2019 HICC Manual CMC

HOSPITAL INFECTION CONTROL
MANUAL
8th Edition
2019
HOSPITAL INFECTION CONTROL COMMITTEE

CHRISTIAN MEDICAL COLLEGE
VELLORE, TAMIL NADU, INDIA
Hospital Infection Control Manual
8th Edition, 2019
HOSPITAL INFECTION CONTROL COMMITTEE

CHRISTIAN MEDICAL COLLEGE
VELLORE, TAMILNADU, INDIA
0
No part of this manual may be reproduced without prior written permission from the
Medical Superintendent of the Christian Medical College, Vellore
2019
1
FOREWORD
I am delighted to write the foreword for the 8th edition of the Christian Medical College,
Vellore‟s Hospital Infection Control Manual. Healthcare Associated Infections (HAIs)
are on the rise and cause a threat to all hospitals. The rates of these infections directly
indicate the quality of care provided to the patients.
Effective infection control practices and surveillance are of utmost importance to prevent
such HAIs, and also to provide a safe working environment for the healthcare workers.
This manual covers all infection control practices followed in various areas of our
hospital and enumerates the various protocols and procedures that should be followed to
prevent dissemination of any HAIs.
I would like to congratulate all the contributors, especially the members of the Hospital
Infection Control Committee for their commendable effort.
I am sure that this manual will be of immense help to all the healthcare workers and will
help us in delivering the best possible care to our patients.
Dr. K. Prasad Mathews

Medical Superintendent
CHRISTIAN MEDICAL COLLEGE, VELLORE
HICC
Doc No: MAN/HICC/003/P/08/072019 Ver: 08 Issue No: 01 Date: 30/07/2019
HOSPITAL INFECTION CONTROL MANUAL

REVISION HISTORY
Chapter Revision description Page

No No
1.4.3 Organogram of HICC 4
1.5 Organogram of Infection Control Team 5
1.5.1 Duties of Addl. Joint Secretary (added) 6
1.5.1 Duties of data entry operator (added) 7
1.5.1 Functions of HICC 8
2.1.2 Surgical site Infections, Surgeries followed and method of follow up 11
2.1.2 Definition of Central Line Associated Blood Stream Infections 12
2.1.2 VAE, IVAC 12
2.2 Addition of Colistin resistant organisms in the table for MDROs 17
2.2.1 Antimicrobial stewardship activities 22
6.1 Handwashing (description of hand hygiene champions added) 41
6.5 Multiple dose solutions 46
7.3.2 Catheter care 56
9.3 Fogging with hydrogen peroxide 76
9.3 Procedure for hydrogen peroxide spraying 77
10.2 Addition of wound drains in the red category of waste 81
10.7.1 Wound drains added in red category 88
10.7.2 Amendments to bio-medical waste management rules, 2016 89
11 Categorisation of hospital areas 91
11.1 Housekeeping in wards 91
11.2 Housekeeping in isolation wards 92
11.3 Housekeeping in the operation theatre 94
12.5.4 Ventilation systems (modified) 104
12.8 Central sterile supplies department (CSSD) 108
Appendix I Policy in place for use for re-use of single use devices 148
Appendix IV Disinfection procedures for individual items and equipment 156
Initiated by: HICC Approved by: Medical Superintendent
This document is the property of CMC. Making copies of this content in any form without the written
permission of the Director/HOD is illegal and strictly prohibited.
EDITION HISTORY
1stedition.............................1996
2nd edition.............................September 1999
3rd edition.............................January 2003
4thedition.............................January 2008
5th edition.............................August 2011
Re-print...............................August 2015
6th edition.............................May 2015
7th edition.............................January 2018
8th edition..............................July 2019
8th edition..............................October 2019 (Amendment)

TABLE OF CONTENTS
1. ORGANISATION OF THE INFECTION CONTROL PROGRAMME AT CHRISTIAN MEDICAL

COLLEGE HOSPITAL.................................................................................................................................9
PHILOSOPHY OF INFECTION CONTROL.....................................................................................................................9
DEFINITION OF HEALTHCARE ASSOCIATED INFECTIONS...........................................................................................9
GOALS AND OBJECTIVES OF THE INFECTION CONTROL PROGRAMME.....................................................................9
HOSPITAL INFECTION CONTROL COMMITTEE (HICC)..............................................................................................10
HOSPITAL INFECTION CONTROL TEAM...................................................................................................................11
2. SURVEILLANCE AND REPORTING OF INFECTION.................................................................15
INFECTION SURVEILLANCE PROGRAMME FOR HEALTH CARE ASSOCIATED INFECTION...................................................16
ANTIMICROBIAL RESISTANCE (AMR) SURVEILLANCE..............................................................................................17
ENVIRONMENTAL SURVEILLANCE...........................................................................................................................22
REPORTING OF COMMUNITY ACQUIRED INFECTIONS TO GOVERNMENT HEALTH AUTHORITIES....................................23
3. EMPLOYEE HEALTH PROGRAMME...........................................................................................27
HEALTH SERVICE.....................................................................................................................................................27
SPECIFIC PROPHYLAXIS...........................................................................................................................................28
4. PREVENTING TRANSMISSION OF BLOOD BORNE PATHOGENS........................................29
INTRODUCTION.......................................................................................................................................................29
THE RISK OF INFECTION..........................................................................................................................................29
RECOMMENDATIONS.............................................................................................................................................30
RECOMMENDATIONS FOR PATIENTS KNOWN TO HARBOUR BLOOD BORNE PATHOGENS....34
MANAGEMENT OF SPILL.........................................................................................................................................35
5. REGULATIONS FOR STAFF WITH SPECIFIC DISEASES.........................................................37
6. TECHNIQUES......................................................................................................................................38
HANDWASHING......................................................................................................................................................38
USE OF GLOVES.......................................................................................................................................................42
USE OF GOWNS......................................................................................................................................................44
USE OF MASKS........................................................................................................................................................45
INJECTIONS.............................................................................................................................................................46
COLLECTION AND TRANSPORT OF SPECIMENS.......................................................................................................47
7. CARE OF ACCESS SYSTEMS, DEVICES AND WOUNDS...........................................................49
VASCULAR CARE.....................................................................................................................................................49
RESPIRATORY CARE.................................................................................................................................................52
URINARY CATHETER................................................................................................................................................55
WOUND CARE.........................................................................................................................................................56
8. ISOLATION POLICIES AND PROCEDURES................................................................................58
TRANSMISSION OF INFECTIONS..............................................................................................................................58
ISOLATION CATEGORIES.........................................................................................................................................59
PROTOCOL GIVEN FOR CARE OF PATIENTS WITH DRUG-RESISTANTPATHOGENS 63
PROTOCOL GIVEN FOR CARE OF PATIENTS WITH INFLUENZA................................................................................64
TB INFECTION CONTROL POLICY IN CMC HOSPITAL, VELLORE...............................................................................67
PROTOCOL GIVEN FOR CARE OF PATIENTS INFECTED WITH CLOSTRIDIUM
DIFFICILE ASSOCIATED DIARRHOEA...................................................................................................68
PROTOCOL GIVEN FOR CARE OF PATIENT INFECTED WITH RABIES........................................................................69
9. DISINFECTION AND STERILIZATION.........................................................................................70
DISINFECTION.........................................................................................................................................................70
STERILIZATION........................................................................................................................................................74
FOGGING WITH HYDROGEN PEROXIDE..................................................................................................................76
10. HOSPITAL WASTE MANAGEMENT..............................................................................................78
RULES ON BIOMEDICAL WASTE MANAGEMENT AND HANDLING......................................................78
TERMS AND DEFINITIONS...................................................................................................................79
POLICY ON HOSPITAL WASTE MANAGEMENT....................................................................................82
SEGREGATION, TREATMENT, STORAGE, AND TRANSPORTATION OF HOSPITAL .83
WASTE.............................................................................................................................................................83
WASTE MANAGEMENT PLAN.............................................................................................................84
STANDARDS FOR WASTE TREATMENT...............................................................................................85
WASTE SEGREGATION PROTOCOL FOLLOWED IN CMC......................................................................87
11. HOUSEKEEPING................................................................................................................................91
HOUSEKEEPING IN WARDS.................................................................................................................91
HOUSEKEEPING IN THE ISOLATION WARD........................................................................92
HOUSEKEEPING IN THE OPERATING ROOMS......................................................................................93
HOUSEKEEPING IN AK LAB......................................................................................................96
12. COMMON AREAS OF PATIENT CARE.........................................................................................98
LABORATORIES...................................................................................................................................98
BLOOD BANK......................................................................................................................................99
TISSUE PATHOLOGY & AUTOPSY ROOM...........................................................................................101
HEALTH & SAFETY POLICIES IN THE MORTUARY & AUTOPSY ROOM...............................................103
ENGINEERING DEPARTMENT............................................................................................................103
DIETARY AND HOSPITAL KITCHEN.....................................................................................104
LAUNDRY SERVICES..........................................................................................................................107
CENTRAL STERILE SUPPLY DEPARTMENT (CSSD)..............................................................................108
PHARMACY 111
13. SPECIFIC AREAS OF PATIENT CARE........................................................................................114
INFECTION CONTROL IN THE DENTAL CLINIC...................................................................................114
ACCIDENT AND EMERGENCY DEPARTMENT.....................................................................................115
INTENSIVE CARE UNIT......................................................................................................................116
SURGICAL PROCEDURES...................................................................................................................122
OBSTETRICS AND LABOUR ROOM....................................................................................................124
NURSERY 126
INFECTION CONTROL IN OPHTHALMOLOGY..................................................................130
ENT DEPARTMENT............................................................................................................................133
RADIOLOGY 133
PHYSICAL MEDICINE & REHABILITATION (PMR)...............................................................................134
NUCLEAR MEDICINE.................................................................................................................136
CARDIAC CATHETERIZATION LABORATORY..................................................................137
BONEMARROW TRANSPLANT UNIT.................................................................................................138
DIALYSIS UNIT...................................................................................................................................140
14. OUTBREAK MANAGEMENT...........................................................................................................144
APPENDIX - I.............................................................................................................................................148
APPENDIX - II...........................................................................................................................................156
APPENDIX – III.........................................................................................................................................156
APPENDIX - IV..........................................................................................................................................157
1. ORGANISATION OF THE INFECTION CONTROL PROGRAMME AT
CHRISTIAN MEDICAL COLLEGE HOSPITAL
PHILOSOPHY OF INFECTION CONTROL
In order to provide better and safer hospital facilities for its patients and personnel, the Christian Medical
College Hospital has adopted an Infection Control Program involving all sections of the hospital
community
A satisfactory infection control programme requires the co-operation of all personnel involved with
patients
Any break in technique or lapse in discipline on the part of one person can render the efforts of a number
of conscientious individuals ineffective
The infection control programme will support and facilitate not only good hospital practices but also
teach staff and students the necessary values, attitudes and practices to prevent and control hospital-
acquired infections
It may not be possible to eradicate all hospital-related infections. However, an effective infection control
programme will provide optimum protection for both, the patients in the hospital and Health Care
Workers (HCWs). The purpose of this manual is to help all health care providers achieve the best
possible infection control measures and contains both policies and procedures.
DEFINITION OF HEALTHCARE ASSOCIATED INFECTIONS
Health Care Associated Infections (HCAI) or hospital-acquired infections are defined as infections
acquired during or as a result of hospitalization. Patients neither have these infections nor are incubating
these infections on admission. Generally, a patient who develops an infection after 48 hours of hospital
admission is considered to have healthcare associated infections. However, some HCAI may not manifest
as disease immediately and can manifest even after discharge.
GOALS AND OBJECTIVES OF THE INFECTION CONTROL PROGRAMME
As stated above, the goal of the hospital infection control programme is to prevent or minimize the potential for
HCAI in patients, as well as to Healthcare workers (HCWs).
The programme has the following objectives:
i. To develop written policies and procedures for standards of cleanliness, sanitation and asepsis in the
hospital.
ii. To interpret and supervise the implementation of hospital infection prevention and control policies and
procedures in specific situations.
iii. To provide surveillance for HCAI
iv. To review and analyze data on HCAI, in order to take corrective steps to minimize the infection rates and
prevent their transmission
v. To ensure the continuing education of all hospital staff and students on all aspects of infection prevention
and control
Hospital infection prevention and control programme has two arms
Infection control committee

Infection control team
HOSPITAL INFECTION CONTROL COMMITTEE (HICC)
The nature of the authority of HICC

The hospital infection control programme is organized and run by the Medical Superintendent (MS), for
which he/she constitutes the Hospital Infection Control Committee. The HICC is advisory to the Medical
Superintendent and makes its recommendations to him.
While the Medical Superintendent is the administrative officer concerned with infection control and
related activities, the Deputy Chairperson of HICC is authorized to act on behalf of the Medical
Superintendent in emergency situations. The Deputy Chairperson of the HICC assists the MS to ensure
that infection prevention and control policies are adhered to and all departments follow guidelines.
The terms of reference for HICC
The HICC will supervise the implementation of the hospital infection control programme. Specifically, the
committee shall:
i. Oversee surveillance of HCAI.

ii. Develop a system for identifying, reporting, analyzing, investigating and controlling Healthcare-
associated infections.
iii. Develop and implement preventive and corrective measures in specific situations where infection hazards
exist.
iv. Advice the Medical Superintendent on matters related to the proper use of antibiotics, develop antibiotic
policies and recommend remedial measures when antibiotic-resistant strains are detected.
v. Review and update hospital infection control policies and procedures from time to time.
vi. Help provide employee health education regarding matters related to hospital-acquired infections,
vaccination policy for all healthcare workers, occupational hazards like needle stick injury, isolation
policies and handling and management of Biomedical waste.
vii. The committee shall meet twice a year and when necessary.
Organogram of HICC:
An infection control committee provides a forum for multidisciplinary input, cooperation and information
sharing. This committee should include wide representation from relevant departments as follows:
Fig.1.1. Organogram of HICC

Members of the hospital infection control committee:
The Medical Superintendent

Deputy Chairperson of HICC
Additional Deputy Chairperson of HICC
Secretary
Joint Secretary
Additional Joint Secretary
Hospital Infection Control officer (HICO)
Hospital Infection Control Nurses/ Infection Control Nurse (HICN / ICN)
Representative of the Dept. Of Microbiology/Virology
Representative of the Medical Faculty
Representative of the Surgical Faculty
Representative of the Child Health Faculty
Head of the Staff and Students Health Services (SSHS)
Nursing Superintendent
General Superintendent
Operation Room (OR) supervisor (Main OR & CB OR)
Central Sterile Supplies Dept. (CSSD) supervisor
Representative of the Pharmacy department
Epidemiologist
Engineering department
HOSPITAL INFECTION CONTROL TEAM
This is the core committee of HICC is headed by the Medical Superintendent. It carries out the regular activities
of HICC and is involved with the implementation of policies laid down by HICC. An organogram of our HICC
team is as follows:
Fig 1.2. Organogram of Infection Control Team

Duties and responsibilities of the HIC team Members:
Chairperson:
i. The Medical Superintendent will be the chairperson of Infection control committee and the team
ii. The chairperson shall preside over all HIC meetings
iii. He / She may designate a member of HICC to officiate as Deputy Chairperson for a period of four years
iv. He / She in consultation with the deputy chairperson shall nominate the additional deputy chairperson and
the secretaries
v. He or she shall appoint the Infection Control Officer who is assisted by six or more nurses.
Deputy Chairperson:
i. The deputy Chairperson shall act as the liaison between the committee and the hospital administration.
ii. He / She shall preside over all HICC meeting.
iii. He / She shall constitute expert committees/subcommittees for purposes related to the investigation of
outbreaks or control of infection or to develop antibiotic policies.
iv. He / She shall receive surveillance reports, other hospital acquired infection related information and assist
the MS to initiate appropriate action.
v. In the absence of the Medical Superintendent, he/she shall assume the responsibilities of the MS with
regard to the hospital infection control programme.
Secretary/Joint secretary:
i. The Secretary/Joint secretary calls all meetings in consultation with the Chairperson or the deputy
chairperson
ii. He/She ensures that the minutes of the previous meeting and agenda for the next meeting are distributed
at least one week prior to the next meeting
iii. Ensures that the committee functions according to the bye-laws
iv. In the absence of the Deputy Chairperson, the Secretary shall assume all duties and responsibilities of the
Deputy Chairperson
v. Performs any other responsibilities delegated by the Chairperson / Deputy Chairperson
vi. Supervises the activities of HICO, ICNs and Pharmacist appointed for the antimicrobial stewardship
program
Addl. Joint Secretary

i. The Additional Joint Secreatry is the representative of Nursing Superintendent in HICC
ii. Ensures that committee functions according to the bye-laws
iii. He/She is responsible for smooth functioning of infection control activities which require nursing inputs
iv. Supervises the activities of the ICNs and act as a liaison between the hospital infection control nurses and
the nursing service
v. Supervises/monitors the activities (pertaining to infection control) of staffs, link nurses/hand hygiene
champions under him/her
Hospital Infection Control Officer (HICO):
i. Monitors the surveillance of HCAI done by the HICN, evaluates and analyzes the infection rates and
informs the concerned areas
ii. Monitors bio-medical waste segregation, management and disposal
iii. Reporting of notifiable and reportable diseases to the government authorities
iv. Conduct regular audits along with the ICNs to assess the compliance towards the infection control
policies
v. Carries out the outbreak investigations along with ICNsin consultation with the secretary and the deputy
chairperson HICC
vi. Teaching the medical, nursing and allied health sciences staff and students in areas of infection control
practices
vii. Co-ordinates the regular updating and revision of HICC manual and the antibiotic policy of the hospital
viii. To supervise the activities of the infection control nurses, pharmacist and the data entry operator
ix. To organize activities like HICC week / CME / Workshops and institutional interactive sessions like
„Quality circle‟.
x. Prepares the agenda and the minutes of the committee/subcommittee meetings, in consultation with the
Secretary
Hospital Infection Control Nurse (HICN)
i. Responsible for collection and data entry of prospective active targeted surveillance of Health Care
Associated Infections (HCAIs) in eight intensive care units (ICU) and four high dependency units (HDU),
a bone marrow transplant unit (ABMTU), a haematology ward (L ward) and Level III Nursery
ii. Assist the HIC team in identifying, controlling and preventing outbreaks of infection
iii. To carry out audits on aspects of infection control like hand hygiene, segregation of biomedical waste,
surgical prophylaxis, care of IV line, etc.
iv. Education of all healthcare workers in aspects of prevention of hospital-acquired infections and all
components of standard precautions
v. Assist the HIC team in planning, implementation, and evaluation of infection prevention and control
measures.
Antimicrobial Stewardship Pharmacist
i. The pharmacist plays a major role in reducing the transmission of infection, promoting the rational use of
antimicrobials, educating the health professionals, patients and public. He/she will be a member of the
HIC team
ii. To participate in the clinical care plan by collaborating with the multidisciplinary departments during or
after the (ward / ICU) clinical rounds to ensure that prophylactic, empirical and therapeutic uses of
antimicrobials result in positive patient outcome
iii. To liaise with the Clinical Microbiology department and follow up culture reports
iv. To carry out regular surveillance of antibiotic usage in the ICUs
v. To work with the surgical team to ensure that surgical prophylaxis is administered 1 hour prior to the
incision and discontinued after 24 hours unless indicated and advice on dose modification in renal,
hepatic dysfunction and morbid obesity.
vi. Responsible for doing regular audits and providing feedback to the end users responsible for toxic dose
monitoring
vii. To attend antibiotic stewardship rounds with the HIC team
Data Entry Operator
i. Preparing and maintaining daily reports of reportable and Notifiable diseases under IDSP which is sent to
DDHS
ii. Preparing weekly IDSP reports every Monday
iii. Data entry of all the audits carried out by the Infection control nurses, analyzing and preparing reports
iv. Maintaining all the office records and files in HICC
v. To perform duties as assigned by the HICO or HIC team members
The HICC shall have the following functions
i. Define Health Care-Associated Infections, establish the protocols for the early identification, report
HCAIsand determine the prevalence rates of defined infections
ii. Analyze, interpret and disseminate data arising out of surveillance and recommend remedial measures
and ensure follow up action
iii. Establish the ongoing evaluation and review of all techniques in asepsis, isolation, and sanitation
employed in the hospital. Such techniques shall be defined in written policies and procedures
iv. Develop written policies defining the specific indications for patient isolation requirements
v. Ensure proper conduct of sterilization and disinfection practices and ensure that the central services,
housekeeping, laundry, engineering maintenance, food, sanitation and waste management are in
conformity with the hospital infection control policies. The necessary procedures shall be evaluated and
revised periodically
vi. Guide the scope and content of the Employee Health Programme
vii. Help with the education and orientation of all new employees on the importance of infection control and
the relevant policies and procedures
viii. Conducting mandatory training programmes for all new recruits encompassing all aspects of infection
control
ix. Providing focussed training to staff regarding hand hygiene, isolation precautions, etc. whenever deemed
necessary
x. Performing audits, such as Hand hygiene audits (monthly in different areas), BMW audits (quarterly),
PPE audits (every 3-4 months) and surgical prophylaxis audits in General Surgery & OG (monthly)
xi. Act upon recommendations related to infection control received from the administration, departments,
services and other hospital committees
xii. Investigate outbreak of infections within the hospital and to lay down policies and procedures to prevent
such events in future
xiii. Revise the antibiotic policy yearly based on the hospital antibiotic susceptibility pattern in collaboration
with Infectious Diseases and Microbiology departments respectively, as part of the antimicrobial
stewardship program in our hospital.
xiv. Revising and updating hospital infection control manual periodically.
References:
1. Richards C, Emori TG, Edwards J, Fridkin S, Tolson J, Gaynes R. Characteristics of hospitals and
infection control professionals participating in the National Nosocomial Infections Surveillance System
1999. Am J Infect Control. 2001;29:400–3.
2. Guidelines on Prevention and control of Hospital associated infection: WHO regional office of South
East Asia January 2002.
3. Practical Guidelines for Infection Control in Health care facilities: WHO SEARO Regional Publication
No. 41, WPRO Regional Publication WHO 2004.
2. SURVEILLANCE AND REPORTING OF INFECTION
Hospital acquired infections
Hospital Acquired Infections (HAI) or Healthcare Associated Infections (HCAIs) (previously known as
nosocomial infections) are important contributors to morbidity and mortality, as well as to public health. It
increasesthe economic burden on the patient. In developing countries, they are a major cause of preventable
disease and death.
Hospital acquired infection rates are high because of a lack of supervision, poor infection prevention practices and
inappropriate use of limited resources and overcrowding of hospitals. Some of the major contributing factors are:
Inadequate standards and practices in the operation of blood transfusion services.

Increasing the use of invasive medical devices without proper training or laboratory support.
Antibiotic resistance due to irrational use of drugs.
Efforts to prevent patients from acquiring an infection or bad outcome while in a hospital requires that each
healthcare worker uses infection prevention practices and also monitor the care being provided. Infection-
monitoring (surveillance) activities are necessary to guide corrective action based on accurate information.
Although all healthcare facilities need to monitor patient care facilities, thereby enabling to prevent the HAIs and
their undesirable outcomes, it is a labour intensive process.
In facilities with limited resources, the priority should be:
To ensure that infection prevention practices, such as sterilization of all items that come in contact with
normally sterile tissue.
To ensure the use of standard precautions for all patient care practices performed according to the best
available evidence.
To monitor compliance with recommended practices for certain high-risk procedures, such as inserting
central venous catheters (CVC).
Routine surveillance should not be a substitute for investigating outbreaks, providing safe water, food and
sanitation within the hospital healthcare facilities.
Most commonly occurring Hospital Acquired Infections are:
Catheter Associated Urinary Tract Infections (CAUTI)

Ventilator Associated Pneumonia (VAP)
Central Line Associated Blood Stream Infections (CLABSI)
Surgical Site Infections (SSI)
Use of special infection control software or self-formatted spreadsheets or databases can greatly facilitate the
surveillance process including compiling and management of data, statistical analysis, graphical representation
and report generation.
INFECTION SURVEILLANCE PROGRAMME FOR HEALTH CARE ASSOCIATED
INFECTION
Surveillance encompasses collection, collation, analysis, interpretation and dissemination of relevant data related
to Hospital Acquired Infection (HAI) or the risk of acquiring HAIs.
The surveillance for infection acquired in the hospital may be passive or active. Passive surveillance consists of
the reporting of any occurrence of suspected HAI by clinicians. Active surveillance is the systematic collection of
data by a designated surveillance team.
Active surveillance of HAI
1. Active targeted surveillance is performed daily on all patients in the ICUs based on the CDC/NHSN
definitions. A computerized programme for monitoring hospital acquired infections (HAI) surveillance rate
has been developed which enables the entry of day to day data.
2. HICC is doing active targeted surveillance aimed at high-risk areas i.e. the intensive care units (ICUs). The
four common HAIs under surveillance are:
Catheter Associated Urinary Tract Infection (CAUTI)
Central Line Associated Blood Stream Infection (CLABSI)
Ventilator Associated Pneumonia (VAP) and
Surgical Site Infections (SSI).
3. The ICUs & HDUs which are under daily surveillance are MICU, SICU, PICU, AICU, KNICU, NICU,
NTICU, MHDU, SHDU, PHDU, KNS, NHDU, ABMT, L ward (Haematology) and Level III Nursery. A
standardized proforma, based on the CDC / NHSN definitions for the above mentioned HAIs has been
prepared by the HICC in consultation with the concerned ICUs. The HICC collects the information of all
patients under surveillance in these ICUs daily.
4. The programme enables us to analyze and generate a monthly report which shows the comparison between
two consecutive months or an ad-hoc report which can show us the trend of HAIs over a specified period of
time. The incidence of HAIs for 1000 devices and prevalence (%) of HAIsfor 100 hospitalized patients are
calculated. The evaluation, analysis and report generation is done by the HICO. The HAI rates are made
available to each of the ICUs every month. These reports are also intimated to the Director, Medical
Superintendent and the Nursing Superintendent, in every safety steering committee meeting. HICC calls a
meeting with the concerned ICUs after the dispatch of the reports if needed. The interventions planned by
each ICU on the basis of the HAI rates are monitored by HICC.
Surveillance definitions for HAIs infections
(Modified from Am J Infect Control 2008; 309-32 & CDC device associated events, March 2009&CDC device
associated Module 2019)
1. Catheter Associated Urinary Tract Infection (CAUTI)
a. Patient has indwelling urinary catheter and

b. Fever (>100.4°F) and
c. At least one of the following features:
i. Cloudy urine
ii. Malodorous urine
iii. Pyuria (urine analysis showing >10 WBC/hpf) and
d. Positive urine culture (>105cfu/ml) and
e. No other cause evident
2. Surgical Site Infections (SSI):

Surgical site infections are captured by follow up of the patients who undergo a set of surgeries. HICC
receives a list of the surgeries being followed up for SSIs daily. The patients/patient relatives are
counselled and their contact numbers are noted down. These patients are then contacted through phone at
regular intervals after discharge (once in a fortnight for 30 days follow up surgeries and once every month
for 90 days follow up surgeries). The patients are questioned as per the following criteria to ascertain an
SSI. The criteria followed in our institution for capturing SSIs are as follows:
a. Patient had surgery within the past 30 days (for all surgeries) & within 90 days for surgeries with
prosthetic devices and
b. Any one of the following:
i. Purulent drainage from the incision and positive culture from an aseptically obtained
culture of fluid or tissue from superficial incision.
ii. Abscess at the surgical site involving the deeper layers and a positive pus (swab from
„deep pus‟) culture
iii. Surgeon‟s diagnosis of SSI
The following surgeries are being followed in our institution:
Thirty days follow up Ninety days follow up

Elective LSCS Coronary artery bypass grafting (CABG)
Laparoscopic cholecystectomy Herniorrhaphy with mesh
Abdominal hysterectomy Total hip replacement
Total knee
replacement
If any patient is not reachable telephonically multiple times, we do not consider those cases as SSI.
3. Central Line Associated Blood Stream Infection (CLABSI):
a. Patient has an indwelling central catheter for 48 hours
b. Fever (>100.4°F) or Hypothermia (<97.7OF)
c. Single positive blood culture {Note: Two or more cultures in case of commensals like CONS}
d. No other source evident
4. Ventilator Associated Pneumonia (VAP):

a. Patient mechanically ventilated and
b. Abnormal chest X-ray: Two or more serial chest radiographs with at least one of the following: *
i. New or progressive and persistent infiltrate/consolidation/cavitation
ii. Pneumatoceles in infant‟s < 1year old and
c. Systemic features:
i. Fever (>100.4°F) or Hypothermia (97.70 F) with no other recognized cause and
ii. Leukopenia (total WBC <4000/mm3) or leukocytosis (total WBC>12000/mm3) and
d. Respiratory findings:
i. Purulent ET aspirate or increased respiratory secretions or increased suctioning
requirements.
ii. Worsening gas exchange (pao2/fio2<240), increased oxygen requirements or increased
ventilatory demand.
e. If only one of the two findings mentioned in “d” are present diagnosis needs to be supported by
positive culture (ET aspirate / BAL / blood / pleural fluid)
f. In an immunocompromised patient, any one of the findings mentioned in “c” and “d” with a
positive culture and abnormal chest X-ray to diagnose pneumonia is sufficient.
NB: In patients without underlying pulmonary or cardiac disease, one definitive chest radiograph is acceptable
NOTE: VAE, VAC & IVAC are not being monitored in our institution. Clinical assessment of these doesn‟t
help in improving patient care. Hence, we are not capturing VAC and IVAC cases. It was felt that active VAE
surveillance was not needed given the current evidence and difficulty in executing the same.
12
PROFORMA FOR SURVEILLANCE OF HEALTHCARE ASSOCIATED INFECTIONS
CHRISTIAN MEDICAL COLLEGE & HOSPITAL, VELLORE
Calculation of the incidence and prevalence rate of each HAI
Incidence rate is reported in 1000 device days

Prevalence is reported in percentage
VAP
VAP incidence rate= Number of patients with VAP in a specified time

× 1000
Total number of ventilator days for that period
VAP prevalence rate= Number of patients with VAP in a specified time
× 100
Total number of patients admitted in that period
CAUTI
CAUTI incidence rate = Number of patients with CAUTI in a specified time
× 1000
Total number of catheter days for that period
CAUTI prevalence rate = Number of patients with CAUTI in a specified time
× 100
CLABSI
CLABSI Incidence rate= No of patients with CLABSI in a specified time
× 1000
Total number of central line days for that period
CLABSI Prevalence rate = Number of patients with CLABSI in a specified time
× 100
SSI
SSI Prevalence= Number of patients with SSI for a specific surgery in a specified time
× 100
Total number of patients with specific surgery in that period

Care bundles for prevention of device associated infections
VAP PREVENTION BUNDLE (Modified from SHEA /IDSA guidelines December 2014)
1. Avoid intubation where possible: use non-invasive positive pressure ventilation where feasible and
indicated.
2. Minimize sedation
a. Maintain RASS of 0 to -1
b. Manage ventilated patients without sedation wherever possible
c. If sedation used, titrate to RASS of 0 to -1
d. Assess readiness to extubate once a day
e. Interruption of sedation not recommended
3. Maintain and improve physical conditioning with early physiotherapy and mobilization.
4. Minimize pooling of secretion above the endotracheal tube cuff
a. Use endotracheal tubes with subglottic suction if patients are expected to require ventilation for
longer than 48 – 72 hours
b. Extubating patients to place a sub-glottic secretion drainage ET tube is NOT recommended.
5. Elevate the head end of the bed to 30 to 45o
6. Routine change of ventilator circuits is NOT recommended
7. Oral care with Chlorhexidine twice a day
8. ET tube cuff pressure between 20- 30 cm of water
9. Stress ulcer prophylaxis when indicated
10. Saline instillation before tracheal suctioning
11. Hand hygiene
VAP BUNDLE CHECKLIST
(Modified from SHEA /IDSA Guidelines December 2014)
1. Maintain RASS score 0 to -1
2. Assess readiness to extubate once a day
3. Early Physiotherapy and mobilization
4. Subglottic suction if possible
5. Oral care with Chlorhexidine twice a day
6. ET Tube cuff pressure between 20- 30 cm of water
7. Stress ulcer prophylaxis only when indicated
8. Saline instillation before suctioning

CLABSI PREVENTION BUNDLE (Based on SHEA/IDSA guideline December 2014, CDC CLIP
guideline-Central Line insertion practices- January 2015 and NHSN CLIP bundle 2016)
CENTRAL LINE INSERTION BUNDLE
1. Hand Hygiene performed
2. Appropriate skin preparation

a. Alcoholic ChlorhexidineGluconate for Skin Preparation
b. Skin preparation has completely dried before insertion
3. All five maximal Barriers should be used

a. Sterile gloves
b. Sterile gowns
c. Cap
d. Mask
e. Large sterile drape to cover the entire body
4. Avoid using Femoral vein for central venous catheters in obese adult patients
whena catheter is placed under planned and controlled conditions
5. Cover the site with transparent, semi-permeable dressings
CENTRAL LINES HANDLING BUNDLE
1. Can we remove the CVC line? Yes No
2. Appropriate skin preparation
3. Wear sterile gloves while handling the line
4. Disinfect catheter hubs, needleless connectors,

insertion ports before accessing the catheter
5. Transparent dressing to be used
6. Site care with Chlorhexidinegluconate antiseptic every 3 days
7. Replace administration sets at intervals not longer than 72 hours

ANTIMICROBIAL RESISTANCE (AMR) SURVEILLANCE
The HICC will also work with the Department of Clinical Microbiology to monitor the incidence and
prevalence of antimicrobial resistant organisms, particularly those of importance in healthcare-associated
infections; such as methicillin-resistant Staphylococcus aureus (MRSA), extended spectrum beta-lactamase
producers (ESBLs), carbapenem-resistant Enterobacteriaceae and vancomycin-resistant Enterococcus (VRE)
etc.
Table. 2.1. Alert forms for multi drug resistant organisms (MDROs)
Alert form sent to
MRSA White form MS office and concerned unit
ESBL Online entry only
CRO Blue form MS office and concerned unit
VRE Pink form MS office and concerned unit
Colistin Resistant Yellow form MS office and concerned unit
Organisms
Controlling multidrug-resistant organisms (MDROs) is important as these:
are resistant to usual antimicrobial therapy

increase patient morbidity and mortality
add to the cost of treatment
have the potential to spread and act as a reservoir of resistance genes for the transmission to other
organisms
In the event of an outbreak, the following recommendation to be followed to identify the source and to
prevent further outbreaks.:
Recommendations and protocols for AMR Screening of:
Gram-positive organisms
1. Methicillin resistant Staphylococcus aureus(MRSA)
2. Vancomycin resistant Enterococci(VRE)
Gram negative organisms
1. Extended spectrum beta lactamases (ESBL)
2. Carbapenem resistant Enterobacteriaceae(CRE)
3.Colistin resistant organisms
Gram-Positive Organisms
1. Methicillin resistant Staphylococcus aureus(MRSA)screening protocol
Conventional strategies for the control of MRSA have focused on the prevention of spread from patient to
patient (horizontal transmission). MRSA screening is receiving greater attention for its potential value in
identifying carriers of MRSA to prevent further transmission. Colonised patient constitute the major reservoir
for transmission of HAIs. The approach of screening outlined in Table 2.2is recommended
Definition of MRSA
MRSA: Includes S. aureuscultured from any specimen that tests oxacillin-resistant, cefoxitin-
resistant, or methicillin-resistant by standard susceptibility testing methods, or by a laboratory test for MRSA
detection from isolated colonies; these methods may also include a positive result by any FDA approved test
for MRSA detection from specific sources.
Table. 2.2. Suggested patient population, frequency of screening and screening sites for screening of MRSA
carriers
Organism Targeted patient population Frequency of Screening sites

screening
MRSA Inter-hospital transfer Screen on admission Nose, perineum
Transfer from long term care facilities and groin
Patient is known to be infected or
colonised with MRSA
Patient admitted to high-risk units Screen on
(Intensive care unit, high dependency admission, weekly
Unit, spinal unit, pre-operative clinics and thereafter and on
patients with planned prosthetic surgery) discharge
Rationale:
Allows detection of carriage/colonisation prior to admission to a healthcare setting, and through targeted
decolonisation therapy and isolation.
Admission screening to “high-risk clinical units” (within 6 h of admission) detects MRSA carriage in
patients.
Protects carrier patients from the risks of MRSA infection (risk reduction from MRSA), and reduces the
risk of MRSA spread to other patients (risk containment)
Sampling sites:
The Standard set of „MRSA Screen‟ comprises of:
1. Nose (both anterior nares)

2. Throat swab
Additional swabbing sites
3. a swab from the perianal area or groin

4. a swab from skin lesions, wounds, incisions, ulcers and exit sites of indwelling devices (if present)
Collection of nasal specimen:
Specimens from the anterior nares result in the highest yield of MRSA. Flocked swab in combination with Amies
transport medium or saline is recommended for nasal swab collection. Flocked swabs provide better sample
collection due to their brush-like tip, which releases higher numbers of target cells and retains more liquid sample
than foam swabs. Nasal swabs have higher MRSA detection rates than do axillary and groin swabs. The CDC
outlines the following steps,
Insert the swab approximately 2 cm (approximately 3/4 inches) into one nostril
Rotate the swab against the anterior nasal mucosa for 3 seconds
Using the same swab, repeat for the other nostril
Place swab back into the transport tube
2. Vancomycin resistant Enterococci (VRE) screening protocol
Enterococci form part of the normal human flora and are found in the intestinal tract and
female genital tract. It is known that Enterococci, including VRE, can be transmitted via direct or indirect contact.
VRE has been recovered from countertops as long as 7 days to 2 months after inoculation. The approach of
screening outlined in Table 2.3is recommended.
Definition of VRE:
Enterococcus faecalis, Enterococcus faecium, or Enterococcus species unspecified (only those not identified to
the species level) that is resistant to vancomycin, by standard susceptibility testing methods or by results from
any FDA-approved test for VRE detection from specific specimen sources
Table 2.3Suggested patient population, frequency of screening and screening sites for screening of VRE
carriers
Organism Targeted patient population Frequency of Screening sites

screening
VRE Inter-hospital transfer Screen on admission Stool
Transfer from long term care specimen/rectal
facilities swab
Patient is known to be infected
or colonised with MRSA
Patient admitted to high-risk Screen on
units (Haemodialysis patients, admission, weekly
oncology/haematology patients thereafter and on
Solid organ transplant patients discharge
Intensive care unit patients)
Rationale:
• Allows detection of carriage/colonisation prior to admission to the healthcare setting and through targeted
decolonisation therapy and isolation
• Admission screening to “high-risk clinical units” (within 6 hrs of admission) detects carriage in patients
• Protects carrier patients from the risks of infection (risk reduction from MRSA), and reduces risk of spread to
other patients (risk containment)
Sampling sites:
Stool or rectal swab is recommended. Stool specimens are preferred as they provide a higher yield. Screen once a
week for 4 weeks (day 7, 14, 21, and 28). Then screen once a month as long as the patient is hospitalized.
Collection of rectal swabs
Before rectal swab collection, lubricate the swab with sterile saline. Insert the swab into the anal canal and rotate
five times
Gram Negative Organisms
1. Screening for Extended Spectrum β-lactamase (ESBL) E. coli, K. pneumoniae and K. oxytoca
ESBLs are enzymes that mediate resistance to extended-spectrum (third generation) cephalosporins (e.g.,
ceftazidime, cefotaxime, and ceftriaxone) and monobactams (e.g., aztreonam) but do not affect cephamycins
(e.g., cefoxitin and cefotetan) or carbapenems (e.g., meropenem or imipenem). The presence of an ESBL-
producing organism in a clinical infection can result in treatment failure if one of the above classes of drugs is
used. ESBLs can be difficult to detect because they have different levels of activity against various
cephalosporins. Thus, the choice of which antimicrobial agents to test is critical.
Inclusion criteria for screening: (when and whom to screen)
1. Patients with a history of colonization or infection with ESBL E. coli, K. pneumoniae and K. oxytoca
2. Patients epidemiologically linked to cases of ESBL E. coli, K. pneumoniae and K. oxytoca
3. Patients admitted from long term care facilities
4. Patients admitted to high-risk areas such as intensive care units, haematology, oncology and transplant
wards. Screening on admission and weekly thereafter is recommended.
Risk assessments for screening:
Exposure to cephalosporins
Prolonged treatment with cephalosporins
Prolonged hospitalization
ICU admission
Immunocompromised patients (haematology, oncology and transplant wards)
2. Screening for carbapenem resistant Enterobacteriaceae(CRE)
Carbapenem-resistantEnterobacteriaceae (CRE) are usually resistant to all β-lactam agents as well as most other
classes of antimicrobial agents. The treatment options for patients infected with CRE are very limited.
Healthcare-associated outbreaks of CRE have been reported frequently among adults and neonates. Hence
carbapenem resistance and carbapenemase-production in any species of Enterobacteriaceae is an infection
control concern.
Carbapenem resistance in Enterobacteriaceae occurs when an isolate acquires a carbapenemase or when an

isolate produces an extended-spectrum cephalosporinase, such as an AmpC-type β-lactamase, in combination
with porin loss. Patients colonized with CRE are thought to be a source of transmission in the healthcare setting.
Identifying patients who are colonized with CRE and placing these patients in isolation precautions may be an
important step in preventing transmission.
i. Patients epidemiologically linked to other cases of resistant Enterobacteriaceaeinfection or colonization.

ii. Patients who received prolonged carbapenem therapy.
iii. Patients who have undergone recent invasive procedures and implantation of permanent foreign devices.
LTAC: Long term acute care facilities
LTCF: Long term care facilities
3. Screening for colistin resistance
Considering local antimicrobial susceptibility profile and available resources into account, patients admitted to
high-risk areas (ICU, haematology/oncology, organ transplantation, prolonged antimicrobial administration)
should be considered for routine surveillance for the carriage of colistin resistant organisms (including
chromosomal mediated or plasmid mediated resistance mechanisms) on admission and weekly thereafter
Any patient with a known history of colonization or infection with colistin resistant organisms
Any patient with a history of admission for more than 48 hours in a facility reporting an outbreak of
colistin resistant organisms in the past 12 months
Any patient with a history of admission for more than 48 hours to a foreign healthcare facility in the past
12 months
Any patient transferred from a healthcare facility in any foreign country
Any patient previously identified as colonised or infected with colistin resistant organisms, upon
readmission to hospital
Risk assessments for screening:
Exposure to colistinmonotherapy/inadequate dosing

Prolonged colistin therapy
Prolonged hospitalization
ICU admission
Note: Currently screening for MDROs is not a routine practice in our institution. It is undertaken in specific areas
and in certain situations if needed.
Antimicrobial Stewardship activities
The usage/prescription of high end antibiotics are monitored in our ICUs by the antimicrobial stewardship
pharmacist. The reports or data generated through this antibiotic consumption audit is shared with the Heads of
Critical care areas and administrators to sensitise the staff.
Post prescription review and feedback is followed for certain antibiotics such as colistin. Administration of
colistin to the patient is reviewed by the Infectious Disease department. The drugs are continued on evaluating the
indications for it.
Caution is advised before prescribing other reserve antibiotics such as Fosfomycin, Polymixin, etc.
ENVIRONMENTAL SURVEILLANCE
Environmental surveillance will be restricted to areas of need, such as certain theatres and ICUs. In case of
outbreaks or on completion of construction or repair work, environmental surveillance will be carried out only if
the infection control team identifies a need for such surveillance. The bacterial load in the air will be monitored
by using the air sampler.
Measuring bacterial air load using air sampler:
Ensure that the air sampler is charged

Sieve to be sterilized daily / alternate days
Sieve to be cleaned with alcohol after use in one place and moving to another place
The equipment is to be placed at a height of 4ft
The equipment is to be carried in the designated box
Sterility of the sieve is to be maintained until the point of usage
The flow rate is to be maintained at 100 litres (High)
If the flow rate is other than high, the following steps need to be followed.
o The display shows SPE with the previous rate.
o To set the flow rate press start key
o On each press of start key speed will change from low to medium to high
o To save the flow rate press set key at the desired speed
The air sampler is to be carried in the designated box especially when going to stem cell, animal house
and bone marrow transplant unit.
Table 2.4. Interpretation of results

Air sampler MPN/Cubic Mt Interpretations
Regular operating room (Class7,8) 100-200 Within normal limits
Special operating room 0-10 Within normal limits
Cardiothoracic surgery
(Class 5,6)
Recovery room ICU, CCU, Nursery (Class 6, 7) 10-100 Within normal limits
Labs (class 7,8) 100-200 Within normal limits
Not used in LAF & Incubators.

