FOREWORD

Healthcare Associated Infections (HAI) are one of the most common adverse events in delivery
of care and a major public health problem with an impact on morbidity, mortality and quality of life. A
large percentage of HAIs are preventable through effective Infection Prevention and Control (IPC)
measures.
I congratulate Department of MICROBIOLOGY in taking the lead and developing the
guidelines with inputs from all the Hospital Infection Control committee members. These guidelines
are intended to guide all the health-care staff to implement the infection control practices and to
provide safer healthcare services to the patients.

Dr. A.V. Bhore

MBBS MD (Microbiology)
Director
Smt. Kashibai Navale
Medical College &
General Hospital
 FOREWORD

Effective infection prevention and control is central to providing high quality

healthcare for patients and a safe working environment for those who work in
healthcare setting. It is important to minimize the risk of spread of infection to
patients and staff in the hospital by implementing a robust infection control
programme. Preventing infections is at the core of public health and is also the best
way to reduce the use of antimicrobials.
The overall aim of this document is to provide evidence-based information in
the prevention and control of infections in healthcare settings. It is relevant to all
staff including doctors, nurses, technicians, and other staff working in hospital. It is
my sincere hope that all the healthcare providers of our hospital will adhere to these
guidelines and implement the guidelines in their day to day practice so that we can
minimize the healthcare associated infection rates in our hospital. I congratulate the
infection control team and Department of Microbiology for their sincere efforts. I
look forward to these new guidelines being implemented in our hospital.

Dr. Krishnakant B. Patil

MBBS MD (Physiology)
DEAN
Smt. Kashibai Navale Medical College &
General Hospital
1.
CONTENTS
Organization of Hospital infection control committee SKNMC& GH. 1

2. Objectives of HICC 3

3. Standard /Universal Precautions 4

4. Isolation policies & procedures 20

5. Disinfection & Sterilization 28

6. Laundry services 39

7. Housekeeping 45

8. Biomedical Waste Management 57

9. Protocol for Needle stick injury & post exposure prophylaxis 65

10. Central Sterile Supplies Department (CSSD) 70

11. Outbreak Investigation. 77

12. High risk areas and High risk procedures 79

13. Perioperative Policy 87

14. COVID-19 Pandemic Guidelines 99

15. Dietary & Kitchen services 122

16. Abbreviations 124

17. Appendix 126

 HOSPITAL INFECTION CONTROL COMMITTEE MEMBERS:
[Link] Role Name of member Designation
1. Chairperson Dr. K. B. Patil Dean
2. Member [Link] Professor & HOD
secretary Microbiology
3. Infection Dr. Ratna R. Prasad Asst. Prof
control Microbiology
officer

4. Member -1 Dr. Nanda Dhavale Medical

Superintendent
5. Member -2 [Link] Natu Prof. Paediatrics
6. Member -3 [Link].D.D Prof. Medicine
7. Member -4 Dr. Girish Saundattikar Prof. & HOD
Anaesthesiology
8. Member -5 [Link] Bhosale Prof. & HOD
Pharmacology
9. Member -6 Dr. Viraj Shinde [Link]
10. Member -7 [Link] Acharya Asso. Prof
Anaesthesiology

11. Member -8 [Link] Shraddha Asso. Prof. OBGY

Anaesthesiology
12. Member -9 Mrs. Sangita Deputy Nursing
Dhawade Superintendent

13. Member -10 [Link] Ganesh Biomedical

Engineer
14. Member -11 Mr. Ingawale In-charge
Nanasaheb Maintenance
15. Member -12 [Link] Sitaram In-charge
Electrical
Department
16. Member -13 Mrs. Girme Shubhangi Incharge Laundry
Ganesh section
17. 5 ICNs a) [Link] Infection control
Diwakar Nurses
b)[Link]
Shashikala
c)[Link]
Pradhan
f)[Link] Shalan
g)[Link]

18. 2 MPWs [Link] Kamble, Multi Purpose

Mrs. Sumita Kudale Workers
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1. ORGANIZATION OF HOSPITAL INFECTION CONTROL COMMITTEE SKNMC&GH.

The Hospital Infection Control (HIC) Manual is a reference guide containing policies as well as procedures
to prevent nosocomia linfection among patients and staff. Nosocomial infections or Hospital Acquired
Infections (HAI) are defined as infections acquired during or as a result of hospitalization. Any patient
who develops an infection after 48 hours of hospitalization is considered to have nosocomial infection.
It may not be possible to eradicate all hospital-related infections. However, an effective infection control
program provides optimum protection for both the hospital patients and the staff. The purpose of this
manual is to achieve the best possible infection control measures.
The overall aim of this document is to provide evidence-based information on the prevention and control of
infection. To fulfill this aim, a Hospital Infection Control Committee (HICC) needs to be formed that will
look after the infection control needs of the hospital. An HICC provides a forum for multidisciplinary input
and cooperation, and information sharing.
We have actively functioning HICC in Smt. Kashibai Navale Medical College & General
Hospital. HICC is having
1. Dean as a Chairman,
2. HOD of Microbiology as a Member Secretary
3. Members are:- Medical Superintendent,
Infection control officer,
Professor & HOD Pharmacology,
Professor & HODAnesthesia,
Professor of Medicine
Professor of Pediatrics,
Professor of Surgery,
[Link] Obstetrics &Gynaecology.
[Link] of Anaesthesia

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Deputy Nursing Superintendent.

Infection control nurses.
Sanitary Inspector
Representatives from electrical, maintenance, laundry & supporting departments are co-opted members.
HICC meets every month to discuss and decide various polices and to fix any issue related to hospital
infection. This document will be reviewed and updated at regular intervals by the HICC.

Responsibilities of Committee Members

Sr. No. Designation Role

1 Chairman Dean Establishing a multidisciplinary Infection Control

HICC Committee
Making Provision for appropriate resources for Infection
Control Program
Develop hospital wide infection control program

2 Member Head of Dept. Responsible for effective implementation of Infection

Secretary of Microbiology Control Program in the hospital
Prepare Infection Control policies and protocols. Presenting
quarterly data of prevalent organisms and their antimicrobial
susceptibility pattern to the antibiotic stewardship group and
helping in formulating the Hospital Antibiotic Policy.
Conducting Monthly HIC team meetings & present actionable
feedback to committee
To circulate the agenda and minutes of the meetings
Present Outbreak investigation report.

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3 Infection Microbiologist Responsible for the prevention, investigation,

control monitoring and reporting of nosocomial infections.
officer Investigation & control of outbreaks.
Training of ICNs to implement infection control
program in the hospital.
Audit of infection control measures.
4 Members Representatives Monitoring the use of alert antibiotics in the hospital.
of clinical Present deviations in Biomedical waste disposal, hand
departments, hygiene, staff immunization status and needle stick injuries
Medical report, Implementing and monitoring the Infection control
Superintendent practices in the OTs, ICU, NICU, SICU & PICU. Notifying
&Incharge any outbreak in the ICU to the Infection Control team.
sister OT Helping the Antibiotic Stewardship group in
formulating the Antibiotic policy. Implementing and
monitoring the Infection control practices in respective
department. Present OT cleaning and fogging reports

4 Invitees Additional members from the institution who are invited for a
particular meeting when there is a scheduled discussion
pertaining to their field of expertise.

2. OBJECTIVES
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 following objectives:

i. To develop written policies and procedures for standards of cleanliness, sanitation, and
asepsis in the SKNMC &GH.
ii. To interpret, uphold, and implement the HIC policies and procedures in
SKNMC & GH.
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iii. To review and analyze on infections that occur in order to take corrective steps.
iv. To review and give input regarding investigations of epidemics.
v. To develop a mechanism to supervise infection control measures in all phases of
hospital activities and to promote improved practice at all levels of SKNMC& GH.
vi. Formulate policies on the proper use of antibiotics, develop antibiotic policies, and
recommend remedial measures when antibiotic resistant strains are detected.
vii. To ensure continuing education of employees on aspects of infection control.

viii. Regulate and give recommendation regarding infection control for any construction or
renovation activity in the hospital.

3. STANDARD PRECAUTIONS

3.1 Universal Precautions

Rules of universal precautions

3.1.1 Consider ALL patients potentially infectious.
3.1.2 Assume ALL blood and body fluids and tissue to be potentially infectious.
3.1.3 Assume ALL unsterile needles and other sharps to be similarly contaminated.

3.2 Standard Precautions

These precautions should be followed in all patient care situations. All staff should be informed of the need
to report exposure to blood or potentially infectious bodyfluids to the duty doctor without any delay.
Certain standard precautions should be taken in all health care settings as given below:

3.2.1 Wash hands before and after all patient or specimen contact.
3.2.2 Handle the blood of all patients as potentially infectious.
3.2.3 Wear gloves for potential contact with blood and body fluids.

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3.2.4 Prevent needle stick/sharp injuries.

3.2.5 Wear personal protective equipment (PPE) while handling blood or body fluids.
3.2.6 Handle all linen soiled with blood and/or body secretion as potentially infectious.
3.2.7 Process all laboratory specimens as potentially infectious.
3.2.8 Wear a mask for TB and other contagious respiratory infections.
3.2.9 Correctly process instruments and patient care equipment.
3.2.10 Maintain environmental cleanliness.
3.2.11 Follow proper waste disposal practices.

Reducing Person-To-Person Transmission

3.3.1 Hand Washing and Antisepsis (hand hygiene)
Appropriate hand hygiene can minimize microorganisms acquired on the hands during daily duties and when
there is contact with blood,body fluids, secretions, excretions, and known and unknown contaminated
equipment or surfaces
3.3.2 “My Five Moments for Hand Hygiene”Approach
Then newly developed “Five Moments for Hand Hygiene” approach has emerged from the WHO
Guidelines on Hand Hygiene in Health Care to add value to any hand hygiene improvement strategy. This
includes:
a. Before touching a patient
b. Before clean or aseptic procedure
c. After body fluid exposure risk
d. After touching a patient
e. After touching patient surroundings

Posters prompting and reminding healthcare workers about the importance of hand hygiene
And about the appropriate indications and procedures for performing it are displayed in various
sections of hospital.

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3.3.3 Steps on how to use alcohol-based handrub (duration of the entire procedure is 20-30
seconds).
Step 1 –Apply a palmfull of the hand sanitizer in a cupped hand, covering all surfaces.
Step 2 -Rub hands palm against palm.
Step 3-Right palm over left dorsum with interlaced fingers and viceversa.
Step 4 –Palm against palm with fingers interlaced.
Step 5 -Backs of fingers to opposing palms with fingers interlocked.
Step 6 -Rotational rubbing of left thumb clasped in right palm and viceversa.
Step7- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left
palm and vice versa.

Once dry, your hands are safe.

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3.3.4 Steps on how to wash hands when visibly soiled (Duration of the entire procedure is 40-60 seconds):

Step 0 - Wet hands with water.

Step 1- Apply enough soap to cover all hand surfaces.

Step 2 - Rub hands palm against palm.

Step 3 - Right palm over left dorsum with interlaced fingers and vice versa.

Step 4 - Palm against palm with fingers interlaced.

Step 5 - Backs of fingers to opposing palms with fingers interlocked.

Step 6 - Rotational rubbing of left thumb clasped in right palm and vice versa.

Step7- Rotational rubbing, backwards and forwards, with clasped fingers of right hand in left palm
and vice versa.

Step 8 - Rinse hands with water.

Step 9 - Dry hands thoroughly with a single use towel.

Step 10 - Use towel to turn off faucet; your hands are now safe.

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3.3.5 Gloves
a. Wear gloves when it can be reasonably anticipated that contact with blood or other
potentially infectious materials, mucous membranes, nonintactskin, or potentially
contaminated intact skin (for example, with stool or urine in an incontinent patient) could
occur.
b. Wear gloves with fit and durability appropriate to the task.
c. Wear disposable medical examination gloves for providing direct patient care.
d. Wear disposable medical examination gloves or reusable utility gloves for cleaning the
environment or medical equipment.
e. Remove gloves after contact with a patient and/or the surrounding environment (including
medical equipment) using proper technique to prevent hand contamination.
f. Do not wear the same pair of gloves for the care of more than one patient.
g. Do not wash gloves for the purpose of reuse as this practice is associated with transmission
of pathogens.
h. 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).

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3.3.6 REMEMBER
a. Remove all jewellery from the hands when working in the hospital.
b. Do not wear artificial fingernails or extenders when in direct contact with patients
c. Keep natural nails short.

3.3.7 Hand washing could be of two types:

a. Hand washing before general procedures called Routine Hand Washing.
b. Hand scrubbing before a surgical procedure.
3.3.8 Surgical hand scrubbing: The aim of surgical hand scrubbing with an antiseptic agent is to minimize
the number of microorganisms on hands under the gloves. This reduces the risk of infection to a
client if gloves develop a small hole, tears or nicks during the procedure.
a. Remove all jewellery on hands and wrists.
b. Hold the hands above waist level and wet hands in water.
c. Apply sufficient antiseptic solution; use firm, circular motions to wash hands and arms up to the
wrists, covering all areas including palms, back of the hands, fingers, between fingers, and lateral
side of thumb, knuckles, and wrists for at least three to five minutes. Repeat the procedure twice.
e. Rinse both hands one-by-one and keeps the hands above waist level at all times.
f. Dry the hands with a sterile towel keeping them above waist level.
g. Do not touch any thing except the gloves after washing hands for a surgical procedure.

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3.4 Personal Protective Equipment (PPE)

Personal protective equipment should be used by:
• Health care workers who provide direct care to patients and who work insituations where
they may have contact with blood, body fluids, excretions, and secretions.
• Support staff including medical aids, cleaners, and laundry staff in situations where they may
have contact with blood, body fluids, secretions, and excretions.
• Laboratory staff, who handle patient specimens.
• Family members who provide care to patients and are in a situation where they may have
contact with blood, body fluids, secretions, and excretions.

Personal protective equipment includes:

• Gloves
• Protective eyewear (goggles)
• Mask
• Apron
• Gown
• Boots or shoe covers
• Cap or hair cover

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3.4.1 Gown
a. Wear a gown that is appropriate to the task, to protect skin and prevents soiling or
contamination of clothing during procedures and patient care activities when contact with blood,
body fluids, secretions, or excretions is anticipated.
b. Wear a gown for direct patient contact if the patient has uncontained secretions or excretions
c. Remove the gown and perform hand hygiene before leaving the patient’s environment.
d. Do not reuse gowns, even for repeated contacts with the same patient.
e. Routine donning of a gown when entering a high-risk unit (for example-ICU, NICU) is
not indicated.

3.4.2 Mouth, Nose, Eye Protection

a. Use PPE to protect the mucous membranes of the eyes, nose, and mouth during procedures and
patient care activities that are likely to generate splashes or sprays of blood, body fluids,
secretions and excretions. Select masks, goggles, faceshields, and combinations of each
according to the need anticipated by the task performed

b. During aerosol-generating procedures (for example, bronchoscopy, suctioning of the respiratory

tract [if not using in-line suction catheters],endotracheal in tubation) in patients who are not suspected of
being infected with an agent for which respiratory protection is otherwise recommended (for example,
[Link], SARS or hemorrhagic fever viruses), wear one of the following: a faceshield that fully
covers the front and sides of the face, mask with attached shield, or a mask and goggles (in addition to
gloves and gown).

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3.5 Guidelines for Collection of Blood Samples

Use gloves and take special care if there are cuts or scratches on the hands.
Take care to avoid contamination of hands and surrounding area with the blood.
3.5.1 Use disposable or autoclaved syringes and needles.
3.5.2 Use 70 % ethanol or isopropl alcohol swabs or sponges for cleaning the site of needle puncture.
3.5.3 Use thick dressing pads or adsorbent cotton below the forearm when drawing blood and tourniquet
above.
3.5.4 Tourniquet must be removed before the needle is withdrawn.
3.5.5 Place dry cotton swab and flex the elbow to keep the swab in place till bleeding stops.
3.5.6 Place used needles and syringes in a puncture-proof container containing disinfectant.
3.5.7 Do not recap used needles.

3.6 Proper Disposal of Needles

3.6.1 Needles and sharps are the commonest mode of transmission of blood-borne pathogens to the
healthcare worker.
3.6.2 Precautions should be taken to prevent injuries by sharp instruments, especially hollow bore
needles that have been used for venipuncture or other vascular access procedures.
3.6.3 Needles should not be recapped, bent or broken by hand. Disposable needles and other sharps
should be disposed immediately after use into puncture-resistant containers which should be
located at the site of the procedure.
3.6.4 When a needle has to be removed from a syringe, do it with utmost care.

3.7 Good Practice for Safe Handling and Disposal of Sharps

3.7.1 ALWAYS dispose of your own sharps.
3.7.2 NEVER pass used sharps directly from one person to another.

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3.7.3 During exposure-prone procedures, the risk of injury should be minimized by ensuring that the
operator has the best possible visibility; for example, by positioning the patient, adjusting the
light source, and controlling bleeding.
3.7.4 Protect fingers from injury by using forceps instead of fingers for guiding suturing.
3.7.5 Locate sharps disposal containers close to the point of use, for example, in patients’
room, on the medicine trolley, and in the treatment room.
3.7.6 Puncture proof, translucent containers are used for sharps.

