TABLE OF CONTENT:

Sr. No. Chapter Page no

1 Introduction and overview 2
1.1 Goals & Objectives 5
2 (Infection Control Committee) 6
3 Process and standards 8
3.1 Infection Control Surveillance Programme 8
3.2 Microbiological Surveillance Programme 9
3.3 Sterilization, Disinfection & Decontamination Practice 10
3.4. Cleaning , Disinfectant and Sterilization 11
3.5. Universal Precaution 14
3.5.1 I. Hand Washing 14
3.5.2 II. Protective Equipments 16
3.5.3 III. Handling of Sharps 17
3.6 Airborne Isolation 17
3.7. Guidelines for Collection of Blood Samples 19
3.8. Special procedure: For prevention of Infection 21
3.9. Employees Health Programme 33
3.10 Housekeeping 34
3.11 Cleaning & disinfection of Various Items Commonly Used in Hospital 36
3.12 Linen Management 36
3.13 Kitchen Sanitation & Food Handling 37
3.14 Engineering Controls 38
3.15 Isolation Practices 40
4.0 Antibiotic Policy 43
5.0 Operation Theatre Protocol 46
6.0 MRSA Protocols 50
7.0 Outbreak Policy 50
8.0 Notifiable Diseases 52
Section II- Bio Medical Waste Management 53-70
Biomedical Waste Management
Handling & Treatment of Bio Medical waste
I. Sharps
II. Handling of Hazardous Spill
Categorization of Biomedical waste & Segregation

Biomedical Waste - Transport & Storage

Biomedical Waste – Final disposal
 INFECTION CONTROL MANUAL
Policy:
The hospital recognizes the control of hospital acquired infections as an important issue and is committed to
fulfilling its responsibility by ensuring that proper safeguards are instituted to identify and prevent HAI.

Important components of the policy are:

1. Monitoring of hospital acquired infections
a. Microbiological surveillance
b. Investigations and control of outbreaks if any
c. Monitoring of antimicrobial resistance
2. Providing facilities to the hospital staff to maintain good infection control practices
3. Conducting on-going educational / training programmes for all cadres of hospital staff
4. Making provisions for staff health activities
5. Having a written document (infection control manual) outlining the various infection control policies and
procedures and periodically updating it.

Purpose: Control issues to minimize the risk of infection to patient, staff and visitors

Responsibility: Head of the Institution, Infection Control Nurse.

Scope: Infection Control Manual is applicable hospital wide to all the clinical areas.

1. INTRODUCTION

Nosocomial infection or Hospital acquired infection has caused a worldwide concern, the enormity of financial
burden and personal harm done by these infections not only affects the patients but indirectly affects the health
of all those doctors nurses health Care Workers employed in any hospital or Health Care centre.

Nosocomial infection

Infection that is neither present nor in the pretrial stage when a patient enters a hospital but may become
apparent during stay in the in the hospital or after discharge from the Hospital up to a period of six weeks is
called Nosocomial infection infections. Some of these infections can often become fatal. Majority of Nosocomial
infections are endogenous in origin that is they involve the patients own microbial flora. This is determined by.
 Susceptibility of the patient to the infection
 Virulence of the infecting organisms
 Nature of exposure to the infecting organism.

Foreign objects like intravenous catheters and urinary catheters also break the body’s natural barriers to
infection. Nosocomial infection may never be completely eliminated but can be controlled.

To provide better and safer hospital facilities all sections of hospital community have to be involved. A joint
effort by all not only ensures good hospital practice but also teaches the staff and all concerned necessary values
attitudes and behavior required in the staff of a good hospital.

Observations show that Hospital acquired infections (HAI) are mostly Blood Borne With special reference to HIV
and Hepatitis group.
Indiscriminate use of antibiotics has led to growth of antibiotic resistant bacterial flora which are very difficult to
control Common blood borne infections are both bacterial and viral in origin.

Bacterial are: Brucella, Salmonella etc.

Some important viruses in order of prevalence are:

Hepatitis B, HIV I & II, Epstein bar Virus, Hepatitis C etc.

Preveillance of HAl in staff depends upon state of immunization habit of taking precautions amount of exposure
last but not the least hospital policy for staff safety measures and waste disposal.

Table1: Procedure carrying potential risks of HIV, HBC and other blood Borne agents

Procedures Person at risk Mode of Transmission

Collection of blood sample Patient * Contaminated needle

Transfer of specimens
(with in laboratory)
HIV serology and
Virology
Health Worker
Laboratory Personnel/
transport worker
Laboratory Personnel/
transport worker
Contaminated hands
or Gloves of health
worker
* Skin puncture by needle or broken specimen
Container
Contamination of hands by blood.
* Contaminated exterior
of specimen container
* Broken container
* Spill or splash of specimen
* Skin puncture of
Contamination of skin
or mucous membrane
* Contaminated exterior
of specimen container
* Contaminated work
surface
* Spill or splash or
Specimen
* Broken specimen
container
* Perforated gloves

Procedures Person at risk Mode of Transmission

Cleaning and maintenance Laboratory * Skin puncture or skin
Personnel contamination waste
Support staff * Spill or splashes
* Contaminated work surface
Waste Disposal Laboratory * Contact with
Personnel contamination waste
Support staff * Puncture wounds and
Transport worker cuts
Shipment of specimens Transport worker * Broken or leaking
(To other centers) postal worker specimen containers and packages

Severity of viral infections depends on viral load at the time of infection whether the virus is free in circulation
or cell associated of strain variant. The severity of infection is also determined by the portal of entry by Potential
route are most severe, where as entry by coetaneous route is least severe size of inoculums also matters: prick by
a hollow bore needle is more dangerous than a solid needle puncture as it carries more infected material.

Table 2: Risk of transmission of Blood borne viruses to health care workers

Human immunodeficiency virus (HIV)

Precautious exposure-0.05-0.4%
Mucocutaneous exposure-0.006-0.05%

Hepatitis B Virus (HBV)

Precautious exposure -9-30%

Related to the above observation it is very important for a hospital to lay down specific guidelines for a
protection scheme for waste handlers. To ensure that the guidelines are followed every hospital should have a
hospital in faction control and a waste management committee. This committee recommends rules for safety in
accordance with the universal safety proposals sees that they are followed and takes corrective measures of any
difficulties or defaults.

1.1 GOAL & OBJECTIVES

1. Develop written policy & procedures, standards for cleanliness and asepsis in the Hospital.

2. Implement hospital infection control policies as and when laid down.

3. Provide surveillance for nosocomial infections and routine bacteriological surveillance.

4. Take corrective measures in case of nosocomial infection.

5. Develop measures to minimize, control and prevent the risk of nosocomial infections.

6. Develop a mechanism to supervise infection control measures and see that they are properly
implemented.

7. To maintain on-going education programme for the staff.

8. Have proper employee’s health care facilities.

 2. INFECTION CONTROL COMMITTEE

Hospital Infection Control Committee is an integral part of a Hospital

Committee
Chairperson:
Members:
No MEMBERS DESIGNATION

4.

10

11

12

13

14

FUNCTIONS
 Continued surveillance of hospital acquired infections.
 Development and formulation of preventive and corrective programmes in view of infectious hazards.
 Develop a hospital antibiotic policy.
 Formulate and update patient care policies from time to time.
 Develop a system of identifying, reporting, investigating and controlling the hospital acquired infection.
 Periodically educate the healthcare workers of the institution on infection control policies and protocol.
 Regularly meet every month to discuss any issues and develop outcomes.
 Formulates policies and protocols on the methods of sterilization and disinfection.
 Guidelines for segregation and disposal of hospital waste.
 Continuous Monitoring of Hospital Infection Control Practices

MEETING SCHEDULES:
1st Tuesday of every month
Infection Control Committee Will Look After:
1. To develop an effective surveillance system.
2. Identify report and do control measures of Hospital infections with update on new techniques.
3. Update and development of antibiotic policy.
4. Have a proper Employees health programme.
5. Shall meet regularly not less than once a month and on as required basis.
6. To develop a method of supervising infection control measures in all phases of hospital activities.
 3.0 PROCESS & STANDARDS

3.1 INFECTION SURVEILLANCE PROGRAMME

Definition: Surveillance is defined as the continuing scrutiny of all aspects of the occurrence and the spread of a
disease that are pertinent to effective control. It is an ongoing systematic collection, analysis and interpretation
of health essential to planning, implementation and evaluation of the public health practice closely integrated
with timely dissemination of this data to those who need to know. Nosocomial infection surveillance is a
program designed to investigate, control and prevent hospital acquired infection.

Method of surveillance covers:

A. Lab record scrutiny
 Infection control nurse examines lab reports daily and discusses it with the microbiology lab technicians.
 She then visits the relevant patients and gathers necessary information then determines whether it is
hospital acquired infection or community acquired infection.
 Helps in identifying cross infections and outbreaks.

Daily visits to all wards and units:

Infection control nurse will visit all the wards on daily basis and examine all records of all clinical infections.

List of high risk areas

1. Operation Theatres
2. MICU, SICU
3. Labour Room/Delivery Room
4. Laboratory
5. Emergency/Casualty
6. Biomedical Waste Management

The programme includes calculation of following infection rates.

 Surgical site infection
 Urinary tract infection
 Ventilator associated pneumonia
 Intravascular device infection

3.2 MICROBIOLOGICAL SURVEILLANCE

Routine microbiological surveillance is necessary because a dirt free environment is difficult to maintain. Routine
Microbiological examination carried out for the areas selected for active surveillance is as follow.

Table 3: Microbiological Surveillance

S.R AREA FREQUENCY COLLECTION POSSIBLE

NO SITE PATHOGENES
1. MICU, SICU, Labour Every month Swab from various Pseudomonas
Room ( According to patients dust settling areas. Staph.
occupancy) Swab form dressing Species,Acenatobact
trolly’s, patient’s bed, er,E.Coli,Klebsiella
 floors and equipments,
Air & A. C. filters
,suction bottles
2. Central Sterile Every 15 days Chemical check tubes Same as above
Supply department Physical check
Chemical check
3. Operation Theatre: Swabs form Operating Swab from various
Tables. Lights , dust setting area’s as
Every Month Trolleys ,Suction above.
Air sampling-once a machine ,A.C.& Air etc For bacteria (as
OT Number : 1 - 3 month Anesthesia trolley, above)
floor
5. Drinking water Every month Canteen Presence of coli form
RO plant and TVC(Total viable
count)

3.3 STERLIZATION, DISINFECTION & DECONTAMINATION PRACTICES

Decontamination encompasses cleaning, disinfecting and sterilizing. It is required in the following situations:
 Before use of a contaminated equipment/device for any patient.
 Before sending contaminated equipment for further processing in the CSSD.
 Before sending used & contaminated needles and syringes for disposal.
 For the inanimate environment which is likely to be infected and could be a potential source of HAI.
Before any item is subjected to disinfection/sterilization thorough cleaning is made to remove organic material
that may interfere with these processes.

Decontamination

Sterilization Cleaning High Level Disinfection

Steam Dry Heat Chemical Boiling Chemical Steam

USE OR STORAGE

FIG: SCHEMATIC REPRESENTATION OF DISINFECTION PROCESS

3.4. Cleaning, Disinfection and Sterilization

Cleaning: Physical removal of organic matter to reduce microbial growth prior to killing the microbes. Organic
material can interfere with the action of antiseptics, disinfectants which prevents adequate penetration. Soap
and water with friction is still standard. Cleaning must precede disinfection/sterilization.

Disinfection: Disinfection kills or eliminates nearly all pathogenic microorganisms on inanimate surfaces but not
necessarily bacterial spores. Chemicals are often used as disinfectants for devices, which cannot withstand high
temperatures. The best disinfection is procedure is the use of hot water between 70° and 90°C.

ITEMS CLEANING/DISINFECTION TIME REMARKS

Nebulizer set ETO N.A Individual
preferred
Stethoscope Clean with detergent and water and N.A After each use
BP instruments dry.
Disinfect with isopropyl alcohol.
BP cuff Soap and water followed by
disinfection with isopropyl alcohol.
Thermometer Isoprophyl alcohol swab
or soap and water
Laryngoscope Blade: with soap & water Handle & N.A
bulb-isoprophyl alchohol
Nasal prongs ETO N.A Individual
Oxygen masks ETO N.A Individual
Ambubag Clean with detergent,dry and send N.A
for ETO.
Sputum mug Soap and water, Immerse in 1% 20 mts to 1 hr Keep a minimal
sodium hypochlorite amount of water in
the mugs prior giving
to patient.
Ventilator tubing Non-infectious-plain water rinse and 1 hour
E.T.O sterilization.

