This document outlines the policies and procedures for infection control and prevention in a hospital setting. It discusses establishing an infection control team to develop, implement, and monitor infection control programs and training. The roles and responsibilities of different departments in preventing infection transmission are defined. Standard precautions like hand hygiene, use of personal protective equipment, safe disposal of sharps and waste, and cleaning/disinfection of equipment and environment are emphasized. Surveillance activities to monitor infection rates and identify outbreaks are also summarized.

2.  Every policy and procedure , contributing in
hospital infection control should be
documented.

3.  INFECTION • Definition: Injurious contamination
of body or parts of the body by bacteria,
viruses, fungi, protozoa and rickettsia or by the
toxin that they may produce
 The risk of infection is always present.
 Patient may acquire infection before admission
to the hospital i.e. Community acquired
infection.
 Patient may get infected inside the hospital i.e.
Nosocomial infection.:

4. It includes infections :
• infections that appear more than 48 hours
after admission,
• those acquired in the hospital but appear
after discharge ,also occupational infections
among staff.
• not present nor incubating at admission

5.  Prevention of nosocomial infection -
responsibility of all individuals and services
provided by healthcare setting.
 To practice good asepsis, one should
always know: what is dirty, what is clean,
what is sterile and keep them separate.
 Hospital policies & procedures are applied
to prevent spread of infection in hospital.

6. • A comprehensive, effective and supported
program is essential for reducing infection risk
and increasing hospital safety.
• It should include surveillance, preventive
activities and staff training

7.  coordinates implementation of all infection
prevention and control activities. The team is
responsible for day-to-day functioning of
infection control program.
 Periodical training of all category staff about
Infection Control Protocols and Policies.
 Establish standard operational procedures for
Infection Control practices.
 Introduce new policies and protocols on the
method of disinfection and sterilization.

8.  Maintain and implement biomedical waste
management protocols.
 Regular monitoring of water supply system.
 Supervision of biomedical waste
management activities
 Team should have authority to manage an
effective control program.
 Team should have a direct reporting with
senior administration

9.  Multidisciplinary committee responsible for
monitoring program policies implementation and
recommend corrective actions. It includes :
 Hospital Incharge
 Pathologist
 R.O.- Scientist - 4
 Nurse Incharge
 . They meet monthly. It establishes standards for
patient care, it reviews and assesses IC reports
and identifies areas of intervention.

10.  Hospital have a nosocomial infection
prevention manual compiling recommended
instructions and practices for patient care.
 This manual should be developed and
updated in a timely manner by the infection
control team. It should be revised and
updated on annual basis
 It is to be reviewed and accepted by infection
control committee.

11.  Role of every hospital department and
service units is identified, documented as
manuals kept in accessible place
 . Job description of every hospital staff;
defining details of his duties is discussed.
Infection control precautions should be part
of the routine work and stressed for that.

12.  Physicians have unique responsibilities for
the prevention and control of hospital
infections:
- By providing direct patient care using
practices which minimize infection e.g. using
disinfected equipments ( thermometer etc.)
- By following appropriate practice of
hygiene (e.g. handwashing, isolation)

13.  Supporting the infection control team.
 Protecting their own patients from other
infected patients and from hospital staff who
may be infected
 Complying with the practices approved by the
Infection Control Committee
 Obtaining appropriate microbiological
specimens when an infection is present or
suspected
 Notifying cases of hospital-acquired infection to
the team, as well as the admission of infected
patients

14.  The hospital pharmacist is responsible for:
Obtaining, storing and distributing pharmaceutical
preparations using practices which limit
transmission of infectious agents to patients .
 Before initiating the dispensing of medicines, staff
must wash their hands properly with soap and
water.
 Dispensing area must be free from dust and germs.
 Dispensing vials should be cleaned .
 Entry of unauthorized staff should be restricted.

