SHAMSHAD ASLAM HOSPITAL

Hospital Name: SHAMSHAD ASLAM HOSPITAL

PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

REVISION HISTORY

ISSUANCE DATE: 15-3-2019

EFFECTIVE DATE: 17-3-2019
ST
1 REVISION DATE: 01-12-2022
ND
2 REVISION DATE 29-03-2024

Particulars Name Designation Signature

Prepared By: Dr. Saira Salim HOD Pathology/ Infection Control Officer

Reviewed By: Dr Malik Hassan Raza Dy. Director

Approved By: Brig. Dr. Muhammad Iqbal CEO

1|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

1- DECONTAMINATION PROCEDURE FOR PATIENT CARE EQUIPMENT

Any item in contact with patient needs decontamination before reuse of it.

Article Standard Procedure Comments

Ambubag Should be cleaned with detergent and
water; dried and sterilized.

Applinators Immersion in 0.05% hypochlorite (500 A fresh solution should be

parts per million available chlorine) for 10 prepared at the start of each
(Tonometer prisms)
minutes. clinic.

Arterial catheters Sterile single use only, must be discarded

after used.
Baby equipment 1) Disposable - single use. Should be soaked for a minimum of
Feeding bottles & 2) Re-usable – should be returned to 1 hour.
teats CSSD or washed in hot detergent and
water, rinsed and immersed in Milton
fluid, freshly made up from tablets
according to manufacturer's
instructions.

Crockery and cutlery Should be washed after each use with

Baby weighing scales
detergent and water
A fresh liner should be used for each
baby. If contaminated should be wiped
Clean tray as necessary with detergent with hypochlorite 1000ppm after
and water. washing.

Baby bath Should be cleaned after each use with

detergent and water

Beds and Should be cleaned with detergent and If contaminated with body fluids,
couches Frame water between patients and as see spillage policy. If used in
required. isolation room - after cleaning,
should be wiped with a
disinfectant

2|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

Mattresses and pillows Should be cleaned with detergent and
water between patients and as
required.
Bedpans and urinals Should be cleaned and disinfected with
0.5% sodium hypochlorite or hot water. It
must be ensured that the item is dry
before re-use.
If contaminated with body fluids,
the blood spills policy should be
implemented.
Should not be used if cover is
damaged.
Contaminated pillows must be
discarded. Torn mattress covers
must be replaced before mattress
in re -used.

Breast pumps Should be washed with detergent and

water, immersed in sodium hypochlorite,
freshly made up from tablets according to
manufacturer's instructions.

Brushes 1) Disposable - single use. Should not be left on sink after

Nail 2) Re-usable – to be returned to CSSD use.
after each use.
Toilet
Should be rinsed well in flush water and
stored dry.

Carpets Vacuum daily. Should be shampooed or steam

cleaned in isolation rooms as part
of terminal cleans.

Commodes Seat and arms should be cleaned with If soiled or used in isolation,
detergent and water, and dried. should be wiped with sodium
hypochlorite 2%, and dried, after
cleaning.

Cradles Should be cleaned with detergent and

water, and dried.

Crockery and cutlery Should be heat disinfected in dishwasher.

If washed in sink - hot water and
detergent.

3|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

Curtains Should be changed as part of a rolling Should be changed as part of

programme by domestic services. terminal clean.

Denture pots 1) To be cleaned by patients themselves

with detergent and water
2) Disposable with lid - single use.

Drainage bottles 3) Disposable - single use

4) Re-usables -rinse and return to CSSD
Should be cleaned with detergent and
Drip stands water and dried.
After use in isolation, should be
wiped with sodium hypochlorite
2%, and dried after cleaning.

Ear pieces for auroscope Should be cleaned with detergent and To be returned to CSSD after use
water and dried. in isolation.

Earphones Should be cleaned with detergent and Foam should be replaced after use
water and dried. in isolation.

Leads and monitors Should be dismantled to smallest

components and cleaned with detergent
and water and dried.

