NABH STANDARDS

CHAPTER 5
HOSPITAL INFECTION CONTROL
(HIC)

Dr Chithra Valsan
 INTENT OF THE CHAPTER

The organization should

have:
• An effective (HAI) healthcare-associated
associated infection prevention and
control programme
• Measures and takes action to prevent or reduce the risk of HAI in
patients and employees.
• Provides facilities and resources to support the Programme.
• Has effective antimicrobial management program
• Action plan to control outbreaks, disinfection/ sterilization activities,
biomedical waste (BMW) management, training of staff and employee
health.
STANDARDS- 9
STANDARDS
STANDARDS 9
STANDARDS-

* This implies that this objective element requires documentati

Objective Elements
• The hospital IPC programme is documented-
documented aims at preventing
and reducing risk of HAI*
- policies and procedures for IPC + monitoring.
• HIC manual- structure, all processes, activities and surveillance
procedures related to the program.
shall be based on current scientific knowledge, guidelines
WHO guidelines, CDC Guidelines and Manual for Control of Hospital Associated Infections, Standard
Operative Procedures by NACO, Ministry of Health and Family Welfare, Govt. of India.
• IPC programme is a continuous process and updated at
least once in a year.
- based on newer literature, audit results

• Risk-reduction
reduction goals and measurable objectives are
established by the committee at least annually - reviewed on
a monthly basis by the ICT.
 The hospital has a multi-disciplinary infection control committee, which co-
ordinates all infection prevention and control activities. *
- shall preferably have Hospital Administrator,
- Microbiologist,
- Physician/Infection control specialist,
- Surgeon,
- Nursing Manager (Nursing Supervisor),
- staffs from CSSD and other support services
- hospital infection control nurse.
- also include invitees from various departments
he committee shall lay down the policies and procedures to guide the
mplementation.
he composition, frequency of meetings, the minimum quorum required and
he minutes of the meeting shall be documented.
• The hospital has an infection control team, which coordinates
implementation of all infection prevention and control activities.*
The team is responsible for
- day-to-day
day functioning of IPC programme.
- shall support surveillance process and detect outbreaks.
- shall also participate in audit activity and in infection prevention
and control on a day-to-day
day basis.
• The team shall at least comprise of
ICO, ICN(s) Infection control team
• The committee and the team shall not be the same. However, the team
shall be part of the committee.
• The hospital has designated infection control officer as part of the
infection control team. *
- a doctor, who is knowledgeable in infection control practices.
-Preferably
Preferably a clinical microbiologist – if not – a surgeon / physician.

• The responsibilities of the Infection control officer (ICO) are defined in

the privileging document.

• The hospital has designated infection control nurse(s) as part of the

infection control team. *
- either by qualification (Registered Nurse) and based on training.

• The responsibilities of the ICN(s) are defined - preferable to have a

short-term
term training programme on IPC nursing.
Objective Elements
1. The organisation identifies the various high-risk
high areas and
procedures and implements policies and/or procedures to prevent
infection in these areas. *
- shall include all areas of the hospital
- the high-risk
risk areas of the hospital ,
e.g. ICU, HDU, OT, post-op op ward, Blood bank, CSSD,
mortuary
- high-risk
risk procedures should be identified
Eg:: cardiac catheterization, endoscopies, surgery >2 hrs,
BMT, etc.
• The policies and procedures shall be directed at prevention of
infection in these areas and include monitoring.
The organisation adheres to standard precautions at all times.*
The organisation adheres to hand-hygiene
hygiene guidelines. *
international/national guidelines.
A good reference is the WHO guidelines of 2009.
The organisation could display the necessary instructions near
very hand- washing area.
The organisation adheres to transmission-based
transmission precautions at all times* -
airborne, droplet and contact.
Personal protective equipment (PPE) in various situations identified and used
appropriately - applicable across the organisation. ( Ref: international guidelines-CDC)
The organisation adheres to safe injection and
infusion practices.*
-shall
shall include ―One needle, One syringe, Only one time
Ref: WHO best practices for injections a related procedures toolkit‖
The organisation adheres to cleaning, disinfection and sterilization
practices. *
- addressed at all levels of the organisation-
organisation ward, OT & CSSD
- It is preferable to follow a uniform policy
Ref: CDC Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008.
• Organisation shall identify disinfectants used in patient
care units.
-The
The disinfectants‘ use is identified, dilution protocols
established and monitored.
- Risks and hazards due to usage of disinfectants are
identified and staff is aware of these - through display of
material safety data sheets (MSDS)
An appropriate antibiotic policy is established and documented *
- develop a system of monitoring antimicrobial susceptibility
- develop antibiotic policy, reviewed at periodic intervals.
- refer to guidelines while framing the policy.
The organisation implements the antibiotic policy and monitors rational use of
antimicrobial agents. *
- identify clinical conditions in which antimicrobials used (antibiotics, anti-funga
anti
- type of the agent, monotherapy Vs combination therapy, escalation and de-
de
calation of therapy, dose and duration.
Deviations informed to concerned clinicians –CAPA to taken
The organisation adheres to laundry
nd linen management processes. *
- can be in-house or outsourced.
- policy for change of linen.
- separate washing protocols for different categories of linen
- defined process of handling linen in patient care units, during transport and
inside the laundry.
The organisation adheres to kitchen sanitation and food-handling
food issues.*

