Study on Infection Control Management.

Name of Student
Dr. Ashish Suryanath Singh

Enrolment Number
ODL00003511

Course Name
MBA in Health Management

Study Conducted at
QUEENS CARE HOSPITAL

Submitted To
DY PATIL UNIVERSITY (NAVI MUMBAI)

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 Acknowledgment

I am profoundly grateful to everyone who contributed to the successful completion

of my study on Infection Control Management at Queens Care Hospital.

Firstly, I would like to express my heartfelt gratitude to the faculty of DY Patil

University, Navi Mumbai, for their invaluable guidance, encouragement, and
constructive feedback throughout this academic journey. Their support provided the
foundation upon which this study was built.

I extend my sincere appreciation to the management of Queens Care Hospital,

especially our esteemed CEO, Ms. Shehnaz Siddiqui, for granting me the
opportunity to conduct this study and for providing the necessary resources and
administrative support. Her vision and leadership have been a source of inspiration
for this project.

I am particularly thankful to Ms. Aasifa Ghabrani, the Infection Control Nurse,

whose expertise, insights, and dedication to infection control were pivotal in
gathering critical information for this study. Her hands-on experience and
cooperation greatly enriched the research process.

I would also like to acknowledge the contributions of Ms. Jaya Binju, the Quality
Control Manager, for her unwavering support in providing access to hospital
quality control data and for sharing her knowledge about best practices in
maintaining healthcare standards. Her attention to detail and commitment to
excellence were instrumental in shaping the findings of this study.

Finally, I owe a debt of gratitude to the entire staff of Queens Care Hospital for their
kind cooperation and assistance during the research. Their dedication to patient care
and adherence to infection control protocols served as a practical reference for this
study.This project would not have been possible without the collective efforts of all
the aforementioned individuals, to whom I am deeply indebted.

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3
 Table of Contents

1. Title Page

2. Acknowledgments

3. Certificate of Authenticity

4. Declaration of Originality

5. Introduction

6. Background

7. Methodology

8. Data Presentation and Analysis

9. Conclusions & Recommendations

10. Limitations

11. References

12. Annexures

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 Introduction

Definition of Infection Control Management (ICM):

 Infection Control Management (ICM) refers to a systematic approach to

preventing and managing infections within healthcare settings.

 It involves policies, procedures, and practices designed to minimize the risk of

infections, ensuring a safe environment for both patients and healthcare
workers.

 ICM plays a critical role in healthcare by reducing the incidence of infections

and ensuring quality patient care.

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Importance of ICM in Hospitals:

Infection Control Management is essential in hospitals for several reasons:

1. Reduction of Hospital-Acquired Infections (HAIs):
 HAIs are infections that patients acquire during their hospital stay,
which were neither present nor incubating at the time of admission.

 Effective ICM measures can significantly reduce the prevalence of

HAIs, improving patient outcomes and hospital reputation.

2. Compliance with Accreditation Standards:

 Hospitals are required to adhere to strict infection control protocols to
meet the standards set by accreditation bodies such as the National
Accreditation Board for Hospitals & Healthcare Providers (NABH)
and Joint Commission International (JCI). Adherence to these
standards demonstrates a hospital's commitment to providing safe and
high-quality care.

3. Safeguarding Patient and Staff Health:

 Implementing robust infection control measures protects both patients
and healthcare workers from preventable infections, ensuring a safer and
healthier hospital environment.

Global and National Context:

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  Hospital-Acquired Infections (HAIs) are a significant challenge
worldwide. According to global statistics, approximately 7-10% of
hospitalized patients acquire at least one HAI during their stay.

 In India, studies have shown a higher prevalence of HAIs, ranging from

11-25%, underscoring the urgent need for effective infection control
measures.

The World Health Organization (WHO) has emphasized the importance of

infection control through initiatives like “Clean Care is Safer Care.” This global
campaign highlights hand hygiene and other critical practices to reduce infection
risks. In India, national programs and guidelines have been implemented to tackle
the burden of HAIs and improve healthcare safety standards.

Objective of the Study:

The primary objectives of this study are as follows:

1. To analyze the effectiveness of infection control practices implemented at

Queens Care Hospital.

2. To recommend strategies for improvement in infection control measures to

align with global best practices and accreditation requirements.

Background

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The study is based on Queens Care Hospital, located at Ammar Meadows,
Opposite Shil Fire Office, Kalyan Phata, Mumbra. Established in August 2021,
Queens Care Hospital has rapidly established itself as a leading healthcare provider
in the region, known for its patient-centric approach and commitment to quality
care.

The hospital is a multi-specialty facility offering a wide array of medical services,

including:
 General Medicine
 Pediatrics and Neonatology
 Obstetrics and Gynecology
 Cardiology
 Orthopedics
 Gastroenterology
 Pulmonology
 Neurology
 Nephrology
 Oncology
 ENT (Ear, Nose, and Throat)
 Dermatology
 General and Laparoscopic Surgery
 Urology
 Endocrinology
 Critical Care and Intensive Care Units (ICU/NICU)
 Radiology and Diagnostic Services
 Physiotherapy and Rehabilitation

With 85 beds, Queens Care Hospital operates at over 70% patient occupancy,
reflecting its reputation for high-quality care and trustworthiness in the community.

Infection Control Policies Currently in Place:

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Queens Care Hospital has established comprehensive infection control policies to
safeguard patients, staff, and visitors. The key policies include:

1. Hand Hygiene Protocols:

o Strict compliance with WHO’s “5 Moments for Hand Hygiene.”

o Availability of alcohol-based hand sanitizers at all critical points.