Collection of samples:
Samples are taken from appropriate equipment and processed as per standard operating protocol in the
Department of Clinical Microbiology.
Note: Environmental surveillance (air, water and surface surveillance) is carried out by the Department of
Clinical Microbiology. HICO & ICNs liaise with technicians & technologists of the Department of Microbiology
if required.
REPORTING OF COMMUNITY ACQUIRED INFECTIONS TO GOVERNMENT HEALTH

AUTHORITIES
The healthcare system is broadly divided into preventive and curative services. Traditionally, disease-preventing
activities belong to the public health arm of the health services and curative care to hospitals, dispensaries and
clinics. When people with illnesses come to curative services, it is the duty of the HCW to remember that certain
illness may have public health importance and for this reason, the public health system should be alerted.
CMCH reports notifiable diseases to the local health authorities (Deputy Director of Health Services (DDHS),
Collector and City Health Officer, Vellore). For certain infections, even one case may be important in the context
of present day epidemiology. Childhood vaccine-preventable diseases are reportable since a case is evidence for
inadequate immunization in the area of residence of children with such diseases. Notifiable diseases should be
reported without delay and with a complete residential address to the health authorities.
AIDS and HIV infection have recently been included in the list of reportable diseases by a government directive.
Strict confidentiality of the identity of the person is to be maintained; hence the report does not contain the
identity of the individual.
Reporting Methodology
Although the Medical Superintendent is ultimately responsible for reporting, the reporting process begins from
the diagnosis, either at the bedside or in the laboratory. Thus, the flow of information will be from the clinicians
and microbiologists to the Medical Superintendent‟s office, from where information is collected by HICO &
reported on a specific format to the City Health Officer (CHO). To avoid delay in transmission of information
from the CHO to DDHS, a copy of the report will also be sent directly to the DDHS, Vellore.
Table 2.5.List of reportable diseases
To be reported by laboratories
Clinical Microbiology Clinical Virology Clinical Pathology
Anthrax Chikungunya Malaria
Cholera HIV
Diphtheria Dengue fever
Enteric fever Hepatitis A& E
Meningococcal meningitis Poliomyelitis
Plague Influenza A H1N1
Tuberculosis
To be reported by clinical staff

Acute influenza Diphtheria Pertussis
AIDS Enteric fever Viral encephalitis
Anthrax Influenza outbreaks Scarlet fever
Cerebro-spinal fever Measles Small pox
(meningitis) Leprosy Tetanus
Chickenpox Pneumonia Tuberculosis
Rabies
Participation in the Integrated Disease Surveillance Programme
Integrated Disease Surveillance Programme (IDSP) was launched with World Bank assistance in November 2004
to detect and respond to disease outbreaks quickly. The project was extended for 2 years in March 2010 i.e. from
April 2010 to March 2012. World Bank funds were available for Central Surveillance Unit (CSU) at NCDC & 9
identified states (Uttarakhand, Rajasthan, Punjab, Maharashtra, Gujarat, Tamil Nadu, Karnataka, Andhra Pradesh
and West Bengal) and the rest 26 states/UTs were funded from domestic budget. The Programme continues
during the 12th Plan (2012-17) under NHM with an outlay of Rs. 640 Crore from the domestic budget only.
Surveillance units are established in all states and districts.
Under the project, weekly disease surveillance data on epidemic-prone diseases are being collected from
reporting units such as sub centers, primary health centers, community health centers, hospitals including
government and private sector hospitals and medical colleges. The data is being collected on „S‟ syndromic; „P‟
probable; & „L‟ laboratory formats using standard case definitions.
As a hospital allied to the Medical College, we also are required to play a role in the National Integrated Diseases
Surveillance Program (IDSP), although this is not directly linked to hospital infection control. In IDSP, one
faculty member from each of the following departments will constitute an institutional IDSP sub-committee;
Principal / Medical Superintendent (Chairperson)

Community Medicine
Medicine
Paediatrics
Chest and Tuberculosis
Microbiology
The chairperson of the sub-committee is the nodal person who will report to the district surveillance officer and
ensure that relevant information is sent on time. The „L‟ laboratory format is reported from HICC through the
Medical Superintendent. Forms and further information are available in the IDSP manual.
References:
1. Tersa C Horan, Mary Andrusand Margret ADdudeck.CDC / NHSN surveillance Definition for health
care associated infection and criteria for specific types on infection in acute care settings. American
Journal of Infection Control, Volume 36, Issue 9, November 2008, Page 655
2. Naomi P O Grandy, Mary Alexander, Lillian A Burns et. Al. Guidelines for prevention of Intravascular
Catheter related infection, Healthcare infection Control Practical Advisory, 2011.
3. Surgical site infection (SSI) Event: procedure associated module,. January 2015 http://www.cdc.gov/
nhsn/acute-care-hospital/ssi/
4. Metha S et.al. Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for
With a Sedation Protocol. A Randomized Controlled Trial. JAMA. 2012;308 (19):1985–1992.
doi:10.1001/jama.2012.13872.
5. Burry L et.al. Daily sedation interruption versus no daily sedation interruption for critically ill adult
patients requiring invasive mechanical ventilation. Cochrane Database Syst Rev. 2014 Jul 9;
(7):CD009176. doi: 10.1002/14651858.CD009176.pub2.
6. Training Manual for Medical Officers for Hospital Based Surveillance Project, Integrated Disease
Surveillance project NCDC
7. Public Health England. B 29 - Investigation of Specimens for Screening for MRSA.
Available at:
http://www.hpa.org.uk/ProductsServices/MicrobiologyPathology/UKStandardsForMicrobiologyInvestiga
tions/TermsOfUseForSMIs/AccessToUKSMIs/SMIBacteriology/smiB29InvestigationofSpecimensforScr
eeningforMRSA/ Last accessed 10 January 2018.
8. Department of Health expert advisory committee on Antimicrobial Resistance and Healthcare Associated
Infection (ARHAI). Implementation of modified admission MRSA screening guidance for NHS (2014).
9. Healthcare Infection Control Special Interest Group (HICSIG) (2011) Screening
and Clearance Process-MRSA http://www.asid.net.au/hicsigwiki/index.php?
title=Screening_and_Clearance_Pro cess-MRSA.
10. Department of Health. Saving Lives: a delivery programme to reduce Healthcare Associated Infection
including MRSA. Screening for Meticillin-resistant Staphylococcus aureus (MRSA) colonisation: A
strategy for NHS trusts: a summary of best practice. Department of Health. 2006.
11. Malhotra-Kumar S, Abrahantes JC, Sabiiti W, et al. Evaluation of chromogenic media for detection of
methicillin-resistant Staphylococcus aureus. J ClinMicrobiol 2010; 48: 1040.
12. Creamer E, Dolan A, Sherlock O, etal.The effect of rapid screening for methicillin-resistant
Staphylococcus aureus (MRSA) on the identification and earlier isolation of MRSA-positive patients.
Infect Control HospEpidemiol 2010;31(4):374–381.
13. Muto CA, Jernigan JA, Ostrowsky BE, Richet HM, Jarvis WR, Boyce JM et al. SHEA guideline for
preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and
enterococcus. Infec Control HospEpidemiol. 2003;24(5):362-86.(http://www.shea-
online.org/Assets/files/position_papers/SHEA_MRSA_VRE.PDF)
14. Cookson et al ., Guidelines for the Control of Glycopeptide Resistant Enterococci in Hospitals. A report
of the combined working party of the Hospital Infection Society, Infection Control Nurses Association
and British Society for Antimicrobial Chemotherapy, Journal of Hospital Infection, 2006; 62: 621.
15. NICE quality standard (2014) Guidelines for Infection Prevention and Control.
16. Suwantarat N, Roberts A, Prestridge J, Seeley R, Speser S, Harmon C, Zhang C, Henciak S, Stamper PD,
Ross T, Carroll KC. 2014. Comparison of five chromogenic media for recovery of vancomycin-resistant
enterococci from fecal samples. J ClinMicrobiol 52:4039–4042.
17. Platteel TN, Leverstein-van Hall MA, Stuart JC, Thijsen SF, Mascini EM, van Hees BC, Scharringa J,
Fluit AC, Bonten MJ. Predicting carriage with extended-spectrum beta-lactamase-producing bacteria at
hospital admission: a cross-sectional study. Clinical Microbiology and Infection. 2015 Feb 28;21(2):141-
6.
18. CLSI. Performance Standards for Antimicrobial Susceptibility testing. 27th ed. CLSI Supplement M100-
S. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
19. Tellevik MG, Blomberg B, Kommedal Ø, Maselle SY, Langeland N, Moyo SJ. High Prevalence of
Faecal Carriage of ESBL-Producing Enterobacteriaceae among Children in Dar es Salaam, Tanzania.
PloS one. 2016 Dec 9;11(12):e0168024.
20. CLSI. Performance Standards for Antimicrobial Susceptibility testing. 27th ed. CLSI Supplement M100-
S. Wayne, PA: Clinical and Laboratory Standards Institute; 2017.
21. Richter SS, Marchaim D. Screening for carbapenem-resistant Enterobacteriaceae: Who, When, and
How?. Virulence. 2016 Nov 23:1-0.
3. EMPLOYEE HEALTH PROGRAMME
General considerations
Several surveys of infections in developed countries have shown that occupationally acquired infections are
greatest among some categories of health care workers (HCWs) such as medical and technical staff, attenders and
cleaners, while such risk is low among secretarial staff. This is essentially because of the potential for coming
into contact with pathogens or infected patients or specimens.
The most effective method of preventing occupationally acquired infections is adopting safe working practices.
Immunization is not a substitute for good working practices. Based on a risk assessment of staff and procedures,
specific protective equipment or practices may be recommended. The assessment takes into account the
pathogens they may be exposed to, the local epidemiology of the disease, the nature of specimens/infective
material and the frequency of exposure/contact with potentially infected material or patients. Staff considered to
be at risk will be offered specific protection (largely pre-exposure, and post-exposure where indicated), including
immunization. IMMUNIZATION SHOULD TAKE INTO ACCOUNT THE SAFETY AND EFFICACY OF
AVAILABLE VACCINES. For staff who are at low risk, post-exposure prophylaxis may be necessary at times.
The workplace also provides an opportunity to protect individuals who have not received immunization, such as
tetanus toxoid, etc., that are universally recommended.
HEALTH SERVICE
Employees who are in contact with patients have a risk of acquired infection in their workplace. CMCH has a
Staff Students Health Services (SSHS), which is primarily responsible for staff health but also handles potential
occupational exposure to infection.
3.1.1 Activities of the SSHS
All services provided to individuals by the SSHS will be confidential and the staff of this department will give a
signed undertaking to the Head of the Department stating this.
i. Placement Evaluation
When personnel is appointed initially, a medical check-up is performed and baseline data on certain infections is
collected. A placement evaluation is made to ensure that persons with special health problems are not placed in
jobs that would pose an undue risk of infection to them. At this time, the health service also confirms that
vaccinations required are taken. If the vaccination is not complete, the SSHS shall advise completion of the
vaccine schedule.
ii. Employee health & safety education/orientation

Safety education starts at the time of employment. Staff training department conducts induction program about
hazards and prevention in the workplace for all staff employed in CMC soon after appointment. All staff are
informed of the need to report exposure to blood or potentially infectious body fluids to the SSHS duty doctor
without any delay. Other health and safety education will also be carried out as appropriate.
iii. Health counselling

The SSHS will conduct health counselling and offer prophylaxis when required (for example, following
accidental exposure to blood or potentially infectious body fluids).
iv. Work restrictions for staff

It is the responsibility of the staff to report suspected illness to the SSHS. The SSHS arranges for prompt
diagnosis and management of illness of personnel.When required the heads of departments are alerted of the
infections in the respective staff, keeping in mind the confidential nature of the information. The SSHS shall
recommend the exclusion of personnel from specific areas in which direct contact with patients may pose a risk
for the HCW or to the patient and also give clearance after the work restriction is terminated.
v. Health check-up
The SSHS will carry out an annual health check-up for all staff.
SPECIFIC PROPHYLAXIS
Pre-employment and upon employment

According to the National policy, everyone is expected to have had immunization against diphtheria,
pertussis, tetanus, poliomyelitis, and measles in early childhood, with boosters for diphtheria, pertussis
and tetanus subsequently.
The immunization history of all prospective staff shall be documented by the SSHS. If tetanus
immunization is not updated, the SSHS will provide the necessary doses free of cost
Prospective staff who have not had a full course of hepatitis B immunization will be offered the same
upon employment the expenses of which will be borne by the respective staff. The hepatitis B immune
status of staff who claim to have had the vaccine previously will be tested by serology on payment of the
expenses involved. Non-immune subjects will be offered immunization as stated above. All staff are
informed that accidental exposure to blood or potentially infectious body fluids should be immediately
communicated to the SSHS.
Immunization for all conditions other than the above will be based on a risk assessment of the individual
and his/her workplace, by the SSHS. Staff working in different sections of laboratories will have a risk
assessment in conjunction with the HOD and appropriate vaccines administered, when available.
Post-exposure Prophylaxis
Post-exposure prophylaxis and follow-up is given to HCWs who are exposed to the following infections;
a. Bloodborne pathogens (refer chapter 4)

b. Diphtheria
c. Meningococcal meningitis
d. Rabies
4. PREVENTING TRANSMISSION OF BLOOD BORNE PATHOGENS
INTRODUCTION
The occupational risk with blood borne pathogens among health care workers (HCW) has been recognized for a
long time. However, it was the emergence of the human immunodeficiency virus (HIV) that highlighted the need
to elucidate the epidemiology of occupational blood contact, the risk of infection from blood contact and to
formulate strategies to prevent the transmission of blood borne pathogens to HCWs from patients and vice versa.
Many countries have developed comprehensive guidelines for the prevention of blood borne infection among
different categories of HCWs. The known risks from blood borne pathogens and recommended safety
precautions to prevent occupational infection among HCWs are reviewed in this section. More detailed
discussion on this subject can be found in “Guidelines and Policies in HIV care”, 2001 prepared by the Hospital
Infection Control Committee.
Common situations when needle stick injuries occur:
Recapping the needle

Discarding sharps in bags instead of sharps container
Discarding sharps into an overfilled sharps container
Abandoned needles
Bending or breaking of needles
Transferring of sharps from one person to another
Table No.4.1. Do‟s and Don‟ts to prevent Needle stick injury
S.no. Do‟s Don‟ts

1. Sharps container should be available at the Do not recap the needle
procedure site
2. Dispose the sharps immediately into the Do not break or bend the needle
sharps container
3. Reusable needles should be sorted out with Do not allow the sharps to overflow
thick rubber gloves
4. Remove the needle from the syringe with Do not directly transfer sharps to another
care using a forceps or a clamp person (Use K - basin)
5. Dispose the sharps container when it is 3/4th Do not ask another person to hold the hand of
filled the patient while doing phlebotomy, instead
use a tourniquet
THE RISK OF INFECTION
Risk of transmission of infection from patient to

HCW Hepatitis B virus (HBV)
Numerous seroprevalence studies in developed countries have shown that the prevalence rate of past or present
HBV infection in HCWs are three to five-fold higher than in the general population. Cohort studies in the 1970s
and early 1980s in the United States, before the widespread use of hepatitis B vaccine in HCWs, showed an
annual rate of infection among HCWs of 0.5% to 5%, compared to 0.1% in the general population. Thus, in
regions such as India where precautions are not rigorously followed and the prevalence of infection in the general
population is much higher than in the United States, infection and mortality among HCWs from HBV are likely
to be much higher.
The commonest mode of transmission of infection from patient to health care worker is percutaneous injury from
a sharp object contaminated with infected blood. The rate of transmission of HBV infection by percutaneous
injury is estimated to be 30% from HBsAg and HBeAg positive patient and 6% from an HBsAg positive but
HBeAg negative patient.
There is very limited information on the prevalence of HBV infection among HCWs in India. The frequency of
HBsAg positivity, indicating a chronic infection in different centers in India ranges from 0.6% to 16.5%. In a
study in Delhi, the rate of HBsAg positivity among high-risk HCWs was 13.2% compared to 3.6% among the
general population.
Hepatitis C Virus (HCV)
HCV is an RNA virus in the Flaviviridae family. Exposure to blood is the major mode of transmission. The rate
of HCV transmission from an HCV positive source via a needle stick injury/sharps is estimated to be 1.8% (range
0-7%). Of patients infected with HCV, fewer than 25% have acute hepatitis. However, almost all of those who
have acute hepatitis develop chronic infection. Follow up studies show that 26%-50% of those infected with HCV
develop chronic active hepatitis and 3% to 26% go on to develop cirrhosis.
Data on the seroprevalence of HCV infection among HCWs is limited. Available data shows seroprevalence rates
of 0% to 1.7%. In a study among dentists and oral surgeons in New York City, the rates of anti-HCV antibody
among oral surgeons, other dentists and the general population (blood donors) were 9.3%, 0.97% and 0.14%,
respectively. There is no available data on the prevalence of HCV infection among HCWs in India. However,
rates of HCV infection among voluntary blood donors in Delhi was close to 1%, a rate substantially higher than
that reported in the United States. Hence, the risk of infection among HCWs in India is likely to be higher than
that reported in the United States.
Human Immunodeficiency Virus (HIV)
The most comprehensive data on the prevalence of HIV is from USA. Seroprevalence surveys among
orthopaedic surgeons and general surgeons who reported appreciable blood contact, including blood from HIV-
infected patients have shown extremely low rates of seropositivity; the majority of those who tested positive had
non-occupational risk factors for infection.
The average risk of seroconversion among HCWs who had occupational exposure to blood from an HIV-infected
patient was 0.3%; nearly all seroconversions occurred after injury with a hollow bore needle. In vitro studies have
shown that injuries with solid suture needles result in inoculation of 50% less blood than hollow needles of the
same gauge. These studies also showed that one layer of surgical gloves reduced the volume of blood injected by
solid needles by 70% or more and a second layer of gloves resulted in a further 50% reduction in the amount of
blood injected; the magnitude of reduction was less with hollow bore needles.
The risk of transmission of HIV from mucous membrane exposure is considerably less than with percutaneous
injury. Data from prospective studies have documented only 1 seroconversion from 1107 mucous membrane
exposures (0.09%).
Risk of transmission of infection from HCW to patient
There are many instances of transmission of HBV infection from HCWs to their patients. Most instances of
transmission occurred when standard precautions were not followed, though in some instances transmission has
occurred despite standard precautions. Thus, the use of standard precautions not only prevents infection from
patient to HCW but also prevents transmission of infection in the reverse direction.
RECOMMENDATIONS
A. Vaccination
The most important approach for the prevention of occupational HBV infection is the use of hepatitis B vaccine
among HCWs. The currently available vaccines are safe and highly effective in preventing infections. Over 90%
of adult recipients respond to the vaccine with protective levels of antibody. The minimum protective level of
anti-HBs is 10mlU/mL.Ongoing cohort studies suggest that the protection lasts for at least 13 years. Therefore,
testing to determine antibody persistence and booster vaccinations are not routinely recommended.
However, vaccines are currently not available for other blood borne pathogens, including HCV and HIV.
Therefore, prevention primarily consists of taking adequate barrier precautions to prevent transmission. With
HIV, post-exposure chemoprophylaxis may reduce, but not completely prevent, the transmission of infection.
B. Standard Precautions
Rationale:
In 1983, guidelines were published for prevention of transmission of infection from patients suspected to be
infected with blood borne pathogens. These precautions were termed “Blood and Body Fluid Precautions”. It was
soon realized that the majority of patients infected with HBV, HCV or HIV were asymptomatic and that the
infection status of most patients would be unknown at the time of presentation. This realization lead to the
recommendation that the category of blood and body fluid precautions be applied to ALL patients, a concept
known initially as Universal Precautions and now as Standard Precautions. The term “Standard Precautions”
refers to all patients. It is procedure based and not person based.
There is an erroneous impression that Standard Precautions are cumbersome and expensive and not practical in
countries with limited resources. However, if one scrutinizes the recommendations for Standard Precautions, they
are relatively simple. The precautions to be taken vary with the degree of anticipated exposure. In most instances,
this only means the use of gloves for all patients where contact with blood or body fluids is anticipated. Masks
and eyewear are only required when a splash is anticipated. More rigorous barrier precautions are only required
where massive exposure to blood or body fluids is anticipated. Even when they are uniformly applied for all
patients, these precautions are less expensive and more effective than universal testing of all patients for infection
with selected blood borne pathogens and use of precautions in only those who test positive. Most cases of
transmission of infection, at least of HIV, take place outside the setting of the operating room and pathogens such
as HCV are much more transmissible than HIV, and equally dangerous.
What fluids are potentially infectious?
The Centers for Disease Control considers the following body fluids as potentially infectious: blood, semen,
vaginal fluid, cerebrospinal fluid, synovial fluid, peritoneal fluid, pleural fluid, pericardial fluid, amniotic fluid,
saliva in dental procedures, breast milk in breast milk banking procedures, anybody fluid that is visibly
contaminated with blood, all body fluids in situation where it is difficult to differentiate between body fluids and
unfixed tissue or organs from humans.
Standard precautions may not apply to the following unless they contain visible blood: faeces, urine, saliva, nasal
secretions, sweat, tears, vomitus and human breast milk.
Cardinal rules of standard precautions:
Consider all patients potentially infectious

Assume all blood and body fluids and tissue are contaminated with a blood borne pathogen
Assume all unsterile needles and other sharps are similarly contaminated.
What does one need to do after he/she has a needle stick injury?
Immediate care:
For needle stick injuries: Wash with soap and water. There is no evidence that the use of antiseptics or
squeezing the wound reduces the risk of HIV transmission.
For non-intact skin exposure: Wash with soap and water.
For mucous membrane exposure (eg. Splash into eyes): Irrigate copiously with normal saline over 10
minutes.
Reporting:
All sharps injury (break of skin with any sharp instrument such as hypodermic needle previously used on a
patient) and mucosal exposure (blood or body fluids coming into contact with eyes, mouth etc.) should be
reported to the immediate supervisor and the SSHS within 2 hrs, immediately following exposure (8am– 4.30pm
SSHS (Mobile no. 05121), after 4.30pm Accident & Emergency).
All blood and body fluids with visible blood are considered infectious.
Other body fluids may be potentially infectious (see the section on Standard Precautions in the chapter
„Prevention of transmission of blood borne pathogens‟) and must be evaluated on a case-to-case basis.
C. Management:
Assessing the risk of transmission of HBV or HIV infection
For ALL exposures the following investigations need to be done:
i. Index patient should be checked for the following:
Human Immunodeficiency Virus antibody

Hepatitis B surface antigen
Hepatitis C virus antibody
ii. Health care worker: Depending on the exposure, blood of the health care worker is checked for the
following after getting consent:
HIV – HIV antibody up to 24 weeks (0,6,12 & 24 wks)
HBV– Anti HBS antibody testing
HCV – HCV antibody up to 24 weeks (0, 12, & 24 wks)
The blood samples for the investigations listed are sent for “rapid” testing. The SSHS duty doctor will check the
results within 45 minutes.
(a) If the index case is HBsAg positive
Table.4.2. Post-exposure prophylaxis for exposure to HBV
S.No HCW status Action

1. Anti-HBS antibody titre>100mIU/ml Reassurance
2. Anti-HBS antibody titre between 10 and One booster dose of HBV vaccine
100 mIU/ml
3. Anti-HBS antibody titre is negative or < HBIG and full course of vaccination (0,1 & 6
10 mIU/ml month)
Follow up: Staffs are asked to come back for completion of vaccination. At present, any staff who has been in
service for more than six months and is not fully immunized (3 doses) will not be eligible for free Hepatitis B
Immunoglobulin or vaccine. The pharmacy will stock Hepatitis B Immunoglobulin (HBIG) at all times.
HBIG is prepared from human plasma known to contain a high titer of antibody to HBsAg (anti-HBs). The
plasma from which HBIG is prepared is screened for HBsAg and antibodies to HIV and HCV. The process used
to prepare HBIG inactivates and eliminates HIV from the final product. Serious adverse effect from HBIG, when
administered as recommended, have been rare. Local pain and tenderness at the injection site, urticaria and
angioedema might occur; anaphylactic reactions, although rare, have been reported following the injection of
human immune globulin (IG) preparations. Persons with a history of anaphylactic reaction to IG should not
receive HBIG.
(b) If the index case is HCV positive
If the index is Hepatitis C positive, the HCW is screened for HCV antibody and liver function test (LFT) at 0, 3
months and 6 months, and followed up as appropriate.
There is no post-exposure prophylaxis recommended for HCV. Recommendations for post exposure management
are intended to achieve early identification of chronic disease and, if present, referred for evaluation of treatment
options.
(c) If the index case is HIV positive and the HCW is HIV negative
For the Indian setting, all HIV seropositive index patients are to be considered as highly infectious (HIV status
code 2 of CDC).
Chemoprophylaxis is best when started within 1-2 hours following exposure. The cut off period for
chemoprophylaxis is 72 hours following exposure.
The following investigations are to be done at the time of starting chemoprophylaxis. Do not delay starting
chemoprophylaxis while the results of these investigations are awaited.
Haemoglobin
Platelet count
Reticulocyte count
WBC-Total & Differential counts
Serum creatinine
Liver function tests
Random blood glucose
Regimen:
Tenofovir combined with either lamivudine (3TC) or emtricitabine (FTC) as preferred backbone drugs for
treating HIV. The recommended third drug is ritonavir-boosted lopinavir (LPV/r) or atazanavir (WHO
guidelines, CID 2015; 60 (Suppl 3): S161-4).
Note: H2 blockers should be avoided along with the treatment.
If in doubt, immediately consult a senior person (HOD, SSHS or ID) as soon as possible.
It is preferred to dispense the ART for the full 28days and monitor the HCW for side effects.
Follow up of HCW:
The HCW should be tested for HIV antibodies after 6 weeks, 3 months and 6 months following the exposure,
irrespective of the HIV status of the index patient.
Counselling
Counselling of the HCW is performed regarding;
Benefits of PEP
Risks & Side effects of PEP
Prevention of further transmission.
Needle stick review committee

A needle stick review committee is functional since December 2010. The objectives of this committee are
1. To review the incidences of all reported needle stick injuries occurring in the hospital.
2. To identify the section of health care workers most affected.
3. To analyze the circumstances and situations leading to the injury.
4. To plan out modules and interventions of education and training at various levels of health care workers.
5. To develop teaching aids in the form of posters, intranet flashes, presentations and videos to emphasize
on the right practices of handling sharps and needles thus aiming to increase awareness
6. To inform the monthly statistics to the Medical Superintendent and the Nursing superintendent, as well as
to display the statistics on the intranet
7. To advice the administration on the supply of Personal protective equipment for healthcare workers at
risk.
The committee consists of members from the following departments:
Head of SSHS- Chairman

HICC officer
Deputy Chairman HICC
Secretary and Joint Secretary of HICC
One representative from the Nursing Superintendent
Vice principal- Allied Health Sciences
Nursing representative from the supervisors of Out-Patient areas
Nursing in charge of the emergency services
Representative from the quality management services
Safety officer
The committee will meet at least once in three months on every third Wednesday in the SSHS. The minutes of the
meeting will be drawn by the HICC officer and will be circulated to all members.
RECOMMENDATIONS FOR PATIENTS KNOWN TO HARBOUR BLOOD BORNE PATHOGENS
Instructions for wards

Admission
Patients with HIV disease but presenting with unrelated illnesses may be admitted in any ward as per existing
rules. Patients with AIDS requiring isolation on account of secondary infectious diseases will be isolated as
recommended (see the chapter on Isolation Policies and Procedures). Confidentiality shall be maintained with
appropriate precautions to prevent transmission of infections in hospitals.
Preparation of the patients
It is the responsibility of the attending physician to ensure that patients testing positive are informed about the
result and receive counselling (either by the attending physician or in the Infectious Disease Clinic). Results of
the HIV test must be kept strictly confidential. When information on HIV status needs to be shared with a
member of the family, the patient‟s consent should be obtained. This does not apply to young children or those
with dementia / deficient sensorium.
The nursing staff will explain to patients, attendants and visitors (when necessary), the purpose and methods of
hand washing, body substance and excreta precautions, and other relevant precautions.
Red bag (Reusable non-sharp material)
The charge nurse must ensure that the prescribed red bag is obtained from CSSD when a patient with HIV, HBV
or HCV infection is admitted. All contaminated items that are to be sent to CSSD for disinfection are placed in
the red bag and sent for autoclaving. In CSSD the red bag is autoclaved and the instruments are washed, sorted,
repacked and autoclaved again. Sharps are not to be discarded in the red bag.
Specimens
Adequate precautions are to be taken while collecting specimens. The specimens are to be transported in leak-
proof containers are placed inside a leak-proof plastic cover. Ensure that the cover and the outside of the
container are not contaminated. Attach a “Biohazard” label.
Waste disposal
A bin lined by a yellow plastic bag is placed in the patient‟s room for infectious waste. When the bag is 3/4 full it
is sent for incineration. (Refer to the section on waste management for more details)
Non-infectious waste does not require special precautions and is disposed in a manner similar to non-infectious
waste generated from any other patient.
Sharps are discarded into the sharps container.
Death of a patient
Nursing staff must inform the Pathology duty doctor before sending the body to the mortuary. Those cleaning the
body should use gloves and other protective equipment. Before leaving the ward, the body is bagged as for any
case.
MANAGEMENT OF SPILL
Blood spill clean up
Large spills:
Wear a pair of gloves

Place a dry mop cloth over the spillage area, to allow the excess of blood and debris to get absorbed.
Pick this up with gloved hands and discard it in the yellow bag
Prepare 1% sodium hypochlorite solution (Dakin‟s) fresh
Pour it over the spillage area
Cover this with a rag piece
Leave it for 10-15 minutes (contact time)
Remove the rag piece with gloved hands and discard it in the yellow bag
Mop the area
Discard the gloves in a red bag
Wash hands with soap and water
Small spills:
Wear a pair of gloves

Cover the area with rag piece soaked with 1% sodium hypochlorite solution freshly prepared
Leave it for 10-15 minutes (contact time)
Clean the area with mop cloth and discard it in the yellow bag
Wash hands with soap and water
References:
1. FDA / NIOSH / OSHA; Blunt tip Surgical suture reduce Needle stick injuries and the risk of subsequent
Blood borne pathogen transmission to surgical personal May 2012.
2. How to prevent Needle stick and sharp injuries DHHS (NIOSH) Publication No. 2012-123, February
2012.
3. U.S. Department of Labour Occupational Safety & Health Administration. (n.d.). Blood borne Pathogens
and Needle stick Prevention. Retrieved fromwww.osha.gov/SLTC/blood borne pathogens /index.html.
4. David T Kuhar, David K Henderson, et.al. Updated US Public health Services guidelines for the
management of Occupational exposure to Human Immunodeficiency Virus and Recommendations for
post exposure prophylaxis. ICHE; Sept 2013, vol 34, No 9.
5. REGULATIONS FOR STAFF WITH SPECIFIC DISEASES
Proposed criteria for staff with pulmonary tuberculosis to return to work
All staff members with TB should have appropriate samples sent for Mycobacterial smear, PCR
(XpertMtb / Rif assay) and Mycobacterial culture & susceptibility studies (preferably MGIT method)
All staff members with sputum smear-positive pulmonary TB will be followed up by SSHS
They may return to work when determined to be non-infectious by meeting all criteria mentioned below;
o Have completed at least one month of standard anti-tuberculous treatment (Cat.1 RNTCP
regimen or daily treatment with 4 drugs Isoniazid+Rifampicin + Ethambutol+Pyrazinamide) and
o Report significant improvement in symptoms, and
o Have had three consecutive negative sputum AFB smears or decrease in sputum AFB smear
grade (e.g., „3+‟ to „1+‟ or „scanty‟), and
o Have continued medical supervision and monitoring of treatment until cured.
Proposed criteria for staff exposed to chicken pox
Healthcare workers with significant exposure to the varicella-zoster virus and who have already received two
doses of varicella vaccine are considered immune 4 weeks after the receipt of second dose or those having a
definite history of chickenpox or zoster can continue working (as they are considered protected), but should be
advised to contact Staff Students Health Services (SSHS) department before patient contact if they feel unwell or
develop a rash.
References:
1. Prevention of Varicella: Recommendations of the Advisory Committee on Immunization Practices

(AICP) MMWR:June 2007/56(RR04);1-40
6. TECHNIQUES
The section deals with techniques that are followed in patient care areas. They are;
i. Hand washing
ii. Use of gloves
iii. Use of Gowns
iv. Use of masks
v. Injections
vi. Collection and transport of specimens
HANDWASHING
Introduction: The hands of healthcare workers are the most common cause for transmission of microorganisms
between patients, and frequently implicated as the route of transmission in outbreaks of infection. Hand
decontamination is a procedure intended to remove microorganisms from the hands before transfer of these
microorganisms can occur. Microorganisms on the hands may be:
i.Resident flora: These microorganisms reside under the superficial cells of the stratum corneum and
are also found on the skin surface. They are a part of the body surface. As they are deep-seated in the
epidermis they are not easily removed by hand hygiene.
ii. Transient flora: These microorganisms are acquired on the surface of skin through direct contact
with other people, objects or the contaminated environmental surfaces, e.g Methicillin resistant
Staphylococcus aureus(MRSA). As these organisms usually survive for a limited period of time, they
are easily removed by hand washing with soap and water or use of alcoholic based hand rubs, which
removes dead skin squamous epithelium and the bacteria present on the skin.
As a minimum standard, hands should be decontaminated:
Before and after each work shift

Between every patient contact
Before and after any invasive procedure
After using the toilet, blowing your nose, covering a sneeze or cough
Before putting on and after removing protective clothing
Whenever hands become visibly soiled
After removal of disposable glove
Fig. 6.1 Five moments of hand hygiene

The use of Soap:
Soap should be used;
When the hands are visibly soiled

On arriving and departing from duty
Before and after taking a break
Before and after food
On entering and working in the ward kitchen
After removal of gloves to prevent cross contamination
The use of Alcoholic Hand rubs:
Alcoholic hand rubs should be used;
On hands which are not visibly soiled

Before and after attending a patient
Before and after aseptic procedures
When immediate handwashing facilities are not available
Handwashing technique
Turn the tap on, using elbow or automatic tap. The method varies from unit to unit.
Do not soil the tap.
Wet hands thoroughly.
Dispense one measure of the liquid soap into the palm of the hand, (use the elbow to activate the
dispensing button).
Take care when dispensing bactericidal detergent to avoid splashes.
Rub hands to produce lather, including all areas of hand and wrist in the following manner;
i. Rub palm to palm.
ii. Right palm over the left dorsum and left palm over the right dorsum.
iii. Palm to palm fingers interlaced.
iv. Backs of fingers to opposing palms with fingers interlocked
v. Rotational rubbing of right thumb clasped in left palm and vice versa.
vi. Rotational rubbing back and forwards with clasped fingers of right hand in left palm and vice versa.
vii. Rub both wrists in a rotating manner. Rinse and dry thoroughly.
Hand drying
Hand drying is an essential part of hand hygiene

Healthcare workers must ensure that hands are dried thoroughly
In clinical settings, disposable paper towels are the method of choice because communal towels are a
source of cross contamination
Used disposable paper towels should be thrown away in household waste, foot-operated bin
Do not use hands to lift the lid or they will become unclean
Fig. 6.2. Seven steps of effective hand washing
Fig. 6.3. Frequently missed areas