15.  Implementation of patient care practices for
infection control is the role of the nursing staff.
The senior nursing administrator is responsible
for:
 Participating in the Infection Control
Committee
 Promoting the development and improvement
of nursing techniques, and ongoing review of
aseptic nursing policies, with approval by the
Infection Control Committee

16.  Standard Precautions – Should be applied
for ALL patients
 Transmission-based Precautions
-Contact
-Droplet
-Airborne
 Transmission-based precautions are often
used empirically

17. 1. Hand hygiene.
2. Personnel Protective Equipments
3. Safe Handling and Disposal of Sharps
4. Follow needle stick injury protocol
5. Safe Handling and Disposal of Wastes
6. Managing Blood and Body Fluids
7. Disinfection of the Equipments
8. Environmental Disinfection
9. Immunization
10. Isolation

18.  Jjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjjj  Gloves – protect hands
 Gowns/aprons – protect
skin and/or clothing
 Masks and respirators–
protect mouth/nose –
Respirators /N95 mask –
protect respiratory tract
from airborne infectious
agents
 Goggles – protect eyes
 Face shields – protect
face, mouth, nose

19. Always wear gloves when …
 Direct contact with body fluids is anticipated
(nosebleeds, bleeding abrasions, etc.)•
 Handling clothes soiled by urine, faeces, vomit
or blood, Diapering children
 One time use.
 If gloves not immediately available, use barrier
such as paper towels.
 When removing, peel off hands and roll glove
outside in
 Wash hands after removing gloves.
 Not a substitute for hand washing,.

20.  Use carefully – don’t spread contamination
 Remove and discard carefully, either at the
doorway or immediately outside patient
room; remove respirator/ Masks outside
room
 Immediately perform hand hygiene

21.  “Hand washing is the single most
important means of preventing the
spread of infection” When?
 Before and after duty
 Before each invasive procedures.
 Before and after using gloves
 After touching blood or body fluid
 Before and after touching patients
 Before touching invasive devices
 After toileting , urination
 Hand Rub
 In Chlorhexidine /alcohol 70% hand rub
in all areas
 When?
› Before touching invasive devices
› After touching the patient
› Before handling the patient

22.  PATIENT ACCOMMODATION
 Separate wards, areas or establish rooms for infectious patients
where isolation facilities do not exist.
 Separate patients by at least 1 meter
 Isolate patients with droplet or airborne spread diseases from
other patients.
 Only patients with epidemiological and clinical information
suggestive of a similar diagnosis should share room
 RESPIRATORY HYGIENE AND COUGH ETIQUETTE- Source
control measures ( cover mouth to prevent dissemination of
infectious droplets)Spatial separation (> 1 meter) of persons
with acute febrile respiratory symptoms.

23.  Needle stick and sharp injuries carry the risk of
blood born infections e.g. AIDS, HCV,HBV and
others.
 Sharp injuries must be reported and notified so that
treatment & post exposure prophylaxis can
possible.
 Reusable sharps must be handled with care to
avoid injury during procedure.
 Never recap needles, if necessary use one hand
scoop method.

24.  Dispose used needles and other sharps
immediately in puncture resistant boxes
(sharp container ).
 Sharp Containers: must be easily accessible
and at eye level, must not be overfilled,
labeled or color coded.

25.  Cover spills of blood or body fluids with 1%
of freshly prepared sodium hypochlorite for
10 minutes.
 Then mop dry.
 A second decontamination may be done if
required.
 Wash the area with detergent and water.
 Gloves must be worn during cleanup and
decontamination procedures

26.  Floor cleaning – atleast twice a day. Detergent and water for
first time. Rest of cleaning can be done with ecoshield moping
,depending upon cleanliness status of hospital.
 The walls are to be washed with a brush, using detergent and
water once a week
 High dusting is to be done with a wet mop
 Fans and lights are to be cleaned with soap and water once a
month.
 All work surfaces are to be disinfected by wiping with Ecoshield
and then cleaned with detergent and water twice a day.
 Cupboards, shelves, beds, lockers, IV stands, stools and other
fixtures are to be cleaned with detergent and water once a
week.
 Curtains are to be changed once a month or whenever soiled.

