immune HCWs;

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patient until no recommendation for type of

disseminated infection protection, i.e. surgical mask or
ruled out respirator; for susceptible HCWs.
Localized in patient with Susceptible HCWs should not
intact immune system provide direct patient care when
S DI
with lesions that can be other immune caregivers are
contained/covered available.
Human
Post-exposure chemoprophylaxis
immunodeficiency S
for some blood exposures
virus (HIV)
Infectious
S
mononucleosis
Influenza
5 days except DI
Human (seasonal in
D
influenza) immunocompro
mised persons
Pandemic influenza
(also a human influenza D 5 days from onset of symptoms
virus)
Kawasaki syndrome S Not an infectious condition
Leprosy S
Leptospirosis S
person
person except through transfusion
rarely and through a failure to
follow Standard Precautions
during patient care. Install screens
in windows and doors in endemic
Malaria S
areas. Use mosquito repellants and
clothing to cover extremities
Susceptible HCWs should
4 days after not enter room if immune care

onset of rash; DI providers are available; no
Measles (rubeola) A in recommendation for face
immunocompro protection for immune HCW; no
mised recommendation for type of face
protection for susceptible HCWs,
i.e., mask or respirator. For

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exposed susceptibles, post-

exposure vaccine within 72 hrs. or
immune globulin within 6 days
when available. Place exposed
susceptible patients on Airborne
Precautions.
Meningitis
Aseptic (nonbacterial or
Contact for infants and young
viral; also see S
children
enteroviral infections)
Bacterial, gram-negative
S
enteric, in neonates
Fungal S
Haemophilus
influenzae, type b D U 24 hrs
known or suspected
Listeria monocytogenes
S
(See Listeriosis)
Neisseria meningitidis
(meningococcal) known D U 24 hrs
or suspected
Streptococcus
pneumoniae / Other S
diagnosed bacterial
Concurrent, active pulmonary
disease or draining cutaneous
lesions may necessitate addition of
Contact and/or Airborne
M. tuberculosis S Precautions; For children, airborne
precautions until active
tuberculosis ruled out in visiting
family members (see tuberculosis
below)
advised Post exposure
Meningococcal chemoprophylaxis for household
disease: sepsis, contacts, HCWs exposed to
D U 24 hrs
pneumonia, respiratory secretions; post
meningitis exposure vaccine only to control
outbreaks
Mucormycosis S

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Multidrug-resistant
organisms (MDROs Contact Precautions recommended
e.g., MRSA, VRE, in settings with evidence of
VISA/VRSA, ongoing transmission, acute care
S/C
ESBLs, resistant S. settings with increased risk for
pneumoniae), transmission or wounds that
infection or cannot be contained by dressings.
colonization
After onset of swelling; susceptible
Mumps (infectious
D U 9 days HCWs should not provide care if
parotitis)
immune caregivers are available.
Mycobacteria,
nontuberculosis Pulmonary / wound S Not transmitted person-to-person
(atypical)
Mycoplasma
D DI
pneumonia
Necrotizing Contact Precautions when cases
S
enterocolitis clustered temporally.
Nocardiosis, draining
lesions, or other S Not transmitted person-to-person
presentations
Parainfluenza virus
infection, respiratory Viral shedding may be prolonged
C DI
in infants and young in immunosuppressed patients
children
Single patient room preferred.
Cohorting an option. Post-
Pertussis (whooping exposure chemoprophylaxis for
D U 5 days
cough) household contacts and HCWs
with prolonged exposure to
respiratory secretions
Pinworm infection
S
(Enterobiasis)
Pneumonia
In immunocompromised hosts,
extend duration of Droplet and
Adenovirus D,C DI
Contact Precautions due to
prolonged shedding of virus
Bacterial not listed
elsewhere (including S
gram-negative bacterial)
Unknown Avoid exposure to other
B. cepacia in patients
C persons with CF; private room
with CF, including
preferred.