Eye protection Should be cleaned with detergent and For blood splashes blood
water and dried. spillage policy should be
followed.
Floors Should be vaccumed daily. For blood splashes blood
A damp mop with detergent and water spillage policy should be
should be used. followed.

Flower vases Should be clean with detergent and

water and dried. Should be stored
inverted.

Furniture Should be damp dusted with detergent

and water.
Humidifiers Should be cleaned and sterilized at low
temperature.

4|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

Incubators Should be cleaned with detergent and Terminal sterilization with

water and switch on to dried. ethylene oxide gas may be
required after some infections.

Intravenous monitoring Should be cleaned with detergent and After use in isolation wipe with
pumps (and feed pumps) water and dried. sodium hypochlorite 2%, and dry,
after cleaning.
Instruments Single use only. To be returned to
CSSD.
Linen Should be soaked in hot water; returned to
laundry
Mops Disposable - use for one day. Mops must not be stored wet
Re-usable to be laundered in washing or cleaned in disinfectant
machine. solutions.

Peak flow Disposable - single patient use.

Nebulizers Cleaning and low temperature

sterilization.
Pressure relieving devices Should be clean with detergent and
water and dried.

Proctoscopes Disposable - single use,

Re-usables to be rinsed and returned to
CSSD.
Raised toilet seats Should be cleaned after each use with
detergent.
Razors Safety - single use – disposable
Electric - patients own. Razors should
not be shared. Detachable head and clean
with 70% isopropyl alcohol swab.

Shaving brush Should not be used unless supplied by the

patients for their own use.

Skin disinfection Showers are preferred to bath or bed

baths.
Soap dispensers Should be cleaned weekly with detergent
and water and dried.

5|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

Sphygmomanometer cuffs After use in isolation, should be

laundered in washing machine.

Spillages Should be cleaned with detergent.

Sputum pots Disposable with close fitting lid.

Should be
discarded into clinical waste for
incineration.
Stethoscopes Should be cleaned with detergent and
water and dried.
Should be wiped with 70% alcohol.

Suction bottles Disposal liners. Must be sealed when

75% full and placed in yellow plastic bag.
Re-usable; should be cleaned with
sodium hypochlorite and dried. Must be
changed daily and in between each
patient.
To be stored dry when not in use.

Telephones To be wiped with 70% alcohol.

Thermometers To be covered with disposable sleeve

before use and stored dry in

individual holder. In between patients,

should be cleaned and wiped with 70%
isopropyl alcohol (swab).
If disposable sleeve not used, in between
patients, should be washed in general
purpose detergent and tepid water then
wiped with 70% alcohol (swab).
To be stored in individual holder inverted.

Toilet seats To be cleaned at least twice daily with

detergent.

6|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

Toys Toys should be cleaned with detergent For isolated patients, toys that
and water and dried. cannot be decontaminated to be
avoided. Heavily contaminated
toys may have to be destroyed.

Trolleys (Dressing) To be cleaned daily with detergent and

water. After each use should be wiped
with 70% isopropyl alcohol.

Urine measuring jugs To be heat disinfected after each use in

bed pan washer.

Venilators To be sent to respiratory therapy unit.

Contents must be emptied into sluice
Vomit bowls then rinsed and washed and disinfected
with hot water and detergent

Wash bowls Patients must have own dedicated bowl.

After each patient’s use, should be cleaned
with detergent.

Wheel chairs Patient’s own – should be cleaned with

detergent and water as necessary.
Hospital – clean between patients with
detergent and water

*Reference: Guidelines on Prevention and Control of Hospital Associated Infections, World Health
Organization Regional Office for South-East Asia New Delhi January 2002.

7|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

2- HAND WASHING TECHNIQUE

Indications

According to the CDC, hand hygiene encompasses the cleansing of your hands with soap and water,
antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels, or surgical
hand antisepsis. Indications for hand washing include when hands are visibly soiled, contaminated with blood
or other bodily fluids, before eating, and after restroom use. Hands should be washed if potential there was
potential exposure to Clostridium difficile, Norovirus, or Bacillus anthracis.

