Hospital Infection Control Manual

SMVMCH/MB/HIC/01 Page 1 of 123
Amendment No:04 Issue No:05
POLICY AND PROCEDURE -

Amendment Date :16.08.2021 Issue Date:18.08.2021
HOSPITAL INFECTION CONTROL
STANDARD OPERATING PROCEDURES

SMVMCH
VALIDITY: THIS MANUAL IS VALID FOR 3 YEARS

POLICY AND PROCEDURE –

TABLE OF CONTENT
TABLE OF CONTENT
Sl. No STANDARD OPERATING PROCEDURE Page No.

1 HOSPITAL INFECTION CONTROL 3
2 SURVEILLANCE AND REPORTING OF INFECTION 7
3 HIGH RISK AREAS 10
4 SAFE INJECTION AND INFUSION PRACTICE 12
5 ISOLATION CARE 14
6 SPILL MANAGEMENT 22
7 CARE FOR DEVICES 25
8 RESPIRATORY CARE 28
9 DISINFECTION POLICY 35
10 HOUSEKEEPING 50
11 LINEN AND LAUNDRY MANAGEMENT 60
12 BIO MEDICAL WASTE MANAGEMENT 64
13 FOOD HANDLERS 68
14 LIST OF NOTIFIABLE DISEASES 70
15 SPECIAL CARE UNITS 75
16 OCCUPATIONAL EXPOSURE 80
17 STAFF HEALTH: WORK RESTRICTION 89
18 CSSD 95
19 INFECTION CONTROL RISK ASSESSMENT 105
20 ANNEXURE 114

1. Purpose:
1.1 To maintain standards in infection control measures and minimize hospital acquired
infections in patients, visitors and staff
1.2 To define policy and procedure regarding hospital acquired infections in the hospital.
1.3 To ensure implementation of the effective action plan for prevention of infection.
1.4 To ensure compliance from all health care personnel to make the measures effective.
2. Scope:
2.1 Prepare document and issue infection control procedure.
2.2 Conduct training in infection prevention techniques.
2.3 Perform surveillance and monitoring ICP.
2.4 Develop action plan and function accordingly.
3. Responsibility:
3.1 Hospital Infection Control Committee.
4. Hospital Infection Control Committee:

Members:
4.1 Dr. M.Pragash – Medical superintendent, Chairperson.
4.2 Dr.T.Mangaiyarkarasi – Prof, Department of Microbiology, Member, Secretary
4.3 Dr.S.Girija – Prof & Head Department of Gen. Medicine, Member.
4.4 Dr.R.Gopal - Prof & Head Department of Microbiology, Member.
4.5 Dr. M.Shanthi- Prof & Head Department of Pharmacology, Member.
4.6 Dr.G.Manoharan - Prof & Head Department of Surgery, Member.
4.7 Dr.M.Jayasree - Prof & Head Department of OBG, Member.
4.8 Dr.T.Bharath kumar - Prof & Head Department of Paediatrics, Member.

4.9 Dr.Suneeth. P. Lazarus - Prof & Head Department of Anesthesia, Member.

4.10 Mrs.Greeta Gunaseelan – Nursing Superintendent, Member.
4.11 Mrs.M.Mohana –ICN, Member.
4.12 Mr.R.Naresh – Housekeeping In charge, Member
5. Infection control Team:

5.1 Infection Control Officer.
5.2 Infection Control Nurses.
5.3 Housekeeping In-charge.
5.4 CSSD In-charge.
5.5 Lab Technician.
5.6 Kitchen In-charge.
5.7 Laundry In-charge.
6. Responsibilities of the committee:

6.1 To minimize the risk of infection to patients, staff and visitors.
6.2 To identify the roles and responsibilities of key personnel involved in the prevention and
control of infection
6.3 To maintain Surveillance over hospital acquired infections.
6.4 To develop a system for identifying, reporting, analyzing, investigating and controlling
hospital acquired infections.
6.5 To develop and implement preventive and corrective programs in specific situations
where infection hazards exist.
6.6 To provide advice on matters related to the proper use of antibiotics, develop antibiotic
policies and recommend remedial measures when antibiotic resistant strains are detected.
6.7 To review and update hospital infection control policies and procedures from time to
time.

6.8 To help to provide employee health education regarding matters related to hospital
acquired infections.
7. Responsibility of infection control team:

7.1 Advice management of at risk patients.
7.2 Carry out targeted surveillance of hospital acquired infections and act upon data
obtained.
7.3 Provide a manual of policies and procedures for aseptic, isolation and antiseptic
techniques.
7.4 Investigate incidence of reported infection and take corrective action.
7.5 Assist in training of all new employees as to the importance of infection control and the
relevant policies and procedures.
7.6 Surveillance of infection, data analyses and implementation of corrective steps.
7.7 Biomedical waste management
7.8 Supervision of isolation procedures.
7.9 Monitor employee health programme.
7.10 Addresses all requirements of infection control and employee health as specified by
NABH, state and local laws.
8. Infection Control Officer (ICO):

The Microbiologist serves as Infection Control Officer.
8.1. Duties of Infection Control Officer:
The ICO supervises the surveillance of hospital acquired infection as well as preventive
and corrective programmes.
8.2. Review and revision of Infection control Manual:


Written policies and procedures shall be reviewed at least every year by the Infection
Control Committee.
9. Responsibility of infection control nurse:

9.1 The duties of the ICN are primarily associated with ensuring the practice of infection
control measures by nursing and housekeeping staff. Thus the ICN is the link between
the HICC and the wards/ICUs etc.
9.2 Identifying problems in implementing infection control policies and provide solutions.
9.3 In addition the ICN conducts infection control rounds and maintains the registers.
9.4 The ICN is also involved in education of paramedical staff including nurses and
housekeeping staff.
10. Meetings:
10.1. The infection control committee meets every month. Documentation of meetings and
recommendations are maintained in the office of the Medical Superintendent.
10.2. Infection control team meets once every month to discuss the proceedings.
Documentation of meetings are maintained by ICN.
10.3. Infection control officer keeps the committee updated on the states of infection in the
hospital.
11. Records:
11.1 Circular and minutes of meeting of HICC
11.2 Minutes of meeting of infection control team
11.3 Infection control audit record
12. REFERENCES :
12.1 Guidebook for NABH Accreditation 5th Edition April 2020.

Amendment Date :16.08.2021 SURVEILLANCE AND REPORTING Issue Date:18.08.2021
OF INFECTION
1. PROCEDURE:
1. SURVEILLANCE AND REPORTING OF INFECTION:
Surveillance for infection can be active or passive
1.1.1 PASSIVE CLINICAL REPORTING:
1.1.1.1 Clinicians suspecting occurrence of HAI may report this to the Medical
Superintendent (Honorary Head of the Infection Control Committee). All details
regarding the patient, procedures, medication etc. are made available.
1.1.1.2 The Senior Consultant in-charge of the Microbiology Department shall be responsible
for reporting any information about infections suspected to be hospital acquired.
1.1.2 ACTIVE SURVEILLANCE:
Active Surveillance is done in high risk areas of the hospital.
1.1.2.1 Operation Theatres:
Culture swabs and air sampling plates are sent from Operation Theatres before and after
fumigation every month.
1.1.2.2 Monitoring of working OT:
Air sampling is done once a month.
1.1.2.3 In use disinfectants:

1.1.2.3.1 In use disinfectants are tested once in three months
1.1.2.3.2 Records are kept with OT in charge. In case of unacceptable results decision on
corrective measures are taken by HICC.
1.1.2.4 Intensive care units:
1.1.2.4.1 Surveillance samples: Central line tips
1.1.2.4.1.1 Water samples from humidifiers
1.1.2.4.1.2 ET tube secretions
1.1.2.4.1.3 Urine samples from catheterized patients

OF INFECTION
1.1.2.4.1.4 Surveillance samples are sent per patient on device to microbiology laboratory.
Analyses of data are presented at the subsequent HICC meeting. Records are
maintained by microbiologist HICN.
1.1.2.4.1.5 Samples of disinfectant in use: random two samples of 1 ml of disinfectant per ICU
are sent in a sterile container monthly. Swabs may be sent after cleaning.
1.1.2.4.1.6 Records are maintained by respective ICUs.
1.1.2.5 Dialysis unit:
Water from different sites are collected aseptically and sent for microbiological
analysis once every 3 months.
1.1.2.6 Wards:
Samples of disinfectant in use: random two samples of 1 ml of disinfectant in use are
sent in a sterile container monthly once to check for sterility. Register to be maintained
by ward sister / NS office.
1.1.2.7 Glutaraldehyde monitoring:
In use glutaraldehyde may be sent for sterility check: 5 ml of in use glutaraldehyde to
be sent in a sterile container to the microbiology laboratory once in 3 months from:
Endoscopy room, Operation theatre. Records shall be maintained by the concerned
Department.
1.1.2.8 Food handlers:
1.1.2.8.1 Screening of food handlers is done biannually. Samples include nasal swabs and
stool samples.
1.1.2.8.2 Records shall be maintained by Kitchen In-charge (dietician).
1.1.2.9 Drinking Water :
Bacteriological surveillance is to be done monthly in microbiology laboratory. Records
maintained by Microbiology Department/ HCN.
1.1.2.10 Central Sterile Supply Department:

OF INFECTION
Sterilized gauge, instruments, spore strips are sent every week for sterility check.
Records maintained by CSSD Department.
1.1.3 SPECIAL STUDIES:
Special studies will be conducted as needed. These may include:
i) The investigation of clusters of infections above expected levels.
ii) The investigation of single cases of unusual or epidemiologically significant

hospital acquired infections.
iii) Prevalence and incidence studies, collection of routine or special data as needed and
sampling of personnel or the environment as needed.
1.1.4 Surgical site infections:

Prescribed format is filled up by surgeons.Records maintained by infection control
nurse. Data collected every quarterly by ICN- HICC and presented.
2. REFERENCES :
2.1 Guidebook for NABH Accreditation 5th Edition April 2020.

HIGH RISK AREAS
1. High Risk Areas:

1.1. ICU
1.2. ICCU
1.3. RICU
1.4. NICU
1.5. PICU
1.6. DIALYSIS UNIT
1.7. CSSD
1.8. Operation theaters
1.9. Post -operative ward
1.10. Laboratories
2. Moderate Areas:
2.1. General wards
2.2. OPDs
3. Low Risk Areas:

3.1. Office areas
4. Amendment:
4.1. High risk area:
4.1.1 Blood bank
4.1.2 Endoscopy unit
4.1.3 Cath lab
4.1.4 Pulmonology OPD & ward
4.1.5 Isolation ward
4.1.6 Chemotherapy ward

HIGH RISK AREAS
4.1.7 Labour room

4.1.8 Radiology
5. REFERENCES :
5.1. Guidebook for NABH Accreditation 5th Edition April 2020.

Amendment Date :16.08.2021 SAFE INJECTION AND INFUSION Issue Date:18.08.2021
PRACTICE
1. Handling of disposable syringes and needles:

1.1. After administering the medicine, do not recap the needle to avoid needle stick injury.
1.2. Never try to disassemble the needle and syringe.
1.3. Place the needle and syringe in the puncture resistant container and take it to the needle
destroyer.
1.4. Once needle is destroyed the syringe alone is discarded in the red bin.
2. Policy for safe use of multiple dose solutions:

2.1. The person administering a multiple dose medication must read the label to confirm that
the medication is intended for multiple uses.
2.2. Label the date of opening and also mark the number of discharges each time.
2.3. It is the responsibility of the person to determine its safety for future use. If breaks in
technique have occurred, the solution must be discarded.
2.4. Solutions used for injections can be left open for a maximum of one day only.
2.5. Do not use the same needle to load the solution for different injections.
2.6. A fresh needle must be used for loading the solution and another fresh needle should be
used for injecting the solution every time.
2.7. After loading the solution for one injection, remove the needle from the vial and discard
it in the sharps container.
2.8. The multiple dose vial can be used at maximum 10 pricks or 15 days whichever is earliest.
3. Guidelines for safe infusion:

3.1. The bottle must be carefully checked for damage and for leaks before use.
3.2. The expiry date should be checked before connecting the bottle for use.
3.3. All old stock fluids should be used before starting a new batch.
3.4. Discard after single use even if some fluid remains in the container.

Amendment Date :16.08.2021 SAFE INJECTION AND INFUSION Issue Date:18.08.2021
PRACTICE
3.5. Do not reuse bottles that have been used previously.

3.6. Do not puncture bottles with needles to create airways.
3.7. If there are visible contaminants in the bottle, do not use the fluid. Send the bottle to the
Department of Microbiology for culture.
3.8. Inform pharmacy so that the particular batch of fluids can be withdrawn and inform the
Hospital Infection Control Officer.
4. REFERENCES :

ISOLATION CARE
1. ISOLATION:
1.1. CRITERIA FOR ISOLATION AND PROCEDURES:
1.1.1. To prevent –the transmission of pathogenic microorganisms within the hospital
1.1.2. To recognize - The importance of all body fluids, secretions and excretions in the
transmission of nosocomial pathogens
1.1.3. To practice - adequate precautions, to avoid infections transmitted by airborne droplet &
contact.
1.2. Measures for reduction of transmission:

1.2.1. HAND WASHING: Frequent hand washing is the most important measure.
2.1.4.1. Patient care Hand wash:
1.2.1.1.1. Wash hands after touching blood, body fluids, secretions, excretions and
contaminated items, whether gloves are worn or not. Wash hands immediately after
gloves are removed. Wash hands between tasks and procedures on the same patient
to prevent cross contamination of different body sites.
1.2.1.1.2. Use a plain soap for routine hand washing.
1.2.1.1.3. Use antiseptic soap or an alcohol based disinfectant followed by thorough hand
washing for accidental skin contamination.
1.2.1.1.4. Antimicrobial hand washing products should be used for hand washing before
personnel care for newborns and when otherwise indicated during their care,
between patients in high-risk units, and before personnel take care of severely
immune compromised patients.
2.1.4.2. Surgical Hand Wash
1.2.1.2.1. Procedural hand hygiene includes a full surgical scrub using running water and 4%
chlorhexidine scrub solution from the fingertips to the elbow. The scrub should be
performed for a minimum of 2 to 3 minutes.

ISOLATION CARE
1.2.1.2.2. GLOVES: Clean, unsterile gloves may be worn as a protective barrier during
procedures.
1.2.1.2.3. Sterile gloves are worn when sterile procedures are undertaken.
1.3. PERSONAL PROTECTIVE EQUIPMENT: (PPE)

1.3.1. Gowns: A clean, nonsterile, gown is worn to prevent contamination of clothing and skin
of personnel from exposure to blood and body fluids. When gowns are worn to attend to
a patient requiring barrier nursing, they are removed before leaving the patients
environment and hand washing is done.
1.3.2. Masks: This equipment is worn to provide barrier protection.
1.3.3. Mask should cover both the nose and the mouth.
1.4. PATIENT ISOLATION:

Patients are isolated when
1.4.1. Suffering from highly transmissible diseases e.g. chicken pox. Patient is placed in a
separate room.
1.4.2. Infected with epidemiologically important microorganisms such as MRSA, Imipenem
resistant Acinetobacter spp.
1.4.3. Viral Hepatitis, Tuberculosis, Infectious Diseases.
1.5. BARRIER NURSING:

1.5.1. The aim is to erect a barrier to the passage of infectious pathogenic organisms between the
contagious patient and other patients and staff in the hospital, and hence to the outside
world. Preferably, all contagious patients are isolated in separate rooms, but when such
patients must be nursed in a ward with others, screens are placed around the bed or beds
they occupy.
1.5.2. Cohort nursing may be practiced as re-infection with the same organism is unlikely.

