Hicn Protocols

Hospital Infection Control FH/MAN/HIC/011/23
FERNANDEZ HOSPITAL
(A UNIT OF FERNANDEZ FOUNDATION)
HOSPITAL INFECTION CONTROL

Document Version Information

Document Reference number: FH/MAN/HIC/011/23
Document Version: 11.0
Document Release date: 17thJuly 2023
Document Prepared by: Dr.Nirupama
Document Approved by: Dr.Manokanth
Document Classification: Manual
Document Expiry 16thJuly 2024
Version Release date Prepared by Approved by

Name: Dr.Nirupama Name: Dr.Manokanth
Designation: Infection Control Designation: Chairperson –

Officer Infection Control Committee
11.0 17thJuly 2023 Sign: Sign:
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Table of Contents
1. Introduction 7
2. Purpose 7
3. Infection control structures at Fernandez Hospital 8
4. Hospital Infection Control Committee 8
OBJECTIVES 8
SCOPE 8
MEMBERS OF THE HICC 9
INFECTION CONTROL TEAM 9
5. Roles and Responsibilities 10

INFECTION CONTROL NURSES (ICN) 10
INFECTION CONTROL OFFICER (ICO) 11
ROLE OF NURSING SUPERINTENDENT 11
ROLE OF HOSPITAL MANAGEMENT 12
6. Review and Revision of Infection Control Manual 12

7. Reporting of Infection 12
STATUTORY NOTIFICATIONS 12
NOTIFIABLE DISEASES 13
8. Nosocomial Infections 13
SURGICAL SITE INFECTION (SSI) 14
VENTILATOR ASSOCIATED PNEUMONIA (VAP) 15
CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION (CLABSI) 16
CATHETER ASSOCIATED URINARY TRACT INFECTION(CAUTI) 16
9. Surveillance of Nosocomial Infections 16
DEFINITION 16
OBJECTIVES OF SURVEILLANCE 17
METHODS OF SURVEILLANCE 17
PASSIVE SURVEILLANCE 17
ACTIVE SURVEILLANCE 19
10. Infection rates 21

SURGICAL SITE INFECTION RATE: 21
INTRA-VASCULAR DEVICE INFECTION RATE: 21
VAP INFECTION RATE: 21
URINARY TRACT INFECTION RATE: 21
11. Standard Infection Control Precautions 21

RULES OF UNIVERSAL PRECAUTIONS 22
SAFE INJECTION & INFUSION PRACTICES 22
SAFE SHARPS PRACTICES 23
12. Hand Washing 24

INTRODUCTION 24
HAND WASHING INDICATIONS 24
HAND WASHING TECHNIQUE 25
HAND WASHING FACILITIES 30
HAND CARE 30
HAND WASH AUDIT 30
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13. Personal Protective Equipments (PPE) 30

GLOVES 30
GOWNS AND APRONS 31
FACE PROTECTION 31
MASKS 31
14. Needle Stick Injuries 31

INTRODUCTION 32
PRINCIPLES: 32
RISKS OF BLOOD-BORNE VIRUS (BBV) INFECTION 32
HANDLING AND DISPOSAL OF SHARPS 33
PREVENTION AND EDUCATION 34
PRE EXPOSURE PROPHYLAXIS -HEPATITIS BVACCINATION 34
PROTOCOL FOLLOWING A SHARPS INJURY 35
POST EXPOSURE PROPHYLAXIS 36
FOLLOW UP ACTION 38
15. Standard precautions in clinical laboratory and transfusion services 39

PRINCIPLE. 39
GENERAL TRANSFUSION SERVICE GUIDELINES. 39
GLOVES 40
PROTECTIVE CLOTHING 40
HANDLING SPECIMENS 40
HANDLING NEEDLES 41
CLEANING SPILLS AND DECONTAMINATION 42
OTHER SAFETY PRECAUTIONS 42
HANDLING BLOOD PRODUCTS/REAGENTS IN TRANSFUSION SERVICES. 42
HANDLING KNOWN INFECTIOUS PATIENTS 43
16. Spills 43
SPILLAGE OF BLOOD AND OTHER BODY FLUIDS 43
MAJOR SPILLS (> 30 ML) 43
MINOR SPILLS (< 30 ML) 44
MAJOR SPILL KIT 45
MINOR SPILL KIT 45
17. Biomedical Waste 45

WASTE MANAGEMENT IN HOSPITAL 45
OBJECTIVES 45
PRINCIPLES OF WASTE MANAGEMENT 45
STEPS IN THE MANAGEMENT OF HOSPITAL WASTE INCLUDE 47
COLOUR CODING AND TYPE OF CONTAINER FOR DISPOSAL OF BMW 2016 48
18. Staff Health Programme 49

PRE EMPLOYMENT MEDICAL CHECK UP 49
VACCINATION 49
ANNUAL HEALTH CHECK 50
HEALTH TRAINING PROGRAMS 50
19. Isolation Policies & Procedures 50

INTRODUCTION 50
AIM 50
TRANSMISSION-BASED PRECAUTIONS 51
FUNDAMENTALS OF ISOLATION PRECAUTIONS 51
CONTACT PRECAUTIONS 51
DROPLET TRANSMISSION 53
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AIR-BORNE TRANSMISSION 54
PATIENT ISOLATION 54
BARRIER NURSING 56
CLEANING OF EQUIPMENT AND ARTICLES 56
LAUNDRY 57
TERMINAL CLEANING 58
ISOLATION POLICY FOR CERTAIN GROUPS OF ORGANISMS 59
PREVENTION OF INFECTION FOR NEWBORNS OF A SUSPECTED OR CONFIRMED INFLUENZA POSITIVE MOTHER 62
VISITOR'S POLICY WHEN PATIENT IS IN ISOLATION 63
VISITOR'S POLICY FOR ICU PATIENTS: 63
20. High-Risk Areas and High-Risk Procedures 64

INTRODUCTION 64
FIVE MAIN INFECTION CONTROL MANEUVERS TO CONTROL TRANSMISSION 65
GENERAL PRINCIPLES TO BE FOLLOWED IN HIGH-RISK AREAS 65
SURVEILLANCE OF HIGH-RISK AREAS 66
21. Care of systems and indwelling devices 66

GENERAL GUIDELINES 66
VASCULAR CARE 66
RESPIRATORY CARE 69
URINARY CATHETER 70
WOUND CARE 70
22. Re-use Policy 71

23. Disinfection and Sterilization 71
TERMINOLOGY 72
LEVELS OF DISINFECTANT ACTIVITY 73
RESPONSIBILITIES 73
RECOMMENDATIONS 73
METHODS OF STERILIZATION 74
BIOLOGICAL MONITORING OF STERILIZATION 74
CHEMICAL INDICATORS 74
24. Decontamination 75
SUCTION EQUIPMENT 75
HUMIDIFIER 75
25. Decontamination and Disinfection of general items 78

26. CSSD 79
RECALL PROCEDURE 80
27. House Keeping 80

GENERAL CLEANING 80
PREPARATION OF SODIUM HYPOCHLORITE SOLUTION (1%) 81
ROOM CLEANING 81
BATHROOM CLEANING 81
CHEMICALS USED 82
OT CLEANING 83
ISOLATION ROOMS 83
28. Laundry and linen management 84

WASHING OF INFECTED LINEN 85
29. Investigation of an out break 85
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EPIDEMIOLOGICAL APPROACH 85
IMMEDIATE CONTROL MEASURES 87
MICROBIOLOGICAL STUDY 87
SPECIFIC CONTROL MEASURES 87
EVALUATION OF EFFICACY OF CONTROL MEASURES 88
30. Post Operative ward / Intensive Care Units 88

HOUSEKEEPING 88
INFECTION CONTROL PRACTICES 88
31. Hospital Antibiotic Policy 89
32. Antibiotic Stewardship Policy 89
33. COVID POLICY 92
HAND HYGIENE 92
BMW COVID -19 Guidelines: 97
Environmental Cleaning and Disinfection: 98
DISINFECTANTS: 99
FREQUENCY OF CLEANING: 99
LINEN AND LAUNDRY: 100
34.High risk pathogen – epidemic action plan 101
Strategic Planning and operational management for infection prevention control 101
High Risk Pathogens 101
Strategic Planning, Screening & Triage 102
Rapid Resposnse Team 103
Classification of Infective Microorganisms by Risk Group 103
35. INFECTION CONTROL MEASURES DURING CONSTRUCTION ACTIVITY: 104
36. Hazards/ High-risk activities in Health care facilities & HCW safety: 109
37. Food safety, Responsibilities of Catering staff, kitchen sanitation protocols and cleaning
process 111
Annexure I - Reporting Form for Exposure / COVID 19 symptoms of a Healthcare Worker
(HCW) 117
Annexure II – Schedule for Collection of Surveillance Areas 118
Annexure III – Disinfectants and Dilutions 119
Annexure IV – Infection Control Compliance Checklists for Staff 120
Annexure V –List of Invasive, High-Risk or Surgical Procedures 123
Annexure VI – TASK FORCE for COVID – 19 124
Annexure VII – Infection Control Audit Tool for Kitchen 125
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1. Introduction
 Infection control includes the prevention and management of infection through the
application of research-based knowledge to practices that include standard precautions,
decontamination, waste management, minor surgery, surveillance and audit.
 Scope:The Hospital Infection Control Manual is a reference guide containing policies as

well as procedures to prevent nosocomial infection among patients. Applicable to all the
policies and procedures for infection prevention and control protocols and policies
The overall aim of this document is to provide evidence-based information in the prevention
and control of infection at Fernandez Hospital. The hospital infection control committee will look
after the infection control needs of the hospital.The infection control committee is an essential
component of the infection prevention and control program by authorizing and directing the
activities of the Infection Control Team, communicating policy, surveillance, monitoring,
educational and problem resolution issues, and information to all the clinical and non-clinical
departments, and acting as liaison between the management and departmental heads.
 It is incumbent on all staff including doctors, nurses other clinical professionals and
managers working at Fernandez Hospital to fulfill their legal and professional obligations
with regard to both communicable diseases and infection control.
 This document will be reviewed and updated by the HICC every year by reviewing and
revising its chapters, if so required.
2. Purpose
The primary aim of the Hospital Infection Control (HIC) program is to prevent or
minimize the potential for nosocomial infections in patients as well as in staff by
breaking the chain of transmission.
The program should have the following objectives:
 To develop written policies and procedures for standards of cleanliness, sanitation, and
asepsis at Fernandez hospital.
 To interpret, uphold, and implement the HIC policies and procedures in the hospital.
 To review and analyze data on infections that occurs, in order to take corrective steps.
 To review and input into investigations of epidemics.
 To develop a mechanism to supervise infection control measures in all phases of hospital
activities and to promote improved practice at all levels of the hospital.
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 To ensure continuing education of employees on aspects of infection control.

 To frame the antibiotic policy and monitor its adherence by the prescribing doctors.
3. Infection control structures at Fernandez Hospital
 Fernandez Hospital recognizes that the control of Hospital Associated Infections (HAI) is
of prime importance and is committed to fulfill its responsibility by ensuring that proper
safeguards are instituted to identify and prevent HAI. All aspects of hospital functions are
included in this activity.
4. Hospital Infection Control Committee

Objectives
 To minimize the risk of infection to patients, staff and visitors.
 To identify the roles and responsibilities of key personnel involved in prevention and
control of infection.
 To recommend an antibiotic policy for the hospital and to curb the irrational use of
antibiotics in hospital areas.
Scope
 Maintenance of surveillance of hospital acquired infections.
 Develop a system for identifying, reporting, analyzing, investigating and controlling

hospital acquired infections.
 Develop and implement preventive and corrective programs in specific situations where
hazards for infection exist, or in the event of an outbreak.
 Advice the management on matters related to the proper use of antibiotics, develop
antibiotic policies and recommend remedial measures when antibiotic resistant strains
are detected.
 Review and update of hospital infection control policies and procedures from time to
time and monitor sterilization and disinfection policies.
 Conduct employee health education programme regarding matters related to hospital

acquired infections.
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 Frequency of meeting:To meet regularly, at least once in a month and can be extended
to once in two months if the quorum is not met, if required auditing and discussing its
activities can be done as clinical meetings with different clinical teams.
 Quorum: Minimum quorum for the HICC meeting is 5 members from Clinial heads
&Administration team.
Members of the HICC
S. No. Department Members

Chair person Anesthetist Dr Manokanth
Members: Infection Control Officer Dr Nirupama
(ICO) - Microbiologist
Managing Director Dr Pramod Gaddam
Medical Directors Dr Krupa, Dr Sailaja, Dr. Rajitha
Administration Dr. Ashraf, Dr. Tejaswini, Ms. Swati
Obstetrics / Gynecology Dr. Tarakeswari/ Dr. Kameshwari
Neonatologist Dr. Tejo Pratap/ Dr Rajeev
Anesthesia Anesthetist
Nursing Superintendent Ms. Tyna, Ms. Sandhya, Ms. Glory
Hospital Infection control Ms.Sadguna, Ms. Saumya, Ms. Anju
nurse (HICN)
In charge OT/CSSD OT/ CSSD In charge
Biomedical Head of the Department
Housekeeping Head of the Department
Maintenance Head Head of the Department
Environmental Engineer Dr. Gurmeet Singh(whenever necessary)
Quality Head Quality/ Unit Coordinator
Infection control team
 Infection control teamcomprises:

o ICO
o HICNs
 The infection control team meets at least once in a month and otherwise as necessary.
 The ICNs (Infection control nurses) conduct inspection rounds on a daily basis and the
microbiologist also may take rounds once a month. Registers are maintained by ICN.
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 Advise staff on all aspects of infection control and maintain a safe environment for
patients and staff.
 Advise management of at risk patients.
 Carry out targeted surveillance of nosocomial infections and act upon data obtained e.g.
investigates clusters of infection above expected levels.
 Investigate outbreaks of infection and take corrective measures.
 Provide relevant information on infection problems to management.
 Assist in training of all new employees as to the importance of infection control and the
relevant policies and procedures.
 Have written procedures for maintenance of cleanliness and hygiene, sanitation and
environment control in and around hospital areas.
 Surveillance of infection, data analysis, implementation of corrective steps. This is based

on the reviews of lab reports, reports from nursing in charge etc.
 Waste management & implementation of all infection control activities.
 Supervision of isolation procedures.
 Monitor employee health program.
5. Roles and Responsibilities

Infection Control Nurses (ICN)
Duties of infection control nurses:
 The duties of the ICNs are primarily associated with ensuring the practice of infection
control measures by nursing and housekeeping staff. Thus the ICN is the link between
the HICC and the wards / ICUs etc in identifying problems and implementing solutions.
 The ICN conducts infection control rounds daily and maintains the registers and reports
to ICO.
 The ICN is also involved in the education of paramedical staff including nurses and
housekeeping staff.
 Maintains registers and data of sharps / needle stick injuries and post exposure
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prophylaxis and follows all protocols and policies of HIC.
 Initiates and ensures proper immunization against Hepatitis-Bby providing Hbs -Ag
vaccine, in consultation with microbiologist (ICO) in case of suspected exposure to any
hospital worker.
 Ensures that all positive culture cases have been tracked. All probable cases of
nosocomial infections and anomalous / irrational use of antibiotics are discussed in HICC
meetings.
 Track the indicators of infection control and present the audit data to the HICC meetings
on regular basis.
 Conducts special tasks given to him /her regarding infection control, e.g.; notifying
various MDR strain infection and communicable diseases.
Infection Control Officer (ICO)
The microbiologist serves as Infection Control Officer. The duties of Infection Control
Officer are:
 The ICO supervises the surveillance of hospital acquired infection as well as preventive
and corrective programs in the hospital.
 He / She prepare the antibiotic policy and various protocols or SOP’s of the hospital in
consultation with the clinicians and HICC.
 He/Shemonitor the implementation of various policies regarding HIC practices.
Role of Nursing Superintendent
 To ensure that Nursing Staff maintains ward hygiene and follow disinfection &
decontamination policies, isolation protocols and visitor policies.
 To ensure that Nursing Staff follows universal standard precautions like use of PPE, hand
wash etc.
 To implement various HICC policies.
 To participate actively in HICC programs and its epidemiological surveillance etc, and
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promoting improvements in nursing techniques.
 To encourage nursing training programmes.
Role of Hospital Management
 Establish multidisciplinary infection control and coordinate activities of HICCommittee

and Team.
 Identify and allocate adequate resources from annual budget for implementation of
various HICC programmes and policies.
 To ensure all CME activities for its staff.
 To review quality indicators of HICC and encourage surveillance activities.
 To implement induction training pertaining to HIC policies for all its new employees.
 To ensure adequate supplies of gloves, masks, disinfectants etc.
 To ensure employee health programmes and policies.
 To ensure pre- and post-exposure prophylaxis programs.
 To discuss and implement corrective measures during HICC meetings.
6. Review and Revision of Infection Control Manual
 Written policies and procedures shall be reviewed at least once in a year. This shall be
done in consultation with the entire HICC.
 Appropriate amendments and changes (if any),are incorporated in the manual with the
signatures of the authorized individuals.
7. Reporting of Infection
Statutory Notifications
 Infectious diseases, which are listed below, whether confirmed or suspected, must be
notified by the attending doctor. The Monthly lists of notifiable diseases, if any, are
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informed to the DMHO.
 The objectives of notification are:
o To collect accurate and complete epidemiological information on the disease.
o To ensure prompt and appropriate control measures to prevent the spread of

infection.
Notifiable Diseases
 Cholera
 Small pox
 Plague
 Chicken Pox
 Tuberculosis
 Leprosy
 Enteric fever
 Meningitis
 Diphtheria
 Dengue hemorrhagic fever
 Acute flaccid paralysis
 In case of an epidemic
 Acute gastroenteritis
 Swine Flu
 Viral Hepatitis
Please notify the infection control team immediately when the following organisms/
conditions are confirmed:
 MRSA including site of colonization / infection

 Beta hemolytic streptococcus-Group-A( Streptococcus pyogenes )
 Pseudomonas aeruginosa (MDRS Strains)
 Acinetobacter specie (MDRS Strains)
 Enterococci (VRE)
 Any other uncommon or unusual organisms
 Hepatitis B and C
 Human Immunodeficiency virus ( HIV )
8. Nosocomial Infections
 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 onadmission. This definition is not used for surgical site infections.
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 An infection is considered a HAI if all elements defined by Centers for Disease Control
and Prevention (CDC) / National Healthcare Safety Network; USA (NHSN)for site-
specific infection criterion are first present together on or after the 3rd calendar day of
admission to the facility (the day of hospital admission is day 1)
 For a HAI, an element of the infection criterion may be present during the first 2 calendar
days of admission, as long as it is alsopresent on or after calendar day 3.
Surgical Site Infection (SSI)
 Superficial Incisional SSI
Must meet the following criterion:
o Infection occurs within 30days after an operative procedure and;

o Involves only skin and subcutaneous tissue of the incision and;
o At least one of the following:
 Purulent drainage from the incision.
 Positive culture of fluid or tissue from the superficial incision.
 Superficial incision that is deliberately opened by a surgeon and is culture
positive and patient has at least one of the signs and symptoms of
infection like pain or tenderness, localized swelling,redness or heat.
 Diagnosis of SSI by a surgeon.
 Deep Incisional SSI
o Infection occurs within 30 or 90 days after an operative procedure and;

o Involves deep soft tissues of the incision (e.g.facial and musclelayers) and;
 Purulent drainage.
 A deep incision that spontaneously dehisces or is deliberately opened by
a surgeon and is culture positive and patient has one of the following
signs or symptoms (fever, localized pain ortenderness).
 An abscess or other evidence of infection found on directexamination,
histopathology examination or imaging test.
 Organ / Space SSI

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o Infection occurs within 30 or 90 days after an operative procedureand;

o Infection involves any part of the body, excluding the skin incision, fascia, or
muscle layers, that is opened or manipulatedduring the operative procedure
and;
 Purulent drainage from a drain that is placed into the organ /space.
 Positive culture of fluid or tissue in the organ / space.
 An abscess or other evidence of infection found on directexamination,
histopathology examination or imaging test.
o Meets at least one criterion for a specific organ/ space infection.
 Surveillance period for deep Incisional or Organ/ Space SSI
o 30 days surveillance examples: Caesarean section, Abdominal and Vaginal

hysterectomy.
Note:SuperficialIncisional SSIs are followed for a 30 day period for all
procedure types
o Surveillance of shall be done both retrospectively and prospectively by the

HICN
o During Post operative period wound is observed on a daily basis.
o Wound careinstructions are included in the discharge ummary

s and explained
by ward sisters.
o In case of p roblems with wound healing HICN CUG Numbers are included in
discharge summary and to be followed up by HICN.
o Ward in charges will be calling patients after every 3 days until 6 weeks to
enquire about wound healing and general health.
o In case of any wound healing issues they are advised to visit Admission room &
the same MR No is forwarded to HICN
Ventilator Associated Pneumonia (VAP)
 All site specific infections must first meet the HAI definition beforea site specific infection
(e.g. VAP) can be reported.
 Ventilator: A device to assist or control respiration continuously, inclusive of the wearing

period, through a tracheotomy or byendo-tracheal intubation
 Note: Lung expansion devices such as IPPB, PEEP, CPAP are not considered ventilators
unless delivered via tracheotomyorendo-tracheal intubation (e.g. ET-CPAP)
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 VAP:
o A health care associated Pneumonia where the patient is on mechanical
ventilation for > 2 calendar days on the date of event, with day of ventilation
placement being day 1 and;
o The ventilator was in place on the date of event or the day before. If the
patient is admitted or transferred into a facility on a ventilator the day of
admission is considered day 1.
Central Line Associated Blood Stream Infection (CLABSI)
 A laboratory confirmed blood stream infection (LCBI) where a central line (CL) or
umbilical catheter (UC) was in place for >2 calendar days, with day of device placement
being day 1, when allelements of criterion were first present together.
 A LCBI occurring on the day of CL/UC discontinuation or the following calendar day are
considered CLA BSIs if the CL/UC hadbeen in place for >2 calendar days.
 Note: If admitted or transferred into a facility with a CL/UC in place (e.g., tunneled or
implanted central line), day of first access isconsidered day 1.
Catheter Associated Urinary Tract Infection(CAUTI)
 An UTI meeting the HAI definition is considered a CAUTI, if the device was in place for > 2
calendar, days, with day of device placement being day 1, and catheter was in place
when all elementsof the UTI criterion were first present together.
 UTIs occurring on the day of catheter discontinuation or the following calendar day are
considered CAUTI, if the device hadbeen in place already for > 2 calendar days.
9. Surveillance of Nosocomial Infections

The nosocomial infection rate in patients in a hospital is an indicator of the quality and
safety of care. The development of a surveillance process to monitor this rate is an essential
first step to identify local problems and priorities, and evaluate the effectiveness of infection
control activity.
Definition
 Surveillance is defined as the continuing scrutiny of all aspects of the occurrence and the
spread of a disease that are pertinent to infection control. (CDC)
 It is the systematic collection, analysis and interpretation of health data essential to

planning, implementation and evaluation of the public health practice, closely integrated
with timely dissemination of this data to those who need to know. Nosocomial infection
surveillance is a program designed to investigate, control and prevent hospital acquired
infections.
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Objectives of Surveillance
 To recognize any unusual level of incidence or outbreak which is a continuous and

ongoing practice
 To judge the desirability of introducing special control measures.
 To assess the efficiency of regular preventive measures.
 To provide feedback , verify and compile data about HIA rates
 To reduce the level of avoidable infection.
 To establish endemic baseline data.
 To identify high-risk patients.
 To track and analyze the data concerning hand wash and hand-rub compliance.
 To monitor the effectiveness of housekeeping services.
Methods of surveillance
Two methods of surveillance are Passive and Active Surveillance.
 Passive surveillance refers to the strategy where problems are identified by those other
than infection control professionals using data generated in the routine course of patient
care. This method requires the fewest resources, but it is inherently unreliable and leads
to underestimation of problems. Outbreaks are recognized at a much later stage, often,
when little can be done to contain them.
 Active surveillance refers to the use of multiple data sources to detect problems by
trained practitioners at an early stage. It often includes routine patient screening for
pathogens of concern and involves a multidisciplinary approach for the management and
control of health care-associated infections.
Passive Surveillance
Laboratory based ward liaison surveillance is used in conjunction with “Alert organism
/Alert condition” surveillance. The system is managed by the infection control Team and
details are reported back to the Infection Control Committee.
 Laboratory based ward liaison surveillance (alert organism)Positive microbiology

reports are screened and may result in a case review, a search for other carriers or
infected patients and ward visits by the infection control nurse. Approximately 70% of
infections are alert organisms and can be detected in this way. Patient may be placed in
source isolation, if considered to be a source of infection to other patients.
 Ward based surveillance (alert conditions)

