Hic Manual

OMEGA HOSPITALS
MLA COLONY,
BANJARA HILLS, HYDERABAD
HIC MANUAL
HOSPITAL INFECTION
CONTROL MANUAL
OMEGA HOSPITALS
MLA COLONY, BANJARA HILLS,
HYDERABAD
MANUAL CONTROL TABLE

PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)
THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

PRINTED AND UNLESS STAMPED WITH MASTER COPY/CONTROLLED COPY.
Page 1 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Manual Control Information:

Manual Title
HOSPITAL INFECTION CONTROL MANUAL
Manual Code
OH/QAD/HIC.MNL
Version Number
1.0
Manual Status
Approved
Issue Date
10th March 2014
Effective Date
11th March 2014
Date of Next Review
Annually
Reference
NABH 3rd edition
Manual Review:
Version
0.1 & 0.2
Amendment
Few Documentation & Procedures changed.
1.0
Header and Footer changed.

Final approved copy
Controlled Copy Distribution Record:

Sl. Controlled
Copy No. of Issued to
No. Document No.
PREPARED BY:
Copies
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
Receiver Sign.
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 2 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
01/02
01
HIC Department
01/02
01
Nursing Department
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 3 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
RELEASE AUTHORISATION
This update HIC Manual is released under the authority of
Dr. W.I. Kiran
Omega Hospitals, Hyderabad and is the property of
OMEGA HOSPITALS
MLA COLONY, BANJARA HILLS, HYDERABAD
ANDHRA PRADESH, INDIA
SIGNATURE
NAME
: DR. W.I. KIRAN
DESIGNATION
PREPARED BY:
: MEDICAL
CHECKED &DIRECTOR
REVIEWED
APPROVED BY:
CONTENTS
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Dr. W.I. KIRAN

(MEDICAL
DIRECTOR)

Page 4 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Sl. No.
TITLE
Page No.
1
2
INTRODUCTION
INFECTION CONTROL PROGRAM
9
10
INFECTION CONTROL COMMITTEE
12
3.1
HIERARCHY
13
3.2
FUNCTION
14
3.3
FREQUENCY OF MEETING
14
INFECTION CONTROL TEAM
15
4.1
5
FUNCTION
REPORTING OF COMMUNITY ACQUIRED INFECTIONS TO GOVT
15
26
5.1
HEALTH AUTHORITIES
REPORTING METHODOLOGY
26
5.2
NOTIFIABLE DISEASES
27
VARIOUS HICC SURVEILLANCE
28
NOSOCOMIAL INFECTION
31
7.1
CDC GUIDELINES
31
7.2
INFECTION PREVENTION METHODOLOGY
34
STANDARD PRECAUTIONS
44
8.1
STANDARD PRECAUTIONS IN CLINICAL LABORATORY
48
TRANSFUSION SERVICES
RECOMMENDATIONS FOR PATIENTS KNOWN TO HARBOR BLOOD
53
9.1
BORNE PATHOGENS
INSTRUCTION FOR WARDS
53
9.1.1
HAND HYGIENE & GLOVING
54
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 5 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
9.2
CARE OF SYSTEMS AND INDWELLING DEVICES
64
10
11
ISOLATION POLICIES & PROCEDURES

VISITORS POLICY
71
79
12
12.1
INFECTION CONTROL IN SPECIAL CARE UNITS/HIGH RISK AREAS

INFECTION CONTROL PRACTICE IN OT
80
81
12.2
INTENSIVE CARE UNITS
88
13
COLLECTION AND TRANSPORTATION OF SPECIMENS
94
14
15
16
SAFETY IN LABORATORY
INFECTED OR SOILED LINEN MANAGEMENT
HANDLING OF HIV POSITIVES PATIENTS
97
98
100
16.1
NURSING CARE
101
16.2
HOUSEKEEPING WITH HIV PATIENTS
103
17
CSSD RECALL POLICY
105
18
ENGINEERING CONTROL
107
19
EMPLOYEE HEALTH
111
20
PROTOCOL OF SCHEDULE FOR ACTIVE SURVEILLANCE SWAB
116
21
INFECTION CONTROL PRACTICES IN AMBULANCE
118
22
SHARP DISPOSAL
121
23
MEDICATION INJECTION PRECAUTION & PROTOCOL OF LOADED
124
24
25
26
27
SYRINGES
RE-USE SINGLE USE MEDICAL DEVICES
ENVIRONMENTAL CONTROL
INFECTION CONTROL IN ANCILLARY AND RISK AREAS
DECONTAMINATION & DISINFECTION OF GENERAL ITEMS
126
134
136
144
27.1
HIGH RISK CATEGORY
149
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 6 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
27.2
INTERMEDIATE RISK CATEGORY
150
27.3
28
LOW RISK CATEGORY

OUTBREAK MANAGEMENT
151
153
29
30
FREQUENCY FOR UPDATING INFECTION CONTROL MANUAL

QUALITY INDICATOR
157
158
31
RECORDS HIC DEPARTMENT
159
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 7 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
1. INTRODUCTION
Infection control includes the prevention and management of infection through the application
of research based knowledge to practices that include: standard precautions, decontamination,
waste management, surveillance and audit.
The overall aim of this document is to provide evidence based information in the prevention and
control of infection in this hospital. To fulfill this aim the hospital infection control committee
has been formed that will look after the infection control needs of the hospital.
It is relevant to all staff including doctors, nurses, other clinical professionals and managers
working at Omega Hospital, Hyderabad to help fulfill their legal and professional obligations
with regard to both communicable diseases and infection control.
The manual identifies the high risk areas of the hospital.
It outlines the methods of surveillance in the identified high risk areas.
It focuses on adherence to standard precautions and isolation policies & procedures.
Disinfection and sterilization practices.
Kitchen sanitation and food handling issues.
Engineering controls to prevent infection.
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 nosocomial infections at Omega Hospital,
Hyderabad.
3. To frame antibiotic policy and monitor its adherence by the prescribing authorities.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 8 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Scope
All inpatient and outpatient areas including diagnostic facilities
Responsibilities
Hospital Wide
2. INFECTION CONTROL PROGRAM
The infection Control Program is a method of preventing hospital-acquired infections.
OBJECTIVES
i.
To develop written policies and procedures for aseptic practices in the hospital
ii.
To implement these procedures in specific situations and areas.
iii.
To provide surveillance for nosocomial infection.
iv.
To review and analyse the infections that occur in order to take corrective steps.
v.
To develop corrective measures to control, prevent or minimize the risk of nosocomial

infections.
vi.
Statutory provisions with regard to bio-medical waste management are complied with.
vii.
To train the staff and support employee health.
Purpose
i.
To provide maximum protection, against infection, for patients, personnel, and visitors
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 9 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
while in health care setting.
ii.
To ensure compliance with standards for infection control.
iii.
To ensure continuous feedback of information related to the prevention and control of

infection, especially communicable infections, to physicians, dentists and other
healthcare providers.
iv.
To recommend risk reduction practices by integrating infection control principles into

all standards of practice.
Policies
i.
There shall be an active infection control program.
ii.
Staff shall be made aware of infection control policies and procedures and their role in
surveillance, prevention and control.
iii.
There shall be specific departmental infection control policies and procedures written
for all hospital departments.
iv.
The prevention and control methods and surveillance strategies shall be evaluated for
effectiveness throughout Hospital.
3. INFECTION CONTROL COMMITTEE

Organization of infection control committee
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 10 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
The ICC is responsible for day-to-day infection control activities within the hospital. It has the
following members
CEO/NABH COORDINATOR/
MEDICAL Director/CHAIRMAN HICC
Consultant Microbiologist & HICO-HICC COORDINATOR
Clinician from different specialties (HOD Surgical oncology and HOD Medical
oncology).
Consultant Anaesthetist
Quality manager.
Nursing In-charge
Kitchen In-charge /Dietician
CSSDIn-charge
HousekeepingManager
Infection Control Nurse
3.1 Organogram or Heirarchy for HICC:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 11 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
CEO / NABH Coordinator
Chairperson HICC /Medical Director

Quality HOD
Microbiologist / HICC Coordinator
Nursing Superintendant
HICN
Inputs from all wards, inpatients and house keeping & kitchen depts.,etc.
3.2 FUNCTIONS
The HICC carries out the following functions:
Develops infection control policies and procedures in hospital
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 12 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
The ICC acts as a source of expertise on matters relating to infection control:
Ensure that corrective action and control measures are taken in the event of outbreaks of
infection.
Monitors functional compliance with infection control policies and procedures.
Develops educational program about infection control policies and practices for hospital
staff.
Reviews hospital infection control policies and procedures every two years.
Designs and determines the type of surveillance and reporting programs.
Assigns responsibility to an individual or a department to carry out actions or

recommendations.
Advises on specific areas of hygiene and infection control like ICU, CSSD, ventilation,
operating theatres, etc in High risk wards and kitchen food safety policy etc.
Involves the HICC team for any HIC programme implementation.
Work after employee health policy and vaccination programme.
3.3 FREQUENCY OF MEETING

The infection control committee meets regularly (once in A month).
The head operation appoints the chairperson, infection control committee, and the
members of the infection control committee and their alternates.
Head of the department notifies the infection control committee, of any change of
representatives or alternates.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 13 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
4. HIC TEAM
It is a subcommittee of the infection control committee meant for field implementation of the
various HIC activities and for corrective actions implementations.
It takes care of hospital environmental engineering and maintenance engineering and public
health measures and also high risk ward care and visitors policy care etc and BMW
management, safe water supply, water tank cleaning, A/c cleaning, ROR plant maintenances etc.
Its members comprise some of the members of HICC along with BMW In-charge, biomedical
engineer, OT incharge, CSSD incharge, High risk wards in-charge, Laundry in-charge, Quality
department, Nursing superintendant, Housekeeping in-charge and supervisors, Security, Front
office incharge in OPD, Radiology and Lab department in-charges, Medical records incharge,
Stores and purchase manager,Kitchen incharge, food safety committee member or dietician,
Physiotherapist, etc.etc.
HICC Committees functions and Responsibilities:
4.1 HICC FUNCTIONS:i.
CEO / NABH coordinator/
Approves the nominated chairperson and other member of HICC committee and team.
He represents the management.
Authorises HICC for corrective actions to be taken for control and prevention of HAI
infections.
He sanctions infection control budget and monitor various activities and academic
programmes.
He personally monitors the surveillance activities thro quality department and MD etc.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 14 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
And advises accordingly.
ii.
Chairman, HICC / Medical Director/

Convens meeting of the infection control committee not less than once in two monthly;
more often if necessary.
If an urgent matter arises, assembles as many members of infection control committee as
possible, but not less than the following:
Him / herself, Here vies recommendations from preventive and control members.
The chief of the concerned department service and discuss with HICO and other
department and HICC team to solve any HIC related problem.
Serves as a permanent core member of the infection control committee.
Coordinates the field-wide implementation of the Hospital infection control program.
Supervises the accurate collection of infection control data and participation in the
analysis of the data; prepares summary report for the infection control committee.
Informs Hospital staff of new developments in infection control and acts as a
professional resource regarding state-of-the-art development.
Conducts prospective prevalence studies periodically to evaluate the effectiveness of the
surveillance system to keep all HIC rates within benchmark levels.
Serves on or consult with committee in-charge of evaluating procedures or equipment,
which has an impact on infection control activities.
Coordinates and assists with employee orientation and in-service education program
related to infection control
Collaborates with all departments in the development, review and revision of infection
control manual.
Acts as a consultant regarding infection control issues.
iii.
HICC Co-ordinator /Consultant Microbiologist/HICO
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 15 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Convenes meeting of the infection control committee and HIC team also:
Does detailed tracking analysis report for any outbreak / HAI within hospital and discusses
in HICC meeting for corrective action and implementation.
Takes active part in surveillance activities and HIC programme implementation along with
HICN.
Advises and reports to the head operation on all matters relating to infection control.
Supervises the infection control nurse and NS for infection control activities fir HICC.
Develops and improve infection control policies and procedures for Hospital.
Organize the infection control committee meetings during any outbreak or emergency.
Implement surveillance activities and audit the kitchen, CSSD etc.
Provide adequate infection control training for the staff as part of CNE and CME
programme.
Monitors all the functions of HICN and helps her with valuable advices reqd. HIC topics
and monitors high risk wards functions and isolation care etc.
Implements all corrective actions thro HIC team for control of HAI'S in hospital.
iv.
Quality Manager / HOD
They will be taking active part in passive and active surveillance program meat for HICC
in order to prevent and control of HAI.
They will be collecting data and monitoring the activities of the department and keeping
the records.
They will be reporting the updation and developments about the HICC activities to the
CEO/MD.
They will be coordinating HICC activities along with other department activities.
Monitoring the CNE / CME teaching programs and also ward training programme to
housekeeping staff and ward nurses by HICN and nursing department, etc.
Take active role in induction training HBV vaccination programmes and employee health
policy, food safety protocols implementation etc.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 16 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
v.
Infection Control Nurse (ICN)

The ICN proves assistance to the Microbiologist for the prevention and control of infection
in the hospital.
Detects and investigates suspected nosocomial infections on a systematic and current basis,
and collects relevant information from wards and staff and housekeeping staff.
Investigates all significant infection control problems, implements all
HICC
recomendations and brings all HIC related swabs and samples to lab.
Prompts the initiation to inform for Notification of infectious Diseases, when indicated and
distributes minutes to all wards.
Initiates follow-up cultures on patients and contacts when indicated, and recommends
other studies to confirm or rule out a suspected infection and take part proactively in HICC
surveillance programme
Assists in the development and the annual review and revision of infection control policies
and procedures and monitor their implementation and maintains all HIC related records
and informs quality department / Nursing superindant etc.
Inspect the environment and observes personnel activities for the purpose of detecting
possible infection hazards and evaluating compliance with standards set by the infection
control committee, does daily and weekly rounds and reports to microbiologist and hicc
coordinator and instructs, the housekeeping staff also.
Routinely monitors compliance with Hospital policy on isolation of patients with
community-acquired or nosocomial infections, which require special care and monitors
bundle care and fumigation in high risk areas.
Also monitors kitchen hygiene and food handlers screening, NSI victims care, isolation
care, All high risk wards, BMW central collection area, infected linen policy and visits GJ
multiclave company and laundry also periodically.
Takes part activity in internal audit activities and reivew meetings submits monthly reports
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 17 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
look after Hospital employee health programme, maintain food and water analysis reports.
Coordinates and assists with employee orientation and in-service education and also
takesup programs related to infection control training to by ward cleaners, to nurses and
housekeeping staff classroom and wards trainings also to them..
Follow-up of all infections in Hospital personnel and assists in the development of the
Hospital Employee Health program and HBV vaccinatic programs and MRSA carriers
screenigprogramme etc.
Collaborates with the clinician and nurses about the routine monitoring of the units, which
are particularly vulnerable to infection problems.
Works with the Microbiologists and nursing superindant and quality department etc, to
identify, analysis and determination of HIC indicators and its report dissemination to wards
and assists in outbreak investigations SOS.
vi.
Nursing Staff and Nursing In-charge
Adhere to the infection control policies and procedures and maintain ward hygeine.
Knows the nursing functions essential to the prevention, recognition and management of
infection and monitor housekeeping staff functions in ward.
Adhere to measures of infection control, including hand washing and isolation techniques
and use of PPE and implement aseptic precautions in barrier nursing.
Report any signs of infection to the attending physician/surgeon and record the findings in
the nurse's notes and them alerts any cross infections.
Alert infection control nurse of suspected or confirmed infections or NSI or outbreaks etc.
Institute isolation or precautionary measures when an infectious disease is suspected ;
inform the attending physician/surgeon as soon as possible.
Participate, in orientation and continuing education program for infection control.
Adhere to the Hospital Employee Health program and HBV vaccination programme.
Nursing in-chargecoordinates with quality department and HICO and HICN and MD etc.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 18 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
vii.
Microbiology Laboratory and Environment Health departments
Provide laboratory support for infection control activities especially in microbiologist lab
and perform serology HAV, HCV, HBV screenings etc.
Processes all surveillance swabs and reports to concerned department as per protocols and
schedules.
Kitchen swabs and samples and MRSA screening is also done for staff.
Maintenances department looks after A/c, plumbing sanitation works, sewage plant, water
plant, ROR plant, safe water supplies and other environmental engineering controls and
food safety rules etc.
viii.
Housekeeping department:
To carry out lab investigations of HICC surveillance and develop guidelinesfor transfer
and handling of lab samples.
To review antibiogram and provide summary report of prevalence of resistance, to detect
carrier among staff does environmental surveillance when needful.
Special about for MRSA, VRE etc.
To coordinate with ICO / Infection Control nurse.
To provide inputs to develop policies for appropriate cleaning techniques
To provide inputs to procedure, frequency, agents used, etc., for each type
of room, from highly contaminated to the most clean, and ensuring that these practices
are followed
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 19 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
To provide inputs develop policies for collection, transport and disposal ofdifferent types
of waste (e.g. containers, frequency).
To ensure that liquid soap and paper towel dispensers are replenished regularly
To inform the maintenance service of any building problems requiring repair:Cracks,
defects in the sanitary or electrical equipment, etc.
To care for flowers and plants with in hospital premises.
To carryout pest control (insects, rodents) activities.
To provide inputs to develop policies for the collection and transport of dirty linen.
To provide inputs to develop criteria for selection of site of laundary services for
ensuring appropriate flow of linen, separation of clean and dirty areas and
recommending washing conditions(e.g. temperature, duration)
To provide inputs to ensuring safety of laundary contaminated with potential pathogens.
ix.
Role of Clinician
Taking all aseptic precautions in patient care, try to minimize nosocomial infection rate.
Following procedures of frequent hand wash, supporting and implementing all policies
of HICC team.
Protecting their patient from infections, complying with antibiotic and disinfection policy
and notify communicable diseases.
Advising patients, visitors & staff on techniques and preventive care infections and other
transmission of infections.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 20 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
x.
Role of CSSD
The responsibilities of the central sterilization service are:

To clean, decontaminate, test, prepare for use, sterilize, and store aseptically all sterile
hospital Equipment & linen.
To work in collaboration with the Infection Control Committee and other hospital programs
to develop and monitor policies on cleaning and decontamination of:
Reusable equipment.
Contaminated equipment including
To oversee the use of different methods Chemical and bacteriological indicators to monitor
the sterilization process of autoclave and ETO sterilization .reprocessing of single use
disposable items are sterilized in ETO sterilizersesp. the plastic and rubber material tubes
and catheters etc
To ensure technical maintenance of the equipment according to manufacturers'
recommendations the items supplied by CSSD aredressing sets and padsand packs,
&instruments sets. We have to check for integrity or tears or breakages in packages
To report any defect to administration, maintenance, infection control and other appropriate
personnel. Whenever HBV OR HCV OR HIV positive pts. usedinstruments are sent it is
handled with spl. Care and soaked in cidex for 1 hr and rinsed in hypochlorite also.
To maintain complete records of each autoclave run, and ensure long-term availability of
records items are received and after cleaning they are packed and sterilized .the recall
register is also maintained whenever there is breakdown or whenever controls are not
working .in case of installation of new autoclave 3 consecutive spore tests are obtained when
running an load and it is not used till all are negative.
To collect or have collected, at regular intervals, all outdated sterile unit the sterile storage
room is also cleaned with bacillocid and postfumigation swabs are also sent, in order to
maintain sterile atmosphere there.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 21 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
To communicate, as needed, with the Infection Control Committee,the nursing service, the
operation theatre .recall policy isapplied for inappropriate packing &loading, poorsteam,
insufficient time sterilizer malfunctions, biological indicators not showing correct results,if
packs are open or blood stained because of improper cleaning etc.
xi.
ROLE OF PHARMACIST
To maintain all drug records including for antibiotics,high risk medicines & narcotic
drugs,, TO store and dispense vaccines ,disinfectants ,antiseptics and distilled water and
IV fluids etc .
The storage conditions are to be monitored .viz. temperature, light,humidity etc and to
maintain pharmacopeia of drugs
To restrict high end antibiotic usages and its sale at counter.they are proactive members
of antibiotic usage and drugs committee and also HICC committee.THEY are the most
proactive members of pharmaceutical and drugs committee .
xii.
MANAGEMENT ROLE IN HIC PROGRAMME:
The management makes available all resources which are needful for conductivity HIC
program, and HIC surveillance at hospital. They allot separate budget for HIC committee
program implementations. All the supplies for PPE and spillage kit supply and pharmacy
and drug supplies are adequate.
The organization take proactive role in adequate training of staff home keeping staff and
doctors (DMOs) by periodically cleaned. Our HR department Conducts induction training
class for new staff. Our organization are also encourage our lab doctors and staff to attend
once in year at leastcertificate training program for HICNS, Doctors and consultants and in
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 22 of 260
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charges etc, by their training schedule his is the management this is done as part of quality
implement programs.
The standards are maintained and monitored in various departments and regular meeting are
also here by management in quality committee, safety committee, and HIC committee.
The feedback data is analyzed and discussed for further important which has to be
sustained. The quality program of service should be integrated into organizational quality
plan.
The organization defenses its sanctioned events. And monitors all programme
implementations .thy are the ultimate supervisory body for this HIC programme
xiii.
ROLE OF HOSPITAL MANAGEMENT IN HICC ACTIVITIES:
Establish multidisciplinary infection control committee and coordinate activities of

HICC and infection control team and the clinicians and nursing or HK staff etc
Identify and allocate adequate resources from annual budget for implementation of
various HICC programs and policies.
To ensure all CME, CNE activities for its staff, HK staff etc
To review quality indicators of HICC and encourage surveillance activities.
To implement induction training for all new employee and explain aim, objectives and
mission of the hospital through HR dept.
To ensure adequate supplies of gloves, masks, disinfectants etc
To ensure employee health programs and policies, and to monitor the correct spending of
HIC budget for its purposes.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 23 of 260
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To ensure pre-and post exposure prophylaxis programs. to notify the reportable diseases
as per given list to the GHMC public health authorities.
To discuss and implement corrective measures during HICC meetings. And do tracking
analysis in case of any outbreaks. They should also encourage the staff and drs to attend
any academic summits to update themselves.
They should allocate separate budgetary provisions to HIC dept and see that it is spent
properly for active and passive surveillances and suastainances and monitoring of
various HICC activities.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 24 of 260
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5. REPORTING OF NOTIFIABLE DISEASES AND ANY EPIDEMICS, CASES TO
GOVT HEALTH AUTHORITIES: (AT GHMC)
Hospital should have the policy to reportable diseases to the local health authorities. For certain
infections, even one case may be of extraordinary importance in the context of present day
epidemiology. Every such case has to be considered significant by the public health authorities
and immediate steps taken to find further cases and to prevent further infection.
Dengue and cholera are examples.
Childhood vaccine preventable diseases are reportable since a case is evidence for
inadequate.immunization in the area of residence of children with such disease. For the above
reasons, reportable disease should be informed without delay and with complete residential
address to the health authorities.
Acquired immune deficiency syndrome and human immunodeficiency Virus infection HBV /
HCV infections have recently been included in the list of reportable disease by government
directive. However reporting is only for statistical purposes of determining the time-trend of
prevalence. Moreover, strict confidentiality of the identity of the person is to be maintained,
hence the report will not contain the identity of the individual.
5.1 REPORTING METHODOLOGY
Although the medical supt. is ultimately responsible for reporting, the reporting process begins
from the time of diagnosis, either at the bedside or in the laboratory. Thus the flow of
information will be from the clinicians and microbiologists, to infection Control Nurse, to the
MRD department and Medical Director to public health authorities. (GHMC). Omega hospitals
sent the notifiable diseases to the GHMC on monthly basis.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 25 of 260
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Notifiable diseases
Cholera
Cerebro-spinal fever
Diphtheria
Denguefever
Enteric Fever
Gastro-enteritis and cholera
Hepatitis
Leptospirosis
Measles
Plague
Paralytic Poliomyelitis
Rabies
Scarlet Fever
Tuberculosis
Leprosy
Typhus
Viral encephalitis
Infective Hepatitis (A,B,C)
Typhoid
Whenever sputum AFB positive open case of TB is detected at our hospital or if any pt
with swine or bird flu symptoms
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
are coming across at our hospital IP/OP then
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 26 of 260
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immediately they are referred to chest hospital/OGH/GH etc for further management and
domiciliary treatment as ours is basically only an superspeciality oncology hospital with
scarecely visiting physician services here .NO INFECTIOUS AND COMMUNICABLE
DISEASED PTS ARE ADMITTED HERE .
In case of an epidemic:
1. Acute gastroenteritis
2. Viral hepatitis
Hospital staff informs the infection control team immediately when the following
Organism/conditions are confirmed
MRSA- POSITIVE site of colonization/infection
Beta- Haemolytic Streptococcus Group B
Pseudomonas aeruginosaMDR strain
Acinetobacter spp.
Enterococci vancomycin resistant
Any other uncommon or unusual organisms
Hepatitis B and C
Human immunodeficiency Virus (HIV)
As ours hospital is an basically oncology hospital we do not admit above said

communicable diseases cases and we refer them to OGH/GH/TROPICAL MEDIINE
FEVER hospital . The only notifiable diseases which we intimate to GHMC authorities is
about HBV, HCV, HIV CASES ONLY MONTHLYWISE.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 27 of 260
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6. VARIOUS HICC SURVEILLANCE (BOTH PASSIVE AND ACTIVE TYPES)

ACTIVITIES UNDER TAKEN AT OMEGA HOSPITALS HYDERABAD
We do OT Environment Surveillance by post fumigation Swabs and Open settle plate
methods.PESTICIDE SPRAY IN HOSPITAL IS MONITORED REGULARLY and spillage
incidences are recorded and documented.
CSSD Sterile storage room post fumigation swabs are done periodically .BMW
policy ,INFECTED LINEN POLICY AND ITS DISPOSAL and BMW segregation is
monitored daily and sharps policy and safe injection practices are also monitored closely and
advices given to staffSOS .
ETO Sterilized items swabs taken for each lot for microbial growth if any AND BIOLOGICAL
CONTROLS
FOR
AUTOCLAVE AND ETO
STERILISER
ARE
ALSO
TESTED
PERIODICALLY and RECALL POLICY MONITORED.

All device tips are also sent routinely for culture and sensitivity for Surveillance purpose. &FOR
CONFIRMATION OF COMMON NOSOCOMIAL INFECTIONS. We also monitor whether all
nurses and HK staff are following all universal standard precautions for barrier nursing and
aseptic care of pts to prevent cross infections and nosocomial infections etc IN WARDS and
HIGH RISK AREAS.
Disinfectant from OT and Casualty OP or Surgical Wards & minor OT and dressing room are
also sent periodically for culture and Sensitivity. THE use of savlon in hospital is discouraged
THE HICN visits BMW company site twice or thrice in year and laundry and linen outsourcing
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 28 of 260
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area once in quarterly or so to note down their standard protocols and their improvement.
All the High risk wards including isolation room etc Post fumigation Swabs are also
processed.After NSI serology testing is done for victim and ptsalso and HBV Vaccination
programme among staff is also monitored monthlywise . NSI injury file is also maintained
.ALL HIC indicator rates data are documented and disseminated to all wards and quality dept
.HICC minutes of monthly meeting are prepared and corrective actions will b discussed for its
effective implementationsake.
After Hand Wash or Hand Rub Swabs are taken from Hand to assess the effective
implementation of its procedural steps. Hand wash audits are regularly conducted monthly by
studying its compliance among Consultants, DMOs and Nurses and Housekeeping staff etc
A/C Filters Swabs are sent periodically from high risk wards and OT to see any mold or aerobic
spore bearers contaminations. Bed sores healing among inpatients is recorded & alpha beds use
is noted.
CME, CNE, and Health education Training and induction training etcprogrammes are regularly
conducted for Duty doctors Nurses and HK Staff and Strict Compliance is advised for their
attendance purposes. THE Regular classroom training and daily ward wise intensive training is
also given.
Swabs from Nose and Throat and Hands are periodically taken for all Staff especially from High
Risk wards and food handlers for MRSA carriers detection. Daily rounds are done for
monitoring of HIC surveillance activities .Notifiable diseases are reported to GHMC authorities
monthly wise through MRD dept.
Water Samples & food samples are tested every month in NABL Accreditated lab from all
sources and ROR water plant functions are monitored.
During Tracking Analysis report study various samples are tested to detect the possibility of
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 29 of 260
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Nosocomial infections. And to detect any outbreaks etc corrective actions will b undertaken to
prevent any such recurrences .CHLOREHEXIDINE antiseptic is used for IV site preparation for
preventing Peripheral thrombophlebitis and CLABSI infections .Similarly Bundle care and
preventive care methods are advised to all staff to prevent VAP/HAP/SUTI/SSI/CLABSI etc
Nosocomial infections .
THE HIGH end antibiotic audit is done every month and its use monitored and culture samples
sending is encouraged to justify our antibiotic prescriptions etc DEescalation of antibiotics to
lower level after seeing antibiogram reports or stopping of such antibiotics after clinical
improvement is advised after its use for 5 to 7 days for critical care pts especially in order to
control and prevent growing Bacterial Resistance in Hospital.
Kitchen workers are screened serologically and they are periodically tested for any carrier state
and they revisited daily for assessing area hygiene and personal hygiene of food
handlers.working surface areas are tested by swabs weekly to assess any bacterial
contaminations etc . Microbiologist is a regular member of food safety committee also.
6.1 PROTOCOL OF SCHEDULE FOR ACTIVE SURVIELLANCE SWAB
1.
SICU, MICU
Every
Swab from various dust Aerobic bacteria
month(According to settling areas. Swab from

patients occupancy)
dressing
trolleys,
patients bed, floors and

equipments,
2
Central
Sterile Weekly
tables
A/C. filters
once(post Chemical check
&
tube, Aerobic bacteria
Supply department. fumigation)
Biological
(CSSD)
from each cycle. Settle
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
indicators
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 30 of 260
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plate count & Swabs
from CSSD every week
3
Operation Theatre: After

I & II
every Swabs
fumigation
Twice a month
4.
5.
6.
Operation theatres
After
3 &4
fumigation
from
operating Swab from

various dust
Tables, lights, Trolleys,
setting areas as
Suction machine, A/C above. For
Bacteria (as
filters & anaesthesiatrolly
above)
& floor etc.
every Settle plate count method
turbid
AEROBIC
& swabs are taken from ORGANISMS

different articles & sites n
/every Swabs taken from the Pseudomonas
Disinfectants
If
Nursing staff
month
disinfectant
QUARTERLY FOR Swabs are taken from MRSA,
HIGH RISK WARD hands of nursing staff and
STAFF
nostrils randomly.
s,
Swabs taken table tops at MRSA
all nursing station
7.
Drinking water & Every month

ROR
water
periodically
Coolers and suppliers
sent
Presence of coli
form and TVC
to
(Total
NABL accreditated
count)
lab
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
viable
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 31 of 260
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8
General ward
Quarterly
For aerobic Organisms
Swabs are sent
7. NOSOCOMIAL INFECTIONS
A nosocomial infection is one that is acquired in a hospital or health care facility and was
notincubating at the t-ime of admission. For most bacterial infections the onset of symptoms
more than 48-72 hrs after admission and within 10days after hospital discharge are defined
as nosocomial or hospital acquired. Surgical site infections are considered nosocomial if the
infection occurs within 30days after the operative procedure or within 1year if a device or
foreign material is implanted.
The hospital takes action to prevent or reduce the risks of hospital associated infections (HAI)
The organization monitors urinary tract infections of all indoor patients.
The organization monitors respiratory tract infections
The organization monitors intra vascular device infections
The organization monitors surgical site infections
7.1 CDC Guidelines:

Center for Disease Control has given case definitions for various nosocomial infections
I.
Surgical site Wound Infections
a. Superficial Incision surgical site infection:

Infection occurs within 30 days after operation and involves skin or
Subcutaneous tissues of incision site.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 32 of 260
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HIC MANUAL
i.
Purulent drainage from superficial incision with or without laboratory confirmation.
ii.
Organisms isolated from aseptically collected fluid or tissue from superficial

incision.
iii.
At least one of the signs and symptoms of infection-paint/tenderness, localized

swelling and redness.
b. deep incision surgical site infection:

Infection occurs within 30days after the operation if no implant is left in place or within one year
if implant is in place and infection appears to be related to the operation. Infection involves deep
soft tissues (eg: facial and muscle layers) of the incision.
1. Purulent drainage from deep incision but not from organ/space component of the surgical
site.
2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the
patient has at least one of the following signs and symptoms-fever>38 deg Celsius,
localized pain or tenderness unless culture of the incision is negative.
3. An abscess or other evidence of infection involving the deep incision is found on direct
examination, during re-operation or by histopathologic or radiologic examination.
c. Organ / space surgical site infections:
i.
Purulent drainage from a drain placed through a stab wound into the organ or space.
ii.
Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ
or space. Within one month period after operation .
iii.
An abscess or other evidence of infection involving organ or space on direct

examination, during re operation or by histopathologic or radiologic examination.for
cases of prosthetic surgeries it is one year cutoff period it is confirmed by pus c/s or
by surgeons opinion . FOR PTS WITH PROSTHESIS OR IMPLANTS the time limit
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 33 of 260
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for SSI taken is one year period
II.
IV Catheter Related Blood Stream Infection

i.
Systemic signs of infection
ii.
Colonization of more than 102c fu in quantitative or >=15 colonies in qualitative

culture of the catheter.
iii.
Isolation of same organism from catheter and from a concurrent blood culture of a
patient with sepsis syndrome. ,,along with s/s of inflammation at the site of central
cannula wih discharge .
III.
Nosocomial Pneumonia/VAP/HAP
i.
New or progressing pulmonary infiltrate, fever, leucocytosis and purulent tracheal

secretions. ,,for ventilated pts only after 2 to 3 days of devicie insertion .
ii.
Clinical evaluation plus positive quantitative cultures of endotracheal

aspirate/PSB/BAL and microscopic examination of recovered cells from fluid.
iii.
HAP is described for pts wih naso or orogastric intubations with aspiration
pneumonia development after 2 to 3 days of admission .
IV.
Blood Stream Infection/sepsis

i.
Blood culture positive for a bacterium/fungus that is obtained in a patient more

than 48 hrs after being admitted to the hospital.
ii.
Clinical sepsis, fever>38 deg C hypertension and oliguria.focus of infection may

or may not be present at the time of admission .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 34 of 260
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V.
Catheter associated Urinary Tract Infection

a. Clinical sings and symptoms of UTI with a positive urine culture with significant
bacteriuria and microscopy after 2 days of catheterization for those wo develop s/s of
UTI .
b. A count more than 105 cfu/ml can indicate a clinically significant bacteriuria in
catheterized patients.
7.2 INFECTION PREVENTION METHODOLOGY: various bundle care preventive

components strategies are circulated to all staff especially from SICU /MICU etc so
that if followed there can be lowered incidence of such common nosocomial infections
altogether .moreover an checklist is also prepared for various nosocomial infections as
an monitoring process .the other nosocomial infections which occurs on very small
scale are bed sores development during inpatient stay at hospital ,IV line therapy
complications , etc which are too rare in incidences .most of these infections can be
prevented by following hand wash and by use of PPE ETC BARREIR NURSING
TECHNIQUES ETC
Prevention and monitoring of CAUTI
I.
Appropriate Urinary Catheter Use

