Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) M a n u a l o f O p e r a t i o n s o f H o s p i t a l A c q u i r e d I n f e c t i o n C o n t r o l C o m m i t t e e ( H A I C C ) Service Name : Hospital Acquired Infection Control Committee Date Created : 01-01-2018 President:- Shri I. P. Mishra Signature : Final approval for implementation: Vice President:- Mrs. Jaya Mishra Signature : Dean Issued By : Name : Dr C. K. Mankikar Signature : Chief Medical Superintendent Approved By : Name : Dr Gourav Gupta Signature : Prof. & Head of Microbiology Dept. Prepared & Reviewed By : Name :Dr Amit A. Rangari Signature : Senior Consultant Microbiologist Responsibility of Updating : Name :Dr Aakansha Sharma Signature : - 0 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) Page of Contents Sl.Order Particulars Page no. A Purpose 03 B Scope 03 C Hospital Acquired Infection Control Committee(HAICC) 03 D Policy 04-42 1.Hospital Acquired Infection Control Team(HAICT) 04 2.Responsibilities of the Hospital Acquired Infection Control Team 04 3.Infection Control Nurse (ICN) 05 4.Infection control Officer (ICO) 05 5.Surveillance and Reporting of Infections 05 6.Surgical site Infections 06 7.Staff Health Programme 07 8.MRSA 08 9.Treatment of Personnel 08 10.Guidelines for Special Situations 08 11.Isolation 09 12.Cleaning of Equipment’s and Articles 10 13.Precautions against Blood Borne Transmission 11 14.Precautions against Airborne Transmission 12 15.Precautions against Contact Transmission 12 16.Isolations Rooms 13 17.Care of Systems and Indwelling devices 13 18.Vascular care 13 19.Respiratory Care 14 20.Urinary Catheter 16 - 1 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) 21.Wound Care 17 22.Disinfection and Sterilization 17 23.General guidelines for disinfections 18 24.Sterilization 19 25.Hospital Waste Management 20 26.Food Handling/Handlers 26 27.Laundry and Linen Management 27 28.Mortuary Practices 27 29.Investigation of an Outbreak 28 30.Special Care Units 30 31.Visitors Policy 31 32.Emergency Services 31 33.Occupational Exposure 33 34.What to do on exposure to HIV Infected Blood 36 35.Responsibilities of Infection Control Officer 40 36. Hospital Antibiotic Policy 40 - 2 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) A.Purpose: 1. To maintain standards in infection control measures and minimize hospital acquired infections in patients and staff. 2. To define policy and procedure regarding hospital acquired infections in the hospital. B.Scope: Hospital Wide. C. Hospital Acquired Infection Control Committee: 1. Members: Chairperson(Chief Medical Superintendent) :- Prof. Dr Gaurav Gupta. . Member Secretary(Professor & Head of Microbiology Department) :- Prof. Dr Amit A. Rangari. Infection control officer(Senior Consultant Microbiologist) :- Asst. Prof. Dr Aakansha Sharma. Other Members:- Head’s of all Clinical Departments, Head of Surgery department:- Prof. Dr Gaurav Gupta. Head of Medicine department:- Prof. Dr Shubhangi H. Verma Head of Obstetric& Gynaecology department:- Prof. Dr N.K. Vashisht. Head of E.N.T. department:- Asst. Prof. Dr Paromitra Patra. Head of Ophthalmology department:- Asst. Prof. Dr Anand Deshpande. Head of Paediatrics department:- Prof. Dr Vinayak Deshmukh. Head of Orthopaedic department:- Asso Prof. Dr Naresh . Head of Anaesthesia department:- Prof. Dr Ashok M. Takhalate. Head of Skin & V.D. department:- Asst. Prof. Dr Neelprabha. Head of Chest & Tuberculosis department:- Prof. Dr Pillai D. Vivekan. Chief of Blood Bank service:-Dr Somendra Dhariwal. Medical officer(CMO):- Dr D N Sharma. Chief of Nursing services:- Mrs. Vijaylakshmi Pillai. Infection Control Nurse(I.C.N.):- Mrs. Rachna Philip. Invited members:- Chief of all supportive services OT.:- Prof. Dr Ashok M. Takhalate (Anaesthesia department) C.S.S.D.:-Mr. Vijaykumar Singh. Laundry:- Mr Naveen Jain. House keeping:- Mr Satyajeet. 2.Objectives of the committee:  To minimize the risk of infection to patients, staff and visitors.  To identify the roles and responsibilities of key personnel involved in the prevention and control of infection.  To maintain Surveillance over hospital acquired infections. - 3 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC)  To develop a system for identifying, reporting, analyzing, investigating and controlling hospital acquired infections.  To develop and implement preventive and corrective programmes in specific situations where infection hazards exist.  To Advice the Chief Medical Superintendent on matters related to the proper use of antibiotics, develop antibiotic policies and recommend remedial measures when antibiotic resistant strains are detected.  To review and update hospital infection control policies and procedures from time to time.  To help to provide employee health education regarding matters related to hospital acquired infections. 3.Meetings The Hospital acquired infection control committee(HAICC) should meet at least once a month and otherwise as necessary, to formulate and update policies related to hospital infection. Documentation of meetings and recommendations are kept by the Chief Medical Superintendent. The ICN (Infection Control Nurse) and Infection control officer(Senior Consultant –Microbiologist)conduct inspection rounds once a month. Registers are maintained by ICN. D. Policy: HAICC will have a Hospital Acquired Infection Control Team(HAICT) , to take day to day responsibilities. 