ISOLATION CARE
1.5.3. The nurses, attending consultants as also any visitors must wear gowns, masks, and
sometimes rubber gloves and they observe strict rules that minimize the risk of passing on
infectious agents. Surgical standards of cleanliness in hand washing are observed after
they have been attending the patient.
1.5.4. Bedding is carefully moved in order to minimize the transmission of airborne particles,
such as dust or droplets that could carry contagious material.
1.5.5. Barrier nursing must be continued until subsequent cultures give a negative report.
2. CLEANING OF EQUIPMENT AND ARTICLES:

2.1. Contaminated disposable articles are bagged appropriately in leak proof bags and
disposed.
2.2. Critical reusable medical equipment is disinfected or sterilized after use.
2.3. Non-critical equipment is cleaned, disinfected after use.
2.1.1. LAUNDRY:
Soiled linen should be handled as little as possible and with minimum agitation to prevent
gross microbial contamination of the air and of persons handling the linen. All soiled linen
should be bagged or put into carts at the location where it was used; it should not be sorted
or pre-rinsed (1% sodium hypochlorite solution) in patient-care areas. Linen soiled with
blood or body fluids should be deposited and transported in bags (Yellow colour plastic
bag) that prevent leakage.
2.1.2. EATING UTENSILS:

Routine cleaning with detergent and hot water is sufficient.
2.1.3. TERMINAL CLEANING:
Terminal cleaning of walls, blinds, and curtains may be done. Disinfectant fogging is not
recommended.

ISOLATION CARE
2.1.4. CONCEPT OF STANDARD PRECAUTIONS:

They are a set of precautions designed to protect health care workers from exposure to
blood borne pathogens. Since the majority of patients infected with HIV/HBsAg/ HCV
are asymptomatic at the time of presentation all patients are approached as having
potentially infectious blood and body fluids. Precautions may vary based on anticipated
exposure.
2.1.4.1. Features of universal precautions:

2.1.4.1.1. Use of Personal protective equipment and gloves
2.1.4.1.2. Prevention of injury with sharps: Sharps injuries commonly occur during use of
needles and surgical instruments and after use during disposal.
Precautions to be observed:
2.1.4.1.2.1. Needles should not be recapped, bent or broken by hand.
2.1.4.1.2.2. Disposable needles & other sharps should be discarded into puncture resistant
containers
2.1.4.1.2.3. 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 can be
used to transport sharps.
2.1.4.1.2.4. All sharps containers to be discarded when 3/4th full.
2.1.4.1.3. Hand washing (as mentioned above).
3. PRECAUTIONS AGAINST BLOOD BORNE TRANSMISSION :

Instruction for wards:
3.1. ADMISSION:

ISOLATION CARE
Patients with HIV / HBV / HCV disease but presenting with unrelated illnesses may be
admitted in any ward as per existing rules. Confidentiality shall be maintained with
appropriate precautions to prevent nosocomial transmission.
3.2. PREPARATION OF PATIENTS :

3.2.1. It is the responsibility of the attending physician to ensure that patients, testing
positive are informed about the result and receive counseling.
3.2.2. The nursing staff will explain to patients, attendants and visitors (when necessary),
the purpose and methods of hand washing, body substance and excreta precautions,
and other relevant precautions.
3.3. SPECIMENS :
Adequate precautions are to be taken while collecting specimens. The specimens are to be
transported in leak-proof containers placed inside a leak-proof plastic cover. Ensure that
the cover and the outside of the container are not contaminated. Attach a ‘Biohazard’ label.
3.4. WASTE DISPOSAL :

3.4.1. A bin lined by a Red plastic bag is placed in the patient’s room for infectious waste.
When the bag is 3/4thfull it is sent for disposal.
3.4.2. Non-infectious waste does not require special precautions and is disposed in a manner
similar to non-infectious waste generated from any other patient.
3.5. DEATH OF A PATIENT :

Those cleaning the body should use gloves and other protective gear. Before leaving the
ward, the body is bagged as for any case.

ISOLATION CARE
4. PRECAUTIONS AGAINST AIRBORNE TRANSMISSION:

These precautions are designed to reduce the risk of airborne and droplet transmission of
infectious agents, and apply to patients known or suspected to be infected with
epidemiologically important pathogens that can be transmitted by these routes.
5.1. Components of respiratory isolation:

4.1.1. Place the patient in a single/private room with closed doors. Patients with same
illness (but no other infection) can be cohorted in one room.
4.1.2. Masks to be worn by those who enter the patient’s room. Susceptible persons should
not enter the room of patients known or suspected to have measles or varicella
(chicken pox).
4.1.3. Gowns are not routinely necessary. Use gowns if soiling is likely.
4.1.4. Gloves are necessary while handling patients.
4.1.5. Hand must be washed after touching the patient or potentially contaminated articles
and before taking care of another patient.
4.1.6. Articles contaminated with infective material must be discarded or bagged and
labeled before being sent for decontamination and reprocessing.
5. PRECAUTIONS AGAINST CONTACT TRANSMISSION:

Contact isolation precautions are recommended for specified patients known or suspected
to be infected or colonized with epidemiologically important microorganisms that can be
transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs
when performing patient – care) or indirect contact (touching) with contaminated
environmental surfaces or patient-care items.
5.1. Components:
5.1.1. Gowns are indicated if soiling is likely.

ISOLATION CARE
5.1.2. Gloves are indicated for touching infected material / area

5.1.3. Hands must be washed after touching the patient or potentially contaminated articles
and before taking care of another patient.
5.1.4. When possible, dedicate the use of non-critical patient – care equipment to a single
patient (or cohort of patients infected or colonized with the pathogen requiring
precautions) to avoid sharing between patients. If use of common equipment or
items is unavoidable, then adequately clean and disinfect them before use for another
patient.
5.1.5. Articles contaminated with infective material must be discarded or bagged and
labeled before being sent for decontamination and reprocessing.
6. ISOLATION ROOMS:
6.1. A private room is indicated for patients with infections that are highly infectious or are
caused by microorganisms that are likely to be virulent when transmitted.
6.2. When an infected patient shares a room with non-infected patients, patients and personnel
shall take measures to prevent the spread of infection. Personnel shall wear gloves and
wash hands when indicated and ensure that contaminated articles are discarded or returned
for decontamination and reprocessing.
6.2.1. Isolation policy for special groups of organisms:
Methicillin Resistant Staphylococcus aureus (MRSA):
The Microbiology department shall send an alert to the N.S. / D.N.S .head of the
concerned unit when report ascertains existence of MRSA. Measures will be
immediately ascertained by the Hospital Infection Control Committee for isolation
of MRSA.
6.2.2. Use respiratory (contact with mask) precautions:

6.2.2.1. Accommodate these patients away from those with open wounds or immuno-
compromised.

ISOLATION CARE
6.2.2.2. Handwashing is the single most important factor in controlling MRSA.
6.2.2.3. Linen – sheets, pillow cases, and blankets should be changed on a daily basis and
more often if soiling occurs. Linen should not be shaken in order to prevent
dissemination of micro-organisms into the environment. Linen should be
autoclaved before being sent to the laundry. The same will apply to masks, gowns
and gloves.
6.2.3. Pulmonary tuberculosis:

6.2.3.1. Respiratory precautions should be taken for smear positive tuberculosis patients.
6.2.3.2. A separate room is recommended only for adult patients with sputum positive
pulmonary tuberculosis.
7. REFERENCES :

SPILL MANAGEMENT
1. SPILL CLEAN UP:

1.1. Cover spills of blood or body fluids with gauze pad soaked with 1% of freshly prepared
sodium hypochlorite for 30 minutes. Then mop dry. A second decontamination may be
done if required. Wash the area with detergent and water. Gloves must be worn during
cleanup and decontamination procedures.
1.2. Record the incident in the register kept in the floor & report to DNS incharge.
1.3. No environmentally mediated transmission of HIV has been documented to date.
2. Principles of spill management:
2.1. Blood and body fluid spillage should be dealt with immediately or as soon as it is safe
to do so.
2.2. Other persons should be kept away from the spillage until the area has been cleaned
and dried.
2.3. Care should be taken if there are sharps present and should first be disposed of
appropriately into sharps container.
2.4. Spills should be removed before the area is cleaned.
2.5. Area should be well ventilated if using chlorinating agents.
2.6. Avoid adding liquid to the spills as it increases the size.
2.7. 10% hypo chlorate is generally recommended on small spill.
2.8. Hypo chlorate is not recommended for using on soft furnishings.
2.9. Spill management kit is provided in all clinical area. Consists of PPE, paper towels,
yellow waste bag, scoop & scraper, detergent, bleach, rough cloth, two cardboard
piece, sharp container, item list, instruction chart.
2.10. If non-disposable cloths / mops are used they must be thermally or chemically
disinfected.

SPILL MANAGEMENT
3. Management of blood & body fluid spillage:
Select appropriate
PPE
wipe up spot immediately with a

damp cloth, tissue or paper towel
Spot
Discard contaminated
materials in hypochlorate
Perform hand Select appropriate

hygiene PPE
Spills
Wipe immediately
with absorbant
material
Place contaminated
material in disposal bag
Small upto 10cm
Large spills
Next diagram Wipe the area with 10%sodium
>10cm
hypochlorite and allow to dry
Perform hand hygiene


SPILL MANAGEMENT
4. Large Spill Management:
Blood & blood stained Sputum/pus/ faeces/

fluids vomitus/ urine
Prepare all items required to Is visible blood

manage spill. Don PPE present.
Place disposable paper towels YES

over spill to absorb and
contain it. • Manage as of Blood
Apply 10% sodium

hypochlorite and leave for 20 NO
minutes.
• remove paper towels
• wash with etergent &
water, rinse & dry
Discard all into Yellow bag
Ensure nondisposable items are cleaned and stored appropriately

Perform hand hygiene. Replace all discarded items.
5. REFERENCES :

CARE FOR DEVICES
1. CARE OF SYSTEMS AND INDWELLING DEVICES:

General guidelines to be followed for all procedures:
1.1. Hand washing is mandatory before, after and in-between procedures and patients.
1.2. Each health care worker has to ensure the personal protection (Universal precautions)
required for each procedure. These precautions should be strictly adhered to.
1.3. Follow proper waste segregation & disposal after each procedure.
2. VASCULAR CARE:
2.1. Hand washing
Wash hands before every attempted intravascular catheter insertion. Antimicrobial
handwashing soaps are desirable, and are preferred before attempted insertions of central
intravenous catheters, catheters requiring cut downs, and arterial catheters.
2.2. Preparation of skin

Povidone-iodine (PVP) or 70% alcohol may be used for cleaning the skin. Insertion sites
should be scrubbed with a generous amount of antiseptic. Start at the center 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.
2.3. Applying dressings

Sterile dressings should be applied to cover catheter insertion sites. Unsterile adhesive
tape should not be placed in direct contact with the catheter-skin interface.
2.4. 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

CARE FOR DEVICES
of catheter related complications. Inspect for signs of infection (redness, swelling,

drainage, tenderness) or phlebitis and also palpate gently through intact dressings.
2.5. Manipulation of intravascular catheter systems

Strict aseptic technique should be maintained when manipulating intravascular catheter
systems. Examples of such manipulations include the following:
2.5.1. Placing a heparin lock
2.5.2. Starting and stopping an infusion
2.5.3. Changing an intravascular catheter site dressing
2.5.4. Changing an intravascular administration set
2.6. Flushing IV lines
Solutions used for flushing IV lines should not contain glucose which can support the
growth of microorganisms. One syringe is used for flushing only one IV line once. Do
not reuse syringes used for flushing.
2.7. Peripheral IV sites (short term catheters):

2.7.1. Dressing changes:
Peripheral IV site dressings should not usually require routine changes, since peripheral
IV catheters, should be removed within 72 hours.
2.7.2. Replacement of Peripheral IV Catheters

Peripheral IV catheters should be removed 72 hours after insertion, provided no IV-
related complications, requiring catheter removal are encountered earlier. A new
peripheral IV catheter, if required, may be inserted at a new site.
2.8. Central intravascular catheters (long term catheters):

2.8.1. Dressing changes:
Central IV catheter dressings should be changed every 72 hours.
2.8.2. Replacement of central IV catheters:


CARE FOR DEVICES
Central IV catheters do not require routine removal and reinsertion. The catheter can
be kept for a maximum of 3 months, provided there is no sign of catheter related
infection or other complications.
2.8.3. 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 ointment or blood present on the skin around the catheter is first removed
with alcohol. The catheter is withdrawn with sterile forceps, the externalized portion
being kept directed upward and away from the skin surface. (If 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, (20.3 cm
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.
3. REFERENCES :

RESPIRATORY CARE
1. 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 pneumonia in ventilated patients.

Frequent chlorhexidine mouthwashes minimize the chances of pneumonia.
1.1. Ventilator:
1.1.1. Sterile water is to be used in nebulizers and humidifiers. This should be replaced once
or twice a day.
1.1.2. Pneumatic circuits (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.
1.1.3. 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.
1.1.4. Oxygen masks, venture devices and nebulizer chambers are cleaned carefully and then
sterilized.
1.1.5. Humidifier domes are sterilized. Ambu bags are cleaned thoroughly and are then sent
for Sterilization.
1.2. Tracheostomy Care / Endotracheal Tube:

1.2.1. Careful attention to post-operative wound care is mandatory.
1.2.2. The patient should receive aerosol therapy to prevent dessication of the tracheal and
bronchial mucosa or the formation of crusts. The skin around the tracheostomy tube

RESPIRATORY CARE
should be cleaned with betadine (Povidone-iodine 5%) every four hours or more
frequently, if necessary.
1.2.3. In case of metal tracheostomy tubes, the inner cannula should be cleaned every four
hours and more often if necessary to prevent the formation of crusts. The inner cannula
is cleaned with water, immersed in hydrogen peroxide for 15 minutes and then rinsed
with fresh & sterile normal saline. The plastic tracheostomy tubes are removed, another
plastic tube is inserted, and the tube is cleaned, with hydrogen peroxide, and rinsed well
before reuse.
1.2.4. The tracheostomy tape securing the tube should be changed every 24 hours. This tape
must be tied securely at all times.
1.2.5. The first complete tube change should be performed no earlier than 4-5 days to allow
time for the tract to be formed. Subsequent changes should be done weekly or as
necessary.
1.2.6. Clean technique should be used to change the tracheostomy tube unless there is a
medical indication for sterile technique.
1.2.7. The obturator should be at the bedside (preferably taped to the head of the bed) to be
used if the tracheostomy tube accidently is dislodged or is removed for any reason.
1.3. Suctioning of endotracheal / tracheostomy tube:

Nursing staff shall 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.
1.4. Sterile Suctioning:

1.4.1. Wash your hands.
1.4.2. Use a catheter with a blunt tip.


RESPIRATORY CARE
1.4.3. The wall suction should be set no higher than 120 mm Hg for adults and between 60
and 80 mm Hg for children.
1.4.4. Attach the suction catheter to the suction tubing; do not touch the catheter with bare
hands (leave it in its protective covering).
1.4.5. Put on sterile gloves. The wearing of a mask is also strongly recommended.
1.4.6. However, if saline does need to be instilled, '1/2 cc of sterile saline is put into the
tracheostomy tube on inspiration only.
1.4.7. 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.
1.4.8. Insert the catheter gently through the inner cannula until resistance is met. Do not apply
suction during insertion.
1.4.9. Withdraw the catheter approximately 1 cm and institute suctioning.
1.4.10. Carefully withdraw the catheter, rotating it gently between the thumb and forefinger
applying intermittent suctioning.
1.4.11. Continuous suctioning for longer than 10 seconds may create an unacceptable level of
hypoxia.
1.4.12. The patient should be given time to rest between suctioning episodes. If possible, this
time should be from two to three minutes. If the patient is receiving oxygen or
ventilatory support, reapply the oxygen or ventilator for at least two minutes before re-
suctioning.
1.4.13. Observe for unfavourable reactions such as increased heart rate, hypoxia, arrhythmia,
hypotension,cardiac arrest, etc.