A. Insert catheters only for appropriate indications, and leave in place only as long as
needed.
1. Minimize urinary catheter use and duration of use in all patients, particularly those at
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 35 of 260
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HIC MANUAL
higher risk for CAUTI or mortality from catheterization.
2. Use urinary catheters in operative patients only as necessary, rather than routinely.
3. For operative patients who have an indication for an indwelling catheter, remove the
catheter as soon as possible postoperatively, preferably within 24hours, unless there
are appropriate indications for continued use.
B. Consider using alternatives to indwelling urethral catheterization in selected patients
when appropriate.
1. Consider using external catheters as an alternative to indwelling urethral catheters in
cooperative male patients without urinary retention or bladder outlet obstruction.
2. Consider alternatives to chronic indwelling catheters, such as intermittent
catheterization, in spinal cord injury patients.
3. Intermittent catheterization is preferable to indwelling urethral or suprapubic
catheters in patients with bladder emptying dysfunction.
II.
Proper Techniques for Urinary Catheter Insertion

a. Perform hand hygiene immediately before and after insertion or any manipulation of the
catheter device or site.
b. Ensure that only properly trained persons who know the correct technique of aseptic
catheter insertion and maintenance are given this responsibility.
c. In the acute care hospital setting, insert urinary catheters using aseptic technique and
sterile equipment.
1. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 36 of 260
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HIC MANUAL
periurethral cleaning, and a single-use packet of lubricant jelly for insertion.
2. Routine use of antiseptic lubricants is not necessary.
d. In the non-acute care setting, clean (i.e., non-sterile) technique for intermittent
catheterization is an acceptable and more practical alternative to sterile technique for
patients requiring chronic intermittent catheterization.
e. Properly secure indwelling catheters after insertion to prevent movement and urethral
Traction
7.3 Appropriate infrastructure for preventing CAUTI
Proper Techniques for Urinary Catheter Maintenance
A. Following aseptic insertion of the urinary catheter, maintain a closed drainage system
1. If breaks in aseptic technique, disconnection, or leakage occur, replace the catheter
and collecting system using aseptic technique and sterile equipment.
2. Consider using urinary catheter systems with preconnected, sealed catheterubing
junctions.
B. Maintain unobstructed urine flow.
Keep the catheter and collecting tube free from kinking.
Keep the collecting bag below the level of the bladder at all times. Do not rest the
bag on the floor.
Empty the collecting bag regularly using a separate, clean collecting container for
each patient; avoid splashing, and prevent contact of the drainage spigot with the
nonsterile collecting container.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 37 of 260
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HIC MANUAL
C. Use Standard Precautions, including the use of gloves and gown as appropriate, during
any manipulation of the catheter or collecting system.
D. Complex urinary drainage systems (utilizaing) mechanisms for reducing bacterial entry
such as antiseptic-release cartridges in the drain port) are not necessary for routine use.
E. Changing indwelling catheters or drainage bags at routine, fixed intervals is not
recommended. Rather, it is suggested to change catheters and drainage bags based on
clinical indications such as infection, obstruction, or when the closed system is
compromised.
F. Unless clinical indications exist don not use systemic antimicrobials routinely to prevent
CAUTI in patients requiring either short or long-term catheterization.
Catheter Materials
A. If the CATI rate is not decreasing after implementing a comprehensive strategy to reduce
rates of CATI, consider using antimicrobial/ antiseptic- impregnated catheters.
The comprehensive strategy should include, at a minimum, the high priority
recommendations for urinary catheter use, aseptic insertion, and maintenance.
B. Hydrophilic catheter might be preferable to standard catheters for patients requiring
intermittent s catheterization.
C. Silicone might be preferable to other catheter materials to reduce the risk of encrustation
in long term catheterized patients who have frequent obstruction.
7.4 STRATEGIES TO PREVENT SSI
1. Infrastructure requirements
a. Trained personnel
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 38 of 260
OMEGA HOSPITALS
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HIC MANUAL
i.
Infection prevention and control personnel must be specifically trained in

methods of SSI surveillance and be adept at providing feedback and
education to healthcare personnel when appropriate.
b. Education
i.
Regularly provide education to surgeons and preoperative personnel through

continuing education activities directed at minimizing preoperative SSI risk
through implementation of recommended process measures.
ii.
Provide education regarding the outcomes associated with SSI, risks for SSI,
and methods to reduce risk to all patients, patients families, surgeons, and
preoperative personnel.
iii.
Education for patients and patients families is an effective method to reduce

risk associated with intrinsic
c. Education
a. Educate surgeons and perioperative personnel about SSI prevention Aand
inform strictly our OPD nurses to write history of operations and site of pus
swab before sending the swab sample to lab for post op pts .
2. Educate patients and their families about SSI prevention, as appropriate
a. Provide instructions and information to patients before surgery, describing strategies
for reducing SSI risk. Specifically provide pre printed materials to patients.
Special approaches for the prevention of SSI
Perform an SSI risk assessment. These special approaches are recommended for use in locations
and/ or population within the hospital that have unacceptably high SSI rates despite
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 39 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
implementation of the basic SSI prevention strategies listed above.
1. Perform expanded SSI surveillance to determine the source and extent of the problem and
to identify possible targets for intervention.
Approaches that should not be considered a routine part of SSI prevention
1. Do not routinely use vancomycin for antimicrobial prophylaxis
a. Vancomycin should not routinely be used for antimicrobial prophylaxis, but it can be an
appropriate agent for specific scenarios. Reserve vancomycin for specific clinical
circumstances, such as a proven outbreak of SSI due to MRSA, high endemic rates of SSI
due to MRSA, targeted high-risk patients who are at increased risk for SSI due to MRSA.
7.5 SRATEGIES TO PREVENT VAP
The core recommendations are designed to interrupt the 3most common mechanisms by which
VAP develop:
i.
Aspiration of secretions
ii.
Colonization of the aero digestive tract
iii.
Use of contaminated equipment
2. General strategies that have been found to influence the risk of VAP
a. General strategies
i.
Conduct active surveillance for VAP
ii.
Adhere to hand-hygiene guidelines
iii.
Use noninvasive ventilation whenever possible.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 40 of 260
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iv.
Minimize the duration of ventilation.
v.
Perform daily assessments
vi.
Educate healthcare personnel who care for patients
b. Strategies to prevent aspiration

i.
Maintain patients in a semirecumbent position
c. Strategies to minimize contamination of equipment used to care for patients receiving

mechanical
d. Strategies to minimize contamination of equipment used to care for patients receiving
mechanical ventilation
i.
Use sterile water to rinse reusable respiratory equipment.
ii.
Remove condensate from ventilatory circuits. Keep the ventilatory circuit

closed during condensate removal.
iii.
Change the ventilatory circuit only when visibly soiled or malfunctioning.
iv.
Store and disinfect respiratory therapy equipment properly
Basic practices for prevention and monitoring of VAP

A. Education
1. Educate healthcare personnel who care for patients undergoing ventilation about VAP,
including information about the following.
a. Local epidemiology
b. Risk factors
c. Patient outcomes
2. Educate clinicians who care for patients undergoing ventilation about noninvasive
ventilatory strategies
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 41 of 260
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3.
HAP is an infection mostly seen in admitted pts due to aspiration pneumonia in pts with
oro or naso gastric feeding tubes . actually they will not have any s/s of pneumonia at all
at the time of admission or before operation but after 3 days of admission he may
develop all s/s of pneumonia which is iatrogenic due to faulty or negligent procedure of
feeding by the concerned nurse .its incidence is very rare at our hospital .
7.6 STRATEGIES TO PREVENT CLABSI

1. Infrastructure requirements
a. An adequately staffed infection prevention and control program responsible for
identifying patients with CLABSI
b. Information technology to collect and calculate catheter- days as a denominator
for computing rates of CLABSI and patient-days to allow calculation of CVC
utilization; catheter days from information systems should be validated against
a manual method.
c. Resources to provide appropriate education and training
d. Adequate laboratory support for timely processing of specimens and reporting
of results
2. Practical implementation
a. Educate physicians, nurses, and other healthcare personnel about guidelines to
prevent CLABI. These guidelines should be easily accessible.
b. Develop and implement a catheter insertion checklist. Educate nurses,
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 42 of 260
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physicians, and other healthcare personnel involved in catheter insertion,
regarding the use of the catheter insertion checklist.
c. Educate healthcare personnel about the insertion and maintenance of catheters.
d. Establish catheter insertion kits/carts containing all necessary items for
insertion.
Basic practices for prevention and monitoring of CLABSI
A. Before insertion
1. Educate healthcare personnel involved in the insertion, care, and maintenance of CVCs
about CLABSI prevention
a. Include the indications for catheter use, appropriate insertion and maintenance,
the risk of CLABSI, and general infection prevention strategies.
b. Ensure that all healthcare personnel involved in catheter insertion and
maintenance complete an educational program regarding basic practices to
prevent CLABSI before performing these duties.
c. Periodically assess healthcare personnel knowledge of and adherence to
preventive measures.
d. Ensure that any healthcare professional who inserts a CVC undergoes a
credentialing process
B. At insertion
1. Use a catheter checklist to ensure adherence to infection prevention practices at the time of
CVC insertion
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 43 of 260
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a. Use a checklist to ensure and document compliance with aseptic technique.
b. These healthcare personnel should be empowered to stop the procedure if
breaches in aseptic technique are observed.
2. Perform hand hygiene before catheter insertion or manipulation
a. Use an alcohol-based waterless product or antiseptic soap and water.
3. Avoid using the femoral vein for central venous access in adult patients
4. Use maximal sterile barrier precautions during CVC insertion
PREFERRABLY USE
BETADINE OR CHLORHEXIDINE FOR PREPARATION OF iv SITE AREA

C. After insertion
1. Disinfect catheter hubs, needleless connectors, and injection ports before accessing
the catheter
2. Remove nonessential catheters
3. Replace administration sets not used for blood, blood products, or lipids at intervals
not longer than 96 hours
4. Perform surveillance for CLABSI
Special approaches for the prevention of CLABSI
Perform a CLABSI risk assessment. These special approaches are recommended for use in
locations and/or populations within the hospital that have unacceptably high CLABSI rates.
7.7 SURVEILLANCE OF NOSOCOMIAL INFECTIONS
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 44 of 260
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MLA COLONY,
HIC MANUAL
Surveillance of nosocomial infection is the foundation for organizing and maintaining an
infection control programme. Information obtained from surveillance data is a useful tool in
identifying areas of priority and allocating resources accordingly. Various swabs are taken for
surveillances and for tracking analysis report sake and root cause is known and thereafter
corrective action is implemented and for sake of further prevention CME & CNE classess are
also conduced for staff to prevent any such rcurrances .
Objectives of Surveillance
Reducing the infection rates within health care facilities.
Establishing endemic infection rates.
Identifying outbreaks.
Convincing medical personnel to adopt recommended preventive practices.
Evaluating control measures.

Targeted surveillance aimed at high risk areas is more effective and manageable. It can be site
specific, unit specific, or outbreak associated surveillance. Both active and passive surveillance
measures are being conducted along with involvement of whole HICC and HIC team etc
.detailed tracking analysis investigation are done and root cause analysis is also done in detail.
Various corrective measures are advised and preventive steps like health education is taken in
order to prevent any such recurrances in future at our hospital.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 45 of 260
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8. STANDARD PRECAUTIONS
Under standard precautions, all patients receiving care in hospitals, irrespective of their
diagnoses or presumed infections statues, should be treated in such a manner as to reduce the
risk of transmission of micro-organisms from health care worker to patient, patient to healthcare
worker, and from patient to healthcare worker to patient.
Cardinal rules of standard precautions
Consider all patients potentially infectious
Assume all blood and body fluids and tissue covered by standard precautions are
contaminated with a blood borne pathogen.
Assume all non sterile needles and other sharps are similarly contaminated.
Purpose
To establish individual responsibilities in order to minimize the transmission of infection to,
from, and between patients and all other people in facilities. The aim is to reduce the risk of
transmission of micro-organisms from both known and unknown sources of infection in the
hospital.
Definition
The measures designed to reduce the risk of transmission of blood borne pathogens and other
micro-organisms from both recognized and unrecognized sources of infection.
Policies
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 46 of 260
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a. Standard precautions are to be used for all patients, to minimize risk to staff and patients.
b. Standard precautions are to be used for contact with.
i.
Blood, body fluids, secretion and excretions regardless of whether or not they
contain visible blood.
ii.
Non- intact skin.
iii.
Mucous membrane.
c. Body fluids which may contain blood borne viruses (e.g. Hepatitis B, Hepatitis C, and
HIV include: Blood, blood- stained body fluids, CSF, semen, tissues, vaginal secretions,
pericardial, amniotic, peritoneal and pleural fluids.
d. Body fluids which may contain other pathogens include;
i.
Faeces, urine.
ii.
Vomitus, sputum.
Procedure for standard infection control precautions

a) Hand Washing
Hand washing is the single most important measure in infection control.
Hand washing should be done:
i.
Before and after patient contact.
ii.
After using gloves
iii.
Before & after any procedure.
iv.
Immediately after contact with blood, body fluids, secretions, excretions, non intact
skin or mucous membranes, and contaminated equipment.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 47 of 260
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HIC MANUAL
v.
Always wash hand before leaving the ward.
vi.
Before handling food.
vii.
After contact with patient beds, lockers etc.
b) Marks
i.
No need to be routinely worn.
ii.
Any time the healthcare worker anticipates the possibility of being splashed with
blood, body fluids, secretions or excretions.
iii.
For barrier protection.
c) Protective Eye Wear And/or Face Shields

i.
Any time the health care worker anticipates the possibility of being splashed
with blood, body fluids, secretions or excretions.
d) Gloves (Clean, non sterile)

i.
Wear for contact with blood, body fluids, secretions, excretions, mucous
membranes, non-intact skin or surfaces soiled with visible blood or body fluids
and contaminated equipment and articles.
ii.
Gloves should be changed between patients.
iii.
Gloves should be changed if they are torn, punctured & contaminated.
e) Plastic Aprons/Grown, caps, shoe covers, boots

PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 48 of 260
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i.
For contact with infective material. To protect against transmission of highly

transmissible organisms e.g. MRSA
ii.
Any time that clothing is likely to be soiled by splattering of blood, body fluids,
secretion and excretions.
f) Handling needles and small sharp

i.
Do not recap needles
ii.
Dispose of used needles and small sharps in puncture-resistant container.,

Which are located as close as possible to the area of use
iii.
Needles should not be recapped, bent or broken by hand.
iv.
If a needle has to be removed from a syringe, use forceps or do it with utmost care.
v.
Do not overfill a sharps container. All sharps containers to be discarded when 3/4ths
full.
vi.
Sharps should not be passed from one HCW (Health Care Worker) to another. The
person using the equipment should discard it. If necessary a tray be used to
transport sharps
g) Cleaning Spills
i.
Wear protective measures like gown, mask, gloves etc.
ii.
Wet the area with Sodium hypo chloride and dry carefully using disposable paper
towel.
iii.
Clean with detergent & keep the area dry.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 49 of 260
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h) Patient Placement
i.
Place a patient who contaminates the environment with highly transmissible

organisms or who does not assist in maintaining appropriate hygiene in a single
room.
ii.
If a single room is not available, consult infection control team for other
alternatives.
8.1 Standard Precautions in Clinical Laboratory Transfusion Services

A. Principle
i.
Recommendations by the Centre for disease control (CDC) and regulations by the
occupational safety and health administration (OSHA) have been developed for standard
precautions for prevention of occupational exposure to blood-borne pathogens.
ii.
These requirements apply to blood and body fluids from all patients regardless of
diagnosis. No distinction is made between patients who are known to be infected and all
others. Standard precautions constitute a safe approach to prevent infection because
employees have a single behavioral standard, and errors in assessing patient status will
not endanger employee safety.
iii.
The standard precautions do acknowledge a difference between hospital patients and

healthy donors, in whom the prevalence of infectious disease markers is significantly
lower.
B. General transfusion service guidelines.

PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 50 of 260
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MLA COLONY,
HIC MANUAL
i.
Hand washing
Frequent, effective hand washing is the first line of defense in infection control. Bloodborne pathogens of concern generally do not penetrate intact skin, so immediate removal
reduces the likelihood of transfer to a mucous membrane or broken skin area or of
transmission to others.
Hands should always be washed:

Before & after handling a patient.
Before & after touching the patient unit.
Before leaving a work area.
Immediately after coming into contact with blood or other body fluids.
Immediately after removing rubber gloves.
After using toilet.
ii.
Gloves
The use of gloves by all technicians when cleaning up spills or handling waste
materials.
Gloves should be worn routinely whenever there is the possibility of exposure to a

patients blood or body fluids (e.g. collecting a therapeutic unit on the wards).
Use gloves for any task where blood or body fluids may be encountered if your hands
have any cuts, scratches or abrasions.
By persons who are receiving training in phlebotomy.
When collecting or handling any open blood container or specimen.
When cleaning up spills or handling waste materials.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 51 of 260
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C. General guidelines for the safe use of gloves include:
Change gloves immediately if they are torn, punctured, or contaminated; after handling
high-risk samples; or after performing a physical examination, e.g., on an aphaeresis
donor/patient.
Remove gloves by keeping outside surfaces in contact only with outside, and by turning
the glove inside out while taking it off.
Wash hands with soap or other suitable disinfectant after removing gloves.
Do not wash or disinfect gloves for reuse.
D. Protective Clothing
Lab coats should be worn at all the time.
Contaminated clothing should be removed promptly.
Protective clothing should be removed before leaving the work area and should be
placed in a suitable container and laundered as potentially infectious.
Masks, safety glasses, should be worn to protect the eyes and the mucous membranes.
E. Handling needles
Dispose of used needles and small sharps in puncture-resistant containers that are located
as close as possible to the area of use.
Sharps containers are to be sealed and discarded weekly or when they are two thirds full.
F. Cleaning Spills and Decontamination
Surfaces and equipment that are contaminated with blood require daily cleaning and
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 52 of 260
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decontamination with 1% (1:4 dilution of 5% sodium hypochlorite (bleach) in water).
When spills occur, the following steps should be taken in the order listed.
o Leave the area for 30minutes if an aerosol has been created and post warnings to keep
the area clear. Remove clothing if it is contaminated. If the spill occurs in the
centrifuge, turn the power off immediately and leave the cover closed for 30minutes.
o Wear appropriate protective clothing and gloves. If sharp objects are involved, gloves
must be puncture-resistant, and a broom or other instrument should be used during
cleanup to avoid injury.
o Cover the spill completely with absorbent material. Remove the absorbent layer and
broken glass with brush and pan.
o Flood the area with disinfectant, such as a freshly made 1:4 dilution of 5% sodium
hypochlorite (Clorox) solution, and let it stand for 20minutes.
o Wipe up the disinfectant.
o Dispose of all materials safely in accordance with biohazard guidelines.
o Biological and/or other infectious waste generated by the blood storage centre such as
outdated or damaged blood products, salvage plasma, contaminated needles, tubing,
sharps, etc. are to be disposed of in an appropriate manner.
All used test tubes, contaminated applicator sticks, discarded blood samples
outdated or otherwise unacceptable blood or blood components are to be
disposed of in the appropriate biohazard containers.
All trash and/or waste generated by the Donor Centre and Transfusions Service
is considered a biohazard and handled as such by the Housekeeping Services
unit.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 53 of 260
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Other safety precautions
There should be no casual visitors where open blood specimens are handled.
Mouth pipetting is not permitted.
Eating, drinking, smoking, or the application of cosmetics is prohibited in all

working areas of Transfusion services and blood storage centre.
Immediately report any needle-sticks or other contamination incidents to the nursing

supervisor on duty.
G. Handling Blood Products/Reagents In Transfusion Services.

i.
Every sample of blood and body fluids should be handled as if potentially infectious.
Care is to be taken when handling opening all specimens received in the blood storage
centre.
Use an appropriate barrier (gloves, gauze, etc)to prevent splashing when opening
Any blood sample.
Hands should be washed immediately after handling patient or donor samples, and /or
after removing gloves.
Protective clothing should be changed if grossly contaminated with any patient or donor
specimen.
ii.
Even though all commercial human-based blood band reagents have been tested (cells,
antisera, etc.), handle them as if they are potentially infectious.
H. Handling Known Infectious Patients

It may be necessary in special circumstances to collect and process blood from a patient known
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 54 of 260
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HIC MANUAL
to be at high risk for an infectious agent (e.g.therapeutic procedures):
i.
Additional precautions are to be taken, i.e. protective gowns, gloves masks, and eye
shields if necessary.
ii.
Complete cleaning and disinfection of all equipment used is to be performed between
iii.
Complete cleaning and disinfection or all equipment used is to be performed between

donor and patients and before being returned to routine use.
iv.
All disposable materials are to be disposed of immediately.
I. Disinfection of Equipment
Re-use instruments, tubing, etc only after decontamination and sterilization
Do not touch equipment with soiled gloves or gloves used for patient care. Surfaces of
large equipment should be disinfected with a 1% dilution of sodium hypochlorite or an
approved disinfectant. Heavy soiled equipment may require additional cleaning with
detergent and water. Gloves must be worn while cleaning the equipment.
J. Waste disposal
Non plastic items soiled with blood, bloody drainage or potentially infected material
must be placed in the yellow biohazard plastic bags. Items that may tear the bag must not
be placed in the plastic bag.
Infected plastic items should be discarded into Red bag.
Excreta, blood or body fluids must be emptied down the drain with adequate amount of
water.
K. Linen
Line soiled with blood or potentially infectious body fluid must be soaked in 1% sodium
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 55 of 260
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HIC MANUAL
hypochlorite for one hour, placed in a leak proof bag and then sent to the laundry.
9. RECOMMENDATIONS FOR PATIENTS KNOWN TO HARBOR BLOOD BORNE
PATHOGENS LIKE HBV,HIV,HCV etc
9.1 INSTRUCTIONS FOR WARDS
Admission
Patients with HIV disease but presenting with unrelated illnesses may be admitted in any ward.
Patients with AIDS requiring isolation on account of secondary infectious disease will be
isolated as per the isolation policies and procedures.
Preparation of the patients
It is the responsibility of the attending physician to ensure that pre test counseling of any
patient before HIV testing is done and after that patients are informed about the result
they receive post test counseling. The results of the HIV test must be kept strictly
confidential.
The ward sister must ensure that when a patient with HIV, HBV, or HCV infection is
admitted, all contaminated reusable items are disinfected with sodium hypo chloride
placed in Yellow bag with biohazard symbol and sent to CSSD for disinfection &
autoclaving. Sharps are not to be discarded into the Red bag.
Specimens
Adequate precautions are to be taken while collecting specimens. The specimens are to be
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 56 of 260
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HIC MANUAL
transported in leak-proof containers. Ensure that the cover and the outside of the container are
not contaminated.
Waste disposal
A Bin Colour by a yellow plastic bag is placed in the patients room for infectious waste.
When the bag is th full it is sent for incineration.
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 nursing supervisor then medical administrator before sending the
body from hospital.
Those cleaning and packing the body should use gloves and other protective gear. Before
leaving the ward, the body is bagged.
9.1.1 HAND HYGIENE & GLOVING
Indications For hand washing & Hand Antisepsis
When hands are visibly dirty of contaminated with proteinaceous material or are visibly
soiled with blood or other body fluids, wash hands with soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely
decontaminating hands.
Decontaminate hands before having direct contact with patients.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 57 of 260
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Decontaminate hands before donning sterile gloves when inserting a central intravascular
catheter.
Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical procedure
Decontaminate hands after contact with a patients intact skin (e.g., when taking pulse or
blood pressure, and lifting a patient.)
Decontaminate hands after contact with body fluids or excretions, mucous membranes,
non-intact skin, and wound dressing if hands are not visibly soiled.
Decontaminate hands if moving from a contaminated body site to a clean body site
during patient care.
Decontaminate hands after removing gloves.
Decontaminate hands after contact with inanimate objects (including medical equipment)
in the immediate vicinity of the patient.
Before eating and after using rest room, wash hands with soap and water.
Wash hands with soap and water if exposure to Bacillus anthracis is suspected or proven
as alcohols, iodophors, chloro-hexidine are not effective against spores.
Decontaminate hands when moving from one patient to another.
Hand Hygiene Technique
When decontaminating hands with an alcohol based hand rub, apply product to palm of
one hand and rub hands together, covering all surfaces of hands and fingers until hands
are dry.
When washing hands with soap and water, wet hands first with water, apply soap (liquid)
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 58 of 260
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HIC MANUAL
and rub hands together vigorously for at least 15seconds, covering all surfaces of hands
and finger. Rinse hands with water and dry thoroughly with a disposable towel use towel
to turn off the faucet. Avoid using hot water, as repeated exposure to hot water may
increase the risk of dermatitis.
Soap bars are acceptable when washing hands with non antimicrobial soap and water
Use soap racks that facilitate drainage and small bars should be used.
Multiple use cloth hand towels are not recommended for use in hospitals Disposable
paper towels can be used for hand drying.
Other Aspects of Hand Hygiene
Do not wear artificial fingernails or rings when having direct contact with patient at high
risk. Keep natural nail tips less than inches log & no nail polish.
Remove watch &jewellery from hands.
Wear gloves when contact with blood or other potentially infectious materials, mucous
membranes, and non intact skin could occur.
Remove gloves after caring for a patient. Do not wear the same pair of gloves for the
care of more than one patient, and do not wash gloves between uses with different
patients.
Change gloves during patient care if moving from a contaminated body site to a clean
body site.
Surgical Hand Antisepsis
Remove rings, watches and bracelets before beginning the surgical hand scrub.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 59 of 260
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MLA COLONY,
HIC MANUAL
Remove debris from underneath fingernails using a nail cleaner under running water.
When performing surgical hand antisepsis use 7.5% Povidine iodine scrub, scrub hands
and forearms for 2-6 minutes. Long scrub times (e.g. 10min) are not necessary.
MONITORING OF HAND HYGIENE PRACTICES

Compliance with proper hand hygiene is monitored regularly. HAND hygiene audit is done by
neutral observers and compliance percentages are calculated among nurses ,doctors and
consultants and HK staff etc monthly wise .,,, and those who defer it are warned and their hand
swabs are taken from nail beds and nostrils to rule out any MRSA carrier state ., so that other
staff are alerted about importance of hand washing and hand rub procedure in between the care
of the pts .,,which is an basic barrier nursing practice along with use of PPE and good BMW
management implementations . THE regular CNE AND CME classes are conducted routinely
laying about its importance to them to all staff and housekeeping staff ,.no visitor is allowed to
touch bed or equipment etc .during infection control yearly graph is also taken to note
improvement in hand wash compliance by staff .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 60 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 61 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 62 of 260
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MLA COLONY,
HIC MANUAL
Technique of Gloving
There are two categories of gloves available in the hospital:
Examination gloves: These gloves are clean but not sterile. They are used for all
procedures that do not required sterile technique.
Sterile gloves: these are used for all procedures where sterile technique is mandatory.
Each pair of gloves is supplied in sealed covers.
Procedure for wearing gloves

Pairs of sterile gloves are packed in such a way as to facilitate handling without touching the
outside of the gloves with bare hands. A2 cuff is folded on each glove
The packet containing the gloves is first peeled open.
Pick up the powder packet from the right hand glove and powder both hands away from
the sterile field. This is to avoid risk of accidental spilling of powder over sterile gloves.
Open Method:
Pick up the first glove by gripping its cuff with one hand and slip the other hand in. with
the gloved hand, pick up second glove by slipping hand under the cuff (outside of the
glove) and slip the ungloved hand in and release the grip.
At this stage adjust the fingers of the gloves properly.
If gowned, the cuff of the second glove is pulled over the stockinet sleeve of the gown.
The cuff of other glove is then pulled over the stockinet sleeve.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 63 of 260
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HIC MANUAL
Closed Method:
The hands are not pushed beyond the stockinet cuffs of the gown.
The cuff of the left hand glove is grasped through the stockinet part of the right sleeve.
The left hand is inserted into the glove and the glove grasped by the right hand is pulled
over the left hand.
After stretching the cuff, the glove is pulled over the sleeve, and the hand is forced
through the stockinets cuff into the glove.
The second glove is put on in a similar manner except that the cuff can be grasped with
the already gloved hand and the right hand is forced through the stockinet cuff into the
glove. Glove powder can cause irritation and induce postoperative adhesions between
intestinal loops and the wound. Hence, it should be wiped off with a sterile wet mop.
There is no strict protocol for wearing unsterile (examination) gloves.
To prevent outer surface of gloves from contaminating hands, the gloved fingers of one
hand grip the outer surface of the cuff and pull off the glove inside out.
To prevent contamination of the ungloved hand, the inside of the cuff of the opposite
glove is held and pulled off the hand.
Gloves are discarded into the Red bag.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 64 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 65 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 66 of 260
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MLA COLONY,
HIC MANUAL
Use of Masks
The traditional masks 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 wearers breath.
More efficient masks are of high filtration disposable type several brands are available,
any may be used. These masks can be moulded to facial contours and actually filter the
respiration as compated to deflection with paper or cellophane insert masks.
Such masks achieve 98 percent efficient filtration compared with only 40percent with
muslin mask.
Procedure for using a mask
When wearing the mask, care should be taken to see that the nose, mouth and facial hair
are well covered.
Mask should be changed at least every operating session and should never be worn
around the neck
Mask wiggling is also a potential source of infection.
When removing a mask, care should be taken to avoid touching the part which has acted
as the filter. The hands can easily become contaminated with bacteria.
Use of Gowns
Gowns are available as different types:
Isolation gowns: These gowns are clean but not sterile. They are used while handling
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 67 of 260
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MLA COLONY,
HIC MANUAL
patients who require isolation. These prevent transmission of infection from the patient
to the health care worker
Surgical gowns: They are sterile gowns that are used for aseptic procedures.
Plastic aprons: They are used whenever spills are expected. They prevent fluids from
soaking the clothes of the health care worker.
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:
Hands must be washed thoroughly.
Pick up the gown holding it well away from the trolley and your own body.
Hold the neck band and unroll until the sleeves are seen.
Slide both hands and arms into the sleeves at the same time.
The floor nurse/ assistant slide her hands under the gown at the shoulder and pulls out
and fastens all the back tapes.
Cover the back with the black flap with the help of the scrub nurse.
Remember:
Do not keep the hands lower than the waist line.
Do not keep the hands near ones neck or shoulder.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 68 of 260
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MLA COLONY,
HIC MANUAL
Do not touch the axillary area once gowned.
Do not touch the back of the gown.
Removal of Gown at the end of the procedure
The circulating nurse will unfasten the grown.
The gown is carefully removed by the scrub nurse leaving the gloves on.
The gown with the inside folded out is placed in the appropriate bin.
The gloves are then removed by holding the inside of the cuff and placed in appropriate
container.
9.2 CARE OF SYSTEMS AND INDWELLING DEVICES

General Guidelines to Be Followed For All Procedures
Hand hygiene is mandatory before, after and in-between procedures and patients.
Each health care worker should be familiar with the personal protection (Standard
precautions) required for each procedure. These precautions should be strictly adhered
to.
Follow proper waster segregation & disposal after each procedure.
Vascular Care
Hand Hygiene
Wash hands before every attempted intravascular catheter insertion. Antimicrobial hand
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 69 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
washing / hand hygiene is desirable, and preferred before attempted insertions of central
intravenous catheters, catheters requiring cut downs, and arterial catheters.
Preparation of Skin
Povidone-iodine (PVP) or 2% chlorhexidine may be used for cleaning the skin. Insertion
sites should be scrubbed with a generous amount of antiseptic. Beginning 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.
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

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
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 70 of 260
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MLA COLONY,
HIC MANUAL
Flushing IV lines
Solutions used for flushing IV lines should not contain glucose which can support the
growth of micro-organisms. Do not reuse syringes used for flushing. One syringe is used
for flushing IV line once.
Peripheral IV sites (Short term catheters):

Dressing Changes
Peripheral IV site dressings should not usually require routine changes, since peripheral
IV catheters should be changed within 72 hours.
Replacement of Peripheral IV Catheters
Peripheral IV Catheters should be removed 72hors after insertion, provided no IVrelated 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)

Dressing changes
Central IV catheter dressings should be changed every 72hours. And transparent plasters
have to be used for securing or anchoring the cannula .
Replacement of central IV catheters

PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 71 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Central IV catheters do not require routine removal and reinsertion. The catheter can be
kept for a maximum of 3months, provided there is no sign of catheter related infection or
other complications.
Catheter related infection:
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 onintment 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 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 catheter, (20.3cm and 60.9 cm in length), two 5-7 cm 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 container.
Three way with extension is used only when multiple simultaneous infusates or Central
Venous pressure monitoring are required.
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 development of nosocomial in ventilated patients. Frequent

chlorhxidine mouthwashes minimize the chances of pneumonia.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 72 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Ventilator
Sterile water is to be used in nebulizers and humidifiers. This should be replaced within
24 hrs& after each patient use.
Pneumatic circuirs (masks, Y connection and tubes) are to be changed every 24-48 hours.
Condensate in tubing should not be drained into the humidifier or airway as they contain
large numbers of pathogenic organisms. This should be drained only into water traps.
Use disposable circuits if cost permits.
Use heat and moisture exchanging filter (HMEF) at Y connection for all patients if
feasible and cost permits. Heat and moisture exchanging filter (HMEF) is to be changed
every 24-48 hours. It should not be removed from circuit except at the time of changing.
Microbiological surveillance of respiratory therapy equipment is practiced in our hospital

in case of epidemiological surveillance in an outbreak situation. \
Tracheostomy care / Endotracheal Tube
Careful attention to postoperative 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 Betadine (Povidon-iodine 5%) every four hours or more
frequently, if necessary.
The tracheostomy tape securing the tube should be changed every 24hours. This tape
must be tied securely at all times.
The first complete tube change should be performed no earlier than 7 days to allow time
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 73 of 260
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MLA COLONY,
HIC MANUAL
for the tract to be formed. Subsequent changes should be done weekly or as necessary.
Clean technique should be used to change the trachestomy tube unless there is a medical
indication for sterile technique. Aseptic Wound care is taken of traceostomy area.
The obturator should be at the bedside (preferably taped to the head of the bed) to be
used if the tracheostomy tube accidentally is dislodged or is removed for any reason.
Suctioning of endotracheal /tracheostomy tube
Employee should be instructed and supervised by trained personnel in proper technique

before performing this procedure on their own. Assess the patient using auscultation, ECG,
(if available) and vital signs prior to suctioning.
Wash your hands.
Use a catheter with a blunt tip.
The wall suction should be set no higher than 120 mm Hg for adults and between 60 and 80
mm Hg for children.
Attach the suction catheter to the suction tubing; do not touch the catheter with bare hands
(leave it in its protective covering).
Put on sterile gloves. The wearing of a mask is also strongly recommended.
However, if saline does need to be instilled, cc 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 depressing the manual ventilation button
three or four times.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 74 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Insert the catheter gently through the inner cannula until resistance is met. Do not apply
suction during insertion.
Withdraw the catheter approximately 1 cm and institute suctioning.
Carefully withdraw the catheter, rotating it gently between the thumb and forefinger
applying intermittent suctioning.
Continuous suctioning for longer than 10 seconds may create an unacceptable level of
hypoxa.
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 ventilator support,
reapply the oxygen or ventilator for at least two minutes before re-suctioning.
Observe for unfavorable reactions 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 mucous 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
labeled 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 be secures between
suctioning periods so that it will not fall to the bed, floor, etc.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 75 of 260
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MLA COLONY,
HIC MANUAL
Urinary Catheter
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.
Hand washing
Hand washing 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 a possible, consistent with good drainage, should be used to

minimize urethral trauma.
Indwelling catheters should be properly secured after insertion to prevent movement and
urethral traction.
SECURELY Anchoring Catheter is must and avoid accidental removal of device by

PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 76 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
irritable pt .
Strapping of the catheter is done to lateral side of thigh in male patients. 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 to prevent
stricture of the penile urethra if the patient is on a catheter for a long duration.
Wound Care
Surgical wounds
Surgical wounds after an elective surgery are inspected on the third postoperative day, or
earlier if wound infection is suspected.
All personnel doing dressings should wash their hands before the procedure. Ideally, a 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, using
povidone-iodine to clean the wound and applying dry absorbent dressings.
10. ISOLATION POLICIES & PROCEDURES
Isolation practices are meant prevent transmission of pathogenic micro-organisms within

the hospital. We have a positive pressure isolation room for our patients.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 77 of 260
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MLA COLONY,
HIC MANUAL
PURPOSE
To establish individual responsibilities in order to minimize the transmission of infectious agents
to, from and between patients and all other people in PH facilities.
To ensure that all staff, including the housekeeping staff are aware of the correct precautions to
take. It is preferable that a dedicated nursing staff with barrier nursing methods is assigned to the
isolated patients.
SCOPE:
This policy describes the pace Hospitals isolation precaution.
RESPONSIBILITY
PH personnel with patient contact. Comply with the isolation policies and procedures
established in this policies.
Nursing services department personnel:
Documentation: Record the type of isolation initiated in the nurses notes and the patients
medical record with time and category of isolation and the name of the person who initiated
isolation. Also document the date and time the isolation is discontinued.
Ensure the availability of adequate and proper supplies for isolation patients at all times, as
well as for cleaning, bagging and removing all CSSD supplies and equipment, linen etc.,
once used and when isolation is discontinued.
Attending clinician. Order the initiation and discontinuation of isolation precautions.