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respiratory tract
colonization
B. cepacia in patients
without CF (see
Multidrug-resistant
organisms)
Fungal S
Haemophilus
influenzae, type b
Adults S
Infants and children D U 24 hrs
Meningococcal D U 24 hrs See meningococcal disease above
Mycoplasma (primary
D DI
atypical pneumonia)
Use Droplet Precautions if
Pneumococcal
S evidence of transmission within a
pneumonia
patient care unit or facility
Avoid placement in the same room
Pneumocystis jiroveci
S with an immunocompromised
(Pneumocystis carinii)
patient.
Staphylococcus aureus S For MRSA, see MDROs
Streptococcus, group A
See streptococcal disease (group A
Adults D U 24 hrs streptococcus) below. Contact
precautions if skin lesions present
Infants and young Contact precautions if skin lesions
D U 24 hrs
children present
Adults S
Poliomyelitis C DI
Pressure ulcer (decubitus ulcer, pressure sore)
infected
If no dressing or containment of
drainage; until drainage stops or
Major C DI
can be contained by dressing
If dressing covers and contains

Minor or limited S
drainage

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Person to person transmission rare;

transmission via corneal, tissue
and organ transplants has been
reported. If patient has bitten
Rabies S another individual or saliva has
contaminated an open wound or
mucous membrane, wash exposed
area thoroughly and advise post
exposure prophylaxis.
Respiratory syncytial Wear mask according to Standard

virus infection, in Precautions. In
infants, young immunocompromised patients,
C DI
children and extend the duration of Contact
immunocompromised Precautions due to prolonged
adults shedding.
Rheumatic fever S Not an infectious condition
Ringworm
(dermatophytosis, Use Contact Precautions for
S
dermatomycosis, outbreak.
tinea)
Susceptible HCWs should not
enter room if immune caregivers
are available. No recommendation
for wearing face protection (e.g., a
surgical mask) if immune.
Pregnant women who are not
Rubella (German U 7 days after
D immune should not care for these
measles) onset of rash
patients. Advised to administer
vaccine within three days of
exposure to non-pregnant
susceptible individuals. Place
exposed susceptible patients on
Droplet Precautions;
Scabies C U 24 hrs
DI plus 10 days
after resolution
of fever,
Severe acute Airborne Precautions preferred; D
provided
respiratory syndrome A, D,C if AIIR unavailable. Vigilant
respiratory
(SARS) environmental disinfection.
symptoms are
absent or
improving

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Staphylococcal
disease (S aureus)
Skin, wound, or burn
No dressing or dressing does not
Major C DI
contain drainage adequately
Dressing covers and contains
Minor or limited S
drainage adequately
Enterocolitis S diapered or incontinent children
for duration of illness
Pneumonia / Toxic
S
shock syndrome
Consider healthcare personnel as
Scalded skin syndrome C DI potential source of nursery, NICU
outbreak
Streptococcal disease
(group A
streptococcus)
Skin, wound, or burn
Major C, D U 24 hrs
Minor or limited S
drainage adequately
Endometritis (puerperal
S
sepsis)
Pharyngitis in infants
and young children /
Pneumonia/ Scarlet D U 24 hrs
fever in infants and
young children.
Contact Precautions for draining
Serious invasive disease D U 24 hrs
wound as above.
(group B
S
streptococcus),
neonatal
(not group A or B)
S
unless covered
elsewhere
Strongyloidiasis S
Syphilis

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Latent (tertiary) and

seropositivity without
lesions / Skin and
S
mucous membrane,
including congenital,
primary, Secondary
Tapeworm disease
Hymenolepis nana /
Taenia solium (pork) / S
person
Other
Tetanus S
person
Tinea (e.g.,
dermatophytosis, Rare episodes of person-to-person
S
dermatomycosis, transmission
ringworm)
Toxoplasmosis /
Trichuriasis S
(whipworm disease)
Tuberculosis (M. tuberculosis)
Discontinue precautions only
when patient is improving
clinically, and drainage has ceased
Extrapulmonary,
A, C or there are three consecutive
draining lesion)
negative cultures of continued
drainage. Examine for evidence of
active pulmonary tuberculosis.
Examine for evidence of
pulmonary tuberculosis. For
Extrapulmonary, no
infants and children, use Airborne
draining lesion, S
Precautions until active pulmonary
meningitis
tuberculosis in visiting family
members ruled out.
when patient on effective therapy
Pulmonary or laryngeal is improving clinically and has
A
disease, confirmed three consecutive sputum smears
negative for acid-fast bacilli
collected on separate days
when the likelihood of infectious
Pulmonary or laryngeal
A TB disease is deemed negligible,
disease, suspected
and either 1) there is another
diagnosis that explains the clinical

