MALABAR CANCER CENTRE, THALASSERY

(An Autonomous centre under of Kerala)

 HAI RATES FROM JULY23 TO SEPTEMBER 23

JULY 23 AUGUST 23 SEPTEMBER 23

INFECTIONS (BSI) 8 3 4
CENTRAL LNE DAYS 887 845 707
RATE 9 3.6 5.7

INFECTIONS (UTI) 1 0 0
CATHTER DAYS 555 509 572
RATE 1.8 0 0

INFECTIONS (SSI) 2 4 5
SURGERIES 132 138 145
RATE 1.5 2.9 3.4

INFECTIONS (VAP) 0 0 0
VENTILATOR DAYS 110 158 167
RATE 0 0 0

INCIDENCE OF PHLEBITIS 9 23 10
CANNULA INSERTION 694 718 603
RATE 1.3 3.2 1.4
 HAND HYGIENE COMPLAINCE RATE (AREA WISE) JULY 23 TO SEPTEMBER 23

JULY 23 AUGUST 23 SEPTEMBER 23

Opportuni

Opportuni

Opportuni
AREA

Action

Action
Action

%
%
ties

ties

ties
INTENSIVE CHEMO 31 31 100 32 32 100 46 46 100

BMT 24 24 100 15 15 100 19 19 100

DAYCHEMO 54 50 93 32 29 91 40 37 93

MICU 110 75 68 41 31 86 71 71 100

SW 60 55 92 36 31 86 60 55 92

PAEDIATRIC WARD 36 34 94 32 32 100 39 39 100

FW 29 29 100 40 38 95 55 54 98

HDU 52 38 73 31 27 87 54 49 91

RR 46 36 78 44 44 100 55 51 93

MW 35 32 91 32 22 71 43 37 86

TOTAL 477 404 85 334 301 90 482 458 95

 HAND HYGIENE COMPLAINCE RATE (STAFF WISE) JULY 23 TO SEPTEMBER 23

JULY 23 AUGUST 23 SEPTEMBER 23

CATEGORY
Opportunities

Opportunities

Opportunities
%
Action

Action

Action
%

%
DOCTORS 94 65 69 73 54 74 119 12 94

STAFF NURSE 275 255 93 221 210 95 242 233 96

RON 7 7 100 10 10 100 33 27 82

NURSING 28 28 100 20 17 85 64 62 97
ASSISTANT

WARD 73 49 67 10 10 100 24 24 100

ASISSTANTS
 CLEANING AND DISNFECTION COMPLIANCE ACROSS HCO JULY 23 TO SEPTEMBER 23

% COMPLIANCE
AREA JULY 23 AUGUST 23 SEPTEMBER 23

RR 100 100 100

BLOOD BANK 100 100 100
X RAY 100 100 100
MW 100 100 100
FW 86 100 100
MICU 100 100 100
SW 100 100 100
HDU 86 100 71
DAYCHEMO 100 100 100
INTENSIVE 100 100 100
CHEMO
PAEDIATRIC 100 100 100
BMT 100 86 100
CVAD 100 100 100
PALLIATIVE 100 100 100
4DCT 100 100 100
PVTR 100 100 100
CLINICAL 86 100 100
LAB
CT SCAN 100 100 100
OPD 86 100 100
PATHOLOGY 100 86 100
CASUALITY 100 100 100
FEED ROOM 86 86 100
MALE PRE-OP 86 100 100

120

100

80

60
Jul-23
40
Aug-23
20 Sep-23

0
 OTHER REPORTS – A Quick Glance- 2023

JULY 23 AUGUST 23 SEPTEMBER 23

Notification of Notifiable Diseases NIL NIL NIL

Number of Potable water Testing 7 9 12
Number of environmental sample testing 52 56 71
Number of RO water testing 1 1 1
Number of Disease Outbreak Reported NIL NIL NIL
Number of MRSA reported 1 4 2
Number of MDRO cases reported 23 26 17
Number of needle stick injuries 1 3 1
Number of blood and body fluid NIL 1 NIL
exposurereported
Number of mock drills conducted in 1 NIL NIL
CSSD
Number of HIC Training sessions 3 3 3
Audit of BMW management 73% 97% 82%
practicesacross HCO
Audit of Laundry Practices 95% 95% 95%

The audit report is prepared by Infection control Team and the report reflects
the practices across the HCO. Since the report is based on real time audit, the results
shall not be applied as such. Every effort shall be made from each staff to improve the
infection control practices. Any error of breach in infection control practices shall be
notified to ICN for inspection, verification and appropriate corrective action.

“IT IS IN YOUR HANDS”

Hospital Infection control committee

MCC