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Alert conditions are medical syndromes such as acinetobacterbacteraemia or

pseudomonas pneumonia which are immediately suspected to be nosocomial infections.
It is the responsibility of the ward staff to notify the infection control team if they suspect
an infection which may be a risk to others. Appropriate specimens must be taken and
sent promptly, properly labeled, to the lab. Source isolation precautions must be
instituted immediately that infection is suspected.
 Action-Plan
When an organism/s is/are detected by the lab based surveillance or ward
basedsurveillance, the microbiologist and the treating clinician will discuss the
possibilityof nosocomial infections and action will be recorded in the nosocomial
infectionassessment form. Every effort will be made to evaluate critically each and
everypositive culture report from the in-patient units including critical care areas.
 Response
Appropriate measures will be taken in case of suspected outbreak or sudden increase in
rates of suspected nosocomial infections. Control measures to prevent spread of infection
and decrease the incidence of nosocomial infections may be suggested in feedback
report to the concerned units. In case urgent intervention is required the response may be
communicated more frequently.
 List of alert organisms (suggested list but NOT limited to)
o BACTERIA
 Methicillin- resistant Staphylococcus aureus MRSA
 Vancomycin resistant Enterococci VRE
 Penicillin resistant Streptococcus pneumoniae
 Haemophilus influenzae
 Glycopeptide resistant Staphylococci GRSA
 Salmonella spp / Shigella spp
 Multiresistant gram negative bacilli
 Mycobacterium tuberculosis – MDR Strain
 Any unusual bacteria
o VIRUSES
 Hepatitis B
 Hepatitis C
 HIV
 Varicella zoster
 Rubella
 Measles
o ALERT CONDITIONS
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 Post surgical sepsis

 Exanthemata (Acute rash illness)
 Chicken pox or Shingles
 Mumps , measles, rubella, parvo virus
 Whooping cough
 Poliomyelitis
 Diphtheria
 Scabies
 Meningitis
 Viral hepatitis
 Ophthalmia neonatorum
 Pyrexia of Unknown origin
 Typhoid and paratyphoid fevers
 Viral Haemorrhagic fevers
Active Surveillance
 Active surveillance of HAI
o The microbiology department shall be responsible for reporting any

information about infections suspected to be hospital acquired, to the ICN.
The ICN in consultation with ICO may proceed for investigation of HAI.
o Active surveillance of High Risk Areas

o High risk areas of the hospital are identified which includes
 Intensive care units- ICU/NICU/ Post op ward

 Operation Theatres
 CSSD
 Labour Ward
 Lab
 Operation Theaters
Microbiological sampling of OT is done for following instances:

o Before reopening of OT after any construction work.
o Any suspected growth / outbreak of organisms in OT
o Routine surveillance of OT by collecting swabs and air sampling shall be done

monthly
 Intensive care units
o Based on requirement Surveillance samplescan be collected as follows:

 Clinical material
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 Central line tips

 ET tube secretions
 Urine samples from catheterized patients
 Others
 Environmental sampling:
 Water samples from humidifiers
 Ventilators
 Walls, bed
 Suction tubing, other medical equipment
 Disinfectants and dressing trolleys
 Others
o Samples are sent to microbiology lab and on the basis of clinical data and
microbiological reports. Any positive sample will be analyzed critically to
detect nosocomial infections. The data will be maintained by ICN and
presented in subsequent HICC meeting.
o Routine surveillance shall be done quarterly in all high risk areas.
 Drinking water
Bacteriological surveillance is to be done every month in the microbiology lab.

Responsibility of sending the samples and records maintenance is of HICN.
 CSSD
o At Fernandez Hospital Unit II, the Bowie Dick Test (mechanical sterility indicator
for the autoclave instrument) is being used with the first batch every day.
o A chemical indicator (TST strip) is put into each batch, in a dummy pack.
o Biological indicator for autoclave is used twice a week.After the sterilization cycle,
this indicator tube is sent to the Microbiology Lab, after recording all the details of
biological indicator used with batch number, date etc. in the biological indicator
register.All the test reports received from the lab are filed in the culture report file
at CSSD.
o If lab culture report is positive and significant, the Supervisor and HICN have to be
informed immediately. The Machine will not be used further until culture is
negative. All the items which were sterilized using the concerned machine,
including the ones kept on the store, as well as those distributed to OT and other
departments will be recalled with the help of batch number.
o All Records to be kept by CSSD.
o Surveillance of sterile zone and from sterile sets shall be done monthly
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 Special studies
Special studies will be conducted as needed. These may include:

 The investigation of clusters of infections above expected levels during any
suspected outbreak
 The investigation of single cases of unusual or epidemiologically significant
nosocomial infections.
 Prevalence and incidence studies, collection of routine or special data as
needed and sampling of personnel or the environment as needed.
10. Infection rates

Surgical site infection rate:
Number of Surgical Site Infections in a given month X 100
Number of Surgeries performed in that month

Benchmark – 2 %
Intra-vascular device infection rate:
Number of central line associated blood stream infections in a month X 1000
Number of central line/device days in that month

Benchmark – 5.1
VAP infection rate:
Number of ventilator associated pneumonias in a month X 1000
Number of ventilator days in that month

Benchmark – 6.74
Urinary tract infection rate:
Number of Urinary Catheter associated UTIs in a month X 1000
Number of Urinary Catheter days in that month

Benchmark – 1.63
11. Standard Infection Control Precautions
 Standard (previously known as universal) precautions are the practices adopted by all
healthcare workers when potentially coming into contact with any patient’s blood or
body fluids. They are a set of principles designed to minimize exposure to and
transmission of a wide variety of micro-organisms. Since every patient is a potential
infection risk, it is essential to apply standard precautions to all patients at all times.
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 Transmission-based precautions supplement standard precautions in patients known or

suspected to be infected or colonized with highly transmissible or
epidemiologicallyimportant-pathogens.
Rules of universal precautions
 Consider ALL patients potentially infectious.

 Assume ALL blood and body fluids and tissue to be potentially infectious.
 Assume ALL unsterile needles and other sharps to be similarly contaminated.
 Personal protective equipment should be used by:

o Healthcare workers who provide direct care to patients and who work in
situations where they may have contact with blood, body fluids, excretions,
and secretions.
o Support staff including medical aides, cleaners, and laundry staff in situations
where they may have contact with blood, body fluids, secretions, and
excretions.
o Laboratory staff, who handle patient specimens.
o Family members who provide care to patients and are in a situation where
they may have contact with blood, body fluids, secretions, and excretions.
 Standard infection control precautions include:
o Hand hygiene
o Protective clothing and equipment
o Collection, labelling and handling of specimens
o Management of sharps
o Needle stick injury
o Immunization of staff
o Management of spillage
o Safe disposal of contaminated waste
o Decontamination of equipment
o Management of exposure to blood and body fluids
o Education of patients and healthcare workers
Safe Injection & Infusion Practices
Infection control problems identified in the course of outbreak investigations sometimes

indicate the need for reinforcement of existing infection control recommendations to
protect patients. Failure to adhere to recommendations for safe injection practices has
resulted in several outbreaks of hepatitis B and C. Lack of oversight of personnel and
failure to follow up on reported breaches of practice have contributed to these
outbreaks.
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 Use aseptic technique to avoid contamination of sterile injection equipment.

 Do not administer medications from a syringe to multiple patients.
 Needles, cannulae, and syringes are single-patient-use items.
 Use IV bags, tubing, and connectors for one patient only.
 Do not use bags of IV solution as common source of supply for multiple patients.
 Consider a syringe or needle/cannula contaminated after it has entered an IV bag or set.
 Use single-dose vials whenever possible.
 Do not use one single-dose vial for several patients or combine contents of several vials.
 If multidose vials must be used, both the needle/cannula and syringe used to access them
must be sterile.
 Do not keep multidose vials (such as insulin) in the immediate patient-care areas. Store
as recommended by the manufacturer and discard if sterility is compromised.
 IV sets for fluids to be changed every 24 hours. New IV set for A/B to be used each time.
Injection and Access Caps/Ports:
 Injection and access caps/ports which include needle free caps, catheter hubs must be
decontaminated using aseptic technique prior to accessing.
 The integrity of the access caps should be confirmed before and immediately after use. If
the integrity of the injection or access cap is compromised, it should be replaced
immediately; consider changing the device and administration set.
 Under no circumstances should devices be left with caps open or exposed.
Administration Sets:
 Administration sets for continuous infusion : to be changed every 24 hours
 Intermittent Solution Sets:
o Should be changes using aseptic technique and observing standard precautions
o Should be discarded after each use if discontinued
o Date and time labels must be applied to ensure administration sets are changed
at correct interval.
Safe Sharps Practices
Work practice controls to prevent percutaneous exposure from sharps include:

 Avoid unnecessary use of needles and other sharps.
 Use care in handling and disposing of needles and other sharps.
o Do not recap unless absolutely medically necessary and use a mechanical
device or one-handed technique when recapping is necessary.
o Do not pass sharp instruments from hand to hand. A designated “safe zone”
should be used.
o Disassemble sharp instruments using forceps or other devices.
o Close are replace sharps containers when they are full; do not overfill them.
o Use forceps, suture holders, or other instruments for suturing.
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o Avoid holding tissue with fingers when suturing or cutting.

o Avoid leaving exposed sharps of any kind on procedure work surfaces. (In
many facilities, the person who uses the sharp is responsible to dispose of it
safely. If this is not done, the person who leaves the sharp should report its
presence to the person who will discard it.)
 Use safety devices as designed.
 Always activate safety features that require activation.
12. Hand Washing

Introduction
 Hand washing is the single most important procedure for preventing nosocomial
infections. Hand washing is defined as a vigorous, brief rubbing together of all surfaces of
lathered hands, followed by rinsing under a stream of water. Although various products
are available, hand washing can be classified simply by the nature of the products used:
o Soap: Hand washing with soaps suspends microorganisms and allows them to
be rinsed off; this process is often referred to as mechanical removal of
microorganisms.
o Antimicrobial/Disinfectants –Hand-rub: In addition, hand washing with

antimicrobial containing products kills or inhibits the growth of
microorganisms; this process is often referred to as chemical removal of
microorganisms.
Hand Washing Indications
In the absence of a true emergency, personnel should always wash their hands. As per
W.H.O guidelines 5 moments of hand washing are:
 Before touching a patient
 Before clean and aseptic procedure
 After body fluid exposure
 After touching a patient
 After touching patient surroundings
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Hand Washing Technique
 For routine hand washing, a vigorous rubbing together of all surfaces of lathered hands
for at least 20 to 30 seconds, followed by thorough rinsing under a stream of water, is
recommended.
 Hand Washing Sequence (As per WHO guidelines):
o Wet hands with water

o Apply enough soap to cover all hand surfaces
o Rub hands palm to palm
o Right palm over left dorsum with interlaced fingers and vice versa
o Palm to palm with fingers interlaced
o Backs of fingers to opposing palms with fingers interlocked
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o Rotational rubbing of left thumb clasped in right palm and vice versa.
o Rotational rubbing backwards and forwards with clasped fingers of right hand
in left palm and vice versa.
o Rinse hands with water
o Dry thoroughly with air dryers / single use towel
o Use towel to turn off faucet
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 Surgical Scrub Technique (5 mins):
o Remove all jewellery (rings, watches, bracelets).
o Wash hands and arms with antimicrobial soap. Excessively hot water is harder
on the skin, dries the skin, and is too uncomfortable to wash with for the
recommended amount of time. However, because cold water prevents soap
from lathering properly, soil and germs may not be washed away.
o Clean subungual areas with a nail file.
o Start timing. Scrub each side of each finger, between the fingers, and the back
and front of the hand for two minutes.
o Proceed to scrub the arms, keeping the hand higher than the arm at all times.
This prevents bacteria-laden soap and water from contaminating the hand.
o Wash each side of the arm to three inches above the elbow for one minute.
o Repeat the process on the other hand and arm, keeping hands above elbows
at all times. If the hand touches anything except the brush at any time, the
scrub must be lengthened by one minute for the area that has been
contaminated.
o Rinse hands and arms by passing them through the water in one direction
only, from fingertips to elbow. Do not move the arm back and forth through
the water.
o Proceed to the operating room suite holding hands above elbows.
o If the hands and arms are grossly soiled, the scrub time should be lengthened.
However, vigorous scrubbing that causes the skin to become abraded should
be avoided.
o At all times during the scrub procedure care should be taken not to splash
water onto surgical attire.
o Once in the operating room suite, hands and arms should be dried using a
sterile towel and aseptic technique. You are now ready to don your gown and
sterile gloves.
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 Hand washing with soap:
o Antimicrobial liquid soap should be used for hand washing unless otherwise
indicated.
o Antimicrobial liquid soap is used to clean visibly contaminated/soiled hands.
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o If Antimicrobial liquid soap is used, the dispenser should be replaced or

cleaned and filled with fresh product when empty; liquids should not be added
to a partiallyfull dispenser.
o All High-risk areas are provided with antimicrobial chlorhexidine based liquid
soap for hand-wash.
o General areas are provided with normal liquid soap.
 Hand Rub using Alcohol based or Chlorhexidine based disinfectants.
Alcohol/Chlorhexidine is an effective decontamination agent but should only be used on

visibly clean hands. It should only be used 2-3 times consecutively before a hand wash, as
build up can occur. Hand rubs process is as follows:
o Dispense the required amount of solution on to the hands.

o Ensure solution covers all hand surfaces
o Rub vigorously using hand washing technique (refer WHO guideline as stated
above) until dry.
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Hand Washing Facilities
 Hand washing facilities should be conveniently located throughout the hospital

 Hand washing facilities should be located in or adjacent to rooms where diagnostic or
invasive procedures that require hand washing are performed.
 Adequate supplies of hand wash soaps, antiseptic solutions and tissue paper are
provided.
 Elbow operated taps are provided in all high risk areas.
Hand Care
 Keep nails clean and short

 Remove rings
 Do not wear artificial or gel nails or nail polish
 When washing hands, wrist watches should be removed
 Sleeves should be rolled up to the elbow.
 Nail brushes should not be used for routine hand washing as they damage the skin and
encourage shedding of cells.
 Nail brushes, where used must be single use disposable or single use autoclavable.
Hand Wash Audit
Monitoring of compliance is done every month by HICN. Staff is regularly trained on

importance of hand wash. All categories of staff involved in direct patient care are
monitored.This Audit is based on WHO form for hand wash au it and is done through
d
surveillance cameras, Sample size being 150. Consumption of hand rub & liquid soap on a
monthly basis is monitored. Department In-charge gives inputs.
13. Personal Protective Equipments (PPE)

PPE are must in infection control as they act as barrier to the spread of infections from
health care workers to patients and vice versa. Following are the important PPE used in
hospital:
Gloves
Hands are the most common source for spread of infections and gloves play very crucial role
in preventing this spread .Various types of gloves used in Hospital are:
 For Surgeries - Sterile, Powder free Latex gloves

 For Aseptic Procedures - Sterile, powdered gloves
 ForPatient Examination - Ethylene Vinyl Acetate (EVA) disposable gloves
 For House Keeping Activities - Rubber gloves
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If staff has any allergy with a particular type of glove they should try different material
gloves but must use gloves where necessary.
 Wear gloves when it can be reasonably anticipated that contact with blood or other
potentially infectious materials, mucous membranes, nonintact skin, orpotentially
contaminated intact skin (for example, with stool or urine in an incontinent patient) 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.
 Do not wash gloves for the purpose of reuse since this practice is associated with
transmission of pathogens.
 Change gloves during patient care if the hands are moved from a contaminated body site
(for example, perineal area) to a clean body site (for example, face).
Gowns and aprons
The purpose of wearing gowns and aprons is to protect susceptible patients from infection
and protect the wearer from contamination as well as maintaining the uniform or clothes
worn under the Apron in a clean and dry state. Gowns and aprons should not be worn
outside the area they are intended to be used. Remove your gowns / aprons when moving
out of the area; they are intended to be used.
Face protection
Protective eye or face wear should be considered where risk of blood or other body fluids
splashing in to the eyes is a possibility, including the preparation of some drugs and during
the physical decontamination or cleaning of instruments.
Masks
There is no clear guidance available for the efficacy of masks in the prevention of air borne
infections. However, they may offer protectionagainst potential splashing of the mouth and
face during certain procedures such as minor operations, physical decontamination or
cleaning instruments with brush.
14. Needle Stick Injuries

Introduction
Exposure to blood or other potentially infectious body fluids may result in the transmission
of blood borne viruses (BBVs), including HIV, hepatitis B virus (HBV) and hepatitis C virus
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(HCV). This policy is intended to reduce the risk of transmission of these infections following
needle stick or other exposures. It is primarily concerned with occupational risks for health
care staff but may also be applied to patients attending the emergency after needle stick or
other exposures in the community, when HBV infection is generally likely to be the most
important risk. This policy must also be applied to exposure of patients or visitors to risk.
Principles:
 All exposure incidents should be reported including incidents involving exposure to body
fluids.
 A risk assessment of all incidents and risk counseling for the recipient should be carried
out.
 When the source is of unknown serological status, urgent serological testing for blood
borne virus (BBV) infection with an informed consent should be taken.
Risks of Blood-Borne Virus (BBV) Infection
In the health care setting, transmission of BBV infection most commonly occurs after a
needle stick or other sharp injury exposure to blood or other body fluids. These include
amniotic fluid, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural
fluid, saliva when blood contaminated, semen, synovial fluid, any other blood stained body
fluid, exudates or other tissue fluid from skin lesions and unfixed tissues and organs.
The risk of transmission of infection depends on:
 The virus involved
 The type of exposure/injury
 Risk factors in the source
a) The virus involved:

The occupational risk of transmission following a significant needle stick /sharp injury has
been shown to be about 1 in 3 when the source is infected with HBV and is HBe
antigen positive, about 1 in 30 when the patient is infected with HCV, and about 1
in 300 when the patient is infected with HIV.
b) The type of exposure/injury:

Transmission of BBV from an infected person can occur following significant contacts
or injuries. These are:
 Percutaneous injury – a needle stick or other contaminated sharp object injury.

 Exposure of mucous membranes, including the eyes or mouth, or broken skin.
 Bites that break the skin of the person bitten.
There is no evidence of transmission of BBV infection after non-significant exposures such as:
 Exposure of intact skin.

 Exposure to vomit, faeces or urine (unless visibly blood stained)
 Exposure to sterile or uncontaminated sharps.
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c) The source of the exposure/injury (risk factors in the source):

Not all patients with BBVs have had their infections diagnosed. Therefore all blood
and body fluids and tissues are to be regarded as potentially infectious and staff
should scrupulously avoid contact with them in all circumstances. Informed consent
for testing of the source for HIV and HCV antibodies and HBsAg should be sought
urgently. This consent should be obtained by someone other than the needle stick
recipient.
Handling and Disposal of sharps
 Safe handling and disposal of sharps is a vital component of the standard precautions
practiced to reduce the risk of transmission of blood borne virus.
 All areas in the hospital using needles shall cut and dispose the needles first in BD
container (self sealing, hub cutter and needles disposal box) and then dispose the
syringe in red colour coded container.
 Adequate number of sharps bins, should be located and conveniently placed in clinical
areas.
 Ensure that the sharps bin has been closed correctly with lid.
 It is the responsibility of the person using the sharp to dispose it safely.
 Sharps (Needles, syringes, scalpel blades, razor blades, glass ampoules, suture needles
etc) should be placed directly into sharps disposal container.
 Whenever possible take a sharp bin to the point of use.
 Needles must not be recapped, bent or broken.
 Where it is necessary to disassemble a needle, and syringe, such as before transferring

blood from a syringe to a pathological specimen bottle the needle should be placed in
the sharps container before transferring the blood.
 Sharps bins should be carried by their handles and held away from the body.
 Avoid rushing when handling needles.
 Avoid pulling hard when encountering resistance in withdrawing needles from patients.
 Seek assistance when using a needle in caring for an uncooperative patient.
 Never leave needles on beds, stretchers, or bedside tables since they may injure staff,
patients, or visitors. Do not throw them into regular garbage containers where they
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may injure housekeeping staff.
 Never put needles in your pocket.
 Sharps bins should not be filled more than three - forth.
 Never try to remove anything from a needle container or force needles into a full
container.
 Pick up improperly discarded needles with care and dispose of them in a puncture proof
container.
Prevention and Education
 Exposure prevention remains the primary strategy for reducing occupational Blood
borne pathogen infections; however, occupational exposures will continue to occur.
 Hospital has made available to their personnel a system that includes written protocols
for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational
exposures that might place health care professionals at risk for acquiring a blood borne
infection.
 All staff is educated on needle stick injuries, prevention strategies, prophylaxis, post
exposure first aid treatment and follow up through regular trainings.
 The staff is educated concerning the risk for, and prevention of blood borne infections,
including the need to be vaccinated against hepatitis B.
 Employees who are at risk for occupational exposure to blood borne pathogens i.e.
Doctors, nurses, housekeepers, maintenance staff and technicians in the laboratory / OT
are familiarized with the principles of post exposure management as part of job
orientation and ongoing job training.
 The hospital has provided appropriate training to all personnel on the prevention of and
response to occupational exposures.
 Employees have been educated to report occupational exposures immediately after they
occur, by conducting training classes, demonstrating on how to fill up the Needle stick
injury form and emphasizing to them the importance of early reporting.
Pre Exposure Prophylaxis -Hepatitis BVaccination
 Any employee who performs tasks involving contact with blood, blood-contaminated
body fluids, other body fluids, or sharps is vaccinated against hepatitis B.
 Any newly joined employee (if not already vaccinated in any previous medical
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organization) from the following departments are Vaccinated:

o Doctors
o Nurses
o Laboratory technicians
o OT technicians
o Housekeepers
 Vaccination Card of each staff is maintained by HR.