Areas most often missed are:
The thumbs.
Web spaces between the fingers
Tips of the fingers
Back of the hands
Compliance to the hand hygiene method should be monitored by the Infection Control Nurses.
Few staff nurses, trained in good hand hygiene practices serve as hand hygiene champions of different wards.
These nurses inculcate the habbit of good hand hygiene practices among our staff and act as link nurses.
6.1.1. Hand hygiene in high-risk areas
A. Intensive Care Unit & Nurseries:
Patients in these areas are at a higher risk of infection. Therefore the importance of hand washing cannot be
overemphasized. The procedure described above must be adhered to strictly at all times.
B. Operating theatres:
Surgical Scrub:
Strict aseptic techniques are to be followed by all personnel involved in surgical procedures. Surgical scrub
refers to the act of washing the fingernails, hands, forearms and 5cms above the elbow, with a bactericidal
solution in a prescribed manner for a specific period before a surgical procedure.
Surgical scrub helps to decrease the resident flora of the skin to an irreducible minimum, suppresses the growth
of microorganisms and reduces the hazard of microbial contamination of the surgical wound by skin flora.
Preparation:
Articles required:
i. Betadine 7.5%
ii. Chlorhexidine 4%
iii. Sterile hand towel
iv. Disposable mask and cap
Prior to Surgical Scrub:

Make sure that your skin and nails are clean. Nails should be short with no cuticles
Fingernails should not reach beyond the fingertip to avoid glove puncture
Inspect hands for cuts and abrasions
Remove all jewellery
Make sure that your hair is covered by cap.
Adjust the disposable mask. Make sure that the mask is perfectly fitted and you are comfortable with it.
Make sure that scrub area is clean, antiseptic solution is clean and water supply is available.
Technique for Surgical Hand Scrub
Prewash the hands and forearms with non-antimicrobial soap

The scrub should begin at the fingertips and end 2"above the elbows without returning to a clean area
The fingers, hands and forearms should be visualized as having four sides (planes) that must be
thoroughly scrubbed including the web space between each digit
Hold hands higher than the elbows so that water runs from finger tips towards the elbow. Additionally,
keep the hands and arms away from the scrub attire, while keeping the elbow in a flexed position
If possible, when the water is not in use, the tap should be turned off to conserve.
The surgical team member, after entering the OR should thoroughly dry hands and arms using aseptic
technique prior to donning the sterile gown to prevent contamination. If alcohol based scrubs are used, it
is necessary that the hands and arms be completely dry
Performing the surgical scrub without a brush or sponge is acceptable
o The practice of using a brush can damage the skin resulting in increased shedding of
microorganisms from the hands and arms. Scrubbing with a brush also contributes to an increase
in shedding of skin
o Studies have demonstrated lower bacterial counts when a brushless surgical scrub is performed,
in particular when alcohol-based scrubs (1% chlorhexidinegluconate and 61% to 70% alcohol)
are used compared to the use of a brush
Steps of surgical scrubbing
Thoroughly wet hands from finger tips to 5 cms above the elbow under running water
Apply disinfectant solution and lather on hands and arms
Continue scrubbing as follows for 5 min or repeat all the steps twice keeping hands above the elbow
throughout;
o Palm to palm
o Right palm over the left dorsum and vice versa
o Palm to palm with finger interlaced
o Back of the fingers to opposing palms with fingers interlaced
o Rotational rubbing backwards and forwards of right thumb clasped in the left palm and vice versa
o Rotational rubbing backwards and forwards with clasped fingers of the right hand in left palm
and vice versa
Rinse hands thoroughly, keeping hands up and away from the body. Avoid splashing of water over
Operation Room(OR) attire
Turn off the tap using the elbow
Grasp the edge of the sterile towel and dry one hand from fingertip to elbow, and repeat the same,
grasping the unused end of the towel for the other hand
Discard the towel in the receptacle.
C. Isolation wards/units
The general principles of handwashing before and after each shift, between patient contact and after attending to
personal toilette are to be observed. Emphasis is to be placed on the need for extreme care. Handwashing in
between and especially after handling soiled articles, cleaning up patients and attending to isolation patients
requires a mandatory 60 seconds scrub.
USE OF GLOVES
There are two categories of gloves available in the hospital;
i. Examination gloves:
These gloves are clean but not sterile. They are used for all procedures that do not require sterile
technique
ii. Sterile gloves:
These are used for all procedures where sterile technique is mandatory. Each pair of gloves is
supplied in a sealed cover.
Gloves uses and recommendations:
Health care workers are recommended to wear gloves to;
i. Reduce the risk of personnel acquiring infections from patients

ii. Prevent health-care worker‟s flora from being transmitted to patients
iii. Reduce transient contamination of the hands of personnel by flora that can be transmitted from one
patient to another
Gloves used by HCWs are usually made of natural rubber latex and synthetic non-latex materials (e.g., vinyl,
nitrile, and neoprene [polymers and copolymers of chloroprene]).
When to Glove?
Gloves should not be worn unnecessarily as their prolonged and indiscriminate use may cause adverse reactions
and skin sensitivity.
The following caveats regarding the use of gloves by HCWs must be considered. Personnel should be informed
that gloves do not provide complete protection against hand contamination. Bacterial flora colonizing patients
may be recovered from the hands of <30% of HCWs who wear gloves during patient contact. Further, wearing
gloves does not provide complete protection against acquisition of infections caused by hepatitis B virus and
herpes simplex virus.
Gloves must be worn for invasive procedures, contact with sterile sites, and on intact skin or mucous membranes,
and all activities that have a potential risk of exposure to blood, body fluids, secretions and excretions and when
handling sharps or contaminated instruments.
Gloves must be worn as single use items. They are put on just before an episode of patient contact or treatment
and removed as soon as the activity is completed. Gloves are changed between caring for different patients, or
between different care/treatment activities for the same patient.
Gloves must be disposed off as clinical waste and hands decontaminated, ideally by washing with liquid soap and
water after the gloves have been removed.
Choice between sterile and unsterile gloves must be made by the health care worker based on contact with
susceptible sites or clinical devices.
Techniques for wearing and removing gloves:
Wearing gloves
i. Pick up the cuff of the right glove with your left hand.
ii. Slide your right hand into the glove until you have a snug fit over the thumb joint and knuckles
iii. Your bare left hand should only touch the folded cuff – the rest of the glove remains sterile
iv. Slide your right fingertips into the folded cuff of the left glove. Pull out the glove and fit your left hand
into it
v. Unfold the cuffs down over your gown sleeves. Make sure your gloved fingertips do not touch your bare
forearms or wrists.
Glove Removal:
The key to removing both sterile and non-sterile gloves is “Dirty to Dirty – Clean to Clean”, that is,
contaminated surfaces only touch other contaminated surfaces: your bare hand, which is clean, touches only clean
areas inside the other glove.
i. Take hold of the first glove at the wrist

ii. Fold it over and peel it back, turning it inside out as it goes. Once the glove is off, hold it with your
gloved hand
iii. To remove the other glove, place your bare fingers inside the cuff without touching the glove exterior.
iv. Peel the glove off from the inside, turning it inside out as it goes and use it to envelope the other glove.
USE OF GOWNS
Surgical gowns were first used to protect patients from microorganisms present on the abdomen and arms of
healthcare staff during surgery. Surgical gowns made of fluid-resistant materials do play a role in keeping blood
and other fluids, such as amniotic fluid, off the skin of personnel, particularly in operating, delivery and
emergency rooms. Lightweight cloth gowns, however, which are generally available, offer little protection.
Under these circumstances, if large spills occur, the best thing to do is shower or bathe as soon as possible after
completing the operation or procedure. If surgical gowns are worn, sleeves should either taper gently toward the
wrists or end with elastic or ties around the wrists. (Large, droopy sleeves invite accidental contamination). In
addition, the cuffs of the surgical gloves should completely cover the end of the sleeves.
Aprons made of rubber or plastic provide a waterproof barrier along the front of the health care worker‟s body.
An apron should be worn when cleaning or during a procedure in which blood or body fluid spills are anticipated
(e.g. Caesarean section or vaginal delivery). Aprons keep contaminated fluids off the healthcare worker‟s
clothing and skin. During surgery, wearing a clean plastic apron over the scrub suit will not only help prevent the
surgeon or assistant from being exposed to blood or body fluids (e.g. Amniotic fluid), but also prevent the
surgeon‟s or assistant‟s abdominal skin from being a source of contamination for the patient.
Gowning technique (For sterile gowns)
Sterile gowns are always folded inside out to avoid contamination. As it is impossible to render the hands sterile,
they must not come in contact with the outside of the gown or gloves.
Procedure:
i. Hands must be washed thoroughly

ii. Pick up the gown holding it well away from the trolley and your own body
iii. Hold the neck band and unroll until the sleeves are seen
iv. Slide both hands and arms into the sleeves at the same time
v. The floor nurse/assistant slides her hands under the gown at the shoulder and pulls out and fastens all the
back tapes
vi. Cover the back with the back flap with the help of the scrub nurse.
Remember:
i. Do not keep the hands lower than the waist

ii. Do not keep the hands near one‟s neck or shoulder
iii. Do not touch the axillary area once gowned
iv. Do not touch the back of the gown
Removal of Gown at the end of the Procedure:
i. The circulating nurse will unfasten the gown

ii. The gown is carefully removed by the scrub nurse leaving the gloves on
iii. The gown is then removed by holding the inside cuff
iv. The gown with inside folded out is placed in the appropriate bin.
Eyewear protects staff in the event of an accidental splash of blood or other body fluid by covering the eyes.
Eyewear includes clear plastic goggles, safety glasses, face shields and visors. Prescription glasses or glasses with
plain lenses also are acceptable. Masks and eyewear or face shields should be worn when performing any task
where an accidental splash into the face is likely (e.g., performing caesarean section or vaginal delivery or when
cleaning instruments). If face shields are not available, goggles or glasses and a mask can be used together.
Footwear is worn to protect feet from injury by sharps or heavy items that may accidentally fall on them. For this
reason, sandals, “thongs” or shoes made of soft materials (cloth) should not be worn. Rubber boots or leather
shoes provide more protection, but they must be kept clean and free of contamination from blood or other body
fluid spills. Shoe covers are unnecessary if clean, sturdy shoes are available for use only in the surgical area. One
study suggests that cloth or paper shoe covers may increase contamination because they allow blood to soak
through to shoes and they are often worn outside the operating room where they are then removed with ungloved
hands.
USE OF MASKS
Masks should be large enough to cover the nose, lower face, jaw and facial hair. Health care workers (and
sometimes patients) may use standard surgical facemasks to prevent respiratory droplets from the mouth and nose
being expelled into the environment. Facemasks are also used, often in conjunction with eye protection, to protect
the mucous membranes of the wearer from exposure to blood and/or body fluids when splashing anticipated.
The traditional mask of four to six layers of muslin offers very limited protection. When first worn it may be
reasonably efficient, but soon becomes saturated with moist vapour from the wearer‟s breath. More efficient
masks are of high filtration disposable type. Several brands are available, any may be used. These masks can be
molded to facial contours and actually filter the respiration as compared to deflection with paper or cellophane
insert masks. Such masks achieve 98 percent efficient filtration compared to only 40 percent with muslin mask.
Procedure for using a mask
i. When wearing the mask, care should be taken to see that the nose, mouth and facial hair are well covered.
ii. Masks should be changed at least every operating session and should never be worn “around the neck”.
iii. Mask „wiggling‟ is also a potential source of infection.
iv. When removing a mask, care should be taken to avoid touching the part which has acted as the filter.
v. The hands can easily become contaminated with bacteria
INJECTIONS
Safe handling of disposable syringes and needles
i. The needle used for withdrawing medicine is discarded and a new needle is used for injecting a patient.
ii. Do not handle/touch the body of the plunger while loading and administering the medicine.
iii. After administering the medicine, do not recap the needle to avoid needle stick injury.
iv. Remove the needle with forceps or clamp and drop the disposable needle directly into the puncture
resistant plastic disposable sharps container.
v. When the sharps container is full till the fill line, dispose it in the temporary storage area and replace with
a new sharps container.
vi. Use gloves while sorting syringes and needles. Handle with extreme care, to avoid accidental injury.
Reusable syringe and needle (eg: Liver biopsy needle and bone marrow biopsy needle)
i. Do not recap needle or disassemble needle and syringe

ii. Soak the needle and the stylet in a K-basin with soap and water for 30 minute
iii. If bone marrow aspiration is done using a plastic disposable syringe, discard the syringe in red bag
iv. Wear gloves while washing the reusable needles. Dry it completely, then clean with 70% alcohol, pack it
and send it for gas sterilization to CSSD
v. Disposable biopsy needles are also available
vi. Follow the policy on tracking the single-use device for multiple use
Policy for Multiple dose solutions:
i. The person administering a multiple dose medication must read the label on the container to confirm that
the medication is intended for multiple uses.
ii. The date and time of opening the multi-dose vial should be labelled.
iii. It is the responsibility of the person using a multiple dose solution to determine its safety for future use
based on any perceived compromise to the solution‟s sterility. If breaks in technique have occurred, the
solution must be discarded
iv. Do not use the same needle to load the solution for different injections. A fresh needle must be used for
loading the solution and another fresh needle should be used for injecting the solution every time
v. After loading the solution for one injection, remove the needle from the vial and discard it in the sharps
container.
vi. Use of multi dose vials:
Ideally, multi dose vials should be kept for single patient only. If it is to be used for more than one
patient, the vial after use should be stored in medication area and not near the patient`s zone.
If a multi dose vial is punctured, it should be dated and discarded within 28 days of opening unless
until specified by the manufacturer.
Always check for the expiry date whether it falls within the 28 days range from the date of opening
and discard accordingly.
WHO qualified vaccines can be stored upto 28 days of opening when it meets the following criteria:
 Vaccine stored at appropriate temperature.
 Vaccine vial monitor is visible properly and can be monitored.
 Vaccine expiry date is not crossing within 28 days.
IV Fluids:
As IV fluids can be contaminated with microorganisms, the following guidelines for use of IV fluids are
recommended;
i. All old stocks of IV fluids are to be used before a new batch is started
ii. The expiry date should be checked before connecting the bottle for use
iii. Do not reuse bottle that has been used previously
iv. Discard after single use, even if some fluid remains in the container
v. Do not puncture bottles with needles to create airways
vi. The bottle must be carefully checked for damage and for leaks before use.
vii. If there are visible contaminants in the bottle, do not use the IV fluid. Send the bottle to the Microbiology
department for culture and inform the pharmacy, so that particular batch of IV fluids can be withdrawn
and inform the hospital infection control officer also.
COLLECTION AND TRANSPORT OF SPECIMENS
A. Specimens for general investigations:
Adequate precautionary measures are to be followed while collecting any specimen for investigations. (Refer to
„Standard precautions‟ under the chapter on preventing transmission of blood borne pathogens). For skin
disinfection before drawing blood, cleaning with 70% alcohol is adequate.All specimens should be transported in
covered, leak-proof containers. Use appropriate carriers for transportation.Lab request forms should not be soiled
with liquid specimens.
B. Specimens for culture:
All specimens for culture for etiological diagnosis must be taken before the institution of antimicrobial therapy.
However, therapy should not be delayed unnecessarily. For each specimen, the appropriate container must be
used and spillage must be avoided during collection, containerization and transportation. All specimen containers
should be labelled with the name and hospital number of the patient. Specimens from patients with suspected
blood borne pathogens or other highly infectious organisms should be placed in plastic bags and should bear the
biohazard label. Specimens should be transported to the laboratory immediately after collection. Blood once
inoculated for cultures should be transported immediately to the laboratory but can be incubated in the emergency
incubator in the microbiology department during the out of duty hours and never refrigerated. Other specimens
should be transported immediately to the laboratory but can be kept in the emergency refrigerator in the
microbiology department during the out of duty hours.
1. Blood for culture
Draw under strict aseptic conditions.

Prepare skin as for minor surgical procedures.
Ensure povidone-iodine/ 2% chlorhexidine is applied from the centre to the periphery.
Allow a contact time of three minutes.
Alternatively, 2% chlorhexidine or 70% alcohol (spirit), tincture iodine, and spirit sequence may be used.
After the needle is withdrawn, inject blood directly into blood culture bottles.
2. CSF and body fluids such as aseptic joint, peritoneal and pleural fluids
Collect the specimens in sterile containers provided for this purpose, with aseptic precautions.
3. Ear, nose & throat swabs
Take two swabs of specimen and place in one sterile tube. It is not necessary to wet the swabs with saline or
distilled water.
4. Feces
Place small quantity (5g) of feces in a sterile, wide mouthed, screw-capped container. Close tightly with a screw
cap.
5. Miscellaneous Specimens (ulcer exudates, swabs from wounds, burns, cervix, vagina,etc)
Do not apply antiseptic solution before taking the specimens
Place 2 swabs of the specimen in a sterile test tube
Send additional swabs when multiple examinations are requested
6. Pus
Place 1-2 ml pus in a sterile test tube. If this is not possible, take as much as possible on 2 sterile swabs
and place in a sterile test tube
Send sufficient material in separate containers for multiple examinations (e.g. M. Tuberculosis,
anaerobes, and fungi)
7. Sputum
Collect an early morning, coughed up specimen after rinsing the mouth with plain water.
Place 5-10 ml specimen into sterile screw cap bottle and send to the laboratory within 30 minutes. If there
is a delay, refrigerate and send within 1 hr.
8. Urine
Midstream clean catch sample is obtained.

Suprapubic aspiration is a better method for collecting urine for culture but is invasive. Use a 24 gauge
21/23 needle (longer than the usual needle) for this purpose.
Transportation of specimens
All specimens should be transported in covered containers. Laboratory request forms and the outside of the
container should not be soiled with liquid specimens. If soiling has occurred, discard and collect another sample.
References:
1. Who guidelines on Hand Hygiene in Health care.2009

2. Http://www.cdc.gov/niosh/npptl/respirators/ respsars.html
7. CARE OF ACCESS SYSTEMS, DEVICES AND WOUNDS
This section deals with vascular, respiratory and urinary care of patients with indwelling devices. Wound care is
also included in this section because similar principles are involved.
General guidelines to be followed for all procedures are;
Hand washing is mandatory before, after and in between procedures and patients.
Each health care worker should be familiar with personal protection (standard precautions).
Follow proper waste segregation and disposal after each procedure.
VASCULAR CARE
The use of intravascular devices, both venous and arterial, to deliver sterile fluids, medications and nutritional
products, as well as for central monitoring of blood pressure and other hemodynamic functions, has dramatically
increased during the past decade. It is estimated that about 50% of all patients admitted to hospital will receive
intravenous therapy, creating a large population at risk for local and systemic bloodstream infections.
Because catheters inserted into the venous or arterial bloodstream bypass the normal skin defense mechanism,
these devices are a way for microorganisms to enter the bloodstream from:
The device at the time of insertion

Subsequent contamination of the device or attachments (e.g., tubing connected to the blood monitoring
apparatus or the fluids being administered), or
Pathogens on the skin surrounding the insertion site.
The risk of infection associated with the use of intravascular devices can be reduced by following recommended
infection prevention practices related to their insertion (e.g.,use of the aseptic technique) and by better
management of the device once it is in place.
In addition to the general guidelines listed above, the following points apply to all intravascular catheters.
Hand hygiene and aseptic technique
Wash hands before every attempted intravascular catheter insertion. Hand hygiene should be performed
before and after touching the catheter insertion site, before and after inserting, replacing, accessing,
repairing or dressing an intravascular catheter.
Wash hands with soap and water before attempted insertions of central intravenous catheters, catheters
requiring cut downs, and arterial catheters.
Do not palpate the insertion site after application of antiseptics. Wear clean gloves for insertion of
peripheral intravascular catheters.
Sterile gloves should be worn for the insertion of arterial, central and midline catheter.
Preparation of skin
2% Chlorhexidinegluconate is to be used for cleaning the skin. No safety or efficacy recommendations for
chlorhexidine can be made for children < 2 months (other alternatives 70% alcohol or tincture of iodine). Begin at
the centre of the insertion site, use a circular motion and move outward. Antiseptics should have a contact time of
at least 30 seconds prior to catheter insertion. Antiseptics should not be wiped off with alcohol prior to catheter
insertion. Antiseptics should be allowed to dry before catheter insertion.
Applying dressings
Sterile dressings should be applied to cover catheter insertion sites. Unsterile adhesive tape should not be placed
in direct contact with the catheter-skin interface.
Inspecting catheter insertion sites
Intravascular catheters should be inspected daily and whenever patients have unexplained fever or complaints of
pain, tenderness, or drainage at the site for evidence of catheter-related complications. Inspect for signs of
infection (redness, swelling, drainage, tenderness) or phlebitis and also palpate gently through intact dressings.
Manipulation of intravascular catheter systems
Strict aseptic technique should be maintained when manipulating intravascular catheter systems. Examples of
such manipulations include the following;
Placing a heparin lock

Starting and stopping an infusion
Changing an intravascular catheter site dressing
Changing an intravascular administration set
Flushing IV lines
The solution used for flushing IV lines should not contain glucose, which can support the growth of
microorganisms. Do not reuse syringes used for flushing. One syringe is used for flushing only one IV line once.
Peripheral IV sites (short term catheters)
a. General principles
For adults, hand veins are preferred over arm veins, and arm veins over leg and foot veins. (Needles and
catheters inserted in leg and foot veins are more likely to cause inflammation at the insertion site or
phlebitis)
Rotating sites at 72-96 hours will reduce phlebitis and local infection.
Teflon or polyurethane catheters are preferred over steel needles because they are less likely to perforate
the vein with movement.
If only short-duration (less than 48 hours) IV injection is planned, straight or butterfly needles are less
than irritating than plastic catheters and have lower rates of infection.
Because straight and butterfly needles frequently infiltrate, they should not be used with a solution that
could cause tissue necrosis.
b. Dressing changes
Peripheral IV site dressings should not usually require routine changes, as peripheral IV catheters can be
removed within 72 hours.
All dressing must bear the labels with date and time of change.
Wear clean or sterile gloves while changing the dressing on intravascular catheters.
c. Use of bungs
Clean the bung using sterile swabs and spirit before each injection.
d. Replacement of Peripheral IV Catheters
Peripheral IV catheters should be removed 72 hours after insertion, provided no IV-related complications
requiring catheter removal are encountered earlier. A new peripheral IV catheter, if required, may be
inserted at a new site.
Central intravascular catheters (long term catheters)
A. General principles
The following general principals must be kept in mind while choosing the type of catheter:
Use a single lumen catheter unless multiple ports are essential for the management of the patient.
If a multi-lumen catheter is used, identify and designate one port exclusively for hyper alimentation to
administer parenteral nutrition.
Use a tunneled venous access device (one with a subcutaneous port) for patients for whom long term
(more than 3-4 weeks) vascular access is anticipated.
Unless medically contraindicated, use the subclavian site in preference to the jugular or femoral sites for
non-tunneled catheter placement.
Use maximum sterile barriers, including a sterile gown, sterile gloves, and a sterile drape for the insertion
of central venous access devices.
b. Catheter Site Care

Designate only trained personnel who have demonstrated competency in the maintenance of central
intravascular catheters.
Preferably, sterile, transparent semi-permeable polyurethane dressing should be used to cover the catheter
insertion site
Promptly remove any central venous catheter (CVC) that is no longer required.
Do not routinely replace CVCs, PICCs, haemodialysis catheters, or pulmonary artery catheters.
Do not remove CVCsor PICCs on the basis of fever alone. Use clinical assessment to determine if
aninfection is evidenced elsewhere or if there is another non-infectious cause of the fever.
A sterile gauze dressing can also be used if the insertion site is bleeding or oozing. The site must be
inspected daily and changed when the dressing becomes damp, loosened or soiled.
2% Chlorhexidine should be used for catheter site care.
Change of administration set and 3-way extension
IV tubing and 3-way extension should be changed 24 to 48 hours
** According to CDC 2011 guidelines;
o In patients not receiving blood, blood products, or fat emulsions, administration sets used
continuously can be replaced in 96 hours to 7 days.
o Replace the tubing used to administer propofol infusions every 6 - 12 hours.
o Replace the tubing used to administer blood, blood products, or fat emulsions within 24 hours of
initiating the infusion
c. Catheter replacement strategies
Do not routinely replace catheters as a method to prevent catheter-related infection

When adherence to aseptic technique cannot be ensured (i.e. Catheters inserted during a medical
emergency), replace the catheter as soon as possible, i.e. Within48 hours.
As far as possible, do not change CVCs over guidewire exchanges for non-tunnelled catheters.
In the presence of suspected or definite infection, do not use guidewire exchanges to replace a non-
tunnelled catheter suspected of infection.
If there is no other option available, guide wire assisted catheter exchange may be used to replace a
malfunctioning catheter or to exchange an existing catheter only if there is no evidence of infection at the
catheter site or proven catheter-related bloodstream infection.Use new sterile gloves before handling the
new catheter when guide wire exchanges are performed.
Replace all fluid administration tubing and connectors when the central venous access device is replaced.
IV Catheter-related infection
The following are the various types of infections related to central IV catheters:
Exit site infection (microbiologic diagnosis). Clinical infection in which culture of the discharge (pus or
fluid) at the exit site yields a microorganism, with or without microbiologic evidence of bloodstream
infection.
Phlebitis. Area of swelling, redness, warmth, and tenderness of the skin around the site where the
intravascular catheter comes out of the skin (the exit site). If phlebitis is associated with other signs of
infection, such as fever and pus coming from the exit site, it is classified as a clinical exit site infection.
Pocket infection. Infected fluid isolated from the area around a totally implanted intravascular device,
with or without microbiologic evidence of bloodstream infection.
Tunnel infection. Tenderness, redness and swelling for more than 2cm (about 1inch) along the tract of
an intravascular catheter, with or without microbiologic evidence of local or bloodstream infection.
Removal of infected IV catheter
At the time of catheter removal, the site is examined for the presence of swelling, erythema,
lymphangitis, increased tenderness, and palpable venous thrombosis.
Any antimicrobial ointment or blood present on the skin around the catheter is first removed with
alcohol.
The catheter is withdrawn with sterile forceps, the externalized portion being kept directed upward and
away from the skin surface.
If an infection is suspected, after removal, the wound is milked in an attempt to express purulence.
For 5-7 cm catheters, the entire length, beginning several millimeters inside the former skin surface
catheter interface, is aseptically cut and sent for culture.
With longer catheters (20.3cm and 60.9cm in length), two 5-7cm segments are cultured: a proximal one
beginning several millimeters inside the former skin catheter interface and the tip.
Catheter segments are transported to the laboratory in a sterile tube.
Needleless connectors:
o Change the needless connectors every 72 hours.
o Minimize contamination risks by scrubbing the access port with an appropriate antiseptic
(chlorhexidine or 70% alcohol).
RESPIRATORY CARE
In addition to the general guidelines that are to be adhered to, the following should also be noted with regard to
respiratory care.
Mouth flora influences the development of Healthcare associated pneumonia in ventilated patients. Frequent
chlorhexidine mouthwashes minimize the chances of pneumonia.
Ventilator
All reusable equipment needs to be adequately cleaned between patients by washing with running hot
water (soap is used if necessary). If still soiled, they are immersed for 2 hours in hydrogen peroxide
solution/enzyme.
Oxygen masks, venturi devices, and nebulizer chambers are cleaned carefully and then disinfected by
immersing in 2% glutaraldehyde for 8 hours after which they are thoroughly rinsed with sterile water and
dried. If facilities are available, these may be gas sterilized
Items that are disinfected with glutaraldehyde are then washed with adequate amounts of water to remove
the glutaraldehyde.
Humidifier domes are autoclaved.
Ambu bags and Bain‟s circuits are cleaned thoroughly and are then sent for ETO gas sterilization.
Although routine microbiological surveillance of respiratory therapy equipment is NOT required, it is
necessary for the epidemiological evaluation of an outbreak.
Pneumatic Circuit Changing :
i. The pneumatic circuit includes catheter mount, Y connection, water traps, nebulizing chambers,
T piece, spacer device (If MDI is used).
ii. Disposable (single use) pneumatic circuits need to be used.
iii. Routine change of the pneumatic circuit is not encouraged.
iv. When a pneumatic circuit or any other accessories therein as mentioned in (i) is found to be
soiled, it is mandatory that the pneumatic circuit is changed.
v. Ventilators are to be cleaned thoroughly before they are connected to the next patient.
Humidifiers:
i. Sterile water only should be used.
ii. Autofill humidifying chambers are used. However, using autofill chambers may escalate the cost.
iii. HME filters are better suited to those patients who have fewer secretions, otherwise, frequent
soiling and blocking may take place.
Tracheostomy Care/Endotracheal tube

The patient with a tracheostomy is at risk for Healthcare associated pneumonia since this procedure
bypasses the nasopharyngeal defense mechanisms.
Tracheostomy should be an elective procedure, done in an operating room, under sterile conditions,
unless an emergency is indicated. If so, sterile techniques must be maintained at the bedside.
Careful attention to post-operative wound care is mandatory.
The patient should receive aerosol therapy to prevent desiccation of the tracheal and bronchial mucosa or
the formation of crusts. The skin around the tracheostomy tube should be cleaned with chlorhexidine
every four hours, or more frequently if necessary.
In the case of metal tracheostomy tubes, the inner cannula should be cleaned every four hours and more
often if necessary to prevent the formation of crusts. The inner cannula is cleaned with water, immersed
in hydrogen peroxide/enzyme for 15 minutes, followed by boiling for 10 minutes and then rinsed with
fresh and sterile normal saline. The plastic tracheostomy tubes are removed, another plastic tube is
inserted and the tube is cleaned with hydrogen peroxide and rinsed well in lukewarm water before reuse.
The tracheostomy tape securing the tube should be changed every 72 hours. This tape must be tied
securely at all times.
The first complete tube change should be performed no earlier than 4-5 days to allow time for the tract to
be formed. Subsequent changes should be done weekly or as necessary.
Sterile technique should be used to change the tracheostomy tube unless there is a medical indication for
sterile technique.
The obturator should be at the bedside (preferably taped to the head of the bed) to be used if the
tracheostomy tube is accidentally dislodged or is removed for any reason.
Suctioning of Endotracheal/tracheostomy tube
Suctioning of the tracheostomy should be done frequently to ensure that the airways are free of secretions.
However, too frequent or excessive suctioning may irritate the tracheobronchial tree. Employees should be
instructed and supervised by trained personnel in the use of proper techniques before performing this procedure
on their own. Assess the patient using auscultation, ECG (if available) and vital signs prior to suctioning.
Sterile Suctioning
Wash your hands.

Use a catheter with a blunt tip.
The wall suction should be set no higher than 120mmHg for adults and between 60 and 80mmHg for
children.
Attach the suction catheter to the suction tubing; do not touch the catheter with the bare hand (leave it in
its protective covering).
Put on sterile gloves. The wearing of a mask is also strongly recommended.
If saline needs to be instilled, 1/2cc of sterile saline is put into the tracheostomy tube on inspiration only.
If on a respirator, pre-oxygenate the patient by connecting the resuscitation bag to the artificial airway
and ventilating the patient with three or four deep breaths. A mechanical ventilator, on 100% oxygen,
may also be used by pressing the 100% oxygen which will deliver 100% oxygen for 2 minutes
Insert the catheter gently through the inner cannula until resistance is met. Do not apply suction during
insertion.
Withdraw the catheter approximately 1cm and institute suctioning.
Carefully withdraw the catheter in a circular motion, rotating it gently between the thumb and forefinger
applying intermittent suctioning.
Continuous suctioning for longer than 10-15 seconds may create an unacceptable level of hypoxia.
The patient should be given time to rest between suctioning episodes. If possible, this time should be
from two to three minutes. If the patient is receiving oxygen or ventilatory support, reapply the oxygen or
ventilator for at least two minutes before re-suctioning.
Observe for an unfavourable reaction such as increased heart rate, hypoxia, arrhythmia, hypotension,
cardiac arrest, etc.
If oral suctioning is necessary, it should be done after the tracheostomy is suctioned.
When suctioning is completed, clear the catheter and tubing of mucus and debris with sterile water or
saline.
Discard the catheter, water container, and gloves appropriately.
Wash hands.
The tubing and suction canister should be changed every 24 hours. The canister should be labelled with
the date and time when they are changed. If debris adheres to the side of the tubing or the canister, either
or both should be changed. The tubing should be secured between suctioning periods so that, it will not
fall to the bed, floor, etc.
Do not:
Place the ventilator connection / Ambu bag mouthpiece touching the bed/sheet/ gown.
Reuse the contaminated catheters.
Wash the ventilator connections / T-piece in water or spirit and reuse.
Self-suctioning
Patients are taught clean suctioning techniques following the above guidelines. The importance of careful hand
washing and correct catheter care must be emphasized.
URINARY CATHETER
The urinary tract is a common site for HAIs. Most of these infections follow instrumentation of the urinary tract,
mainly urinary catheterization. Proper technique of inserting and maintaining an indwelling catheter will reduce
the chance of HAIs.
Catheter-associated infection is caused by a variety of pathogens, including E. Coli, Klebsiella, Proteus,and

Pseudomonas. Many of the microorganisms are part of the patient‟s endogenous bowel flora, but they can also be
acquired by cross contamination from other patients or hospital personnel or by non-sterile techniques.
Urethral catheterization
Personnel
Only persons who know the correct technique of aseptic insertion and maintenance of catheters should handle
catheters.
Catheter Use
Urinary catheters should be inserted only when necessary and left in place only as long as medically
necessary.
They should not be used solely for the convenience of patient-care personnel. For selected patients, other
methods of urinary drainage such as condom catheter drainage, suprapubic catheterization, intermittent
urethral catheterization, and adult disposable diaper pads can be useful alternatives to indwelling urethral
catheterization.
Handwashing
Handwashing should be done immediately before and after any manipulation of the catheter site or
apparatus.
Catheter insertion
Catheters should be inserted using aseptic technique and sterile equipment.

Use an appropriate antiseptic solution for periurethral cleaning.
As small a catheter as possible, consistent with good drainage, should be used to minimize urethral
trauma according to the gender.
Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction
on the opposite side if there is a femoral CVC.
Anchoring the catheter
Strapping of the catheter is done to the lower anterior abdominal wall in male patients. Shaving is done
for all patients prior to catheterization on the abdominal wall before applying adhesive, to secure the
catheter. This is to prevent direct transmission of the weight of the bag on the catheter so that pulling and
inadvertent dislodgment of the catheter does not occur. This also helps prevent stricture of the penile
urethra if the patient is on a catheter for a long duration.
Transportation of a patient with a urinary catheter
The urine collecting bag has straps – make sure that these are untied before shifting the patient to avoid
inadvertent pulling of the catheter with resultant trauma.
During transit, maintain the closed drainage system. Empty the urine bag before transport and record the
volume of urine. The urine bag has a stopper which has to be replaced properly after emptying the bag.
See that the urine bag tubing does not get pulled away from the Foley‟s catheter.
Though most of the commercially available urine bags have a non-return valve, maintain the level of the
urine bag below the level of the bladder during transit. This is to ensure that no reflux of urine occurs
from either the tubing or the bag, back into the bladder.
Avoid inadvertent clamping or occluding of the catheter or the tubing. See that the urine bag does not get
entrapped beneath the patient. Ensure that continuous bladder drainage is maintained throughout the
transit period.
A leg bag is preferred if the patient is to be discharged on continuous bladder drainage with a Foley‟s
catheter for a long time.
Check the patency of the catheter to ensure continuous bladder drainage especially for patients who have
undergone an operation on the urinary bladder.
Look for the position, and ensure a closed drainage system on receiving the patient. Also, note the
volume and character of urine.
Use the port for collecting the urine sample. Do not disconnect the catheter for collecting the sample.
Catheter care:
Perineal wash with soap and water is encouraged for ambulant patients.
For bedridden patients, Povidone iodine is used for catheter cleaning and benzalkonium chloride for
perineal care.
WOUND CARE
Surgical wounds
Surgical wounds after an elective operation are inspected on the third post-operative day, or earlier if
wound infection is suspected
All personnel doing dressings should wash their hands before the procedure
Ideally, the two-member technique is followed. One to open the wound, and one to do the dressing
If two health care workers are not available, then, take off the dressing, wash hands again before
applying a new dressing
A clean, dry wound may be left open without any dressing after inspection
If there is any evidence of wound infection or purulent discharge, then dressings are done daily. Dry
absorbent dressings are applied.
Care of ulcers
Dressings of ulcers, of whatever cause should be done at least daily, or more often, depending on the
amount of discharge from the ulcer
The same technique as for surgical wound dressing is used
After inspecting the wound, all the devitalized tissue should be removed, using sharp dissection with a
scalpel or scissors if necessary
After debridement of the wound, a sterile absorbent dressing is applied. Application of solutions
/medications is probably unnecessary and should be left to the discretion of the treating team.
Care of open surgical wounds, fistulae
Open surgical wounds and fistulae discharge a lot of fluid. Using a „wound manager‟ or stoma adhesive
wafer with ostomy bags helps to keep the wound dry
A wound manager is useful as it facilitates regular inspection of the wound and debridement, if
necessary. It also helps if continuous irrigation of the wound with normal saline is required
The skin around intestinal fistulae should be inspected daily for excoriation. If excoriation is present, zinc
oxide paste can be applied around the skin. Commercially available products include stoma adhesive
wafers, paste and duoderm.
Table 7. 1. Transportation of patients with drainage or shunts
Procedure Rationale
1. Drainage – maintain a closed
drainage system during transportation
a. Make sure that the drainage bag is closed Closed sterile drainage system reduces the entrance
with the attached cork/spiget. of microorganisms
b. Avoid disconnection while transportation
c. Do not raise the drainage bag/bottle above Drainage apparatus must be kept at a lower level
the level of the body cavity from which than the body cavity to prevent backflow of fluid
drainage is connected.
into the pleural space or body cavity that may
cause infection
d. Do not clamp the drainage tubes or If clamped for a long time, pressure may build up
catheter or anything to disrupt the drainage and produce tension pneumothorax
system
e. Use portable stands/holders for drainage

bottle/bags while transporting
f. Have a clamp available while transporting In the event of breakage of the bottle, clamp to
a patient with an intercostal drainage tube prevent air entry and to prevent infection
2. Shunts - Make sure that the shunt is
covered with sterile dressing during
transportation
Reference:
Naomi P O Grandy, Mary Alexander, Lillian A Burns etal. Guidelines for prevention of Catheter-related
infection, Healthcare infection Control Practical Advisory, 2011.
8. ISOLATION POLICIES AND PROCEDURES
Isolation procedures are meant to prevent or interrupt transmission of pathogenic microorganisms within the
hospital. Selected patients may require specific precautions to limit transmission of potential infecting organisms
to other patients.
TRANSMISSION OF INFECTIONS
There are three primary modes of transmission of infectious diseases in the hospital, in addition to blood and
body fluids. They are:
I. Contact transmission
Infectious agent (bacteria, virus or parasite) transmitted directly or indirectly from one infected or colonized
individual to a susceptible host (patient), often on the contaminated hands of a healthcare worker.
Ii. Droplet transmission
Contact of the mucous membranes of the nose, mouth or conjunctiva of the eye with infectious particles larger
than 5μm in size that can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or
suctioning. Droplet transmission requires close contact between the source and the susceptible person because
particles remain airborne briefly and travel only about 1 meter (3 feet) or less.
Iii. Airborne transmission
Transfer of particles 5μm or less in size into the air, either as airborne droplets or dust particles containing the
infectious microorganisms; can be produced by coughing, sneezing, talking or procedures such as bronchoscopy
or suctioning; can remain in the air for up to several hours; and can be spread widely within a room or over
longer distances. They remain suspended in the air for long periods. As these particles are very light they can
travel through bronchial tree and reach alveoli to cause infection. Therefore the healthcare workers should wear a
respirator when entering the room. Special air handling and ventilation are needed to prevent airborne
transmission.
Table. 8.1. Clinical syndromes or conditions to be considered for “Empiric Use” of transmission based
precautions
Clinical Syndrome or Conditiona Potential Pathogensb Empiric Precautions

Diarrhoea Enteric pathogens Contact
1. Acute diarrhea with a likely
infectious cause in an
incontinent or diapered
patient.
2. Diarrhoea in an adult with a Clostridium difficile Contact
history of recent antibiotic use
Meningitis
1. Rash or exanthems, Neisseria meningitidis Droplet and contact
generalized, etiology
unknown. Petechial/
ecchymotic patches with fever
Respiratory infections
1. Fever, coryza with Varicella (Chicken pox) Airborne and contact
maculopapular/vesicular rash Rubeola (Measles)
2. Cough/ fever/ upper lobe Mycobacteriu Airborne

pulmonary infiltrate in an m tuberculosis
HIV
negative patient or a patient at
low risk for HIV infection
3. Cough/fever/pulmonary Mycobacteriu
infiltrate in any lung location m tuberculosis Airborne
in an HIV infected patient or a
patient at high risk for HIV
infection
4. Paroxysmal or severe Bordetella pertussis

persistent cough during Droplet
periods of pertussis activity
5. Respiratory infections Respiratory syncytial or

particularly bronchiolitis and parainfluenza virus Droplet and contact
croup in infants and young
children
Risk of multidrug resistant

microorganisms
1. History of infection or Multidrug resistant Contact
colonization with multidrug bacteria
resistant organisms
2. Skin, wound or urinary tract Multidrug resistant Contact

infection in a patient with a bacteria
recent hospital or nursing
home stay in a facility where
multi drug resistant
organisms are prevalent
3. Skin or wound infection Staphylococcus aureus,

group A Streptococcus Contact
A
Patients with the syndromes or conditions listed above may present with atypical signs or symptoms. The
clinician‟s index of suspicion should be guided by the prevalence of specific conditions in the community, as
well as clinical judgment.
B
The organisms listed under column “Potential Pathogens” are not intended to represent the complete or even
most likely diagnosis, but rather possible etiologic agents that require additional precautions beyond Standard
Precautions until they can be ruled out.
ISOLATION CATEGORIES
The appropriate isolation precautions should be initiated once an infectious disease is suspected. This decision
may be reviewed after confirming the diagnosis. The basic purpose of isolation of a patient is to confine the
infectious agent to a restricted area until its danger of spread has been controlled. The following categories are
recommended, taking into consideration the route of infection and the infectivity of the organism.
The Isolation Procedures involve a two-level approach:
i. Standard Precautions which apply to all patients attending the hospital.

ii. Transmission-Based Precautions which apply primarily to hospitalized patients with specific conditions
Standard precautions
Standard precautions are guidelines and procedures designed to reduce the risk of transmission of
microorganisms from both recognized and unrecognized sources of infection in healthcare settings.
Standard precautions are designed for the care of all patients regardless of whether or not they are known to be
infected with a blood-borne pathogen (every patient is considered potentially infectious) and apply to blood and
all other body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes.
Cardinal rules of standard precautions
Consider all patients as potentially infectious
Assume all blood, body fluids and tissues to be contaminated with bloodborne pathogens.
Assume all unsterile needles and sharps to be similarly contaminated.

