NABH ON –

ACCREDITION 1. HAND HYGIENE STANDARDS

STANDARDS 2. CONSENT POLICY

3. PREVENTIVE MAINTENANCE IN ICU
5TH EDITION, 4. VISITOR’S POLICY
2020
SAVE
LIVES,
CLEAN
YOUR
HANDS
 WHY ?
• Thousands of people die every day around the world from infections acquired
while receiving health care.

• Hands are the main pathways of germ transmission during health care.

• Hand hygiene is therefore the most important measure to avoid the

transmission of harmful germs and prevent health care-associated infections.

• This presentation will explain how and when to practice hand hygiene.
 WHO ?
• Any health-care worker, caregiver or person involved in direct or indirect patient
care needs to be concerned about hand hygiene and should be able to perform it
correctly and at the right time.

• Visitors involved in direct patient contact should also do proper hand wash/rub
and maintain hand hygiene.
WHEN TO DO IT?
A) Before shaking hands, before stroking a child’s forehead

B) before assisting a patient in personal care activities:

To move, to take a bath, to eat, to get dressed, etc

C) before delivering care and other non-invasive treatment:

Applying oxygen mask, giving a massage

D) before performing a physical non-invasive examination:

Taking pulse, blood pressure, chest auscultation, recording ECG
a) Before brushing the patient’s teeth, instilling eye drops, performing a digital
vaginal or rectal examination, examining the mouth, nose, ear with or without
an instrument, inserting a suppository / pessary, suctioning mucous

b) Before making a percutaneous injection/puncture, dressing a wound with or

without instrument, applying ointment on vesicle.

c) Before inserting an invasive medical device (nasal cannula, nasogastric

tube, endotracheal tube, urinary probe, percutaneous catheter, drainage),
Disrupting/opening any circuit of an invasive medical device (for food,
medication, draining, suctioning, monitoring purposes)

d) Before preparing medications, pharmaceutical products, sterile material,

food.
a) When the contact with a mucous membrane/non-intact skin.

b) After a percutaneous injection or puncture; after inserting an invasive

medical device (vascular access, catheter, tube, drain, etc); after disrupting and
opening an invasive circuit.

c) After removing an invasive medical device.

d) After removing any form of material offering protection

(napkin, dressing, gauze, sanitary towel, etc)

e) After handling a sample containing organic matter, after clearing excreta and
any other body fluid, after cleaning any contaminated surface and soiled
material (soiled bed linen, dentures, instruments, urinal, bedpan, lavatories, etc)
a) After shaking hands, stroking a child’s forehead

b) After you have assisted the patient in personal care

activities: to move, to bath, to eat, to dress, etc

c) After delivering care and other non-invasive treatment:

changing bed linen as the patient is in, applying oxygen mask,
giving a massage

d) After performing a physical non-invasive examination:

taking pulse, blood pressure, chest auscultation, recording ECG
A) After an activity involving physical contact with the patients
immediate environment: changing bed linen with the patient out of
the bed, holding a bed trail, clearing a bedside table

B) After a care activity: adjusting perfusion speed, clearing a

monitoring alarm

C) After other contacts with surfaces or inanimate objects (note –

ideally try to avoid these unnecessary activities): leaning against a
bed, leaning against a night table / bedside table)
WHEN WHAT
TO DO ?
• When to hand wash ??

• When to use hand rub??

• If your hands are visibly dirty or visibly soiled with blood or body fluids or
after using the toilet, then wash your hands with soap and water.

If exposure to potential spore-forming pathogens is strongly suspected or

proven, including outbreaks of Clostridium difficile, hand washing with soap
and water is the preferred means.

• If hands are not visibly soiled, use alcohol-based hand rub.

Clean your hands by rubbing them with an alcohol-based formulation, as the
preferred mean for routine hygienic hand antisepsis.
INDICATIONS FOR STERILE GLOVES USE -

• Any surgical procedure;

• Vaginal delivery; invasive
• Radiological procedures;
• Performing vascular access and procedures (central lines);
• Preparing total parental nutrition and chemotherapeutic agents.
 INDICATIONS FOR EXAMINATION GLOVES USE

• DIRECT PATIENT EXPOSURE:

Contact with blood; contact with mucous membrane and with non-intact skin;
potential presence of highly infectious and dangerous organism;
epidemic or emergency situations;
IV insertion and removal;
drawing blood;
discontinuation of venous line;
pelvic and vaginal examination;
suctioning non-closed systems of endotrcheal tubes.