 Three doses of Hepatitis B vaccine are given, First dose at joining, Second dose after 1
month and Third dose after 6 months.
Protocol following a Sharps Injury
a) Immediate Steps:
 For Injury: Wash with soap and running water

 For non-intact skin exposure: wash with soap and water
 For Mucosal Exposure: Wash thoroughly
 Do not squeeze or rub the injury.
 Do not use strong solutions like bleach or iodine to clean the site as these may irritate
the wound.
b) Reporting:
All sharps injury and mucosal exposure must be reported to the immediate supervisor
and/or to the HICN. Details of the NSI should be filled up by the HICN within 24 hours
of the incident and followed up.
The staff shall be assessed by the doctor on duty in the admission room/ER /
physician on call. The doctor will advice on risk assessment, counseling and need for
post exposure prophylaxis (PEP).
Patient’s or visitor’s exposures should be notified to the administrator of the hospital

and then the doctor in the admission room. Their management will follow the policy
as detailed for staff.In case of any NSI, irrespective of the source, post exposure
prophylaxis will be provided in Admission room or Labour room within 24 hours and
the cost of PEP will be borne by the management for one month.
c) Management
Management shall be on a case to case basis as referred by the General Physician.
 The risk assessment of the source concerning possible indicators of BBV infections
including risk factors, previous tests and suggestive medical history will be
undertaken. The source patient will be counseled and informed consent of testing
HBV, HCV and HIV obtained. This should ordinarily be done by the administrator (but
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not by the recipient of the injury) with support as necessary from patient’s doctor. For
patients with known HIV infection, details of past and current antiretroviral therapy
should be obtained as this may influence PEP.
 For all significant occupational exposures, obtain a baseline blood specimen for
storage from the exposed health care worker. This may be tested later, with the staff
member’s consent, for HBV, HCV or HIV infection.
d) Follow-up:
Follow up and statistics of NSI are done by the HICN on a monthly basis. This
information is presented at the HICC meeting and preventive actions to avoid NSI, if
any, are recorded. Root cause Analysis is done for each case of NSI.
Post Exposure Prophylaxis
a) HIV Infection
 PEP should be recommended to health care workers if they have had a significant
exposure to blood or other high-risk body fluid or tissue known to be, or strongly
suspected to be infected with HIV. HIV post-exposure prophylaxis (PEP) usually
consists of;
o For low and intermediate risk injury, a combination of Zidovudine 300mg +

Lamivudine 150 mg twice daily for 28 days.
o For high risk injury, Zidovudine 300mg + Lamivudine 150 mg twice daily +
Efavirenz 600mg once aday for 28 days.
 PEP should not be offered following exposures to low risk materials (e.g. urine, vomit,
saliva, faeces) unless they are visibly blood stained.
 When the HIV status of the source is unknown, assessment of possible infectivity will
be necessary. This may depend on information from the history, the examination and
the results of previous investigations of the patient. Testing the source for HIV
antibody should be the norm but will usually entail obtaining informed consent from
the patient. If the source is strongly suspected to be infected with HIV the health care
worker should take PEP until consent has been obtained and the rest result is known.
 If the patient is unable to give consent, or refuses to, but is strongly suspected to be
infected with HIV, the health care worker should take PEP, if appropriate, until
consent has been obtained and the test result is known. If there are delays in
obtaining test results, in situations where the source has significant risks, the HCW
should take PEP until definitive information is available.
 In cases where there is heavy exposure (eg: NSI from large bore needle), even though
the source is know and negative, the staff is started on PEP, considering that the
source may be in window-period. The rest of the protocol to test at 6 weeks, 3
months, and 6 months after the exposure will be carried out.
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 PEP should preferably be commenced within an hour of the exposure or as soon as

possible after significant exposure. When recommending PEP it is important to take
into account the views of the affected health care worker. Some members of staff do
not wish to take PEP after they have considered the risk of the injury.
 In certain circumstances the choice of drugs may require modification e.g. depending
on the medical history of the member of staff, depending on whether they are taking
any other medication; whether the virus may have developed resistance to the
recommended drugs, or if the member of staff is pregnant. In such circumstances,
expert advice should be obtained immediately, before starting PEP.
 Pharmacy will ensure that PEP starter packs are kept in stock.
b) Hepatitis B Infection
 Following significant exposures, the source should be tested urgently, with consent,
for hepatitis B surface antigen. If the source refuses consent, manage as though
exposure has been to an HBsAg positive source. Serological and clinical follow up for
other BBV should also be undertaken.
 If the source patient is unidentifiable or unavailable for testing, manage as an

unknown source exposure. Serological and clinical follow up (including other BBV)
should be undertaken.
 The exposed staff’s hepatitis B (HB) vaccination status and anti-HBs results, should be
established from existing records or though urgent testing and hepatitis B prophylaxis
given according to HBsAg/Ab status of the source and the victim.
 Following unknown sourceexposures, victims with no history of hepatitis B

vaccination, and those who have previously received only one dose of the vaccine,
should be offered an accelerated course of HbsAg vaccine (with doses at 0, 1, and 2
months, and a booster dose at 12 months for those at continuing risk of exposure to
hepatitis B). Staff who have previously received two or more doses of HbsAg vaccine,
but are of unknown hepatitis B status, should be offered a single dose of the vaccine.
 Known responders to HB vaccine, i.e. hepatitis B surface antibody (anti-HBs) level

>10 miU/ml following initial course or booster dose(s) of vaccine, will not require
prophylaxis after unknown source exposure incidents, though the occasion may
provide an opportunity to give a ‘routine’ booster dose of HB vaccine.
 Specific hepatitis B prophylaxis is not required for exposures to HBsAg negative

sources or non-significant exposures, but exposed staff who have no previously
received HB vaccine and who are at continuing risk of exposure to hepatitis B should
start a course of vaccine. Staffs who have received part of a course should complete it
as originally planned.
c) Hepatitis C Infection
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 Following significant exposures, the source should be tested, with consent, for
hepatitis C antibody. Patients who are hepatitis C antibody positive should also be
tested for HCV RNA. Source patients found to be hepatitis C antibody positive and/or
HCV RNA positive should be referred to a consultant physician with an interest in
hepatitis C infection.
 If the source cannot be identified or if they refuse consent to be tested, management

should be based on risk assessment. If the patient is considered to be ‘high risk’ the
staff may be managed as though they were exposed to a positive source.
Follow Up Action
 Counseling should be made available to any member of staff who reports a potential
risk of blood-borne virus infection, and may include advice about testing for HBV,
HCV and/or HIV infection, and advice about treatment or prophylaxis.
 Exposure Report:The circumstances and post exposure management should be

recorded in the needle stick injury reporting form.
a) HIV
 Staff who have had significant exposures to HIV infection should be offered HIV
testing at 6 weeks, 3 months and 6 months post-exposure, and should avoid further
possible transmission (protected sexual intercourse; avoidance of pregnancy, blood,
organ and semen donation).
 If PEP is given, staff should be followed up by one of the Internal Medicine

Consultants. Potential drug toxicity should be monitored including a full blood count,
and LFT at baseline and 2 weeks after starting prophylaxis. If toxicity occurs, dose or
drug modification will be considered.
 Pending serological follow up after occupational exposure to HIV, the staff member
need not avoid performing exposure prone procedures. Advice should be given about
safer sex and avoiding blood and other biological donation during the follow up
period.
b) Hepatitis B
Appropriate advice on safer sex, avoidance of blood donation etc should be given.
Follow-up visits should be arranged for further doses of HbsAg vaccine where
necessary. Those who were given HbsAg vaccine will be tested at 6 months for
hepatitis B surface antibody to confirm a vaccine response. Non-responders will
should be counseled, and with their consent, tested for hepatitis B surface antigen
and assessed by physician.
c) Hepatitis C
 If the source is not infected with HCV, no further follow up action with respect to HCV
is required unless the member of staff develops liver disease. For staff who have had
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significant exposures to hepatitis C infection (or to a source whose hepatitis C status is

unknown but who is assessed to be at ‘high risk’), blood should be obtained at 6
weeks, 3 months and 6 months post-exposure. The member of staff should be tested
for HCV RNA at 6 weeks and 3 months and for hepatitis C antibody at 3 and 6 months.
 Provided that risks of hepatitis B and or HIV infection have been excluded, it is
NOTnecessary to advise staff to have only protected sexual intercourse during the
follow-up period or to discontinue breast-feeding or to avoid pregnancy.
15. Standard precautions in clinical laboratoryandtransfusion services
Principle:
 Recommendations by the Centre for Disease Control (CDC) and regulations by

Occupational Safety and Health Administration (OSHA) have been developed for
Standard Precautions for prevention of occupational exposure to blood-borne
pathogens.
 These requirements apply to blood and body fluids from all patients regardless of
diagnosis. No distinction is made between patients who are known to be infected and
others. Standard Precautions constitute a safe approach to prevent infection because
employees have a single behavioral standard, and errors in assessing patient status will
not endanger employee safety.
 The Standard Precautions do acknowledge a difference between hospital patients and

healthy donors, in whom the prevalence of infectious disease markers is significantly
lower.
General Transfusion Service Guidelines:
Hand washing
Frequent, effective hand washing is the first line of defense in infection control. Blood-borne
pathogens of concern generally do not penetrate intact skin, so immediate removal reduces the
likelihood of transfer to a mucous membrane or broken skin area or of transmission to others.
As per W.H.O guidelines 5 moments of hand washing are:
 Before touching a patient

 Before clean and aseptic procedure
 After body fluid exposure
 After touching a patient
 After touching patient surroundings
Gloves
 All technicians when cleaning up spills or handling waste materials should wear gloves.
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 Gloves should be worn routinely whenever there is the possibility of exposure to a

patient's blood or body fluids (e.g. collecting a therapeutic unit on the wards).
 Use gloves for any task where blood or body fluids may be encountered if your hands
have any cuts, scratches or abrasions.
 By persons who are receiving training in phlebotomy.
 When collecting or handling any "open" blood container or specimen.
 When cleaning up spills or handling waste materials.
 Change gloves immediately if they are torn, punctured, or contaminated; after handling
high-risk samples; or after performing a physical examination, e.g., on a donor/patient.
 Remove gloves by keeping outside surfaces in contact only with outside, and by turning
the glove inside out while taking it off.
 Wash hands with soap or other suitable disinfectant after removing gloves.
 Do not wash or disinfect gloves for reuse.
Protective Clothing
 Lab coats should be worn at all the time.

 Contaminated clothing should be removed promptly.
 Protective clothing should be removed before leaving the work area and should be
placed in a suitable container and laundered as potentially infectious.
 Masks, Safety Glasses, should be worn to protect the eyes and the mucous membranes.
Handling Specimens
 Full patient information is essential on both the request form and the sample container.
It is the responsibility of the person taking the blood sample (or sending a urine/ feces
sample) to ensure that the patient information is correct. It is also helpful to include
relevant clinical information.
 Samples should be sent to the lab with the minimum delay. Other samples can be
refrigerated with the exception of blood culture samples.
 All lab samples must be treated as potentially infectious and all investigations should be
treated as potentially hazardous. This helps to protect people against risks to their health
from any hazardous substance encountered at work. While such substances are generally
classified as very toxic, toxic or harmful, corrosive or irritant. The hazardous also includes
micro organism hazards to health which arise from work activity.
 The labeling and transportation of specimens is the responsibility of the dept sending the
specimen.
 Specimens are regarded as high risk if taken from patients known or suspected of being
infected with a blood borne virus such as hepatitis B virus and HIV.
 If a spillage of blood, fluids or tissues or of other specimens occurs, this should be made
safe and disposed off, no matter what the risk status of the patient is.
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General guide lines on specimen collection are:
 Standard precautions should be adhered to at all times
 Send sample to the lab in the appropriate container for the test required.
 Microbiology specimens should be obtained, if possible, before antimicrobials are

administered
 An adequate quantity of material must be obtained for complete examination
 Sterile equipment and aseptic technique must be used for collecting specimens
particularly for those from sterile site.
 Material must be transported promptly to the lab.
 Ensure that the container is properly closed and there is no spillage or leaking
 Keep the request form separate from the specimen
 Write legibly
 Full patient information and specimen details are essential on both request form and
container.
 Staff involved in transporting specimens should be trained to cope with spillages
Handling Needles
 Dispose of used needles and small sharps in puncture-resistant containers that are
located as close as possible to the area of use.
 Sharps containers are to be sealed and waste to be discarded when they are two thirds
full.
Cleaning Spills and Decontamination
 Surfaces and equipment that are contaminated with blood require daily cleaning and
decontamination with 1% Hypochlorite.
 When spills occur, the following steps should be taken in the order listed:
 Leave the area for 30 minutes if an aerosol has been created and post warnings to keep
the area clear. Remove clothing if it is contaminated. If the spill occurs in the centrifuge,
turn the power off immediately and leave the cover closed for 30 minutes.
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 Wear appropriate protective clothing and gloves. If sharp objects are involved, gloves
must be puncture-resistant, and a broom or other instrument should be used during
cleanup to avoid injury.
 Cover the spill completely with absorbent material.
 Flood the area with disinfectant, 1% Hypochloriteand let it stand for 20 minutes.
 Remove the absorbent layer and any broken glass with brush and pan.
 Wipe up the disinfectant.
 Dispose of all materials safely in accordance with biohazard guidelines.
 Biological and/or other infectious waste generated by the Blood storage centre such as
outdated or damaged blood products, contaminated needles, tubing, sharps, etc. are to
be disposed of in an appropriate manner:
Other safety precautions
 There should be no casual visitors where open blood specimens are handled.
 Mouth pipetting is not permitted.
 Eating, drinking, smoking, or the application of cosmetics is prohibited in all working

areas of Transfusion Services and blood storage area.
 Immediately report any needle-sticks or other contamination incidents to HICN.

Handling blood products/reagents in transfusion services
 Every sample of blood and body fluids should be handled as if potentially infectious.
 Care is to be taken when handling all specimens received for Blood storage
 Use an appropriate barrier (gloves, gauze, etc.) to prevent splashing when opening any
blood sample.
 Hands should be washed immediately after handling samples, and/or after removing
gloves.
 Protective clothing should be changed if grossly contaminated with any patient or donor
specimen.
 Even though all commercial human-based Blood Bank reagents have been tested (cells,
antisera, etc.), handle them as if they are potentially infectious.
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 Safe injection and infusion practices are implemented in the hospital and they are
regularly monitored by incidence of thrombophlebitis rates etc.
Handling known Infectious Patients
It may be necessary in certain circumstances to collect blood from a patient known to be at

high risk for an infectious agent:
 Additional precautions are to be taken, i.e. protective gowns, gloves, masks, and eye
shields if necessary.
 Complete cleaning and disinfection of all equipment used is to be performed before

being returned to routine use.
 All disposable materials are to be disposed of immediately.
16. Spills
Spillage of Blood and Other Body Fluids
 Body fluid spills are spills which contain blood or any other potentially infected spills like
urine, faeces or vomitus
 Spillage of blood should be dealt with as soon as possible.
 Splashes of blood (or any body fluid) on the skin should be washed off immediately with
soap and water.
 If there is broken glass, do not touch even with gloved hands. Use a paper or plastic
scoop and dispose in the sharps box.
 Spills may be divided into :
 Major spills ( > 30ml / approx 2 tablespoons)
 Minor spills ( < 30 ml)
Major spills (> 30 ml)
 Evacuate the area or room and alert all personnel regarding the spill and take care not to
breathe in any aerosolized material
 The staff will ring the house keeping supervisor at “3317” (Unit-1)/ “2317” (Unit-2)/ “7317”
Unit-5) and inform about the major spill.In case the extension does not connect till 5
rings, the call will get diverted to the CUG mobile phone of the manager.
 The housekeeping staff will reach the spill site with the major spill kit kept in the H/K
department.
 Only the designated staff have to enter the area to clear the spill and the staff cleaning
the spill should ensure that they use the appropriate PPE (available in the major spill kit)
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 Use old cloths or newspapers to cover the spill.
 Pour disinfectant (1 % sodium hypochlorite solution) over the entire area of the spillage
and let it remain for 20 min
 The absorbent cloth or paper is picked up from the outer edges to the centre, and placed
in the yellow bag and disposed in the infected waste container.
 Carefully clean the spill site of any visible material from the edges of the spill to the
center with Bacillocid
 Rinse the spill site with Bacillocidand air dry
 Discard the gloves and mask used for clearing the spillage site into the red container
 Wash hands with soap and water
Minor spills (< 30 ml)
 Spill kit available in the ward is to be used.
 Nursing / ward H/K staff will segregate the area of spill
 Similar to the procedure for major spills except evacuation of personnel working in the
area may not be essential.
 Put on gloves and mask
 Use disposable cloth roll or tissue to cover the spill
 Pour disinfectant (1 % sodium hypochlorite solution) over the entire area of the spillage
and let it remain for 20 min.
 The absorbent cloth is picked up and placed in the yellow bag and disposed in the
infected waste container.
 Carefully clean the spill site of any visible material from the edges of the spill to the
center with an aqueous detergent solution.
 Rinse the spill site with soap and water and air dry
 Discard the gloves and mask used for clearing the spillage site into the red container
 Wash hands with soap and water.
 Replace the items used in the spill kit.
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Major Spill Kit
Items Quantity
1. Gloves 4 pairs
2. Mask 4
3. Cap 4
4. Goggles 2
5. Gum Boots 2 pairs
6. Conc. Hypochlorite solution 10% 1 bottle 100 ml
7. Water to dilute 1 bottle 900 ml
8. Old cloth / newspapers 1 bundle
9. Yellow plastic cover 2
10. Adhesive tape 1
Minor Spill Kit
Items Quantity
1. Gloves 2 pairs
2. Mask 1
3. Cap 1
4. Conc. Hypochlorite solution 10% 1 bottle 10 ml
5. Water to dilute 1 bottle 90 ml
6. Old cloth roll 1 bundle
7. Yellow plastic cover 2
8. Adhesive tape 1
17. Biomedical Waste

Waste Management in Hospital
Waste management policy at FERNANDEZ FOUNDATION has been implemented in

accordance with the rules of Telangana State Pollution Control Board and Biomedical
Waste Management and Handling Rules 1998 and The Telangana State Pollution Control
Board 2016
Objectives
 To prevent infection by maintaining good hygiene and sanitation.

 To protect the patient, attendants and all health care personnel from avoidable
exposure to infection
 To prevent environmental pollution
Principles of Waste Management
 Develop a waste management plan that is based on an assessment of the current
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situation and which minimizes the amount of waste generated.

 Segregate clinical (infectious) waste from nonclinical waste in dedicated containers.
 Transport waste in dedicated trolleys.
 Store waste in specified areas with restricted access.
 Collect and store sharps in sharps containers. Sharps containers should be made of
plastic or metal and have a lid that can be closed. Mark the storage areas with a
biohazard symbol.
 Ensure that the carts or trolleys used for the transport of segregated waste collection
are not used for any other purpose – they should be cleaned regularly.
 Identify a storage area for waste prior to treatment or being taken to final disposal
area
 To manage waste in a clean healthy economical and safe manner
 To minimize waste
Types of Waste:
 Biomedical Waste
Bio-medical waste means any waste, which is generated during the diagnosis,
treatment or immunization of human beings, animals or in research activities
pertaining thereto or in the production or testing of biological and including
categories mentioned in Schedule 1 of BMW Rules 1998 and 2016
 Infectious Waste
Infectious is all those medical wastes which have the potential to transmitViral,
Bacterial or parasitic diseases. It includes both human and animalinfectious waste and
waste generated in laboratories and veterinary practice.
 Hazardous Waste
Hazardous Waste is any waste with a potential to pose a threat to Human health and
life .e.g.: infectious waste.
 Soiled Waste
Soiled waste is any item contaminated with blood, body fluids including cotton,
gauze, dressings, bandages, soiled plaster casts, linen, beddings, and any other
material contaminated like- wise ,cytotoxic drugs & expired medications.
 Solid Waste
Solid waste is waste generated from disposable items other than sharp wastes, such
as tubing’s, catheters, intravenous sets, gloves and any other such wastes.
 Liquid Waste
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Liquid waste is waste generated from Laboratories, washing, cleaning,house-keeping

and disinfecting activities.
 Chemical Waste
Chemical waste is chemicals used in production of biological, chemicalsused in
disinfection, as insecticides etc
 Disinfection
Treatment or process which causes the destruction of Pathogenic organisms but
limited to vegetative forms and not spores
Steps in the management of hospital waste include

 Generation
 Segregation/separation
 Collection
 Transportation, storage
 Treatment
 Final disposal
a) Segregation:
 Segregation is considered the most important aspect of bio-medical waste

management and handling rules, 1998&2016
 It refers to the basic separation of different categories of waste done at source of
generation of bio-medical waste for e.g.: All patient areas, diagnostic service areas,
Operation theatres, Labour rooms, treatment rooms etc. The one bin system is
replaced by a three bin system, thereby reducing the risks of infection and injury as
well as cost of treatment and disposal. Segregation is the most important aspect and
crucial step in bio-medical waste management. Effective segregation alone can
ensure effective bio-medical waste management.
 The waste should be segregated, imposing segregated practices within hospitals to
separate biological and chemical hazardous waste; this will result in a clean solid
waste stream, which can be recycled easily. If proper segregation is achieved through
training, clear standards, and tough enforcement, then resources can be tuned to the
management of the small portion of the waste stream needing special treatment.
 Segregation of the waste shall be done at the point of generation itself
 A colour code is followed and appropriately coded waste bags are placed in bins in all
patient care areas. The HICN is designated to carry a surprise rounds in every unit of
hospital and check for proper segregation and educating new staff then and there.
Regular employee education programmes are held at FERNANDEZ HOSPITALS for
constant sensitization of health workers.
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 All waste containers are discarded when they are 3/4ths full.
b) BMW Transportation:
 Waste from various patient care areas is removed once a day (3-4 times a day for
OT’s, Labour Wards), or more if necessary. All BMW bags are tied at the mouth to
avoid spillage during transport. These are tied at night and kept in the Dirty Utility
Room by the ward/area housekeeper.
 The bags are then collected the next morning by the house keeper specifically
designated for BMW collection.
 Bags are transported to the central waste receiving terminal with the help of a trolley,
via the ramp.
 Avoid the transport of too many bags at one time and contact of the bag with the
body of the personnel.
 Mixing of segregated waste should NEVER be done. It is the duty of unit in charge to
ensure that the bag from the unit is properly transported without mixing.
 The staff is provided with personal protective equipment (PPE).
 Collected Biomedical waste bags are labeled and weighed by the biomedical waste
collection staff.
 Bar coding is done by medi-care company
c) Final disposal:
No final disposal of waste is undertaken within the hospital premises. This is

undertaken by the out sourced agency which is approved by TSPCB. Daily report of
waste generated will be maintained by Housekeeping Department.
Colour Coding and Type of Container for Disposal of BMW 2016
Color Coding Type of Waste Category

Container
Yellow Plastic bag Human tissues, organs, body parts, human foetus, blood and
body fluids,Waste from laboratory cultures, Solid waste
items contaminated with blood or body fluids including
cotton, dressings, soiled plaster casts, linen, bedding and
other material contaminated with body fluids, expired
medicines.
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Red Disinfected Infected Plastic waste. Solid waste generated from

container/Plastic disposable items other than the waste sharps such as
bag tubing’s, catheters, intravenous sets, vacutainers
Sharps Disposal Puncture proof Sharps - Waste material which could cause the person
Boxes - BD container handling it a cut or puncture of skin, wastes like fixed
needles, suture needles, blades, lancets, scalpels etc. This
includes both used and unused sharps.
Blue Glassware Broken/unbroken glassware – used and unused vials,
ampoules other sharps, glass slides, metallic implants
Black Plastic bag General Waste, such as paper cups, paper, tissues, food
articles, wrappers, plastic water bottles etc.
Note: Used and Unused blood products are autoclaved and discarded.
Discarding of Blood Bags unused blood bags are sent to Lab for autoclaving, and then discarded in to
yellow bag.
18. Staff Health Programme
Pre employment Medical Check up
 A medical checkup is performed during placement process according to protocol laid

down. This ensures that the health status and needs of all employees joining the
hospital are assessed.
Vaccination
 Vaccination against Hepatitis-B is provided to all staff members involved in direct

patient care.Housekeeping, Laundry & Maintenance staffs are also given TT Vaccine.
 Prophylactic Vaccinationsare given to staff in case of any outbreak or as and when

required as decided by the HICC time to time.
 All new canteen staff shall henceforth be tested for the following:
 Stool Culture test
 Stool examination
 Blood Grouping
Stool culture & sensitivity & Stool examination, shall be done at the time of joining,
once in every three months or if the staff rejoins after aleave of 15 days or more.
Typhoid Vaccine shall also be provided to all canteen staff followed by booster every 3
years.
Records of all test results and vaccinations shall be maintained with the infection
control nurse.
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Annual health Check
 Annual health check is done for all staff.
Health Training Programs
 Periodic education programs are conducted for paramedical staff by the ICO/ICN.
 All employees MUST attend these programs.
 All employees are instructed to adhere to standard precautions, isolation policies,

hand washing protocols and waste management.
 All staff is informed that they should report exposure to potentially infectious body
fluid to their immediate supervisor who in turn informs the ICN. Action is taken after
assessment of risk at each situation. It is mandatory to report all such exposures on
prescribed form.
 Personnel shall adhere to policies and practices to minimize the potential spreadof
diseases and or infection.
 Personnel shall adhere to existing employee health requirements and pre- and post-
exposure prophylaxis programmes etc.
19. Isolation Policies & Procedures

