HIC Manual (2015-2016) PDF

INFECTION CONTROL MANUAL
HCG MULTISPECIALTY HOSPITAL

AHMEDABAD
TABLE OF CONTENTS
Section 1 - Introduction ………………………………………………………………………………………….. 01

Section 2 – Vision & Mission …………………………………………………………………………………… 02
Section 3 – Scope of Services ………………………………………………………………………………….. 03
Section 4 – Organogram …………………………………………………………………………………………. 04
Section 5 – Staffing …………………………………………………………………………………………………. 04
Section 6 – Job Descriptions ……………………………………………………………………………………. 05
Section 7 – Key Result Areas …………………………………………………………………………………… 09
Section 8 – Key Performance Indicators ………………………………………………………………….. 09
Section 9 – Budget Considerations………………………………………………………………………….. 10
Section 10 – Policies & Procedures …………………………………………………………………………. 11
Section 11 – Trainings …………………………………………………………………………………………….. 138
Section 12 – Forms & Formats ………………………………………………………………………………… 139
Section 13 – Quality Indicators ……………………………………………………………………………….. 140
Section 14 – Annexure ……………………………………………………………………………………………. 141
HCG MULTISPECIALTY HOSPITAL, AHMEDABAD
Issue No. :- 04
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Issue Date :- 30th November 2015
Rev. No. :- 03
HCGMS/HIC/01
Rev. date: - 30th October 2015
SECTION 1 - INTRODUCTION
HCG Hospital Infection prevention and control department is committed to prevention and safety of all
patients, Visitors and health care workers
The Core functions and activities carried out by IC department are as follow:
1. Education, training and feedback regarding Infection prevention and control to Patients, Visitors and
health care workers.
2. a. Induction of staff
b. Daily rounds
c. Biomedical waste segregation and monitoring
d. Monitoring, recording and PEP for NSI and spillage
e. Immunization
f. Local Epidemiology
g. Isolation requirement
h. CSSD monitoring
i. Active and Passive surveillance
j. Ambulance monitoring.
k. Six monthly Evaluation of all activities.
l. Generation of monthly HAI data.
m. Implementation of all the above.
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Prepared by: Approved by: Issued by:
Infection Control Officer CEO & Medical Director Sr. Manager - Quality
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SECTION 2 – VISION & MISSION
VISION STATEMENT:
Department of Infection Prevention and control works in a direction of minimizing HAI, targeting zero HAI.
Preparedness of all Health care workers (HCW) in handling all situations related to Infection prevention.
Confidence amongst HCW’s, patients and visitors on Infection control safety.
MISSION STATEMENT:
It is the Mission of the Infection prevention and control department to work on the safety of :
a. Safety of Health care workers.

b. Safety of Patients
c. Safety of Visitors.
To provide a safe and tested environment for clinicians and surgeons to perform their day to day activity
with confidence related to Infection Control.
Current education of Infection prevention and control to all staff which makes a big team with involvement
of everybody as Infection prevention is everybody’s business.
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SECTION 3 – SCOPE OF SERVICES
Scope of Services:
1. Infection prevention and control program
2. Prevention of HAI. (Hospital acquired Infection)
3. Safety of Patients, HCW’s and Visitors.
4. Active and Passive surveillance
5. Training, education, Feedback, Evaluation and further planning based on evaluation.
6. Regular monthly IC meetings to meet current requirements with CAPA.
7. Bridge between management and staff for IC requirements.
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SECTION 4 – ORGANOGRAM
CEO / MD
Sr. Manager - Infection Control

Nursing Officer
Technical
Administrative
Reporting
Reporting
Infection Control Nurse

(NUR/ICN/02)
SECTION 5 – STAFFING
Department’s staff – No. of staff, Designation, Shifts:
1. Infection Control Nurse ( One staff : Full time)
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SECTION 6 – JOB DESCRIPTIONS
Position: INFECTION CONTROL NURSE REMARKS
Reporting To: Infection control officer ,
Head of Nursing Department
Qualification: Nurse must hold a BSC/MSC degree
Minimum Respective nurse must carry experience, trained in infection courses

Experience:
Pay Band Skills:
Competencies  Clinical Supervisor / Investigator / Coordinator

 Education
 Research
 Nursing care skills( in all emergency cases)
 Administrative skills
 Computer skills
 Soft communication skills
Job Description: Clinical Function
 Nursing care is a direct service, which includes various components

needed to maintain or restore individual’s optimum health status.
 Assessing and reporting physiological, pathological, and
psychological, signs symptoms of the patient.
 Nursing care starts from entry to exit: (from admission to discharge)
 ICN supervises and advises on the already established protocols for
infection prevention
 ICN along with the infection control team traces down the source of an
organism which has proliferated into an infection
 ICN coordinates with the various departments in the hospital as well as
the ICC within and outside, so as to get the best information and
thereby helping the staffs to work smoothly
 Observes changes in-patient's condition and records, takes necessary
action and reports to the concerned authority.
 Accompanies patients while transferring to other department or
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transporting for any purpose.

 Giving psychological support to the patient.
 Liaise closely with the hospital microbiology laboratory for scrutiny of
inpatients investigation reports to detect pathogenesis.
 Correlates the pathogenic organisms to the respected areas in the
hospital.
 Collects and records data daily the number and time of infections etc
using the established system and procedures.
 Examines the medical records of the concerned patient, right from
the time of admission. Doubts are cleared by checking with the
nurses, doctors and patients accordingly and documenting it.
 Interpret microbiology reports to relevant nursing staff.
 Compiling the data in the logbook daily while on rounds and also a
monthly report of statistical data to the ICC, which is neatly tabulated.
 Supervise and advice on isolation techniques generally and in specific
clinical situation.
 Provide clinical advice and support to nurses, health care workers and
non-clinical personnel on infection control issues.
 Establishes a follow up surveillance of discharged patients.
 Reviews all infection data with chairman of ICC.
 Identify potential infection hazards and suggest appropriate remedial
action to relevant personnel e.g. use of sharps, appropriate use of
gloves, footwear etc.
 Maintains records of needle stick injuries and post exposure
prophylaxis.
 Point surveillance and spot surveillance.
Non-clinical Function
 Participate in informal and formal teaching programs for nurses and

other appropriate staffs.
 Keep abreast with recent advances by reading relevant literature and
attending appropriate courses, seminars, workshops, meetings, and
exhibitions.
 Participate in staff induction program as required.
 Provide advice and information in staff undertaking audit project.
 Provide training programs for all staff on infection control issues.
Managerial / Supervisory/Administration Responsibilities
 Assist Nurse Administrator in unit management.

 Supervise nursing assistants, DPCA students, and hospital attendants
and provide appropriate education and guidance.
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 Helps in the orientation of new staff.

 Teaches and guide junior nurses and student nurses.
Non-Core Areas
 This job description is not exhaustive & the post holder maybe
required to undertake additional duties as the post develops, as
decided by the Chief Nursing Officer and the deputies.
 It is not only the job of the ICN to talk or practice Infection Control,
but the duty of each and every person in the hospital and particularly
the ones who are in close care with patients, to imbibe the infection
control policies / protocols. This will definitely make the hospital
within and outside healthier and happier place to work.
Key Area Infection Control Nurse should be aware about :
Result:
 Infection control indicators.
 Patient’s right and responsibilities.
 Their own benefits from hospital side/management side.
 Employee’s rights and responsibilities.
 Some of the new designation assigned to the staff viz. Accreditation
coordinator, Safety officer, RSO, ICN, Quality team and department.
 Medical audit briefing.
 Emergency exit location.
 Hierarchy of the hospital.
 Credentials and privileging process of medical Professional.
 Should take care about safety aspects of patients and staff.
Key  Needle stick injuries
Performance  Training
 Meeting
Indicators:
 Infection control indicators
Training: All training held by the organization related to policy, protocols and codes.
General: Departmental training
Departmental:  ACLS
 BLS
 Infection control and its prevention
 Inventory management
 Triage and its protocol
 MLC and its importance
 Antibiotic policy
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 Documentations
 Medication management( error, narcotics)
 CSSD and its development
 All Biomedical equipments
Appraisal  Attendance and absenteeism
Criteria:  Training
 Consultant and patient/ relative feedback
 Overall performance/ development in the academic year
Succession  Respective nurse must carry experience, trained in infection courses
Planning:  Administrative skills
 Computer skills
 Clinical skills
SECTION 7 – KEY RESULT AREAS
Please refer Section – 05 for Key Result Areas
SECTION 8 – KEY PERFORMANCE INDICATORS
Please refer Section – 05 for Key Result Areas
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SECTION 9 – BUDGET
The particulars considered for annual HIC Budget is listed below:
HIC BUDGET – HCG MULTI SPECIALTY HOSPITAL

Sr. No. PARTICULARS
A Training and Education
1. Leaflet and Literature
2. CME's and Workshops
B Disinfectants
3. Antimicrobial Solutions
4. Disinfectants for Terminal Cleaning
C CSSD
5. Consumable for steam sterilization
6. Consumable for ETO sterilization
7. Electricity consumed for Steam Sterilizer
8. Electricity consumed for ETO Sterilizer
9. Pharmacy items
D Miscellaneous
10. Staff Immunization
11. Spillage Kits
12. Medication for post exposure prophylaxis
13. Surveillances
14. Bio-medical Waste Management
15. Stationery
GRAND TOTAL
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SECTION 10 – POLICIES & PROCEDURES
INFECTION CONTROL PROGRAMME

A. Purpose:
A.1 To maintain and monitor safety of Patients and Healthcare workers
A.2 To maintain standards in infection control measures and minimize hospital acquired infections in patients,
staff and visitors.
A.3 To define policy and procedure regarding prevention of nosocomial infections in the hospital.
B. Scope:
B.1 All patients undergoing treatment at HCG Multispecialty Hospitals and the staff working at HCG
Multispecialty Hospitals
C. Responsibility for implementation
C.1. Responsibility of overall implementation of this policy is with all members of administration, medical,
nursing, technical, paramedical and housekeeping staff at HCG Multispecialty Hospitals under
supervision and monitoring of the Infection Control Committee.
C.2. Infection control team is responsible for the day to day monitoring program.
C.3. All HODs are responsible for the monitoring and educating staff of their respective department
about hospital infection control practices with coordination of infection control team.
C.4. Medical Record Department is responsible for the regular reporting of Notifiable Diseases (Cross
Reference) to the Government authorities.
C.5. Hospital management is responsible for the providing regular resources to committee as well as to
the staff.
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D. Infection Control Policy

D.1 The hospital recognizes the control of hospital acquired infections as an important issue and is
committed to fulfilling its responsibility by ensuring that proper safeguards are instituted to identify
and prevent Healthcare Associated Infection (HAI).
D.2 Important components of the policy are:
D.2.1 Monitoring of hospital acquired infections
D.2.2 Microbiological surveillance
D.2.3 Investigations and control of outbreaks, if any
D.2.4 Monitoring of antibiotic policy and antimicrobial resistance
D.3 Providing facilities and resources to the hospital staff to maintain good infection control practices.
D.4 Conducting on-going educational/training program at Induction for all cadres of hospital staff
D.5 Making provisions for staff health activities
D.6 Having a written document (infection control manual) outlining the various infection control policies
and procedures and periodically updating it.
D.7 Supervise the work of infection control team.
E. Hospital Infection Control Committee

E.1 Objective: To minimize the risk of infection to patient, staff and visitors
E.2 Terms of reference
E.2.1 Oversee and direct all Infection Prevention and Control activities within the Hospital
and provide the management with relevant information and advice
E.2.2 Review infection surveillance data, monitor performance and make recommendations
for further actions
E.2.3 Introduce, maintain and approve infection prevention and control policies and
guidelines that promote a quality patient experience
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E.2.4 Advise the management on its statutory requirements in relation to Infection

Prevention and Control and the sterilization of medical and surgical equipment
E.2.5 Ensure that training and supervision systems are in place for all staff and contractors
working within the hospital and that those systems are regularly monitored.
E.2.6 Document and issue infection control manual including policies
E.2.7 Periodically educate the healthcare workers of the institution on infection control
policies and protocol
E.2.8 Develop and implement policies for Outbreak control
E.2.9 Develop biomedical waste handling and treatment plans in compliance to the state rules and
regulations.
E.2.10 Ensure all other compliances to regulatory requirements
E.3 Frequency of Committee: Monthly

E.4 Member of Infection Control Committee:
Sr. No. Members Designation
1 Clinician Chairperson
2 Clinician Member secretary
3 CEO & MD Member
4 Consultant Microbiologist/ICO Member
5 Head - Nursing Services Member
6 Clinician Member
7 Clinician Member
8 Clinician Member
9 Deputy Medical Administrator Member
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10 ICU – Registrar Member
11 Centre Manager Member
12 Head – F & B Member
13 Coordinator – Quality Member
14 Nurse Administrator - OT Member
15 Infection Control Nurse Committee Coordinator
F. Infection Control Team

F.1 In addition to the Infection Control Committee an additional group is included in the Infection
Control Team to implement and monitor the day to day activities of ICD. It also implements the
educational and training program for the hospital staff. Along with the Infection Control
Committee, the following form the Infection Control Team:
 Pharmacist
 Canteen In charge
 Housekeeping Supervisor
 Head – HR
 Supervisor Attendant
F.2 ICO / DESIGNEE is responsible for the day to day operations and monitoring of surveillance
activities assisted by infection control team.
F.3 Responsibilities of Infection Control Team
F.3.1 Advice staff on all aspects of infection control and maintain a safe environment for patients
and staff.
F.3.2 Advice management of patients at risk.
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F.3.3 Carry out targeted surveillance of nosocomial infections and act upon data obtained. e.g.
investigates clusters of infection above expected levels.
F.3.4 Provide a manual of policies and procedures for aseptic, isolation and antiseptic techniques.
F.3.5 Investigate outbreaks of infection and take corrective measures.
F.3.6 Provide relevant information of infection problems to the management.
F.3.7 Assist in training of all new employees for the importance of infection control and the
relevant policies and procedures.
F.3.8 Have written procedures for maintenance of cleanliness.
F.3.9 Surveillance of infection, data verification and analysis, implementation of corrective steps
are done on a regular basis. This is based on reviews of lab reports, reports from nurse
administrator etc.
F.3.10 Monitors effectiveness of Housekeeping Services
F.3.11 Supervision of isolation procedures
F.3.12 Monitors employee health programme
F.3.13 Addresses all requirements of infection control and employee health as specified by national,
state and local laws.
F.3.14 Provide feedback regarding HAI rates on a regular basis to medical and nursing staff.
F.3.15 Monitor the appropriate implementation of biomedical waste management.
F.3.16 Supervision of isolation procedures
F.3.17 Work under Infection Control Committee
F.4 Infection control nurse

F.4.1 Qualified and experienced infection control nurses are appointed fulltime on this position and
their functions are described below:
F.4.1. Regular visits to all wards and high risk areas.
F.4.2. Checking nurse administrator registers and patient case records for cases
suggestive of infections.
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F.4.3. Collection of samples from different areas of the hospital for surveillance
purpose and sending them to lab.
F.4.4. Daily contact to microbiology lab to ascertain results of samples collected for
surveillance and to liaise between microbiology and clinical departments.
F.4.5. Compilation of ward wise, specialty wise and procedure wise statistics for HAI.
F.4.6. Monitoring and supervision of infections amongst hospital staff.
F.4.7. On job training of nursing staff and paramedical personnel on correct hygiene
practices and aseptic techniques (Refer – Training & Development Records,
Department of Human Resource)
F.5 Meetings
F.5.1 The infection control team meets once in a month and otherwise as necessary/urgent.
Documentation of meetings and recommendations are kept by the ICN/quality.
F.5.2 The ICN (Infection Control Nurse) and ICO conduct inspection rounds once a month.
Registers are maintained by ICN.
F.6 Review and Revision of Infection Control Manual

F.6.1 Written policies and procedures shall be reviewed at least every year. Signatures of CEO,
Head - Quality, and ICO shall be affixed.
F.7 Budget Allocation

F.7.1 Adequate resources, infrastructure and fund will be allotted by the hospital administration
and management for effective functioning for infection control program.
F.8 Surveillance and Reporting of Infection

B.8.1 Surveillance is defined as the continuing scrutiny of all aspects of the occurrence and the spread
of a disease that are pertinent to effective control.
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B.8.2 It is as the ongoing systematic collection, analysis and interpretation of health essential to
planning, implementation and evaluation of the public health practice closely integrated with timely
dissemination of this data to those who need to know.
B.8.3 Nosocomial infection surveillance is a program designed to investigate, control and prevent
hospital acquired infections. (Refer – Section E – Prevention of Nosocomial Infections)
B.8.4 Objectives of Surveillance

Surveillance is an ongoing process. Surveillance helps in the following:
B.8.4.1 To recognize any unusual level of incidence or outbreak
B.8.4.2 To judge the desirability of introducing special control measures
B.8.4.3 To assess the efficiency of regular preventive measures
B.8.4.4 To provide feedback
B.8.4.5 To reduce the level of avoidable infection
B.8.4.6 To establish endemic baseline data
B.8.4.7 To identify high-risk patients
B.8.5 Surveillance for infection can be active or passive:
B.8.5.1 Passive Clinical Reporting:
B.8.5.1.1 Clinicians suspecting occurrence of HAI may report this to the Chairperson of the HIC
team. All details regarding the patient, procedures, medication etc. are made available.
B.8.5.1.2 Infections control nurse examines lab reports daily and discusses it with the ICO.
B.8.5.1.3 She/He then visits the relevant patients and gathers necessary information. She
determines whether it is healthcare associated infection and community acquired infection which
helps in identifying cross infections and outbreaks.
B.8.6.2 Active Surveillance

B.8.6.2.1 Daily visit to all wards and high risk area
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B.8.6.2.2 Infection control nurse has to visit all the wards daily or several times a week and
examine all records of all clinical infections.
B.8.6.2.3 High risk areas of the hospital are identified as:
 Operation Theaters
 ICCU
 CSSD
 SICU
 Cath Lab
 Canteen
 House Keeping
B.8.6.2.4 High risk procedures in the hospital are identified as:
 Cardiac Catheterization
 Endoscopies
 Surgery lasting more than 2 hours
 TKR and THR
B.9 Nosocomial Infection Rates

B.9.1 Surgical site infection (SSI) rates (percentage) in clean as well as clean contaminated wounds
B.9.2 Intravascular catheter infection rates per thousand catheter days.
B.9.3 Ventilator associated pneumonia rates per thousand ventilator days.
B.9.4 Urinary tract infection rates per thousand catheter days.
B.9.5 Appropriate case definitions of each nosocomial infection as described by the C.D.C. (Centers for
diseases control and prevention) are used.
B.9.6 Since continuous surveillance of nosocomial infections is often difficult, time consuming and
costly these rates can be determined periodically to define time trends.
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B.9.7 Appropriate feedback regarding HAI Rates are provided on a regular basis to medical and
nursing staff in Infection control files placed in all facilities. The in-charge transfer all the
information to the other staff for continuous improvement. .
B.10 Periodical tests done by Infection Control Department :
B.10.1 Hospital Surveillance Calendar

HCG Hospitals: Surveillance Calendar
Location Jan Feb March April May June July August Sept Oct Nov Dec
CTOT 10,24 14,21 13,27 10,24 8,22 12,26 10,24 14,28 11,25 09,23 13,27 11,25
General OT (1 to 5) 03 07 06 03 01 05 03 07 04 02 06 04
Cath Lab 03 07 06 03 01 05 03 07 04 02 06 04
CSSD 10 14 13 10 08 12 10 14 11 09 13 11
Dialysis+R.O water 10 14 13 10 08 12 10 14 11 09 13 11
Dialysis-Endotoxin
test EVERY MONTH
ICU (3,monthly) February May August November
General SICU February May August November
Cardiac SICU February May August November
Casualty February May August November
ICCU February May August November
HDU March June September December
Mortuary March June September December
Ambulance March June September December
Laboratory March June September December
Drinking water March June September December
Random
Environmental January April August December
surveillance
Canteen Food EVERY MONTH
Water tank May November
All floors, OPD’S & management areas will be “Deep Cleaned” as and when required. (Maximum within 6 months)
Department of Infection Control
Note: There can be change in surveillance date due to administrative reason. Any major changes in the calendar
are documented in Infection Control Department.
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B.11 Following protocols shall be followed to monitor the occurrence of an infection in the patient:
B.11.1 Urinary Tract Infection
B.11.1.1 This shall be done for all symptomatic catheterized patients. Urine sample shall be send to microbiology
for culture test.
B.11.2 Respiratory tract infection
B.11.2.1 This shall be done for all patients on ventilator and showing clinical features suggestive of infection.
Sputum or ET/ tracheostomy secretions or protected specimen brushing (PSB) or mini-bronchoalveolar lavage
(BAL), shall be send for culture test.
B.11.3 Intravascular device infection