• INDIRECT PATIENT EXPOSURE:

Emptying emesis basins;
handling/cleaning instruments;
handling waste
cleaning up spills of body fluids.
 GLOVES NOT INDICATED (except for CONTACT precautions)

• DIRECT PATIENT EXPOSURE:

Taking blood pressure, temperature and pulse;
performing SC and IM injections;
bathing and dressing the patient;
transporting patient;
caring for eyes and ears (without secretions);
any vascular line manipulation in absence of blood leakage.

• INDIRECT PATIENT EXPOSURE:

Using the telephone;
writing in the patient chart;
giving oral medications;
distributing or collecting patient dietary trays;
removing and replacing linen for patient bed;
placing non-invasive ventilation equipment and oxygen cannula;
moving patient furniture.
 Consent Policy
1. Purpose: To obtain appropriate consent for medical treatment, procedures,
surgeries.
2. Scope : All the patients getting admission and procedure done in the ICUs
3. Responsibility: All ICU doctors and nurses
4. Procedure: For patients (not relatives) undergoing invasive procedures in ICU should
sign the ICU consent form, which will be counter signed by the ICU nurse and doctor
performing procedure.
5. In case of incompetent patient (sedated, coma, disoriented, mentally retarded or
encephalopathy pts), undergoing major invasive procedures like percutaneous
tracheostomy, angiography, permanent pacemaker insertion require completion of
consent form.
In case of emergency procedure, the form need to be signed by 2 doctors and when
time permits or for non-urgent procedures, it is to be signed by the next of kin (third
party consent)
Third party consent
• This is not necessary for routine ICU procedures. However, relatives should be
informed prior to the procedure about the indication, method, and complication of
procedure which should be documented in case file.
• Next of kin or relative, preferably one of the identified spokesperson from the
family must always be informed of any procedure and consent.
• For unknown patient requiring emergency procedures, authorization by the
Medical Superintendent should be required after a request is made
 PREVENTIVE MAINTENANCE IN ICU
• Purpose is To maintain equipment properly and prevent avoidable breakdowns.
• Responsibility : All ICU staff including In-charge.
• ICU nursing in-charge or ICU technician will carry physical audit of all equipment’s
like monitors, ventilators, defibrillators, panels on the head side of the bead, electric
and gas points to ensure their functioning in the beginning of starting the shift.
• For electrical and civil issues, maintenance department should be informed for
necessary action on timely basis.
• In case problem doesn’t get solved then it should be brought to the knowledge of
the medical administrator.
• For problems in the medical equipment the department of biomedical engineering
personnel should be informed who will take remedial action.
• Any deficiency must be brought to the knowledge of the HOD of ICU or Medical
administrator.
 VISITOR’S POLICY
1. Responsibility: ICU nurse in-charge
2. Visiting hours: Morning: 10: 30 am to 11: 01 am and Evening: 4: 30 pm to 5: 01 pm
3. Front office will issue visiting passes.
4. Visitors / attendants entry to the critical care area will be regulated by the security guard
5. The security guard should allow only one person at a time per patient to the critical area
and maximum number of visitors allowed are two in the given time period.
6. Visitor/ attendant should wear a shoe cover / remove shoes before entering the ICU
7. The front office executive will also coordinate the activities during visiting hours when the
are appointed counselling
8. Brief counselling will be given in the clinical area
9. Detailed counselling will be given in the Consultants’ chamber
10. End of life counselling will be given in the room of HOD of ICU.
Central Line Care Bundles
• Recent studies have demonstrated that consistent application of
evidence-based practices can lead to significant, sustained reductions in
CLABSI rates.
• The Institute for Healthcare Improvement (IHI) describes bundles as
“groupings of best practices with respect to a disease process that
individually improves care, but when applied together result in
substantially greater improvement.
• The science supporting the bundle components is sufficiently established
to be considered standard of care.”
• 2 bundles - INSERTION BUNDLE
MAINTENANCE BUNDLE
 Insertion Bundle Components
1. Hand hygiene - “5 Moments of Hand Hygiene”
2. Use of full barrier precautions/personal protective equipment
3. Chlorhexidine skin antisepsis - A solution of 2% chlorhexidine gluconate in 70%
isopropyl alcohol is used and allowed to dry for at least 30 seconds. If a patient
is sensitive to this agent, a single patient use povidone-iodine application may
be used.
4. Optimal catheter type selection – PICC/CVC.
5. Optimal catheter site selection - patient comfort, patient-specific factors
6. Dressing – sterile transparent dressing
7. Safe disposal of sharps
8. Daily review of line necessity, with prompt removal of unnecessary CVCs
9. Documentation
 Maintenance Bundle Components
1. Daily review of line necessity with prompt removal of unnecessary CVCs
and documentation - Daily review of the continued need for CVCs can be
done in the following ways: During multidisciplinary patient care rounds
o By using reminders (such as stickers on patient records or order sets) o
Via automated computer alerts
2. Details of removal documented in the records (including date, location,
signature, and name of operator undertaking removal)
3. Hand hygiene before manipulation of the IV system
4. Catheter injection ports - Access ports are sanitized with alcohol,
chlorhexidine/alcohol, povidone-iodine, and iodophors before and after
each use, a method known as the “Scrub the Hub” protocol. Caps are
changed no more often than 72 hours (or according to the manufacturer’s
recommendations.
 Maintenance Bundle Components – cont.
5. Proper procedures for catheter site dressing monitoring/changes -
Change gauze dressing every 2 days, clear dressings every 7 days
(and more frequently if soiled, damp, or loose)
6. Catheter access/manipulation - Catheter site care is performed with
chlorhexidine at dressing changes. In the absence of chlorhexidine,
use povidone iodine. Ports or hubs are cleaned using “Scrub the
Hub” protocol prior to catheter access.
7. Administration set (primary and secondary) replacement - Set is
replaced no more frequently than every 96 hours, and at least every
7 days, after initiation of use unless contamination occurs.
8. Infusate preparation using aseptic technique
 Antibiotic Lock Therapy in Adults
TWO MILLILITER LOCK SOLUTION
Antibiotic Additive
Antibiotic Stability
Concentration Concentration
1.Add 5 mL Linezolid 2 mg/mL (10 mg) to a 20 mL
syringe
Heparin 10
Cefazolin 10 mg/mL units/mL 30 hours
2.Add 4 mL Bacteriostatic NS to the 20 mL syringe.
Heparin 10 Attach a “universal syringe tip adapter”
Ceftazidime 10 mg/mL units/mL 30 hours