Introduction
The term “Isolation” is the use of Infection Prevention and Control precautions aimed
at controlling and preventing the spread of infection.
Isolation precautions should be used for patients who are either known or suspected to
have an infectious disease, are carrying a multi-resistant organism or are particularly
vulnerableto infection. It is important however, that staff ensure that standard Infection
Prevention controlprecautions are used for all patients regardless of their status.
The Organization’s Infection Prevention and Control policies must be used in conjunction
with this advice. These include:
Standard Precautions Policy
Hand Hygiene Policy
Laundry Policy
Sharps Policy
Decontamination Policy – Cleaning, disinfection and sterilisation ofmedical equipment and
the environmentBiomedical Waste Management Policy
Influenza Policy
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There are two types of isolation –
A) Source Isolation (barrier nursing) where the patient is the source of infection and is
designed to prevent the transmission of pathogens from an infected patient to other
patients, hospital personnel and visitors.
B) Protective Isolation (reverse barrier nursing) where the patient requires protection i.e. they
are immunocompromised.Microorganisms are transmitted by three main routes.The type
of isolation precautions determined by the way the organism or disease is transmitted.
 Infection by direct or indirect contact: Infection occurs through direct contact

between the source of infection and the recipient or indirectly through contaminated
objects. (e.g., Herpes simplex virus [HSV], respiratory syncytial virus, Staphylococcus
aureus),
 Air-borne infection: Infection usually occurs by the respiratory route, with the agent
present in aerosols (infectious particles less than 5 μm in diameter).(e.g., M.
tuberculosis).
 Droplet infection: Large droplets carry the infectious agent (greater than 5 μm in
diameter)(e.g., influenza virus, B. pertussis)
 Some infectious agents, are transmitted by more than one route.
A two-tiered approach to precautions is used to interrupt the mode of transmissionof infectious

agents.
A) Standard precautions:
B) Transmission-based precautions(Contact based precautions): areprecautions required to be
taken based on the route of transmission oforganisms like contact precautions, airborne
precautions&Droplet precautions, etc.
If successfully implemented, standard and transmission-based precautions preventany infection
from being transmitted.
Standard Precautions:are routine IPC precautions that should apply to ALL patients, in all
health-care settings.
The key components of standard precautions are:
1. Hand hygiene:section 12
2. Personal protective equipment:section 13
3. Respiratory hygiene and cough etiquette
4. Prevention of injuries from sharps:section 14
5. Safe handling of patient-care equipment
6. Environmental infection control
a. Patient placement
b. Environmental cleaning
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c. Linen and laundry

d. Waste disposal
B.1.3. Respiratory hygiene

Controlling the spread of pathogens from infected patients (source control) is key to avoiding
transmission to unprotected contacts. For diseases transmitted throughlarge droplets or droplet
nuclei, respiratory hygiene should be applied by all individuals with respiratory symptoms (90).
Respiratory hygiene refers to covering themouth and nose during coughing or sneezing using
medical masks (Annex A, Section A.2.2), cloth masks, tissues or flexed elbow, followed by hand
hygiene to reducethe dispersal of respiratory secretions containing potentially infectious
particles.
Health-care facility management should promote respiratory hygiene as follows:
Promote the use of respiratory hygiene by all health-care workers, patients and family members
with ARIs.
Educate health-care workers, patients, family members and visitors on the importance of
containing respiratory aerosols and secretions to help prevent thetransmission of ARI
pathogens.
Consider providing resources for hand hygiene (e.g. dispensers of alcohol-based hand rubs and
handwashing supplies) and respiratory hygiene (e.g. tissues);prioritize areas of gathering, such
as waiting rooms.
Transmission-based precautions
These apply to patients with any of the following conditions and/or diseases:
o Presence of stool incontinence (may include patients with norovirus, rotavirus,
or Clostridium difficile), draining wounds, uncontrolled secretions, pressure
ulcers, or presence of ostomy tubes and/or bags draining body fluids.
o Presence of generalized rash or exanthemas.
 Prioritize placement of patients in an examination room if they have stool
incontinence, draining wounds and/or skin lesions that cannot be covered, or
uncontrolled secretions.
 Perform hand hygiene before touching the patient and prior to wearing gloves. Also
perform hand hygiene after touching the patient and after removing gloves.
 Instruct patients with known or suspected infectious diarrhoea to use a separate
bathroom, if available; clean or disinfect the bathroom before it can be used again.
 In addition to Standard Precautions, use contact precautions for specified patients
known or suspected to be infected or colonized with epidemiologically important
microorganisms that can be transmitted by direct contact with the patient or patient
care items.
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 Patient placement: A single room is preferable. Cohort only with patients who are
affected by the same organism. Isolation Rooms for Unit-1 are 213, 114. There are 2
designated isolation Rooms for Unit-2 – one in ICU, one in 203.
 Patient transport: Limit the movement and transport of the patient from the room
for essential purposes only. Where necessary ensure that adequate precautions are
taken to minimize the risk of transmission to others, and contamination of
environmental surfaces or equipment.
Patient care equipment: Where possible dedicate the use of patient care equipment to a
single patient. Otherwise, ensure that all items are adequately cleaned or disinfected before
use for another patient.
Droplet Transmission
In the case of droplets (large particle droplets more than 5μm in size), the mechanism
of transfer of the organism is quite distinct from either direct or indirect contact
transmission. Droplets are generated from the patient primarily during coughing,
sneezing, and during certain procedures such as suctioning and bronchoscopy.
Transmission occurs when droplets containing microorganisms generated from the
infected person are propelled a short distance through the air and deposited on the
host’s conjunctivae, nasal mucosa, or mouth. Because droplets do not remain
suspended in the air, special air handling and ventilation are not required.
 Droplet precautions:
These should be applied to patients known or suspected to be infected with a
pathogen that can be transmitted by the droplet route. These precautions include,
but are not limited to:
o Respiratory viruses (for example, influenza, parainfluenza virus, adenovirus,
respiratory syncytial virus, human metapneumovirus).
o Bordetella pertussis.
o For first 24 hours of therapy: Neisseria meningitides, group A streptococcus.
Place the patient in an examination room with a closed door as soon as
possible (prioritize patients who have excessive cough and sputum
production); if an examination room is not available, the patient should be
provided a face mask and placed in a separate area as far from other patients
as possible while awaiting care.
 PPE use:
o Wear a face mask, such as a procedure or surgical mask, when in close contact
with the patient; don the face mask upon entering the examination room.
o If substantial spraying of respiratory fluids is anticipated, gloves and gown as
well as goggles (or face shield in place of goggles) should be worn.
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o Perform hand hygiene before and after touching the patient and after contact
with respiratory secretions and contaminated objects or materials. Use soap
and water when hands are visibly soiled (for example, with blood, body fluids).
o Instruct the patient to wear a face mask when exiting the examination room,
avoid coming into close contact with other patients, and practice respiratory
hygiene and cough etiquette.
o Clean and disinfect the examination room accordingly (in addition to Standard
Precautions).
 Patient placement
o Single Room: Special air handling or ventilation is not necessary. Only cohort
with patient/patients who are infected with the same organism.
o Wear a mask when working within three feet of a patient with meningitis.
o Spacing between beds. In open wards there should be adequate spacing
between each bed to reduce the risk of cross-contamination or infection
occurring from direct or indirect contact or droplet transmission. Optimum
spacing between beds is 1-2 meters.
 Patient transport: Limit the movement and transport of the patient from the room
for essential purposes only. If transport or movement is necessary minimize dispersal
of droplets from the patient.
 Patient care equipment: Where possible, dedicate the use of patient care equipment
to a single patient. Otherwise, ensure that all items are adequately cleaned/
disinfected.
Air-Borne Transmission
This occurs through dissemination of either air-borne droplet nuclei (small particle
residue less than 5μm in size) of evaporated droplets containing microorganisms that
remain suspended in the air for long periods of time, or dust particles containing the
infectious agent. Microorganisms carried in this manner can be dispersed widely by air
currents and may be inhaled by a susceptible host within the same room or over a
longer distance from the source patient.
Microorganisms transmitted by air-borne transmission include mycobacterium
tuberculosis, measles, and the varicella virus.
 Air-borne precautions
Apply to patients known or suspected to be infected with a pathogen that may be
transmitted by the air-borne route; these include, but are not limited to:
o Tuberculosis
o Measles
o Chickenpox (until lesions are crusted over)
o Localized (in immunocompromised patient) or disseminated herpes zoster
(until lesions are crusted over)
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o Have the patient enter through a separate entrance to the facility (for
example, dedicated isolation entrance) if available, to avoid the reception and
registration area.
o Place the patient immediately in an air-borne infection isolation room (AIIR).
o If AIIR is not available, provide a face mask (for example, procedure or surgical
mask) to the patient and place the patient immediately in an examination
room with a closed door.
o Initiate protocol to transfer patient to a healthcare facility that has there
commended infection-control capacity to properly manage the patient.
 PPE use:
o If substantial spraying of respiratory fluids is anticipated, gloves and gown, as
well as goggles or face shield should be worn.
o Perform hand hygiene before and after touching the patient and after contact
with respiratory secretions and/or body fluids and contaminated objects or
materials.
o Use soap and water when hands are visibly soiled (for example, with blood,
body fluids).
o Instruct patient to wear a face mask when exiting the examination room, avoid
coming in close contact with other patients, and practice respiratory hygiene
and cough etiquette.
o Once the patient leaves, the examination room should remain vacant for
generally one hour before anyone enters; however, adequate wait time may
vary depending on the ventilation rate of the room and should be determined
accordingly.
o If staff must enter the room during the wait time, they should use respiratory
protection (in addition to Standard Precautions).
 Patient Placement:
o Single room. Negative air pressure.
o Self-closing devices on doors to keep the door closed.
o Ventilation system should provide a means to discharge air from the room to
the outside, such as an exhaust fan. Exhaust fan should be on emergency
power.
o Ensure that all doors and windows remain properly closed in the isolation
room. The slit at the bottom of the door is sufficient to provide a controlled
airflow path.
o The TB isolation room needs to be checked for negative pressure.
o Tissues Test to check negative pressure: A thin strip of tissue should be held
parallel to the door with one end of the tissue in front of the gap. The direction
of the tissue’s movement will indicate the direction of air movement.
 Respiratory Protection:
o Heavy duty N95 or N97 masks should be used for Open Pulmonary
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Tuberculosis or suspected Pulmonary Tuberculosis, Surgical Mask for

Meningococcal or suspected Meningococcal Meningitis.
o Nonimmune or pregnant staff should not enter the room of patients known or
suspected to have rubella or varicella. Persons with immunity to Varicella and
Rubella do not require masks.
 Patient Transport:
o Limit movement or transport of patient from the room to essential purposes
only.
o If transport or movement is necessary, minimize patient dispersal of
organisms.
Patient isolation
Patients are isolated when

 Suffering from highly transmissible diseases e.g. chicken pox, pulmonary
tuberculosis, cholera, H1N1 positive cases. Patient is placed in a single room with
hand washing and toilet facilities.
 Infected with epidemiologically important micro-organisms such as MRSA,
Carbapenem (CRAB) resistant Acinetobacter spp. /Pseudomonas, ESBL positive Gram
negative organisms, Vancomycin resistant Enterococci.
Barrier Nursing
 The aim is to erect a barrier to the passage of infectious pathogenic organisms

between the contagious patient and other patients and staff in the hospital.
Preferably, all contagious patients are isolated in separate rooms, but when such
patients must be nursed in a ward with others, screens are placed around the bed or
beds they occupy.
 Cohort nursing may be practiced as re-infection with the same organism is unlikely.
 The nurses, attending consultants as also any visitors must wear gowns, masks, and
sometimes rubber gloves and they observe strict rules that minimize the risk of
passing on infectious agents. Hand hygiene practices are observed after they have
been attending the patient.
 Bedding is carefully moved in order to minimize the transmission of airborne particles,
such as dust or droplets that could carry contagious material.
 Barrier nursing must be continued until subsequent cultures give a negative report
Cleaning of equipment and articles

 Contaminated disposable articles are bagged in appropriate color coded and leak
proof bags and disposed.
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 Critical reusable medical equipment is disinfected or sterilized after use.

 Non-critical equipment is cleaned, disinfected after use.
Laundry
 Soiled linen should be handled as little as possible and with minimum agitation to
prevent gross microbial contamination of the air and of persons handling the linen. All
soiled linen should be bagged and sent to the laundry as infectious to be treated
separately.
Terminal Cleaning
 Terminal cleaning of walls, blinds, and curtains may be done. Disinfectant fogging is
not recommended.
Isolation Policy for Certain Groups of Organisms

 MRSA (Methicillin Resistant Staphylococcus Aureus)/VRE(Vancomycin Resistant
Enterococcus).
o When MRSA is isolated in the lab the microbiologist will inform the /sister-in-
charge/duty doctor/head of unit.
o Patient is isolated and barrier nursed. Hand washing is strictly adhered to by all
concerned. Linen is changed on a daily basis. Any contamination of linen
requires to be decontaminated by autoclaving before sending to the laundry.
o In case of out breaks, selected staff will be screened. If any staff is found to be
colonized, they are restricted from work, advised mupirocin ointment 2% for 1
wk for eradication of nasal carriage and allowed to return to work after 2
consecutive culture drawn 1 wk apart are found to be negative.
o Screen hospital transfer patients, where the hospital of transfer carries a risk of
MRSA. Infection
o Isolate the MRSA/VRE positive patient under Contact Isolation with mask
category. Accommodate such patients away from those with open wounds
orthose who are immune compromised.
o Hand washing is the single most important factor in containing MRSA.
o The bed used by the patient, and other equipment used for the patient should
be disinfected before use for another patient.
o Disinfection procedures should be carried out on a daily basis, as outlined
under Isolation Procedures.
o Linen: Sheets, pillow cases, and blankets should be changed on a daily basis
and more often if soiling occurs. Linen should not be shaken in order
topreventdissemination of microorganisms to the environment. The same
applies to masks, gowns and gloves. Soiled linen should be placed in a laundry
bag in the patient’s room or at the location where it was used. It should be
placed in bags that prevent leakage.
o Disposable dishes and utensils used for eating are not required for patients in
isolation. Reusable dishes may be used for patients in isolation, because the
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combination of dishwasher detergents and high water temperature

adequately decontaminates dishes.
o Procedures for decolonization of the patient which include daily bath with an
antimicrobial soap should be followed.
o When the patient is discharged, terminal disinfection should be carried out as
outlined under Isolation Procedures.
 Multi-resistant bacteria
o E.g.Carbapenem resistant Acinetobacter,multi-resistant Pseudomonas
aeruginosa
o The aim is to curtail the spread of such bacteria. Hence patient is to be placed
on strict barrier nursing precautions irrespective of whether the organism is a
coloniser or the cause of infection
 Pulmonary tuberculosis
o Masks should be used during the care of all patients with sputum positive
pulmonary tuberculosis.
o Isolation precautions are to be followed until all previous culture sites are
negative
o Respiratory precautions should be taken for smear-positive pulmonary
tuberculosis.
o Elective surgery for patients with active TB infection is recommended.Elective
operative procedures on patients with active pulmonary or laryngeal TB should
be postponed until the patient is no longer infectious.
 HIV/HBV/ HCV/ H1N1: All standard precautions to be followed strictly.
 Duration of Contact Precautions:For patients, colonized or infected with

microorganisms like MRSA or VRE, three negative cultures taken one week apart can
be used to discontinue contact precautions. In other patients, resolution of symptoms
that lead to the isolation (such as diarrhea in the case of C. difficile infection) may be a
reasonable time to stop the isolation.
Guidelines for Suspected H1N1 patients:

 When a patient with symptoms of Swine flu comes to Fernandez Hospital, patient will
be taken directly to ER. When suspected swine flu patients are in ER, they will not
receive other normal patients. Normal patients will be directed to admission room.
 ER will be cleaned horoughly once the patient leaves.
t
 Those patients who are not significantly ill will be sent home and those with more
critical symptoms will be admitted in designated isolation rooms. (As per Primary
consultant& instructions)
 Face masks will be made available in ER for patients and attendants to minimize the
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spread of virus
 Isolation Rooms for Unit-1 are 213, 114. 2nd floor rooms at FH2 will be used for all
suspected and swine flu positive patients.
 Unbooked/referral patients with respiratory failure who are brought in ambulance will
be seen in the ambulance itself and will be sent to other hospitals.
 Oseltamivir tablets are stocked in the pharmacy so that the treatment can be started
Immediately.
 H1N1 testing kits are made available in Laboratory. In case a sample has to be sent to
IPM, a lab technician will collect the sample and will send it to IPM
 IPM processes the samples only till 12:30 PM. Any sample taken after 12:30 pm will be
processed only the next day. However, they collect the samples till 3:30 pm.
 IPM is not accepting any OP samples. A suspected OP patient has to be sent to IPM
where they collect the samples themselves
When single rooms or isolation rooms are not available and where several patients with the
same confirmed organism have been identified these patients may be nursed together in a bay
or ward. This is called Cohort nursing. Examples may include diarrhoea and vomiting,
Clostridium difficile diarrhoea, norovirus and influenza. This will be done with the advice of a
member of the HICC.
It is acknowledged that there are constraints to placing every patient who is either colonised
with a pathogen or who is showing clinical signs of transmissible disease into aisolation room.
However, a Risk Assessment must be carried out, in conjunction with the Infection Prevention
and Control Team.
Where a patient is isolated, the appropriate information relating to the risk assessment must
be documented in the patients’ notes.
An ongoing daily review must be undertaken by the Nurse in Charge to ensure to prevent
patients remaining in isolation unnecessarily i.e.Clostridium difficile patient who has had no
further diarrhoea for 48 hours etc.
Risk Assessment
4.1 All patients identified with infectious diseases or alert organisms will be risk assessed for
the need for isolation. This will take place between the Infection Prevention and Control Team
and the clinical team.
4.2 Risk assessment is the assessment of the factors that influence the transmission of a
pathogen and its impact. It enables staff to prioritise the use of isolation facilities.
4.3 However, the need for isolation of specific infections in side rooms does not take into
account the limited resources available which may lead to inconsistent decisions.
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4.4 In order to minimize inconsistent decisions, a risk assessment must be undertaken. A

discussion must take place between the clinical team and Infection Prevention and Control
Team. This Risk Assessment must be clearly documented in the patient’s medical records.
The following factors will be considered:

The classification of the pathogen and the ability to protect against or treat individual
infections
The probable route of transmission and evidence of transmission
Susceptibility of the other patients near to the infected patient in the same bay i.e. do the
other patients have open wounds or an invasive device
Whether the organism is antibiotic resistant
Possible detrimental effects of isolation to the patient i.e. risk of falls, confusion or depression
weighed against severity of the risk of transmission to other patients.
5. Effective Communication
1. Effective communication must be cascaded to other members of the team both verbally, by
documentation and through appropriate signs/ door labels etc. ensuring that patient
confidentiality is maintained.
2.The patient must be informed as to the reasons why they require isolation. A full explanation
as to procedures and precautions must be provided.
3. If nursing and medical staff have discussed the reasons why the patient needs isolation and
when they have additional questions that cannot be answered the Infection Prevention and
Control Team can be contacted to discuss these issues with the patient.
Protective Isolation
6.1 Protective isolation is intended to prevent a more susceptible patient acquiring infection e.g.
patients with lowered immune systems.
6.2 This is best achieved in a positive pressure side room, although a general side room may be
used with the door remaining closed.
6.3 Staff/ visitors with infections including colds, flu like symptoms and active cold sores should not care for or visit
the patient.
The room/ furniture should be cleaned with detergent and water prior to admitting the patient.
6.4 Staff must ensure that they decontaminate their hands and put on a clean apron before
entering the room.
6.5 Compliance with this policy can be monitored via exception only which may be reported via
associated standing agenda items for committees, (i.e. increased outbreaks of MRSA of C Diff,
may prompt a further investigation of compliance with Infection Prevention Control Policies).
7. Responsibilities
7.1. Management responsible for:
The provision of a safe environment within health-care premises. This included the provision of
adequate isolation facilities.
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Ensuring that the environment in which patients are nursed is designed so that the risks of
transmission of infection are minimised.
Ensuring that the Infection Prevention and Control Team are involved in design of new or
refurbished clinical facilities from an early stage such that sufficient isolation facilities can be
provided.
Funding additional resources necessary to prevent / control an outbreak as appropriate
Ensure that the provision of existing isolation facilities or single rooms are not compromised by
future service developments and ward reconfigurations.
7.2. The Infection Prevention and Control Team are responsible for:
Providing education to clinical staff on the early detection of possible infectious conditions and
possible outbreaks.
Providing training on the Isolation policy.
Communicating up to date information relating to isolation issues and outbreaks to appropriate
personnel within the organization and the Government Health Authority.
Advising and co-ordinating the appropriate action to be taken to isolate patients and
prevent/limit hospital outbreaks.
7.3 The Infection Prevention and Control Team should be informed about:
Individual patients needing isolation, where a side room is not deemed appropriate for the
patient i.e. detrimental to the patient’s condition e.g. confusion, risk of falls, psychological
effect etc.
Infectious patients and / or staff members where contact tracing will be required e.g.
chickenpox, shingles, pulmonary Tuberculosis etc.
Potential outbreaks so that advice about appropriate isolation of patients can be givenWhere
side rooms are not available for patients requiring isolation.
7.4 Managers/Senior Sisters are responsible for:

Ensuring dissemination of this policy.
Ensuring compliance with this policy and ensuring patient safety is maintained.
Facilitating the delivery of education provided by the Infection Prevention and Control Team.
Ensuring staff in their area have the knowledge and skills to work safely.
Ensuring correct equipment e.g. gloves, aprons, alcohol hand gels are available.
Co-ordinating staff, linen and glove supplies etc., during an outbreak following the outbreak
policy.
Take action when staffs fail to follow the principles of this policy.
7.5 Clinical teams are responsible for:
The prompt notification of Infectious diseases.
Communicating to Infection Prevention and Control details of patients known or suspected of
infectious disease.
Ensuring that they comply with this policy.
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10.6 All staff are responsible for:

Implementing standard infection prevention and control precautions for all patients and abiding
by the guidance of this policy.
Providing the special requirements for the management of patients with specific infections that
are either known or suspected by:
Ensuring that prompt action is taken and the Isolation policy followed whenever a patient is
suspected or known to be infectious
Undertaking a risk assessment on suspected or known infectious patients and moving patients
to a side room as appropriate
Ensuring effective communication to other members of the team both verbally and through
appropriate signs patient care plans etc. (See appropriate policies relating to MRSA, Varicella,
Tuberculosis etc.)
Ensuring the appropriate PPE is readily available and easily accessible
Liaising, as appropriate, with the Infection Prevention and Control Team and the bed manager
when a side room is not available so that a risk assessment can be under taken
Ensuring that the room/ bed space is cleaned to the appropriate standard after the discharge/
transfer of the patient
Ensuring that they report to Occupational Health/Line manager prior to attending work if they
have an infectious illness such as diarrhoea and vomiting, flu like symptoms or a rash of
unknown origin.
Prevention of Infection for Newborns of a suspected or confirmed Influenza positive mother
1. To reduce the risk of influenza virus transmission to the newborn, consider temporarily
separating the mother following delivery during the hospital stay.
2. Throughout the course of temporary separation, Mothers who intend to breastfeed should
be encouraged to express their milk to establish and maintain milk su ply.
p
3. The optimal length of t mporary separation in the hospital will be till the mother has been
e
a febrile without antipyretics for >24 hours
4. If co-location (sometimes referred to as “rooming in”) of the newborn with his/her ill
m
mother in the same hospital room occurs in accordance with the mother’s wish:
 Physical barriers (e.g. a curtain between the mother and newborn)
 Keeping the newb rn ≥6 feet away from the ill mother
o
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 A mother with suspected or confirmed influenza should put on a facemask and then
practice hand hygiene before each feeding. Mother is on Droplet Precautions in a
health care facility.
5. Once contact between mothers and newborn is resumed, Droplet Precautions for influenza
should continue to be observed in the hospital until at least 7 days after maternal illness
onset.
NICU
 Newborn of a mother with suspected or confirmed Influenza should be closely
observed for signs of infection using Standard Precautions.
 Symptomatic mothers,
h care givers, and family members should not enter the NICU.
 A newborn that develops signs of possible illness should be placed on Droplet
Precautions and examined by a physician. Influenza testing should be part of
the assessment and treatment with Oseltamivir should be considered.
Before Hospital Discharge
 Influenza vaccination should be strongly encouraged and, when possible, provided for
any unvaccinated family members aged 6 months and older and caregivers who will
be in contact with the newborn.
 Caregivers should be advised to:
o Contact their health care provider promptly if the newborn develops signs that
suggest influenza virus infection.
o Isolate any individuals in the home who become ill in order to minimize
exposure to the newborn.
If possible, have vaccinated non-ill adults provide care to the newborn at home
o
until the m ther’s illness resolves.
o
o Ensure that the ill postpartum woman follows hand ygiene and respiratory
h
hygiene and cough etiquette when having contact with her newborn.
d
Reference: CDC GUIDELINES: Guidance for the Prevention and Control of Influenza in the
Peri- and Postpartum Settings, 2017-2018 influenza season
Visitor's Policy When Patient is in Isolation
 The ward sisters and doctors concerned have the responsibility of informing the
patients’ relatives of the measures to be taken and the importance of restriction of
visitors.
 The patient and the relatives must be given health education about the cause, spread,
and prevention of the infection in detail. The need for isolation and restriction of
visitors should be discussed with them.
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 Hand washing after all contact with the patient has to be stressed.
 Visitors need to wear an N95 respirator. Be aware ofrestrictions on visitation due to
outbreak or other conditions within the facility.
 No more than two adult visitors should be allowed at a time during the hospital
visiting hours and the length of stay should be governed by the needs of the patient.
 Children below 12 years of age should not be allowed into isolation areas.
 Visitors’ footwear, bags, and other belongings should be left outside the room.
 Visitors should not be allowed to sit on the patient’s bed.
 Visitors should wash their hands well with soap and water before entering andwhen
leaving the room.
 Any prophylactic medication or active immunization for attendants should
beconducted by the physician in charge.
Visitor's Policy for ICU Patients:
For Routine ICU observation:

 Patients who are under routine observation followed by LSCS or other surgeries
attendees are allowed see the patients provided see through glass door. No
attendee’s are allowed inside the ICU
For critical ill patients:
 Attendee’s are allowed to see the patients wearing PPE (gown, mask and cap) for
10min
 Patients who are ambulating requiring ICU stay more than 12 Hrs:
 Patients who are ambulating made to sit in the adjusting room (PAC); attendees can
spend some time with patients for 15-20min.
20. High-Risk Areas and High-Risk Procedures

Introduction
 Nosocomial Infection rates in the intensive care units are higher than in the general
population. This is related to severity of illness and greater susceptibility to acquiring
microorganisms related to the ICU.
 ICUs have higher rates of invasive procedures, patients on ventilators for prolonged
periods, and a large category of health workers. The risk of transmission of Potentially
Pathogenic Microorganisms (PPMs) is very high.
 In the ICU, during urgent critical care interventions there is often a possibility of
suboptimal infection control practices.
Five Main Infection Control Maneuvers to Control Transmission
 Hand hygiene
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 Personal protective equipment (gloves, gowns and aprons)

 Isolation where required
 Proper handling and decontamination of patient care equipment
 Proper handling of patient care environment.
Certain areas of the hospital are identified as high-risk areas for acquisition and
transmission of pathogenic microorganisms. The Manual has identified the following
high-risk areas and highrisk procedures which have a high potential for healthcare
associated infections.
General Principles to be followed in High-Risk Areas
Standard precautions: Standard precautions as appropriate should be followed by all

staff while handling patients or samples (refer to the section on Standard Precautions
in Healthcare described in this manual).
 Hand washing: Importance of this cannot be overemphasized in the ICU setting. Use
hand rubs with 2 percent chlorhexidine between patients and clinical hand wash
solution (4 percent chlorhexidine) prior to invasive procedures.
 Aprons and gloves: Wear aprons and gloves when necessary. Remove and discard
them into the appropriate bin immediately after each patient. Use gloves when in
contact with body fluids (examination gloves) and invasive procedures (sterile gloves).
 Mask: Wear a mask while examining patients with potential air-borne pathogens.
Wearing a mask is mandatory when in isolation areas.
 Goggles: Use goggles when you anticipate a splash or when handling bio hazardous
materials.
Some of the High-Risk Areas:
 Intensive care units

o Medical: Neonatal
o Surgical: Postoperative ICU
 Operation theatres
 Obstetrics and labour room
 Emergency Medicine
 CSSD
Surveillance of High-Risk Areas
 High-risk areas are an important area of targeted surveillance in the SHCO.
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 High risk cases are :

o Mechanical ventilation
o Central line catheterization
o Arterial line catheterization
o TLH/TAH/VH
o Neonatal laparotomies, colostomy
o Re-Laparotomy
o Blood patch for post Dural puncture head ache(PDPH)
 The staff and doctors in high-risk areas should actively liaise with the Infection
ControlDepartment in monitoring reporting and analyzing infections.
 Surveillance is done actively in the following cases:

o Hospital acquired infections:
 Catheter Associated Urinary Tract Infection (CAUTI)
 Central Line Associated Bloodstream Infection (CLABSI)
 Surgical site infection (SSI)
 Ventilator associated pneumonia (VAP)
o Bed sore analysis
o Needle-stick injuries
o Multidrug-resistant organisms:
 Methicillin Resistant StaphylococcusAureus (MRSA)
 Vancomycin Resistant Enterococci (VRE)
o Environmental surveillance.
21. Care of systems and indwelling devices

General guidelines
 Hand hygiene is mandatory before, after and in-between procedures and patients.
 All health care workers should be familiar with the personal protection (Standard
precautions) required for each procedure. These precautions should be strictly
adhered to.
 Follow proper waste segregation & disposal after each procedure.

Vascular Care
 Hand Hygiene:Wash hands with 2% chlorhexidine before every attempted

intravascular catheter insertion. Antimicrobial hand washing /hand hygiene is
desirable, and preferred before attempted insertions of central intravenous catheters,
catheters requiring cut downs, and arterial catheters.
 Preparation of skin:10% Povidone-iodine (PVP) or 70% alcohol may be used

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forcleaning the skin. Insertion sites should be scrubbed with a generous amount of
antiseptic. Beginning at the centre of the insertion site, use a circular motion and
move outward. Antiseptics should have a contact time of at least 30 seconds prior to
catheter insertion. Antiseptics should not be wiped off with alcohol prior to catheter
insertion. Do not palpate after skin preparation.
 Inspecting catheter insertion sites:
o Intravascular catheters should be inspected daily andwhenever patients have

unexplained fever or complaints of pain, tenderness, or drainage at the site for
evidence of catheter related complications.
o Inspect for signs of infection (redness, swelling, drainage, tenderness) or

phlebitis and also palpate gently through intact dressings.
 Manipulation of intravascular catheter systems:
o Strict aseptic technique should be maintained when manipulating

intravascular catheter systems. Examples of such manipulations include the
following:
 Placing a heparin lock

 Starting and stopping an infusion
 Changing an intravascular catheter site dressing
 Changing an intravascular administration set
o Clean injections ports with betadine solution before injecting.
o Flush with normal saline before and after medication.
o Cap all stopcocks when not in use.
 Flushing IV lines:Solutions used for flushing IV lines should not contain glucose which
can support the growth of micro-organisms. Do not reuse syringes used for flushing.
One syringe is used for flushing IV line only once.
 Peripheral IV sites (short term catheters):
o Dressing Changes: Peripheral IV site dressings should not usually require daily
changes, since peripheral IV catheters, should be changed within 72 hours.
o Replacement of Peripheral IV Catheters:Peripheral IV catheters should be

removed 72 hours after insertion, provided no IV-related complications,
requiring catheter removal are encountered earlier. A new peripheral IV
catheter, if required, may be inserted at a new site.
 Central intravascular catheters (long term catheters)
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o Dressing changes:Central IV catheter dressings should be changed every 72

hours.
o Replacement of central IV catheters:Central IV catheters do not require

routine removal and reinsertion. The catheter can be kept for a maximum of 3
months, provided there is no sign of catheter related infection or other
complications.
 Catheter related Infection
o At the time of catheter removal, the site is examined for the presence of
swelling, erythema, lymphangitis, increased tenderness and palpable venous
thrombosis. Any antimicrobial ointment or blood present on the skin around
the catheter is first removed with alcohol. The catheter is withdrawn with
sterile forceps, the externalized portion being kept directed upward and away
from the skin surface.
o If infection is suspected, after removal, the wound is milked in an attempt to
express purulence. For 5.7 cm catheters, the entire length, beginning several
millimeters inside the former skin surface catheter interface, is aseptically cut
and sent for culture. With longer catheters, (20.3 cm and 60.9 cm in length),
two 5-7 cm segments are cultured a proximal one beginning several
millimeters inside the former skin catheter interface and the tip. Catheter
segments are transported to the laboratory in a sterile container.
o Three way with extension is used only when multiple simultaneous infusions or
Central Venous Pressure monitoring are required.
 Arterial Lines
o Placement of radial and dorsalis pedis arterial lines can be performed after
hand hygiene and wearing of sterile gloves.
o All femoral arterial catheterization should be done using maximal sterile

barrier precautions (Full Sterile Gown, Cap, and Mask Sterile Gloves & Sterile
Drapers).
o A sterile gauze or transparent dressing should be used.
o Dressing to be changed after 2 days if intact and immediately if moist,

loosened, or soiled.
o Arterial catheters can be left in situ for 96 hours(if site of insertions is infection
free)
o Maintain potency using a closed continuous flush system.
o Keep all components of pressure monitoring system sterile
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Respiratory Care
In addition to the general guidelines that are to be adhered to, the following should
also be noted with regard to respiratory care:
 Mouth flora influences development of nosocomial pneumonia in ventilated patients.

Frequent chlorhexidine mouthwashes minimize the chances of pneumonia.
 Ventilator
o Sterile water is to be used in nebulizers and humidifiers. This should be

replaced once a day.
o Pneumatic circuits (masks, Y connection and tubes) are to be changed every

24-48 hours. Condensate in tubing should not be drained into the humidifier or
airway as they contain large numbers of pathogenic organisms. This should be
drained only into water traps. Use disposable circuits if cost permits.
o Use heat and moisture exchanging filter (HMEF) at Y connection for all
patients if feasible and cost permits. Heat and moisture exchanging filter
(HMEF) is to be changed every 24- 48 hours. It should not be removed from
circuit except at the time of changing.
o Disposable Oxygen masks, venture devices and nebulizer chambers are being
used.
o Humidifier domes are disinfected with soap and water.Ambu bags are cleaned
thoroughly DiyMantel,soak in 3m multi-enzyme,wash with water, soak in
Parasef,Rinse with water, sterile water ,dry and store it.
o Microbiological surveillance of respiratory therapy equipment is practiced in

the hospital in case of epidemiological surveillance in an outbreak situation.
 Tracheotomy Care/ Endotracheal Tube care
o Careful attention to post-operative wound care is mandatory.
o The patient should receive aerosol therapy to prevent desiccation of the

tracheal and bronchial mucosa or the formation of crusts. The skin around the
tracheotomy tube should be cleaned with Betadine (Povidone-iodine 5%)
every four hours or more frequently, if necessary.
o The tracheotomy tape securing the tube should be changed every 24 hours.
This tape must be tied securely at all times.
o The first complete tube change should be performed no earlier than 7 days to
allow time for the tract to be formed. Subsequent changes should be done
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weekly or as necessary.
o Clean technique should be used to change the tracheotomy tube unless there
is a medical indication for sterile technique.
o The obturator should be at the bedside (preferably taped to the head of the
bed) to be used if the tracheotomy tube accidentally is dislodged or is removed
for any reason.
Urinary catheter
 Urethral catheterization
o Personnel:Only staffs who know the correct technique of aseptic insertion and
maintenance of catheters should handle catheters.
o Catheter Use: Urinary catheters should be inserted only when necessary and
left in place only as long as medically necessary.
o Hand washing: Hand washing should be done immediately before and after
any manipulation of the catheter site or apparatus.
o Catheter Insertion
 Catheters should be inserted using aseptic technique and sterile

equipment.
 Use an appropriate antiseptic solution for periurethral cleaning.
 As small a catheter as possible, consistent with good drainage, should
be used to minimize urethral trauma.
 Indwelling catheters should be properly secured after insertion to
prevent movement and urethral traction.
o Anchoring the catheter: Strapping of the catheter is done to lateral side of
thigh in patients. This is to prevent direct transmission of the weight of the bag
on the catheter, so that pulling and inadvertent dislodgment of the catheter
does not occur.
Wound Care
 Surgical wounds
o Surgical wounds after an elective surgery are inspected on the third post-
operative day, or earlier if wound infection is suspected.
o All personnel doing dressings should wash their hands before the procedure.
Ideally, a two member technique is followed. One to open the wound and one
to do the dressing.
o If two health care workers are not available, then, take off the dressing, wash
hands again before applying a new dressing.
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o A clean, dry wound may be left open without any dressing after inspection.
o If there is any evidence of wound infection, or purulent discharge, then

dressings are done daily, using Povidone-iodine to clean the wound and
applying dry absorbent dressings.
o Adequate PPEs, soaps, disinfectants are made available always to practice

barrier nursing techniques and hand hygiene practices.
22. Re-use Policy
 No other single-use instrument apart from those listed below shall be re-used.
 Each single-use instrument which is authorized for re-use shall have a sticker mentioning
the date of re-use, as well as the number of its re-use. The sticker shall be smudge-proof.
S. NAME OF THE NO. OF TIMES IT

METHOD OF DISINFECTION
NO INSTRUMENT CAN BE REUSED
Wash under running water and dry. Pack with 1gm of

Harmonic
1. formalin tablets in a specified rack for 24 hrs or till further 4 Times
Scalpel
re-use. Before re-using wash with normal saline.
Endopath Wash under running water, soak in Peracetic acid

2. Scissors (Rely+onParasafe) for 10 minutes, and then wash with Thrice
(ETHICON) distilled water before re-using.
Wash under running water; soak in Peracetic acid

3. GA Mask (Rely+onParasafe) solution for 10 minutes. Wash with 5 times
distilled water before re-using.
23. Disinfection and Sterilization

 There will be an itemized list of all patient care practices together with particulars of
the disinfectant to be used and the details of the procedure.
 Routine supervision will be carried out to ensure that the disinfectants are used
according to the instructions.
 Regular in-use testing is usually required to check the efficiency of disinfection

procedures and proper use of disinfectants.
 The infection control team is responsible for the training of potential users of
disinfectants and continuing education of employees and professional staff on the
proper use of disinfection.
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 The pharmacy department shall perform its role in offering technical assistance in the
choice and effective use of disinfectants in addition to precautions and safety
measures to these chemical agents.
 The Infection Control Committee will update this policy every two years.
 Adequate space and appropriate zoning is available for sterilization activities in OT

and CSSD.
Terminology
Any micro-organism, including bacterial spores that come in contact with normally
sterile tissue can cause infection. All items that come in contactwith normally sterile
tissues should be sterilized. Bacteria and viruses can be transmitted to patients on
instruments or equipment. These must be decontaminated between patients. Various
terms used in this context are:
 Non-critical items are those that either do not touch the patient or touch only intact
skin. Such items include crutches, bed boards, bedpans, blood pressure cuffs,
bedrails, linen, some food utensilsand bedside tables. These itemsvery rarely transmit
disease. Intact skin acts as an effective barrier to most organisms and sterility is not
critical.Consequently, depending on the particular piece of equipment or item,
washing with a detergent may be sufficient. In some instances, however, the added
assurance of chemical disinfection with an intermediate to low-level chemical
germicide may be considered appropriate
 Semi critical items are those that come in contact with intact mucous membranes,
but they do not ordinarily penetrate body surfaces of the degree of risk of infection.
They must be free of all micro-organisms except bacterial spores. Intact mucous
membranes are generally resistant to infection by common bacterial spores but are
susceptible to tubercle bacilli and viruses.
 Critical items are instruments or objects that are introduced directly into the
bloodstream or into other normally sterile areas of the body. Examples are surgical
instruments, needles, cardiac catheters, implants, and the blood compartment of
hemodialyses. Most of the items in this category are either purchased sterile or are
sterilized by autoclaving if possible. Heat-sensitive objects can be treated with
ethylene oxide, hydrogen peroxide gas plasma or chemo sterilizers.
 Cleaning:It is the removal of contaminant e.g. soil, organic matter, and large number
of micro organisms. Cleaning is a useful and essential prerequisite to any sterilization
or disinfection procedure.
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 Disinfection: It is the destruction of most forms of micro-organisms but not usually of

bacterial spores thus reducing them to a level that is notharmful to health.
 Sterilizations: Sterilization is the total destruction or removal of all livingorganisms

including bacterial spores.
 Decontamination: The removal of pathogenic micro-organisms from objects so that

they are safe to handle.
 Germicide: Anything that destroys micro-organisms, particularly pathogenic

organisms (germs). Usually refers to chemicals that will destroy pathogens but not
necessarily spores. Germicides apply to compounds used on both living tissue and
inanimate objects while disinfectants are applied only to inanimate objects.
 Antiseptic:A chemical used externally or on the skin or in and around wounds in order
to control surface microbial contamination that could cause infection.
Levels of Disinfectant Activity
 High Level Disinfection is the minimum treatment for critical or semi-critical

instruments. An essential property of a high level disinfectant is a demonstrated level
of activity against bacterial endospores.
 Intermediate Level Disinfection does not necessarily kill bacterial spores, but
inactivates M. tuberculosis. It is also effective against fungi as well as lipid and non-
lipid medium sized and small viruses.
 Low Level Disinfection rapidly kills most vegetative forms of bacteria and most fungi
as well as medium sized or lipid-containing viruses.
Responsibilities
 The supervisor for area, performing sterilization procedures, develops sterilization

policies and procedures for their area, in liaison with the Infection Control Team.
 Infection Control Team monitors adherence to the above policy.
 Central Sterile Supply Department staff monitors the sterilization process by using
biological and non-biological indicators of steam penetration.
Recommendations
 Cleaning:All objects to be disinfected or sterilized should first be thoroughly

cleaned to remove all organic matter (blood and tissue) and other residues.
 Indications for Sterilization and High Level Disinfection:
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o All critical medical devices or patient-care equipment that enter normally

sterile tissue or the vascular system or through which blood flows, should be
subjected to a sterilization procedure before each use.
o Laparoscopes and other scopes that enter normally sterile tissue should be
subjected to a sterilization procedure before each use.
o Disinfection of Laparoscopic instruments:Rinse under running water, soak in

Peracetic acid (Rely+onParasafe) for 10 min, wash under running water,
detach all parts, soak in 3M rapid for 10 min, wash under running water, dry
and fix. Before using put it in Peracetic acid (Rely+onParasafe) solution for 10
min, wash in distilled water.
Methods of Sterilization
 Autoclaving to be done as per the standards.
 Whenever Sterilization is indicated, a steam sterilizer should be used unless the object
to be sterilized will be damaged by heat, pressure or moisture, or is otherwise
inappropriate for steam sterilization.
Biological Monitoring of Sterilization
 Biological indicators to be used twice a week for autoclave.
 If spores are not killed in routine spore tests, the sterilizer should immediately be
checked for proper use and function and the spore test repeated. Since only one
biological indicator is being used per load , twice a week , if indicator is positive , all
items need to be recalled.
 If the spore tests remain positive, use of the sterilizer should be discontinued until it is
serviced.
Chemical Indicators
 Chemical indicators that will show a package has been through a sterilization cycle.
 Documented SOP procedures are followed for cleaning, packing, disinfection,

sterilization and storage of items in CSSD and OT
 CSSD draft guidelines :

o Mechanical indicator Bowie-dick test has to be put everyday in 1st load for
autoclaves with pre vacuum cycles.
o Chemical indicators to be put in every major pack across all units.
o Biological indicators to be tested on every Wednesday and Saturday in 1st load.
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All units will uniformly test single biological indicator, advised to place at the drain site.
24. Decontamination
Suction Equipment
When emptying non-disposable suction jar the following precautions should be taken:
 A plastic apron and household gloves should be worn. A mask should be worn to
prevent against any splash/in case of patients with pulmonary tuberculosis.
 The jar must be disconnected from the vacuum system, carried carefully to the dirty
utility room and poured gently into sink. The contents should be flushed with copious
amounts of running water.
 The jar should be rinsed and washed with neutral pH detergent and hot water
solution. It should be rinsed again in fresh water and dried.
 The bottle should be emptied when full and cleaned daily irrespective of the amount
of fluid aspirate. Fresh tubing should be attached just prior to use.
 The routine use of disinfectant is not necessary for cleaning suction jars as organic
matter in the contents readily inactivates disinfectants. The only exception to this is
when patient has pulmonary tuberculosis. in such cases, send the jar to CSSD for
decontamination.
Humidifier
 Clean and disinfect the device between patients with soap and water and fill with
sterile water which must be changed every 24 hrs, or sooner if necessary.
S.NO NAME OF THE INSTRUMENT METHOD OF DISINFECTION

Clean with water and immerse in Multi-enzyme
solution, Rinse with water and dry. Bulb of the
laryngoscope should be removed and cleaned with
1. Laryngoscope with blades
alcohol swab.
In case of suspected infection/blood, the blade
should be sent for sterilization to CSSD.
Wash under running water; Should be cleaned with
2. Ambu bag with mask
Enzymatic detergent and water, dried.
Wash under running water; soak in Peracetic acid
(Rely+onPerasafe).
3. Ventouse cup
Solutions for 10 minutes, Wash under running
water, wash with DISTILLED WATER.
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Wash under running water, Soak in 3M rapid

enzyme for 10 mins, immerse in clean water and
rinse all channels with tap water, Purge all
Laparoscopic instruments and
4. endoscope channels with air to ensure removal of
accessory parts
water and immerse endoscope in PERACETIC
ACID (RELY+ON PERASAFE) for 10 mins and wash
in distilled water thoroughly and dry.
Wash under running water, Soak in in 3M rapid
rinse all channels with tap water, and immerse
5. Telescope
inPERACETIC ACID (RELY+ON PERASAFE) for 10
mins and wash in distilled water thoroughly and
dry.
Wash under running water, Soak in in 3M rapid
rinse all channels with tap water, Purge all
6. Resectoscope endoscope channels with air to ensure removal of
water and immerse resectoscope inPERACETIC
ACID (RELY+ON PERASAFE) for 10 mins and wash
in distilled water thoroughly and dry.
Single use.
7. LMA Fastrach
8. Doppler machine Wipe with Bacillol Spray
9. Syringe pumps Wipe with Bacillol Spray
10. Infusion pumps Wipe with Bacillol Spray
11. Monitor Probes Wipe with Bacillol Spray
12. IV pole Wipe with Bacillol Spray
Cleaned with 1% sodium hypochlorite and dried.

13. Suction Bottles Must be changed daily and in between each
patient. Store dry.
14. Oxygen Flow Meter Wash with soap and water
single use
15. Suction and Oxygen Tubings
16. Oxygen Hood Wash with soap and water

Disinfect with alcohol swab/ hand rub between
patients.
17. Stethoscope Use dedicated stethoscopes in high-risk area
eg.ICU/NICU or patients with infection or
colonization with MDROs.
Wash sleeve with soap and water once a week.
18. BP apparatus
In between patients disinfect with 70% alcohol
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wipe or hand rub, tubing & inflation bulb.