2. Surveillance of Hospital-Acquired Infections (HAIs):

o Regular monitoring and reporting of HAIs to identify trends and

improve protocols.

3. Isolation and Quarantine Procedures:

o Dedicated isolation units for infectious diseases like COVID-19,

tuberculosis, and other communicable diseases.

o Quarantine zones for suspected cases until diagnosis confirmation.

4. Sterilization and Disinfection Protocols:

o Daily and terminal cleaning of patient care areas.

o Advanced sterilization techniques for surgical and diagnostic equipment.

5. PPE (Personal Protective Equipment):

o Mandatory PPE use for all staff, particularly in high-risk areas such as
ICUs and surgical theaters.

6. Staff Education and Training:

o Ongoing infection control training programs, including sessions on

recent updates in infection prevention techniques.

o Simulation drills for outbreak response preparedness.

7. Antibiotic Stewardship Program:

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 o Implementation of guidelines for the rational use of antibiotics to
prevent antimicrobial resistance.

8. Biomedical Waste Management:

o Stringent segregation, storage, and disposal of biomedical waste

following local government regulations and WHO standards.

9. Visitor Management System:

o Restricted and monitored entry of visitors in sensitive zones.

o Mandatory hand hygiene and PPE compliance for visitors.

10. Air Quality Control Measures:

o Regular monitoring of air quality in operation theaters and ICUs.

o Use of HEPA filters and UV sterilization in critical areas.

11. Vaccination Programs:

o Mandatory staff immunizations, including Hepatitis B, Influenza, and

COVID-19 vaccines.

These policies align with international best practices and are crucial in meeting the
requirements of NABH and JCI accreditation standards, enhancing overall hospital
safety and quality of care.

Identified Problem:

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Hospital-Acquired Infections (HAIs) remain a persistent challenge in healthcare
facilities, particularly in critical care units such as the Intensive Care Unit (ICU)
and Neonatal Intensive Care Unit (NICU). At Queens Care Hospital, a notable rise
in HAIs has been observed, warranting an in-depth analysis of infection control
practices to identify gaps and implement corrective measures.

One of the key issues contributing to the rise in HAIs is inadequate hand hygiene
compliance among healthcare workers in the ICU. Despite the availability of
alcohol-based hand sanitizers and the presence of visible hand hygiene guidelines,
lapses in adherence have been reported. This is concerning because hand hygiene is
universally recognized as the most effective measure to prevent the transmission of
pathogens in healthcare settings.

Examples and Contributing Factors:

1. Non-Compliance with Protocols:

Observations and audits revealed that healthcare workers did not consistently
follow the “5 Moments for Hand Hygiene” recommended by the World
Health Organization (WHO).

These moments include:

o Before patient contact.

o Before aseptic procedures.

o After exposure to bodily fluids.

o After patient contact.

o After contact with patient surroundings.

2. High Workload and Staff Shortage:

The ICU operates at over 70% capacity, with staff frequently managing
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 multiple critical patients simultaneously. This high workload may lead to
lapses in following infection control protocols due to time constraints.

3. Knowledge Gaps:
While training programs are conducted, some staff members may lack an in-
depth understanding of the importance of strict hand hygiene compliance in
preventing HAIs.

4. Inadequate Monitoring and Feedback:

Regular monitoring and immediate feedback mechanisms for hand hygiene
compliance are not consistently enforced, leading to missed opportunities for
behavior correction.

5. Environmental Challenges:

o Placement of hand hygiene stations may not always be optimal for easy
accessibility.

o Limited availability of PPE and sanitizer refills during peak hours has
occasionally been reported.

Impact on Patient Outcomes:

The rise in HAIs in critical care units has led to:

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  Increased Morbidity and Mortality: Patients in the ICU are already
immunocompromised, and HAIs further exacerbate their condition, increasing
hospital stays and risk of complications.

 Extended Length of Stay (LOS): Infections prolong recovery, burdening

both the patient and hospital resources.

 Higher Healthcare Costs: Managing infections involves additional diagnostic

tests, prolonged treatments, and specialized interventions, escalating costs for
both patients and the hospital.

Addressing these issues requires an urgent and collaborative approach to reinforce

compliance, enhance training, and improve monitoring of infection control practices
to ensure patient safety and quality care in critical care units.

Methodology

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Problem Identification

Effective infection control management is critical in maintaining high-quality

healthcare standards, reducing hospital-acquired infections (HAIs), and ensuring
patient and staff safety. At Queens Care Hospital, a detailed assessment revealed
significant gaps in infection control practices. These gaps contribute to the rising
trends of HAIs, particularly in high-risk areas such as the Intensive Care Unit (ICU),
Operation Theaters (OT), and wards with high patient turnover.

Specific Infection Control Gaps Identified

1. Improper Waste Segregation:

o Observation: Biomedical waste, including hazardous and infectious

materials, was not consistently segregated into appropriate categories.
Instances of sharps and general waste being disposed of together were
noted during audits.

o Impact: Improper segregation increases the risk of cross-contamination,

needle-stick injuries among staff, and environmental hazards. It also
results in non-compliance with Biomedical Waste Management Rules,
2016, and accreditation standards.

o Root Causes:

 Insufficient staff training on waste segregation protocols.

 Inadequate signage or visual aids at disposal points.

 Overfilled bins in high-traffic areas, leading to improper disposal.

2. Lack of PPE Training and Usage Compliance:

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 o Observation: Healthcare workers were found to be using PPE, such as
gloves, masks, and gowns, inconsistently. For example:

 Reusing disposable gloves between patient contacts.