In 2009, the World Health Organization (WHO) highlighted preset guidelines known as the "Five Moments for
Hand Hygiene."

1. Before touching or coming into contact with a patient

2. Before performing a clean or aseptic procedure

3. After an exposure risk to bodily fluids and glove removal

4. After contact with a patient and their immediate surroundings

5. After touching an inanimate object in the patient's immediate surroundings even if no direct patient
contact

Alcohol-based hand sanitizers are the recommended product for hand hygiene when hands are not
visibly soiled. Apply alcohol-based products per manufacturer guidelines on dispensing of the product.
Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all surfaces on both hands get covered, about
20 seconds is required for all surfaces to dry completely.

Patient and facility healthcare professionals are monitored for hand-washing practices, and they are
conforming to hand-hygiene practices. This practice is becoming increasingly popular as healthcare
professionals strive for a safer environment.

Contraindications

Artificial nails and nail extensions contain pathogens in the subungual spaces; thus posing a threat to
microorganism transmission in the healthcare arena. Therefore, it is recommended that
healthcare professionals do not use them. Well-manicured nails and adherence to artificial nail policies
outlined in facility-specific guidelines are vital to hand hygiene practices. The WHO guidelines recommend that
nails should be kept less than 0.5cm long.

Hand rubbing with an alcohol-based rub should not be performed when the hands are visibly soiled. In this
case, the CDC and WHO guidelines recommend that hand washing with soap and water.

8|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

Equipment

Hand washing is the act of washing hands with soap, either antimicrobial or non-antimicrobial, and water for at
least 15 to 20 seconds with a vigorous motion to cause friction making sure to include all surfaces of the hands
and fingers.

It requires a specific skill set to ensure proper technique.

Hand washing Technique:

 Begin by standing in front of the sink and taking care not to touch sink surfaces with hands or
uniform/lab coat.

 If hands touch sinks at any time during this process, they are considered contaminated, and you must
start the process over.

 Turn on the warm water. Allow water to wet hands and wrists thoroughly.

 Remember to keep hands and forearms lower than your elbows, so cross-contamination from water
running back does not occur.

 Water should flow in a manner from least to most contaminated areas such as the hands.
Microorganisms get washed down the sink.

 Apply approximately 3 mL to 5 mL of an antiseptic soapy solution. Soap requires even distribution with
a nice lather making sure all areas of hands receive covering in soap.

 Next, use friction or rubbing of hands and wrists for no less than 15-20 seconds to ensure the removal
of germs.

 Use a timer or timed sink if available.

 This vigorous rubbing of hands and wrists will include anterior and posterior surfaces, cuticle area,
underneath nails, and in between each finger.

 Leave no part of the hand or wrist untouched.

 Interlace fingers, rub palms and backs of hands at least five times each to ensure all areas have
coverage.

 The World Health Organization (WHO) recommends 6 steps in hand hygiene. This includes palm to
palm, right palm over the left dorsum and vice versa, palm to palm with fingers interlaced, backs of
fingers to opposing palms, rubbing of thumbs and fingertips.

 Rinse hands and wrists making sure all soap has been successfully washed off.

 When rinsing off water remember to keep hands down and elbows up, then dry hands and wrists
entirely with clean or disposable towels.

9|Page
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

 Throw towels away if disposable or place in the appropriate place/hamper/bin without coming into
contact with these objects.

 The end of hand washing will involve making sure you do not re-contaminate your hands by touching
the sink or faucet handles to turn the water off. Once hands are washed and dried, use a towel to turn
off the water and then dispose of it in the appropriate container.

 Surgical sinks/hand washing stations have timers such as in trauma bays that automatically shut off at
specific time intervals. This guard against recontamination of hands/wrists by ensuring there is no
need to turn the water off manually.