Infection control committee.
Develops reviews, revises and approves all isolation policies and procedures.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 78 of 260
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MLA COLONY,
HIC MANUAL
Monitors adherence to isolation policies and procedures.
Housekeeping services unit personnel. Clean floors, bathrooms, walls etc. and remove trash,
etc., in accordance with the housekeeping services unit policies.
In case of patients with hepatitis A, E or Typhoid fever the bathrooms and toilets shall be
cleaned with sodium hypochlorite (Bleach ) 3 times a day.
PROCEDURE
DEFINITION:
Isolation. The separation, for the period of communicability, of infected persons from others in
order to prevent or limit the direct or indirect transmission of the infectious agent from the
infected person to those who are susceptible or who may spread the agent to others.
Universal Standard Precautions. The measures designed to reduce the risk of transmission of
blood borne pathogens as well as micro organisms from both recognized sources of infection
(moist body substance).
Transmission- Based precautions.
The measures designed for patients suspected to be infected or colonized with highly
transmissible or epidemiological important pathogens for which additional precautions, beyond
standard precautions, are needed to interrupt transmission in hospital.
There are three types of transmission- based precautions:
Airborne precautions dissemination of either airborne droplet nuclei (<5 in size)
Droplet precautions droplet transmission involves contact of the
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
conjunctiva or the mucous

APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 79 of 260
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MLA COLONY,
HIC MANUAL
membranes of the nose or mouth of a susceptible person with large particle droplets ( >5 in size)
containing micro organisms or during the performance of certain procedures such as suctioning
and bronchoscopy.in case of open cases of tb which are sputum positive for AFB ,such cases are
subjected to strict respioratory isolation to avoid droplet or air borne spread of infection. Mask is
given to pt and attenders and nurses and drs and visitors when they visit them. Sputum is
collected in an sample collector containers with sand and it is disinfected and decontaminated
with betadine solution and send in yellow bag with label for BMW management and discard. As
ours is basically an oncology institute we do not keep such open case of tb here and after
knowing result we immediately transfer the pt to nearby tb and chest hospital for further
management ,..
Contact precautions The measures designed to reduce the risk of transmission of
microorganisms by direct or indirect contact:esp for MRSA,VRE
AND MDR organisms
infected pts .
A. DIRECT CONTACT: involves person with blood borne pathogen infections. Double gloves
etc are used and safe injection practices are followed and needle prick injuries are avoided.. For
GE cases enteric precautions during isolation are followed.
B. INDIRECT CONTACT: involves personal contact of the susceptible person with a
contaminated intermediate object (bed, linen, clothing, instruments, etc.). Carriers among staff
are detected and treated to prevent any transmission of infections.
Whether the three types of transmission based precaution are used singly or in combination,
they are to be used in addition to standard precautions. Especially for immune-compromised
host more care is taken .pesticide spray is done to block vector borne spread of any such
infections .use of PPE is done more.
Hand washing/ Barrier protection. The appropriate use of hand washing, gloves, gowns,
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 80 of 260
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MLA COLONY,
HIC MANUAL
masks, goggles and face shields, to minimize exposure to blood and body fluids. Reverse
isolation care is taken in positive pressure room for pts. with severe leucopenia and
neutropenia and leukemia or lymphoma pts ,burns pt and pts after transplant surgery on
immunosuppressive therapy etc .
POLICIES:
Standard universal precautions for blood and body fluids, excretions, mucous membranes
and non- intact skin shall be used in the care of all patients.
Transmission- based precautions ( droplet, airborne and contact precautions) shall be used,
as appropriate, for patients with suspected or diagnosed communicable infections.
Any inpatient with a suspected communicable disease/infection shall be placed in the
appropriate category of isolation precautions while a more definitive diagnosis is pursued.
Transmission based precautions shall be continued until one of the following happens:
a. A definitive diagnosis, which renders such precautions unnecessary, is made
b. The physician makes a determination that such precautions are not necessary.
c. Treatment is given which renders the patient non-infectious.
Transmission based precautions shall be ordered and discontinued by the attending
physician. In the event that this is not done, nursing personnel shall initiate transmission
based precautions and shall notify the attending physician of this action. Infection control
committee personnel also have the authority to institute appropriate control measures.
The immunity profile of employees shall be checked before assigning any staff member to a
patient on isolation precautions.
Hand washing:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 81 of 260
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Hand washing is an important means of preventing the spread of infection. Personnel
shall always wash their hands before and after patient contact, even when gloves are worn.
Gloves:
a. Gloves shall be worn when specified for contact with patients on specific isolation precautions
and in situations where the health care worker judges that hand contamination with blood, body
fluids, excretions, secretions, mucus membranes or non-intact skin may occur.
b. Gloves shall be worn once and then discarded, used gloves shall not be worn outside the
isolation room.
c. Hands shall be washed after removing gloves.
d. Gloves are put on after gowning so they can be pulled up over the cuffs of the gown.
Gowns:
a. Gowns shall be worn if soiling of clothing with blood or body fluids, excretions or secretions,
is likely and whenever specified for contact with patients on specific isolation precautions and
shall not be worn outside the patients room or the area where procedures are performed, except
when transporting an isolation patients.
b. In some instances, such as with extensive burns or extensive wounds, sterile gowns must be
worn when changing dressings.
MASKS (Regular Surgical Masks):
a. Masks shall be fitted snugly over the nose with the metal strip facing outward. The top strings
shall be tied just above the tops of the ears. The lower part shall cover the nose and mouth and
shall be tied around the neck and shall not be worn outside the isolation room.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 82 of 260
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b. Masks shall never be lowered around the neck and then reused.
Equipment:
A. Equipment and other articles necessary to protect health care workers and visitors shall be
kept available at the nurses station or near the patients bedside.
Sharps and all used needles and syringes shall be placed in the impervious container. 3/4th
containers shall be removed by housekeeping services unit personnel shall place them in yellow
bags for deep burial.BMW management should be proper.
Needles shall not be bent or broken. Recapping shall be avoided but when it is necessary to re
cap a needle, the scoop method shall be used.
All equipment and supplies being returned to central supply services (CSSD) shall be bagged
and labelled. Decontamination is done by bacillocidsolution.
Remove all the nonessential equipment from the room before the patient is isolated.
ROOM:
A. Soap & alcohol based hand wash system
B. Disposable gloves & plastic aprons
C. Special bag to collect infected linen yellow labeled bag orspl. Bucket for its collection
D. Color coded waste disposal bins including one for sharps
E. Display the standard isolation card at the entrance of the room
F. The room should be kept closed always & negative pressure room should be preferred .
G. Once the patient is discharged, clean and fumigate the room. Send post fumigation swabs.,
For confirmation sake .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 83 of 260
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MLA COLONY,
HIC MANUAL
Disposal of Disposable items:
a. In most cases, used disposable items shall be placed in covered waste receptacles in the nurses
stations for removal by housekeeping services unit personnel.
b. Fluid-Filled containers, which must be emptied shall be emptied with care into the toilet in the
patients room. The health care worker shall wear protective barriers to prevent contamination by
splashing.
c. Liquid food and drink shall be discarded into the toilet in the patients room. Solid food waste
shall be discarded into the waste bin in the patients room.
Patient Placement: When possible, a single room is indicated for the following:
a. Patient with highly transmissible or epidemiologically important micro organisms (e.g.
vancomycin-resistant enterococci, methicillin-resistant S. aureus , tuberculosis, chickenpox)
b. As determined by an infectious disease specialist or infection control group personnel.
When isolation is discontinued, the patient shall be either be moved to another room (to allow
terminal cleaning of the contaminated room) or be discharged, as ordered by the attending
physician.
c. When a single room is not available, infected patients shall be placed with appropriate roommates ( cohorting)/single rooms will be converted to isolation rooms/ patient will be placed
with partial isolation by drabs and spacing with barrier nursing. Patients infected by the same
micro organisms can usually share a room, provided:
They are not infected with other potentially transmissible microorganisms. & cross
infections are avoided by strict barrier nursing techniques and aseptic care etc.
The likelihood of re-infection with same organism is minimal. All corrective and
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 84 of 260
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preventive actions have to be undertaken.
Laboratory Specimens:
All specimens from patients shall be handled with as if they are contaminated.
Bagging of articles:
Bagging is intended to prevent exposure of personnel to article contaminated with infective
material and to prevent contamination of the environment. A single bag is adequate if the bag is
impervious and sturdy other wise double bags shall be used.
Linen Handling:
Refer to on handling of solid and clean linen.
Cleaning:
b. Although microorganisms may be present on environmental surfaces such as walls, floors
etc., these surfaces, unless visibly contaminates, are not associated with the transmission of
infection to patient or staff. Cleaning should, however, be done routinely.
c. When cleaning isolation rooms, isolation techniques/procedures shall be followed. Staff shall
wear appropriate protective apparel when they anticipate exposure to blood or body fluids
while cleaning rooms.
REVERSE
ISOLATION
POLICY
IS
FOLLOWED
HERE
FOR
ALL
CHEMOTHERAPY PTS WIH LEUCOPENIA BELOW 500 COUNT AND WITH

SEVERE NEUTROPENIA ALSO .
At our hospital we follow this method especially for isolation of highly susceptible patients that
is severe leucopenia pts with WBC counts of lower than 500 with severe neutropenia also. as
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 85 of 260
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they acquire infections easily ,hence visitors are strictly restricted and pt kept in positive
pressure room and all above said precautions of barrier nursing and aseptic techniques are
followed by separate nurse who looks after the pt care .hand hygiene practices and use of PPE is
done invariably also. And whoever enters pt. room is mostly given sterile gown and mask etc
.even pt is requested to wear mask also the pt. is given inj.graffyl or colony stimulating factors
by which the WBC count also improves and once it is above 1000 , then pt is shifted to other
spl.room or ward as per consultants orders . we have posiive pressure room provided for it .
VISITORS:
Visitors to patient on isolation precautions shall be limited to one if needed and shall observe
posted precautions. Children and susceptible visitors should be discouraged from entering the
room
WHENEVER PATIENT IS TRANSFERRED TO OTHER HOSPITAL LABELLING AS
BIOHAZARD INFECTED case is done and mask etc isworn by pt. to prevent transmission of
infection to others.
Patients clothing soiled with blood or body fluids: shall be bagged before being sent home. The
patient/family shall be told to wash the clothing with a detergent and if possible with hot water
and bleach.
HANDLING OF DEAD BODY:
The bodies of patients who have had varicella, pneumonic plaque, herpes zoster hemorrhagic
fever or AIDS; shall be double-wrapped so that the outside of the shroud is uncontaminated.
Label the outside wrapper ISOLATION And BIOHAZARD. THERE is no mortuary cold
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 86 of 260
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HIC MANUAL
storage practices here at our hospital .
11. VISITORS POLICY

No Children are allowed inside wards except admissions.
No bouquets and flowers etc. Should be accepted by patients from Visitors.
Strict timing policy for visitors to be followed with compliance.
Separate space should be provided for foot wear.
In high risk ward areas hardly visitors will be allowed. The ICU wards security has to
implement it strictly.
For nosocomial infection cases and isolation cases like open TB cases etc, Visitors are
requested to wear masks and co operate and follow isolation precautions
Outside brought food or fruits should not be stale to avoid any food poisoning in ward.
No bedding and other household materials should be allowed inside wards and special
rooms for attenders.
Already infected or sick visitors is not allowed inside hospital.
Confidentiality of disease state has to be maintained and need not be revealed to all
visitors except close blood relatives.
Maintenance of personal hygiene of attender & relatives to be explained to visitors by
careful counselings for infectious cases and notifiable disease patient.
They have to maintain silence in ward and follow all hospital protocols,which benefits
patient mostly.
In CTICU and ICU visitors should wear gowns and mask before entering to ward.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 87 of 260
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MLA COLONY,
HIC MANUAL
They should not over stay nor crate problems nor quarrel with nurses they can consult
PRO , DMO , consultant for any clarifications
In high risk areas and isolation ward the attender entry is restricted.
They are encouraged to spend less time and not to sit on bed nor handle any equipment
or instrument and disturb other patients.
Any modifications of restrictions or Instructions will be imposed in hospital upon the
visitors as per the demanding situation SOS.
12. INFECTION CONTROL IN SPECIAL CARE UNITS /HIGH RISK AREAS

List of High Risk Area in the Hospital
1. OT and CSSD sterile storage room
2. Surgical Intensive care unit ,MICU
3. Day care surgery
4. Emergency Room
5. Laboratory
6.
BMW Waste Storage Area and infected linen room.
7. BMT room
12.1
INFECTION CONTROL PRACTICES IN OT AND CSSD ROOM
Purpose:
To keep the theater complex absolutely clean and sterile at all times.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 88 of 260
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MLA COLONY,
HIC MANUAL
Scope:
This policy describes the PH infection control policies in the operation theater.
Responsibility:
Operation theatre in charge
PROCEDURE
Policies:
Theater complex is absolutely clean at all times. Dust should not accumulate at any region of
theater.
Soap solution is used for cleaning floors and other surfaces. Operating rooms (ORs) are cleaned
daily and the entire theater complex is cleaned thoroughly once a week.
Before the staff of the 1st case
Wipe all equipment, furniture, room lights, suction points, OR table, surgical light reflectors,
other light fittings, slabs, roof etc. with Bacillocid spray (0.25%). This should be completed at
least one hour before the start of surgery.
Cleaning theaters after a case:

a. Minor spills of blood or infectious body fluid are to be disinfected by pouring 1% sodium
Hypochlorite over the spill and leaving it for 20 minutes. The area of the spill should be cleaned
with soap and water.
b. For major spills, disinfect as above, and clean the whole room with soap and water./Desnet
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 89 of 260
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MLA COLONY,
HIC MANUAL
(Aldehyde free cleaning solution)
c. At the end of the day, through cleaning of the floor with soap and water/ Desnet (Aldehyde
free cleaning solution) is necessary.
Linen and gloves:
Gather all soiled linen and towels in the receptacles provided. The dirty linen is then sent to the
laundry in a sealed labeled yellow bag. Use gloves while handling dirty linen.
Instruments:
Instruments are rinsed to clear blood with 3M rapid enzymatic cleaner followed by water and
then sent to CSSD for sterilization by autoclaving. Instruments used for infected cases for e.g.
HIV, HBsAg must be disinfected by soaking in 1% sodium Hypochlorite 3M rapid enzymatic
cleaner followed by water and send to CSSD. In the CSSD these instruments are autoclaved
after packing.
Environment:
Wipe used equipment, furniture, OR table etc., with disinfectant.If there is a blood spill,
disinfectant with 1% sodium hypochlorite and bacillocid.
After the last case:
The same procedures as mentioned above are followed and in addition the following are carried
out.
Wipe overhead lights, cabinets, waste receptacles, equipment, and furniture with a disinfectant.
Wash floor and wet mop with liquid soap and then remove water and wet mop with a
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 90 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
disinfectant solution. Desnet shelves and scrub area.
Clean the storage shelves and scrub area.
Weekly cleaning procedure:
Remove all portable equipment.
Damp wipe lights and other fixtures with Bacillocid.
Clean doors, hinges, facings, glass inserts and rinse with a cloth moistened with bacillocid.
Wipe down walls with clean cloth mop by bacillocid
Scrub floor using Desnet/ Soap water
Stainless steel surfaces- clean with bacillocid spray.
Replace portable equipment: clean wheel castors by rolling across towel saturated with
bacollocid every week before fumigation or if taken out of OT.
Wash (clean) and dry all furniture and equipment. (or table, suction holders, foot and sitting
stools, mayo stands, iv poles, basin stands, x-ray view boxes, hamper stands, all tables in
the room, hoses to oxygen tank, kick buckets and holder wall cupboards).
After washing floors, allow bacillocid solution to remain on the floor for 10 minutes to
ensure destruction of bacteria.
Do not remove or disturb delicate equipment.
While wiping cabinets, see to it that the solution does not get inside and contaminate sterile
supplies.
Operating rooms and scrub rooms should never be dry dusted.
After thorough cleaning fog with Ecoshiled/ silvicide(1hr).
Maintenance and Repairs:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 91 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Machinery and equipment should be checked, cleaned and repaired routinely on Saturdays
before weekly fumigation.
Urgent repairs should be carried out at the end of the days list.
Air conditioners and suction points should be checked, cleaned and repaired on a weekly
basis.
Preventive maintenance on all theater equipment to be carried out every week.
Recommendations for administrations of anesthesia:
Endotracheal tubes and other equipment which come into contact with the mucosa of the
patient or which are visibly contaminated with blood or infectious body fluids, should
either be discarded after single use (for infectious cases)/ sterilized by using ETO.
Internal circuits in the anesthesia machine may be cleaned when the soda lime containers
are changed.
Care of the environment
The operating team should take absolute care regarding disposal of blood and stained
items.
All swabs, sponges, etc should be discarded / placed only in the assigned containers/
areas.
Gloves should be discarded directly into the lined by a yellow plastic cover.
Used instruments should be carefully segregated.
Used linen should be collected directly in an assigned area 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 surgery.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 92 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
For example, small plastic containers for small spills (Neursurgery) and buckets to
collect draining fluids (Urology) are necessary.
Surveillance for environmental infection control:

Air quality as required for OTs shall be monitored on weekly basis using an settle plate method.
The recommended standards are 35 CFU/ml for normal OTs & 1 CFU/ ml for ultra clean OTs.
A record of the results will be kept.weekly after fumigation postfumigation swabs are taken
along with open settle plate method plate examination for any aerobic bacterial growth , if at all
any positive growth is seen then we subject that OT for refumigation ,which did not happen till
now ,
Protection for furniture and equipment:
Equipments should not be handled with gloves that have been used for invasive
procedures. Vacuum cleaners can be used for removing dust wipe light furniture and OT
table with hypochlorite
Waste segregation should be in accordance with the guidelines on HOSPITAL WASTE
MANAGEMENT.OT linen should be treated as soiled or infected linen .suction bottles
cleaning is handled by housekeeping staff .weekly cleaning procedures has to be
followed also HEPA filters are checked and cleaned periodically by company people
.preventive maintenance has to be done for all equipment in staff .BMW management
has to be handled efficiently.
Specific cases in the operating room: Additional steps to be taken in this area:
Minimize equipment to be used.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 93 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Remove all items from which cannot be properly sterilized or disinfected and those
which are not likely to be used.

Cover the bed and armrest with plastic sheets, which will be discarded after the surgery.
Keep sufficient containers for collecting used items.
Handle used items with forceps or after wearing examination gloves.
Post one person to wait outside the or to obtain additional equipment, supplies and help.
At the end of the surgery, the scrub nurse stays in the or without removing gloves and
masks sure that the used items are carefully disposed.
OT CLEANING & CARBOLISATION

Mop the room thoroughly.
Wash floors, walls, ceilings with clean warm soap water. Let it dry.
Make proper concentration solution of water with cleaning agent (E.g. Bcillocid). Read
manufacturers instructions on how to make the solution.
Use hard brush (not a mop) to scrub floors, walls ceilings etc. thoroughly, mechanically,
effectively.
Clean beds, furniture, fans with soft cloth soaked in Bacillocid solution.
Careful while cleaning equipments. E.g .Ventilators, monitors etc.
Leave room and its contents to dry for 15 to 30 minutes.
Spray BACILLOCID wait for 2 hours before using the facility.
Fumigation is outdated and should not be done. Through 1 to 8 steps mentioned above
means proper disinfection.
A new washed mop and a fresh chemical solution will be used for next OT.
PROCEDURE FOR PREVENTION OF NOSOCOMIAL INFECTION IN OPERATION
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 94 of 260
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MLA COLONY,
HIC MANUAL
THEATRE
Following steps must be ensured to prevent nosocomial infection in the OT:
GENERAL
Restricted entry of personnel. Only the concerned people must be allowed to work area.
Only personnel in OT dress cap and mask to be allowed inside sterile zone.
Slippers must be earmarked and used for the area. The slippers for bathroom must be
marked. (Do not use same slippers for both areas)
No septic cases must be posted in the main complex. Minor OT should be used. The sister
in charge must be informed by doctor if any septic cases are being done prior
Due precautions must be adhered to if seropositive patients for HIV / HbsAg / HCV is
posted for surgery. The doctor must be informed about the patients status prior to posting,
must inform the theatre personnel.
Terminal cleaning must be done of each theatre at the end of the day..disinfection and
sterilization process to be done separately for noncritical ,semicritical and critical items .
The nurse who is assisting must ensure proper disposal of sharps, blood stain, linen, gauze
pieces and body parts at the end of the each case.
During surgery, the nurse assisting must ensure that minimal spillage of blood, body fluids
occur.
Weekend cleaning and mechanical scrubbing of the OT must be done. Only minor OT to
be used for emergency cases on Sunday. No elective cases on Sunday.
One senior nurse must supervise the weekly cleaning and scrubbing as per the Cleaning
protocol for critical care areas
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 95 of 260
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MLA COLONY,
HIC MANUAL
WORK INSTRUCIONS FOR NURSES IN OPERATION THEATRE:
All bins and sterile sets must be ensured that they are sterilized. Certify from the CSSD
that pack has passed the process challenge device test. (Stickers are to be pasted, color
change to be identified).
All sharps must be disposed off in the puncture proof bin only. No sharps must be put
into the buckets.
Nurses assisting must ensure that blood drops / spills are covered with 1 % sodium hypochloride and cleaned before leaving theatre after a case.
Nurse must supervise the proper disposal of gauze, human body parts, and the OT
suction apparatus contents.
The nurse assisting the case must supervise all samples for investigations being sent to
lab.
Nurse must use aseptic technique while using the bins.IN CSSD also we regularly check
biological controls for autoclave and also exam swabs weekly after fumigation of sterile
instruements storage room .
Nurse in charge must ensure frequent changing of the suction apparatus tubing.
12.2 INTENSIVE CARE UNITS
Design of the Unit
Space around and between beds should be adequate for placement and easy access to
equipment and to patients.
A single, closed cubicle is used only for patients needing isolation; e.g. open
tuberculosis, anthax, enteric fever, cholera, MRSA colonization or infection with other
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 96 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
multi-drug resistant organisms.
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.
Special precautions
a. Hand washing
For routine hand washing, liquid soap can be used. A hand disinfectant approved by the ICC
should be used prior any procedure. For or rapid disinfection of clean hands, alcoholic
chlorhexidine can be used.
b. Gloves, mask and Aprons
Gloves mask and aprons must be worn for all procedures where contact with blood or body fluid
is anticipated and for close contact with the patient e.g. lifting or turning a patient. They must be
removed after each procedure and before contact with another patient.
c. Oral Toilet
Wear gloves when performing mouth toilets for the patient.
d. Nasogastric suction
Gloves must be worn for passing nasogastric. Sysringes used for aspiration should be changed
daily. A clean syringe should be used if fluids or drugs are being given via the nasogastric tube.
e. Care of Intravenous Lines
Aseptic technique should be used when inserting intravenous lines. Hands should always be
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 97 of 260
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MLA COLONY,
HIC MANUAL
washed before and after manipulation of these lines. The use of transparent film dressing
(tegaderm) for dressing the cannulation site allows the insertion site to be viewed without
disturbing the site. Cannulation sites dressing should be changed if it become wet or blood
stained. Ensure all IV giving sets are well supported and not pulling against the patients skin or
touching the floor while being infused. Label date and time all lines changes and insertion.
f. Peripheral Intravenuous Lines
I/V sets should be changed every 24 hours and always after blood transfusion peripheral venous
catheters should be re-sited every 72hours and should be documented.
g. Central Venous Lines
All arterial, central, monitoring and drug line administration sets should be changed every 3
weeks unless indicated otherwise. All sets for blood/blood products should be discarded after
use. Central lines should be covered with sterile dressing. When re-dressed, the site should be
cleaned with Betadine. The site dressing should be changed once in a week and whenever
necessary. Central venous cannula should be changed every 14 th day or if cannulation site is
visually inflamed or if the patient is showing signs or sepsis. Ventilator set to be changed every 7
days and filter every day.
h. Parenteral Nutrition Lines

These lines should not be used for administrating other drugs because of serious risk of infection
associated with total parenteral nutrition (TPN). Change infusion line every 24 hours.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 98 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
i. Percutaneous Tracheostomy Tubes
The first change of tracheostomy tube is 14 days after insertion, thereafter it should be changed
weekly. The tracheostomy tube needs to be changed any time if signs of obstruction are noted
(follow the manufacture instructions).
j. Naso Gastric Tube (NGT)
Wash hands and wear gloves when attaching NG feeds. And avoid aspiration pneumonia ,
k. Urinary Catheter
Catheterize patients only when required.
i.
Stress on the importance of hand washing. Hand washing should be done immediately
before and after any manipulation of the catheter site or apparatus.
ii.
Catheter inserted under aseptic technique using sterile equipment.
iii.
Secure catheter properly.
iv.
Maintain closed sterile drainage.
v.
Maintain free urine flow.
vi.
Use irrigation only when required (e.g. to prevent or relieve obstruction.)
vii.
Catheter should changed after 7days including uro bag.
viii.
Consider, as appropriate, alternative techniques of urinary drainage before using an

indwelling urethral catheter.
l. Suctioning
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 99 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Hands should be washed before and after the procedure. Wear clean disposable gloves for
suctioning. Use saline to clean the suction tubing each procedure. Use disposable suction
catheters for each endotracheal or trachestomy suction procedure.
m. Ventilators
When a heat moisture exchange filter (HME) is used after the catheter mount theVentilator
tubing need to be changed only between patients. The internal parts of the ventilator do not need
to be autoclaved if a (HME) is used on the expiratory port of the ventilator exist.
i.
Catheter / mount: Use disposable if available and replace if necessary.
ii.
Tubing: replace between patients.
Ventilators using water bath humidification.