RESPIRATORY CARE
1.4.14. If oral suctioning is necessary, it should be done after the tracheostomy is suctioned.
1.4.15. When suctioning is completed, clear the catheter and tubing of mucous and debris with
sterile water or saline.
1.4.16. Discard the catheter, water container, and gloves appropriately.
1.4.17. Wash hands.
1.4.18. 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 should be
secured between suctioning periods so that it will not fall to the bed, floor, etc.
2. URINARY CATHETER:
2.1. Personnel:
Only persons who know the correct technique of aseptic insertion and maintenance of
catheters should handle catheters.
2.2. Catheter Use:

Urinary catheters should be inserted only when necessary and left in place only as long
as medically necessary.
2.3. Hand washing:

Hand washing should be done immediately before and after any manipulation of the
catheter site or apparatus.
2.4. Catheter Insertion:

2.4.1. Catheters should be inserted using aseptic technique and sterile equipment.
2.4.2. Use an appropriate antiseptic solution for periurethral cleaning.
2.4.3. As small a catheter as possible, consistent with good drainage, should be used to
minimize urethral trauma.

RESPIRATORY CARE
2.4.4. Indwelling catheters should be properly secured after insertion to prevent movement
and urethral traction.
2.5. Anchoring the catheter:
Strapping of the catheter is done to the lower anterior abdominal wall 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.
3. WOUND CARE (Surgical wounds):

3.1. Surgical wounds after an elective surgery are inspected on the third post-operative day,
or earlier if wound infection is suspected.
3.2. 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.
3.3. If two health care workers are not available, then, take off the dressing, wash hands again
before applying a new dressing.
3.4. A clean, dry wound may be left open without any dressing after inspection.
3.5. 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.
4. FOLLOW UP OF SSI SURVEILLANCE:
Surgical site infections are captured by follow up of patients who undergo a set of
surgeries. HICC receives a list of surgeries being followed up for SSIs daily. The patients
are pre counseled and their contact numbers are noted down. These patients are then

RESPIRATORY CARE
contacted over phone at regular intervals after discharge (once in 15 days for 30 days
follow up surgery and every month for 90 days follow up surgeries)
The patients are questioned to ascertain SSI. If any patient is not reachable telephonically
for more than 3 times on repeated contact, we exclude them for calculation.
Points noted are:
4.1. Surgery history
4.2. Purulent discharge from incision site
4.3. Positive culture report if any
4.4. Abscess at surgical site involving deeper tissue
4.5. Surgeon’s diagnosis as SSI
30 days follow up surgeries 90 days follow up surgeries

Elective LSCS Cardiac surgery
Abdominal hysterectomy Open reduction of fracture
Vaginal hysterectomy Knee / Hip prosthesis
Ovarian surgery
Thyroid & Parathyroid surgery
Appendix surgery
Shunt for dialysis
Gall bladder surgery
Colon surgery
Limb amputation

RESPIRATORY CARE
Prostate surgery
Exploratory laparotomy
Herniorrhaphy
5. REFERENCES :

DISINFECTION POLICY
1. DISINFECTION AND STERILISATION:

1.1. DISINFECTION:
Disinfection is a process where most microbes are removed from defined object or
surface, expect bacterial endospores.
1.1.1 Disinfectants can be classified according to their ability to destroy different categories
of microorganisms
1.1..1.1 High Level disinfectants: glutaraldehyde2%, ethylene oxide.
1.1..1.2 Intermediate Level disinfectant: alcohols, chlorine compounds, hydrogen
peroxide,chlorhexidene, glutaraldehyde(short term exposure)
1.1..1.3 Low level disinfectants:benzalkonium chloride, some soaps.
1.1.2 Levels of action of disinfectants:
Bacteria
Lipid viruses low
Fungi
Non lipid viruses
Mycobacteria intermediate
Spores high
1.2. GENERAL GUIDELINES FOR DISINFECTION:

Critical instruments /equipments (that are those penetrating skin or mucous membrane)
should undergo sterilization before and after use. e.g. surgical instruments and implants
Semi-critical instruments /equipments (that are those in contact with intact mucous
membrane without penetration) should undergo high level disinfection before use and
intermediate level disinfection after use. e.g endotracheal tubes

DISINFECTION POLICY
Non-critical instruments /equipment’s (that are those in contact with intact skin and no
contact with mucous membrane) require only intermediate or low level disinfection
before and after use. e.g. ECG electrodes.
1.2.1. Disinfectants:
1.2.1.1. Glutaraldehyde:
Rapid acting -can be used up to 14 days after activation
Long acting - can be used up to 28 days after activating
Contact time - for disinfection 15-30 minutes
- for sterilization 8-10 hours
1.2.1.2. Sterilium :
Contains 2-propanol,1-propanol,macetronium ethyl sulfate
Contact time for patient care hand wash: 1.5ml for 30 secs.
Contact time for surgical hand wash: 9 ml for 3minutes
1.2.1.3. Ecosan:
Contains Natural polymer of glucosamine 120mg/ ml, Benzalkonium chloride
65mg/ml, Lactic acid natural perfume oil 0.10mg/ml
For surface disinfection: 10% v/v solution in de-ionized water with contact time
of 60 minutes.
For fumigation: 1 litre of 20% v/v solution /1000 cu ft of space in 60 min.
1.2.1.4. Bodedex:
For cleaning of heat-sensitive and heat-resistant instruments
30 ml in 1 litre of water – contact time 30 mts
1.2.1.5. Bacillocid:
Contains chemically bound formaldehyde, glutaraldehyde and benzalkonium
chloride.

DISINFECTION POLICY
Used as surface disinfectant at 2% solution in operation theatres and at 0.5% in

wards and dressing rooms.
Can be sprayed onto wet surfaces with a low pressure sprayer and allowed to
dry slowly.
1.2.1.6. Betadine:
Iodophor. This is a high level disinfectant. Used for surgical hand scrub, skin
disinfection.
1.2.1.7. Sodium Hypochlorite 10% stock:
Used for containing blood spills, disinfecting counter tops and other hard
surfaces at 1 %.
Used in laboratory for decontamination of waste from equipment as well as
glassware at 5%.
1.2.1.8. Alcohol -70% :

Used for disinfection of non-disposable patient care items in outpatient
departments and also in laboratory for cleaning of microscope lenses and
surfaces of critical work surfaces.
1.2.1.9. Alcohol -99%:
Used for preparation of cotton swabs in phlebotomy cell etc.
1.2.1.10. 5% Lysol:
Mopping floor - 100ml in 1 liter water
1.2.2. Endoscopes - cleaning and disinfection
1.2.2.1. Mechanical cleaning: This is the most important step. Flush the air/water channel for
10-15 seconds to eject any blood or mucus. Aspirate detergent through the
biopsy/suction channel to remove gross debris. Use a cleaning brush suitable for the
instrument and channel size to brush through the suction channel.

DISINFECTION POLICY
1.2.2.2. Disinfection: The endoscope and all internal channels should be soaked in 2%
glutaraldehyde for 20 minutes.
1.2.2.3. Rinsing: Following disinfection, rinse the instrument internally and externally to
remove all traces of disinfectant.
1.2.2.4. Drying: Dry the endoscope externally. Flush air through each channel.
1.3. STERILIZATION:
Sterilization is defined as a process where all microbes are removed from a defined
object, inclusive of bacterial endospores.
1.3.1. STEAM:
1.3.1.1. Autoclaves (gravity displacement) are used in CSSD for instruments, certain plastics
linen gauze and other items. Flash sterilization is used for OT in emergency situations.
1.3.1.2. Decontamination autoclave is available separately for laboratory glassware.
1.3.2. ALDEHYDE:
1.3.2.1. Glutaraldehyde may be used in places like the endoscopy unit, cardiac catheterization
labs.
1.3.2.2. For steam and gas methods, chemical as well as microbiological indicators are used
to check the effectiveness of sterilization.
1.3.2.3. Microbiological indicators are used once a week: namely spores of Bacillus
stearothermophilus for steam sterilizers and Bacillus subtilis for ethylene oxide. Vials
are removed from sterilizers and sent to microbiology laboratory where they are
incubated at relevant temperatures for 48 hours. Report is sent to CSSD.
1.3.2.4. An expiry date is given for sterile articles based on the packing material used.
1.3.3. FUMIGATION:
1.3.3.1. Eco-shield is used for fumigation using Fog spraying machine.
1.3.3.2. For details see above

DISINFECTION POLICY
1.3.3.3. Operation theatres are fumigated once a week and if necessary such as in case of a
septic wound being drained.
1.3.3.4. Other patient care areas are not regularly fumigated and not recommended.
1.3.3.5. Decision as to necessity is taken by in charge of concerned patient care area.
2. Disinfection Policy:
Spaulding classification scheme is logical to be retained and successfully used to control

infection in hospitals.
2.1. Spaulding classification of medical devices
Medical Device Definition Examples Recommended

sterilization /
disinfection method
2.1.1. Critical device Enter a normally Surgical Heat based
sterile site instruments, cardiac sterilization,
and urinary Chemical sterilant or
catheters, implants, High-level
eye & dental disinfectant
instruments
2.1.2. Semi-critical Comes in contact Respiratory therapy High-level
device with the mucus equipment, disinfectant
membranes or anesthesia
minor skin breaches equipment,
endoscopes
laryngoscope,
rectal/ vaginal/
esophageal probes
2.1.3. Non-critical Comes in contact BP cuff, ECG Intermediate-level
device with intact skin electrodes, disinfectant or low
stethoscope, level disinfectant
thermometer, bed
pan, crutches
2.1.4. Non-critical Less direct contact Surfaces of medical Low-level
environmental with patient equipment, disinfectant
surfaces

DISINFECTION POLICY
examination table,
computers
Sterilization of equipment’s are mostly carried out in CSSD.

Disinfectant products used in Sri Manakula Vinayagar Medical College and Hospital.
1. Cidex (Glutaraldehyde 2%)
2. Formaldehyde solution
3. Ecoshield (5%)
4. Bodedex forte
5. Sodium hypochlorite solution
6. Lysol
7. Taski cleaning agent
2.2. Disinfection procedure for individual items or equipment’s
Items Procedure Comments

2.2.1. Airways Clean with soap, water &
gas (ETO)sterilization
(CSSD) or use disposable
2.2.2. Ampoules / vials Wipe neck or rubber top Do not immerse ampoules
with 70% isoprophyl / vials in disinfectant
alcohol and allow drying solution.
before opening or piercing.
2.2.3. Auroscope Use single- use disposable Chemical method is used
tips. only when other methods
If reusable tips are used then are unavailable.
send to CSSD for
sterilization.
2.2.4. Oxygen – masks Clean with soap & water.
Send to ETO sterilization.
2.2.5. Ambu bag Should be cleaned with
detergent & water, dried &
sterilized (ETO)
2.2.6. Arterial catheters Sterile, single use only Must be discarded after
use.
2.2.7. Baby equipment Not recommended
feeding bottles &
teats Autoclaving.

DISINFECTION POLICY
2.2.8. PALADAI to be used

for baby feeding
2.2.9. Baby weighing scales Clean tray as necessary with If contaminated should
2.2.10. A fresh liner should detergent & water wiped with 1%
be used hypochlorite after
2.2.11. (or) baby towel for washing.
each baby
2.2.12. Baths/showers/shower Not recommended
chairs
2.2.13. Baby bath Separate basins for each
baby.
2.2.14. Beds and couches Refer housekeeping section If contaminated with body
frame or sofa fluids, the blood spills
management policy
should be implemented.
If used in isolation room,
after cleaning should
wiped with a disinfectant.
(1% hypochlorite)
2.2.15. Bowls (surgical) Primary wash and return to

CSSD.
2.2.16. Bowls (washing) Wash with detergent &
water. Decontaminate with
1% hypochlorite solution,
rinse & dry after each use.
Store inverted & separated.
2.2.17. Mattresses and Refer housekeeping section If contaminated with body
pillows should be fluids, the blood spills
covered with rexine management policy
sheet every 6 months should be implemented.
check for durability Should not be used if
cover is damaged.
Contaminated pillows
must be discarded in
yellow bin.
Torn mattress covers must
be replaced before reuse.

DISINFECTION POLICY
2.2.18. Bedpans and urinals Refer housekeeping section Bedpan holders & storage
racks must be cleaned
with detergent on daily
basis.
2.2.19. Buckets Refer housekeeping section
2.2.20. Breast pumps For single patient use. Heat sterilize before use
Should be washed with by subsequent patients.
detergent & water,
immersed in hypochlorite
solution X 30 minute.
(Follow manufacture’s
instruction)
2.2.21. Brushes (Toilet) Refer housekeeping section
2.2.22. Cardiac and urinary Use sterile single-use
catheters, IV devices disposable item only.
and other invasive
devices.
2.2.23. Cardiac monitors, Clean & disinfect ECG
defibrillators and leads & machine with 70%
ECG equipment alcohol.
2.2.24. Cheatle forceps Do not use.
If used autoclave daily and
store in sterile container.
Use separate dressing packs
for dressing.
2.2.25. Cleaning equipment Refer housekeeping section
2.2.26. Couches Refer housekeeping section
(examination)
2.2.27. Cots Refer housekeeping section
2.2.28. Cradles Refer housekeeping section
2.2.29. Curtains Refer housekeeping section
2.2.30. Curtains (between Refer housekeeping section
patients)
2.2.31. Drainage bottles Disposable – single use Wash with detergent
Reusable – rinse & return to &water; put the jars in the
CSSD disinfectant solution for
30 minutes. Rinse & store
dry or send to CSSD.
Weekly autoclaving is
highly recommended.

DISINFECTION POLICY
2.2.32. Drip stands, Urobag Refer housekeeping section

stands
2.2.33. Ear piece for Should be cleaned with CSSD after use in
auroscope and after detergent & water. Kept isolation.
use in isolation dried.
2.2.34. Endoscopes – Refer endoscopy treatment
Invasive policy
2.2.35. Endoscopes – Refer endoscopy treatment
Noninvasive policy
2.2.36. Endotracheal tubes Single use only
2.2.37. Eye protection Should be cleaned with For blood splashes blood
detergent & water. Kept spillage policy should be
dried. followed.
2.2.38. Fixtures, fittings and Refer housekeeping section
ledges
2.2.39. Floors Refer housekeeping section For blood splashes blood
spillage policy should be
followed.
2.2.40. Furniture Refer housekeeping section
2.2.41. Haemodialysis Thoroughly clean between
machines patients & disinfect at the
end of the day as per
manufacture’s
recommendations.
2.2.42. Hoist / sling Refer housekeeping section
2.2.43. Humidifiers Should be cleaned and Drain daily, clean with
sterilized at low temperature detergent and water.
(ETO) Refill with sterile water &
label
Not in use should be
cleaned and kept dry.
2.2.44. Infant incubators Should be cleaned with Terminal sterilization with
detergent and water and ethylene oxide gas may be
switch on to dry. required after some
Daily: routinely wash with infections.
detergent and dry with When baby is discharged,
disposable wipe. dismantle and wash,
Colonized / infected patient: disinfect as per
after cleaning wipe with recommendation of
manufacturer’s.

