HICC MEETING

FEBRUARY 2023
Agenda:

S.N Points discuss

1 Last minutes of meeting HICC .

2 It is mandatory for all the staffs to wear surgical mask inside the Critical care unit during aerosol generating procedure.

3 Surveillance status of water culture and Air culture of OT

4 Infection control observation.

5 M-o-M comparison report of HAI up to month of January-2022 and trend analysis.

6 Hand Hygiene, NSI, Surgical Prophylaxis trend analysis.

Hospital cleanliness & infection control committee

LAST MOM OF HICC -January 2022
EDC
POINTS DISCUSSED RESPONSIBILITY

 NICU staff should wear mask inside the NICU & staffs should not come inside NICU with own dress. NICU incharge sister. Closed

Mr. Santosh Prusty &

 Attendants should wear gown and mask while coming inside the NICU. Done
NICU incharge sister.

 Negative isolation air should not come outside the room. Maintenance Done

 Link nurses will inform to ICN , if they will observe hospital acquired infection. All Link nurses Pending

 Micro organism(Pseudomonas) should not come with drinking water. Maintenance NA

Aqua guard Water Surveillance Status -January’23
Result Result Result
Area (17/01/23) (30/01/23)
(23/01/23)
Before cooler -No growth
LG After cooler –Pseudomonas aeruginosa Not sent After cooler –No growth

Before cooler -No growth

Ground Floor After cooler –Pseudomonas aeruginosa Not sent
After cooler –No growth
Not sent Before cooler -No growth
1st Floor After cooler –Pseudomonas aeruginosa
After cooler –No growth
Before cooler -No growth
2nd Floor After cooler –Pseudomonas aeruginosa
After cooler –No growth
Not sent

Before cooler –Pseudomonas

Before cooler -No growth
3 Floor
rd After cooler –Pseudomonas aeruginosa aeruginosa
After cooler –pseudomonas aeruginosa
Before cooler -No growth
Not sent
4 Floor
th After cooler –Pseudomonas aeruginosa After cooler –pseudomonas aeruginosa

Before cooler -No growth

Not sent
5 Floor
th After cooler –Pseudomonas aeruginosa After cooler –pseudomonas aeruginosa

Not sent
RO Water No growth Not sent
No growth
Treated Water No growth Not sent
Kitchen Surveillance Status -January’23 :

Result Result
Sample Sample
(17/01/23) (31/01/23)
Paneer curry No Growth
RICE CLEANER WATER No Growth
Curd No Growth

Rice No Growth
CUTTING SECTION TAP WATER Staphylococcus aureus

Khichid No Growth
LIQUID SECTION AQUAGUARD
No Growth
WATER Dal No Growth

DOCTOR CAFETERIA DRINKING Pseudomonas Janhi curry No Growth

WATER
No Growth
Jhudanga bhaja
STAFF CAFETRIA DRINKING Pseudomonas
WATER No Growth
Salad
OT Surveillance Status January’23-February’23

Month of January-23 Month of February-23

Area
Sample Date Result Sample Date Result
Air c/s,
Air c/s,
Swab c/s from OT
OT-1 Swab c/s from OT 04/01/23 No Growth 01/02/23 No Growth
Table
Table

Air c/s,
Air c/s,
Swab c/s from OT
OT-2 Swab c/s from OT 06/01/23 No Growth 01/02/23 No Growth
Trolly
Table

Air c/s,
Air c/s, 08/02/23(OT Table) &
OT-3 03/01/23 No Growth Swab c/s from OT
Swab c/s from OT 18/02/23(OT Table) No Growth
Table
Light
Air c/s
Air c/s,
Swab c/s from OT
OT-4 07/01/23 No Growth Swab c/s from OT 06/02/23 No Growth
Table
Table

Air c/s ,Swab c/s

Swab c/s from OT
OT-5 02/01/23 No Growth from OT Table 05/02/23 No Growth
Light, Table, Air c/s
OT Surveillance Status January -23 to February-23 :

Month of January-23 Month of February-23

Area
Sample Date Result Sample Date Result

Air c/s
Air c/s
02/01/23 No Growth Swab c/s from OT
OT-6 Swab c/s from OT Table , RO 05/02/23 No Growth
Table , RO Water
Water

Air c/s Air c/s

Swab (OT Swab c/s from OT
OT-8 02/01/23 No Growth 06/02/23 No Growth
Table,Light,Trolly,IV Table
stand,Wall)
Air c/s
Air c/s
OT-10 02/01/23 No Growth Swab from Suction 5/02/23 No Growth
Swab from Wall

Blood agar-No
Growth Air c/s Blood agar-No Growth
Air c/s 02/01/23 Swab (OT
SDA-Aspergillus SDA-No Growth
EYE Swab (OT Table,Trolly,IV species Table,Trolly,IV
5/02/23
OT stand,Phaco stand,Phaco
machine,Microscope) machine,Microscope)
15/01/23 No Growth No Growth
 CAUTI
Benchmark: NHSN-1.2
Numerator: No of patients having CAUTI
Denominator: Total no of catheter days in a month

Month CAUTI Rate Neum Deno

July-22 1.92 5 2591

Aug-22 2.0 5 2492

Sept-22 1.27 3 2355

Oct-22 1.16 3 2574

Nov-22 1.13 3 2642

Dec-22 1.16 3 2585

Jan-23 2.26 7 3085

 VAP
Benchmark: NHSN-1.1
Numerator: No of patients having VAP
Denominator: Total no of ventilator days in a month