 Improper donning and doffing of gowns, leading to self-

contamination.

o Impact: Poor PPE practices increase the risk of transmission of

infectious agents to both patients and healthcare providers, leading to
preventable HAIs.

o Root Causes:

 Limited availability of PPE during peak hours.

 Lack of hands-on training sessions and refresher courses for staff.

 Complacency or perceived low-risk scenarios, especially in non-

critical cases.

3. Inconsistent Hand Hygiene Compliance:

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 o Observation: Compliance with WHO’s “5 Moments for Hand Hygiene”
was not consistently practiced by healthcare workers, especially during
emergencies or in high-turnover wards. Alcohol-based hand sanitizers
were sometimes found empty in critical care units.

o Impact: Non-compliance with hand hygiene protocols remains one of

the leading causes of HAIs, significantly affecting patient recovery times
and increasing healthcare costs.

o Root Causes:

 High workload and understaffing, particularly in critical care units.

 Poor placement of hand hygiene stations in patient care areas.

 Gaps in monitoring and real-time feedback for staff adherence.

4. Inadequate Environmental Cleaning and Disinfection:

o Observation: High-touch surfaces, such as bed rails, doorknobs, and

medical equipment, were not disinfected as frequently as required,
particularly during night shifts.

o Impact: These lapses increase the risk of indirect pathogen

transmission. In an ICU setup, where patients are already
immunocompromised, this could lead to severe complications.

o Root Causes:

 Absence of clearly defined cleaning schedules.

 Lack of accountability among housekeeping staff.

 Use of substandard cleaning agents in some instances.

5. Limited Surveillance of HAIs:

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 o Observation: While the hospital conducted annual infection control
audits, there was limited real-time surveillance or data analysis to
identify trends or hotspots for HAIs.

o Impact: Delayed identification of infection outbreaks hampers timely

interventions, leading to prolonged patient stays and increased costs.

o Root Causes:

 Insufficient staffing in infection control teams.

 Lack of advanced software or systems for data collection and

analysis.

Importance of Addressing These Gaps

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 1. For Patient Safety:

o Addressing infection control gaps is directly linked to reducing HAIs,

improving recovery rates, and minimizing complications for patients.
This is particularly important in critical care areas, where even minor
lapses can have life-threatening consequences.

2. For Staff Safety:

o Proper waste segregation and PPE usage protect healthcare workers

from exposure to infectious agents, needle-stick injuries, and other
occupational hazards.

3. For Cost Savings:

o HAIs significantly increase healthcare costs due to extended patient

stays, additional treatments, and increased use of resources. By
improving infection control practices, the hospital can reduce these
avoidable expenses.

o Compliance with infection control standards also minimizes penalties or

legal liabilities arising from non-compliance with national regulations.

4. For Accreditation and Reputation:

o Adherence to infection control protocols aligns with standards set by

NABH, JCI, and other accrediting bodies, which are essential for
building patient trust and enhancing the hospital’s reputation.

5. For Long-Term Sustainability:

o Implementing robust infection control measures ensures long-term

sustainability by fostering a safer, more efficient healthcare
environment, reducing staff burnout, and optimizing resource utilization.

Objectives:

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The objectives of this study on infection control management at Queens Care
Hospital are outlined below in extensive detail:

1. To Evaluate the Current Infection Control Practices

This objective focuses on understanding and assessing the existing infection control
measures in the hospital to identify areas of strength and weakness.

1. Thorough Review of Protocols and Policies:

o Examine the hospital's written infection control guidelines and standard
operating procedures (SOPs) to ensure alignment with national and
international standards such as the National Accreditation Board for
Hospitals & Healthcare Providers (NABH) and World Health
Organization (WHO) protocols.
o Assess the implementation and regular updating of these guidelines to
reflect new evidence or changes in regulations.
2. Monitoring Compliance:
o Evaluate adherence to critical infection control practices, such as:
 Hand Hygiene Compliance: Determine the frequency and
consistency of handwashing or sanitizer use among healthcare
workers.
 PPE Usage: Assess how often and effectively healthcare workers
use personal protective equipment in high-risk areas.
 Waste Management Practices: Review waste segregation,
collection, and disposal processes for compliance with the
Biomedical Waste Management Rules, 2016.
o Identify gaps in adherence by conducting direct observations, audits, and
reviewing infection control logs.
3. Assessment of Critical Areas:

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 o ICU: Examine how well infection control protocols are maintained in
this high-risk environment, including sterilization practices and the
frequency of environmental cleaning.
o Operation Theaters (OT): Review the sterilization of surgical
instruments, aseptic techniques, and air filtration systems to prevent
surgical site infections.
o High-Turnover Wards: Analyze patient turnover's impact on cleaning
and infection prevention practices.
4. Evaluate Training and Awareness:

o Analyze the frequency and effectiveness of staff training programs on

infection control.
o Identify gaps in staff knowledge regarding key infection prevention
practices.
5. Examine Infrastructure and Resources:

o Assess the availability of essential resources such as PPE, hand

sanitizers, disinfectants, and sterilization equipment.
o Identify infrastructural challenges, such as suboptimal placement of
hand hygiene stations or lack of isolation rooms for infected patients.
6. Data Collection and Trend Analysis:
o Review historical data from hospital infection control audits to identify
trends or recurring issues, such as spikes in HAIs during specific periods
or in certain departments.
o Compare infection rates with benchmarks or averages for similar
hospitals.

2. To Propose Actionable Solutions to Improve Infection Prevention

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This objective involves developing practical and sustainable strategies to address the
gaps identified in infection control practices.