B.11.3.1 The patient on central line with symptoms suggestive of intravascular device infection shall be monitored.
B.11.3.2 For patients on peripheral lines, clinical evidence of thrombophlebitis shall be looked to identify infection.
It is not monitored in HAI.
B.11.4 Surgical site infection
B.11.4.1 Aspirated pus or swab will be sent for culture of patients having signs and symptoms of SSIs.
B.12 Indicators – Following formats are used for monitoring of above mentioned indicators:
B.12.1 Type of Indicator form –
A. Indicator for Surgical site infection (SSI) (HCG MS/HIC/01)
B. Indicator for Catheter related blood stream infection (CRSBI) (HCG MSH/HIC/02)
C. Indicator for Ventilator associated pneumonia (VAP) (HCG MSH/HIC/03)
D. Indicator for Urinary tract infection (CAUTI) (HCG MS/HIC/04)
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LINEN MANAGMENT
A. Purpose
A.1 To provide process, instructions and methodology for Management of Laundry process in the
hospital.
B. Scope
B.1 Hospital Wide
C. Responsibility
C.1. Overall responsibility of implementation of this policy shall lie with Nursing and Housekeeping
Staff under supervision of the Infection Control Department.
about hospital infection control practices in coordination with infection control team.
D. Definition-NIL
E. Policy
E.1 This applies to the management of hospital’s linen ensuring adequate cleaning of the linen for
better hygienic hospital environment and their proper accountability.
F. Procedure
F.1 Introduction
F.1.1. Soiled linen can be a source of microbial contamination which may cause infections in hospital
among patients and personnel, though, infection through linen has not been commonly
documented. In addition, improperly processed linen can cause chemical reactions or
dermatitis in those who come in contact with them.
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F.1.2. A hospital’s linen service should process the soiled linen so that the risk of disease to patients
who may be unusually susceptible or to employees who may handle linen is avoided.
F.1.3. Adequate procedures for collecting, transporting, processing and storing linen should therefore
be established.
F.2 Handling of Linen:
F.2.1 The handling of linen consists of 4 processes:
1. Collecting
2. Transporting
3. Processing
4. Storing
F.2.2 Collection of Used Clean Linen from patient areas:
1. Used clean linen is collected from all patient areas daily.
2. This linen is placed carefully in the covered linen basket in their respective areas until it is collected
by the linen keeper.
3. This covered basket is transferred in service lift to the central linen collection room.
F.2.3 Collection of Soiled Linen from patient areas:

1. Linen soiled with blood, body fluid, etc should never be soaked on site.
2. All soiled linen are packed in BMW double yellow bags after donning required PPE..
3. Operators should wear proper personal protective equipments (PPE’s) for their safety (Ref. Safety
Manual) before packing soiled linen.
4. Bags are taken in a trolley to soiled linen washing area (5th floor).
5. All soiled linen are soaked in the required disinfectant for 30 minutes.
6. This linen can now be treated as used clean linen.
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F.2.4 Collection of Used Clean Linen by outsourced services

1. All used clean linens are collected by the outsourced laundry services daily (Cross Ref: MOU File)
F.2.5 Linen which need special handling before dispatch to laundry

1. Soiled linens - Soaked in 1% Sodium Hypochlorite solution for 30 minutes.
2. HIV and HBsAg - Soaked in 1% Sodium Hypochlorite solution for 30 minutes.
3. Linen soiled with Cholera and other diarrhea fluids - Soaked in EPA approved linen disinfectant in
dilution recommended by the manufacturer/ Sodium hypochlorite for 30 minutes..
4. Gas gangrene anthrax – Bagged in autoclavable bag and autoclaved before dispatch to Laundry.
All wet linen is considered contaminated and is bagged in bags in the ward area, and such linen should
be handled using standard precautions / soiled linen.
F.2.6 Collection of unused Clean Linen from Laundry

1. Linen is received at the security desk by the designated person.
2. This linen is transported to the Linen Room at fifth floor in the clean lift. The linen keeper verifies the
quality and quantity of linen received. Any disparity is notified to the Laundry.
3. The linen is arranged on shelves in the Linen Room.
F.2.7 Transportation of Clean Linen
1. All clean linen should be stored and transported in carts used exclusively for this purpose
2. The clean linen section should be cleaned every day; Cupboards and walls damp dusted and the
floor mopped.
F.2.8 Processing of Sterile Linen

1. Only linen used in procedures requiring sterile technique should be sterilized. This process is
done in the CSSD. (Cross ref: HCGMS/HIC/05- Management of sterilization)
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F.2.9 Supply & Storage of Clean Linen

1. Clean linen is delivered to the user in such a way as to minimize microbial contamination from
surface contact or airborne deposition.
2. It is desirable to protect linen in individual patient care areas. But once clean linen is distributed
for individual patient use, protection or covering is not required. There is no need to provide
further protection. There need to be a functional separation of clean and soiled linen during
storage and transport.
F.3 Flow sheet of used linen

USED LINEN
Soiled Non Soiled
To be soaked for 30 minutes in Transported in close

dilution of hypochlorite (1 tablet in containers for washing
2L of water) at the Facility (Outsourced)
Responsibility: Attendant Responsibility: Supervisor/

attendant
Responsibility: Sister In charge
Rinsed in
clean water
Linen can now be transported as used

non soiled linen transported in closed
containers to linen assembling area.
Responsibility: Supervisor/ Attendant
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NOTE: Linen from all facilities is collected at the linen assembling area in closed containers. They are
then taken by the Outsourced agency for washing. It is mandatory that all soiled linen is disinfected
before leaving the parent hospital.
The ICN and In-charge Nurse will be responsible for supervising and monitoring the Entire process.
1. The soiled linen should be collected in BMW yellow bag (Double bag).
2. The Attendant on the particular floor should take it to 5 th Floor (Soiled Linen Room).
3. PPE is to be worn during the entire process.
4. Clean-n-Sept tablets are to be collected from the 5th floor housekeeping / brought from the
particular floor if available.
5. Rinsed and dried linen should be collected in BMW yellow bag and then send to Linen Room
(Basement 1).
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STANDARD PRECAUTIONS
A. Purpose
A.1 To ensure the use of Standard precautions by the staff engaged in patient care as this is one of the
most important step towards decreasing the hospital infections.
B. Scope
B.1 Hospital Wide
C. Responsibility
C.1. Overall responsibility of implementation of this policy is lying with infection control committee.
C.2. Infection control team is responsible for the day to day monitoring programme.
C.4. Hospital Management is responsible for availability of personal protective equipments.
D. Introduction
D.1 The advent of HIV/AIDS epidemic by the mid 1980s, created an urgent need for new strategies to protect
health care workers (HCWs) from blood-borne viral infections. In 1985, Centers for Diseases Control and
Prevention (CDC) proposed universal blood and body fluid precautions or universal precautions.
A. Definition
E.1 Universal Precautions
E.1.1 Universal precautions are a set of precautions designed to prevent transmission of HBV, HCV, HIV
and other blood-borne pathogens while providing healthcare to all patients regardless of their diagnosis or
presumed infective status.
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E.2 Rational
E.2.1 Since medical history and examination cannot reliably identify all patients infected with HIV or other
blood borne pathogens, blood and body-fluid precautions should be consistently used for ALL patients
(regardless of presumed infectious status), especially including those in emergency care settings in which
risk of blood exposure is increased and infection status of patient is usually unknown.
E.2.2 Later, it was accepted that other body fluids contained micro-organisms which could cause cross-
infection, e.g. MRSA (Methicillin Resistant Staphylococcus aureus), Clostridium difficile, VRE (Vancomycin
Resistant Enterococcus). Hence, Standard Precautions have replaced Universal Precautions.
E.2.3 Besides this, additional precautions go beyond standard precautions and are based on the basis of
the mode of transmission of microorganisms or infectious agents leading to infection.
E.3 Following are the additional transmission based precautions:
E.3.1 Airborne precautions
E.3.2 Droplet precautions
E.3.3 Contact precautions
“Standard precautions are the precautions to be used by ALL healthcare workers in ALL situations involving the
care of patients or contact with the environment.”
B. Components of Standard Precautions

F.1 Hand hygiene
F.2 Use of Personal Protective Equipments
F.2.1 Gloves
F.2.2 Apron/Gown/Footwear
F.2.3 Mask, Eye protection, Face shield
F.3 Prevention of Occupational Exposure
F.4 Patient Placement – Isolation
F.5 Decontamination of Patient Care Equipments
F.6 Environmental Cleaning and Sanitation
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F.7 Laundry and Linen Management

F.8 Spillage Management
F.9 Bio-Medical Waste Management
G. Hand Hygiene
G.1 Perform hand hygiene before and after handling of patient.
G.2 Perform hand hygiene between each direct patient contact.
G.3 It may be necessary to perform hand hygiene and change gloves between tasks on the same patient.
G.4 Hand hygiene with alcohol hand rub is acceptable provided the hands are not visibly soiled. (Refer:
Policy on Hand washing - HCGMS/HIC/04-00)
G.5 Wash hands immediately after contact with blood, body fluids, secretions, excretions and items
contaminated with body fluids.
H. Use of Personal Protective Equipments

H.1 Gloves
H.1.1 Wear gloves, (clean, non-sterile gloves are adequate for non invasive procedures) when in
contact with blood, body fluids, secretions, excretions and contaminated items / equipment.
H.1.2 Change gloves between tasks and procedures on the same patient.
H.1.3 Remove gloves promptly after use before touching non-contaminated items.
H.1.4 Perform hand hygiene immediately after removal of gloves.
H.2 Apron/Gown/Footwear
H.2.1 Wear a clean plastic apron to protect the uniform from:
H.2.2 Soiling during procedures and patient care activities that are likely to generate splashes or
sprays of blood or body fluids
H.2.3 Contamination with micro-organisms during direct patient care or direct contact with the
environment of an isolated patient
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H.2.4 Select an apron/gown that offers most protection. Remove promptly and perform hand
hygiene.
H.2.5 Use protective footwear, to prevent contamination of the feet, e.g. during operations.
Remove contaminated footwear when procedure is complete.
H.3 Mask, Eye protection, Face shield

H.3.1 A mask, eye protection or face shield must be worn to protect mucous membranes of the
mouth, eyes and nose if there is a risk of splashing or spray of blood or other body fluid.
H.3.2 Consider the risk of splashing / spraying and need for personal protective equipment before
you start any procedure!
I. Prevention of Occupational Exposure

I.1 Cover all cuts and abrasions with waterproof dressings.
I.2 Take care to prevent sharps injuries.
I.3 Use gloves (industrial) when handling sharps.
I.4 Do not reheat or recap needles.
I.5 Never manipulate any sharp that involves directing the point of a needle toward any part of the
body.
I.6 Dispose of sharps immediately into a hospital approved container.
I.7 Take a sharps container to the point of use.
I.8 Follow needle stick and sharps injury guideline in case of injury from needles or sharps. (Refer
HCGMS/HIC/01-01 – HIC Manual for NSI Guidelines)
I.9 HCWs with skin conditions must seek the advice of an Infection Control Nurse.
J.4. Patient Placement - Isolation

J.1 Place a patient who could contaminate the environment, with blood, body fluid or faeces in a
single room.
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J.2 Two single rooms are designed on the third floor in the ICU, which are designated as isolation
rooms. If a single room is not available, special arrangements are made (Refer – HCGMS/AAC/ 03-
01 – Admission Policy).
J.3 If the patient is clinically unsuitable to be placed in a single room a risk assessment must be
undertaken by the clinical team in conjunction with a member of the I.C.T.
J.4 Babies and children will be isolated if they have symptoms suggestive of an infectious disease
which can spread person to person. The I.C.T will advise for the same.
J.5 It is the decision of ICO /Critical care / ID specialist to take the final call on patients who do/ or do
not require isolation.
K. Decontamination of Patient Care Equipments

K.1 Patient-care equipment should be decontaminated as per the ‘Management of sterilization of
instruments - HCGMS/HIC/05-00.’
K.2 Wear protective clothing when handling contaminated equipment.
K.3 Patient-related equipment, e.g. pumps, drip stands, etc, must be kept clean.
L. Environmental Cleaning and Sanitation

L.1 Ensure that the clinical areas are clean.
L.2 Particular attention must be paid to cleaning of horizontal surfaces, floors, beds, bed-side
equipment and other frequently touched surfaces. (Refer: HCGMS/HIC/08-01 – Hospital Cleaning
Policy)
M. Laundry and Linen Management

M.1 Always wear proper PPE’s when handling soiled linen.
M.2 Never place linen (soiled/used or clean) on the floor.
M.3 Do not expose clean linen to potential contamination by storing inappropriately before it is used.
(Refer: Policy on Linen Management - HCGMS/HIC/02-00)
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N. Spillage Management
N.1 Disinfect all blood and body fluid spillages immediately wearing protective clothing (gloves, apron
and if risk of splash, goggles). (Refer- HCGMS/FMS/01-01 – Safety Manual)
N.2 Decontaminate spillages as per the Spill Management section of the HCGMS/FMS/01-01.
N.2.1. Spillage Management
N.2.1.1 Blood and body fluid spillage management
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N.2.1.2 Mercury spillage management.
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O. Bio-Medical Waste Management

(Refer: Policy on Biomedical Waste Management - HCGMS/HIC/06-01)
P. Standard Precaution Displays
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HAND WASHING
A. Purpose
A.1 To promote and standardize regular hand washing by the staff engaged in patient care as this is one
of the most important step towards decreasing the hospital infections.
B. Scope
B.1 All areas where patient care activities are undertaken
C. Responsibility for implementation
C.1 Overall responsibility of implementation of this policy shall lie with Medical and Nursing Staff under
supervision of the Infection Control Department.
C.2 Infection control team is responsible for the day to day monitoring program
C.3 All HODs are responsible for the monitoring and educating staff of their respective department
about hospital infection control practices with coordination of infection control team. (Cross Ref:
Training Records)
D. Definition-NIL
E. Policy
The policy is based mainly on the technical manual of hand hygiene, WHO 2009. This is the basic
policy for hand hygiene, for details request for ‘Technical manual of hand hygiene, WHO 2009’ in IC
department. The main five moments of hand hygiene are:
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For Reference only (Table):
F. Procedure
F.1 Guideline
F.1.1. All healthcare workers shall comply for practice of hand washing to prevent infections. Seven
points hand wash is recommended as an ideal method for hand washing. Following general
guidelines shall be followed.
1. On entering the workplace (on joining duty)
2. Before leaving work place (on completion of duty)
3. Before and after drinking, eating and food contact
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4. After using restroom or toilet

5. Before performing any invasive procedure
6. Before entering in to and leaving from an isolation room
7. Before wearing and after removing gloves
8. Before taking care of susceptible patients, such as those who are severely immune compromised
and newborns
9. Between contacts with different patients
10. After contact with mucous membranes, blood or body fluids, and secretions or excretions
11. After touching inanimate surfaces those are likely to be contaminated by virulent or
epidemiologically important microorganisms.
12. After taking care of an infected patient or one who is likely to be colonized with microorganisms
of special clinical or epidemiological significance, for example multiple-resistant bacteria
13. Before and after touching the wound, whether surgical, traumatic or associated with an invasive
device
14. Whenever hands are visibly soiled.
F.2 Routine Hand Washing Procedure
F.2.1. Hand wash is done when hands are visibly soiled. Wet hands with water
F.2.2. Apply enough soap to cover all hand surfaces (Liquid soap with dispenser)
F.2.3. Rub hands palm to palm.
F.2.4. Rub back of each hand with palm of other hand with fingers interlaced.
F.2.5. Rub palm to palm with fingers interlaced.
F.2.6. Rub with back of fingers to opposing palms with fingers interlocked.
F.2.7. Rub each thumb clasped in opposite hand using a rotational movement.
F.2.8. Rub tips of fingers in opposite palm in a circular motion.
F.2.9. Rub each wrist with opposite hand.
F.2.10. Rinse hands with water.
F.2.11. Use elbow to turn off tap.
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F.2.12. Dry thoroughly with a single use towel.

F.2.13. Multiple use cloth towels of the hanging or roll type are not recommended for use in health-care
settings. Duration of the entire procedure: 40-60 seconds
F.2.14. Hand washing should be practiced strictly at all patient care areas.
F.3 Method of Hand Hygiene (Hand rub using alcoholic preparation when hands are not visibly soiled)
F.3.1 Apply an alcohol based hand rub, to palm of one hand and rub hands together, covering all
surfaces of hands and fingers until hands is dry. Duration of the entire procedure: 20-30 seconds.
F.3.2 Follow the manufacturer’s recommendations regarding the volume of product to use.
F.4 Surgical Hand Wash

F.4.1 Remove rings, watches and bracelets before beginning the surgical hand scrub.
F.4.2 Remove debris from underneath fingernails using a nail cleaner under running water.
F.4.3 Surgical hand antisepsis using either an antimicrobial soap or an alcohol based hand rub with
persistent activity is recommended before donning sterile gloves when performing surgical
procedures.
F.4.4 When using an antimicrobial soap, scrub hands and forearms for the length of time
recommended by the manufacturer, usually 3-5 minutes.
F.4.5 When using an alcohol-based surgical hand rub product with persistent activity, follow the
manufacturer’s instructions.
F.4.6 Before applying the alcohol solution, prewash hands and forearms with non-antimicrobial soap
and dry hands and forearms completely
F.4.7 Allow hands and forearms to dry thoroughly before donning sterile gloves.
Note: Hand wash when visibly soiled otherwise use hand rub.
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F.4 Indications for Hand Hygiene When Medical Gloves are required
F.4.1 The indications for hand hygiene are independent of those that justify the use of gloves (whether
sterile or non-sterile). Glove use neither alters nor replaces the performance of hand hygiene:
1. where an indication for hand hygiene precedes a task involving contact that necessitates the
use of gloves, hand hygiene must be performed before donning gloves;
2. where an indication follows a task involving contact that requires the use of gloves, hand
hygiene must be performed after the gloves are removed;
3. where an indication occurs while the health-care worker is wearing gloves they must be
removed to allow hand hygiene performance and, if necessary, changed. The use of gloves
does not determine indications for hand hygiene; rather, hand hygiene influences the
appropriate use of gloves.
F.5 Hand hygiene audit

F.5.1 Hand-Hygiene (HH) Compliance Monitoring
 Observations will be done in the morning, afternoon and night shifts.