19. Breast Pump with tubings For single patient use. Wash with soap and water.
20. Steel and plastic procedure trays Wash with soap and water
21. Crash Trolley Wipe with Bacillol Spray
22. Cardiac Tables Wipe with Bacillol Spray
23. NST machine Wipe with Bacillol Spray
24. Ventilator panel Wipe with Bacillol Spray
First soaked in sodium hypochlorite for 20 min,
Surgical Instruments, dressing then rinsed under running water, soak in 3M
25.
sets, speculums rapid for 15 min in the ultrasonic machine, wash
under running water and sterilize by autoclave.
Cleaning and disinfection of Ambu bag:
Disassembly for cleaning as shown below:
Ambu bag parts that can be cleaned and sterilized
Part Disinfection & Sterilization

Autoclave 1340c for 10 mins, dry
30 mins
Patient valve 
Bag 
Inlet valve 
Extension tube 
Silicon Facemask 
Oxygen reservoir bag X
Oxygen reservoir tube X
Inspection of parts:
 After cleaning, disinfection or sterilization inspect all parts for damage and replace if
necessary.
 When inserting the valve housing of the inlet valve: Make sure that the bag opening
seats smoothly against the flange.
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 When inserting the patient valve disc: Make sure that the butt of the stem is pushed
through the hole in the middle of the patient valve housing
 When mounting the outlet cap: note that the slot of the outlet cap should face the
patient connector.
Test of function:
25. Decontamination and Disinfection of general items
Equipment/Site Methods of Disinfection

Non-infected patients: Wipe with detergent solution and rinse.
Chemical cleaning may be used for stain and scum removal.
Baths
Infected patients and patients with open wounds: Chlorine
compound with detergent.
Non-infected patients: Wash with detergent and dry.
Bed frames
Infected patient: Chlorine compound/ Phenol.
Washing and chemical disinfection.
Bed pans
Patients with enteric infections: Heat disinfection after emptying
and washing or chemical disinfection with Chlorine compounds.
Bowls (surgical) Autoclave
Wash and dry, Store inverted.
For infected patients use Individual bowls and disinfect on
Bowls (washing)
discharge.
Heat disinfection / Chlorine/ Phenol
Floors (Dry cleaning) Sweeping
Wash with detergent solution; routine disinfection not required.
Floors (wet cleaning)
Known contaminated area: Chlorine / Phenol
Damp dust with detergent
Furniture and Fittings and
Known contaminated and special areas (ICU): Damp dust with
Locker tops
Bacillocid
Instruments Heat (autoclave)
Wash with detergent solution and dry

Mattresses and Pillows
Contaminated: Disinfect with Bacillocid
Mops (dry, dust
Do not use for more than 2 days without washing and drying
attracting)
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Manual: Rinse after each use, wring and store dry. Chemical
disinfect periodically
Mops (wet) If chemical disinfection required after usage on infected areas:
House keeping rinse in water, soak in Chlorine (1000 ppm av Cl for 30 min) rinse and
store dry.
Rooms Non infected patients: Wash surfaces in detergent solution
(terminal cleaning/ Infected patients: Wash surfaces with 1% sodium hypochlorite
disinfection) Fogging/ Fumigation not recommended
Individual thermometers: wipe with alcohol swab and store dry.
Thermometers (Oral) Terminal disinfections: Disinfect with Alcohol for 10 min, wipe and
(Digital)
store dry.
Clean with soap and water and disinfect with 70% alcohol for 10
Thermometers (Rectal) minutes, Wipe and store dry
Wash with detergent and dry.
Toilet seats After use by infected patients or if grossly contaminated, Disinfect
with Chlorine. Rinse and dry.
Trolley tops (Dressing) Clean with detergent.
If contaminated: Clean first, then use Chlorine.
Tubing (Anaesthetic or
ventilation) Single use.
Urinals Use Chlorine/ Phenol
26. CSSD
 Central sterile supply department (CSSD) is a specialized area in support services of a
hospital responsible for the collection, decontamination, assembling, packing,
sterilization, storing and distribution of a multiplicity of goods and equipments to
areas in the hospital that provide patient care.
 Operation theatre, POW/ICU, Wards, Lab, OPD etc. are the important areas
concerned with CSSD. Ref CSSD Manuals, FH1/MAN/CSSD/004/22&
FH2/MAN/CSSD/004/22
 Sterility check cultures from the various areas of CSSD are sent monthly.
 Regular validation test of sterilization is done for chemical and biological indicators in
CSSD.
 The validation test for the hot air oven in the laboratory shall be carried out monthly,
via a biological indicator. Records shall be maintained for the same.
 Recall procedure is followed for any breakdown in sterilization system. The same is
reviewed and corrective action is taken.
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Recall Procedure
As soon as CSSD staff receive the result from the microbiologist about biological
indicators notbeing satisfactory, the CSSD In-charge or Staff nurse should take the
following action:
o Inform to the Chief Nursing Officer and Hospital Infection Control Committee.
o Check the autoclave number, batch number, and expiry date.
o Trace out the department which issued the items and the specific date.
o Inform the ward in-charge regarding the biological indicator growth.Take back
all the items to CSSD.
o Rewash all the articles and repack for re-autoclave.
o Clean the autoclave thoroughly with clean water.
o Sterilize the items with Bowie-Dick (FH2) and biological indicator.
o Wait for the report; only then issue the items to the wards.
o Update the register.
27. House Keeping
A patient admitted to the hospital can develop infection due to bacteria that survive in the
environment. Therefore, it is important to clean the environment thoroughly on a regular
basis. This will reduce the bacterial load and make the environment unsuitable for growth of
micro organisms.Reference: Housekeeping Manual
General Cleaning
 Primarily sweeping and mopping is done in general areas and is maintained by dry
mopping in regular intervals
 The washroom cleaning staff should keep the washrooms clean and dry. Scrubbing in
washrooms is done during morning and night shifts and all areas scrubbed at regular
intervals. The staircases are scrubbed daily and crowded areas such as the lobby are
scrubbed during weekend nights.
 Glass cleaning inside the room to be done every day, outside glass to be done at
regular intervals.
 The outside area of the hospital within the campus is to have staff in the morning and
evening shift to keep the surrounding tidy.
 To collect cleaning supplies before starting the actual work and reach the workplace.
o Empty all trash from the room and put it in the waste bag
o Start sweeping with the sweeping brush pushing the loose soil from the end of
the room to the front of the room
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o Collect the dust in a dustpan and empty into a waste bag
o Dusting to be done with a damp duster using germicidal solution. Dust the
window slits, table tops, TV tops, sofas, chairs etc.
o Work in a pattern, clean each item as you progress’
o Mopping is done and the room left to dry
o Once the bin is emptied, the cover is replaced by a fresh cover.
Preparation of Sodium Hypochlorite Solution (1%)
10% Sodium hypochlorite is procured in cans from the manufacturer, and diluted to 1%
(which is the most common dilution level for disinfection), by adding 1 part sodium
hypochlorite to 9 parts water.
The Minor Spill Kits contain 10 ml of 10% sodium hypochlorite and 90 ml of water
separately, which are added together for use in case of a minor spill.
Room Cleaning
 Switch off the room air conditioner. Draw all curtains and open the windows for airing
the room.
 Check the maintenance requirement and report the same to the nursing staff.
 Empty the entire waste paper basket in the room. Collect other loose trash on tables
and floor and put them in the waste paper basket.
 Clean the entire surface in single circular motion with the dry cloth. Use a hand dust
pan to collect any unwanted matter on the surface without lifting dust in the air.
 Thorough cleaning of the following must be done with a clean duster and disinfectant
solution.
o Bed frame
o Side rails
o Cardiac tables and base
o Wheels
o Overhead lights and all horizontal surfaces
o Television’
o Doors and walls
o Sink and tap
o Flooring
 Disinfect telephone mouthpiece. Wipe remaining of the telephone apparatus with a

damp cloth. Check phone for the dial tone.
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 Sweep, scrub and mop the floor and ensure it is dry.
 Arrange furniture if necessary
 Close the window.
 Switch on the air conditioner.
Bathroom Cleaning
 Carry the basket of cleaning supplies to the bathroom.
 Floors are cleaned from the wall farthest to the door to the exit.
 Scrub the floor with a scrubbing hand brush, rinse and dry, clean the drain, clean the
mug and bucket, wipe the floor dry with germicidal solution.
 Clean the mirror, counter, walls, window slates with a dump duster and germicidal
solution. Restock toilet rolls.
 Collect all the trash in bathroom waste basket.
 Scrub the wash basin inside and out with the help of R7 and nylon scrubber
 Clean the drain, rinse and wash off. Scrub and clean all chrome fixture pipesetc under
the wash basin
 Scrub the toilet bowl with sanitizer. Inner rim should be cleaned.
 Flush and rinse, wash the surrounding surfaces, wall etc& wipe it dry, disinfect the
toilet bowl
Chemicals Used
Name Purpose Dilution/Mode of Use

Spiral Floor cleaner, disinfectant 30 ml in 1 l water (low strength)
50 ml in 1 l water (high strength)
Lizol Washroom cleaner 2 capful in 1 liter water
Vim Powder Stainless Steel Sink Cleaner Ready-to-use
Wheel Powder Doormat Cleaner Ready-to-use
Bacillocid extra Surface cleaning, mopping, 10ml in 1 liter of water.
fogging of high risk areas
Colin Glass surface cleaner Ready to use
Harpic Toilet bowl cleaner Ready to use
OT Cleaning
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 Daily routine cleaning starts at around 6 am by night shift staff.
 At the beginning of the day, all the theatres including OT tables, trolleys, Mayo’s
stands, OT lights etc. are cleaned with Bacillocid.
 Floor sweeping is done by Daya and OT equipments and surfaces are disinfected by
OT Technicians and Nurses.
 After each case, the theatre is cleaned with Bacillocid solution.
 At the end of the day, OTs floor is swept and OT tables, equipmentsetc are cleaned
with Bacillocid.
 Each day after surgery, all equipments are cleaned with 3M rapid Enzyme.
 Used instruments are washed with water, soaked in 3M rapid Enzyme, and sent to
CSSD department.
 Weekend cleaning: Apart from regular cleaning thorough cleaning is done on

weekends.
o On Friday evening – Elective OT Cleaning is done.
 All trolleys, racks, buckets, bins etc are cleaned.

 All surfaces are like walls etc. are cleaned with water and Bacillocid.
 After drying, the OT is prepared and necessary equipments are
covered.
 Fogging is done. Logs for fogging are maintained.
 Theatre is closed for 4 hours.
 AC Vents are cleaned by Maintenance department.
 Electrical cleaning of electrical points etc is done by electricians.
o On Saturday – EOT and clean zone cleaning is done.
o On Sunday –Outer Zone cleaning is done

Isolation rooms
 Pre-requisites for Isolation
o The mattress and pillows should have an impervious cover such as mackintosh so
that it can easily be damp dusted.
o Clean gowns should always be available.
o Separate urinals, bedpans and thermometers are to be used for each patient.
o Bins lined with the appropriate color coded plastic cover should beavailable in
each room for disposal of medical waste.
o Rooms should be isolated according to disease conditions and should be well lit.
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 Cleaning procedure for isolation room
o Linen should be stripped from the bed with care taken not to shake the linen
during this action. Linen should be soaked in1% Sodium Hypochlorite solution for
15-20 min by laundry staff.
o All other articles like IV stands and furniture should be cleaned with detergent and
disinfected withBacillocid.
o The bathrooms should be cleaned with detergent and disinfected with Spiral and
Harpic
 At discharge (terminal disinfection)

o The pillows and mattress covers are to be cleaned with detergent, disinfected with
1 % Sodium Hypochlorite.
o Bed sheets, curtains, gowns and dusters must be removed and soaked in 1%
sodium hypochlorite for 15- 20 min.
o After disinfection, wash the room, wall, window, doors, bathroom, sink and
furniture with soap solution after doing thorough high dusting in that room.
o Soak bed pan, urinal, kidney basin in 1 % Sodium Hypochloritesolution for 15 – 20

min., wash with detergent and dry it.
o Bath basins, multi-bin, bucket, jugs, mugs are washed with soap solution and
dried.
o Rubber sheets (mackintosh) are to be cleaned with 1 % Sodium Hypochlorite,

dried, powdered and replaced.
o Soak the thermometer tray and its contents in 1 % Sodium Hypochloriteafter

cleaning.
28. Laundry and linen management
Proper management of hospital linen is important, ensuring adequate cleaning of linen for
better hygienic hospital environment.(Refer Linen Manual)
 All linen from all units of Fernandez Hospital is sent to Unit 2, located in Hyderguda,
which contains an in-house laundry on the 5th floor.
 Linen from unit 1 :
o Soiled linen from unit 1 is not treated at unit 1but is brought unprocessed at unit 2
where it is processed as per the guidelines existing for the same.
 Linen from unit 2:
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o Soiled Linen is bundled, put into trolleys and taken up to the 5th floor from each
ward, through the service lift, along with the ward linen register.
o Infected linen in Unit 2 will be put in a separate bucket (red) labelled and kept for
infected linen, and transported directly in a separate trolley to the 5th floor.
o In the Unit 2 OT, the infected linen is put in yellow bags and sent directly to the
Laundry in the red bucket.
o Linen used for patients with MRSA, HIV, Hepatitis B, cholera and other
infectious diseases is decontaminated by soaking it for 30 min to one hour in
1% Sodium Hypochlorite solution.
o All staff handling infected linen wears protective gloves, and training on hand-
wash is provided regularly.
Washing of Infected Linen
 The infected linen is washed at the end, after the soiled linen.
 All the infected linen received in the Laundry( from unit 1 and unit 2 ) is first soaked in 1%
Sodium Hypochlorite solution for 15-20 mins in the “Spotting Station” and then removed
and allowed to semi-dry.
 In case stain removal has not been successful, the boiler is turned on 15 mins prior to
putting the load into the washing machine. This generates steam to pass into the
machine, and the internal temperature to rise, in order to enable complete disinfection of
the infected linen.
 Extra bleach and “Remifield” is added to the washing machine to ensure complete stain
removal. The Load is then put into the washing machine, and the remaining process of
regular washing is carried out.
29. Investigation of an out break
 The occurrence of 2 or more similar cases relating to place and time is identified as
cluster or as an outbreak and needs investigation to discover the route of transmission of
infection and possible sources of infection in order 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 possibly due to person
to person spread. On the other hand, if a large number of cases occur following a shared
exposure, e.g.after surgery, then it is termed a common source outbreak, implying a
common source for the occurrence of disease.
Epidemiological Approach
 The investigations of an outbreak may require expert epidemiological advice on

procedures. Formulation of a hypothesis regarding source and spread is made before
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undertaking microbiological investigations in order that the most appropriate

specimens are collected.
 Steps to be taken to investigate an outbreak:

o Step 1:Recognition of the outbreak.
 Is there an increase in the number of cases of a particular infection or a rise in

prevalence of an organism? Such findings indicate a possible outbreak.
 Preliminary investigation must be begun by developing a case definition,

identifying the site, pathogen and affected population.
 Determination of the magnitude of the problem and if immediate control

measures are required. If so general control measures such as isolation or
cohorting of infected cases; strict hand washing and asepsis should be
immediately applied.
 Verification of the diagnosis. Each case should be reviewed to meet the

definition.
 Confirmation that an outbreak exists by comparing the present rate of

occurrence with the endemic rate should be made.
o Step 2: Notification :
 The appropriate departments and personnel and the hospital administration

should be notified and involved.
o Step 3 :Analysis
 Additional cases must be searched for, by examining the clinical and

microbiological records
 Line listing for every case,patient details, place and time of occurrence and
infection details should be developed
 An epidemic curve based on place and time of occurrence should be

developed, the date analyzed, the common features of the cases, age, sex,
exposure to various risk factors, underlying diseases etc should be identified.
 Hypotheses based on literature search and the features common to the cases
should be formulated to arrive at hypotheses about suspect causes of the
outbreak.
 Microbiological investigations depending upon the suspected epidemiology of

the causative organism should be carried out. This would include:
 Microbial culture of cases, carriers andenvironments
 Epidemiological typing of the isolates to identify clonal
relatedness
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 The hypotheses should be tested by reviewing additional cases in a case

control study, cohort study and microbiological study
o Step 4 : Control Measures
 Specific control measures should be implemented as soon as the cause of the

outbreak is identified.
 Monitoring for further cases and effectiveness of control measures should be

done.
 A report should be prepared for presentation to the HICC, departments

involved in the outbreak and administration.
Immediate control measures
 Control measures should be initiated during the process of investigation. An intensive

review of infection control measures should be made and general control measures
initiated at once.
 General measures include:

o Strict hand washing
o Intensification of environmental cleaning and hygiene
o Adherence to aseptic protocols
o Strengthening of disinfection and sterilization
o Educating Staff and Patients
Microbiological study
 Microbiological study is planned depending upon the known epidemiology of the

infection problem. The study is carried out to identify possible sources and routes of
transmission. The investigations may include cultures from other body sites of the
patient, other patients, staff and environment. Careful selection of specimens to be
cultured is essential to obtain meaningful data.
Specific control measures
 Specific control measures are instituted on the basis of nature of agent and
characteristics of the high risk group and the possible sources. These measures may
include:
o Identification and elimination of the contaminated product.
o Modification of policies and procedures
o Identification and treatment of carriers
o Rectification of lapse in technique or procedure
o Possible Prophylaxis
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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.
 The outbreak will be documented and corrective action reviewed in order to prevent
recurrence.
30. Post Operative ward/ Intensive Care Units

 POW/ICU is situated on 2ndfloor in Unit-1and 4th floor in Unit-2.
 After surgeries patients are shifted to POW for observation and recovery.
Housekeeping
 Strict Housekeeping practices are followed to clean the ward as follows:
Cleaning Process Frequency
Sweeping & Mopping Daily twice & as and when required

Mopping in High Risk Areas Every 4th Hourly
Scrubbing Daily
Restrooms Daily &as and when required
Cots, chairs and tables Daily
Doors, windows, glass panels Daily
Fixtures & Fittings Daily
Cobwebs cleaning Daily
Clearing of dustbins Daily twice & as and when required
Rubber sheets After every discharge &as and when required
Curtains Monthly twice
Infection Control Practices
 Strict Hand washing practice to be followed.
 Standard precautions: As appropriate should be followed by all staff while handling

patients or samples (Refer:Standard precautions). Wear plastic aprons and gloves for
all procedures. Remove and discard them immediately after each patient.
 Use gloves for all patient contact. Wear masks while examining patients with
uncertain diagnosis.
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 No visitors are allowed inside this ward.
 Regular maintenance of Air conditioners is done.
 Microbiological sampling to be done if any outbreak is suspected.
 All instruments are properly sterilized and used.
31. Hospital Antibiotic Policy

 Antibiotics are essential treatments for serious infections. They are one of the most
important and valuable discoveries of modern medicine. Howeveradministrationof
antibiotics can lead to the selection of antibiotic-resistant organisms. These
organisms can give rise to healthcare-associated infections which are associated with
increased morbidity and mortality.
 Therefore it is important to ensure that antibiotics are prescribed in a way which

minimizes the risk of healthcare-associated infections. The Hospital Antibiotic
Guidelines have been designed to treat common infections effectively and with the
minimum risk of healthcare-associated infections. The current antibiotic policy
describes the procedures to encourage the use of the Antibiotic Guidelines and to
ensure that antibiotics are not prescribed in a way which is likely to lead to healthcare-
associated infections.
 This policy deals with the processes by which recommendations for specific antibiotic
treatments are made and the procedures to support these recommendations. It does
not provide specific advice on which antibiotics should be used in specific infections.
This policy also does not provide information on which antibiotics are regarded as
having the highest risk of causing healthcare-associated infections nor on which
antibiotics can only be used following advice from a microbiologist or infectious
diseases physician. This is because this will vary between clinical areas depending on
recent infection surveillance data.
For complete antibiotic policy, refer FH/POL/ANTB/009/22
32. Antibiotic Stewardship Policy

Introduction:
Antimicrobial stewardship programme (AMSP), aims to facilitate the establishment of effective

and rational antibiotic use. This facilitates the prevention of infections caused by antimicrobial
resistant pathogens.
An effective antimicrobial stewardship program should have appropriate:
 drug selection
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 dosing
 route of administration and
 duration of antimicrobial therapy
This coupled with comprehensive infection control program has shown to limit the Emergence
and transmission of antimicrobial resistant pathogens.
Antibiotic stewardship team:
A multidisciplinary team of health care professionals called as Antibiotic stewardship team has
been instituted at Fernandez Hospital. This team includes doctors from various specialties,
Infection control officer and Pharmacy Head.
The role of this team is to monitor and implement appropriate Antibiotic usage regimes in the
clinical areas of the Hospital.
This team constitutes of the following members:
 Obstetrics team – Dr.Tarakeswari, Dr. Pallavi Chandra

 Gynecology team – Dr. Padmaja Y
 Neonatology team – Dr. Sai Kiran
 Anesthesia team – Dr.Manokanth
 Physician – Dr. Usha
 HICO – Dr.Nirupama
 Pharmacy Head – Mr.Rajendran V.
FH- List of Restricted high-end Antibiotics:
S.No Generic Name Antimicrobial agent

1 InjXylistin 1MIU Colistimethate Sodium 1 million IU
2 InjMeromac 0.2g/0.5g/1g Meropenem
3 InjInvanz Inj Ertapenem
4 InjMagnex forte 1.5g Sulbactam 0.5g+Cefoperazone 1g
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5 InjMagnex 1g Sulbactam 0.5g+Cefoperazone 0.5g

6 InjLupinem 500mg IMIPENAM500MG+ CILASTATIN
500MG
7 InjNovapime 1g Cefepime 1000mg
8 InjForzid 1g/Fortum Ceftazidime 1g
9 InjTigez 50mg Tigecycline 50mg
10 InjVanking 500mg Vancomycin 500mg
11 INJ ACIVIR 250mg Acyclovir 25mg/ml 10ml
12 Fluvir/dry Oseltamivir
13 Amphotret Amphotret 50mg
14 Ambisome/Fungilip
g Liposomal Amphotericin B
15 Micafungin Micafungin
16 InjForcan 200mg/100ml Fluconazole 200mg/100ml
17 Falcigo Mefloquine
18 Lariago Chloroquine
19 HCQS200 Hydroxychloroquine
Steps To implementation of Antimicrobial stewardship program:
 Follow the hospital antibiotic policy for prescribing antibiotics.
 Restricted antibiotics list will be placed in the Pharmacy and the pharmacy staff will be
trained on the restricted antibiotics.
 Alert system for restricted antibiotics will be incorporated into the pharmacy software.
 Whenever pharmacy is dispensing the restricted antibiotics an E-mail alert will be sent to
the AMSP team members and HICNs, with the patient UHID.
 The specialty doctor(s) of the AMSP team will review the case at the earliest/ before the
next dose and after the justification and appropriateness, the rest of the medication will
be issued by the Pharmacy with approval of the AMSP team. If the clinical details suggest
that the prescribed antibiotic should be restricted, then in discussion with the consultant
the antibiotic regime for that patient will be changed.
 All the details of each case handled by the AMSP team is documented in High end
Antibiotics Monitoring form
 Weekly audit on the use of restricted antibiotics will be done by the HICO & HICN.
 Monthly audit will be done by the AMSP team and discussed in the HICmonthly meeting.
 Ongoing education on rational use of antibiotics to clinicians and ensuring

implementation of antibiotic policy will be done periodically in HICC training sessions by
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HICO.
 “High end Antibiotic Monitoring form” will be documented for patients requiring High
end antibiotics and filed in the respective case sheet.
33. COVID POLICY
COVID-19
Infection Prevention & Control Standard Operating Procedure
HICC team is a part of rapid response team- will be meeting daily/as and when required to discuss
and to attend the patient & HVW safety.
FHF HICC protocols are applicable to all non covid areas.
Infection prevention and control (IPC) SOP of covid-19 Fernandez hospital
 Introduction
 Screening &Triage
 Hand hygiene
 Rational use of PPE
 Environmental cleaning and disinfection protocol (High touch surfaces)
 Laundry infection control SOP
 Biomedical waste SOP
 Spill management SOP
 After discharge infection control SOP
INTRODUCTION
Corona virus disease 2019 (COVID-19) is a potentially severe acute respiratory infection
caused by severe acute respiratory syndrome corona virus 2 (SARS-CoV-2). The virus was
identified as the cause of an outbreak of pneumonia of unknown cause in Wuhan City, Hubei
Province, China, in December 2019. The clinical presentation is that of a respiratory infection
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with a symptom severity ranging from a mild common cold-like illness, to a severe viral
pneumonia leading to acute respiratory distress syndrome that is potentially fatal.
TRANSMISSION OF INFECTION
Person-to-person transmission of COVID virus occurs via droplet and contact transmissions.
SCREENING AND TRIAGE
Daily COVID-19 screening protocol for screening (using non-contact methods) of all employees,
patients & visitors. For the symptoms of COVID-19 infection
1. Thermal screening.
2. Screening questionnaire
” respiratory infection symptoms: e.g., cough, runny nose, fever” and with a history
of exposure to people with COVID-19 OR TRAVEL HISTORY within a period of 14 days.
Loss of taste/smell. Headache, Body aches.
3. Advise everyone to wear a facemask.
4. People with Covid sym ptoms, follow triage procedures at entrance by security& guide
them to the screening area.
5. They will be further assessed by a doctor and advised accordingly. (Either refer to a Covid
designated hospital or follow FH Covid protocol).
Patients who are not suspected of Covid infection will be directed to admission room/ER.
HAND HYGIENE
This is essential before entering into the hospital, before and after all patient contact, removal of
protective clothing and decontamination of the environment.
Use soap and water to wash hands or a 70 % alcohol hand rub if hands are visibly clean.
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Rings (other than a plain smooth band), wrist watches and wrist jewellery must not be worn by staff.
Personal Protection Equipment (FH Protocol)
(Based on HONG KONG PROTOCOL, revised on 22.6.2020, changes highlighted in red)
Visor / Foot
Cap Mask Gown Gloves
goggles wear*
SECURITY
YES N95 YES - YES Covered shoes
STAFF
Screening
SCREENING UNIT YES N95 YES Y ES Shoe covers
gown
Screening
General ER YES N95 YES YES Covered shoes
gown
Surgical Option
OP Doctors YES YES Covered shoes
Mask al
OP MANAGERS, Surgical
- YES - - Covered shoes
Staff Mask
Surgical Option
FMU Doctors - YES - Covered shoes
Mask al
Receptionist,
Surgical
Pharmacy, - YES - YES Covered shoes
Mask
Canteen
Surgical
LDR, HDU YES YES - - BOOTS
Mask
Screening
LDR, Birthing time YES N95 YES YES BOOTS
gown
Surgical
Wards - YES - - Covered shoes
Mask
Surgical
NICU, routine - YES - - Covered shoes
Mask
NICU, AGPs YES N95 YES Surgical gown YES BOOTS
Surgical
Lab technicians YES YES YES Covered shoes
Mask
AAMI 3 or 4
ISOLATION gown with
WARD YES N95 YES leggings + ES BOOTS
Y
COVID +ve/ PUI hood or
Hazmat suit
ISOLATION AAMI3 / 4
N95
WARD gown with
YES as a YES ES BOOTS
COVID +ve/ PUI – leggings + Y
MUST
OT / Intubation, hood or
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AGPs Hazmat suit
Drivers, AAMI3 / 4
Ambulance, Ward gown with
boys YES N95 YES leggings + YES Shoe covers
COVID +ve hood or
transfers Hazmat suit
Drivers,
Ambulance Medical
- - - YES Covered shoes
Ward boys mask
NO direct contact
* Covered shoes are personal footwear to ensure skin exposure is minimized
COVID Policy Flow Chart:
(if in hostel)
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LAB -
REPORTS
HC Do not report to the

work. Inform HOD or PATIENTS
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ADMINISTRATOR ADMINISTRATOR /MD