If a HME filter is not used after the catheter mount then the ventilator should be dismantled. If
bacterial filter is used the expiratory inspiratory lines, change the filter every 48 hours or more
frequently if visibly moist. Water traps should be emptied regularly to prevent build-up of fluids
within the tubing.
n. Nebulizers and use sterile distilled water only and not tap water for humidifiers and
nebulisersetc
Intubating Equipment
i.
Laryngoscopes
Detach blade and clean thoroughly with detergent and water. Wipe handle clean with
alcohol.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 100 of 260
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ii.
Spiro meter.
Wipe with alcohol swab
iii.
Chest Drains
Using disposable tube
iv.
Mattresses
Clean with detergent and water between patients.
v.
Urinal
Using disposable urinal
Procedures to be followed by health care personnel:
Hand washing: importance of this cannot be over-emphasised in the ICU setting.
Standard Precautions: as appropriate, should be followed by all staff while handling

patients or samples (refer to the section on Standard Precautions). Wear plastic aprons
and gloves for all procedures in isolation rooms. Remove and discard them immediately
after each patient. Use gloves for / all patient contact. Wear masks while examining
patients with uncertain diagnosis. Continuous mopping of floor by bacillocid is done 4
to 6 times daily and all equipment is cleaned twice with bacillocid .visitors are restricted
in high risk wards in general .and fumigation is also done eriodically and all the time
post fumigation swabs were found sterile only .
Instruments
Although disposable items are, reusable items are often used, for reducing the cost.
Separate thermometers should be used for each patient.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 101 of 260
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Separate Ambu bag and mask should be used each patient. This should be ETO
sterilized before use on another patient.
Microbiological monitoring
Swabs for culture are taken from common dust setting areas and air conditioners once a
week.
SURGICAL INTENSIVE CARE UNIT (SICU)
Any patient, with communicable diseases or infection or considered potentially infected

should be placed in the Isolation section.
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.
All personnel working in ICU are expected to change into the clothes and put on the
slippers provided in the changing room, before entering patient care area.
All visitors (medical and non-medical) are expected to remove their foot wear or wear
overshoes and wear a gown over their street clothes before entering the ICU.
ICU personnel and other members of the caring team should strictly follow hand
hygiene precautions after all patient contact.
Aseptic precautions are to be followed for all techniques.
Disinfection of ventilators and tubing:

PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 102 of 260
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Disposable ventilator tubings are used for each patient. The bacterial filter is changed
every 24 hours.
Humidifier jars are autoclaved every12 hours.
Catheters used for suctioning are to be discarded and a fresh one used every time.
Isolation is indicated in the following:
Enteric diseases with perforation.
Draining wounds with airborne pathogens, coagulase positive Staphylococcus and beta
haemolytic Streptococcus.
Draining wounds with non-air borne pathogens (Proteus, E.coil, Pseudomonas).
Gas gangrene.
Infectious and serum hepatitis with surgical problems.
Tetanus with surgical condition.
Septic abortion.
Poly trauma e.g. following road traffic accident or treated outside.
Any patient transferred from the ward with potential infection.
Traffic and Visitor Control

In ICU, daily one person is allowed to see the patient during visiting hours. If the condition is
critical the clergy, close relatives or friends may be permitted to see the patient in a screened
area for a few minutes if the situation allows. Consideration must be made for total department
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 103 of 260
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HIC MANUAL
activity. Not more than one person will be allowed to visit at a time. Only visitors and personnel
in proper attire will be allowed into the department into the department this policy will be
strictly enforced at all times. There are no exceptions.
13. COLLECTION AND TRANSPORT OF SPECIMENS:

Specimens for general investigations;
Adequate precautionary measures are to be followed while collection of any specimen for
investigations. For skin disinfection before cleaning 10% Betadine is adequate. But 2%
Chlorhexidine solution will be better for cleaning the IV site. All specimens should be
transported in covered, leak proof and break proof containers. Use appropriate carrier transport
boxes with ice pack for transportation. Lab request forms should not be soiled with liquid
specimens. Pl. check to avoid hemolysis etc of blood samples .any seropositive sample is
handled safely and biohazard label is given. ALL rejection criteria rules for samples are
followed. Identification of pt and correct data entry and bar coding is done for accuracy sake.
Hand wash is done properly and use of PPE like gloves and masks etc is done .AFTER prick
Band-Aid is applied.
Specimens for culture:
All specimens for culture for etiological diagnosis must be taken before institution of
antimicrobial therapy.
However, therapy should not be delayed unnecessarily.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
For each
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 104 of 260
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HIC MANUAL
specimen the appropriate container must be used and spillage must be avoided during collection
containerization and transportation. All specimen containers should be labeled with the name
and hospitals number of the patient and the test to be performed. Specimens from patients with
suspected blood borne pathogens or other highly infectious organism should be placed in plastic
bags and should bear the Biohazard label. Specimens can be kept at 4-8c.Check with the
laboratory regarding this. Blood and CSF for cultures should be incubated or sent immediately
and never refrigerated, once it is inoculated into the medium.ALL the samples should be sent in
specially designed transport boxes which has
ice pack also in it and thus spillages and
breakages and leakages can be prevented .

a. Blood:
Draw under strict aseptic conditions.
Before drawing the blood prepare skin with 2% Chloro-hexidine or Betadine solution.
b. CSF and body fluids such as ascetic, joint, peritoneal and pleural:
Collect the specimens in sterile containers provided for this purpose with aseptic precautions.
And it should be sent immediately to lab.
c. 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.
d. Faeces;
Place small quantity of faeces in a sterile, wide mouthed faeces bottle.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 105 of 260
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Close the bottle tightly
e. Miscellaneous specimens: (ulcer exudates, swabs from wounds, burns, cervix, vagina
etc.)
Do not apply antiseptic solutions before taking the specimens
Place 2 swabs of specimen in a sterile test tube.
Send additional swabs when multiple examinations are requested.
f. 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 write the site of pus
(e.g. M. tuberculosis, anaerobes, fungi.)
g. Sputum:
Collect an early morning, coughed up specimen after rinsing the mouth with plain water.
h. Urine:
Mid-Stream clean Catch sample is obtained with all precautions.
14. SAFETY IN THE LABORATORY
Eating, drinking, smoking and applying cosmetics are prohibited in the laboratory.
Mouth pipetting is prohibited.
Staff must behave in a safe and responsible manner at all times & avoid lab hazards and be
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 106 of 260
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HIC MANUAL
careful with electrical appliances.
Appropriate protective clothing must be worn at all times when in the laboratory and
wheneverpossible, gloves should be worn.
The laboratory must be kept clean and tidy and should contain items necessary for the work
to be carried out.
All work surfaces must be appropriately decontaminated at the end of each working day and
after any spillages with hypochlorite solution.
All staff must wash their hands when leaving the laboratory.
Care must be taken to avoid the formation of aerosols or the splashing of materials.
All contaminated, wasted or reusable materials must be appropriately decontaminated before
disposal or reuse.
Access to the laboratory is restricted to authorize personnel only.
All incidents / accidents must be reported immediately, and appropriate action should be
taken to prevent further occurrences.
In case of accidents with splashes and shower it (fitted in each laboratory) immediately. EYE
splashes can be washed by normal saline solution preferably.
All staff working in laboratories must be adequately trained, both in the duties that they
perform as well as in all safety aspects of laboratory work.
Centrifuge care has to be taken. Spillage care and sharps care is undertaken.
Strict Barrier Nursing techniques are followed. Working surfaces are cleaned with
hypochlorite solution.
All staffs are vaccinated against Hepatitis B especially. & BMW management care is
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 107 of 260
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undertaken.
All sero positive samples are autoclaved and soaked in hypochlorite. Microbiology lab is
subjected for fumigation periodically .all the used culture plates are autoclaved and
thereafter it is disposed off to BMW as per pollution control board protocols .
15. INFECTED OR SOILED LINEN MANAGEMENT

Purpose
To prevent gross microbial contamination of air hospital environment and also protect persons
handling infected or soiled linen.
Scope:
This policy describes the handling of used / soiled and clean linen in our hospital to prevent
blood borne pathogens infections.
Responsibilities:
All Hospital personnel handling soiled and clean linen,Supervisors Hospital Infection Control
committee
PROCEDURE:
All used linen shall be considered contaminated and shall be bagged at the location of
use before being taken to laundry. Laundry is out sourced.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 108 of 260
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Clean and soiled linen should be transported separately in separately in SPECIFIC
COLOUR bucket with 1% Sodium Hypochlorite solution Infected linen should be
handled as little as possible and with minimum agitation to prevent gross microbial
contamination of the air and of persons handling.
All infected linen should be rinsed in running water then soaked in 1% hypochlorite
solution for 30 min in the buckets specially designated location in the 4 th floor /or
cellar/roof only where soiled linen is disinfected. Separately and it is not mixed with
general linen. Nor thrown on floor.
This linen is then placed in black leak proof bags, or separately labeled as infected linen
andthen transported to the laundry collection point Personnel handling soiled linen
should be provided PPE, gum boots and heavy gloves up to elbow etc Any linen dropped
shall be considered soil Clean linen is shifted toward wrapping it neatly in a cloth
wrapper and send to cellar area where infected linen is stored in hypochlorite solution
and thereafter it is handed over to BMW people with spl precautions .
Clean linen shall be stored in a clean, dry area.
FACILITIES:
Hand washing facilities are available to all employees in the linen area andPPE supplies
are adequately given for linen handlers.
Barriers to protect employees from blood, body fluids, secretionsand excretions are
located in the laundry area. Employees shall be informed of the location and of barriers
at the time of orientation to the unit. Hepatitis B vaccination are given to all linen
handling staff also care is take during transport regarding avoiding any leakages or
spillages etc. is supplied to outsourced laundry people carry it in separate bags only with
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 109 of 260
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HIC MANUAL
warning The bucket carrying soiled linen should not have any leakage or breakage and
the
spillages and splashes have to be handled accordingly etc. an separate area is
earmarked for storing and disinfecting the soiled linen especially on fourth floor orcellar.
By following all these precautions to prevent the transmission of blood borne viruses like
HIV, HBV, and HCV ETC all the infected linen is soaked in hypochlorite solution big
bucket provided for 1 hr and thereafter it is disposed off to BMW people. Our infected
linen management room is just beside central BM,W staorage room only in the cellar
area ,which is neatly and cleanly maintained and washed periodically wih bacillocid and
phenyl etc along with regular insecticide and rodenticide sprays there . the BMW and
infected linen are weighed daily by company people daily as per protocols, our staff
periodically visits outsourced laundry dept and BMW company and see for improvement
changes than that of the past visits and also advise them for good suggestions also .
16. HANDLING OF HIV POSITIVE PATEINTS
To define the policies and procedures for handling patients who are HIV reactive.
Scope:
This policy describes the proper procedure for handling patients who are HIV reactive. And also
blood bank issues positive viz. Hepatitis B & C.
Responsibility:
Laboratory staff: shall inform any HIV positive cases to the infection control nurse.
Infection control nurse: The infection control personnel should collect demographic details of
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 110 of 260
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the patient and inform the patient counselor.
Counselor: The counselor in association with the physician or doctor in charge takes care of the
counseling aspects.
Universal standard precautions are mandatory in handling all patients. If a patient is known to
have AIDS, extra care needs to be taken to ensure that this immuno-suppressed individual does
not acquire a nosocomial or opportunistic infection. All this samples and fluids are handled with
extra careand double gloves are used along with more PPE also and special precautions are
taken in his BMW -management.
PROCEDURE:
HIV positive patients without secondary infections, that necessitate isolation, can be admitted in
any general or private ward. Those with infections such as pulmonary tuberculosis are isolated
from others.
Confidentiality:
The patient while in the ward should not be identified separately as being HIV positive.
That information will of course be included in the medical chart, which is a confidential
Documented.
The nursing staff should be sensitive to the fact that the stigma, still associated with the disease,
may be hurtful to the patient.
16.1
NURSING CARE:
Be aware of infectious body fluid and substances and its spillages and splashes etc
Clean gowns and the equipment to take personal protection such as glove, masksand goggles
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 111 of 260
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should be available and easily accessible in all wards.
Bed linen should be changed daily or when soiled. Patient's gown should also bechanged
once every day or whenever soiled.
These are to be transported to the laundry in separate plastic bags. Plastic bags should be
labeled with BBF sticker.
Separate urinals, bedpans and thermometers are to be used for all patients.
Mackintoshes should be washed with detergent and water and then disinfectedwith Dispel
antiseptic lotion.
Reusable auto-clavable items used on patients known to harbor blood borne
Pathogens (and organisms such as MRSA) are collected in a plastic bag kept atthe nursing
stations in each ward. There is no need to use separate bags fordifferent patients. These bags
should never be placed at the patient's bedside.
This instrument is to be autoclaved before cleaning and then reassembled forsterilization.
Waste disposal is as per hospital guidelines. Adequate numbers of these bags andsharps
containers should be available in all wards.
In the event of death, death care is to be given as per the nursing protocol.
Nursing Care in special areas
Nursing in Intensive Care: Patients in the ICU are generally more vulnerablebecause of the
number of interventions that are done for intensive care. For thesame reasons staff also have
a higher risk of exposure.
Care to be taken with ventilated patients. Ensure barrier protection, sterileequipment and
sterile technique for all invasive procedures including suction.
Patients with tracheostomies can pour out secretions initially. Extra care mustbe taken to
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 112 of 260
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ensure that the wound site does not become infected. Mask andgoggles are mandatory for
suctioning.
Type of exposure
Examples
Protective barriers
Low Risk
1. Injections
Contact with skin with no visible
2. Minor wound dressing
Gloves
blood
Medium Risk
1.
Insertion
or
removal
of
Gloves
Probable contact with blood; splash intravenous cannula

unlikely
2.
Handling
of
laboratory
specimens
Gown or Aprons may be

necessary
3. Large open wounds dressing

Probable contact with blood &
1. Vein puncture
Gloves, apron
splash likely
2. Cleaning spills of blood
Goggles, mask
3. Intubation
High Risk
Probable
1. Major surgical procedure

contact
with
blood,
Gloves
Water proof gown or apron
splashing, uncontrolled bleeding

Eye wear, Mask, Shoes
Avoid sharps and needle prick injuries, Avoid recapping and spillages etc, dispose off
contaminated waste safety, All barrier nursing care and aseptic precautions are taken sharing
of equipment is and sterile linen is treated as
infected linen is disinfected and sent to
laundry. If for operation spl. Barrier precautions are taken like double gloves, Cidex /
Hypochlorite soaking of instruments, double autoclaving, aseptic and disposable deeper are
used.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 113 of 260
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HIC MANUAL
Special care during delivery is taken in labor room for HIV positive patients. The newborn is
also tested for serology and spl. Care is taken of such babies .double gloves are weared
whenever handling such pts. Blood borne precautions are undertaken and PPE like masks etc
are also used. Safe injection practices are followed up.
16.2
HOUSEKEEPING IN WARD/ROOM WITH HIV PATIENT
Cleaning schedules are the same in all areas regardless of the HIV status ofthe patients
being cared there. If there has been contamination of the ward withblood or body fluids,
disinfection must be undertaking using 1% sodiumhypochlorite.
The floor is to be cleaned at least twice a day using detergent and water.
Immediatedisinfection and then cleaning should be undertaken if there is a spill.
The walls are to be washed with a brush using detergent and water once in two weeks.
High dusting must be done with a wet mop at least one a week.
Fans and lights are to be cleaned with soap and water once a month.
All work surfaces are to be disinfected by wiping with antiseptic lotion and then
cleaned with detergent and water twice a day. Immediate and appropriate cleaning should
be undertaken if there is contamination with any infectious material.
Cupboards, shelves, beds, lockers, IV stands, stools and other fixtures should be cleaned with
detergent and water once a week, after each patient and when contaminated.
Curtains should be changed once a month or whenever soiled. In general wards and
intensive care units curtains are more frequently.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 114 of 260
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HIC MANUAL
If the cot is soiled with blood or infectious body fluids, immediate disinfection with 1% sodium
hypochlorite and cleaning should be carried out.
Storerooms are to be mopped and high dusted frequently.
Bathrooms should be cleaned twice a day. Toilets are cleaned with Germ Free.
Chlorine solutions for decontaminating.
Sodium Hypochlorite: 1% Sodium hypochlorite is used for disinfection of spills.
This also can be used for the disinfection of instruments and to clean and disinfect surfaces.
Housekeeping in the Operation theater for HIV pts .
The theatre is an area that requires regular and satisfactory cleaning. There are no changes
in the general housekeeping protocol for the theatres when handling HIV positive patients.
Special emphasis must be placed on waste segregation and handling of sharps.
HIV positive patients may be taken up for surgery in any operation theatre. Septic theatre
is used if the patient has a secondary disease condition that requires the use of this facility.
HOUSEKEEPING for MDR/NOTIFIABLE DISEASE/MRSA
HIV /ISOLATION
PTS .Cleaning of all articles in the room including the walls and the bathroom should be
done with detergent and disinfect.
After discharge fumigation can be done
Clean pillows and mattress with detergent, disinfect with 1% Sodium hypochloritefor 24
hours.
Remove bed sheets, curtains, gowns and dusters and send
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
to laundry in a plastic bag

APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 115 of 260
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HIC MANUAL
labeled as INFECTIOUS. This linen has to be soaked in 1% Sodium hypochlorite for
one hour in the laundry.
Soak bedpan, urinal and kidney basin in 1% Sodium hypochlorite for one hour. Wash
with detergent and dry in sunlight.
Utensils used by the patients are washed, boiled and replaced.
Counseling:
All patients undergoing surgeries and other major procedures shall undergo screening for
Hepatitis B and HIV. It is the counselors responsibility to get the consent from the patient and
give pre and post counseling. Beside consultant physician the contacts and family is counseled
by social work degree holding counselors the confidentiality process ofseropositivity is
maintained for patients.
17. CSSD RECALL POLICY:
Purpose
To Prevent Infection by using sterile instruments and material and to avoid use of contaminated
and open surgical sets.
Every Load with lot number in first tested with Chemical test tape and biological indicators and
in events of break down,, guide all wards and OT and inform not to use treated lot number and
send it back for re autoclaving purposes. HIC department also inform about it. in case of any
mechanical problem in Autoclaving of CSSD Biomedical
Engineering department will
rectifying the same as soon as possible .If Any kit or set is found to be open or blood stained or
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 116 of 260
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HIC MANUAL
contaminated then it is returned back to the CSSD department and the event is entered in to
recall register also. ETO sterilized items are sent for surveillance swabbing to micro lab to see
whether any growth is seen IF it is positive than those lot tubes are sent back again and
subjected to re autoclaving by ETO method .thus such items are recalled back.AN RECORD IS
MAINTAINED IN RECALL REGISTER ALSO recall is also done whenever there is breakage
of function of autoclave or whenever the biological controls of Bacillus stereo thermophiles and
Bacillus subtlis are not working properly .WHENEVER THERE IS OUTBREAK OF SSI in
wards then all those involved lot no. sets are recalled back for Re auto-Calving procedures
.sterile storage room in CSSD is also fumigated or cleaned with bacillocid promptly and
periodically swabs are sent to lab along with open settle plate method to know about any
environmental contamination there .all aseptic techniques are followed in cleaning and
preparation of sets .all the staff are vaccinated for HBV and they are told to use PPE also ,and
maintain good personal hygiene also .THE biomedical dept. always does preventive
maintenance of all the instruments present in CSSD dept. the ETO sterilized reusable tubings
etc are subjected to swab culture and if found positive then all the lot no set is desterilized ..
OTHER CARE FOR ICU
Floor cleaning for 4-6 times at least during morning hours.
Spillage care under taken, avoid spillages and splashes etc
Work Surface Cleaned with 1% HYPOCHLORITE.
Equipment cleaned with bacillocid before sharing with other pts.
Curtains Changed periodically to Cleaned 3-4 times in a day toilets and wash basins are
cleaned 3 to 4 times a day.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 117 of 260
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Ambo bag are sent for ETO Sterilization.
Suction Catheter cleaned periodically.
Blood Borne pathogen Control Measure undertaken
Water and air environmental qualityis maintained and rechecked periodically
Universal Standard Precautions are followed and aseptic barrier nursing techniques are
followed Blood borne pathogen transmission is minimized by aseptic precautions Barrier
Nursing techniquesare followed.
Movement of people should be minimized and restricted .and visitors are allowed by
wearing sterile gowns and trafficking should be mostly restricted in high risk wards.
Nurse: Patient ratio is maintained.
Hand rub and hand wash Compliance as monthly data is recorded for HK and nursing
staff, and also m, DMOS, Consultants, especially from HighRisk Wardsetc.
18. ENGINEERING CONTROL

Policy:
The preventive maintenance of all equipment will ensure efficiency of all staff 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 dept and its personnel are important links in the chain of activities towards
hospital infection control. They should maintain Positive or Negative pressure in given
room.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 118 of 260
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All personnel should apply universal Precautions when in contact with patients or blood and
body fluids. It identifies infection hazards during construction and maintenance work and
plumbing due to dust and airborne and waterborne hazards etc. and biomedical dept. should
do preventive maintenances to reduce any air or water contaminations,a/plumbing lines and
sanitary lines and avoid dust formation etc.
GENERAL:
Engineering personnel shall report to the ward sister prior to commencing work in a
patient's room or area, and follow her directions with regard to dressing, scrubbing etc.
Engineering personnel shall checkout with the ward sister upon completion of work.
Engineering employees shall maintain a neat, clean appearance at all times. Personnel
hygiene such as washing after using toilet facilities etc will be observed. All engineering
personnel must be aware of universal precautions and case of immune compromised
patients.
Prior to entering areas requiring sterile attire such as the OT, engineering employees shall
wear the prescribed clothing. Engineering personnel shall check in and out with the
permission of the supervisor.
Hand washing should be followed before and after leaving the patient care area. To
identify mold growth and take preventive actions. Wipe off work surfaces with
disinfectant.mold growths are identified and documentation of corrective action is taken
and more care is taken during repairs and construction and demolition and
maintenanceworks etc.
PLUMBING JOB GUIDELINES:
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 119 of 260
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Hospital water supply systems shall not be connected with any other piping system or
fixtures that could allow contamination without the use of adequate air gaps or approved
back flow preventer's or vacuum breakers.
When using implements to unstop faulty drains, wear rubber gloves. Better to block off and
seal air ventilators and place dust mat at entrance and exit of work area.
When rubbing out main sewer lines, or when exposed to gross contaminated wastes, wear
rubber boots and rubber gloves.
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. Sanitary hygiene has to be maintained without leak or break in
plumbing pipeline which are changed if old. Avoid water pipeline contamination s and any
biofilm formation.
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 Maintenance Officer, who will inform the concerned departments so that
patient may be shifted if required.
When work is carried out in areas where immune compromised patients or that requires a
sterile atmosphere, adequate physical barriers must be present to prevent the spread of
fungus and other such microbes, through dust and debris generated.
All areas that require a sterile atmosphere must be fumigated before use following
construction work; environmental care is of priority wipe work surfaces with disinfectant
vacuum the work area. OT and ICU area Infectious hazards of construction and maintenance
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 120 of 260
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work has to be identified esp. from fungal spores for immuno-compromised pts staying in
hospital .pl. cover transport receptacles or cart well. Please vacuum the work areas and do
wet mopping also. When working in gross contaminated areas or sewer lines pl. use masks,
goggles and rubber gloves etc
Ventilation Systems:
Regular cleaning of all window AC filters must be carried out in a systematic manner
throughout the hospital. And mold growth monitors by periodic swabs testings
AC filters should be placed in formalin/cidex solution for at least an hour at each
cleaning and cleaned with detergent and rinsed with hypochlorite etc.
In areas such as the microbiology labs where handling of infected material is carried
more frequent checks and cleaning of AC filters is required preventive maintenances is
done regularly and records maintained .high risk areas are OT,CSSD,ICU,AMCU etc
In situations where HEPA filters are used regularly checks must be carried out as the
environmental dust load is very heavy in these areas and the filters get clogged quickly.
When microbial load increase as evidenced by results from the environmental
surveillance, the filters must definitely be checked..
In areas where central air-conditioning is used the moisture of the air and the ventilator
air changes must be carefully monitored. All ducts must be washed thoroughly at
regularly intervals and fumigated. Documentation to maintain positive and negative
pressures in OT &ISOLATION rooms have to b done .they should check OT by wearing
sterile dress only .the maintains dept staff also should maintain good personal hygiene
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 121 of 260
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.and follow use of PPEV and hand wash techniques etc . They should block off or seal
AIRVENTS .HEPA filters should be overhauled periodically by its company people.
Methods for reporting and follow-up:
The goal of reporting and follow-up is to focus on interventions that will improve patient
outcomes.
Surveillance reporting will be an on-going component of the infection control
committee agenda.
Report will be given to the appropriate unit, department, service, or committee in a
timely manner by the infection control, or through the quality improvement department
for medical staff issues as appropriate.
Whenever possible, infection indicators will be expressed as rates while reporting data.
Denominators will vary based on appropriateness and availability (e.g. admissions,
discharge, patient days, procedure, device days, at-risk days).
Air filters are used, exhaust fan are also installed for maintaining air change, Quality
Assurance maintained periodically. Microbiological Surveillance done by the open
settles plate method. THE A/C filters are cleaned regularly as per protocols by
maintainance dept . and fixed. Random swabs are taken to see for any fungal growth due
to improper cleaning .
Monitoring frequency is kept Quarterlygoggles and masks and elbow type heavy gloves
are also used.
All AC filters are soaked in cidex for I hour and rinsed in hypochlorite after washing in
detergent. THE FILTERS are changed every year in operation theatre .air filters are used
and exhaust fans are placed in needful areas and quality assurance dept also checks and
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 122 of 260
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monitors maintenance dept works also.
19. EMPLOYEE HEALTH PROGRAMME
Purpose:
To provide a system of primary and preventive health care for OmegaHospital forOmega
Hospital staff specifically for employees seeking immediate care and consultation.
Preventive health care for staffs includes communicable disease screening, immunizations
and treatment of blood/body fluid exposures, possible hospital related accidental HIVs
exposures as well as an overall health promotion program that emphasizes wellness.
Referrals to specialists will be arranged as appropriate by general medicine consultants.
Patients with medical problems of an emergency nature will be seen in the emergency
department.
SCOPE:
This policy is applicable to all Omega Hospital Employees.
RESPONSIBILITIES:
Employee shall:
Report illness to his/her supervisor
Report to the general medicine OP for the scheduled appointment.
Report to his/her supervisor any exposure to blood or body fluids.
Policies:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 123 of 260
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Initially the employee will be seen in General Medicine OP and thereafter referred other
specialties SOS concentration or discount is given to staff for any lab and radiology
investigations.
PROCEDURES
Annual Health Checkup
After completion of one year every staff shall undergo physical health examination at the
general medicine OP, this includes only a physician consultation. Only if the doctor requests
blood and other investigation shall be carried out, at concessional rates. Sick leaves are given to
employee as per needs and demands found fit by the treating clinician accordingly.
Vaccination
All new staff shall be screened and their medical and (immunization)history shall be
obtained in order to determine their vaccination status.
Hepatitis-B vaccination shall be done in accordance with employee Hepatitis- B
vaccination
All health care workers at risk should be vaccinated against hepatitis B, if they have no
history of Hepatitis B vaccination.
If staff fails to produce vaccination certificate the Physician initiate to detect antibody
titer and if it is less than 10 a booster dose isPost exposure prophylaxis of Hepatitis B:
After contaminated needle stick or sharps injuries
If the source is (patient)HBSAg positive, and staff is not vaccinated. HBIG (0.06ml/kg)
and initiate Hepatitis B vaccination series (3 doses to be given)
If the source is (patient) HBSAgpositive and staff is not vaccinated.
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 124 of 260
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MLA COLONY,
HIC MANUAL
a. Known responder (Antibody>10lu/ml)

No treatment require
b.
Known non responder

HEBIG*1 dose of hepatitis B vaccination
c. Antibody responds unknown

Test for Anti HBs-if adequate No treatment
d. If inadequate HBIG (<10u/ml)
HEBIG*1 dose and give booster dose.
If the source is HCV positive then specific interferons are given to the victim for
protection sake for all seropositive contaminated pricks serology testing is also done
periodically to know the status of infection by blood borne viruses.
If the pt is pricked by known HIV positive contaminated needle then prophylax is started
immediately and thereafter the victim is referred to OMEGA HOSPITALS for further
management.
Chemo with cap rifampicin is given staff is exposed to menigococcus and hospital
infection meningitis etc. Its vaccine is also given SOS during patient stay. Annual
checkups are also done for employees and also hotel care food handlers etc .
UNIVERSAL STANDARD PRECAUTIONS
Purpose:
The purpose of this is to explain the Universal precautions for all employees.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 125 of 260
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Scope:
This procedure explains the universal precautions for all employees of PH.
Responsibility:
Medical & Nursing Staff
Procedure:
Universal precautions are to protect and PATIENTS and STAFF from the spread of blood borne
viruses (HIV/Hepatitis) or other harmful microorganisms that may be present in blood or body
fluids.
Universal precautions apply to blood, body fluids
containing visible blood ,semen, vaginal
fluid cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluid needles, scalpels
and other sharp instruments Universal precautions do not apply to Feces, nasal secretions,
sputum, sweat, tears, urine, vomitus
Consider all blood and certain body fluids of all patients as potentially infectious for HIV, HBV
and other blood borne pathogens. Infections material must be handled in a manner that
minimizes splashing, spraying, and generation of droplets. Wear personal protective equipment
Gloves are to be worn when hand exposure to blood and/or OPIM is anticipated, such
procedures include phlebotomy, IV start, specimen collection, open wound contact and when
handling or touching contaminated items or surfaces.
Cover any existing cuts or lesions with a waterproof dressing/plaster before wearing gloves.
Gowns and disposable plastic aprons are required during Procedures when splashing with blood
is anticipated.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 126 of 260
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MLA COLONY,
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Masks, face shields, ventilation devices and protective eye wear are required during procedures
when splashing, spraying, splatter or droplets of blood and OPIM to the eyes, nose or mouth is
anticipated.
A) N-95 respirator masks are required for protection when ever indicated (for suspected
H1N1cases). Regular masks are required for protection against other airborne transmitted
diseases such as chickenpox.
B) Use good HAND HYGIENE. It is required before and after contact with patients and
specimens, wearing gloves or other PPE, contact with mucous membranes, and preparing
food. Hand hygiene may be accomplished with either waterless disinfectant or soap and
water washing.
C) Always dispose of SHARPS at the point of use in puncture proof containers. Do not
dispose of sharps with other clinical waste
D) Do not RECAP OR MANIPULATE needles should not be recapped or manipulated in
any way. Dont break, or bend needles. Dont reach your hand into a container that might
contain sharps.
E) Disinfect blood/body fluid SPILLS correctly.Dispose of waste and excreta carefully.
F) Disinfect linen heavily contaminated with blood/body fluids by soaking in 1% sodium
hypochlorite solution before sending to laundry.
Flush eyes, nose, or mouth with water as soon as possible after contact with blood or potentially
infectious materials.
Dont eat, drink, smoke, apply cosmetics, or handle contact lenses in areas that could contain
infectious materials
Hepatitis B vaccination is strongly recommended for all employees who have the potential for
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 127 of 260
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MLA COLONY,
HIC MANUAL
occupational exposure to blood and OPIM. This is administered in a series of three injections.
Also food handlers are vaccinated additionally with typhoid vaccine and they are all screened
for Stool exam and Stool c/s etc .all the staff have to inform about their illness to their
supervisors also .dialysis and OT CSSD employees are screened for any MRSA career status and
treated with muciprocin ointment in case of positive finding also .food handlers are prevented
from working if they have severe cold ,GE,jaundice or boils and other skin infections etc they
are instructed to follow depts. Dress codes also .
20. INFECTION CONTROL PRACTICES IN AMBULANCE
Purpose:
The purpose of the infection control policy in the ambulance is to the emergenceworker and the
public served from exposure to the transmission of infectious or contagious diseases
Scope:
This SOP includes the infection control activities in ambulance on days to day
PATIENT CARE: Shall mean all tasks involving patient care and tasks related to access to the
Patient shall be considered as a potential for an infectious exposure
ROUTINE CLEANING DECONTAMINATON AND MAINTENANCE: of the ambulance
and patient care equipment shall be considered as a potential for an infectious exposure.
CONTAMINATED APPAREL worn during patient care that becomes soiled with bleed or
other body fluids from the patient or other responders shall be considered as having a potential
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 128 of 260
OMEGA HOSPITALS
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HIC MANUAL
for infectious exposure and shall be decontaminated or disposed of according to policy.
FULL BODY SUBSTANCE ISOLATION GEAR: includes gloves masks, gowns, and
protectiveeyewear.
PRE EXPOSURE PLAN:
Any responder knowing they well have immediate patient contact shall wear protective gloves
and other personal protective equipment as needed. Prior to putting on the
Protective gloves, the responder should wash his/her hands with soap and water or an antiseptic
cleanser for at least ten (10) seconds.
Anyone who may have the potential of coming in contact with blood or other body fluidstissue
or any articles potentially contaminated by a sick or injured person should wear appropriate
body substance isolation gear.
All emergency workers should wear heavy gloves over the protective gloves when the
possibility exists of injury from sharp object I.e.Motor vehicle accident farm machinery
Extrication, etc.
in a multi-trauma situation you could be caring for more than one patient the possibility exists to
transmit an infectious disease to other patient The caregiver will either put on several layers of
gloves or carry extra gloves in order to change then between patient The disposal of gloves will
be according to policy for discarding contaminated clothing and equipment.
When the responder is doing assisted breathing a pocket mask a resuscitation bag or other
ventilation devices with a one -way valve is required those in danger of exposure to spurting
blood splashing body fluids or from individuals with known respiratory infection should wear
full body substance isolation gear.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 129 of 260
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HIC MANUAL
FIRST AID KIT: Will be emptied and cleaned with soap and water or as instructed by the
manufacturer
DECONTAMINATION OF AMBULENCE:
The equipment and emergency unit shall be cleaned after infectious disease run. The
decontamination of the ambulance will be documented and kept on file. ALL bmw BASKETS
ARE KEPT FOR COLLECTION AND EMERGENCY MEDICINES ARE ALSO KEPT
ALONG WITH DAILY MONITORING OF AMBULANCE CHECKLIST .
SPECIAL CARE SHOULD BE GIVEN TO THOROUGHLY CLEANING THE

FOLLOWING AMBULANCE PARTS AND WQUIPMENT:
The sliding on the inside compartment doors (1% hypochlorite)
The wooden spine boards (1% hypochlorite)
All equipment made of canvas (1% hypochlorite)
All equipment used in taking vitals .(70%alcohol)
The defibrillator. (70%alcohol)
DISPOSAL OF CONTAMINATED EQUIPMENT AND SUPPLES:
Contaminated equipment, clothing and supplies will be double bagged in a biohazard bag
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 130 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
and disposed as per hospital policy.Theambulance is cleaned with bacillocid periodically
and after use. To prevent any contamination of surfaces and fomites etc.BMW bags are
kept in ambulances
All general supplies used in cleaning the ambulance or equipment that has not been
exposed to blood or air contamination may be placed in the trash container or poured into
the drainage system.
TRANSPORT OF PATIENTS WITH COMMUNICATBLE DISEASES:
Movement of patient restricted to bare minimum
Surgical mask to worn by patient.
Open wounds to be covered by dressing
All the personnel in the receipt area of the patient to be informed prior of patient arrival
Conscious, coherent patient educated about his disease and how to limit speed
DETAILS OF Pateint are written whenever we are referring these pts and mask is also
used by ambulance staff and also to attenders and pt. himself .,,especially infections like
MRSA and MDR strain infections have to be mentioned in our discharge note please .
21. SHARP DISPOSAL POLICY

Purpose:
To define the policies and procedures for the disposal of sharps and to bring down the incidence
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 131 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
of needle stick and cut injuries which have a potential for transmitting blood borne pathogens.
Scope:
This policy describes the proper procedure for the disposal of used disposable needles, syringes
and other sharps in PH.
Responsibility:
The implementation and adherence of these policies are the responsibility ofPH Personal
handling needles, syringes and other sharps
Housekeeping unit personal
Infection control personal
Procedure
Disposal is the correct method for discarding used needles, syringes and sharps use by
immediately a burning it off & thorn in PPC.
Used disposable needles, Syringes and other sharps are those, which have been used
and/or are contaminated.
Sharps are anything, which can puncture skin and may be contaminated with blood
and/or other body fluids. These include glass ampoules, hypodermic suture needles and
blades.
DESCRIPTION:
GENERAL POLICY
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 132 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Used disposable needles and syringes and other sharps shall be placed in the sharps
container containing 1% sodium hypochlorite, designated for this purpose.
Sharps containers shall be placed throughout PH in locations, which facilitate their
immediate use. These locations shall be such that they exclude injury to patients, visitors
and staff.
Lancets and other sharps shall be placed in sharps containers unless used in areas with
special procedures, such as the operating room.
When sharps containers are full they shall be securely removed and disposed
Filled sharps containers shall be placed in yellow bags and removed for disposal on a
trolley.
Used syringes shall be placed in red bins and removed from unit.
Recapping of needles should be avoided where at all possible. When it is ABSOLUTELY
NECESSARY (e.g. because there is no sharps container available for disposable, etc.)
needles shall be recapped using the scoop method, as follows:
Place the cap on a flat surface
Without holding the cap, use the needle to scoop the cap onto the needle.
Shake the cap down over the needle. NEVER RECAP WITH BOTH HANDS AND IN
CASE OF EMERGENCY IT CAN BE CAPPED WITH SINGLE HAND
Press the cap firmly into place.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 133 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Blades shall be removed by an appropriate tool and discarded by the use of a tool.
Sharps shall never be left lying around. Loose needles shall never be placed in the
trashcan or left in the patients linen.
Any procedure /action, which require the operator to move his/her, hand towards the
needlepoint, or the needlepoint towards the hand, is not safe.
HANDLING SHARPS CONTAINERS:
DO NOT hold sharps container at the bottom of the contents compartment. Hold it near the
top.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 134 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
DO NOT shake sharps container to settle its contents to make room for more sharps.
DO NOT wipe sharps container to clean it. If the surface has become contaminated or
unsightly, discarded the container. Wipe the brackets only when the container is not inside.
If it is absolutely necessary to clean a sharps container use a brush. NEVER use a handheld cloth. Rinse with water & shake & through it off.
22. PROTOCOL OF SCHEDULE FOR ACTIVE SURVIELLANCE SWAB