27. B.P Apparatus &
Stethoscope
Clean properly with sprit Daily
B.P Apparatus- Cuff
Wash thoroughly with Soap and
water and dry it properly
Wash and dry the B.P cuff if
used for an infected patient
after the discharge.
Weekly
Clean if used for an infected
patient after the discharge.
Digital Thermometer
Clean properly with
Sprit/Ethanol 70% Daily - After the use of every
patient
Glucometer Clean properly with sprit Daily
Dressing Trolley
Clean with Super shine
Keep the Store solutions in their
original bottles. Avoid refilling
to smaller bottles.
Daily
Steel Tray Wash with soap and water Daily

28. Measuring Tape & Torch Clean properly with spirit Daily & SOS
Refrigerator Defrost and Wash with soap and
water
Weekly
Weighing Machine Clean with soap and water Daily
Electronic Weighing
Machine
Clean with Super shine
Daily
Telephone Clean with sprit Daily
Patient Trolley & Wheel Chairs Clean with soap & water Daily
E.C.G. & Transducer Cables
Clean with spirit daily.
.
After each use

29. Bedpan, Measuring jar, Commode Clean properly with soap and water.
Immerse in 1% antiseptic solution for 45
mts.
Solution to be changed every week.
Urinal and Sputum Mug Disposable

30.  :All used linen shall be considered contaminated
and shall be bagged at the location of use before
being taken to laundry.
 Soiled linen:
› shall be collected in the designated container and taken to
laundry
› Designated container shall be covered during transport of
soiled linen.
› Cloth liners /containers shall be washed daily
› shall be handled as little as possible and with minimum
agitation, in order to prevent gross microbial
contamination of the air and of persons

31. › handling the linen
› shall be bagged at the location of use, l not be
sorted in-patient care areas.
› Bags containing soiled linen shall be tied before
being taken to laundry in order prevent spillage
 Dirty utility room shall be swept daily and
washed /Mopped with a
detergent/Disinfectant weekly and whenever
visibly soile

32.  food is prepared and served into covered
containers and set into trays in the main kitchen
and then sent to wards. This activity is
supervised by trained personnel.
 Hot and cold food is transported in such a
manner that appropriate temperatures will be
maintained during transportation.
 Food returned to the kitchen is discarded into
black bags. Mouths of bags are tied before
disposal.
 .

33.  no contamination of cooked food from raw
food, no interchange of personnel working
on raw food and those on cooked food.
 Personnel handling and serving the food are
trained to observe universal precautions to
protect themselves

34.  Hand washing should cover exposed portions of
arms and hands with special attention to
fingernails and areas between fingers.
 Clothing should be free from obvious dirt and
food spills.
 Hair nets should be used while on duty
 Food should not be consumed in preparation or
serving areas.
 Utensils should be used to handle food

35.  Steps in surveillance
 Definition of the event
 Systematic collection of data
 Summarization of data
 Analysis and interpretation
 Evaluation and corrective and preventive
ction

36.  Reducing infection rate within the hospital
 Identifying outbreaks
 Satisfaction of patients and staff

37.  Sources of data:
 Daily lab and radiology department reports
 Medical records of febrile patients, isolated
patients
 Daily interview with nurses and patients
 Periodic review of medical records of staff

38.  ACTIVE SURVEILLANCE:

 High risk areas of the hospital are identified as:
 Food handlers
 Drinking water
 Toilets and bathrooms


 Food handlers

 Screening of food handlers is done biannually. Samples include nasal swabs and stool samples.
 Records to be maintained by Kitchen In charge.

 Drinking Water

 Bacteriological surveillance to be done monthly by the concerned government authority. Records maintained by
Pathology Department.


 Toilets and Bathrooms
 Toilets are cleaned with a brush using a detergent twice a day (in the morning and evening). Disinfection and
stain removal solution may be used.
 Wash basins are to be cleaned every morning

39. The surveillance activity includes:
 monitoring of compliance with hand hygiene guidelines
 monitoring of effectiveness of house keeping service on a regular basis using a checklist.
 Report regarding HAI rates is informed to all the departments’ monthly wise.
DDPRCRI shall identify all Notifiable diseases and ensures that this is sent at the specified
frequency and in format as required by statutory authorities.
 Acute diarrheal disease
 Acute Dysentery – Amoebic /Bacillary
 Acute flaccid paralysis
 Cholera or Cholera- like disease
 Diphtheria

Encephalitis
 Plague
 Hepatitis-viral
 Leptospirosis

40.  Malaria
 Measles
 Meningitis – Pyogenic/ Prescribed disinfectant
 Rabies
 Tetanus
 Enteric fever
 Pertussis
 Dengue
 Chickenpox
 Chikungunya
 H1N1(Swine flu)