Hospital Infection control

Dec2019– Dec 2020

Infection Control Program

• A designated mechanism for the coordination of the Infection Control

Program

• A well coordinated, multidisciplinary Infection Prevention &Control

Committee(IPCC)

• The committee meets every month.

 Infection control committee Members
Member Designation
Mr. Gunjan U.V Administrator

Dr.Ratna Mani Microbiologist

Dr. Aftab Ahmed M.S,Consultant Internal

Medicine
Dr. Satish Infection Control Officer

Dr. Ehsaan DY.MS

Dr. Sree Devi Pathologist

Dr. shazia HOD Emergency

Ms.Soma Das, Quality

Ms.Sandhya
Ms. Marina ANS
Ms.Kavitha ICN
Mr. Venu Pharmacy In charge
 Co-opted Members

• Dr.Ratna Mani HOD Microbiologist

• Food & Beverages In –charge
• Operational Manager
• Maintenance
• Housekeeping In- charge
Responsibilities of ICT
Meets Monthly.
Emergency meetings if required.
Representation from relevant speciality.
Policy making ,Trends discussion and Relevant intervention
deliberated and approved
Two way communication

IPCC
PLAN AND
NURSING FOLLOW
DOCTORS HEAD UP

ANCILLARY
ICT
SERVICEREP

ICN, FACILITATORS
MASTER
TRAINER
LINK NURSE

SIC
IMPLEMENTERS

S AS
Surveillance and Tracking
• Respiratory tract infections

• Urinary tract infections

• Intravascular invasive devices infections

• Surgical site infections

• Epidemiologically significant like TB ,H1N1, COVID-19,

• organisms like MRSA, VRE, MDROs are a part of the program

• Emerging and reemerging infections like Influenza are

• also included as a part of the program

• The infections are monitored and action taken accordingly to prevent them/
reduce their incidences
 HIC Quality Indicators
Process

• HH compliance

• Bundle Compliance

• BMW Management

• Outbreak management

• Pandemic management
Surveillance Activities
 Activities

Weekly Monthly
 Hand Hygiene Compliance
from Dec 2019 – Dec 2020

NO OF HAND HYGIENE MISSED OPPURTUNITIES IN A MONTH

TOTAL NO OF OPPURTUNITIES IN A MONTH

X 100
 Hand hygiene Compliance Dec 2019 – Dec 2020
expressed in %

Desirable
Trend

NO OF HAND HYGIENE MISSED OPPURTUNITIES IN A MONTH

X 100
TOTAL NO OF OPPURTUNITIES IN A MONTH
 Improvement in Hand Hygiene

• Hand wash facilities at a minimum distance to

encourage hand washing.

• Alcohol rub dispensers at every bed side.

• Alcohol hand rub at all waiting areas.

• On job trainings for all the staff .
Hand hygiene improvement project

Measures adopted to improve the hand hygiene

 VAP FROM DEC 2019- DEC 2020
1
0.9 SUSTAINANCE
0.8
Strict Adherence to
0.7 Bundle components
0.6
0.5 Continuous Monitoring
by ICN
0.4
0.3 Staff aware of VAE
0.2 criteria
0.1
0 0 0 0 0 0 0 0 0 0 0 0 0
Desirable
Trend

NO OF VENTILATOR ASSOCIATED PNEUMONIA IN A MONTH

1000
NO OF VENTILATOR DAYS IN A MONTH
VAP Bundle
 SUSTAINANCE

Strict Adherence to
Bundle components

Continuous Monitoring
by ICN

Staff aware of CLBSI

criteria

Desirable
Trend

NO OF CENTRAL LINE BLOOD STREAM INFECTIONS IN A MONTH

1000
NO OF CENTRAL LINE DAYS IN A MONTH
CLBSI bundle
 CAUTI From Dec 2019 –Dec 2020
ACTION TAKEN
Strict Adherence to
Bundle components

Continuous
Monitoring by ICN

Staff aware of
CAUTI criteria

Desirable
Trend

JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20 JUL-20 AUG-20 SEP-20 OCT-20 NOV-20 DEC-20

Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20
Series1 0 0 0 0 0 0 0 0 0 0 0 0

NO OF CATHETER ASSOCIATED INFECTIONS IN A MONTH

X 1000
NO OF URINARY CATHETER DAYS IN A MONTH
 CAUTI BUNDLE

CAUTI PREVENTIVE BUNDLE

 SSI Rate from Dec 2019-Dec 2020

Desirable
Trend

NO OF SURGICAL SITE INFECTIONS IN A MONTH

X 1000
NO OF SURGERY IN A MONTH
SSI BUNDLE
SSI Prevention (Education on
Pre-op Showers,SSI Bundle)
Infection Control Training Annual Plan-2020
s.no Month Topics
1 January Basic infection control practices