4. ISOLATION POLICIES AND PROCEDURES

Isolation procedures are meant to prevent or interrupt transmission of pathogenic microorganisms within
the hospital. Selected patients may require specific precautions to limit transmission of potential infecting
organisms to other patients.

4.1 Recommended Isolation Precautions: Routes of Transmission

Microorganisms are transmitted by three main routes:
•Contact
• Air
• Droplet
In nosocomial infections, transmission by contact, droplet, and air plays a major role.
4.1.1 Infection by direct or indirect contact: Infection occurs through direct contact between the source of
infection and the recipient or indirectly through contaminated objects.
4.1.2 Air-borne infection: Infection usually occurs by the respiratory route, with the agent present in
aerosols (infectious particles less than 5 µmin diameter).
4.1.3 Drople tinfection: Large droplets carry the infectious agent (greater than 5µm in diameter).

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4.2 Contact Precautions

These apply to patients with any of the following conditions and/or diseases:

4.2.1 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.
4.2.2 Presence of generalized rash or exanthemas.

4.2.3 Prioritize placement of patients in an examination room if they have stool in continence, draining
wounds and/or skin lesions that cannot be covered, or uncontrolled secretions.
4.2.4 Perform hand hygiene before touching the patient and prior to wearing [Link] perform hand
hygiene after touching the patient and after removing gloves.

4.2.5 PPE use

a. Wear gloves when touching the patient and the patient’s immediate environment
or belongings.

b. Wear a gown if substantial contact with the patient or the patient’s environment is
anticipated.
c. Perform hand hygiene after removal of PPE. Use soap and water when hands are visibly
soiled (for example, with blood, bodyfluids), or after caring for patients with known or
suspected infectious diarrhea (for example, Clostridium difficile, norovirus).
d. Clean or disinfect the examination room accordingly.
e. Instruct patients with known or suspected infectious diarrhea to use a separate bathroom, if
available; clean or disinfect the bathroom before it can be used again.
f. IN ADDITION to Standard Precautions, use contact precautions for specified patients
known or suspected to be infected or colonized with epidemiologically important
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microorganisms that can be transmitted by direct contact with the patient or patient care items.
4.2.6 Patient placement
A single room is [Link] only with patients who are affected by the same organism.
4.2.7 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.
4.2.8 Patient care equipment
Where possible dedicate the use of patient care equipment to a single [Link], ensure that
all items are adequately cleaned or disinfected before use for another patient.

4.3 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 conjunctiva, nasal mucosa,
or mouth. Because droplets do not remain suspended in the air, special air handling and ventilation are not
required.

4.3.1 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:
• Respiratory viruses (for example, influenza, parainfluenzavirus, adenovirus,
respiratory syncytial virus, human metapneumo virus).

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• Bordetella pertussis.
• For first 24 hours of therapy: Neisseria meningitides, groupA 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.
4.3.2 PPE use
a. Wear a facemask, such as a procedure or surgical mask, when in close contact with the
patient; don the facemask upon entering the examination room.
b. If substantial spraying of respiratory fluids is anticipated, gloves and gown as well as
goggles (or faceshield in place of goggles) should be worn.
c. 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).
d. Instruct the patient to wear a facemask when exiting the examination room, avoid coming
into close contact with other patients, and practice respiratory hygiene and cough etiquette.
e. Clean and disinfect the examination room accordingly (in addition to Standard Precautions).

4.3.3 Patient placement

a. Single Room. Special air handling or ventilation is not necessary. Only cohort with
patient/patients who are infected with the same organism.
b. Mask. Wear a mask when working within three feet of a patient with meningococcal meningitis.
c. 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 [Link] spacing between beds is1-2 meters.
4.3.4 Patient transport purposes only. If transport or movement is necessary minimize dispersal

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of droplets from thepatient.

4.4 Air-BorneTransmission
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.
4.4.1 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:
• Tuberculosis
• Measles
• Chickenpox (until lesions are crusted over)
• Localized (in immunocompromised patient) or disseminated herpes zoster (until lesions
are crusted over)
a. 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.
b. Place the patient immediately in an air-borne infection isolation room (AIIR).
c. If AIIR is not available,provide a facemask (for example, procedure or surgical mask) to the
patient and place the patient immediately in an examination room with a closed door.
d. Initiate protocol to transfer patient to a healthcare facility that has the recommended
infection-control capacity to properly manage the patient

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4.4.2 PPE use

a. If substantial spraying of respiratory fluids is anticipated, gloves and gown, as well as

goggles or faceshield should be worn.
b. Perform hand hygiene before and after touching the patient and after contact with
respiratory secretions and or body fluids and contaminated objects or materials. Use soap
and water when hands are visibly soiled (for example, with blood,body fluids).
c. 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.
d. Once the patient leaves, the examination room should remain vacant for generally one hour
before any one enters; however, adequate wait time may vary depending on the ventilation
rate of the room and should be determined accordingly.
e. If staff must enter the room during the wait time, they should use respiratory protection (in
addition to Standard Precautions).

4.4.3 Patient Placement

a. Single room. Negative air pressure.

b. Self-closing devices on doors to keep the door closed.
c. 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.
d. 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 air flow path.
e. TheTB isolation room needs to be checked for negative pressure.
f. 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.

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4.4.4 Respiratory Protection

a. Heavy duty N95 or N97 masks should be used for Open Pulmonary Tuberculosis or
suspected Pulmonary Tuberculosis, Surgical Mask for Meningococcal or suspected
Meningococcal Meningitis.
b. Non-immune 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.

4.4.5 Patient Transport

a. Limit movement or transport of patient from the room to essential purposes only.

b. If transport or movement is necessary, minimize patient dispersal of organisms

4.5 Isolation Policy for Special Groups of Organisms

4.5.1 MRSA (Methicillin Resistant Staphylococcus aureus)/ VRE(Vancomycin Resistant
Enterococcus).The following procedures should be followed in addition to Standard
Precautions:

a. Isolate the MRSA/VRE positive patient under Contact Isolation with mask category. Accommodate such
patients away from those with open wounds or those who are immunocompromised.
b. Hand washing is the single most important factor in containing MRSA.
c. The bed used by the patient, and other equipment used for the patient should be disinfected before use
for another patient.
d. Disinfection procedures should be carried out on a daily basis, as out lined under
Isolation Procedures.
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e. 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 to prevent dissemination 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.
f. 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 combination of dish washer
detergents and high water temperature adequately decontaminates dishes.
g. Procedures for decolonization of the patient which include daily bath with an antimicrobial soap
should be followed.
h. When the patient is discharged, terminal disinfection should be carried out as outlined under
Isolation Procedures.
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 diarrhoea in the case of [Link] infection) may be a
reasonable time to stop the isolation.

4.5.2 Tuberculosis
a. Respiratory precautions should be taken for smear-positive pulmonary tuberculosis.
b. A separate room is recommended for such patients.
c. 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.

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4.6 Visitor's policy when patient is in isolation

4.6.1 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.
4.6.2 The patient and their 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.
4.6.3 Hand washing after all contact with the patient has to be stressed.
4.6.4 Visitors need to wear a N95 respirator. Be aware of restrictions on visits due to outbreak or other
conditions within the facility.
4.6.5 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.
4.6.6 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 and when
leavingthe room.
• Any prophylactic medication or active immunization for attendants should be
conducted by the physician in charge.

5. DISINFECTION AND STERILIZATION

5.1 Sterilization

5.1.1 Sterilization is defined as a processes where all microbes are removed from a defined object,
inclusive of bacterial endospores.

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5.1.2 Methods of Sterilization Used

i. Steam autoclave
ii. Hot air oven

STERILIZATION RECOMMENDATIONS

Hot Air Oven 160 ℃ for1 hr, 180℃for 30 min

Gravity-Displacement:
• 15 min holding time at 121℃
2 2
• 1.1 kg/cm or 15lb/in (PSI)
Autoclave Pre-vacuum:
• 3 min holding time at 134℃
2 2
• 2.2 kg/cm or 32lb/in (PSI)

5.2 Disinfection
Disinfection is a process where most microbes are removed from a defined object or surface, except
bacterial endospores. Disinfectants may be classified according to their ability to destroy different categories
of microorganisms.
i) Low level disinfectant: The agent which destroys only vegetative bacteria. E.g. benzalkonium
chloride, some soaps.
ii) Intermediate level disinfectant: It is capable of rendering mycobacteria non viable. It is safe to
assume that all the other categories of microbes which are classified more susceptible are also
destroyed if efficacy against mycobacteria can be demonstrated. E.g. alcohols, chlorine compounds,
hydrogen peroxide, chlorhexidine, glutaraldehyde (short-term exposure).

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iii) High level disinfection is in other words sterilization where in all microbial life is destroyed
inclusive of endospores. E.g. glutaraldehyde2%, ethylene oxide.

5.3 General Equipment

Disinfection of General Equipment

Equipment FrequencyofChange Recommendation
After each use, the thermometer is
disinfected by wiping with a swab
saturated with 70 percent isopropyl
Oral Thermometer Single for all IPD patients alcohol.
For OPD: Each thermometer is kept in a
separate holder. After each outpatient
session,the thermometer holder is
Washed in warmwater and detergent, and
the thermometer is disinfected in 70
percent alcohol for 5 minutes.
Other methods for thermometer:
immersing in glutaraldehyde, or
hexachlorophene and cetrimide.

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Change covers regularly (1per week) and

Sphygmomanometer Cuffs As required
wash inflatable section in detergent and
water, dry thoroughly
Or use 70 percent alcohol.
Change after each use in infected patient.

Thoroughly wash with detergent and

Rectal Thermometer After eachpatient water, then dry. Store dry and
separately from oral thermometers.
Disinfect with 70 percent alcohol for
5 minutes.

Disposable earpieces should be used

Auriscope After each patient where possible; when not available
clean in detergent and water. Disinfect
in CSSD or 70percent alcohol for 5
minutes.
Earpieces After each patient Wash with hot water and detergent,
store dry. Disinfection in CSSD or 70
percent alcohol for 5 minutes.

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Equipment Recommendation
Bed ends and frames, Bedside
Mop with1percent sodium hypochlorite. Allow to dry.
locker, Cardiac table,
Baby bassinets
Bowls-Bedpans/Urinals Heat disinfection in a rinse temperature of minimum 82°C for 2
minutes. If not possible, bedpans, urine pots, and kidney trays
should be kept in 7 percent Lysol for 24 hours or 3-5 percent
sodium hypochlorite solution for 30 minutes; then they are
washed with soap and water and dried in sunlight.
Bowls(washing) Clean with detergent and water and store dry or as above.

Hand Basins Clean with detergentand water.

Cleaning cloths, Brushes, and Supplied daily from the laundry. They are provided for use and
Equipment then discarded to wash.
Wash brushes and buckets in detergent and water, then hang or
invert to dry, then store dry.
Disposable cloths are also available.

Curtain Rails As for bed ends.

Lockers Detergent and water as necessary and after patient discharge.

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Mattresses and Pillows All should be covered with an impervious plastic cover and should
be wiped over with detergent and water if visibly contaminated.
Mattresses should be cleaned regularly, and if contaminated, with
the covers removed. If possible keep in sunlight for 24 hours.
Plastic and rubber covers of mattresses and pillows should be
washed with soap and water, cleaned with a suitable disinfectant,
for example, 7 percent Lysol.

Mop Heads 7Daily

percentLysol.
cleaning of mops. At the completion of each task of floor
mopping, the mops should be thoroughly washed in a bucket
containing HOT water and detergent. Squeeze as much water out
of mop as possible and shake strands loose; leave hanging to dry
in the sun if possible, or alternatively, in the cleaner’s room. The
bucket should be turned upside down to allow over night
drainage.

Detachable mop heads should be sent to the laundry, while

reusable mops should be cleaned in hot soapy water, then left to
dry ideally in the sun.

Nail Brushes The useof nail brushes are discouraged as they may cause skin
damage that may result in increase in bacterial flora. If a nail brush
is required, a sterile, antiseptic impregnated brush may be used.
Reusable brushes require autoclaving between uses.

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Toilet Bowls At least daily brushing with a commercial bowl cleanser.

Additional cleaning as necessary for stubborn stains.
Toilet Brushes Should be rinsed in flushing water, and stored to dry.
Walls Remove visible soiling with detergent as necessary.
Clinic Trolleys Clean with a cloth dampened with detergent and water.
Ampoules/vials Wipe neck (ampoule) or top surface of rubber cap(vials)with a 70
percent isopropylalcohol impregnated swab and allow to dry
before opening or piercing.
Cardiac monitors, If patient contact, then surface is cleaned and disinfected.
Defibrillators and
ECG equipment
Fixtures and fittings In clinical areas wipe damp, dust daily with detergent solution. In
known contaminated and special areas, wipe damp dust with a
disinfectant solution.
Furniture and ledges In clinical areas clean damp dust daily with warm water and detergent.

Disinfection of Specialist Outpatient Equipment:

A tooth brush may be used for cleaning the instruments. Workers should be asked to wear utility
gloves while cleaning instruments.

5.4 Decontamination

The objective of decontamination is to protect individuals who handle surgical instruments and other items
which have been in contact with blood or body fluids, from serious diseases. Once instruments and other
items have been decontaminated, they can be safely further processed. This consists of cleaning and finally
either sterilization or high-level disinfection.

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5.4.1 DecontaminationTips: Use a plastic container for decontamination to help prevent:

• Dulling of sharps (for example, scissors) due to contact with metal containers.

• Rusting of instruments due to a chemical reaction (electrolysis) that can occur between
two different metals when placed in water.
• Do not soak metal instruments that are electroplated (that is, not100 percent stainlesssteel)
even in plain water for more than an hour because rusting will occur.
5.4.2 How to prepare a disinfectant cleaning solution: A disinfectant cleaning solution is one that contains
both a disinfectant and a detergent (soap).
5.4.3 Precautions when using chlorine solutions: Although chlorine-containing solutions (sodium
hypochlorite) are excellent, inexpensive disinfectants, they should NOT be mixed with cleaning solutions
containing an acid (for example, phosphoric acid), ammonia or ammonium chloride (NH2Cl). Doing this
will release chlorine gas and other by-products that can result in temporary illness (nausea, tearing, headache
or shortness of breath) to staff breathing fumes in a poorly ventilated area.
NOTE: To find out if a cleaning solution contains ammonia, first check the label. If it does not say there is
ammonia, you may be able to detect ammonia when opening the product by its pungent, burning smell.
If you are exposed to chlorine gas or ammonium chloride or other unpleasant (noxious) gases with strong
odors, leave the room or area immediately until the room can be completely ventilated.
5.4.3 Instructions
Step 1: Prepare a 0.5 percent chlorine solution from liquid concentrates or from chlorine
compounds.
Step2: Add enough detergent to the 0.5 percent chlorine solution or other disinfectants to make a
mild, soapy cleaning solution.

5.4.4 After decontamination, instruments should be rinsed immediately with cool water to remove visible

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organic material before being thoroughly [Link] example, some healthcare facilities now keep
two buckets in the procedure areas or operating rooms, one filled with 0.5percent chlorine solution
and one with water, so that the instruments can be placed in the water after soaking in the chlorine
solution for10 minutes. Although this will help to prevent corrosion, even leaving the instruments in
plain water for more than 1 hour can lead to rusting.
WHO recommends 0.5percent chlorine solution to be used for decontaminating instruments before cleaning
[Link] objective of decontamination is to protect individuals who handle surgical instruments and other
items which have been in contact with blood or body fluids, from serious diseases. Once instruments and
other items have been decontaminated, they can safely be further processed. This consists of cleaning and
finally either sterilization or high-level disinfection.
5.4.5 Disinfection of endoscopes: Glutaraldehyde 2%(cidex) solution is effective high level disinfectant for
flexible endoscopes & other devices which cannot withstand high temperature methods of
sterilization. Soak instruments in cidex for 20 min to achieve high level disinfection.
Precautions:
eep away from eyes.
Wear gloves while preparing the solution.
contact.
in well ventilated area.
activator solution to 5 liter of glutaraldehyde.
ce prepared it can be used for14 days.
5.5 Fogging
5.5.1 Fogging is done by using 0.25%Virkon(10g m in 4 liter of water) by fogger method for 20
[Link] room must be kept closed for12 hours before use by housekeeping personnel.