 Observations must be a “shadow study” type, meaning that it will take place without any notice
to personnel regarding the task that is being performed.
 Observations will last 30 minutes once a week for each shift.
 An average of two forms for each shift to be filled resulting in 6 forms every week.
 This form is filled in once a month.
F.5.2 The compliance feedback of hand hygiene audit will be circulated to the concern unit monthly
along with HAI feedback
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F.5.3 Evaluation is done six monthly, to pinpoint improvement or scope for improvement .Corrective
action, preventive actions are taken accordingly.
Hand Hygiene Poster
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References:
Hand hygiene: Technical reference manual. World health organization. Patient safety. A world alliance
for safer healthcare. 2009
Larson E, Girard R, Pessoa-Silva CL, Boyce J, Donaldson L, Pittet D.Skin reactions related to hand hygiene
and selection of hand hygieneproducts. American Journal of Infection Control 2006; 34:627-35.
Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa da Silva C, Donaldson L, Boyce J.Evidence-based model for
hand transmission duringpatient care and the role of improved practices. Lancet Infectious Diseases 2006;
6:641-52.
Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. “My fivemoments for hand hygiene” – a user-
centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital
Infection 2007; 67:9-21.
Allegranzi B, Pittet D. The role of hand hygiene in healthcare associated infection prevention. Journal of
Hospital Infection 2009 (in press).
Pittet D, Allegranzi B, Boyce J; on behalf of the WHO World Alliance for Patient Safety First Global Patient
Safety Challenge Core Group of Experts. The WHO guidelines on hand hygiene in health care and their
consensus recommendations. Infection Control and Hospital Epidemiology 2009; 30:611-22.
Pittet D. Hand hygiene promotion: 5 moments, 5 components, 5 steps, and 5 May 2009. International
Journal of Infection Control 2009; 5:1-3. H Sax, B Allegranzi, M-N Chraïti, J Boyce, E Larson, D Pittet. The
World Health Organization hand hygiene observation method. American Journal of Infection Control 2009
(in press).
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STERILIZATION OF INSTRUMENTS
A. Purpose
A.1 To standardize of sterilization processes within hospital and to ensure that adequate space is
provided for sterilization activities, regular validation tests for sterilization are carried out and
documented and there is an established recall procedure when breakdown in the sterilization system
is identified.
B. Scope
B.1 All areas of the hospital where different types of instruments are used which needs sterilization
C. Responsibility
D. Definition-NIL
E. Procedure
E.1 There are four steps for processing instrument used during clinical and surgical procedure:
1 Cleaning
2 Sterilization/high level disinfection
3 Use/storage
4 Transportation
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E.2 Cleaning/ Multi-enzyme

E.2.1 While decontamination makes items safer to handle, cleaning is the second step in processing,
removes organic, dirt and foreign matter that can interfere with sterilization or HLD (high level
disinfectant). Cleaning also drastically reduce the number of microorganisms (bioburden),
including bacterial endospores on instrument.
E.2.2 Cleaning refers to scrubbing with a brush, detergent and water. This is crucial step in re-
processing. Multi enzyme removes organic matter from the instrument.
E.2.3 Steps of cleaning

1 Using a soft brush, detergent/ multi-enzyme, water scrub for the instruments to completely
remove all blood, other body fluid, tissue and other foreign matter.
2 Hold items submerged in water while scrubbing and cleaning to avoid splashing.
3 Disassemble instrument with multipart and be sure to brush in the grooves, teeth and joints
of items where organic material can collected and stick.
4 Rinse items thoroughly with clean water to remove all detergent.
5 Any detergent left in the items can reduce the effectiveness of sterilization/high level
disinfection.
6 Allow items to dry.
7 After drying, items are inspected and packed prior to sterilization.
8 Before steam sterilization wrapping items helps decrease the likelihood that sterilized items
will be contaminated before use.
9 Place instrument in center of the wrapper. The wrapper should be positioned so that the
points not the flat edges are at top, bottom and side.
10 Fold the bottom section of the top wrapper to the center and fold back the point
11 Fold left section to the center and fold back point
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12 Fold the right section to the center and fold back the point
13 Fold top section to the center and fold back point
14 Fold the bottom section of the bottom wrap to center and fold back the point
15 Follow the same step for all side and fasten the folds securely using autoclave tape.
E.3 Sterilization
F.3.1. Sterilization ensures that items are free of all microorganisms including bacterial endospores
that can causes infection to client.
F.3.2. Steam sterilization in an autoclave is most commonly used form of sterilization
F.3.3. Steps of steam sterilization
1 Arrange wrapped packs or linen packs, in the chamber of the autoclave in a way that
allows circulation of steam freely.
2 Follow the instruction of manufacturer. if it’s not available than in general sterilization
wrapped items for 30minutes and unwrapped items 20 minutes at 121C and 1 bar (106
KPa) pressure.
3 Note down the starting and end time. If it’s not automatic than after 30 mints switch off
autoclave
4 Wait till pressure reaches to zero. After that open the lead or door and allow residual
steam to escape. Leave instrument in autoclave until they dry completely.
5 Remove packs, drum and unwrap items from autoclave to prevent condensation, place
baskets, packs, drums or trays on a surface padded with paper or fabric until they cool.
E.3.4 Steps for ETO sterilization

1 All items to be gas sterilized will be packaged according to the appropriate procedure using
polypropylene or peal open packaging.
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2 The package must have the ETO specific indicator on it.

3 Place all items in the basket and place wrapped items on edge. Paper or Plastic pouches
must also be placed on edge with plastic side of one package facing the paper side of the
one next to it. If pouches must be placed flat, the paper side should face down.
4 Expiration date of sterilization is required on all gas-sterilized items.
5 Arrange load in the basket so that gas mixture can circulate freely.
6 Do not overload shelves. Do not compress packages, since air and gas must be able to
circulate during the cycle.
7 Do not allow load components to contact the sterilizer chamber wall.
8 Provide at least 3 inches between the sterilizer chamber ceiling and the topmost package
of the load.
9 Place biological indicator pack once a week. Follow incubation procedures and record test
data in logbook.
10 Check cartridge before beginning the cycle.
11 Check thermal paper roll for printer.
12 Open door by turning handle anti-clockwise until it stops and pull the door open.
13 Load the sterilizer.
14 Place basket into sterilizer chamber following above loading guidelines
15 Close door securely. Select appropriate cycle.
16 Start the sterilizer.
17 After sterilization cycle is completed, the aeration cycle begins.
18 Unload after allowing minimum hours of aeration, as per manufacturer’s instructions.
19 Process biological indicator according to procedure.
20 The manufacture should perform routine preventive maintenance.
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21 If personnel exposure is suspected, give FIRST AID (As per the User’s Manual or MSDS) and
send for further medical treatment.
E.4 Receiving of cleans items

F.4.1. All clean items received in the department and documented.
F.4.2. After that the sterile trays/packs are checked again.
F.4.3. Wrapped packs and trays are labeled with indicator tape; load the sterilizer as per its
capacity. Leave adequate space for sterilant circulation.
E.5 Procedure for Sterilizing Linen

F.5.1. All linen used for sterile supplies must be inspected for holes, tears or other defects. Any
linen found with defect should be returned for repair prior to use.
F.5.2. A simplified method of folding is to fold in half, the left over right. This produces linen of
uniform sizes. This method also is designed to save time for the person using the sterile linen
as well as the person folding it.
F.5.3. Different packs will have different types of sheets. The master lists are to be used as a guide
while preparing a pack. (Cross Refer: CSSD Master List of Surgical Packs)
F.5.4. Linen wrappers should be used to provide protection against contact contamination as well
as serve an effective dust cover.
F.5.5. The surgeon gown will be folded inside out to enable aseptic gowning procedures.
F.5.6. The wrappers used should be large enough to cover the item, without excessive bulk and to
provide a sterile field if necessary.
F.5.7. All items sterilized will have the expiration dates marked.
F.5.8. All linen that has been sterilized will be laundered prior to being re-sterilized. This will
prevent super heating of excessively dry linen.
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F.5.9. The packs should be assembled so that the item to be used first in sterile area is the last item
to be placed on the pack.
F.5.10. Linen packs will be sterilized following the appropriate sterilization method.
E.6 Storing and distributing sterilized items

F.6.1. The sterilized materials are stored temporarily at the sterile store in CSSD.
F.6.2. The materials are issued as per the need of user department and documented in register
(Cross Refer: CSSD – Stock Issue Register)
F.6.3. Shelf life of sterilized items
F.6.3.1 The packs sterilized by steam autoclave can be stored for 6 days in a dust-free
designated area after which it has to be sterilized again.
F.6.3.2 The ETO packs can be kept for one year, when pack is undamaged and stored in dust
free designated environment, though event related expiry is the latest guideline..
E.7 Quality check

E.7.1 Many procedures are carried out to check the level of sterilization in each load.
E.7.2 Mechanical Indicators:
1 The mechanical control of sterilizer is achieved by running Bowie-Dick Test, thermographs,
thermal and computer printouts. The computer printout describes the sterilizer cycle accurately.
It gives information regarding the exposure time and aeration time. This enables to have a check
on the sterilizer.
E.7.3 Chemical Indicators:
These are strips impregnated with certain dyes, which change color when the required parameters for
sterilization are met. Hence chemical indicators reach their end point in the form of a chemical (color)
change.
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1 After sterilization the packs are issued for use only if the indicator affixed on the pack shows the
prescribed color change.
2 An integrator strip that changes color only if all three parameters – temperature, time and steam
match with prescribed values is used a check for every load.
E.7.4 Biological Indicator: They are designed for use with specific types of sterilization. Bacillus
stearothermophilus for steam sterilization and Bacillus subtilis for ethylene oxide sterilization.
1 Biological monitoring is done once a week to confirm efficacy of the sterilization.
2 A test pack of Bowie Dick is used on an empty cycle on alternate days for mechanical checks.
3 The biological indicator is placed at a place where steam penetration is not easy. After
processing, the indicator can be taken out.
4 After the completion of the sterilization cycle, the test package is removed and the biological
indicator is removed. This is then sent to the laboratory for further incubation.
E.7.5 Frequency of Indicator
Indicators Steam ETO

Physical Bowie Dick (Mechanical) Graph For Temp & Pressure
Every Alternate Day Every Cycle
GRAPH FOR TEMP &PRESSURE EVERY -
CYCLE
Chemical Internal (Class 5 Test) Every Load -
EXTERNAL (CLASS1) STICKER,ROLL EVERY (CLASS 1) STICKER, ROLL
PACK EVERY PACK
Biological G. Stearothermophilus Once A Week Bacillus Atrophaeus Once a
Week
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E.8 Environmental Cleanliness

F.8.1 Storage racks and carts should be cleaned on a weekly basis with an approved germicide.
F.8.2 Tabletops, counter, sinks and cupboards doors require daily cleaning.
F.8.3 Floors surfaces should be kept dry and dust free after each procedure.
F.8.4 Specifically designated lint free mops used only for cleaning of the Sterile Area.
F.8.5 The walls and ceilings should be cleaned at least once in a month.
F.8.6 Exhaust fan must be on.
F.8.7 Only assigned person should enter the Sterile Area.
F.8.8 Deep cleaning should be done once a month.
F.8.9 Fogging of Sterile Area
E.8.9.1 Though fogging is not recommended, the hospital performs fogging on every Sunday before
closing the department.
E.9 Procedure for Outdated Items

F.9.1 All supplies with the expiration date should be removed from service before 12 noon on the
day of expiry and returned for reprocessing.
F.9.2 If unopened, repack all received items before re-sterilization.
F.9.3 Manufacturer sterilized products will be re-sterilized as per the manufacture’s written
instructions for re-sterilization. This instruction must include specific sterilization parameters
for type of sterility to be used i.e. time and temperature.
F.9.4 Items should be marked as whether it is “single use” or “disposable”.
E.10 Recall of items in case of sterilization breakdown

E.10.1 Policy
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E.10.1.2 Items dispatched from CSSD to wards/ICUs/OTs and other patient care areas, shall be recalled
immediately if
 Any breakdown is noticed in sterilization of the batch that was sterilized.
 Any evidence suggestive of improper sterilization came into notice.
E.10.2 Recall shall be made as per given procedure.
Sr. No. Procedure Steps Responsibility

1 CSSD maintains the inward outward register in which they CSSD Technician
mention REF.NO for each items. & In-charge
2 REF. No. (=Batch No.) includes:
 Cycle number
CSSD Technician
 No of pack
& In-charge
 Name/ number of the sterilizer
 Date and time of sterilization
3 TST (Time, Steam and Temp) Strips is being used as the quality CSSD Technician
assurance for the sterilization. & In-charge
4 The color of the TST strips is converted from pink to Black which
indicates complete and satisfactory sterilization. CSSD Technician
In ETO - Color change from Pink to Yellow ( colors may change as & In-charge
per manufacturer)
5 After dispatch of the items if any pack or any unit is found CSSD Technician,
damaged or indicator indicates failure, the unit in-charge informs Unit In-charge
the CSSD in-charge. The CSSD In-charge re-calls the whole batch
for quality check and if required carry out re-processing or re-
sterilization as appropriate.
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Flow sheet for Sterilization of instruments:

Sterile goods dispatched from CSSD
Goods are used
Primary cleaning including multi enzyme use done at user end
All instruments Dried and cleaned
Packed properly for autoclave / Loosely packed for ETO
Submitted at CSSD and receipt documented.
Autoclavable material goes into the autoclave. ETO dried and packed in ETO packing with
respective labels.
Sterile goods stored temporarily in CSSD. Dispatched in closed trolley hospital facilities.
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BIO MEDICAL WASTE MANAGEMENT
A. Purpose
A.1 To meet the statutory provisions with regard to Bio medical Waste Management and comply with
A.2 The policy outlines how the biomedical waste is to be segregated, stored, transported and
disposed for the safety of patients, staff and environment
B. Scope
B.1 All patient care areas where Bio Medical Waste is generated, segregated and stored.
C. Responsibility
D. Definition
D.1 Biomedical wastes shall be handled as per biomedical waste management and handling rules, 1998
and an approval for the same shall be available from Gujarat Pollution Control Board (GPCB).
D.2 Biomedical waste consists of solids, liquids, sharps, and laboratory waste that are potentially
infectious or dangerous and are considered bio waste.
E. Policy
Biomedical wastes shall be:

E.1. Segregated and collected in different color coded bags (as per local law) and containers at the
place of waste generation.
E.2. Infected Segregated waste shall be treated in the hospital before sending it to disposal agency.
e.g. Sharps, Microbiological waste etc..
E.3. This shall be transported every day through closed transport vehicles in color code bags to the
earmarked site.
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E.4. The hospital shall outsource the authorized B.M.W. management agency for treatment and
disposal of biomedical wastes.
E.5. Personnel handling bio-medical waste shall wear personal protective equipments i.e. gloves,
masks and gowns.
E.6. The outsourced agency shall be audited by HCG multi specialty every six months.
F. Procedure
F.1 Types of biomedical waste:
a) Human Anatomical Waste

The consists of all animal tissues, organs and body parts, but does not include teeth, hair and
nails.
b) Animal Waste
This consists of all animal tissues, organs, body parts, carcasses, bleeding ,fluid blood and blood
products, items saturated or draping with blood, body fluids contaminated with blood, and body
fluids removed for diagnosis or removed during surgery, treatment or autopsy.
c) Microbiological laboratory waste

This consists of laboratory culture, stocks or specimens of microorganisms, live or attended
vaccines, human or animal cell cultures used in research and laboratory material that has come in
to contact with any of these.
d) Human blood and body fluid waste
This consists of human fluid blood and blood products, items saturated or dripping with blood,
body fluids contaminated with blood and body fluids removed for diagnosis during surgery,
treatment or autopsy .This does not include urine or feces.
e) Waste Sharps
Waste Sharps are clinical laboratory materials consisting of needle, syringes, blades or laboratory
glass capable of causing punctures or cuts.
F.2 Treatment of waste

F.2.1 Non-Infectious Waste:
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1) This category may be treated as household waste and need to collect in green bag. Plastic lined
bins. It includes waste papers, kitchen waste, packing materials etc. This category of waste does
not need any pretreatment and can be handed over as general waste to the municipal waste
management squad.
F.2.2 Infectious Waste:
1) This category of waste must be segregated at the point of generation itself. Persons handling
infected waste should be wearing suitable protective gear-gloves, mask and protective apron.
Polythene bags in the bins have to be changed with each shift or when they are 3/4 th full to
prevent spillage around the bin. The bags have to be tied or sealed at the top wherever the waste
is being transported. Infected waste needs to be destroyed by incineration or autoclaving. Any of
the following categories of the waste can be infectious. Linen that is soaked with blood or body
fluids is to be collected in yellow bag after decontamination and tied securely. In case of leakage,
linen should be packed and tied securely.
F.2.3 Cytotoxic Chemical Waste – Not Applicable at HCG Multispecialty Hospital
F.2.4 Human Blood and body fluids wastes:
1. Definition:
1) Waste that consists of fluid blood, blood products and fluids used for diagnosis or removed
during surgery, treatment and autopsy
2. Strategy:
1) Interim waste management protocol for liquid wastes of this nature include carefully pouring the
waste down the sanitary sewer being caution to prevent the formation of aerosols or spills.
2) Items saturated or draping with blood or body fluids that are wet, shall be contained In leak proof
container.
3. Handling, Packing and Transportation Details:
1) Standard Precaution shall apply to the handling of blood and body fluids wastes for all
patients/Clients/Residents. Hazardous wastes should be segregated at the point of generation.
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Human blood and body fluids wastes should be segregated from other classes of biomedical and
general waste. Disposal of disinfected blood and body fluids waste can be via the sanitary sewer.
2) Chemical disinfection is to be employed as a part of spill cleanup; a 5,000 ppm. Sodium

hypochlorite is recommendation for an interval sufficient to destroy the agent of concern
.Chemical disinfection is most appropriate for spills of liquids. The solution is to be preparing
when required.
F.2.5 Laboratory Wastes
1. Definition:
1) Waste that consists of laboratory cultures, stocks or specimens of microorganisms, live or

attenuated vaccines, human or animal cell cultures used in research as well as laboratory
material that has come into contact with such, all blood and sera samples.
2.Strategy:
1) Treatment and disposable procedures include autoclaving followed by disposable so sanitary

sewer for liquids and disposable at a solid waste disposable site for solids. In some instances such
as liquid spills, high level chemical decontamination using solution containing 10,000 ppm of
available chlorine may be acceptable as treatment protocol. ( Clean n sept tablets are used at
HCG multispeciality hospital)
3.Handling, Packaging and transportation Details;
1) Hazardous waste shall be segregated at the point of use and dispose in yellow colored bags with
a biohazard label. Microbiology laboratory wastes should be segregated from other classes of
biomedical wastes. However, careful attention must be paid to the treatment methods to ensure
that he wastes are in fact decontaminated by the autoclave process. This is done by checking the
autoclave sterility indicators incorporated in each load of the autoclave. If the waste is
autoclaved, the waste can be disposed of with general waste provided it is labeled as
documented.
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F.2 .6 Sharp waste:
1. Definition:
1) This waste consists of any objects that can penetrate the skin. A sharps waste includes more than
the obvious items used in animal or human patient care: hypodermic needles, re-sheathed
needles. Syringes (with or without the attached needle which are contaminated by blood and/or
body fluids),scalpel blades, capillary tubes, broken pipettes and medical glassware, broken
culture dishes (regardless of presence of infectious agents) it also includes other types of broken
or unbroken items that have, or are likely to have, come in contact with infectious agents.
Examples of these include slides and cover slip, tubing with the needle still attached.
2) Sharp waste may also include be classified as infectious wastes, regulated medical waste, solid
waste, or hazards chemical waste. However, sharp wastes are universally recognized as requiring
stringent regulation for several reasons. These include their association with blood diseases
among health care workers, drug abuse, physical injury, and environmental degradation issue
that are associated with used sharps.
2.Strategy:
1) While proper classification is important, a more common concern with sharp wastes is that of
physical hazards (needle puncture)t those individuals who handle and dispose of the sharp waste
must be handled and contained equally to minimize the risk of infectivity. Thus care and
attention must be directed towards the proper handling and packaging of this class of waste.
2.Handling, packaging and transportation Details:
1) Sharps wastes shall be marked with a biohazard label, Sharp containers should be label with the
bio hazardous symbol and have lids that can be tightly secured. Sharps containers should be
conveniently located close to the point of use to reduce the likelihood of injury. Fresh solution of
1 % sodium hypochlorite is added in all containers for sharp disposal. These containers are
discarded daily and replaced by fresh puncture proof containers with disinfectant.
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3. Packaging:
1) All sharps wastes shall be discarded immediately into readily available puncture proof containers.
Attention shall be given to ensuring that the container is not over filled. Needles should not be
bent. Recapping of needles should be avoided to prevent needle stick injury. Sharp containers
should not be filled to more than three-quarters of their useable volume in order to prevent
injuries due to overfilling. Sharp should never be forcible pushed into the container.
F.3 Segregation & Disposal of Bio-Medical Waste:
F.3.1 Segregation / collection of hospital waste in specific different color coded bins will be as below:
Color Code Type of waste Pre-disposal and Final treatment

Yellow All infection waste (non-plastic) is Final treatment is incineration
collected in this color-coded
bucket/container
Red All infected plastic waste collected in Mutilation prior to disposal is required to
this color-coded bucket/container prevent re-use and final treatment is land filling
Blue All sharps are collected and Mutilation prior to disposal to prevent re-uses
disinfected before disposal disinfection with 1% hypochlorite solution, and
disposal in a narrow-mouthed, puncture-proof
plastic container. Final treatment is land filling
or deep burial
Black Cytotoxic waste and expiry dated Incineration
medicine
Green Paper, kitchen waste, etc. (domestic Collected by municipal corporation
waste). It is disposed in municipal bin
F.4 Storage and transportation
F.4.1. The bin and bags should also be labeled with the biohazards symbol and if required, for the
types of waste they have to be used for.
F.4.2. The collected biomedical waste shall be transported in color coded carrying bags placed in
covered trolleys.
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F.4.3. The waste shall be transported to the central storage area in Basement 1.
F.4.4. Waste shall be transported to central storage area daily in night hours as per the schedule and
during need-based (SOS) calls..
F.4.5. The transportation timing should be low-traffic timings.
F.4.6. The stored waste shall be sent for final disposal daily on working days. Waste shall not be
stored for more than 48 hours.
F.5 Safety
F.5.1. All healthcare workers MUST immunize for hepatitis B virus
F.5.2. Staff handling biomedical waste shall follow standard precaution (document) and follow all safety
and infection control recommendations / guidelines / instruction given to them through in-house
training program and other educational initiatives. Staff involved with transportation and storage
of biomedical waste shall wear following personal protective gears.
1. Head gear
2. Mask
3. Glove-up to elbow, heavy duty
4. Plastic Gown
5. Covered shoes / gum shoes
F.5.3 FOR SPECIFIC INFECTED CASES

Though all patients are to be treated as infective and standard precautions should be followed, the hospital has
documented sero positive cases handling for its own safety measures.
Sr. No. Responsibilities