Transducer Alchohol swab,E.T.O sterilization N.A

Ventilator isoprophyl alcohol N.A Externally and
internally
Urinal Soap and water immerse in 1% 20mts to 1hr
sodium hypochlorite
Emesis basin Soap and water N.A
Furniture/Bed/
Sterilization: Removal or destruction of all microorganisms and their spores. All items that enter sterile tissue or
vascular system must be sterile, i.e. implants, scalpels, needles, surgical instruments, etc. (Critical items). The
process of check is done for every 15 days.

METHODS OF STERLIZATION:
Classification Item Use Goal Appropriate Process Method:
Critical Items Item entering sterile Objects will be Sterilization or use sterile 1. Steam
tissue, the body cavity, sterile, free from all product. Steam Sterlization, sterilization:
the vascular systems microorganisms Low temperature methods. All metal
and non intact mucus including bacterial (ethylene oxide, peracetic articles
membranes eg. surgical spores. acid. sterilized in
instruments. high
Semi Critical Items that make Objects will be free High level disinfection
Items contact, directly or from thermal disinfect chemical
indirectly, with intact microorganisms disinfection (gluteraldehyde)
mucus membranes or with the exception It is always preferable to
non intact skin e.g. of high numbers of sterilize semi critical items
endoscope, anesthetic bacterial spores. whenever they are
Equipment compatible with available
sterilization process.
Non critical Objects that come into Objects will be Low level disinfection
items contact with intact skin clean cleaning (manual mechanical)
but not mucous
membranes e,g.B.P.
cuffs, table tops.
temperature for surgery and other procedures.
2. E.T.O: All single use instruments which are sterilized by low temperature.
Steam Sterilization:
 Preparation for steam sterilization is done centrally and then loaded on autoclave carriages and are
subjected to steam sterilization.
 Autoclaving is done at 134 C. for 10 mts and 121 C for 20mts with a holding time of 1 hour or I hour 10
minutes .Each load has a class 6 emulating indicator, that changes the colour only when all three critical
parameters have been achieved. These parameters are Time, Steam and temperature.

Monitoring of Steam Sterilization Process

Chemical check:
 Daily Bowiedick test is carried out in an empty cycle. This cycle is the first cycle of the sterilizer. This is
to check the proper air removal by the sterilizer.
 Weekly an air leak test is carried out on each of the sterilizers. To check the efficiency of the sterilizer.
This is to check the proper air removal by the sterilizer.
 Every cycle class 6 indicators is processed to check the correct exposure time, quality of steam and the
accurate temperature.

Biological check:
 Weekly an ampoule containing G.stearothermophilus is processed in a challenge pack in the sterilizer
and thereafter is incubated along with the positive control.

Physical check.
 Each sterilization cycle gives the print out of temperature and pressure under which the Cycle is
processed.

ETO Sterilization:
 Articles are checked for complete drying.
 They are then packed in the peel pouches.
 The peel pouches have an in-built chemical indicator for changes colour after the article is sterilizes.
  They are then subjected for sterilization.

Monitoring of E.T.O Sterilization Process:

Biological check
In each cycle an ampoule containing G.stearothermophilus is processed in a challenge pack in the
sterilizer and thereafter is incubated along with the positive control check the sterilization process.

Physical check
Each sterilization cycle gives the print out of cycle process that consists of preconditioning, time of gas
exposure, gas removal and there after completion of the cycle followed by aeration.
Chemical check
A process indicator affixed on the peel pouches changes the colour once the pouches are subjected to
sterilization. Every cycle class 5 integrating indicator is process to check the correct exposure time, gas
penetration and the accurate temperature.

3.5 UNIVERSAL (STANDARD) PRECAUTIONS

Potentially infectious materials include: Blood, CSF, Synovial fluids, Pleural fluid, pericardial fluid, peritoneal
fluid, amniotic fluid, saliva, breast milk, semen, vaginal secretions and blood contaminated fluids body, tissue
organ (not fixed by formalin): culture media solution with HIV contamination.

Universal precautions aim at providing a barrier between infected substance and HCW.

The following are the recommended barriers to be used:

1. Hand-washing
2. Mask and other protective equipment face shields goggles etc.
3. Gloves.
4. Protective clothing, gowns, lab coats, caps, hoods & shoe covers.
5. Handling needles and sharps carefully.
6. Put adhesive plastic dressing on skin cuts or from where the blood is oozing, before starting work.

3.5.1. Hand Washing

Hand washing is most important for preventing nosocomial infection it is defined as vigorous brief rubbing
together of all surfaces of lathered hands followed by rinsing under water

Effective hand washing:

The following is recommended as an effective technique using soap and running water and 10 seconds action
per set [(about 5 strokes).

1.Palm to palm 2.Palm over dorsum 3.Palm to palm fingers

interfaced
4.Back of fingers to opposing 5.Rotate thumbs in 6.Rotate fingers in palm
Palms palm

Which soap?
Choose neutral pH soap with no added substances , like strong perfumes of alcoholic drying chemicals They tend
to dry out the skin especially if you hand- wash frequently Any good quality moisturizing cream will help restore
the moisture of your hand if they are “Washed out”.

When to wash?
 On arrival in the department
 Before & after patient care
 Before and after gloving
 After any cleaning session
 After blowing/wiping the nose
 After going to the toilet
 Prior to leaving the building
 Prior to eating meals

Hand washing techniques are classified as:

1. Social Hand Wash or routine hand wash

Social Hand Wash with plain soap and water, it removes transient flora from moderately dirty hands. This should
be done before eating or feeding; after visiting the toilet, for nurses after touching patients and after bed
making. Wet hands thoroughly and lather vigorously using neutral pH soap. Rinse under running water.

Technique (How): Do not touch taps with hands if elbow or foot controls are not available, use paper towel to
turn taps off.
Duration: 10-15 seconds
Drying: Pat dry using paper towel
Example (When): Before eating or smoking
After going to the toilet
Before significant contact with patients, e.g. physical examination, emptying & drainage reservoir (Catheter bag)
Before injection or vein puncture
Before and after routing use of gloves
After handling any instruments or equipment soiled with blood or body substances.

2. Hygienic Hand wash-hand wash prior to aseptic procedures (non surgical)

After Washing with soap and water, a disinfectant or an antiseptic detergent is also used. It should be done
before doing invasive procedures, handling immunocompromised patient or handling blood and secretions.

Technique (How): Wash hands thoroughly using a soap or skin cleanser. Rinse carefully “Do not touch” taps with
clean hands if elbow or foot controls are not available, use paper towel to turn off.

Duration: 1 Minute

Drying: air dry

1.1 Example (when): Before any non-surgical procedure which require aseptic techniques (such as inserting
intervene us catheters). Handling immuno compromised patient handling blood and secretions.
1.2 Surgical Hand wash: Surgical Hand wash is being done before surgical procedures or interventions. In
this soap/water and or detergent with thorough scrubbing hand fingers with a soft brush is done after
washing hands are kept upright and are dried. The surgeon then puts on gown and gloves.

Technique (How): Wash hands, nails and forearms thoroughly and apply an antimicrobial or skin cleanser
(Containing 4 % w/v chlorhexidine or detergent based providence iodine containing 7.5% available iodine. Rinse
carefully keeping hands above the elbows.
 No – touch techniques apply.

Duration: First wash for the day 5 minutes and subsequent washes 3 minutes
 Drying: Dry with sterile towels
Example (When): Before any invasive surgical procedure (operating room procedures).

3.5.2. Protective Equipment

a. Masks: A particulate mask capable of filtering one-micron particles and best possible fit
should be worn when attending patients with infectious pulmonary tuberculosis. Masks must always
be worn in the operating theatre.

Mask must:
 Be worn and fitted according to the manufactures instructions;
 Not be touched by hand while being worn;
 Be removed after 20 minutes continuous exposure to aerosols or as soon as practicable after
they become moist or visibly soiled;
 Be removed by touching the strings and loops only; and
 Not be worn loosely around the neck, but removed and discarded as soon as practicable after
use.

b. Gloves: Wearing gloves can protect Hands. Sterile latex gloves are used in surgery or laboratory or wherever
precision is required. Unbroken natural rubber latex is impermeable to air, water and Human
immunodeficiency virus (HIV). Nurses while caring for hospitalized patients can use disposable vinyl gloves.
Heavy-duty gloves are necessary for cleaning personnel. Hands are to be washed after removing gloves.

C. Other Protective: Plastic aprons, caps, gloves and lab coats and shoes and shoes covers to be worn, whenever
needed protection from splashes and directly from waste is also required for the clothing worn by persons
coming in contact with hazardous material. For this, plastic aprons and overalls are available. Eyes are very
sensitive and can be injured easily; therefore to protect those glasses or glass shields are used.

3.5.3 Handling of Sharps:

 Sharps of all types are handled with precaution.

 Those who are handling needles and syringes should remember that once the needle is out of the cap
and used, NEVER try to put back into the cap.

 Destroy the needle and syringe by a needle cutter / electric burner before putting them in hypochlorite
solution for disposal.

 AIDS, Hepatitis, Needle stick Injuries go together. Most people are aware of the risk of contracting HIV,
the virus, which causes AIDS, from dirty needles and syringes, however, many health workers and
patients are NOT aware of the high risks of contracting Hepatitis B or Hepatitis C from those same dirty
syringes and needles. Like HIV, Hepatitis B and C are deadly infections – they can cause liver disease,
cirrhosis and liver cancer.

Hepatitis B virus can remain infectious outside the body for at least one week!

HIV remains infective up to 7 days even in dry blood, at room temperature 11-15 days.

As a health care worker, avoid dangerous needle stick accidents by handling needled and syringes, carefully- as if
you know they are infected.
 3.6. AIRBORNE ISOLATION

 Negative pressure room preferred.

 For patients with chicken-pox, measles only immunized staff to provide care.
 For patients with open tuberculosis, wear a mask before entering the room.
 Limit patient’s movement, place a surgical mask if patient is to be transported outside.

Contact Isolation:
Private room preferred else cohort patients of similar pure illness.
Wear gloves prior any patient contact.
Wear clean non sterile gown if any contact with body fluids, infections materials or spillage anticipated.
Remove the gloves and gown before leaving the room or patient care areas.
Do not touch environmental surfaces.
Limit patient transportation.

Droplet Isolation:
Private room preferred or else cohort patients with same pure illness or else ensure 3 feet special separation
Between the patients. Wear a mask at all times when delivering care or when within the 3 feet space around the
patient.
Limit patient transportation.

Blood Borne Pathogen Isolation:

Hand washing before and after patient contact or wearing gloves.
Wear gloves if contact with blood, body fluid, secretions, excretions and contaminated items anticipated.
Wear mask, eye protection and gown before activities likely to generate splashes and sprays.
Take utmost care to prevent needle stick injury use safety cannulas.
Handle all patient care items properly, dispose appropriately waste and sharps.

Empiric isolation precautions to be instituted till diagnosis established

Condition Potential Pathogens Type of isolation

Diarrhoea Enteric pathogens Contact

Meningitis Meningococci Droplet
Petechial rash Meningococci Droplet
Vesicular rash Varicella zoster Airborne & contact
Maculopapular rash in child Measels Airborne
Cough, fever and upper lobe Tuberculosis Airborne
pulmonary infiltrate in an adult
Paroxysmal severe persistent Pertusis(whooping cough) Droplet
cough
Respiratory infections in infants RSV & Parainfluenza Contact
and children
History of infection or Resistant bacteria Contact
colonization with multidrug
resistant organisms
Skin, wound or urinary tract Resistant bacteria Contact
infection in a patient with recent
stay at hospital or nursing home
Abscess or draining wound that Staph aureas Contact
can not be covered

POLICY FOR PATIENTS WITH SMEAR POSITIVE PULMONARY TUBERCULOSIS

 Ascertain whether hospitalization is required for the patient.