DISINFECTION POLICY
70% isopropyl alcohol / The cleaning &

hypochlorite solution. disinfection should be
done in separate area.
2.2.45. Intravenous Should be cleaned with After use in isolation wipe
monitoring pumps detergent and water and with 2% hypochlorite and
and feed pumps dried. dry after cleaning.
2.2.46. Instruments After single use to be
returned to CSSD.
2.2.47. Linen Refer laundry section
2.2.48. Laryngoscope Decontaminate with 0.5% Blub of the laryngoscope
hypochlorite solution if should be removed and
blood stained. cleaning with sprit swab.
Clean with detergent and
water and HLD is done with
2% glutaraldehyde.
2.2.49. Locker tops Damp dust daily with Colonized / infected
detergent solution and allow patient: after cleaning
to dry. disinfect with
hypochlorite solution and
allow drying.
2.2.50. Medicine trays / To be cleaned with If spillages, ensure and
trolleys detergent and water - cleaned promptly as per
weekly spillage policy.
2.2.51. Peak flow Disposable – single patient
use.
2.2.52. Proctoscope Disposable – single use Reusable to be rinsed and
returned to CSSD.
2.2.53. Nebulizers Cleaning and low Send for cleaning and
temperature sterilization reprocessing to CSSD.
(ETO) between patients.
Fill with sterile water only.
2.2.54. Nebulizer tubing Wash with detergent and
water and send to CSSD
(ETO)
2.2.55. Pressure relieving Should be cleaned with
device detergent and water and
dried.
2.2.56. Razors (hair removal NOT RECOMMENDED
for OT preparation) Clippers can be used
2.2.57. Rooms Refer housekeeping section

DISINFECTION POLICY
2.2.58. Scissors Surface disinfect with

alcohol wipe before use.
If visibly soiled clean first
with detergent solution.
For sterile use - HLD
2.2.59. Shaving brush Should not be used unless
supplied by the patient for
their own use.
Rinse under running water
and stored dry.
2.2.60. Skin disinfection Showers are preferred to
bath or bed bath.
2.2.61. Soap dispensers Should be cleaned weekly
with detergent and dried.
2.2.62. Sphygmo-manometer Use dedicated items in high- After use in isolation
cuffs risk areas. Wash sleeve with should be laundered in
soap and water once a week. washing machine.
Disinfect tubing and
inflation bladder with
alcohol wipes.
2.2.63. Spillage Refer to spill management
policy
2.2.64. Splints & walking Wash and clean with
frames detergent and allow to dry.
2.2.65. Sputum pots Disposable with close fitting Pre-treat with 15 ml
lids. hypochlorite then toilet
Should be discarded into flush.
yellow bin for incineration.
2.2.66. Stethoscopes Surface disinfect with 70%
alcohol impregnated wipe
between patients.
Use dedicated stethoscope
in high risk area.
2.2.67. Suction bottles Disposable liners. Must be Wherever applicable at
sealed when 75% full and least weekly autoclaving
placed in yellow bag. should be done.
Reusable should be cleaned 1/10 volume of the jar
with 1% sodium should be filled with 1%
hypochlorite and dried. sodium hypochlorite
solution.

DISINFECTION POLICY
Must be changed daily and After use, add equal

in between each patient. To quantity of hypochlorite
be stored dry when not in for disinfection at source
use. before discarding the
content.
2.2.68. Surgical instruments Transport safely in a closed
rigid container to CSSD for
sterilization.
Clean manually or use
thermal washer – disinfector
and then steam sterilize the
instruments in CSSD.
2.2.69. Thermometers Oral: Single-patient use
thermometers must be
dedicated for infection
patients and patients in
high-risk areas.
They should be cleaned
&wiped with 70% isopropyl
after each use & stored dry.
On discharge of patient,
wash both thermometer &
holder with detergent,
immerse in 70%alcohol for
10 min. Wipe & store dry.
Communal thermometers:
Wipe clean, wash with cold
neutral detergent, dry &
immerse in 70% alcohol for
10 min. Wipe & store dry.
Rectal: Clean & wash in
detergent solution after each
use, wipe dry & immerse in
70% alcohol for 10min.
Wipe & store dry.
Electronic: Where possible
use a single-use sleeve. If
possible, use either single-

DISINFECTION POLICY
use thermometer or clean &

disinfect between uses.
Do not use without sleeve
on patients with an
infectious disease.
Single-use sleeve, single-
patient use in high-risk
areas or infected patient.
Clean, wipe with alcohol
impregnated wipes after
each use.
Tympanic: Single-use
sleeve
2.2.70. Telephones To be wiped with 70%

alcohol
2.2.71. Toilet seats Refer housekeeping section
2.2.72. Toys Avoid use of soft toys. For children with
Hard toys: wash with infectious diseases do not
detergent and disinfect with use communal toys or
alcohol impregnated wipes / those which cannot be
hypochlorite solution. easily disinfected.
2.2.73. Trolleys (Dressing) Clean and wipe trolley top

with 70% alcohol
impregnated wipe before
use.
If contaminated, clean with
detergent and disinfect with
and dry.
2.2.74. Ultrasound machine Damp dust with detergent Disinfection based on

solution & allow surface to manufacture’s
dry before use. recommendation.
2.2.75. Vaginal speculum After use immerse in hypo

for 20 minutes and send to
CSSD for sterilization.
Use – single use

DISINFECTION POLICY
2.2.76. Ventilator & Use single use Never use gluteraldehyde

breathing circuits Heat disinfect/sterilize in to disinfect respiratory
CSSD. equipment.
2.2.77. Ventilators After every patient, clean & After removing of

disinfect ventilators. ventilator tubes wash it
Dismantle and with detergent & water
disinfect/sterilize as per and send for CSSD for
manufacture’s autoclaving.
recommendation.
Daily cleaning and
disinfection of tubing must
be done.
After 72 hrs of use
autoclaving should be done
forautoclavabletubings.
Humidifier water must be
changed atleast every 8 hrs.
Daily autoclaving of
humidifier is recommended
where autoclavable.
2.2.78. Vomit bowls Contents must be emptied

into sluice then rinsed,
washed & disinfected with
hot water and detergent.
Stored dried.
2.2.79. Walls Refer housekeeping section

2.2.80. Wash bowls Dedicated bowl.
After use cleaned with
detergent
2.2.81. Wheel chairs Clean with detergent and
water, rinse and dry.
2.2.82. Medicine Trolley Wash at least weekly with Ensure spillages are
hot soapy water cleaned properly

DISINFECTION POLICY
3. REFERENCES :

HOUSEKEEPING
1. HOUSE KEEPING:
1.1. House Keeping in Wards:
A patient admitted to the hospital can develop infection due to bacteria that survive in
the environment. Therefore, it is important to clean the environment thoroughly on a
regular basis. This will reduce the bacterial load and make the environment unsuitable
for growth of micro-organisms.
1.1.1. The floor is to be cleaned at least twice a day. Detergent and copious amounts of water
should be used during one cleaning. ECOSAN may be used to mop the floor for the
remaining times.
1.1.2. The walls are to be washed with a brush, using detergent and water once a week
1.1.3. High dusting is to be done with a wet mop
1.1.4. Fans and lights are cleaned with soap and water once a month.
1.1.5. All work surfaces are to be disinfected by wiping with ECOSAN and then cleaned with
detergent and water twice a day.
1.1.6. Cupboards, shelves, beds, lockers, IV stands, stools and other fixtures are to be cleaned
with detergent and water once a week.
1.1.7. Curtains are to be changed once a month or whenever soiled. These curtains are to be
sent for regular laundering. In certain areas, eg. Transplant units and ICUs, more
frequent changes are required.
1.1.8. Patient’s cot is to be cleaned every week with detergent and water. 1% hypochlorite to
be used when soiled with blood or body fluids. In the isolation ward, cleaning is done
daily.
1.1.9. Store rooms are to be mopped once a day and high dusted once a week.

HOUSEKEEPING
1.1.10. The floor of bathrooms is to be cleaned with a broom and detergent once a day and then
disinfected.
1.1.11. Toilets are cleaned with a brush using a detergent twice a day (in the morning and
evening). Disinfection and stain removal solution may be used.
1.1.12. Wash basins are to be cleaned every morning
1.1.13. Regular AC maintenance is required. The AC section should draw up a protocol for
this.
1.2. Patient linen:

1.2.1. Bed linen is to be changed daily and whenever soiled with blood or body fluids.
1.2.2. Dry dirty linen is to be sent to the laundry for regular wash.
1.2.3. Linen soiled with blood or body fluids, and all linen used by patients diagnosed to have
HIV, HBV, HCV and MRSA, is to be decontaminated by autoclaving before being sent
to the laundry.
1.2.4. The hospital does not provide any patient gown (except for patient prepared for surgery)
however patient and their relatives are encouraged to change the patients clothes every
day.
1.3. Miscellaneous items:
Kidney basins, basins, bed pans, urinals, etc to be cleaned with detergent and water and
disinfected with 7% Lysol.
1.4. Housekeeping in the operation theatre

1.4.1. Theatre complex should be absolutely clean. Dust should not accumulate at any area of
the theatre.
1.4.2. Soap solution is recommended for cleaning floors and other surfaces. Operating rooms
are cleaned daily and the entire theatre complex is cleaned thoroughly once a week.
1.4.3. Before the start of the 1st case

HOUSEKEEPING
1.4.4. Wipe all equipment, furniture, room lights, suction points, OT table, surgical light
reflectors, other light fittings, slabs etc with soap solution. This should be completed at
least one hour before the start of surgery.
1.4.4.1 Linen & gloves:

Gather all soiled linen and towels in the receptacles provided. Take them to the service
corridor (behind the theatre) and place them in trolleys to be taken for sorting. The dirty
linen is then sent to the laundry. Use gloves while handling dirty linen.
1.4.4.2 Instruments:
Used instruments are cleaned immediately by the scrub nurse and the 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.
They are then sent for sterilization in the CSSD. After septic cases the instruments are
sent in the instrument tray for autoclaving. Once disinfected, they are taken back to the
same instrument cleaning area for a manual wash described earlier. They are then
packed and re-autoclaved before use.
1.4.4.3 Environment:
1.4.4.3.1 Wipe used equipment, furniture, OR table etc., with detergent and water. If there is
a blood spill, disinfect with sodium hypochlorite before wiping.
1.4.4.3.2 Empty and clean suction bottles and tubing with disinfectant.
1.4.4.4 After the last case:
The same procedures as mentioned above are followed and in addition the following
are carried out.
1.4.4.4.1 Wipe over head lights, cabinets, waste receptables, equipment, furniture with
ECOSAN.

HOUSEKEEPING
1.4.4.4.2 Wash floor and wet mop with liquid soap and then remove water and wet mop
with Bacilli floor solution. Clean the storage shelves scrub & clean sluice room.
1.4.4.5 Weekly cleaning procedure:
1.4.4.5.1 Remove all portable equipment.
1.4.4.5.2 Damp wipe lights and other fixtures with detergent.
1.4.4.5.3 Clean doors, hinges, facings, glass inserts and rinse with a cloth moistened with
detergent.
1.4.4.5.4 Wipe down walls with clean cloth mop with detergent.
1.4.4.5.5 Scrub floor using detergent and water or Bacillo-floor.
1.4.4.5.6 Stainless steel surfaces – clean with detergent, rinse & clean with warm water.
1.4.4.5.7 Replace portable equipment: Clean wheel castors by rolling across toweling
saturated with detergent.
1.4.4.5.8 Wash (clean) and dry all furniture and equipment (OT table, suction holders, foot &
sitting stools, Mayo stands, IV poles, basin stands, X-ray view boxes, hamper stands,
all tables in the room, holes to oxygen tank, kick buckets and holder, and wall
cupboards)
1.4.4.5.9 After washing floors, allow disinfectant solution to remain on the floor for 5 minutes
to ensure destruction of bacteria (Bacillofloor).
1.4.4.6 Maintenance and Repairs:

1.4.4.6.1 Machinery and equipment should be checked, cleaned and repaired routinely
1.4.4.6.2 Urgent repairs should be carried out at the end of the days list
1.4.4.6.3 Air conditioners and suction points should be checked, cleaned and repaired on a
weekly basis.

HOUSEKEEPING
1.4.4.6.4 Preventive maintenance on all theatre equipment to be carried out weekly and major
work to be done at least once every year.
2. HOUSEKEEPING IN WARDS.
A patient admitted in hospital can get infected by microorganisms in the environment.
Hence, it is essential to clean the environment thoroughly on a regular basis, to reduce
the microbial load.
ITEMS VERY HIGH RISK MODERATE LOW RISK METHOD
HIGH RISK AREA RISK AREA AREA
AREA
2.1. Bed Clean frame Clean frame Clean frame N/A Detergent
daily daily daily Detergent +
Clean Clean Clean disinfectant
underneath underneath underneath for MDRO
weekly weekly weekly
Clean whole Clean whole Clean whole
on discharge on discharge on discharge
2.2. Bed Clean twice Clean twice Clean twice Clean Detergent
rails daily & after daily & after daily & after weekly & Detergent +
discharge discharge discharge after disinfectant
discharge for MDRO
2.3. Beside Clean twice Clean daily Clean daily Clean Detergent
table daily & after & after use weekly Detergent +
use disinfectant
for MDRO
2.4. Catheter Clean daily Clean daily Clean before Clean before Detergent
stand / & after use & after use initial use, initial use, and
bracket after use & after use & disinfectant
monthly monthly
2.5. Ceiling Spot clean Spot clean Spot clean Spot clean Detergent
/ High and damp
dusting cloth
Monthly Monthly Monthly Monthly

HOUSEKEEPING
2.6. Chair Clean twice Clean twice Clean daily Clean Detergent
daily daily weekly Detergent +
disinfectant
for MDRO
2.7. Chair, NA NA NA Clean daily Detergent

dental and & when
surround visibly
soiled
2.8. Cleaning Clean after Clean after Clean after Clean after Detergent
equipment use use use use Detergent +
disinfectant
for MDRO
2.9. Chappals Wash once Wash once NA NA Detergent
daily & dry daily & dry
2.10. Clipboard Clean daily Clean daily Clean daily Clean Detergent
&between &between &between weekly
patient patient patient
2.11. Commodes After each After each After each Daily Detergent
use use use and
Daily twice Daily twice Daily twice disinfectant
2.12. Curtains Bed Bed Bed Bed Replace with
and blinds curtains – curtains – curtains – curtains – laundered
(ICU change or change or change or change or curtains
entrance clean clean clean 3 clean
should not weekly , monthly months annually
have any upon
curtains) discharge
Patient Patient Patient Patient Replace with
with with with with laundered
MDRO or MDRO or MDRO or MDRO or curtains
other other other other
infectious infectious infectious infectious

HOUSEKEEPING
disease – disease – disease – disease –

change bed change bed change bed change bed
curtains or curtains or curtains or curtains or
clean upon clean upon clean upon clean upon
discharge discharge discharge discharge
2.13. Door mat Weekly / Weekly / Weekly / Weekly / Detergent &
whenever it whenever it whenever it whenever it water
gets fully gets fully gets fully gets fully Dry in
wet wet wet wet sunlight
2.14. Elevators Damp Damp Damp Damp Detergent
cleaning cleaning cleaning cleaning
daily daily daily daily
2.15. Door knob/ Clean daily Clean daily Clean daily Clean Detergent
handle / weekly
fridge /
general
2.16. Drip / Clean Clean Clean Clean Detergent
intravenous contact contact contact contact Detergent +
stands points after points after points after points after disinfectant
use use use use for MDRO
2.17. Fan Clean Clean Clean Clean Detergent
weekly & weekly & weekly weekly
between between once once
patient use patient use
2.18. Floor, Damp mop Damp mop Damp mop Damp mop Detergent
nonslip twice daily twice daily daily daily Detergent +
disinfectant
for MDRO
2.19. Fridge Clean Clean Clean Clean Detergent
(drug) weekly weekly weekly weekly
2.20. Hoist Clean Clean Clean Clean Detergent
contact contact contact contact
points after points after points after points after
use use use use
2.21. IV stand & Clean daily Clean daily Clean Clean Detergent
poles & after use & after use weekly & monthly Detergent +
after use &after use disinfectant
for MDRO
2.22. Light switch Clean daily Clean daily Clean Clean Detergent
weekly weekly