Activity
HIV POSITIVE CASES
1 To wear double gloves, face mask and apron while handling the waste Housekeeping staff
2 To collect all the linen of identified and marked (by the nursing staff) Housekeeping staff
case in yellow color double bags after treatment. (Soak in Sod.
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Hypochlorite solution for 30 mins.)
3 To collect solid and mutilated / shredded plastic waste in yellow color Housekeeping staff
double bags.
4 Bags thus collected are transported to the BMW curb point, to be Housekeeping staff /
collected by authorized contractor. authorized
contractor.
HEPATITIS – B and C Cases

1 To wear double gloves, face mask and apron while handling the waste Housekeeping staff
2 To collect all the linen of identified and marked (by the nursing staff) Housekeeping staff
case in yellow colour coded bin and soak in 1% Sod. Hypochlorite
Solution for 30 mins.
3 The treated linen to be washed thoroughly dried and sent for laundry. Housekeeping staff
4 To segregate and collect solid and mutilated / shredded plastic waste Housekeeping staff
in yellow colour coded bins with yellow bags.
5 To transfer the waste along with the yellow bag into another labelled Housekeeping staff /
yellow bag and transported to BMW curb point, to be collected by authorized
authorized contractor. contractor
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A. Biomedical Waste Poster
Note:
Cytotoxic waste is not applicable for HCG multispecialty hospitals. It has been kept in the poster for
general information of all healthcare workers.
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Label for transport of BMW bags
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F. Flow sheet for Bio-medical waste
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POLICY ON ISOLATION
A. Purpose
A.1. To ensure proper infection control practices in isolation area

A.2. The aim of isolation is to confine organisms and block routes of spread is just one aspect of an
organization-wide strategy to reduce and prevent Healthcare Associated infections and requires an
overall corporate commitment.
A.3. To establish guidelines for Isolation Precautions at HCG Multi Specialty Hospitals, Ahmedabad to
meet the following objectives:
1. To employ epidemiologically sound isolation practices;
2. To recognize the importance of all body fluids, secretions, and excretions in the
transmission of nosocomial infections;
3. To contain adequate precautions for infections transmitted by the airborne, droplet and
contact routes of transmission; and
A.4 To be as simple and user friendly as possible.
A.5 The aim of isolation is to confine organisms and block routes of spread is just one aspect of an
organization-wide strategy to reduce and prevent Healthcare Associated infections and requires an
overall corporate commitment.
B. Scope
B.1 All health care workers associated with Isolation room, Patient’s relatives and visitors.
C. Responsibility
C.1. Overall responsibility of implementation of this policy lies with infection control committee,
Infection control team, doctors, nursing staff and housekeeping staff.
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D. Definitions:
D.1. Standard Precautions are designed to reduce the risk of transmission of microorganisms from
both recognized and unrecognized sources of infection in hospital.
D.2. Transmission-based Precautions are designed for patients documented (confirmed) or suspected
to be infected or colonized with highly transmissible or epidemiologically important pathogens
for which additional precautions beyond Standard Precautions are needed to interrupt
transmission in hospital. Transmission-based Precautions are to be used on an empiric,
temporary basis until a diagnosis can be made; these empiric, temporary precautions are to be
used in addition to Standard Precautions.
D.3. There are three types of Transmission-based Precautions: Airborne Precautions, Droplet
Precautions, and Contact Precautions. They may be combined for diseases which have multiple
routes of transmission. When used either singularly or in combination, they are to be used in
addition to Standard Precautions.
D.4. Universal Precautions – the name the CDC uses to describe a very aggressive plan which treats all
blood and body fluids as a source of contamination and infection.
D.5. Chain of Infection – the spread of infection within a hospital requiring three elements: a source of
infecting microorganisms, a susceptible host, and a means of transmission for the microorganism.
D.6. Source – human sources of the infecting microorganisms in hospitals may be patients, personnel,
or on occasion, visitors. Other sources of infecting microorganisms can be patient’s own
endogenous flora and inanimate environment objects which have become contaminated,
including equipment and medications.
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D.7. Host – an organism which harbors and provides nourishment for a parasite
D.8. Transmission – Microorganisms transmitted in hospitals by several routes. The same
microorganism may be transmitted by more than one route. There are five main routes of
transmission – contact, airborne, common vehicle and vector borne.
D.9. Direct-contact transmission – a direct body surface-to-body surface contact and physical transfer
of microorganisms between a susceptible host and an infected or colonized person.
D.10. Indirect-contact transmission – contact of a susceptible host with a contaminated intermediate
object, usually inanimate, such as contaminated instrument or dressings, or contaminated gloves
not changed between patients.
D.11. Droplet transmission – droplets generated from the source person primarily during coughing,
sneezing, talking and during the performance of 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 hosts
conjunctivae, nasal mucosa or mouth.
D.12. Airborne Transmission occurs by dissemination of either airborne droplet nuclei (small-particle
residue [5 microns or smaller in size] of evaporated droplets containing microorganisms which
remain suspended in the air for long periods of time) or dust particles containing the infectious
agents. Microorganisms carried in this manner can be widely dispersed by air currents and may
become inhaled by a susceptible host within the same room or over a longer distance from the
source patient depending on environmental factors.
D.13. Common Vehicle Transmission applies to microorganisms transmitted by contaminated items
such as food, water, medications, devices and equipment.
D.14. Vector-borne Transmission occurs when vectors such as mosquitoes, flies, rats, and other vermin
transmit microorganisms.
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E. Policy
E.1 HCG-MS will have two-tiers of isolation precautions:
E.1.1 In the first, and most important, tier are those precautions designed for the care of all patients in hospital
regardless of infectious status. Implementation of these “Standard Precautions” is the primary strategy for
successful nosocomial infection control.
E.1.2 In the second tier are precautions designed only for the care of specialized patients. HCG multispecialty
hospital has two isolation rooms on the third floor, which admits patients requiring special care. One room is a
positive pressure isolation room and the other Negative pressure isolation room. Both rooms have different
AHU’s. “Transmission-based Precautions” are used for all patients suspected to be infected or colonized with
epidemiologically important pathogens which can be transmitted by airborne or droplet transmission or by
contact with dry skin or contaminated surfaces.
Patients who are suspected of transmissible diseases are kept in these rooms according to their conditions till
there is documented evidence of positive or negative result. In case of negative finding the patient is shifted to
ICU/room as per the clinical demands.
F.PROCEDURES
F.1 Fundamentals of isolation precautions:
F.1.1 A variety of infection control measures are used for decreasing the risk of transmission of
microorganisms in hospital. These measures make up the fundamentals of isolation precautions.
F.2 Hand washing and gloving
F.2.1 Hand washing is frequently called the single most important measure for preventing spread of
infection.
F.2.2 Washing hands as promptly and thoroughly as possible between patient contacts and after blood,
body fluids, secretions, excretions and equipment or articles contaminated by them is an important
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component of infection control and isolation precautions. In addition to hand washing, gloves play an
important role in the prevention of the spread of infection.
F.2.3 Gloves are worn for three important reasons in hospitals. First, gloves are worn to provide a
protective barrier and prevent gross contamination of the hands when touching blood, body fluids,
secretions, excretions, mucous membranes and non-intact skin; the wearing of gloves in specified
circumstances to reduce the risk of exposures to blood borne pathogens. Second, gloves are worn to
reduce the likelihood microorganisms present on the hands of personnel will be transmitted to patients
during invasive or other patient-care procedures involving touching a patient’s mucous membranes and
non-intact skin. Third, gloves are worn to reduce the likelihood the hands of personnel contaminated
with microorganisms to another patient. In this situation, gloves must be changed between patient
contacts and hands washed after gloves are removed.
F.2.4 Wearing gloves does not replace the need for hand washing because:
F.2.4.1 Gloves may have small in apparent defects or be torn during use, and
F.2.4.2 Hands can become contaminated during removal of gloves.
F.2.5 Failure to change gloves between patient contacts is an infection control hazard.
F.3 Patient Placement

F.3.1 Appropriate patient placement is an important component of isolation precautions. When
possible, patients with highly transmissible or epidemiologically important microorganisms are placed in
an isolation room with hand washing and toilet facilities to reduce opportunities for transmission of
microorganisms. A private (isolation) room is also important to prevent direct- or indirect-contact
transmission when the source patient has poor hygienic habits, contaminates the environment, or
cannot be expected to assist in maintaining infection control precautions to limit transmission of
microorganisms.
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F.3.2 When a private single room is not available, infected patients are placed with appropriate
roommates. Patients infected by the same microorganism can usually share a room provided:
F.3.2.1 They are not infected with other potentially transmissible microorganisms and
F.3.2.2 The likelihood of re-infection with the same organism is minimal.
F.3.3 Such sharing of rooms, also referred to as cohorting patients, is especially useful during outbreaks
or when there is a shortage of private rooms. When a private room is not available and cohorting is not
achievable or recommended, it is very important to consider the epidemiology and mode of
transmission of the infecting pathogen and the patient population being served in determining patient
placement. Under these circumstances, consultation with infection control professional is advised
before patient placement.
F.4 Transport of Infected Patients:
F.4.1 Limiting the movement and transport of patients infected with virulent or epidemiologically
important microorganisms, and ensuring such patients leave their rooms only for essential purposes,
reduces opportunities for transmission of microorganisms in hospital. When patient transport is
necessary, it is important that:
F.4.2 Appropriate barriers (i.e. mask, impervious dressings) are worn or used by the patient to reduce
the opportunity for transmission of pertinent microorganisms to other patients, personnel and visitors
and to reduce contamination of the environment.
F.4.3 Personnel in the area to which the patient is to be taken are notified of the impending arrival of
the patient and of the precautions to be used to reduce the risk of transmission of infectious
microorganisms; and
F.4.4 Patients are informed of ways by which they can assist in preventing the transmission of their
infectious microorganisms to others.
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All notifiable diseases as per local regulatory laws are informed by MRD (Refer policy: MRD)
F.5 Mask, Respiratory Protection, Face Shields:
F.5.1 Various types of masks, goggles and face shields are worn alone or in combination to provide
barrier protection. A mask which covers both the nose and mouth, and goggles or face shields are worn
during procedures and patient care activities likely to generate splashes or sprays of blood, body fluids,
secretions or excretions to provide protection of the mucous membranes of the eyes, nose and mouth
from contact transmission of pathogens. A surgical mask is generally worn to provide protection against
spread of infectious large particles droplets transmitted by close contact and generally travel only short
distances (up to 3 feet) from infected patients who are coughing or sneezing.
F.6 Gowns and Protective Apparel

F.6.1 Various types of gowns and protective apparel are worn to provide barrier protection and to
reduce opportunity of microorganisms in hospital. Gowns are worn to prevent contamination of
clothing and protect the skin of personnel from blood and body fluid exposures. Gowns especially
treated to make them impermeable to liquids, leg coverings, boots or shoe covers provide greater
protection to the skin when splashes or large quantities of infective material are present or anticipated.
F.7 Patient Care Equipment and Articles

F.7.1 Many factors determine whether special handling and disposal of used patient-care equipment
and articles is prudent or required, including the likelihood of contamination with infective material; the
ability to cut, stick, or otherwise cause injury (needles, scalpels and other sharp instruments[sharps]);
the severity of the associated disease; and the environmental stability of the pathogens involved. Used
sharps are placed in puncture-resistant containers; other articles are placed in a bag.
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F.7.2 Contaminated reusable critical medical devices or patient-care equipment (i.e. equipment which
enters normally sterile tissue or through blood flows) or semi-critical medical devices or patient-care
equipment (i.e., equipment which touches mucous membranes) are sterilized or disinfected
(reprocessed) after use.
F.7.3 Non-critical equipment (i.e., equipment which touches intact skin) contaminated with blood, body
fluids, secretions or excretions is cleaned and disinfected after use. Contaminated disposable (single-
use) patient care equipment is handled and transported in a manner which reduces the risk of
transmission of microorganisms and decreases environmental contamination in the hospital. The
equipment is disposed of according to hospital policy and applicable regulations.
F.8 Linen and Laundry

F.8.1 Although soiled linen may be contaminated with pathogenic microorganisms, the risk of disease
transmission is negligible if it is handled, transported and laundered in a manner which avoids transfer
of microorganisms to patients, personnel and environments.
Rather than rigid rules and regulations, hygienic and common sense storage and processing of clean and
soiled linen are recommended.
(Refer Management of Linen policy HCGMS/HIC/02)
F.9 Dishes, Glasses and Cups and Eating Utensils

F.9.1 No special precautions are needed for dishes, glasses and cups, or eating utensils. Either
disposable or reusable dishes or utensils can be used for patients on isolation precautions. The
combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate
dishes, glasses and cups, and eating utensils.
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F.10 Routine and Terminal Cleaning

F.10.1 The room or cubicle and bedside equipment of patients or isolation precautions are cleaned
using the same procedures used for other patients unless the infecting microorganism(s) and the
amount of environmental contamination indicates special cleaning.
F.11 Standard Precautions

F.11.1 Standard Precautions synthesize the major features of Universal (Blood and Body Fluid)
Precautions (designed to reduce the risk of transmission of blood borne pathogens) and Body Substance
Isolation (designed to reduce the risk of transmission of pathogens from moist body substances) and
applies them to all patients receiving care in hospital regardless of their diagnosis or presumed infection
status. Standard Precautions apply to:
1. Blood
2. All body fluids, secretions and excretions regardless of whether or not they
contain visible blood
3. Non-intact skin, and
4. Mucous membranes
F.12 Transmission-Based Precautions
F.12.1 Transmission-based Precautions are designed for patients documented or suspected to be
infected with highly transmissible or epidemiologically important pathogens for which additional
precautions beyond Standard Precautions are needed to interrupt transmission in hospital. There are
three types of Transmission-based Precautions: Airborne Precautions, Droplet Precautions and Contact
Precautions. They may be combined together for diseases that have multiple routes of transmission.
When used either singularly or in combination, they are to be used in addition to Standard Precautions.
F.12.1.1 Airborne Precautions are designed to reduce the risk of airborne transmission of infectious
agents. Airborne transmission occurs by dissemination of either airborne droplet nuclei (small-particle
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residue [5 microns or smaller in size] of evaporated droplets containing microorganisms which remain
suspended in the air for long periods of time) or dust particles containing the infectious agents.
Microorganisms carried in this manner can be widely dispersed by air currents and may become inhaled
by a susceptible host within the same room or over a longer distance from the source patient
depending on environmental factors. Airborne Precautions apply to patients known to or suspected to
be infected with epidemiologically important pathogens that can be transmitted by the airborne route.
F.12.1.2 Droplet Precautions are designed to reduce the risk of droplet transmission of infectious
agents. Droplet transmission involves contact of the conjunctivae, or the mucous membranes of the
nose or mouth of a susceptible person with large-particle droplets (larger than 5 microns in size)
containing microorganisms generated from a source person who has a clinical disease or is a carrier of
the microorganisms. Droplets are generated from the source person primarily during coughing,
sneezing, talking and during the performance of certain procedures such as suctioning and
bronchoscopy. Transmission via large particle droplets requires close contact between source and the
recipient persons since droplets do not remain suspended in the air and generally travel only short
distances, usually 3 feet or less, through the air. Droplet Precautions apply to any patient known or
suspected to be infected with epidemiologically important pathogens which can be transmitted by
infectious droplets.
F.12.1.3 Contact Precautions are designed to reduce the risk of transmission of epidemiologically
important microorganisms by direct or indirect contact. Direct –contact transmission involves skin-to-
skin contact and physical transfer of microorganisms to a susceptible host from an infected or colonized
person, such as occurs when personnel turn a patient, give a patient a bath or perform other patient-
care activities requiring physical contact. Direct-contact transmission can also occur between two
patients (e.g., by hand contact), with one serving as the source of infectious microorganisms and the
other as a susceptible host with a contaminated intermediate object, usually inanimate in the patient’s
environment. Contact precautions apply to specific patients known or suspected to be infected or
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colonized (presence of microorganisms in or on patient but without clinical signs and symptoms of
infection) with epidemiologically important microorganisms which can be transmitted by direct or
indirect contact.
F.13 Empiric Use of Airborne, Droplet or Contact Precautions

F.13.1 In many instances, the risk of nosocomial transmission of infection may be highest before a
definitive diagnosis can be made and precautions based on a diagnosis implemented. The routine use of
Standard Precautions for all patients should greatly reduce this risk for conditions other than those
requiring Airborne, Droplet or Contact Precautions. While it is not possible to prospectively identify all
patients needing these enhanced precautions, certain clinical syndromes and conditions carry a
sufficiently high risk to warrant the empiric addition of enhanced precautions while a more definitive
diagnosis is pursued.
F.14 Standard Precautions

(Refer Policy on Standard Precautions HCGMS/HIC/03)
F.15 Airborne Precautions

F.15.1 In addition to Standard Precautions, use Airborne Precautions, or equivalent, for patients known
or suspected to be infected with microorganisms transmitted by airborne droplet nuclei (small-particle
residue [5 microns or smaller in size] of evaporated droplets containing microorganisms which remain
suspended in the air and can be widely dispersed by air currents within a room or over a long distance.
F.15.2 Keep the room door closed and the patient in the room. When a private room is not available,
place the patient in a room with a patient who has active infection with same microorganism, unless
otherwise recommended, but with no other infection. When a private room is not available and
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cohorting is not desirable, consultation with infection control professionals is advised before patient
placement.
F.16 Respiratory Protection

F.16.1 Wear respiratory protection when entering the room of a patient with known or suspected
infectious tuberculosis. Do not enter the room of patients known or suspected to have measles (rubella)
or varicella (chickenpox) if susceptible to these infections.
F.17 Patient Transport

F.17.1 Limit the movement and transport of the patient from the room for essential purposes only. If
the transport or movement is necessary, minimize patient dispersal of droplet nuclei by placing a
surgical mask on the patient, if possible.
F.18 Droplet Precautions

F.18.1 In addition to Standard Precautions, use Droplet Precautions, or equivalent, for a patient known
or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets [larger
than 5 microns in size]) generated by the patient during coughing, sneezing, talking or the performance
of procedure.
F.19 Patient placement

F.19.1 Place the patient in a private room. When a private room is not available, place the patient in a
room with patient(s) who has /have active infection with the same microorganism, but with no other
infection (cohorting). When a private room is not available and cohorting is not achievable, maintain
spatial separation of at least 3 feet between the infected patient and other patient and visitors.
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F.19.2 Mask
F.19.2.1 In addition to Standard Precautions, wear mask when working within 3 feet of the patient.
F.20 Patient Transport

F.20.1 Limit the movement and transport of the patient from the room for essential purposes only. If
the transport or movement is necessary, minimize patient dispersal of droplet nuclei by masking the
patient, if possible.
F.21 Contact Precautions

F.21.1 In addition to Standard Precautions, use contact Precautions, or equivalent for specified patients
known or suspected to be infected or colonized with epidemiologically important microorganisms
transmitted by direct contact with the patient (hand or skin-to-skin contact occurring when performing
patient-care activities requiring touching the patient’s dry skin) or indirect contact touching with
environmental surfaces or patient-care items in the patient’s environment.
F.22 Patient placement

F.22.1 Place the patient in a private room. When a private room is not available, place the patient in a
room with patient(s) who has /have active infection with the same microorganism, but with no other
infection (cohorting). When a private room is not available and cohorting is not achievable, consider the
epidemiology of the microorganism and the patient population when determining patient placement;
consultation with infection control professionals is advised before patient placement.
F.23 Gloves and Hand washing

F.23.1 In addition to wearing gloves as outlined under Standard Precautions, wear gloves (clean, non-
sterile gloves are adequate) when entering the room. During the course of providing care for a patient,
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change gloves after having contact with infective material which may contain high concentrations
microorganisms (fecal material and wound drainage). Remove gloves before leaving the patient’s room
and wash hands immediately with an antimicrobial agent. After glove removal and hand washing,
ensure hands do not touch potentially contaminated environmental surfaces or items in the patient’s
room to avoid transfer of microorganisms to other patients or environments.
F.24 Gown
F.24.1 In addition to wearing a gown as outlined under Standard Precautions, wear a gown (a clean,
non-sterile gown is adequate) when entering the room if you anticipate your clothing will have
substantial contact with the patient, environmental surfaces, or items in the patient’s room, or if the
patient is incontinent, or has diarrhoea, an ileostomy, a colostomy, or wound drainage not contained by
a dressing. Remove the gown before leaving the patient’s environment. After gown removal, ensure
clothing does not contact potentially contaminated environmental surfaces to avoid surfaces to avoid
transfer of microorganisms to other patients or environments.
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Policy on Hospital cleaning