 Hospitalization not required
 Inform the register of the concerned consultant for immediate discharge of the patient.
 Meanwhile make sure that there is no post operative patient or immuno compromised patient in the
near vicinity.
 Hospitalization required
 ICU care not required
 Shift the patient to the isolation room. These rooms are provided with an exhaust fan that should be kept
running all the time. The AC air is not be connected to the general system.
 Provide filter mask to the patient.
 Inform the healthcare workers about the isolation of the patient.

3.7. GUIDELINES FOR COLLECTION OF BLOOD SAMPLES

1. Use gloves and take special care if there are cuts of scratches on the hands.

2. Take care to avid contamination of hands and surrounding area with the blood.

3. Use deposable syringes and needles.

4. Use 70% ethanol or isopropyl alcohol swabs/sponges for cleaning the site of needle puncture.

5. Use thick dressing pad or absorbent cotton below the forearm when drawing blood and tourniquet above.

6. Tourniquet must be removed before the needle is withdrawn.

7. Place dry cotton swab flex the elbow to keep this in place till bleeding stops.
8. Place used needles and syringes in a puncture resistant container containing disinfectant.

9. Do not recap used needles.

10. Do not remover needles from syringes.

11. Use disposable screw-capped vials to avoid task of leakage breakage or spells.

12. Seal specimen containers securely .Wipe off the exterior of the container free of any blood with a
disinfectant.

13. These vials should preferably be placed in small plastic bags, which should be appropriately tied.

14. Plastic ‘Bread boxes’ with proper ‘Caution’ labels should be used for transporting the specimen to the
laboratory.
 15. Wash hands following completion of blood collection.

16. In the event of needle sick/other skin puncture /wound wash thoroughly with soap and water and let
bloods flow freely then apply iodophory Tincture of iodine.

17. All material contaminated with blood must be regarded as infectious.

18. Report all accidental exposure to the authorities.

19. No paper work to be done on potentially contaminated surfaces.

20. Label all specimens care fully without soiling the test request fours.

21. Decontaminate all potentially contaminated material used in the laboratory before disposal by putting in a
bucker containing sodium hypo chlorite solution 2 %.

Handling syringes and Needles

Do’s
*Pass syringes and needles in a tray preferably cut it
with needle cutters
*Put needle and syringes in2% hypo-chlorite solution if
needle cutter is not available
*Remove cap of needle near the site of use
Don’ts
*Never pass syringes and needle on directly to next
person
*Do not bend/or break used needle with hands
*Never test the fineness of the needle’s tip before use
with bare or gloved hand

*Pick up open needle from tray/drum with
Forceps
*Destroy syringes by burning their tips/or if
cutters not available
*Never pick up open needle by hand
*Never dispose it off breaking it with hammer/stone
*Do not recap needle after use.

 Dispose used sharps in a puncture-resistant container.

 Never place used in other waste container.

 Keep all sharps and. Sharps disposal containers our of the reach of children

 Prevent overflow by sending disposal containers for decontamination incineration when three-quarters
full.

Selection of Protective Barriers

Type of exposure Protective barriers Examples

Low risk:
Contact skin, no visible blood
Medium risk:
Probable contact with blood
splashing unlikely
Gloves helpful but not Injection : minor wound dressing
Essential
Gloves Vaginal examination insertion or
Gowns and apron may removal of intravenous cannula,
Be necessary handling of laboratory specimens
 large open wound dressing ,
Vene puncture spills of blood
High risk: Gloves Major surgical
Probable contact with blood , Waterproof gown of Procedures particularly
Splashing uncontrolled bleeding Apron In orthopedic surgery
Eye wear And oral surgery, vaginal
Mask Delivery
3.8. SPECIAL PROCEDURES: PREVENTION OF INFECTION

A. URINARY CATHETERIZATION:

Urinary Tract Infections may be the most frequent of nosocomial infections. These are prevented by reducing
unnecessary and inappropriately prolonged use of drainage devices and by the use of closed drainage systems
and standard aseptic technique. Urinary catheterization is an aseptic procedure but is a common cause of
bacteria due to micro or macro trauma caused at the time of insertion or removal. Therefore, think twice before
using a urinary catheter.

Procedure
The following steps may be followed while catherizing a patient-
 Inform the patient of the reasons for catheterization and explain the details of procedure.
 Collect all the requisite equipment and material required.
 Scrub hands thoroughly with soap and water.
 Select a catheter that fits the urethra without traumatizing the patient.
 If the patient is male, fore skin of penis is withdrawn and in case of females secretions are cleared with
sterile water and never with spirit / disinfectants.
 Sterile xylocaine jelly is squeezed into the urethra, and waits for a while till mucosa is anaesthetized.
 Advance the catheter into the meatus by gripping through inner plastic sleeve of covering. Do not directly
touch the catheter.
 Once the catheter is inside the bladder, urine starts coming. Collect the urine in a suitable container.
 Fill the balloon with 5-10 ml sterile water, for its retention inside the bladder (Foley's catheter).
 Anchor the catheter to the patient's thigh with leucoplast.
 Connect up the urine drainage and hang it below the level of the bed to stop reflux.
 Wash hands with soap and water.

It is important to use the correct urinary catheter for the condition. The balloon can cause obstruction and stasis
of the urine if it is too large, thus increasing the risk of infection.
Indwelling catheters should not be changed at arbitrary fixed intervals but should be removed as soon as not
needed.
To minimize the chances of cross infection, infected and uninfected patients with indwelling catheters should
not share the same room.

B. INTRAVENOUS (I.V.) CANNULATION / CATHETER ASSOCIATED INFECTION

Indications for IV cannulation or catheterization should be strictly followed (e.g.) severe dehydration, blood
transfusion or parentral feeding) Alternative routes may be tried for minimal dehydration or for parental
therapy. Following are the factors that lead to infection during cannulation/catheterization-

SOURCES OF INFUSION/TRASFUSION
RELATED INFECTION
 Infection related to equipment and fluids:

 Cannula material that it self is thrombogenic, e.g.

polyethylene and polypropylene which is more reactive than
Teflon which in turn is more reactive than steel or silicon
coated Teflon.
 Contaminated administration sets or fluids.
 Contaminated hypodermic needle used as air inlets.
 Disconnected I.V. cannulas also may act as source of aerial
influx.
 3-way cannula.
 Contaminated splints used for sprained/operated joints.
 Large bandages over the insertion site (contaminated by
patient's blood and fluids.)

2. Infection related to the insertion of devices and its duration:

 Skin flora and inadequate disinfection.

 Skin flora/transient flora of staff / other patients / visitors.
 Contaminated disinfectants.
 Unstable cannula-movement increases the risk of bacterial
contamination.
 If IV infusion is to be given for over 72 hours, alternate arms
should be used for I.V. therapy for longer than 72 hours.
 Pre-existing infection/venous thrombus/septic focus.

B. CANNULA ASSOCIATED INFECTIONS

When a plastic catheter is inserted in a vessel, a loose fibrin sheaths formed around the IV portion of the device
within 24-48 hours, a nidus is formed and micro organisms multiply.

Procedure:
Intravenous cannulation is to be considered an OT procedure.

1. Proper hand washing

2. Use sterile gloves
3. Thoroughly disinfect site for 30 seconds.
4. Scrub and leave the site for 30 seconds.
5. Increasing the distance between the skin surface and vein by creating a subcutaneous tunnel may reduce the
incidence of catheter related sepsis.
6. Prick the skin with another deposable needle before inserting the IV cannula.
7. Not more than 3 pricks by one person.
8. Once inserted the cannula should be firmly anchored and dressed with sterile dressing.

Recommended…
 Redressing the catheter every day-first cleaning the site with disinfectant and reapplying a topical
antimicrobial ointment.
 Change the cannula after every 72 hours. Medication should be administered through a 3-way stopcock.

SOURCES OF VASCULAR CATHETER

RELATED INFECTION

Hazards appear greater with…

 Long catheters>short catheters
 Catheter in central circulation>peripheral circulation
 Catheters placed with surgical cut down.

Potential sources for contamination of infusion fluid

 C or bag should hang for more than 24 hours.
 Don't manipulate administration sets
 Don't use same administration set for different fluids / pints.
 Change entire delivery system every 48 hours.

PREVENTION OF HEALTH CARE ASSOCIATED PNEUMONIA

Ventilator associated pneumonia

1. Use non invasive ventilation to reduce the need or shorten the duration of endotracheal intubation.
2. Unless contraindicated by the person’s condition perform endotracheal rather than nasotracheal intubation.
3. Perform endotracheal intubation with sterile technique after procedural hand wash with anti microbial soap/
hand rub and sterile gloves.
4. Avoid frequent endotracheal intubation.
5. If feasible, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage of
tracheal secretions that accumulate in the patient’s subglottic area.
6. Before deflating the cuff of an endotracheal tube in preparation for tube removal or before moving the tube,
ensure that secretions are cleared from above the tube cuff.
7. Before any manipulation of the tube or suctioning hand hygiene with anti microbial soap and water or hand
rub is important. There is no evidence at present that sterile gloves are superior to non sterile gloves.
8. At present there is no evidence of superiority of the multi use closed system of suctioning with the single use
open system of suctioning.
9. If the multi use closed catheter is used no routine change of catheter is recommended unless the catheter is
blocked or visibly soiled.
10. If the open system suction is employed, use a sterile single use catheter. Use only sterile fluid to remove
secretions from the suction catheter if the catheter is to be used for re-entry in to the patient’s lower
respiratory tract.
11. Do not routinely sterilize or disinfect the internal machinery of mechanical ventilators.
12. Do not change routinely change the breathing circuit (i.e. ventilator tubing and exhalation valve and the
attached humidifier) that is in use on an individual patient. Change the circuit when it is visibly soiled or
mechanically malfunctioning.
13. Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator taking
precautions not to allow condensate to drain toward the patient. Perform hand hygiene with soap and water
or hand rub and wear clean gloves before this procedure.
14. Use sterile water to fill bubbling humidifiers.
15. No evidence that heat moisture exchangers are superior to heated humidifiers to prevent pneumoniae in
patients receiving mechanically assisted ventilation.
16. Do not routinely changed an HME that is in use on a patient.
17. Change an HME that is in use on a patient when it malfunctions mechanically or visibly soiled.
18. In the absence of medical contraindications, elevate at an angle of 30-45 degrees of the head of the bed of a
mechanically ventilated patient to prevent aspiration.
19. Routinely perform surveillance tracheal cultures it intubated patients.
20. Maintain good oral hygiene to prevent or pharyngeal colonization and subsequent aspiration.
21. Do not routinely perform surveillance tracheal cultures in intubated patients.

Prevention of post operative pneumoniae

> Instruct preoperative patients, especially those at high risk for contracting pneumonia, about taking deep
breaths and ambulating as soon as medically indicated in the postoperative period.
> Use incentive spirometry on postoperative patients at high risk for pneumonia.
Care of patients with tracheostomy
>Perform tracheostomy under aseptic conditions.
> When changing a tracheostomy tube wear a gown use aseptic technique and replace the tube with one that
has undergone sterilization or high level disinfection.

C.NEBULIZATION

Source of infection:
A. Contaminated medicament
B. Room air via open end
C. Organisms from patient’s Nose/mouth
D. Mistaken hand contact while filling of jar.

Recommended…
 Main body of nebulizer can be cleaned with a damp cloth.
 After every inhalation wash the nebulizer, disinfect and then make it work for a few seconds with distilled
water in it / normal saline before reuse.
 The tubing, jar rubber hood can e disinfected by boiling.
 Oxygen mask can be disinfected by boiling / autoclaving.
 The whole set with tube, jar, mask can be disinfected with CIDEX for 30 minutes and then washed properly
with normal saline.

D.MINOR SURGICAL PROCEDURES:All the surgical procedures including dental procedures, lumbar punctures
etc. are invasive procedure breaking the continuity of skin and / or mucous membrane. There is lot of handling
of blood, tissues, organs and body fluids during these procedures.
Floors and surfaces (table tops, floor, light, walls etc.) dressing material (sponges, swabs) linen (mask, gown,
caps etc.), equipment, instruments, gloves and other articles used during surgery get contaminated with blood
or body fluids or blood contaminated material like pus and tissue etc. and must be disinfected before
sterilization or disposal.

Any surface, which has been contaminated with the blood or body fluid, must be disinfected first by covering it
with absorbent material. Disinfectant fluids should first be poured around the contaminated area and then over
the absorbent material and left for more than 10 minutes.