1.
SICU, MICU
Every
Swab from various dust Aerobic bacteria
month(According to settling areas. Swab from

patients occupancy)
dressing
trolleys,
patients bed, floors and

equipments,
2
Central
Sterile Weekly
tables
A/C. filters
once(post Chemical check
&
tube, Aerobic bacteria
Supply department. fumigation)
Biological
indicators
(CSSD)
from each cycle. Settle

plate count & Swabs
from CSSD every week

every Swabs from operating Swab
Operation Theatre: After

I & II
fumigation
Tables, lights, Trolleys, various
Twice a month
Suction
filters
machine,
&
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
dust
A/C setting areas as
anaesthesia above.
trolly & floor etc.
from
Bacteria
For
(as
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 135 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
above)
4.
Operation theatres
After
every Settle plate count method Clostridium
fumigation
& swabs are taken from tetani

different articles & sites n
OT
an
inoculated
in
Robertons cooked meat

Medium
5.
6.
Disinfectants
Nursing staff
or
If turbid
Thyoglycolate broth
Swabs taken from the Pseudomonas
Monthly
disinfectant
Swabs are taken from MRSA,
hands of nursing staff and Pseudomonas,
nostrils randomly.
Ecoli
Pseudomonas,
Swabs taken table tops at Staphylococcus
7.
Drinking water
Every month
all nursing station
species
Coolers and suppliers
Presence of coli
form and TVC
(Total
General ward
Quarterly
Swabs are sent
viable
count)
For aerobic
Organisms
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 136 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
23.
SAFE MEDICATION INJECTION PRECAUTIONS AND PROTOCOL OF

LOADED SYRINGES
Timely administration of medication I.V/ I.M with aseptic technique & barrier
precaution & by use of PPC.
Standard Concentration of drug Maintenance
High alert medication care
Avoidance of medication errors
Following Loaded syringe policy
Reporting near miss incidents
Legible hand writing of Drs is needful in capital letters
Trademark , package ,label, safety Testing noted
Calculation of doses as per body weight , using syringes only one time
Knowledge of side effects and complications and drug interactions along with route of
drug administration noted
Nurse should know about dos and donts about basic safe aseptic injection practices. The
staffs are updated about it and special care is taken for LP, central and peripheral cannula
insertion methods etc.CME, CNE classes are taken regularly for staff.
Use aseptic techniques and barrier nursing practices .do not administer medications from
syringe to multiple pts.
All health care workers should be vaccinated for Hepatitis-B
Needle prick injuries and sharp injuries should avoided
The common infections transmitted by Blood and Syringes or Injections are Hepatitis-B,
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 137 of 260
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Hepatitis-C and HIV and septicemias, infected abscess etc. By various bacteria
Reuse of syringes avoided and store vials in accordance with manufacturers instructions.
Apply Betadine or 1% Chlorohexidine for IV line area preparations and cleaning esp. in
high risk wards
Segregation policy and & BMW Protocols should be followed along with sharp
management and use of PPE and PPC etc.
Use fluid injections and administration sets for one patient only avoid multiple injections
in IV injection bottles Dont reuse bottle after 18-24 hrs gap period of opening it up. If
fluid it is already contaminated and turbid please report the matter to pharmacy
department without fail.
Please do hand wash , use PPE Before any invasive IV lines procedures & staff is trained
for that
Oily preparations are given with more caution; avoid injection abscess formation by
aseptic precautions. No RECAPPING needle allowed. One hand scoop technique used
for needle recapping
Loaded syringe policy during name is labeled along with time and date of preparation; it
is discarded within 4 to 8 hours of preparation. Syringe is loaded and kept for heparin
injections and chemotherapy injections SOS. If there is turbidity and discoloration of
syringe please discarded it, it is kept with capping of needle. No leakage or spillage
should occur; the syringe is kept at room temperature. Handling of syringe can be done
preferably after hand wash please. High risk medicines are not loaded at all. Please keep
loaded syringes in safe and secluded places in ward. In separate trays etc. Multi dose
vials are is minimized.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 138 of 260
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Store multiple dose vials as per manufactures recommendations & discarded if srcility is
compromised.
Quality assurance assessment done by detecting CLBSI & Peripheral thrombophlebitis
rats.
Provide ongoing training for staff.MULTIDOSE VIALS ONCE OPENED SHOULD BE
USED WITHIN 24 HRS OR AS PER MANUFACTURRS INSTRUCTIONS ,normal
saline bottles used for suction should be discarded after 12 hrs use without fail .suction
cannulacatheter should be used disposable one .
LOADED SYRINGE POLICY
Whenever any syringe is loaded esp. with normal saline or dilute Heparin saline for
removing blockages in IV Cannula fluids etc. Then the DATE & TIME of Reconstitution
is noted & it has to be dispose off to BMW within 18- 24 hrs time.
It should also be disposed off if there is any visible contamination or changing in color of
injection etc. if not labeled then better not to use it at all.MOSTLY HEPLOCK
SOLUTION IS KEPT IN LOADED SYRINGE FOR 12 HRS PERIOD only .multi dose
vials are stored as per manufacturers instructons ..
PEST CONTROL MEASURES

we have outsourced to an company whose personnel visits our hospital daily /alternate ly
and sprays the insecticide which kills cockroaches flies and mosquitoes etc esp in kitchen
and BMW storage room and other pt care areas. Even rodenticides are used to kill rats in
kitchen etc areas. We have MOU with them ,
4.
SHARPS MANAGEMENT
A.
Needle Sticks
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 139 of 260
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Occupational exposure to, and the transmission of, Hepatitis B
(HBV) and human immunodeficiency virus (HIV) are of the
utmost importance from a risk management standpoint because of
the need to protect health care workers, patients and visitors from
these viruses. Needle stick injuries are the largest source from which
occupational exposures to these agents arise in the hospital
workplace. Since all hospital workers are at risk of needle stick
injury, adherence to the following practices is useful in preventing
needle sticks
Avoid rushing when handling needles.
Avoid pulling hard when encountering resistance in
withdrawing needles from patients.
Seek assistance when using a needle in caring for an
uncooperative patient.
Avoid recapping under all circumstances, but never recap a
needle that has been used on a patient.
Dispose of needles properly in puncture resistant containers.
Never leave needles on beds, stretchers, or bedside tables

since they may injure staff, patients, or visitors. Do not throw
them into regular garbage containers where they may injure
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 140 of 260
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HIC MANUAL
housekeeping staff.
Never put needles in your pocket.
Never try to remove anything from a needle container or
force needles into a full container.
Pick up improperly discarded needles with care and dispose
of them in a puncture-resistant container.
In the event a needle stick does occur, promptly wash the area with
soap and water, record the patient's name and hospital number,
prepare an incident form and report the event to ICN. Attempts to
"milk" the wound to express contaminants are ineffective and only
damage tissues further
Safe handling and disposal of sharps is a vital component of the

standard precautions practiced to reduce the risk of transmission of
blood borne virus.
Good practice involves
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 141 of 260
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Correct assembly of the bin with the lid
Labeling of the bin upon assembly and closure of the bin
Bins no more than full
Being aware of the first aid treatment following a needle

stick injury.
Being aware of the follow up treatment after a used needle

stick injury.
NEEDLE STICK INJURIES, BLOOD CONTAMINATION AND POST
EXPOSURE PROPHYLAXIS ( PEP )
A.
EXPOSURE
An exposure that might place a Health Care Personnel (HCP) at risk
for HBV, HCV, or HIV infection is defined as a percutaneous injury
(e.g., a needle stick or cut with a sharp object) or contact of mucous
membrane or non intact skin (e.g., exposed skin that is chapped,
abraded, or afflicted with dermatitis) with blood, tissue, or other
body fluids that are potentially infectious
In addition to blood and body fluids containing visible blood, semen
and vaginal secretions also are considered potentially infectious.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 142 of 260
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Although semen and vaginal secretions have been implicated in the
sexual transmission of HBV, HCV, and HIV, they have not been
implicated in occupational transmission from patients to HCP.
The following fluids will also be considered potentially infectious:
cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid,
pericardial fluid, and amniotic fluid. Feces, nasal secretions, saliva,
sputum, sweat, tears, urine, and vomitus are not considered
potentially infectious unless they contain blood.
B.
RECOMMENDATIONS FOR THE MANAGEMENT OF HCW

POTENTIALLY EXPOSED TO HBV, HCV, HIV
(i)
PREVENTION
Exposure prevention remains the primary strategy for
reducing occupational Blood borne pathogen infections;
however, occupational exposures will continue to occur.
Prime Hospital has made available to their personnel a
system that includes written protocols for prompt reporting,
evaluation, counseling, treatment, and follow-up of
occupational exposures that might place HCP at risk for
acquiring a blood borne infection.
The HCP are educated concerning the risk for, and prevention
of blood borne infections, including the need to be vaccinated
against hepatitis B .
HCP who are at risk for occupational exposure to blood
borne pathogens ie, doctors, nurses, housekeepers and
technicians in the laboratory, OT, Cath lab are familiarized
with the principles of post exposure management as part of
job orientation and ongoing job training.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 143 of 260
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HIC MANUAL
The hospital has provided appropriate training to all
personnel on the prevention of and response to occupational
exposures.
The HCP have been educated to report occupational
exposures immediately after they occur, by conducting
training classes, demonstrating on how to fill up the
inoculation injury form and emphasizing to them the
importance of early reporting .
(ii)
Any newly joined employee from the following departments :

o Doctors
o Nurses
o Laboratory technicians
o OT technicians
o Housekeepers
will be given three doses of hepatitis B vaccine at the time of
joining( at intervals of one month between doses), if not
vaccinated in any previous medical organization.
HCP who have contact with patients or blood and are at ongoing
risk for percutaneous injuries will be tested annually to evaluate
their antibody status.
already
C.
HEPATITIS B VACCINATION
Any person who performs tasks involving contact with blood,
blood-contaminated body fluids, other body fluids, or sharps will
be vaccinated against hepatitis B .
POST EXPOSURE
(i)
TREATMENT OF AN EXPOSURE SITE
Wounds and skin sites that have been in contact with blood or
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 144 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
body fluids should be washed with soap and water; mucous
membranes should be flushed with water / saline.
The use of antiseptics has not proven to be beneficial but is
not contraindicated. Hypochlorite soln can be used to just
rinse hands as it is one of the best viricidal antiseptic .
DO NOT apply any caustic agents (e.g., bleach) or inject
antiseptics or disinfectants into the wound.
(ii)
POST EXPOSURE PROPHYLAXIS

The hospital has established exposure-control plans that
include post exposure follow-up for the employees.
A clinician ( physician ), who can provide post exposure care,
is available during all working hours, and on telephone
during off hours and holidays.
Once the HCP reports to them, the physician, after examining
and checking the immunization status of the individual, will
liase with the Medical Superintendent who is responsible for
providing post exposure management to the staff. He / she
will be familiar with the treatment protocols and the facilitys
plans for accessing HBIG, Hepatitis B vaccine, and
antiretroviral drugs for HIV PEP.
Hepatitis B vaccine, and antiretroviral agents for HIV PEP
are available for timely administration (both on-site and by
linking with Osmania Hospital / Gandhi Hospital to make
them available off-site).
(iv)
HBV exposures
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 145 of 260
OMEGA HOSPITALS
MLA COLONY,
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Initiation of hepatitis B vaccine series to any susceptible,
unvaccinated person is to be done.
Also PEP with hepatitis B immunoglobulin (HBIG) is
recommended if the person is unvaccinated.
(v)
HCV exposures
Determine the status of source and the exposed HCP,
Follow up if the source is positive for infection.
Immunoglobulin and antiviral agents like pegylated interferon
with or
without ribavarin are NOT recommended.
(vi)
HIV exposures
Treatment with retroviral drugs to be instituted at the earliest
but not later than 72 hrs depending upon exposure code and
HIV status code.
Basic regimen
o Zidovudine 300mg BD for 4 weeks or Tenofovir 300
mg OD for 4 weeks
o Lamivudine 150 mg BD for 4 weeks
The drugs may be obtained through the pharmacy free of cost,
for the first two days. The concerned employee is in the
meanwhile, referred to Osmania Hospital / Gandhi Hospital,
where the medicines are provided free of cost from the AIDS
cell established there by the Government.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 146 of 260
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MLA COLONY,
HIC MANUAL
HIV Elisa to be done immediately after exposure, and again at
6 weeks, 12 weeks and 6 months post exposure
D.
EXPOSURE REPORT
If an occupational exposure occurs, the circumstances and post
exposure management will be recorded in the accidental
inoculation injury reporting form
Pre- and post- exposure prophylaxis is provided to all concerned
staff members
24. RE-USE OF SINGLE USE MEDICAL DEVICES

PURPOSE:
To identify where single use items can be safely reused
To ensure the process for reuse of medical devices is both appropriate and safe
RESPONSIBILITY:
All Omega hospital staff who deal with medical devices
SINGLE USE MEDICAL DEVICES
There are three single use medical devices
Open and unused
Open and used
Unopened and expired
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 147 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Re-Processing
To successfully reprocess a device that has been used on a patient, institutions must be
able to clean it thoroughly, sterilize it to acceptable norms, and ensure that reprocessing
and reuse will not degrade its functioning. In order that a used or opened but unused
SUD can be reused, a protocol has to be established which identifies the method for
Reprocessing, repackaging, and resterilising for all items open and unused.
Cleaning, packaging, and sterilization for all items that is open and used.
DEFINITION
Single Use device
Single-use devicemeans a device that is intended for one use, or on a single patient during a
single procedure. The labelling identifies the device as disposable and does not provide
instructions for reprocessing.
Disposable single-use device is one whose sterility has been breached or whose sterile package
was opened but the device has not been used is termed as opened but unused single use device.
Reprocessed, with respect to a single-use device, means an originaldevice that has previously
been used on a patient and has beensubjected to additional processing and manufacturing for the
purpose ofan additional single use on a patient. The subsequent processing andmanufacture of a
reprocessed single-use device shall result in a devicethat is reprocessed within the meaning of
this definition.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 148 of 260
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MLA COLONY,
HIC MANUAL
BEST PRACTICE GUIDELINES

Single use medical devices for reprocessing based on this available evidence.
The reprocessing protocol should consider the material properties and design of the
specific device.
The protocol should ensure safety, efficacy and reproducibility.
Essential quality assurance should be performed during reprocessing.
Maximum number of reprocessing cycles should be specified according to devices
features, use conditions, and reprocessing protocol.
Pre-sterilization processing conditions and techniques are critical for sterilization
success.
Decontamination, cleaning, and washing procedures, together with sterilization
techniques could induce chemical, physical and morphological modifications on the
treated surfaces and potential toxicity of the sterilized device.
Identify SUDs to be Re-used
This is essentially an activity that individual HCFs need to undertakebefore proceeding any
further. These best practice guidelines is dictatedby the following factors:
The ability to achieve effective cleaning.
The ability to achieve effective sterilization.
The compatibility of the device with the cleaning agent, process and sterilant.
Validation of the process of sterilization to assure safety.
The ability to achieve safe pyrogen and endotoxin levels.
The absorption of the sterilant by the device, which could
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
then be transferred to the

APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 149 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
recipient (patient) i.e. toxic residues.
The presence of a quality assurance programme demonstrating thatthe device has not
deteriorated in either form or function during theprocessing cycle.
The ability to demonstrate that the original performancespecifications continue to be
met.
The cost effectivity of reuse is calculated for each device based on thecost of:
Performing the reprocessing procedure
Sterilisation
Validation (quality assurance)
Maintaining relevant documentation.
STANDARD OPERATING PROCEDURE - REUSE

Clinical Departments / User Departments
Each user department prepares a
List of single use devices that are to be reused.
Cost-benefit analysis for each reusable item.
User Departments, ICC, CSSD, Biomedical Engineers, Microbiologists

A method for completing each of the components/steps to support thereuse of a disposable or
single-use patient-care item. Each component/step must be measurable or observable so that it
may be consistentlyrepeated. Each component/step must be accompanied bydocumentation to
support the method for reprocessing, which includes:
Reprocessing area
Personnel
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 150 of 260
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MLA COLONY,
HIC MANUAL
Cleaning and decontamination
Disinfection
Rinsing
Inspection for physical integrity and functionality
Drying
Packaging
Labelling
Sterilisation
Validation of sterilisation process
Storage
Distribution
Inspection
Informed written consent
Billing schedule
Adverse event reporting
Time to withdraw a device
Documents for completion of each task above
Authorisation
Dissemination
Monitoring and Review
PACKAGING
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 151 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Appropriate packaging ensures the sterility of the product through itsintended shelf life, as well
as its efficacy at the time of use. For effectiveETO sterilization the packaging material must be
breathable to allow thehigh-humidity ETO gas mixture to infiltrate the package.
PROCEDURE
The items are wrapped in medical grade packaging roll (one sidepolythene and other side
medical grade paper). Double wrapping shallbe ensured to avoid contamination.
Excess air must be removed from packets before sealing, to avoid bursting. This process may
not be required while using polypropylene pouches. What is important is to cheque the integrity
of sealing.
The devices shall be identified by writing cycle number and date of expiry on the packages.
Commercially available heat sealable pouches and rolls specially made from medical grade
paper and polyethylene film (thickness 1-3 mils [one thousandth of an inch] and width 7.530
cm) must be used.
They have the advantage that the contents are readily visible after packing, to allow for easy
identification. These come with printed chemical indicator hence separate chemical indicator
need not be used.
STERILISATION
The device shall be sterilized by an appropriate sterilization method for that device for e.g.
ethylene oxide gas sterilization method or vaporized hydrogen peroxide. The process of
sterilization should be strictly controlled and as per the manufacturers instructions. The Cycle
parameters must be verified, using the sterilizer manufacturers instruction manual for specific
sterilizer and load configuration, to be used.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 152 of 260
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HIC MANUAL
ETHYLENE OXIDE (ETO)////PLASMA STERILSER/H2O2 STERILISER for reusable

items .
Prerequisites
Sterilization by ETO requires that the devices are dry.
Parameters
for
ETO
Sterilization///HYDROGEN
PEROXIDE
OR
PLASMA
STERILISERS .
The critical parameters of an ETO sterilization cycle are typically given as temperature,
pressure, humidity, ETO concentration, and gas dwell time.
The cycle parameters and aeration time should be as per the manufacturers recommendations.
Monitoring ETO Sterilization
Chemical indicator (as per ISP 11140-1) shall be placed externally in the form of strips or
printed on packaging material itself to differentiate processed from non-processed packages.
Class 5chemical indicators can be used in the same test pack which helps to take immediate
decisions about issuing the load instead of waiting for the BI report.
A HCF SUD reprocessor should prove during validation studies that each sterilization process
is capable of achieving sterility for each run.
The sterilization process should achieve a sterility assurance level (SAL) of 10-6 for devices
used in normally sterile areas of the body.
The efficiency of ETO sterilizer shall be tested by challenging a biological indicator (Bacillus
subtilis1264 from 3M or any other supplier) in the centre of each load. The test pack of BI
should be placed at the diagonally opposite end.
Process chart readings, particularly showing the temperature and pressure reading shall be
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 153 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
monitored for each cycle.
Aeration time and temperature shall be noted for each load.
STERILISATION VALIDATION
Definition
The term Validation means confirmation by examination and provision of objective evidence
that the particular requirements for a specific intended use can be consistently fulfilled.
Process validation means establishing by objective evidence that a process consistently
produces a result or product meeting its predetermined specifications.
Documentation
Maintain documentation to show that
Equipment has been installed correctly and operates as intended.
The sterilization process has been validated as being effective in achieving sterility without
adversely affecting the devices (chemical and biological indicators, physical parameters).
For each run the specifications for sterilization parameters have been met.
INSPECTION BEFORE REUSE
On receiving a sterile reprocessed device, the sterilization, package integrity, useful shelf-life
and any damage should first be ascertained before use on a patient. One should also ascertain
that there is no moisture inside the pack.
Commonly Reprocessed Single-use Devices:
Arthroscopic shavers
Blood pressure cuffs
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 154 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Soft tissue ablators
External fixation devices
Electrophysiology catheters
Scissors and staplers
Biopsy forceps
Laparoscopic scissors and forceps
Clamps and dissectors
Compression Sleeves (DVT)
Phaco tips
Pneumatic tourniquet cuffs
Pulse oximeter sensors
Orthopedic drill bits and burrs
Cardiac catheter
Orthopedic surgical blades
Laproscopy accessories saw blade
Ultrasound catheter
Pulse oximetry probes
Trocars
25. ENVIRONMENTAL CONTROL
Purpose:
To disseminate information on how to prevent and control infections and environmental hazards.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 155 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Scope:
This policy describes the program for preventing infections and environmental hazards in PH.
Responsibility:
Infection control department & Quality department investigates nosocomial infections and
disease outbreaks.
Infection control committees review environmentally- related problems brought before
them review investigation results and recommend corrective action.
All hospital facilities follow guidelines, policy and procedures established in the given
hospital infection control manual and in this policy which is applicable to their specific
area.
Procedure:
The environment includes inanimate surroundings:
Physical facilities and grounds
Patient care equipment, supplies and drugs
Water
Air
Food
Solid waste
Liquid waste
Environmental control is the surveillance and monitoring of all aspects of the
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 156 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
environment in order to maintain a clean, safe and infection free facility.
We have sewage water treatment plants which after processing the residual water is sent to
municipal discard in order to decrease the harmful environmental effects .
Policies:
The hospital environment is closely relat6ed to nosocomial infections and plays a prominent
role in other health hazards. For this reason the environment health section shall:
Conduct microbiological sampling as appropriate decndfit .
Provide information on current standards, practices and procedures related to environmental
health.
All the microbiological waste is autoclave & discarded off. The hospital is licensed &
recognized from Telangana pollution control Board. Water is tested for coliform count, bore
water is also tested for Endotoxins, OT Environment is tested by swabs, settle plate method.
Food safety guidelines are followed & regular swabs are obtained from kitchen working
surfaces & food handlers are also tested for any carrier state. Food & kitchen water supply
are also tested in NABL Accrediatated laboratory. Plumbing & sanitation & drainages are
checked regularly. Any Air pollution possibility near to hospital environment is to be
checked solid & liquid waste disposal is to be monitored by maintenance dept.
Parking facility for Doctors & patients & attenders &vallet parking has to be provided for
hospital. Cool drinking water has to be provided for Attenders & out patients etc. Adequate
toilets & lavatories facilities also should be provided. Fire safety of the building structure is
an important aspect of facility & staff should be trained for fire extinguishment.
Pest control measures are under taken for prevention of arthropods borne diseases.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

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Rodenticide is also used. Bouquets & Flowers are not allowed from out side. Ventilator
must provide > 12 air exchange per hour.
Eating and drinking facility to staff and
ptsattenders have to be provided in hospital only.BMW storage room area should b neat and
clean .
26. INFECTION CONTROL PRACTICES IN AMBULANCE

Purpose:
The purpose of the infection control policy in the ambulance is to the emergence worker and the
public served from exposure to the transmission of infectious or contagious diseases
Scope:
This SOP includes the infection control activities in ambulance on days to day
PATIENT CARE: Shall mean all tasks involving patient care and tasks related to access to the
Patient shall be considered as a potential for an infectious exposure
ROUTINE CLEANING DECONTAMINATON AND MAINTENANCE: of the ambulance
and patient care equipment shall be considered as a potential for an infectious exposure.
CONTAMINATED APPAREL worn during patient care that becomes soiled with bleed or
other body fluids from the patient or other responders shall be considered as having a potential
for infectious exposure and shall be decontaminated or disposed of according to policy.
FULL BODY SUBSTANCE ISOLATION GEAR: includes gloves masks, gowns, and
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 158 of 260
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protective eyewear.
PRE EXPOSURE PLAN:
Any responder knowing they well have immediate patient contact shall wear protective gloves
and other personal protective equipment as needed. Prior to putting on the
Protective gloves, the responder should wash his/her hands with soap and water or an antiseptic
cleanser for at least ten (10) seconds.
Anyone who may have the potential of coming in contact with blood or other body fluids tissue
or any articles potentially contaminated by a sick or injured person should wear appropriate
body substance isolation gear.
All emergency workers should wear heavy gloves over the protective gloves when the
possibility exists of injury from sharp object I.e. Motor vehicle accident farm machinery
Extrication, etc.
in a multi-trauma situation you could be caring for more than one patient the possibility exists to
transmit an infectious disease to other patient The caregiver will either put on several layers of
gloves or carry extra gloves in order to change then between patient The disposal of gloves will
be according to policy for discarding contaminated clothing and equipment.
When the responder is doing assisted breathing a pocket mask a resuscitation bag or other
ventilation devices with a one -way valve is required those in danger of exposure to spurting
blood splashing body fluids or from individuals with known respiratory infection should wear
full body substance isolation gear.
FIRST AID KIT: Will be emptied and cleaned with soap and water or as instructed by the
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 159 of 260
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manufacturer
DECONTAMINATION OF AMBULENCE:
The equipment and emergency unit shall be cleaned after infectious disease run. The
decontamination of the ambulance will be documented and kept on file.
SPECIAL CARE SHOULD BE GIVEN TO THOROUGHLY CLEANING THE

FOLLOWING AMBULANCE PARTS AND WQUIPMENT:
The sliding on the inside compartment doors (1% hypochlorite)
The wooden spine boards (1% hypochlorite)
All equipment made of canvas (1% hypochlorite)
All equipment used in taking vitals .(70%alcohol)
The defibrillator. (70%alcohol)
DISPOSAL OF CONTAMINATED EQUIPMENT AND SUPPLES:
Contaminated equipment, clothing and supplies will be double bagged in a biohazard bag
and disposed as per hospital policy. The ambulance is cleaned with bacillocid periodically
and after use. To prevent any contamination of surfaces and fomites etc
All general supplies used in cleaning the ambulance or equipment that has not been
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 160 of 260
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exposed to blood or air contamination may be placed in the trash container or poured into
the drainage system.
TRANSPORT OF PATIENTS WITH COMMUNICATBLE DISEASES:
Movement of patient restricted to bare minimum
Surgical mask to worn by patient.
Open wounds to be covered by dressing
All the personnel in the receipt area of the patient to be informed prior of patient arrival
Conscious, coherent patient educated about his disease and how to limit speed
27. SAFE MEDICATION INJECTION PRECAUTIONS AND PROTOCOL OF LOADED

SYRINGES THE PROTOCOL NEEDED ARE
Timely administration of medication I.V/ I.M with aseptic technique & barrier
precaution & by use of PPC.
Standard Concentration of drug Maintenance
High alert medication care
Avoidance of medication errors
Following Loaded syringe policy
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 161 of 260
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Reporting near miss incidents
Legible hand writing of Drs is needful in capital letters
Trademark , package ,label, safety Testing noted
Calculation of doses as per body weight , using syringes only one time
Knowledge of side effects and complications and drug interactions along with route of
drug administration noted
Nurse should know about dos and donts about basic safe aseptic injection practices. The
staffs are updated about it and special care is taken for LP, central and peripheral cannula
insertion methods etc.CME, CNE classes are taken regularly for staff.
Use aseptic techniques and barrier nursing practices .do not administer medications from
syringe to multiple pts.
All health care workers should be vaccinated for Hepatitis-B
Needle prick injuries and sharp injuries should avoided
The common infections transmitted by Blood and Syringes or Injections are Hepatitis-B,
Hepatitis-C and HIV and septicemias, infected abscess etc. By various bacteria
Reuse of syringes avoided and store vials in accordance with manufacturers instructions.
Apply Betadine or 1% Chlorohexidine for IV line area preparations and cleaning esp. in
high risk wards
Segregation policy and & BMW Protocols should be followed along with sharp
management and use of PPE and PPC etc.
Use fluid injections and administration sets for one patient only avoid multiple injections
in IV injection bottles Dont reuse bottle after 18-24 hrs gap period of opening it up. If
fluid it is already contaminated and turbid please report the matter to pharmacy
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 162 of 260
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department without fail.
Please do hand wash , use PPE Before any invasive IV lines procedures & staff is trained
for that
Oily preparations are given with more caution; avoid injection abscess formation by
aseptic precautions. No RECAPPING needle allowed. One hand scoop technique used
for needle recapping
Loaded syringe policy during name is labeled along with time and date of preparation; it
is discarded within 4 to 8 hours of preparation. Syringe is loaded and kept for heparin
injections and chemotherapy injections SOS. If there is turbidity and discoloration of
syringe please discarded it, it is kept with capping of needle. No leakage or spillage
should occur; the syringe is kept at room temperature. Handling of syringe can be done
preferably after hand wash please. High risk medicines are not loaded at all. Please keep
loaded syringes in safe and secluded places in ward. In separate trays etc. Multi dose
vials are is minimized.
Store multiple dose vials as per manufactures recommendations & discarded if srcility is
compromised.
Quality assurance assessment done by detecting CLBSI & Peripheral thrombophlebitis
rats.
Provide ongoing training for staff.
LOADED SYRINGE POLICY
Whenever any syringe is loaded esp. with normal saline or dilute Heparin saline for
removing blockages in IV Cannula fluids etc. Then the DATE & TIME of Reconstitution
is noted & it has to be dispose off to BMW within 18- 24 hrs time.
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 163 of 260
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It should also be disposed off if there is any visible contamination or changing in color of
injection etc. if not labeled then better not to use it at all.
28. RE-USE SINGLE USE MEDICAL DEVICES

PURPOSE:
To identify where single use items can be safely reused
To ensure the process for reuse of medical devices is both appropriate and safe
RESPONSIBILITY:
All Omega hospital staff who deal with medical devices
SINGLE USE MEDICAL DEVICES
There are three single use medical devices
Open and unused
Open and used
Unopened and expired
Re-Processing
To successfully reprocess a device that has been used on a patient, institutions must be
able to clean it thoroughly, sterilize it to acceptable norms, and ensure that reprocessing
and reuse will not degrade its functioning. In order that a used or opened but unused
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 164 of 260
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SUD can be reused, a protocol has to be established which identifies the method for
Reprocessing, repackaging, and resterilising for all items open and unused.
Cleaning, packaging, and sterilization for all items that is open and used.
DEFINITION
Single Use device
Single-use device means a device that is intended for one use, or on a single patient during a
single procedure. The labelling identifies the device as disposable and does not provide
instructions for reprocessing.
Disposable single-use device is one whose sterility has been breached or whose sterile package
was opened but the device has not been used is termed as opened but unused single use device.
Reprocessed, with respect to a single-use device, means an original device that has previously
been used on a patient and has been subjected to additional processing and manufacturing for the
purpose of an additional single use on a patient. The subsequent processing and manufacture of a
reprocessed single-use device shall result in a device that is reprocessed within the meaning of
this definition.
BEST PRACTICE GUIDELINES

Single use medical devices for reprocessing based on this available evidence.
The reprocessing protocol should consider the material properties and design of the
specific device.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 165 of 260
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The protocol should ensure safety, efficacy and reproducibility.
Essential quality assurance should be performed during reprocessing.
Maximum number of reprocessing cycles should be specified according to devices
features, use conditions, and reprocessing protocol.
Pre-sterilization processing conditions and techniques are critical for sterilization
success.
Decontamination, cleaning, and washing procedures, together with sterilization
techniques could induce chemical, physical and morphological modifications on the
treated surfaces and potential toxicity of the sterilized device.
Identify SUDs to be Re-used
This is essentially an activity that individual HCFs need to undertake before proceeding any
further. These best practice guidelines is dictated by the following factors:
The ability to achieve effective cleaning.
The ability to achieve effective sterilization.
The compatibility of the device with the cleaning agent, process and sterilant.
Validation of the process of sterilization to assure safety.
The ability to achieve safe pyrogen and endotoxin levels.
The absorption of the sterilant by the device, which could then be transferred to the
recipient (patient) i.e. toxic residues.
The presence of a quality assurance programme demonstrating thatthe device has not
deteriorated in either form or function during the processing cycle.
The ability to demonstrate that the original performance specifications continue to be
met.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 166 of 260
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The cost effectivity of reuse is calculated for each device based on the cost of:
Performing the reprocessing procedure
Sterilisation
Validation (quality assurance)
Maintaining relevant documentation.
STANDARD OPERATING PROCEDURE - REUSE

Clinical Departments / User Departments
Each user department prepares a
List of single use devices that are to be reused.
Cost-benefit analysis for each reusable item.
User Departments, ICC, CSSD, Biomedical Engineers, Microbiologists