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syndrome or 2) the results of three

sputum smears for AFB are
negative.
Skin-test positive with
no evidence of current S
active disease
Vaccinia
Until lesions dry
Generalized/Progressive For contact with virus-containing
C and crusted,
vaccinia lesions and exudative material
scabs separated
Postvaccinia
S
encephalitis
Secondary bacterial Follow organism-specific (strep,
infection (e.g., S. aureus, staph most frequent)
S/C
group A beta hemolytic recommendations and consider
streptococcus) magnitude of drainage
Until lesions dry and crusted.
Susceptible HCWs should not
enter room if immune caregivers
are available; no recommendation
for face protection of immune
HCWs; no recommendation for
Varicella Zoster A, C
type of protection, i.e. surgical
mask or respirator for susceptible
HCWs. In immunocompromised
host with varicella pneumonia,
prolong duration of precautions for
duration of illness.
Wound infections
Major C DI
Minor or limited S
drainage adequately

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Annexure 7: EPINET – Blood and Body Fluid Exposure Report

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Annexure 8: Needle stick and Sharp Object Injury Report

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Annexure 9: Post exposure Follow-up

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Annexure 10: CLABSI Event form

CLABSI EVENT FORM
Patient ID:
Patient Name:
Gender: M/ F Date of Birth/ Age:
Event Type: CLABSI Date of Event:
Date of Procedure:
Date Admitted to Facility: Location:
Diagnosis
Location of Central Line Insertion: Any haemodialysis catheter present: Yes/ No

________________
Any other device: __________________________

Date of Line Insertion: ___ /___ /________
Date of Line Removal : ___ /___ /________
Date of Line Reinsertion (if applicable): ___ /___

/____
Event Details
Specific Event: Laboratory-confirmed
Specify Criteria Used:

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Signs & Symptoms (check all that apply) Laboratory (check one)
□ Fever □ Recognized pathogen from one or more blood

cultures
□ Chills
□ Common commensal from ≥ 2 blood cultures
□ Hypothermia
□ Hypotension
□ Bradycardia
Pathogens Identified: Yes/ No [If Yes, specify]
COMMENTS:

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Annexure 11: CAUTI event form

CAUTI EVENT FORM
UHID: IPD No: AFFIX PATIENT LABEL

HERE
Patient Name:
Date of Admission:
Gender: □ F □ M Age:
Date of Event:
Location:
Risk Factors
□ Urinary Catheter in place for > 2 days on date of event
□ Urinary Catheter in place for > 2 days but removed on the date of event or the day before
Location of Catheter Insertion: ________ Date of Insertion: ___/___/_____ Date of

Removal:___/___/____
Event Details
Specify Criteria Used: (check all that apply) Laboratory & Diagnostic Testing
5
Signs & Symptoms □ 1 positive culture with ≥10 CFU/ml with no
more than 2 species of microorganisms
□ Fever
□ Urgency
□ Frequency
□ Dysuria

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□ Suprapubic tenderness
□ Costovertebral angle pain or tenderness
Secondary Bloodstream Infection: Yes No
*Pathogens Identified: Yes No *If Yes, specify on page 2
Remark (if any)
Laboratory Report:
Comments:
Person filling the form________________ Signature______________ Date_______________

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Annexure 12: Ventilator-Associated Pneumonia (VAP) Event Form
Patient ID:
Patient Name:
Gender: Date of Birth/ Age:
Date of Event:
Post-procedure VAP: □ Yes □ No Date of Procedure:
Date Admitted to Facility: Location:
Location of Mechanical Ventilation Initiation: ______________________
Date Initiated: __ /__ /_____ APRV: □ Yes □ No

Event Details:
Pneumonia Type*: □ PNU1 □ PNU2 □ PNU3

Patient Immunocompromised: □ Yes □ No
Specify Criteria Used:
Criteria 1: Imaging Test Evidence
With Underlying disease with two or more serial chest Without Underlying disease with one or more
imaging test results and at least one of the following: definitive chest imaging test results and at least one of
the following:
□ Infiltrate □ Consolidation □ Cavitation
□ Infiltrate □ Consolidation □ Cavitation
Above finding(s) is/are: □ New and persistent □ Progressive and persistent
Criteria 2: Signs/ Symptoms