- even if outsourced.

- adhere to national and international guidelines

- includes the periodic screening of kitchen workers and food hand

The organisation has appropriate engineering controls to prevent infections.*
- include the design of patient care areas (optimum spacing between beds
is one-two metres),
- operating rooms, air quality, ACs and equipment maintenance, cleaning
of AC ducts/filters, AHUs, cleaning / replacement of filters, seepage leading
to fungal colonization, replacement/repair of plumbing
- Water-supply
supply sources and system of supply, testing for water quality.
- Any renovation work in hospital patient-care
patient areas should be planned with
infection control team with regard to architectural segregation, traffic flow,
use of materials, etc.
The organisation adheres to
housekeeping procedures. *
categorization of areas/surfaces,
cleaning procedures for surfaces,
and items used in patient care.
It shall also include procedures for terminal cleaning, blood and bod
luid cleanup,, isolation rooms and all high-risk
high (critical) areas.
Brooming and a dry dusting of any sorts inside the clinical areas
should be avoided.
Surveillance activities are appropriately directed towards the
identified high-risk
risk areas and procedures.
- provide evidence of conducting periodic surveillance activities
- It shall define the frequency and mode of surveillance.
- The surveillance system shall be appropriate and adhering to
national/ international guidelines.
- include areas where demolition, construction or repairs are
undertaken, especially in high-risk
high areas.
- use a judicious mix of active and passive surveillance.
- lay down the parameters that need to be captured and the
process for reporting.
• Collection of surveillance data is an on-going
on
process.
-There
There has to be a process in place to collect
surveillance data and also to ensure that it is able to
capture all such data.
- Verification of data is done on a regular basis by
the infection control team.
-The
The team shall preferably verify every serious
infection (as defined by the organisation) report.
The scope of surveillance activities incorporates tracking and
analyzing of infection risks, rates and trends.

- shall be done at regular intervals (maybe monthly and

consolidated into an annual report)
- and the organisation shall take suitable steps based on the
analysis.
• Surveillance activities include monitoring the compliance with hand-
hand
hygiene guidelines.
minimum once every month.
The compliance levels shall be shared with the relevant staff.
The
AA good tool is the WHO‘s ―Observation Form.

• Surveillance activities include mechanisms to capture the occurrence

epidemiological significant diseases, multi-drug-resistant
multi organisms a
highly virulent infections.
• In cases of notifiable diseases, information (in relevant format) is sen
appropriate authorities.
• Surveillance activities include monitoring the effectiveness
of housekeeping services.
- done on a regular basis. - define the periodicity. It could
be done using a checklist.

• Appropriate feedback regarding HAI rates is provided on a

regular basis to appropriate personnel.
- include the rates, trends and opportunities for
improvement including data from other surveillance
activities.
- It could also provide specific inputs to reduce the HAI
rate. This could be in the form of a bulletin/newsletter.
The organisation takes action to prevent catheter-associated urinary
tract Infections.
The organisation takes action to prevent Ventilator Associated
Pneumonia.
The organisation takes action to prevent catheter linked blood stream
infections.
The organisation takes action to prevent surgical site infections.

A good reference is the CDC/WHO/SHEA guidelines.