/PRIMARY CONSULTANT
POSIT Quarantine in a single

room with an attached WARDEN
bathroom. HOD fills the form &
Arrange physician appointments.
Informs
Concern after resolving the Meena/facility
symptoms
Negative report
Returns to work with fitness
HOD takes Appointment

HOD takes with physician Positive test
Appointment report
withHCW
PATIENTS
ADMINISTRATOR Physici Symptomatic
Isolation for 17 days Isolation & follow up by

Follow WARDEN doctors and team
Concerned HCW &
Explain about
BMW COVID -19 Guidelines:

The Central Pollution Control Board has laid some guidelines for Handling, Treatment &
Disposal of Waste Generated during Treatment/ Diagnosis/Quarantine of COVID-19 patients:
Isolation wards:
 Keep separate color-coded bins/bags/containers in wards and maintain proper

segregation of waste as per BMWM Rules, 2016.
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 YELLOW COLOUR bags TWO (Double layered) should be used for collection of
waste from COVID-19 isolation wards so as to ensure adequate strength and no-leaks.
 Use dedicated collection bin labeled as “COVID-19”to store COVID-19 waste and keep
separately in temporary storage room prior to handing over to authorized staff of
CBWTF.
 Maintain separate record of waste generated from COVID-19 isolation wards.
 Use dedicated trolleys and collection bins in COVID-19 isolation wards. A label “COVID-
19 Waste” to be pasted on these items also. Should be disinfected with 1% sodium
hypochlorite solution daily.
 Depute dedicated sanitation workers separately for biomedical waste.
 Please follow these guidelines for COVID-19 PATIENTS/SUSPECTS.
After discharge infection control SOP:
All surfaces of the isolation area (floors, bed railings, side table,IVstand,etc) should be wiped
with 1%Sodium hypochlorite solution: allow a contact time of 30minsand then allowed to air
dry.
Environmental Cleaning and Disinfection:

Fernandez Hospital Disinfection policy is applicable with the following changes:
 Designated specific, well-trained housekeeping personnel for cleaning and disinfecting of

COVID-19 patient Isolation rooms/ cohort areas/Examination rooms.
 Use a checklist to pro ote accountability for cleaning responsibilities.

m
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 Conduct refreshment training for HK staff. Train them on Donning and doffing of the
PPE, Importance of hand hygiene, Cough etiquette and Droplet precautions.
 Keep cleaning supplies away from patient care areas.
 Keep areas around the patient free of unnecessary supplies and equipment to facilitate
thorough cleaning.
 The disinfectants and the frequency of cleaning will be as follows: for the Triage area,
OPD, Isolation rooms/area for COVID-19 suspects & Common areas with patient
exposure.
Disinfectants:
 70% ethyl alcohol (Bacillol spray) for small areas – reusable dedicated equipment (e.g.
thermometers)
 Sodium hypochlorite at 1% (equivalent 5000 ppm) for surface disinfection.
Frequency of cleaning:
Patient care equipment (Stethoscope, BP apparatus, baby weighing scale, Thermometer, Tables,
chairs, Phone etc) will be cleaned with Bacillol spray (70% alcohol) after every patient.
Housekeeping surfaces will be divided into two groups and cleaned as follows:
Please maintain the checklists.
 Those with minimal hand contact surfaces should be cleaned 2nd hourly with 1%
Hypochlorite solution. Floor will be cleaned 4th hourly with 1% Hypochlorite solution.
 “High touch surfaces” – ( those with frequent hand-contact) like Doorknobs, Bedrails,
Light switches, Wall areas around the toilet in the patient’s room, Edges of privacy
curtains, TV control, call button, telephone care areas should be disinfected every half an
hour with 1% hypochlorite solution/ 70% alcohol as per the disinfection policy.
 Privacy curtains to be removed after patient discharge and placed in yellow bag for
transportation to the laundry. It will be disinfected in 1% hypochlorite solution and
cleaned.
 After discharge follow standard procedures for terminal cleaning of an isolation room.
Washrooms
After routine cleaning, will be cleaned every 4th hourly with 1% Hypochlorite solution
Note:
 Always move from cleanest area to dirtiest area.

 Damp dusting and wet mopping is recommended to minimize dust
 Spraying of disinfectants is not recommended
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Linen and laundry:
Fernandez Hospital linen policy will be followed.
 Scrub suits, linen from isolation rooms and examination rooms, OPD used for the patient
care will be sent to laundry department in yellow bag.
 Linen use for COVID-19 suspected patient care will be soaked in 1% Hypochlorite solution
for 15-20 minsand cleaned as per the linen policy.
 Wear appropriate PPE – heavy duty gloves, mask, eye protection (goggles/face shield),
long-sleeved gown, apron (if gown is not fluid resistant), and boots or closed shoes.
Note:
 Never carry soiled linen against body, place soiled linen in a leak-proof Yellow bag in
infected bin.
 Do not shake or otherwise handle soiled linen and laundry in a manner that might
aerosolize infectious particles.
Dishes and eating utensils used by a patient with known or suspected infection
 Use only disposable plates, glasses and cups if required.

 Wear gloves when handling patient trays, dishes, and utensils.
Calculations for Preparing Sodium Hypochlorite Solution
• 1% solution is 1 gm in 100 ml
• OR 10 gm in 1000 ml OR 10,000 mg/L
• OR 10,000 ppm
Sodium hypochlorite solution is available as 5% or 10% solution commercially
• 1% or 10,000 mg/L is prepared by taking 100 ml of this solution and diluting it with
900 ml of water
34. High risk pathogen – epidemic action plan
High-risk pathogens: Strategic planning and operationalmanagement for infection prevention

and control
High-risk pathogens
 Filoviruses: Ebola, Marburg
 Crimean Congo–haemorrhagic fever
 Kyasanur forest disease
 New strain of influenza
 MERS-CoV, SARS-CoV, novel-CoV
 Nipah virus
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 Multidrug-resistant or extremely drug resistant tuberculosis

 Multidrug-resistant Gram-negative bacilli
Strategic planning
Awareness of stakeholders
Adequate awareness and training programs will be conducted for the HCW at all the levels.
– Healthcare facility administrators
– Microbiologists
– Infectious disease physicians/ Physicians.
– Nursing administration
– Housekeeping manager
– Senior clinicians
Adequate communication will be shared, and training sessions will be conducted for the HCW,
regarding the incidence, prevalence, casedefinition, IPC, case management, laboratory diagnosis,
notification.
Screening and triage:
Triaging system will be planned as per the guidelines and the training of staff of first contact,
security, reception (customer care), nurse,emergency doctors, on-call doctors will be taken up by the
HICC.
Isolation precautions will be followed as per the contact precautions required for the given disease.
Refer to section 19 of the manual.
Ensuring consumable availability:
Adequate supply of Personal protective equipment& medicines (for example Specific antimicrobial
agents for empirical or targeted therapy (e.g., antiviral agents) will be taken care by the pharmacy.
Rapid response team will be formed, and Clinical referral pathways will be
designed as per the requirement.
1.Patient reception:
– Reception and security staff awareness about high-risk pathogen causing disease
2.Triage
– Training of triage staff (nurse) on triaging questions
– Use of PPE
3.Communication
– Communication of triage nurse with physician or consultant in suspectedcases.
4.Risk assessment and communication
– Checking current case definition
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– Reaching at a provisional and differential diagnosis

5.Isolation
– Isolation of suspected and confirmed cases in single rooms.
6Use of PPE by staff and caregivers
– Appropriate use
– Proper donning anddoffing of the PPE
7.Clinical management
– Taking care to prevent sharps injury and splash exposure
– Treatment administration as per standard guidelines
– Care plan for patients requiring intensive care
8.Intra-hospital transportation.
– Identification of transport route
– Use of PPE
– Communication to other staff and visitors
– Cleaning/ decontamination of the route
9.Patient transportation outside the hospital
– Identification of High Security Infectious Disease Unit
– Identification of ambulance and its requirements
– Training of transportation team
– Ambulance for patients on ventilator
10.Planning for laboratory diagnosis
– Identification of the referral laboratory and signing MOU.
–National Guidelines for transportation of clinical specimens or isolates will be followed.
11.Planning for biomedical waste disposal
– Guidelines for high-risk biomedical waste segregation and transportation will be followed as per
the guidelines.
– Training of housekeeping staff will be taken up.
12.Nodal officer will be identified and share adequate communication with the public health
authorities.
– Identification and contact details of local and central public health authorities for
discussion and communication
13. Decision will be made on Staff quarantine as per the guidelines.
 Duration of quarantine
 Identifying quarantine area: in a single room in the hostel.
 Information about quarantine: dos and don’ts will be shared with the staff.
14.Planning for the dead patient – mortuary, post-mortem, cremation/ burial
– Communication with public health according to the Guidelines to deal with the dead.
Classification of infective microorganisms byrisk group
Risk Group 1 (no or low individual and community risk): A microorganism that is unlikely
to cause human or animal disease.
Risk Group 2 (moderate individual risk, low community risk): A pathogen that can cause
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human or animal disease but is unlikely to be a serious hazard to laboratory workers,

the community, livestock or the environment. Laboratory exposures may cause serious
infection, but effective treatment and preventive measures are available and the risk of
spread of infection is limited.
Risk Group 3 (high individual risk, low community risk): A pathogen that usually causes
serious human or animal disease but does not ordinarily spread from one infected
individual to another. Effective treatment and preventive measures are available.
Risk Group 4 (high individual and community risk): A pathogen that usually causes
serious human or animal disease and that can be readily transmitted from one individual
to another, directly or indirectly. Effective treatment and preventive measures are not
usually available.
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35.INFECTION CONTROL MEASURES DURING CONSTRUCTION ACTIVITY:
Infection control permit is required for initiation of construction activity in the hospital. The
construction activity type (Table 1) and the patient risk group (Table 2) are considered according to
the tables mentioned below for preparing the infection control matrix (Table 3). The infection
control measures for each of the classes are mentioned in Table 4. Infection control permit is
mandatory for Classes III & IV. The completed permits are kept with the Engineering Department.
Table 1: Construction Activity Types

Type A Inspection and minor non-dust producing activities:
Includes but is not limited to:
Removal of one (1) ceiling tile for every 50 square feet or one (1) ceiling tile for every 10
linear feet, whichever is less.
Painting (but not sanding)
Installation of wall covering, electrical trim work, minor plumbing (setting toilets or sink
fixtures), and activities which do not generate dust or require cutting walls or access
to ceilings other than for visual inspection.
Small Scale Activities less than 24-hours which create minimal dust:
Removal of wall covering that is properly sized.
Type B Access to chase spaces
Cutting of walls or ceiling equal to or less than 24 linear inches. Dust migration is able to
be controlled.
Minor pipe work (reaming conduit, sanding copper pipe ends).
Work that generates a moderate to high level of dust or requires demolition or removal of
any fixed building components or assemblies and is within the confines of a suite or office
space. Corridor walls are not demolished or removed.
Type C Includes but is not limited to:
Sanding of walls for painting or wall covering, Removal of wall coverings, floor coverings,
ceiling tiles and casework, New wall construction
Any HVAC, plumbing or electrical work that doesn’t fall under TYPE B
Major demolition and construction projects that extend beyond the confines of a suite or
office space.
Type D
Demolition or removal of entire ceiling system, New construction
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Table 2: Infection Control Risk Groups

Low
Medium Risk High Risk
Risk
Adult Inpatient Areas:
Operating Rooms/Delivery Rooms
ICU,POW,NICU
Adult Clinic Areas serving immune
 Inpatient and outpatient
compromised patients.
areas not listed in the high
Office areas Adult Service Areas:
risk category
CSSD ,ER
Food Preparation and Service Areas
Unit Based Equipment Processing
Pharmacies
Table 3: Infection Control Matrix to determine the Class of Construction Activity

Construction Activity Type
Infection control risk group Type A Type B Type C Type D
Low Risk Group Class I Class I Class II Class III/IV
Medium Risk Group Class I Class II Class III Class IV
High Risk Group Class II Class III/IV Class III/IV Class IV
Note: Infection Control approval must be obtained prior to commencement of the project
when construction activity and risk level indicate that Class III or Class IV control procedures are
necessary.
Table 4: Infection Control Precautions by Class of Construction Activity
 Complete Infection Control Permit before construction begins.

 Notify unit manager/ Doctor in charge before construction begins.
Class I  Use work methods that minimize generation of dust.
 Immediately replace ceiling tile displaced for visual inspection.
 Clean up work upon completion of task
 Perform all requirements of Class I.
 Provide active means to prevent airborne dust from dispersing into atmosphere.
 Use water mist on work surfaces to control dust while cutting.
Class II  Block off and seal air vents. All duct openings, whether new installation or existing
duct, are encapsulated to prevent exposure to dust.
 Place dust mat inside the project at entrance of work areas. Change mats as often as
necessary so that the mats remain tacky, preventing accumulation of dust outside
the job site. Mats are placed outside the job site only if they are not in an exit
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corridor and the area is not frequented by staff and patients

 Remove or isolate HVAC system in areas where work is performed
 Clean up by wiping work area with disinfectant
 Contain construction waste before transport in tightly covered containers.
 Wet mop before leaving work area
 Perform all requirements of Class I and II.
 Submit Infection Control Permit for approval by Infection Control at least 72
hours before work begins.
 Complete all critical barriers (i.e., sheetrock, plywood, plastic) to seal area from
non-work area or implement control cube method before construction begins.
Airtight plastic or drywall barriers extend from floor to ceiling. Joints are sealed
to prevent dust and debris from escaping.
 Entrances are draped with overlapping plastic. Plastic overlaps at a minimum of
24 inches
 Seal all penetrations to ensure an air-tight barrier. Barriers are placed at
penetration of ceiling envelopes, chases, and ceiling spaces to stop movement of
air and dust.
 If plastic is used as a barrier, use opaque plastic sheeting.
 Remove debris in tightly covered containers. Contain construction waste before
transport. Cover transport receptacles or carts. Tape covering unless lid is solid.
 Waste container and wheels are wiped down before exiting the project site
Class III
 Housekeeping and dust control are performed by the individual or group
performing the construction.
 Wet mop with a hospital-approved disinfectant daily or more frequently as
needed.
 Immediately clean any dust tracked outside of construction barrier using a damp
mop and hospital approved disinfectant
 Before barriers are removed, the area is thoroughly cleaned with a hospital
approved disinfectant
 Removal of construction barriers and ceiling protection may require temporary
dust protection, as determined at final project review.
 Remove dust barriers carefully to minimize spreading of dust associated with
construction.
 After work is complete remove isolation of HVAC system in areas where work
was performed.
 Perform thorough cleaning of the area, fogging of OT and take post-fogging
swabs for culture, before the area is used for patient care.
Perform all requirements of Class I, II and III
 Construct anteroom and require all personnel to pass through this room so that
Class IV
they can wear coveralls that are removed each time they leave the work site
 All personnel entering the work site are required to wear shoe covers. Shoe
covers are changed each time the worker exits the work area.
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INFECTION CONTROL PERMIT FOR INITIATION OF CONSTRUCTION WORK
Job site:
Details of the proposed construction activity:
Date of initiation of proposed work: Duration of proposed work:
Type of construction activity (Encircle): Type A/ Type B/ Type C/ Type D
Infection control risk group (Encircle): Low risk/ Medium risk/ High group
Class of construction project (Encircle): Class I/ Class II/ Class III/ Class IV
(Infection Control Approval for Class III/ Class IV Mandatory)
Signature of Engineer/ Contractor Date:
For ITU/CCU/ Cath lab: To be signed below by the doctor in charge of the area
Permission granted for carrying out construction activity in the above mentioned area.
Signature of In-charge Doctor Date:
Other areas: To be signed below by the Medical Director/Hospital Administrator
Signature of Medical Director/Hospital Administrator Date:
The following part is to be filled by Infection Control Chairman

Nature of infection control practices to be applied in the area:
Signature of Infection Control Chairman Date:
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COORDINATION WITH OTHER INTERFACING DEPARTMENTS
OPERATIONTHEATRES CSSD,
ICU’s and WARDS
STORES, LAUNDRY INFECTION MANAGEMENT & NURSING
& CANTEEN CONTROL
OUT LAB MEDICINE

MEDICAL RECORDS, PHARMACY, HUMAN
H OUSE KEEPING, RESOURCES, QUALITY
ENGINEERING & DEPARTMENT
MAINTENANCE
Conclusion
Hospital Infection control team will oversee and review the maintenance of all
facilities in the hospital from engineering controls point of view by regular liaison with the building
management systems Department. This includes
a. Infection-control impact of ventilation system and water system performance.
b. Establishment of a multidisciplinary team to conduct infection-control risk
assessment.
c. Use of dust-control procedures and barriers during construction, repair,
renovation, or demolition.
d. Environmental infection-control measures for special care areas with patients at
high risk;
e. Use of airborne particle sampling to monitor the effectiveness of air filtration
and dust-control measures.
f. Procedures to prevent airborne contamination in operating rooms when
infectious tuberculosis.
g. Guidance regarding appropriate indications for routine culturing of water as
part of a comprehensive control program for legionellae.
h. Guidance for recovering from water system disruptions, water leaks, and
natural disasters [e.g., flooding]
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Air Quality:
Issues such as air conditioning plant equipment maintenance cleaning of A/C ducts,
AHUs regular replacement of filters (6 monthly), any Seepage leading to fungal colonization will be
monitored.
Water Quality:
Water supply sources and system of supply replacement / repair for fault plumbing
and sewer lines will be included for review.
Construction Activities:
Any renovation work like construction demolition refurbishment in patient care areas
should be planned with infection control team with regard to architectural segregation (Negative
pressure room, OT Positive pressure room with negative pressure corridors, CSSD negative pressure
room in sterile area, with appropriate air exchanges) traffic flow risk management and usage of
materials etc.
Demolition Activities:
In-case of any demolition activities in the hospital the infection control team is
involved in decision making in shifting the immune-suppressed patients if any so as to prevent the
risk of fungal infection.
36. Hazards/ High-risk activities in Health care facilities & HCW safety:
Healthcare workers (HCWs) perform a wide range of activities in varying environments that can put
their health and well-being at risk.
At the same time, HCWs are also responsible for adopting safe work practices and taking necessary
precautions to mitigate the risk during their work.
Workers at risk in the healthcare environment:
Medical staff
Cleaning staff
Laboratory technicians
Employees of healthcare (contractual) services
Cleaning services
Property management
Environmental hygiene services: collection and disposal of BMW
Hazards/High-risk activities in Health care:
Physical:MusculoskeletalInjuries:duetoPoor posture while performing repetitive activities such as
repeatedly bending over to treat reclining patients can strain the muscles in your neck, shoulders
and back. Lifting patients and moving heavy equipment are also high-risk activities. It can be
avoided by
Use proper lifting and transfer techniques—use the knees, not the back
 Keep the objects or patients being lifted as close to the midsection as possible and bend
from the back
 Wear comfortable shoes with good shock absorption to counteract the effects of
prolonged standing and walking
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 Maintain muscle strength and flexibility
Chemical: Exposure to toxic chemicals such as disinfectants while cleaning,while priming IV tubing,
transferring a medication to a different container, removing syringes from a port, touching
equipment that has been contaminated by the medication, or coming in contact with the blood and
body fluids of the patients, who has taken the medication.
Exposure to hazardous drugs such as antivirals, cytotoxic drugs, can cause acute/ chronic health
effects such as rashes, infertility and possibly cancer. Can be avoided by wearing appropriate PPE.
Biological: Blood-borne infections: HBV, HCV, HIV, while working with blood & body fluids or NSI.
Respiratory infections: Covid, influenza, TB & Others while attending infectious patients, during
Aerosol generating procedures (Intubation, GA, Nasopharyngeal swab collection, fewinfections can
be transmitted by: Percutaneous and mucocutaneous route &Contact with Body, fluids or
contaminated objects.
Adherence to standard precautions and transmission-based precautions help in protecting
HCWs as well as patients from transmission of infection in HCFs (see Chapter 11,12,13,14,15 of
HICC manual).
Radiation: radiation in X-ray and radiotherapy units by wearing TLD badges
Psychological: Stress due to understaffduring night shifts/pandemics -lean staffing.
Ergonomic: Backache or neck ache or eye strain due to poorly designed seats, computer
workstations
Accidents/ falls due to lack of patient safety arrangements
Human factors effecting safety Several individual factors affect a person’s performance, thus
predisposing them to error. Two factors with the greatest impact are fatigue and stress.
Strong scientific evidence links fatigue and impaired performance, making it a known risk factor in
safe practice. It is important to recognize that low levels of stress are also counterproductive, as they
can lead to boredom and failure to attend to a task with appropriate vigilance.
These human factors can be overcome by Occupational health program.
An occupational health programme is essential for an effective IPC programme and has implications
for patient safety. The components of such a programme are: 1. Evaluation for general health of
employees including infectious diseases at entry, periodically as required.
2. Pre-employment assessment Before being allowed to work in high-risk areas, all staff should be
assessed and offered testing and/or vaccination for specific infectious diseases. Details of medical
history, particularly for infectious diseases such as rubella, measles, mumps, chickenpox (varicella),
hepatitis B, immune disorders, and skin conditions, and for prior exposure to tuberculosis should be
recorded.
3.Annual health checkup.
4.Routine screening of HCWs for carrier state is not recommended. Besides following safe work
practice,
HCWs can be protected from HAIs by preventive health checkups once a year,
immunization, and PEP after accidental occupational exposure to patient’s blood and body
fluids.
Occupational vaccination programme: Ref: Chapter 18,Staff health program page 49.
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37. Food safety, Responsibilities of Catering staff, kitchen sanitation protocols

and cleaning process
PURPOSE: This section talks about the Food safety, Responsibilities of Catering staff, kitchen
sanitation protocols and cleaning process in Fernandez Hospital.
SCOPE:
Food Safety: the way food is handled, prepared & stored to prevent subsequent food-borne illness
& product contamination. Nutritious food plays a major role in the quick healing process &It is
essential for the wellbeing and optimal performance of the Employees.
Importance of Food Safety: Hospital is a potential source of all types of Infectious diseases.
 Hospitalized patients are more susceptible to infectious diseases because of their immune
status and disease related comorbidities.
 Hospital kitchen deals with much wider assortment of diet including special diet like enteral
feeds and neonatal feeds.
 Delay in transport of food and inappropriate storage during the process may lead to
contamination or spoiling of the food.
Factors contributing to the spread of foodborne infections in HealthCare facilities:
Factors Comment
Food items  Proper selection & monitoring of raw food ingredients
 Type of meal served and time lapse between preparation
and serving
Food Handlers &  Inadequate hygiene while preparing or serving of fresh
Servers salads & simultaneous handling of other ready to eat items
may lead to cross contamination.
 Undue delay in serving may permit release of toxins such as
Staphylococcus enterotoxins.
 Asymptomatic infection among food handlers
 Lack of vaccination of HCWs- Typhoid vaccine.
Facilities  Improper design & maintenance of food storage, meal
preparation/serving facilities.
Pathogen  Bacterial: Staphylococcus aureus, Bacillus cereus,
Clostridium botulinum, Clostridium perfringens, Vibrio
cholerae, Enterotoxigenic Escherichia coli,
Enterohemorrhagic E. coli, Salmonella spp, Campylobacter
jejuni, Shigella spp, Listeria monocytogenes, Yersinia spp,
Brucella abortus.
 Viral: Hepatitis A, Norovirus, Rotavirus, Hepatitis E
 Parasitic: Cryptosporidium parvum, Giardia lamblia,
Toxoplasma gondii, Cyclospora cayetenensis, Entamoeba
histolytica.
Patients  Patients with comorbid illness like diabetes, Extremes of
age, immunosuppression therapy are more susceptible to
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foodborne illness.
 Patients on dietary restrictions, e.g. enteral foods
Visitors, caregivers  Bringing outside food to the patients
 Unhygienic handling of served meal
INFECTION CONTROL PRACTICES IN KITCHEN:

1. Physical design of Kitchen Department: should be located away from the patient care and waste
collection areas, preferably in the ground floor of the hospital which eases the accessibility for
receiving and distribution, it should take shortest possible time in delivering food to the wards.
2. Dedicated Areas in Kitchen: Following physically separate areas should be present in the kitchen
department:
 Raw supply receiving and checking area.
 Storage area for raw material, vegetables with appropriate numbers of refrigerators, racks,
etc.
 Areas of functional kitchen include:
 Processing of raw food (washing, cutting vegetables, etc.)
 Cooking area.
 Handling area for cooked food
 Dispensing counter/area
 Separate area for storing environmental cleaning equipment, e.g. mops, buckets and
cleaning disinfectants should be made available. This should not be connected to the food
storage area in any manner.
 A dedicated toilet and dress room facility for kitchen personnel.
 Food waste storage area.
3. Essential Requirements in Kitchen Area:

 Restricted Entry board: entry restricted to authorized staff.
 Adequate supply of treated water
 Secured windows.
 Food supplier: The food material should be bought only from a reliable supplier to
ensure the quality of the raw food materials.
 Storage facility: All food grain storage should be done on raised pallets/ stands with a
minimum clearance of 8-12 inches from the floor. All refrigerators, freezers & other
storage should have the same clearance above the floor. Storage pallets, refrigerators
should have clearance from all sides to enable inspection & cleaning. The storage
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room should not have high temperature, should be adequately ventilated.