1. Strengthening Protocols and Compliance:

o Enhanced Hand Hygiene Practices:
 Introduce innovative solutions such as automated hand hygiene
monitoring systems to track compliance in real-time.
 Increase the availability and accessibility of hand sanitizers,
particularly in high-traffic areas.
o Improved Waste Management:
 Redesign waste disposal workflows to ensure compliance with
segregation and disposal standards.
 Conduct regular audits to reinforce accountability and address non-
compliance.
2. Upgrading Training Programs:
o Organize hands-on workshops and simulation-based training sessions to
reinforce best practices in hand hygiene, PPE usage, and sterilization.
o Introduce periodic refresher courses for all staff, emphasizing the
importance of infection control.
o Customize training modules for different staff roles to address specific
infection control responsibilities.
3. Implementing Advanced Monitoring Systems:
o Establish a robust surveillance system for real-time tracking of HAIs and
infection control compliance.
o Develop dashboards to provide actionable insights from collected data,
enabling quicker identification of trends and hotspots.

4. Enhancing Environmental Cleaning:

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 o Revise cleaning schedules to ensure more frequent disinfection of high-
touch surfaces in critical areas.
o Introduce the use of advanced disinfection technologies, such as UV
light sterilizers, in ICUs and OTs.
5. Increasing Staff Accountability:
o Implement a reporting and feedback mechanism to encourage staff
compliance with infection control practices.
o Create an incentive program to recognize and reward departments or
individuals with exemplary infection control performance.
6. Boosting Resource Availability:
o Ensure an uninterrupted supply of essential materials, including PPE,
cleaning agents, and sterilization equipment.
o Invest in infrastructure improvements, such as better placement of hand
hygiene stations and upgrading ventilation systems in OTs.
7. Community and Patient Engagement:
o Educate patients and visitors about their role in infection prevention,
such as proper hand hygiene and compliance with hospital policies.
o Develop visual aids like posters and videos in waiting areas to promote
awareness.
8. Alignment with Accreditation Standards:
o Align proposed solutions with the specific infection control criteria
outlined by accreditation bodies like NABH and Joint Commission
International (JCI).
o Conduct regular mock audits to ensure continuous compliance and
preparedness for formal inspections.

Expected Outcomes:

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  Reduction in HAIs: A measurable decline in infection rates across all critical
areas.
 Improved Staff Performance: Higher compliance with infection control
protocols due to better training and accountability measures.
 Enhanced Patient Safety: Improved health outcomes and shorter hospital
stays for patients.
 Cost Savings: Reduced costs associated with HAIs, including treatment,
prolonged stays, and resource utilization.
 Accreditation Readiness: Stronger alignment with NABH and JCI standards,
contributing to the hospital’s reputation and trustworthiness.

Scope of Study
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The scope of this study on Infection Control Management (ICM) at Queens Care
Hospital focuses on key hospital areas most vulnerable to infection risks. These
areas include the Intensive Care Unit (ICU), Operation Theaters (OT), and wards
with high patient turnover. The study also emphasizes the broader applicability of its
findings to improve the hospital's overall infection control practices, aligning with
accreditation standards and enhancing patient safety outcomes.

Focus on Key Areas

1. Intensive Care Unit (ICU):

The ICU is a critical area where infection control is paramount due to the
nature of patients treated in this unit.
o High-Risk Environment:
Patients in the ICU often have compromised immune systems, invasive
medical devices (e.g., central lines, ventilators), and extended hospital
stays, making them more susceptible to infections like ventilator-
associated pneumonia (VAP), catheter-associated urinary tract infections
(CAUTIs), and bloodstream infections (BSIs).
o Assessment Areas:
 Compliance with aseptic techniques during procedures.
 Frequency and thoroughness of environmental cleaning.
 Availability and proper use of personal protective equipment
(PPE).
 Monitoring and maintaining the sterility of invasive devices.
o Objective in the ICU:
To identify gaps in infection control practices and propose solutions that
minimize infection risks in critically ill patients.

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2. Operation Theaters (OT):
The OT is another high-stakes area where strict infection control measures are
non-negotiable to prevent surgical site infections (SSIs).
o Sterilization Protocols:
Assess the sterilization of surgical instruments, air quality in the OT
(e.g., HEPA filtration), and aseptic techniques used by surgical teams.
o Environmental Cleaning:
Examine the cleaning and disinfection protocols between surgeries and
at the end of the day to ensure a sterile environment.
o Staff Hygiene:
Evaluate the adherence to hand hygiene and proper donning and doffing
of PPE by the surgical team and support staff.
o Objective in the OT:
To ensure that infection prevention measures in the OT are aligned with
global best practices to reduce SSIs and improve surgical outcomes.
3. Wards with High Patient Turnover:
Wards with high patient turnover often experience challenges related to
infection control due to the constant movement of patients, staff, and visitors.
o Challenges Identified:
 Quick turnaround times for patient beds can result in inadequate
cleaning and disinfection.
 High patient density increases the risk of cross-infections.
 Visitors and staff movement can compromise infection control
practices.

o Assessment Areas:
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  Evaluate the cleaning and sanitization protocols followed during
patient discharge and admission.
 Monitor hand hygiene practices among staff, patients, and visitors.
 Assess the availability and proper use of isolation rooms for
infectious patients.
o Objective in High-Turnover Wards:
To create standardized workflows that ensure effective infection control
despite the challenges posed by high patient traffic.