2 February Mechanism and Prevention of HAI

3 March Transmission based precautions,COVID-19 update

4 April Biomedical waste Management,COVID-19 update

5 May Hand Hygiene &Donning and Doffing of PPE,COVID-19 update

6 June Disinfection and sterilization,COVID-19 update

7 July NSI Prevention,COVID-19 update

8 August Infection control Bundles(VAP,CLBSI,CAUTI,SSI)

Surveillance programme -HAI,OT,Laminar flow dialysis, Eye wash,
9 September Environmental monitoring and water analysis
Cleaning protocols of common articles used in patient care ,COVID-19
10 October update
Specific organism management-MDR,VRE,MRSA,TB,HepB,HIV,COVID-
11 November 19 update
Specific protocols-Invasive line care,Suctioning,Trachestomy
care ,Handling of central lines, sample collection and
12 December cultures(ET,Tracheal,Blood,urine)
Re processing equipment cleaning & sterilization

• IPCC approved disinfectants are used in the hospital.

• High level risk process are listed and uniform policy is followed across
the hospitals

• Reprocessing of scopes, instruments ,CSSD monitoring Endotoxin

assay , commonly used articles disinfection ,safe water
supply,envirnomental services has ICT oversight
Re use of single use devices

• Used in CTOT .

• List of devices and materials that can be reused with maximum number
of reuses is documented
• Cleaning process, sterility checks in place
• Functionality check done
• Tracking of patients on whom SUD is used
• Documentation of SUD use and discard
 Cleaning disinfection and sterilization
 

• Disinfectants review - RECOMMENDATION FOR DISINFECTANTS USE

IN THE HOSPITAL IPCC 2020

Non critical Semi critical Critical areas

area area
• Sterilization practices and
monitoring Main lobby Patient room OT

Corridor Kitchen ICU

Conference Dining area Recovery room

• Environmental cleaning and hall

monitoring All offices All toilets Dialysis

Administra Consult cssd

tive block rooms

• Infective cases rooms Pharmacy  waiting areas Lab

    Endoscopy
   
 Transmission based precautions

Type of Isolation Used for Equipment Needed Use For

Pathogens That

Can be spread by direct Gloves, gowns upon MRSA, VRE, scabies, C.

Contact contact; often entering room (Even if difficile, MDR
contaminate the no patient contact is organisms, rotavirus,
environment expected) RSV

Require close contact Surgical masks; gloves if Influenza, N.

Droplet for transmission handle secretions meningitidis, pertussis,
parvovirus
SARS CoV -2
Can be transmitted via N95 respirator upon Pulmonary TB
Airborne airborne route entering room; (confirmed or
Patient must be in suspected), varicella,
negative pressure room smallpox, measles
Transmission of Infections
 BMW
• Disposal of waste and body
fluids

• Handling and disposal of

blood and blood components

• Operations of mortuary

• Dedicated, puncture proof

containers

• Disposal as per local

govt.regulation to Contracted
organization

• Agreement with the contracted

organization
• Regular visit to the final
disposal area.
 Occupational safety

• Pre and Post

exposure prophylaxis

• Availability of PPE
and resources.
 NSI Incidence From Dec 2019– Dec 2020

Desirable
Trend

NO OF NEEDLE STICK INJURIES IN A MONTH

X 1000
NO OF INPATIENT DAYS IN A MONTH
Action taken plan:
1.
Retrained the staff
regarding BMW
2.
Educated the staff
regarding NSI
prevention ad post
exposure prophylaxis
 Incidence of Blood and body fluid
exposure (Dec2019-Dec 2020)

Feb202 Mar202 Apr202 May202 Aug202 SEP202 Oct Nov Dec202

Dec19 Jan2020 Jun2020 Jul2020
0 0 0 0 0 0 2020 2020 0
 

Number of Needle Stick

Injuries
0 0 0 0 0 0 0 0 0 0 0 0 0

No of IP patients 2434 1934 2153 1532 568 1028 1336 1219 1721 2174 2017 1943 1640

SUSTENANCE:

1.Training staff on Prevention of Accidental Exposure to

blood and body fluids management.
2.Adequate Knowledge on PEP provided

3.Availability of PPEs.
 EMPLOYEES PROVIDED PRE –EXPOSURE
PROPHYLAXIS
  Dec2019 Jan2020 Feb2020 Mar2020 Apr2020 May2020 Jun2020 Jul2020 Aug2020 Sep2020 Oct 2020 Nov2020 Dec2020
No of Employees
Who Were Provided
11 10 12 10 5 5 5 1 1 4 255 100 5
Pre Exposure
Prophylaxis
No of Employees
Who Were Due to be
11 10 12 10 5 5 5 1 1 4 255 100 5
Provided Exposure
Prophylaxis
Percentage of
employees provided
pre-exposure
prophylaxis 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

DISCUSSION:
The ICN ensures all the employees in patient care areas are provided with the pre-exposure prophylaxis. It
is provided to nursing, paramedical and house-keeping staff on a regular basis. The status of vaccination is
discussed in the monthly infection control meeting and the same is monitored by the infection control
officer.