10 | P a g e
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

11 | P a g e
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

3. SURGICAL HAND ANTISEPSIS.

Personnel
Healthcare professionals caring for high-risk patients that are immune-compromised must take great care in
performing proper hand hygiene as this patient population is at high risk for opportunistic infections. Hand
washing with soap and water will remove nearly all transient gram-negative bacilli in 10 seconds while
chlorhexidine may be more appropriate than soap and water for the removal of transient gram-positive
bacteria.

Hand washing is a requirement if potential there was potential exposure to Clostridium difficile, Norovirus,
or Bacillus anthracis. Clostridium difficile and Bacillus anthracis contain spores, and none of the agents used in
antiseptic handwash or hand-rub preparations are reliably sporicidal. In these cases, vigorous handwashing
with soap will assist in the removal of the spores from the skin.

According to the CDC, established guidelines recommend that agents used for surgical hand scrubs should
reduce microorganisms on intact skin in a substantial manner, contain a nonirritating antimicrobial preparation,
have broad-spectrum activity, and be fast-acting and persistent. Studies have demonstrated that formulations
containing 60% to 95% alcohol alone or 50% to 95% in combination with other products lower bacterial counts
on the skin immediately post-scrub more effectively than other agents.

Technique or Treatment
Surgical hand antiseptic practices began in the late 1800s and remain vital to the prevention of infection today.
Surgical hand antisepsis or hand hygiene for surgery requires a different set of skills than regular hand
washing techniques. The inadvertent transfer of microorganisms to a patient's surgical site can result in a
surgical site infection; these are one of the most common forms of hospital-associated infections for surgical
patients. Carrying out the correct hand hygiene steps prior to surgery can help reduce the risk of surgical site
infections.

According to the CDC, "Hand Hygiene in the Healthcare Settings," hand hygiene for surgery follows
specific vital steps using either an antimicrobial soap or an alcohol-based hand sanitizer before donning sterile
gloves for surgical procedures. In contrast to hygienic hand washing, surgical hand preparation must remove
the transient flora and reduce the presence of resident flora.

Surgical Hand Antisepsis Steps

 Remove all jewelry such as rings, watches, and bracelets before beginning the surgical hand scrub.

 Inspect hands for cuts, cuticle damage, open lesions or abrasions.

 Apply surgical shoe covers, hats, caps, masks, and eye protection next.

 Turn on water using foot/knee controls to the desired warm temperature.

 Perform a pre-rinse ensuring soap gets to about two inches above the elbows remembering the hands
must be kept above the elbows at all times during this process as well as during the rinse.

12 | P a g e
 SHAMSHAD ASLAM HOSPITAL
Hospital Name: SHAMSHAD ASLAM HOSPITAL
PHC REGISTRATION # R-58811
DEPARTMENT NAME HOSPITAL INFECTION CONTROL DEPARTMENT
DOCUMENT NAME HOSPITAL INFECTION CONTROL PLAN

 Begin debris removal from underneath fingernails using a nail pick while the water is running.

 When performing surgical hand antisepsis using an antimicrobial agent, scrub hands, fingers, and
forearms for 2 to 6 minutes typically, but follow manufacturer guidelines and facility-specific policies
and procedures. Some institutions suggest a certain number of strokes when cleansing the nails,
palms, hands, and forearms.

 Brush methods may be used and are facility-specific. Long scrub times (e.g., 10 minutes) are not a
recommendation due to the potential to irritate hands and non-supporting evidence of its benefit
versus risk.

 Shorter scrub times with a two-stage surgical scrub technique may be standard in some institutions.

 Remember, when rinsing soap/agent off, allow water to run off at the elbows, ensuring the hands
remain clean and free of microbes.

 Foot or knee controls are used to turn the water off.

 Hands stay elevated and away from the body at all times.

 Approach sterile field, grasp towel, avoid dripping excess water on your sterile field, and dry one hand.

 Obtain a new sterile towel or reverse the first towel and dry the other hand.

 Drop towel into a nearby linen hamper or carefully handoff to another member of the healthcare team.

 After application of the alcohol-based product or antiseptic hand rub as recommended, allow hands
and forearms to dry thoroughly before donning sterile gloves.

13 | P a g e