1. Hospital Acquired Infection control Team composition : The Hospital Acquired infection control team(HAICT) consist of the: Infection Control Officer(Senior Consultant-Microbiologist):- Dr Aakansha Sharma(M.B.B.S., M.D.). Infection Control Nurse:- Mrs. Rachna Philip. Clinician:- Dr Samarth Sharma (M.B.B.S., M.D. Medicine Department). HAICT should meet at least once a week and will look after surveillance, control of infection, monitoring of hygienic practices and advising HAICC on matters of policy for prevention of hospital infection. 2. Responsibilities of the Hospital Acquired Infection Control Team:  Advise staff on all aspects of infection control and maintain a safe environment for patients and staff  Advise management of at risk patients  Carry out targeted surveillance of hospital acquired infections and act upon data obtained e.g. investigates clusters of infection above expected levels.  Provide a manual of policies and procedures for aseptic, isolation and antiseptic techniques.  Investigate outbreaks of infection and take corrective measures.  Provide relevant information on infection problems to management.  Assist in training of all new employees as to the importance of infection control and the relevant policies and procedures  Have written procedures for maintenance of cleanliness - 4 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC)  Surveillance of infection, data analyses, and implementation of corrective steps. This is based on reviews of lab reports ,reports from nursing in charge etc.,  Waste management  Supervision of isolation procedures.  Monitors employee health programme.  Addresses all requirements of infection control and employee health as specified by NABH, state and local laws. 3.Infection Control Nurse (ICN): Duties of Infection Control Nurse: The duties of the ICN are primarily associated with ensuring the practice of infection control measures by nursing and house keeping staff. Thus the ICN is the link between the HAICC and the wards/ICUs etc. in identifying problems and implementing solutions. In addition the ICN conducts Infection control rounds and maintains the registers. The ICN is also involved in education of paramedical staff including nurses and housekeeping staff. 4.Infection Control Officer (ICO): The Senior Consultant Microbiologist serves as Infection Control Officer. Duties of Infection Control Officer:  The ICO supervises the surveillance of hospital acquired infection as well as preventive and corrective programmes in con.  Review and revision of Hospital Acquired Infection Control Committee Manual :Written policies and procedures shall be reviewed at least every year by the Hospital Infection Control officer and Committee. 5.SURVEILLANCE AND REPORTING OF INFECTION : Surveillance for infection can be active or passive a. PASSIVE CLINICAL REPORTING: Clinicians suspecting occurrence of HAI may report this to the Chief Medical Superintendent (Honorary Head of the Hospital Acquired Infection Control Committee). All details regarding the patient, procedures, medication etc. are made available. The Senior Consultant incharge(ICO) of the microbiology department shall be responsible for reporting any information about infections suspected to be hospital acquired. b. ACTIVE SURVEILLANCE: High risk areas of the hospital are identified as :Operation Theatres Transfusion services unit Food handlers Drinking water Toilets and bathrooms Central Sterile Supply Department - 5 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) i.Operation Theatres: Culture swabs(aerobic and anaerobic) and air sampling culture plates are sent from Operation Theatres after fumigation every month . Monitoring of working OT: Air sampling of a working OT is done once a month. Sampling of in use disinfectants: 1ml of sample of in-use disinfectants, hand wash agents are sent to microbiology laboratory in a sterile container once a month/ 6month or annually. Records are kept with OT in charge. In case of unacceptable results decision on corrective measures are taken by HAICC. ii.Intensive care units: Surveillance samples: Central line tips Water samples from humidifiers ET tube secretions Urine samples from catheterized patients Surveillance samples are sent per patient on device microbiology laboratory. Data is sent to microbiologist in the prescribed format. Analyses of data are presented at the subsequent HAICC meeting. Records are maintained by microbiologist(ICO). Samples of disinfectant in use: random two samples of 1 ml of disinfectant per ICU are sent in a sterile container monthly. Swabs may be sent after cleaning. Records are maintained by respective ICUs. iii.Transfusion services unit Cleaning of transfusion unit storage areas is done and swabs are sent for culture monthly. iv.Wards Swabs are sent from the wards , post fumigation once in a month. Samples of disinfectant in use: random two samples of 1 ml of disinfectant in use are sent in a sterile container monthly once to check for sterility. Register to be maintained by ward. v.Glutaraldehyde monitoring In use glutaraldehyde