Tissues, organs and any part of the body removed during surgery should be buried deep with bleach or lime.
Blood and body fluids removed during operation must be disinfected before disposal.

E. NON-INVASIVE PROCEDURES

F. These include vaginal, anal and rectal examinations, prostatic massage, measurement of intra-ocular
pressure, tracheal, laryngeal, throat and nasal examinations and different imaging processes like
echocardiography, ultra sound, X-ray and CAT scan. It is highly possible that during some of these non-
invasive procedures, break in the continuity of mucous membrane may be encountered which may result in
contamination of instruments used for the examination. The blood and the body secretions may act as a
source of infection for number of diseases including AIDS and Hepatitis. Further, if un-sterile instruments
have been used they may infect the patient.
The vaginal and rectal examinations are particularly hazardous.
Since HIV and other organisms including those causing sexually transmitted disease may be present in these
situations. Therefore, only sterile instruments, equipment or material should be used for such non-invasive
procedures. After use they must be regarded as 'contaminated' and must not be used on other patients without
proper disinfection and sterilization.

Disinfection of the instruments for non-invasive procedures

Immediately after use the instruments (like vaginal speculum. Proctoscope, nasal speculum and instruments
used for laryngeal and tracheal examination) should be immersed in suitable disinfectant fluid (2%
Gluteraldehyde i.e. Cidex) for at least 20 minutes. After disinfection, they may be washed/rinsed with water and
preferably autoclaved. In case of non-availability of autoclave facility due to workload or other reasons, the
instruments used for non-invasive procedures can be boiled for 20 minutes and then reused. A high level of
disinfection of the instruments and equipment can be achieved by continuous boiling for 20 to 30 minutes.

PREVENTION OF NOSOCOMIAL INFECTIONS

Prevention of catheter related blood stream infections (CRBSI) Peripheral catheters
  Establish the vein prior disinfection. Upper extremity preferred over lower extremity.

 Practice procedural hand washing technique with antimicrobial soap or alternatively use hand rub.

 Disinfect the site selected using “3 swab method” with isopropyl alcohol and 10% betadine alternately
and wait till dries.

 Non-sterile gloves are appropriate if no touch technique is used.

 Do not touch the site ungloved after disinfection.

 Do not reuse a vascular access device.

 Leave site visibly dry after access is established.

 Apply a transparent dressing.

 Change every 72 hrs or earlier if infected or any signs of infiltration.

 In case of pediatric patients do not change unless any signs of phlebitis.

CENTRAL VENOUS CATHETERS (CVC)

General
 Train staff in catheter insertion, maintenance and infection control measures.
 Regularly assess compliance and knowledge about infection control practices.
 Maintain good staff levels in ICU to prevent infection.
Insertion
 Teflon catheters preferred over PVC and polyethylene catheters.
 Subclavian preferred over jugular preferred over femoral.
 In children no such preference, use route one is most comfortable with.
 Use minimum number of lumens.
 Antibiotic coated catheters superior to routine catheters if they are expected to remain in place for more
than 5 days.
 Practice surgical hand washing prior to procedure.
 Use maximum barrier precautions( cap, mask, gown and sterile gloves).
 Clean the site 70% isopropyl alcohol and 2% aqueous chlorhexidine alternatively for 3 times.
 If 2% aqueous chlorhexidine not available then 0.5% alcoholic chlorhexidine or 10% betadine may be
used. Clean in circular manner each time, for 1minute.
 30 seconds scrub time and 30 seconds dry time. If povidone iodine is used allow at least 2mts of dry time.
 Leave site dry after insertion.
 Use either plain sterile gauze with opaque dressing or sterile transparent dressing (do not use
betadine or any other antibiotic ointment).

Dressing and maintenance

 Regular dressing every 2 days for gauze and 7 days for transparent dressings.

 Change dressing earlier if damp, loosened or soiled.

  Proper hand hygiene with sterile gloves before dressing.

 Inspect any evidence of catheter site infection.

 If multilumen catheter is used designate one port exclusively for hyperalimentation.

 Clean all stopcocks with 70% alcohol or 10% betadine prior to use.

 Cap all stopcocks when not in use.

Removal

 Remove when no longer necessary.

 No routine removal of catheters.

 No need to send routine surveillance cultures from the catheters.

 Do not routinely culture tips on removal.

 If catheter was placed in an emergency and aseptic technique was not followed then replace before
48hrs have elapsed and place new catheter.

 Replace catheters if there is any evidence of infection at exit site.

 Remove all catheters if person is hemodynamically unstable and CRBSI is suspected.

 If CRBSI suspected do not replace catheters over a guidewire.

ARTERIAL CATHETERS

 The same principles for insertion, maintenance and removal as for CVC apply.
 Use disposable transducers preferably.
 Use sterile reusable transducers in accordance with manufactures instructions if disposable transducers
not available.
 Replace the transducer at 72hrs interval along with other components of the system including the tubing,
the flush solution and the continues flush device.
 Keep all components of the pressure monitoring system sterile.
 Minimize manipulations and keep a closed flush system.
 When the pressure monitoring system is accessed through a diaphragm rather than stop cock wipe
diaphragm with 70% alcohol prior to access.
 Do not use any parenteral fluids or dextrose containing fluids through the system.
Umbilical Catheters
 The same principles as for CVC apply.
 Do not apply tincture of iodine for skin disinfection.
 Umbilical artery catheters should ideally not be left for more than 5 days.
 Remove earlier and do not replace if CRBSI, thrombosis, vascular insufficiency is suspected.
 Umbilical venous catheters can be kept up to 2 weeks if aseptic precautions followed.
 Remove earlier and do not replace if CRBSI or thrombosis suspected.

ADMINISTRATION SETS, FLUIDS & MEDICATION

 Replace administration sets with add on devices (tubings, stop cocks, needle less devices) every 72 hours.

 Replace sets used to administer blood, blood products, lipid emulsions every 24 hours.

 Complete infusions of lipids within 12 hours of initiation and of blood products within 4 hrs of initiation.

 Use collapsible bags for IV fluids whenever possible especially for patients at high risk for nosocomial
infections. (Avoid using needles for air inlets).

 Preferably use single dose vials.

 If multidose vials are used, refrigerate after every use and wipe the access surface with 70% alcohol
before inserting the needle.

 In line filters are not routinely required.

PREVENTION OF URINARY TRACT INFECTIONS

 Educate personnel in correct techniques of catheter insertion and care. Periodically re-educate personnel
in catheter care.
 Catheterize only when necessary. Condom catheter drainage, suprapubic catheterization, and
intermittent urethral catheterization can be useful alternatives to indwelling urethral catheterization.
 Use smallest suitable bore catheter consistent with good drainage and to minimize urethral trauma.
 Procedural handwashing with antimicrobial soap or use hand rub.
 Insert catheter using aseptic technique and sterile equipment.
 Use sterile gloves, sterile drape, swabs, single packet of lubricant jelly, and antiseptic solution (savlon or
betadine).
 Secure catheter properly to prevent movement and urethral traction.
 A sterile continuously closed drainage system should be maintained.
 The catheter and collecting tube should be kept from kinking.
 The collecting bag should be emptied regularly using a separate collecting container for each patient.
 The collecting bags should always be kept below the level of the bladder.
 The catheter and drainage tube should not be disconnected unless the catheter must be irrigated.
 If breaks in aseptic technique, disconnection, leakage occur, the collecting system should be replaced
using aseptic technique after disinfecting the catheter tubing junction.
 Routine irrigation and use of antimicrobials for irrigation should be avoided.
 To relieve obstruction due to clots, mucous or other causes an intermittent method of irrigation may be
used.
 The catheter tubing junction should be disinfected before disconnection. A large volume sterile syringe
and sterile irrigant should be used and then discarded. The person performing irrigation should use
aseptic technique.
 If the catheter becomes obstructed and can be kept open only by frequent irrigation, the catheter should
be changed if it is likely that the catheter itself is contributing to the obstruction.
  If small volumes of fresh urine are needed for examination, the distal end of the catheter or preferably
the sampling port if present, should be cleansed with a disinfectant, and urine then aspirated with a
sterile needle and syringe.
 Larger volumes of urine special for special analyses should be obtained aseptically from the drainage bag.
 Daily care with providence-iodine solution and daily cleansing with soap and water does not reduce the
incidence of urinary tract infections and is not routinely recommended.
 Indwelling catheters should not be changed at arbitrary fixed intervals but should be removed as soon as
not needed.
 To minimize the chances of cross infection, infected and uninfected patients with indwelling catheters
should not share the same room.
 Regular bacteriologic monitoring of catheterized patients is not recommended.

3.9. EMPLOYEES HEALTH PROGRAMME

Guidelines of working for employee’s health programme:

1. Education – Central focus of all health programmes is continuing education programme. The hospital has a
system of health check up programme for every new employee joining the hospital.

2. Counseling – Facility for proper counseling of staff at risk, especially in situation like pregnancy
etc. should be available.

3. Immunization – as per the HR Policy (Refer Vaccination Policy)

3.10. HOUSE KEEPING: - Measures for Infection Control

1. Each patient’s area is considered to be an individual, with toilet facilities.

2. Each patient has his own utensils including plate drinking glass thermometer and other equipment which
includes pan, urinal, bath basin, kidney basin bucket and mug.

3. Each patient has own linen blanket, pillow.

4. The furniture and articles kept inside the patient’s cubicle are considered to be contaminated items and
the articles kept outside the patient’s cubicle are considered cleaner.

5. Dust and mop flop daily with disinfectant solution (Sodium Hypochlorite Solution in 1%Strength).

6. Dust furniture and window grills daily in the patient’s cubicle.

7. Bed, locker, stool, and mattress are cleaned with diluted Lysol solution.

8. Clean sink daily with disinfectant.

9. Clean the toilet, bathroom with disinfectant solution several times a day.

10. Clean the bedpan urinal kidney basin and bath basin daily.
11. Empty waste basket are sent to the waste disposal.

12. Change the sputum cups daily collect it in the plastic bag and seal it.

13. Change the thermometer disinfectant solution once in two days.

14. Syringes needles dressing packs procedure sets inhaler mouth pieces, bottles gloves, must be put inside
the red-bag, tie it securely and send it to the central sterile service department.

15. Periodic cleaning of walls doors and windows with soap solution is necessary.

16. Never allow the patients to keep unnecessary items inside the cubicle (Own bedding suitcases, book,
magazines etc,)

17. Restrict visitors. Allow them to visit during the visiting hours only As far as possible they should stand
outside the patient cubicle and talk with them.

18. Soak all the infected linen in the1% hypochlorite for 24hours then send linen to the laundry

Routine cleaning:
Standard precautions should be implemented when cleaning surfaces and facilities. Staff should wear
suitable gloves and other protective clothing appropriate for the task; Protective eyewear should be used
where splashing likely to occur.

Standard precautions should be implemented; toilets, sinks wash basins, and surrounding areas should be
cleaned regularly or as required.

Bed pans and urinals should be cleaned with an abrasive, rinsed in warm water then dried and stored
appropriately Cleaning methods for these items should avoid generation of aerosols.

They are cleansed regularly of as required Bedpans surfaces should be cleaned on a regular basis using only
cleaning procedures, which minimize dispersal of microorganisms into the floors should be cleaned daily or
as necessary with a vacuum cleaner fitted with a bacteria-retaining filter, which should be changed in
accordance with manufacturer’s instruction.

The exhaust air should be directed away from the floor to avoid dust dispersal; a sucked vacuum cleaning
system can also be used: this is not used in patient areas.

Routine surface cleaning should proceed as follows:-

 Clean and dry work surfaces before and after each session or when visibly soiled.
 Spills should be dealt with immediately.
 Use detergent and warm water for routine cleaning
 Where surface disinfection is required, use in accordance with manufactures instructions.
 Clean the surfaces before and after applying disinfectants.
 Empty the buckets after use, wash with detergent and warm water and store dry
 Mops should be cleaned in detergent and warm water then stored dry.
Chemical disinfectants are not recommended for routine cleaning although coloring releasing agents (CRAS) are
still recommended and are widely used in circumstances during which significant risk of infection transfer may
be identified for example treatment of spillage of contaminated exudates from infected patients.