A method for completing each of the components/steps to support the reuse of a disposable or
single-use patient-care item. Each component/ step must be measurable or observable so that it
may be consistently repeated. Each component/step must be accompanied by documentation to
support the method for reprocessing, which includes:
Reprocessing area
Personnel
Cleaning and decontamination
Disinfection
Rinsing
Inspection for physical integrity and functionality
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 167 of 260
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Drying
Packaging
Labelling
Sterilisation
Validation of sterilisation process
Storage
Distribution
Inspection
Informed written consent
Billing schedule
Adverse event reporting
Time to withdraw a device
Documents for completion of each task above
Authorisation
Dissemination
Monitoring and Review
PACKAGING
Appropriate packaging ensures the sterility of the product through its intended shelf life, as well
as its efficacy at the time of use. For effective ETO sterilization the packaging material must be
breathable to allow the high-humidity ETO gas mixture to infiltrate the package.
PROCEDURE
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 168 of 260
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MLA COLONY,
HIC MANUAL
The items are wrapped in medical grade packaging roll (one sidepolythene and other side
medical grade paper). Double wrapping shall be ensured to avoid contamination.
Excess air must be removed from packets before sealing, to avoid bursting. This process may
not be required while using polypropylene pouches. What is important is to cheque the integrity
of sealing.
The devices shall be identified by writing cycle number and date of expiry on the packages.
Commercially available heat sealable pouches and rolls specially made from medical grade
paper and polyethylene film (thickness 1-3 mils [one thousandth of an inch] and width 7.530
cm) must be used.
They have the advantage that the contents are readily visible after packing, to allow for easy
identification. These come with printed chemical indicator hence separate chemical indicator
need not be used.
STERILISATION
The device shall be sterilized by an appropriate sterilization method for that device for e.g.
ethylene oxide gas sterilization method or vaporized hydrogen peroxide. The process of
sterilization should be strictly controlled and as per the manufacturers instructions. The Cycle
parameters must be verified, using the sterilizer manufacturers instruction manual for specific
sterilizer and load configuration, to be used.
ETHYLENE OXIDE (ETO)
Prerequisites
Sterilization by ETO requires that the devices are dry.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 169 of 260
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Parameters for ETO Sterilization
The critical parameters of an ETO sterilization cycle are typically given as temperature,
pressure, humidity, ETO concentration, and gas dwell time.
The cycle parameters and aeration time should be as per the manufacturers recommendations.
Monitoring ETO Sterilization
Chemical indicator (as per ISP 11140-1) shall be placed externally in the form of strips or
printed on packaging material itself to differentiate processed from non-processed packages.
Class 5chemical indicators can be used in the same test pack which helps to take immediate
decisions about issuing the load instead of waiting for the BI report.
A HCF SUD reprocessor should prove during validation studies that each sterilization process
is capable of achieving sterility for each run.
The sterilization process should achieve a sterility assurance level (SAL) of 10-6 for devices
used in normally sterile areas of the body.
The efficiency of ETO sterilizer shall be tested by challenging a biological indicator (Bacillus
subtilis 1264 from 3M or any other supplier) in the centre of each load. The test pack of BI
should be placed at the diagonally opposite end.
Process chart readings, particularly showing the temperature and pressure reading shall be
monitored for each cycle.
Aeration time and temperature shall be noted for each load.
STERILISATION VALIDATION
Definition
The term Validation means confirmation by examination and provision of objective evidence
that the particular requirements for a specific intended use can be consistently fulfilled.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 170 of 260
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Process validation means establishing by objective evidence that a process consistently
produces a result or product meeting its predetermined specifications.
Documentation
Maintain documentation to show that
Equipment has been installed correctly and operates as intended.
The sterilization process has been validated as being effective in achieving sterility without
adversely affecting the devices (chemical and biological indicators, physical parameters).
For each run the specifications for sterilization parameters have been met.
INSPECTION BEFORE REUSE
On receiving a sterile reprocessed device, the sterilization, package integrity, useful shelf-life
and any damage should first be ascertained before use on a patient. One should also ascertain
that there is no moisture inside the pack.
Commonly Reprocessed Single-use Devices:
Arthroscopic shavers
Blood pressure cuffs
Soft tissue ablators
External fixation devices
Electrophysiology catheters
Scissors and staplers
Biopsy forceps
Laparoscopic scissors and forceps
Clamps and dissectors
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 171 of 260
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HIC MANUAL
Compression Sleeves (DVT)
Phaco tips
Pneumatic tourniquet cuffs
Pulse oximeter sensors
Orthopedic drill bits and burrs
Cardiac catheter
Orthopedic surgical blades
Laproscopy accessories saw blade
Ultrasound catheter
Pulse oximetry probes
Trocars
29. ENVIRONMENTAL CONTROL

Purpose:
To disseminate information on how to prevent and control infections and environmental hazards.
Scope:
This policy describes the program for preventing infections and environmental hazards in PH.
Responsibility:
Infection control department & Quality department investigates nosocomial infections and
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 172 of 260
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HIC MANUAL
disease outbreaks.
Infection control committees review environmentally- related problems brought before
them review investigation results and recommend corrective action.
All hospital facilities follow guidelines, policy and procedures established in the given
hospital infection control manual and in this policy which is applicable to their specific
area.
Procedure:
The environment includes inanimate surroundings:
Physical facilities and grounds
Patient care equipment, supplies and drugs
Water
Air
Food
Solid waste
Liquid waste
Environmental control is the surveillance and monitoring of all aspects of the
environment in order to maintain a clean, safe and infection free facility.
Policies:
The hospital environment is closely relat6ed to nosocomial infections and plays a prominent
role in other health hazards. For this reason the environment health section shall:
Conduct microbiological sampling as appropriate decndfit .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 173 of 260
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Provide information on current standards, practices and procedures related to environmental
health.
All the microbiological waste is autoclave & discarded off. The hospital is licensed &
recognized from Telangana pollution control Board. Water is tested for coliform count, bore
water is also tested for Endotoxins, OT Environment is tested by swabs, settle plate method.
Food safety guidelines are followed & regular swabs are obtained from kitchen working
surfaces & food handlers are also tested for any carrier state. Food & kitchen water supply
are also tested in NABL Accrediatated laboratory. Plumbing & sanitation & drainages are
checked regularly. Any Air pollution possibility near to hospital environment is to be
checked solid & liquid waste disposal is to be monitored by maintenance dept.
Parking facility for Doctors & patients & attenders & vallet parking has to be provided for
hospital. Cool drinking water has to be provided for Attenders & out patients etc. Adequate
toilets & lavatories facilities also should be provided. Fire safety of the building structure is
an important aspect of facility & staff should be trained for fire extinguishment.
Pest control measures are under taken for prevention of arthropods borne diseases.
Rodenticide is also used. Bouquets & Flowers are not allowed from out side. Ventilator
must provide > 12 air exchange per hour.
Eating and drinking facility to staff and pts
attenders have to be provided in hospital only.BMW storage room area should b neat and
clean .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 174 of 260
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30.
ENDOSCOPES AND BRONCHOSCOPES-USAGE AND CARE:
ENDOSCOPES CLEANING PROCEDURE

Beginning of each list: Cleaning & Disinfection shall be undertaken before the endoscopy list.
Specialized training & knowledge of the working of the instrument are essential for this to be
done effectively.
External cleaning:
Totally immerse the instrument in warm water & neutral detergent. Wash the outside of the
instrument, thoroughly with gauze swabs. Brush the distal end with a soft toothbrush, paying
particular attention to the air/ water outlet nozzle & bridge /elevator where fitted. All valves are
removed, cleaned and disinfected. Clean biopsy channel opening and suction port using cotton
buds.
Brushing through the suction biopsy channel:
Introduce the cleaning brush from biopsy port through the patient tube, until it emerges from the
distal end at least three times.
Pass the cleaning brush through the suction port and down the patient tube until it emerges from
the suction connecter at least three times.
Pass the cleaning brush through the suction port, through the umbilical cord, until it emerges
from the suction connector at least three times.
After the cleaning has been thoroughly brushed either put the equipment through an automated
processor sequence to complete cleaning & disinfection or follow the described manual method
as below:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 175 of 260
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Flushing internal channels: flush each internal channel with detergent fluid. This shall be
done independently for each separate channel.
Rinsing: Flush all channels are above using clean water followed by air to expel as much
water as possible prior to disinfection.
Disinfection: If a closed system is not available, this shall be carried out under a fume hood
or canopy wearing gloves and avoiding splash. Totally immerse the instrument in either 2%
glutaradehyde. Fill each internal channel with disinfectant & leave the instrument for the
recommended contact time. Before and after the list this is 20 minutes and between cases 4
minutes.
Rinsing: Following disinfection, rinse instrument internally and externally to remove all
traces of disinfection.
Drying: Dry endoscope externally. Flush air through each channel. Reconnect the
endoscope to the light source & fit disinfected valves. Switch on the light source & expel
fluid from air /water channel by simultaneously occluding the water bottle connectors on the
endoscope & depressing the air/water valve. Connect the instrument to the suction machine
& dry suction channel by depression the suction valve several times.
Pressured air supply can be useful & better for drying equipment.
IN BETWEEN PATIENTS:
Flush the air/ water channel for 10-15 seconds to eject any refluxed blood or mucous. Aspirate
detergent through the biopsy / suction channel for about 10-15 seconds to remove gross debris.
Disconnect the instrument from light sources & disinfection for 4 minutes.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 176 of 260
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END OF LIST
Disinfection for 20 minutes. Rinse thoroughly & dry. Check equipment, stor4e hanging, in
security cupboard.
A log book is to be maintained indicating for each endoscopy done, the patients name. ID NO,
procedure done, consultant using endoscopy, the time at which the endoscopy started and
finished and time of putting the endoscope in disinfectant and time of taking out the endoscope
from disinfectant.
ENDOSCOPE ACCESSORIES DISINFECTION
This equipment can be divided into 2Groups:
Items forming part of the endoscope as attachments e.g., Valves, water bottles & cleaning
equipment, wash pipes brushes and tooth brushes.
Item used during procedures & for diagnostic & therapeutic purpose, e.g. Mouth guards,
biopsy forceps, cytology brushes, ERCP cannula etc.
METHODS
Wash immediately after use in fresh detergent.

Dismantle as far as possible.
Brush away adherent debris with cleaning brush.
Flush detergent solution through lumen of all hallow components.
Ultrasonic clean- it is impossible without this to clean sharp angulated & spiral metallic
structures.
Then either disinfect or sterilize:
Disinfect
Immerse in disinfectant with lumen filled for 20 minutes
Rinse & dry
Sterilize
Ethylene oxide gas.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 177 of 260
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BRONCHOSCOPE
CLEANING
Clean the scope immediately after procedure:
Put on gloves on the hands.
Wipe with gauge/paper towel.
Such clean water for 10 seconds and then air, slowly, so as not to generate aerosols.
Repeat it many times.
Remove suction valve and biopsy valve from the scope.
Immerse the scope completely into soap solution and scrub the external surface.
Clean the channel with channel cleaning brush. Dismantle both the valves and clean it
thoroughly.
Attach suction cleaning adapter and do alternate suction of clean water and air many
times.
Dry the scope.
CLEANING HAS TO BE FOLLOWED BY DISINFECTION

DISINFECTION
Immerse the scope completely in 2.0% glutaraldehyde (undiluted Cidex) with syringe
attached to suction cleaning adapter (withdraw the plunger until the syringe is filled with
Cidex).
Disconnect the suction cleaning adapter and let the scope and adapter be completely
immersed in 2% glutaraldehyde (undiluted Cidex) for prescribed time.
* Minimum:
30 minutes.
*Suspected HIV:
30 minutes.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 178 of 260
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*Suspected TB:
1hr.
*Suspected MDR TB:
24 hrs.
Remove the scope from cidex and thoroughly clean & scrub the external surface with sterile
water.
Reattach the suction cleaning adapter and do alternate suction of air and water.
Dry the scope with sterile gauze and the channel by sucking air, for sufficient time.
Attach the suction and biopsy valve, after cleaning them with sterile water.
Hang the scope or keep it in trolley over sterile sheet for the next procedure.
Biopsy forceps/ cytology brushes, reusable accessories penetrating mucosal barriers shall
be cleaned and then ideally steam sterilized failing which immersed in 2% glutaraldehyde, in
between each patient use.
IMPORTANT
Make fresh activated Cidex every week(label the date on the container).
Make sufficient volume to completely immerse the scope.
Note down the t5ime of immersion and time of removal of scope from Cidex solution.
Insist on minimum of 30 minutes immersion.
Post disinfection and rinsing with sterile water, the equipment has to be kept dry.
A log book shall be maintained indicating for each bronchoscopy done, the patients name,
ID NO., procedure done, consultant using endoscopy, the time at which the endoscopy
started and time of putting the endoscope in disinfectant and time of taking out the
endoscope from disinfectant.
31. MRSA/VRE/MDR STRAINS INFECTED PTS POLICY

PURPOSE:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 179 of 260
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To establish individual responsibilities in order to: Identify sources of MRSA, if possible and
prevent the transmission of MRSA to, from and between patients and other people in prime
hospital facilities.
RESPONSIBILITIES:
All OMEGA Hospital personnel:
Employ standard precautions in the care of all patients.
Understand the risks posed by the presence of MRSA.
Adhere to control measures as recommended by the infection control committee.
Wash hands for fifteen seconds between patients.
PHYSICIANS:
Verify the MRSA status of the patient upon readmission and isolation if found culture
positive for MRSA during a previous admission.
Request screening culture if a previously identified MRSA infected or colonized patient
is admitted to determine whether or not the patient continues to be infected or colonized
with MRSA.
Place the private room in contact isolation if:
The patient is known to be colonized or infected.
If screening results are awaited.
Provide follow up care for all colonized and /or infected patients.
Order the discontinuation of isolation as appropriate.
For patients requiring transfer to a designated medical facility, ensure that the discharge
summary states the MRSA status of the patients.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 180 of 260
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NURSING SUPERVISOR:
Ensures that all staff complies with the control measures as recommended by the
infection control committee.
Documents MRSA in the diagnosis section of the patients nursing care plan.
Places the infected / colonizes patients in a single room.
Notifies charge nurse, emergency personnel are transferring emergency in charge about
MRSA status if a patient to other Hospitals.
General supervisor, clinical laboratory services division.
Informs infection control nurse whenever MRSA is identified.
Performs surveillance cultures as recommended by the infection control personnel or the
infection control committee.
Ensure that all staff complies with the control measures as recommended by the infection
control committee.
HOUSEKEEPING PERSONNEL:
Disinfect the MRSA patients bed and the room everyday by using disinfectant
authorized by the hospital.
After the discharge of an infected / colonized MRSA patient from a ward, the patients
room shall be cleaned using standard housekeeping practices and fumigate the patient
room before admitting other patients.
Clean the ambulance with disinfectant following the transportation of an MRSA patient
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 181 of 260
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and whenever they are visibly soiled.
INFECTION CONTROL PERSONNEL:
Ensure that appropriate isolation measures are implemented.
Investigate and monitor whenever a hospital acquired case of MRSA is reported.
Assist in providing in-service education among OMEGA Hospital personnel.
MAINTAIN AN MRSA DATABASE OF ALL IDENTIFIED MRSA INFECTED /
COLONIZED PATIENTS AND MRSA CARRIER.
Monitor the effectiveness of control measures and recommended new measures as
necessary.
Infection control committee: reviews and approves all policies and procedures regarding
the control and prevention of MRSA within our facilities.
PROCEDURE
DEFINITION
Methicillin resistant staphylococcus aures is a strain of staphylococcus aureus, which is
resistant to Methicillin and related antibiotics (e.g. Oxacillin and Nafcilin).
Methicillin Resistant Staphylococcus aureus (MRSA) is a variant of the common bacterium
Staphylococcus aureus. MRSA can behave in two distinct ways on the body. First, the organism
can colonies the body. A patient is said to be colonized when they carry the organism on their
body, but do not suffer any harmful effects, or associated problems. Second, it may cause
infection. This happens when the bacteria multiply and show recognized signs and symptoms of
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 182 of 260
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infection in the form of inflammation, plain, swelling, fever, redness, etc. when the infection
does occur it presents itself in the from of boils, carbuncles and wound infections. In most cases
these infections remain localized to the area of broken skin and can be treated and are not
serious, however, in some cases MRSA may be very resistant and become difficult to treat.
Under certain circumstances, however, particularly in elderly and debilitated people and in
people with lowered resistance to infection the organism can cause more widespread infection
such as septicemia and osteomyelitis. These life threating infections are more likely to affect
people who already have a serious underlying condition which has weakened the bodys
defiance mechanism.
COLONIZATION and infection

Colonization is the condition resulting from the multiplication of a specific infectious agent at a
body site with no clinical or immunological consequences.
Infection is the condition resulting from the multiplication of an infectious agent causing clinical
manifestations or an immune response.MUCIPROCIN OINTMENT IS PRESCRIBED TO
SUCH CARRIERS AND AFTER A WEEK RPT CULTURES ARE AGAIN TAKEN FROM
NASA CARRIERS AND WE FOUND THAT IT IS MOSTLY ERADICATED ,.moreover such
carriers are askd to be absebnt from duty or that treatment period
COHORTS:
A patient cohort consists of two or more patients in a facility roomed together and physically
separated from other patients by their location.
A nursing cohort is a group of patients segregated from other patients care
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 183 of 260
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ISOLATION:
Contact isolation is the method of isolation, which requires barrier precautions (gloves and
gown) to prevent direct contact with substances contaminated with an infectious agent and hand
washing after removal of barrier precautions.
Standard precautions are the requirement that all health workers consider the blood and body
fluids, secretions, excretions, non- intact skin and mucous membranes of all patients to be
potentially infectious for blood-borne and other pathogens and to use protective barriers and safe
work place practices to reduce the risk of exposure.
SCREENING CULTURES:
PATIENT: Nose, throat, axilla, tracheostomy site, groin, wound if applicable.
STAFF: Swabs to be taken from the nostrils (anterior nares) and/or intertrigenous areas of the
staff.
PROCEDURES:
SPORADIC CASES: The following shall be implemented when sporadic case occurs.
ISOLATION OF THE PATIENT(Contact Isolation)
A private room is required or cohort with other MRSA patients single room with the door
closed.
NB: Remove unnecessary equipment, furniture, etc, from the room before admitting the patient.
Do not store items in cupboard since they will be potentially contaminated.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 184 of 260
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Limit unnecessary movement in patients room.
Keep the patients room clean and tidy.
All equipment used in the room must be decontaminated prior to removal. Any equipment used
for MRSA patients shall be cleaned with a disinfectant.
Gowns are used for activities that may contaminate the clothing. The wearing of gowns and
routine patient care activities shall be used based on the likelihood of soiling clothing, not on the
knowledge of the MRSA status of the patients.
Hands are washed with antiseptic detergent or alcohol rub for 10 to 15 seconds before leaving
the patients room.
Gloves are worn for direct contact with infected tissue and for the care and dressing of wounds.
A contact isolation card is posted on the door of the room.
Potentially infected items are disposed of according infection control policy.
The physician or nurse shall explain the need for isolation to be the patient/ patients family.
Gowns and gloves shall be used routinely while caring for a colonized/ infected patient in the
burns unit.
There is no need for a disposable dietary tray.
Clothing : All hospital gowns shall be changed daily after bathing or if soiled.
Linen : Bed linen shall be changed daily and whenever necessary
Laundry
Soiled linen will carry skin scales and must be handled with care. Place gently into red bags in
room then red hamper outside room.
Do not use fabrics in room which cannot be hot washed.
CLEARANCE CRITERIA
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 185 of 260
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Whenever isolation of patients is being carried out it is essential that specific clearance criteria
be agreed before isolation precautions are discontinued. It is recommended that isolation
precautions continue until a negative screen has been obtained. (Frequency of screening to be
determined by infection control team).
MANAGEMENT OF THE COLONIZED / INFECTED PATIENTS:
To determine the extent of MRSA infection, the following specimens shall be taken:
SWABS:
Nose (one swab for both nostrils).
Tracheostomy site.
All wounds and skin lesions.
Sputum(if available).
Care of Lesions:
Skin lesions (infected or colonized) shall be covered with dressing at all times.
Strict aseptic techniques shall be adhered to when changing dressings.
The patient shall have a chlorhexidine bath once a day for a week, then less frequently (every
third day).
32.
BACTERIOLOGICAL ANALYSIS OF DRINKING WATER
Drinking Water & Cooking Water

Water samples are collected using standard techniques. The sample is then subjected for testing
for presumptive coliform count.,which is done at an NABH accreditated laboratory ..
Water from different sources in the distribution system and prior to entry in to the distribution
system shall be periodically tested bacteriologically.
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 186 of 260
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Water shall be collected in appropriate heat-sterilized bottles using standard techniques ( Make&
Me Cartney: Practical medical microbiology, volume 2,12th Ed)as below:
Aseptically pipette one 50ml volumes and five 10 ml volumes of the water in to vessels
containing corresponding 50ml and 10ml volumes of double strength medium(Mac Conkey
Broth with indicator).
Such water sample shall be then subjected to multiple tube test methods for presumptive
coliform count (MPN), interpretation and determination of bacteriological standards applied are
in keeping with those recommended by WHO (1971) and the European Community (1980) as
below:
Grades of the quality of drinking water supplies determined by the results of periodic.
Escherichia coli and coliform count.,, by mackonkeys broth method . Done for quantitative
analysis sake .
We are doing semiquantitaive method by inoculating on mackonkey agar and blood agar plates
and reporting it and advising maintainancedept for corrective action and preventive
maintainancesetc .
Quality of supply
Results
from Routine
E .Coli Tolerance
coliform count / samples
Excellent
100ml
count/
100ml
0
In all samples provided that coliform
Satisfactory
organisms do not occur in any
Intermediate
sample.
E . Coli
4-9
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
does
not
occur
in
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 187 of 260
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consecutive samples or in more than
Unsatisfactory
>10
10
5% of samples.
Any coliform organisms present in
consecutive samples (or) pressure of
any coliform organisms in more than
50% of routine sample.
Information is transmitted and appropriate action is taken by relevant department.MOST OF

THE TIMES FOOD ITEMS AND ror WATER AND PORTABLE DRINKING WATER IS
SENT TO AN NABL ACCREDITATED LABORATORY OUTSIDE ON MONTHLY OR
QUARTERLY BASIS
33. INFECTION CONTROL IN ANCILLARY AND NON HIGH RISK AREAS
This section deals with the units that do not necessarily come into direct patient contact but have
a vital whole infection control in the hospital. Personnel in these areas have varying degrees of
risk of acquiring infection. Therefore, infection control measures are to be strictly enforced in
these areas.
Radiology
The various interventional procedures carried out in the department of Radio diagnosis are:
a. Ultrasound guided biopsies
b. Drainage procedures.
For all these procedures:
1. Use sterile equipment and aseptic technique
2. Observe standard precautions strictly. All staff should be immunized against hepatitis B.
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 188 of 260
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No one with any open sores, cuts or nicks takes part in the procedure.
3. Meticulous housekeeping is very important (Refer to the section Housekeeping).
Ultrasound guided:
The person doing the procedure washes up and dons sterile gloves. The part to be biopsied is
painted with povidone-iodine and draped with sterile towels.
Drainage procedures:
If any infective material like pus is collected into the tray or bowl, the procedure is treated as
infected. The reusable materials are separated. After the procedure, the room is mopped with
Lizol solution and the parts of the machine that may have come in contact with the patient are
cleaned with disinfectant.
Infectious / Isolation Ward Patient
If any patient is identified as infectious before hand, cases are adjusted such that the waiting
time and transit time of this patient is minimal and spread of infection is minimal. The
procedure is done preferably at the end of a session.
As far as possible only disposable equipment is used, all re-usable things are collected in a
red bag and sent to CSSD. Line is decontaminated by soaking in Sodium Hypo chloride for
1 hour and then sent to the laundry.
The room is then mopped with Bacillocid solution and machine parts are cleaned with 1%
sodium hypochlorite.
Ultrasound intra cavitary probes are washed and put in 2%gluteraldehyde for 30 minutes
before using on the next patient.

PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 189 of 260
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Casualty / Emergency Services
Standard precautions are to be strictly adhered to
Engineering Policy on Infection Control
After cleaning of the AHUs it is be sprayed with 5% of disinfectant (Bacillocid) solution

and the total unit is to be aerated for 4 hours before the usage
If in case of the air vector borne bacteria is found swabs is to be taken from HVAC ducts and
if it is positive and the total unit is to be fogged.
No moisture accumulation is allowed in the AHUs the water drains are to be checked
regularly.
All the tap filter and health faucet filter are to be cleaned every month and it is to be
immersed in Sodium hypochlorite solution 1:1000 concentration
At all given time engineering personnel working with any of this should use the personal
protective equipments
All the HEPA filters to be changed every year in all the areas such as major operation room,
Minor Operation room.
After changing the HEPA filters it is to be validated with the Laser particle count test
In case of problem with the suction apparatus the technician to take all the standard
precautions like wearing gloves and PPE etc Preferably disinfect with the 1:1000 concentrate
solution of the hypochlorite solution prior to doing any active repair work.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 190 of 260
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HIC MANUAL
A very high degree of precaution is to be taken by the engineering staff while handling any
equipments relating to patients
In case if the biological indicator or the bowie dick test fails in the Autoclave is to be
immediately intimated to engineering service
Dietary Department
Procurement & Receiving of Raw Material
Only properly labeled raw materials are received from reputed suppliers with whom a
rate contract is made each year.
All the materials are physically inspected by the Chef / Cook on duty for quality.
Fresh supplies, which include fruits, vegetables, milk and milk products, eggs are
procured on a daily basis.
Provisions and other dry commodities are indented from the main stores on a daily basis.
Substandard materials, if any are rejected at the time of delivery.
Storage
Provisions and other dry materials are stored on shelves 6 above the floor at room
temperature, which are segregated from the processed foods and are stored separately.
First in first out principle is followed for provisions and other material.
Milk/ milk products are stored in refrigerator.
Food Preparation
Pre- preparation and preparation of food shall be carried out in hygienic conditions.
Each meal is freshly prepared and consumed during the mealtime.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 191 of 260
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HIC MANUAL
Leftover, if any, are discarded within 5hours.
Food Distribution
Specified food delivery schedule is followed.
During transportation and service the food is supplied in covered trays for the hospitals
standard Beds and Critical care units and in hot bags for other areas.
Food handlers use apron, caps and gloves while serving the food to the patients.
Based on consultants prescription and dieticians advice, patients choose their menu.
Due to risk of food borne illness, family and visitors are not allowed to bring food from
outside except in a situation permitted by the consultant.
Cleaning Process
Vessels used for food production are cleaned in the pot washing area with soap, oil and
water.
Vessels used for food service are cleaned with soap oil and water and sterilized with
steam in dish washer.
Hygiene & Sanitation Practices

Cleaning material and sanitizers are used to maintain high standards of cleanliness.
A cleaning schedule is followed for the cleaning of entire F&B areas as well as the
equipment used in the dept.
Food handlers are routinely instructed about food handling techniques and personal
hygiene.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 192 of 260
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MLA COLONY,
HIC MANUAL
Fruits and vegetables intended for raw consumption are washed in disinfectant solution.
Hands are washed frequently with soap and water in the designated hand washing areas.
Food handlers cover their head with a cap.
Eating and drinking are confined to designated areas.
Employee Health & Hygiene
Employees with respiratory infection, intestinal disease, or diarrhoea, jaundice, boils, or

any skin infection particularly on the fingers and hands are not allowed to work.
Food handlers are subjected to stool examination for pathogenic organisms and parasites
once in six months & suitable treatment is provided whenever required.
The employees report illness and accidents to the supervisors immediately.
All employees adhere to the departmental dress code.
Food Microbiology
Random sampling of food material is carried out in the microbiology lab. The following
are subjected for sampling.
a. Cooked food material once in a month
b. Juice and Blended (in house) food items once in 15 days.
Food sample to be kept for 24 hours in case there is an outbreak the same can be tested.
Waste Disposal
In food production area food waste and plastic waste are segregated in separate bins with
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 193 of 260
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HIC MANUAL
white covers.
It is cleared twice in a day.
House Keeping
The following procedures need to be followed by the housekeeping department in order to
maintain a minimal infection rate in the hospital:
The floor should be cleaned at least 5-7 times in 24 hours.
Mopping: 5-7 times daily
High dusting should be done twice a week with a wet mop
All work surfaces are to be disinfected by wiping with disinfectant solution and water
Toilets are cleaned 5times a day.
Wash basins in the Gents toilets are to be cleaned with Johnson items.
Follow proper procedures for effective uses of mops, cloths, and solutions.
Prepare cleaning solutions daily or as needed, and replace with fresh
solution frequently.
Clean mops and cloths after used and allow drying before reuse.
Plastic buckets are to be cleaned daily.
Miscellaneous items: K basins, bed pans, urinals, etc. are to be cleaned
regularly.
Cleaning Procedure for Isolation Ward:

-
Walls should be cleaned with detergent and disinfected with 2% bassilocoid.
The bathrooms should be cleaned with detergent and disinfected with 2% bassilocoid.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 194 of 260
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HIC MANUAL
At Discharge (terminal disinfection):

After disinfection, wash the room, walls, windows, doors, bathrooms, sink with
soap solution after doing thorough high dusting.
Soak bed pan, urinal, and kidney basin in disinfected solution for one hour, wash
with detergent and dry.
Bucket, jugs, mugs are washed with solution and dried.
Fumigation with bacillocid is done if indicated.
Housekeeping in the Operation Theatre:
Theatre complex should be absolutely clean at all times. Dust should not accumulate at
any region in the theatre.
Soap solution is recommended for cleaning floors and other surfaces. Operation rooms
(ORs) are cleaned daily and the entire theatre complex is cleaned thoroughly once a
week.
After each case:

Linen and Gloves Gather all soiled linen and towels in the receptacles provided. Take
them to the service corridor (behind the theatre) and place them in linen box to be taken
for sorting. The dirty linen is then removed by laundry dept. Use gloves while handling
soiled linen.
Instruments Used instruments are cleaned immediately by the scrub nurse and the
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 195 of 260
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HIC MANUAL
attender. Reusable sharps are decontaminated in Lysol / hypochlorite and then washed in
the room adjacent to the respective OR by scrubbing with a brush, liquid soap and vim.
Environment Wipe used equipment, furniture, OR table, etc. with detergent and water.
If there is a blood spill, disinfect with sodium hypochlorite before wiping. Empty and
clean suction bottles and tubing with disinfectant.
Operation Theatre:
Surface Cleaning: All surfaces in OT have to be cleaned with 6% Carbolic Acid
thoroughly.
Biohazard Cleaning: After Biohazard/ Infected cases, all surfaces have to be cleaned with
2% Bacillocid spray.
Linen: All Soiled Linen (blood and body fluids) Soak in 1% Hypochlorite and then
forward to Laundry and dry linen is forwarded to laundry
Every month thorough cleaning is done.
Intensive Care Unit:
In addition to routine cleaning, once a week, thorough cleaning with Soap & Water + 1% hypo is
to be done. Brush can be used in hard to reach areas.
Surveillance of housekeeping procedures is done on a routine basis by the HIC Team as per
Standard operating procedure for the same.
34. DECONTAMINATION AND DISINFECTION OF GENERAL ITEMS

PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 196 of 260
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HIC MANUAL
Equipment/Site
Routine/Preferred Method
Airways and Endo-
1) Single use
tracheal tubes
2) Heat (Autoclave, ETO,
For MTB patients
Acceptable /Alternative/
Additional recommendation
Chemical disinfection
(Chlorine based/ Gluteraldehyde)
Low temp steam)
Humidifiers &
3)wash with cidex and rinse
ambubags
with hypochlorite
Autoclave at low temp OR ETO
Baths
Non infected patients
process
Infected patients and patients with
Wipe with detergent solution
open wounds
and rinse: chemical cleaning
Chlorine compound with detergent.
may be used for stain and scum

removal
Bed s
Bed pans
After infected patient
Wash with detergent and after
/ phenol / bacillocid in high risk
drying use hypochlorite
wards.
Washer-disinfector
Patients with enteric infections :

Heat disinfection after emptying and
washing.
Or chemical disinfection with
Chlorine compounds/ Lysoformin
Bowls (surgical)
Autoclave
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 197 of 260
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Bowls (washing)
Wash and dry, Store inverted
For infected patients use

Individual bowls and disinfect on
discharge
1) Heat disinfection
Dishwasher with rinse temp
2) Chlorine/ Phenol
For patients with enteric infections
above 80 degree C and air dry
or open tuberculosis, if possible heat
Drip stands
Clean with hypochlorite or
disinfect; if not only single use.
Drains
spirit solution
Clean regularly
Chemical disinfections is not
Crockery and Cutlery
advised/ Medichlor (Sodium

Floors (Dry cleaning)
1) Vacuum clean
Hypochlorite 1%)
No brooms in patient areas
Floors (wet cleaning)
2) Dust attracting dry mop

Wash with detergent solution;
Known contaminated area:
Furniture and Fittings
routine disinfection not reqd

Damp dust with detergent
Chlorine / Phenol
Known contaminated and special
and Locker tops
solution
areas (ICU): Damp dust with

chlorine/ Phenol
Instruments
Heat (autoclave/ ETO)
Mattresses and Pillows
Water impermeable cover: wash Contaminated: Disinfect with
Mops (dry, dust
with detergent solution and dry

Do not use for more than 2 days
attracting)
without washing and drying
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
hypochlorite/ Phenol
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 198 of 260
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Mops (wet)
Manual: rinse after each use,
If chemical disinfection required
House keeping
wring and store dry. Heat
after usage on infected areas: rinse in
disinfect periodically
water, soak in Chlorine
(1000
ppm av Cl for 30 min) rinse and

Nail Brush
Use only if essential
store dry
Sterile nail brush should be used
(Surgeons hands)
Razors
Disposable / autoclaved
Alcohol immersion for 10 min
(safety and open)

Rooms & beds
Infected patients
couches & furniture
Wash surfaces in detergent
Wash surfaces in 500 ppm available
(terminal cleaning/
solution
Chlorine,/ Phenol ( bacillocid
disinfection)
solution in high risk wards )
Shaving brushes
Do not use for clinical shaving
Use brushless cream or shaving foam
Sputum container
Disposable (Single use only)
Dispose
Thermometers
Individual thermometers: wipe
Terminal disinfections
with alcohol and store dry
Disinfect with Alcohol for 10 min,
Telephones
Use spirit for cleaning
wipe and store dry.

Bacillocid cleaning in high risk
Thermometers
Single patient use
wards.
Do not use without sleeve for oral or
(Electronic, clinical)
Immerse probe in Alcohol for
rectal temperature for pt. With an
10 minutes, dry
infectious disease.
(Oral)
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 199 of 260
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MLA COLONY,
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Toilet seats
Wash with detergent and dry
After use by infected patients or if

grossly contaminated,
Disinfect with Chlorine / Phenol/
Bacillocid, Rinse and dry.
Tonometer prisms
Wash, disinfect with 500 ppm
Tooth mugs
Chlorine for 10 min then rinse

Single patient use (Disposables)
Heat disinfection if not disposable
Trolley tops
Clean with detergent and dry at
If contaminated: Clean first, then use
(Dressing)
beginning of dressing round and Chlorine. Bacillocid and dry.

at the end of it also
Alcohol can also be used
Tubing (Anesthetic or
Heat disinfection
After cleaning it first.

For patients with tuberculosis
ventilation)
Washer disinfector
Use single use tubing OR
Low temperature steam
Heat (washer disinfector/ Low temp
Urinals
Use washer with heat
steam)
Use Chlorine/ Phenol/ Bacillocid.
Suction bottle
disinfection cycle
Reusable ::soaked in cidex for
Glass one also treated in same way
2 hrs washed with detergent
and thereafter kept in hot air oven .
Ventilator External
and rinsed with hypochlorite

As per guidelines Washing
Rinsed in alcohol / cidex after
circuit and Humidifiers
machine at temp of 80 degree C
cleaning
Humidifier should be
for 1 min Low temp steam at 73
Its disposable & change for every
cleaned, dried and
degree
patients. Autoclave or ETO sterilize
refilled with sterile water

PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
the indicated parts.