HOUSEKEEPING
2.23. Locker Clean Clean Clean NA Detergent

contact contact contact Detergent +
points points points disinfectant
twice daily twice daily daily for MDRO
2.24. Mattress Clean Clean Clean Clean Detergent
preferably weekly & weekly & weekly & weekly & Detergent +
covered by after after after after disinfectant
rexin (every discharge discharge discharge discharge for MDRO
6 months Preferable
check for the entire
durability) mattress has
waterproof
cover
2.25. Medical gas Clean daily Clean daily Clean daily Clean Detergent
equipment weekly
2.26. Microwave Clean Clean Clean daily Clean daily Detergent
thrice daily thrice daily
2.27. Case sheet Clean daily Clean daily Clean Clean Detergent
folder weekly weekly
2.28. Oxygen Clean daily Clean daily Clean Clean Detergent
equipment & after use & after use weekly & weekly &
after after
discharge discharge
& before & before
initial use initial use
2.29. Patient slide Clean daily Clean daily Clean daily Clean daily Detergent
/ cover & after use & after use & after use & after use Detergent +
2.30. bed table disinfectant
for MDRO
2.31. Pillow Clean Clean twice Clean Clean Detergent
(waterproof weekly & monthly & monthly & monthly & Detergent +
cover) after after after after disinfectant
discharge discharge discharge discharge for MDRO
2.32. Shower Clean daily Clean daily Clean daily Clean daily Detergent
& after use & after use Detergent +
disinfectant
for MDRO
2.33. Sink (hand Clean twice Clean daily Clean daily Clean daily Detergent
washing) daily

HOUSEKEEPING
2.34. Surfaces Clean twice Clean twice Clean daily Clean Detergent
(general) in daily & daily & & after weekly & Detergent +
patient after after discharge after disinfectant
room discharge discharge discharge for MDRO
2.35. Telephone Clean twice Clean twice Clean daily Clean Detergent +
daily daily weekly 70%
isopropyl
alcohol
2.36. Toilet Clean Clean Clean Clean daily Detergent +
thrice daily thrice daily thrice daily OPD – disinfectant
frequent
cleaning
2.37. Trolley, Clean Clean Clean Clean Clean &
dressing before & before & before & before & wipe with
after use after use after use after use 70%
isopropyl
alcohol
impregnated
wipes. If
contaminated
with
detergent &
then disinfect
with 70%
isopropyl
alcohol
2.38. Trolley, Clean Clean Clean Clean Detergent
linen / contact contact contact contact
medicine / points daily points daily points daily points
food weekly
Clean Clean Clean Clean Detergent
whole whole whole whole
trolley trolley trolley trolley
weekly weekly weekly weekly
2.39. Trolley, Clean daily Clean twice Clean Clean Detergent
resuscitation weekly weekly weekly
2.40. TV Clean Clean Clean Clean Detergent
weekly weekly weekly weekly

HOUSEKEEPING
2.41. Walls / Spot clean Spot clean Spot clean Spot clean Detergent /
windows / & regular & regular & regular & regular damp dusting
doors cleaning cleaning cleaning cleaning
once a once a once a once a
month month month month
2.42. Wash bowl Clean Clean Clean Clean Detergent
(each between between between between Detergent +
patient patient use patient use patient use patient use disinfectant
should have for MDRO
a dedicated
bowl)
2.43. Waste Clean Clean Clean Clean Detergent
receptacle weekly & weekly & weekly & weekly &
spot clean spot clean spot clean spot clean
as required as required as required as required
2.44. Wheel chair Clean daily Clean daily Clean Clean Detergent
& after use & after use weekly & weekly &
after use after use
3. REFERENCES :

Amendment Date :16.08.2021 LINEN AND LAUNDRY Issue Date:18.08.2021
MANAGEMENT
1. LINEN AND LAUNDRY MANAGEMENT:

1.1. Scope:
The purpose of this policy is the prevention of infection in patients and health care staff
involved in the use, handling or laundering of hospital linen.
1.2. Categories of Linen:
1.2.1. Dirty linen: (Green bag)
1.2.1.1. Used linen, but not visibly contaminated/ soiled with blood or blood tinged
secretions
1.2.1.2. Linens which may be slightly contaminated with excreta.
1.2.2. Soiled linen: (Yellow bag)
1.2.2.1. All linen which is grossly contaminated with excreta, blood or body fluids
1.2.2.2. Contaminated linen from patient suspected or diagnosed to be infectious.
1.2.3. Collection and handling
1.2.3.1. Soiled linen is considered to be contaminated and shall be bagged at the point of
origin and placed in the soiled linen container (Yellow)
1.2.3.2. Soiled linen shall be sluiced.
1.2.3.3. Wet linen shall be placed in a fluid impervious bag.
1.2.3.4. Linen shall be handled with minimum of agitation and shaking.
1.2.3.5. Sorting shall never occur in patient care area.
1.2.3.6. Never place soiled linen on the floor or any clean surface.
1.2.3.7. Heavy soiled linen- large amount of solid soil, feaces or blood shall be removed
with gloved hand and placed in toilet for flushing.
1.2.3.8. Never remove the excrement by spraying with water.
1.2.3.9. While handling soiled linen, personnel as well as person collecting at the laundry
shall wear heavy-duty gloves and a gown.
1.2.3.10. Linen shall be held away from the body to prevent contamination of clothing.
1.2.3.11. Hands shall be washed after removal of gloves.

MANAGEMENT
1.2.4. Bagging and containment

1.2.4.1. Soiled wet linen shall be placed in plastic bags to prevent leakage.
1.2.4.2. Dry linen shall be transported in sealed bags to laundry.
1.2.4.3. Bags shall be tied securely when 3/4th full and transported to laundry.
1.2.4.4. Separate carts shall be used for dirty, soiled and clean linens.
1.2.4.5. Linen handlers must have heavy-duty rubber gloves available.
1.2.4.6. Carts used to transport soiled linen shall be cleaned and disinfected after each use.
1.2.4.7. Clean linen shall be transported and stored in cupboards to prevent contamination
and ensure its cleanliness.
1.2.5. Reprocessing:
Linen that is thought be not cleaned properly must be returned to the laundry for
reprocessing.
1.2.6. Infection control measures in laundry
1.2.6.1. No person shall be permitted to work in or handling of any article while suffering
from an infection or skin disease.
1.2.6.2. They should report such conditions to Infection control nurse who will guide them
for treatment.
1.2.6.3. Personal protective equipment is made available and is must to worn when handling
linen.
1.2.6.4. Reusable gloves must be cleaned and dried daily.
1.2.6.5. A hand hygiene facility complete with soap and towel made available close to
working area.
1.2.6.6. Staff must be aware of the possibility of extraneous items like sharps / noninfectious
items
1.2.6.7. Sharps shall be placed in sharp containers placed in the point of use.
1.2.6.8. Staff must be aware of actions to take in the event of a sharp injury.
1.2.6.9. No crossing over in the path of soiled and laundered linen to prevent reinfection.

MANAGEMENT
1.2.7. Spillage of soiled linen

1.2.7.1. Wearing gloves replace the linen in yellow bag.
1.2.7.2. Clean the surface as per bio-spill management policy.
1.2.7.3. Wash the surface with detergent and water and dry.
1.2.7.4. Remove gloves and perform hand hygiene.
1.2.8. General measures to prevent infection
1.2.8.1. All surfaces shall be kept free from dust, debris and pests.
1.2.8.2. There will be a system for regular cleaning of the environment including high level
surfaces.
1.2.8.3. All washing machines shall be kept clean and free from algae.
1.2.8.4. All washing machines are fitted with accurate heat sensors that are correctly
positioned.
1.2.8.5. These are tested at predefined interval and calibrated.
1.2.8.6. Records must be kept of this and of regular monitoring of wash temperatures.
1.2.9. Sterile linen
Surgical gowns and liens used in sterile procedures shall be sterilized by steam after
washing and drying to destroy any residual spores which done in CSSD.
1.2.10. Processing linen
1.2.10.1. Involves drying, checking and folding linen
1.2.10.2. Completely air or machine dry before processing.
1.2.10.3. Air dry in direct sunlight, keep the fabric off the ground away from dust and
moisture.
1.2.10.4. After total drying, check for holes and threadbare areas.
1.2.10.5. If present item must be discarded or repaired before reuse or storage.
1.2.10.6. Clean and dry linen shall be ironed as needed and folded before placing it on a
shelf or in a container for storage.
1.2.10.7. Do not iron surgical drapes; they have to send to CSSD for sterilization.

MANAGEMENT
1.2.11. Storing, Transporting and distributing clean linen

1.2.11.1. Keep clean linen in clean, closed storage areas.
1.2.11.2. Keep shelves clean.
1.2.11.3. Handle stored linen as little as possible.
1.2.11.4. Clean linen should be transported separately.
1.2.11.5. Clean linen must be wrapped or covered when transporting to avoid
contamination.
1.2.11.6. Protect clean linen until it is distributed for use.
1.2.11.7. Do not leave extra linen in patients’ room.
1.2.11.8. Clean soiled mattresses before putting clean linen on them.
2. Amendment:
2.1. Soiled linen: (Yellow bag)
2.1.1. All linen which is slight/grossly contaminated with excreta, blood or body fluids
2.1.2. Contaminated linen/ dirty linen from patient suspected or diagnosed to be infectious.
2.1.3. These are considered infective and treated first with disinfectant (soaking in 1%
hypochlorite solution) for 20 minutes, then washed as other items.
3. REFERENCES :

Amendment Date :16.08.2021 BIO MEDICAL WASTE Issue Date:18.08.2021
MANAGEMENT
1. BIOMEDICAL WASTE MANAGEMENT (BMWM):

1.1. Purpose:
To ensure and maintain proper standards in biomedical waste management and provide
safe environment. To define policy and procedure regarding biomedical waste management
in the hospital.
1.2. Scope: Hospital Wide
2. Biomedical waste management committee:

2.1. Members:
2.1.1. Medical Superintendent.
2.1.2. Microbiologist.
2.1.3. Senior Consultants.
2.1.4. Resident Medical officer.
2.1.5. Nursing Superintendent.
2.1.6. Infection control Nurse.
2.1.7. Health Inspector
2.1.8. Waste Management is the responsibility of Infection Control Team
3. Objectives of the BMWM committee:

3.1. To prevent infection by maintaining good hygiene and sanitation.
3.2. To protect the patient, patient attendants and all health care personnel from avoidable
exposure to infection.
3.3. To prevent environmental pollution.
3.4. To manage waste in a clean, healthy, economical and safe manner.
3.5. To minimize waste

MANAGEMENT
4. Meetings
The infection control / BMWM committee shall meet once in three months and otherwise
as necessary. Documentation of meetings and recommendations shall be kept by the
Medical Superintendent.
5. BIO-MEDICAL WASTE (BMW) IS HANDLED IN AN APPROPRIATE AND SAFE

MANNER.
5.1. The organization adheres to statutory provisions with regard to Bio-medical Waste.
5.2. Waste management policy at Sri ManakulaVinayagar Medical College & Hospital has
been implemented in accordance with the rules of Biomedical Waste Management Act.
The hospital has got the consent to operate under pollution control board.
5.3. HOSPITAL adopts colour coded segregation of biomedical waste in all patient care
areas. This will be monitored by sanitary inspector, house keeping in-charge and ICN on
daily basis.
Colour coded bags Contents
Yellow Infected Non-plastic materials only

Red Infected plastics only
White puncture proof box Metal sharps only
Blue cardboard box Glass sharps, body implants
Green General waste
5.4. Segregation is done at source. (Posters of proper segregation are displayed Annexure -
1)
5.5. A color code is followed and appropriately coded waste bags are placed in bins in all
patient care areas.

MANAGEMENT
5.6. All waste containers are emptied when they are 3/4th full.
5.7. Segregated bio medical waste is transported to the central waste collection area
(temporary storage area) of the hospital in properly covered containers in secured
manner.
5.8. Waste from various patient care areas is removed twice a day or more if necessary. All
bags that are being transported to the temporary storage area will have to be tied at the
mouth to avoid spillage during transport.
5.9. Smaller bags are collected into larger bags and carried by the on-duty housekeeping staff
to designated storage areas on trolleys. Bags shall be picked up and then transported
when 3/4th full.
5.10. Avoid the transport of too many bags at one time and contact of the bag with the body
of personnel.
5.11. Avoid mixing of segregated wastes.
5.12. The staff is provided with personal protective equipment (PPE).
5.13. Biomedical waste segregation audit is done by ICN daily (Annexure -2)
5.14. Daily register is maintained regarding the amount of waste generated in different
category (Annexure -3)
6. DISPOSAL OF CONTAMINATED NEEDLES AND SYRINGES

Contaminated needles are discarded in puncture proof container (white)
Contaminated syringes with needles are discarded in puncture proof container (white)
At segregation, only syringes are discarded in red color coded plastic bags.
7. BIO MEDICAL WASTE TREATMENT FACILITY:-

7.1. The hospital has tie- up with Pondicherry Solid Waste Management Private Limited
(Common waste management facility). The waste is collected from the temporary

MANAGEMENT
storage area of hospital by outsourced workers and transported in a covered vehicle to

the treatment facility at Thuthipet, Puducherry-605 502.
7.2. The hospital BMWM committee members or their authorized person shall visit the
outsourced facility at Thuthipet, Puducherry once in 6 months to ensure waste disposal
according to BMW rules.
7.3. Annual report of waste generated is maintained by chairman BMWM committee and
report submitted to Puducherry Pollution Control Board.
7.4. All categories of staff handling bio medical waste are given strict instructions regarding
usage of appropriate personal protective equipment.
7.5. All categories of staff involved in bio medical waste management are provided free
health checkups and vaccination against hepatitis B and tetanus.
7.6. Any accidents involving workers shall be reported in casualty.
8. RECORDS:
8.1. Infection Control Committee Register
8.2. Disinfectant Register
8.3. Infection Register
8.4. Fumigation Register
8.5. BMW Register
8.6. Microbiology Surveillance Register
9. REFERENCES
9.1. Bio-Medical Waste management and handling Rules, 2016.

FOOD HANDLERS
1. FOOD HANDLING / HANDLERS:

1.1. Guidelines to ensure that food served to patients, visitors and employees is processed in
a manner that avoids contamination:-
1.1.1. All food is prepared and served into covered containers and set into trays in the main
kitchen and then sent to wards. This activity is supervised by trained personnel.
1.1.2. Hot and cold food is transported in such a manner that appropriate temperatures will be
maintained during transportation.
1.1.3. Food returned to the kitchen is discarded into black bags. Mouths of bags are tied before
disposal.
1.1.4. Housekeeping is done according to the set procedures of the department
1.1.5. The arrangement of work stations in the kitchen should be such that there is no
contamination of cooked food from raw food. There should be no interchange of
personnel working on raw food and those on cooked food.
1.1.6. Personnel handling and serving the food are trained to observe universal precautions to
protect themselves.
1.1.7. Personnel are also trained to protect food consumers from body substances of handling
Personnel. Training should include the following aspects.
1.1.8. Hand washing should cover exposed portions of arms and hands withspecial attention
to fingernails and areas between fingers.
1.1.9. Clothing should be free from obvious dirt and food spills.
1.1.10. Hair nets should be used while on duty
1.1.11. Food should not be consumed in preparation or serving areas.
1.1.12. Utensils should be used to handle food.


FOOD HANDLERS
1.1.13. Clean gloves may be used.
1.2. Surveillance is done biannually for detection of carriage of Salmonella and MRSA.
1.3. Stool samples and nasal swabs are submitted to the microbiology laboratory.
1.4. Records are maintained by in charge of the department.
2. REFERENCES :

LIST OF NOTIFIABLE DISEASES
1. List of Notable Disease:
The infection control team verifies the data on a regular basis.
2. Monitoring activities includes:
2.1. Monitoring of compliance with hand hygiene guidelines.