Disposable covering (For example, plastic-backed single-use paper bench liners) may be used to reduce surface
contamination. They are often a viable and economical alternative to surface disinfection but should be changed
frequently and when visibly soiled or damaged.

When liners are changed the underlying, bench surface should be cleaned as above and disinfected in
contaminated Trays(which can be disinfected or sterilized according to need ) to hold and carry instruments
should also be used where possible to assist in reducing surface contamination.

3.11. CLEANING AND DISINFECTION OF VARIOUS ITEMS COMMONLY USED IN THE HOSPITAL

General Use articles Bath water Add Savlon when necessary

Bed Pans Wash with hot water and keep dry.
Disinfect with sodium hypochlorite 1% after used by
infected patients.
Bowls Autoclaved/wash with hot water and keep dry.
Crockery cutlery Wash with hot water and detergent Keep dry.
Floors Mopping with 1% Sodium hypochlorite

Furniture, Bed Frames- Cleaning with isopropyl alcohol

Trolley tops Wipe with water and detergent to remove dust and keep
dry

Thermometers Immerse in 70%alcohol for two minute and keep dry

3.12. LAUNDRY AND LINEN MANAGEMENT

Soiled linen can be a source of microbial contamination, which may cause infection in Hospital patients and
personnel. All soiled linen should be handled in the same manner regardless of the patient’s diagnosis.
Although the risk of disease transmission from soiled linen is minimal, the following infection control guidelines
apply:

For the management of linen and laundry contaminated with blood and body fluids.

 Hand washing should be performed after having contact with all soiled linen.
 Using colour coded liners to segregate used and infected linen. Blue liners are used for clean, non-
infected linen, and red liner for soiled or infected linen. It is then labled at the department by specific
linen-carrying trolleys.
 Decontamination is carried out by soaking infected linen in 10% Bacillocid solution for ½ hour. This
linen is then sent to the laundry for further processing.
 Linen once decontaminated is considered noninfectious and is handled similar to used, non infected
linen.
 Protective barrier apparel should used as follows:
  Gloves should be worn for actual or potential contact with soiled linen
 Contaminated with blood or body substances.
 Mask should be worn if there is potential for exposure to aerosolized blood or body substances. This
may occur if soiled linen is extensively agitated
 All linen contaminated with blood or body fluids is considered potentially infectious.
 Handle soiled linen as little as possible and with a minimum of agitation to prevent gross microbial
contamination of the air and of the of the persons handling the linen.
 Linen should not be sorted or rinsed in patient care areas.
 All soiled linen should be bagged at the location where it was used.
 Place all linen in the designated laundry bags.
 Caution must be exercised to help prevent laundry bags from being overfilled.

3.13 Kitchen Sanitation & Food Handling

In-campus catering ensures safe and healthy food to patients.

1. Kitchen Cooks and other personnel handling food:

 Health and hygiene of dietary personnel are checked from time to time .Specially for diseases communicable
through food stuffs.
 Persons dealing with food are provided with barriers like apron caps gloves etc. to avoid contamination of
food.
 Finger nails to be kept short.
 Hand washing to be done properly between fingers and unto finger nails with soap and water Refer to
hygienic hand wash.
 Hand washing to be made mandatory after.
I. Using toilet
II. Smoking
III. Eating or drinking.
IV. Touching hair face nose eyes etc.
V. Handling raw food
VI. Touching unclean utensils or surface.

 Regular check ups of staff and kitchen.

 Waste to be discarded in proper bags and kept outside the kitchen. NB. Food returned from hospital is to be
discarded.
2. Food temperature:

Need to maintain food temperature is a must in order to prevent multiplication of contaminating organisms.

 Cold food items to be kept in refrigerators in cold stores at very low temperature:

Vegetables and fruits -0-40C

Dry stuff i.e. lentils, rice flour condiments etc-Room temperature.

 Food prepared to be served cold should be brought to 40C or below from their preparation time should be
served within 4 hrs.
 Hot foods are held at 630C or below.
 For special foods their dietary manual should be checked
  In-patient food distribution should be strictly supervised Trays are served by dietary personnel only
 For taking food to isolation room dietary personnel should observe precautions.

3. Cleaning:

 Vim and liquid soap used.

 Food is emptied form trays directly in waste bins
 Trays are rinsed in tap water scrubbed with soap and water washed in hot water then dried.

3.14 ENGINEERING CONTROL TO PREVENT INFECTION

The preventive maintenance of all equipment will ensure efficiency of all staff and reduce chances of
contamination of air and water. The proper care and maintenance of the entire physical structure will also
reduce accumulation of dust and spores in the environment. Thus the engineering dept and its personnel are
important links in the chain of activities towards hospital infection control.

All personnel should apply universal precautions when in contact with patients or blood and body fluids.

General

 Engineering personnel shall report to the ward sister prior to commencing work in a patient’s room or area,
and follow her directions with regard to dressing, scrubbing etc. Engineering personnel shall check out with
the ward sister upon completion of work.
 Engineering employees shall maintain a neat, clean appearance at all times. Personnel hygiene such as
washing after using toilet facilities etc will be observed. All engineering personnel must be aware of universal
precautions.
 Prior to entering areas requiring sterile attire such as the OR, engineering employees shall wear the
prescribed clothing. Engineering personnel shall check in and out with the permission of the supervisor.
 Hand washing should be followed before and after leaving the patient care area.
 Water culture should be taken once in 3 months.

Plumbing job guidelines

 Hospital water supply systems shall not be connected with any other piping system or fixtures that could
allow contamination without the use of adequate air gaps or approved back flow preventers or vacuum
breakers.
 When using equipments to unstop faulty drains, wear rubber gloves.
 When robbing out main sewer lines, or when exposed to gross contaminated wastes, wear rubber boots and
rubber gloves.
 After exposure to sewer lines or gross contaminated waste, clean exposed areas of body with soap and
water. Change uniform if necessary. Do not return to patient care areas before cleaning up.

Physical barriers between repair area and patient care facility.

 When any construction or repair work is carried out in patient care areas the supervisors must inform the
medical administrator(manager for medical opetation,PRO,medical superintendent), who will inform the
heads of the concerned departments so that patient may be shifted if required.
 When work is carried out in areas where immune compromised patients or that require a sterile atmosphere,
adequate physical barriers must be present to prevent the spread of fungus and other such microbes,
through dust and debris generated.
 All areas that require a sterile atmosphere must be fumigated before use following construction work.

Ventilation Systems.

 Regular cleaning of all window AC filters must be carried out in a systematic manner throughout the
hospital.
 AC filters should be placed in formalin solution for at least an hour at each cleaning.
 HEPA filters should be checked once in every six (6) months and changed once in every two (2) years or as
required as per the calibration report as the environmental dust load is very heavy in these areas and the
filters get clogged quickly.
 When microbial load increase as evidenced by results from the environmental surveillance, the filters must
definitely be checked.
 In areas where central air-conditioning is used the moisture of the air and the ventilator air changes must be
carefully monitored. All ducts must be washed thoroughly at regular intervals and fumigated.

3.15 ISOLATION PRACTICES

Isolation procedures are used to prevent spread of infection from patient to patient, patient to HCWS (Health
Care Workers): Patient to attendants Basic idea is to confine the infectious agent to a small area till the danger of
spread is under control, General precautions to be taken are:

 Hands to be washed with soap and water or Skin disinfectant before and after touching the patient.

 Wear Gown before handling infectious patients.

 Wear masks while handling cases with respiratory ailments.

 Wear gloves while doing any procedures.

 Linen used by infectious patients to be soaked in antiseptic solution 1% Hypo chlorite solution for 30
minutes and then washed before sending it to Laundry. Never shake linen before bagging.The infectious
organisms will spread all around

 Disposable needles and syringes to be used.

 Regular cleaning of the patient’s rooms to be done at least twice or thrice. Remove dust with damp mops
or vacuum cleaner. Use laundered and dry mops. Sweeping with brooms is to be avoided.

 Disinfection of the room after patient leaves:-

(a) Furniture with 1% Sodium hypochlorite
(b) Room with fumigation and mopping with antiseptic solution
(c) All equipment in the room must be disinfected
(d) If the previous patient was admitted with AIDS, the room has to be cleaned with 1%Hypochlorite
solution as well.
  In case of gas gangrene destroy the linen by burning. If it cannot be burnt then place the linen in the red
bag first send for autoclaving then send to laundry.
 In rabies place the linen in red bag: first send for autoclaving then send to laundry.
 In AIDS soak the dry linen in 1% Hypochlorite after this place them in double red bag and send for
autoclaving on return send to laundry, wet linen are soaked in 1% hypochlorite solution for hour dry the
linen and send it to laundry.
 Dispose all magazines books used by the patient.(rubber sheets
1. Few specified situations call Strict Isolation such as diphtheria ,Plague etc, Persons entering the patients
room should:
 Wear masks
 Wear gowns
 Wear gloves
 Hands to be washed after touching the patient
 All articles used by the patient to be bagged &labeled “Biohazard”

2. Another situation is where Bed Isolation is required. This is done in infection by:
G.I. Tract involvement
 Dysentery
 Cholera
 Salmonella
 Enteric Fever

By droplets and air

 Measles
 Influenza
 Meningitis
 Mump
 H1N1
 Tuberculosis etc
By close contact:
 Conjunctivitis
 Gram Negative bacteria Resistant to gentamycin, tobramycin & amikacin specially
 Staphylococcus resistant to mythically wailing or naficillin
 Pneumococcus resistant to penicillin.

In such case persons entering the room should:

 Wear masks
 Wear gown where soiling is likely
 Wear gloves
 Wash hands after contact with one patient, before touching another patient
 Articles to be discarded are bagged and labeled

N.B –In case of active tuberculosis patients are required to wear masks, while moving about.

Special mention of Methicallin Resistant Staphylococcus Aureus is made here as it creates infection problems
once established
Once MRSA is isolated it should be informed to the treating clinician and infection control officer.
Infection control for MRSA
3. In immuno compromised patients prevention of infection from HCW is required. This is called reverse
isolation as burns leukemia, immunosuppressive therapy patients AIDS patients and patient with severe
Neutrogena require this.
Before prescribing any antimicrobial,please confirm your choice with the consultant/microbiologist.

Rationale Regulations of the antibiotic usage in the hospital is necessary for three reasons.

1. To ensure an antibiotic is available to overcome infection caused therefore be kept in reserve.

2. To curtail the emergence of the resistant strains of microorganisms.
3. To reduce the cost of treatment.
4.0. ANTI BIOTIC POLICY

Antibiotic Prophylaxis for surgery

S.No Procedure Preferred drug

1 Clean surgeries(eg.elective hernia and breast Cefazolin/Cefuroxime/Ceftriaxone
surgeries)
2 Orthopedic surgeries Cefazolin/Cefuroxime/Ceftriaxone
3 Cardiovascular /Vascular surgery Cefazolin/Cefuroxime/Ceftriaxone
4 Neurosurgery Cefazolin/Cefuroxime/Ceftriaxone
5 Ophthalmic surgery Cefazolin/Cefuroxime/Ceftriaxone
6 Opthal
7 Head,Neck and ENT surgery Topical quinolone,Immediate pre-
operative betadine system
Cefazolin/Cefuroxime/Ceftriaxone

8 Gastroduodenal Cefazolin/Cefuroxime/Ceftriaxone
9 Appendicular/cororectal surgery Cefuroxime/CefazolinCeftriaxone/BL/BLI
and Metronidazole
10 Biliary Cefazolin/Cefuroxime/Ceftriaxone
11 Abdominal,Vaginal hysterectomy and Caesarian Cefazolin/Cefuroxime/Ceftriaxone
section
12 Urologic Surgery Cefuroxime or as guided by urine culture

Antibiotic Policy

Drug Standard dose Weight based dose Duration for

bolus Injection(infusion)
Cefazolin < 80 kg 1 gm 20-30 mg/kg/dose 3-5 min (20-60 min)
> 80 kg 2 gm
Cefuroxime 1.5gm 50 mg/kg 3-5 min (20-60 min)
Metronidazole O.5gm-1gm 15 mg/kg initial 30-60 min
dose(7.5 mg/kg
subsequent doses)
Ceftriaxone 1-2 gms 3-5 minutes
 Antibiotic Policy