□ Fever (>38.0°C or >100.4°F) □ Leukopenia (≤4000 WBC/mm3) or leukocytosis (>12,000 WBC/mm3) □
For adults >70 years old, altered mental status with no other recognized cause
AND
□ New onset of purulent sputum or change in character of sputum, or increased respiratory secretions, or
increased suctioning requirements
□ New onset or worsening cough or dyspnea, or tachypnea
□ Rales or bronchial breath sounds

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□ Worsening gas exchange

□ Hemoptysis (in Immunocompromised patient only)
□ Pleuritic chest pain (in Immunocompromised patient only)
Criteria 3: Laboratory
□ Organism identified from blood □ Virus, Bordetella, Legionella, In Immunocompromised
□ Organism identified from Chlamydia or Mycoplasma □ Identification of matching
pleural fluid identified from respiratory Candida spp. from blood and
secretions or tissue one of the following: sputum,
□ Positive quantitative culture or
corresponding semi-quantitative □ Fourfold rise in paired sera endotracheal aspirate, BAL or
(IgG) for pathogen protected specimen brushing
culture result from minimally-
contaminated LRT specimen □ Fourfold rise in Legionella □ Evidence of fungi (excluding
Candida and yeast not
□ ≥5% BAL-obtained cells pneumophila serogroup 1
antibody titer to ≥1:128 in otherwise specified) from \
contain intracellular bacteria on
paired acute and convalescent minimally-contaminated LRT
direct microscopic exam
sera specimen
□ Positive quantitative culture or
corresponding semi-quantitative □ Detection of L. pneumophila
culture result of lung tissue serogroup 1 antigens in urine
□ Histopathology shows
evidences of pneumonia
Pathogens Identified: □ Yes □ No
[If Yes, specify_______________________________________________________________________]
Specimen type: □ Blood □ Sputum □ Pleural fluid □ Lung tissue

□ Endotracheal Aspirate
□ Bronchoscopically obtained Bronchoalveolar lavage (B-BAL)
□ Bronchoscopically obtained Protected BAL (B-PBAL)
Death: □ Yes □ No VAP Contributed to Death: Yes/ No / Not applicable
Discharge Date:

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Annexure 13: Surgical Site Infection (SSI) event form
Surgical Site Infection (SSI) Form
UHID: IPID:
Patient name: Age: Gender: M F
Date of Admission: Location:
Date of Surgery: Surgical service:
Type of surgery: Emergency Elective
Event Type: SSI Date of Event:
Risk factors Perioperative and postoperative variables

Diabetes mellitus ASA Score:
Obesity Duration of Surgery:
Anaemia Surgical prophylaxis (Drug):
Concurrent infection
Smoker Timing of SP: Duration of SP:
Site of infection:
Event Details
*Specific Event:
Superficial Incisional Primary (SIP) Deep Incisional Primary (DIP)
Superficial Incisional Secondary (SIS) Deep Incisional Secondary (DIS)
Organ/Space (specify site): Stitch infection
*Specify Criteria Used (check all that apply):
Signs & Symptoms Laboratory & Diagnostic Testing

Purulent drainage or material Positive culture
Sinus tract Pain or tenderness Not cultured
Hypothermia Localized swelling Positive blood culture
Redness Heat Blood culture not done or no organisms
Fever Apnoea detected in blood
Bradycardia Lethargy Positive Gram stain when culture is negative or

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Cough Nausea not done

Vomiting Dysuria Positive culture from ≥ 2 separate tissue or fluid
Other evidence of infection found on direct samples from affected joint
exam, during invasive procedure, or by Other positive laboratory tests‡
diagnostic tests‡ Imaging test evidence of infection
Other signs & symptoms‡
Clinical Diagnosis
Physician diagnosis of this event type
Physician institutes appropriate antimicrobial
‡
per organ/space specific site criteria therapy‡
Detected
A (During admission) P (Post-discharge surveillance)
RF (Readmission to facility where procedure performed)
RO (Readmission to facility other than where procedure was performed
Informed by doctor Informed by Nurse ( OPD/ IPD) Lab based surveillance

