HOSPITAL INFECTION CONTROL ST.

Martha’s
COMMITTEE Hospital
J A N U A RY – J U LY 2 0 1 8 R E P O RT
Bangalore
 INFECTION CONTROL PROGRAM

- Comprehensive.

- Evidence based medicine.

- Integrates the best practices and the current guidelines from CDC, WHO,
SHEA,IDSA,NABH etc.

- Well coordinated, multidisciplinary Infection Control Committee

- Priority is to ensure patient and health care personnel safety.

 HOSPITAL INFECTION CONTROL COMMITTEE

Members:
Medical Superintendent
Chairperson
Infection Control Officer
Infection Control Nurse
Quality Manager
Clinical Microbiologist
Consultant Physician
Consultant Surgeon
Consultant Anesthetist
Consultant Gynecologist
Consultant Orthopedician
Nursing Superintendent / Deputy Nursing Superintendent /
Assistant Nursing Superintendent
Pharmacy– In-charge
Incharge of Housekeeping services
Senior dietician
CSSD In-charge
OT In-charge
Hospital Engineer
 HOSPITAL INFECTION CONTROL TEAM

HICC Chairman
Infection Control Officer
Infection Control Nurse
Quality Manager
Assistant Nursing Superintendent

4
INFECTION CONTROL COMMITTEE
MEETINGS

The HICC meets monthly apart from the daily infection control
rounds by the ICN and/or ICO

To review and update hospital infection control policies and

procedures from time to time

To review our HAI data and other infection control issues with
root cause analysis and corrective actions
 FUNCTIONS OF IC TEAM
Surveillance over hospital acquired infections
Appropriate isolation precautions are initiated
once a transmissible infectious disease is
confirmed
Infection control practices – hand hygiene,
PPE, BMW disposal, etc.
Disinfection and Sterilization – validation of
sterilising agents and disinfectants
Reuse of certain devices – in OT, endoscopy
department
CSSD – oversee of sterility practices in CSSD
Housekeeping – monitoring their activities
Biomedical waste disposal – education,
monitoring, biannual visit
Canteen – sterility, quality, employee health
Environmental surveillance - sterility, quality
Laundry – linen traffic
Employee health – Vaccination, NSI, Blood
and body spill
Investigation of outbreaks and epidemics –
source identification, preventive management
and surveillance
Continued education regarding antibiotic
resistance – implementation of antibiotic
policy, compliance in restricted antibiotic
usage
Surgical prophylaxis – formulating policy and
monitoring its compliance
 SURVEILLANCE
CLINICAL SURVEILLANCE
- Respiratory tract infections - VAP/VAE
- Urinary tract infections – CAUTIs
- Intravascular device infections –
CLABSI
- Surgical site infections – SSI
ENVIRONMENTAL SURVEILLANCE- OT, Wards, Labour Room, Dialysis and if any outbreaks
EPIDEMIOLOGICAL SURVEILANCE
- Environmental Surveillance (Sterility of
air, water, food)
- Notifiable diseases informed to Local
Health authorities as per P & L forms
[weekly].
- Emerging and reemerging infections like
H1N1, Dengue, Malaria, Chikungunya
are informed
- Epidemiologically significant diseases
like MTB, MDR TB, MDR organisms,
MRSA, etc are tracked
- Appropriate action plan is drawn to
contain/eradicate outbreaks
 NOTIFIABLE DISEASES

MAY JUNE JULY

Tota OPD IPD Tota OPD IPD Total OPD IPD

l l
Dengue 2 1 1 13 1 12 11 1 10
Malaria 0 0 0 3 2 1 5 2 3
Sputum AFB 5 1 4 4 0 4 2 0 2
positives
H1N1 positives 0 0 0 0 0 0 0 0 0
Chicken pox 0 0 0 1 0 1 1 0 1
Leptospirosis 0 0 0 0 0 0 0 0 0
Chikungunya 0 0 0 0 0 0 0 0 0
Shigella 0 0 0 1 0 1 0 0 0

Typhoid 4 1 3 7 0 7 6 1 5
Cholera 0 0 0 0 0 0 0 0 0

*Ward- IC measures-adhered-MMW,SBE,SBC,NB,MITU,BW,MITU,
HAI QUALITY INDICATORS
S No Indicator Formula Freq.