may be sent for sterility check: 1 ml of in use glutaraldehyde to be sent in a sterile container to the microbiology laboratory fortnightly from: Endoscopy room ,Operation Theatre. Records to be maintained by the concerned Department. vi.Food handlers Screening of food handlers is done biannually. Samples include nasal swabs and stool samples. Records to be maintained by Kitchen Incharge. vii.Drinking Water Bacteriological surveillance to be done monthly. Records maintained by Microbiology Department. viii.Central Sterile Supply Department Swabs are sent for sterility check after cleaning weekly. Records kept by Microbiology Department. SPECIAL STUDIES Special studies will be conducted as needed. These may include:  The investigation of clusters of infections above expected levels.  The investigation of single cases of unusual or epidemiologically significant hospital acquired infections.  Prevalence and incidence studies, collection of routine or special data as needed and sampling of personnel or the environment as needed. 6. Surgical site infections Prescribed format is filled up by surgeons .Records maintained by ICO. Data collected every quarterly by secretary HAICC and presented. - 6 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) 7.STAFF HEALTH PROGRAMME a.Health evaluation: A pre-employment medical check up is performed at the time of joining services for all staff under the ambit of Health and Family Welfare Department, Government of Chhattisgarh/Medical board SSIMS Bhilai(CG). All staff are required to submit a medical certificate from a government medical official/MO of Medical board SSIMS Bhilai(CG) , as an evidence of fitness prior to their joining duty. An annual medical check up will be done for all staff of the hospital. Records are maintained by the administrative office . Vaccination for Hepatitis B is provided to all staff members who are not vaccinated. b.Employee health programme: Employee health education: Periodic classes are conducted for paramedical staff by the Infection Control Officer(Senior Consultant Microbiologist)/Infection Control Nurse. All employees are instructed about universal precautions & PEP, isolation policies, hand washing protocols and waste management. All infections including cutaneous and or other diagnosed communicable diseases e.g. hepatitis, mumps, rubella, measles, chicken pox, diarrhoea, productive cough more than two-three weeks, rashes etc., are to be reported by staff to their immediate supervisor at which time appropriate action to protect the patients in the hospital will be taken. All staff is informed that they should report exposure to potentially infectious body fluid to their immediate supervisor who in turn informs the Infection Control Nurse or concerned person in absence of ICN. Action is taken after assessment of risk at each situation. Work restrictions may be imposed in situations which call for such action. Personnel shall adhere to policies and practices to minimize the potential spread of diseases and /or infection. Personnel shall adhere to existing employee health requirements. c.Managing exposure to potentially infectious body fluid: Categories of exposure: 1. Needle stick injuries 2. non- intact skin exposure 3. Mucosal exposure e.g. Splash into eye Immediate action to be taken 1. Needle stick injuries: Briefly induce bleeding from the wound. Wash for 10 minutes with soap and water. Immediately report (within 2hours , maximum 72 hours of accidental/occupational exposure) to supervisor and direct the exposed Health Care Worker staff to Infection Control Officer who will assess SC(Source Code) & EC(Exposure code) and in consultation with Physician, advice for appropriate PEP(Post Exposure Prophylaxis).Record of such exposure to staff will be maintained by Hospital Superintendent Office. 2. Non intact skin exposure: Wash for 10 minutes with soap and water. Immediately report to supervisor and direct the exposed Health Care Worker staff to Infection Control Officer who will assess SC(Source Code) & EC(Exposure code) and in consultation with Physician, advice for appropriate PEP(Post Exposure Prophylaxis). Record of such exposure to staff will be maintained by Hospital Superintendent Office. 3. Mucosal exposure e.g. splash into eyes Wash for 10 minutes by using clean water or normal saline to irrigate the eye. The eyelid should be held open by another person wearing sterile gloves. Do not use soap and water or disinfectant. - 7 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) Immediately report to supervisor and direct the exposed Health Care Worker staff to Infection Control Officer who will assess SC(Source Code) & EC(Exposure code) and in consultation with Physician, advice for appropriate PEP(Post Exposure Prophylaxis). Record of such exposure to staff will be maintained (in written record format) by Hospital Superintendent Office. Management: If index patient is known, patient is checked for HIV antibodies(after obtaining written informed consent), HBsAg & HCV . Injured/exposed health care worker is checked for HIV antibodies(after obtaining written informed consent), HBsAg & HCV . For HIV: NACO guidelines are followed for assessment of risk and suggestions are acted upon. Guidelines are appended to this manual(Appendix I on page no.33). For HBV infection: In case source patient is positive: If health care worker has adequate anti HBs titre - >100MIU- only reassurance need be given. If titre is <10 give first dose of vaccine and immunoglobulin 1000units.Advise to complete vaccination. If titre is between 10& 100 MIU give booster. In case source patient is negative: Check health care worker’s anti HBs titre and proceed accordingly. 