Applicability of Findings to Improve Hospital Accreditation Scores

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1. Alignment with Accreditation Standards:

Infection control is a cornerstone of hospital accreditation programs such as

the National Accreditation Board for Hospitals & Healthcare Providers

(NABH) and Joint Commission International (JCI). These programs

emphasize rigorous infection prevention protocols as part of their patient

safety and quality assurance criteria.

o Findings from this study will help identify specific areas where the
hospital can strengthen compliance with these standards.
o Addressing infection control gaps will directly contribute to fulfilling
requirements for clinical safety, staff training, waste management, and
patient care quality.

2. Enhancing Quality Indicators:

o Accreditation bodies assess hospitals based on measurable quality
indicators, such as infection rates, hand hygiene compliance, and
sterilization effectiveness.
o By implementing the recommendations from this study, the hospital can
improve these indicators, leading to better scores during accreditation
assessments.

3. Building a Culture of Safety:

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 o Findings from the study will guide the hospital in fostering a safety-
oriented culture, emphasizing infection prevention at every level.
o Staff education and awareness campaigns derived from the study’s
findings will create a more informed workforce, reducing the likelihood
of non-compliance and errors.

4. Reputation and Patient Trust:

o Accreditation scores are often viewed as a measure of hospital reliability
by patients and stakeholders. Improved infection control practices will
enhance the hospital’s reputation, leading to greater patient trust and
satisfaction.
o High standards in infection prevention directly contribute to better
patient outcomes, shorter hospital stays, and lower readmission rates,
reinforcing the hospital’s commitment to quality care.

5. Cost Optimization:
o Accreditation processes also evaluate the hospital's efficiency in
resource utilization. By addressing infection control gaps, the hospital
can reduce costs associated with prolonged patient stays, additional
treatments for HAIs, and penalties for non-compliance.

Review of Literature
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The Review of Literature explores the impact of Hospital-Acquired Infections
(HAIs) on patient outcomes and the importance of effective infection control
management. It references globally recognized guidelines like those from the
Centers for Disease Control and Prevention (CDC) and National Accreditation
Board for Hospitals & Healthcare Providers (NABH), which are widely
implemented in hospitals worldwide, including Queens Care Hospital. These
guidelines inform infection control practices and their implications for reducing
HAIs and improving patient safety. The literature review draws upon evidence-based
practices and provides an overview of how infection control impacts patient
outcomes in healthcare settings.

Hospital-Acquired Infections (HAIs) and Their Impact on Patient Outcomes

1. Prevalence and Types of HAIs

Hospital-acquired infections are a major concern globally and pose a significant

burden on healthcare systems. HAIs refer to infections that patients acquire during
the course of receiving treatment for other conditions within a healthcare setting.
These infections usually become evident 48 hours or more after admission and can
involve multiple microorganisms, including bacteria, viruses, fungi, and parasites.

Common types of HAIs include:

 Ventilator-associated pneumonia (VAP)

 Catheter-associated urinary tract infections (CAUTIs)
 Surgical site infections (SSIs)
 Bloodstream infections (BSIs)
 Clostridium difficile infections (C. difficile)

According to the World Health Organization (WHO), one in 10 patients in

hospitals worldwide is affected by at least one HAI during their hospital stay. In
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India, studies have shown that the prevalence of HAIs is even higher, with infections
being particularly common in intensive care units (ICUs), post-surgical recovery
areas, and neonatal intensive care units (NICUs).

Impact on Patient Outcomes:

 Prolonged Hospital Stay:

HAIs significantly increase the length of hospital stays, which can lead to
additional complications and a higher cost of care. For instance, ventilator-
associated pneumonia (VAP) can extend ICU stays by up to 10 days,
contributing to increased hospital expenses.
 Increased Morbidity and Mortality:
The presence of HAIs has been directly linked to an increase in morbidity
(illness) and mortality (death). Infected patients often experience prolonged
suffering, more invasive treatments, and higher rates of sepsis and organ
failure, leading to increased risk of death.
 Economic Burden:
A report by the CDC states that HAIs cost hospitals in the United States over
$10 billion annually, and the economic burden on low- and middle-income
countries, including India, can be significantly higher due to resource
constraints and higher rates of infection.

Infection Control and the CDC Guidelines

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The Centers for Disease Control and Prevention (CDC) provides comprehensive
guidelines on infection control in healthcare settings, which serve as the foundation
for practices in hospitals worldwide. According to the CDC Guidelines for
Infection Control:

1. Hand Hygiene
Hand hygiene is considered one of the most effective ways to prevent the
transmission of infections in healthcare settings. The CDC emphasizes the need for
healthcare workers to wash their hands with soap and water or use alcohol-based
hand sanitizers, especially after patient contact, before procedures, and when
touching potentially contaminated surfaces.

 According to a study by the CDC published in the American Journal of

Infection Control (AJIC), compliance with hand hygiene protocols in
healthcare facilities can reduce the incidence of healthcare-associated
infections by up to 50%.

2. Use of Personal Protective Equipment (PPE):

PPE, including gloves, gowns, masks, and face shields, plays a crucial role in
preventing the spread of infections between patients and healthcare workers. The
CDC's guidelines outline proper procedures for donning and doffing PPE, which is
vital to ensure that contamination is not spread within the healthcare setting.

3. Environmental Cleaning and Disinfection:

Routine cleaning and disinfection of hospital rooms, especially high-touch areas like
doorknobs, bedrails, and light switches, is vital for reducing environmental
contamination. The CDC recommends cleaning these areas regularly using hospital-
grade disinfectants that are effective against a wide range of pathogens, including
MRSA (Methicillin-resistant Staphylococcus aureus) and Clostridium difficile.

4. Antimicrobial Stewardship:
The CDC also recommends antimicrobial stewardship programs to prevent the
31
overuse and misuse of antibiotics, which can contribute to the development of
antimicrobial resistance (AMR). The guidelines emphasize that hospitals should
implement strict protocols for prescribing and administering antibiotics.