3.Add 1 mL Heparin 100 units/mL (100 units) to

Gentamicin 2.5 mg/mL
Sodium Citrate
30 hours the 20 mL syringe
40 mg/mL (4%)

4.Agitate solution
Heparin 10
Linezolid 1 ml/mL units/mL 30 hours
5.Transfer 2 mL of Linezolid-Heparin solution to a
Heparin 10 10 mL syringe
Vancomycin 2 mg/mL units/mL 30 hours

6.Label with 30-hour expiration date

Foley’s catheter
care
• All catheter care including Catheter
insertion is carried out using an
Aseptic Non Touch Technique (ANTT)
• The catheter and drainage bag should
be adequately fixed to prevent
trauma.
• A ‘closed’ drainage system is essential
to prevent infection.
• The drainage bag and tube should
always be positioned below the level
of the bladder.
 Foley’s catheter care - cont.
• There should be no kinks or occlusions in the tubing
• The bag must be kept off of the floor
• The separate single-use clean container be has to be used and the drainage valve must
not touch the container on emptying the bag
• Empty the bag when 2/3 full
• The tubing should be the correct length to prevent kinking or pressure on the bladder
• For patients who are unable to bath or shower daily, staff should wash the urethral
opening at least twice daily with soap and water and following bowel movement
• Hand washing and wearing non-sterile gloves before and after performing catheter
care is always essential by nurses/carers
THANK YOU
References
• https://www.nabh.co
• www.jointcommission.org
• https://cdn.who.int/media/docs/
default-source/documents/healt
h-topics/hand-hygiene-why-how-
and-when-brochure.pdf
• www.uptodate.com
• https://idmp.ucsf.edu/content
/antibiotic-lock-therapy-adults