Key components of standard precautions:
i. Hand hygiene
Perform 5 moments of hand hygiene using alcohol-based hand rub or soap and water
Before patient contact
Before aseptic task
After blood/ body fluid exposure
After patient contact
After touching the patient environment
ii. Use of personal protective equipment (PPE)

Gloves: Use gloves for contact with blood, body fluids, secretions and contaminated items, mucous
membranes and non-intact skin.
Goggles and face mask: Use to protect mucous membranes of eyes, nose and mouth when contact
with blood and body fluids is likely.
Gowns: Use gowns to protect skin from blood or body fluid contact and prevent soiling of clothing
during procedures that may involve contact with blood or body fluids.
iii. Safe handling and disposal of sharps

Avoid recapping used needles.
Avoid removing used needles from disposable syringes with hands.
Avoid bending, breaking or manipulating used needles by hand.
Place used sharps in designated puncture-resistant containers.
iv. Waste disposal
Waste to be segregated at source and disposed of as per guidelines (Refer the chapter on Hospital
waste management)
v. Environmental cleaning
Routine care, cleaning and disinfection of equipment and furnishings in patient care area
vi. Patient care equipment

Handle soiled equipment in a manner to prevent contact with skin or mucous membranes and to
prevent contamination of clothing or the environment. Clean and disinfect/ sterilise reusable
equipment prior to reuse.
Transmission-based precautions
Contact Precautions
These precautions reduce the risk of transmission of organisms from an infected or colonized patient through
direct or indirect contact.
These apply to patients with any of the following conditions and/or diseases:
Patients infected or colonized with enteric pathogens (Salmonella, Shigella, Vibrio cholerae, Hepatitis A
& E)
Patients infected with multi-drug resistant (MDR) organisms like MRSA, VRE & CRO
Patients with generalized rash or exanthemas
Patients with draining wound
a. Patient placement
Single room is preferable. Cohort only patients who are affected by the same organism. Ensure that patients are
physically separated (i.e., >3 feet apart) from each other. Draw the privacy curtain between beds to minimize
opportunities for direct contact.
b. PPE use:
Before the patient care, HCWs are advised to:
Perform hand hygiene

Wear a disposable plastic apron
Wear gloves
After the patient care and before leaving the patient room HCWs to
Discard gloves and apron in the red bag (Bin should be inside the patient room / near patient cot)
c. Patient transport
Limit the movement and transport of the patient from the room for essential purposes only. Where necessary
ensure that adequate precautions are taken to minimize the risk of transmission to others, and contamination of
environmental surfaces or equipment.
d. Patient care equipment
Where possible dedicate the use of patient care equipment to a single patient. Otherwise, ensure that all items are
adequately cleaned or disinfected before use for another patient.
Droplet precautions
These should be applied to patients known or suspected to be infected with a pathogen that can be transmitted by
the droplet route. These precautions include, but are not limited to:
Respiratory viruses (e.g. Influenza, parainfluenza virus, adenovirus, respiratory syncytial virus, human
metapneumovirus)
Corynebacteriumdiphtheriae
Neisseria meningitides
Bordetella pertussis
Single room is preferable and the door of isolation room to be kept closed all the time with signboard for isolation
precautions. Cohort only with patients who are affected by the same organism. Special air handling and
ventilation are not necessary. Spatial separation of patients by > 3 feet and drawing the curtain between patient
beds is especially important for patients in multi-bed rooms with infections transmitted by the droplet route.
b. PPE use:
Educate the patient and caregivers about respiratory hygiene and cough etiquette
Before entering the patient room, HCWs to

Wear a surgical mask
Wear a disposable plastic apron
Wear gloves
After the patient care and before leaving the patient room HCWs to
Discard gloves and apron in a red bag and mask in the yellow bag (Bin should be inside the patient room
/ near patient cot)
Limit the movement and transport of the patient from the room for essential purposes only. Where necessary
ensure that adequate precautions are taken to minimize the risk of transmission to others, and contamination of
environmental surfaces or equipment. Patients on droplet precautions who must be transported outside the room
should wear a surgical mask if tolerated and follow respiratory hygiene/cough etiquette.
Air-borne precautions
Apply to patients known or suspected to be infected with a pathogen that may be transmitted by the air-borne
route; these include, but are not limited to:
Tuberculosis (Pulmonary TB & TB larynx)

Measles
Chickenpox (until lesions are crusted over)
Localized (in an immunocompromised patient) or disseminated herpes zoster (until lesions are crusted
over)
Single room with negative pressure is preferable (Airborne isolation room). Self-closing devices on doors to keep
the door closed. The TB isolation room needs to be checked for negative pressure.Ventilation system should
provide a means to discharge air from the room to the outside, such as an exhaust fan. The exhaust fan should be
on emergency power. Ensure that all doors and windows remain properly closed in the isolation room. The slit at
the bottom of the door is sufficient to provide a controlled airflow path.
b. PPE use
Patients with TB are asked to wear a surgical mask covering the nose and mouth during the entire hospital stay.
HCWsand caregivers to wear N95 mask
Limit movement or transport of the patient from the room to essential purposes only.
If transport or movement is necessary, minimize patient dispersal of organisms
PROTOCOL GIVEN FOR CARE OF PATIENTS WITH DRUG-RESISTANTPATHOGENS
Contact Isolation Precautions
i. Admit patients to a single room or multi-bedded room (if they have the same illness). The door may be
left open
ii. Health care personnel to wear gowns if soiling is likely (esp. When the patient has diarrhoea, large open
wounds,etc)
iii. Wear clean, non-sterile examination gloves when examining or carrying outpatient care
iv. Change gloves after contact with infectious material (e.g., faeces or wound drainage)
v. Remove gloves before leaving the patient room
vi. Perform hand hygiene either with soap and water or alcohol-based hand rub after removing gloves
vii. Patient care equipment: Reserve non-critical patient care equipment for use with a single patient
wherever possible
viii. Use disposable items wherever possible.
Cleaning procedure for isolation room or bed
i. Linen should be stripped from the bed with care taken not to shake the linen during this action. Linen
should be soaked for 1/2 hour in 1% Sodium Hypochlorite and then sent to the laundry
ii. All other articles like I.V stand and furniture should be thoroughly cleaned with detergent and disinfected
with 7% Lysol
iii. Walls should be thoroughly cleaned with detergent and disinfected with 7% Lysol
iv. The bathrooms should be cleaned with detergent and disinfected with 7% Lysol
v. Used CSSD items should be collected in a red bag and sent for double autoclaving.
At discharge (terminal disinfection)
i. Keep an ultraviolet light in the room facing each direction for half an hour in a 2 bedded room and for 1
hour in a 4 bedded room
ii. The pillows and mattress are to be thoroughly cleaned with detergent, disinfected with 7% Lysol and
dried in sunlight for 24 hours
iii. Bed sheets, curtains, patient gowns and dusters must be removed, soaked in 1% Sodium Hypochlorite for
1/2 hour and then sent to the laundry
iv. After disinfection, wash the room, wall, window, doors, bathroom, sink and furniture with soap solution
after doing thorough high dusting in that cubicle
v. Soak bedpan, urinal, kidney basin in 7% Lysol for 1 hour, wash with detergent and dry it under sunlight
vi. Bath basins, multi-bin, bucket, jugs, mugs are to be washed with soap solution and dried in sunlight
vii. Rubber sheets (mackintosh) are to be cleaned with Lysol, dried, powdered and replaced
viii. Each patient must have a separate digital thermometer for use
ix. Utensils used by the patient are washed, boiled and replaced.
PROTOCOL GIVEN FOR CARE OF PATIENTS WITH INFLUENZA
It is important that healthcare workers, patients and visitors follow appropriate infection control precautions in
order to minimize the possibility of transmission with healthcare. Human to human transmission of the virus is
primarily through droplets. Therefore, patients with suspected or confirmed influenza A virus (pandemic H1N1,
H3N2 or Flu Aunsubtypable) infection, as well as those with influenza-like illness (ILI), should ensure the spread
of droplets. The overwhelming majority of patients with flu (pandemic influenza A H1N1) have mild symptoms
and recover even without medical treatment within a week of the onset of symptoms.
The most common clinical presentation of influenza is an “acute (<7 days) febrile (oral temperature >101 0 F)
respiratory illness (sore throat, cough, etc.)”. Not all individuals with ILI need to have the diagnosis confirmed or
admitted to the hospital, particularly if the illness is mild.
Patients fulfilling the above criteria (triaged by Staff Nurse/MRO) are given a surgical mask and evaluated
further by doctors
Patients who require testing for influenza should be sent wearing a surgical mask to;
Adult patients - Medicine OPD treatment room.
Staff and students - SSHS treatment room.
Paediatric patients - Paediatric OP treatment room.
Patients who are seen in the Emergency Department or admitted to CMC with severe pneumonia (defined as
fever, cough, dyspnea and presence of chest x-ray infiltrates, AND any TWO of the following features -
respiratory rate >30/minute, oxygen saturation (spo2) < 90% on room air, blood pressure <90 mm Hg systolic,
confusion) may have samples sent to the Virology Department for influenza testing.
Pnemonic for severe influenza “TROPICAL”
T for temperature 1010F

R for Respiratory rate >30 per minute
O for oxygen saturation
P for blood pressure < 90 mm Hg systolic
I for Image chest x-ray infiltrates
C for confusion
A for Azotemia urea increased
L for Laboratory: real-time RT - PCR
ILI (Acute onset fever,
cough, headache, myalgia,
malaise, coryza, sore throat
Category A: Category B: Category C:

Uncomplicated illness Uncomplicated illness in Severe illness
patients at higher risk for
Patient not at higher risk
influenza complications*
for complicated illness
Testing at the discretion

Test and treat with antivirals
No need of testing or antivirals of clinicians. Start
(oseltamivir)
antivirals (oseltamivir)
Fig. 8.1.Influenza like illness (ILI) management protocol
*Patients at high risk for influenza complications

Children ≤ 2 years
Adults ≥ 65 years
Pregnant women
Persons with the following morbidity
 Morbid obesity
 COPD, bronchial asthma
 CAD, Heart failure
 Chronic kidney disease
 Chronic liver disease
 Haematological conditions (including sickle cell disease)
 Diabetes mellitus
 Neurological & neuromuscular disorders
 Immunosuppression (HIV infection & immunosuppressive treatment)
For children, very severe pneumonia for purposes of H1N1 testing may be defined as follows:
History of cough or difficult breathing AND temperature >380 C, PLUS fast breathing (defined as respiratory rate
above 60 breaths per minute (bpm) for infants less than 2 months of age, above 50 bpm for 2 to 12 months of age
and above 40 bpm from 1 to 5 years of age), PLUS chest in drawing AND presence of any of the following
danger signs: cyanosis, abnormally sleepy or difficult to wake, failure to drink or breastfeed, vomiting,
convulsions, lethargy or unconsciousness, and stridor in the calm child.
OPD:
Information on cough etiquette will be provided to both patient and caregivers.
Masks will be available for staff and patient in all OPD areas.
Alcohol-based hand rubs should be used between patient contacts.
Wards:
i. All patients suspected to have severe influenza (as defined above) will be admitted to the Isolation Ward
or single room in general or private ward (including A ward) or cohorted with other patients with
confirmed influenza or ILI.
ii. Precautions to be followed: droplet and contact precautions
Door of isolation room to be kept closed all the time with signboard of droplet isolation precautions
Patient to wear a surgical mask if he/she can tolerate it
Caregivers to wear a surgical mask
Before entering the isolation room, HCWs to
 Perform hand hygiene
 Wear surgical mask
 Wear a disposable plastic apron
 Wear gloves
On leaving the isolation room, HCWs to
 Discard gloves and apron in the red bag and mask in the yellow bag (Bins should be inside
the room)
 Perform hand hygiene
iii. Avoid performing aerosol generating procedure (e.g bronchoscopy) on patients with ILI; If such
procedure is essential HCW should wear appropriate PPE including N95 mask
iv. Discharge the patient if
 Afebrile for 48 hours
 Systolic BP > 90mm Hg
 Heart rate < 100/ minute
 Respiratory rate <24/ minute
 Oxygen saturation> 94%
v. If the patient requires prolonged admission, patient to be kept in isolation till the completion of 5 days
oseltamivir therapy
vi. Thorough cleaning and disinfection as per protocol
MICU/ MHDU:
All patients suspected to have severe influenza (as defined above) who need advanced life support or intensive
monitoring will be admitted to the Medical ICU/ HDU.
Infection control practices to be followed:
i. Strict droplet precautions and contact precautions to be followed

ii. Information on cough etiquette will be provided to the caregivers
iii. No visitors for first 5 days; this can be overruled if the patient is dying and relatives want to be at the
bedside
iv. No aerosol-generating procedures (e.g nebulization, bronchoscopy, suctioning) to be done on suspected
patients. If sucha procedure is essential HCW should wear an N95 mask
v. Ventilators to be fitted with a device to exhaust exhaled gas to the vacuum system.
vi. Use closed system for ET suctioning (surgical mask adequate)
vii. Oral suctioning – use N95 mask
TB INFECTION CONTROL POLICY IN CMC HOSPITAL, VELLORE
Objective: To minimize the risk of transmission of TB within the hospital
1. Promote cough etiquette and cough hygiene.

a. Display posters in appropriate languages in OPD, A & E, and wards: “Cover your mouth and nose
with a piece of cloth or tissue when coughing or sneezing”.
2. Screening for TB: Prompt identification of patient with TB symptoms at the time of the first contact with
the clinician: (To be done at the time of registration) Ask for:
a. History of cough more than 2 weeks
b. Past / current h/o TB treatment
3. Patients who respond "YES" to any of these screening questions (“TB suspects”) should have an alert for
"respiratory isolation" in the clinical workstation.
a. All these patients should be instructed on cough etiquette and given a surgical mask to wear
b. Order sputum Xpert TB PCR for all TB suspects.
4. Policy on admission to wards:

As far as possible, pulmonary TB (proven / suspect) patients to be managed in the OPD.
If requiring admission, admit to Isolation ward / single rooms in other wards (except A Ward)
a. Criteria for admission of TB patients
i. Drug intolerance
ii. Haemoptysis
iii. Oxygen therapy
b. Patients suspected to have pulmonary TB (based on history, chest x-ray findings) can be admitted
to Isolation ward; they will be moved out of isolation ward once the sputum Xpert TB PCR is
reported negative.
c. Do not admit patients with pulmonary TB (proven and suspect) in A Ward.
5. Isolation ward rooms for patients with TB (proven/suspected) will be designed to enhance natural
ventilation.
6. Personal protection equipment: All health workers when caring for patients with infectious TB should wear
fit-tested N95 masks.
7. TB isolation protocol in isolation ward

i. Bed nos.9 – 12 & 16 – 19 have been made for isolation of TB patients.
ii. As per the guidelines laid down by WHO regarding environmental measures and personal protective
equipment, HICC recommends the following measures;
a. All the windows must be left open 24 hrs.
b. Exhaust blowers must be on 24 hrs if patient is admitted in these rooms.
c. Entrance door to each room should be kept closed and should have an automatic closing system.
d. Air exchange/ hour must be monitored by EMD department every week and documented.
e. All patients admitted with TB should be wearing an ordinary mask constantly and should be
educated by the staff on duty.
f. All the staff and students who take care of these patients must wear an N95 mask
g. All patients admitted in the isolation ward must be given a prescription for 500ml alcohol-based
hand rub bottle, which is to be kept at the bedsides.
8. Patient placement
A single or double room with a closed door is necessary. Patients are to be directly admitted to the
isolation ward, as far as possible.
If a private room is not available, place the patient in a room with a patient having active infection
with the same disease, but with no other infection (cohorting).
Only authorized personnel should enter the room.
9. Respiratory protection
Patients with TB are asked to wear a surgical mask covering the nose and mouth during the entire
hospital stay to minimize the risk of expelling droplet nuclei into the air.
HEPA filter (N95) masks are to be worn by staff and student nurses, registrars and interns involved
in the care of patients known or suspected to have TB, influenza and other highly infectious
respiratory pathogens.
10. Patient transport

Limit transport of the patient unless for essential investigations.
Inform the area prior to receiving the patient (Eg. Radiology, Operation theatres)
During transport, the patient must wear a surgical mask.
PROTOCOL GIVEN FOR CARE OF PATIENTS INFECTED WITH CLOSTRIDIUM DIFFICILE

ASSOCIATED DIARRHOEA
Clostridium difficileis normally fastidious in its vegetative state but is capable of sporulating when environmental
conditions no longer support its growth. The capacity to form spores enables the organisms to persist and survive
in the environment for months. Environment contamination can be heavy especially if diarrhoea is severe or
accompanied by incontinence. Asymptomatic patients after infection may continue to shed organisms in their
stools.
The following infection control measures should be taken:
Promptly diagnose and isolate all patients with C.difficile in a single room with toilet facilities as soon as
possible (preferably within 2 hours) or cohort all symptomatic patients.
As far as possible restrict the transfer of patients between wards/ units unless considered essential, this
will prevent the spread of infection.
Strict handwashing with soap and water before and after contact with patient and environmental surfaces
is the most effective measure to prevent cross- infection.
Alcohol disinfectants are effective against vegetative forms only andNOT against C.difficle spores,
therefore disinfection of hands must be done ONLY with soap and water.
Strict contact precautions including non-sterile single-use gloves and plastic apron must be used during
patient care activity.
PPE must be removed before leaving the room and hands must be washed.
The patient‟s immediate environment and other areas (e.g sluice, commodes, toilets, bedpans, sinks and
hand touch areas in patient‟s bathroom) and other soiled areas must be thoroughly and frequently cleaned
with soap and water and then disinfected with1000 ppm of the freshly prepared sodium hypochlorite
solution.
Separate cleaning equipment must be reserved for this purpose. Mop heads should be disposable or
laundered after each use and single-use disposable cloths must be used.
As the patient can remain colonized for a long time after discharge from the hospital, patient and relatives
must be informed and explained the infection prevention measure
PROTOCOL GIVEN FOR CARE OF PATIENT INFECTED WITH RABIES
Human to Human transmission of Rabies is very rare and has been demonstrated in patients who have received
corneal graft.
Rabies is transmitted when infected saliva contaminates mucous membrane or an open wound. The following
precautions are recommended:
The patient should be isolated in a single room with standard infection control precautions.
The staff should wear appropriate personal protective clothing including gloves, gown, mask, goggles
particularly while intubation and suctioning and must follow standard precautions.
Staff with open skin lesions should not be allowed to have contact with the patient.
Pregnant female staff should not attend the patient.
Specimens from the patient should not be sent to routine diagnostic laboratories without prior
consultation with the senior member for staff.
Equipment soiled by secretions or excretion should either be single-use disposable or sterilized using heat
sterilization in the sterile supply department.
All non-critical items to be labelled & disposed.
All clinical equipment to be labelled & sent for reprocessing.
All patient linen should be disinfected with hot water and 1% Sodium hypochlorite solution for 30 min
(should not be mixed with other linen)
Strict Hand washing should be observed
Staff who are certain that they were bitten by the patient/or his /her mucous membrane or non-intact skin
was directly exposed to potentially infectious saliva or neural tissue should be immunized as per
protocol.
Mouth-to-mouth resuscitation should not be performed.
Post-mortem examination should not be undertaken. Where such examination may be of value, the
indications and arrangements must be discussed with the histopathologist.
Government official(Dy.Director Health services, Vellore) must be informed and instructions given by
them to be followed.( Subject of change in Govt. Policies)
References:
1. Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf
2. Guidelines on Airborne infection control in Healthcare and other settings. DGHS; Ministry of Health and
family welfare, New Delhi.2010.
3. Ministry of Health, Govt. Of India (http://mohfw-h1n1.nic.in/)
4. WHO (http://www.who.int/csr/disease/swineflu/en/index.html)
5. CDC (http://www.cdc.gov/h1n1flu/general_info.htm)
6. HIPAC Guidelines for prevention and control of Multi-drug resistant organisms.
7. Manual of infection prevention and control by NizamDamani 3rd Edition 2012
9. DISINFECTION AND STERILIZATION
Definition
Sterilization is defined as a process where all microbes are removed from a defined object, inclusive of bacterial
endospores. Disinfection is a process where most microbes are removed from a defined object or surface, except
bacterial endospores. Certain chemicals are capable of sterilizing an object if exposed for long periods of time
and serve as disinfectants at shorter exposure time. However, a common practice is to call all chemical agents
“disinfectants”, which is a misnomer.
DISINFECTION
Disinfectants can be classified according to their ability to destroy these categories of microorganisms as given
below:
a) Low level disinfectants: Kills only vegetative bacteria, fungi and lipid-enveloped viruses, eg: Quaternary
ammonium compounds, common soap.
b) Intermediate level disinfectants: Kills all pathogens including Mycobacteria and non-enveloped viruses but
no action on spores. Includes Phenols, Iodophores, and Alcohols, etc.
c) High level disinfectants: All microbial life is destroyed, inclusive of endospores but it might not be effective
for killing large number of spores, example: Hydrogen peroxide. Such disinfectants are capable of
sterilization if the contact time is long (i.e.6-10 hours). These are used for a short period of time (i.e. 10-30
minutes) as a high level disinfectant.
Micro-organisms
ilus Mycobacteria Mycobacterium tuberculosis Non-lipid or small viruses Polio virus High level
pergillus spp. Candida spp.
disinfectant
phylococcus spp. Salmonella spp.
um sized viruses
cy Virus Herpes simplex virus
Intermediate
level disinfectant
Low level
disinfectant
Fig.9.1 spectrum of activity of various levels of disinfectants

Several methods of disinfection are available, but standardization and uniformity throughout a hospital is
essential. It is also necessary that all disinfectants should undergo testing in the laboratory against common
hospital pathogens. The testing should be done regularly “in use”, as well as periodically under standard test
conditions. This must be done in order to detect emerging resistance, which is a real possibility in our situation.
This will be done at the initiative of the HICC in conjunction with the Microbiology Department. It is also
mandatory that any new disinfectant or a new brand of disinfectant must undergo “capacity testing” before
inducted into use for the patient care areas.
According to Spaulding‟s classification, the various items which are used for patient care can be classified as
critical, semi-critical and non-critical items. The disinfection/sterilization method used for each class of
instruments are as follows:
Table. 9.1. Spaulding‟s classification

Equipment / Instruments Method before use Method after use
Penetrating skin/mucous High level disinfection Intermediate level

Membrane (Critical) Or sterilization Disinfection
Contact with intact mucous High level disinfection Intermediate level

Membrane without penetration Disinfection
(Semi-critical)
Contact with intact skin, Intermediate level or Intermediate level or

No contact with mucous Low level disinfection Low level disinfection
Membrane (Non-critical)
Low level disinfection
This comprises of benzalkonium chloride (a quaternary ammonium salt), certain soaps, etc.
Intermediate level disinfection
Intermediate level disinfection is effected by a large group of chemicals, and this is the major group of chemicals
that are being used in the hospital setting. These include alcohols (ethyl alcohol and isopropyl alcohol); halogens-
chlorine compounds (hypochlorite, bleach) and iodine compounds (iodine and povidone iodine); chlorhexidine;
phenol (Lysol, phenol); aldehydes (formaldehyde, Glutaraldehyde-limited exposure time), etc. Of all these,
certain compounds are chosen for use in specific situations depending on various factors including time of action,
toxicity, corrosiveness, shelf life, etc.
Universally, the disinfectant of choice that can be safely used on inanimate objects is 7% Lysol and 1% sodium
hypochlorite solution. Other chemicals can be used on special permission from the HICC.
High level disinfection
Glutaraldehyde, Ortho-pthalaldehyde (OPA), Peracetic acid and Hydrogen peroxide (at a specific length of
exposure time) can be called high level disinfectants. Ethylene Oxide can also be considered as High Level
Disinfectant/Chemical Sterilant. Certain chemicals display some degree of sporicidal action and can overlap in
the spectrum of high level disinfectants though in reality, they limit themselves to the intermediate range (eg.
Povidone iodine)
Disinfection of ward items
The disinfection procedure for the various items used in the wards is as mentioned below
 Stethoscope & BP cuff Wipe with spirit.
 Furniture, equipment & fittings Refer to the section on housekeeping
 Floor and walls Refer to the section on housekeeping
 Toilets Refer to the section on housekeeping
 Linen Refer to the section on housekeeping & laundry
 Endoscopes Refer to the section on endoscopes, later in this chapter
Disinfectants used in CMCH
2% glutaraldehyde: This is marketed by various companies

o Rapid acting: Can be used up to 14 days after activating.
o Long acting: Can be used up to 28 days after activating
o Contact time for disinfection: 20-30 minutes; for sterilization: 8-10 hours
Ortho-pthalaldehyde (OPA): 0.55% W/W

o Can be used up to 14 days after activating
o Contact time for disinfection: 5 to 10 minutes
Sodium hypochlorite (Dakin‟s): It is a 1 % solution of sodium hypochlorite; the active ingredient is

nascent oxygen. Only a freshly prepared solution will be active. If not available, household bleach can be
used for this purpose (Calcium hypochlorite).
Lysol 7%: Lysol is a highly corrosive fluid, especially to the eyes. No concentrated solution should be
kept in the wards or departments. When using, ensure that splashing does not occur. Wash hands
thoroughly after use.
Boiling: Where it is necessary to boil, the article being boiled must be completely immersed in the water
and hollow tubes filled with the water. Rubber goods should be boiled for three minutes and other items
should be boiled for 20 minutes.
Table9.2. Antimicrobial activities of various disinfectants
Disinfecting Level of Antimicrobial properties

agent disinfection
Bacteri- Virucidal Viru- Tuberculo- Fungi- Spori-
cidal (hydrophilic) cidal cidal cidal cidal
Iodophors Intermediate + + +/- +/- + -
Phenolics Intermediate + + - + + +/-
Quaternary Low + - - - + -
ammonium
compounds
Alcohols Intermediate + + + + + -
2% High + + + + + +
Glutaraldehyde
Chlorine Intermediate + + + + + +/-
releasing to high
compounds
Peracetic Acid High + + + + + +
6% Hydrogen High + + + + + +
Peroxide at
pH 1 – 8
Tests for disinfectants:
„In use‟ testing of disinfectants from various wards is performed once a month in Microbiology department, for
which a sample of the disinfectant in use is cultured to identify the growth of organisms.
Endoscopes: Cleaning and disinfection
Every patient undergoing endoscopy should be examined with clean, disinfected equipment. In order to ensure a
uniform standard of safety for each patient, the cleaning and disinfection procedures should be carried out
immediately before each endoscopic procedure.
 Mechanical cleaning of endoscope
The most important step in the prevention of infection during endoscopy is mechanical cleaning. If the
endoscope is rigorously cleaned, there is little risk of cross-infection from this source. Alcohol and
aldehyde compounds must not be used for mechanical cleaning because they denature and coagulate
protein. Non-immersible endoscopes should be phased out.
 Immediate action on removal from the patient
Flush the air/water channel for 10-15 seconds to eject any refluxed blood or mucus. Aspirate detergent
through the biopsy/suction channel for about 10-15 seconds to remove gross debris.
 Cleaning
o Wash the outside of the instrument thoroughly with disposable sponges or swabs.
o Brush the distal end with a soft tooth brush.
o Using a cleaning brush suitable for the instrument and channel size, brush through the suction
channel.
o Flush each internal channel with detergent fluid. This should be done independently for each separate
channel.
o Flush all channels, as above using water followed by air to expel as much water as possible, prior to
disinfection. If the water contains particles, which can lead to blockage, filtered water should be used.
 Disinfection
The endoscope and all internal channels should be soaked in 2% Glutaraldehyde/OPA/Per acetic acid
or disinfectant of similar potency for at least 20 min. This period of disinfection will not necessarily
destroy all Mycobacterium or bacterial spores, but if rigorous mechanical cleaning has been performed
prior to disinfection, the likelihood of the instrument containing an infectious inoculum is negligible.
 Rinsing
Following disinfection rinse the instrument internally and externally with drinking quality/RO water to
remove all traces of disinfectant.
 Drying
Dry the endoscope externally, paying particular attention to the light guide connector and eyepiece. Flush
air through each channel.
Sclerotherapy needles
Separate needles are used for patients known to harbour blood borne pathogens.
All equipments used for procedures during ERCP are sterilized in CSSD.
Precautions for fibreoptic rhino pharyngo laryngoscopy and rigid Hopkins telescopes
The same principles as those for endoscopes apply here.
STERILIZATION
Sterilization can be defined as the process by which all microorganisms are removed from a surface or object,
inclusive of bacterial endospores. The diagram given at the beginning of this chapter explains the gradation of
organism type according to the order of susceptibility to disinfectants. Any process that will destroy the whole
range of organisms is termed as sterilization.
Sterilization can be through physical and chemical means. Physical means include heat and radiation. Chemical
sterilizing agents are relatively expensive and are used in specific situations. In our hospital, 2% Glutaraldehyde
(activated) and ethylene oxide are the two chemical sterilizing agents used.
Heat can be employed as dry heat (Hot air oven, flaming, infra-red rays) which oxidizes and denatures
proteinsand as moist heat (autoclave) which coagulates and denatures proteins. It is to be noted that boiling is not
a mode of sterilization, but only of disinfection.
Gamma radiation is inappropriate for a small setup and is used in industry for sterilizing articles in bulk e.g.
Disposable syringes etc.
Sterilization by heat
This is by far the most popular method because of its simplicity, reliability and environment friendliness, in
addition to being inexpensive. Autoclaves, hot air ovens, and infrared sterilizers are used.
Autoclave
Autoclaves function under the principle of steam under pressure in order to raise the temperature of steam. This is
very effective because of the emission of the latent heat of vaporization of steam. Various models are in use
ranging from gravity displacement models to completely auto cycled high-pressure vacuum models. Various
models may vary in their specifications.
CMCH has two types of autoclaves
Pre-vacuum autoclave: mainly for syringes and other glassware and has a holding time of 4
minutes at 132oc.
Gravity displacement autoclave: requires a holding time of 30 minutes at 121 o C.
Almost any article which is heat stable can be sterilized using the autoclave. Powders, creams, and oils cannot be
sterilized using this method.
Hot air oven
The dry heat employed in this method is not as effective as moist heat. Hot air is provided by an electric heating
element and is circulated using fans (convection currents) inside the oven. The specific advantage of this is the
ability to sterilize powders, oils, creams, and all glass articles. General specifications include cycles of 1 hour at a
temperature of 160oc. Small models of hot air ovens can be used in separate patient care areas and requires
minimal skill to use.
For indicators for effective sterilization, refer to the section on CSSD, under the chapter „Service Units‟.
Chemical sterilizing agents
These include 2% glutaraldehyde and ethylene oxide. They are expensive and are to be used in the sterilization of
heat labile substances.
2% glutaraldehyde is an effective sterilizing agent when alkaline (ph7.4 – 8.9). The articles should be clean of
any bioburden and should be kept immersed in this solution for at least 8-10 hours for sterilization, with 20-30
mins adequate for disinfection. This is used in disinfecting endoscopes, respiratory tubings, etc. Hypersensitivity
to glutaraldehyde (local or systemic) may be a problem for handlers.
Ethylene oxide is a toxic gas and a very effective sterilizing agent. Precautions include scrupulous cleanliness and
drying of the object otherwise, a toxic residue (Ethylene glycol) forms on the surface. Adequate aeration – at least
12 hours after cycling is necessary to allow dissipation of free toxic gas. ETO can be used for all heat sensitive
articles.
Requirements for ETO gas sterilization
Moisture 20 – 40% relative humidity
Concentration 540 mg/lt- 900 mg/lt
Temperature 50oc
Cycling & aeration time16 hours
Rubber items, Polythene and plastic items, electronic items and cables, instruments used for scopy and parts of
operating microscopes are sterilized using ETO gas.
Dosimeters: placed with every run
Biological indicator: Used every week
Monitoring of sterilization:
i. Chemical Indicator: Quality of Sterilized goods are assessed by the use of chemical indicators. A
chemical indicator is used with every pack that is sterilized.
ii. Steam Sterilizer: In Steam sterilizer class 5 steam strips are used in each load which is sensitive to three
parameters time, temperature and pressure.
iii. Gas Sterilizer: In Gas Sterilizer, dose meter to be used in each bag, which is sensitive to three
parameters time, temperature and gas dosage.
iv. Mechanical Controls: A time temperature and pressure chart is maintained in each sterilizer
v. Bowie-Dick test: A Bowie-Dick test to determine the adequacy of air removal from the chamber, load
during the pre-vacuum stage done daily, and steam quality before starting the cycle.
Penetration time – 12 minutes
Holding time-12 minutes
Safety time-6 minutes (Drying time)
vi. Biological test: This test is done once in a week in all the sterilizers. A Biological spore strip-containing
Geobacillusstearothermophilus is tested in each steam-sterilizer weekly. A biological spore‟s strip
containing Bacillus atrophaeus is tested in each ethylene oxide gas sterilizer weekly. A Biological spore
strip containing Bacillus atrophaeusis tested in each dry heat sterilizer.
FOGGING WITH HYDROGEN PEROXIDE
Fogging with Hydrogen peroxide (Eg: Ecoshield.,Mikrozid.,) is to be carried out by the EMD and the request is
issued only after obtaining approval from the Nursing Superintendent and HICC. The request has to be sent to
HICC office which sends an official request to the EMD. The date, time and place of fogging must be mentioned
in the request. Fogging will be done any time between 6:00am to 10:00pm daily. Contact No. is 09894703056.
Indications
If there is a case of anthrax, gas gangrene, or an open septic wound with laboratory evidence of C.tetani, in
any area where surgical procedures are carried out, fogging is mandatory after the procedure
If any new construction or reconstruction of any theatre is done, then fogging is mandatory before the
functioning of the same.
When routine surveillance reveals C.tetani or any other pathogenic spore former, fogging is mandatory.
Hydrogen peroxide spraying should also be done in operation theaters and burns units.
Procedure for Hydrogen peroxide spraying:

The floor and walls upto 6 feet are to be washed with soap and water one hour prior to fogging on the same
day.
As per the room size, pour water followed by fogging disinfectant (Eg: Mikrozid HP-10 – Stabilised
formulation of hydrogen peroxide 10% v/v with 0.01% w/v silver nitrate solution) into a fogger tank to make
it a 20% v/v solution
The table below highlights the dilution and the duration of fogging for rooms of different sizes.
Table 9.3. Recommendations for fogging
Space Dilutions in water Fogging time Contact time

Cu.ft 3 Mikrozid HP-10 Water
m
1000 28 200 ml 800 ml 20 min 20 min after fogging

Take the fogger and mount it at least 2 feet above the floor surface, 3 feet away from the walls. Its nozzle
head should be kept at an angle of 45 0 directed towards the joint of the ceiling and the walls, along the
diagonal of the floor.
Just when the fogging is about to start, switch on the air-conditioner
Set the timer on the fogger as per the volume of solution in the tank
Switch on the fogger and ensure that the nozzle is not blocked
After 10 minutes of fogging, switch off the air-conditioning
After completion of fogging, allow 40 minutes for the suspended dust particles to settle down
Mop all floor and walls with a dry mop
Switch on the AC after one hour of fogging, this includes the contact time also. (For eg: if fogging started at
7am, then AC should be switched on at 8am)
Within 1 hour of switching off the machine, the OT can be used, with AC switched on.
References:
1. William A. Rutala, David J. Weber. Guideline for Disinfection and Sterilization in Healthcare Facilities,
Healthcare Infection Control Practices Advisory Committee (HICPAC);2008.
2. Hospital Infection Prevention and Control Guidelines, National Centre for Disease Control.
3. Hospital Infection Control Guidelines, Indian Council of Medical Research, New Delhi.
10.HOSPITAL WASTE MANAGEMENT
Introduction
A modern hospital is a complex multidisciplinary system, which consumes thousands of items for delivery of
medical care and is part of the physical environment. All products consumed in hospitals leave some unusable
leftovers which are called hospital/clinical wastes as they are generated as a result of clinical activity. Bio-
medical waste (BMW) is a broader term applied to waste generated in the diagnosis, treatment or immunization
of human beings or animals, in research, or in the production or testing of biological products. Infectious wastes
include all medical wastes which have the potential to transmit viral, bacterial or parasitic diseases. It includes
human and animal infectious waste and waste generated in laboratories, and veterinary practice. Any waste with
the potential to pose a threat to human health and life is called hazardous waste.
Since the early recovery of the patient and health of clinical staff directly depends on a clean and hygienic
environment, it is essential that hospital waste is collected, stored and disposed of appropriately. Hospital waste
management is part of hospital hygiene and maintenance activities. General hospital hygiene is a prerequisite for
good medical waste management. It will be useless in terms of prevention of HAIs to start improving hospital
waste management if the hospital does not have a reliable supply of safe water and basic sanitation facilities
accessible to hospital personnel, patients and visitors.
It is important to note that not all hospital waste has the potential to transmit infection. It is estimated that 80-85%
is non-infectious general waste, 10-15% is infectious and 5% is other hazardous waste. However, if the infectious
component gets mixed with the general non-infectious waste, the entire bulk of hospital waste becomes
potentially infectious.
RULES ON BIOMEDICAL WASTE MANAGEMENT AND HANDLING
The government of India under the provision of the Environment Act 1986, notified the Bio-Medical Waste
Management and Handling rules on 20 th July 1998 (BMW Rules ‟98). The Rules regulate the disposal of Bio-
Medical wastes, including human anatomical waste, blood and body fluids, medicine and glassware, soiled liquid
and biotechnology wastes and animal wastes.
In order to implement these rules more effectively and to improve the process of collection, segregation,
processing, treatment and disposal of waste in an environmentally friendly manner, and reduce the generation of
Bio-medical waste, the Central Government of India reviewed the existing rules and after deliberations issued the
revised guidelines as “Bio-Medical Waste Management Rules 2016”
These rules apply to all who generate, collect, receive, store, transport, treat and dispose Bio-Medical waste in
any form and is applicable to large and small healthcare setups and Laboratories.
These rules do not apply to the following:
a. Radioactive wastes as covered under the provision of the Atomic Energy Act, 1962
b. Hazardous chemicals are covered under the Manufacture, storage and Import of Hazardous Chemical
Rules 1989 made under the Act
c. Solid wastes covered under the Municipal Solid Waste (Management and Handling Rules, 2000 under
the Act.
d. The lead acid batteries covered under the Batteries (Management & Handling Rules) 2001.
e. Hazardous waste covered under the Hazardous Waste( Management, Handling and Transboundary
Movement) Rules 2008
f. Waste covered under e-waste (Management & Handling Rules) 2011.
g. Hazardous microorganisms, genetically engineered microorganism and cells covered under the
Manufacture, Use, Import, Export and storage of Microorganisms, Genetically Engineered
Microorganisms or cells Rules 1989.
The Bio-medical Waste Rules make the generator or occupier of wastes liable to segregate, pack, store, transport
and dispose of the Bio-Medical wastes in an environmentally sound manner.
The agency responsible for the implementation of the Rules in Tamil Nadu is the state Pollution Control Board.
The tasks of the administering agencies include the grant of authorization, record keeping, monitoring the
handling of wastes and accidents, and of supervising the implementation of rules. Recycling and re-use of bio-
medical wastes, except plastics and glassware have been prohibited.
TERMS AND DEFINITIONS
Biomedical Waste Definition
Biomedical waste means any waste, which is generated during the diagnosis, treatment or immunization of
human beings or animals or in research activities pertaining thereto or in the production or testing of biologicals
and including categories mentioned in Schedule I of BMW Rules, 2016.
Classification of Biomedical Waste
The detailed categories of Biomedical Waste as given in Schedule I rules 3(e), 4(b), 7(1), 7(2), 7(5), 7(6) & 8(2)
of Biomedical Waste Rules 2016 are:
Category Type of Waste Type of Bag or Treatment and Disposal