5.5.2 Fogging is done only in the high-risk areas like OTs, ICU, PICU, NICU, Labor room. Wards
are excluded for fogging (done only if required).
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5.5.3 Frequency of fumigation in all OTs is weekly and in all ICUs is once in three months.
5.5.4 1%Virkon(10gm in1lit water) is used for surface cleaning of OTand in-between the operative cases.
5.5.5 1%Virkon is used for carbolization of OT material (OTlights, OTtable,
Trolleys, OT pendant, ICU pendant & ICU beds)
Application

Surface Disinfection & Cleaning Floors;Walls; Ceiling

Disinfection Of Equipment OTLight, OT Table,Trolleys, Pendant,
(Carbolisation) ICU Beds; ICU Pendant;
Fogging Aerial Fogging

Dilution & Preparation

AREA CONCENTRATION DILUTION

For SurfaceDisinfection 1 % Concentration Mix 10gram(1 Spoon) of RelyOn Virkon

&Cleaning Powder in1 Litre of TapWater
Recomandedfor critical area.
For SurfaceDisinfection 0.5 % Concentration Mix 10gram(1 Spoon) of RelyOn Virkon
&Cleaning Powder in 2 Litre of TapWater
Recomanded for non-critical area.
For Equipment 1 % Concentration Mix 10gram(1 Spoon) of RelyOn Virkon
Disinfection Powder in1 Litre of TapWater for critical
area.
For Equipment 0.5 % Concentration Mix 10gram (1 Spoon) of
Disinfection RelyOn Virkon Powder in 2 Litre of
TapWater for non-critical area.
For Fogging 0.25%Concentration Mix 10gram(1 Spoon) of RelyOn Virkon
Powder in 4 Litre of TapWater

After Fogging close the door for 45 minutes. After 45 Minutes you can use OT, ICU, Wards,
CathLabs, etc where the area has been fogged.

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Dry Fogging:

The EIROXTM critical area fogging disinfectant has been tested by independent laboratories. The product has
shown efficacy on the following micro-organisms:

Benefits of dry fogging:

 No effect on respiration track, no toxic gases or waste, no residual odors
 No or low rinsing of surfaces required after use
 Can be used in air conditioning or heating systems
 Based on biodegradable ingredients
 Non irritating, non-flammable
 No Volatile Organic Compounds used

Type of Organism Name of Organism 99% reduction

contact time
Bacterial Spores Bacillus subtilis 15 mins

Fungal Spores Aspergillus niger 3 mins

Yeast Candida albicans 3 mins

Gram negative Pseudomonas aeruginosa 3 mins

Escherichia coli 3 mins

Gram positive Staphylococcus aureus 3 mins

Enterococcus faecalis 3 mins

Usage: Ready to use product. 100 ml Eirox for 1000 cuft area.
No dilution [Link] not mix the product with other chemicals.
Read carefully the material safety data sheet.
Available Packing: 5 Liters& 1 Liter
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6. LAUNDRY SERVICES
Soiled linen can be a source of large amounts of microbial contamination which may cause infections in
hospital patients and personnel. Inaddition, improperly processed linen can cause chemical reactions or
dermatitis in those who come in contact with the linen. A hospital’s linen service should process soiled linen
such that the risk of disease to patients who may be unusually susceptible or employees, who may handle
linen, is avoided. Adequate procedures for collecting, transporting, processing, and storing linen should
therefore be established.
Washing with hot water and detergent has been shown to result in adequate cleaning of laundry. If needed
for other reasons, bleach or ironing will reduce microbial contamination. Textile softeners added in the final
rinse, though of no value in preventing infections, make linen easier to handle and rewash, and reduce lint.
6.1 Principles and Key Steps in Processing Linen
6.1.1 Housekeeping and laundry personnel should wear gloves and other PPE as indicated when
collecting, handling, transporting, sorting, and washing soiled linen.
6.1.2 When collecting and transporting soiled linen, handle it as little as possible and with minimum
contact to avoid accidental injury and spreading of microorganisms.
6.1.3 Consider all cloth items (for example, surgical drapes, gowns, wrappers) used during a procedure as
[Link] if there is no visible contamination, the item must be laundered.
6.1.4 Carry soiled linen in covered containers or plastic bags to prevent spills and splashes, and confine
the soiled linen to designated areas (interim storage area) until transported to the laundry.
6.1.5 Carefully sort all linen in the laundry area before washing.

6.2 Recommended PPE for Processing Linen

6.2.1 Gloves (preferably household utility gloves) and closed shoes that protect feet from dropped items
(sharps) and spilled blood and body fluids, should be used when:
• Handling disinfectant solutions
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• Collecting and handling soiled linen

• Transporting soiled linen
• Sorting soiled linen
• Hand washing soiled linen
• Loading automatic washers
6.2.2 Plastic or rubber apron and protective eye wear should be worn when
• Sorting soiled linen
• Hand washing soiled linen
• Loading automatic washers

6.3 Sorting Soiled Linen

6.3.1 Soiled linen should be handled as little as possible with a minimum amount of agitation to prevent
gross microbial contamination of the air and of personnel handling the linen.
6.3.2 The processing area for soiled linen must be separate from other are as such as those used for
folding and storing clean linen, patient care areas, and food preparation areas.
6.3.3 In addition, there should be adequate ventilation and physical barriers (walls) between the clean and
soiled linen areas.
6.3.4 Safe sorting of linen is extremely [Link] must be carefully performed because soiled
linen (large drapes and towel drapes) from the operating room or other procedure areas, frequently
contain sharps (for example, scalpels, sharp-tipped scissors, hypodermic and suture needles, and
sharp-tipped towel clips). In addition, bedding from patients’ rooms may contain soiled dressings
and be blood-stained or wet with other bodyfluids.
6.3.5 Soiled linen and items containing sharps must be handled carefully by wearing protective gloves,
protective eyewear and plastic or rubber apron, and should be disposed of properly. Though
infrequent, infections related to sorting have been attributed to failure of hand washing and proper
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use of PPE.

REMEMBER: Disposable sharps (suture needles, scalpel blades, and hypodermic needles)
Must be placed in sharps containers located near the point of use.
Soiled linen may also contain non-infectious items such as dentures, eyeglasses, and hearing
aids. These items pose no threat of infection and require no special handling.
6.4 Laundering Linen
6.4.1 Washing and Drying
a. All linen items (for example, bed sheets, surgical drapes, masks, gowns) used in the direct
care of a patient must be thoroughly washed before reuse.
b. Decontamination prior to washing is NOT NECESSARY; unless linen is heavily soiled and
will be hand washed (repeated soaking of linen in chlorine, even dilute solutions, will cause
the fabric to deteriorate more quickly).
c. In addition, workers should not carry wet, soiled linen close to their bodies even if they are
wearing a plastic or rubber apron.

REMEMBER: The storage time for soiled linen before washing is related to practical issues, such as
available storage space and aesthetics, NOT to infection prevention concerns.

6.4.2 Washing Linen by Hand

Step 1: Wash heavily soiled linen separately from no soiled linen.

Step2: Wash the entire item in water with liquid soap to remove all soilage, even if not
visible.

REMEMBER: Pre-soak in soap, water and bleach ONLY if linen is heavily soiled.

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• Use warm water if available.

• Add bleach (for example, 30–60ml [about2-3 table spoons], of a 5 percent
chlorine solution) to aid cleaning and bactericidal action.
• Add sour(a mild acid agent) to prevent yellowing of
linen, if desirable.
Step 3: Check the item for cleanliness. Rewash if dirty or stained.
Step 4: Rinse the item with clean water.

6.4.3 Machine Washing

Step 1: Wash heavily soiled linen separately from no soiled linen.
Step 2: Adjust the temperature and time cycle of the machine according to
manufacturer’s instructions and the type of soap or other washing product being used.
Both cold and hot water washing cycles that include bleach reduce bacterial counts in
the linen.

Hot water washing:

a. Use hot water above 71ºC (160 F) and soap to aid in loosening soil.
b. Washing linen at 80-90oC for over 20 minutes with a detergent in water is an effective
method for cleaning and killing most vegetative bacteria.
c. Add bleach.
d. Adjust the time cycle of the machine according to the manufacturer’s
instructions.
Step3: When the wash cycle is complete, check the linen for cleanliness. Rewash if it is dirty or
stained. (Heavily soiled linen may require two wash cycles.)

NOTE: Uniforms and scrub suits or gowns worn by housekeeping or cleaning staff can be safely
laundered at home (that is, home laundering does not increase the risk of infection to patients or staff).
Lower temperatures or cold water washing are satisfactory if the cleaning products (type of soap or
detergent, amount of bleach and other additives) are appropriate and used in proper concentrations.
Using cold water also saves energy.

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6.5 Processing Linen

6.5.1 Drying, Checking and Folding Linen. For both hand and machine washed linens, the steps are the
same.
Step1: Completely air or machine dry before further processing. Air dry in direct sunlight, if
possible, keeping the fabric off the ground, away from dust and moisture.
Step2: After linen items are totally dry,check for holes and thread bare areas. If these are
present, the item must be discarded or repaired before reuse or storage. (If there are any holes or
many repaired areas, the item should not be used as a drape. It can be cut into pieces to be used
as cleaning rags.)
Setting standards helps determine when drapes (lap sheets) or linen wrappers should be made into rags.
For example, a drape should have no more than 5 patches per 1foot (12 inches) square area or when 20
percent of the drape is covered with patches. Patches should be avoided because they increase the
thickness of the linen item and decrease steam penetrability if sterilization is required.
Step3: Clean and dry linen should be ironed as needed and folded. For example, if a clean, dry
drape is acceptable, the drape can be ironed before placing it on a shelf or in a container for
storage.

NOTE:If surgical drapes are to be sterilized, do not [Link] dries out the material, making
autoclaving more difficult. If sterile linens are required, prepare and sterilize wrapped packs.

6.5.2 Sterile Linen

Only linen used in procedures requiring sterile technique should be sterilized. This process is done in
the TSSU and CSSD.
If tap water is contaminated, use water that has been boiled for10 minutes and filtered to remove particulate
matter (if necessary),or use chlorinated water,that is,water treated with a dilute bleach solution (sodium
hypochlorite) to make the final concentration 0.001 percent.

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6.6 Storing, Transporting, and Distributing Clean Linen

6.6.1 Storing Clean Linen

a. Keep clean linen in clean, closed storage areas.

b. Use physical barriers to separate folding and storage rooms from soiled areas.
c. Keep shelves clean.
d. Handle stored linen as little as possible.

6.6.2 Transporting CleanLinen

a. Clean and soiled linen should be transported separately.

b. Containers or carts used to transport soiled linen should be thoroughly cleaned before being
used to transport clean [Link] different containers or carts are used to transport
cleanand soiled linen, they should be labeled.
c. Clean linen must be wrapped or covered when transporting to avoid contamination.

6.6.3 Distributing CleanLinen

a. Protect clean linen until it is distributed for use.
b. Do not leave extra linen in patients’ rooms.
c. Handle clean linenas little as possible.
d. Avoid shaking clean [Link] releases dust and lint into the room.
e. Clean soiled mattresses before putting clean linen on it.

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7. HOUSEKEEPING

7.1 General Principles

Routine cleaning is necessary to ensure a hospital environment which is visibly clean and free from dust
and soil.
7.1.1 90 percent of microorganisms are present within “visible dirt”, and the purpose of routine cleaning is
to eliminate this dirt. Neither soap nor detergents have antimicrobial activity, and the cleaning
process depends essentially on mechanical action.
7.1.2 The frequency of cleaning and cleaning agents used for walls, floors, windows, beds, curtains,
screens, fixtures, furniture, baths and toilets, and all reused medical devices must be specified.
7.1.3 Methods must be appropriate for potential contamination, and the necessary level of a sepsis. This
may be achieved by classifying areas into one of four hospital zones:
Zone A: No patient contact. Normal domestic cleaning is recommended (for example,
administration, and library).
Zone B: Care of patients who are not infected, and not highly susceptible, should be done by a
procedure that does not raise dust. Dry sweeping or vacuum cleaners are not [Link] use
of a detergent solution improves the quality of cleaning. Disinfect any areas with visible
contamination with blood or body fluids prior to cleaning.
Zone C: Infected patients (isolation wards). Clean with a detergent or disinfectant solution, with
separate cleaning equipment for each room.
Zone D: Highly susceptible patients (protective isolation) or protected areas such as operating suites,
delivery rooms, intensive care units, premature baby units. Clean using a detergent or disinfectant
solution and separate cleaning equipment.
All horizontal surfaces in Zones B, C, and D, and all toilet areas should be cleaned daily.

7.1.4 Disinfectant or detergent formulations registered with the Environment Protection Agency (EPA)

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are used for environmental surface cleaning, but the actual physical removal of microorganisms and
soil by wiping or scrubbing is as important, if not more so, than any antimicrobial effect of the
cleaning agent used.

7.1.5 Housekeeping surfaces can be divided into two groups–those with minimal hand contact (for
example, floors, and ceilings), and those with frequent hand contact (“high touch surfaces”).
7.2 Housekeeping in Wards

7.2.1. The floor should be cleaned at least three times in 24 hours. Detergents and copious amounts of water
should be used during one cleaning. Floor cleaning solution or any other equivalent disinfectant
may be used to mop the floor for the remaining time.
7.2.2. The walls should be washed with a scrubber, using detergent and water.
7.2.3. High dusting should be done once in a month and whenever necessary.

7.2.4. Fans and lights should be cleaned with soap and water once a [Link] should be handled by the
electrical department.
7.2.5. All work surfaces should be disinfected by wiping with 1percent bacillocid and then cleaned with
detergent and water twice a day.
7.2.6. Cupboards, shelves, beds, lockers, IV stands, stools and other fixtures should be cleaned with
detergent and water once a week.
7.2.7. Curtains should be changed once a month and once in 15days in critical areas or whenever soiled.
7.2.8. In certain high-risk areas such as the ICU, more frequent changes of curtains are required.

7.2.9. Patients cots should be cleaned every day with 1 percent bacillocid solution. In the isolation ward,
cleaning should be done daily.
7.2.10. Store rooms should be mopped once a day and high dusted once a month.

7.2.11. Bathroom floors should be scrubbed with a broom and cleaning powder once a day and cleaned at

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frequent intervals. For disinfection, phenol can be used.

7.2.12. Toilets should be cleaned with a brush using a detergent thrice daily. Disinfection may be done using
phenol. A stain removing liquid can be used to remove stains.
7.2.13. Wash basins should be cleaned with cleaning powder every morning and with a stain removing
liquid once a month.

7.2.14. Regular air-conditioning maintenance is [Link] electrical section should draw up a protocol
for this.
7.2.15. Follow proper procedures for effective uses of mops, cloths, and solutions.
The three bucket system should ideally be practised. The first bucket contains water with detergent used
in the beginning. The mop is then rinsed in the second bucket and dipped in the third bucket which
contains a disinfectant and the mopping is done again.

7.2.16. Prepare floor cleaning solutions daily or as needed, and replace with fresh solution.

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7.2.17. Clean mop heads daily, at the beginning and end of each day.

7.2.18. The mop head should be changed every day and the wash sent to the laundry everyday.

7.2.19. A laundered mop head to be used in the morning.

7.2.20. The water should be changed twice in a room when it appears to be dirty.

7.2.21. When cleaning patient rooms or contaminated areas at any time,washing laundry or instruments,
collecting and disposing of trash, or using any type of cleaner (cleaning
equipment), personnel must wear utility gloves and protective shoes. Wear a mask, rubber apron,
and goggles if there are spills or when expecting anything to splash.
7.2.22. For mopping floors and cleaning blood spills, a housekeeping trolley should be used.

7.3 Patient Linen

7.3.1. Bed linen may be changed once in two days and when ever soiled with blood and bodyfluids.
7.3.2. Patients’gown should be changed every day and when ever soiled with blood and bodyfluids.
7.3.3. Dry dirty linen should be sent to the laundry for regular wash.

7.3.4. Linen soiled with blood or body fluids and all linen should be packed in leak-proof bags and sent for
primary wash.
7.4 Mattresses and Pillow Covers
7.4.1. Clean and disinfect moisture resistant mattress covers between patient uses by using bacillocid.
7.4.2. If the mattress cover is completely made of fabric, change these covers and launder before patient use.
7.4.3. Launder pillow covers and washable pillows in the hot water cycle before patient use or when they
become contaminated with body substances

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7.4.4. Rubber sheets: Rubber sheets should be cleaned with soap and water, disinfected, dried,
powdered, rolled and stored.
7.4.5. Thermometer: In areas where a common thermometer is used like OPDs, it should be washed with
plain tap water and disinfected between patients with an alcohol swab.
7.4.6. Plastic buckets and dustbins should be cleaned with detergent powder once every week.
7.4.7. Miscellaneous items: K basins, bedpans, urinals, should be cleaned with detergent powder and water
once in a week.
7.5 Housekeeping in Isolation Ward
7.5.1. Before admission: The admitting physician should inform the Sister In-charge of the Isolation Ward at
least one hour prior to admission, mentioning the diagnosis, sex, and the general state of the patient.
7.5.2. Prerequisites for Isolation

a. A provision for disinfecting of the hands is ideally placed prominently at the entrance of an
isolation room.
b. The mattress and pillow should have an impervious cover such as mackintosh so that it can
easily be damp dusted.
c. Clean gowns should always be available.
d. Separate urinals, bed pans should be used for each patient.
e. A bin lined with an appropriate color-coded plastic cover should be available in each room
for disposal of biomedical waste.
f. Rooms should be isolated according to disease conditions and should be well lit.