National Accreditation Board for Hospitals (NABH) Standards

The National Accreditation Board for Hospitals & Healthcare Providers

(NABH) provides a comprehensive framework for infection control in Indian
hospitals. NABH’s standards emphasize patient safety, quality care, and effective
infection control. Hospitals seeking NABH accreditation must comply with stringent
infection control protocols, including:

1. Infection Surveillance and Control:

 Hospitals must have an infection control committee that monitors infection

rates, implements infection control measures, and audits hospital practices.
The committee is responsible for tracking the occurrence of HAIs and
identifying root causes of outbreaks.
 Routine audits are mandatory to track infection rates and ensure compliance
with infection control practices.

2. Training and Education:

 Continuous training for healthcare workers is crucial. NABH standards

mandate regular workshops on infection prevention, hand hygiene, and PPE
usage.
 Patient education on hygiene practices, especially in high-risk departments
like ICUs and post-operative wards, is also required.

3. Aseptic Techniques in Clinical Procedures:

NABH guidelines emphasize the need for aseptic techniques during invasive
procedures such as surgeries, catheterizations, and IV insertions to prevent the risk
32
of infections. Hospitals must also ensure that all medical equipment and surgical
instruments are properly sterilized.

4. Waste Management:
Proper disposal of biomedical waste is another important element in NABH
standards. Healthcare facilities must adhere to strict protocols for segregating,
storing, and disposing of hazardous waste, including sharps, blood-soaked
materials, and other infectious items.

Data Collection

The study on infection control management at Queens Care Hospital will utilize
primary and secondary data sources to gather comprehensive insights into the
current infection control practices and identify areas for improvement.

Primary Data Collection

1. Observational Studies on Hand Hygiene Compliance:

Observations will be made to assess whether healthcare workers are following hand
hygiene protocols as recommended by the CDC and NABH standards. This will
include:

 Tracking the frequency of hand hygiene practices before and after patient
contact.
 Observing the correct technique of hand hygiene and whether healthcare staff
are adhering to the 5 Moments for Hand Hygiene.
 Evaluating the use of alcohol-based hand sanitizers versus soap and water,
depending on the context of patient care.

Expected Outcome: This data will identify specific gaps in hand hygiene practices
that contribute to the spread of infections. Interventions can then be designed to
improve compliance and reduce HAIs.
33
2. Interviews with Infection Control Officers (ICOs):
Interviews will be conducted with the hospital’s infection control officers to
understand their perspectives on the existing infection control practices, challenges,
and areas for improvement. The interview will focus on:

 Current infection control protocols.

 Obstacles faced by the infection control team (e.g., staff non-compliance, lack
of resources).
 Suggestions for improving infection control practices at the hospital level.

Expected Outcome: The data will provide insight into the practical challenges
faced by the infection control team and inform recommendations for better practice
implementation.

Secondary Data Collection

1. Hospital’s Annual Infection Control Audit Reports:

Secondary data will be sourced from the hospital’s infection control audit reports,
which contain historical data on infection rates, compliance with protocols, and
specific infection outbreaks. These reports will help analyze trends over time,
identifying areas where infection rates are high and the effectiveness of existing
protocols.

2. Patient Feedback on Cleanliness and Safety:

Surveys and feedback forms from patients will be analyzed to gauge their
perceptions of the hospital’s cleanliness, the visible adherence to infection control
practices, and their overall safety during hospital stays.

References

34
 1. Centers for Disease Control and Prevention (CDC). (2020). Guidelines for
Infection Control in Health-Care Settings. Retrieved from CDC Guidelines
2. National Accreditation Board for Hospitals & Healthcare Providers
(NABH). (2021). Standards for Infection Control in Hospitals. Retrieved from
NABH Standards

Data Presentation in Bar Chart Format

Chart Title
7

0
Ventilator-Associated Surgical Site Infections Catheter-Associated UTIs Bloodstream Infections
Pneumonia (VAP) (SSIs) (CAUTIs) (BSIs)

ICU OT NICU

Current Infection Control Practices

1. Frequency of Disinfecting High-Touch Surfaces:

35
 High-touch surfaces such as door handles, bed rails, light switches, and
equipment in patient rooms (e.g., infusion pumps, remote controls, monitors)
are known to harbor and transmit pathogens.
 Current Practice:
o ICU: High-touch surfaces are disinfected every 2 hours and after any
patient interaction.
o OT (Operation Theater): These areas are disinfected after every
procedure using hospital-approved disinfectants.
o General Wards: High-touch surfaces are disinfected once a day or as
needed, depending on patient turnover.
 Protocols and Disinfectant Use:
o WHO Guidelines: The hospital follows WHO’s “Clean Care is Safer
Care” campaign, recommending cleaning every 2 hours in high-risk
areas like the ICU.
o CDC Guidelines: Recommendations for hospitals to disinfect high-
touch areas at least twice daily in patient rooms and more frequently in
areas with high infection rates.
 Challenges:
o Inconsistent adherence to the cleaning schedule in certain wards,
especially with high patient turnover.
o Staff shortages in some areas, causing delays or skipped disinfecting
procedures.

Impact of Non-Compliance

1. Case Study: Recent Outbreak Traced to Improper Sterilization

36
 Background: A recent outbreak of surgical site infections (SSIs) was linked
to improper sterilization of surgical instruments in the Orthopedic Surgery
Unit.
 Incident Details:
o A patient underwent knee surgery in the orthopedic surgery unit. Post-
surgery, the patient developed a severe post-surgical infection.
o On investigation, it was found that the sterilization process was not
thoroughly followed. Instruments were not autoclaved at the required
temperature and duration, potentially due to a malfunctioning sterilizer
or human error during the sterilization process.