2.2. Monitoring of effectiveness of housekeeping service on a regular basis.
2.3. Reports of HAI rates are informed to all departments monthly wise.
2.4. Monitoring needle stick injury and post exposure prophylaxis.
2.5. Identify all notifiable diseases and ensure to reporting in format as required by
statutory authorities.
2.5.1. Acute flaccid paralysis
2.5.2. Cholera or cholera like disease
2.5.3. Diphtheria
2.5.4. Encephalitis
2.5.5. Plague
2.5.6. Hepatitis – viral
2.5.7. Leptospirosis
2.5.8. Malaria
2.5.9. Measles
2.5.10. Meningitis – Pyogenic
2.5.11. Rabies
2.5.12. Tetanus
2.5.13. Enteric fever
2.5.14. Pertussis
2.5.15. Dengue
2.5.16. Chickenpox
2.5.17. Chikungunya & H1N1

3. INVESTIGATION OF AN OUTBREAK:
The occurrence of two or more similar cases relating to place and time is identified as a
cluster or an outbreak and needs investigation to discover the route of transmission of
infection, and possible sources of infection in order to apply measures to prevent further
spread. If the cases occur in steadily increasing numbers and are separated by an interval
approximating the incubation period, the spread of the disease is probably due to person to
person spread. On the other hand if a large number of cases occur following a shared
exposure e.g an operation, it is termed a common source outbreak, implying a common
source for the occurrence of the disease.
3.1. Epidemiological methods:

The investigation of an outbreak may require expert epidemiological advice on procedures.
Formulation of a hypothesis regarding source and spread is made before undertaking
microbiological investigations in order that the most appropriate specimens are collected.
3.1.1. Steps to be taken to investigation an outbreak

3.1.1.1. Step 1
3.1.1.1.1. Recognition of the outbreak. Is there an increase in the number of cases of a
particular infection or a rise in prevalence of an organism? Such findings indicate
a possible outbreak.
3.1.1.1.2. Preliminary investigation must be begun by developing a case definition,

identifying the site, pathogen and affected population.
3.1.1.1.3. Determination of the magnitude of the problem and if immediate control measures
are required. If so general control measures such as isolation or cohorting of
infected cases; strict hand washing and asepsis should be immediately applied.
3.1.1.1.4. Verification of the diagnosis. Each case should be reviewed to meet the definition.

3.1.1.1.5. Confirmation that an outbreak exists by comparing the present rate of occurrence
with the endemic rate should be made.
3.1.1.2. Step 2
The appropriate departments and personnel and the hospital administration should be
notified and involved.
3.1.1.3. Step 3
3.1.1.3.1. Additional cases must be searched for by examining the clinical and
microbiological records.
3.1.1.3.2. Line listings for every case, patient details, place and time of occurrence and
infection details should be developed.
3.1.1.3.3. An epidemic curve based on place and time of occurrence should be developed,
the date analyzed, the common features of the cases e.g age, sex, exposure to
various risk factors, underlying diseases etc. should be identified.
3.1.1.3.4. A hypothesis based on literature search and the features common to the cases;
should be formulated to arrive at a hypothesis about suspected causes of the
outbreak.
3.1.1.3.5. Microbiological investigations depending upon the suspected epidemiology of the

causative organism should be carried out. This will include (a) microbial culture
of cases, carriers and environments (b) epidemiological typing of the isolates to
identify clonal relatedness.
3.1.1.3.6. The hypothesis should be tested by reviewing additional cases in a case control
study, cohort study, and microbiological study.
3.1.1.4. Step 4
3.1.1.4.1. Specific control measures should be implemented as soon as the cause of outbreak
of identified.

3.1.1.4.2. Monitoring for further cases and effectiveness of control measures should be done.
3.1.1.4.3. A report should be prepared for presentation to the HICC, departments involved in
the outbreak and administration
3.1.2. Immediate control measures:

3.1.2.1. Control measures should be initiated during the process of investigation. An intensive
review of infection control measures should be made and general control measures
initiated at once. General measures include:
3.1.2.1.1. Strict hand washing;
3.1.2.1.2. Intensification of environmental cleaning and hygiene.
3.1.2.1.3. Adherence to aseptic protocols, and
3.1.2.1.4. Strengthening of disinfection and sterilization.
3.2. Microbiological Study:

Microbiological study is planned depending upon the known epidemiology of the
infection problem. The study is carried out to identify possible sources and routes of
transmission. The investigation may include cultures from other body sites of the patient,
other patients, staff and environment. Careful selection of specimens to be cultured is
essential to obtain meaningful data.
3.3. Specific control measures

Specific control measures are instituted on the basis of nature of agent and characteristics
of the high-risk group and the possible sources. These measures may include:
3.3.1. Identification and elimination of the contaminated product ;
3.3.2. Modification of nursing procedures ;
3.3.3. Identification and treatment of carriers, and
3.3.4. Rectification of lapse in technique or procedure


3.4. Evaluation of efficacy of control measures

3.4.1. The efficacy of control measures should be evaluated by a continued followed-up of
cases after the outbreak clinically as well as microbiologically. Control measures are
effective if cases cease to occur or return to the endemic level.
3.4.2. The outbreak should be documented.
4. REFERENCES :

SPECIAL CARE UNITS
1. SPECIAL CARE UNITS: OBSTETRICS AND LABOUR ROOM:

1.1. Policies regarding admission for pregnant women with infection.
1.1.1. Pregnant women suffering from infections:
1.1.1.1. Not in Labour : Admit in medical wards/isolation ward , just as one would admit
a non-pregnant woman with similar illness
1.1.1.2. In Labour : Admit to isolation side of labour room.
1.1.2. Indications for admission to isolation side in labour room:
Pregnant women with at least 22 weeks of gestation and in labour with:
1.1.2.1. Hepatitis (A, E or unknown)
1.1.2.2. Diarrhoea (severe, watery, with blood and mucous)
1.1.2.3. Known infection with a blood borne pathogen (HBV, HCV & HIV)
1.1.2.4. Suspected or confirmed communicable disease requiring isolation.
1.1.3. Labour Room:

1.1.3.1 Housekeeping has to be meticulous:
1.1.3.1.1 Clean the floor at least four times in 2 4hours. One of these should be with
detergent and copious amounts of water. Lysol may be used to mop the floor
for the remaining times
1.1.3.1.2 Any spill of blood or fluids should be immediately decontaminated with 1%

Sodium hypochlorite 10 minutes, mopped dry and then cleaned thoroughly with
detergent and water.
1.1.3.1.3 Environment and equipment should be maintained dust free.
1.1.3.1.4 Strip the bed and wipe clean with detergent and water and then once more with
ECOSAN after each patient. Wear gloves for this procedure.
1.1.3.1.5 Use fresh linen for each patient.


SPECIAL CARE UNITS
1.1.3.2 Personnel:
Follow universal Precautions with absolute care.
1.1.3.2.1 Sterile gloves, gown, plastic apron, goggles, mask and impervious footwear
(covering dorsum and sole) are recommended while conducting delivery and
any other procedure where spill / splash is expected.
1.1.3.2.2 Wear gloves and plastic apron for performing vaginal examination and
preparing parts.
1.1.3.2.3 Anyone with open wounds or exudative skin lesions should not be involved in
invasive procedures.
1.1.3.2.4 Wash hands after each procedure and between patients.
2. VISITORS POLICY:
Although instructing and preparing visitors for patients in isolation is time consuming and
often frustrating, their presence is valuable to the emotional well being of the patient.
2.1. The ward sisters and the doctors concerned shall have the responsibility of informing the
patients' relatives of the measures to be taken and the importance of restriction of visitors.
This should be done at admission of the patient.
2.2. The patient and the relatives must be given health education about the cause, spread and
prevention of the infection, in detail. The need for isolation and restriction of visitors
should be discussed with them.
2.3. Hand washing after all contact with the patient will have to be stressed.
2.4. No more than two adult visitors should be allowed 'at a time' during the hospital visiting
hours and the length of stay should be governed by the needs of the patient.

SPECIAL CARE UNITS
2.5. Children below 12 years are not allowed into the isolation areas. The policy of our
hospital is to allow one female attendant to stay in the ward with the patient. The
attendants are individually trained to avoid infection.
2.6. Before entering the room, visitors must enquire at the nurses' station for instructions and
for gown and mask if indicated. Visitor's footwear, bags etc., should be left outside the
room. Only articles that can be discarded, disinfected or sterilized should be taken into
the room.
2.7. Visitors are not allowed to sit on the patient's bed.
2.8. Visitors should wash their hands well with soap and water before entering and when
leaving the room.
2.9. Active immunization of attendants and other follow up steps, where applicable must be
conducted by the physician in-charge.
3. EMERGENCY SERVICE:
3.1. Standard precautions are to be strictly adhered and all patients are to be treated as
potentially infected with blood – borne pathogens. Importance of this cannot be over
emphasizes in this area:
3.1.1. Wash hands with soap and water before and after patient contact.
3.1.2. Wear gloves preferably for all patient contact. It is a must for all invasive procedures,
however minor. Examination gloves are placed in the shelves in all patient care
areas.
3.1.3. Wear masks for all situations where a splash is expected, and where infection that
spreads through the respiratory route is possible diagnosis.
3.1.4. Wear plastic aprons, in addition to a mask if splash to the body area is expected.

SPECIAL CARE UNITS
3.1.5. Use disposal needles and discard them into the sharps container which is placed in
al patient care areas. Dispose IV canula, stilettes, scalpel blades and razor blades
into the sharps containers immediately after use.
3.1.6. Attenders and Sweepers are to wear gloves while handling lab samples and
performing sanitation work.
3.2. Additional precautions for patients known to harbor blood borne pathogens:
3.2.1. Use plastic aprons during procedures where body fluids may be split.
3.2.2. Disinfect all items following discharge, transfer or death of the patient (as per
hospital protocol refer to the chapter on housekeeping). Mattress, pillow and
mackintosh are to be disinfected with 1% sodium hypochlorite solution and dried in
sunlight.
3.3. Infectious diseases:

3.3.1. Refer to the chapter on Isolation Policies
3.4. Wound and Skin Infections:
3.4.1. Hands are to be washed before and after handling the patient.
3.4.2. Wear gloves while handling infected wounds.
3.4.3. Cover the wounds (as far as possible) before transferring the patient
3.4.4. Dispose waste as per hospital guidelines.
3.5. Trauma:
3.5.1. Use protective equipment such as gloves, mask, gown, apron and goggles under
appropriate situations.

SPECIAL CARE UNITS
3.6. Housekeeping:
3.6.1. The treatment rooms and trauma resuscitation room is cleaned with soap and water
after every patient. Blood spills are disinfected by using 1% Sodium hypochlorite
for a contact time of 10 minutes.
3.6.2. Equipment and instruments that are to be reused are cleaned before sending it for
sterilization.
3.6.3. Discard medical waste as per the guidelines given in the chapter on Hospital Waste
Management.
4. REFERENCES :

OCCUPATIONAL EXPOSURE
1. OCCUPATIONAL EXPOSURE:
1.1. PREVENTION OF OCCUPATIONAL EXPOSURE:
1.1.1. Standard precautions (universal work precautions) and safe practices
1.1.2. Wash hand after patient contact, removing gloves.
1.1.3. Wash hands immediately if hands contaminated with body fluids.
1.1.4. Wear gloves when contamination of hands with body substances anticipated
1.1.5. Protective eyewear and masks should be worn when splashing with body substance is
anticipated
1.1.6. All health care workers should take precautions to prevent injuries during procedures
and when cleaning or during disposal of needles and other sharp instruments.
1.1.7. Needle should not be recapped
1.1.8. Needles should not be purposely bent or broken by hand
1.1.9. Not removed from disposable syringe nor manipulated by hand
1.1.10. After use disposable syringes and needles, scalpel blades and other sharp items should
be placed in a puncture resistant container.
1.1.11. Health care workers who have exudative lesions or dermatitis should refrain from direct
patient care and from handling equipment
1.1.12. All needle stick injuries should be reported to infection control officer.
1.1.13. Handle and dispose of sharps safely
1.1.14. Clean & disinfect blood / body substances spills with appropriate agents
1.1.15. Adhere to disinfection and sterilization standards
1.1.16. Regard all waste soiled with blood/body substance as contaminated and dispose of
according to relevant standards

1.1.17. Vaccinate all clinical and laboratory workers against hepatitis B
1.1.18. Other measures double gloving changing surgical techniques to avoid “exposure prone"
procedures use of needle-less systems and other safe devices.
1.2. BODY FLUIDS TO WHICH UNIVERSAL PRECAUTIONS APPLY:

1.2.1. Blood
1.2.2. Other body fluids containing visible blood
1.2.3. Semen
1.2.4. Vaginal secretions
1.2.5. Cerebrospinal fluid (CSF)
1.2.6. Synovial fluid
1.2.7. Pleural fluid
1.2.8. Peritoneal fluid
1.2.9. Pericardial fluid
1.2.10. Amniotic fluid
1.3. BODY FLUIDS TO WHICH UNIVERSAL PRECAUTIONS DO NOT APPLY:
The risk of HIV transmission is extremely low or negligible
1.3.1. Nasal secretions
1.3.2. Sputum
1.3.3. Sweat
1.3.4. Tears
1.3.5. Urine
1.3.6. Vomitus
1.3.7. Saliva
Unless these contain visible blood


1.4. USE OF PROTECTIVE BARRIERS:

1.4.1. Protective barriers reduce the risk of exposure of the HCWs skin or mucus membrane
to potentially infective materials
1.4.2. Protective barriers include gloves gowns, masks, and protective eye wears.
1.4.3. Selection of protective barriers.
Type of exposure Examples Protective barriers

Low Risk  injections Gloves helpful but not essential
contact with skin with not visible  minor wound dressing
blood
Medium Risk  vaginal examination, Gloves, Gowns and Aprons may
probable contact with blood, splash  insertion or removal of be necessary
unlikely intra venous cannula
 handling of laboratory
specimens
 large open wounds dressing
 venepuncture, spills of
blood
High Risk  major surgical procedures, Gloves, Water proof Gown or
probable contact with blood, particularly in orthopaedic Apron, Eye wear and Mask
splashing, uncontrolled bleeding surgery and oral surgery;
 vaginal delivery
The use of double gloves is not recommended. Heavy duty rubber gloves should be worn
for cleanings instruments, handling soiled linen or when dealing with spills

1.5. WHAT TO DO ON EXPOSURE TO HIV INFECTED BLOOD?

1.5.1. PROMPT MEASURES
1.5.1.1. Do not Panic
1.5.1.2. Do NOT put cut / pricked finger into your mouth
1.5.2. POST-HIV EXPOSURE MANAGEMENT / PROPHYLAXIS (PEP)

1.5.2.1. It is necessary to determine the status of the exposure and the HIV status of the
exposure source before starting post-exposure prophylaxis(PEP)
1.5.2.2. Immediate measures:
1.5.2.2.1. wash with soap and water
1.5.2.2.2. no added advantage with antiseptic/bleach
1.5.2.3. Next step:

1.5.2.3.1. prompt reporting
1.5.2.3.2. post-exposure treatment should begin as soon as possible
1.5.2.3.3. preferably within two hours
1.5.2.3.4. not recommended after seventy -two hours
1.5.2.3.5. Late PEP? may be yes
1.5.2.3.6. Is PEP needed for all types of exposures? NO
1.5.2.4. Post exposure Prophylaxis:

The decision to start PEP is made on the basis of degree of exposure to HIV and the
HIV status of the source from whom the exposure/infection has occurred.
1.5.2.5. Determination of the Exposure Code (EC):
Exposure code can be defined as per the flow chart given below. It may be classified
into three categories, EC1, EC2 and EC3, depending upon the nature of exposure.