7.5.3. Cleaning Procedure for Isolation Ward

a. Linen should be stripped from the bed taking care not to shake the linen during this
[Link] linen should be bagged properly before being sent to the laundry in a leak-proof
bag.

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b. Articles like IV stands and furniture should be cleaned with detergent and disinfected
with 2 percent bacillocid.
c. Walls should be cleaned with detergent and disinfected with 2 percent bacillocid.
d. Bathrooms should be cleaned with detergent and disinfected with phenol.

7.5.4 At Discharge (terminal disinfection)

a. The pillows and mattress should be cleaned with detergent, disinfected with 2 percent
bacillocid and dried in sunlight for 24 hours.
b. Bedsheets, curtains, gowns, and duster smust be removed, and then sent to the laundry.
c. After disinfection, washther room, walls, windows, doors, bathrooms, sink and furniture
with soap solution after thorough high dusting in that cubicle.
d. 1percent sodium hypochlorite solution should be used to soak bedpan, urinal, and kidney
basin for15-20 minutes, wash with detergent, and dry.
e. Bathbasins, multi bin, bucket, jugs, mugs should be washed with solution and dried in
sunlight, if possible.
f. Rubber sheets should be cleaned with detergent and dried.
g. Soak the thermometer tray and its contents in 2 percent bacillocid after cleaning.
h. Fumigate with bacillocid if indicated.

7.6 Housekeeping in Operating Theatre (OT)

The OT complex should be absolutely clean at all times. Dust should not accumulate
on any part of the OT. Soap solution is recommended for cleaning floor and other
surfaces. Operating rooms (ORs) should be cleaned daily and the entire OT complex
cleaned thoroughly once a week.

7.6.1. Before the start of the first case

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a. Wipe all furniture, equipment, roomlights, suction points, OR table, surgical light reflectors,
other light fittings, slabs with 2 percent bacillocid [Link] should be completed at least
one hour before the surgery.
7.6.2. After each case
a. Linen: Gather all soiled linen and towels that are blood-stained, pack in a leak-proof bag or
closed bin, and transport to laundry suite for wash. Other linen should also be transported to
the laundry suite. Appropriate PPE should be used while handling soiled linen. Disposable
drapes should be disposed of in the Biomedical Red bag.

b. Instruments: Used instruments should be cleaned immediately by the scrub nurse and the
attender. All the instruments should first be decontaminated in1percent sodium hypochlorite
solution for 20 minutes and then soaked in a multi enzyme cleaner for 30minutes followed
by scrubbing with a brush using liquid soap in warm water and then dried. They should then
be sent for sterilization to CSSD.
c. Environment: Wipe used equipment, furniture, OR table with detergent and water.
If there is a bloodspill, disinfect with sodium hypochlorite before [Link] and clean
suction bottles and tubing with disinfectant.

7.6.3. After the last case

The same procedure as mentioned above should be followed. In addition, the following should
be carried out:
a. Wipe over head lights, cabinets, waste receptacles, equipment, and furniture with a
detergent.
b. Wash floor and wet mop with liquid soap and then remove water, and wet mop with a
disinfectant solution.
c. Clean the storage shelves, scrub and clean sluice room.

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7.6.4. Surface cleaningin OT

a. SurfaceCleaning: All surfaces in OT have to be cleaned with 2percent bacillocid thoroughly
in between cases.
b. Biohazard Cleaning: After biohazard or infected cases, all surfaces must be cleaned with 2
percent bacillocid spray.

7.6.5. Primary Disinfection

Following surgery, primary decontamination should be performed before forwarding to Laundry or CSSD.
Use freshly prepared disinfectant and discard disinfectant after use. Persons handling linen should be
adequately protected with gloves.

7.6.6. Boyles Apparatus

a. Surface Cleaning: Use 2 percent bacillocid.

b. Biohazard Cleaning: Disinfect with 2 percent bacillocid.

7.6.7. The air-conditioner filter should be washed once a week before refixing.
7.6.8. Complete servicing for OT should be done for a week, once a year. Each OT is done in rotation.

7.7 Housekeeping in Intensive Care Unit, Labor Room, and Postpartum Recovery Room
In addition to routine cleaning it is suggested that thorough cleaning with soap and water should be
done once a week. A brush can be used in hard-to-reach areas.

7.8 Routine Cleaning Procedure

7.8.1. Remove all portable equipment.
7.8.2. Damp wipe lights and other fixtures with detergent.
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7.8.3. Clean doors, hinges, facings, glass inserts, and rinse with a moistened cloth.
7.8.4. Wipe down walls with clean cloth and detergent.
7.8.5. Scrub floor using detergent and water.

7.9 Stainless Steel Surfaces

7.9.1. Wash with detergent, rinse and clean with warm water.
7.9.2. Replace portable equipment: clean wheel castors by rolling across toweling saturated with
detergent.
7.9.3. Wash (clean) and dry all furniture and equipment, such as suction holders, foot and
sitting stools, Mayo stands, IV poles, basin stands, X-Ray view boxes, hamper stands, all tables in
the room, hoses to oxygen tank, kick buckets and holder, and wall cupboard.
7.9.4. After washing floors, allow disinfectant solution to remain on the floor for 5 minutes to ensure
destruction of bacteria.
7.9.5. Do not remove or disturb delicate equipment.
7.9.6. While wiping cabinets, see to it that the solution does not get inside and contaminate sterile
supplies.
7.9.7. Operating rooms and scrub rooms should never be dry dusted.

7.10 Maintenance and Repairs

7.10.1 Machinery and equipment should be checked, cleaned and repaired routinely on Sundays.
Urgent repairs should be carried out at the end of the day’s list.
7.10.2 Air-conditioners and suction points should be checked, cleaned and repaired on a weekly basis.
7.10.3 Preventive maintenance on all theatre equipment should be carried out every Saturday, and

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major work to be done at least once a year.

7.10.4 Surveillance of housekeeping procedures should bed one on a routine basis every month by the
HIC Nurse as defined by the ICO

7.11 Cleaning Methods for Blood Spills and Body Substances

7.11.1 Clean spills with a 1.0 percent Hypochlorite solution.

7.11.2 Clean spills of blood, bodyfluids and other potentially infectious fluids immediately:

a. Cover the area immediately with any absorbent material like tissuepaper, old newspaper, and gauze
piece.
b. For small spills: While wearing utility or examination gloves, remove visible material using a cloth
soaked in a 0.5-1.0 percent chlorine solution,then wipe clean with a disinfectant cleaning solution.
For large spills: While wearing gloves, flood the area with a 0.5-1.0 percent chlorine solution,
mop up the solution, and then clean as usual with detergent and water.
NOTE: Wait for a few minutes, preferably 15-20 minutes after pouring chlorine solution. After disinfection
thorough cleaning of the floor with soap and water is necessary.

The formula for making a dilute chlorine solution from any concentrated hypochlorite solution
is:
- Check concentration (percentage of concentrate) of the chlorine product you are using.
- Determine total parts water needed using the formula below.
Total Parts (TP) water= [%Concentrate ]-1
%Dilute
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- Mix1 part concentrated bleach with total parts water required.

Example: Make a dilute solution (0.5 percent) from 5 percent concentrated solution.
Step 1: Calculate TP water:[5.0%]-1 =10 – 1 =9
0.5%
Step 2: Take1 part concentrated solution and add to 9 parts water

Formula for Making Chlorine Solutions from Dry Powders

- Check concentration (percentage of concentrate) of the powder you are using.
Determine quantity of bleach needed using the formula below.

Bleach (g/l)= [ %Dilute ] x1000

% Concentrate
Mix measured amount of bleach powder with 1 liter of water.
Example: Make a dilute chlorine-releasing solution (1.0 percent) from a concentrated Powder
(35 percent).

Step 1: Calculate g/l: x1000 =[1.0percent] X 1000 =28.57 g/1

35 percent
Step 2: Add 28.57 g (approximately 29g) to 1 liter of water.

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7.12 Cleaning Soiled and Contaminated Cleaning Equipment

Step1: Decontaminate cleaning equipment that has been contaminated with blood or bodyfluids by
soaking it for 10minutes in a 0.5percent chlorine solution or other locally available and approved
disinfectants.
Step2: Wash cleaning buckets, cloths, brushes and mops with detergent and water daily,or sooner if
visibly dirty.
Step 3: Rinse in clean water.
Step 4: Dry completely before reuse. (Wet cloths and mop heads are heavily contaminated with
microorganisms.)
NOTE: Hot water may be used as an alternative to disinfection for environmental cleaning for some
objects.

Disinfection with hot water Temperature Duration

1. Sanitary Equipment 80 degree Celsius 45–60 seconds

2. Linen 70 degree Celsius 25 minutes

or 95 degree Celsius 10 minutes

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8. BIOMEDICAL WASTE MANAGEMENT

Hospital waste is a potential reservoir of pathogenic microorganisms and requires appropriate, safe and
reliable handling. The main risk associated with infection is sharps contaminated with blood. There should
be a person or persons responsible for the organization and management of waste collection, handling,
storage and disposal. Waste management should be conducted in coordination with the infection control
team.
In SKNMC&GH we have separate Biomedical Waste Management committee for proper handling
and disposal of Biomedical Waste. Committee includes
1. Dean
2. The medical superintendent.
3. The HOD of Microbiology.
4. The HOD of PSM.
5. The Professor of surgery.
6. The Professor of medicine.
7. The officer in charge of central store.
8. The nursing superintendent.
9. The accounts officer.
10. The administrative officer.
11. The housekeeping incharge.
12. The sanitary inspector.
13. The officer in charge BMW (Microbiologist).
Steps in the management of hospital waste include:
• Generation
•Segregation/separation

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•Collection
•Transportation, storage
•Treatment
• Final disposal
Waste management practices must meet national and local requirements.

Biomedical wastes categories and their segregation, collection, treatment, processing

and disposal options
Type of bag or
Treatment & disposal
Category Type of waste Container to be
options
used
Yellow (a)Human anatomical Yellow colored non- Incineration or plasma
waste: chlorinated plastic Pyrolysis or deep burial
Human tissues, organs, bags
Body parts and fetus below
the viability period (as per
the Medical Termination
ofPregnancy Act 1971,
amended from time to time).

(b)Animal Anatomical
Waste:
Experimental animal
carcasses, bodyparts,
organs, tissues, including
the waste generated from
animals used in
experiments or testing in
veterinary hospitals or
colleges or animal houses.

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(c) Soiled Waste: Incineration or Plasma

Items contaminated with Pyrolysis or deep burial
blood, body fluids like In absence of above facilities,
dressings, plaster casts, autoclaving or microwaving/
gloves, cotton swabs, hydroclaving followed by
vacutainers and bags shredding or mutilation or
containing residual or combination of sterilization
discarded blood and and [Link] waste
blood components. to be sent for energy
recovery.

(d) Expired or Discarded Yellow colored non- Expired `cytotoxic drugs

Medicines: Pharmaceutical chlorinated plastic and items contaminated with
waste like antibiotics, bags or containers. cytotoxic drugs to be
cytotoxic drugs including all Cytotoxic material is returned back to the
items contaminated with marked as“C”on manufacturer or supplier for
cytotoxic drugs along with the yellow bag. incineration at temperature
glass or plastic ampoules, >1200 °C or to common bio-
vials etc. medical waste treatment
facility or hazardous waste
treatment, storage and
disposal facility for
incineration at >1200°[Link]
Encapsulation or Plasma
Pyrolysis at >1200°C.

All other discarded

medicines shall be either
sent back to manufacturer or
disposed by incineration.

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(e) Chemical Waste: Yellow colored non- Disposed of by

Chemicals used in chlorinated plastic incineration or Plasma
production of biological bags or containers Pyrolysisor Encapsulation in
and used or discarded hazardous waste
disinfectants. treatment, storage and
disposal facility.
(f) Discarded linen, Non-chlorinated Non- chlorinated chemical
mattresses, beddings yellow plastic bags disinfection followed by
contaminated with blood or or suitable packing incineration or Plasma
body fluid. material Pyrolysis or for energy
recovery.
In absence of above
facilities, shredding or
mutilation or combination of
sterilization and
[Link] waste to
be sent for energy
recoveryor incineration or
Plasma Pyrolysis.
(g) Microbiology, Autoclave safe Pre-treat to sterilize with
Biotechnology and other plastic bags or Nonchlorinated chemicals
clinical laboratory containers on-site as per National
waste: Blood bags, AIDS Control Organisation
Laboratory cultures, stocks or World Health
or specimens of micro- Organisation guidelines
organisms, live or thereafter for Incineration.
attenuated vaccines, human
and animal cell cultures
used in research, industrial
laboratories, production of
biological, residual toxins,
dishes and devices used for
cultures.

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Category Type of waste Type of bag or Treatment &

container to be used disposal options
Red Contaminated Waste Red colored non- Autoclaving or micro-
(Recyclable) chlorinated plastic waving/ hydroclaving
(a) Wastes generated bags or containers followed by shredding
from disposable items or mutilation or
such as tubing, combination of
bottles, intravenous sterilization and
tubes and sets, [Link] waste
catheters, urine bags, to besent to registered or
syringes(without authorized recyclers
needles) vaccutainers or for energy recovery
and gloves. or plastics to diesel or
fuel oil or for road
making, whichever is
possible.
Plastic waste should
not be sent to landfill
sites.

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White(Translucent) Waste sharps Puncture proof,Leak Autoclaving or Dry

including Metals: proof, tamper proof Heat Sterilization
Needles, syringes containers followed by shredding
with fixed needles, or mutilation or
needles from needle tip encapsulation in metal
cutter or burner, container or cement
scalpels, blades, or any concrete; combination of
other contaminated shredding cum
sharp object that may autoclaving; and sent for
cause puncture and final disposal to iron
cuts. This includes both foundries (having
used, discarded and consent to operate from
contaminated metal theState Pollution
sharps Control Boards or
Pollution Control
Committees) or sanitary
landfill or designated
concrete waste sharp pit.
Translucent (a)Glassware: Plastic or Cardboard Disinfection (by
container with blue Broken or discarded boxes with blue Soaking the washed
marking and contaminated colored marking glass waste after
glass including medicine cleaning with detergent
vials and ampoules and Sodium
except those Hypochlorite treatment)
contaminated with or through autoclaving
cytotoxic wastes or microwaving or
hydroclaving and then
(b)Metallic Body sent for recycling.
Implants

Green Wet waste Green colored bin and Organic waste

Bag converter
Blue Dry waste Blue colored bin or Organic waste
Bag converter

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Type of waste Type of bag or container to Treatment & disposal

be used options
Chemical liquid waste: Separate collection system After resource recovery,the
Liquid waste generated due to Leading to effluent treatment Chemical liquid waste shall be
use of chemicals in system pre-treated before mixing with
production of biological and other waste water.
used or discarded disinfectants,
Silver X-ray film developing
liquid, discarded Formalin,
infected secretions, aspirated
body fluids, liquid from
laboratories and floor
washings,cleaning, house-
keeping and disinfecting
activities etc.

 Chemical treatment using at least 10% Sodium Hypochlorite having 30%residual chlorine
for twenty minutes or any othere quivalent chemical reagent that should demonstrate Log104
reduction efficiency for microorganisms.

STANDARDS FOR EFFICACY OF CHEMICAL DISINFECTION

 Microbial inactivation efficacy is equated to “Log10 kill” which is defined as the difference
between the logarithms of number of test microorganisms before and after chemical treatment.
Chemical disinfection methods shall demonstrate a 4Log10 reduction or greater for Bacillus subtilis
(ATCC19659) in chemical treatment systems.

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STANDARDSFOR LIQUID WASTE-

(1) The effluent generated or treated from the premises of occupier or operator of a common bio
medical waste treatment and disposal facility, before discharge into the sewer should
conform to the following limits-
PARAMETERS PERMISSIBLELIMITS
pH 6.5-9.0
Suspended solids 100 mg/l
Oil and grease 10 mg/l
BOD 30 mg/l
COD 250 mg/l
Bio-assay test 90% survival of fish after 96
hours in 100% effluent.

(2) Sludge from Effluent Treatment Plant shall be given to common bio-medical waste treatment facility
for incineration or to hazardous waste treatment, storage and disposal facility for disposal.

STANDARDS FOR AUTOCLAVING OF BIO-MEDICAL WASTE

When operating a gravity flow autoclave, medical waste shall be subjected to:
 The autoclave should be dedicated for the purposes of disinfecting and treating bio-medical waste.
 i) Temperature of not less than 121° C and pressureof 15pounds per square inch (psi) for an
autoclave residence time of not less than 60 minutes or
 ii) Temperature of not less than 135° C and a pressureof 31psi for an autoclave residence time of not
less than 45 minutes; or
(iii) Temperature of not less than 149° C and a pressureof 52psi for an autoclave residence time of not
less than 30 minutes.