 Analysis of the Impact:

o Infection Rates: The infection rate in the Orthopedic Surgery Unit
increased by 30% over the next month after the incident.
o Patient Outcomes: The patient required extended hospitalization,
additional surgical interventions to clean the infection, and antibiotics,
leading to an increased cost of care and prolonged recovery time.
o Staff and Patient Safety: Other patients in the ward were also at risk of
infection due to improper sterilization.
o Cost Implications: The outbreak increased hospital costs by 15% for
additional treatments, extended stays, and antimicrobial therapies.
Additionally, the hospital faced the risk of negative patient reviews,
which could affect its reputation and accreditation status.

 Root Cause:
o Improper sterilization was identified as the primary cause.

37
 o Failure to follow established sterilization protocols and insufficient
monitoring of the sterilization equipment.
o Lack of training for staff on how to handle sterilization equipment
properly, especially during high-demand periods.

Conclusion from Analysis

The analysis of current infection control practices and the impact of non-
compliance reveals key areas for improvement at Queens Care Hospital:
1. Frequency of Disinfection:
o The current disinfection practices, especially in high-touch areas like
ICUs and OT, should be consistently enforced. Regular audits should be
conducted to ensure adherence to cleaning schedules, especially during
high patient turnover.
2. Sterilization Protocols:
o Improper sterilization of surgical instruments was directly linked to the
outbreak. Regular checks of sterilization equipment and better staff
training are essential to mitigate risks.
o Immediate Action: Ensure that sterilization procedures are followed
rigorously, with audits after each surgery, and regular checks of sterilizer
functionality.
3. Recommendations for Improvement:
o Increased Training: Focus on enhancing staff knowledge and
adherence to sterilization protocols.
o Invest in Better Equipment: Ensure the availability of well-maintained
sterilizers and cleaning tools.
o Strengthen Monitoring: Implement routine checks of infection control
practices across all hospital departments to identify non-compliance
early.

Conclusions & Recommendations

38
 Conclusions
The study on infection control management at Queens Care Hospital has
provided several key findings that highlight both strengths and areas needing
attention in infection control practices.
Key Findings:
1. Areas of Strong Compliance:
o The hospital has demonstrated strong compliance in high-risk areas such
as ICU and OT where disinfection procedures are carried out regularly.
o Infection Control Nurse Aasifa Ghabrani and Quality Control
Manager Jaya Binju have been instrumental in ensuring compliance
with protocols, especially in critical areas.
o Sterilization practices are generally well-managed in operation
theaters, but challenges remain in certain surgical units.

2. Gaps Needing Attention:

o Inconsistent compliance with hand hygiene protocols, particularly in
patient rooms with high turnover.
o Improper waste segregation in non-critical areas, with a lack of clear
guidelines for staff on how to separate hazardous and non-hazardous
waste.
o Sterilization lapses in some surgical units, contributing to infection
outbreaks.
o A lack of regular monitoring and feedback mechanisms for staff
compliance in less critical areas.

3. Importance of Consistent Monitoring and Staff Training:

39
 o The study emphasized the critical role of regular monitoring and
continuous staff training. Compliance with infection control protocols is
often inconsistent due to staff turnover, fatigue, and gaps in training.
o Regular audits and refresher training sessions are essential to ensure
that infection control practices are followed consistently across all units.

Recommendations

Short-Term Recommendations:
1. Install Additional Hand Hygiene Stations:
o Rationale: Increased access to hand hygiene stations can encourage staff
and visitors to follow hand hygiene protocols.
o Action: Install alcohol-based hand sanitizers at strategic locations
across the hospital, especially in areas with high patient traffic like
waiting areas, patient rooms, and corridors.

2. Conduct Surprise Audits to Monitor Compliance:

o Rationale: Surprise audits will help identify non-compliance and ensure
that infection control practices are followed.
o Action: Infection control officers should conduct unannounced checks
on hand hygiene, sterilization procedures, and waste management.

Long-Term Recommendations:

1. Adopt Automated Infection Surveillance Systems:

o Rationale: Automated systems can track infection trends in real-time,
allowing for quicker intervention.
o Action: Implement automated infection tracking software that
integrates with the hospital’s electronic health record (EHR) system.

40
 This system can alert staff to spikes in infection rates and help in
identifying problem areas.

2. Regular Refresher Courses for Staff on Infection Control:

o Rationale: Staff training must be an ongoing process to ensure
knowledge retention and adherence to protocols.
o Action: Develop a regular training schedule where staff across all
departments are reminded of proper infection control measures. The
training could focus on topics like hand hygiene, waste segregation, and
sterilization practices.

Quantifiable Benefits:

1. Potential Reduction in HAIs by 30%:

o With the implementation of the recommended short-term and long-term
strategies, the hospital could see a reduction in hospital-acquired
infections (HAIs) by as much as 30%. This would result in better patient
outcomes and reduced strain on hospital resources.

2. Cost Savings from Reduced Length of Hospital Stays:

o Improved infection control could lead to shorter patient recovery times,
reducing the average length of stay and, consequently, the overall
hospital expenditure on each patient.

41
 Other Techniques:

1. Introduction of Color-Coded Waste Bins for Easier Segregation:

o Rationale: Color-coded waste bins would simplify the segregation of
infectious and non-infectious waste, reducing the risk of cross-
contamination.
o Action: Implement color-coded waste bins for different types of waste
(e.g., red for infectious waste, green for non-infectious waste) and
ensure that staff members are trained on how to use them properly.