1.6. EXPOSURE CODE (EC):
HIV status of exposure source
HIV - Negative Source Unknown Source Unknown Source Unknown
No PEP required
Low titer Exposure High titer exposure e.g. -

(eg – asymptomatic advanced AIDS, primary HIV
/ high CD4 count) Infection / high viral load or Low
CD4 count
Source
Source
Unknown
Unknown
HIV SC
Unknown

Is the source material blood, body fluid, other potentially infectious material (OPIM),
or an instrument contaminated with one of these substances
No PEP Required No Yes
OPIM, Blood/ body fluids
Type of exposure?
Muoous membrane / skin or Percutaneous exposure

Intact Skin Integrity compromised
Small Less severe Less severe More severe (eg – large

volume (eg bore hollow needle, deep
– few drops (eg – solid (eg – solid puncture, visible blood on
/ short needle, needle, device or needle used in
duration superficial superficial patients artery / venin
scratch) scratch)
EC 1 EC 2 EC 2 EC 3

1.7. Determination of PEP Recommendation:
EC HIV SC PEP Recommendation
1 1 PEP may not be warranted
1 2 Consider Basic Regimen

Recommend Basic Regimen(most exposures are in
2 1 this category)
2 2 Recommend Expanded regimen
3 1 or 2 Recommend expanded regimen

If setting suggests a possible risk (epidemiological
2/3 Unknown
risk factors) and EC is 2 or 3,consider basic regimen
1.8. Basic regimen: Tenofovir (300 mg) + Lamivudine (300 mg) + Dolutegravir (50mg) FDC
– One tablet OD for 28 days.
1.9. Testing and Counseling
The health care provider should be tested for HIV as per the following schedule-
1.9.1. Base-line HIV test - at time of exposure
1.9.2. Repeat HIV test - at six weeks following exposure
1.9.3. 2nd repeat HIV test - at twelve weeks following exposure
On all three occasions, HCW must be provided with a pre-test and post-test counseling.
HIV testing should be carried out on three ERS (Elisa/ Rapid/ Simple) test kits or
antigen preparations. The HCW should be advised to refrain from donating blood,
semen or organs/tissues and abstain from sexual intercourse. In case sexual intercourse
is undertaken a latex condom is used consistently. In addition, women HCW should
not breast -feed their infants during the follow-up period.
1.10. Duration of PEP:

1.10.1. PEP should be started, as early as possible, after an exposure. It has been seen that
PEP started after 72 hours of exposure is of no use and hence is not recommended.
The optimal course of PEP is not unknown, but 4 weeks of drug therapy appears to
provide protection against HIV.
1.10.2. If the HIV test is found to be positive at anytime within 12 weeks, the HCW should
be referred to a physician for treatment.
1.11. Pregnancy and PEP:
Based on limited information, anti-retroviral therapy taken during 2nd and 3rd trimester
of pregnancy has not caused serious side effects in mothers or infants. There is very
little information on the safety in the 1st trimester. If the HCW is pregnant at the time
of exposure to HIV, the designated authority/physician must be consulted about the use
of the drugs for PEP.
1.12. Side-effects of these drugs:
Most of the drugs used for PEP have usually been tolerated well except for nausea,
vomiting, tiredness, or headache.
1.13. Steps to be undertaken by the Infection control officer on receiving information
about exposure:
1.13.1. All needle-stick/sharp injuries should be reported to the State AIDS Control societies
giving the Exposure Code and the HIV Status code.
1.13.2. The State AIDS Societies should in-turn inform NACO about the cases periodically.
1.13.3. A register should be maintained in all hospitals and at the level of the State AIDS
Control societies
1.13.4. NACO has decided to supply PEP drugs to all cases in government hospitals through
the State AIDS Control societies
1.13.5. Infection control officers in all hospitals have been directed to ensure that PEP drugs
are available at all times.

2. REFERENCES :

Amendment Date :16.08.2021 STAFF HEALTH: WORK Issue Date:18.08.2021
RESTRICTION
1. Purpose:
1.1. To prevent transmission of infection from exposed / diseased HCW’s to patients,
residents, co-workers.
2. Scope:
2.1. To increase self-reporting
2.2. To evaluate the communicability nature of disease
2.3. To recommend work restrictions
3. Responsibility:
3.1. Health care worker – Self report
3.2. Staff clinic
3.3. Hospital infection control committee
4. Procedure:
4.1. Self-reporting of the HCW to staff clinic / HICC regarding known infection or
unprotected exposure to a communicable disease (Work related / non-work related)
4.2. Evaluation done by medical officer in staff clinic.
4.3. If needed work restriction recommendation is given and informed to Medical
Superintendent Office.
4.4. When a HCW is restricted from work duties they get paid leaves to receive.
5. List of communicable diseases recommended with work restrictions:
Sl. No. Active diseases Restriction Duration

1. Acute febrile respiratory illness Exclude from work Until acute symptoms
/ influenza-like illness resolve and afebrile for at

RESTRICTION
least 24 hours without

antipyretics
2. Conjunctivitis due to Exclude from work Until discharge ceases
adenovirus and for 24 hours after
initiation of effective
treatment.
3. Diarrheal diseases: Exclude from work Until symptoms resolve.
E.coli, Salmonella, Shigella. Educated on hand
hygiene. Food handlers:
2 negative stool culture.
4. Diphtheria Exclude from work Until symptoms resolve,
completion of treatment
and 2 negative cultures
obtained 24 hours apart.
5. Enterovirus Exclude from work Until symptoms resolve
6. Hepatitis A & Hepatitis E Exclude from work A: Until 7 days after
onset of jaundice or 14
days after diagnosis if no
jaundice
E: 14 days after onset of
jaundice
7. Hepatitis B & Hepatitis C May not perform Not excluded from work
exposure – prone at all HBV DNA > 1000
procedures until IU/ml – work in low risk
evaluated areas.
8. Herpes Simplex:

RESTRICTION
Genital No restriction
Hand (herpetic whitlow) Exclude from work Until lesions are healed /
dry and crusted
Orofacial HICC must evaluate Until lesions are healed /
assess the restriction dry and crusted
9. Measles Exclude from work Until 4 days after onset
of rash and afebrile
without the use of
antipyretics.
10. Meningococcal Exclude from work Until 24 hours after start
of effective therapy.
11. MRSA Exclude from work Until documentation of
Must be cleared by staff negative nasal culture
clinic for working and negative site culture.
(Culture obtained > 24
hours after completion of
antibiotics)
12. Mumps Exclude from work Until 9 days after onset
of par otitis.
13. Pediculosis Exclude from work Until 24 hours after
treatment and observed
to be free from adult and
immature lice
14. Petussis Exclude from work Until 5 days after start of
effective therapy

RESTRICTION
15. Rubella Exclude from work Until 7 days after onset

of rash and afebrile
without the use of
antipyretics.
16. Scabies Exclude from work Until 24 hours after
application of effective
therapy.
17. MSSA:
Active draining lesion May work if lesions can
be adequately covered
If not exclude from Until lesion resolves
work
18. Group A Streptococcus Exclude from work Until 24 hours after
adequate treatment
started and no draining
lesions.
19. Tuberculosis
Positive Mantoux test of IGRA Needs evaluation to Once active disease is
verify absence of active ruled out return to work
disease with no restrictions
Active Exclude from work Until 3 negative AFB
smears or negative
culture.
20. Vancomycin-resistant Exclude from work Until cleared by staff
enterococcus clinic / HICC on a case-
by-case evaluation.

RESTRICTION
21. Chicken pox and shingles Exclude from work Until lesion are dry and
crusted.
6. Recommended work restrictions for post exposure of HCW’s to communicable

diseases.
Sl. No. Post exposure Restriction Duration
1. Measles Exclude from work From day 5 till 21 days
of post exposure and 4
days after onset of rash.
2. Mumps Exclude from work From day 12 till day 26
of post exposure. (or)
until 9 days after onset of
par otitis.
3. Rubella Exclude from work From day 7 till day 21 of
post exposure.
4. Varicella:
Non-immune HCW Exclude from work From day 8 till day 21 of
post exposure.
Vaccinated HCW Monitor daily and Until varicella is ruled
exclude from work out / lesions dry and
immediately if crusted.
symptoms develop.
5. Pertussis:
Asymptomatic HCW No restriction Prophylaxis is
recommended.

RESTRICTION
Symptomatic HCW Exclude from work Until 5 days after

initiation of antimicrobial
therapy.
6. Meningococcal:
Asymptomatic HCW No restriction Prophylaxis is
recommended.
Symptomatic HCW Exclude from work Monitor close contacts
and family members.
7. COVID-19
Symptomatic HCW Exclude from work Self-monitor and until
afebrile for at least 24
hours without
antipyretics.
8. Ebola virus (other hemorrhagic Determine the exposure Asymptomatic – No
fever virus) and verify. Follow restriction self-monitor
CDC guidelines and for symptoms for 21 days
assess for symptoms. from last contact.
7. References:
7.1. Damini N pittet D.Manual of Infection Control Procedures. 3rd ed. London: Oxford
university press; 2012.

CSSD
1. CENTRAL STERILE SUPPLIES DEPARTMENT (CSSD):

The purpose of the CSSD is to provide all the required sterile items in order to meet the
needs of all patient care areas.
1.1. Items Supplied by CSSD:

1.1.1. Instrument packs for various procedures
1.1.2. 34.1.2 Dressing pad
1.1.3. 34.1.3 Dressing packs, cotton and gauze
1.2. Protocol:
The central processing area(s) ideally should be divided into at least three zones: soiled
zone (decontamination), clean zone (packaging), and sterile zone (sterilization and
storage).
1.2.1. Soiled zone: In the decontamination area reusable contaminated supplies (and
possibly disposable items that are reused) are received, sorted, and decontaminated.
1.2.2. Clean zone: The packaging area is for inspecting, assembling, and packaging clean,
but not sterile, material.
1.2.3. Sterile zone: The sterile storage area should be a limited access area. Following the
sterilization process, medical and surgical devices must be handled using aseptic
technique in order to prevent contamination. Medical and surgical supplies should
not be stored under sinks or in other locations where they can become wet. Sterile
items that become wet are considered contaminated because moisture brings with it
microorganisms from the air and surfaces. Closed or covered cabinets are ideal but
open shelving may be used for storage. Any package that has fallen or been dropped
on the floor must be inspected for damage to packaging and contents (if the items
are breakable). If the package is heat-sealed in impervious plastic and the seal is still
intact, the package should be considered not contaminated. If undamaged, items
packaged in plastic need not be reprocessed.

CSSD
1.3. Collection and Distribution of Items:

1.3.1. All items should be collected and distributed twice a day, if necessary whenever
required.
1.3.2. CSSD items should be transported to the wards in a manner so as to ensure that
sterility of the items is maintained
1.3.3. When the items are collected back from the patient care areas the quantity of each
item that is collected is recorded in a book. These items are transported to CSSD.
Another set of personnel transport sterile items to the various wards, depending on
the requirement.
1.3.4. Items which have crossed the expiry date should be returned and new ones
obtained.
1.4. Monitoring Sterilization:
1.4.1. There are two ways of monitoring sterilization of CSSD items:
1.4.2. All sterile items can be monitored by using the chemical indicator tape which shows
that the item has been adequately sterilized
1.4.3. In addition to chemical sterilization, microbiological surveillance may be conducted
using B.stearothermophilius spore suspension which is kept in the autoclave to
check the efficiency.
1.5. Moist Heat Sterilization:
1.5.1. This is used for steel instruments, latex rubber tubes, gloves, dressing packs, cotton
and gauze.
1.5.2. CSSD has electric autoclaves, gravity type of autoclaves, and a high pressure
autoclave. The high pressure autoclaves operate using a central steam supply.
1.6. Recommended Practice Guidelines for All Types of Steam Sterilizers:
1.6.1. Device Preparation:
Devices should be prepared for sterilization in the following manner:
1.6.1.1. Clean, and remove excess water.

CSSD
1.6.1.2. Jointed instruments should be in the open or unlocked position.

1.6.1.3. Multipiece or sliding pieces should be disassembled unless otherwise indicated
by the device manufacturer.
1.6.1.4. Devices with concave surfaces that retain water should be placed in a manner
such that condensate does not collect.
1.6.1.5. Instruments with lumens should be moistened with distilled water immediately
prior to sterilization.
1.6.1.6. Heavy items should be arranged so as to not damage lighter more delicate items.
1.6.1.7. Sharp instruments should have tips protected.
1.6.2. Packaging: Packaging materials for steam sterilization should:
1.6.2.1. Be validated for steam sterilization.
1.6.2.2. Contain no toxic ingredients or dyes.
1.6.2.3. Be capable of withstanding high temperatures.
1.6.2.4. Allow air removal from packages and contents.
1.6.2.5. Permit sterile contact with the package contents.
1.6.2.6. Permit drying of the package and contents.
1.6.2.7. Prevent the entry of microbes, dust, and moisture during storage and handling.
1.6.2.8. Have a proven and tamper-proof seal.
1.6.2.9. Withstand normal handling and resist tearing or puncturing.
1.6.3. Unloading:
Upon completion of the cycle, the operator responsible for unloading the sterilizer
should:
Review the sterilizer printout for the following:
1.6.3.1. Correct sterilization parameters.
1.6.3.2. Cycle time and date.
1.6.3.3. Cycle number matches the lot control label for the load.

CSSD
1.6.3.4. Verify and initial that the correct cycle parameters have been met.
1.6.3.5. Examine the load items for:
1.6.3.5.1. Any visible signs of moisture.
1.6.3.5.2. Any signs of compromised packaging integrity.
Printed records of each cycle parameter (that is, temperature, time) should be retained in
accordance with the healthcare settings requirements.
1.6.4. Load Cool-Down:
Upon removal of the sterilized load the operator should:
1.6.4.1. Visually verify the results of the external chemical indicators.
1.6.4.2. Allow the load to cool to room temperature (the amount of time for cooling
depends on the devices that have been sterilized).
1.6.4.3. Ensure cool down occurs in a traffic-free area without strong warm or cool air
currents.
1.6.5. Troubleshooting - Wet Pack Problems:
Packages are considered wet when moisture in the form of dampness, droplets or
puddles is found on or within a package. There are two types of wet packs; those with
external wetness and those with internal wetness. Sterility is considered compromised
and the package contents considered contaminated when wet packs are found. There
are several causes of wet packs. The following is a list of possible causes:
1.6.5.1. Packages are improperly prepared or loaded incorrectly.

1.6.5.2. Condensation drips from the sterilizer cart shelf above the item.
1.6.5.3. Condensation drips from rigid sterilization containers placed above absorbent
packaging.
1.6.5.4. Condensate blows through the steam lines into the sterilizer chamber.
1.6.5.5. Instrument or basin sets are too dense or lack absorbent material to wick moisture
away.

CSSD
1.6.5.6. Linen packs are wrapped too tightly.

1.6.5.7. Sterilization containers with a low metal-to-plastic ratio.
1.6.6. Flash Sterilization / Immediate Use Steam Sterilization:
This form of sterilization is used only when there is an immediate requirement for items
to be sterilized. Containers used for Immediate Use Steam Sterilization of devices should
be validated for that purpose.
Immediate Use Steam Sterilization should not be used to:
1.6.6.1. Sterilize implants

1.6.6.2. Sterilize complete sets or trays of instruments
1.6.7. Compensate for inventory shortages or scheduling difficulties.
1.7. Quality Assurance:
1.7.1. All documentation should be dated and signed by the person completing the
documentation and/or verifying the test results.
1.7.2. Documentation of the sterilization process should include:
1.7.3. Package label:
1.7.3.1. Name of device (when necessary).
1.7.3.2. Initials of technician packaging the device.
1.7.3.3. Lot control information which includes a load or cycle number, sterilizer
number, and the date of sterilization.
1.7.3.4. Detailed list of sterilizer load contents
1.7.3.5. Date, time, and results of all tests performed (for example, printout, Chemical
Indicator, Biological Indicator, Bowie-Dick, leak test).
1.7.3.6. Sterilizer physical parameters should be verified by the individual responsible
for releasing the load prior to load release. Verification should be documented
(for example, printout is initialed).