CHECKED & REVIEWED
BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 200 of 260
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every 24 hrs
Nebulizer / Ambu bags
Cleaned with detergent and
ETO sterilization
Ventilator
water / cidex if contaminated

As per guidelines
ETO
Internal circuit
Wash basin
Autoclave
Clean with detergent.
Contaminated
Use cream cleaner for stains,
Use chlorine detergent solution or
scums etc.
non- abrasive chlorine powder.
Disinfection not normally

Nebulizer
required
Washed with clean water &
Alternatively can be sent for ETO
cleaned with 70% Lysol

BI-PAP
alcohol.
Inter phase mask applied on
face. Frequently changed every
IV stands& other
week.
Clean with sodium hypochlorite
Use bacillocid/ cidex in high risk
routinely
Stethoscopes
/ carbolisation
Wipe with alcohol
wards for cleaning.

Bacillocid can also be used for high
Wheel chairs and
Cleaned with detergent &
risk wards patients.

Use bacillocid in high risk wards.
trolleys
alcohol
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 201 of 260
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34.1
HIGH RISK CATEGORY
It defined as the items that come into contact with patients mucus membrane, entry into sterile
cavities or vascular system e.g. Surgical instruments, laparoscopes, arthroscopies etc.
ITEM
CLEANING
DISINFECTION
STERILIZATION
/WASHING
/ FINAL
All-surgical
With multi rapid
Dip for 15 minutes in
TREATEMENT
Steam autoclave
instruments
enzymatic agent
glutaraldehyde solution and
Laparoscopes,
With multi rapid
wash it with plain water

Before keeping in
Cystoscopes
enzymatic agent
proper place 70 %
flush it with distilled water
alcohol wipe to be
done.
Before keeping in
Arthroscopies &
With multi rapid
and properly dry it.

bronchoscopes
enzymatic agent
proper place 70 %
alcohol wipe to be
With multi rapid
and properly dry it.

done.
Ethylene oxide
enzymatic agent
(sterilization)
With multi rapid

Ethylene oxide
enzymatic agent
(sterilization)

Wash and flush with 1%
Ethylene oxide
hypo/ bacillocid
(sterilization)
Cardiac Catheter
Ventilator tubings
Suction tubings
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 202 of 260
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HIC MANUAL
34.2
INTERMIDIATE RISK CATEGORY
The items that come in contact with patients intact mucus membrane, body fluids and
secretions. E.g. respiratory and anesthetic equipments, gastrointestinal scopes, bronchoscopes,
thermometers
ITEM
All types scopes
CLEANING
DISINFECTION
STERILIZATION /
/WASHING
FINAL
With multi rapid
TREATEMENT
Rinse it with sterile
enzymatic agent
glutaraldehyde
water.
solution and wash it

with plain water
Wash it with water
Laryngoscope blade
Keep it in sterile tray
and wipe it with

Disposable
alcohol
Wash it with water
Oxygen mask, nasal
Disposable
and dry it properly

Daily cleaning with
prongs
Ambu bag
1/ bed in ICU and 1/
70% alcohol
Wash it with water
Ethylene oxide
Suction bottle
OT
1/ bed in duplicate
and dry it properly

Wash it with 1% hypo
(sterilization)
Ethylene oxide
Thermometer (individual
Wash under running
and dry it properly

Clean with spirit swab
(sterilization)
Keep it dry.
for each patient)

Nebulizer
water
Run with saline
Wash with running
Keep it dry
E-T Tube / air way
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
water and soap.1%

CHECKED & REVIEWED
APPROVED BY:
BY:
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(MEDICAL
OFFICER)
DIRECTOR)

Page 203 of 260
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MLA COLONY,
HIC MANUAL
hypochlorite if visibly
Oxygen flow meter
contaminated
Wash with running
Keep it dry
water and soap.1%

hypochlorite if visibly
contaminated.
34.3
LOW RISK GROUP
It is defined as the items that come in contact with normal with normal skin or are not in direct
contact with patients e.g. operating table, trolley, bed sheet, bed pans, urinals B.P cuffs etc.
ITEM
Laryngo scope handle
CLEANING
With multi rapid enzymatic
FINAL TREATMENT
Alcohol wipe and keep it dry
agent
Stethoscope (one / bed in
ICUs)
Bed sheets
Alcohol wipe and keep it dry

Wash in laundry
Change daily once, if stained

change immediately
Green sheet
Sputum mug containing 5ml
Disposable
Wash with water and
conc. Dettol
detergent (after minimum
NA
Dry it
contact of sputum with Dettol

for 1 hr) to be dipped in 1 %
sodium hypochlorite solution
for 15 minutes.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 204 of 260
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MLA COLONY,
HIC MANUAL
ENDOSCOPES AND BRONCHOSCOPES USAGE
Do external cleaning and immerse instrument in warm water and neutral detergent and
mucolytic enzymatic agents are added to clean it .all valves are removed cleaned and
disinfected. Brush the suction biopsy channel.
Introduce cleaning brush from biopsy port thro pt tube until it emerges from distal end 3
times and also pass brush from suction port thro umbilical cord
To pt tube until it emerges from suction connector 3 times.
Flush the internal channels with detergent fluid and also flush all channels using water
followed by air.
Use gloves while disinfecting and avoid splashes and soak it in cidex for 30-50 min. and
rinse well to remove any disinfectant and dry the endoscope & reconnect it to light
source.
Connect instrument to suction machine and dry it .any debris stichking has to be
removed .all these procedures and time taken is recorded inn logbook.
Endoscope attachments like valves mouth guards, biopsy forceps, cytology brushes, ercp
cannula etc are also disinfected .all adherent debris are removed.
Ultrasonic cleaning can also be tried alternatively .channels are cleaned with brush .we
have to scrub the external surfaces with sterile water preferably.
Make fresh activated cidex every week. Insist for about 1 hr immersion.
35. OUT BREAKS MANAGEMENT:

DEFINITION:
An outbreak is defined as an unusual or unexpected increase of cases of a known nosocomial
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 205 of 260
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MLA COLONY,
HIC MANUAL
infection or the emergence of cases of a new infection.
Single sporadic occurrence of unusual disease and MDR strain infection will trigger
investigation.
Infection Indications are expressed as rates, denomination will vary based on Admission,
Discharge, Patient days, Procedures, Device days etc. whenever remarked changes in
HIC indicator rates is seen for consecutive months or for same months of different
calendar years then it is counted as an outbreak .
INVESTGATION OF OUTBREAK
Purpose
The purpose of an outbreak investigation is to identify ways to prevent further transmission or
outbreaks of the disease.we have to break the transmission chain at contact or airborne or water
or food borne agent levels.
Objective
The three main objectives are:
To identify the responsible etiologic agent
To find the source of infection by studying the occurrence of the disease among persons,
place or time, as well as determining specific attack rates
Formulate recommendations to prevent further transmission
Verification
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 206 of 260
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MLA COLONY,
HIC MANUAL
To compare the number of current cases with the usual baseline incidence, from
previous datais available.
ESTABLISHMENT OF DIAGNOSIS OF REPORTED CASES
To define cases based on the following common factors
Population risk factors: e.g. age, race, sex, socioeconomic status
Clinical data (e.g. onset of signs and symptoms, frequency and duration of clinical
features associated with the outbreak, treatments, devices).
Laboratory results
To search for other cases that may have occurred retrospectively or concurrently.
To collect critical data and specimen information from
Laboratory records
Medical records
Patient charts
Physician and nursing staff
Public health data (if any)
CHARACTERISATION OF CASES
To assemble and organize available information (in terms of time, place and person) for
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 207 of 260
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MLA COLONY,
HIC MANUAL
analysis and also note the incidences of notifiable diseases admission at given place .most of the
times communicable disease cases are sent or referred to fever hospital here . we have to
identify first an outbreak and thereby do tracking analysis reporting .
TIME
The exact period of the outbreak
The probable period of exposure
Date of onset of illness for cases, (if required)
Is the outbreak common source (single point source)
PLACE
Service, ward, operating room
Clustering of cases & we have to notify within hospital about any outbreaks.
PERSON
Patient characteristics (i.e. age, sex, underlying disease)
Possible exposures (i.e. surgery, nursing and medical)
Therapeutic modalities (i.e. invasive procedures, medications, antibiotics)
From this information, the population at risk can be accurately described
INCIDENCE RATE
To calculate incidence rate and prevalence rates .epidemiological typing is done and detailed
data analysis is also done .after hypothetical study and critical analysis various corrective and
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 208 of 260
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MLA COLONY,
HIC MANUAL
preventive actions are undertaken like modification of nursing procedures ,identification and trt
of carriers and correction of lapses in techniques .
INCIDENCERATE
=No. of new cases occurring (during a specified period of time)in a month
No. of admissions (in a month)
DETERMINATION OF SOURCES OF INFECTION IN AN OUTBREAK
The source of infection may be:
a. Common source (single-point source):Same origin (i.e. the same person or vehicle is
identified as the primary reservoir or means of transmission). Long term preventive
measures are also undertaken.
b. Propagated or continuing source (ongoing transmission): Infections are transmitted from
person to person in such a way that cases identified cannot be attributed to agent (S)
transmitted from a single source or single reservoir source only.
c. Both common and propagated source (intermittent source): Intermittent exposure to common
sources produces an epidemic curve with irregularly spaced peaks. Epidemeiological
surveillance Data collected is analyzed and validated after tracking analysis. Feedback is
given from HICC to nurses and management for evaluation of implemented policies.
Corrective and preventive actions taken are recorded after analyzing the data so as to prevent
similar out breaks in future. The transmission chain has to be interrupted. In the next followed
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 209 of 260
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MLA COLONY,
HIC MANUAL
month only the incidences rate of such infection has to come down. All the environmental
factors involved can also be considered if any. Various tests are done to detect any carriers
among staff, if involved in outbreak.any HIC indicator rate if increased alarmingly and
comparatively to last months or same month of last year ,, then an outbreak control measure and
detailed tracking analysis report is undertaken in order to contain the infection. THE
epidemiological survey is undertaken and active and passive surveillance is also done .and all
corrective measures are discussed in HICC meetings and their by implemented and monitored
thro quality dept.
MANAGEMENT AND HANDLING OF BIOMEDICAL WASTES
1.0 Introduction
The Ministry of Environment and Forests, Govt. of India notified the Bio-Medical Waste
(Management and Handlings) Rules on 27th July 98; under the provisions of Environment
Act 1986. These rules have been framed to regulate the disposal of various categories of BioMedical Waste as envisaged therein; so as to ensure the safety of the staff, patients, public
and the environment
The Hospital is a referral, tertiary care hospital. It has the clinical specialties like General
Medicine, Surgery, Orthopaedics, Radiodiagnosis, and Anaesthesiology etc. The para/nonclinical specialties which provide support to the hospital are Physiotherapy, Rehabilitation,
Blood Bank, Pathology, Microbiology, Histopathology and Biochemistry
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 210 of 260
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MLA COLONY,
HIC MANUAL
All departments of the hospital generate a lot of waste which should be managed properly
with a waste management policy.
2.0 Objectives
The Bio-Medical Waste Management policy at Hospital has been framed to meet the
following broad Objectives
Changing an age old mind set and attitude through knowledge and training.
Defining the various categories of waste being generated in the hospital
Segregation and collection of various categories of waste in separate containers, so
that each category is treated in a suitable manner to render it harmless.
Identifying and utilizing proper treatment technology depending upon the category
of waste.
Creating a system where all categories of personnel are not only responsible, but also
accountable for proper waste management.
Rules governing the protection of workers health and safety
Reduction in the incidence of infection and accidental injuries to the hospital staff
Reduce the impact of this waste on the community in general and
Cost- effective disposal of the hospital waste.
3.0 Policy Statement
The policy of Hospital aims to provide a system for management of all potentially infectious
and hazardous wastes in accordance with the Bio-Medical Waste (Management and
Handling) Rules 1998 and to motivate and train manpower involved in handling Biomedical
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 211 of 260
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MLA COLONY,
HIC MANUAL
waste.
4.0 Definitions
(a) Bio-Medical Waste: Bio-Medical 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 biological, including categories
mentioned in the schedule I of the Bio-Medical Waste ( Management & handling ) Rules
, 1988 (BMW, 1988)
(b) Medical Waste: Is a term used to describe any waste that is generated in the diagnosis,
treatment or immunisation of human beings or animals, in research pertaining thereto, or in
the production or testing of biologicals.
(c) Clinical Waste: Is defined as any waste coming out of medical care provided in
hospitals or other medical care establishments, but does not include waste generated at
home.
(d) Hospital Waste: Refers to all waste, biological or non-biological that is generated from a
hospital, and is not intended for further use.
(e) Pathological Waste: Is defined as waste removed during surgery/autopsy or other
medical procedures including human tissues, organ, body parts, body fluids and specimens
along with their containers.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 212 of 260
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MLA COLONY,
HIC MANUAL
(f) Infectious Waste: Refers to that portion of Bio-Medical Waste which may transmit viral,
bacterial or parasitic diseases, if concentration and virulence of pathogenic organisms is
sufficiently high.
(g) Hazardous Waste: Refers to that portion of Bio-Medical Waste which has a potential to
cause hazards to health and life of human beings.
(i) Pressurized Waste: Include compressed gas cylinders, aerosol cans and disposable
compressed gas containers.
(j) General Waste: Includes general domestic type waste from offices, public areas, stores,
catering areas, comprising of newspapers, letters, documents, cardboard containers, metal cans,
floor sweepings and also includes kitchen waste.
5.0 Need For Bio- Medical Waste Management
i.
Legal Obligation (Statutory): In accordance with the provisions of the BioMedical Waste (Management and Handling) Rules 1998,
ii.
Health hazards associated with improper hospital waste management: A number

of hazards and risks are associated with this.
Injuries from sharps to all categories of hospital personnel and waste handlers.
Nosocomial infections in patients from poor infection control and poor waste
management.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 213 of 260
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MLA COLONY,
HIC MANUAL
Risks of infections outside hospitals for waste handlers, scavengers, and (eventually)
the general public.
Risks associated with hazardous chemicals, drugs, being handled by persons handling
wastes at all levels.
iii.
Environmental hazards: Improper hospital waste management also results in air, water
and soil pollution, especially due to imperfect treatment and faulty disposal methods.
6.0 Color coding of Waste containers

The Hospital follows the prescribed color coding of waste containers for different types of
wastes according to the Biomedical Waste (Management and Handling) Rules introduced in
July 1998.
The colour coding of waste containers:
assists staff in proper segregation of wastes;
identifies the types of wastes contained in the bag/receptacle;
identifies the potential hazard(s) that may be associated with those wastes; and
Designates the prescribed treatment and disposal requirements for that waste.
6.1 SEGREGATION OF WASTE

Segregation of waste in Hospital is done at the site of generation of Bio-Medical waste. The
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 214 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
following wastes generated at Hospital
Type
Non-Hazardous (General)
Site of Generation
Disposal By (from
Office
site of generation)
House Keeping
Kitchen
Staff
Cafeteria
Billing
Administrative departments
Rest room
Nursing hostel, Residential areas
Hazardous station (Toxic)
Pantries in ward and Stores etc

All in patient Wards, Operation House Keeping
theaters, Intensive care unit, rest Staff
room,
Post operative recovery room
Medical stores All laboratories
OPDs
Injection Room
Procedure room
Dialysis and Endoscopy room
CT scan, MRI Room and Various
follow up clinics
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 215 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
6.2 Responsibility of Segregation of waste
Segregation is the responsibility of the generator of Bio-Medical Waste
1. Doctor
2. Nurse
3. Paramedical staff
4. House Keeping Staff
The Bio-Medical Wastes will be segregated as per categories available.
6.3 Collection of Bio-Medical Waste
Collection of Bio- Medical Waste will be done as per Bio- Medical Waste
(Management & handling ) rules, 1998 ( Rule -6 Schedule II)
Sl. No
1
Category
Human anatomical waste
Type of container
Plastic bag
Color coding
Yellow
Animal waste
Plastic bag
Yellow
Microbiology and biotechnology
Plastic bag
Yellow/ Red/blue
Waste sharp
Plastic bag, Puncture Blue
Discarded Medicines
proof container
Plastic bag
Black
Solid Waste ( Soiled)
Plastic bag
Yellow/ Red/blue
Solid Waste ( Plastic)
Plastic bag
Blue
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

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8
Liquid waste
Plastic containers
White
9
10
Chemical waste
Cytotoxic Waste
Plastic bag
Plastic bag
Black
Black with
the
Symbol of C
Those plastic which contains liquid like blood, urine, pus, will also be put into red color bag for
microwaving and autoclaving and other items will be put into blue bag after chemical treatment
by 1% Hypochlorite
6.4 Labelling:
The bags in which waste is collected is pre printed with the name of the hospital and have
the bio hazard symbol on it. (Schedule-III symbol of Biohazard and cytotoxics).
The yellow, red, blue and blue containers will have bio-hazard symbol.
6.5 Location of Container
Wards
Equipment
Responsibility
Treatment Room Yellow, and black at the both Sister In-charge

and sluice Room
Frequency
Twice a day
these places Two large bins (with

cover) Container
lined
with
appropriate colored polythene

Bath room and
bags
Only green colored bins lined
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 217 of 260
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Toilet
Nursing Station
by green polythene bags

Needle Destroyer Puncture proof Sister
In-Charge
containers (Double bin) with 1% will

hypochlorite
coded
solution
(Yellow,
blue,
Regularly
replaced
Color Ensure that the

and equipment is
black) large size bins
functional at all
1.1% hypochlorite solution should times.

be prepared and changed daily
Doctor/ nurse and paramedical
staff will
be instructed to
destroy the needles by the

needle destroyer and put the
needles in the puncture proof
Laboratory
container
Color coded ( yellow, red
and black) medium sized bins
lined with colored polythene
bags Needle Destroyer Puncture
proof containers (Double bin)
with 1% hypochlorite solution
Clinical
Regularly
and
replaced
paramedical Staff
Operation
Color coded medium and

Sister
In-Charge/ Regularly
large sized
bag ( depending
theaters
Supervisor
replaced
upon quantity of waste
and Intensive
generated ) with colored
polythene yellow, red and black
Care Unit
medium sized bins lined with
colored polythene bags Needle
Destroyer Puncture proof
containers (Double bin) with 1%
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 218 of 260
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MLA COLONY,
HIC MANUAL
hypochlorite solution
A separate container for general and office waste will be placed at every point of
generation and disposed of through Municipal authority.
6.6 Packing of Bags
The waste bag is filled up to three-fourth capacity only.
They are tied securely by rope.
Bags are removed from the site of the generation to the storage area regularly and
timely.
The category of waste (cat 4, 7, 8 and 10)
which requires pre-treatment.
(Decontamination /disinfection) at the site of generation such as sharp material will be

removed from the site of generation only after the pre- treatment.
6.7 Packaging of Sharps
Sharps shall be handled differently to all other hospital wastes as they are potentially
the most dangerous.
Needles and syringes shall be placed into the sharps container after use. No resheathing of needles or separation of needles from syringes shall occur as these
practices can cause physical injury and potential infection with Hepatitis or HIV
infection.
Cleaners will unlock the cabinets and remove the sharps containers and replace them
with clean disinfected sharps containers. The sharps will be placed into a blue plastic bin
containing disinfectant (1% hypochlorite) in preparation for shredding prior to disposal
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 219 of 260
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or recycling.
Cytotoxic Sharps contained within a reusable sharps container shall be transported to
the incinerator within a yellow bin upon which both the biohazard and cytotoxic
symbols are displayed.
6.8 Operational Aspects

From Waste generation site, the housekeeping staff will collect the waste during morning,
afternoon and evening, under the supervision of the staff nurse and house keeping supervisor.
The color plastic bags should always be replaced by a new one once the used bag is removed.
Each time a bin is emptied it must be thoroughly cleaned and disinfected with a 1%
hypochlorite solution by the cleaners prior to being returned to service within the hospital and
lining with the bag.
6.9 Documentation
The quantity of waste collected is documented in a register maintained by the Sister
In-charge /Senior Staff nurse on duty.
The total waste collected from the entire hospital is also documented and signed by the
housekeeping staff and the person from outsourced facility who comes to collect the waste.
This is done daily.
6.10
Storage of Waste
After collection of Bio-Medical Waste from various areas in the hospital it is stored for not
more than 48 hrs of generation till its transit for treatment and final disposal.
Waste is stored in the areas of generation for an interim period varying from two to twelve
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 220 of 260
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MLA COLONY,
HIC MANUAL
hours, after which it is transported for treatment and disposal by the housekeeping staff.
During this period it is the responsibility of the clinical and para-medical staff to check
that there is proper segregation and no subsequent recycling of disposables and other items.
No untreated Bio-Medical waste will kept stored for not more than 48 hours.
6.11
Transportation of Waste
Transportation of Bio-Medical Waste can be divided into intramural (internal) and extra
mural (external) transportation
The trolley which is used to collect hospital waste, is designed in such a way that there is
1. No leakage or spillage
2. Color coded according to the color of the waste bags.
3. Has biohazard symbol painted on it.
4. Covered with lid
5. No sharp edges
6. Easily loadable
6.11.1 Transportation of Waste with in the Hospital
Within the hospital, the route for the trolleys is so designed so as to avoid the passage of
waste through patient care area as far as possible.
From all the floors and wards, the waste will be transported to the -2 floor, to a
separate designated area from there it is taken away by the outsourced agency .
Every trolley will be thoroughly cleaned and disinfected after the last shift of
collection of waste.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 221 of 260
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6.12
Treatment and Disposal of Hospital Waste
Civic Authorities : Most of the waste (about 80%-90%) generated in the hospital is general
waste which is similar to the waste generated in house and offices.
The waste which is
non toxic and non infectious, and comprises of paper, left over food
articles, peels of fruits, disposable and paper containers for tea/coffee etc., card boards boxes,
outer cover or wrapping of disposable items like syringes, needles sets etc. This general
wastes will be put into black colored polythene bags and deposited at the municipal dump area.
It is subsequently collected by the local municipal authorities for disposal every day.
It is the responsibility of the hospital security/contractor to ensure that rag pickers are not
allowed entry into the dumps areas.
Liquid and Chemical Wastes will be disinfected by chemical treatment using at least 1%
sodium hypochlorite solution; and then discharged into drains/sewers where it is taken care of
by the principle of dilution and dispersal. The responsibility for proper disposal of liquid wastes
lies with the housekeeping staff cleaning the indoor patient care areas; and with the nursing staff
in case of routine cleaning. Responsibility of chemical waste should be with the persons/staff
using the chemicals and generating the waste.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 222 of 260
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7.0 ROLE OF PERSONNEL INVOLVED IN WASTE MANAGEMENT
7.1 Role of Manager Hospitality Manager
He has the overall responsibility for the formulation and implementation of guidelines
for hospital waste management and has to ensure that waste is handled without any
advance effect to human health and environment.
As the occupier, she/he is responsible for applying for grant of authorization (in
Form I) to the prescribed authority (Pollution Control Board).
He is also responsible for submitting an annual report in Form II to Pollution Control
Board (prescribed authority) by 31st January regarding information about categories and
quantities of Bio-Medical Wastes handled during the previous year.
he is answerable to the higher authorities in the Ministry.
he will form the waste Management committee and clearly spell out duties and
responsibilities of the members.
7.1.1
Functions of Hospital Waste Management Committee
To ensure the circulation of enough copies of Bio-Medical Waste Rules and

guidelines for implementation of the same in Clinical Departments.
The responsibilities of the individual professionals will be highlighted in these
guidelines.
To conduct Awareness Programme: Clinical combined/grand round will be held for
making the Faculty and the Residents aware of the Biomedical Waste (Management
& Handling) Rules 98.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 223 of 260
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To conduct training programmes for Medical Professionals, Nursing Professionals
and Sanitation Professionals.
To hold meeting of the Hospital Waste Management Committee and formulate the
detailed plan of action in regard to segregation, collection, storage and transport of waste
from all the patient care areas. To procure the items required in this regard and
make them available in all patient care areas. Each Clinical Department (Unit), Lab
Services, Blood Bank, Microbiology, Pathology will make one Faculty Member
responsible for supervision of segregation in their area of activities.
Floor wise one Nursing staff (Nursing Supervisor) will be responsible for supervision of
segregation in the wards of each floor. In each and every OT the same instruction of
supervision will be followed and the Sister Incharge will be responsible.
7.2 Role of Officer In-charge of Waste Management
The Officer In-charge of waste management will be incharge of implementation and will
liaise with the Heads of Departments, Infection Control Officer and Nursing superintendent.
S/he will be the member of the Hospital Waste Management Committee. He will be
responsible for monitoring the programme from time to time at various levels i.e.
generation, segregation, collection, storage, transportation and treatment including
disposal.
S/he will be responsible for circulation of all policy decisions and the hospital waste
management manual. He will be responsible for accident reporting in Form III to the
prescribed authority.
S/he will be responsible for total Bio- Waste management and for accidental spill etc.,
which will be reported to him.
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 224 of 260
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HIC MANUAL
S/he will also responsible for preparing statistics on waste generated and for necessary
documentation system and submission of annual as well as interim reports.
7.3 Role of concerned Heads/In-charge of Laboratory, Units/Departments:

They will be responsible for carrying out the policy and procedures laid down by the institution
under the control of the office in-charge of the waste management and higher Authority.
They will
be
responsible
for
the
formulation
and
implementation
of
waste
management Procedures for their departments in conformity with the general guidelines issued
by administration.
They will also be responsible for getting all staff, doctors, nurses, paramedics and class IV
staff, trained in hospital waste management, and will liaise with the Officer In-charge of waste
management for administrative support. With regard to the departments which generate
radioactive waste there will be a designated Radiation Safety officer and he will be responsible
for implementation of the necessary guidelines.
7.4 Role of Nursing Head In-charge:

The Matron will designate one of the senior Nurses as Sister In-charge of Hospital Waste
Management, who will be responsible for close monitoring of the activity.
She will conduct surprise rounds and will review and evaluate the various aspects of scientific
hospital waste management at all levels from generation and segregation to final disposal.
She will also attend the meetings of Hospital Waste Management Committee on behalf of
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 225 of 260
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MLA COLONY,
HIC MANUAL
the Matron and co-ordinate the training of nurses on Hospital Waste Management with
administration.
7.5 Role of Housekeeping In-charge who will work as Sanitation Inspector

The In-charge Sanitation Inspector will be responsible for the implementation,
monitoring and evaluation of hospital waste management from collection and storage of
hospital waste to its final disposal.
He will attend the Hospital Waste Management Committee meetings and will ensure
the training of the staff posted under him. Regular in-service training and evaluation of
the sanitation attendants will be carried out by him. He will also provide feedback
information to Officer In-charge Waste Management in case of accidents and spills
7.6 Role of Staff
Waste Segregation
After classification of the biomedical waste it is the responsibility of the doctor or
nurse who has generated the waste to ensure that such waste is placed into the
designated colour coded waste container displaying the appropriate hazard warning
symbol (if required).
The task of segregation may take place by other staff under the supervision of doctors or
PREPARED BY:
CHECKED & REVIEWED
APPROVED BY:
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
Dr. W.I. KIRAN
(INFECTION CONTROL
(INFECTION CONTROL
(MEDICAL
NURSE)
OFFICER)
DIRECTOR)

Page 226 of 260
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MLA COLONY,
HIC MANUAL
nurses.
It is essential that hazardous biomedical wastes are not mixed with non-hazardous
general wastes. It is also important not to place non-hazardous general wastes into
designated hazardous biomedical waste containers. This is the responsibility of all
staff.
Waste Collection and Transfer:
It is the responsibility of House keeper and cleaners to ensure colour coded waste
containers are collected in a timely manner and transferred to the appropriate area
for storage, treatment or disposal.
Cleaning of Waste Containers, Bags and Bins:
The cleaning and disinfection of sharps containers and mobile garbage bins is the
responsibility of cleaning staff under the direction of the In-charge of cleaning
department.
8.0 Training of Hospital

In order to implement the Bio-Medical Waste (Management and Handling) Rules 1998, it is
mandatory to provide training to all categories of staff i.e. resident doctors, nurses, paramedical
staff, hospital and sanitation attendants, patient and their attendants, canteen staff, operation
of Bio-Medical Waste treatment facilities. Before the training is carried out the training
needs to be identified content varied accordingly. It will be interactive and include
awareness sessions, demonstrations and behavioral science inputs. It includes the following:
Awareness of different categories of waste and potential hazard
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 227 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Waste minimization, reduction in use of disposables
Segregation policy
Proper and safe handling of sharps
Use of protective personal protective equipment
Color coding of containers
Appropriate treatment of waste
Management of spills and accidents
Occupational health.
9.0 Points to remember for Waste Management in the Hospital

Do segregate waste at point of generation to:
Infection
Non-Infectious/Garbage
Sharps/Needles.
Do collect waste in color coded containers/bags:
Yellow Infectious waste for incineration.
Black Garbage for dumping in municipal bin.
White Sharps/needles.
Do decontaminate all sharps and plastic waste by chemical/autoclave.
Do shred plastic waste (cut all tubing into pieces by scissors).
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 228 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Do use syringe and needle destroyer.
Do incinerate blood soaked dressings/body parts etc.
Do cover waste collection containers.
Do transport through covered trolleys/wheel barrows.
Do provide protective wear (mask, gloves, plastic aprons, gum boots to transporters
and handlers.
Do immunise all waste handlers.
9.1 Donts for handling and Disposal of Hospital Waste:

Dont mix the infectious with non-infectious waste.
Dont throw sharps in the trash or into non-puncture proof containers.
Dont recap the needle or bend or break needles by hand.
Dont fill the waste container more than 3/4th of capacity.
Dont allow un-authorized persons access to waste collection/storage areas.
Dont use open buckets for infectious waste or sharps.
Dont incinerate plastic waste.
9.2 Dos and Donts for Chemical Treatment
Do apply to sharp or infected plastic waste.
Do use 1% hypochlorite or equivalent disinfectant. Proper concentration is essential.
Do let the contact time be at least 30 minutes.
Do change chemical solutions frequently (with every shift).
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 229 of 260
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Do handle with gloves and mask. Wear apron and boots if splashing is expected.
Dont chemically treat incinerable waste.
10.0
ACTIVITY AND RESPONSIBILITY:
Sl. NO.
1
ACTIVITY
RESPONSIBILITIES
To always wear gloves, facemask and apron while Housekeeping staff
handling biomedical waste.

Segregation / collection of hospital waste in Ward staffs / sisters /
specific different color coded bins.
Housekeeping staff
Black/Green General municipal waste like

paper leftover food etc.
Yellow Solid waste like Dressings, gauze, cotton
swabs, POP casts, Human tissues and body fluids.
Red Plastic like rubber gloves, syringes, catheters,
I.V. sets, E.T. tubes, urine bags etc.
White puncture proof - Sharp waste used needles,
3
blades, scalpels, broken glass etc.

Mutilation / shredding of needles / syringes and Sister in-charge ward
putting them in designated bins.

Mutilation / shredding with scissors of plastic / Sister in-charge ward
rubber, IV sets, ET tubes and catheters etc.

To transport bio-medical waste in color coded bins Housekeeping
staff,
with color coded bags on daily basis from wards to Authorised Contractor
the exit point to be collected by the concerned
authorised contractor for Incineration.
6
Sharp waste after mutilation to be collected in
PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 230 of 260
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MLA COLONY,
HIC MANUAL
White color puncture proof bins. To add 1% hypo Housekeeping staff
chlorite solution
7
to
the
waste
for
chemical
treatment, one hour before emptying the bin.

Waste human organs from Histopathology lab to Housekeeping staff
be transported in yellow color coded bin with yellow Authorized Contractor
bag on trolley to the exit point to be collected by the
concerned authorized contractor for Incineration.

Always ensure that bags are securely tied and less Housekeeping staff
Authorized Contractor
than 3/4th full.
10.1
Sl. No.
FOR SPECIFIC INFECTED CASES
Activity
Responsibilities
HIV POSITIVE CASES
To wear double gloves, face mask and apron while Housekeeping staff
handling the waste

To collect all the linen of identified and marked (by the Housekeeping staff
nursing staff) case in yellow color double bags after
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 231 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
treatment. (Soak in Sod. Hypochlorite solution for one
3
hour)
To collect solid and mutilated / shredded plastic waste in Housekeeping staff
4
5
yellow color double bags.

To label all the bags as HIV POSITIVE
Housekeeping staff
Bags thus collected are transported to the BMW Housekeeping
staff
exit point, to be collected by authorised contractor.
authorized contractor.
HEPATITIS B and C Cases

To wear double gloves, face mask and apron while Housekeeping staff
handling the waste

To collect all the linen of identified and marked (by the Housekeeping staff
nursing staff) case in yellow color coded bin and soak in
1% Sod. Hypochlorite Solution for one hour.

The treated linen to be washed thoroughly dried and Housekeeping staff
sent for laundry.