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Validation test for autoclave:

 The validation test shall use four biological indicator strips, one shall be used as a control and
left at room temperature, and three shall be placed in the approximate center of three containers
with the waste.
 Occupier or operator of a common biomedical waste treatment facility shall conduct this test
once in three months and records in this regard shall be maintained.
 RoutineTest: A chemical indicator strip or tape that changes colour when a certain
temperature is reached can be used to verify that a specific temperature has been achieved. The
occupier or operator of a common bio medical waste treatment facility shall conduct this test
during autoclaving of each batch and records in this regard shall be maintained.
 Spore testing: Biological indicator for autoclave shall be Geobacillus stearothermophilus

spores using vials or spore Strips; with at least 1X106spores. Under no circumstances will an
autoclave have minimum operating parameters less than a residence time of 30 minutes, a

temperature less than 121oC or a pressure less than 15 psi. The occupier or operator of a common
biomedical waste treatment and disposal facility shall conduct this test at least once in every
week and records in this regard shall be maintained.

9. PROTOCOL FOR NEEDLE-STICK INJURY

9.1 Immediate
9.1.1 ForInjury: Wash with soap and running water.
9.1.2 For Non-intact Skin Exposure: Wash with soap and water.
9.1.3 For Mucosal Exposure: Wash thoroughly.

9.2 Reporting
All sharps injury and mucosal exposure MUST be reported to the immediate supervisor and to the
Casualty Medical Officer to evaluate the injury. Details of the needle-stick injury should be filled by the
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supervisor and handed over to the HIC nurse for further follow-up

9.3 Management
Management is on a case to case basis.

9.4 Follow-Up
Follow-up and statistics of needle-stick injury are done by the HIC nurse on a weekly basis. This
Information is presented at the HICC meeting and preventive actions to avoid needle-stick injuries, if any,
are recorded.

9.5 Post-HIV Exposure Management / Prophylaxis (PEP) It is necessary to determine the status of
the exposure and the HIV status of the exposure source before starting post exposure prophylaxis (PEP).

9.6 Immediate measures

9.6.1. Wash with soap and water.
9.6.2. Do not use antisepticor bleach.

9.7 Next steps

9.7.1. Prompt reporting
a. All needle-stick/sharp injuries should be reported to the immediate supervisor, and then to
the Casualty Medical Officer.
b. An entry is made in the Needle-StickInjury Register in the Casualty.
Post exposure treatment should begin as soon as possible preferably within two hours, and is not
recommended after 72 hours.
PEP is not needed for all types of exposures.
9.8 Postexposure Prophylaxis
The decision to start PEP is made on the basis of degree of exposure to HIVand the HIV status of the source
from where the exposure/infection has occurred.

ART PEP
ART PEP is best initiated within 2 hours of the incidence and maximum within72 hours
oLow risk– asymptomatic, viral load <1500 copies/ ml
oHigh risk – symptomatic with opportunistic infections or AIDS, acute seroconversion, high
viral load.

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Serological status Status of index case Recommendations for health care worker Followup of health care
of index case worker

If positive Counselling. Check HIV antibody

Initiate HAARTwithin1-2 hours and Levels at 6 weeks 3
continue for 28days months and 6 months

HAART regimen is a combination

HIV of
ATV/r+ TDF/FTCor
RAL+ TDF/FTCor
LPV/r(once or twice daily)+
TDF/FTCor EFV+ABC/3TC(only
for patients who are HLA-
B*5701negative)

(Combination of ATV/r,RAL,
LPV/r,with ABC/3TC only for
patients who are HLA-B*5701
negative)
If negative Counselling Check HIV antibody
Leaves at 6weeks 3
No prophylaxis needed months and 6 months
HBV If positive Counselling Follow up is not required

GiveHBIG prophylaxis (0.6mIU/ml intra

muscularly)within 24 hours Anti-HBs
antibody levels in HCW
>100mIU/ml-no vaccination needed
10-100mIU/ml-Booster only
<10mIU/ml–Full vaccination+ HBIG
If negative Counselling Follow up is not required
No prophylaxis needed
HCV If positive No prophylaxis available Check anti–HCV
Early identification of the disease Antibody levels at 3
by regular follow-up months and 6months
Treatment if disease occurs

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Hepatits B PEP
HBPEP depends upon the immunization history of the victim, anti-HBsAg level and the
serological status of the source.
 HBIG is given immediately, preferably within 24 hours, and definitely within 7 days of the
incidence.
Persons who have previously been infected with HBVare immune and do not need HB PEP.
Table: Post exposure management of health-care personnel after occupational percutaneous and mucosal
exposure to blood and body fluids, by health-care personnel HepB vaccination and response status
Health-care Post exposure testing Postexposure prophylaxis Post-vaccination
personnel status HCP testing HBIG vaccination serological testing
Source (anti-HBs) 0.06ml/
patient(HBsAg) kg
Documented Responder No action needed
after complete series
(≥3doses)
Documented Positive -** HBIGx2 Initiate Yes
nonresponder /unknown separated by revaccination
after 6 doses 1 month

Negative No action needed

Response Positive/ <10mIU/mL** HBIGx1 Initiate Yes

unknown after 3 unknown revaccination
doses Initiate
Negative <10mIU/mL none revaccination Yes

Any result ≥10mIU/mL No action needed

Positive/ -** HBIGx1 Complete Yes

Unvaccinated? unknown vaccination
in completely Complete
vaccinated or -
vaccine refusers Negative none vaccination Yes

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Antibody to hepatitis B surface antigen; HBIG=hepatitis B immune globulin.

*HBIG should be administered intramuscularly as soon as possible after exposure when indicated. The
effectiveness of HBIG when administered >7days after percutaneous, mucosal, or non intact skin exposures is
unknown. HBIG dosage is 0.06mL/kg.
†Should be performed 1–2 months after the last dose of the HepB vaccineseries (and 4–6 months
after administration of HBIG to avoid detection of passively administered anti-HBs) using a quantitative
method that allows detection of the protective concentration of anti-HBs (≥10mIU/mL).
A responder is defined as a person with anti-HBs ≥10 mIU/mL after ≥3 doses of HepBvaccine.
A non responder is defined as a person with anti-HBs<10mIU/mL after≥6doses of HepB
vaccine.

**HCP who have anti-HBs<10mIU/mL, or who are unvaccinated or incompletely vaccinated, and sustain an
exposure to a source patient who is HBsAg- positive or has unknown HBsAg status, should undergo base line
testing for HBV infection as soon as possible after exposure, and follow-up testing approximately 6months
[Link] base line tests consist of total anti-HBc; testing at approximately
6 months consists of HBsAg and total anti-HBc.

(Source: Adapted from CDC guidelines 2013)

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10. CENTRAL STERILE SUPPLIES DEPARTMENT (CSSD)

The purpose of the CSSD is to provide all the required sterile items in order to meet the needs of all patient
care areas.
10.1 Items Suppliedby CSSD
10.1.1 Instrument packs for various procedures
10.1.2 Dressing pad
10.1.3 Dressing packs,cotton and gauze

10.2 Protocol
The central processing area(s) ideally should be divided into at least three zones: soiled zone
(decontamination), clean zone(packaging), and sterile zone(sterilization and storage).
10.2.1. Soiled zone: In the decontamination area reusable contaminated supplies (and possibly disposable
items that are reused) are received, sorted, and decontaminated.
10.2.2. Clean zone: The packaging area is for inspecting, assembling, and packaging clean, but not sterile,
material.
10.2.3. Sterile zone:The steriles to rage area should be a limited access area. Following the sterilization
process, medical a n d s u r g i c a l d e vi ce s mu s t be handled using aseptic technique in order to
prevent contamination. Medical and surgical supplies should not be stored under sinks or in other
locations where they can be come wet. Sterile items that become wet are considered contaminated
because moisture brings with it microorganisms from the air and [Link] or covered
cabinets are ideal but open shelving may be used for [Link] package that has fallen or been
dropped on the floor must be inspected for damage to packaging and contents (if the items are
breakable). If the package is heat-sealed in impervious plastic and the seal is still intact, the
package should be considered not contaminated. If undamaged, items packaged in plastic need not

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be reprocessed.
10.3 Collection and Distribution of Items
10.3.1. All items should be collected and distributed twice a day, if necessary whenever required.
10.3.2. CSSD items should be transported to the wards in a manner so as to ensure that sterility of the items
is maintained
10.3.3. When the items are collected back from the patient care areas the quantity of each item that is
collected is recorded in a [Link] items are transported to CSSD. Another set of personnel
transport sterile items to the various wards, depending on the requirement.
10.3.4. Items which have crossed the expiry date should be returned and new ones obtained.

10.4 Monitoring Sterilization

There are two ways of monitoring sterilization of CSSD items:
10.4.1. All sterile items can be monitored by using the chemical indicator tape which shows that the item has
been adequately sterilized
10.4.2. In addition to chemical sterilization, microbiological surveillance may be conducted using
[Link] spore suspension which is kept in the autoclave to check the efficiency.
10.5 Moist Heat Sterilization
10.5.1. This is used for steel instruments, latex rubber tubes, gloves, dressing packs, cotton and gauze.
10.5.2. CSSD has electric autoclaves, gravity type of autoclaves, and a high pressure autoclave.
The high pressure autoclaves operate using a central steam supply.
10.6 Recommended Practice Guidelines for All Types of Steam Sterilizers
10.6.1. Device Preparation
Devices should be prepared for sterilization in the following manner:
a. Clean, and remove excess water.

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b. Jointed instruments should be in the open or unlocked position.

c. Multipiece or sliding pieces should be disassembled unless other wise indicated by the
device manufacturer.
d. Devices with concave surfaces that retain water should be placed in a manner such that

condensate does not collect.

e. Instruments with lumens should be moistened with distilled water immediately prior to
sterilization.
f. Heavy items should be arranged so as to not damage lighter more delicate items.
g. Sharp instruments should have tips protected.

10.6.2. Packaging: Packaging materials for steam sterilization should:

a. Be validated for steam sterilization.
b. Contain no toxic ingredients or dyes.
c. Be capable of with standing high temperatures.
d. Allow air removal from packages and contents.
e. Permit sterile contact with the package contents.
f. Permit drying of the package and contents.
g. Prevent the entry of microbes, dust, and moisture during storage and handling.
h. Have a proven and tamper-proof seal.
i. Withstand normal handling and resist tearing or puncturing.

10.6.3. Unloading
Upon completion of the cycle, the operator responsible for unloading the sterilizer should: Review
the sterilizer printout for the following:

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a. Correct sterilization parameters.

b. Cycle time and date.
c. Cycle number matches the lot control label for the load.
d. Verify and initial that the correct cycle parameters have been met.
e. Examine the load items for:
• Any visible signs of moisture.
• Anysigns of compromised packaging integrity.

Printed records of each cycle parameter (that is, temperature, time) should be retained in
accordance with the health care settings requirements.

10.6.4. Load Cool-Down

Upon removal of the sterilized load the operator should:
a. Visually verify the results of the external chemical indicators.
b. Allow the load to cool to room temperature (the amount of time for cooling depends
on the devices that have been sterilized).
c. Ensure cool down occurs in a traffic-free area with out strong warm or cool air currents.

10.7 Troubleshooting-Wet Pack Problems

Packages are considered wet when moisture in the form of dampness, droplets or puddles is found on or
within a [Link] are two types of wet packs; those with external wetness and those with internal
wetness. Sterility is considered compromised and the package contents considered
Contaminated when wetpacks are [Link] are several causes of [Link] following is a list of
possible causes:
10.7.1 Packages are improperly prepared or loaded incorrectly.
10.7.2 Condensation drips from the sterilizer cart shelf above the item.
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10.7.3 Condensation drips from rigid sterilization containers placed above absorbent packaging.
10.7.4 Condensate blows through the steam lines into the sterilizer chamber.
10.7.5 Instrument or basin sets are too dense or lack absorbent material to wick moisture away.
10.7.6 Linen packs are wrapped too tightly.
10.7.7 Sterilization containers with a low metal-to-plastic ratio.

10.8 Flash Sterilization/ Immediate Use Steam Sterilization

This form of sterilization is used only when there is an immediate requirement for items to be sterilized.
Containers used for Immediate Use Steam Sterilization of devices should be validated for that purpose.
Immediate Use Steam Sterilization should not be used to:
a. Sterilize implants
b. Sterilize complete sets or trays of instruments
10.8.1. Compensate for inventory shortages or scheduling difficulties.

10.9 ETO
10.9.1 Only devices that can’t be sterilized by other means and that are compatible with ETO should be
processed by [Link] device manufacturers’instructions for cleaning, preparation and packing
should be followed.
10.9.2 Cycle Parameters:
Written instructions of the Manufacturer of ETO sterilizer in respect of temperature, humidity, time
and sequence of aeration, exposure etc must be followed.
10.10 Quality Assurance
10.10.1. All documentation should be dated and signed by the person completing the documentation
and/or verifying the test results.
10.10.2. Documentation of the sterilization process should include:
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10.10.3. Package label:

a. Name of device (when necessary).
b. Initials of technician packaging the device.
c. Lot control information which includes a load or cycle number, sterilizer number, and the
date of sterilization.
d. Detailed list of sterilizer load contents
e. Date, time, and results of all tests performed (for example, print out, Chemical
Indicator, Biological Indicator, Bowie-Dick, leak test).

f. Sterilizer physical parameters should be verified by the individual responsible for releasing
the load prior to load [Link] should be documented (for example, printout is
initialed).
g. If any indicator fails, the failure should be investigated. Loads may be recalled according to
the results of the investigation. All actions associated with an investigation should be
documented.
h. A process to address any indicator failure, for example, printout, chemical indicator or
biological indicator.
i. Record retention according to corporate administrative directives and/or quality
management system requirements.

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10.11 Recall Procedure

As soon as CSSD staff receive the result from the microbiologist about biological indicators not being
satisfactory, the CSSD In-charge or Staff nurse should take the following action:

a. Inform to the Chief Nursing Officer and Hospital Infection Control Committee.
b. Check the autoclave number, batch number, and expiry date.
c. Trace out the department which issued the items and the specific date.
d. Inform the ward in-charge regarding the biological indicator growth.

e. Take back all the items to CSSD.

f. Rewash all the articles and repack for reautoclave.
g. Clean the autoclave thoroughly with clean water.
h. Sterilize the items with Bowie-Dick and biological indicator.
i. Wait for the report; only then issue the items to the wards.
j. Update the register.

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11. OUTBREAK INVESTIGATION

The occurrence of two or more epidemiologically related infections caused by an organism of the same type
relating to place and time is defined as an [Link] the factors causing the occurrence of the outbreak
are defined, appropriate control and prevention measures can be formulated.
The team of outbreak investigations will include HOD Microbiology, HOD Pathology and HOD PSM.
Depending on the type of outbreak in the hospital, these members will report Dean and form the committee.
In an outbreak investigation, data are collected, collated accordingto time, place and person, and analyzed
to draw inferences. This may be done according to the following steps:
11.1.1. Identify the outbreak.
11.1.2. Describe the outbreak.
• Formulate a hypothesis on the type of infection.
• Identify the source and route of infection.
Suggest and implement initial control measures.

11.1.3. Control measures and follow-up

• Immediate control measures
• Specific control measures
11.1.4. Evaluation and efficacy of control measures
11.1.5. Communication

Legislation requires that the relevant public health authority be informed of outbreaks related to notifiable
infections. It may also be prudent to involve public health officers at an early stage, if an outbreak is likely to
come to the attention of the [Link] principles for investigating outbreaks in health care facilities are the
same as for community-based [Link] are three basic steps
1. Describing the outbreak
2. Developing a hypothesis
3. Testing the hypothesis with analytical epidemiology.

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The tasks involved in any investigation can be summarized as follows:

Confirm that an outbreak is occurring.
 Determine the background rate of infection, as a temporal cluster of cases may be due to chance alone.
 Confirm the diagnosis using microbiological methods. If possible, confirm that cases are related by
typing methods (which may require reference laboratory facilities).
 Define a case, and count [Link] a case definition that may include clinical and laboratory data.
Start with a broad definition that can be redefined later. In healthcare establishments, case definition
can be relatively easy, with data available through laboratory records and infection prevention and
control surveillance data. Remember that cases may have been discharged from the establishment.
Describe the data in terms of time, place and person and construct an epidemic curve. In healthcare
facilities, age, gender and underlying disease are the most useful ‘person’ attributes to record. The
location may suggest risk factors.
Determine who is at risk of becoming ill.
 Look at changes that may have affected the rate of infection ([Link] staff, new procedures, new
tests, new units and health care worker: patient ratios).
Develop a hypothesis and test it by comparison with the facts.
Undertake analytical epidemiology, such as a case–control or retrospective cohort study, to test the
hypothesis quickly.
 After interim control measures are in place, a larger, more systematic study may be warranted,
possibly with a different analytical methodology.
Evaluate the data and prepare a written report.
 Implement longer-term infection prevention and control measures for the prevention of similar
outbreaks.
In the interests of public safety (and because of the threat of litigation), all outbreaks, however minor, should
be investigated thoroughly and the outcomes of such investigations documented.