1 Central Line Associated Blood stream no of central line associated blood stream infections in a M
infection rate month/total no of central line days in a month X 100

2 Catheter Associated Urinary tract infection no of urinary catheter associated infections /no of urinary M
rate catheter bed days in that month X 100

3 Ventilator Associated Pneumonia rate no of "VAP" in a month /no of ventilator bed days in that M
month X 100

4 Surgical site infection rate no of surgical site infections in a given month /total no of M
surgeries performed in that month X 100

5 Needle stick injuries rate No of parenteral exposures/ no of inpatient bed days X 100 M

9
 QUALITY INDICATORS
KQI JANUARY 2018 FEB 2018 MARCH APRIL 2018 MAY 2018 JUNE 2018 JULY 2018
2018
CLABSI 37/277/1 68/308/1 50/400/0 47/241/0 32/344/0 51/277/1 0/183(0%)
No of (0.37) (0.32) (0%) (0%) (0%) (0.36%)
infected/no of
daysX100

CAUTI 211/726/0 394/723/0 164/625/0(0 186/561/0 138/529/0 191/554/0 1/397(0.25%)

No of (0%) (0%) %) (0%) (0%) (0%)
infected/no of
daysX100

VAP 24/100/0 33/58/0 16/77/1 15/42/0 19/86/1 18/54/1 0/55(0%)

No of (0%) (0%) (1.29%) (0%) (1.16%) (1.85%)
infected/no of
daysX100

SSI 317/1 336/1 315/3 353/1 401/3 381/2 0/391(0%)

No of (3.17%) (0.29%) (0.95%) (0.28%) (0.74%) (0.52%)
infected/no of
daysX100

NSI 1 0 1 1 3 2 1
TREND ANALYSIS OF VARIOUS
INDICATORS
CENTRAL LINE ASSOCIATED
BLOOD STREAM INFECTION 0.4 0.37
CLABS-KQI
0.36
0.3 0.32
0.2
0.1
CLABSI 0
JAN
0 0
FEB MARCH APRIL
0
MAY JUNE
0
JULY
450
400
400
344
350
308
300 277 277
250 241

200 183

150

100
68
50 47 51
50 37 32
1 1 0 0 0 1 0
0
JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY

No. of pts No. of days No. of infected

CATHER ASSOCIATED URINARY
TRACT INFECTION 0.3
CAUTI-KQI
0.25
0.2
0.1
CAUTI
0 0 0 0 0 0 0
JAN FEB MARCH APRIL MAY JUNE JULY
800
726 723
700
625
600 561 554
529
500
394 397
400

300
211 191
200 164 186
138
100
0 0 0 0 0 0 1
0
JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY

No. of pts No. of days No. of infected

VENTILATOR ASSOCIATED
EVENT 2
VAE-KQI
1.85
1.5 1.29
1 1.16
0.5
VAE 0 0 0 0 0
JAN FEB MARCH APRIL MAY JUNE JULY
120

100
100
86
80 77

60 58 55
54
42
40 33
24
16 19 18
20 15

0 0 1 0 1 1 0
0
JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY

No. of pts No. of days No. of infected

SURGICAL SITE INFECTION SSI-KQI
4
3 3.17
2
1 0.95 0.74 0.52
SSI 0
JAN
0.29
FEB MARCH
0.28
APRIL MAY JUNE
450
401 391
400 381
353
350 336
317 315
300

250

200

150

100

50
1 1 3 1 3 2
0
JANUARY FEBRUARY MARCH APRIL MAY JUNE JULY

No. of infected No. of surgeries

NEEDLE STICK & SHARP
INJURY
NSI
3.5

3 3
2.5

2 2
1.5

1 1 1 1 1
0.5

0
JANUARY
0
FEBRUARY MARCH APRIL MAY JUNE JULY

NSI
 THROMBOPHLEBITIS IN
PATIENTS
VIP SCORE 1-4
20
18
18

16

14

12
10
10

8
6 6 6 6
6 5
4

2 1 1 1 1
0 0 0 0 0 0 0 0 0 0
0
JAN FEB MARCH APRIL MAY JUNE JULY

VIP 1 VIP 2 VIP 3 VIP 4

BLOOD CULTURE
CONTAMINATION RATE
Month Blood Culture Contamination Rate (in %)