Thermometer to measure room temperature and a log should be maintained.
 Separation of cooked and raw food: holding/storage areas for the two should be
separated from each other.
 Hand wash facility: hand wash basins should be available in the food preparation
area. These should be separate from the basin used for washing raw food.
 Separate weighing/ measuring apparatus: for raw & clean/ cooked foods should be
maintained.
Plants & Pets completely avoided in kitchen vicinity.
4. Cleaning and Disinfection in Kitchen:
Environmental Cleaning: is extremely important to prevent contamination of food with
environmental microorganisms.
a. Dedicated cleaning items: Separate mops & buckets, cleaning solution (detergents) and
disinfection products (1% hypochlorite).
B. Floor Cleaning:
Frequency: Depends on the work carried out in that area of kitchen. All floors in the kitchen
complex should be cleaned at least twice a day using soap & water.
Cleaning sequence: Cleaning should begin with the food storage room and proceed to preparation
and cooking area. The waste storage area and the cleaning equipment storage area at the end
Additional cleaning: Spill should be cleaned immediately and also when the floor is dirty,
should be cleaned immediately.
c. Food storage pallets: Should be cleaned by wiping with soap and water at least weekly.
d. Surface cleaning: Tables and surfaces should be wiped with soap and water at least twice a day or
before and after food preparation.
E.Weighing machines: should be cleaned once a day or whenever required with soap and Water.
f. cooking stoves: should be cleaned with soap and water before and after use. Gas cylinders also,
should be cleaned.
g. Changing of mop heads/mop and brushes: should be done when they become frayed or at least
every two weeks, whichever is earlier. Clean with soap and water before each use.
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5. Medical care and education for food handlers: all persons handling food should undergo
Periodic medical examination and laboratory testing.
 At the time of joining& periodically
 Medical test Frequency

 Blood group At the time of joining
 Stool examination for ova,  at the time of joining, once in
cysts, and parasites every three months or if the staff
rejoins after a leave of 15 days or
more
 Stool culture/sensitivity  at the time of joining, once in
every three months or if the staff
rejoins after a leave of 15 days or
more
Personal Hygiene of Kitchen Workers:

 Fresh washed clothes every day.
 Clean apron while handling food.
 Hand hygiene: at the beginning and after completion of each task or whenever visibly
soiled.
 Clean & short nails.
 Hair should short and tied. Netted cap covering all head hair must be worn by kitchen
workers on duty.
 Diagnosis of any illness should be promptly reported, and the employee should undergo
appropriate examination and treatment without delay.
 Open wound should be covered with waterproof dressing while on duty.
 Smoking and alcohol consumption must not be allowed.
 Respiratory hygiene and cough etiquette must be strictly followed all the time.
6. Education and Training: should b conducted at the time of joining and at least twice yearly
and during outbreak situations.
Topics: Pathogens causing food borne infections, common symptoms to identify foodborne
illness, personal hygiene, processing of food. Etc.
Posters & visual signages: to reemphasize personal hygiene, hand wash posters.
Vaccination: Typhoid Vaccine shall also be provided to all canteen staff years. Records of all test
results and vaccinations shall be maintained with the infection control nurse.
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FOOD PREPARATION:
 Use correct temperatures.

 Cook eggs appropriately.
 Use a clean container/measuring apparatus to measure out food portions.
 Food should not be consumed in preparation area.
Storage and dispensing of prepared food:
 The prepared food should be covered during transport and served as soon as possible.
 Clear plastic gloves should be worn while dispensing the food.
 Clean serving equipment should be used.
Care of refrigerators:
 Temperature: maintained between 2-4°C.

 Electronic sensors may be used.
 Defrosting: done regularly and any spillage should be cleaned immediately.
 Labelling should be done on all covered items.
 Routine inspection of refrigerator should be done at least twice daily to ensure temperature
and to discard the food which is not labelled.
 Clean the fridge at least once in a week.
 Out of range temperatures should be documented with CAPA.
Waste disposal: Segregate into dry and wet waste at the point of generation.
 Waste should be always kept covered.
 Waste bags should be tied and disposed of daily or when three fourths full, whichever is
earlier.
Pest Control:
 The entire kitchen area should be sprayed with pesticides once a week.
 Rodent traps should be in place in various areas.
 Pest infestation should be looked for daily and reported immediately when detected.
Record Maintenance:
 All parameters of kitchen service: Temperature logs, cleaning schedules, food preparation
menu, and time of dispatch to patients should be documented. This should be counter
signed by office in-charge.
 Temperature record display on each machine.
 Cleaning schedule chart should be maintained and displayed in respective areas.
 Stock register should be maintained which include date of procurement, expiry and best use
before. Strictly follow FIFO.
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Kitchen audit: Should be done by HICC team once in six months using the checklist.
HACCP: Staff can demonstrate HACCP (Hazard Analysis and Critical Control Point) procedures for
testing and evaluating safety of food.
The HACCP plan keeps your food safe from biological, chemical, andphysical food safety hazards. To
plan we must: identify any hazards thatmust be avoided, removed, or reduced.
Staff safety and staff hygiene. Staff should be visibly healthy and shouldbe aware of work restriction
requirements.
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Annexure I - Reporting Form for Exposure / COVID 19 symptomsof a Healthcare

Worker (HCW)
To potentially suspected or confirmed cases of COVID 19
Name: Age in years:

Employee ID: Telephone
Work Department: number:
Job designation
Current residing address: Unit:
Last Date of exposure:
Medical conditions (known):
Type of exposure:
Was patient wearing a mask
Type of contact:
1. Direct physical contact: YES / No

2. Contact with body fluids: YES / No
3. Close contact > 15 min, < 6 feet: YES / No
4. Proximal contact – > 1 hour in the same room > 6 feet: YES / No
5. Specify please:
Type of PPE used Yes No Do not remember

1. Surgical mask
2. N95 / respirator
3. Eye protection
4. Gloves
5. Gown
Mention any NON occupational exposure to a possible case of COVID, outside hospital, in
the community:
COVID Screening Symptoms
Day of onset of symptoms: _

☐ Fever, since_ _
☐ Cold, Cough, since Symptoms of worsening disease, infective lung
☐ Diarrhea, since injury (ILI)
☐ Myalgia, since_ ☐Worsening cough, fever, blood in sputum
☐ Loss of smell, taste, ☐Shortness of breath
since ☐Persistent pressure/ pain in chest
☐ Mental confusion & inability to arouse
☐ Bluish discolorations of lips and face
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High Risk Category
☐ Age > 65
☐ Diabetes
☐ Chronic renal disease
☐ Chronic liver disease
☐ Chronic lung disease, moderate to severe asthma
☐ Immunocompromised, on steroids, HIV, chemotherapy
☐ Serious cardiac conditions
☐ Severe obesity BMI > 40
☐ Serious cardiac conditions
Consulted by DR _ on date
Covid test advised ☐ Yes ☐ No
Rx
Annexure II – Schedule for Collection of Surveillance Areas

1. OT, CSSD – Monthly
2. ICU, NICU, Labour Room, Disinfectants – Quarterly
3. Water - Monthly
NICU OT LR
Incubator/Warmer Wall Delivery Table
O2 Flowmeter Floor LR Warmer
Infusion Site Table PT Table
Steth Light Top Light
Ventilator Ventilator NST Machine
Humidifier AC Medicine Trolley
Breast Pump Monitor Sterile Pack
Tap Handle Suction Bottle AC
Cardiac Table Instrument Trolley Infusion Pump
Phototherapy Boyle’s O2 Flowmeter
AC Scissors
Medicine Trolley Mayo
Baby Warmer
Medicine Trolley
Anesthesia Work
station
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Annexure III – Disinfectants and Dilutions
S. Name of the
Composition Quantity Purpose Dilution Shelf life
No disinfectant
900 ML OF
WATER+100ML
CLEANING OF OF SODIUM
SODIUM BLOOD AND HYPOCHLORITE
10% STAYS FOR 1
HYPOCHLO LIQUID AVIALABLE IN BODY FLUIDS SOLUTION
1 YEAR, 1% STAYS
RITE CHLORINE 5 LITERS SPILLS, MAKE 1%
FOR 24 HOURS
SOLUTION WASHING OF SODIUM
INFECTED LINEN HYPOCHLORITE
SOLUTION
ETHYLENE
GLYCOL,
SURFACTANTS, FOR CLEANING
2- MEDICAL ,
METHOXYMETH SURGICAL 10 ML PER 1
3M RAPID
YLETHOXY INSTRUMENTS LITER LUKE AFTER MAKING
MULTI AVIALABLE IN
2 PROPANOL, (E.G. DELIVERY WARM WATER FOR 1% STABLE
ENZYME 1LITER
SODIUM TETRA SETS AND OT SOAK IT FOR 10- FOR 24 HOURS
CLEANER
BORATE SURGICAL 15 MIN
DECAHYDRATE, INSTRUMENTS,
C10-C16 ALKYL DRESSING SETS)
DERIVATIVES
TRIPLE SALT:
POTASSIUM FOR 10GMS OF
MONOPAERSUL DISINFECTION BACILLOCID IN 1
STABLE FOR 7
PHATE, SODIUM OF SURFACES LITER OF WATER
DAYS IF COLOUR
C10-13 LIKE BED AND MAKES 1%, FOR
3 BACILLOCID 500GMS CHANGESFROM
ALKYLBENZENE FLOOR OTHER FOGGING 5GMS
WHITE DISCARD
SULFONATE, ENVIRONMENTA OF BACILLOCID
IMMEDIATELY
SODIUM L SURFACES IN 1 LITER OF
CHLORIDE AND FOGGING WATER
AFTER OPENING
USE FOR
INDIVIDUAL
AVAILABLE IN PRE AND POST READILY PATIENTS,
10% POVIDONE
4 BETADINE 100ML AND SURGICAL SKIN AVAILABLE IN ACCORDING TO
IODINE
500ML ANTISEPSIS 10% THE
MANUFACTURE
GUIDELINES
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Annexure IV – Infection Control Compliance Checklists for Staff

a) NICU staff
Parameter evaluated (YES/ NO/Comments)
1. Adhesion to hand hygiene guidelines/procedures.
2. Use of PPE (caps, mask and scrubs) during invasive procedures.
3. Respect of asepsis in the management of central venous catheters and venous lines
connection.
4. Disinfection of glucometer after everysingle use.
5. .Preparation of infusional therapy on a dedicated work surface treated with high level
disinfectant.
6. Use of single patient trays (Stethoscope, thermometer, gauzes, medicines)
7. Proper waste disposal
8. Safe needle disposal
9. Administration of single dose saccharose solution for single patient.
10. Hand hygiene of visitors.
OBSERVATIONS:
b) ICU staff
1. Adhesion to hand hygiene guidelines/procedures
2. Use of PPE ( caps, mask and scrubs) during invasive procedures
3. Respect of asepsis in the management of central venous catheters and venous lines
connection
4. Proper waste disposal
5. Safe needle disposal
c) Labour Ward staff

1. Adhesion to hand hygiene guidelines/procedures
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2. Cleaning of floors and other areas done as specified in housekeeping SOP.
3. Cleaning of delivery tables.
4. Cleaning of warmer, cots, suction apparatus, oxygen hood etc
5. Cleaning of spills
6. Disposal of waste and soiled linen
7. Disposal of needles and sharps
8. Cleaning of newborn care corner.
d) OT staff
Outer zone:
- Main access corridor.
- Transfer area.
- Supervisor office.
- Documentation area.
- Pre operative patient holding areas.
- Changing facilities.
Clean/ Semi – Restricted:
- Clean corridor.
- Sterile and equipment sterile store.
- Anaesthesia and recovery room.
- Rest areas.
Restricted Zone:
- Scrub sinks.
- Operating room.
1. Staff to change into theatre clothes and shoes before entering the clean/ semi restricted
area.
2. OT should be restricted to just the personnel involved in actual operation.
3. Sterile personnel not to reach across un-sterile areas or to touch un-sterile items
4. Standard precautions
- Hand hygiene
- PPE
- Aseptic technique
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- Environmental cleaning
- Instruments reprocessing
- Waste management
- Universal precautions.
5. Pre operative :
- Preparation of patient : Treatment of all remote infections, Hair removing techniques

- Hand antisepsis for surgical team: Short nails, surgical scrub (2 – 5 mins), donning of
sterile gowns and gloves.
- Anti microbialprophylaxis:within 15 – 60 min before incision.
6. Intra Operative :
- Ventilation System :
 Positive pressure ventilation.
 20 air changes/ hr(atleast 4 fresh air )
 Operating room doors closed except as needed for passage of equipment personnel
and patient.
- Cleaning and disinfection of environmental surfaces :

 When visible soiling and contamination with blood/ body fluids of surfaces/
equipment.
 Use approved disinfectant to clean before next operation.
- Sterilization of surgical instruments: According to guidelines.
- Surgical attire and drapes :

 Full PPE
 Mask
 Cap
 Gloves
 Gown
7. Preoperative period
- The knowledge and the actual implementation of the guidelines for SSI prevention.
- Patient skin preparation (hair removal and skin antisepsis).
- Setting up of sterile drapes.
- Surgical hand disinfection of the surgical team.
- Quality of air ventilation (type of flux, type of air contamination, pressures).
8. Operative period
- Permanent wearing of scrub suits by every person in the operating room (OR)
(mask/surgical caps).
- Permanent wearing of specific sterile suits for the operating staff.
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- Wearing of a surgical cap covering all hair surfaces by all persons in the OR during the
surgical procedure.
- Wearing of a mask covering the nose and mouth by all persons in the OR during the
surgical procedure.
- Systematic replacement of material of wear in case of asepsis fault.
9. Postoperative period
- Minimum time required for cleaning and refurnishing the OR between two surgical
procedures
10. Movement tracking

- Number of people in the OR during the surgical procedure.
- Frequency of opening of OR doors.
- Respect of the OT cleaning time between two interventions. Limitation of the traffic in
the OT.
Annexure V –List of Invasive, High-Risk or Surgical Procedures

1. Any procedures involving skin incision
2. Any procedures involving general or regional anesthesia, monitored anesthesia care, or
conscious sedation
3. Injections of any substance into a joint space or body cavity
4. Percutaneous aspiration of body fluids or air through the skin (e.g., arthrocentesis, bone
marrow aspiration, lumbar puncture, paracentesis, thoracentesis, suprapubic
catheterization, chest tube)
5. Biopsy (e.g., bone marrow, breast, liver, muscle, kidney, genitourinary, prostate, bladder,
skin)
6. Cardiac procedures
7. Endoscopy
8. Laparoscopic procedures
9. Invasive radiological procedures
10. Dermatology procedures (biopsy, excision and deep cryotherapy etc)
11. Invasive ophthalmic procedures, including miscellaneous procedures involving implants
12. Skin or wound debridement performed in an operating/procedure room
13. Central line placement / PICC line or UVC in neonates.
14. Artificial rupture of membranes, Colposcopy, and/or endometrial biopsy
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Annexure VI - TASK FORCE for COVID – 19
S No Name Designation Department

1 DrEvita Fernandez Chairperson Administration
2 DrPramod G Managing director Administration
3 DrPallavi Chandra Senior Consultant Obstetrics
4 DrKrupa Patalay Medical Director & Senior Obstetrics (Unit 1)
Consultant
5 DrTarakeswariS. Senior Consultant Obstetrics (Unit 2)
6 Dr. Sailaja Medical Director Obstetrics (Unit 2)
7 DrRajitha Reddy DirectorOperations& Consultant Operations
Obstetrician
8 Mr. Rahul Datta Chief Operating Officer Administraion
9 DrKameswariSurampudi Senior Consultant& HOD Gynaecology
10 DrSuseela Vavilala Senior Consultant Fetal Medicine

11 DrHemamalini Senior Consultant General Medicine
12 DrAnisha gala Senior Consultant Obstetrics
13 DrPadmaja Yelisetty Senior Consultant Obstetrics
14 DrShanthi Anaesthetist Anaesthesiology
15 Dr Geetha Kolar Senior Consultant Fetal Medicine
16 DrNirupama Padmaja B Microbiologist / Infection Control Lab Services
Officer
17 Dr SiddiquaDehgani General Manager / Administrator Administration (Unit 1)
18 DrTejaswini B Kushnoor General Manager / Administrator Administration (Unit 2)
19 Bathula Swathi Paulina Assistant General Manager / Administration (Unit 5)
Administrator
20 Shirley Thomas T Deputy General Manager / Administration (Unit 4)
Administrator
21 Ayyagari V N Assistant General Manager / Administration (Miyapur)
Satyadurga Administrator
22 Ms. Upasna Head HR Human Resources
23 Head Quality Quality
24 Inderjeet Kaur Director Midwifery Midwifery
25 Bitla Ruth Sireesha Manager Branding&Communication
26 Neil Campos Head of Interiors & Renovations Projects
27 Mr. Masih Head IT Information Technology
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Annexure VII - Infection Control Audit Tool Checklist for Kitchen Sanitation
Please mark  / X / NA (not applicable)/Write comment appropriately
CRITERIA
1 Adequate infrastructure
Unidirectional flow of activities (clean/dirty)
2 The floor is free of water, dust or other liquids.
3 Inaccessible areas are free of dust.
4 Spilled food is cleaned up immediately.
5 Fly screens are in place where required.
6 Pest control
7 Fans & expel airs are free of dust and grease.
8 Hand wash, sink, liquid soap & disposable paper towels are available.
9 Shelves, cupboards & drawers are clean outside & out and are free from
damage and dust.
10 Kitchen trolleys are clean and in a good state.
11 Refrigerators are clean and free of ice build-up.
12 Daily temperature monitoring of fridge.
13 Food is labelled with date and stored.
14 Water supply is visibly clean and on a planned maintenance program.
15 Bread is stored in a clean bread bin or suitable segregated area.
16 Milk is stored under refrigerator conditions.
A Storage of raw materials
B Raw supply receiving & checking area
C Storage area for raw material adequate and systematically arranged
with FIFO
D All food products are within expiry date.
17 Posters and visual signage’s at various areas of kitchen
18 Areas of functional kitchen
A Processing of raw food (Washing, cutting vegetables etc)
B Cooking area
C Holding area for cooked food
D Dispensing counter area
19 Microwave ovens are visibly clean inside and out.
A Food is transported under clean conditions, properly covered to prevent
contamination
B Food is transported in dedicated vehicles by dedicated staff.
20 There is a satisfactory system for cleaning of crockery and cutlery.

A Separate area for environment cleaning equipment and away from
food.
B Disposable utensils are properly discarded after single use.
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C Waste bins are foot operated and in good working order

21 Cleaning schedules are available.
22 Waste bins are clean and labeled for general waste.
23 Direct questioning of staff:
A Personal hygiene: Fresh washed clothes, HH, Hair should be kept short,
short nails. Training on
Respiratory hygiene and Cough etiquette.
B Food handlers keep their personal clothing and over-alls clean.
C Hands are not contaminated, and a clean plastic apron is worn to serve
patients meals and
drinks
D Examination for open wounds/ any illness /smoking/alcohol/
E Training on Food hygiene and food borne illness.
F Vaccination for Typhoid, booster every three years
G Screening of food handlers, at the time of joining/ yearly/if on long leave
for 15 days.
Issues identified and comments:
Signature of the Auditor:
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Hospital Infection Control FH/MAN/HIC/011/23

HOSPITAL INFECTION CONTROL

Document Version Information

Version Release date Prepared by Approved by

Designation: Infection Control Designation: Chairperson –

5. Roles and Responsibilities 10

6. Review and Revision of Infection Control Manual 12

10. Infection rates 21

11. Standard Infection Control Precautions 21

12. Hand Washing 24

13. Personal Protective Equipments (PPE) 30

14. Needle Stick Injuries 31

15. Standard precautions in clinical laboratory and transfusion services 39

17. Biomedical Waste 45

18. Staff Health Programme 49

19. Isolation Policies & Procedures 50

20. High-Risk Areas and High-Risk Procedures 64

21. Care of systems and indwelling devices 66

22. Re-use Policy 71

25. Decontamination and Disinfection of general items 78

27. House Keeping 80

28. Laundry and linen management 84

30. Post Operative ward / Intensive Care Units 88

 Scope:The Hospital Infection Control Manual is a reference guide containing policies as

The program should have the following objectives:

 To ensure continuing education of employees on aspects of infection control.

3. Infection control structures at Fernandez Hospital

4. Hospital Infection Control Committee

 To minimize the risk of infection to patients, staff and visitors.

 Maintenance of surveillance of hospital acquired infections.

 Develop a system for identifying, reporting, analyzing, investigating and controlling

 Conduct employee health education programme regarding matters related to hospital

Members of the HICC

S. No. Department Members

Infection control team

 Infection control teamcomprises:

 Advise management of at risk patients.

 Investigate outbreaks of infection and take corrective measures.

 Provide relevant information on infection problems to management.

 Surveillance of infection, data analysis, implementation of corrective steps. This is based

 Waste management & implementation of all infection control activities.

 Supervision of isolation procedures.

 Monitor employee health program.

5. Roles and Responsibilities

Duties of infection control nurses:

prophylaxis and follows all protocols and policies of HIC.

Infection Control Officer (ICO)

 He/Shemonitor the implementation of various policies regarding HIC practices.

Role of Nursing Superintendent

 To implement various HICC policies.

promoting improvements in nursing techniques.

 To encourage nursing training programmes.

Role of Hospital Management

 Establish multidisciplinary infection control and coordinate activities of HICCommittee

 To ensure all CME activities for its staff.

 To review quality indicators of HICC and encourage surveillance activities.

 To ensure adequate supplies of gloves, masks, disinfectants etc.

 To ensure employee health programmes and policies.

 To ensure pre- and post-exposure prophylaxis programs.

 To discuss and implement corrective measures during HICC meetings.

6. Review and Revision of Infection Control Manual

informed to the DMHO.

 The objectives of notification are:

o To collect accurate and complete epidemiological information on the disease.