To segregate and collect solid and mutilated / shredded Housekeeping staff
plastic waste in yellow color coded bins with yellow
bags.
To transfer the waste along with the yellow bag into Housekeeping
another
staff
curb point, to be collected by authorised authorised contractor
contractor labelled yellow bag and transported to

BMW
11.0
LABEL FOR BIO-MEDICAL WASTE CONTAINERS/BAGS
HAZARD SYMBOLYTOTOXIC HAZARD SYMBOL

PREPARED BY:
CHECKED & REVIEWED
BY:
Mrs. RAMANJANAMMA
Dr. K. AMRUTH RAO
(INFECTION CONTROL
(INFECTION CONTROL
NURSE)
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 232 of 260
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HIC MANUAL
BIOHAZARD
CYTOTOXIC
36. FREQUENCY OF UPDATING HIC MANUAL

Hospital infection Control (HIC) manual is updated or revised and updated once in a
year or as and when required.
HIC manual is to be updated based on the inputs from internal Quality Audit, External
Quality Audit, changes referred in good infection Control practices (time to time),
Continuous Quality improvement (CQI) activities, etc and whenever changes are
required based on revisions in Quality Accreditation Standards like NABH.
Infection Control Officer (ICO) and HICN are responsible to identify the need for changes, to
review and updates the changes after fruitful discussions and approval from management and all
the members of HICC and its team.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 233 of 260
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MLA COLONY,
HIC MANUAL
GENERAL PRINCIPLES OF ANTIMICROBIAL

THERAPY
Antimicrobial therapy is to Minimize or eradicate indiscriminate and injudicious or unnecessary
or irrational use of antibiotics. (Especially for viral infections and contaminants and commensal
or colonization flora growths in culture studies etc.) and Minimize bacterial resistance
development, along with restricted high end antibiotic usages (for about 5-7 days depending on
clinical condition) which has to be supported by culture studies and protocols has to be
followed for first and second line of antibiotic preferences in treatment .THE policy Emphasizes
avoiding use of powerful antibiotics for initial treatment except for the critical care patients &
thus patients save money and doctors saves lives ,because right drug for right bug policy is
better .the policy is reviewed and updated periodically with clinicians cooperation and they are
encouraged to deescalate or stop the high end antibiotic usages .for more than one week period
or so unless called for ... the synergistic antibiotic combinations are preferred for kochs and
MDR ,MRSA,VRE,ESBL infections, for critically ill patients with mixed infections of gram
positive and gram negative infections.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 234 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
IN order to minimize the nosocomial infections all preventive and corrective actions are taken
and HIC protocols are followed like use of personal protective equipment, strict hand hygiene
,aseptic barrier nursing techniques are implemented STRICTLY to control cross infections
.,Good BMW management rules are followed along with sharps policy, bundle care protocols
are also followed to minimize MDR (Muti drug resistant) nosocomial infections rate which are
quality indicators for hospital patients services . The nosocomial MDR pathogens infections
carry increased morbidity and mortality. The Microbiologist and Clinicians will cooperate to
follow envisaged antibiotic policy guidelines, and the surgical prophylaxis for antibiotics is
restricted for about 1-3 days only. Separate empirical or presumptive therapy is advocated for
community acquired and nosocomial infections and ICU/AMCU infections and OP therapies.IN
case of penicillin allergy amoxicillin, piperacillin etc. has to be avoided. Colonization of flora
and contaminant & commensal organisms possibility in culture has to be ruled out for planning
treatment of pt. and thus prevent development of antibiotic associated diarrhea etc iatrogenic
complications .
1. Diagnosis
(a) Clinical: A working clinical diagnosis is essential for the rational choice of an antibiotic,
even if the diagnosis is later changed.
(b) Bacteriological: Appropriate specimens for bacteriology must be taken before treatment is
started. It may be extremely difficult to isolate the causative organism, once treatment has been
given. Moreover, antibiotics may alter the normal flora (e.g. of the oropharynx) resulting in
colonization with potentially pathogenic bacteria. This may further confuse the
Bacteriological diagnosis, hence better to collect samples before antibiotic treatment pl.
2. Choice of antibiotics:
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 235 of 260
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HIC MANUAL
Strategies are made to improve compliance through proper feedbacks HICC formulates
antibiotic policy and guidelines for empirical and prophylaxis therapy and for commonly
community acquired and nosocomial pathogens.
I. The Site Of Infection The chosen drug must reach the site of infection to be effective.
Certain sites (e.g. the CSF-cerebrospinal fluid) are less accessible to antibiotics and treatment
must be chosen accordingly. preferences also differs separately for gram positive and gram
negative and anaerobes or fungal infections and also the penetration power of antibiotic to site of
infections like brain and bones and joints etc.
II. Cost: Many high end antibiotics are expensive and the volume of antibiotic prescribing is
such that purchases of these drugs accounts for a considerable (and increasing) sum of surcharge
burden on patients each year. Cost may be contained as far as possible by only using an
antibiotic when it is clearly indicated and commensal flora or colonisation organisms, if isolated
in culture are mostly ignored for further treatment and by de-escalation therapies etc. which also
helps in lowering the growing bacterial resistances. THE lenghth of stay of pt will increase in
cases of MDR organism causing nosocomial infections developes in hospital.
3. Dose
Factors influencing the dose include:
I. The sensitivity of the organism moderately sensitive organism may require higher doses for
treatment than fully sensitive ones owing to invitro & in vivo possibilities.
II. The site of infection some infection (e.g. meningitis, endocarditis) need higher doses than
usual because of the relative in accessibility of the infected areas.
III. Impairment of excretion if the main route of excretion is impaired then dosages is affected,
by keeping in mind the toxicity and side effects of drug prescribed for liver and kidney tissues
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 236 of 260
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etc .
General observations
Most of the rare pathogens and virulent MDR pathogens like pseudomonas and Acinetobacter
and ESBLS
GNBs etc. were found sensitive to most of the higher antibiotics like colistin,
tigicycline, piperacillintazobactam, carbapenams, netilmycin, aminopenicillins and third and

fourth generation cephalosporins with tazobactam-sulbactam and clavulanic acid combinations,
carbenicillin and mezlocillin and aztreonam & mecillinam etc. combinations which are costly
antibiotics. These organisms were also found moderately sensitive to levofloxacin and
moxifloxacin, lomefloxacin & nitrofurantoin etc. quinolones which can preferred for deescalation treatments follow-ups.
The gram positive organisms and MRSA, VRSA etc were found commonly sensitive to
linezolid, teicoplannin, carbapenams, colistineand tigicyclines, clarithromycins, streptogramins,
muciprocin, rifampins, cloxacillins azithromycins etc most of the staphylococci isolated were
found sensitive for oxacillins and methicillins etc and MRSA incidence was rare at our hospitals
except for outsourced infections for patients brought from other hospital with indwelling
devices like catheters and cannulas and ET tubes and outside operated patients etc, which are
admitted and cured completely by appropriate treatment and management and thereafter
discharged with good condition of health and disease .
The other non-resistant common gram positive and gram negative species were found sensitive
to third and fourth generation cephalosporins, amoxyclav, ampicillinsulbactam
comnbinations,and also to all above said drugs etc. some were also found sensitive surprisingly
to rarely used drugs like cotrimexazole,. The urinary pathogens were also found sensitive or
intermediate sensitive to nitrofurantoin and fluoroquinolones group of drugs .THE incidence of
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 237 of 260
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HIC MANUAL
antibiotic associated diarrhea or any food poisoning cases was rare entity at our hospital. In
immunocompromised hosts with h/o chemotherapy and immunosuppressive therapy etc. the
candidial infections were found to be common in our setup. we also have facility of growing
fungal infections in sabourauds dextrose agar media .WE mostly refer the open case of
tuberculosis to Government chest hospital for further management and when kept at our place
we admit him in strict respiratory isolation care of patient ,THE incidence of bedsores and
cellulitis and skin infections and peripheral throbophlebitis among our inpatients is very less
because we undertake CNE and CME teaching programmes to patients regularly and teach
them about HAI preventive methods and practises etc .and moreover special aseptic care is
undertaken for any immunocompromised host whenever admitted here .NO notifiable cases are
admitted nor treated here because of their communicability and infectious trends, except for
HBV, HCV & HIV cases . Such cases are referred to fever hospital of tropical and
communicable diseases institute.
AS our hospital is an tertiary care superspeciality hospital hence most of the patients are
already treated with many antibiotics outside and hence were found sensitive mostly to high end
antibiotics as mentioned above. WE have separate data collection forms for high end antibiotic
usages and they are followed up and observed for de-escalations to lower end antibiotics and
stoppages of trt if felt necessary. The clinicians are encouragingly motivated to send culture
studies to support justifiably, such prescriptions from them. Many a times immunocompromised
host patients are admitted (like DM, HIV, leukemia & lymphoma patients, patients on
chemotherapy and immunosuppressive therapy, extremes of age, etc.)
We also impart health education and CNE and CME programmes to make our staff aware about
antibiotic policy. The staff is also made aware that culture samples are to be sent before
antibiotic prescriptions. The feedback reports about our policy is obtained from ward nurses by
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 238 of 260
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HIC MANUAL
retrospective examination of medical file records, AND all the surveillance reports are reviewed
regularly at monthly HICC and safety committee meetings etc. The compliance of our guidelines
has to be studied by follow-up studies etc., The staff of our hospital are also taught about good
sample collection methods especially for microbiology lab by quality manager of laboratory
services department.
The ultimate aim of our antibiotic policy is to discourage the development of growing bacterial
resistance and prevention of MDR Nosocomial pathogens incidence in hospital by undertaking
all preventive care as per HIC protocols, to monitor the empirical or provisional treatment
protocols to follow the quality control in antibiogram studies and ATCC (American type culture
collection) strains are also used as standards along with McFarlands TurbidOmetry standards
for our Kirby-Bauers disc diffusion methods on Mueller-Hinton agar plates during our
universally standard antibiogram methods at our microbiology lab. The antibiotic discs are used
from famous HI media company and expired ones are discarded off. The minimum inhibitory
concentration method of reading antibiogram along with antibiotic assay studies etc., will be
introduced in future as per recent advances studies etc.
The common organisms isolated as pathogens in our set up are Esch.coli, klebseilla species
proteus, pseudomonas with rarely, Acenetobacter, Enterobacter & Citrobacter etc, and
coliforms., AND AMONG gram positives staphylococci, pneumococci, streptococci,
enterococci, etcare isolated . EVEN disinfectants are tested for culture periodically to examine
for any bacterial contaminations and to reduce any such spread of infection routes.
The high end antibiotics list for which monthly Audit is kept along its prescription, de-escalation
or stoppage are as follows
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 239 of 260
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HIC MANUAL
:piptaz,colistine,carbapenams,cefaperazonesulbactam,cefaperazonetazobactamand other
sulbactam-tazobactam-clavulanicacid combinations with third and fourth generation
antibiotics,cefepime,carbenicillin,mezlocillin,aminopenicillins,linezolid,teicoplannins,vancomyc
in,azetreonam,tigicycline,etc etc
MOST of the time MDR&ESBL infections are most commonly seen in highriskwards like
AMCU,ICCU,CTICU,NICU,SICU areas & common in immunocompromised pts like DM
,IMMUNOSUPPRESSED & OLD AGE ETC.THEIR outbreaks can b controlled by following
universal std.precautions & by following barrier nursing aseptic techniques strictly ,by use of
PPE,by efficient BMW & Sharps &Spillage management& by strict hand wash and hand rub
methods.THE high end antibiotic use is monitored and restricted by dishonouring such
prescriptions SOS BY PHARMACY DEPT .VIRAL&Fungal infections are not treated by
bacterial antibiotics .THE Deescalation process has to b encouraged & the clinicians have good
knowledge about not treating colonized or commensal flora infections by clinicopathological
lab correlations.THE recent advances study like computerized antibiograms,serum bactericidal
assays and MIC methods will be shortly practiced here.WHEREVER deep seated infections are
present then they can be better and rapidly healed by attempting minor or major surgical
techniques upon it . THE associated anaerobic or fungal or MYCO TB infections have to be
treated for early and complete cure from such infection focus,.WE have to reserve such high end
antibiotics for lifethreatening and critical or viruleninfectionsmostly .THE Synergistic
combination therapies are given to critical care pts &for mixed infections and for
immunocompromised hosts and device related severe infections etc .
THE surgical prophylaxis is given in various surgeries as
per protocols laid down as per HICPAC & OSHA &CDC guidelines .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 240 of 260
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MLA COLONY,
HIC MANUAL
Antibiotic recycling is practiced to lower bacterial drug resistance .here antibiotics are restricted
and rotated to maintain antibiotic heterogenicity in order to alter selective pressure and thus
combat and prevent reemergence of rights to prescribe any particular antibiotic and thus lenghth
of each cycle of antibiotic prescriptions are favorably adjusted accordingly.THE pharmacy
monitors various antibiotic consumtion at counter in any hospital and high end antibiotic use
.software devices can be modulated to monitor antibiogram patterns or type of organisms etc
LASTLY pts also should be educated against self and across the pharmacy medications and any
preferences due to ignorances .IN some countries only 1-2 such doses are given on humanitarian
sympathetic grounds in case of s/s of any infection foci .THRO TV,ELECTRONIC MEDIA
AND RADIO newspapers ,magazines ETC can be used to advertise about antibiotic misuse and
its sideeffects and complications by its indiscriminate use .THE lack of opportunity for followups of pts progress and possible fear of forums and legal litigations about delay in diagnosis and
treatment are the main hurdles for effective and strict implementation of good antibiotic policy
protocols in our country .THE veterinary prescriptions should be restricted and govt should lay
down acts etc for antibiotics restricted use by legislations and ban on across pharmacy sales in
villages etc has to be followed .
WE HAVE to rule out and discriminate between the commensal flora and growth from that of
pathogen by correlating s/s clinically and also correlating with xray and cbp etc lab parameter
findings we have also to rule out the possibility of colonization of flora growth also from the
reports given. And also the secondary infection focus possibility .
THE various group of antibiotics which are prescribed are
aminoglycosides.,macrolids,aminopenicillins,carbapenams,penicillin
gp,beta
lactam
antibiotics,first to fourth generation cephalosporins and its combinations with tazobactams and
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 241 of 260
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MLA COLONY,
HIC MANUAL
sulbactams
and
clavulanic
acid,sulfas,imidazole
gp.,tetracycline
gp,colistine,metallobetalactams,etc etc . we have to justify our high end antibiotic prescriptions

by sending for cultures and we have to stop or deescalate high end antibiotics to that of lower
end or oral antibiotics depending upon clinical improvement of pt . in community acquired
infections we have to give first low antibiotics and if pt worsens switch on to high end
anribiotics. As ours is tertiary care superspeciality hospital we get pts who are already treated by
antibiotics outside and hence the sensitivity pattern is that we may have to start high end
antibiotics to such pts and thereafter deescalate or stop the antibiotics depending upon clinical
improvements .these basic rules of antibiotic policy we have to follow .HICO should insist on
encouragement for de-escalation or stoppage of high end antibiotics by issuing stop orders to
pharmacy after fruitful discussions with concerned clinicians after convincing them in order to
discourage the growing number of MDR strains in our hospital .moreover they should b
encouraged to send cultures whenever they prescribe high end
SURGICAL PROPHYLAXIS OF OUR HOSPITAL(dose in

gms ///as per body wt )
Second preference antibiotics are given to pt with infection focus or anticipated
sepsis OR immunocompromised pts OR pts with major or prolonged surgeries etc
the aim of prophylaxis is to remove or neutralize the normal flora of skin and see
that it does not enter thro into body cavity etc thro incision and contaminate the
wound .predominantly the flora comprises mostly of gram positive cocci like
staphylococci or streptococci or anaerobes etc along with enteric bacteria or
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 242 of 260
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MLA COLONY,
HIC MANUAL
coliforms in some areas and in some given situations .GNB MAY CONTAMINATE
SURGERIES INVOLVING GI TRACT,GYNAEC & urinary tract and biliary
SURGEREIS
,APPENDECTOMY
,COMPOUND
FRACTURES
AND
PENETRATING WOUND SURGERIES ETC
THE RECOmmended doses of drug are as per body wt mostly . for ampicillinsulbactam it will b 3 gm,aztreonam -2g,cefazolin-2-3g,cefotaxime 1g,cefoxitin or
cefitriaxone
both
-2g,clindamycin-1gm,carbapenam-1g,gentamivcin800mg,levofloxacin-500mg,metronidazole-500mg,pip[taz3gm,vancomicin-800
mg,etc the recommended duration schedule varies from 1 to 3 days as per situation
demands .the second preference drugs cabn also be given in betalactam antibiotic
allergies .
Any changes if u make in admn of surgical prophylaxis ,pol. Inform us so that we
can incorporate it in our antibiotic policy protocols .this is given to minimize our
postoperative wound infection rates in our set up .besides these we have to
underatake many preventive precautions in ot and cssd dept and reduce trafficking
in ot also to rteduce ouyr ssi rates .post fumigation swabs should b sterile in ot and
cssd sterile storage room areas and biological controls should be negative for
autoclave and for ETO sterilizers also .the HEPA filters also should be checked by
company people and A/C filters are cleaned as per protocols by maintainance dept
people in order to prevent molds or fungal infections in post operative pts. The staff
of OT AND CSSD dept are periodically tested every quarterly for any nasal MRSA
carrier state also .no staff with severe respiratory infections nor with any
discharging pyogenic infections of hand etc are allowed to work in OT and CSSD
depts. .NO eating and drinking etc activities are allowed in OT area.the use of
chlorhexidine and h2o2 and betadine has to be done to bathe and clean the
operating area of pt. water from scrub areas are tested periodically for any
bacterial contaminations etc .cleaning protocols for OT are followed for sake of safe
and sterile environment in OT premises .POST operative dressing care is to b
undertaken aseptically also .ALL THE PREVENTIVE BUNDLE CARE IN
UNDERTAKEN TO PREVENT SSI IN POSTOPERATIVE infections of SSI in pts.
Moreover pts should be prescribed surgical prophylaxis drugs by iv route and that
too for 1 to 3 days only depending upon major or mi9nor surgery .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 243 of 260
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HIC MANUAL
SURGICAL PROPHYLAXIS USED IN THE HOSPITAL( dose can b wt.based )

A.
GYNAECOLOGICAL PROCEDURES---rarely done
S.No. Name of Surgery
duration
1.
2.
Abdominal
Hysterectomy------1 to
days sos
3.
Laproscopic
Hysterectomy ----1 to
days
4.
Ovariectomy ---1 to
days
5.
/ 1st preference
2nd preference
Inj. Cefotaxim 1gm IV

3 Inj. Amikasin 80mg iv
Inj Metrogyl
Inj. Cefotaxim 1gm IV
3 Inj. Amikasin 80mg iv
Inj Metrogyl
3 Inj Cefotaxim 1gm iv
Inj. Augmentin 1.2 gm iv
D&C
B.
Inj.Cefotaxime
Inj.Metrogyl
Inj. Augmentin 1.2gm

Inj. Augmentin 1.2gm with
Inj. Metrogyl
Levofloxacin + metrogyl
ENT SURGERIES
S.No. Name of Surgery / duration
1st preference
1.
Augmentin
Tonsillectomy 1-2 days
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
2nd preference
Inj. Cefotaxime / Inj.
Monocef
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 244 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
2
Oral or neck surgeries

/ESOPHEGIAL SURGERIES
2 to 3 days
3
3.
C.
Inj Cefazolin
Inj. Augmentin
Inj Gentamycin and

cefitriaxone
Inj. Amikacin with inj

piptaz
Inj. Metrogyl
Lymph Node Biopsy 1-2 days
Inj. Monocef or Inj.

Cefotaxim 1gm
Inj cefipime wih

metrogyl sos
NEUROSURGICAL PROCEDURES
S.No. Name of Surgery / duration
1st preference
2nd preference
1.
Major Brain / Spine Surgery

3 days
Inj.Cefotaxim + Inj.
Amikacin (in select
cases of long duration /
instrumentation of
spine)
Inj piptaz with

linezolid and
metrogyl
2.
Meningitis Post Op
Inj cefazolin +
metrogyl
Inj.Vancomycin
+ / ///Inj.carbapenams
sos
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 245 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
3.
Brain Abscess
If anaerobic
metyrogyl etc
Antibiotics based on
culture & Sensitivity
4.
Routine Brain / Spine Surgery
Inj.cefazolin /
Inj.aminoglycoside
Inj.piptaz/
vancomycin with
metrogyl sos
D.
ORTHOPEDIC PROCEDURES
S.No. Name of
Procedure
Surgery
1.
All Soft tissue surgeries /

Closed fracture surgeries
2.
a)
All open / compound

injuries
b)
1st preference
Inj.Cefazoline/Inj.
Cefotaxim +
Inj. Gentamycin or
Inj. Metrogyl sos
2nd preference
Inj.cefepime / with Inj
Amikacin + Inj. Metrogyl
in RTA injury surgeries
Inj.Cefazoline / + Inj. . Inj. //vancomycin+piptaz

Gentamycin 1 gm
All contaminated injuries
Or
Inj.
add metrogyl
Cefaperazone-sbactam
with metrogyl sos
Inj.Cefipime +
gentamicin OR
Inj.CefoperazoneSulbactum +Linezolid+
with Metronidazole /
Open # Joint Replacement

& post op
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 246 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
E.
CARDIOTHORACIC SURGERY
/ 1st preference
S.No. Name
of
Surgery
Procedure
Elective Open Heart and
1.
Closed Heart Surgery
2.
F.
Infected Cases/ Emergency

Cases/lung surgeries
Inj. Cefazoline/with
metrogyl
Inj. Vancomycin +
Inj.piptaz
Inj. Piptaz with

Inj. Vancomycin
Inj. Targocid +
Inj. Linozolid and
metrogyl sos
PLASTIC SURGERY
S.No. Name of
Procedure
1.
Minor cases
2.
2nd preference
Surgery
Major cases
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
/ 1st preference
2ndpreferene
Inj Cefotaxime
/cefuroxime
Inj. Inj
cefaperazonesulbactam
Inj. Cefotaxime + inj

Amikacin + Inj Metrogyl
Inj cefepime + Inj

AMikacin with
metrogyl sos.
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 247 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
3.
Major cases-suspected /
proved pseudomonas
Ceftazidime / cefipime
+Gentamicin with
Metronidazole sos
Inj piptaz /// azetronam

withMetronidazole
Add linezolid sos
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 248 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Major cases- suspected
/proved MRSA
4.
+ Linezolid
or
piptaz + Metronidazole /
Linezolid + tigicycline
with metrogyl
Inj cefazolin /inj cefepime

withmetrogyl
5
G.
Breast surgery
Injpiptazwith metrogyl
UROLOGY
S.No
.
Name
Surgery
Procedure
1.
Minor cases
///cystoscopy
of 1st preference
/
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
Inj.cefazolin *
Inj. Gentamycin
or
Fluroquinolones + sulfas
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
2nd preference
Piptaz with
aminoglycoside with
metrogyl sos .
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 249 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
2.
3.
Major cases
without sepsis
Minor / Major
cases with sepsis
Inj cefazolin +gentamicin with

metrogyl sos
Inj. Cefoperozone sulbactum + Inj.

Metrogyl
(nephrectomy )
4.
Prostatectomy
Inj. Cefotaxime + Inj. Amikacin/
H.
GENERAL SURGERY
S.No. Name of Surgery / Procedure
1.
1st preference
Clean Cases
Thyroid
2.
Inj.PIPTAZ or inj
Augmentin with Inj.
Metrogyl
OR levofloxacin sos .
Inj piptaz &levoflox
2nd preference
Inj Cefazolin or Inj.
Augmentin + / Inj
Amikacin
Hernia,
Breast,
Inj piptaz with

aminoglycoside and
metrogyl sos
Inj. Cefotaxime + Inj

Gentamycin
Clean Contaminated
Gastroduodenal,
Biliary,
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
Inj Cefazolin/Inj.
CHECKED & REVIEWED
BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Inj Piptaz with

metrogyl + Inj.
Aminoglycoside
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 250 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
Cefuroxime + Inj.
Gentamycin +
Metrogyl sos
Appendix
3.
Contaminated
Diabetic Foot
Amputation Ischemic Limb
GI Spillage
Trauma
Perforated viscus with
established infection
4.
SSI
I.
NEPHROLOGY
S.No. Name of Surgery /
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
Inj. Cefoperazone
Sulbactum or
Inj.Carbepenem +
Inj.Metrogyl +
linezolid sos
SEVERE
Inj. Cefuroxime or
Inj. Piptaz +
Inj. Metrogyl
with
Antibiotics continued
as per co-morbid
conditions
Inj. Aminoglycoside
Inj cefaperazone
sulbactam with metrogyl
1st preference
CHECKED & REVIEWED
BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Inj piptaz or
carbapenam with
metrogyl and
vancomycin --SOS
2nd preference
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 251 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
1.
Procedure
UTI
2.
Recurrent UTI
3.
PyelonePhritis
4.
Catheter Infection
I.
Norfloxacin/
Nitrofurontoin?
with
Ofloxacin / CoTrimoxazole x 6 month

Piperacillin- Tazobactum/
with levofloxacin
Inj. Amikacin/ with
cefaperazonesulbacrtam
Inj. Levofloxacin +
Inj. PIPTAZ sos
PipTAZ / WITH
nitrofurantoin sos
Tigicycline Or
Colistin SOS
Severe Infection Inj.
Carbapenem / Inj.
Piptaz / Inj.
Tigicycline WITH
AMINOGLYCOSIDE
SOS
CARDIOLOGY
S.No. Name of Surgery / Procedure
1st preference
2nd preference
1.
Infective Endocarditis with

valvular heart disease with
prosthetic valve
IV Inj Ampicillin +
InjGentamycin ( 2
doses)
Inj cefazolin =
VANCOMYCIN
WITH METROGYL
2.
Cardiac Catheterisation for

valvular heart disease
IV InjCefazolin + Inj
Gentamycin
INJ PIPTAZ WITH

METROGYL
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 252 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
3
Permanent Pacemaker
implantation
IV Inj.Amoxyclav +
gentamicin , 30 mins
before procedure and 6
hrs after procedure
Inj piptaz with

metrogyl
PTCA
IV Inj.Cefazolin
Inj piptaz
Coronary Angiography
IV Inj.Cefazolin + Inj.
Gentamycin
Inj piptaz
+vancomycin
GASTROINTESTINAL SURGERIES
1 Small bowel surgeries
Inj Cefuroxime + Inj.
Gentamycin + Inj Metrogyl
2 co
Colorectal surgeries
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)

CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Inj piptaz or Inj.

Cefoperazone sulbactum +
Inj. Metrogyl + inj.
Linezolid sos
Inj piptaz or Inj.

Linezolid sos
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 253 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
3
Liver and pancreatic

surgeries

Inj piptaz or Inj.

Linezolid sos
Gastric or upper gi
surgeries

Inj piptaz or Inj.

Linezolid sos
GENERAL MEDICINE EMPIRICAL OR PRESUMPTIVE THERAPY

S.No.
1.
2.
1st preference for empirical 2nd

preference
for
Name Of medical
therapy
presumptive therapy of
illness
medical conditions
Community Acquired INJ AUGMENTIN OR
Inj cefepime // Carbapenem
Pneumonia
LEVOFLOXACIN WITH INJ
OR piptaz with metrogyl sos
metrogyl sos
Nosocomial Pneumonia Gram negative- Inj. Piperacillin Inj cefepime ///Carbapenem
or VAP
Tazobactum//////Carbapenem+ with metrogyl sos
with metrogyl
Gram positive-Inj. Vancomycin Inj linezolid with cefipime
/ / Amoxyclav
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 254 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
4.
SOFT
TISSUE Inj 3 or 4 generation
INFECTION
OR cephalosporins with inj
CELLULITIS OR BED metrogyl with topical
SORES
antibiotics also
/Inj. Carbapenam//inj piptaz

With metrogyl and linezolid
sos
Sinusitis
or URTI INJ 2 OR 3 GENERATION
/pharyngitis
CEPHALOSPORINS WITH
//tonsillitis ,CSOM etc
ANTITUSSIVES If gram
positive is suspectedtab
amoxyclav or azithromycin is
given
Inj piptaz /inj carbapenam

with inj aminoglycoside or
metrogyl sos
6.
Sepsis////deep
abscess etc
Inj. piptaz //Inj.Imipenem/

OR Inj. Tigecycline with
metrogyl sos
7.
Meningitis
Pyogenic
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
seated Inj cefepimewith vancomycin

and metrogyl sos
Inj cefazolin/cefipime with

gentamicin
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Inj piptaz with amikacin

and metrogyl sos
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 255 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
8.
Inj piptaz //carbapenam with

+Metronidazole
Post OP for major

surgeries
Aspiration pneumonias
9.
10.
Candida infections
Inj carbapenam/inj
tigicycline / inj metrogyl
and linezolid sos (for gram
positive suspicion )
Inj 2 or 3 generation
cephalosporins with inj
amikasin and metrogyl
Inj piptaz//inj carbapenam

with metrogyl
Flucanazole or nystatin
Itraconaczole or triconazole
///inj amphotericin b
Severe inf. Cases
11.
Neutropenic pts on
chemotherapy
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
amikasin and inj vancomycin
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Inj piptaz/inj
carbapenams/inj tigicycline
with inj linezolid and
metrogyl and antifungal also
.
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 256 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
12.
Secondary infections in
HIV pts
amikasin with metrogyl and
vancomycin sos
Inj piptaz/inj carbapenam/inj

tigicycline with linezolid
and metrogyl
Advised
immunopotentiation in
severely infected pts
13
COPD with
bronchiectasis
Inj cefipime with metrogyl
14.
Complicated intraabdominal infection
Piperacillin Tazobactum /
Carbapenem with
Metronidazole
Inj tigicycline /inj colistine

with linezolid and metrogyl
Septic Arthritis /
Osteomyel itis
3rd & 4th Generation

Cephalosporins / Cefoperazone
Sulbactum //Vancomycin sos
Inj piptaz /inj tigicycline

/inj carbapenam with
linezolid sos
15.
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
Inj piptaz/////tigicycline
with metrogyl or
clarithromycin sos
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 257 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
16.
Acute G.E
Moderate : ofloxacin with

Metronidazole
Inj levoflox with inj

amikasin and metrogyl
NOTE: LASTLY WE WANT TO MENTION THAT SOME OF THE REMAINING POLICIES

AND PROTOCOLS ETC ARE MOSTLY INCORPORATED IN OUR SEPARATE BOOK OF
STANDARD
OPERATIVE
PROCEDURES
ON
HOSPITAL
INFECTION
CONTROL,LAUNDRY AND LINEN POLICY . PEST CONTROL MEASURES ,, ETC

WHICH ARE UNDERTAKEN FROM OUTSOURCING AGENCY WHO USE REGULARLY
INSECTICIDES AND RODENTICIDES ETC THEIR WORK IS ALSO MONITORED BY
OUR STAFF IN WARDS .WE HAVE HAZMATH KIT PROVISION ALSO TO HANDLE
LARGER SPILLAGES OF MORE THAN 30 ML. OR SO IN HOSPITAL ESPECIALLY IN
LAB AND OT ETC . MSDS IS PROVIDED FOR ALL CHEMICALS ALSO .A/C FILTERS
CLEANING PROTOCOLS ARE EXpLAINED IN DETAIL TO MAINTAINANCE DEPT
AND SCHEDULE PROTOCOLS ARE EXPLAINED. HEPA FILTES ARE CHECKED BY
OUTSOURCING COMPANY PEOPLE .WATER TANK CLEANING AND CHLORINATION
OF PORTABLE
WATER
IS ALSO DONE SSREGULARLY AND MONITORED BY
MAINTAINANCE DEPT . THE MICROBIOLOGICAL CULTURE PLATE WASTE IS

AUTOCLAVED REGULARLY AND SENT TO BMW MANAGEMENT . WE VISIT
PERIODICALLY THE LAUNDRY AND ALSO BMW COMPANY ALSO TO MONITOR ITS
WORKING AND OBSERVE ITS WORKING AND IMPRONVEMENTS
in their
organizations ETC .
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 258 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
37. QUALITY INDICATORS
Urinary tract infection (UTI) Rate
Ventilator Associated Pneumonia (VAP) Rate
Central Line Associated Blood Stream Infections Rate
Surgical Site Infection (SSI) Rate
Peripheral Thrombophlebitis Rate
No. of bed sores development after admission
Needle stick injury Rate
Overall infection rate
Hand hygiene audit report
High end antibiotic usage
HBV VACCINATION RATES TO OUR EMPLOYEES
38. RECORDS
LIST OF REGISTERS:
CAUTI REGISTER
VAP REGISTER
THROMBOPHLEBITS REGISTER
SSI & BEDSORE REGISTER
INTERNAL TRAINING REGISTER
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 259 of 260
OMEGA HOSPITALS
MLA COLONY,
HIC MANUAL
BMW AUDIT REGISTER
CULTURE & SENTIVITY REGISTER
LIST OF FILES:
CAUTI File
SSI File
Thrombophlebitis File
Notifiable Disease File
Needle Stick Injury Reporting File
Quality Indicators File AND its distribution in wards
Minutes of Meeting File
Training attendance File
Weekly Rounds File
OT settle plate File
Devices day file
Personal hygiene file
Hand wash audit file
MRSA Sample report file
Spillage incidence file
Circular file
LIST OF FORMS:
Hand washing audit checklist
Needle Stick injury Form
Incident reporting forms
CAPA forms
PREPARED BY:
Mrs. RAMANJANAMMA
(INFECTION CONTROL
NURSE)
CHECKED & REVIEWED

BY:
Dr. K. AMRUTH RAO
(INFECTION CONTROL
OFFICER)
APPROVED BY:
Dr. W.I. KIRAN
(MEDICAL
DIRECTOR)

Page 260 of 260

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OMEGA HOSPITALS

MANUAL CONTROL TABLE

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

Manual Control Information:

HOSPITAL INFECTION CONTROL MANUAL

10th March 2014

11th March 2014

Date of Next Review

NABH 3rd edition

Header and Footer changed.

Controlled Copy Distribution Record:

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

: DR. W.I. KIRAN

Dr. W.I. KIRAN

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

INFECTION CONTROL COMMITTEE

INFECTION CONTROL TEAM

VARIOUS HICC SURVEILLANCE

INFECTION PREVENTION METHODOLOGY

STANDARD PRECAUTIONS IN CLINICAL LABORATORY

HAND HYGIENE & GLOVING

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

CARE OF SYSTEMS AND INDWELLING DEVICES

ISOLATION POLICIES & PROCEDURES

INFECTION CONTROL IN SPECIAL CARE UNITS/HIGH RISK AREAS

INTENSIVE CARE UNITS

COLLECTION AND TRANSPORTATION OF SPECIMENS

HOUSEKEEPING WITH HIV PATIENTS

CSSD RECALL POLICY

PROTOCOL OF SCHEDULE FOR ACTIVE SURVEILLANCE SWAB

INFECTION CONTROL PRACTICES IN AMBULANCE

MEDICATION INJECTION PRECAUTION & PROTOCOL OF LOADED

HIGH RISK CATEGORY

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

INTERMEDIATE RISK CATEGORY

LOW RISK CATEGORY

FREQUENCY FOR UPDATING INFECTION CONTROL MANUAL

RECORDS HIC DEPARTMENT

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

It outlines the methods of surveillance in the identified high risk areas.

It focuses on adherence to standard precautions and isolation policies & procedures.

Disinfection and sterilization practices.

Kitchen sanitation and food handling issues.

Engineering controls to prevent infection.

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

To implement these procedures in specific situations and areas.

To provide surveillance for nosocomial infection.

To develop corrective measures to control, prevent or minimize the risk of nosocomial

To train the staff and support employee health.

CHECKED & REVIEWED

THIS DOCUMENT IS ISSUED BY QUALITY DEPARTMENT. UNCONTROLLED COPY WHEN

To ensure compliance with standards for infection control.