A. Purpose
A.1 To provide guideline for the hospital Housekeeping service which further ensure that
1. Cleaning of each and every area of hospital
2. Proper monitoring of cleaning
3. Availability of resource
A.2 To maintain the hospital environment, interiors and exteriors in hygienic and best sanitary condition
and to ensure that the environment is safe, aesthetically pleasing and clean at all times.
B. Scope
B.1 Hospital wide
C. Responsibility
C.1. Overall responsibility of implementation of this policy lye with infection control committee.
E. Policy
E.1 Complete hospital including patient care and non-patient care areas shall be kept clean from dust, garbage and
other wastes. It shall be ensured that all rooms, corridors, toilets, corners, floors, ceilings, walls, window sills,
doors etc. shall be kept clean and kept dust free all the times.
E.2 Housekeeping shall define the frequency of cleaning of various areas as per the cleaning requirement and
workload.
E.3 Cleaning and sanitation activities in the hospital shall focus on following aspects:
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E.3.1 Basic cleaning – This includes dusting, sweeping, polishing and washing of various areas of the hospital.
These procedures shall be carried out as per standardized method documented in this document.
E.3.2 Special cleaning – This includes special cleaning requirements for certain types of floors, walls and ceilings,
doors and windows, furniture and fixtures and blinds. Housekeeping staff shall be aware of these special
cleaning requirements and these shall be monitored by their supervisors.
E.3.3 Cleaning of toilets – Toilets in patient rooms, wards, public areas and offices shall be specially focused to
keep them clean and hygienic. Cleaning schedule shall be fixed by housekeeping department and monitored
by housekeeping supervisor.
E.3.4 Odour control – Housekeeping shall identify and treat various types of unwanted odor in hospital premises.
These odors shall be controlled and removed through use of appropriate room fragrance.
E.3.5 Waste management – General and Biomedical waste shall be segregated, transported, collected and
disposed off strictly as per document ‘Management and handling of Biomedical waste, (document no.
HCGMS/HIC/06-00) and as per the defined frequency).
E.3.6 Pest, rodent and animal control – Pest and rodent repellant sprays shall be used at all areas for effectively
controlling pests and rodents. Animals shall not be allowed in the hospital premises. No unwanted openings
in walls and ceilings shall be kept, to prevent entry of birds and insects. Complete pest control activity shall
be undertaken at regular interval.
E.3.7 Interior décor – Interiors shall be kept in such condition so as to:
1. Create environment pleasant to patient, staff and visitors
2. Create and maintain aesthetic colour scheme
3. Make aesthetic and suitable arrangement in wards / departments
4. Ensure proper lighting and ventilation in public areas
E.3.8 Housekeeping equipment maintenance – For effective sanitation activities, all housekeeping equipments
and materials shall be in appropriate stock and stored at designated places. These shall always be
maintained at best functional condition and replaced after its expiry period.
E.3.9 Cleaning agent – Best cleaning agent and good cleaning products shall be used for housekeeping activities
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E.4 General cleaning agent

COMPANY: Taski Diversey
Product Product Description Usage
Taski R1 Super Bathroom cleaner-cum-Sanitizer 20 ml in 1 lt. of water

concentrate
Taski R2 Hygienic hand surface cleaner 20 ml in 1 lt. of water

concentrate
Taski R3 Glass cleaner concentrate 20 ml in 1 lt. of water
Taski R4 Furniture maintainer Ready-to-use
Taski R5 Air freshener Ready –to-use
Taski R6 Toilet bowl cleaner Ready-to-use
Taski R7 Floor cleaner concentrate 20 ml in 1 lt. of water
Taski R9 Bathroom cleaner concentrate 20 ml in 1 lt. of water
(Specific to hard water location)
E.4.1 Deep cleaning agent

Product name: Bacillocid Extra
Composition: Each 100 gm contains: (Ethylenedioxy) dimethanol-14.1 g
Glutaraldehyde-5.0 g
Preparation:
To 5 lt. of water add:
 25 ml bacillocid to get 0.5% solution-Standard disinfection

 Or 50 ml bacillocid to get 1% solution-O.T disinfection
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Uses:
1. For consulting rooms, dressing rooms, wards, etc.

(Use 0.5% solution. wash floors and other tiled surfaces and other inaccessible areas)
2. For Operation Theaters & Critical Care Areas.

(Use 1% solution; Wet surfaces of tiled walls, trolleys, operation tables & floors evenly. Solution can also
be used in Fogging Machines)
E.5 Cleaning of generally neglected areas – Following areas which generally are neglected should be focused and
included in hospital sanitation program. These areas include:
1. Terrace
2. Lift room
3. Rooms with water plant or other heavy machineries installed
4. Window sills
5. Door knobs
6. AC ducts
7. Outer ground areas of the hospital
8. Parking spaces
9. Biomedical Waste Storage area
10. Rarely used storage areas
E.6 Standard Time Requirement

E.6.1 Although standard time to be dedicated for various cleaning and sanitation activities shall be determined as
per workload and operational situation, following standard can be taken as a reference:
Cleaning activity Time required per 1000 sq. ft.

Dry Mopping 6 Min.
Wet Mopping 12 minutes
Machine scrubbing 2 hours
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F.7 Standard procedure for cleaning activities

F.7.1 Dusting
1. Fold cloth in series of squares. (This permits many clean surfaces.) A surface cannot be cleaned with a soiled
cloth, and a cloth carelessly wadded provides insufficient clean areas.
2. For dusting the room, commence at entrance and proceed around the room clockwise.
3. To prevent overlapping of strokes and skipping corners and edges, use long straight strokes. Hold cloth
loosely so that it will absorb dust easily. Avoid flicking duster since this action raises dust.
4. Start with highest point to be dusted and work down towards the floor.
5. Two cloths-one in each hand-may be used to save lime.
6. Inspect work. A properly dusted area will be bright and will appear clean. It will be free of dust streaks, oily
spots and smudges
F.7.2 Sweeping
1. In unobstructed floor area where relatively large amount of small dirt particles accumulate, the 60-inch
stroke is most efficient.
2. If dirt consists of small particles, the 3-foot push stroke is recommended. The brush may be tapped on the
floor to clear it of dirt at the end of each stroke.
3. If the outer edges of an area are particularly dirty, sweep dirt away from wall to about a foot before
continuing general sweeping. Use counter brush in corners.
4. If dirt consists mainly of large particles and fine soil and if area is unobstructed, the continuous stroke may
be used.
5. If area is busy thoroughfare, one side should be swept while traffic is directed to the other
F.7.3 Mopping
1. Fill one container two-third full with cleaning solution. If bucket is not on cart, place on mat, tie cloth around
bucket, or place on a little spilled water to avoid staining floor.
2. Fill second container two-third with clear warm water.
3. Sweep floor first if necessary, moving furniture to simplify operation.
4. Dip one mop into cleaning solution and wring slightly to prevent dripping.
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5. At beginning of stroke, stand with feet well apart. Place mop flat on floor about 4 feet to left side. Handle at
40 degree angle. Pull mop along edge of floor next to baseboard to depth of 6 to 8 inches. This prevents
splashing baseboard.
6. Take position. Move mop to right in arc-like stroke, in front of body, parallel to baseboard to avoid splashing
wall. Mop stroke should be spread out for maximum coverage.
7. At end of 6 to 9 foot stroke, renew direction by tapping mop and swinging it from right to left. By developing
rhythm, no time is lost in change of direction. (By push-pull method one-third more time is consumed. Worker
is in awkward position, causing him to become tired and limiting him to four-foot stroke.) Width of stroke
depends on height and weight of worker. The person performing mopping works backward, continues figure
"8" in front of him until mop is ready for second dipping (after about 120 square feet)
8. Dip second mop in container of clean water, wring out and rinse the floor.
9. Dip the second mop again into water rinse, wring it thoroughly and dry floor using side to side stroke.
10. Continue the three steps of mopping, rinsing and drying until the area has been covered. To avoid streaks,
overlap strokes.
11. Wipe of baseboards immediately with a damp cloth if any water has been splashed.
12. Change solution and water frequently.
13. Inspect work. A properly mopped floor should have a clean surface. There should be no water spots. The
corners should be clean.
14. After mopping is completed, clean mops and buckets.
E.7.4 Washing
1. Fill one container two-third full with cleaning solution.
2. Fill second container two-third full with warm water.
3. Wipe away loose dirt in area with dry, clean cloth.
4. Dip cloth or sponge into cleaning solution. Wring cloth or squeeze sponge to prevent dripping.
5. Wash small area with circular motion.
6. Dip second cloth or sponge into clear water; remove excess water, rinse-wash area with up-and-down motion.
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7. Dip cloth or sponge, rinse same area with side-to-side motion.

8. Dry with third dry cloth.
9. Continue washing, rinsing and drying over entire area; overlap strokes to prevent streaking.
10. Use ladder or scaffold to wash high places or fixtures.
11. Change water frequently.
12. Inspect work. A properly washed area should be uniformly clean with no streaks; no water spilled on the floor
or other furnishings.
13. Clean equipment as directed and return to proper place.
E.7.5 Scrubbing
1. Sweep floor if necessary.
2. Dampen area to be scrubbed (as described under mopping)
3. Sprinkle cleanser lightly over area which has been dampened, if necessary.
4. With scrub brush or scrubbing machine, scrub area with back and forth motion. Machine scrubs in circular
movements. Start in corner of room and work towards door.
5. For particularly soiled area, use steel wool by hand or under brush.
6. Remove dirty solution with squeezes mop or vacuum. Never put soiled solution in clean container.
7. Dip second mop into container of clear water, wring out, and rinse floor with' side to side motion and to avoid
streaks, overlap strokes.
8. Continue wetting, scrubbing, picking up soiled solution and rinsing until entire area has been covered.
9. Change solution and water frequently.
10. Inspect your work. A properly scrubbed floor has no soiled spots, is not streaked, and has no water spots
remaining on it.
11. After scrubbing is completed, clean equipment as directed and return them to proper place.
E.7.6 Cleaning of toilets
E.7.6.1 The public toilets and the staff toilets are cleaned thoroughly twice a day i.e. at 8:00am and 8.00pm.
The cleaning procedure is as follows:
1. Wash the room with water
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2. Remove all the cobwebs, if found.

3. Take a cloth and rinse it in water and squeeze it. Clean the tiles above the shoulder level using the wet cloth.
4. Put 10ml toilet cleaner Harpick solution to the WC and do the brushing. Keep aside for 20 minutes.
5. Take one bucket of water (20 Liters) and add 50mL of Bacillofloor (disinfectant cleaning solution). Take a nylon
brush and clean all the fixtures such as taps, geysers, washbasin and walls using the solution.
6. Wash the WC thoroughly with water.
7. Sprinkle the Bacillofloor solution onto the floor and scrub the ground with the Brush for 10 minutes and then
wipe the floor. Take a bucket of water and add 50mL of Lyzol (Disinfectant cleaning solution) and mop the
floor by using this solution.
8. Take a dry cloth or mop and wipe the bathroom completely.
9. Toilet Cleaning – Thorough Cleaning: All the toilets are cleaned thoroughly once a week. The procedure is as
follows:
10. Flush the toilet thoroughly.
11. Remove the water from the WC by using cloth. Drain the water completely.
12. If any stains appear, clean it with bleaching powder. Put Harpik solution and brush and keep aside for 15
minutes.
13. Clean with water and flush.
14. Close the valve to the Flush Board. Remove the water from the Board and clean with brush thoroughly.
15. Clean with water and remove the water from the board and open the valve and flush the toilet.
E.7.7 Pest Control

1. The contractor’s assigned employee must carry out pest control of the entire Hospital and its premises.
2. Sanitary inspector must allot the Pest control supervision work to Housekeeping Supervisor of the area where
the pest control activity is taking place. The work of Pest control involves spraying the pest control solution in
vacant patient rooms, all the bathrooms, hospital Records keeping areas, patient waiting areas etc. This will be
performed every day and the person will get endorsement from the person who is in the department in a
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prescribed form for maintenance of record. In case the cleaning staff finds rodents or cockroaches, immediate
action must be taken to destroy them.
3. The contractor’s employee assigned for pest control activities shall report to the sanitary inspector of the area.
The assigned employee has to report on completion of his task of designated spraying pesticides in various
areas.
4. The Pest control personnel will also report to sanitary inspector/ operations manager and take his signature in
the above form and record will be maintained.
E.7.8 Biomedical waste management
1. Housekeeping staff is responsible for in-hospital transportation, packing, documentation and storage in
central storage area till GPCB registered contract personnel collects the duly segregated waste for final
disposal of Bio-medical waste.
2. Refer biomedical waste management Policy Ref. No. HCGMS/HIC/08
E.7.9 House Keeping in Wards
1. A patient admitted to the hospital can acquire infection due to microorganisms that survive in the
environment. Therefore, it is important to clean the environment thoroughly on a regular basis. This will
reduce the microbial or bio-burden and make the environment safe.
2. The floor is to be cleaned at least twice in 24 hours. Detergent and copious amounts of water should be used
during cleaning. EPA approved non-aldehyde based surface disinfectant may be used to mop floor and other
horizontal surfaces.
3. The walls are to be washed with a brush, using detergent and water once a week
4. High dusting is to be done with a wet mop
5. Fans and lights are cleaned with soap and water once a month.
6. All work surfaces are to be disinfected by wiping with EPA approved non aldehyde based surface disinfectant.
After that they should be cleaned with detergent and water twice daily.
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7. Cupboards, shelves, beds, lockers, IV stands, stools and other fixtures are to be cleaned with detergent and
water once a week.
8. Curtains are to be changed once a month or whenever soiled. These curtains are to be sent for regular
laundering. In critical patient care areas, e.g. Transplant units and ICUs, chemotherapy unit etc., more
frequent changes are required.
9. Patient’s cot is to be cleaned every week with detergent and water. 1% sodium hypochlorite to be used when
soiled with blood or body fluids. In the isolation ward, cleaning is done in this manner daily.
10. Store rooms are to be mopped once a day and high dusted once a week.
11. The floor of bathrooms is to be cleaned with a nylon brush and 1% sodium hypochlorite once a day and then
disinfected.
12. Toilets are cleaned with a brush using a detergent twice a day (in the morning and evening). Disinfection and
stain remover solution may be used.
13. Wash basins are to be cleaned every morning.
14. Regular maintenance of A.C. should be performed by maintenance department as per the scheduled protocol.
E.7.10 Patient linen
1. Bed linen is to be changed daily and whenever soiled with blood or body fluids.
2. Patient’s gown/dress is to be changed every day and whenever soiled with blood or body fluids.
3. Dry dirty linen is to be sent to the laundry for regular wash.
4. Linen soiled with blood or body fluids, and all linen used by patients diagnosed to have HIV, HBV, HCV, VRE
and MRSA, is to be decontaminated before being sent to the laundry.
E.7.11 Miscellaneous items
1. Kidney tray, basin, bed pan, urinal, etc. will be decontaminated as per hospital guidelines for decontamination
of reusable medical devices.
E.7.12 Housekeeping in the operation theatre
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1. Theatre complex should be absolutely clean at all items. Dust should not accumulate at any region in the
theatre.
2. Soap solution is recommended for cleaning floors and other surfaces. Operating rooms are cleaned daily and
the entire theatre complex is cleaned thoroughly once a week.
3. Before the start of the 1st case:
3.1 Wipe all equipment, furniture, room lights, suction apparatus, OT table, surgical light reflectors, other light
fittings, slabs etc with soap solution. This should be completed at least one hour before the start of surgery
E.7.12.1 Linen & gloves
1. Gather all soiled linen and towels in the receptacles provided. Take them to the service corridor (behind the
theatre) and place them in trolleys to be taken for sorting. The dirty linen is then sent to the laundry. Use
gloves while handling dirty linen.
E.7.12.2 Instruments
1. Used instruments are cleaned immediately by the scrub nurse and the attendant. Reusable sharps are
decontaminated in Lysol / hypochlorite and then washed in the room adjacent to the respective O.R. by
scrubbing with a soft brush and liquid soap. They are then rinsed and sent for sterilization in the CSSD. After
septic cases the instruments are sent in the instrument try for autoclaving. Once disinfected, they are taken
back to the same instrument cleaning area for a manual wash described earlier. They are then packed and re-
autoclaved before use.
E.7.12.3 Environment
1. Wipe used equipment, furniture, OR table etc., with detergent and water. If there is a blood spillage, disinfect
with sodium hypochlorite before wiping.
2. Empty and clean suction bottles and tubing with sodium dichloroisocyanurate, clean-n-sept tablets
appropriately diluted freshly as per manufacturer’s recommendations, please refer product leaflet.
E.7.12.4 After the last case
1. The same procedures as mentioned above are followed and in addition the following are carried out.
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2. Wipe over head lights, cabinets, waste, equipment, furniture etc with EPA approved, non-aldehyde based
surface disinfectant.
3. Wash floor with floor disinfectant and remove water with wet mop.
4. Clean the storage shelves and clean the sluice room.
E.7.12.5 Weekly cleaning procedure

1. Remove all portable equipment.
2. Damp wipes lights and other fixtures with detergent.
3. Clean doors, hinges, facings, glass inserts and wipe with a cloth moistened with detergent.
4. Wipe down walls with clean cloth, mop with detergent.
5. Scrub floor using detergent and water or use a floor disinfectant.
6. Stainless steel surfaces – clean with detergent, rinse & clean with warm water.
7. Replace portable equipment: Clean wheel castors by rolling across toweling saturated with detergent.
8. Wash (clean) and dry all furniture and equipment (OT table, suction holders, foot & sitting stools, Mayo
stands, IV poles, basin stands, X-ray view boxes, hamper stands, all tables in the room, holes to oxygen tank,
kick buckets and holder, and wall cupboards)
9. After washing floors, allow disinfectant solution to remain on the floor for at least 5 minutes to ensure
disinfection activity.
E.7.12.6 Maintenance and Repairs (to be carried out by the Biomedical Engineer)
1. Machinery and equipment should be checked, cleaned routinely and repaired when needed.
2. Urgent repairs should be carried out at the end of the days list
3. Air conditioners and suction points should be checked, cleaned and repaired on a weekly basis.
4. Preventive maintenance on all theatre equipment to be carried out weekly and major work to be
done at least once every year
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E.7.13 Monitoring of system

1. Sanitary inspector: He is responsible for allocating the resources i.e. manpower and consumables.
Liaise between the Management and the Agency regarding the attendance, salary and bills. He is also
responsible for Quality of material and work; and monitoring of system.
2. Housekeeping Supervisor: is responsible for allocating the duty to the housekeepers. Supervises the
work, attendance and conduct of the housekeepers.
3. House Keeper: is responsible for carrying out the cleaning activities in the assigned area. Is also
responsible for other activities such as shifting and arranging, whenever the supervisor or the
departmental head/ in charge orders it.
E.7.14 Housekeeping Rounds and Inspections

1. Sanitary inspector/Manager operations will evaluate and check all the cleaning agents for quality and
ensure that there is an optimum assessment and utilization of all the cleaning agents.
2. Supervises floor inspects all the areas assigned under them on a daily basis to identify malfunctioning
/ breakdown, leaks of flushing systems, taps, electric systems, air conditioners, televisions, telephone,
geysers, furniture, building areas, cupboards / lockers etc.
3. Sanitary inspector interacts with the patients and staff members to identify such problems /
complaints in cases where he/she may not have directly inspected the site.
4. Sanitary will prepare a service job requisition and send it to the facility Maintenance Department in
case of any problems regarding the engineering services. The housekeeping supervisors must follow
up with the engineering department till the service job requisition has been completed.
5. supervisor daily inspects and monitors the housekeeping activities of the areas assigned to them
through the Housekeeping Checklist
6. Sanitary inspector will go on rounds everyday to various areas, patient rooms and wards to ensure
that best services are provide to the patients and the housekeeping standards of the hospitals are
maintained.
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7. Every month sanitary inspector will check the quality of consumable used and report is submitted to
the high authority
8. Sanitary inspector is responsible for conducting the surprise visit to the any department and keep
watch on housekeeping work.
E.7.15 Staff/contractor Coordination