Container to be Options
Used
Yellow a. Human Anatomical Waste: Yellow colored non- Incineration or plasma

Human tissues, organs, body parts and chlorinated plastic pyrolysis
fetus below the viability period (as per bags or containers Or deep burial**
MTP Act 1971)
b. Animal Anatomical waste:

Experimental animal carcasses, body
parts, organs, tissues including the
animals used in experiments or testing in
veterinary hospitals, colleges or animals
houses.
c. Soiled waste: Incineration or plasma
Items contaminated with blood, body pyrolysis or deep burial
fluids like dressings, plaster casts, cotton In the absence of the above
swabs and bags containing residual or facilities autoclaving or
discarded blood and blood components. microwaving/ hydroclaving
followed by shredding or
mutilation or combination
of sterilization and
shredding
d. Expired or Discarded Yellow colored non- Expired „cytotoxic drugs‟

Medicines: chlorinated plastic and items contaminated
Pharmaceutical waste like antibiotics, bags or containers. with cytotoxic drugs to be
cytotoxic drugs including all items returned back to the
contaminated with cytotoxic drugs along manufacturer or supplier for
with glass and plastic ampoules, vials, incineration at >1200oc or
etc. CTF or hazardous waste
treatment, storage and
disposal facility for
o
incineration at >1200 c or
Encapsulation or plasma
pyrolysis at >1200oc.
All other expired medicines
to be sent back to the
manufacturer or sent for
incineration.
e. Chemical waste: Yellow coloured Disposed by incineration or
Chemicals used in the production of Non- chlorinated plasma pyrolysis or
biological and used or discarded Plastic bags or encapsulation in hazardous
disinfectants. containers. waste treatment, storage,
and disposal facility.
f. Chemical liquid waste: Separate collection After resource recovery, the

Liquid waste generated due to the use of system leading to an chemical liquid waste shall
chemicals in the production of biological effluent treatment be pre-treated before mixing
and used or discarded disinfectants. system with other waste water.
Silver X-Ray film developing liquid, The combined discharge
discarded Formalin, infected secretions, shall conform to the
aspirated body fluids, liquids from discharge norms given in
laboratories and floor washing, cleaning, schedule III.
housekeeping, and disinfecting activities.
g. Discarded Linen, mattresses and Non-chlorinated Non-chlorinated chemical
beddings contaminated with yellow plastic bag or disinfection followed by
blood or body fluids suitable packing incineration or plasma
material pyrolysis or energy
recovery.
In the absence of the above
facilities shredding or
mutilation Or combination
of sterilization and
shredding. Treated waste to
be sent for energy recovery
or incineration or plasma
pyrolysis
h. Microbiology, Biotechnology, Autoclave safe Pre-treat to sterilize with

and other Clinical Laboratory Plastic Bags or non-chlorinated chemicals
waste: containers. on site as per NACO or
Blood bags, laboratory cultures, stock or WHO guidelines thereafter
specimens of micro-organisms, live or for incineration.
attenuated vaccines, human and animals
cell cultures used in research, dishes, and
devices used for culture, etc.
Red Contaminated waste ( Recyclable) Red colored non- Autoclaving, microwaving/
Waste generated fromdisposable items chlorinated plastic hydroclaving followed by
such astubing, bottles, intravenous tubes bags or containers shredding or mutilation or
and sets, catheter, urine bags, syringes combination of sterilization
(without needles and fixed needles and shredding. Treated
syringes),wound drains and gloves waste to be sent to
authorized recyclers or for
energy recovery etc.
whichever is possible.
Plastic waste should not be
sent to landfill sites.
White Waste sharps including Metals: Puncture proof, leak Autoclaving or dry heat
(translucent) Needles, syringes with fixed needles, proof, tamper proof sterilization followed by
Needles from needle tip cutter or burner, containers shredding or mutilation or
scalpel, blade or any other contaminated encapsulation in a metal
sharp object that may cause puncture or container or cement
cuts. This includes both used, discarded concrete; Combination of
and contaminated metal sharps. shredding and autoclaving
and send for final disposal
to iron foundries(having
consent to operate from
state Pollution Control
Board) or sanitary landfill or
designated concrete waste
sharp pits
Blue a. Glassware: Cardboard boxes Disinfection of glass slides
Broken or discarded and contaminated with blue colored contaminated with blood
glass including medicine vials and marking (by soaking the glassware
ampoules except those contaminated by *According to 2018 after cleaning with detergent
cytotoxic waste. Amendment, these and sodium hypochlorite
can be puncture treatment) or through
proof containers with autoclaving or microwaving
a blue liner or hydroclaving and then
recycling.
b. Metallic body implants: Cardboard boxes
with blue colored
marking
*According to 2018
Amendment, these
can be puncture
proof containers with
a blue liner
There will be no chemical pre-treatment before incineration except for microbiological, lab and highly infectious
waste.
Incineration ash should be disposed of through hazardous waste treatment, storage and disposal facility if toxic or
hazardous constituents are present beyond the prescribed limits as given in the hazardous waste management
rules 2008 or as revised from time to time.
**Disposal by deep burial is only in rural or remote areas where there is no access to Common biomedical waste
treatment facility. This should be carried out with prior approval from the prescribed authority as per the
standards specified in Schedule III
General Waste: Includes general domestic type waste from offices, public areas, stores, catering areas,
comprising of newspapers, letters, documents, cardboard containers, metal cans, and floor sweepings. This also
includes kitchen waste.
POLICY ON HOSPITAL WASTE MANAGEMENT
Managerial responsibilities
The Head of Hospital or Health care facility (HCF) shall apply for authorization to the prescribed authority in
Form II (Annexure A rule 8). He will be responsible for the implementation of the policy on hospital waste
management, shall appoint a Waste Management officer (WMO) and shall form a waste management
committee/team to develop a waste management plan for the HCF. Provision for hospital waste management
should be made in the annual budget. * As advised by the Tamil Nadu Pollution Control Board, our institution
has a contract with a licensed waste management authority or common treatment facility (Ken Bio-links) who
is responsible for Vellore and Thiruvannamalai districts of Tamil Nadu.
Waste minimization: As far as possible the use of disposables should be minimized.
Survey of waste generated: The waste management team shall initiate a survey of the amount, types of waste
generated in the hospital. The waste generated should be classified according to the categories given in Schedule
I Part 1. Waste Management Officer is responsible for coordinating and analyzing the results.
SEGREGATION, TREATMENT, STORAGE, AND TRANSPORTATION OF HOSPITAL
WASTE
Segregation: Biomedical waste and general waste must not be mixed and must be collected, stored
and transported separately.
Colour coding for waste containers: Biomedical and general waste should be segregated at source and placed in
colour coded plastic bags and containers of defined specification prior to collection and disposal.
All HCF should adopt the following colour coding* (As given in the Schedule I of BMW rules, 2016) as follows.
i. Yellow: For infectious waste for incineration

ii. Red: For infectious waste for autoclaving/microwave/chemical treatment, and land disposal
iii. White translucent sharps container: For needles and metal sharps.
iv. Cardboard box with the blue line: Broken, discarded and contaminated glassware and metallic body
implants.
Sharps containers: Syringes, needles, and other sharps should be pre-treated by disinfection and mutilation, or
collected in puncture proof suitable sharp containers (White translucent, puncture resistant disposable containers
in CMC) for autoclaving/ microwaving/chemical treatment and destruction/shredding. Needles, lancets, blades
can be buried or smelted. They are autoclaved and discarded in cemented tanks where they remain as such for 15
years.
Plastic disposables: Plastic disposables such as I.V.bottles, catheters must be mutilated (cut in two pieces)
disinfected followed by shredding to prevent reuse and can be considered for recycling.
Microbiology and biotechnology waste: This waste must be autoclaved before disposal.
Storage of waste: Central storage of biomedical waste must be at a separate site from general waste.
Biomedical waste must be stored in a secure area under a responsible person. Biomedical waste must be removed
daily from bulk storage areas and should not be stored for more than 48 hours.
Transportation of biomedical waste:

Within the hospital (internal transport): Dedicated closed trolleys or wheeled containers with appropriate
markings must be used for transportation to storage, treatment or disposal facility. Vehicles should be designed
for easy cleaning and draining. Appropriate personal protective equipment (PPE) such as gloves, masks, etc.
should be worn by the HCWs while transporting the waste.
Outside the hospital (off-site transport):Should be done in designed dedicated vehicles, with a fully enclosed
body and bulk-head separating the driver‟s compartment from the load compartment.
Labelling: Waste containers should be appropriately labelled, as given in Schedule IV of part A of BMW Rules
2016 with the type of waste, site of generation, name of generating hospital or facility, which will allow the waste
to be traced from point of generation to the disposal areas.
Barcoding: Barcoding of bags has also been made a requirement as per the new rules. Currently, yellow and red
bags are being barcoded (by using barcoded stickers) in our institution.
Disposal of waste generated in the hospital
Infectious waste: Disposed of by the Common Bio-Medical Waste Treatment Facility (Ken Bio-links) after
collection.
Radioactive waste: All waste containing radioactive materials should be properly labelled and its handling,
storage, and disposal must comply with all the requirements and regulation of Atomic Energy Licensing Act.
Chemical waste: Chemical waste must be stored in leak-proof containers and labelled to identify the contents.
Chemical waste must be disposed of by an authorized waste management organization.
Pressurized containers: Should not be incinerated. Compressed gas cylinders should be returned to
manufacturers. Aerosol cans should be disposed of with the general waste.
General waste: Arrangements for the transportation and disposal of general waste must be separate from that of
biomedical waste.
Liquid waste: Can be discharged into hospital sewage system or waste treatment plant after appropriate
disinfection and neutralization.
Recycling of Waste: Recycling of infectious plastic waste can be considered only after adequate
disinfection/sterilization. Disposable items like gloves, syringes, etc. should be mutilated after use to prevent
illegal packing and reuse. Wastes should be recycled by an authorized manufacturer only.
WASTE MANAGEMENT PLAN
Review of Existing Waste Management Arrangements
The waste management committee must review the existing waste management arrangements in light of the
waste management policy and guidelines and make recommendations on how the policy can be implemented in
their particular areas. On the basis of their recommendations and on the basis of statistics on waste generated, the
WMO shall develop the waste management plan.
The Waste Management Plan
Preparation of a waste management plan should be done in consultation with members of the waste management
committee and the local health authority. Equipment, procedures, and practices should be selected on the basis of
practicality, cost-effectiveness, and feasibility.
The waste management plan should include
The detailed specification of containers, bags for waste collection

Paths for waste collection trolleys through the hospital
A timetable of the frequency of collection of waste from the various areas
The estimated cost of containers, bags, ties, labels, trolleys and all other equipment to be used in the
waste management
Definitions of the duties and responsibilities in terms of segregation, pre-treatment, handling and storage
for each of the different categories of hospital personnel who through their daily work will generate
hospital waste
An estimate of the number and categories of personnel required for the collection, transportation, storage,
and treatment; the responsibilities of this personnel
Procedures for segregation, treatment, storage, and handling of wastes requiring special treatment before
disposal
Contingency plans showing arrangements in case of breakdown or maintenance.
Training courses and programs
Emergency procedures
Occupational safety
Policy for recycling.
Although the segregated institutional Bio-Medical waste is taken for offsite disposal, standards for autoclaving,
liquid waste and deep burial are given below for reference.
STANDARDS FOR WASTE TREATMENT:
Standards for waste autoclaving

The autoclave should be dedicated for the purposes of disinfecting and treating bio-medical waste,
1. When operating a gravity flow autoclave, medical waste shall be subjected to:
(i) A temperature of not less than 121°C and pressure of 15 pounds per square inch (psi) for an
autoclave residence time of not less than 60 minutes; or
(ii) A temperature of not less than 135°C and a pressure of 31(psi) for an autoclave residence time of
not less than 45 minutes; or
(iii) A temperature of not less than 149°C and a pressure of 52 (psi) for an autoclave residence time of
not less than 30 minutes.
2. When operating a vacuum autoclave, medical waste shall be subjected to a minimum of three pre-vacuum
pulses to purge the autoclave of all air. The air removed during the pre-vacuum cycle, should be decontaminated
by means of HEPA and activated carbon filtration, steam treatment or any other method to prevent the release of
pathogens. The waste shall be subjected to the following:
(i) A temperature of not less than 121oCand pressure of 15 (psi) for an autoclave residence time of not
less than 45 minutes; or
(ii) A temperature of not less than 135oCand pressure of 31 (psi) for an autoclave residence time of not
less than 30 minutes;
3. Medical waste shall not be considered properly treated unless the time, temperature and pressure indicators
indicate that the required time, temperature and pressure were reached during the autoclave process. If for any
reasons, time, temperature or pressure indicator indicates that the required temperature, pressure or residence time
was not reached, the entire load of medical waste must be autoclaved again until the room temperature, pressure,
and residence time was achieved.
4. Recording of operational parameters
Each autoclave shall have graphic or computer recording devices which will automatically and continuously
monitor and record dates, time of day, load identification number and operating parameters throughout the entire
length of the autoclave cycle.
5. Validation test for autoclave: validation test shall use four biological indicator strips, one should be used as
control and left at room temperature and three shall be at the centre of the three containers of waste. Personal
Protective equipment shall be used to open the containers for the purpose of placing the biological indicators in
the containers. At least one of the indicators should be placed in the most difficult location for steam to penetrate.
The operator should conduct this test three consecutive times to define minimum operating conditions. The
temperature, pressure and residence time at which all biological indicators for the three consecutive test show
complete inactivation of spores shall define the minimum operating condition for the autoclave.
6. Spore testing
The autoclave should completely and consistently kill the approved biological indicator at the maximum design
capacity of each autoclave unit. Biological indicator for autoclave shall be Geobacillusstearothermophilus spores
using vials or spore strips; with a least 1 X 10 6 spores per milliliter. Under no circumstances will an autoclave
have minimum operating parameters less thanthe residence time of 30 minutes, temperature less than 121 oCor
pressure less than (15 psi).
Standards for liquid waste
The effluent generated from the premises of the hospital before discharge into sewer should conform to the
following limits:
Parameters Permissible Limits
Ph 6.5-9.0
Suspended solids 100 mg/I
Oil and grease 10 mg/I
BOD 30 mg/I
COD 250 mg/I
Bio-assay test 90% survival of fish after 96 hours in 100% effluent.
These limits are applicable to those hospitals which are either connected with sewers without terminal sewage
treatment plant or not connected to public sewers. For discharge into public sewers with terminal facilities, the
general standards as notified under the Environment (Protection) Act, 1986 shall be applicable.
Standards for deep burial
i. A pit or trench should be dug about two meters deep. It should be half filled with waste, then, covered
with lime within 50 cm of the surface, before filling the rest of the pit with soil
ii. It must be ensured that animals do not have any access to burial sites. Covers of galvanized iron/ wire
meshes may be used.
iii. On each occasion, when wastes are added to the pit, a layer of 10 cm of soil shall be added to cover the
wastes.
iv. Burial must be performed under close and dedicated supervision.
v. The deep burial site should be relatively impermeable and no shallow well should be close to the site
vi. The pits should be distant from habitation and located so as to endure that no contamination occurs of
any surface water or groundwater. The area should not be prone to flooding or erosion.
vii. The location of the deep burial site will be authorized by the prescribed authority.
viii. The institution shall maintain a record of all pits for deep burial.
WASTE SEGREGATION PROTOCOL FOLLOWED IN CMC
Segregation:
BIO-MEDICAL WASTE
Category Type of container Type of waste
Yellow Non-chlorinated yellow 1. Human and animal anatomical waste
plastic bag with a 2. Soiled waste (contaminated with blood and body
biohazard symbol fluids like dressing, cotton swabs, plaster casts,
etc.)
3. Discarded linen, mattress contaminated with
blood and body fluids
4. Personal protective equipment (PPE) –
disposable mask, cap, shoe cover, and surgical
gown
5. Chemical waste- Chemicals used in the
production of biological and used or discarded
disinfectants
6. Blood bags (after autoclaving)
7. Microbiology, biotechnology and other clinical
laboratory waste (after autoclaving) - laboratory
cultures, stock or specimens of microorganisms,
live or attenuated vaccines, human or animals cell
cultures used in research, dishes and devices
used for culture, specimen containers, etc.
Red Non-chlorinated red Contaminated recyclable waste like plastic tubes, bags,
plastic bag with the bio- IV cannula, a disposable syringe without a needle, wound
hazard symbol drains, gloves, and disposable plastic gown
White White translucent Needles, syringes with fixed needle and metal sharps
(translucent) puncture-resistant only
disposable plastic sharps
container
Blue Blue plastic bag in Broken glassware (ampoules, test tubes, slides),
cardboard box discarded (contaminated) glassware (slides) and metal
*puncture-proof container implants only
with blue lining
Blue drum Plastic IV bottles, glass vials, glass bottles
Yellow Non- chlorinated yellow Expired medicines, cytotoxic drugs and PPE used for
plastic bag with the handling them
cytotoxic symbol
NON-INFECTIOUS WASTE
Green Green plastic bag Bio degradable, wet waste – kitchen and food waste only
Brown Brown plastic bag Non-bio degradable, dry waste – plastic water bottle,
cups, syringe wrapper, paper, etc.
Pre-treatment of laboratory waste:
All clinical laboratory waste and blood bag are collected in the transparent autoclave safe bags at source and send
to the temporary storage area (TSA) along with other waste. A new temporary storage area with facility for
storing waste as per the colour has been built and was inaugurated in September 2018. There is a dedicated
autoclave near the TSA to disinfect the laboratory waste, where all laboratory waste and blood bags are
autoclaved and discarded into the yellow bag.
Transport and temporary storage
The mouths of all the bags when 3/4 th filled are tied. All bags are labelled to identify the site of waste generation
and barcoded stickers stuck on the BMW bags. The yellow bag when containing anatomical waste is to be
labelled with anatomical waste label. The hospital has been divided into three zones to make the collection of
these bags more efficient. The bags from the busy areas are collected three times a day, while in the other areas
twice a day. Each area has been allotted a specific timing for collection and they are instructed to keep the bags in
the designated area outside the wards half an hour before the collection timing. These bags are then collected by
the maintenance and carried in closed trolleys and are stored in the area designated (behind MIQ) for infectious
and non-infectious waste in 2-3 shifts within 24 hours. Barcoding facility is available in the temporary storage
area.
Final Disposal
The infectious waste is weighed and is taken in close dedicated vans by Ken bio-links which is our designated
common treatment facility. This is situated at Kandipedu, which is at a distance of 18 km from CMC hospital.
Biomedical waste from CMC hospital as well as the peripheral hospitals of Schell, Low-cost effective care unit
(LCECU), Community health and development (CHAD), Mental health centre (MHC) and Rehabilitation centre,
is collected twice a day by Ken biolinks, in closed dedicated vans and taken to Kandipedu. Here the final disposal
of the waste is done in the following manner:
Treatment and Disposal
Category of waste Final treatment and disposal

Yellow Incineration followed by secured landfilling of ash
Red Autoclaving followed by shredding
White Autoclaving followed by shredding
Blue Disinfection followed by recycling
Regular site visits to Ken bio links, Kandipedu (once in 6 months) are organised to assess the final disposal
practices.
Solid Waste Management
The solid waste is taken care of by a self-help group known as “MALARGAL Women‟s FEDERATION”.
These bags are carried in tricycles or in dedicated vehicles daily. This consists of 210 women and about 16 men
who work in shifts for 12 hours to further segregate this waste into dry and wet waste and their recycling. A
“zero-waste management” policy is followed. This site is situated in the Bagayam campus of CMC.
Dry waste: Mainly consists of plastics, papers, cardboard, etc. These are segregated and sold off for recycling.
Plastics are sold for recycling and are used for repacking of non-food items.
Wet waste: Consists of food and vegetable matter. These are reduced and reused in the following ways:
Sold to the farmers for feeding the animals.

Vermicomposting using the earthworms. Manure produced after this process is used for Gardening and
also sold to the farmers.
BMW Committee functions under the leadership of GS, which aims at looking after the waste management in the
hospital campus. This committee meets once in two months.
Amendments to Bio-medical waste rules
BMW rules were amended in 2018 and 2019. The amendment in 2018, mainly was to clarify certain areas and
made a puncture proof container with a blue lining a suitable bin for discarding broken glassware. The 2019
amendment stipulates that monthly record of biomedical waste and annual report should be displayed on the
website of the healthcare institutions. This rule has also made it mandatory for facilities having less than ten beds
to comply with output discharge standard for liquid waste.
References:
1. Biomedical waste (Mgt& Handling) rules 1998, as amended in 2000.Tamil Nadu Pollution Control
Board
2. Biomedical Waste ( Mgt& Handling ) rules 2016
3. Biomedical waste (Mgt& Handling) rules 2016, amended in 2018 & 2019
11. HOUSEKEEPING
Good cleaning practices are mandatory in a hospital environment to prevent healthcare-associated

infections (HCAI). Patient admitted to a hospital can develop infections due to micro-organisms that survive in
the environment. Therefore, it is important to clean the environment with appropriate disinfectants thoroughly on
a regular basis. This will reduce the bacterial load and make the environment unsuitable for the growth of
microorganisms, thereby preventing HCAI.
Categorization of hospital areas:
(Adapted from National infection control guidelines, NCDC 2015 and 2017)
Categories Areas included Disinfection method
High-risk areas OR, ICUs, HDUs, Casualty, Labour room, Surgical Disinfection with 7% Lysol twice a
wards, Postoperative wards, CSSD, AK lab, isolation day, cleaning with soap and detergent
wards, chemotherapy, Radiotherapy wards, BMT lab, rest of the times.
blood bank
Moderate risk areas Medical wards, laboratory areas, pharmacies, Doctors Disinfection with 7% Lysol once a
and Nurses stations, Psychiatric wards, Dietary day, cleaning with soap and detergent
services, Laundry services, Mortuary rest of the times.
Low-risk areas Department officers, OPD, Library, Conference hall, Cleaning with soap and detergent
Staff areas, Medical record section, Cafeteria, Visitors once a day
waiting lounges
HOUSEKEEPING IN WARDS
a. The floor is to be cleaned with a disinfectant 7% Lysol at least twice a day. Detergents may be used to mop
the floor rest of the times.
b. All work surfaces are to be disinfected by wiping with 7% Lysol and then cleaned with detergent and water
twice a day
c. The walls are to be washed with a brush, using detergent and water once a week.
d. High dusting is to be done with a wet mop once a week.
e. Cupboards, shelves, beds, lockers, IV stands, stools, and other fixtures are to be cleaned with detergent and
water once a week.
f. The patient‟s cot is to be cleaned every week with detergent and water.
g. Storerooms are to be mopped once a day and high dusted once a week.
h. Fans and lights are cleaned with soap and water once a month.
i. Curtains are to be changed once a month or whenever soiled. These curtains are to be sent for regular
laundering. In certain areas (eg. Transplant units and ICUs) more frequent changes are required.
j. In the isolation ward, cleaning is done daily with 7% Lysol, when soiled with blood or body fluids.
k. The floor of bathrooms is to be cleaned with detergent twice a day. For disinfection, 7% Lysol is to be used.
l. Toilets are cleaned with a brush using a detergent thrice a day. Disinfection should be performed using 7%
Lysol. Solutions like R6 can be used once a week.
m. Wash basins are to be cleaned with detergentpowder every morning and with hydrochloric acid or a solution
such as R6 once a month.
n. Regular AC maintenance is required. The AC section has a protocol and wards should ensure that whether it
is followed.
o. No broomingis allowed inside clinical areas.
Patient linen
Bed linen is to be changed once in 2 days and whenever soiled with blood or body fluids.
a. The patient‟s gown is to be changed every day and whenever soiled with blood or body fluids.
b. Dry dirty linen is to be sent to the laundry for a regular wash.
c. Linen soiled with blood or body fluids, and all linen used by patients diagnosed to have HIV, HBV, HCV,
and MRSA, are to be decontaminated in the ward by soaking in 1% sodium hypochlorite (eg: Dakin‟s)
solution for half an hourand then sent to the laundry.
Rubber goods (Eg. Mackintoshes)
They are to be cleaned with soap and water, disinfected with 7% Lysol, dried in the sun, powdered, rolled and
stored.
Miscellaneous items
a. K basins, basins, bedpans, urinals, etc. to be cleaned with water and detergent powder then disinfected
with 7% Lysol.
b. Metal buckets are to be cleaned with detergent powder every week.
HOUSEKEEPING IN THE ISOLATION WARD Before
admission
The admitting physician should inform the sister-in-charge of isolation ward at least one hour prior to admission,
mentioning the diagnosis, sex and the general state of the patient.
Pre-requisites for Isolation
a. A source of running water should be available in the treatment room and the nursing station
b. The mattress and pillows should have an impervious cover such as a mackintosh so that it can be easily
cleaned with moist duster
c. Clean gowns should always be available
d. Hand rub, gown, mask, shoe covers, and cap should be available at the entrance of each room
e. Separate urinals, bedpans, and thermometers are to be used for each patient
f. A waste bin lined with the appropriate colour coded plastic cover should be available in each room for
disposal of bio-medical waste
g. Rooms should be isolated according to disease conditions and should be well lit.
Cleaning procedure for the Isolation room
a. Linen should be stripped from the bed with care taken not to shake the linen during this action. Linen should
be soaked for 30 min in 1% Sodium hypochlorite (eg: Dakin‟s) and then sent to the laundry
b. All other articles like I.V. stands and furniture should be cleaned with detergent and disinfected with 7%
Lysol
c. Mattress and pillows should be wiped with a mop soaked in 7% Lysol
d. Walls should be cleaned with detergent and disinfected with 7% Lysol
e. The bathrooms should be cleaned with detergent and disinfected with 7% Lysol.
At discharge (terminal disinfection)
a. Keep an ultraviolet light in the room facing each direction for half an hour in a 2 bedded room and for 1 hour
in a 4 bedded room
b. The pillows and mattress are to be cleaned with detergent, disinfected with 7% Lysol (the Mackintosh cover)
and dried in sunlight for 24 hours
c. Bed sheets, curtains, patient gowns, soaked in 1% Dakin‟s for 30 min and then sent to laundry
d. After disinfection, wash the room, wall, window, doors, bathroom, sink and furniture with soap solution after
doing thorough high dusting in that cubicle.Soak bedpan, urinal, kidney basin in 7% Lysol solution for 1
hour, wash with detergent and dry it under sunlight
e. Bath basins, multi-bin, bucket, jugs, mugs are to be washed with soap solution and dried in sunlight
f. Rubber sheets (mackintosh) are to be cleaned with 7% Lysol, dried, powdered and replaced
g. Utensils used by the patient are to be washed, boiled and replaced.
HOUSEKEEPING IN THE OPERATING ROOMS
The operating room (OR) complex is divided into zones that are designed to minimize dust entry into the
operating suite since OR must be maintained absolutely clean at all times.
Surface disinfection in OR
OR complex is disinfected on a regular basis in two different ways to keep micro-organism to its irreducible
minimum:
a. Daily surface disinfection

b. Weekly surface disinfection
c. Fogging
The surfaces in the OR that require disinfection include:
a. Walls & Floor

b. Articles & Equipment inside OR;
i. OR table
ii. Dome light (outer surface)
iii. Diathermy Machine
iv. Anaesthesia Machine
v. Instrument Layout trolleys
vi. Storage Trolleys
vii. Racks & IV stands
viii. Computer (monitor & keyboard)
ix. Telephone
x. Suction Apparatus
Daily Surface Disinfection Protocol
a. OR must be disinfected as frequent as possible to keep the micro-organism to its irreducible minimum.
b. Following the end of the day washing, OR must be completely surface disinfected once prior to the
commencement of the day‟s surgery and partially disinfected in-between the surgeries.
c. Complete surface disinfection means disinfecting all the above-mentioned surfaces and partial
disinfection means disinfecting only the essential surfaces, which are frequently handled; those include:
i. OR table
ii. Instrument layout trolleys
iii. Dome light (inner surface) if blood splash is noticed. Cleaning of the inner surface of the dome
light must be done with sterile water.
iv. Floor
d. The preferred disinfectant for surfaces are as follows:
Table 11.1.Surface disinfectants
S.No Surface Disinfectant

1. Walls, Articles, and Equipment 10% Hydrogen Peroxide (eg: Ecoshield. Microzid
etc.)
2. Floor 7% Lysol
e. In case the surgery is performed on a patient with BBVS status positive, the following disinfectants must
be used on specific surfaces:
Table. 11.2. Surface disinfectants for BBVS positive patients
S.No BBVS Positive Surfaces Disinfectant
1. HIV Walls, Articles, and Equipment 1% Sodium hypochlorite
2. HIV Floor 1% Sodium hypochlorite
3. HBs Ag Walls, Articles, and Equipment 20% Hydrogen Peroxide
4. HBs Ag Floor 7% Lysol
5. HCV Walls, Articles, and Equipment 20% Hydrogen peroxide
6. HCV Floor 7% Lysol
7. MRSA Walls, Articles, and Equipment 20% Hydrogen peroxide
8. MRSA Floor 7% Lysol
Weekly Surface Disinfection Protocol
a. OR suite must be cleaned thoroughly during the weekends.

b. The OR suite must be high dusted, cleaned, washed, AC filter changed and completely surface
disinfected during the weekend.
c. Position articles must be washed, dried and disinfected.
d. The scrub room and the sink must be cleaned and washed.
e. Cupboards with sterile items and registers must be cleaned, disinfected and arranged.
f. Sluice rooms must be cleaned and washed.
g. Packing area must be high dusted, cleaned, washed, dried and essential articles must be arranged.
Fogging Protocol
a. OR suite must be fogged once a month and also following surgeries performed on patients with:
i. Anthrax
ii. Tetanus
iii. Gas Gangrene
iv. Fungal infections
v. Diphtheria
vi. Infectious abscesses
b. Fogging must be done using 20% Hydrogen peroxide (eg: Microzid, Ecoshield, etc.).
c. The fogging request must be sent across to EMD, through the HICC.
d. Scheduled fogging must be done as follows:
i. Fogging must be done in an OR suite with stationed articles and equipment pertaining to that OR.
ii. Spraying of the disinfectant in all direction must be done for the first 20 minutes with AC on.
iii. Spraying of the disinfectant in all direction must be done for the next 20 minutes with AC off.
iv. The room must be sealed for the next 10 minutes.
v. After 10 minutes the AC must be switched on for 5 minutes for the fog to clear.
vi. Following which partial surface disinfection must be carried out with 20% Hydrogen peroxide.
Patient linen disinfection in OR
a. All used reusable linen must be segregated.

b. Blood soiled linen must be prewashed using Hi-fabric liquid soap and sent to laundry for a second wash.
c. Dry linen used for surgeries must be considered contaminated and must be stored in a designated place.
Later it has to be sent to laundry for a second wash.
d. Disposable linen must be used for all surgeries performed on patients with BBVS positive. In-case
reusable linen is used, the following protocol must be carried out:
S.No BBVS Positive Disinfectant to be used Protocol

1. HIV 1% Sodium hypochlorite (Dakin‟s) All linen must be soaked for
2. HBs Ag 1% Sodium hypochlorite (Dakin‟s) half an hour.
3. HCV 1% Sodium hypochlorite (Dakin‟s) Following soaking the linen
4. MRSA 1% Sodium hypochlorite (Dakin‟s) must be pre-washed with Hi
fabric soap and must be sent to
laundry for further washing.
e. Disposable linen must be disposed of appropriately and labelled as BIOHAZARD.
Instrument disinfection and sterilization in OR
a. Instruments can be classified depending upon the usage as critical and non-critical instruments.
b. Critical instruments are those which are used inside the surgical wound and non-critical instruments are
those which are used over the skin.
c. Critical instruments must be used cleaned with saline while on the field and at the end of the surgery it
must be soaked in normal saline.
d. After surgery, all instruments, both used and untouched, must follow the belowmentioned steps:
Table 11.3. Steps of instrument disinfection and sterilization in OR
S.No Steps Protocol

1. Pre-washing Wash with soap and water
2. Soaking Using enzymatic solution, soak for 30 minutes
3. Washing Wash using a brush; concentrate on the serrations and the box
junction
4. Drying Air dry solid instruments. Use compressed air to dry hollow
instruments
5. Checking & Check for broken instruments and lubricate using silicone
Lubricating free lubricant.
6. Assembling Assemble the instruments into a porous tray with the tip of
the instrument slightly opened. Assemble the heavy
instruments below and light instruments above. Assemble
according to the number in each set.
7. Packing Double wrap the instrument sets. The inner layer must be a
thin material and the outer with a thick oven material.
8. Labelling Label the sets appropriately.
9. Sterilizing Choose a sterilization method according to the material of the
instruments.
10. Storing Store the sterile sets in a clean and dry cupboard.
e. In case the instruments are used on a patient with BBVS status positive follow the below-mentioned
protocol:
i. Soak all instruments (both used and untouched) in 7% Lysol for 30 minutes.
ii. Drain the Lysol at the end of 30 minutes and transfer the instruments to red bag and send it for 1st
sterilization. (Decontamination)
iii. After decontamination, follow the 10 steps in the care of instruments and send it for 2 nd
sterilization. (Disinfection).
HOUSEKEEPING IN AK LAB
Daily Cleaning
a. The floor is to be cleaned (swept & mopped) before starting each haemodialysis shift, 7% Lysol is used
for mopping.
b. All work surfaces are to be disinfected with 7% Lysol twice a day
c. Toilets are cleaned with a brush using detergent thrice a day, for disinfection 7% Lysol can be used. To
remove the stains, Hydrochloric acid based solutions (Eg: Taski R6) can be used once a month.
d. Wash basins are to be cleaned with detergent powder every morning and with disinfectants once a week.
Weekly Cleaning
a. The walls are to be cleaned using detergent and water once a week (usually on Sundays)
b. High dusting is to be done every Sunday and whenever cobwebs are seen.
c. Cupboard, shelves, beds, TV stands, stools, chairs, and other fixtures to be cleaned with detergent and
water once in a week.
d. The cot is to be cleaned every week with 7% Lysol. Cots should be cleaned with 7% Lysol after the death
of a patient or if the patient is bio-hazard positive.
e. Dialysis zones in CAPD room and OR is disinfected by hydrogen peroxide (Eg. Ecoshield, Microzid,
etc.)spray as per cleaning protocol of unit.
f. AC filters are cleaned by the people arranged by the department (AC Section) once a week and whenever
needed.
g. Fans and lights are cleaned with soap and water once a month. This is the responsibility of the electrical
section.
Patient linen
a. Bed linen to be changed for each patient and whenever it is soiled

b. Dry dirty linen is to be sent to the laundry for a regular wash every day.
c. Linen soiled with blood or body fluid and all linen used by patients diagnosed to have HBV, HCV, HIV &
MRSA is to be decontaminated in the ward by soaking in 1% Sodium hypochlorite (Dakin‟s) for 30 minutes
and then sent to laundry
d. Curtains are changed once a month or as and when needed
e. Rubber goods as Mackintosh are to be cleaned with soap and water and is disinfected with 7% Lysol, dried in
the sun, powered, rolled & stored
f. Miscellaneous items: K basins, basins, bedpans, urinals, etc. to be cleaned with detergent powder and water
and disinfected with 7% Lysol as it is used and once a week.
Fogging is done using the fogger with 20% Hydrogen peroxide (Microzid, Ecoshield, etc.) solution
a. Fogging of zones are done once a month

b. OR is fogged before any major invasive procedure as follows;
i. 800ml of water is mixed with 200ml of hydrogen peroxide (Ecoshield, Microzid, etc.) and poured
into the fogger. Fogging is done for 20 min
ii. Before spraying the area is swept and mopped with clean water. Evenly spray and close the room and
allow it to dry for 40mins. Mop the floor with plain water with a clean mop cloth.
Disinfection of equipment
a. Stethoscope & BP apparatus – Wipe with spirit

b. Pulse oximeter – Wipe with spirit
c. Defibrillator – Use soap and water
d. NIBP Machine- Use soap and water
e. Ultrasound scanner – Wipe with 10% hydrogen peroxide
f. O2 flow meter – Washed with liquid soap once a week. Gas sterilization done for OR O 2 flow meter
g. Suction apparatus – Washed with liquid soap & disinfected with 7% Lysol.
12. COMMON AREAS OF PATIENT CARE
LABORATORIES
(Clinical Pathology, Clinical Microbiology, Clinical Virology, and Clinical Biochemistry)
Collection and processing of specimen

Refer to the chapter “Techniques” for details on collection of specimens for culture and for other investigations.
Policies for laboratory personnel

(Also refer to the chapter on „Employee Health Programme‟)
The basic principle is strict adherence to standard precautions.