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12. HIGH-RISK AREAS AND HIGH-RISK PROCEDURES

12.1 Introduction
[Link] Infection rates in the intensive care units are higher than in the general
[Link] is related to severity of illness and greater susceptibility to acquiring
microorganisms related to the ICU.
12.1.2. 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 is very high.
12.1.3. In the ICU, during urgent critical care interventions there is often a possibility of suboptimal
infection control practices.

12.2 Five Main Infection Control Maneuvers to Control Transmission

12.2.1. Hand hygiene
12.2.2. Personal protective equipment (gloves, gowns and aprons)
12.2.3. Isolation where required
12.2.4. Proper handling and decontamination of patient care equipment
12.2.5. Proper handling of patient care environment.
Certain areas of the hospital are identified as high-risk areas for acquisition and transmission of
pathogenic [Link] Manual has identified the following high-risk areas and high-risk
procedures which have a high potential for healthcare associated infections.

12.3 General Principles to be followed in High-Risk Areas

12.3.1 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).
12.3.2 Handwashing: Importance of this cannot be over emphasized in the ICU setting. Use
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handrubs with 2 percent chlorhexidine between patients and clinical handwash solution (4
percent chlorhexidine) prior to invasive procedures.
12.3.3 Aprons and gloves: Wear aprons and gloves when necessary. Remove and discard them in to the
appropriate bin immediately after each [Link] gloves when in contact with body fluids
(examination gloves) and invasive procedures (sterile gloves)
12.3.4 Mask: Wear a mask while examining patients with potential air-borne pathogens.
Wearing a mask is mandatory when in isolation areas.
12.3.5 Goggles: Use goggles when you anticipate a splash or when handling biohazardous
materials.
12.4 Some of the High-Risk Areas
12.4.1. Intensive care units: MICU, PICU, NICU & SICU.
12.4.2. Operation theatres
12.4.3. Obstetrics and labor room
12.4.4. Emergency Medicine
12.4.5. Hemodialysis unit
12.4.6. CSSD
12.4.7. Laboratories
12.4.8. Gastroendoscopy unit
12.4.9. Blood bank
12.4.10. Cardiac cathlab

12.5 Surveillance of High-Risk Areas

High-risk areas are an important area of targeted surveillance in the HOSPITAL.

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12.5.1. The staff and doctors in high-risk areas should actively liaise with the Infection
Control Department in monitoring reporting and analyzing infections.
12.5.2. Surveillance is done actively in the following cases:

a. Hospital acquired infections:

- Catheter Associated Urinary Tract Infection (CAUTI)
- Central Line Associated Bloodstream Infection (CLABSI)
- Surgical site infection (SSI)
- Ventilator associated pneumonia (VAP)
b. Bed sore analysis
c. Needle-stick injuries
d. Multidrug-resistant organisms:
- Methicillin Resistant Staphylococcus Aureus (MRSA)
- Vancomycin Resistant Enterococci (VRE)

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Environmental surveillance:
Following protocol is followed in SKNMC and GH

SrNo Location Settle plate Aerobic swabs

1 All operation theaters weekly -

2 Ophthalmology OT weekly weekly

3 MICU, SICU, BICU, IRCU & 3 monthly 3 monthly

ICCU
4 Labor room - weekly

5 NICU, PICU monthly monthly

6 Surgery minor OT monthly -

7 Cathlab weekly weekly

8 CSSD weekly -

9 Dialysis unit 3 monthly 3 monthly

10 Dental OPD 6 monthly

11 RHTC Kondhawa (minor OT & - monthly

Labor room)

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12.6 Definitions

12.6.1 CLABSI is defined as follows: Central line-associated BSI: A laboratory-confirmed bloodstream

infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for >2 calendar days on
the date of event, with day of device placement being Day 1,
AND
The line was also in place on the date of event or the day before calendar days and then removed; the date
of event of the LCBI must be the day of discontinuation or the next day to be a CLABSI.
Laboratory-Confirmed Bloodstream Infection (LCBI) must meet one of the following criteria:
1. LCBI 1-Patient of any age has recognized pathogen identified (i.e., an organism which is not on
the NHSN common commensal list) from one or more blood specimens by a culture or non-
culture based microbiologic testing method.
AND
Organism(s) identified in blood is not related to an infection at another site
2. LCBI 2: Patient of any age has at least one of the following signs or symptoms: fever

(>38.0oC), chills, or hypotension

AND
Organism(s) identified from blood is not related to an infection at another site.
AND
The same NHSN common commensal is identified from two or more blood specimens drawn on separate
occasions by a culture or non-culture based microbiologic testing method.
3. LCBI 3: Patient≤1 year of age has at least one of the following signs or symptoms:

Fever (>38.0oC), hypothermia (<36.0oC), apnea, or bradycardia

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AND
Organism(s) identified from blood is not related to an infection at another site
AND
The same NHSN common commensal is identified from two or more blood specimens drawn on separate
occasions by a culture or non-culture based microbiological testing method. If a CL or UC was in place
for>2
12.6.2 There are three definition tiers within the VAE algorithm:

1) Ventilator-AssociatedCondition (VAC);
2) Infection-related Ventilator-Associated Complication (IVAC); and
3) PossibleVAP (PVAP).

VAE: VAEs are identified by using a combination of objective criteria: deterioration in respiratory status
after a period of stability or improvement on the ventilator, evidence of infection or inflammation, and
laboratory evidence of respiratory infection.

NOTE: Patients must be mechanically ventilated for at least 4 calendar days to fulfil VAE criteria (where
the day of intubation and initiation of mechanical ventilation is day1). The earliest date of event for VAE
(the date of onset of worsening oxygenation) is day 3 of mechanical ventilation.

NOTE: The baseline period of stability or improvement on the ventilator is defined as the 2 calendar days
immediately preceding the first day of increased daily minimum PEEP or FiO2, and must be characterized
by ≥2 calendar days of stable or decreasing daily minimum FiO2 or PEEP values (i.e., the daily minimum
PEEP or FiO2 on the second day of the base line period of stability or improvement must be equal to or
less than the daily minimum PEEP or FiO2 on the first day of the base line period of stability or
improvement). The definitions of “daily minimum PEEP”and“daily minimum FiO2”are included below.
Note that the minimum daily PEEP or FiO2 used for VAE surveillance is the lowest setting during a

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calendar day that was maintained for atleast1hour (see daily minimum PEEP and FiO2 definitions for
exception to1 hour requirement).
12.6.3 Catheter-associated UTI (CAUTI): A UTI where an in dwelling urinary catheter was in place
for>2 calendar days on the date of event,with day of device placement being Day1,
AND
An in dwelling urinary catheter was in place on the date of event or the day before. If an indwelling
urinary catheter was in place for>2 calendar days and then removed, the date of event for the UTI must be
the day of discontinuation or the next day for the UTI to be catheter-associated.

12.6.4 Superficial incisional SSI

Must meet the following criteria:
Date of event for infection occurs within 30 days after any NHSN operative procedure (where day1=the
procedure date)
AND
involves only skin and subcutaneous tissue of the incision
AND
patient has at least one of the following
a. purulent drainage from the superficial incision
b. organisms identified from an aseptically-obtained specimen
from the superficial incision or subcutaneous tissue by a culture or non-culture based microbiologic
testing method which is performed for purposes of clinical diagnosis or
treatment (e.g., not Active Surveillance Culture/Testing (ASC/AST).
c. superficial incision that is deliberately opened by a surgeon, attending physician**or other
designee and culture or non-culture based testing is not performed
AND
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Patient has at least one of the following signs or symptoms: pain or tenderness; localized swelling;
erythema; or heat.
Diagnosis of a superficial incisional SSI by the surgeon or attending physician**or other designee
Deep incisional SSI
Must meet the following criteria:
The date of event for infection occurs within 30 or 90days after the NHSN operative procedure
(whereday1 =the procedure date) according to the list in
AND
involves deep soft tissues of the incision (e.g., fascial and muscle layers)

AND
patient has at least one of the following:

a. Purulent drainage from the deep incision.

A deep incision that spontaneously dehisces, or is deliberately opened or aspirated by a

surgeon, attending physician**or other designee and organism is identified by a culture or non-
culture based microbiologic testing method which is performed for purposes of clinical diagnosis or
treatment (e.g., not Active Surveillance Culture/Testing(ASC/AST) or culture or non-culture
based microbiologic testing method is not performed
AND
Patient has atleast one of the following signs or symptoms: fever(>38°C); localized pain or tenderness. A
culture or non-culture based test that has a negative finding does not meet this criterion.
An abscess or other evidence of infection involving the deep incision that is detected on gross
anatomical or histopathologic exam, or imaging test.

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13. PERIOPERATIVE POLICY

The benefit of the routine use of antimicrobial prophylaxis prior to non-clean and implant surgery has long
been recognized. Several experimental and clinical studies demonstrated an effect of the timing of surgical
antimicrobial prophylaxis, on surgical site infections (SSI) but the optimal timing remains to be defined.
Antimicrobial Resistance (AMR) has assumed greater importance in healthcare settings. Immunocompromised,
bedridden, obese and geriatric patients spend more and more amounts of time in hospitals or long-term care
facilities. These patients are at risk for morbidity and mortality associated with HAI. Further, there is an association
between the development of resistance in Staphylococcus aureus, enterococci, and Gram-negative bacilli. Strategies
to prevent the emergence and spread of healthcare-associated antimicrobial-resistant organisms are essential. The
situation on the development of new antimicrobial agents is not very encouraging. Hardly any promising agents are
in the pipeline for the treatment of some common multidrug-resistant nosocomial organisms.
Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure
an infection while minimizing toxicity and conditions for the selection of resistant bacterial strains.

The comprehensive and consistent practice regarding the routine perioperative antibiotic prophylactic measures
requires the coordination of the entire perioperative interprofessional healthcare staff. This includes but is not
limited to the entire operating room and perioperative staff members (including surgical techs, perioperative-based
nursing staff, floor nurses, advanced practitioners, pharmacists, and all clinicians participating in the care of
surgical patients). This interprofessional approach optimizes antibiotic prophylaxis, minimizes adverse events, and
drives optimal patient outcomes.

Wound Classifications
Wound types can be classified as clean, clean-contaminated, contaminated, or dirty/infected, according to the
Centres for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN)
 Clean wounds are not infected, without inflammation, primarily closed, and do not include the organ
systems outlined in a clean-contaminated wound

 Clean-contaminated wounds involve the respiratory, alimentary, genital, and urinary tract as long as the
tract is entered without unusual contamination

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 Contaminated wounds include open, fresh accidental wounds, including those with non-purulent
inflammation. Contaminated wounds also include procedures with significant breaks in sterile technique or
gross spillage from the gastrointestinal tract.

 Dirty or infected wounds are old traumatic wounds with devitalized tissue, existing clinical infection, or
perforated viscera.
During clean procedures, skin florae such as coagulase-negative staphylococci (e.g., Staphylococcus
epidermidis or Staphylococcus aureus) are predominant pathogens in surgical site infections. In clean-contaminated
procedures, the most commonly found organisms causing surgical site infections are skin flora, gram-negative rods,
and Enterococci. The most common organisms implicated as causes of surgical site infections include
Staphylococcus aureus, Staphylococcus epidermidis, aerobic streptococci and anaerobic cocci.

Key Features of PAP

 Hospital antimicrobial management team takes care of perioperative antibiotic prophylaxis policy which
includes a surgeon, anaesthetist, nurse, pharmacist, and clinical microbiologist
 The protocol is reviewed and updated regularly. It considers adjustment of PAP for patients who are at risk
for SSI due to Multi-Drug Resistant Organisms or who have a BMI over 30
 To ensure appropriate timing, antibiotic prophylaxis before and during surgery is the responsibility of the
anaesthetist. If not available, then another professional present at the time of surgery is designated
 PAP is administered within 60 minutes before the incision Exceptions include vancomycin and
levofloxacin,
 The majority of preoperative prophylactic antibiotics are administered intravenously (IV).
 Although a single dose of PAP is preferred, subsequent doses are given depending on the duration of the
procedure and the half-life of the antibiotic, and if significant blood loss occurs during surgery
 Unless there is a known infection, prophylactic antibiotics should be discontinued within 24 – 48 hours
 Patients with renal failure, major burns pregnancy are managed as per different designated protocol
 Patients are monitored after the dose for any adverse effect or allergic reactions

Other preoperative actions include basic infection control strategies, instrument sterilization, and a patient's
skin preparation and hand hygiene which is supposed to prevent 60 to 80% of SSI.

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Clinical condition 1st Line antibiotic Alternative antibiotic Remarks

VAP Piperacillin- Ceftriaxone 2g IV Modify based on the culture of

Meropenem once daily for 5-7 days lower respiratory tract
(Ventilator Associated Amikacin secretions. Stop antibiotics after
Pneumonia)) 15mg/Kg/day OR 5 days of clinical response
Gentamicin
7.5mg/kg/day OD i.m
or i.v for 10 days
Piperacillin –
Tazobactam 4.5gm IV
8hourly for 7-10 days
Imipenem 1g IV
8hourly or
Meropenem 1g IV
8hourly Vancomycin
15mg/kg IV 12 hourly

VAP (Ventilator Piperacillin- Modify based on culture of

Associated Tazobactam lower respiratory tract
Pneumonia) Paediatric 300mg/kg/d 8days

Inj Amoxicillin Inj. Meropenem 2 gm

SSI (Surgical site +Clavulanic acid 1.2 8hrly + Inj
infection) G.U.T. gm BD , Inj. Vancomycin 1gm 12
Cefotaxim 500 mg IV hrly
6 hrly Inj. Cetriaxone
IV Inj. Piperacillin
1 gm 24 hrly,
with Tazobactam
InjPipercillin 3.375 IV 6hrly Inj.
+Tazobactam 3.375gm Teicoplanin 6mg/kg
every 6 hrly OR 4.5gm 12 hrly IV or IM
every 8hrly IV, Tab
Doxycycline 100 mg
12hrly Tab
Metronidazole 500 mg
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8 hrly IV

Wound infection Inj. Amoxycillin Inj. Meropenem 2 gm

+Clavulanic acid 1.2 8hrly +
gm BD Inj. Cetriaxone InjVancomycin 1 gm
1 gm 24 hrl 12hrly IV
[Link] with
Tazobactam 3.375 iv
6hrly Inj. Teicoplanin
6 mg/kg 12 hrly IV or
IM

LSCS Single dose Inj. If allergic, single dose Puerperal endometritis is

Cefotaxime 2gm IV clindamycin 600- polymicrobial, (aerobic
Dose is 3gm if patient 900mg IV + anaerobic). These organisms are
is >100 kg Gentamicin 1.5 mg/kg part of vaginal flora and are
IV introduced into the upper
genital tract coincident with
vaginal examinations during
labor and/or instrumentation
during surgery Tita et al
showed the addition of 500mg
azithromycin to cefazolin for
(in labour or with membranes
ruptured) reduced
Endometritis& wound infection
significantly

Rescue cervical Inj. Ampicillin 2 gm To prevent ascending infection

encerclage single dose from vaginal flora to exposed
membranes

Hysterectomy Inj. Cefotaxime 2gm Cefuroxime 1.5gm IV

(AH,VH, IV single dose Dose is single dose OR if
Laparoscopic) and 3 gm if patient is allergic to
surgeries for pelvic cephalosporin,
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organ prolapsed and/or >100kg Clindamycin 600 -

stress urinary 900mg IV +
incontinence Gentamicin 1.5 mg/kg
IV

Laparoscopy (uterus Inj. Cefazolin 1gm InjCefotaxim 1gm IV

and/or vagina not single dose IV single dose
entered)/
Hysteroscopy/ ectopic
pregnancy

Abortions (medical Tab. Azithromycin Doxycycline 100mg No prophylaxis for missed/

and surgical) 1gm orally+ Tab orally twice daily for 7 incomplete abortion
Metronidazole 800 mg days, starting on day
orally at time of of abortion +
abortion Metronidazole 800mg
orally at time of
abortion

Postoperative Surgical InjAmoxycillin + Inj Metronidazole

site infection Clavulanic acid 1.2 500mg TDS OR
Obstetrics gm BD + Gentamicin 5mg/kg
IV OD + Inj.
Metronidazole 500 mg
8 hrly.
Preop–prophylaxis a) Inj. Ceftriaxone /
Laminectomy Cefotaxime 1 to 2gm /
day IV or IM+ Inj
Gentamicin 5mg/kg
IV OD for 3 days

b) THR/TKR Inj. Vancomycin 15

mg/kg IV 12 hrly Inj.
Ceftriaxone / Inj.
Cefotaxime 1 to 2 gm/
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day IV or IM

c) Prosthetic / implant Inj. Ceftriaxone + Inj.

associated infection Vancomycin 1gm
12hrly OR Inj.
Teicoplonin 400mg 12
hrly IV OR Inj
Clindamycin 600-900
mg 8 hrly
Cataract Sx Tab. Ciplox 500mg
BD for 5 days e/d
Ciprofloxacin 0.3%
OR e/d Moxifloxacin
0.5% QID

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PREOPERATIVE MEDICATION POSTOPERATIVE MEDICATION

For Ocular Surgeries For Ocular Surgeries

Moxifloxacin 0.5% Eye Drop Qid(48 Hours Preop) Moxifloxacin 0.5% Eye Drop Qid For 4 Weeks

[Link] 500mg Bd( On Admission 48hrs [Link] 500mg Bd(Total 5 Days Course)
Preop)

Povidone Iodine 5% Eye Drops (1 Drop ,10

Minutes Preop)

Intracameral Moxifloxacin Preservative Free 0.5% (At

The End Of Surgery)

Chloramphenicol Eye Ointment with Eye patch (at the

End of Surgery )

POSTOPERATIVE OCULAR INFECTIONS

(BLEBITIS / ENDOPHTHALMITIS)
TOPICAL MEDICATION (EYE INTRAVITREAL INJECTION SURGERY IV Antibiotics
DROPS)

Moxifloxacon 0.5% (4th Generation Vancomycin 1mg/0.1ml Vitrectomy +/- Iol SOS
Fluroquinolone) 1hourly Removal

Foertified Tobramycin (14mg/Ml) Ceftazidime 2.25mg/0.1ml OR

1hourly Amikacin 0.4mg/0.1ml

Fortified Vancomycin (25-50 Mg Voriconazol 50-100 µg/0.1ml OR

/Ml)
Or Amphotericin B 5 µg /0.1ml
Fortified Cefazolin (50mg/Ml)
(Alternating Q30 Min For 48
Hours,Then Taper As Qid)

Department of Orthopaedics Peri-Operative Antibiotic Policy

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1. Patient’s with Compound Fractures:  INJ. CEFUROXIME 1.5 GM BD

For 5 Days
 [Link] 500 MG OD for 3
days
 INJ METRONIDAZOLE 500 MG (
100ML) TDS for 3 days.