CSSD
1.7.3.7. If any indicator fails, the failure should be investigated. Loads may be recalled
according to the results of the investigation. All actions associated with an
investigation should be documented.
1.7.3.8. A process to address any indicator failure, for example, printout, chemical
indicator or biological indicator.
1.7.3.9. Record retention according to corporate administrative directives and/or quality
management system requirements.
1.8. Recall Procedure:

As soon as CSSD staff receive the result from the microbiologist about biological
indicators not being satisfactory, the CSSD In-charge or Staff nurse should take the
following action:
1.8.1. Inform to the Chief Nursing Officer and Hospital Infection Control Committee.
1.8.2. Check the autoclave number, batch number, and expiry date.
1.8.3. Trace out the department which issued the items and the specific date.
1.8.4. Inform the ward in-charge regarding the biological indicator growth.
1.8.5. Take back all the items to CSSD.
1.8.6. Rewash all the articles and repack for re-autoclave.
1.8.7. Clean the autoclave thoroughly with clean water.
1.8.8. Sterilize the items with Bowie-Dick and biological indicator.
1.8.9. Wait for the report; only then issue the items to the wards.
1.8.10. Update the register.
2.4. ENGINEERING CONTROL TO PREVENT INFECTION:

1.9.1. Patient care areas are designed to ensure optimum bed spacing.
1.9.2. Operation rooms are provided with HEPA filter to ensure double air filtration.
1.9.3. Periodical checking of water resources.

CSSD
1.9.4. Periodical checking and maintenance of equipment, AC ducts, AHUs,

replacement of filters.
1.9.5. Periodical checking, replacement or repair of plumbing and sewer lines.
1.9.6. Machinery and equipment are checked, cleaned and repaired routinely.
1.9.7. Urgent repairs should be carried out at the end of the day list.
1.9.8. Air conditioners and suction points should be checked, cleaned and repaired on
weekly basis.
1.9.9. Preventive maintenance on all theatre equipment to be carried out weekly and
major work to be done at least once every year.
1.9.10. OT Air changes / Hour:
1.9.10.1. Air change / Hour:
Minimum 5 – 10 air exchange / hour
(Not more than 25 / hr)
Fresh air component minimum 4 out of 25
1.9.10.2. Temperature and Humidity
Inside OT all time: 21±3°C
Humidity between 40 to 60%
2. PROTOCOL FOR REPROCESSING OF SINGLE USE DEVICES:
2.1. Definition / Abbreviation
2.1.1. Single use or disposable devices: A device that is marketed or labeled for single patient
use or single procedure use. It is not marketed or labeled with the intent of reusing the
device on another patient. The labeling identifies the device as single use or disposable
and does not include instructions for reprocessing.
2.1.2. Note: Some SUD’s are marketed and labeled as non-sterile and include appropriate pre
use sterilization or processing instructions to make the device patient ready. This is not
considered as “reprocessing”.

CSSD
2.1.3. Open but Unused: An “Open but Unused” product is a SUD whose sterility has been
breached or whose sterile package was opened but the device has not been used on a
patient. This also includes a device whose packaging has expired as identified by the
label on the package.
2.1.4. Reuse: The repeated use or multiple use of any medical device on the same patient or
different patients, with applicable reprocessing (cleaning, functionality verification,
and or disinfecting /sterilization) between uses.
2.1.5. Reprocessing: Reprocessing includes all operation performed to assure that a

previously used SUD is clean, sterile and will function as intended by the original
equipment manufacturer (OEM). The process includes, but is not limited to,
disinfection, cleaning, functional verification, packaging and possibly, sterilization.
2.1.6. Resterilization: The repeated application of a terminal process designed to remove or

destroy all viable forms of microbial life, including bacterial spores, to an acceptable
sterility level.
2.1.7. SUD: Single Use Device
2.1.8. OEM: Original Equipment Manufacture
2.2. Responsibility:
2.2.1. Infection Control Committee
2.2.2. Medical and Emergency Department
2.2.3. Nursing Department
2.2.4. CSSD
2.3. Policy:
The hospital has adopted the following policy regarding the reprocessing of SUD:

CSSD
2.3.1. The hospital is committed to reprocess SUD’s in a manner so as to ensure patient

safety and stringent quality control.
2.3.2. SUD’s that may be reprocessed are listed. SUD’s not listed cannot be reprocessed and
should be discarded after single use.
2.3.3. Authority:Authority for the program is vested with the Infection Control Committee.
The Infection Control Committee will follow the policies set forth regarding the
reprocessing of SUD’s.
2.4. Procedure:
Since disposable devices are expensive and there is evidence of reprocessing a variety of
instruments, in SMVMCH we have a list of devices that we utilize after ETO sterilization.
Whenever reprocessed device is utilized it is documented and informed to patients.
2.5. List of single-use devices reutilized in SMVMCH:
Sl.No Device reprocessed once Device reprocessed twice

1 Nasal prong yellow Teflon 260 cm catheter
2 Ventilator –T-tube JR catheter
3 Venous cannula PN Femoral sheath
4 Aortic cannula Valve sizer
5 Aortic punch TIG 5F catheter
6 Vein cannula Angio set
7 Bain circuit PTCA set
8 CPAP circuit EBU 5F catheter
9 Ventilator circuit Balloon catheter
10 Aortic root cannula Femoral sheath
11 Shunt Radial sheath

CSSD
12 Octopus
2.5.1. The devices to be reprocessed will be decided by the hospital infection committee
along with the discussion with concerned consultants who requested their devices
to be reprocessed.
2.5.2. Once approved the device shall be sent to CSSD after recording in the register.
2.5.3. In the CSSD the device is received and disinfection process is carried out
immediately by enzyme treatment for ½ hr.
2.5.4. Then the device is washed with water air dried completely
2.5.5. The device is then marked using markers of different colors to identify the number
of reprocessing as follows,
2.5.5.1. Red color – 1st time
2.5.5.2. Black color – 2nd time
2.5.5.3. Blue color – 3rd time
2.5.6. When the device with black marking reaches CSSD the devices is discarded. In
special situations with the specific request from consultants, the situation is
reassessed by committee and then reprocessed 3rd time by marking blue.
2.5.7. Even with special request the devices are not reprocessed for the 4th time.
2.5.8. The dried device is checked for integrity and then packed appropriately.
2.5.9. Labeled with batch number, date of sterilization and date of expiry (usually 6
months).
2.5.10. The packed device will be ETO sterilized.
2.5.11. The device is delivered at request.
2.5.12. Record is maintained in CSSD.
3. REFERENCES :

Amendment Date :16.08.2021 INFECTION CONTROL RISK Issue Date:18.08.2021
ASSESSMENT
1. Infection Control Risk Assessment (ICRA)
1.1. Matrix of Precautions for Construction & Renovation
Facility / Site: Project Start Date:

Job Name & Number: Project End Date:
Location of Construction : Estimated Duration:
(Building, Department, Floor, Room)
1.2. Identify the type of construction project activity (Type A-D):
Inspection and Non-Invasive Activities.

Includes, but is not limited to:
 removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50
square feet
TYPE A  painting (but not sanding)

 wall covering, electrical trim work, minor plumbing, and activities which do
not generate dust or require cutting of walls or access to ceilings other than for
visual inspection.
Small scale, short duration activities which create minimal dust

 installation of telephone and computer cabling
TYPE B
 access to chase spaces
 cutting of walls or ceiling where dust migration can be controlled.

ASSESSMENT
Work that generates a moderate to high level of dust or requires demolition or

removal of any fixed building components or assemblies
 sanding of walls for painting or wall covering
 removal of floorcoverings, ceiling tiles and casework
TYPE C
 new wall construction
 minor duct work or electrical work above ceilings
 major cabling activities
 Any activity which cannot be completed within a single workshift.
Major demolition and construction projects

 activities which require consecutive work shifts
TYPE D
 requires heavy demolition or removal of a complete cabling system
 New construction.

ASSESSMENT
1.3. Identify the Patient Risk Groups that will be affected.

If more than one risk group will be affected, select the higher risk group:
Minimal Risk Low Risk Medium Risk High Risk
i. Office i. Cardiology i. CCU i. Any area caring for

areas ii. Echocardiography ii. Emergency Room immunocompromised
iii. Endoscopy iii. Labor & Delivery patients
iv. Nuclear Medicine iv. Laboratories ii. Burn Unit
v. Physical Therapy (specimen) iii. Cardiac Cath Lab
vi. Radiology/MRI v. Medical Units iv. Central Sterile Supply
vii. Respiratory vi. Newborn Nursery v. Intensive Care Units
Therapy vii. Outpatient Surgery vi. Negative pressure
viii. Pediatrics isolation rooms
ix. Pharmacy vii. Oncology
x. Post Anesthesia Care viii. Operating rooms
Unit including C-section

rooms
xi. Surgical Units
1.4. IC MATRIX – DETERMINE CLASS OF PRECAUTION USING IC MATRIX
Construction Project Type

– Dust Level
i. Patient Risk Group TYP TYP TYP TYP
EA EB EC ED
ii. Minimal Risk Group 1 I I I III

ASSESSMENT
iii. Low Risk Group 2 I II III IV

iv. Medium Risk Group 3 I III IV IV
v. High Risk Group 4 II III IV IV
2. Precaution class
2.1. Identify the areas surrounding the project area, assessing potential impact:
Unit Below Unit Above Lateral Lateral Behind Front
Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group
2.2. Identify specific site of activity e.g., patient rooms, medication room, etc.
2.3. Identify issues related to: ventilation, plumbing, electrical in terms of the
occurrence of probableoutages.
2.4. Identify containment measures, what type of barriers? (E.g., solids wall barriers); Will
HEPA filtration is required?
(Note: Renovation/construction area shall be isolated from the occupied areas during
construction)
2.5. Consider potential risk of water damage. Is there a risk due to compromising

ASSESSMENT
structural integrity? (e.g., wall, ceiling, roof)
2.6. Work hours: Can or will the work be done during non-patient care hours?
2.7. Do the plans allow for the required number & type of handwashing sinks? (
specify No) Does the infection prevention & control staff agree with the minimum
number of sinks for thisproject? Y/N
2.8. Does the infection prevention & control staff agree with the plans relative to
clean and soiledutility rooms? Y/N
2.9. Plan of containment issues with the project team.

E.g., traffic flow, housekeeping, debris removal (how and when),
2.10. Additional Requirements:

2.10.1. Provide air monitoring during construction
2.10.2. Construct anteroom outside area of construction
2.10.3. Workers to wear clean paper coveralls and shoe covers when entering or existing job
site.
ICRA Requested By: ICRA Approved By:

Name : Name:
Signature: Signature

ASSESSMENT
Date: Date:
3. Description of Required Infection Control Precautions by Class
During Construction Project Upon Completion of Project

1. Execute work by methods to minimize 1. Clean work area upon completion of
CLASS I
raising dust from construction operations. task.

2. Immediately replace a ceiling tile
displaced for visual inspection
1. Provide active means to prevent airborne 1. Wipe work surfaces with

dust from dispersing into atmosphere. cleaner/disinfectant.
2. Water mist work surfaces to control 2. Contain construction waste before
dust while cutting. transport in tightly covered containers.
3. Seal unused doors with duct tape. 3. Wet mop and/or vacuum with HEPA
4. Block off and seal air vents. filtered vacuum before leaving work
CLASS II
5. Place dust mat at entrance and exit of work area.

area 4. Upon completion, restore HVAC
6. Remove or isolate HVAC system in system where work was
areas where work is being performed. performed.

ASSESSMENT
1. Remove or Isolate HVAC system in 1. Do not remove barriers from work

area where work is being done to area until completed project is
prevent contamination of duct system. inspected by the owner’s
2. Complete all critical barriers i.e. Safety Department and Infection
sheetrock, plywood, plastic, to seal area Prevention & Control Department and
from non work area or implement control thoroughly cleaned bythe owner’s
cube method (cart with plastic covering Environmental Services Department.
CLASS III
and sealed connection to work site with 2. Remove barrier materials

HEPA vacuum for vacuuming prior to carefully to minimize spreading
exit) before construction begins. of dirt and debris associated
3. Maintain negative air pressure within with construction.
work site utilizing HEPA equipped air 3. Vacuum work area with HEPA
filtration units. filtered vacuums.
4. Contain construction waste before 4. Wet mop area with cleaner/disinfectant.
transport in tightly covered containers. 5. Upon completion, restore HVAC
5. Cover transport receptacles or carts. Tape system where work was
covering unless solid lid. performed.

ASSESSMENT
1. Isolate HVAC system in area where work 1. Do not remove barriers from work
is being done to prevent contamination of area until completed project is
duct system. inspected by the owner’s
2. Complete all critical barriers i.e. Safety Department and Infection
sheetrock, plywood, plastic, to seal area Prevention & Control Department and
from non-work area or implement control thoroughly cleaned by the owner’s
cube method (cart with plastic covering Environmental Services Dept.
and sealed connection to work site with 2. Remove barrier material carefully to
HEPA vacuum for vacuuming prior to minimize spreading of dirt and debris
exit) before construction begins. associated with construction.
3. Maintain negative air pressure within
3. Contain construction waste before
CLASS IV
work site utilizing HEPA equipped air transport in tightly covered containers.
filtration units.
4. Cover transport receptacles or
4. Seal holes, pipes, conduits, and punctures.
carts. Tape covering unless solid
5. Construct anteroom and require all
lid.
personnel to pass through this room so
5. Vacuum work area with HEPA
they can be vacuumed using a HEPA
filtered vacuums.
vacuum cleaner before leaving work site or
they can wear cloth or paper coveralls that 6. Wet mop area with cleaner/disinfectant.
are removed each time they leave work 7. Upon completion, restore HVAC
site. system where work was
6. All personnel entering work site are performed.
required to wear shoe covers. Shoe
covers must be changed each time the
worker exits the work area.

ASSESSMENT
4. REFERENCES :

ANNEXURE

ANNEXURE

ANNEXURE

ANNEXURE

ANNEXURE
1. REFERENCES :

AMENDMENTS
Section/
Sl. Page Date of Amendment Reasons For Amended Approved
Clause/
No. No Amendment Made Amendment By by
Para/Line
Review and
Up gradation
of all
Sections of Up-gradation
Hospital of NABH
1
Infection Main NABH
1 to All 25-02-2019
Control Accreditation coordinator
86
Manual as 5th Edition
per NABH April 2020.
Main
Accreditation
requirements.
Up-gradation
of NABH
87
Disinfection Disinfection Main NABH
2 to 30-12-2019
policy policy Accreditation coordinator
96
5th Edition
April 2020.

AMENDMENTS
Section/
Clause/
Para/Line
97 Biomedical Biomedical
to waste waste
Up-gradation
106 management, management,
of NABH
Laundry and Laundry and
Main NABH
3 and linen 27-03-2020 linen
Accreditation coordinator
management, management,
5th Edition
110 High risk High risk
April 2020.
to areas and areas and
116 procedures procedures
Up-gradation
Protocol for Protocol for of NABH
107
reprocessing reprocessing Main NABH
4 to 24.07.2020
of single use of single use Accreditation coordinator
110
devices devices 5th Edition
April 2020.

AMENDMENTS
Section/
Clause/
Para/Line
Review and
Up gradation
of all
Sections of Up-gradation
Hospital of NABH
Infection Main NABH
5 All All 16.08.2021
Control Accreditation coordinator
Manual as 5th Edition
per NABH April 2020.
Main
Accreditation
requirements.
Up-gradation
Hospital
of NABH
Infection
Main NABH
6 3 All 17.07.2023 Control
(Newly
5th Edition
added)
April 2020.

AMENDMENTS
Section/
Clause/
Para/Line
Up-gradation
Staff Health:
of NABH
Work
Main NABH
7 89 All 17.07.2023 Restriction
(Newly
5th Edition
added)
April 2020.
Up-gradation
Infection
of NABH
Control Risk
Main NABH
8 105 All 17.07.2023 Assessment
(Newly
5th Edition
added)
April 2020.

AMENDMENTS
Designation Signature
Dr.T.Mangaiyarkarasi,
Prepared By Professor
Department of Microbiology
Dr.R.Gopal,
Reviewed By Professor and Head
Department of Microbiology
Approved By Dr.D.Rajagovindan, Director
Dr. M. Pragash
Issued By
NABH Coordinator

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SMVMCH/MB/HIC/01 Page 1 of 123

Amendment No:04 Issue No:05

POLICY AND PROCEDURE -

STANDARD OPERATING PROCEDURES