Category First line Alternative

Community Ceftriax /Cefotax Pen G /Amp +chloro
Acq.Menningitis
Menningitis Post ESBL,Amp C Meropenam Till M.R.S.A excluded
Neurosurgical /Trauma +Vancomycin
Shunt infection Vancomycin till M.R.S.A excluded plus Linezolid
meropenam
Primary/contiguous Brain Ceftriax /Cefotax +Metro Pen G +Metro
abcess Meropenam plus Vancomycin
Post surgical Ceftriax/Cefotax+Vanco/Cloxacillin Vanco till MR excluded in
trauma/abcess Surgery OR BL/BLI plus Clinda or post brain
Metro
AOM/Acute sinusitis Amox clav/ Cefuroxime Ceftriaxone
Malignant otitis externa Ciprofloxacin Ceftazidime Piperacillin
Chronic Sinusitis Amox/ clav Respiratory FQ
Streptococcal pharyngitis Amox 1st generation ceph /
Macrolide
AECB Amox/ clav plus Macrolide or Cefuroxime
Fluroquinolones
Or Beta Lactams plus Macrolide or
Fluroquinolones
Community aquired Amox/Newer macrolide Doxy
pneumonia-CAP-OPD
CAP-in patient (non ICU) Amox/ clav/Ceftriax+Newer Macrolide Newer FQ
CAP-ICU IV ceftriazone +Newer macro/Newer a FQ if pseudo amox /clav +
concern Pip Tazo+Cipro Aspiration Newer FQ
Lung abcess Clindamycin plusBeta Lactams Pip Tazo/Amox clav+Amp
sulb
Infective endocarditis Pen G/Amp+Clox+genta Prosthetic Van +genta
Native valve valve vanco +genta +Rif
Pyoderma Localized-mupirocin/fusidic acid
Wide spread-1st gen
Cellulitis(non diabetic) Cefazolin Amox clav
Necrotizing facitis Ceftriazone & Clindamycin OR BL/BLI Amp sulb/pip Tazo/Tie clav/
plus Clinda or Tigecycline or Imipenum
Daptomycin or Carbapenams
Acute Osteomyelitis Cloxacillin OR Vancomycin or Linezolid Cefazolin/Levo and
and BL/BLI rifampicin/clindamycin
Septic arthritis Levo/cipro/ceftriax and clox or BL/BLI
Entric Fever Sick-Ceftriaxone out patient –Cefixime Azithro/cotrimoxazole/high
OR Amikacin Dose quinolones
Vivex malaria Chloroquine and primaquine Artesunate/Artemeter
Uncomplicated falciparum Quinine and Doxy/clinda/SP Artes and Mefloquine
malaria Mefloquine
Severe falciperum malaria IV artesunate and mefloquine on IV quinine and
completion doxy/clinda/SP
 Dysentry Ciprofloxacin/Ceftriaxone Ceftriaxone
Liver abcess Ceftriax/Cefotax&Metronidazole/Amp Ticar clav/Pip Tazo/Cipro
Sul and metro/BL/BLI/Carbapenams
Acute Cholangitis Cefoperazone & metro Ceftriazone & Cipro and metro
Acute appendicitis Metro Pip tazo Imipenum /Meropenum
Secondary peritonitis Ceftriaxone/Cefotax &metro Pip Tazo
Cystitis Cefotax/Ceftriax & metro Cotrimoxazole
Cetriax or Cefotax Amikacin
Pyelonephritis
Norflox or Ciproflox
Cipro/Cefotaxime
All above said indication-
Carbapenams can be given if condition
is very severe.

As a policy, the clinician may add or change the drug as per the clinical condition and need of the patient.
 5.0. OPERATION THEATRE PROTOCOL

 Operation theatres are to be fumigated periodically.

 Floors in the wards are to be mopped by disinfecting solutions.
 These precautions have become essential because of ever increasing spread of HIV and Hepatitis B
virus infections.

The following protocol should be followed:

1. Patient for operation: Jewelry and under garments are to be removed in the ward, Part is prepared by 5
minutes scrubbing with brush, soap, water and scrub lotion Patient changes into clean hospital clothes
Patients head is covered he is transferred to O.T Trolley.

2. Personnel of O.T.
 Health-Must be free of infections especially upper respiratory tract skin particularly face hands nails
scalp eye etc.
 Attire: Cap, mask O.T Clothes & slippers to be worn till in O.T.
 Sterile gown: Cotton wrap-around type.
 Gloves: Sterile made of rubber or latex.
 Rubber Slippers-Washed and cleaned daily.
 Eating drinking smoking is not allowed in designated area of O.T

Training: Regular in service training of all of O.T. should be done. They are advised to report even their minor
Illness.

3. Operation theatre room maintenance: Ventilation –Ideally 20 volume changes per hour of fresh air

Note: - common air borne organisms are Aspergillus, Mucor and Klebsiella: caused due to poor ventilation.
Temperature-65-750.F

Cleaning of O.T. Rooms: Daily- with 1% sodium hypochorite Floors table furniture equipment etc Suction bottles
and tubing overhead light receptacles Floors first with liquid soap then with disinfectant.

Instruments - Cleaned immediately by scrub nurse with brush liquid soap then sent for sterilization O.T. the
instruments are first soaked in cydizyme for ½ to 1 hour then washed as above,

Surgical Light - After cleaning with disinfectant wipe it with 70% isopropyl alcohol to remove detergent.

Linen: Linens if soiled put in 10% bacillocid for ½ hour to one washed and sent to laundry. Blood & body fluid
spills -with gloved hand pour disinfectant over the spill (2%hypo chlorite) let it remain for 20 minutes Put
newspaper and wipe it Then rewipe with disinfectant remove gloves &wash hands.

Weekly Cleaning in Operation Theatre

 Remove all portable articles.
 Wipe all including walls floors etc. with wet mop detergent solution
 Wash and dry all furniture and equipment with detergent.

Maintenance of Instruments and Equipment in Operation Theatre

Instruments are either autoclavable or Non -Autoclavable
For Autocalavable:
Preparation for Sterilization:
 After checking the instruments for count and visible dirt arrange them in a Wire basket in open position.
 Rinse the instruments with cold water.
 For hollow lumen and atraumatic instruments use a soft brush wherever possible and flush the item with
water jet.
 Clean the instrument with enzymatic cleaner.
 Rinse the instrument in hot water to remove the traces of enzyme /detergent.
 Repeat rinse by flushing the instruments with air jet/air gun to remove the excess water.
 Place the basket of instruments in dryer for complete drying.

Inspection
 After drying all the surgical instruments or critical items are then checked thoroughly in the assembly area.
 They are assembled in the respective baskets as per their pre-decided list.
 CSSD technicians sign the lists.
 -Once the instrument set is prepared as per the lists, the sets are packed doubly
 In an appropriate size and type of wrapping materials. These sets are labeled for their contents.
 An expiry date is put and a process indicator is affixed on this label
 These are loaded on autoclave carriages and are subjected to steam sterilization
 Autoclave before washing instruments
 Allow to cool.
 Wash with soapy water
 Rinse
 Re autoclave including brushes for cleaning

For Non autoclavable

 Immerse in gluteraldehyde 2%
 Discard solution
 Wash in warm water and detergent
 Rinse in gluteraldehyde2%, leave to soak for 3 hour.

Suction bottles- Clean with 1% Hypochlorite solution 100 IN WATER, rinse with water and finally autoclave.
Anesthetic Equipment: Utilizable equipment to be used.
Sharps-Put in puncture proof container
Items to be disposed off after one use
Suction tubes
All Catheters
All drains

The OT Staff assisting in operation should do surgical scrub i.e. Hands scrubbed from fingertips to 2” above
elbow for 3-5 minutes with soap and water. Dried with sterile towel before donning gown.

Bio- Hazardous patients in Operation Theatre: (HIV Positive, HB positive):

1. Post them at the end of O.T list
2. Patients to be induced in .O.T. and kept in O.T till full recovery.
3. Minimum equipment in O.T
4. Cover operation table with waterproof sheeting.
5. All equipment for operations should be available in O.T.
E.g. Disinfectant: 2%Gluteraldehyde, 1% Na Hypochlorite
6. Minimum required personnel to be present, Workers to wear plastic aprons eye- covers once they theater
they should not move in and out of theatre.
7. Specimen containers are labeled “Bio hazardous “and double bagged.
8. Used linen and instruments are put in red plastic bags and tied.
9. After operation – O.T. and all equipment to be thoroughly cleaned with hot soapy water followed by
hypochlorite or any other disinfectant.
10. Fumigate the Operation Theater with Ecoshield fogging.

Technique of Gowning: Gowns are folded inside out to avoid contamination

1. Hold the gown well away from trolley and your body.
2. Unroll the gown by holding the neckband till the sleeves.
3. Slide both hands and arms into the sleeves.
4. Assistant slides the hand under the gown at the shoulder and pulls out and fastens the back tapes.
5. Assistant helps in unfastening and removing the Gown.

Technique for Gloving:

Gloves are kept in powdered packets and peeled by the assistant.
Open Method:
1. Pick the first glove by its cuff with one hand and slip the other hand in.
2. With the gloved hand pick the second glove and put the ungloved hand in the glove and release the grip.
3. Adjust the fingers of the gloves properly.
4. Cuffs of the gloves are pulled over the stockinet sleeve of the gown

Closed Method:
1. In the gown both hands are pushed up to the stockinet cuffs only

2. Cuff of the left hand glove is grasped through stockinet part of the right sleeve and pulled over the left hand.
3. The second glove is put on the right hand in the similar manner.

Removal of Gloves: the gloved fingers of one hand grip the outer surface of the cuffs and pull off the glove
inside out .For the second glove the inside of the cuff is held by the ungloved hand and pulled inside out .

Dialysis Unit.
 Operator to follow universal precautions
 Disposable items like needles fistula should be disposed after treatment with 1% bacillocid solution.
 Dialyses and blood tubing’s rubbings after washing to be kept in 4% formalin for at least 24 hours.
 Then flushed with 2 liters of sterile normal and dried and kept in sterile conditions for re –use
 Bio – hazardous patients to be dialyzed separately the materials used should be disposed off.

N.B After ETO sterilization the articles are placed on a clean shelf for at least 3 days for residual ETO in the
packing to be reduced to acceptable levels Then they are stored in an area free from dust and moisture.

MRSA
 OUTBREAK POLICY

Definition

An increase in the isolation rate of an organism or clustering of clinical cases in the same time frame suggests an
outbreak.

Factors suggesting an outbreak:

 A laboratory report of a bacteriology specimen grows an alerting organism.

 Two or more patients are found to have an infection attributed to a species not previously documented,
particularly if it has occurred after a surgical procedure.
 The clinicians or the ward staff reports multiple infections of a similar nature.

Investigation of an outbreak

 An outbreak is an infection control emergency; measures should be taken as soon as an outbreak is

suspected.

 Begin preliminary evaluation and determine a background rate of infection.

 Confirm the existence of an outbreak.

 Confirm the diagnosis using the microbiological methods.

 Create a case definition that may include laboratory and clinical data.

 Start with a broad case definition that can be redefined at a later date.

 Develop line listings by identifying and counting cases or exposures.

 Describe the data in terms of time, place and person.

 Remember that cases may have been discharged from the health care facilities.

 Take immediate control measures. Determine who is at risk of becoming ill. Look at changes that may
have affected the rate of infection e.g. new staff, new procedures, new laboratory tests and health care
worker: patient ratio etc…

 Communicate information to relevant personnel.

 Screen personnel and environment as indicated.

 Write a coherent report (preliminary and final).

 Summarize investigation and recommendations to the appropriate authorities.

 Implement long-term infection control measures for prevention of similar outbreaks.
 7. Notifiable Disease Procedure

The following diseases are “NOTIFIABLE DISEASES” according to Surat Municipal Corporation (SMC) guidelines.

 Acute Gastro Enteritis

 Dysentery
 Viral Hepatitis
 Typhoid Fever
 Malaria
 Dengue Fever/DHF/DSS
 Chickengunya
 Encephalitis
 Meningitis
 Measles
 Diptheria
 Whooping Cough
 Mumps
 Chicken Pox
 Pneumonia
 Tuberculosis
 Poliomyelitis
 Dog bite
 Snake bite
 Leptospirosis
 Swine flu

The hospital (CMO/RMO) immediately informs the SMC on admission of any patient of above notifiable diseases.
The same is reported once a week to SMC.