Month VAP Rate Neum Deno

Aug-22 2.25 1 444

Sept-22 0 0 410

Oct-22 0 0 414

Nov-22 0 0 534

Dec-22 0 0 651

Jan-23 1.57 1 636

 CLABSI
Benchmark: INNIC-4.8,NHSN-0.9
Numerator: No of patients having CLABSI
Denominator: Total no of central line days in a month

CLABSI
Month Neum Deno
RATE

0.00
Aug-22 0 880

Sept-22 1.02 1 973

Oct-22 0 0 958

Nov-22 0 0 1065

Dec-22 0 0 1241

Jan-23 1.56 2 1282

 SSI

Numerator: No of patients having SSI

Denominator: Total no of Surgery performed in a month

Month SSI(%) Neum Deno

Aug-22 0.13 1 763

Sept-22 0.50 4 796

Oct-22 0.57 4 695

Nov-22 0.13 1 732

Dec-22 0.39 3 763

Month on Month HAI Status:

HAI Jan-22 Feb-22 Mar-22 Apr-22 May-22 June-22 July-22 Aug-22 Sept-22 Oct-22 Nov-22 Dec-22 Jan-23

VAE 0 0 0 0 0 0 0 0 0 0 0 0 0

VAP - - - - - 1.78 3.62 2.25 0 0 0 0 1.57

CAUTI 0.50 0.80 0 0.47 0.89 1.21 1.92 2.0 1.27 1.16 1.13 1.16 2.26

CLABSI 0 0.91 1.07 0 0 0 0 0 1.02 0 0 0 1.56

SSI (%) 0.19 0.50 0.39  0.14 0.13 0.36 0.27 0.13 0.50 0.57 0.13 0.39 0

Benchmark:
INNIC: VAE-10.4 , CAUTI-2.1 & CLABSI-4.8
NHSN: VAE-01.1 , CAUTI-1.2 & CLABSI-0.9
Organisms isolated from CAUTI
 NSI
Incident of needle stick injury
Numerator: No of parental exposure
Denominator: number of in patient days
Month NSI Neum Deno

Aug-22 0.24 2 8012

Sept-22 0.19 2 10024

Oct-22 0.39 3 7553

Nov-22 0.26 2 7546

Dec-22 0.32 3 9316

Jan-23 0 0 8174

Root cause analysis/Control plan (Dec-2022)

06/12/22-DOCTOR
At the time of drawing ABG, he got NSI. CAPA
•Education given to the staff tie the tourniquet during canulation.
07/12/22-Nursing(4TH C)
During the IV canulation procedure while holding patient hand above the canulation. •Education given to the staff self awareness of environment &
sorroundind while handling any sharp instrument.

10/12/22-Student(4TH C)
After admission , patient has given open insulin pen ,that time she got NSI.
 Hand Hygiene
Hand Hygiene compliance
Numerator:Total number of action performed
Denominator:Total number of hand hygiene opportunity

Month HH (%) Neum Deno

Aug-22 64 309 482

Sept-22 67.9 382 562

Oct-22 70.4 377 535

Nov-22 74.5 434 582

Dec-22 77.3 495 640

Jan-23 73 482 662

Surgical Prophylaxis trend analysis Status Aug -22 to Jan-23:

Compliance
Month Total OT Non-Compliance Compliance
Percentage
Aug-22 Out of 763 In 22 cases antibiotics were not used like Eye & Local(741) 25 716 96.6%

Sept-22
Out of 796 In 18 cases antibiotics were not used like Eye & Local(778) 30 748 96.1%

Oct-22 Out of 695 In 22cases antibiotics were not used like Eye & Local(673) 37 636 94.5%

Nov-22 Out of 732 In 32cases antibiotics were not used like Eye & Local(700) 35 665 95%

Dec-22 Out of 763 In 29 cases antibiotics were not used like Eye & Local(734) 27 707 96.3%

Jan-23 Out of 745 In 44 cases antibiotics were not used like Eye & Local(701) 27 670 95.5%
 HAI FEBRUARY- 2023
S/ PATIENT PATIENT NAME AREA DATE CONSULTANT SPECIALITY TYPE OF
L ID. OF INFECTION STATUS
HAI

1 AM40127477 MR. SAPNESWAR 3046 07-02-23 DR.AGRAWAL ENDOCRINOLO HAP PATIENT EXPIRED
(MICU-2) GY

2 AM40003167 MR.SUDHANSU 3018 09-02-23 DR.SUKANTAOKIS NEPHROLOGY HAP PATIENT EXPIRED

BARAL (MICU-1) HORE DAS

3. AM40211064 MRS.B.BALADEVI 3010 09-02-23 DR.S.K.BEHERA CRITICAL CLABSI PATIENT IS PRESENT

(MICU-1) CARE ON
BED NO.-3042
4. AM40301894 MR.DILLIP KUMAR 2105 21-02-23 DR.SUNIL KUMAR NEURO SSI DISCHARGED ON
PANDA PATRA SURGEON DATE 26/12/23 & AGAIN
ADMITED ON DATE -
20/02/23

5. AM40308948 MR. S V CHALAM 2108 25-02-23 DR.PR BHUYAN NEURO CAUTI LAMA ON DATE-
SURGEON 27/02/23
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h a n k
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