1. The housekeeping attendants will report to the supervisors at the end of their shift. Housekeeping
supervisors will take the attendance for the next shift staff, and if there is any absenteeism, the shift
attendants are requested to extend their duty hours.
2. If there are any hospital functions or extra work in the hospital like shifting departments, arranging a
new area, the housekeeping In-charge will prepare duty chart for extra duties.
3. Sanitary inspector will monitor the entire process, reports from the supervisors and will solve the
problems, which cannot be solved at the supervisors’ level.
4. The housekeeping equipments are supplied by the agency. The hospital provides the consumables
such as disinfectants, dustbin covers and stationery items.
5. Sanitary inspector must record the details of the internal issues made to the department personnel in
the daily consumption register and complaint register.
6. All the housekeeping staff wears apron and I.D. cards designated and use PPE (Personal protective
equipments) for their safety.
7. All the housekeeping staff shall given vaccination and attend annual health check up, the contractor is
responsible to submit the report to the sanitary inspector.
E.7.16 Training: Training of housekeeping staff shall be given high importance to effectively implement
the standard practice. Regular in-service training of existing staff and induction training of new staff shall
be carried out to train them on various cleaning methodologies.
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E.7.17 Safety: Safety being the utmost important aspect in our hospital, safety of housekeeping shall be
supplied with appropriate PPE and they shall be made aware about personal safety and occupational
health safety.
E.7.18 Hospital Ambulance Cleaning
1. Every morning ambulance deep cleaning should be done using the appropriate disinfectant by
ambulance attendant.
2. Regular cleaning to be done after shifting every patient and before taking patient by the
ambulance attendant.
3. If the ambulance has carried any infected patient, it should be deep cleaned thoroughly. Transfer
of infective patient should be informed to ICN.
4. Ambulance should be washed and dried under sunlight once every month.
5. Deep cleaning checklist to be maintained by ambulance department and cross checked by ICN on
regular basis.
6. Ambulance environmental surveillance shall be taken on quarterly basis in coordination with ICN.
7. Deep cleaning of the ambulance includes cleaning of all surfaces, equipments, patient care
articles, corners, lockers, with disinfectant.
8. Curtains and linens should be changed on weekly basis and whenever soiled or dirty.
9. BMW management to be followed as per the policy (Refer BMW Management Policy). Waste to
be removed from the ambulance after every patient shift.
10. In case blood and body fluid spill, management to be followed as per the policy (Refer Spillage
Management Policy).
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ANTIBIOTIC MANAGEMENT
A. Purpose
A.1 The principal aim of an antibiotic policy is to promote rational antibiotic use. Antibiotic restriction
should lead to a reduction of resistance, decreased cost and improved patient care. The aim of
implementing this policy throughout the Hospital is to ensure that antibiotics are used appropriately.
This should result in more effective treatment of infections so that patient outcomes are optimized.
In addition appropriate antibiotic use should minimize the risk of healthcare-associated infections
occurring and this produces benefits for patients and for service delivery and clinical outcomes.
B. Scope
B.1 All Patient Care Units
C. Responsibility
C.1 Overall responsibility of implementation of this policy is of the Infection Control Team under the
monitoring and supervision of Infection Control Committee.
D. Definition-NIL
E. Policy
E.1. Better definition of empiric treatment and duration of such treatment. Antibiotics usage shall be
monitored for checking the sensitivity pattern amongst microorganisms. Discourage inappropriate
combination antibiotic therapy unless indicated.
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E.2. Microbiology department shall generate a monthly report on sensitivity pattern of

microorganisms towards antibiotics in use. This report shall be circulated to all consultants every
month. Consultants shall use information from monthly microbiological report to structure their
empiric antibiotic treatment. A copy is also given to all facilities of the hospital and it is filed in the
IC file to be shared with inhouse and visiting consultants.
E.3. Consultants shall consider using the antibiotic sensitivity report (antibiogram).
E.4. The copy of the report shall also be send to pharmacy. Pharmacy shall monitor the dispensing of
antibiotic and keep a record of antibiotic usage. Any discrepancy in usage with the report
generated by microbiology department shall be brought in to the notice of infection control
committee. Antibiotic audit will be implemented to check irrational use of antibiotics.
E.5. Infection control committee shall monitor the implementation of this policy and rational use of
antibiotic.
F. Procedure
F.1 Restriction on antibiotic usage
F.1.1 The infection control committee can introduce restriction on the use of antibiotics as an essential
component of infection control program or to influence antibiotic prescribing, in specific clinical
areas where there are significant problems with healthcare-associated infections. Antibiotic
restrictions will only be implemented with the aim of healthcare associated infections.
F.1.2 Following practices shall be followed while prescribing antibiotics: Good practices for use of
antibiotics:
1. Consider whether or not the patient actually requires an antibiotic.

2. Avoid treating colonized patients who are not actually infected.
3. In general, do not change antibiotic therapy if the clinical condition is improving.
4. If there is no clinical response within 72 hours, the clinical diagnosis, the choice of antibiotic
and/or the possibility of a secondary infection should be reconsidered.
5. Give the antibiotic for the minimum length of time that is effective.
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6. Consider the use of pharmacy “stop” policies, where drugs written up for a specified period
and are then only continued if a new prescription is issued.
7. For surgical prophylaxis start the antibiotic with induction of anesthesia/ 45 mins before
incision. A second dose may be given if surgery continues for more than 3 hours. The
further continuation of antibiotic as therapy remains the privilege of the surgeon depending
on the clinical condition and medical situation of the patient, Department of Infection
prevention and control may intervene if required. Antibiotics may be continued in case of
high risk patient group. It is the discretion of the clinician to take this decision.
8. Note: Before prescribing any higher antimicrobial, the Consultant will confirm the choice with
the consultant/microbiologist. The policy is designed as per local epidemiology, IDSA
guidelines and antibiogram of the hospital.
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F.2 Antibiotic Prophylaxis (Surgical):
Usual Preferred High Risk & Alternate

Procedure Comments
Organisms prophylaxis prophylaxis
Abdominal Cefoperazone + Within 45 minutes

Gram negative Ceftriaxone/Amika
surgery ( No Sulbactum to 1 hr before
most likely + cin +
infection ) Or amikacin incision
anaerobes Metronidazole
Ceftriaxone +
Metronidazole
Abdominal Cefoperazone +
or consider ESBL
Surgery ( H/o Sulbactum
Cefuroxime + strain
of past Or
Gram negative Metronidazole or
history of Metronidazole
most likely + If high risk : According to C & S
hospitalizatio +
anaerobes report
n last 3 to 6 Amikacin
Carbapenum + modification
month)
Metronidazole
Metronidazole +
Cefepime + Sulbactum (
pseudomonas)
Metronidazole or
or Piperacillin +
Gram negative According to C & S
Abdominal Cefaperazone Tazobactum
ESBL strain report
surgery +Sulbactum or
Anaerobes modification
(Infection ) + Meropenam /
Carbapenum Ertapenam
+
Amikacin
Piperacilin +
Cefuroxime OR
Tazobactum
Urology Gram negative Ceftriaxone
or
Surgery bacilli +
Cefaperazone
(clean) Amikacin
+Sulbactum
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+
Amikacin
Piperacilin +
Tazobactum
Cefoperazone + or
Sulbactum Merupenum
Urology According to
Gram negative OR or
surgery with culture report
bacilli Cefepime + Ertapenam ( Consider
infection modification
Sulbactum + Hospital acquired
Metrogyl infection )
+ Amikacin
Oncology Gram positive +

Cefotaxime , According to
Head and anaerobics
Amoxilin + clavanic Gentamycin / Amikacin culture report
neck ( clean) Gram negative
acid modification
bacilli
Head and Gram positive + Metronidazole + Cefaperazone +
neck ( anaerobics dalacin c ( gram Sulbactum
infection) Gram negative positive & Piperacilin +
bacilli anaerob) Tazobactum
Breast Gram negative Cefotaxime Amoxicillin + clavanic

24 hr
surgery ( bacilli Cefuroxime acid
clean)
Breast
According to
Surgery ( Gram negative Cefoperazone +
culture report
infection) bacilli Sulbactum
modification
Cefoperazone+
Ortho Augmentin / sulbactum If there is need, To
surgery Mostly Gram Clindamycin + be continued by
(clean) positive + Amikacin request of
Cefuroxime ( In case of old or high clinician.
risk patients)
Ortho Linezolid Vanconycin According to
M RSA
surgery ( Past + or culture report
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history of Cefoperazone/sulb Teicoplanin modification

hospitalizatio actum +
n / MRSA) Or Cefipime/tazobactum
amikacin (pseudo coverage)
Or
Amikacin
Metronidazole / dalacin
Cefaperazone + c ( gram positive &
Gram negative Sulbactum anaerob)
or or According to
Road traffic bacilli
Piperacilin + Piperacilin + culture report
accident
Anaerobes Tazobactum Tazobactum modification
+ or
Amikacin Merupenam /Imipenum
/ Ertapenam (High Risk)
Opthalmo Topical
Gram positive
surgery(not Moxicycline Gentamycin
cocci
frequent)
Cefotaxime
Or Cefoperazone +
Vascular Gram negative
Metronidazole sulbactum
sugery( bacilli
+ +
clean) Anaerobes
Amikacin Amikacin
Cefaperazone + Dalacin
Sulbactum +
Vascular According to
Or Amikacin
surgery ( culture report
Metronidazole +
infection) modification
+ Cefipime+tazobactum
Amikacin (pseudo)
Cefoperazone +
Amikacin
sulbactum
Gram negative +
+
Gyneoncosur bacilli Metronidazole
Amikacin / Gentamycin
gery Anaerobes or
0r
Cefotaxime
Quinolone
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Ceftriaxone
Neuro + Cefepime/Ceftazidime According to
Gram negative
surgery(non- Anaerobic + culture report
bacilli
implant) coverage Anaerobic coverage modification
Linezolid
+
Neuro Vancomycin
Cefoperazone+sulb
contaminate + According to
actum
d(cross sinus M R S A Ceftriaxone culture report
0r
or Or modification
Cefipime+Tazobact
naso/pharynx Cefoperazone sulbactum
um
Ceftriaxone/
Linezolid
Vancomycin
+
+
CSF shunt Cefoperazone+sulb According to
Ceftriaxone
surgery actum culture report
Or
0r modification
Cefoperazone sulbactum
Cefipime+Tazobact
um
Procedure Usual Preferred Alternate Comments

Organism prophylaxis prophylaxis
s
Angiography S.aureus Cefotaxime Patients undergoing sterile
(MSSA) Ceftriaxone vascular procedures do
Or Or not require
prophylactic antibiotics.
Cefotaxime Ceftizoxime Strictly adhere to sterile
+ sulbactum procedures rules
(infected pt)
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Angioplasty S.aureus Ceftriaxone Cefotaxime Administer immediately

(MSSA) prior to procedure.
Or Or Repeat 2 more doses 8
hourly.
Cefotaxime Ceftizoxime
+ sulbactum
(infected pt)
Augmentin Administer immediately
+ Cefotaxime before procedure.
CABG/ S.aureus Cefoperazon + To be repeated after 3hrs if
THORACIC (MSSA) e + Piperacillin/tazo procedure is prolonged
SURGERY Gram sulbactum bactum
negative Or Or
Bacilli Amikacin Netilmycin
S.aureus Administer immediately

CABG/ (MRSA) Linezolid Vancomycin before procedure.
THORACIC Gram + + To be repeated after 3hrs if
SURGERY negative Cefoparazon Piperacillin/tazo procedure is prolonged
(prior hospitalization Bacilli e + bactum
/high risk) sulbactum Or
Or Merupenum
Amikacin
Important Note :
The antibiotic policy is a guideline for surgeons. Clinical findings and situations may require addition or
deletion of antibiotics. The policy is framed on the basis of antibiotic report pattern (epidemiology) of
the hospital. Changes may be made as and when a significant change in pattern is noted. Prophylaxis is
meant to be given only before surgery, if the need arises it may be converted into early therapy. If the
surgery continues for more than 3 hours, a second shot of the same antibiotic should be given. It
should be noted that the first doze of surgical prophylaxis should be given approximately 45 minutes
prior to incision. This decision is at the discretion of the treating clinician.
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Medical Prophylaxis
S. pneumoniae, Ceftriaxone IV +
N. meningitidis, Vancomycin IV +
Listeria spp Ampicillin IV
gram-negative Vancomycin IV +
Meningitis Duration 10 days.
bacilli, Or Aztreonam IV +
(as reqd)
S.aureus Cefepime IV + TMP/SMX IV
S.epidermidis Vancomycin IV
P.aeruginosa
E.coli
K.pneumonaie Ciprofloxacin or Levoflox or
Duration 7-10 days
Urinary tract P.aeruginosa Ampicillin/sulbac Ampicillin/sulbactum or
Amikacin (If ESBL strain) (as reqd)
Infection(UTI) S.aureus (MRSA) tum
S.epidermidis
E.coli Levofloxacin + Duration 10 days.
Levofloxacin +
Complicated K.pneumonaie Amikacin CBC to be done
Cefoperazone/sulbactum
UTI every 3 days to
P.aeruginosa
Add Linezolid (if monitor WBC and
S.aureus (MRSA) Add Linezolid (if MRSA is
MRSA is Platelets if
S.epidermidis suspected)
suspected) linezolid is given.
S. pneumoniae, H.
BRONCHITIS / influenzae, M.
COPD- catarrhalis, M.
EXACERBATI
pneumoniae, C.
ON Azithromycin
pneumoniae PO/IV OR
Duration 05 days
Doxycycline
PO/IV
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Catheter-
associated UTI:
Significant
bacteriuria with
pyuria or
symptoms Piperacillin/tazo
UTI, If PCN-allergic: TMP/SMX Duration : 05 to 07
bactam IV ±
CATHETER- IV/PO + Gentamicin IV days
Common Gentamicin IV
ASSOCIATED
(also cases organisms: E. coli,
transferred K. pneumoniae, P.
from another aeruginosa,
tertiary care Proteus mirabilis,
unit) enterococci
* Empiric therapy is evolving due to change in microbial resistance especially due to ESBI production. In
every case is urged that cultures be obtained relevant specimens before starting empiric therapy.
* Prophylaxis may be changed or modified as per the clinical needs of the patient. This is a guideline for
rational use of antibiotics.
An ID Consult should be considered for all patients with meningitis.

In patients with less severe PCN-allergies (e.g. mild rash in the absence of both Stevens-
Johnson syndrome and anaphylaxis), treatment with a third- or fourth-generation
cephalosporin or a carbapenem antibiotic may be possible and in some situations may be
necessary. ID Consult recommended evaluating risk/benefit.
Intravenous aminoglycoside penetration into the CSF is generally suboptimal for treatment of
gram-negative meningitis/ventriculitis. Intrathecal / intraventricular aminoglycoside
administration may be necessary. ID consult recommended.
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CELLULITIS Acute infection of the skin Non-diabetic Cefazolin IV or 7 days

and subcutaneous tissue Linezolid (if
(local abscess possible) prior history of
MRSA)
Common organisms: S.
aureus, streptococci
DIABETIC Non-limb threatening: Non-limb threatening Ampicillin/sulb 7–10 days
FOOT AND superficial, lack systemic actam IV or Treatment
OTHER toxicity, minimal cellulitis, Pip + depends on
SUPERFICIAL ulceration (if present) not Tazobactum the bacteria
SKIN ULCERS fully extending through the isolated
skin, lacking significant
ischemia.
Common organisms:
polymicrobial (S. aureus,
streptococci, gram-negative
bacilli, anaerobic gram-
positive cocci, and
Bacteroides sp.)
Limb-threatening: more Limb threatening Piperacillin/taz 10–14 days
extensive cellulitis, obactam IV
lymphangitis, ulcers or
penetrating through the skin Carbapenums
into subcutaneous tissue,
prominent ischemia.
Common organisms:
polymicrobial (S. aureus,
streptococci, gram-negative
bacilli, anaerobic gram-
positive cocci, and
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Bacteroides sp.)
WOUND Often polymicrobial (S. Post-trauma / animal Ampicillin/sulb 7 days
INFECTION aureus, streptococci, gram or human bites actam IV OR
negative bacilli) Amoxicillin/cla
vulanic acid PO
Ceftriaxone IV 3–5 days
Community S. pneumoniae, H. influenzae, + Azithromycin 3–5 days
acquired M. pneumoniae, M. PO/IV OR 7 days
Pneumonia catarrhalis, Legionella If suspect
aspiration:
Ampicillin/sulb
actam IV OR
Piperacillin/taz
obactam IV ±
Azithromycin
PO/IV
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Please Note:
1. Always consider Linezolid if MRSA is suspected.Linezolid is a bacteriostatic drug, so it should

not be used for surgical prophylaxis.
2. A higher antibiotic like Carbepenum or Colistin / Tegicycline may be initiated in case of high
risk patients or critically ill patients. These may be de-escalated after receiving the report of
culture and sensitivity.
3. Please send relevant cultures prior to beginning antibiotics. In case of any query, please
contact department of Microbiology.
4. For Hospital Acquired Infection and antibiogram of present epidemiology is provided to all
facilities. Please review it before initiation of antibiotics.
5. It should be noted that for bigger abscesses, draining the abscess and then initiating
antibiotics would give better penetration.
6. Please coordinate verbally with department of infection Control in case you need to use a
different antibiotic. The final treatment regime is at the discretion of the Clinician and his/her
clinical judgment.
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Policy for Construction, Renovation, Remediation, Repair, and Demolition
a. General Information
 Environmental disturbances caused by construction and/or renovation and repair activities (e.g.,
disruption of the above-ceiling area, running cables through the ceiling, and structural repairs) in
and near health-care facilities markedly increase the airborne Aspergillus spp. spore counts in the
indoor air of such facilities, thereby increasing the risk for health-care–associated aspergillosis
among high-risk patients.
 Although one case of health-care–associated aspergillosis is often difficult to link to a specific
environmental exposure, the occurrence of temporarily clustered cases increase the likelihood
that an environmental source within the facility may be identified and corrected.
Ventilation hazards in health-care facilities that may be associated with increased potential of
airborne disease transmission*
Problem Consequences Possible solutions
Inadequate filtration Infectious particles may pass 1. Specify appropriate filters

(270) through during New construction design
phase.
Filters into vulnerable patient
2. Make sure that HVAC fans are
areas.
sized to overcome pressure
demands of
Filter system.
3. Inspect and test filters for
proper installation.
Maintenance disruptions Fan shut-offs, dislodged filter 1. Budget for a rigorous
(271) cake material contaminates maintenance Schedule when
downstream air Supply and designing a facility.
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drain pans. This may 2. Design system for easy

compromise air flow in special maintenance.
3. Ensure communication
Ventilation areas.
between engineering and
maintenance personnel.
4. Institute an ongoing training
program for all involved staff
member
Duct contamination or Debris is released during 1. Provide point-of-use filtration

cleaning. maintenance or cleaning. in the Critical areas.
2. Design air-handling systems
with insulation of the exterior of
the Ducts.
3. Do not use fibrous sound
attenuators.
4. Decontaminate or encapsulate
Contamination.
Water-damaged building Water leaks can soak wood, 1. Replace water-damaged
materials wall board, insulation, wall materials.
coverings, ceiling tiles, and 2. Incorporate fungistatic
carpeting. All of these materials compounds into building
can provide microbial habitat materials in areas at risk for
when wet. moisture problems.
3. Test for all moisture and dry in
This is especially true for fungi
less than 72 hours. Replace if the
growing on gypsum board.
material cannot dry within 72
hours.
Filter bypasses (17) Rigorous air filtration requires 1. Use pressure gauges to ensure
air flow resistance. Air stream that filters are performing at
will elude filtration if openings proper static pressure.
are present because of filter 2. Make ease of installation and
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damage or poor fit. maintenance criteria for filter

selection.
3. Properly train maintenance
personnel in HVAC concerns.
4. Design system with filters
downstream from fans.
5. Avoid water on filters or
insulation.
Ductwork disconnections Dislodged or leaky supply duct 1. Design a ductwork system that
(268) runs can spill into and leaky is easy to access, maintain, and
returns may draw from hidden repair.
areas. Pressure balance will be
2. Train maintenance personnel
interrupted, and infectious
to regularly monitor air flow
material may be disturbed and
volumes and pressure balances
entrained into hospital air
throughout the system.
supply.
3. Test critical areas for
appropriate air flow
Suggested members and functions of a multi-disciplinary coordination team for construction,

renovation, repair, and demolition projects:
Members
1. CEO & MD
2. Surgeon
3. Intensivist
4. ICO
5. ID Specialist
6. CMA
7. DNS
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8. Sr. Clinical Administrator

9. Manager Operations
10. DGM – Admin & Projects
11. ICN
12. F&B Manger Cafe
13. OT Nurse Administrator
14. Concerned HOD’s
Functions and responsibilities of the team:
1. Coordinate members’ input in developing a comprehensive project management plan.