 Untitled6

• Adequate and appropriate personal protective equipment, soaps, and

disinfectants are available and used correctly.

• Personal protective equipment includes:

• Gloves , Protective eye wear (goggles)
• Mask , Apron ,Gown ,Cap/hair cover
• Boots/shoe covers and
• The staff uses PPE appropriate to the risks involved.
• The PPE are removed as soon as the purpose is served.
• Adequate and appropriate facilities for hand hygiene in all
patient-care
care areas are accessible to healthcare providers.

- include large washbasins, hands-free

hands control, soap
and facility for drying hands without contamination.

• Isolation/barrier nursing facilities are available.

• Ideally patients requiring isolation (contact, droplet and

airborne) should be placed in isolation rooms

- airborne cases be kept in negative pressure rooms.

• Appropriate signage shall be used /displayed.

• Appropriate pre- and post-exposure
exposure prophylaxis is
provided to all staff members concerned. *
• Infection Control Nurse maintains documentation of all
occupational injuries and pre-
pre and post-exposure
prophylaxis records.
For example, hepatitis B vaccination and PEP for
needle stick injury.
• Organisation has a documented procedure for identifying an
outbreak.*
• Standard case definitions shall include a unit of time and
place along with specific biological and/or clinical criteria.
• Important to have baseline rates.
• Organisation has a documented procedure for handling such
outbreaks.*
• This procedure is implemented during outbreaks.
identify the outbreak, describe the outbreak by developing
a case definition, designing a data collection form,
collecting data from the affected, constructing an epidemic
curve.

• After the outbreak is over appropriate corrective actions are

taken to prevent recurrence.
implement basic procedures to prevent recurrence such as
source control if source identified,
review of all infection control policies, loopholes and
compliance gaps, strengthening infection control policies,
etc.
Objective Elements
• The organisation provides adequate space and
appropriate zoning for sterilization activities.
• This refers to the CSSD, which should have
suitable location, proper layout (unidirectional
flow, zoning) and separation of clean and dirty areas.
• It is preferable to have separate areas for receiving, washing, cleaning,
packing, sterilization, sterile storage and issue.
• Documented procedure guides the cleaning, packing, disinfection
and/or sterilization, storing and issue of items. *

• Reprocessing of instruments and equipment are covered. *

• documented procedure to address cleaning, disinfection or

sterilization of various accessories, instruments and equipment
between patients.
• The organisation shall have a documented policy and procedure for
reprocessing of devices whenever applicable. *
- re- use policy.
• Regular validation tests for sterilization are carried out and
documented.*
- accepted methods, e.g. bacteriologic, strips, etc.
- Engineering validations like Bowie-Dick
Bowie tape test and leak
rate
test needs to be carried out.
• There is an established recall procedure when breakdown in the
sterilization system is identified. *
- - the sterilization procedure is regularly monitored
- - If breakdown it has a procedure for withdrawal of such
items.
Objective Elements
• The organisation adheres to statutory provisions with regard to biomedical
waste.
- shall be authorized by the prescribed authority for management and
handling of biomedical waste. e.g. pollution control board/committee..
• Proper segregation and collection of biomedical waste from all patient-care
patient
areas of the hospital
- in different colour coded bags and containers as per statutory provisions.
- Monitoring by members of the infection control committee/team.
- Biomedical waste shall be handled in the proper manner.
• Biomedical waste is stored and transported to the site of
treatment and disposal in properly covered vehicles within
stipulated time limits in a secure manner.

• Monitoring of this activity should be done by an infection control

team.
• Appropriate personal protective measures
are used by all categories of staff handling
biomedical waste.
• The management makes available resources required for the
infection control programme.
- ensure that the resources required by the personnel should
be
available in a sustained manner - both men and materials.
• The organisation earmarks adequate funds from its annual budget in
this regard.
- separate budget demarcated for HIC activity.
• The organisation conducts induction training for all staff.
- There must be a documented evidence of induction training for all
categories of staff including doctors before joining department(s)
concerned. - It should include the policies, procedures and practices
of the infection control programme.
programme
• The organisation conducts appropriate ―in-service
―in training sessions for
all staff at least once in a year.
STANDARDS- 9
STANDARDS
STANDARDS 9
STANDARDS-

* This implies that this objective element requires documentati

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