42
 Limitations
Despite the comprehensive study on infection control practices, several
limitations affected the scope and accuracy of the findings:

1. Limited Access to Certain Data Due to Confidentiality Policies:

o Certain patient-level data and internal audits were unavailable due to
confidentiality agreements and privacy concerns, which limited the
depth of analysis for specific infection cases and trends.

2. Difficulty in Changing Deeply Ingrained Staff Habits:

o Some staff members were resistant to adopting new infection control

practices, especially those who had been working with older protocols
for an extended period. Changing these ingrained habits requires a
gradual approach and sustained efforts over time.

Additional Sections
References (Page 25)
The references section will include all the academic articles, guidelines,
reports, and documentation cited throughout the project. Below is a sample
format for the references.

1. World Health Organization (WHO). (2009). "Clean Care is Safer Care".

WHO Guidelines on Hand Hygiene in Health Care.
Retrieved from: https://www.who.int/gpsc/5may/tools/en/

43
2. Centers for Disease Control and Prevention (CDC). (2017). "Guideline for
Hand Hygiene in Healthcare Settings".
Retrieved from:
https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm

3. National Accreditation Board for Hospitals & Healthcare Providers

(NABH). (2021). NABH Standards for Hospitals.
Retrieved from: https://nabh.co/

4. Institute for Healthcare Improvement (IHI). (2018). "How-to Guide:

Prevent Surgical Site Infections".
Retrieved from: http://www.ihi.org/

5. Patel, V., & Desai, P. (2015). "Hospital-Acquired Infections: Current

Trends and Infection Control Practices".
Journal of Infection Control & Hospital Epidemiology, 24(2), 112-117.
6. Bajwa, S. J., & Bhalla, A. (2016). "Evaluation of Infection Control
Practices in ICU: A Study of Five Major Hospitals in India".
Indian Journal of Critical Care Medicine, 20(6), 350-354.
Annexures

The Annexures section is critical for supporting the findings and

recommendations discussed throughout the report. This section includes
essential documents such as infection control Standard Operating
Procedures (SOPs), data tables, audit reports, and visuals that provide
evidence and additional context for the study. These annexures allow for a
deeper understanding of the infection control practices in the hospital and
reinforce the report's conclusions.

44
 Infection Control SOPs

Infection Control SOPs are detailed documents that outline how specific
infection prevention practices should be carried out across different hospital
departments. These SOPs are created to standardize infection control
procedures, ensuring that all staff members follow best practices for infection
prevention. Below are some of the key SOPs included in the annexures:
Infection Control SOP 1: Hand Hygiene
 Objective: To reduce the spread of infections through proper hand hygiene
practices.
 Scope: All healthcare workers, including doctors, nurses, and support staff.
 Procedure:
o Wash hands with soap and water or use alcohol-based hand sanitizers.
o Ensure hands are washed for at least 20 seconds, covering all surfaces.
o Dry hands thoroughly with a clean towel or air dryer.
 When to Perform Hand Hygiene:
o Before and after patient contact.
o After touching any body fluids, mucous membranes, or contaminated
surfaces.
o Before handling medical equipment.
 Monitoring & Compliance: Hand hygiene audits to track compliance, with
continuous feedback and training provided.

Infection Control SOP 2: Waste Segregation and Disposal

 Objective: To prevent cross-contamination by properly segregating and
disposing of hospital waste.
 Scope: All departments involved in waste handling, such as ICU, OT, wards,
pharmacy, and laboratory.
 Procedure:
45
 o Use color-coded bins for waste segregation (yellow for infectious waste,
red for sharps, blue for non-infectious waste).
o Ensure waste is securely packaged to avoid spillage.
o Dispose of waste according to its category (e.g., incinerate infectious
waste).
 Responsibilities: Healthcare staff must follow waste segregation protocols at
the point of origin.

Infection Control SOP 3: Sterilization of Surgical Instruments

 Objective: To ensure surgical instruments are properly sterilized to prevent
infections.
 Scope: Applicable to all surgical staff and equipment handlers in OT and ICU.
 Procedure:
o Clean instruments to remove debris before sterilization.
o Sterilize using appropriate methods (e.g., autoclaving).
o Store sterilized instruments in a sterile environment.
 Frequency: Instruments should be sterilized after every use.
 Monitoring & Compliance: Maintain sterilization logs and perform regular
equipment checks to ensure proper sterilization.

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 Infection Rates in Various Hospital Units

GENERAL WARDS

NICU

Hand Hygiene Compliance

OT

NON COMPLIANCE
ICU

Catheter-Associated
COMPLINACE UTI (CAUTI) Neonatal Sepsis
0Surgical Site
1 Infection
2 (SSI) 3 4 5
Ventilator-Associated 6 7 (VAP)
Pneumonia 8 9
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

EMERGENCY GENERAL WARDS OT

NICU ICU

47
 Infection Control Audit Reports
The audit reports highlight the findings from regular infection control checks,
providing insights into how well infection control protocols are being followed
and areas for improvement.
 2023 Infection Control Audit:
o Findings: Infection rates in high-risk areas such as the ICU and OT
exceeded the desired threshold, primarily due to non-compliance with
hand hygiene protocols.
o Recommendations: Introduce more hand hygiene stations in the ICU,
conduct more frequent audits, and offer refresher training for staff.
 Waste Segregation Audit:
o Findings: Waste segregation practices were inconsistent in the general
wards.
o Recommendations: Train staff to improve waste segregation and install
more clearly marked bins.

48