2. Conduct a risk assessment of the project to determine potential hazards to susceptible patients.
3. Prevent unnecessary exposures of patients, visitors, and staff to infectious agents.
4. Oversee all infection-control aspects of construction activities.
5. Establish site-specific infection-control protocols for specialized areas.
6. Provide education about the infection-control impact of construction to staff and construction
workers.
7. Ensure compliance with technical standards, contract provisions, and regulations.
8. Establish a mechanism to address and correct problems quickly.
9. Develop contingency plans for emergency response to power failures, water supply disruptions,
and fires.
10. Provide a water-damage management plan (including drying protocols) for handling water
intrusion from floods, leaks, and condensation.
11. Develop a plan for structural maintenance.
Preliminary Consideration:
The three major topics to consider before initiating any construction or repair activity are as follows:
a) Design and function of the new structure or area,
b) Assessment of environmental risks for airborne disease and opportunities for prevention, and
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c) Measures to contain dust and moisture during construction or repairs.
Infection-Control Risk Assessment
 An infection-control risk assessment (ICRA) conducted before initiating repairs, demolition,

construction, or renovation activities can identify potential exposures of susceptible patients to
dust and moisture and determine the need for dust and moisture containment measures.
 This assessment centers on the type and extent of the construction or repairs in the work area
but may also need to include adjacent patient-care areas, supply storage, and areas on levels
above and below the proposed project.
 Knowledge of the air flow patterns and pressure differentials helps minimize or eliminate the
inadvertent dispersion of dust that could contaminate air space, patient-care items, and surfaces
 During long-term projects, providing temporary essential services
(e.g., toilet facilities) and conveniences (e.g., vending machines) to construction workers within
the site will help to minimize traffic in and out of the area. The type of barrier systems necessary
for the scope of the project must be defined.
 Depending on the location and extent of the construction, patients may need to be relocated to
other areas in the facility not affected by construction dust. Such relocation might be especially
prudent when construction takes place within units housing immune-compromised patients (e.g.,
severely neutropenic patients and patients on corticosteroid therapy).
 By determining baseline levels of health-care–acquired airborne and waterborne infections,
infection control staff can monitor changes in infection rates and patterns during and
immediately after construction, renovations, or repairs.
Strategies to be followed to reduce dust and moisture intrusion during external demolition and
construction:
Demolition site Shroud the site if possible to reduce

environmental contamination.
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Dust-generating equipment Prior to placing dust-generating equipment,

evaluate the location to ensure that dust
produced by the equipment will not enter the
building through open doorways or windows,
or through ventilation air intakes.
Construction materials storage Locate this storage away from the facility and
ventilation air intakes.
Adjacent air intakes Seal off affected intakes, if possible, or move if

funds permit.
HVAC system Consult with the facility engineer about

pressure differentials and air recirculation
options; keep facility air pressure positive to
outside air.
Filters Ensure that filters are properly installed;

change roughing filters frequently to prevent
dust build-up on high-efficiency filters.
Windows Seal and caulk to prevent entry of airborne

fungal spores.
Doors Keep closed as much as possible; do not prop

open; seal and caulk unused doors (i.e., those
that are not designated as emergency exits);
use mats with tacky surfaces at outside
entrances.
Water utilities Note location relative to construction area to

prevent intrusion of dust into water systems.*
Medical gas piping Ensure that these lines/pipes are insulated

during periods of vibration.
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Rooftops Temporarily close off during active

demolition/construction those rooftop areas
that are normally open to the public (e.g.,
rooftop atrium).
Dust generation Provide methods (e.g., misting the area with

water) to minimize dust.
Immuno-compromised patients Use walk-ways protected from

demolition/construction sites; avoid outside
areas close to these sites; avoid rooftops.
Pedestrian traffic Close off entry ways as needed to minimize

dust intrusion.
Education and awareness Encourage reporting of hazardous or unsafe

incidents associated with construction.
* Contamination of water pipes during demolition activities has been associated with health-care–
associated transmission of Legionella spp.
Minimizing the entry of outside dust into the HVAC system is crucial in reducing the risk for airborne
contaminants. Facility engineers should be consulted about the potential impact of shutting down the
system or increasing the filtration. Selected air handlers, especially those located close to excavation
sites may have to be shut off temporarily to keep from overloading the system with dust and debris.
Internal Demolition, Construction, Renovations, and Repairs:
The focus of a properly implemented infection-control program during interior construction and repairs
is containment of dust and moisture. This objective is achieved by
 educating construction workers about the importance of control measures;
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 preparing the site;

 notifying and issuing advisories for staff, patients, and visitors;
 moving staff and patients and relocating patients as needed;
 issuing standards of practice and precautions during activities and maintenance;
 monitoring for adherence to control measures during construction and providing prompt
feedback about lapses in control;
 monitoring HVAC performance;
 implementing daily clean-up, terminal cleaning and removal of debris upon completion; and
 Ensuring the integrity of the water system during and after construction.
These activities should be coordinated with engineering staff and infection-control professionals.
Issue hazard and warning notices.
 Post signs to identify construction areas and potential hazards.

 Mark detours requiring pedestrians to avoid the work area.
Relocate high-risk patients as needed, especially if the construction is in or adjacent to a PE area.
 Identify target patient populations for relocation based on the risk assessment.
 Arrange for the transfer in advance to avoid delays.
 At-risk patients should wear protective respiratory equipment (e.g., a high efficiency mask)
when outside their PE rooms.
Establish alternative traffic patterns for staff, patients, visitors, and construction workers.
 Determine appropriate alternate routes from the risk assessment.

 Designate areas (e.g., hallways, elevators, and entrances/exits) for construction worker use.
 Do not transport patients on the same elevator with construction materials and debris.
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Control solid debris:
 When replacing filters, place the old filter in a bag prior to transport and dispose as a routine
solid waste.
 Clean the construction zone daily or more often as needed
 Designate a removal route for small quantities of solid debris.
 Mist debris and cover disposal carts before transport (i.e., leaving the construction zone).
 Designate an elevator for construction crew use.
 Use window chutes and negative pressure equipment for removal of larger pieces of debris while
maintaining pressure differentials in the construction zone.
 Schedule debris removal to periods when patient exposures to dust is minimal.
Control water damage:
 Make provisions for dry storage of building materials.

 Do not install wet, porous building materials (i.e., sheet rock).
 Replace water-damaged porous building materials if they cannot be completely dried out within
72 hours
Control dust in air and on surfaces:
 Monitor the construction area daily for compliance with the infection-control plan.
 Protective outer clothing for construction workers should be removed before entering clean
areas.
 Use mats with tacky surfaces within the construction zone at the entry; cover sufficient area so
that both feet make contact with the mat while walking through the entry.
 If possible construct an anteroom as needed where coveralls can be donned and removed.
 Clean the construction zone and all areas used by construction workers with a wet mop.
 If the area is carpeted, vacuum daily with a HEPA-filtered–equipped vacuum.
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 Provide temporary essential services (e.g., toilets) and worker conveniences (e.g., vending
machines) in the construction zone as appropriate.
 Damp-wipe tools if removed from the construction zone or left in the area.
 Ensure that construction barriers remain well sealed; use particle sampling as needed.
 Ensure that the clinical laboratory is free from dust contamination.
Complete the project:
 Flush the main water system to clear dust-contaminated lines.

 Terminally clean the construction zone before the construction barriers are removed.
 Check for visible mold and mildew and eliminate (i.e., decontaminate and remove), if present.
 Verify appropriate ventilation parameters for the new area as needed.
 Do not accept ventilation deficiencies, especially in special care areas.
 Clean or replace HVAC filters using proper dust-containment procedures.
 Remove the barriers and clean the area of any dust generated during this work.
 Ensure that the designated air balances in the operating rooms (OR) and protective environments
(PE) are achieved before occupancy.
 Commission the space as indicated, especially in the OR and PE, ensuring that the room’s
required engineering specifications are met.
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Policy for Outbreaks:
A. Preparedness Planning
Transmissible Viral infections preparedness planning for healthcare facilities is addressed in Supplement
One component with particular relevance to this Supplement is the education and training of healthcare
workers on infection control measures. Observations of healthcare workers caring for e.g SARS patients
during the 2003 epidemic identified numerous breaches in infection control, especially in the use of
personal protective equipment (PPE). These can be corrected through complete and comprehensive
training, provision of properly selected PPE, and monitoring of PPE use. Most important, all healthcare
settings need to re-emphasize the importance of basic infection control measures, including hand
hygiene, for the control of SARS and other respiratory pathogens.
Objective: Reinforce basic infection control practices in healthcare facilities and among healthcare
personnel.
Activities
 Educate staff about the importance of strict adherence to and proper use of standard
infection control measures, especially hand hygiene (i.e., hand washing or use of an
alcohol-based hand rub).
 Reinforce education on the recommended procedures for Standard, Contact, and

Airborne Infection Isolation (AII) Precautions (see
www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)
 Ensure that personnel have access to appropriate PPE, instructions and training in PPE
use, and respirator fit-testing.
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B. Early Recognition and Prevention of Transmission in Outpatient Settings
Objective: Ensure early recognition and prevention of transmission of

SARS-CoV and other respiratory viruses at the initial encounter in a healthcare setting.
The 2003 outbreaks identified weaknesses in the way infection control precautions are implemented at
the time symptomatic patients first visit a healthcare facility for evaluation. To address this deficiency,
CDC is incorporating measures to prevent the transmission of all respiratory infections, beginning at the
first point of contact with a potentially infected person, as one component of Standard Precautions in
healthcare settings (see Appendix I1 and www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm).
These simple preventive measures apply in the absence and presence of SARS-CoV transmission in the
world. Once SARS-CoV transmission is detected, efforts to enhance the early detection of patients with
SARS-CoV disease (described in Section III.C below) should be added to these new Standard Precautions
measures. Public Health Guidance for Community-Level Preparedness and Response to Severe Acute
Respiratory Syndrome (SARS) Supplement I: Infection Control in Healthcare, Home, and Community
Settings (continued from previous page) January 8, 2004 Page 2 of 12
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Activities
Visual alerts
Post visual alerts (in appropriate languages) at the entrance to outpatient facilities (e.g.,
emergency departments, physicians’ offices, outpatient clinics) instructing patient and the
persons who accompany them to:
1) Inform healthcare personnel of symptoms of a respiratory infection when they first register
for care, and
2) Practice respiratory hygiene/cough etiquette
Respiratory hygiene/cough etiquette
To contain respiratory secretions, all persons with signs and symptoms of a respiratory infection,
regardless of presumed cause, should be instructed to:
 Cover the nose/mouth when coughing or sneezing.

 Use tissues to contain respiratory secretions.
 Dispose of tissues in the nearest waste receptacle after use.
 Perform hand hygiene after contact with respiratory secretions and contaminated
objects/materials.
Healthcare facilities should ensure the availability of materials for adhering to respiratory hygiene/cough
etiquette in waiting areas for patients and visitors:
 Provide tissues and no-touch receptacles (i.e., waste container with pedal-operated lid or
uncovered waste container) for used tissue disposal
 Provide conveniently located dispensers of alcohol-based hand rub
 Provide soap and disposable towels for hand washing where sinks are available
Masking and separation of persons with symptoms of respiratory infection

During periods of increased respiratory infection in the community, offer masks to persons who are
coughing. Either procedure masks (i.e., with ear loops) or surgical masks (i.e., with ties) may be used to
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contain respiratory secretions; respirators are not necessary. Encourage coughing persons to sit at least
3 feet away from others in common waiting areas. Some facilities may wish to institute this
recommendation year-round.
Droplet Precautions
Healthcare workers should practice Droplet Precautions (i.e., wear a surgical or procedure mask for close
contact), in addition to Standard Precautions, when examining a patient with symptoms of a respiratory
infection. Droplet Precautions should be maintained until it is determined that they are no longer
needed (see www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm).
C. Early Detection and Isolation of Patients Potentially at Risk for SARS-CoV Disease
Early detection and isolation of patients who may be infected with SARS-CoV are the most important
interventions to prevent the introduction of SARS-CoV into a healthcare setting. However, because
measures to control SARS-CoV can impose a considerable burden, especially if multiple patients with
respiratory illnesses are being seen in an outpatient setting or admitted to a hospital for treatment of
Public Health Guidance for Community-Level Preparedness and Response to Severe Acute Respiratory
Syndrome (SARS)
Supplement I: Infection Control in Healthcare, Home, and Community Settings (continued from
previous page) January 8, 2004 Page 3 of 12
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Pneumonia, the intensity of early detection and control measures should be based on the level of SARS-
CoV transmission in the world. See CDC’s SARS website (www.cdc.gov/sars/) for current information on
SARS-CoV transmission worldwide.
Objective 1: In the absence of SARS-CoV transmission in the world, implement screening to detect the
re-emergence of SARS-CoV, and ensure appropriate triage and management of patients with possible
SARS-CoV disease.
In the absence of person-to-person SARS-CoV transmission, the likelihood that a patient being evaluated
for fever or lower respiratory illness, with or without pneumonia, has SARS-CoV disease will be
exceedingly low unless there are both typical clinical findings and some accompanying epidemiologic
evidence that raises the suspicion of exposure to SARS-CoV. Therefore, patients with respiratory
infections should not be considered as possible cases of SARS-CoV disease unless they have severe
pneumonia (or acute respiratory distress syndrome) of unknown etiology that requires hospitalization
and an epidemiologic history that raises the suspicion of SARS-CoV exposure.
Activities
Screening and triage
Only patients requiring hospitalization for radiographically confirmed pneumonia (or acute respiratory
distress syndrome) of unknown etiology should be screened for SARS epidemiologic risk factors. The
suspicion for SARS-CoV disease is raised if, within 10 days of symptom onset, the patient:
1 2
 Has a history of travel to mainland China, Hong Kong, or Taiwan, or close contact with an ill person
with a history of recent travel to one of these areas, OR
 Is employed in an occupation associated with a risk for SARS-CoV exposure (e.g., healthcare worker
with direct patient contact; worker in a laboratory that contains live SARS-CoV), or
 Is part of a cluster of cases of atypical pneumonia without an alternative diagnosis
Evaluate persons with such a clinical and exposure history according to Figure 1 in Clinical Guidance
on the Identification and Evaluation of Possible SARS-CoV Disease among Persons Presenting with
Community-Acquired Illness (www.cdc.gov/ncidod/sars/clinicalguidanceframe1.htm).
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The 2003 SARS-CoV outbreak likely originated in mainland China, and neighboring areas such as
Taiwan and Hong Kong are thought to be at higher risk due to the large volume of travelers from
mainland China. Although less likely, SARS-CoV may also reappear from other previously affected
areas. Therefore, clinicians should obtain a complete travel history. If clinicians have concerns about
the possibility of SARS-CoV disease in a patient with a history of travel to other previously affected
areas (e.g., while traveling abroad, had close contact with another person with pneumonia of
unknown etiology or spent time in a hospital in which patients with acute respiratory disease were
treated), they should contact the local or state health department.
Close contact: A person who has cared for or lived with a person with SARS-CoV disease or had a
high likelihood of direct contact with respiratory secretions and/or body fluids of a person with
SARS-CoV disease. Examples of close contact include kissing or hugging, sharing eating or drinking
utensils, talking within 3 feet, and direct touching. Close contact does not include activities such as
walking by a person or briefly sitting across a waiting room or office. Public Health Guidance for
Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)
Supplement I: Infection Control in Healthcare, Home, and Community Settings
Outpatient infection control

Follow the infection control recommendations for respiratory hygiene/cough etiquette and Droplet
Precautions outlined in Section III.B above.
Disposition
No special infection control measures are recommended following discharge from an outpatient
setting.
Hospitalization
Patients who require hospitalization for radiographically confirmed pneumonia (or acute respiratory
distress syndrome) of unknown etiology and who have one of the potential SARS risk factors should
be placed on Droplet Precautions until it is determined that the cause of the pneumonia is not
contagious. If the health department and clinicians strongly suspect SARS-CoV disease, then the
patient should be placed on Contact and Airborne Infection Isolation Precautions, in addition to
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Standard Precautions (See Section C below and Clinical Guidance on the Identification and
Evaluation of Possible SARS-CoV Disease among Persons Presenting with Community-Acquired
Illness, www.cdc.gov/ncidod/sars/clinicalguidance.htm).
Objective 2: In the presence of person-to-person transmission of SARS-CoV in the world, ensure the
prompt identification and appropriate management of patients with possible and known SARS-CoV
disease.
Activities
Screening and triage
Once person-to-person SARS-CoV transmission has been documented anywhere in the world, the
probability that a patient presenting with early clinical symptoms of SARS actually has SARS-CoV
disease increases if the patient has an epidemiologic link to a geographic location in which SARS-CoV
transmission has been documented.
Screen all patients with fever or lower respiratory symptoms, with or without pneumonia, to
determine if, within 10 days of the onset of symptoms, they had:
 Close contact with a person suspected of having SARS-CoV disease, or
 A history of foreign travel (or close contact with an ill person with a history of travel) to a
location with documented or suspected SARS-CoV transmission, or
 Exposure to a domestic or occupational location with documented or suspected SARS-CoV
(including a laboratory that contains live SARS-CoV), or close contact with an ill person with
such an exposure history
For persons with a high risk of exposure to SARS-CoV (e.g., persons previously identified through
contact tracing or self-identified as close contacts of a laboratory-confirmed case of SARS-CoV
disease; persons who are epidemiologically linked to a laboratory-confirmed case of SARS-CoV
disease), the clinical criteria should be expanded to include, in addition to fever or respiratory
symptoms, the presence of any other early symptoms of SARS-CoV disease (subjective fever, chills,
rigors, myalgia, headache, diarrhea, sore throat, rhinorrhea). The more common early symptoms
include chills, rigors, myalgia, and headache. In some patients, myalgia and headache may precede
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the onset of fever by 12-24 hours. However, diarrhea, sore throat, and rhinorrhea may also be early
symptoms of SARS-CoV disease.
Evaluate persons with an exposure history suggesting possible SARS-CoV disease according to Figure
2 in Clinical Guidance on the Identification and Evaluation of Possible SARS-CoV Disease among
Persons Presenting with Community-Acquired Illness
(www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm).
Patients who require hospitalization for pneumonia and who do not have a known epidemiologic
link to a setting in which SARS-CoV has been documented should be screened for additional risk
factors using the questions that apply when no SARS-CoV is documented in the world (i.e.,
employment in an occupation at particular risk for SARS-CoV exposure; part of a cluster of atypical
pneumonias without an alternative diagnosis).
Healthcare workers who are the first points of contact (e.g., triage and reception) should be trained
to perform SARS-CoV screening. If screening personnel are not available, healthcare providers
should screen symptomatic patients for SARS-CoV disease risk factors before initiating history-taking
and physical examination. If SARS symptoms and risk factors are present, follow the clinical
algorithm for patient management (www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm).
Outpatient infection control

 Patients with fever or lower respiratory symptoms, with or without pneumonia, who have
been exposed to SARS-CoV or who have SARS risk factors should be suspected of having
SARS-CoV disease and isolated as soon as possible. Such patients should be given a mask
(surgical or procedure) to wear and immediately placed in a private examination room or
cubicle. If available, an AII room (AIIR) should be used.
 Where limited space and examination room capacity preclude these measures, the patient
should sit as far away as possible from other patients in the waiting area.
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 Family members or friends who accompany the patient should be considered at risk for
SARS-CoV disease and screened for fever and lower respiratory symptoms. If either is
present, infection control measures to prevent SARS-CoV transmission should be applied.
 Healthcare workers should wear gown, gloves, respiratory protection, and eye protection (if
needed) as described in Section III.D.5 below.
Disposition
 Hospital admission or discharge of a possible SARS patient should generally be based on the
patient’s clinical condition and healthcare needs. If diagnostic, therapeutic, or supportive
regimens do not necessitate hospitalization, patients with possible SARS-CoV disease should
not be hospitalized.
 Exceptions include persons for whom no other alternative for providing safe infection
control is available. Such persons include travelers, homeless persons, and persons who
would be returned to an environment where infection control measures are not feasible or
practical (e.g., crowded dormitories, prisons and jails, detention centers, homeless shelters,
other multi-person single-room dwellings). These persons should be hospitalized and
isolated as recommended in Section D below. As soon as appropriate arrangements can be
made for out-of-hospital care, the patient can be discharged. Alternatively, the patient may
be admitted to a designated residential facility for isolation of convalescing SARS-CoV
disease cases, if one exists.
 Public Health Guidance for Community-Level Preparedness and Response to Severe Acute
Respiratory Syndrome (SARS) Supplement I: Infection Control in Healthcare, Home, and
Community Settings (continued from previous page) January 8, 2004 Page 6 of 12
 During transport between locations, patients should wear a mask. Public transportation (e.g.,
bus, train) should be avoided. Recommendations for emergency medical transport are
provided in Section IV below.
Hospitalization
Follow recommended precautions for hospitalization of a patient with known or possible SARS
CoV disease as described in Section D below.
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D. Infection Control Precautions for Hospitalized SARS Patients