IMPROVEMENT & SUSTENANCE MEASURES:

All the employees are made aware during the induction about the vaccination and its significance in the
hospital. Hence they also follow up with ICN for the same.
For better tracking, the ICN provides a copy of vaccination taken by the employees with the due dates of
booster in the respective departments/ areas.
  Vaccination

All Doctors ,Staff Nurses,

House Keeping, Lab &
Blood bank personnel
Technicians were all
vaccinated for Hepatitis –B
H1N1 influenza vaccine
given to ICU,ER and
Premium Room Doctors,
Nurses and House keeping
staff
F & B staff vaccinated for
Typhoid
 COVID Vaccine for all the
staff.
 Pressure Injury Rate From Dec 2019
– Dec 2020 REASONS
•Inherent clinical conditions of the
patients HAPI-2020
• Incontinence & Diarrhea
•NIMBUS Mattress not used

1 1 1 1 1
Desirable
Trend 0 0 0 0 0 0
JAN-20 FEB-20 MAR-20 APR-20 MAY-20 JUN-20 JUL-20 AUG-20 SEP-20 OCT-20 NOV-20 DEC-20

Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20
Series1 2 1 1 1 0 0 0 0 1 0 0 1

ACTION TAKEN
•Educated Nursing staff to use foam
dressings as Preventive strategy
NO OF HOSPITAL ACQUIRED PRESSURE ULCERS •Encouraged Staff to use Barriers like
/WORSENING OF PRESSURE ULCER IN A MONTH Cavilon

NO OF INPATIENT DAYS IN A MONTH X 1000 •Patient family educated to strengthened

on the importance of air mattress
•Strict adherence to position clock.
•Pressure injury checklist for patients with
Braden score18 and less than it.
NOTIFIABLE DISEASES
 New Initiatives
• Implementation of
• Pressure Injury Checklist,
• Foam Dressings,
• PUSH(Pressure Ulcer Scale for Healing) tool
–for prevention of pressure injuries.

• Link Nurse Programme.

• Infection Control Month/Week.

• Training on wound Care.

• Hand hygiene Champion for the month.

• Biomedical waste and NSI Prevention

Campaigns

• Project on Hand Hygiene.

• Project on Prevention of Pressure Injury.

VIP scoring for Phlebitis Push tool
 New Initiatives

• Infection Control Practices for all

The staff ,ID Areas Sars COV-2 ICU and
Wards).
• Adherence to WHO,MoFHW,CDC
Guidelines.(Disinfection and
sterilization,Donning ,Doffing,Linen,
BMW, Sample collection)
• Daily screening of staff.
• Green Corridor to prevent
Transmission.
• Triaging Patients accordingly to
prevent covid transmission.
• Educational Videos On Infection
Control Activities.
• Patient and Family Education on
Post Operative Wound care TO
Prevent SSI.
• Scrub the Hub Policy for I.V Phlebitis
 New Initiatives
Dedicated Artery Forceps
BMW COMPAIGN Bed side PPC’S IN ICU
in Dirty utility Room
BIOMEDICAL WASTE MANAGEMENT

CAMPAIGNING
 New Initiatives

Pressure Injury Prevention Check Pressure Injury Compaign

list
 New Initiatives

Awareness
Programmes
Poster presentations Celebrations
Fun Activities and Games
Education on Hand Hygiene
Prize Distribution
  Food and Beverages
• All F and B staff screened for
Stool routine examination
every 3 months & Stool
Culture every 6 months

• House Keeping activities are

monitored
 RED BOOK COMPLIANCE

Namaste Screening at
Culture Entrance
Questionnaire Filled by every Visitor/Hand
Rub Offered.
Screening
Desk Social Distancin
Face Mask and Staff screening
Social Distancing Posters in Waiting Areas
 Donning &Doffing
PPE
EQUIPMENT AND ENVIRONMENTAL
CLEANING
Dedicated Trolleys
OT Process Flow
 Staff With Covid -19 positive

 
 

Desirable
Trend

Tota
l 74