Condition of wound at discharge
Healed Serosanguinous discharge Purulent discharge Indurated
Antibiotics prescribed at discharged: Yes No
Drug: Dose: Duration:
Secondary Bloodstream infection: Yes No Mortality* Yes No

SSI Contributed to Death: Yes No
*Pathogens Identified: Yes No *If Yes, attach report
Organism: MDRO / XDRO / MDSO
Date of discharge:
Remarks / Comments:

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Surgical site infection: YES NO
Infection control Nurse: Date:______________
Consultant: Date:______________

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Annexure 14: ICRA for Civil Engineering - Addition, Alteration & Renovation
Addition, Alteration and Renovation Form
1. Name of Activity: Date of Start:
Date of Completion:
2. Location:
3. Approximate Duration of work:
4. Is the area connected with the AHU air supply feeding air supply to other operation area?
Yes No
If yes, are the Return and Supply damper of area blocked? Yes No
(Responsibility- Team HVAC)
5. Adequate partitions are provided Yes No
6. Wet Curtains are provided. Yes No
7. Mobilization of building material is transported by covered and safe trolley.

Yes No
8. Chemicals like Paint, Thinner, and Sprit, Polish are kept safe and quality only as per the current
requirement. Yes No
Initiating Engineering / Supervisor:
Head Engineering:
Infection Control Nurse / Microbiologist:

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Annexure 15: Terms of Reference Central Infection Prevention and Control Committee
(CIPACC)
1. DEFINITION:
Central Infection Prevention and Control Committee (CIPACC) have been formed to provide guidance
to the organization on matters related to infection prevention and control.
2. PURPOSE
The purpose of CIPACC is to:
a) Provide guidance to Fortis management on matters related to infection prevention and
control.
b) Develop and/or adopt standards for infection prevention and control (e.g. benchmarking).
c) Make recommendations to ensure that Fortis infection prevention and control practices
meet the identified Fortis standards.
d) Make recommendations to ensure that Fortis infection prevention and control practices are
compliant with all applicable legal, statutory and regulatory requirements, and accreditation
requirements.
3. COMPOSITION OF CIPACC
3.1. CIPACC will comprise of a Chairman, Convener and members. The Chairman will be a senior
clinician/microbiologist/infection control expert.
3.2. The members of the CIPACC will include senior clinicians, microbiologists, infection control
experts, and medical administrators from Fortis units.
3.3. MSOG will be the Secretariat and Convener for the CIPACC.

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4. DUTIES OF CIPACC
4.1. Discuss matters relating to Fortis infection prevention and control practices and make
appropriate recommendations.
4.2. To ensure awareness in Fortis units regarding existing (and anticipated) legal, statutory and
regulatory requirements of infection prevention and control.
4.3. To ensure awareness in Fortis units relating to existing accreditation and quality standards of
infection prevention and control.
4.4. To share and disseminate best practices related to infection prevention and control.
4.5. To provide guidance on enhancing Supply Chain efficiency related to infection prevention and
control.
4.6. Assist Fortis Hospitals in collecting data/ conducting scientific studies or trials related to
infection prevention and control.
5. MEETINGS OF CIPACC
5.1. The Chairman shall preside at all meetings. In his absence the meeting will proceed, presided
by the person deputed by the Chairman.
5.2. Meetings will be held once in four months.
5.3. The agenda and the minutes of the previous meeting will be circulated to the members at least
3 working days prior to the meeting.
5.4. Minutes of Meeting shall be prepared by the Convener and circulated for comments within 3
working days of the meeting. Final version shall be circulated within 10 working days.
5.5. For specific agenda items, the CIPACC may call special invitees.
6. QUORUM
The quorum shall be half of the membership of the CIPACC

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Annexure 16: Indicative Checklist for Outsourced Laundry Visit
Checklist
S. No. Area Yes/No Remarks
1 Employee should be trained and knowledgeable of the procedures
2 Overall Plant cleanliness and personal protective equipment in use
3 Clean and soiled linen to be segregated separately. Linen movement
flow should ensure soiled and clean carts are not coming into contact
with each other
4 Equipment required for operations are installed and functional.
Maintenance of Laundry Equipment (i.e. Washing Machine, Hydro
Extractor, Drying Tumbler, Ironing/Calendaring Machine etc. as per
requirement) of reputed Manufacturer, with a documented Preventive
Maintenance and monitoring
5 Standard universal precautions to be followed while collecting and
handling infected/soiled linen
6 Bio-Medical Waste (Management & Handling) Rules, wherever
applicable are followed by the vendor
7 All the detergents/washing chemicals to be of the specification as per
approved washing formula
8 Pest control, fire safety, temperature and humidity monitored and
documented as routine. Water quality testing to be done periodically to
ensure chemical effectiveness
9 All used linen must be washed in accordance with best practices
10 All linen to be segregated category wise and washed as per defined wash
programs