All clinical material must be considered potentially infectious.
All procedures and manipulation should be performed carefully to minimize the creation of aerosol or
spillage.
For containment, a biological safety cabinet with „evacuation‟ and „burn out‟ attachment should be used
for all procedures involving clinical material.
Gloves must be worn for all procedures on infective material. Eye protection and the mask will be
required when splashes are a possibility.
Personnel with open skin wounds, extensive eczema or dermatitis should avoid handling specimens
contaminated with blood and infectious body fluid.
No mouth pipetting is to be performed.
A written protocol should be available for:
o All procedures involving infective material carried out in the laboratory.
o Disinfection & sterilization of various item used in the laboratory Disposal of various infective items.
When centrifugation is necessary, it is advised that buckets be balanced prior to use of the centrifuge to
prevent any accidents. If the specimen container is broken or leaking, then the complete unit should be
autoclaved with the lid of the bucket left loose. Buckets should be routinely disinfected by wiping all
surfaces with 10% bleach at the end of the day whether or not breakage has occurred. To prevent aerosol
spread, open the machine only when the centrifuge has come to a stop.
If breakage has occurred on or in laboratory equipment, report the incident to the supervisor and treat the
situation like a blood spill.
Disinfect contaminated surfaces with an appropriate disinfectant in order that infective material is not
spread to other areas
All personnel must immediately remove their gloves and protective clothing following completion of
work and wash their hands before moving on to other activities.
Gloves should not be worn when coming out of the workplace.
Items of common use (doorknobs, telephone, computer keyboards, freezer handles,etc) are to be handled
only withungloved hands.
Reporting of accidental exposure to bloodborne pathogens – Refer to the chapter “Preventing
transmission of bloodborne pathogens”, but also follow the following steps.
o Skin exposure: Vigorously wash affected skin with plenty of soap and water while removing
contaminated clothing and shoes.
o Eye exposure: Wash eyes for at least 10 minutes with copious amounts of water, lifting the
upper and lower eyelids occasionally.
Procedure for management of blood/body fluid spills
Prior to beginning the cleaning, wear a pair of rubber/latex/ PVC or similar type gloves.
Cover the spill area with a paper towel and then pour freshly prepared 1% sodium hypochlorite solution.
Allow the solution to soak into the contaminated material. Work from the outside edges of the spill
inward when applying the 1% sodium hypochlorite solution.
Any glass, needles, or other sharp objects that may puncture the skin should not be picked up by hand.
Only mechanical means such as a brush and dustpan, tongs, or forceps are allowed.
After 10-15 minutes, wipe bleached material with paper towels or absorbent pads. It may be necessary to
use a scrub brush to remove the material if it impacted a hard porous surface such as concrete. If non-
porous surfaces, such as a carpet have been contaminated, it should be removed and autoclaved.
Place the mop with soaked material, gloves, and other disposable materials into yellow bag designated
for the disposal of infectious non plastic waste.
If handwashing facilities are not available at the job site, use alcohol-based hand rub to disinfect your
hand and then wash hands as soon as possible.
Disposal of laboratory waste

Various categories of waste generated from the lab should be segregated according to the procedure
followed in the hospital (refer to the chapter on “Hospital waste management”).
All cultures should be decontaminated by autoclaving before it leaves the laboratory or should be sent for
incineration in properly secured bags.
All disposable specimen containers should be discarded. Reusable ones are cleaned only after
disinfection by soaking in 1% sodium hypochlorite solution or after autoclaving.
Role of laboratories in infection control in the hospital and community

See the chapter on Surveillance and reporting of infections for notifiable infections to be reported by
laboratories.
The Department of Microbiology takes an active part in:
o Routine monitoring of sterilization & disinfection in various parts of the hospital,
o Investigating outbreaks of infections and
o Making antibiotic susceptibility data available to clinicians periodically.
Tests which have potentially long exposures to blood (e.g.estimation of bleeding time) are performed on
patients known to harbourbloodborne pathogens only when absolutely essential.
Serum or plasma of patients known to harbourbloodborne pathogens is not stored except in certain
specialized laboratories.
BLOOD BANK
Standard Precautions are to be strictly followed while collecting and handling blood. (Refer to the section on
standard precautions in the chapter „Preventing Transmission of Blood Borne Pathogens)
Blood Donors:
Screening of donors for infections

All donors are screened for a history of recent and past infections.
Donors are temporarily deferred for the following conditions and are advised to donate at a later date;
o Fever, sore throat and common cold
o Antibiotic therapy during the past week
o Dental work during the past week
o Jaundice during the past one year
o Infectious diseases such as malaria during the past year
o Possible exposure to rabies during the past year
o Any recent viral infections like chicken pox and measles
o Recent administration of live attenuated viral vaccinations for polio, rabies, small pox, measles,
mumps and yellow fever
o Sexual exposure to any person having venereal infections
o History of a visit to a commercial sex worker or multiple sex partners
Donors are permanently deferred or deferred for longer periods if they give history of;
o Sexually transmitted disease
o HIV infection or AIDS
A personal evaluation form is available in the donor area, for donors to exclude themselves without
identifying the cause for exclusion.
All professional donors are rejected.
After evaluation of the history, a limited physical examination by a medical doctor is done to exclude any
clinical evidence of infection / other illness
Investigations
The donor‟s blood is tested for the following infections:

i. Malarial parasites
ii. Microfilaria
iii. VDRL (syphilis)
iv. HBs Ag
v. HIV I & II antibodies
vi. Hepatitis C virus antibody
vii. Nucleic acid testing for HIV, HBV, and HCV
viii. Cytomegalovirus testing is done if requested by the clinician.
HIV and safe blood transfusion
Since the screening of blood does not ensure complete safety since people in the window period would test
negative, the donor is asked a question regarding sexual practices to ensure that the donor is not in this period.
Screening of a sample of blood is also essential to ensure safety. The sample should be tested for HIV by a highly
sensitive screening procedure. A fourth-generation assay that detects p24 antigen + HIV 1/2 antibody is
recommended. Since HIV-1 and HIV-2 are both prevalent in India, tests which identify either infection id
preferred to those that identify HIV-1 only. In most parts of India at the present time, the presence of HIV-2 is
low. However, the lack of availability of HIV-1 & 2 test system should not be an excuse for not using a good
screening procedure for HIV-1. If the test is reactive, the donor/donated unit of blood is not to be accepted.
However, the donor should not be diagnosed with HIV infection on the basis of a single screening test.
Blood Donation Procedure

i. Safety measures are taken to prevent infection in recipients.
ii. The technician should wash his/her hands with soap and water before bleeding the donor. (Refer to the
section on hand washing in the Chapter “Techniques”).
iii. Linen should be changed if there are blood stains.
iv. The venipuncture site should be cleaned with soap and water and Povidone-iodine.
v. The donated blood should not be kept at room temperature to prevent bacterial multiplication.
vi. If platelets are to be prepared the unit should be kept at 22 oC. If fed cells, FFP (Fresh Frozen Plasma) and
cryoprecipitate are to be prepared, the collected blood should be kept at 4 oc before components are made.
100
Component preparation and storage
i. Component preparation and storage should be done in a clean dust free room and refrigerated centrifuges
should be used for separation. Components are made in a closed bag system.
ii. All extra tubing in the blood collection system is destroyed making sure that they cannot be reused.
iii. All stored red cells, platelets, and liquid plasma should be physically checked every day for haemolysis
and turbidity. Cultures are performed regularly on stored blood components.
iv. All refrigerators and freezers should be fitted with alarm systems and temperature maintenance should be
checked at regular intervals during the day.
Infected units of blood and components
If any unit collected is found to be positive for infectious disease, all samples, and components from that
individual are collected, kept separately put in a red bag and handed over to Common Treatment Facility for final
treatment and disposal. The blood to be discarded should preferably be rendered non-infectious with hypochlorite
or another method of disinfection. In a closed wastewater disposal system, there may be no ill effects of pouring
out blood. However, when large quantities (more than 2-3 pints) are involved, it is advisable to send it directly
for supervised incineration.
Handling of patients and donor samples
i. Standard precautions are to be strictly followed.
ii. No mouth pipetting is allowed.
iii. All used glassware and sample containers are left in 1% sodium hypochlorite before cleaning.
iv. All disposable needles are to be disposed of in the sharps container.
v. If there is any spill of blood in any area, the area is cleaned after decontamination with freshly prepared
1% sodium hypochlorite solution. It is important that the area of spillage is exposed to the disinfectant of
the appropriate contact time of 10-15 min before clean up.
Issuing blood for transfusion

i. All units of blood and components issued from the Blood Bank are checked for any evidence of
haemolysis, icterus or turbidity to prevent transfusion of possibly infected units.
ii. No unit is accepted back in Blood Bank if kept at room temperature for more than 15 minutes.
iii. No unit is to be stored in the ward refrigerators.
iv. All units issued should be negative for Malaria, Microfilaria, VDRL, HBsAg, HCV & HIV-1 & 2
antibodies and NAT negative.
Transfusion reaction investigation

i. In case of transfusion reactions, the transfused units / bags are sent for microbiology culture.
ii. Since there is still a possibility of transmission of infections by blood transfusion, we encourage
appropriate use of blood and also autologous transfusion.
iii. Clinicians are advised to give fewer transfusions and for this, continuing medical education is
encouraged.
iv. The Hospital transfusion committee oversees any problems in the Blood Bank functioning and blood
usage.
Infection Control for Staff

Refer to the chapter „Employee Health Programme‟ and to the earlier section on policies for laboratories.
TISSUE PATHOLOGY & AUTOPSY ROOM
Workers in the pathology lab are among those exposed to the blood, body fluids and tissues which are potentially
infectious.
All workers are advised to adopt Standard precautions in the workplace.
Protective Clothing
In the laboratory, where tissue specimens are handled, gloves and rubber / plastic aprons are
recommended for protection of the healthcare worker.
In the autopsy room, overshoes with plastic foot cover to make them impervious, masks, goggles and
elbow length gloves are additionally recommended.
Work Surfaces
Work surfaces should be treated as blood spills (refer to the management of blood spills)
Handling of fresh, unfixed tissue

Formalin is injected into the body before the autopsy is begun.
During an autopsy, the tissue should be transferred to 10% formalin as soon as possible.
Photography of wet specimens should be done in the autopsy room itself and dedicated space is
necessary which can be thoroughly cleaned after use.
Disposal of Waste and Contaminated Material

This is conducted as per the hospital guidelines.
Routine Biopsy and Autopsy Processing

Tissue should be fixed in 10% formalin as soon as possible and left undisturbed for 24-48 hours
depending on the size of the specimen.
Transport of tissue specimen to the laboratory is recommended after fixation in 10% formalin. Spill
proof, screw-capped bottles are used and they are sent in leak-proof plastic bags.
Tissues are processed after 24 hours, using all precautions as for fresh tissues.
Instruments
Instruments in the lab or autopsy room are decontaminated either by autoclaving or by standing in
freshly prepared sodium hypochlorite solution for 30-60 minutes. They are then washed in detergent
and dried.
Personnel
Entry to the autopsy area and laboratory is restricted.
Autopsy room staffs need to have regular physical check-up.
Accidental exposure to blood and body fluids should be dealt with according to the protocol given
earlier in this chapter and in the chapter on employee health programme.
Body bags
Body bags are available to transport bodies. All bodies will be covered with a body bag before
leaving the mortuary. Routine double bagging of patients known to harbour blood borne pathogens is
not necessary.
Death due to Anthrax
If a patient with Anthrax dies less than 48 hours after antibiotics were started, the body is bagged as
usual.
Minimize handling of the body.
Advice relatives to conduct last rites as soon as possible, avoiding contact with body fluids.
Soiled clothes should be burnt or buried with the body.
In case deep burial is not possible, cremation is recommended.
HEALTH & SAFETY POLICIES IN THE MORTUARY & AUTOPSY ROOM
Any patient who has been brought dead to the hospital, or who dies within 24 hours of admission, and
whose HIV / HCV status is not known, is not autopsied. However, injection with formalin for
preservation of such bodies is permitted.
All HIV, HCV and H1N1 positive bodies are not autopsied. However, injection with formalin for
preservation of such bodies is permitted.
HBV positive bodies can be autopsied after injection with formalin. However, extra care is to be taken
during the post-mortem.
Bodies with anthrax or rabies are not autopsied.
Bodies with tetanus can be autopsied after injection with formalin.
Those who eviscerate organs during autopsy should wear:
o Full sleeved gowns
o Plastic aprons
o Masks
o Gloves (including elbow length gloves if needed)
o Visors
o Protective overshoes
Those dissecting eviscerated organs must wear at least an apron, gloves and mask.
Dissecting tables and the PM room floor are regularly cleaned using appropriate disinfectants.
Wash rooms are available on site and all PM room personnel should use these when necessary.
Waste segregation as per hospital guidelines (Refer chapter on Hospital waste management)
Table.12.1.Safety policy for specific chemical hazards
Substance Uses / areas of risk Safety policy

Formaldehyde (Formalin) 1. Preparation of 10% 1. When handling use gloves and mask
formalin from full and maintain good ventilation or use
strength formalin. fume hood
2. Fixation of tissues 2. Keep in sealed containers
3. Do not mix with phenol
Hydrochloric acid Cleaning 1. Handle with care

2. When diluting concentrated acid
always add acid to water and not
vice versa
Hypochlorite (Chlorine Disinfection and cleaning Handle with care

solution)
Phenol (carbolic acid) Disinfection and cleaning Handle with care
ENGINEERING DEPARTMENT
The preventive maintenance of all equipment will ensure efficiency and reduce chances of contamination of air
and water. The proper care and maintenance of the entire physical structure will also reduce accumulation of dust
and spores in the environment. Thus the Engineering department and its personnel are important links in the
chain of activities towards hospital infection control.
General guidelines
Engineering personnel shall report to the charge nurse prior to commencing work in a patient‟s room or
area, and follow her directions with regard to dressing, scrubbing etc. Engineering personnel shall check
out with the charge nurse upon completion of work
Engineering employees shall maintain a neat, clean appearance at all times. Personal hygiene such as
washing after using toilet facilities, etc. will be observed
All engineering personnel must be aware of standard precautions
Prior to entering areas requiring sterile attire such as the OR, engineering employees shall wear the
prescribed clothing. Engineering personnel shall check in and out with the permission of the supervisor
Handwashing should be followed before entering and leaving the patient care area.
Plumbing job guidelines

Hospital water supply systems shall not be connected with any other piping system or fixtures that could
allow contamination control valves & non-return valves
When using implements to unstop fault drains, wear rubber gloves
When rodding out main sewer lines, or when exposed to gross contaminated wastes, wear rubber boots
and rubber gloves, goggles and mask
After exposure to sewer lines or gross contaminated waste, clean exposed areas of body with soap and
water. Change uniform if necessary. Do not return to patient care areas before cleaning up.
12.5.3 Physical barriers between repair area and patient care facility
When any construction or repair work is carried out in patient care areas, the supervisors must inform the
Medical Superintendent, who will inform the heads of the concerned departments so that patients may be
shifted, if required
When work is carried out in areas with immunocompromised patients or those that require a sterile
atmosphere, adequate physical barriers must be present to prevent the spread of fungal spores and other
such microbes, through dust and debris generated
All areas that require a sterile atmosphere must be sprayed with hydrogen peroxide before use, following
any construction work.
12.5.4. Ventilation systems

Regular cleaning of all window AC filters must be carried out in a systematic manner throughout the
hospital.
In the wards and laboratories the AC filters should be washed in running water and replaced
In high risk areas with centralised AC, such as Operating theatres, ICUs and A block: AC filter is cleaned
with Ecoshield (1:10 ratio), once weekly
In areas such as the microbiology lab where handling of infected material is carried out, more frequent
checks and cleaning of AC filters is required
In areas where central air-conditioning is used, the moisture of the air and the ventilatory air changes
must be carefully monitored.
DIETARY AND HOSPITAL KITCHEN
The dietary department ensures that food prepared and served to patients, visitors and employees is received,
stored, assembled and served in a manner that avoids contamination. The aim is to prevent food/water borne
infections. Food Safety Standard Authority of India (FSSAI) standards are strictly adhered.
Production kitchen
All food is prepared and served into containers/trays in the main kitchen and then sent to the wards.
A. Food Temperatures
Cold food items are maintained in refrigeration at a temperature of 4 to 6°C or below. Walk-in storage facilities
are maintained at the following temperatures. The temperatures are checked daily and a log is maintained of the
temperature.
Foods prepared to be served cold are cooled from their preparation temperature to 4°C or below. The cooling
shall not exceed 4 hours.
Hot foods are held at an internal temperature of 63°C or above.
Both hot and cold food items will be transported in such a manner that appropriate temperatures will be
maintained during the transportation of the food.
Table No.12.2. Recommended storage temperatures
Details Temperature Record Monitoring
Dry provision 21 C (70 F) No
Fresh fruits, salads, vegetables 4-6 C (39-43 F) Yes
Dairy products, vegetables 2 C (35 F) Yes
Fats and oil 21 C (70 F) No
Meat or fish -18 C Yes
Sanitizing Vegetables
Sanitization of vegetables is done with sumatabs before cutting.
Safe Potable Water
Safe water is used for cooking. Periodical microbiological examination is performed on the raw water supplied
to the kitchen area.
Cooking at right temperature
Cooking food at right temperature ensures that food is thoroughly cooked (100°C). For few selected items based
on the nature of preparation, the cooking temperature may vary.
B. Special formula food – Blended Diet
Infant formulas and other formulae prepared by the Dietary Department are subject to specific preparation and
storage policies and procedures that may be found in the Dietary Department Manual. These are checked by
microbiological culture only when epidemics occur.
In-patient Food
Trays of patient food are assembled in the kitchen, supervised by professional and trained personnel. They
are taken to distribution points (floor kitchens) and served by dietary personnel.
Dietary workers are taught to observe standard precautions to protect themselves.
The returned trays are heat treated to render the items sanitized (wash temperature 65-70°C, rinse temperature
85-95°C).
Dietary Personnel
Dietary personnel is taught to protect food consumers from the body substance of dietary personnel. Barriers are
provided for the use of dietary personnel, and the practices are taught and supervised.
For details regarding the health care of the workers, refer to the chapter on Employee health policies.
Hand washing
Personnel should wash exposed portions of their arms and hands with soap and water before starting work. Hand
washing includes special attention to the fingernails and areas between the fingers.
Handwashing should be mandatorily repeated after using the toilet, eating or drinking, arranging or combing the
hair, touching the face, nose or eyes, contact with unclean equipment and work surfaces and after handling raw
food.
/.52Personal habits
Keep clothing free from obvious dirt and food spills.

Use hair nets (hair restraints) while on duty.
Use utensils to handle food whenever possible.
Do not consume food or drinks in the food preparation or serving areas.
Do not use tobacco products in any form while engaged in the preparation or serving of food.
Disposal of waste from the dietary department

Food returned to the kitchen is discarded. Kitchen wastes are collected in green bags which are removed
regularly.
Outbreaks
When a foodborne illness is suspected, the HICC is notified. The Microbiology Department will obtain
specimens from the symptomatic individuals and from suspected food. The HICC will be responsible for
obtaining significant histories and conduction of investigation of a suspected foodborne illness.
Display of Posters
Importance of food safety, hygiene practices, prevention of food area accidents, etc. should be displayed
in the working area.
Pest Control
Pest control is done every 15 days.
Medical Reports
All the food handlers will be subject to medical examination every 6 months. Deworming will also be
done once in a year.
Food Sampling
Selected food samples of the food served to the patients are maintained in the deep freezers for a period of 72
hours.
Equipment & Housekeeping

Refer to the section on housekeeping. Additional points may be obtained from the dietary manual.
HOSPITAL SUPPORT SERVICES
LAUNDRY SERVICES
Soiled linen can be a source of large amounts of microbial contamination which may cause infections in hospital
patient and personnel. In addition, improperly processed linen can cause chemical reaction or dermatitis in those
who come in contact with them. A hospital‟s linen service should process soiled linen so that the risk of disease
to patients who may be unusually susceptible or to employees who may handle linen is avoided. Adequate
procedures for collecting, transporting, processing, and storing linen should, therefore, be established.
Washing with hot water and detergent has been shown to result in the adequate cleaning of laundry. If needed for
other reasons, bleach or ironing will reduce microbial contamination. Textile softeners added in the final rinse,
though of no value in preventing infections, make linen easier to handle and rewash, and reduce lint.
Handling of soiled linen
Soiled linen should be handled as little as possible and with a minimum amount of agitation to prevent gross
microbial contamination of the air and of persons handling the linen
All soiled linen should be bagged or put into special carts at the location where used
Linen soiled with blood or body fluids, and all linen used by patients diagnosed to have HIV, HBV, HCV and
MRSA, is to be decontaminated in the ward by soaking in 1% sodium hypochlorite solution for at least half an
hour and then sent to the laundry.
Pre-rinsing and handling linen in the wards
Linen is soaked in 1% Sodium hypochlorite (Dakin‟s) solution for 30 min in sluice room in the wards if they are
soiled with blood, body fluids. Linen soiled with faeces is washed with water and then soaked in 1% sodium
hypochlorite (eg: Dakin‟s) solution for 30 min in sluice room in the wards. Linen used for patients with MRSA,
HIV, Hepatitis B, cholera and linen from the isolation ward is decontaminated in the ward by soaking it for 30
min in freshly prepared 1% sodium hypochlorite before it is sent to the laundry.
Sorting soiled linen
In the laundry, hand washing facilities and protective clothing (e.g., gowns, gloves, goggles and masks) are
available to personnel who sort laundry. In the wards, sorting of laundry should be done only in the sluice rooms
and not at the bedside.
Clean linen
The clean linen section should be cleaned every day. Cupboards and walls are damp dusted and the floor mopped.
All clean linen should be stored and transported in carts used exclusively for this purpose. Clean linen is
delivered to the user in such a way as to minimize microbial contamination from surface contact or airborne
deposition.
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 to be a functional separation of clean and soiled linen
during storage and transport.
Sterile Linen
Only linen used in a procedure requiring sterile technique should be sterilized. This process is done in the TSSU
and CSSD.
CENTRAL STERILE SUPPLY DEPARTMENT (CSSD)
Purpose of the CSSD
i. To provide sterile equipment and instruments for surgeries and procedure and to prevent infection.
ii. To effect the greater economy by keeping and operating the expensive processing equipment in one
central area.
iii. To achieve greater uniformity by standardizing techniques of operation.
iv. To gain a higher level of efficiency in the operations by training personnel with the appropriate
processing procedure.
Sterilization:
a. Moist heat sterilization
The operation of an autoclave is entrusted to a responsible and fully trained personnel. Regular maintenance is
done by trained artisans and electricians.
b. Dry Heat sterilization:

In this method, hot air oven is used to sterilize the selected items (oil, cream, powder, and sharp instruments) that
cannot be sterilized by steam sterilizer.
For dry heat sterilization, the items are to be packed in flat containers which can withstand 160 oCtemperature.
c. Chemical sterilization:
In this method, ethylene oxide gas sterilizer is used to sterilize the heat sensitive materials like plastic,
polyethylene items, delicate rubber, and electronic items.
Sterilizers of capacities varying from 100 liters to 1000 liters are available for ethylene oxide sterilization. A
temperature of 500 C is maintained.
Monitoring of sterilization:
vii. Chemical Indicator: Quality of Sterilized goods are assessed by the use of chemical indicators. A
chemical indicator is used with every pack that is sterilized.
viii. Steam Sterilizer: In Steam sterilizer class 5 steam strips are used in each load which is sensitive to three
parameters time, temperature and pressure.
ix. Gas Sterilizer: In Gas Sterilizer, dosemeter to be used in each bag, which is sensitive to three parameters
time, temperature and gas dosage.
x. Mechanical Controls: A time temperature and pressure chart is maintained in each sterilizer
xi. Bowie-Dick test: A Bowie-Dick test to determine the adequacy of air removal from the chamber, load
during the pre-vacuum stage done daily, and steam quality before starting the cycle.
Penetration time – 12 minutes
Holding time-12 minutes
Safety time-6 minutes (Drying time)
xii. Biological test: This test is done once a week in all the sterilizers. A Biological spore strip-containing
Bacillus stearothermophilus is tested in each steam-sterilizer weekly. A biological spore‟s strip
containing Bacillus atrophaeus is tested in each ethylene oxide gas sterilizer weekly. A Biological spore
strip containing Bacillus atrophaeusis tested in each dry heat sterilizer.
Protocol
A unidirectional (one way) pattern of work-flow is observed in the department. Items proceed in a stepwise
manner from an unsterile area to the sterile area to avoid backtracking.
Wards Department and Operation
Dirty Receipt
Disassembling
CLEANING
Instrument Rubber goods Glass ware
Assembling and packing
Pre Sterile Storage
STERILIZATION
Dry heat Moist heat Ethylene Oxide Gas
Sterile Storage
Distribution
Fig. 12.1. Work flow of CSSD in CMC
ZONING
Department is typically divided into four zones:
Zone I: Reception, inspection and decontamination (removal of bio-burden).

Zone II: Assembly and packing.
Zone III: Sterilizing.
Zone IV: Storage and distribution
1. In the first zone, used items are received, disassembled, cleaned and decontaminated by means of manual or
mechanical processes.
2. In the second zone, cleaned items are received and then inspected, replaced if necessary, assembled, packed
and labelled for further processing like sterilization.
3. In the third zone sterilized items are received and stored until it is time for them to be issued.
Red bags:
Red bags are used to dispose CSSD items that are used on patient harbouring blood borne pathogens or MRSA.
These bags are taken to CSSD before 10am and placed on a trolley. The trolley with all the bags placed on it is
autoclaved. These are then sorted, washed repacked, autoclave and supplied to the wards
GENERAL NURSING
SUPERINTENDENT SUPERINTENDENT
CHARGE NURSE INCHARGE
CHARGE NURSE
STAFF NURSES CLERK Jr. ENGINEER
ATTENDERS & HOUSE

KEEPING ATTENDERS
MPW-MULTIPURPOSE HEALTHWORKER& AUTOCLAVE OPERATORS, ARTISAN, ELECTRICIAN
NURSING AUXILIARY (Technical)
Fig. 12.2. Organogram of the CSSD
110
Request from Departments/ Wards
Data Entry 1-High end Computer & Laser Printer
1-Barcode Printer Washing/ Packing

Batch no.
Labelling with indicator and bar code
Bar code is scanned & data entered Autoclave no.
1-Barcode printer for autoclave room

Sterilizer
Sterile Unsterile
1-High end Computer
1-Lower end Computer for
Sterile Store Inventory Management
Scanned & Delivered with Bar Code
Expired/ Faulty batch
Fig. 12.3. Process in the CSSD (Recall system)
PHARMACY
Pharmacy Manufacturing Division of Christian Medical College is dedicated to improving the quality of
people‟s lives by being the premier provider of health care products. The Manufacturing Division is committed to
current Good manufacturing practices, safety, and environmental protection. This division provides a vital service
for many years with a goal of manufacturing quality pharmaceuticals at an affordable price and some
pharmaceuticals which are not available in the commercial outlets.
Elements of the manufacturing division
The Manufacturing division develops, formulates and prepares quality medicinal products which are
commercially unavailable. It also prepares pharmaceuticals which offer advantages from a product
formulation standpoint, economic or physicians‟ interest. The services of this division are being
continued to set for the highest standards of manufacturing ethics, patient service, quality, and
productivity.
Manufacturing facility
This manufacturing division houses three main sections;
i. Parenteral manufacturing (I.V. fluids & small volume injections)

ii. Non-Parenteral Manufacturing (Liquid orals & External preparations, ointments, pastes, creams)
iii. Repacking section – Products for internal and external use.
A Pharmaceutical product is being manufactured with the application of exact knowledge and familiarity with
regard to the procedures, techniques, facilities, equipment, and precautionary measures. The pharmacy
manufacturing division is a licensed unit as per revised Schedule “M” (GMP requirements and guidelines) of
Drugs and Cosmetics Act and the rules made thereunder.
Personnel
The manufacture of drug products is conducted under the direct supervision of competent technical staff with
prescribed qualifications and practical experience in the relevant dosage forms.
All manufacturing operations relating to the selection, weighing and measuring of raw material addition
during various stages is performed by trained personnel under the direct personal supervision of approved
technical staff.
The in-house Quality Control Laboratory carry out the analyses of Pharmaceutical raw materials,
chemicals, packaging materials and finished drug products. The testing is conducted under the direct
supervision of competent technical staff.
Stores:
The finished products of manufacturing sections and repacking section are transferred to “M” stores and “R”
stores which are housed within the manufacturing premises from where the issues are made to various dispensing
counters within the hospital campus and to pharmacies of outreach clinics
Specific requirements for the manufacture of small volume injections in amber glass vials
Sterile products, being very critical and sensitive in nature, a very high degree of precautions, prevention
and preparations are being exercised. Dampness, dirt, and darkness are avoided to ensure aseptic
conditions in all areas.
There is strict compliance in the prescribed standards especially in the matter of supply of water, air,
active materials and in the maintenance of the hygienic environment.
Change rooms with an entrance in the form of air-locks are provided before entry into the sterile product
manufacturing areas and then to the aseptic area. Change rooms to the aseptic areas are clearly
demarcated into „black‟, „grey‟, and „white rooms‟ with different levels of activity and air cleanliness.
Material transfer between aseptic areas and outside shall be through suitable airlocks or pass-boxes.
2.9.
Personal welfare areas like restrooms are situated outside and separated from the sterile product
manufacturing area.
Air Handling System (Central Air-Conditioning):
Air Handling Units for sterile product manufacturing areas are different from those for other areas.
Critical areas, such as the aseptic filling area, sterilized components unloading area and change room
conforming to various grades have separate air handling units. The filter configuration in the air handling
system is suitably designed to achieve Grade “C” or Class 10,000.
The products are filled aseptically, using laminar air flow work stations with suitable HEPA filters and
the products are terminally sterilized using AMSCO autoclave. The differential pressure between areas of
different environmental standards is 15 Pascal (0.06 inches or 1.5 mm water gauge) measuredby
Magnehelic gauges. The temperature and humidity in the aseptic areas are 28 oC and relative humidity
58% respectively.
Environmental Monitoring:
All environmental parameters such as particulate monitoring in air, HEPA filter integrity testing (smoke testing),
air change rates, air pressure differentials, temperature and humidity and microbiological monitoring by settle
plates are monitored at periodic intervals.
Health, clothing, and sanitation of workers:
The personnel handling parenteral preparations are periodically examined for health fitness. All
personnel, undergo medical examination including eye examination and should be free from
communicable or contagious diseases.
All persons are trained in practices which ensure personal hygiene. Instructions relating to hygiene are
displayed in change- rooms and other strategic locations.
All personnel wears clean body coverings suitable to their nature of work, before entry into the
manufacturing area.
Sterile Garments required for use by personnel working only in the aseptic area and are made of non-
shedding and tight weave material. The clothing and its quality are adapted to the process and the
workplace and worn in such a way as to protect the product from contamination. Clean, sterilized and
protective garments are used where aseptic filtration and filling operations are undertaken.
Latex gloves are used and the footwear is cleaned daily.
Purified Water, Distilled Water and Water for Injection
Purified water prepared by de-mineralization is being used for hand washing in change rooms. This water is
tested to meet the microbiological specification of not more than 100 CFU per ml and should indicate the absence
of pathogenic micro-organisms in 100 ml.
13. SPECIFIC AREAS OF PATIENT CARE
INFECTION CONTROL IN THE DENTAL CLINIC
Prevention of cross infection

a. Contamination of the work area must be eliminated or reduced by measures such as the use of:
o Disposable plastic barriers over light handles, chair controls, three-way syringe handles and
plastic sleeves for the micromotor and change the same from patient to patient.
o Over gloves to handle material bottles, mixing slabs, patient records,etc,
o Cheatle forceps to pick up sterile instruments and gauze
o Sterile tweezers to pick up small sterile instruments
o Suction to reduce the aerosol formation and to avoid spitting, and
o Anti-retraction valve for air rotor handpieces
b. All procedures especially minor surgery and restorative procedures must be performed with the help of a
Dental Assistant who can manage the suction and also maintain aseptic technique.
c. Materials like a syringe for local anaesthesia, hypodermic needles, suture needles, and blades are
disposable.
d. Anaesthetic syringes should be discarded and not refilled from a vial.
Staff protection measures:

a. All staff working in the clinical areas must be immunized against Hepatitis B and records of
immunization status maintained.
b. Apron, gloves, masks, and goggles should be worn by staff during procedures. In the consultation room,
the clinical examination must be performed with sterile diagnostic instruments and gloves must be worn
for intraoral palpation.
c. Double gloving is mandatory for procedures requiring Inter Maxillary Fixation (IMF).
d. Utility gloves must be worn while cleaning instruments.
e. Staff must take care to avoid injury from sharps, wires, burs, reamers, files and pointed instruments like
the dental probe, periodontal curettes, etc.
f. At the end of a procedure, sharps should be disposed of into a `Sharps Container‟. Sharps should not be
returned with the instruments tray.
g. Handpieces and burs should be disconnected after use. Burs should be placed into the `Used Burs
Container‟ which contains 2% glutaraldehyde (Cidex).
h. Wipe with spirit – the chair surface, handles and spittoon area from patient to patient transfer
time.
Sterilization and disinfection of instruments:

A. Hot air oven (dry heat sterilization)
The following instruments required for each day are packed and sterilized as a batch with a cycle time of 1 hour
at a sterilization temperature of 160-degree centigrade in a hot air oven;
Extraction forceps and elevator, hand scalars, filling instruments (packed as a set), instruments trays and
tumblers, mouth mirror and dental probes, impression trays.
B. Autoclave (steam sterilization)

The autoclave sterilizes articles using high temperature and pressure. The cycle involves moist heat sterilization
with a pressure of 2.1 kg/cm2 with a working temperature of 134-degree centigrade for 15 minutes.
Materials and instruments for stream sterilization include;
Air rotor handpieces, ultrasonic inserts, root canal instruments, surgical towels, suture needles and material,
cotton rolls and gauze, rubber gloves, autoclavable plastic suction tips, and cautery handpiece.
C. Disinfectant solutions (Chemical sterilization)
The following materials are left immersed in Cidex for at least 30 minutes for disinfection or 8-10 hours for
sterilization; surgical burs, diamond air rotor burs.
Note: Watch for hypersensitivity reactions.
ACCIDENT AND EMERGENCY DEPARTMENT
Standard precautions are to be strictly adhered to and all patients are to be treated as potentially infected with
blood-borne pathogens. The importance of this cannot be overemphasized.
Wash hands with soap and water/alcohol based handrub before and after patient contact
Wear gloves, preferably for all patient contact. It is a must for all invasive procedures, however minor.
Examination gloves are placed in the shelves in all patient care areas. Remove and discard gloves in the
appropriate containers immediately after use
Protective eyewear for all the emergency service staff is available in the department. Use them whenever
body fluids spill is anticipated
Wear masks for all situations where a splash is expected, and where infection that spreads through the
respiratory route is a possible diagnosis
Wear a plastic apron, in addition to a mask if splash to the body area is expected
Use disposable needles and discard them into the sharps container, which is placed in all patient care
areas. Dispose ofstylets, scalpel blades and razor blades into the sharps containers, immediately after use
Used laryngoscope blades are soaked in 1% sodium hypochlorite for 30 minutes and washed in running
water
Ambu bag and mask contaminated with blood or body fluids are disinfected with 1% sodium
hypochlorite, washed, dried and gas-sterilized
Attenders and sweepers are to wear gloves while handling lab samples and performing janitorial work
Additional precautions for patients known to harbour bloodborne pathogens

Use plastic aprons during procedures where body fluids may spill
Disinfect all items following discharge, transfer or death of the patient (as per hospital protocol – refer to
the chapter on housekeeping). Mattress, pillow and rubber sheets are to be disinfected with 7% Lysol
solution and dried in sunlight
Infectious diseases
Refer to the chapter on Isolation Policies
Wound and Skin Infections

Hands are to be washed before and after handling the patient
Wear gloves while handling infected wounds
Cover the wounds (as far as possible) before transferring the patient
Dispose of waste as per hospital guidelines
Trauma
Use protective equipment such as gloves, mask, gown, apron, and goggles under appropriate situations
Burns
The patient is received on a stretcher with clean sheets and transferred to the Burns Unit
Housekeeping
The treatment rooms and trauma resuscitation room is cleaned with 7% lysol after every patient
Blood spills are disinfected by using 1% sodium hypochlorite solution freshly prepared, for a contact
time of 10-15 minutes
Equipment and instruments that are to be re-used are cleaned before sending them for sterilization
Discard medical waste as per the guidelines in the chapter on Hospital Waste Management
INTENSIVE CARE UNIT
Medical Intensive Care Unit (MICU)
Design of the unit
Medical ICU (MICU) and Medical HDU (MHDU) are the two units that come under medical critical care. The
Department consists of a professionally managed unit, equipped with a team of skilled and dedicated doctors and
paramedical staff. The highly competent medical specialists, nurses, critical care technicians and ancillary staff
provide holistic, compassionate and excellent care for the critically ill patients at the ICU. The ICU operates on
1:2 nurse to patient ratio, complemented by on-site registrars and senior-level medical consultants and critical
care therapists at all times to ensure continuous high-quality patient care.
The MICU provides care to a wide range of patients with complex and multi-system illnesses. The department
deals with patients suffering from critical conditions of the respiratory, kidney,liver and gastrointestinal systems.
The diseases oftheblood, cancer-related problems, blood infection, poisoning and medical problems in accidents
are also dealt with here. The critical conditions of patients suffering due to diabetes, hypertension, and heart
diseases are dealt with here.
The HDU monitors patients who are less sick as compared to ICU patients. These patients usually suffer from
single organ failure. The patients whose care is being scaled down from the MICU are also admitted into the
HDU. They are admitted from the wards when intensive monitoring is required, that the burden of the ward is
reduced. The 2 isolation rooms can also be used for patients who are being offered palliative care as well.
Beds and bed spacing:
There are a total of 24 beds under Medical Critical Care – 12 in MICU and 12 in MHDU
Isolation rooms
There are 2 isolation rooms each in both MICU and MHDU. Generally, patients who require “isolation ward”
admission eg: Open tuberculosis, anthrax, enteric fever, cholera, MRSA colonization or infection, colonization or
infection with other multi-drug resistant organisms and patients requiring reversed barrier nursing, e.g.
Neutropenicpatients, immunosuppressed patientsare admitted to this isolation room. Patients with tetanus or
infective hepatitis are not isolated in the ICU.
Spacing:
Space around and between beds should be adequate for placement and easy access to equipment and to patients.
The ideal recommended area for a bed in an open type ICU is 13.5 to 18 square meters per bed.
The Indian Society of Critical Care in 2010 put forth guidelines on ICU planning and designing in India and has
recommended that 9-11 square metres may be satisfactory based on feedback received from several ICUs across
the country.
Housekeeping and cleaning
Good housekeeping practices should be followed. This includes regular cleaning of all areas, maintenance, linen,
and curtain changes, etc. Clean floor at least four times a day.
Procedures to be followed by health care personnel
Strict hand washing or rubbing with the hand rub provided at each bedside has to be followed and is
compulsory before and after:
 Physical examination of the patient
 Handling the patient‟s respiratory equipment, infusion pumps, dressing, linen or bed, etc.
 Handling the patient chart, case notes
 After any procedure
Gloves – Disposable gloves must be worn:
 When direct contact with blood, body fluids, mucous membranes, open wounds or dressing is
anticipated.
 Prior to starting vascular access.
 Before any invasive procedure and
 When handling specimens, cultures or tissues gloves must be removed and disposed of
immediately
Facemasks and goggles must be worn before starting any invasive procedure to protect from splash into the
eyes, nose or mouth
Wear protective aprons before starting any invasive procedure
Handling needles and sharps:
 Never recap the needles
 Dispose used needles and sharps in the sharps containers immediately after the procedure
 The person who has done any procedure is responsible for the safe disposal of sharps and other
items used. This is NOT TO BE DELEGATED to others
Instruments such as stethoscope should be cleaned with an alcohol-based solution after use for a patient if
using the same instrument for multiple patients. Ideally, each bed space should have a stethoscope of its own
Avoid resting and leaning on beds, as you are likely to carry “bugs” from the bed space to another.
CENTRAL VENOUS LINE HANDLING FOR DRUGS AND BLOOD SAMPLING
1. All central lines should have Q - Syte bungs or extension line with needleless free valve connectors
Q Syte Direct drug

administration
and for blood
sampling
Extension For IV
line with infusions
needleless
free valve
connectors
2. Cleaning procedure (for both blood sampling and drug administration):

a. Hand hygiene procedures to be followed as recommended in the unit before handling the line
b. Wear sterile gloves
c. Scrub the hub (TWIST BACK AND FORTH) with alcohol swab for 30 seconds – completely air
dry for 30 seconds
3. Blood sampling technique:

a. Do not use the inotrope lumen for taking samples
b. Do not remove the Q syte bung for sampling
c. Aspirate 2 ml of blood from the lumen with a 2ml syringe (DO NOT USE THE NEEDLE). This
sample should be discarded.
d. Connect the syringe for blood sampling and take the necessary volume.
e. Flush the lumen with saline.
ARTERIAL LINE HANDLING FOR BLOOD SAMPLING
Things Needed: Sterile gloves, Alcohol swab, Blunt needeleless cannula, Syringe/vaccutainer adaptor
and vaccutainers to collect the sample.
STEPS TO BE FOLLOWED FOR THE PROCEDURE
1) Pause the alarms on the monitor
2) Hand hygiene with alcohol based hand rub and wear sterile gloves
3 4
Stop Cock Open Stop Cock
Sample Wipe sample

Collecting collecting port
4 with alcohol
Port
swab
Withdraw the blood in the reservoir syringe of the

arterial line system Close the 3 way stop cock and scrub the hub with
alcohol swab (TWIST BACK AND FORTH) of
sample collecting port for 30 secs-completely air dry
for 30 secs.
Blunt
needleless
cannula
Connect the blunt needleless cannula to the sample collecting port.