8.MRSA: Colonised and infected patients are isolated and barrier nursed. In case of outbreaks selected staff will be screened. If any staffs are found to be colonized, they are restricted from work, advised mupirocin ointment 2% for one week for eradication of nasal carriage and allowed to return to work after two consecutive cultures drawn one week apart are found to be negative. 9.Treatment of personnel 1. All personnel with communicable illnesses shall report to their supervisors. Appropriate evaluation and therapy are the responsibility of the clinician. 2. Personnel who develop infections shall be transferred to duties without direct patient contact or released from duty until no longer considered infectious , as decided by the head of the institution. 3. It is the policy of this hospital that no personnel are penalized .This is to encourage reporting of infection by personnel. 4. Prophylactic therapy is provided to employees following occupational injuries unless employee is already immunized. 5. If serologic tests are required to demonstrate immunity employees shall be assisted at no charge in obtaining these tests. 6. Passive immunization with immune globulin (gamma globulin) shall be considered for the following kinds of exposure(Hepatitis/Varicella zoster/Measles/Rubella). 7. Outbreak of infections within the hospital due to organisms such as salmonella, shigella, meningococci, MRSA may prompt a search for carriers among personnel as part of control of the outbreak. Work restrictions may be imposed in situations which call for such action. 10.Guidelines for Special Situations A. Pregnant personnel 1.Shall not be assigned to care for patients with known Hepatitis B or who are carriers unless they have received three doses of hepatitis vaccine and have been documented to have anti-HBs antibody. - 8 - Document No : Shri Shankaracharya Quality Operating Process SSMISBhi/HAICC/01 Institute of Medical Sciences, Bhilai (C.G.) Manual of Operations of Date of Issue : Hospital Acquired infection 01/01/2018 Control Committee(HAICC) 2.Shall not be assigned to care for patients with rubella, or infants with congenital rubella syndrome or rubella. 3.Will be informed of risks associated with parvovirus and cytomegalovirus (CMV) infections, herpes simplex and of infection control procedures to prevent transmission when working with high risk patient groups. B. Personnel not immune to chicken pox shall not be assigned to care for patients with chicken pox or herpes zoster (disseminated or localized) Also refer “Appendix II ” on page no. 36 for Post Exposure Prophylaxis Guidelines for Occupational Exposure. 11.ISOLATION a.CRITERIA FOR ISOLATION AND PROCEDURES Aim: To prevent the transmission of pathogenic microorganisms within the hospital. To recognize the importance of all body fluids, secretions and excretions in the transmission of nosocomial pathogens To practice adequate precautions for infections transmitted by airborne Droplet & contact . Measures for reduction of transmission: b.HAND WASHING: Frequent hand washing is the most important measure. i.Patient care Hand wash Wash hands after touching blood, body fluids, secretions, excretions and contaminated items, whether gloves are worn or not. Wash hands immediately after gloves are removed. Wash hands between tasks and procedures on the same patient to prevent cross contamination of different body sites. Use a plain soap for routine hand washing. Use antiseptic soap or an alcohol based disinfectant followed by thorough hand washing for accidental skin contamination. Antimicrobial hand washing products should be used for hand washing before personnel care for newborns and when otherwise indicated during their care, between patients in high-risk units, and before personnel take care of severely immunocompromised patients. ii.Surgical Hand Wash Procedural hand hygiene includes a full surgical scrub using running water and 4% chlorhexidene scrub solution from the finger tips to the elbow. The scrub should be performed for a minimum of 2 to 3 minutes. c.GLOVES: Clean, unsterile gloves may be worn as a protective barrier during procedures. Sterile gloves are worn when sterile procedures are undertaken d.PERSONAL PROTECTIVE EQUIPMENT: (PPE) Gowns: A clean, nonsterile, gown is worn to prevent contamination of clothing and skin of personnel from exposure to blood and body fluids. When gowns are worn to attend to a patient requiring barrier nursing, they are removed before leaving the patients environment and hand washing is done. Masks : This equipment is worn to provide barrier protection. Mask should cover both the nose and the mouth. e.PATIENT ISOLATION: Patients are isolated when a.Suffering from highly transmissible diseases e.g. chicken pox. Patient is placed in a separate room. - 9 -