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Annexure 17: Specific Site Algorithms for Pneumonia

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Annexure 18: Disease Specific Isolation Recommendations


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FORTIS HEALTHCARE LIMITED Page1of

SOP No. FCIPCM–P-2021-1.0

This document contains proprietary information of FORTIS HEALTHCARE LTD

I Change Control Information 5

II Functional Organizational Structure 6

VI Involved Personnel (Roles & Responsibilities) 14

1 Risk Categorization of Hospital Areas 15

2 Surveillance Mapping to Risk Categorization 18

6 Occupational Exposure to Blood and Body Fluids 52

7 Recommendations for Cleaning and Disinfection 64

B Recommendations for Cleaning & Disinfection of instruments, 65

This document contains proprietary information of FORTIS HEALTHCARE LTD

E Recommendations for Floor and Wall Cleaning 70

F Recommendations for Cleaning & Disinfection of Scopes 71

G Recommendations for Cleaning & Disinfection in Dialysis units 73

I Recommendations for Environmental Surveillance Including 74

10 Policy on Infection Prevention Practices in Transplant Patients 105

11 Policy on Solid Organ Transplant 110

12 Guidelines for Preventing Infectious Complications among 115

14 Investigation and prevention of an outbreak in hospital 139

Annexure 1 Risk Categorization Tool (Example) 144

Annexure 2 Hand Hygiene Tool 146

Annexure 3 Hand Hygiene Poster 147

Annexure 4 Bio Medical Waste Audit Sheet 148

Annexure 5 General Infection Control Audit Sheet 160

Annexure 6 Disease Specific Precautions 163

Annexure 7 Blood and Body Fluid Exposure Report 176

Annexure 8 Needle stick and Sharp Object Injury Report 178

This document contains proprietary information of FORTIS HEALTHCARE LTD

Annexure 9 Post exposure Follow-up 180

Annexure 10 CLABSI Event Form 182

Annexure 11 CAUTI Event Form 184

Annexure 12 VAP Event Form 186

Annexure 13 SSI event form 188

Annexure 14 ICRA form 191

Annexure 15 Terms of Reference of CIPACC 192

Annexure 16 Indicative Checklist for Outsourced Laundry Visit 194

Annexure 17 Specific Site Algorithms for Pneumonia 195

Annexure 18 Disease Specific Isolation Recommendations 199

This document contains proprietary information of FORTIS HEALTHCARE LTD

I. Change Control Information

This document contains proprietary information of FORTIS HEALTHCARE LTD

II. Functional Organizational Structure (Organogram)

This document contains proprietary information of FORTIS HEALTHCARE LTD

A. To standardize infection prevention and control practices across Fortis hospitals

This document contains proprietary information of FORTIS HEALTHCARE LTD

IV. Common Abbreviations

Sl. Abbreviation Full Form

This document contains proprietary information of FORTIS HEALTHCARE LTD

Sl. Term Definition

2 Airborne Precautions Precautions intended to protect against airborne transmission

3 Antisepsis Prevention of infection by inhibiting or arresting the growth

4 Autoclave It is a pressure chamber used to sterilize equipment and

6 Chemoprophylaxis Administration of a medication for the purpose of preventing

7 Cohort The practice of grouping patients infected or colonized with

8 Colonization The presence of microorganisms on skin, on mucous

This document contains proprietary information of FORTIS HEALTHCARE LTD

10 Decontamination The use of physical or chemical means to remove, inactivate,

12 Disinfection Means the use of a chemical or physical procedure that

13 Droplet Precautions Precautions intended to prevent transmission of pathogens

15 Endotoxin A toxic heat-stable lipopolysaccharide substance present in

16 Hand hygiene Any method that removes or destroys microorganisms on

17 High level disinfection Complete elimination of all microorganisms in or on an