Connect the syringe for taking sample to the cannula and take the required sample.
6 7
Stop Cock to
be opened at
the end of
procedure
Vacutainer
connected to blunt
needleless cannula
Sample can also be taken by connecting vaccutainer to

the blunt needleless cannula
Flush back the reservoir syringe followed by flushing
the arterial line with saline
8) After the procedure, ensure that there is no residual blood/clots in the tubing and there is a good arterial
waveform on the monitor.
Sterilization and disinfection
Isolation rooms:
UV light adjusted to reach all parts of the room may be used for 30 minutes each before a new patient is admitted
in isolation room. This does not, however, replace any other measures of cleaning and disinfection. (Refer to the
section on housekeeping)
Disinfection of Ventilators and tubing
New ventilator tubings are used for every new admission to MICU. Ventilator tubings are changed only if there is
visible contamination.
The following items are gas sterilized:
Humidifier chambers
Bain‟s circuits
Ambu bags
Guide wires
Bone marrow needles
Instruments
Although disposable items are ideal, reusable items are often used, for reducing the cost. Separate
thermometers should be used for each patient.
Separate Ambu bag and mask should be used for each patient. This should be disinfected before use on
another patient. (Refer to the chapter on care of systems and indwelling devices).
Trolleys are to be adequately loaded and should be used for bedside procedures.
Quality assurance and audits:
Daily surveillance is conducted in the units by the staff of HICC who monitor HAIs. The infections that are
screened for include Ventilator-associated Pneumonia (VAP), Central line-associated Blood stream infection
(CLABSI) andCatheter-Associated Urinary tract infection (CAUTI). The microbiology results are obtained and
collated by the HICC and analyzed every month and feedback is given to the department. The department (ICU)
also conducts monthly audits of infections in their Quality Assurance meetings.
Handling of hemodialysis unit in the MICU:
Before filling the water tank in MICU, make sure that the lid is firmly closed and that the tank has been
disinfected within a month. There will be a layer of formalin at the bottom of the tank. Siphon the formalin out
and flush thoroughly with RO water. Check the formalin level in the effluent and when negative, fill the tank with
RO (Reserve Osmosis) water.
RO pipeline is kept on 24hrs circulation. Ensure that all valves are tightly closed.
Disinfection of the tank with formalin:
The tank needs to be filled with 4% formalin to dwell for 4-6hrs. The valves are then opened to flush and fill all
the lines. The formalin should dwell in them 4-6hrs. The system is then drained and flushed with water 2-3 times.
Microbiological Monitoring:
Swabs for culture are taken from common dust settling areas and air conditioners once a month. The RO water
used for dialysis is also subjected to Microbiological testing.
120
Surgical intensive care unit (SICU)
Any patient, with a communicable disease or infection or considered potentially infected should be placed in the
Isolation Section.
Patients requiring reverse barrier nursing to be placed in Isolation

Patients without any respiratory or overt wound infection are transferred directly from recovery room to
the clean area.
All personnel working in the area must be free from respiratory and any overt wound infection. Standard
Precautions must be followed (Refer to the chapter on prevention of transmission of bloodborne
pathogens).
All personnel working in ICU are expected to change into the clothes and put on the slippers provided in
the changing room, before entering the patient care area.
A separate apron is to be used every time a HCW goes to another patient for interventions.
All visitors (medical and non-medical) are expected to remove their footwear or wear overshoes and wear
a gown over their street clothes before entering the ICU.
The entry of other personnel (Laundry, Dietary, CSSD, Stores) is not allowed. They are to use entry
points provided at different places for supplying and receiving goods.
ICU personnel and other members of the caring team should wash their hands with either soap or a
disinfectant after all patient contact.
Aseptic Precautions are to be followed for all techniques (Refer to the chapters on Techniques & Care of
Systems and indwelling devices)
Housekeeping: Refer to the section on housekeeping. The floor should be cleaned at least 4 times in 24
hours.
a. Entry:
Patients: Enter and exit through the designated door. Trolley wheels to be cleaned before entering
Personnel and relatives: Should
o Use designated areas through changing rooms
o Use slippers or overshoes
o Not enter with street shoes
o Use alcohol-based hand rub as you enter the unit
o Not enter if suffering from an active respiratory infection
Number: Maximum of two doctors per treating the unit
One relative at a time
b. In the Unit:
Do not wear sleeve dresses. Please roll up your sleeves
Do not wear nail polish
Do not touch the patient or anything on bedside unnecessarily
Avoid direct contact with the patient at all times
Do not use personal stethoscopes
Do not leave personal diaries, notes, bags, purses, stationery, mobiles, etc. on the patient unit
Follow standard hand hygiene procedures – use of alcohol-based hand rub or soap and water as
appropriate before and after contact with a patient or anything on the bedside
Use disposable aprons and during dressing changes or close examination of patients and dispose of
them in the appropriate bins
After dressing changes, please ensure proper disposal of dirty dressings
Do not use scrub clothes to keep warm
Ensure long hair is properly pinned
Do not enter ICU with flowers, bags, etc.
Wear apron before touching the patient
Use hand rub before touching patient, after touching the patient, before touching bedside equipment,
after touching bedside equipment, before & after touching stationary.
House Keeping: Please refer to the section on House Keeping.
Prescription of Antibiotics: In general, the decision should be based on discussion with a senior doctor
in the ICU.
c. Isolation Side (Surgical ICU):
Patients are admitted when they have;
Communicable disease eg: HIV, Hepatitis B, etc. Other conditions needing isolation are Clostridium
difficle, Infective diarrhoea. Treating unit should inform of such conditions before transfer.
Immunocompromised patients or patients on immunosuppressants.
Patients suspecting or diagnosed to be infected with multidrug or extremely drug-resistant organisms.
Enteric diseases with perforation
Gas gangrene
Septic abortion
Polytrauma e.g. Following road traffic accident or treated outside
Obstetric patients with complications, if delivered or operated outside CMC
Patients sent into isolation are received through a separate door. When possible, one nurse is assigned to
care for each patient in the isolation section. Entry into the isolation room should be restricted.
SURGICAL PROCEDURES
Standard precautions are to be followed for all patients and all procedures.
Testing for HBV, HCV, and HIV are not to be considered completely protective, the reasons being:
o Tests cannot detect 100% of infections due to HBV, HCV, and HIV
o There are other pathogens besides HBV, HCV, and HIV that can be transmitted through blood
and body fluid contact. Hence, all patients must be considered as potentially infectious and
preventive measures taken
Though routine preoperative testing is not mandatory, testing may be done in selected procedures with a
high risk of percutaneous injury, especially where procedures may need to be modified, or personnel
performing/assisting the surgery may need to be changed, based on the result. In such cases, the patient
should be checked for HBV, HCV, and HIV. Each surgical specialty should make a list of procedures
where routine testing is not warranted and also a list of procedures where testing may not be beneficial
The patient should be informed when testing for HIV is done and appropriate consent must be obtained.
Patients testing positive should be informed of the result by the surgeon before surgery. The patient is
then sent for counselling to the infectious diseases clinic
No patient will be denied appropriate care if they test positive for any bloodborne pathogen
Hepatitis B vaccination is mandatory for all staff coming into contact with blood or body fluids
Gloves should be worn for all invasive procedures done on patients (including venipuncture and starting
intravenous lines). Gloves should be changed BETWEEN procedures. Gloves should not be used to
handle any equipment. Healthcare workers should not leave the operating room with gloved hands.
Gloves are to be used to sort soiled linen.
Examination gloves are sufficient for:
o Starting intravenous lines
o Intubation
o Sorting out used linen or other unsterile items
Sterile gloves are to be used only for surgical procedures.
Plastic aprons, which are to be worn inside the sterile gowns, are recommended for the surgical team.
They are mandatory in areas where a splash is expected. These are to be removed before leaving the
operating room
Disposable surgical masks are to be worn, covering the nose and lower part of the face completely
Goggles or other eye protection are recommended where there is a risk of splash
Protection for the feet (sole and dorsum) is recommended with appropriate footwear ensuring the entire
foot is covered
All invasive procedures however minor should be carried out with utmost care to prevent injury with
sharps
o Hand to hand passing of sharps during operations should be avoided
o Utmost care should be taken to ensure safe disposal of sharps
o The OR supervisor ensures that appropriate containers for sharps disposal are available in all the
operating rooms. Smaller sharps disposal containers are present on all anesthesia trolleys
Healthcare workers with any open wounds or weeping skin lesions should refrain from activities which
may result in exposure to blood or infectious body fluids
Healthcare workers with blood or body fluids on their clothing should change before they use the staff
lounge or before scrubbing for the next case.
Care of the environment
The operating team should take absolute care regarding disposal of blood stained items. All swabs,
sponges, etc should be discarded / placed only in the assigned containers / areas
Gloves should be discarded directly into the bin lined by appropriate cover
Used instruments should be carefully segregated
Used linen should be collected directly in an assigned bin are immediately after the surgery, fastened
carefully and removed from the operating room
If blood or fluid spill is expected, appropriate measures are to be taken before beginning the operation.
For example, small plastic containers for small spills (Neurosurgery) and buckets to collect draining
fluids (Urology) are necessary. Each specialty should have a written protocol
Protection for furniture and equipment:
o A plastic cover should be used for tables, armboards, etc and should be mopped clean with
appropriate antiseptic solution as per individual hospital protocol
o Equipment should not be handled with gloves that have been used for invasive procedures
Waste segregation should be in accordance with the guidelines given in the chapter „Hospital
Waste
Management‟.
Cleaning theatres after a case
Minor spills of blood or infectious body fluid are to be disinfected by pouring 1% sodium hypochlorite
(Dakin‟s solution) over the spill and leaving it for 10-15 minutes. The area of the spill should be cleaned
with soap and water. The OR supervisor keeps a stock of sodium hypochlorite available for use in
emergencies
For major spills, disinfect as above, and clean the whole room with soap and water
At the end of the day, thorough cleaning of the floor with soap and water is necessary.
Microbiological monitoring
Swabs are taken for cultures every month from all areas, where dust settles e.g. Air conditioners,
operating tables, monitors and lights.
123
Service corridor
The service corridor runs around the back of the theatre complex and is connected to all operating rooms.
Theatre waste, linen and other dirty material leave the theatre room through this route. This corridor leads
to the TSSU (Theatre Sterile Supplies Unit). It is important that asepsis is maintained in this area as well.
Staff using this corridor should wear theatre attire only. They should not come into the main operating
room. The door connecting the service corridor and the main OR should be kept shut at all times when
disposing items from the theatre. Exhaust fans in the dirty corridor are kept working throughout the day.
Septic cases in the operating room
A separate operating room is used for „septic cases‟. The following cases are considered septic:
o Situations where frank pus is present
o Cases for debridement
This theatre has the facility for being sealed air-tight for fogging. If the septic OR is closed for some
reason, septic cases will be taken up at the end of the regular list in the main OR.
Additional steps to be taken in this area are;
o Minimal use of equipment
o Remove all items from the OR which cannot be properly sterilized or disinfected and those
which are not likely to be used
o Cover the bed and armrest with plastic/disposable sheets, which will be discarded after the
operation
o Keep sufficient containers for collecting used items
o Post one person to wait outside the OR, to obtain additional equipment, supplies and help
o At the end of the operation, the scrub nurse stays in the OR without removing gloves and makes
sure of the appropriate and careful disposal of the used items.
OBSTETRICS AND LABOUR ROOM
Policies regarding admission of pregnant women with the
infection Pregnant women suffering from infections requiring
isolation:
Not in labour: Admit in medical wards/isolation ward, just as one would admit a non-pregnant woman
with a similar illness.
In labour: Admit to isolation side in the labour room.
Note: If isolation beds on this side are occupied and another infectious patient comes, the patient with the
least infectious condition should be shifted to a corner bed in the clean side and be isolated from other
patients
Indications for admission to isolation side in labour room

Pregnant women with at least 22 weeks of gestation and in labour with:
o Hepatitis (A, E or unknown)
o Diarrhoea (severe, watery, with blood and mucus)
o Known infection with a bloodborne pathogen (HBV, HCV & HIV)
o Suspected or confirmed communicable disease requiring isolation
Indications for admission to G4 East procedure room

Women with pregnancies less than 22 weeks, but in labour
Patients who needs check curettage &colpocentesis
Septic abortion (most of the patients with septic abortion are admitted in SICU)
Indications for admission to G4 East ward septic side
Puerperal sepsis and postpartum fever
Pregnant women requiring isolation (temporary admission till arrangements is made in isolation ward)
Severe infection following gynaecological surgery
If there are no patients with the above conditions, other patients are admitted to this side when there is a
lack of space in the general side
Labour room
Housekeeping has to be meticulous.

o Clean the floor at least four times in 24 hours. One of these should be with detergent and copious
amounts of water. Lysol may be used to mop the floor for the remaining times.
o Any spill of blood or fluids should be immediately decontaminated with 1% sodium hypochlorite
solution for 10-15 minutes, mopped dry and then cleaned thoroughly with detergent and water.
o Environment and equipment should be maintained dust free.
o Strip the bed and wipe clean with detergent and water after each patient and then once more with 7%
Lysol. Wear gloves for this procedure.
o Use fresh linen for each patient.
Personnel
o Follow standard precautions with absolute care.
o Sterile gloves, gown, plastic apron, goggles, mask and impervious footwear (covering dorsum and
sole) are recommended while conducting delivery and any other procedure where spill/ splash is
expected.
o Wear gloves, mask and plastic apron for performing a vaginal examination and preparing parts.
o Anyone with open wounds or exudative skin lesions should not be involved in invasive procedures.
o Wash hands before and after each procedure and between patients (refer to the section on hand
washing under the chapter „Techniques‟).
o Hand rubs should be available at the bedside, entry to the labour room at both sides.
Procedures
In addition to Precaution mentioned above, the following are required for specific procedures.Pads are
recommended for hygienic collection of secretions and discharge.
Vaginal examination and ARM

Put a clean sheet under the patient.
Introduce electrodes, ARM clamps, etc., without damaging maternal tissue and without contaminating by
touching the outside environment. Do not use scalp electrodes if the mother is HIV positive.
Delivery
Conduct delivery in the middle of the cot, to minimize spill onto the floor.
Spread a rubber Mackintosh under the patient and covering the edge of the cot.
Keep a broader bucket under the cot, to minimize direct contamination of the floor.
Clean and drape patient. Make sure the end of the sheet leads into the bucket placed under the cot, for
collection of blood and amniotic fluid.
Take care to minimize splash and spillage onto the floor.
Perform episiotomies only when indicated taking care to avoid injury to the fingers.
The person receiving the newborn should wear a gown and gloves. Receive the baby using a clean sheet.
The placenta should be collected into the assigned bowl.
Discard potentially infectious solid waste into the bucket lined with a yellow bag.
Sharps should be discarded by the healthcare worker who is conducting delivery immediately after
delivery
Care of the newborn

Follow standard precautions (use gloves, plastic apron or gowns).
Well Baby is received in the mother side in the baby receiving cradle.
Wipe vaginal secretions and discard along with the infectious waste.
Resuscitation of sick babies is to be done in the specially designated area.
Refer to the section on Nursery given in this chapter.
Disinfection/sterilization
Rubber tubing, metal cups, forceps, etc.are soaked in 1% sodium hypochlorite (Dakin‟s) for 30 min, washed in
running water and sent to CSSD for autoclaving
Waste disposal
This should be in accordance with the hospital rules.
The placenta should be put into a yellow bag, labelled as anatomical waste and sent to the temporary
storage area.
Disposable linen which is contaminated must be discarded into the bin lined with a yellow bag.
Patients known to be infected with a blood borne pathogen

These patients are admitted in a specially assigned area in the labour room.
Follow instructions as for similarly infected persons in other areas.
Since HIV and HBV status can influence the management of individual cases with a view to minimize
transmission to the infant, counselling and voluntary testing should be offered to all pregnant women.
NURSERY
Personnel:
Personnel assigned to the nursery should not be posted in other areas of the hospital.
Annual screening at the SSHS is mandatory.
Personnel should be fully immunized. Rubella vaccination and varicella vaccination is recommended.
Personnel with upper respiratory tract infections, gastrointestinal tract infections, fever, open skin lesions
or any suspected infection should not be permitted to work in nurseries during their period of illness.
Preferably only those immune to chicken pox (had a history of chicken pox or vaccine) should be posted
in the nursery. Non-immune roommates of personnel with chicken pox should not work in the nursery.
Attire:
Short-sleeved garments are advised to encourage hand washing.

Gowns are not necessary to enter nurseries
Gowns with long sleeves should be worn when caring for infants requiring isolation.
Sterile long sleeved gowns are required by all personnel involved in surgical procedures.
Standard precautions must strictly be adhered to when handling blood and body fluids.
Hand Washing:
Nursery personnel should wash hands and forearms with Chlorhexidine /alcohol or antiseptic solutions
for 90 seconds in the following times:
o When entering the nursery
o When leaving the nursery
o Before and after touching the baby
o After touching any equipment associated with the baby
o Before sterile procedures
o After handling body fluids.
Chlorhexidine/alcohol hand rub may be used for 20 – 30 seconds between examining babies, before
handling a computer, telephone, etc.
Mothers who come into the nursery to handle or feed their babies should have bathed and changed that
day. They should follow the same protocol of hand hygiene as for the nursery personnel
Equipment:
Incubators and Ventilators: Incubators and isolettes should be washed & decontaminated with an
approved disinfectant between occupancies.
The water in the humidifier is to be changed every day.
Change of tubing every 72 hours or routinely is not recommended.
The air filter in the incubator is to be changed every three months.
Cleaning:
Refer to the section on housekeeping. The following additional points are to be noted:
A disposable cover gown is to be used while cleaning the nursery.
Nursery floor is cleaned 5 times a day with 7% Lysol.
Cradles are to be cleaned every day with soap and water.
Cradles should be cleaned between babies with 7% Lysol.
Mattresses should be exposed to the sun every week for six hours, biweekly if possible.
Wash sinks during each shift.
Clean milk fridge every day. Clean other fridges weekly and discard old medicines, blood samples CSF
bottles.
Humidifier bottles and water and tubing need to be changed every day, even if not used. The bottle,
water, and tubing should be changed again if oxygen is discontinued on one patient and a new patient is
brought to the same point.
Oxygen hoods are to be cleaned with 7% Lysol every day and between babies.
The suction apparatus jar should be cleaned every day with a change of the disinfectant fluid and the
tubing.
Linen and Infant‟s clothing:
Linen for use in the newborn nursery should be free of laundry chemicals that may cause toxic effects
and skin irritation.
New linen should be laundered before initial use.
Soiled linen should be handled with standard precautions to avoid contamination.
Diapers should be freshly laundered. Soiled diapers should be placed in covered containers lined with a
yellow plastic bag and preferably having a step-on lever.
Skin, Cord and Eyecare:
Cleaning and bathing of the skin in the delivery room should be delayed until the newborn's temperature
is stable (after 24 hours).
After initial observation and stabilization, meconium and blood may be wiped off with a sterile cloth.
127
The skin should then be carefully dried to minimize heat loss.
127
Newborn can be bathed with plain water or mild soap only as necessary to clean the diaper area. Except
for cleaning and bathing as needed with water alone or a mild soap, the skin and cord may be kept dry for
the rest of the hospital stay. This reduces heat loss and skin trauma and avoids exposure to topical agents
with possible adverse effects.
The cord needs to be kept clean and dry. Application of antiseptics like acriflavine/betadine etc. is no
longer recommended.
Eyes can be cleaned with sterile water.
IV Infusions:
IV fluid infusion bottles, burette sets, syringes, and IV tubing should be changed simultaneously at least
once every 24 hours.
Minimize breaking into central lines often since this will increase the chances of infection. Plan all fluids
and additives and medications together so that all can be connected at the same time.
Bacterial filters are used especially when using central lines.
Addition of heparin to solutions transfused through central lines has been proven to reduce the incidence
of the line associated infection. (0.5U heparin /ml of fluid infused).
Sterile needles used as airways from bottles should be removed immediately after pouring out the
required quantity of fluid.
When IV fluids are disconnected for any length of time, cap the tip of the tubing with a sterile needle/
cap.
Parenteral fluid bottles, vials, and ampoules should be used only once. Any remaining solution should be
discarded immediately.
IV cannula should be changed every 72 hours.
Splints used to restrain the limb should be clean and dry at all times.
Specialized Nurseries:
A. Neonatal Intensive Care Unit / Level III Nursery:
Newborn who are very preterm/very low birth weight (<1500g), who have severe respiratory distress, birth
asphyxia, surgical problems, fulminant sepsis, and are extremely ill need to be admitted to the intensive care
facility. Neonatal ICUs are often crowded with equipment and patients. Strict adherence to meticulous hand
washing must be observed. Outbreaks are frequently associated with overcrowding, inadequate staff and lack of
hand washing with an approved germicidal solution. The recommended staff ratio is one registered nurse for
every one or two patients in level III nurseries and 150 sq. Ft of floor space per cradle.
B. Special care nursery / Level II Nursery:
Babies improving after intensive care and other infants requiring close monitoring such as growing preterm, post
OP stable babies, babies requiring monitoring of respiration, sugar, jaundice, etc., are considered for admission to
the special care nursery. The recommended ratio is one nurse for every three or four infants in level II nurseries
and one nurse for every 6 babies in level I nurseries. The corresponding floor space is 30 sq. Ft per cot in level II
facilities and 25. Sqft in level I nurseries. Visitors to the intensive and special care nurseries are limited to the
parents of the infant.
C. Isolation Area: An isolation area should be available in the special care nursery after the diagnosis of an
infectious disease is made in the mother or neonate. Infectious diseases in the mother or neonate requiring
isolation precautions include:
Varicella
Congenital rubella
Herpes simplex
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Neonatal gastroenteritis
Widespread staphylococcal disease
Infection control practices to be followed for babies for chicken pox:
Baby should be kept in isolation room and visitors should not be allowed.
Keep the door closed
Mask and gown must be worn while giving care to the baby
Gloves must be worn if the baby has vesicles
Babies with chicken pox should be taken care of by staff with evidence of immunity
Staff who are pregnant or are lactating should not be assigned to care of these babies
All utensils such as ounce glass and paladai should be soaked in 7% Lysol and then washed
Linen must be soaked in 1% sodium hypochlorite (Dakin‟s) for 30 min, then, with minimal handling sent
to the laundry
Follow standard precautions plus airborne and contact precautions until the lesion is dry and crusted
Infection control practices to be followed for babies diagnosed to have infections with multidrug-resistant
pathogens:
Admit babies to a single room or multi-bedded room (if they have the same illness). The door may be left
open
Healthcare personnel must wear non- sterile examination gloves when examining or giving care to the
patients
Change gloves after contact with infectious material (eg. faeces or wound drainage)
Remove gloves before leaving the patient room
Patient care equipment: Remove non-critical patient care equipment for use with a single patient
whenever possible
Use disposable items whenever possible
Infection Control practices to be followed for babies born to mothers with H1N1 influenza:
The newborn need NOT BE treated as infected. There is no need to isolate the baby
The CDC recommends that the newborn should be temporarily be separated from the mother to reduce
the risk of influenza transmission
o Separation should continue until all of the following were met:
 The mother had received antiviral treatment for >48 hours
 The mother was afebrile without antipyretics for >24 hours, and
 The mother was able to control her cough and respiratory secretion
However, the mother should practice droplet precautions until 7 days after the onset of symptoms or until
24 hours after the fever and respiratory symptoms settle even if the baby is transferred to her
If the baby has to stay with the mother, ideally the baby should be kept > 6 feet away from the mother
and a healthy adult can care for the baby. If the mother wants to feed the baby, she has to wear a face
mask and practice hand hygiene each time she comes in contact with the baby
The WHO advises that the baby should NOT be separated from the mother and should be breastfed.
There is no need for testing the newborn for H1N1 unless the baby is symptomatic
If the baby is symptomatic, the WHO recommends the use of oseltamivir 3mg/kg/day in a single dose if
baby <14 days old and 3mg/kg/day in two doses if baby >14 days
Cleaning procedure for isolation room or bed:
Linen should be stripped from the bed with care taken not to shake the linen during this action. Linen should be
soaked for 30 min in 1% Sodium hypochlorite solution and then sent to the laundry. All other articles like I.V
stand and furniture should be thoroughly cleaned with detergent and disinfected with 7% Lysol. Walls should be
thoroughly cleaned and disinfected with 7% Lysol.
INFECTION CONTROL IN OPHTHALMOLOGY
Introduction
The minor lid and ocular surface infections are common. While they do have significant morbidity in the short
term, and long term sequelae are known, they are generally easy to treat. On the other hand, corneal and
intraocular infections, endogenous or exogenously introduced during surgical procedures, can be a disaster. In
other specialties, the sequelae of post-operative infection may be only an ugly scar. However, infection following
intraocular surgery generally results in loss of vision, and even loss of the globe, adding cosmetic insult to serious
functional injury. Virulent pathogens causing corneal infections can be introduced into the eyes by careless
examination techniques or contaminated eye drops. Further, Hepatitis-B and AIDS viruses have been identified in
lacrimal secretions, suggesting that tears may be a potential route of transmission of these serious systemic
illness. A strict protocol of prophylaxis against transmission of infection in clinical ophthalmic practice is
therefore imperative. At the same time, it must be practical enough to involve as little expenditure of time and
resources as possible.
Infection control in the Outpatient Department
i. Hand-washing
This simple step may prevent an epidemic of conjunctivitis or keratoconjunctivitis and should not be omitted.
While a sink and soap is ideal for every examination room, it is usually convenient to have a bowl of the
disinfectant solution and towel handy and to wash and wipe hands between patients. An alcohol hand rub is also
effective in preventing the spread of infections. It should be emphasized that to be effective, hand cleaning must
be incorporated as a mandatory step in the clinical routine after examining every patient. A bowl of disinfectant
and a towel is provided in every room. Disposable napkins are ideal, but cost constraints and environmental
considerations limit their use.
ii. Examination Technique (Lid Eversion etc.)
The examination technique should be designed to permit as little contact between secretion and examiner as
possible. Specifically, the routine eversion of the lids practiced by all ophthalmologists should ideally be
performed using Q-tips (“kutchi”, cotton buds). In this situation too, hand washing is important.
iii. Tonometer and Instrument sterilization
All ophthalmic patients have their intraocular pressure (IOP) measured. The tonometer or tonometer tips are
potential sources of transmission of infection between patients. Applanation prisms are disinfected by immersing
them for 5-10 minutes in 5 parts per million of sodium hypochlorite (Dakin‟s) solution. It is convenient to have at
least two prisms for each tonometer to facilitate patient flow. Schiotztonometers are disinfected by immersing the
footplate in the same solution for 5 minutes. In order to prevent chemical injury to the cornea, these instruments
are rinsed in sterile saline before use. Fluorescein is used in the form of single dose applicators to reduce the risk
of infection due to contamination of the bottles of fluorescein drops.
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Eyelid retractors, epilation and other forceps, etc., are re-sterilized by boiling, autoclaving or any preferred
technique after each use. Where there is a shortage of instruments, immersion for 3-5 minutes in acetone is an
acceptable alternative.
iv. Eye drop Instillation
Ophthalmologists routinely dilate their patient‟s pupils for a complete eye examination. This is done either by the
Ophthalmologist in the consultation room, or in a common area where patients have their pupils dilated by a
nurse/technician. This is a potential area for the transmission of infection through contamination of dropper tips.
It is impractical to have a bottle of dilating drops for each patient, and the technique of eye drop instillation is
important in preventing the spread of infection. The bottle is held between the fingers of the right hand, and the
protective cover removed. The patient is asked to look up, and the lower eyelid pulled away from the globe to
expose the lower fornix as a “pouch”. The eye drop is instilled into this pouch, taking care to avoid any contact
between the dropper tip and the patient‟s tissue (lid, conjunctiva, and lashes) or secretions. The cap is replaced on
the bottle to avoid any airborne contaminants. The eye drop bottles should be freshly opened for each day‟s use.
Infection Control in the Ward
i. Examination Technique
The principle of hand-washing between patients must be adhered in the ward also. This is especially important
when dealing with post-operative patients. The examination unit in the ward is the dressing trolley, which
incorporates a bowl of disinfectant and a towel. Sterile swab sticks are used to clean the lids and avoid
contamination of the hands. It is usual for the nursing staff to open the bandage and perform the external
cleaning of the eye. The rounds in the septic wards (patients with corneal ulcers / other infections) are done by
another team of doctors, using a separate trolley and flashlight. Alternatively, this ward is dealt with at the end of
the rounds. The ward slit lamp is used for “dirty” cases only at the end of the rounds and is cleaned with a
disinfectant solution immediately after.
ii. “Dedicated” Eye Drops
Each patient in the ward has his / her own set of eye drops kept by the bedside. This concept prevents any spread
of infection that may arise through sharing of eye drops (much like sharing of needles). Routine precautions for
prevention of contamination of dropper tips must be maintained. Patients‟ relatives are trained to instill eye drops
for their wards, as this may prevent cross-contamination through the medical personnel involved. Each bottle
must be freshly opened and used for no longer than 7 days. Fresh supplies must be prescribed for use after
surgery. Single application packs, eye drops, and ointments are preferred when the risk of infection is high in the
OR. However, this may not be practical in certain settings.
iii. Isolation Wards
The septic ward is physically removed from the “clean” wards, housing routine pre-and post-operative patients,
and their trolleys and instruments are separately maintained. While it may be impractical to use separate staffing
for these wards, the doctors at least are posted exclusively to these wards. As mentioned, the ward rounds are
done last.
Infection control in the operating room
i. Cleaning procedure (Microscope)
The microscope is an important instrument for any ophthalmologist and its cleaning is often neglected. Many
surgeons sterilize the microscope using formalin powder. The entire microscope is covered in a plastic cover,
with formalin powder enclosed. The formalin, however, is not good for the electronic components of
microscopes, and can also damage the optics. The microscope is routinely wiped with hydrogen peroxide
(microzid, ecoshield etc.) solution. The optics are cleaned with antistatic cloth. Sterile handles are used to
manipulate the microscope and adjust the inter-pupillary distance. Draping the microscope reduces the chances of
accidental touch with while passing instruments/pulling sutures.
ii. Clean Air
In the past cataract surgery consisted of removing the lens in its entirety, and then suturing the incision. However,
modern day cataract surgery entails making a small opening in the lens capsule, meticulously removing all
cortical matter and then implantation of an intraocular lens. Hence the eye is kept open for much longer than in
the past. This makes it imperative to have as clean an atmosphere as possible in the O.R. An air module on the
wall blows in air filtered through 0.3-micron filters. The air conditioning is provided by appropriate split units
which cool and re-circulate filtered air. The O.R. is under positive pressure, and this prevents contamination from
occurring when doors are opened to transfer patients, etc.
iii. Pre-operative and intra-operative care
All cases are cleaned with a povidone-iodine solution before and after the cataract surgery helps in sterilizing the
conjunctival sac. Intraocular implants (intraocular lenses, glaucoma implants, etc.) Are also handled only with
instruments. The intraocular lens is inserted with minimal contact with ocular surfaces (lids and conjunctiva or
surgical drapes. Some surgeons use a plastic glide to avoid contact with conjunctiva and thereby prevent potential
contamination with commensals (eg. Propionibacterium spp.)That have been shown to cause infections. Contact
between instruments, intraocular lenses, sutures etc. And eyebrows/eyelashes is minimized by appropriate
draping using steridrapes (Plastic drapes that cover the brow and lashes). Pre-operative and post-operative
antibiotic installation is also done.
iv. Instrument Sterilization
In addition to the standard techniques used, ethylene oxide sterilization is frequently used in Ophthalmology. It is
advisable to use chemical sterilization with care since residual chemicals in irrigating cannulas and instruments
can lead to corneal decompensation.
v. No-touch Technique
This is the single most important method to prevent surgically acquired infections in Ophthalmology. No part of
any instrument especially the tips or suture that will enter the ocular tissues of spaces is touched by hand, gloved
or otherwise. This means that sutures are always handled and tied using only instruments.
vi. Tissue transplantation
Corneal transplantation is a major, yet common surgical procedure in Ophthalmology. The possibility of
transmitting infections through the donor cornea is real. Cases of rabies transmitted through the donor corneas
have been reported, and the use of material from eye donors known to have transmittable infections such as
rabies, hepatitis B/C and HIV is absolutely contraindicated. Screening of HIV and HBV is done from the blood
collected by cardiac puncture.
vii. Microbiological monitoring
This is conducted once a month. Air sampler with culture plates are kept in the theatres, swabs are taken from
common dust settling areas and anaesthetic apparatus. Fluids that are used in Ophthalmology, such as atropine
and other eye drops are also subjected to microbiological analysis/ in addition to cultures for bacteria, cultures for
fungi are also performed.
Prevention of hospital-acquired infections is important in all fields of medicine, but in Ophthalmology, even a
“minor” intraocular infection could be disastrous.
ENT DEPARTMENT
Routine precautions for all patients

Wear a mask while examining all patients
Use gloves when the intra-oral examination is required
Instruments are disposed into a basin containing 7% Lysol. They are then sterilized by autoclaving at 15
pounds pressure for 15 minutes.
Additional precautions for a patient known to harbour blood borne pathogens

Wear double gloves and a plastic apron for all procedures
After use, instruments are segregated in a red bag and sent for double-autoclaving
RADIOLOGY
The various interventional procedures carried out in the Radiology department are:
i. Vascular and non-vascular intervention
ii. Ultrasound-guided biopsies and drainage procedures
iii. CT guided biopsies and drainage procedures
iv. Other procedures such as Myelograms, Sinusograms, Sialograms etc.
For all these procedures

Use sterile equipment and aseptic technique
Observe standard precautions
All staff should be immunized against hepatitis B
No one with open sores, cuts or nicks takes part in the procedure
Meticulous housekeeping is very important (Refer to the chapter „Housekeeping‟)
Vascular and non-vascular intervention

The people performing and assisting scrub and wear sterile gowns, cap, mas, and gloves. The part is prepared
prior to the procedure, where necessary (eg. Groin). The part of the body where intervention is to be carried out is
painted with povidone-iodine and draped with sterile towels. Any part of the x-ray machine, which may come
into contact with the patient or the examiner, is also draped with sterile towels.
Ultrasound and CT guided biopsies

The person doing the procedure washes up and wears sterile gloves. The part to be biopsied is painted with
povidone-iodine and draped with sterile towels. For ultrasound-guided procedures, a sterile cover is placed
around the probe.
IVU and contrast CT
A disposable scalp vein set is used for the venipuncture and contrast is given. The syringes used for pressure
injection are disposable.
MCU
The perineum is prepared prior to the procedure. The perineum is painted with povidone-iodine and
benzalkonium HCL solution and draped with a sterile surgical towel. Sterile equipment is used for the
catheterization procedure.
Sterilization
The catheters, guidewires, needles, vessel dilators and needles used in interventional and guided
procedures are flushed with hydrogen peroxide and tap water, then disinfected in 2% glutaraldehyde for 6
hours, followed by flushing with tap water and drying with compressed air. They are then dried and
packed in butter-paper covers and sent to CSSD for gas sterilization.
All metal instruments used eg. Clamps, trays, bowls are washed, cleaned, packed and sent for autoclaving
twice a day.
Infectious/Isolation ward patient

If any patient is identified as infectious prior to the procedure, cases are adjusted such that the waiting
time and transit time of this patient is minimal and the spread of infection is minimal. The procedure is
done preferably at the end of a session.
As far as possible, disposable equipment is used. All re-usable material is collected in a red bag and sent
to CSSD and double autoclaved.
The room is mopped with 7% Lysol solution and machine parts are cleaned with Dakin‟s.
HIV/HCV/HBV positive patients

Re-usable materials are separated and put in a red bag and sent for double autoclaving. Following this,
the materials are washed, re-packed and sent for regular autoclaving.
Fogging
Fogging of the rooms is carried out regularly (using Dynafog) in the DSA suite, before chemoport/
Hickmann catheter insertion for patients on chemotherapy
Waste disposal
After all procedures, waste is discarded as per hospital guidelines are given in the chapter on Hospital
waste management.
PHYSICAL MEDICINE & REHABILITATION (PMR)
In the Department of P.M.R the following techniques are used to prevent infections from occurring and
spreading. It is advised that every member of staff assumes that every patient is potentially a carrier of
bloodborne pathogens and that every care is taken to protect herself/himself and to prevent cross infections using
standard precautions.
Outpatients:
Wash hands after examination of each patient
Practice no-touch technique for dressings and simple OP procedures such as local instillation of drugs
with disposable syringe and needle, suture removal with autoclaved packs
Autoclave/gas sterilization of electromyography accessories
In patients:
Wash hands after examination of each patient – preferably alcohol with moisturizer wash solution in a
dispensing unit which is to be pressed with the back of the hand. This is emphasized for both staff and
patient‟s caregiver
Daily dressing of wounds with saline wet to dry dressings without using topical antibiotics/antiseptics so
as to prevent colonization with drug-resistant bacteria
No touch technique is to be followed for daily dressings. Use gloves for dressings and when debriding
wounds etc.
Use antibiotics appropriately when the need arises. For antibiotic usage policy, refer to the Microbiology
guidelines. Special sensitivity will be routinely done for all PMR cultures.
Identify & isolate patients with MRSA, CRO, multiresistantPseudomonas, ESBL GNB and infectious
diseases. (refer to the chapter „Isolation policies and procedures‟)
Change bedding twice weekly or more often if grossly contaminated. Bedside curtains, steel file cover for
patients‟ records in the ward to be cleaned as per schedule
Specific cleaning methods are advised for PMR type of mattress (block mattress, ripple mattress, water
mattress, split mattress, etc.)
Use sterile LP packs/catheter pack/blood culture set when procedures are done
Digital evacuation (with or without suppository) at a fixed time will be done daily for all those with
neuropathic bowel to avoid unexpected faecal contamination of wounds or catheter.
Catheter care
The following methods are recommended for patients requiring continuous bladder drainage. (Refer to
the chapter‟ Care of systems and indwelling devices‟)
Weekly change of urinary catheter by using strict aseptic technique, special catheter packs, non-traumatic
techniques and as far as possible ensuring not to break the seal between the bag and the catheter (a fixed
day in the week for catheter changes (from 2007, catheter changing day is on Wednesday mornings) is
practiced to avoid confusion)
Clamping of the catheter before urine culture collection is discouraged. For collection of urine for
cultures, one of the following techniques is used:
o Suprapubic aspiration
o Clean puncture of the catheter after cleaning with Betadine solution
o Fresh sterile catheter is inserted per urethra to collect urine for culture
Silicon catheters are changed once a month
Every care should be taken not to lift the bag above the level of the catheter at any time
In the later part of the rehabilitation programme, the patient is weaned off the catheter and intermittent
catheterization (ICC) technique is taught to the patient or to the patient‟s relative if he/she is unable to do
it.
Tracheostomy management protocols

For prevention of aspiration pneumonia;
Gauze dressing between skin and tube
Always keep the inner tube locked in place. During cleaning, keep a clean container close to the patient
Maintain humidification with saline gauze
Keep 3 tubes in supply – same size, one above and one below
Suctioning only till the end of the tube – no touching tracheal mucosa
No movements of suction catheter except to insert and remove
Type of secretion and frequency to be recorded
2" block head end elevation
Ranitidine, omeprazole and/or cisapride if aspiration is suspected
Suction tubes on the apparatus in the ward to be changed as per schedule
Suction catheters for each patient to be changed as per schedule
Housekeeping & Waste disposal

Refer to the respective chapters.
NUCLEAR MEDICINE
13.11.1.General principles:
“Good housekeeping” should be maintained at all times

Food is not allowed in the radioisotope handling areas
The laboratory should be kept neat; glassware washed regularly
Set up should be made on easily cleanable tray
All trays and all other work surfaces should be covered with disposable absorbent paper
The wall, floor, and doors of the active areas should be of hard, washable nonporous and leak-proof
material and has to be maintained thus
An automatic pipette should be used for pipetting radioactive material. [Pipetting by mouth is not
allowed]
Disposable gloves and needles should be used for drawing blood samples and injection of radio-
pharmaceuticals in ALL patients
Radiation safety principles:
The radiation symbol and appropriate warning signs should be conspicuously and prominently
displayed at all times
All radio-activity should be stored in appropriate shielded containers in secured areas as per guidelines
of Atomic Energy Regulatory Board‟s safety code, Mumbai
Physical barriers should demarcate areas of high activity and contamination
Areas used for elution of generators, preparation of radio-pharmaceutical and preparation of patient
doses should be surveyed for contamination after each procedure and the end of each working day
The patient treatment area should be surveyed each day to make sure they keep up to the standards
Protective outer garments, such as laboratory coats and rubber gloves, should be worn by personnel
while handling radioactivity
The exhaust from fume hoods should be let out directly into the open after passing through HEPA
filter.
Radiation safety principles concerning radio-active waste
i. The general principles for radioactive waste management should be followed as listed below:
Delay and decay of short-lived radionuclides;

Concentrate and contain activity as practicable; and
Dilute and disperse low-level radioactive waste within the authorized limits
ii. Soiled material;

With short life shall be stored in a secure place until decay
With longer half-lives should be stored longer and disposed
iii. Liquid wastes;
With short half-lives should be disposed into sanitary sewer systems
From high dose therapy suites should be contained in designated leak-proof and corrosion-resistant
delay tanks and disposed as per the above guidelines
iv. Gaseous wastes should be vented at a level above the terrace of the hospital so that recirculation of the
exhaust air does not occur.
v. Isolation wards shall be provided for patients undergoing nuclear medicine therapy requiring
hospitalization.
CARDIAC CATHETERIZATION LABORATORY
Patient preparation: (J Ward & CCU)
Radial, brachial and femoral approach: Perform skin preparation using clippers for the radial, brachial
and femoral sites (arms + groin) excluding axilla and pubic region.
Provide 4% chlorhexidine scrub to the required sites after the use of clippers.
Skin preparation in the lab:
Radial approach: 10% povidone-iodine solution or 4% chlorhexidinegluconate is used to clean the site.
The puncture site is draped (wrist) with a sterile drape.
Femoral approach: 10% povidone-iodine solution or 4% chlorhexidinegluconate is used to clean the
site. The puncture site is draped (groin) with a sterile drape.
Entry to the Cath lab:
Personal – Entry into the Cath lab restricted to the minimum.