December 5.4 (13/238)

2017
January 2018 4.9 (13/264)
February 4.2 (13/309)
2018
March 2018 3.4 (12/351)
April 2018 6.54 (18/275)
*Ward specific training and monitoring
May 2018 2.4 (5/205)
in view of rates being constantly high
June 2018 4.9(13/264)
July 2018 3.1 (9/287)
*Laboratory informs the ward-in
charge as and when
6.54 4.9 CONS/Diphtheroids are isolated to do
5.4 4.9 4.2 3.4 3.1 RCA Analysis and train the respective
2.4 staff

Column1 *Blood Culture bottles are now being

carried in a box/container, not to be
carried in sample transport box or bare
1 %- Benchmark hands
 HAND HYGIENE COMPLIANCE

KQI JANUARY 2018 FEB 2018 MARCH APRIL 2018 MAY 2018 JUNE 2018
2018
HAND Hospital Hospital Workin DOCTORS- Staff S/N=HW-42%
HYGIENE Helpers& g with PICU&NICU- Nurses HR-24%
COMPLIA Hospital aides- Hospital aides- link 100% HW=60% TOTAL=45
NCE 40% 68% nurses NURSES – HR=13% MISSED-15
Staff-70% Staff-80% ALL DPT- H/A H/A-HW=70%
78%(AUDIT HW=72% 20(4 MISSED)
BY SENIOR HR=4% HELPERS=HW-
STAFFS AND HELPERS 66%
IN- HW=63% (18(4 MISSED)
CHARGES) HR-0%
HAI ACTIVITIES INTRODUCED
IN 2018
•Daily ward Rounds based on Checklist-Findings noted and discussed with the ward in-charge for
improvement and reported to the Management

•Ward wise training and demonstration on Hand-Hygiene and Biohazard Spill Management by the ICO &
ICN- Training on kit maintenance, checklist and incident form and periodic mock drills

•Annual Training sessions for all doctors, staff nurses, technicians, housekeeping aids taken by the ICO &
ICN-Training for doctors on Infection Control- 17th, 19th and 21st April 2018

•Training for Second batch of Doctors-27th,29th and 30th June 2018

•Training for technicians (Radiology/Laboratory/ Physiotherapy/NH), Hospital Aides and Class IV Workers -
26th, 28th and 30th June 2018
HAI ACTIVITIES INTRODUCED
IN 2018
Academic activities:

• CME during Clinical Society Meeting for all clinicians on AST Interpretation done on 27th March by Dr.
Vinay, ID Specialist from Apollo Hospitals, Bangalore

• Certification Course in Infection Control & Prevention- Medvarsity completed by our ICN

• Certificate Program in Hospital Infection Control & Patient Safety (CPHICPS) from Symbiosis InstitUte
of Health Care completed by ICO

• CME on 10th June 1, 2018 in association with Anand Diagnostic Laboratory- A Neuberg ASSOCIATE-
1ST Prize in Poster Competition for Role of VITEK 2 system in Outbreaks of Multidrug Resistant

Isolates in Critical Care Units- A Case Study for our Laboratory Staff of Microbiology who play a
active role in reporting and monitoring MDR strains
HAI ACTIVITIES INTRODUCED
IN 2018
Anti HBs titre of employees-
•Anti HBs titre check of current employees done in two batches
•Employees with titre < 10 m IU/m L guided to go for booster dose and repeat titre check after a month.
HR Department informed for follow up and maintenance of records i.e in personal files of all employees.
•Inclusion of antiHBs titre in pre employment discussed with the management and conveyed to the HR
Department
•AntiHBs titre for DNB Students provided at a concessional rate

Biomedical Waste Management

•Blue cardboard boxes introduced, replacing blue covers

•Pre-treatment plant installed in the Central Laboratory for liquid waste

HAI ACTIVITIES UNDER
PROGRESS
•Restricted antibiotic usage forms to be introduced
•Data of annual biomedical waste generation to be updated in the hospital website and
annual visit to outsourced agency
•Classes for Blood Culture collection
•Monthly Antibiogram data from the Microbiology Section of Central Laboratory
provided to all Departments
•Installation of signage across the hospital premises as per HICC Manual
•Inclusion of anti-HBs titre check in pre employment screening
Thank You