2. Patient’s with Closed Fractures and  INJ. CEFUROXIME 1.5 GM IV 30

elective surgeries:
Minute to 1 Hrs. before Surgery &
for 2 Days post Operative Period.

 Oral antibiotic from 3rd day

TAB. CEFUROXIME 500MG BD For 5 days.

3. Patient’s with Infected Fractures:  Antibiotics are given according to

culture sensitivity report.

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References

1. Systematic review and evidence-based guidance on perioperative antibiotic prophylaxis- European

centre for disease prevention and control 2013
2. Surgical Antimicrobial Prophylaxis Prescribing Guideline- Government of South Australia 2021
3. NHSN SSI guidelines CDC Jan 2022

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14. Guidelines for COVID-19 PANDEMIC

Standard precautions to be taken to avoid infection by COVID 19:

1. Hand hygiene
2. PPE
3. Respiratory etiquettes
4. Cleaning and disinfection
5. Biomedical waste management.
6. Standard Precautions to be followed by health care workers while
handling dead bodies of COVID19.
7. Specimen collection, packaging and transport guidelines for 2019
Novel Coronavirus (SARS-CoV-2).

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[Link] HYGIENE

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2. Personal Protective Equipment’ s (Donning & Doffing)

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Steps for Donning of PPE

(1) Do Hand Wash with soap and water.

(2) Put on Shoe Cover.

(3) Wear proper fitting N95 mask to cover your nose and mouth.

(4) Put on Surgical Cap / Hood.

(5) Wear Inner Gloves.

(6) Put on the coverall Body suit.

(7) Wear Surgical Mask.

(8) Put on Goggles.

(9) Put on Face Shield

(10) Finally put on Outer Gloves.

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Steps for Doffing of PPE

(1) Remove outer Gloves.

(2) Remove Shoe Cover.
(3) Remove Face Shield.
(4) Remove Goggles.
(5) Now remove Cover all Body suit INSIDE OUT.
(6) Remove Cap.
(7) Remove outside Surgical mask.
(8) Remove Inner Gloves.
(9) Remove N-95 respirator.

NOTE: HAND RUB TO BE DONE AFTER EVERY STEP

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Protocol for use of Personal protective equipments (PPE) In different hospital

setting
Setting Healt Activity Type of PPE
hcare
worker/pa
[Link] facility tient
a. COVID-19 OPD Doctor/nurses Physical examination of 1. Three layered mask
patient 2. Gown
3. Gloves
4. Face shield/eye
protection
5. Shoe cover
6. Head cover
Patient Any Medical mask

Multipurpose After and between [Link] mask

Workers consultations with 2. Gown
(MPW) patients with respiratory [Link] duty gloves
symptoms 4. Face shield/eye
protection
[Link] or closed work
shoes
b. Other OPDs with Doctor/nurses Physical examination of Three layered mask
Physical patient
examination Patient Any No PPE required
of patients without
Respiratory symptoms.
c. Waiting area patients with Any Provide medical mask
respiratory symptoms Ensure safe distance of
1 m.
patients without Any No PPE required
Respiratory
symptoms.
2. Inpatient facilities
Doctor/nurses Providing direct care 1. Three layered mask

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a. COVID-19 to COVID-19 patients 2. Gown

isolation 3. Gloves
ward 4. Face
shield/eye
protection
5. Shoe cover
6. Head cover
Aerosol generating 1. N95 mask
procedure performed on 2. Gown
COVID-19 patients 3. Gloves
4. Face
shield/eye
protection
5. Shoe cover
6. Head cover
MPWs Cleaning of COVID-19 [Link] mask
patient room 2. Gown
[Link] duty gloves
4. Face shield/eye
protection
[Link] or closed work
shoes

Relatives/visitors Entering the room of 1. Three layered

COVID-19 patients mask
2. Gown
3. Gloves
b. Laboratory Lab technician Manipulation of [Link] mask
services Respiratory samples. 2. Gown
[Link]
4. Face shield/eye
protection

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[Link] teams
Ambulance Healthcare personnel Transport of [Link] mask
suspected COVID- 2. Gown
19 patients to referral [Link]
centre 4. Face shield/eye
protection

Driver Involved only in Ensure safe distance of

driving the patient 1 m.
with suspected No PPE required
COVID-
19disease and the
driver’s compartment
is separated from
theCOVID-19patient

Patient with suspected Transport to the referral Medical mask if

COVID-19disease centre tolerated

MPW Cleaning after and [Link] mask

between transport of 2. Gown
patients with [Link] duty gloves
suspected COVID-19 4. Face shield/eye
disease to the referral protection
centre [Link] or closed work
shoes

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4. Respiratory hygiene/etiquette

 When coughing and sneezing cover mouth and nose with flexed elbow or

tissue

 Throw tissue in closed bin after use

 Clean hands with alcohol based hand rub or soap and water

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Protocol for disinfection of Personal protective equipment’ s (PPE)

1. Gloves – discard in yellow bag

2. Goggles / Face shield-disinfect with 70% Alcohol
3. Gown, head cover, shoe cover and Three layered Mask - discard in the
container with 1% sodium hypochlorite and keep it for 20 min. Wash
with running water. Send to the laundry with proper label and prior
intimation to them.
4. Respirator (N 95 Mask) - Only single use is recommended. Discard
any respirator that is obviously damaged or becomes hard to breathe.
Discard into the yellow bag.
5. Heavy duty gloves and boots- Wash with soap and water and dry.

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USE OF KIOSK FOR SAMPLE COLLECTION AS A BARRIER

PRECAUTION

Nasopharyngeal swab collection Oropharyngeal swab collection

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5. Protocol for environmental cleaning and disinfection

Area Item/equipment Frequency of cleaning / Method of
disinfection cleaning/disinfection
[Link]-19 Floor 2 hourly Clean floor with 1% sodium
OPD hypochlorite solution
Ceiling, wall, window, once a week  Damp dusting

 Change the mop

head/cover when soiled

Door and door knobs, Daily Clean with Damp cloth of

light switches soap and water

Equipments such as After each use Wipe with 70% alcohol

thermometer,
stethoscope, BP
apparatus

Desks, Desk, chairs, 2 hourly Clean with Damp cloth of

telephone, and other soap and water
frequently touched
surfaces








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 For cleaning of COVID 19 ISOLATION WARD and ICU worker should wear:
Rubber boots, heavy duty gloves & triple layer mask with all PPE.

Item/equipment Frequency of Method of cleaning/disinfection

cleaning /
disinfection
[Link]-19 Floor 2 hourly Clean floor with 1% sodium
ISOLATION hypochlorite solution
WARD
Ceiling , wall ,window, Daily  Damp dusting
 Change the mop head/cover
when soiled ( for metal surfaces use
70%alcohol)
High contact Door and door knobs, TWICE Daily Clean with Damp cloth soaked in
surfaces light switches, intercom, 1% sodium hypochlorite solution
public counters
Frequently touch Equipments such as After EACH use Wipe with 70% alcohol
surfaces thermometer, stethoscope,
BP apparatus
Desks, chairs, telephone, 2 hourly Clean with Damp cloth soaked in
and other frequently 1% sodium hypochlorite solution (
touched surfaces for metal surfaces use 70% alcohol)
For infected patient bed After use 0.1% sodium hypochlorite solution
in ICU for contact period of 10 minutes

Area Item/equipment Frequency of Method of cleaning/disinfection

cleaning /
disinfection

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[Link]-19 ICU Floor 2 hourly Clean floor with 1% sodium

hypochlorite solution
Ceiling , wall ,window, Daily Damp dusting
Change the mop head/cover when soiled
( for metal surfaces use 70% alcohol)

High contact surfaces Door and door knobs, TWICE Daily Clean with Damp cloth soaked
light switches, in 1% sodium hypochlorite solution
intercom, public
Frequently touch counters such as
Equipments After EACH use Wipe with 70% alcohol
surfaces thermometer,
stethoscope,
BP apparatus
Desks, chairs, 2 hourly Clean with Damp cloth soaked
telephone,
in 1% sodium hypochlorite solution ( for
and other
metal surfaces use
frequently
70% alcohol)
touched surfaces
High risk equipments Ventilator circuits, After EACH use 1% sodium hypochlorite
O2
solution for contact period of 15 minutes
mask, nasal
prongs, suction
jar & tubes,
blood & body
For large blood spill After each event 10% sodium hypochlorite
fluid
solution for contact period of 15 minutes
stained instruments,
linen
For infected patient bed After use For non-absorbent sheet 0.1%

in ICU(Mattress to be sodium hypochlorite solution for contact

covered with non- period of 10 minutes
absorbent sheet)

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5. Guidelines for Handling, Treatment and Disposal of COVID-19 Biomedical

Waste
In addition to existing BMW Management rules, 2016 and amendments, the following additional
steps need to be followed during management of COVID-19 patients.
 Keep separate dedicated color coded bins (with foot operated lids) in corona isolation
wards & RT PCR laboratory and should be labeled as “COVID-19 Waste”.
 Use double layered bags (using 2 bags) should be used for collection of waste from
COVID-19 isolation wards so as to ensure adequate strength and no-leaks.
 Use dedicated trolley and collection bins and label as “COVID-19 Waste”.

 General solid waste comprising of wrappers of medicines/syringes, fruit peel offs, empty
juice bottles or tetra packs, used water bottles, discarded papers, carton boxes of medicines,
empty bottles of disinfectants, left-over food, disposable food plates etc., should be
collected separately in wet and dry solid waste bags. The wet and dry solid waste bags to
be tied securely in leak-proof bags, sprayed with sodium hypo-chlorite solution and hand
over to waste collector on daily basis.
 Disinfection: The (inner and outer) surface of bags/containers/collection bins/trolleys used
for storage of COVID-19 waste should be disinfected with 1% sodium hypochlorite
solution daily.
 Maintain separate records of waste generated from COVID-19 isolation wards.
 COVID-19 testing laboratory waste: Autoclave viral transport media, plastic vials,
vacutainers, eppendorf tubes, plastic cryovials, pipette tips collect in Red bags.
 PPEs to be used by BMW workers-three layered mask, splash proof aprons/gowns, heavy
duty gloves, gum boots and safety goggles.

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Color coded bags Type of waste disposed

Yellow Triple layered mask,N95 mask, non-
plastic or semi-plastic coverall, disposable head
cove/cap, shoe cover, disposable linen/gown
used masks, tissues and toiletries/ diapers by
COVID-19 patients

Red Goggles, face-shield, splash proof apron,

Plastic Coverall, Hazmat suit, nitrile gloves

White/translucent puncture proof, leak Sharp waste

proof plastic container
White/translucent puncture proof, leak Glassware, metal implants
proof plastic container with blue marking

SEPARATE COVID 19 BINS & DOUBLE BAGS FOR BMW

WITH APPROPRIATE PPE

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Standard operating procedure for biomedical waste

management of COVID-19 waste

Collection and segregation of COVID-19 waste as per guidelines at the point of generation
(Double layered bags and bins with “COVID-19 Waste” label)

The (inner and outer) surface of bags/containers/collection bins/trolleys used for

storage of COVID-19 waste -disinfection with 1% sodium hypochlorite solution

Handing over the collected waste to BMW Worker in designated bins/trolley with
“COVID-19 Waste” label

Transport of COVID-19 Waste to the central storage area

Autoclaving of all COVID waste

Handing over of all COVID waste to the CBWTF ( Passco )

Maintain separate records of waste generated from COVID-19 and autoclave record.

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COVID-19 WASTE SEGRGATION

YELLOW BAG

 Triple layered mask

 N95 mask
 Non-plastic or semi-plastic coverall
 Disposable head cover/cap
 Disposable shoe cover
 Disposable linen/gown
 Used masks, tissues and toiletries/ diapers by COVID-19 patients

RED BAG

 Goggles
 Face-shield
 Splash proof apron
 Plastic Coverall
 Hazmat suit
 Nitrile gloves

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A) COVID -19 Isolation wards / ICU /OPD/ Sample collection centers and
laboratories

 Keep separate color-coded bins/bags /containers in wards and maintain

proper segregation of waste.

 As precaution double layered bags (using 2 bags) should be used for collection of
waste

 Collect and store biomedical waste separately and use dedicated collection bin
labeled as “COVID-19.”

 Maintain separate record of waste generated from COVID-19 isolation wards.

 -Use dedicated trolleys and collection bins in isolation wards

 The inner and outer surface of bins / containers /trolleys used for storage of waste

should be disinfected with 1% sodium hypochlorite solution.

 An extra set of Personal Protective Equipment and Spill management Kit should

be kept ready in case of any emergency.

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6. Standard Precautions to be followed by health care workers while handling dead bodies
of COVID19
1. Hand hygiene.
2. Use of personal protective equipment (e.g., water resistant apron, gloves, masks, eyewear).

3. Safe handling of sharps.

4. Disinfect bag housing dead body; instruments and devices used on the patient.
5. Disinfect linen. Clean and disinfect environmental surfaces.
 Removal of the body from the isolation room or area
 The health worker attending to the dead body should perform hand hygiene, ensure
proper use of PPE (water resistant apron, goggles, N95 mask, gloves).
 All tubes, drains and catheters on the dead body should be removed.
 Any puncture holes or wounds (resulting from removal of catheter, drains,
tubes, or otherwise) should be disinfected with 1% hypochlorite and dressed with
impermeable material.
 Apply caution while handling sharps such as intravenous catheters and other sharp
[Link] should be disposed into a sharps container.
 Plug Oral, nasal orifices of the dead body to prevent leakage of body fluids.
 If the family of the patient wishes to view the body at the time of removal from the
isolation room or area, they may be allowed to do so with the application of Standard
Precautions.
 Place the dead body in leak-proof plastic body bag. The exterior of the body bag
can be decontaminated with 1% hypochlorite. The body bag can be wrapped with a
mortuary sheet or sheet provided by the family members.
 The body will be either handed over to the relatives or taken to mortuary.

 All used/ soiled linen should be handled with standard precautions, put in bio-hazard bag
and the outer surface of the bag disinfected with hypochlorite solution.

 Used equipment should be autoclaved or decontaminated with disinfectant solutions in

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accordance with established infection prevention control practices.

 All medical waste must be handled and disposed of in accordance with Bio-medical waste
management rules.

 The health staff who handled the body will remove personal protective equipment and will
perform hand hygiene.

 Provide counseling to the family members and respect their sentiments.

 Environmental cleaning and disinfection

All surfaces of the isolation area (floors, bed, railings, side tables, IV stand, etc.) should be wiped

with 1% Sodium Hypochlorite solution; allow a contact time of 30 minutes, and then allowed to air

dry.

REFERENCES:

1. CDC guidelines

2. ICMR guidelines

3. WHO guidelines

4. Ministry of health and family welfare

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Infection control and management Training workshop for COVID -19 For All
Medical And Paramedical Staff
As per the instructions of Dean and Officer on special duty (OSD), the Department of
Microbiology organized Infection control and management Training workshop for COVID -19

For All Medical and Paramedical Staff.