In case of Acute Flaccid Paralysis (suspected poliomyelitis) immediately inform to CMO/RMO. So that stool
sample of the patient and other actions can be taken immediately by Government.
 SECTION II

Biomedical waste Management

1.0. BIO – MEDICAL WASTE MANAGEMENT PROGRAMME

The hospital has a well managed policy for collection and disposal of biomedical waste. The objectives of Bio-
medical waste management programmed should be:
 Training of Health care workers
 Reducing Chances of accidental injury
 Proper segregation and treatment of each type of waste with appropriate technology
 Lessen the impact of waste pollution on community at large
Bio Medical Waste ‘means any waste which is generated during the diagnosis treatment or immunization of
human beings or animals or in research activates pertaining thereto of in the production or testing biological
and including categories mentioned in Schedule. Simply put it means:

1. Any waste that consists wholly of partly of human or of animal tissue blood or other body fluids,
excretions drugs, or other pharmaceutical products including anatine plastic drugs, swab drugs swabs
dressings, syringes needles or other sharp instruments being waste which unless reddened safe may prove
hazardous to any person coming in contact with it.

2. Any other waste arising from medical nursing dental pharmaceutical or similar practice investigation
including radioactive waste treatment care teaching or research of collection of blood and blood products
from transfusion being waste which may cause infection to any person coming in contact with it.

Table 7: Treatment and disposal Option of Bio medical waste

 Category Waste Category Treatment and disposal option
No
Category Human anatomical waste (Human tissues Incineration #deep burial*
1 organs body parsec.)

Category Animal waste (tissue organs body parts Incineration #deep burial*
2 fluids blood carcasses etc of
experimental animals etc)
Category Microbiology and biotechnology Local autoclaving/microwaving/incineration#
3 waste(Laboratory cultures
stocks/specimen of micro-organism
live/attenuated vaccines, cell cultures
,etc)
Category Waste sharps (needles syringes scalpels Disinfection (Chemical
4 blades broken glass etc.) treatment##/autoclaving microwaving)and
mutilation/shredding**

Category Discarded medicines and crypto toxin Incineration #/ destruction and disposal in
5 drugs secured landfills

Category Soiled waste (items such as cotton Incineration #/ autoclaving /microwaving

6 dressing plaster casts etc contaminated
with blood/body fluid soiled linen
beading etc )
Category Soiled waste (disposable items other Disinfection by chemical treatment ##/
7 than sharps such as tubing’s, intravenous autoclaving/ microwaving and mutilation/
sets etc.) shredding**
Category Liquid waste (From washing cleaning Disinfection by chemical treatment ##and
8 housekeeping disinfecting laboratory discharge into sewers/drains
etc.)
Category Incineration ash (of any bio-medical Disposal in municipal land fill Secured land fill
9 waste ) it may contain Heavy metal

Category Chemical waste (Chemicals used in Chemical treatment ## and discharge into
10 production of biological disinfection as sewer /drains for liquids and secured landfill
insecticides etc.) for solids

* Deep burial shall be an option available only in towns with population less than 5 lakes and in rural areas.
** Mutilation/shredding must be done in a manner that can prevent the unauthorized use of bio medical
waste.
# there will be no chemical pretreatment before incineration Chlorinated plastic shall not be incinerated.
## Chemical treatment using at least 1% hypochlorite solution or any other equivalent chemical reagent is
recommended it must be ensured the chemical treatment ensures disinfection
Type of solid waste produced
1. General Waste-
 Household waste
  Packing materials
 Office and Kitchen waste

2. Pathological Waste
 Tissue
 Organs
 Body parts
 Human fetuses
 Animal carcasses
 Blood and body fluids

3. Radioactive waste: Solid liquid and gaseous waste contaminated with radio nuclides (generated from in vitro
analysis of body Tissues and fluid and in vivo body organ imaging and tumor localization and therapeutic
procedures)

4. Chemical Waste may be of two types

 Hazardous
 Non –Hazardous

a. Hazardous waste.
Discarded solid liquid and gaseous chemicals from:
 Diagnostics
 Experiments
 Cleaning
 House Keeping
 Disinfecting procedures
b. Non Hazardous
 Chemicals other then above
 Sugar
 Amino acids
 Organic salts and Inorganic salts

5. Infectious waste contains pathogens in sufficient quantity so that exposure to it results in disease.
Cultures
Stocks of infectious agents in laboratory
Waste from autopsy of patients with infectious disease
Waste from isolation wards.
Waste from patients undergoing haemo dialysis (tubing’s filters disposable towels gowns aprons gloves,
Laboratory coats)
Waste from animals inoculated with infectious agents.
Waste from animals suffering from infectious disease e.g. rabies

6. Sharps
 Needles
 Scalpels
 Blades
 Broken glass
 Any other item that can cause cuts or punctures

7. Pharmaceutical Waste
  Drugs and chemicals returned from wards:
 Spills Drugs
 Outdated Drugs
 Contaminated Drugs
 Discarded Drugs

8. Pressurized containers (explode when incinerated)

 Containing innocuous inert gas
 Aerosol cans e.g. ether nitrous oxide room freshener insecticides

World Health organization has given the following general recommendation for Medical Waste
Management:-

1. Bio-medical waste management requires a systematic Approach in

 Handling
 Storage
 Transportation
 Treatment (Technology important)
 Disposal

2. All personnel in healthcare establishment should be made aware of potential risk of mis handling wastes
training for everyone involved in waste management is essential.

3. Emphasis should be placed on need to segregate infectious and hazardous waste from other waste.
 Pathological
 Infectious
 Chemical/hazardous
Color-coding of waste bags and containers should be adopted National standardization is optimal.

4. Reduce quality of waste source

Waste should be recycled whenever possible with due regard to environmental consideration
Solid waste - recycle
Organics - compost
Hazardous- reclaim e.g. xylem

 Incineration though a preferred method for disposing off pathological and infectious waste due to the
environmental degradation emission standards and high cost is internationally discouraged.

6. Radioactive waste
 Very low level radioactivity and has a short half –life
 Store residues until radioactivity has decayed (diffused)

7. Waste disposal plans

8. Legislation on Bio-medical waste management should be enforced strictly on principle leaving individual
healthcare establishment to adopt the system that suit them the best.
1.1. HANDILING AND TREATMENT OF BIO-MEDICAL WASTE

The term treatment refers to process that modify the waste in some ways before it is taken to its final resting
place. Treatment mainly required is to disinfect or decontaminate by chemical disinfection of waste right at
source so that this is no logger the source of pathogenic organisms. After such treatment the residue can be
handed safely transported stored and disposed. The following should be kept in mind while dealing with
infectious wastes:

(a) Infectious waste must be separated at the points of generation itself.

(b) Bins with lids lined with polythene bags or buckets with inner chambers should be used.

(c) A lidded bin will discourage inadvertent use by others.

(d) The bins and bags should also be labeled with the biohazard symbol” and if required for the types of
waste they have to be used for.

(e) Personnel involved in infectious waste handling should be provided with suitable protective wear and
should be properly trained.

(f) Polyethylene bags placed in the bins have to be changed with each shift.

(g) Polythene bags carrying waste have to be sealed /tied at the top whenever the waste is being transported
within or outside the hospital.

(h) Infectious waste form the wards, ICU, OT, OPD, and the should have a allotted area for them at the final
point of disposal. This area should be covered and protected form the public at all times.

In wards and laboratory and wherever infected material has to be treated in liquid chlorine 1% hypochlorite
solution is put in buckets with a perforated container inside for holding the infected material which is kept
immersed in it is kept covered.

ALL Liquid waste is first disinfected then put in Sewer lines

Radioactive waste is kept in closed lead containers till double the ½ life of the radioactive substance then sent
for disposal this is applicable to most of the radioactive isotopes used in medicine.

I.SHARP: Good Practice for the safe handling and disposal of sharps
 ALWAYS dispose of your own sharps.
 NEVER pass used sharps directly from one person to another.
 During exposure prone procedure the risk of injury should be minimized by ensuring that the operator
has the best possible visibility e.g. by positioning the patient adjusting good light source and controlling
 Protect fingers from injury by using forceps instead of fingers for guiding suturing
 NEVER recap bend or break the needles.
 Directly after use place needles and syringes in a rigid container until ready for disposal
 Locate sharps disposal containers close to the point of use e.g. in patient’s room on the medicine trolley
and in treatment room etc.

Always wear gloves while handling sharps. Never recap the needles

Never leave a sharp unattended in open use Destroy the sharp immediately after
Containers or slabs burning.

Always store used sharps in puncture resistant mute After use ensure the disinfection and
 containers Action of needles and syringes

1.1.2. HANDLING OF HAZARDOUS SPILLS

A. Mercury Spill:
 YOU WILL NEED: scotch tape, a 10cc syringe a covered plastic or glass bottle.
 Never touch mercury with bare hands, remove all jewelry :mercury reacts with gold silver and other
metals
 Wear Protective Gear: Nitride Gloves or two paired of latex gloves face mask and protection for the eyes
 Gather the mercury using stiff paper and suck the large droller in a syringe without the needle,
 Pour the contents of the syringe in a bottle containing water
 Put the scotch tape around the bottle Hand over the bottle to the stores.

B. Handling of infected material spills

 Cover the area with paper /Newspaper /Towel
 Put 1% sodium hypo chlorite solution (10.000 ppm of chlorine on and around the spill area)
 Keep it covered for 10 minutes
 Remove paper with gloved hands and discarded with infections waste
 Wash area well /rewire with soap and water

Table 9: CATEGORISATION OF BIO-MEDICAL WASTE FOR MEDICAL/PARA MEDICAL PERSONNEL

a. Blood and semi liquid waste which is infections

b. Anything which releases infectious material on compressing
c. Articles lacked with blood.

Category Description Examples

1. Cultures Any discarded culture or stock of infectious agent and
and stocks associated biological including human and animal cell
cultures from clinical hospital research and industrial
laborites any discarded liver or attenuated vaccine or
serum and any discarded culture dish or device used to
transfer inoculate or mix cell culture
2.Pathological Human pathological waste including any human tissue
waste organ or body part removed during surgery autopsy of
other medical procedures and specimens of body fluids
and their containers.
3. Human -liquid waste human blood
Blood Blood -Products of blood
products any -Items saturated and/or dripping with human blood/or
body fluids caked with dried human blood including serum plasma
and other blood components and their containers.
Laboratory waste
microbiological waste culture
pates and swabs
Specimens of human tissue of fluids
and the containers that hold them
Note:-Foley bags are not infectious
Bio-Medical waste unless the urine
has gross hematuria.
Use blood and blood components
bags blood vials disposable surgical
equipment that cannot be fully
drained of blood (e.g. cardio
thoracic bypass tubing surgical
sponges taps and drapes saturated
with blood patient care items that
cannot be drained of blood
 Evacuation bottles)
patient dressing that are thoroughly
saturated with blood or body fluids
These definitions also apply to
haemodiaysis waste
4.Used sharps Discarded sharps that have been used in human patient As described also lancets capillary
or treatment or medical or research laboratories including tubes suture needles.
hypodermic needles syringed (with or without the
attached needle Pasteur pipettes scalpel blades blood
vials test tubes needles with attached tubing and culture
dishes
(regardless of the presence of infectious agents ) Also
included are other types of broken or unbroken glassware
that were in contact with infectious agents such as used
slides and cover slips.
5. Animal Contaminated animal carcasses body parts and bedding As described
waste of animals that were known to have been exposed to
infectious agents during research in veterinary hospital )
production of biological or testing of pharmaceuticals
7.Isolation Discarded material contaminated with body fluids from Cholera Tetanus Plague
Waste (A) humans who are isolated to protect other from a Gastro enteritis
highly communicable disease and (B) animals which are Hepatitis Chicken pox
isolated because they are known to be infected with in Measles
infectious agent capable of causing a highly
communicable disease
8.Unused Unused sharps must be disposed of as used sharps Hypodermic needles suture needles
sharps syringes and scalpel blades.