The following recommendations apply to patients who have laboratory evidence of SARS-CoV
disease or for whom the attending clinicians and health department strongly suspect SARS-CoV
disease. The level of precautions described will rarely be needed in the absence of SARS-CoV
transmission in the world but will be used increasingly once SARS-CoV transmission is detected.
Contact and AII Precautions, in addition to Standard Precautions, should be applied when caring for
patients with known or possible SARS-CoV disease. (Droplet Precautions also are required but are
subsumed within AII Precautions.) These precautions should be maintained for the duration of
potential infectivity (see (www.cdc.gov/ncidod/sars/clinicalguidance.htm) or until a diagnosis of
SARS-CoV disease has been ruled out.
The objective of all of the following activities is to prevent the transmission and acquisition of
SARS-CoV in the hospital.
1. Patient placement
Admit patients with SARS-CoV disease to an AIIR. An AIIR is a single-patient room in which
environmental conditions are controlled to minimize the possibility of airborne transmission
of infectious agents. These rooms have specific requirements for controlled ventilation,
including: 1) a specified number of required air exchanges per hour (ACH) (i.e., 6 for old
buildings; 12 for new construction or renovation), 2) monitored negative pressure relative to
hallways, and 3) air exhausted directly to the outside preferably or passed through a high-
efficiency purifying air (HEPA) filter if recirculated. These requirements are detailed in the
Guideline for Environmental Infection Control in Healthcare Facilities, 2003
(www.cdc.gov/ncidod/hip/enviro/guide.htm).
If there is a lack of AIIRs and/or a need to concentrate infection control efforts and resources,
patients may be cohorted on a floor or nursing unit designated for the care of SARS patients
only, rather than placed in AIIRs throughout the hospital. This strategy physically isolates
SARS patients and also makes it possible to dedicate resources and appropriately trained staff
to their care. Experience in some settings in Taiwan and Toronto demonstrated that cohorting
SARS patients, without use of AIIRs, effectively interrupted transmission. Thus, although
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single AIIRs are recommended for SARS isolation, other strategies may provide effective
overall infection control, particularly if air-handling systems in existing rooms/units/floors can
be modified to allow these areas to operate under negative pressure relative to surrounding
areas.
Even if a facility has chosen to cohort SARS patients, properly designed and operated AIIRs are
preferred for 1) patients who are known to have transmitted SARS-CoV to other persons and
2) patients in whom the risk of SARS is being assessed.
Public Health Guidance for Community-Level Preparedness and Response to Severe Acute
Respiratory Syndrome (SARS) Supplement I: Infection Control in Healthcare, Home, and
Community Settings (continued from previous page)
Designate “clean” and “dirty” areas for isolation materials. Maintain a stock of clean patient
care and PPE supplies outside the patient’s room. Decide where contaminated linen and
waste will be placed. Locate receptacles close to the point of use and separate from the clean
supplies. Also designate the location where reusable PPE (e.g., goggles, face shields) will be
placed for cleaning and disinfection before reuse.
Limit the amount of patient-care equipment brought into the room to that which is medically
necessary. Provide each patient with patient-dedicated equipment (e.g., thermometer, blood
pressure cuff, stethoscope).
Limit staff to the number sufficient to meet patient-care needs. Using staff who have been
specially trained to care for patients with SARS may reduce opportunities for exposure,
increase adherence to recommended infection control practices, and promote continuity of
care.
2. Patient transport
Limit patient movement and transport outside the AIIR to medically necessary purposes.
Whenever possible, use portable equipment to perform x-rays and other procedures in the
patient’s room.
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 If transport or movement is necessary, ensure that the patient wears a surgical mask, puts
on a clean patient gown, and performs hand hygiene before leaving the room. If a mask
cannot be tolerated (e.g., due to the patient’s age or deteriorating respiratory status),
apply the most practical measures to contain respiratory secretions.
 Limit contact between SARS patients and others by using less traveled hallways and
elevators when possible.
3. Visitors
• Limit visits to patients with known or possible SARS-CoV disease to persons who are
necessary for the patient’s emotional well-being and care.
• Visitors who have been in contact with the patient before and during hospitalization are a
possible source of SARS-CoV. Therefore, schedule and control visits to allow for
appropriate screening for SARS-CoV disease before entering the hospital and appropriate
instruction on use of PPE and other precautions (e.g., hand hygiene, limiting surfaces
touched) while in the patient’s room.
4. Hand hygiene
Hand hygiene (i.e., hand washing or use of an alcohol-based hand rub) should be performed
after contact with a patient on precautions for SARS-CoV disease or their environment of care.
Current guidelines for hand hygiene are provided at: www.cdc.gov/handhygiene/.
5. Personal protective equipment (PPE)

Gloves, gown, respiratory protection, and eye protection (as needed) should be donned before
entering a SARS patient’s room or designated SARS patient-care area. This level of protection is
required for the majority of patient contacts. Additional guidance for performing an aerosol-
generating procedure on patients with SARS Co-V disease is provided in Section III.D.11 below.
Instructions on how to safely don, use, and remove PPE are being developed and will be
provided at www.cdc.gov/ncidod/sars/ when available. Removal of PPE in a manner that
prevents contamination of clothing and skin is a priority. Public Health Guidance for
Community-Level Preparedness and Response to Severe Acute Respiratory Syndrome (SARS)
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• Gown and gloves – Wear a standard isolation gown and pair of non sterile patient-care
gloves for all patient contacts. The gown should fully cover the front torso and arms and
should tie in the back. Gloves should cover the cuffs of the gown.
• Respiratory protection – Wear a NIOSH-certified N-95 filtering face piece respirator for
3
entering an AIIR or designated SARS patient-care area. If N-95 or higher level of respiratory
protection is not available, then wear a snug-fitting surgical mask to prevent nose and mouth
contact with large respiratory droplets. Discard respirators upon leaving the patient room or
area.
• Eye and face protection -- It is not yet known whether routine eye protection is needed to
prevent SARS-CoV transmission. Routinely wear eye protection when within 3 feet of a
patient with SARS-CoV. If splash or spray of respiratory secretions or other body fluids is
likely, protect the eyes with goggles or a face shield, as recommended for Standard
Precautions. The face shield should fully cover the front and wrap around the side of the
face. Corrective eyeglasses or contact lenses alone are not considered eye protection.
• Use safe work practices when wearing PPE:

a. Avoid touching the face with contaminated gloves
b. Avoid unnecessary touching of surfaces and objects with contaminated gloves
6. Medical waste
Medical waste has not been implicated in the transmission of SARS-CoV. Therefore, no special
handling procedures are recommended for SARS-CoV-contaminated medical waste.
• Contain and dispose of SARS-CoV-contaminated medical waste in accordance with facility-
specific procedures and/or local or state regulations for handling and disposal of medical
waste, including used needles and other sharps.
• Discard as routine waste used patient-care supplies that are not likely to be contaminated
(e.g., paper wrappers).
• Wear disposable gloves when handling waste. Perform hand hygiene after removal of gloves.
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7. Textiles (linen and laundry)

• Contact with textiles has not been implicated in the transmission of SARS-CoV. Therefore,
no special handling procedures are recommended for linen and laundry that may be
contaminated with SARS-CoV.
• Store clean linen outside patient rooms, taking into the room only linen needed for use
during the shift.
• Place soiled linen directly into a laundry bag in the patient’s room. Contain linen in a
manner that prevents the linen bag from opening or bursting during transport and while
in the soiled linen holding area.
• Respirators should be used in the context of a complete respiratory protection program as
required by the Occupational Safety and Health Administration (OSHA). This includes
training, fit-testing, and fit-checking to ensure appropriate respirator selection and use. To
be effective, respirators must provide a proper sealing surface on the wearer’s face.
Detailed information on a respiratory protection program is provided at:
www.osha.gov/SLTC/etools/respiratory/.
• Wear gloves and gown when directly handling soiled linen and laundry (e.g., bedding,
towels, personal clothing) as per Standard and Contact Precautions. Do not shake or
otherwise handle soiled linen and laundry in a manner that might aerosolize infectious
particles.
• Wear gloves for transporting bagged linen and laundry.
• Perform hand hygiene after removing gloves that have been in contact with soiled linen
and laundry.
• Wash and dry linen according to routine standards and procedures
8. Dishes and eating utensils

Dishes and eating utensils have not been implicated in SARS-CoV transmission. Therefore, no
special precautions, beyond those for Standard Precautions, are recommended for dishes and
eating utensils used by a patient with known or possible SARS-CoV disease.
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• Wash reusable dishes and utensils in a dishwasher with recommended water temperature
• Wear gloves when handling patient trays, dishes, and utensils.
9. Patient-care equipment
• Follow standard practices for handling and reprocessing used patient-care equipment,
including medical devices. Wear gloves when handling and transporting used patient-care
equipment. Wipe heavily soiled equipment with an EPA-approved hospital disinfectant
before removing it from the patient’s room. Follow current recommendations for cleaning
and disinfection or sterilization of reusable patient-care equipment.
• Wipe external surfaces of portable equipment for performing x-rays and other procedures
in the patient’s room with an EPA-approved hospital disinfectant upon removal from the
patient’s room.
9. Environmental cleaning and disinfection

Cleaning and disinfection of environmental surfaces are important components of routine
infection control in healthcare facilities. Although little is known about the extent of
environmental contamination in SARS patients’ rooms, epidemiologic and laboratory
evidence suggests that the environment could play a role in transmission. Therefore,
cleaning and disinfection are critical to the control of SARS-CoV transmission.
Environmental cleaning and disinfection for SARS-CoV follows the same principles
generally used in healthcare settings.
Cleaning and disinfection of occupied patient rooms

• Consider designating specific, well-trained environmental services personnel for cleaning
and disinfecting of SARS patient rooms/units. Fully define the scope of cleaning that will
be done each day; identify who will be responsible for cleaning and disinfecting the
surfaces of patient-care equipment (e.g., IV pumps, ventilators). Consider using a checklist
to promote accountability for cleaning responsibilities.
• Environmental services personnel should wear PPE as described in Section III.D.5 above.
These staff should be trained in proper procedures for PPE use, including removal of PPE,
and the importance of hand hygiene.
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• Keep cleaning supplies outside the patient room (e.g., in an anteroom or storage area).
• Keep areas around the patient free of unnecessary supplies and equipment to facilitate
daily cleaning.
• Use any EPA-registered hospital detergent-disinfectant. Follow manufacturer’s
recommendations for use-dilution (i.e., concentration), contact time, and care in handling.
• Clean and disinfect SARS patients’ rooms at least daily and more often when visible
soiling/contamination occurs. Give special attention to frequently touched surfaces (e.g.,
bedrails, bedside and over-bed tables, TV control, call button, telephone, lavatory surfaces
including safety/pull-up bars, doorknobs, commodes, ventilator surfaces) in addition to
floors and other horizontal surfaces.
• Because so little is known about environmental transmission of SARS-CoV, placement of
patients in rooms that do not have carpeting is preferred because non-carpeted floors are
easier to clean and disinfect. If use of carpeted rooms cannot be avoided, vacuuming
should be done daily, and personnel should wear the recommended PPE. Follow current
CDC environmental guidelines for vacuuming and shampooing carpeted floors in patient
rooms (www.cdc.gov/ncidod/hip/enviro/guide.htm).
• After an aerosol-generating procedure (e.g., intubation), clean and disinfect horizontal
surfaces around the patient. Clean and disinfect as soon as possible after the procedure.
• Clean and disinfect spills of blood and body fluids in accordance with current
recommendations for Standard Precautions
(www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm).
Cleaning and disinfection after patient discharge or transfer

• Follow standard facility procedures for terminal cleaning of an isolation room.
• Clean and disinfect all surfaces that were in contact with the patient or may have become
contaminated during patient care.
• Wipe down mattresses and headboards with an EPA-approved hospital disinfectant.
• Privacy curtains should be removed, placed in a bag in the room and then transported to
be laundered.
• No special treatment is necessary for window curtains, ceilings, and walls unless there is
evidence of visible soil.
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• Do not spray (i.e., fog) occupied or unoccupied rooms with disinfectant. This is a
potentially dangerous practice that has no proven disease control benefit.
10. Aerosol-generating procedures

Because aerosol-generating procedures may pose a greater risk of SARS-CoV transmission,
additional precautions are recommended for healthcare workers who perform or assist with these
procedures. Procedures that stimulate coughing and promote the generation of aerosols include
aerosolized or nebulized medication administration, diagnostic sputum induction, bronchoscopy,
airway suctioning, endotracheal intubation, positive pressure ventilation via face mask (e.g., BiPAP,
CPAP), and high-frequency oscillatory ventilation.
Healthcare facilities should review their strategies to protect healthcare workers during these
procedures, including the use of PPE and safe work practices. Healthcare workers who perform
these procedures should be alerted to the fact that there may be an increased risk for SARS-CoV
transmission when these procedures are performed.
Infection control measures

• Limit performance of aerosol-generating procedures on SARS patients to those that are
considered medically necessary. Clinically appropriate sedation during intubation and
bronchoscopy may minimize resistance and coughing during the procedure.
• Limit the number of healthcare workers in the room during an aerosol-generating procedure
to those essential for patient care and support.
• Perform aerosol-generating procedures in an AIIR. If an AIIR is not available, perform the
procedure in a private room, away from other patients. If possible, increase air exchanges,
create a negative pressure relative to the hallway, and avoid recirculation of the room air. If
recirculation of air from such rooms is unavoidable, pass the air through a HEPA filter before
recirculation, as recommended for Mycobacterium tuberculosis
(www.cdc.gov/mmwr/preview/mmwrhtml/00035909.htm).
• Air-cleaning devices, such as portable HEPA filtration units, may be used to further reduce the
concentration of contaminants in the air. Keep doors closed except when entering or leaving
the room, and minimize entry and exit during the procedure.
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• Submicron filters on exhalation valves of mechanical ventilators may prevent contaminated

aerosols from entering the environment. Although the effectiveness of this measure in
reducing the risk of SARS-CoV transmission is unknown, the use of such filters is prudent
during high-frequency oscillatory ventilation of patients with SARS-CoV disease.
PPE for aerosol-generating procedures

The optimal combination of PPE for preventing SARS-CoV transmission during aerosol-generating
procedures has not been determined. Wearing PPE during these procedures protects the
respiratory tract from inhalation of droplet nuclei and the mucous membranes, skin, and clothing
from contact with infectious respiratory secretions. PPE should cover the torso, arms, and hands as
well as the eyes, nose, and mouth. PPE must be compatible with the needs of healthcare worker
protection and patient care. The following PPE is recommended:
• Disposable isolation gown, preferably with fluid-resistant properties, to protect the body
and exposed areas of the arms. A disposable full-body isolation suit is an option and may
provide greater protection of the skin, especially around the neck. Surgical hoods, which
fully cover the head, neck, and face, (with the addition of an N-95 or higher-level disposable
particulate respirator), have been used in some settings. It is unknown whether covering
exposed areas of skin or hair on the head will further reduce the risk of transmission.
• Pair of disposable gloves that fit snuggly over the gown cuff
• Eye protection (i.e., goggles) to protect the eyes from respiratory splash or spray. Goggles
should fit snuggly (but comfortably) around the eyes. A face shield may be worn over
goggles to protect exposed areas of the face but should not be worn as a primary form of
eye protection for these procedures.
Evaluation and preventing reoccurrence of Outbreak:

Respiratory protection -- During aerosol-generating procedures, there must be minimal
respirator face-seal leakage to fully protect the worker from exposure to aerosolized
infectious droplets. The following respiratory protection options should be considered:
1. Disposable particulate respirators (e.g., N-95, N-99, or N-100) are sufficient for routine
respiratory protection for Airborne Infection Isolation and are the minimum level of
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respiratory protection required for healthcare workers who are performing aerosol-
generating procedures. To ensure adequate protection, healthcare workers must be fit-
tested to the respirator model that they will wear (www.cdc.gov/niosh/99-143.html) and
also know how to check the face-piece seal. A fit-check should be performed each time a
respirator is put on, before entering the patient room. Workers who cannot wear a
disposable particulate respirator because of facial hair or other fit limitations should wear a
loose-fitting (i.e., helmeted or hooded) PAPR.
2. Healthcare facilities in some SARS-affected areas routinely used higher levels of respiratory
protection for performing aerosol-generating procedures on patients with SARS-CoV
disease. It is unknown whether these higher levels of protection will further reduce
transmission. Factors that should be considered in choosing respirators in this setting
include availability, impact on mobility, impact on patient care, potential for exposure to
higher levels of aerosolized respiratory secretions, and potential for reusable respirators to
serve as fomites for transmission.
Higher levels of respiratory protection include:

 PAPR with loose-fitting face piece that forms a partial seal with the face
 PAPR with hood that completely covers the head and neck and may also cover portions of
the shoulder and torso
 PAPR with tight-fitting face piece (half and full face-piece)
 Full face-piece elsastomeric negative-pressure (non-powered) respirators with N, R, or P-
100 filters
It should be noted that in case of sudden outbreaks, immediate policies will be designed for
pandemics or epidemics as per CDC guidelines and WHO recommendations.
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SECTION 10 – TRAININGS
Trainings – General & Department specific to be covered by the staff of the dept.
 Hand hygiene
 Spillage management (blood and chemical)
 Needle stick injury
 Linen management
 Bio medical waste management
 Standard precautions
 Personal protective equipments
 Bundle care (ICN indicators)
 CSSD and its functions
 Surveillance of the area
 Deep cleaning
 Any outbreak of diseases ( H1N1)
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SECTION 11 – FORMS & FORMATS
Scanned copies of Forms & Formats used in the dept. with brief description
 NSI form
 Employee vacation form
 SSI indicator form
 CA-UTI indicator form
 CR-BSI indicator form
 VAP indicator form
 Spillage management
 Hand hygiene form
 H1N1 information form
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SECTION 12 – QUALITY INDICATORS
Sr. No. Quality Indicator Formula
1 Urinary tract infection rate Number of urinary catheter days in that month * 1000
Number of urinary catheter associted UTIs in a

month
2 Ventilator Associated Pneumonia Number of pneumonia in a month *1000

rate
Number of ventilators in a month
3 Blood stream infection rate Number of central line associated blood stream *1000
infections in a month
Number of centra line days in that month
4 Surgical infection rate Number of surgical site infections in a given *100

month
Number of surgeries performed in that month
5 Incidences of blood body fluid Number of blood body fluid exposures *100
exposures
Number of inpatient days
6 Incidences of needle stick injuries Number of parental exposures *100
Number of inpatient days
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SECTION 12 – ANNEXURES
1. Surveillance Data Form
2. Hand Hygiene Monitoring in ICUs
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3. Daily Monitoring Sheet
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4. Spillage Reporting Form
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5. NSI Reporting Form
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6.
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7.
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8.
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9.
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INFECTION CONTROL MANUAL

HCG MULTISPECIALTY HOSPITAL

Section 1 - Introduction ………………………………………………………………………………………….. 01

SECTION 2 – VISION & MISSION

a. Safety of Health care workers.

SECTION 3 – SCOPE OF SERVICES

Sr. Manager - Infection Control

Infection Control Nurse

Department’s staff – No. of staff, Designation, Shifts:

1. Infection Control Nurse ( One staff : Full time)

SECTION 6 – JOB DESCRIPTIONS

Position: INFECTION CONTROL NURSE REMARKS

Reporting To: Infection control officer ,

Head of Nursing Department

Qualification: Nurse must hold a BSC/MSC degree

Minimum Respective nurse must carry experience, trained in infection courses

Pay Band Skills:

Competencies  Clinical Supervisor / Investigator / Coordinator

 Nursing care is a direct service, which includes various components

transporting for any purpose.

 Participate in informal and formal teaching programs for nurses and

 Assist Nurse Administrator in unit management.

 Helps in the orientation of new staff.

General: Departmental training

SECTION 7 – KEY RESULT AREAS

Please refer Section – 05 for Key Result Areas

SECTION 8 – KEY PERFORMANCE INDICATORS

Please refer Section – 05 for Key Result Areas

The particulars considered for annual HIC Budget is listed below:

HIC BUDGET – HCG MULTI SPECIALTY HOSPITAL

SECTION 10 – POLICIES & PROCEDURES

INFECTION CONTROL PROGRAMME

C. Responsibility for implementation

D. Infection Control Policy

E. Hospital Infection Control Committee

E.2.4 Advise the management on its statutory requirements in relation to Infection

E.3 Frequency of Committee: Monthly

Sr. No. Members Designation

2 Clinician Member secretary

3 CEO & MD Member

4 Consultant Microbiologist/ICO Member

5 Head - Nursing Services Member

9 Deputy Medical Administrator Member

10 ICU – Registrar Member

11 Centre Manager Member

12 Head – F & B Member

13 Coordinator – Quality Member

14 Nurse Administrator - OT Member

15 Infection Control Nurse Committee Coordinator

F. Infection Control Team

F.4 Infection control nurse

F.6 Review and Revision of Infection Control Manual

F.7 Budget Allocation

F.8 Surveillance and Reporting of Infection

B.8.4 Objectives of Surveillance

B.8.6.2 Active Surveillance

B.9 Nosocomial Infection Rates

B.10.1 Hospital Surveillance Calendar

B.11.3 Intravascular device infection

F.2.3 Collection of Soiled Linen from patient areas:

F.2.4 Collection of Used Clean Linen by outsourced services

F.2.5 Linen which need special handling before dispatch to laundry