Training workshop for the teaching faculty, resident doctors and matron, DNS and ANS
was conducted on 7.4.2020 from 11:00 to 1:00 p.m. Dr. Shiva Iyer, Chief Intensivist, BVMC
shared his experience on COVID-19 management. He resolved queries of faculties during
interactive session of question answer. This was followed by training about infection control and
management by the faculties of Department of Microbiology, Anesthesia and Medicine. The
training was conducted on following topics-
1. Hand hygiene
2. Personal protective equipment
3. Surface cleaning and disinfection
4. Biomedical waste management for COVID-19
5. Sample collection and transport
6. Management of COVID-19
Similar training workshop was conducted for nurses, MPWs and other paramedical
staff from 8.4.2020 to 13.4.2020 in four lecture halls with taking care of social distancing. Total
about 581 nursing staff, 334 MPWs and 93 paramedical staff were present. The training also
included demonstration of donning and doffing of PPE. Training session was conducted in Marathi
for MPWs and other paramedical staff.
This training is conducted regularly in all the departments as a part of NABH monthly training
calendar

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15. DIETARY AND KITCHEN SERVICES

15.1 Hygiene and Infection Control

15.1.1. Food service establishments are frequently identified as places that lead to outbreaks of
food-borne diseases. The need for adequate food hygiene facilities is of paramount
importance. Assuring safe food requires management and control of microbiological,
chemical, and physical hazards.
15.1.2. Staff hygiene/health: Everyone who handles, prepares, processes and distributes food
must understand the principles of basic food hygiene and the need for trained personnel
and catering hygiene.
a. All food handlers should complete a pre-employment health check-up which
includes stool routine examination, and past history of enteric fever.
b. All food handlers with infectious diarrhoea, GI infection, must stop working and
return only after communicable disease personnel certify their fitness. Hair and
nails of all food handlers should be checked weekly and recorded.
c. Routine medical check-up should be done twice in a year.
15.1.3 Inspection: Daily inspection of kitchen and food handling areas is a must for hygiene, and
reports documented.
15.1.4 Kitchen: Cleaning procedures should be done on a regular basis.
15.1.5 Food stores should be generally clean and uncluttered with good access for cleaning.
Shelves should be easy to clean.
15.1.6 Any food capable of supporting microbial growth should be stored either below 8°C or
above 65°C. Cooked-chilled food should be stored below 3°C.
15.1.7 Food trolleys should be used to make transport easier and reduce movement of people.
15.1.8 Trolleys should be cleaned daily or more frequently if contamination occurs.
15.1.9 A cleaning schedule for the kitchen is suggested so as to ensure that hygiene is
maintained.
15.1.10 Storage:
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a. All drying ingredients should be cleaned before they are stored in storage
containers (plastic bins)

b. All green leafy and other vegetables should be stored in the

refrigerator and thoroughly washed in water before usage.

15.1.11Milk should be purchased on a daily basis and stored in the refrigerator at (8° C).

15.1.12Food should be prepared half an hour before service and stored in a bain-marie at a
temperature of 75–100°C.

15.1.13Vegetables like potatoes, onion, other root vegetables, should be stored in plastic trays in
the store room.

15.1.14Other vegetables should be bought at an interval of 2-3 days, as and when there is a
requirement. They should be stored in the refrigerator and washed thoroughly when taken
out for cooking.

15.1.15Ingredients (all the drying ingredients) like rice, broken wheat, pulses should be washed
twice in cold water and then in hot water before cooking.

15.2 Waste Disposal

15.2.1. Waste should be identified and collected in color coded containers.

15.2.2. Left over waste, vegetable peels should be collected in the green container and sent for
disposal thorough municipal authorities.

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Abbreviations

1. HIC: Hospital Infection Control

2. HICC: Hospital Infection Control Committee
3. ICT: Infection Control Team
4. ICN: Infection Control Nurse
5. ICD: Infection Control Doctor
6. HCAI: Health care Associated Infections
7. HAI: Hospital Acquired Infections
8. VAE: Ventilator Associated Events
9. VAP: Ventilator Associated Pneumonia
10. CLABSI: Central Line Associated Blood Stream Infections
11. CAUTI: Catheter Associated Urinary Tract Infections
12. SSI: Surgical Site Infections
13. NSI: Needle Stick Injury
14. BMW: Biomedical Waste
15. PPE: Personal Protective Equipment’s
16. HCW: Health Care Worker
17. BICU: Burn ICU

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References
1. [Link]

2. [Link]/Images/PDF/HIC_Guidebook.

3. [Link]/guidelines/Hospital%20Infection%20control%20guidelines-2

4. [Link]/publications/docs/practical_guidelines_infection_control

5. [Link]/writereaddata/mainlinkfile/File571

6. CDC guidelines for PEP: 2013

7. [Link]/biomedical/pdf/BMW_Rules_2016.pd

8. [Link]/.../bio-medical-waste-management-rules-2016

9. CLSI 2022 -M100, 32nd ed. January 2022.

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Smt Kashibai Navale Medical College & General Hospital, PUNE Annexure: 1

CAUTI surveillance form

Patient OPD No : Patient IPD No

Patient Name :
Age/Sex Ward : DOA :
Event Type: UTI Date of Event:
Post-procedure UTI: Yes No Date of Procedure:

MDRO Infection Surveillance:

□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO

Risk Factors
Urinary Catheter status:
□ In place – Urinary catheter in □ Removed – Urinary catheter in □ Neither – Not catheter
place > 2 days on the date of place > 2 days but removed the day associated –Neither in place nor event
before the date of event removed
Location of Device Insertion: Date of Device Insertion:
Event Details
Specific event
□ Symptomatic UTI (SUTI) □ Asym ptomatic Bacterem ic UTI (ABUTI) Urinary system infection (USI)
Specify Criteria Used: (check all that apply) Signs & Symptoms
Any Patient ≤ 1 ye ar o ld Laboratory & Diagnostic Testing
□ Fever □ Urgency □ Fever □ 1 positive culture with no more
□ Frequency □ Dysuria □ Hypothermia than 2 species of organisms, at least one of
which is a bacterium of ≥
105 CFU/ml
□ Pain or
□ Abscess □ Apnea □ Organism(s) identified from fluid or
tenderness
tissue from affected site (excluding Urine)
□ Acute pain, swelling, or tenderness of
□ Bradycardia
Testes, epididymis, or prostate
□ Suprapubic tenderness □ Lethargy □ Organism(s) identified from blood
□ Costovertebral angle pain or tenderness □ Vomiting specimen
□ Purulent drainage from affected site □ Imaging test evidence of infection
□ Other evidence of infection found on
invasive procedure, gross anatomic
exam, or histopathologic exam

Secondary Bloodstream Infection: Yes No

Died: Yes No UTI Contributed to Death: Yes No
Discharge Date: Pathogens Identified: Yes No

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Organism isolated:-

Antibiotic used:-

DAY 1
DAY 2
DAY3
DAY4
DAY5

Remark

Sign of ICN Sign of ICO Sign of Consultant

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Surveillance form for CLABSI

Patient OPD No : Patient IPD No :
Patient Name : Ward :
Age &Sex : DOA :
Event Type: BSI Date of Event:
Post-procedure BSI: Yes No Date of Procedure:
MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the
MDRO
Risk Factors
Location of Device Insertion:
If ICU/Other locations, Central line: Yes No

Date of Device Insertion: /_

/

Event Details
Specific Event: Laboratory-confirmed
Specify Criteria Used:

Signs & Symptoms (check all that apply) Laboratory (check one)
□ Recognized pathogen(s) identified from one or
more blood specimens

□ Common commensal identified from ≥ 2 blood

Any Patient ≤ 1 ye ar o ld specimens
□ Fever □ Fever
□ Chills □ Hypothermia
□ Hypotension □ Apnea
□ Bradycardia

Died: Yes No BSI Contributed to Death: Yes No

Discharge Date: Pathogens Identified: Yes No

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Organism isolated:-

Antibiotic used:-

DAY 1
DAY 2
DAY3
DAY4
DAY5

Remark

Sign of ICN Sign of ICO Sign of Consultant

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Annexure - I
NSI/splash reporting form

Sharps Injury/ Blood-Body Fluid Exposure Reporting Form- Action Taken Trail
Sharps/ Body Fluid Exposure Incident No: Incident Register Sr. No:
Name of the Injured / Exposed Person:
Date & Time of Incident: Date & Time of Reporting:
Job-Title: Department/ Unit:
Place of Injury:
Sharps Injury/ Blood or Body Fluid Exposure
Job-Title and Name of person filling up the form:

To be filled in by CMO
Date, Time and Details of First Aid given:

Name of CMO Sign of CMO Date & Time

To be filled in by ICN/ ICD

Whether Injured/ Exposed person had undergone training on such incident?  Yes /  No
Whether Injured/ Exposed person had undergone vaccination?  Yes /  No
If yes, give details:

To be filled as narrated by person involved in the incident

Exposure Details:
Blood/ Blood Products  Visibly Bloody Solution  Body Fluid (Visibly Bloody or Not)

If Body Fluid:
 Cerebrospinal/ Amniotic/ Pericardial/ Pleural/ Synovial/ Peritoneal/ Semen-
Vaginal/ Urine/ Sputum/ Saliva/ Faces-Stool/ Other:
/Unknown
Body Site of Exposure:
Hand-Finger/ Arm/ Leg/ Face/ Nose/ Mouth/ Eye/ Other:
If Percutaneous Exposure-Depth of Injury:
Superficial (scratch, no blood)/ Moderate (skin penetration with blood)/ Deep (muscular
penetration)
Whether Blood was visible on the device before exposure?
Yes/ No/ Unsure or Unknown

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If Mucous membrane or Skin exposure- Approximate volume of material involved:

Small (few drops)/ Large (major blood splash)

If Skin Exposure- was skin intact before exposure:

Yes/ No/ Unsure or Unknown

Source Information
Was the source individual identified:Yes/ No/ Unknown or Unsure
Provide serostatus of source individual for following’:
HIV Antibody: Positive/ Negative/ Refused/ Unknown HCV
Antibody: Positive/ Negative/ Refused/ Unknown HbsAg:
Positive/ Negative/ Refused/ Unknown
If known, when was the serostatus of source individual determined:
Known at the time of exposure/  Determined by testing soon after exposure
Percutaneous Injury Circumstances
What Device or Item caused the injury:
Hollow Bore Needles
Hypodermic/ Prefilled Cartridge/ Winged steel/ IV stylet/ Phlebotomy/ Spinal or
Epidural/ Bone-Marrow/ Biopsy/ Huber/ Other: specify
Suture Needle:Yes/ No
Glass:
Capillary/ Pipette/ Slide/ Specimen/ Tube/ Vacuum/ Other specify:
Other Sharp Objects:
Bone-Tooth chip/ Bone cutter/ Electrocautery/ Bur/ Explorer/ Extraction forceps/
Elevator/ Cutting Blade/ Lancet/ Pin/ Razor/ Retractor/ Rod/ Root Canal File/
Scaler or Curette/ Scalpel blade/ Scissors/ Tenaculum/ Trocar/ Wire/ Other, specify:
Any other
Mucous Device, Specify:
membrane Exposure Circumstances
What PPE was donned while handling the patient?
Gloves/ Mask/ Goggles/ Eyeglasses/ Face- shield/ Gown/ None
Activity/ Event when exposure occurred:

procedure/

Details of post exposure prophylaxis given:

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Surveillance form for SSI

Patient OPD No : Patient IPD :
Patient Name : :
DOA
Age &Sex : Ward :
Event Type: SSI Date of Event:
Date of Procedure: Outpatient Procedure: Yes No
MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO
Event Details
Specific Event:
□ Superficial Incisional Primary (SIP) □ Deep Incisional Primary (DIP)
□ Superficial Incisional Secondary (SIS) □ Deep Incisional Secondary (DIS)
□Organ/Space (specify site):
Infection present at the time of surgery (PATOS): □ Yes □ No
Specify Criteria Used (check all that apply):
Signs & Symptoms Laboratory
□ Drainage or material† □ Sinus tract □ Organism(s) identified
□ Culture or non-culture based testing not performed
□ Pain or tenderness □ Hypothermia
□ Organism(s) identified from blood specimen
□ Swelling or inflammation □ Apnea
□ Erythema or redness □ Bradycardia □ Organism(s) identified from ≥ 2
□ Heat □ Lethargy periprosthetic specimens
□ Fever □ Cough □ Other positive laboratory tests†
□ Incision deliberately
□ Nausea □ Imaging test evidence of infection
opened/drained
□ Wound spontaneously
□ Vomiting
dehisces
□ Abscess □ Dysuria Clinical Diagnosis
□ Other evidence of infection found on invasive □ Physician diagnosis of this event type procedure,
gross anatomic exam, or □ Physician institutes appropriate histopathologic exam †
antimicrobial therapy
□ Other signs & symptoms

Detected: □A (During admission) □P (Post-discharge surveillance)

□RF (Readmission to facility where procedure performed)
□ RO (Readmission to facility other than where procedure was performed)
SSI Contributed to Death:Yes/No
Secondary Bloodstream Infection: Yes No Died: Yes No
Discharge Date: Pathogens Identified: Yes No

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Organism isolated:-

Antibiotic used:-

DAY 1
DAY 2
DAY3
DAY4
DAY5

Remark

Sign of ICN Sign of ICO Sign of Consultant

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Surveillance form for VAE

Patient OPD No : Patient IPD :
Patient Name : DOA: :
Age &Sex : Ward :
Event Type: SSI Date of Event:
Date of Procedure: Outpatient Procedure: Yes No
MDRO Infection Surveillance:
□ Yes, this infection’s pathogen & location are in-plan for Infection Surveillance in the MDRO
□ No, this infection’s pathogen & location are not in-plan for Infection Surveillance in the MDRO
Event Details
Specific Event: □ VAC □ IVAC □PVAP
Specify Criteria Used:
ST EP 1: V AC ( ≥ 1 REQUIRED)
□Daily min FiO2 increase ≥ 0.20 (20 points) for ≥ 2 days† OR □Daily min PEEP increase ≥ 3 cm H2O for ≥ 2days†
†
after 2+ days of stable or decreasing daily minimum values.

STEP 2: IVAC
□Temperature > 38°C or < 36° OR□W hite blood cell count ≥ 12,000 or ≤ 4,000 cells/mm 3
AND
□A new antimicrobial agent(s) is started, and is continued for ≥ 4 days
STEP 3: PVAP
□Criterion #1:Positive culture of one of the following specimens, meeting quantitative or semi-quantitative
thresholds as outlined in protocol,‡without requirement for purulent respiratory secretions:
□ Endotracheal aspirate □Lung tissue
□ Bronchoalveolar lavage □ Protected specimen brush
OR
□Criterion #2: Purulent respiratory secretions‡ (defined in the protocol) plus organism(s) identified from one of the
following specimens:‡
□ Sputum □ Lung tissue
□ Endotracheal aspirate □Protected specimen brush
□ Bronchoalveolar lavage
OR
□Criterion #3: One of the following positive tests (as outlined in the protocol): ‡
□ Organism(s) identified from
□ Diagnostic test for Legionella species
pleural fluid
□ Lung histopathology □ Diagnostic test for selected viral pathogens
collected after 2 days of mechanical ventilation and within +/- 2 days of onset of increase in FiO2 or PEEP.
Secondary Bloodstream Infection: Yes No
Discharge Date: VAE Contributed to Death : Yes / No

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Organism isolated:-

Antibiotic used:-

DAY 1
DAY 2
DAY3
DAY4
DAY5

Remark

Sign of ICN Sign of ICO Sign of Consultant

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Annexure - I

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Summary of Strategies to prevent Catheter Associated Urinay Tract Infections

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BEDSORE CARE

1. Change position of patient regularly (every 2 hourly)

2. Use of air bed/water bed
3. Patient should be lying on their side at a 30 degree angle.
4. Avoid sliding the patient over a surface to prevent friction.
5. Skin should be washed with water & soap and completely dried.
6. High protein and vitamin diet should be provided
7. Regular dressing with povidone-iodine or normal saline to be done
8. Hydrocolloid/ gel dressing can be used if patient can afford.
9. Surgical debridement and removal of necrotic tissue for grade 3 and 4.
10. Slough removal with hydrogen peroxide if present
BEDSORE GRADING:
STAGE I Skin discolouration/redness/ Change position every 2hourly
non blanchable erythema of and use of air/water bed with the
intact skin application of silver sulfadiazine
cream or local antiseptics

STAGE 2 Partial thickness skin loss Stage I treatment plus regular

with exposed dermis dressing with povidone- iodine
STAGE 3 Full thickness skin loss Stage 2 treatment plus wound
debridement and start of
antibiotics (parenteral)

STAGE 4 Full thickness skin and Regular dressing plus surgical

tissue management with Vacuum
loss assisted closure (VAC) with
antibiotic cover.
UNSTAGEABLE Obscured full thickness skin
PRESSURE INJURY and tissue loss

DEEP PRESSURE Persistent non blanchable

INJURY deep red discolouration

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