Table 10: WASTE CATAGORISATION AS PER COLOR

CODED CONTAINERS/BAGS

Color Type of Waste Category Treatment Option

Code Containers
Yellow Plastic Bags Human Anatomical Wastes Incineration /deep burial
(Human tissues Organs body parts )Animal Waste
(Animal tissues pathogens body parts car cases
bleeding
Part fluid blend and experimental animals used in
research waste generated by veterinary hospitals)
Microbiology and Bio-technology waste
(Waste from laboratory cultures stocks of
specimens of micro organisms live or attenuated
vaccines human and animal cell culture used un
research and industrial laboratories wastes form
biological productions toxins dishes and devise
used to transfer cultures)
(Items contaminated with blood and body fluids
including cotton dressings soiled plaster lines
 bleeding other materials contaminated with
blood )
Red Plastic Bag/ Microbiology and Bio-technology waste Autoclaving/
Disinfected (Waste form laboratory cultures ,sticks or Microwaving
container specimens of micro organisms live or attenuated Chemical treatment
vaccines human and animal cell culture used in
research and industrial laboratories wastes from
biological productions toxins dishes and devices
used to transfer cultures)
Soiled Wasted
(Items contaminated with blood and body fluids
including cotton dressings soiled plaster lines
bleeding other materials contaminated with
blood )
Solid Wastes
(Wastes generated form disposable items other
than the waste sharps such as tubing Catheters IV
sestet)
Blue Plastic Bag/ Waste Sharps Autoclaving/Micro waving
Puncture (Needles Syringes scalpels blades glass etc. that are /chemical treatment
Proof capable of causing puncture and cuts. This includes destruction and
container both used and unused sharps) Shredding
Solid Wastes
(Wastes generated from disposable items other
than the waste sharps such as tubing catheters IV
sestet)
Green Plastic Bag Discarded Medicines and catatonic Drugs Disposal in secured land
(Waste Comprising of outdated contaminated and fills
discarded drugs and medicines )
Incineration ash
(Ash from incineration of any Bio-medical wastes)
Chemical Wastes
(Chemical used in biological production chemical
used in disinfection such as insecticides etc.)
Black Chemothereupatic
Drugs
 TABLE 11: SEGREGATON OF BIO-MEDICAL WASTE

Yellow Bags Red Bags Blue Bags Green Bags Black Bag
(Bio Hazard) (Bio Hazard) (Bio Hazard) (Bio Hazard)
Dressing Plastic Waste Sharp Waste only All General Waste Chemothereuptic
Materials Soiled -Caterers -Needles Plastic/Paper Cups drugs waste
only) -Used IV drip set/ -Blade -Plates
-Swabs -Transfusion set -Prosthesis -Card Board Radioactive
-Gauges with Blood Bags -Vials etc -Metal Containers substance Waste
-Plaster Casts -Gloves -Slides -Office waste etc
-Human Tissues/ -Plastic IV Bottles -Cover Slips -Non Infectious
Parts -Other Plastic Waste
Microbiology Material Bottles  Discarded
Waste Etc medicines
-Culture plates -Tracers  Chemicals /
-Culture specimens insecticides/
-Plastic Loops Disinfectants
etc.

 Segregation at source is the key to effective waste management

 Color bags should be used judiciously
 Gloves and masks are necessary for handling hospital waste
 Waste should be disposed off within 24 hours
 After segregation at the generation point the bags are kept at a designated area form where the waste
collecting picks them up. The area where the bags are put should be accessible to the trolley so that bags are
not carried for long distance to reach the trolley. If bags are to be carried they are to be carried by neck only
to short distance only.
 Waste should not be transferred one bag to another
 Red and Yellow bags are not to be opened any cost
 Red bags should not be incinerated red color contains lead cadmium which result in toxic emission in the
excrement.
o Bag should be two thirds full then tied securely
o Do not compress full bags
o Double bagging to be done in case of bag tears fluid leaks if soiled from outside
o Liquid waste should be emptied in toilet after disinfection
o Wash hands after removing glove
o Red and Yellow bags to removed from patient care area by sanitation staff
o Keep the bags near the work area

1.2. TRANSPORT AND STORAGE OF BIO MEDICAL WASTE:

 BMW Trolley should be smooth running to avoid spillage of waste material should never be over filled.
 It should be covered and should have separate compartments for each color bags. Trolley should be washed
with soap and water after depositing the bags at central collection point.
 The trolley puller should put on protective equipment thick rubber gloves, gumboots plastic apron, mask and
head cover.
 The waste is stored in a common waste collection point which should be at a safe distance from the hospital
building
 Waste housing space should be divide into four(3) compartments each for different color bags. It should
have good sanitation facilities so that it can be washed and cleaned daily. The structure should be that there
is no access for dogs, cats, rats etc. inside the collection site. After the bags are removed area is washed and
chlorine powder is put in the sections to avid emission of foul smells.
 At the site the waste bags are weighed and records maintained separately for each color category.
 Total waste generated is approximately 1.5 kg 2.5 kg per bed per day.

BIOMEDICAL WASTE –FINAL DISPOSAL

Disposal of waste from Red, Yellow, and Blue bags are done away from hospital premises.BLACK??

The common technologies used final disposal of infectious waste are

 Mechanical and chemical disinfection
 Incineration
 Autoclave
 Hydro lave
 Shredding
 Microwave
The upcoming technologies for the same worth mentioning are
 Plasma torch technology
 Detoxification technology
 Electro- kinetic gasification technology
 Cobalt 60
 Zone treatment
 Thermal dry technologies with photo-med-star
 Jays on percolators
 Alkaline hydrolysis process
An effective method of waste outsourced.
Table 12: BIO-MEDICAL WASTE TREATMENT DISPOSAL

Advantages Disadvantages
Incineration *Reduces waste volume and weight Not environment and public friendly
*Waste totally destroyed through toxic emissions of gasses like
*All types of waste can be treated event furans and dioxins sulphurdioxide
chemotherapeutic nitrogen oxide etc metals like lead
*Low cost and mercury leads to disaster
through air ground water & soil
Steam *low Cost Was appearance not changed
Sterilization *Increase volume Weight same or increased
Autoclave *Easy to test working Not suitable for all types of waste
Chemotherapeutic waste cannot be
treated smelling may contain
microorganisms
Hydro clave *Reduces weight Organs cannot be treated
*Waste totally changed in appearance Chemotherapeutic cannot be traded
*Low operation cost Smelling but no micro organisms
*No leach problem
*No air emission
Microwave *Waste volume reduced High cost
*Waste appearance changed Waste weight increased not all
*No liquid discharge wastes
Chemotherapeutic agents can not be
treated
Mechanical *Waste volume reduced Not suitable for all waste types
Chemical *Totally changed
Disinfection *Rapid
*Waste deodorization

LIOUID WASTE MANAGEMENT

Liquid waste to cleaning kitchen rooms etc is drained directly in sewer lines,
Hazardous waste form laboratory shredding room should be first treated with hypo chlorite then thrown sewer
lines,

THE NON INFECTIOUS SOLID WASTE

The noninfectious solid waste contains plenty of organic waste food leafs flowers grass etc It can be finally
disposed of by:

A. Composting the simple method of decomposing of the waste and conversion to Manure.
B. Composting by vermin- culture – In this method worms are needed they convert biodegradable waste to
manure this method is becoming very popular in converting kitchen waste to manure for garden/ lawns.

Medical community the duty of ensuring proper treatment and disposal of medical waste It is just as important
as life saving and healing Therefore remember you have to clean up your act-It is not hard to do so just do it

To sum up proper waste management

-Waste minimization
-Segregation at source
-Identification (Color coded bags)\
-Collection
-Storage
-Weighing
-Transport
-Treatment
-Disposal
-Continuing education for staff

IMPORTANCE OF BIO-MEDICALWASTE:

For awareness of importance of waste management programmed few things should be done.

 Distribution of small cards carrying “Do’s and Don’ts about the waste generated at the bed side to the
patients and their attendants.
 Distribution of small cards about hospital waste man agent to medical and paramedical staff.
 Display of posters pertaining to waste management.
 Improvement training programmed for medical and Para –medical staff
 This will help the hospital authority in their endeavors.

PROTOCOL FOR TECHNICIANS WORKING IN LABORATORY:

1. All staff members are vaccinated according to hospital rules.
2. All staff members are expected to wear gloves masks and aprons while working.
3. No food or drink is allowed in the working area Do not chew gum while working.
4. All needle stick injuries in the laboratory are to be reported for suitable action.
5. No mouth pippeting is done in any procedure Rubber bulb system and automatic pipettes are available.
6. The Specimens are to be stored separately in the laboratory if labeled “biohazardous”.
7. All used specimen bottles and glassware are to be left in 1% Sodium hypochlorite solution.
8. All glass syringes are sent for autoclaving after cleaning with 1% hypochlorite.
9. All needles are to be destroyed by needle cutters/burnt.
10. Disposable syringes to be put in 1%hypochlorite solution.
11. All the laboratory waste is put in coded bags correctly.
12. Used glove to be put in red bags.
13. Plastic and papers to be put in bags.
14. Do not hide labels.
15. Do not apply cosmetics while at work thick application of cosmetics can cause adhering of microorganisms.
16. Only trained personnel should handle instruments connected to power supply.
17. While working minimize formation of aerosol droplets.
18. Keep the working place free of material not needed for the purpose.
19. At the end of the day work surface to be cleaned by a disinfectant.
20. Staff should wash hands every time after handling infected material.
21. All specimens to be discarded properly in appropriate disinfectants and bags.
22. All spills should be cleaned with paper towels or thick cloth soaked in 1% sodium hypo chlorite left for 30
minors on spill and then put in proper container and place re with disinfectant and soap and water.
23. Put a label” danger of infection” whenever necessary on blood and other specimens
24. Unpack specimens in trays.
25. Laboratory clerical staff should not open specimens.
26. Use gloves while handling specimens and take special care if there are cuts or scratches on the hands. They
should be covered by waterproof dressings
27. Take care to avoid contamination of hands and surrounding area with the blood.
28. Use disposable/ autoclaved syringes and needles.
29. Use 70% ethanol or isopropyl alcohol swabs/sponged for cleaning the sit of needle puncture on the hand.
30. Use thick dressing pad or absorbent cotton below the forearm when drawing blood.
31. Tie tourniquet on the arm above elbow after cleaning.
32. Tourniquet must be removed before the needle is withdrawn.
33. Place dry cotton swab and flex-the elbow with the instruction to keep this in place till bleeding stops.
34. Place used needles and syringes in a puncture resistant container containing disinfectant.
35. Do not recap used needles.

POITNTS TO REMEMBER:
DOCTORS:
-Wash Hands before and after and examining the patient.
-Use gloves and cut gloves after use.
-Button aprons while examining patients.
-Dressing must be disposed in the color-coded bags only “NOT IN GENERAL BASKET KEPT NEAR PATIENT “S BED”
-Ensure all infected plastic gloves and needles etc are cut and then put into hypochlorite SO THAT RECYCLING
CAN BE AVOIDED

NURSES:
-Cut Gloves plastics after use before putting in bleach
-Cut syringes and needle before discarding
-Use proper disposal methods according to color-coding for each item

Attendants:
-Use personal protection clothing
-Cut all tubes after use
-Do wet mopping
-Cut gloves after use
-Use proper disposal scheme as told to the SWEEPERS
-Do not eat or drink near waste dump house
-Wash hands before and after eating
-Do not use bare hands to pick waste
-Do not walk bate foot while handling waste
-Use protection equipment as given to you for handling waste

Table 13: RECOMMENDED DILUTIONS OF CHLORINE RELEASING COMPOUNDS

Available chlorine required Clean condition (e.g. cleaned Dirty condition (e.g. blood spills
medical equipment)0.1% (1g/litre soiled equipment 1%
=1000ppm_) (10g/litre =10000 ppm)
If 5% Stock Dill 1:50 Dill 1:5
10% Stock Dill 1:100 Dill 1:10
Dilution
Sodium hypochlorite solution 20ml/litre 100 ml/liter
(5% available chlorine)
Household bleach contains 4-5% of available chlorine that may also be used after diluting so as to have 1%
available chlorine Minimum contact time of 30 minutes is recommended.

Other chemical disinfectants effective in inactivating HIV:

Ethanol 70% =3-5min

2Propanol 70 % (isopropyl alcohol) =3-5min
Providence iodine 2% =15min
Formalin 4% =30min
Glueraldehyde 2% (CIDEX) =30min
Hydrogen peroxide 6% =30min