Staff – To use Cath lab scrub suits, footwear & PPE mandatory.
Operators – Scrubbing done with 7.5% povidone-iodine solution, hand hygiene procedure followed as
per hospital guidelines and aseptic technique for each procedure done.
Disinfection of Cath lab:
Floor – mopped with soap and water – every morning, between cases and at the end of the day
Surface – cleaned with 10% hydrogen peroxide
Fogging – done with 20% hydrogen peroxide for 20 minutes
Blood spill – 1% sodium hypochlorite is poured over the area just cleared of the large spill or over the
small spill and covered with absorbent cotton or cloth, kept for 10-15 minutes and then mopped.
Disinfection of instruments and linen:
Cath labinstrument sets – washed with soap and water, dried, packed and autoclaved.
Linen – Laundered, dried and autoclaved
All autoclaved items to be used before the expiry date
Cleaning of hardware:
Catheters are washed under running water and lumen flushed with water
Cleaned catheters soaked in 2% glutaraldehyde solutions for 20minutes
Soaked catheters washed under running water and lumen flushed with distilled water and dried by using
compressed air and then sent for ETO sterilization
Items sterilized by ETO to be used before the expiry date
Reuse of single-use device:
Hardware used during procedure (balloon, coronary wire, catheter, manifold, etc.) are discarded after
single re-use.
EP catheters to be discarded after 35 times of usage
Waste disposal
As per hospital guidelines.
Microbiological monitoring:
Environment surveillance done every month, recommendation from microbiology department followed.
BONEMARROW TRANSPLANT UNIT

Optimal care of immunocompromised patient is a major factor in the success of any bone marrow transplant
programme. Minimizing life threatening infections requires stringent infection control techniques and policies
involving the co-ordination of both medical and nursing personnel.
Patients undergoing allogenic stem cell transplant are nursed in the Bone Marrow Transplant Unit (BMTU). Each
room is equipped with High Efficiency Particulate Air module (HEPA) filter, which maintains positive pressure
in the room and filters particles larger than 0.3 microns.
1. Monitoring the HEPA filter system
Filters are cleaned once a week, serviced once in six months and changed once in a year. Air flow is checked
once a day. Laser Particulate Count (LPC) count is taken once in 3 months. Positive pressure of 10-20 Pa is
maintained in the unit. The room temperature is maintained at 22-26°C.
2. Microbiology surveillance culture
i. Air quality
Settle plate on the air flow and particle count using automated air sampler is performed in each room
once a month. The room is fogged based on the culture report.
ii. Water
Soft water is provided in the patient‟s room. The soft water is treated with Ultra Violet (UV) rays for
disinfection. The UV bulb is changed after 6000hrs. Water culture is done once a month.
iii. Fogging the Unit

This is done based on the monthly room culture report. Care-P solution (H 2O2 15%) is used for fogging,
followed by thorough cleaning of the entire room including ceiling, walls and all the articles with 7%
Lysol solution. Patient cot is cleaned with 10% hydrogen peroxide solution.
3. Nursing Protocols
Policy on entry of personnel to the unit, food, sterile supplies, care of neutropenic patients and Hickman Catheter
dressings are clearly formulated in the nursing protocol manual. The salient features of the protocol are outlined
below:
a. Entry to the unit

All personnel must shower at their residence before entering the unit
138
Entry to the unit will be only through the changing room after removing the footwear on the racks
provided at the lift lobby
Person with active infections should not enter the unit
Once in the changing room, street clothes should be changed, use alcohol-based hand rub to open the
autoclaved clothes provided. Wear BMTU uniform. Hair must be covered with the disposable caps
Wash hands and feet thoroughly with soap and water in the washroom. Step into the main corridor of the
unit using the clean slippers provided
b. Entry to the patient relatives

One relative is allowed to visit the patient for a limited period of time in the evening
For paediatric patients, the rule is relaxed and the parent may be permitted to stay with patient
c. Entry to the patient‟s room

Use alcohol-based hand rub on both hands before entering the patient‟s room through the swing door,
making sure the door is closed behind you
Autoclaved nurse‟s apron, doctor‟s and visitor‟s gowns are provided in each patient‟s room, which are
changed on a daily basis
Before examining the patient or carrying out any procedure it is mandatory to rub both hands using
alcohol-based hand rub provided at the bedside
All articles required for the patient care (medication, disposable items, pressure cooker, linen bundles,
etc.,) are taken into the room through the “clean” hatch provided for each room
d. Patient care
i. Handling of venous access sites

All procedures involving administration of intravenous medications and blood products are done with
standard sterile precautions as per the nursing protocol. Central line dressing is done once in three days
by the nurses. Any evidence of infection is reported to the physician immediately.
ii. Mouth and skin care of the patient

Proper care of the mouth, skin and mucous membranes is vital in the care of immunocompromised
patient.The nurse also has an opportunity to examine the skin and mouth and to report suspicious findings
to the physician.
iii. Routine mouth care

The aim is to keep the teeth clean and buccal mucosa clean and moist. Teeth are brushed once a day with
a soft bristled brush. In addition, mouth wash with chlorhexidine 0.2% is done four times a day. Diluted
sodium bicarbonate solution (25ml of sodium bicarbonate 7.5% added to normal saline 500ml), is used
when a patient has severe mucositis and excessive plaque. A thin layer of vaseline is applied over the lips
to prevent dryness.
iv. Skin care

All patients are required to bathe or are given a sponge bath once a day using a mild soap. Importance is
given to the cleanliness of the groin, perianal region, and arm pits. The skin is completely dried using a
sterile towel followed by application of Johnson‟s baby lotion. The patient is given a set of autoclaved
linen to wear. A head shower filter containing 0.2mm filter membrane is provided in each room. It is
changed after discharge of the patient.
139
v. Food
All cooked food and water consumed by the patient must be sterilized by pressure cooking for 20
minutes. Salads and fresh fruits should be avoided.
vi. Bowel
Due to the risk of anal fissure and perianal infections in these patients, the perianal region is washed
thoroughly with soap and water after each defecation.
vii. Recreation
Patients are permitted to have recreation items such as books and toys after autoclaving.
viii. Autoclaved supplies

All articles that are sent to the Central Sterile Supply Department (CSSD) for autoclaving should be
double wrapped. Once autoclaved, the outer wrap is removed at the receiving door and the inner wrap is
removed inside the unit. All sterile items are taken into the patient‟s room through the clean hatch.
ix. Prophylactic antibiotics

Prophylactic antibiotics are not used. A stool surveillance culture is sent at the time of entry to BMTU to
document the flora of the GI tract and the sensitivity pattern of the organisms. An appropriate
combination of antibiotics is started after blood culture at the onset of the first spike of fever.
e. Cleaning Schedule
i. Floor: Floor should be mopped thrice a day with 7% Lysol solution using autoclaved mop cloth that are
changed thrice a week for each room
ii. Walls and Surfaces: Walls and surfaces should be cleaned once a day with 7% Lysol solution using
autoclaved towels
iii. Toilet: Clean twice a day using 7% Lysol with the brush, scrubber, and towel provided separately for
each patient‟s toile
iv. Slippers: Slipper should be soaked and washed twice a day using liquid soap
DIALYSIS UNIT
Infection control may be divided into three major areas;

i. Prevention of transmission of bloodborne pathogens (HIV, Hepatitis B, and C) from patient to patient,
and patient to staff or vice versa.
ii. Prevention of spread of microbial infection among patients, especially those with the central venous
catheter as vascular access.
iii. Maintenance of water quality within microbiological standards laid down by the Association for the
Advancement of Medical Instrumentation (AAMI)
Control measures for the prevention of transmission of bloodborne pathogens:
It is mandatory for all employees working with dialysis patients to have a complete course of
immunization with hepatitis B vaccine, with demonstration of protective levels of antibody
All categories of health care workers must be educated on the precautions to prevent transmission of
hepatitis B, C, and HIV. Strict supervision of all work areas is essential
It is mandatory to test all patients for HBsAg, HCV antibody and HIV antibody before haemodialysis,
except in dire emergency situations
140
Complete serology (HBsAg, HIV antibody, HCV antibody) results are obtained within the next 2 weeks,
and the status is reviewed. PCR test may also be performed to confirm the status
Patients positive for hepatitis B, C or HIV are to be dialysed in an area separate from those who are
negative. Single-use dialyzers are used for all patients positive for hepatitis B, C or HIV and separate
machines are allotted for the positive zone
The zone is cleaned at the end of the day with 7% Lysol & fogged with hydrogen peroxide
Hepatitis B & C
All patients negative for HBsAgshould receive vaccination as per the protocol
Strict hand hygiene practices is to beadhered to, following all steps & moments
Hepatitis B and C status is to be monitored monthly
Disposable gloves, gowns or aprons should be used when caring for patients. Mask is to be worn while
handling CVC as per protocol
Gloves must be used while taking blood or handling potentially infectious body fluids
Blood and other specimens from patients infected with a blood-borne pathogen should be transported the
various laboratories for testing in bio-hazard plastic cover
Transducer protectors should be used to prevent blood contamination of venous and arterial pressure
monitors
Utmost care must be taken to avoid accidental needle pricks with sharp instruments which may be
contaminated by the patient‟s blood
If there is accidental blood spillage, pour 1% sodium hypochlorite over the spill. Wait for 10-15 minutes
and then clean the area
The dialysis machine should be disinfected with 1% bleach solution or citro sterile solution (Maleic acid
+ peracetic and ) at the end of the day
Use only disposable hypodermic and fistula needles. These should be discarded into the sharps container
immediately after use
Hot/cold rinse is recommended to disinfect the machine between treatments
Constant vigil should be maintained by the staff to minimize the risk of infections
Non-disposable items in the hepatitis serology positive area should be sent to CSSD in the „red bag‟
Have separate staff designated to care for positive patients
Machine surface cleaning is done with alcohol-based antimicrobial solution
Dialyzers if reused should be reprocessed in designated machines for positive patients following standard
precautions.
HIV positive patients

CAPD may be the more appropriate mode of maintenance dialysis for HIV seropositive individual. If HIV
positive patient requires dialysis support, the following measures to be adopted;
Have separate dialysis machine and staff for dialyzing HIV positive patients
Follow the standard precautions strictly
Do not reuse dialyzers
Take special care to avoid needle stick injury & blood spills during cannulation.
Prevention of spread of microbial infection between patients especially with central venous
catheter as vascular access
Catheter-relatedbloodstream infections are of great concern & hence the following practices are recommended;
Sterile gloves and masks are indicated while handling CVC

Hand washing and the use of disinfectant hand rub is mandatory before accessing the catheter
Do not expose the catheter lumens to air
141
Apply antibacterial ointment at the catheter exit site during dressing
Ensure that JVC is removed within 21 days & femoral CVC catheter within 7 days if it is temporary
Sterile technique is to be used during procedures involving handling of CVC
Access site is to be cleaned thoroughly with 2% chlorhexidine before starting dialysis and sterile dressing
is to be used over the access site at every HD session
Minimal touch technique is to be followed. Do not manipulate the CVC
If MRSA has been isolated from the patient, contact isolation precautions are followed. Surfaces and cot
are to be cleaned with 7% Lysol; linen to be soaked in 1% Dakin's for at least half an hour before being
sent to the laundry. Gloves and aprons to be discarded into red plastic bags and masks into the yellow
plastic bags. Staff assigned to this patient should not rotate to other patients during the HD session. Non-
disposable items should be sent to CSSD in the „red bag‟.
Maintenance of water quality
During each dialysis session, the patient is exposed indirectly to 120 litres of water. Therefore the clinical and
microbiological quality of water used for haemodialysis should be within acceptable standards. The use of water
filters, softeners and reverse osmosis (RO) are necessary to ensure chemical purity if the distribution delivery
system is made of inert material (eg. Stainless steel, or synthetic material).
Reverse osmosis is also effective in minimizing both bacterial counts and endotoxin concentration in the water.
However, stagnation in the delivery system, the presence of loops and bends, use of bicarbonateconcentrate (a
good nutrient medium) and warming of the dialysate to 37 oCare all factors that potentiate microbial
contamination of water.
The AAMI microbiological and endotoxin standards for HD fluids
Microbiological Previous standards New standards Previous action New action level
level level
Colony forming < 200 CFU/ml < 100 CFU/ml ≥ 50 CFU/ml ≥ 50 CFU/ml
units
Endotoxin units < 2 EU/ml < 0.25 EU/ml ≥ 1 EU/ml ≥ 1 EU/ml
The assay performed for the pipelines in our dialysis unit and ICUs in our department is followed as per the kit
manufacturer‟s instructions. Once the assay is validated, the test results are interpreted and reported as <0.125
EU/ml. Samples which have >0.125 EU/ml are retested with dilution to check if levels exceed 0.2 EU/ml.
The following practices/methods are recommended to maintain acceptable water quality:

Use of UV light (253.7nm) disinfection inactivates bacteria and viruses, due to the specific damage
caused by microbial nucleic acids
Use of ultrafilter at the water inlet of the dialysis machine
Periodic cleaning and disinfection of the dialysis machines including all parts of the hydraulic system
Proper design of the distribution and delivery system, with avoidance of blind ends or loops and
preferably a circulation system
Periodic disinfection of the delivery system
The procedure of weekly disinfection of the water used for dialysis is as follows:
o A sample of RO water is tested for chloride level
o Disconnect all machines and move them out. Close all outlet valves
o Close all output valves from the tank
o Clean the RO tank thoroughly and fill the tank with 2% sodium hypochlorite
o After ½ hour, open all valves and allow the hypochlorite to drain
o When 10-20 litres are remaining in the tank, close all the outlet valves and allow the hypochlorite
to dwell in the tubes for ½ hour
o Open all valves and continuously flush with RO water
o Samples of water are collected at terminal outlets of each unit every hour and the chloride levels
are tested. This is continued until it is equal to the pre-disinfection levels. Record all values of
chloride
Periodic microbiology surveillance of water sampled at specific points of the system
Formalin test
Monthly monitoring of endotoxin levels.
Method of disposal of the drained CAPD fluid and the bag
After each exchange procedure, the patient should discard the drained fluid bag into the red plastic bag which is
kept in the sluice room. Then thebag is cut and the fluid will be drained into the sink by the housekeeping
attendant who is assigned. The emptied drained bags will be disposed into the Red plastic bag by the
housekeeping attendant.
If the patient is HIV positive, use a separate dustbin, with lid. Then thebag is cut and the fluid is drained into the
dustbin. Mix equal amount of 1% sodium hypochlorite solution and close the bin with lid and keep it for 30
minutes by the patient relative. The emptied drain bag will be disposed into the separate red plastic bag and
labelled.
14. OUTBREAK MANAGEMENT
Definition
An outbreak may be defined as the occurrence of a disease at a rate greater than that expected within a specific
geographical area and over a defined period of time.
Outbreaks can be in the hospital or community setting.

Major outbreaks of transmissible infection in hospital require appropriate planning to ensure effective
management of such episodes. All healthcare facilities must draw up detailed outbreak control plans appropriate
to local situations. The plan should be discussed and endorsed by the infection control committee.
Outbreak control committee

Depending on the nature of the infectious disease and the number of cases involved, an outbreak control
committee should be formed. The members of this committee vary according to the healthcare facility but each
member of the committee should be aware of his responsibility and the action plan. The aims of this committee
are;
Facilitate the investigation of an outbreak

Implement measures necessary to control the outbreak
Monitor the effectiveness of control measures
Facilitate the medical care of patients
Recognition of an outbreak
Routine surveillance of infections is the most important in the rapid recognition of outbreaks. Types of outbreaks:
Obvious outbreaks like food poisoning which may involve HCWs and patients
Outbreaks among medical and Health care workers
Outbreaks which are insidious and become considerable in proportion when they are recognized.
Outbreaks can be detected by laboratory investigations or by strict vigilance of nursing and medical health care
workers.
Investigation
The principles for investigating outbreaks in hospitals have three basic steps.
1. Describing the outbreak

2. Developing the hypothesis
3. Testing the hypothesis
An effective outbreak investigation needs adequate laboratory support. All outbreak isolates should be stored for
further investigation. This is necessary because many organisms are endemic in the hospital environment and
typing may be necessary to evaluate which isolate is the cause of the putative outbreak. Though the antimicrobial
susceptibility testing may be sufficient, typing of the isolates is helpful.
Once the outbreak is recognized the HICC work to establish a case definition with the help of the information
collected from the laboratories as well as wards. Once the outbreak is confirmed, the severity should be
established and immediate control measures should be taken up.
If the preliminary investigations do not confirm an outbreak, the person who made the initial observation must be
informed with reason. Ward staff should be informed but further reporting should not be discouraged.
Outbreak control
Preliminary control measures should be introduced at the earliest like patient isolation practices and hand
washing. Surveillance of these areas should be increased to see the impact of control measures. The investigation
reports must be conveyed to the risk areas at the earliest.
Communication
During the investigation of an outbreak, timely, up to date information must be communicated to the hospital
administration, public health authorities, and, in some cases, to the public. Information may be provided to the
public and to the media with the agreement of the outbreak team, administration and local authorities. A final
report on the outbreak investigation should be prepared. It should describe the outbreak, interventions, and
effectiveness, and summarize the contribution of each team member participating in the investigation. It should
also make recommendations to prevent future occurrence. This report can be published in the medical literature
and may be considered as a legal document.
End of outbreaks:
At the end of an outbreak, a final report should be prepared by the outbreak control committee and a final
meeting held to:
Review the experience of all participants involved in management of outbreak

Identify any shortcomings and difficulties encountered
Revise the outbreak plan in accordance with the results
Recommend any structural or procedural improvements which would prevent the recurrences.
It is essential that all outbreaks, however minor, should be investigated thoroughly and the outcomes of such
investigations documented.
Outbreak preparedness - A summary of preparatory action:

Formation of a rapid response team
Training of a rapid response team
Regular review of the data
Identification of “outbreak regions”
Provisions of necessary drugs and materials
Strengthening of laboratories
Designation of vehicles for outbreak investigations
Establishment of communication channels in working conditions
Table. 14.1.Immediatecontrol measures for outbreak management
S.no Type of transmission suspected Suggested action

1. Cross-transmission (transmission Patient isolation and barrier precautions
between individuals) determined by infectious agent(s)
2. Hand transmission Improvements in hand washing; cohorting

3. Airborne agent Patient isolation with appropriate ventilation
4. Agent present in water, waterborne agent Checking of water supply and all liquid
containers and use of disposable devices
5. Foodborne agent Elimination of the food at risk

Summary of steps in investigating an outbreak
Begin preliminary evaluation and determine the

background rate of infection
Confirm the existence of an outbreak
Develop line listing by identifying and counting cases and

exposures.
Describe the data in terms of time, place and person
Construct an epidemic curve. This may indicate the source

of outbreak
Develop and test the hypothesis by

Large outbreaks- a case-control method
Single hospital ward- retrospective cohort study
Take immediate control measures
Determine the risk group
Look at factors affecting the infection rate
Communicate information to relevant personnel
Screen personnel and environment as indicated
Prepare a coherent report (preliminary & final)
Summarize investigation and recommendations to appropriate authorities
Implement long term infection control measures for prevention of similar

outbreaks
References:
1. Manual of infection prevention and control by Nizam Damani 3 rd Edition 2012
Protocol for Environmental Cleaning after Flood:
Flood waters can be of different types:
Clear water – water from tap/tanks or uncontaminated rain water
Gray water – water from sinks, showers, tubs and washers
Black water – waters contaminated with human and animal wastes
Cleaning and disinfection:
Non porous materials – Eg: metals, glass and hard plastics can be cleaned, disinfected, sterilized
according to the type of material and can be re used.
Any porous materials which absorbs water – should be discarded
After draining the water from the surfaces, damp wipe the non porous surfaces with water and
detergent solutions.
During cleaning, it is important to minimize the dust disturbance so that the spread of
fungal spores can be avoided. Avoid brooming in those areas.
In high risk areas like ICUs, OR – HEPA filter set up can additionally be done.
Surface can be decontaminated with 1:10 bleach solutions.
All the surfaces should be cleaned with 10% hydrogen peroxide when the fungal bioburden is
higher than the acceptable level.
To avoid fungal growth, area should be thoroughly dried and ventilated.
For all the instruments and scan machines in radiology dept, all the items should undergo
thorough cleaning, disinfection according to manufacturer`s instructions.
Importantly,
All the biological products (Eg: blood bags, vaccines, drugs), once contaminated with flood water
should be discarded.
Ref:
Remediation and Infection Control Considerations for Reopening Healthcare Facilities Closed
Due to Extensive Water and Wind Damage, Centre for Disease Control & Prevention, Atlanta
(https://www.cdc.gov/disasters/reopen_healthfacilities.html)
Ling, M. L., Apisarnthanarak, A., Thu, l., Villanueva, V., Pandjaitan, C., & Yusof, M. Y.
(2015). APSIC Guidelines for environmental cleaning and decontamination. Antimicrobial
resistance and infection control, 4, 58. doi:10.1186/s13756-015-0099-7
(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696151/pdf/13756_2015_Article_99.pdf)
APPENDIX - I
DEPARTMENTAL POLICIES FOR RE-USE OF SINGLE USE DEVICES
DEPARTMENT OF ANESTHESIOLOGY
S.No Name of the device Number of Method of Method of

times reused disinfection and tracking
sterilization
1. Double Lumen Tube 2 times Washing thoroughly Marking with
(DLT) with soap solution green marker
2. Block Needle 2 times and drying, followed after first and red
3. Reinforced Flexometalic 2 times by sterrad marker after
Tubes sterilization second use
DEPARTMENT OF CARDIOLOGY
Coronary Care Unit

sterilization
1. Flow sensor 2 to 3 times Soak the device in Labelling the
2. BAIN‟s Circuit 5 times 2% cidex for 20-30 number of usage
J WARD minutes, wash, dry while packing for
and send for gas gas sterilization
sterilization
3. Flow sensor 3 times
DIALYSIS LABORATORY (AK Lab)

sterilization
1. Renal Biopsy Gun 5 times Washing thoroughly Marking the
2. Bone marrow Needle 5 times with soap and water, number of times
drying and cleaning used on the cover
with ether and send before sending to
for gas sterilization CSSD
DEPARTMENT OF GENERAL SURGERY

sterilization
1. TA-45 Stapler Gun 5times Washing thoroughly Marking on the
2. Harmonic shears 5 times with soap solution instrument before
3. Echelon 12 times and drying followed sending for
by sterrad sterrad
sterilization sterilization
DEPARTMENT OF RADIOLOGY
Name of the device Number of Method of Method of

S.No times reused disinfection and tracking
sterilization
1. Trans Jugular Liver 2 times Washed with soap Marked on the
Biopsy needle (TJLB) and water. Flushed cover while
2. Guide wires: 150cm 2 times with H2O2, soaked packing for gas
3. Guide wires: 260cm 2 times in cidex for 24 hours, sterilization
4 Glide wires: 150cm 2 times then washed with
5. Glide wires: 260cm 2 times running water and
6. Micro wires 200cm 2 times dried with
7 Micro catheters 150cm 2 times compressed air.
8 Micro catheters 165cm 2 times Followed by ETO
9 4F Angiography catheters 2 times gas sterilization
– Glide & Non Glide
65cm, 80cm, 100cm
10 5F Angiography catheters 2 times
– Glide & Non Glide
65cm, 80cm, 100cm
11 Introducer Sheaths – all 2 times
Frenchs and Length
12 Balloon Catheters 2 times
13 Torque devices 2 times
14 Guiding catheters 2 times
15 Inflation Devices 1-2 times
16 Neff set 2 times
17 TIPS set 3 times
18 Needles – Biopsy, 1-3 times
Aspiration, Puncture,
Coaxial
19 Radiofrequency needle Each needle is If the patient returns Labelled with the
being used for for repeat RFA at a patient‟s name
a single later date, this needle and given to the
patient only. is re-sterilized prior patient on request
After use, this to use
is sterilized.
150
DEPARTMENT OF GASTROENTEROLOGY (Endoscopy room)

sterilization
1. Mouth Guard 6 months Thorough cleaning Marking on the
2. Guide wire 10 times with soap and water. instrument cover
3. Pusher 20 times Immersed in enzyme before sending
4 Stone extraction balloon 5 times and cidex solution for sterilization
5. Stone extraction basket 5 times for 20 minutes. Then and documenting
6. Angiocath 10 times washed with RO
7 Biliary balloon dilator 10 times water and dried it.
8 Cannula swing tip 5 times Followed by ETO
9 Snare 10 times gas sterilization
10 Ratchet 5 times
11 Tripod forceps 20 times
12 Eus FNAC needle 2 times
NURSERY

sterilization
1. Bubble CPAP Tubing‟s 4 times Washing thoroughly Colour coding
with soap solution and
and drying followed documentation
by gas sterilization
2. Dome 4 times Cleaning with spirit
3. O2 Tube (rubraflex) 3 times and dried with blow
air dryer
OPERATION ROOM (OR)
DAY CARE OR

sterilization
1. Vein stripper 2 times Washing thoroughly Marking on the
2. RFA sheath 3 times with soap solution instrument before
and drying followed sending for
by sterrad sterrad
sterilization sterilization
SEPTIC OR

sterilization
1. Monopolar cable (Rare) 1 time Soaked in Lysol for Marking on the
2. Suction tip (unused) 1 times 30 minutes, washed instrument before
with water, dried sending for gas
packed and sent for sterilization
gas sterilization
THORACIC OR

sterilization
1. Asepto syringe 10 times Soaked in 3M Marking on the
2. Venous Cannula 6-7 Times solution for 30 cover before
3. Aortic Cannula 3-5 Times minutes, washed sending for gas
4. Root Cannula 3-5 Times with water, dried sterilization
with compressed air
& send for gas
sterilization
UROLOGY OR

sterilization
1. Cable 1 time Soaked in 7% Lysol Marking on the
for 30 minutes, cover before
washed with water, sending for gas
dried, packed and sterilization
sent for gas
sterilization
VASCULAR SURGERY OR

sterilization
1. Arrow catheter 5times Soaked in 7% Lysol Marking on the
for 30 minutes, cover before
washed with water, sending for gas
dried, packed and sterilization
sent for gas
sterilization
GENERAL OR

sterilization
1. Embolectomycath 3 Times/ Soaked in 7% Lysol Marking on the
Single use for for 30 minutes, cover before
Bio-hazard washed with water, sending for gas
patient dried, packed and sterilization
2. RFA 5 Times sent for gas
sterilization
RECOVERY ROOM

sterilization
1. Adult O2 Mask 3 to 6 times Washing thoroughly Marking on the
with soap solution instrument cover
2. Airway 3 to 6 times and drying followed before sending
by gas sterilization for gas
3. O2 mask 3 to 6 times sterilization
4. Tracheostomy mask 3 to 6 times
ICUs
CARDIO THORACIC ICU & SEMI ICU

sterilization
1. Bain circuit 5 times Washing thoroughly Colour coding on
with soap solution the device cover
and drying followed before sending
by gas sterilization for gas
sterilization
NEURO ICU

sterilization
1. Stapler remover 5 times Washing thoroughly Marking on the
2. Bain circuit 3 times with soap solution instrument cover
3. Bone marrow needle 3 times and drying followed before sending
4. T-piece with chamber 3 times by gas sterilization for gas
sterilization
PAEDIATRIC ICU

sterilization
1. Bain circuit Short tube Washing thoroughly Marking on the
reused for 3 with soap solution instrument cover
times and drying followed before sending
2. Ventilator tubing (neonate by gas sterilization for gas
tubes) sterilization
3. High flow oxygen circuit 10 times
4. Nasal cannula 5 times
SURGICAL ICU

sterilization
1. Bain circuit 1 time Washing thoroughly Marking on the
with soap solution cover before
and drying followed sending for gas
by gas sterilization sterilization
BONE MARROW NEEDLE
S.No Name of the ward Number of Method of Method of

sterilization
1. E- Ward 2 times Washing thoroughly Marking on the
2. I -Ward 3 times with soap solution, instrument cover
3. MTS-4 4-5 times drying and wiped before sending
4. Medicine OPD 2-3 times with spirit followed for gas
treatment room by gas sterilization sterilization
5. Child health OPD 5 times
treatment room
6. Q5 East 5 times
CARDIAC CATHETERIZATION LABORATORY

sterilization
1. 3way manifold 1 time Washed with water, Marked on the
2. Bipolar electrode 1 time soaked in 2% cidex cover with the
3. Angio catheter 1 time for 20 minutes, seal “single
4. Angio set (Side arm 1 time washed with distilled reuse” while
catheter, 3 way manifold, water and dried with packing for gas
control syringe, and guide compressed air and sterilization
wire) sent for gas
5. ASD item 1 time sterilization
6. Control syringe 1 time
7. Wire cutter 1 time
8. Delivery cable 1 time
9. Fractional flow rate (FFR) 1 time
wire
10. Guide wire 1 time
11. Gelco 1 time
12. Inflation device 1 time
13. J introducer 1 time
14. Ketch 1 time
15. Long sheath 1 time
16. Metal needle 1 time
17. Microcatheter 1 time
18. Micro puncture.set 1 time
19. Permanent pacemaker 1 time
items
20. Pressure extension 1 time
21. Pacing and screening 1 time
analyser (PSA) cable
22. PTA balloon 1 time
23. PTA guide wire glide 1 time
24. PTCA balloon 1 time
25. PTA guide wire 1 time
26.. PTCA item 1 time
27. Side arm 1 time
28. Sizing plate 1 time
29. Snare 1 time
30. Stent 1 time
31. Electrophysiology study 20 times Wiping with cidex Marking on the
(EPS) items then with H2O2 cover and
maintaining a
register
APPENDIX - II
LIST OF HIGH-RISK AREAS AND PROCEDURES IN THE HOSPITALS
High-risk areas High-risk procedures

1. Intensive care units 1. All surgical procedures
2. High dependency rooms 2. Cardiac procedures
3. Operating room 3. Invasive ophthalmic procedures including
4. Pediatric emergency room implants
5. Dialysis lab 4. Bone marrow transplants
6. Isolation room 5. Skin and wound debridement
7. Blood bank 6. Central line placement
8. Cardiac catheterization lab
9. Bone marrow transplant unit
10. Renal transplant unit
APPENDIX – III
CLASSIFICATION OF DEVICES AND PROCESS OF DISINFECTION
Device classification Device (example) Method before use Method after use
Critical, enters sterile Surgical instruments, High level disinfection Intermediate level
tissue / and vascular cardiac and urinary or sterilization Disinfection
system catheters, implants, needles
and ultrasound probes
Semi-critical, contact Endoscopes, laryngoscope High-level disinfection Intermediate level

with mucous membrane/ blades and cystoscopes using chemical disinfection
non-intact skin disinfectants
Non-critical, contact Thermometers, Intermediate level or Intermediate level or

with intact skin but not hydrotherapy tanks, low-level disinfection low-level disinfection
mucous membrane stethoscope, table tops, and
bedpans
APPENDIX - IV
DISINFECTION PROCEDURES FOR INDIVIDUAL ITEMS AND EQUIPMENT
Equipment or site Suggested method(s)

Airways and endotracheal tubes Single-use disposable or heat sterilize in the CSSD
Ambu bag with mask Clean with detergent followed by gas sterilization
Arm splint Wash with detergent, rinse and dry.
Beds and cots Wash with detergent and dry or clean with 7% Lysol and dry.
Bedpans and urinals Dispose after single-use. If reusable heat disinfect in a

washer/disinfector (80oc for 1min) and store dry or disinfect in
7% Lysol for 1 hour.
Breast pumps For single patient use only. Wash with detergentand water and
then rinse.
BP cuffs Use dedicated item in high-risk areas (e.g. ICU) or on patients
known to be colonized/infected. Wash sleeve and disinfect with
70% alcohol wipe to clean tubing and inflation bladder.
Cardiac monitors, defibrillators, and Use single-use disposable ECG pads. If patient contact, then
ECG equipment surface clean and disinfect unless disposal is necessary (if single-
use item)
Cleaning equipment Commercial Mops: The detachable heads of used mops mustbe
thermally disinfected in a laundry machine or chemically
disinfected and dried daily.
Mop bucket: Wash with detergent, rinse, dry andstore inverted
when not in use.
Scrubbing machine: Drain reservoirafter use and store dry.
Commodes For single patient use only, wash with detergent and rinse.
Between uses clean and disinfect.
Drip stands Clean after each use.
Enteral feeding Single-use disposable.
Floors (dry cleaning) Vacuum clean or use a dust-attracting dry mop.
Floors(wet cleaning) Wash with a detergent solution. Disinfection is notroutinely

required unless spillage of blood or body fluids occurs.
Furniture and ledges In clinical areas damp dust daily with warm water and detergent.
Humidifiers Clean and sterilize device between patients and fill with sterile
water which must be changed every 24 hours or sooner if
necessary. Single-use disposables are available.
Infant incubators After use, wash all removable parts and clean with detergent.
Clean and dry regularly as part of a routine. If contaminated
disinfect and then rinse and dry.
Laryngoscope blade Wash with detergent, rinse, dry and wipe with an alcohol (70%)
impregnated wipe.
Mattresses and pillows Clean and disinfect the cover with 7% Lysol regularly as part of
a routine and dry. Mattresses should be enclosed in a waterproof
cover and routinely inspected for damage.
Nebulizers Wash with detergent and for gas sterilization between

singlepatient‟s uses. Re-fill with sterile water only. Disposeof on
patient`s discharge.
Oxygen tents Wash with water detergent solution, rinse well and dry
thoroughly.
Razors (electric) Detach head, clean thoroughly, and immerse in 70% isopropyl
alcohol for 10 min, remove and allow to dry between each
patient.
Scissors Surfacedisinfectwith a 70% alcohol impregnated wipe before

use.
Sputum containers Use disposable only. Seal and discard as clinical waste daily or
sooner if required.
Stethoscope Surface disinfect with 70% alcohol wipe between patients. Use
dedicated stethoscope in high-risk areas e.g. ICU, Nursery or
patients with infection or colonized with MDROs.
„K‟ Basins Wash with detergent and disinfect in 7% Lysol for 1 hour.
Suction equipment Following use, the reservoir should be emptied into the sluice
hopper, washed with water and detergent, rinsed and stored dry.
Wear a plastic apron and non-sterile disposable for this
procedure. The reservoir of the suction apparatus should be kept
empty and dry when not in use.
Thermometers(digital) Where possible use a single-use thermometer. Clean and

disinfect with 70% alcohol wipe between uses.
Trolleys (dressing, patient theatre Clean and surface disinfection with 7% Lysol
table)
Tubing (anaesthetic or ventilator) Reprocess by washing and sterilization in CSSD
Urinals Wash with soap & water, disinfection with 7% Lysol for 1 hour
Wheel chairs Clean with detergent, rinse and dry.

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HOSPITAL INFECTION CONTROL

HOSPITAL INFECTION CONTROL COMMITTEE

HOSPITAL INFECTION CONTROL COMMITTEE

Dr. K. Prasad Mathews

Doc No: MAN/HICC/003/P/08/072019 Ver: 08 Issue No: 01 Date: 30/07/2019

HOSPITAL INFECTION CONTROL MANUAL

Chapter Revision description Page

Initiated by: HICC Approved by: Medical Superintendent

2nd edition.............................September 1999

3rd edition.............................January 2003

5th edition.............................August 2011

6th edition.............................May 2015

7th edition.............................January 2018

8th edition..............................July 2019

8th edition..............................October 2019 (Amendment)

1. ORGANISATION OF THE INFECTION CONTROL PROGRAMME AT CHRISTIAN MEDICAL

PHILOSOPHY OF INFECTION CONTROL

DEFINITION OF HEALTHCARE ASSOCIATED INFECTIONS

GOALS AND OBJECTIVES OF THE INFECTION CONTROL PROGRAMME

The programme has the following objectives:

Infection control committee

The nature of the authority of HICC

The terms of reference for HICC

i. Oversee surveillance of HCAI.

Fig.1.1. Organogram of HICC

The Medical Superintendent

HOSPITAL INFECTION CONTROL TEAM

Fig 1.2. Organogram of Infection Control Team

Addl. Joint Secretary

Hospital Infection Control Officer (HICO):

Hospital Infection Control Nurse (HICN)

Antimicrobial Stewardship Pharmacist

Data Entry Operator

Hospital acquired infections

Inadequate standards and practices in the operation of blood transfusion services.

In facilities with limited resources, the priority should be:

Most commonly occurring Hospital Acquired Infections are:

Catheter Associated Urinary Tract Infections (CAUTI)

Active surveillance of HAI

Surveillance definitions for HAIs infections

1. Catheter Associated Urinary Tract Infection (CAUTI)

a. Patient has indwelling urinary catheter and

2. Surgical Site Infections (SSI):

Thirty days follow up Ninety days follow up

4. Ventilator Associated Pneumonia (VAP):

Incidence rate is reported in 1000 device days

VAP incidence rate= Number of patients with VAP in a specified time

VAP prevalence rate= Number of patients with VAP in a specified time

Total number of patients admitted in that period

CAUTI incidence rate = Number of patients with CAUTI in a specified time

Total number of catheter days for that period

CAUTI prevalence rate = Number of patients with CAUTI in a specified time

Total number of patients admitted in that period

CLABSI Incidence rate= No of patients with CLABSI in a specified time

Total number of central line days for that period

CLABSI Prevalence rate = Number of patients with CLABSI in a specified time

Total number of patients admitted in that period

Total number of patients with specific surgery in that period

VAP BUNDLE CHECKLIST

(Modified from SHEA /IDSA Guidelines December 2014)

1. Maintain RASS score 0 to -1

2. Assess readiness to extubate once a day

3. Early Physiotherapy and mobilization