Core component 1-Infection prevention and control programmed

Do you have IPC programme?

Yes with clearly defined objectives and annual activity plan
Introduction of IP program:
Infection prevention and control is scientific approach and practice designed to prevent
harm caused by infection to patients and healthcare workers. It focuses on evidence-
based practices and procedures that can prevent or reduce the risk of transmission of
microorganisms.
Importance of Infection prevention and control
• To maintain a safe environment for everyone by reducing the risk of the potential spread
of disease.
• To reduce the risk of hospital-associated infections.
• To protect patients and staff and
• To reduce the costs of healthcare-associated infections (Recent studies suggest that at
least 55% of HAIs could be prevented through infection prevention and control
strategies)
Goals of Infection prevention and control Training
To prevent the spread of infections from
• patient-to-patient
• patients to health care providers
• health care providers to patients
• health care providers to health care providers and to visitors and others in the health care
environment
Functions of Infection prevention and control Training
• To obtain and manage critical data and information.
• To implement evidence-based practice, standards and guidelines through setting-
specific policies and procedures.
• To educate and train healthcare workers (occupational health), patients, and non-
medical caregivers.
• To provide communication of infection-related issues and relevant practices to
management and staff to facilitate improvements.
• To evaluate the program and improve it as necessary
 Members of ICC
1. Chief Executive/Administrator or nominated representative
2. Infection Control Officer/Doctor/Microbiologist who may act as chairperson
3. Infection Control Nurse (ICN)
4. Infectious Disease Physician (if available)
5. Director of Nursing or his/her representative
6. Occupational Health Physician (if available)
7. Representatives from the major clinical specialties
8. Representatives of other departments may be invited as necessary
9. Pharmacy, central supply, maintenance, housekeeping, training services, engineering,
etc
Role and Responsibility of Infection Control Committee
• To review and approve the annual plan and policies for IPC.
• To support the Infection Control Team and direct resources to address problems as
identified.
• To ensure availability of appropriate supplies needed, staff training in IPC and safety.
• To review epidemiological surveillance data and identify areas for intervention.
• To assess and promote improved practice at all levels.
• To review infectious risks associated with new technologies and monitor risks of new
devices and products, prior to their approval for use.
• To review and provide input into an outbreak investigation.
• To review and approve construction/renovation projects regarding infection prevention
• To communicate and cooperate with other committees with common interests, such as
antibiotic/Pharmacy Committee, Occupational Health Committee, etc

We have IP committee:
 Nepal Medical College and Teaching Hospital Pvt. Ltd
Gokarneshwor, Kathmandu

Infection Control Committee

SN Name Designation Position of Phone no. Email
Committee address
1. Prof. Dr. Modhnath Marhatta Hospital Chairman 9851055537
Director
2. Associate Prof. Dr. Jyotsana Microbiology Member 9851182704
Sapakota Secretary
3. Dr. Krishna Chandra Devkota Head of Member 9841619894
Department,
Medicine
4. Dr. Sunil Shrestha Head of Member 9851082443
Department,
Surgery
5. Prof. Dr. Rita Marhattha Head of Member 9841250552
Department,
Obstetrics and
Gynecology
6. Mr. Jyoti Khadka Chhetri Chief Member 9840052296
Administrator
7. Ms. Nabina Singh Matron Member 9811125635
8. Mr. Dilip Shah Hospital Member 9855033837
Incharge
9. Mrs. Bina Kumari Yadav Infection Member 9841792354
Control Nurse
10. Ms. Sushma Lama Infection Member 9860238437
Control Nurse
11. Dr. Anup Raj Uprety Clinical Member 9869151100
Pharmacist
12. Mr. Ganga Bahadur Khatri Environmenta Member 9849733147
l Health and
Safety Officer
13. Mrs. Nita Shrestha Biomedical Member 9860534157
Engineer
14. Ms Anita R. C. Central Sterile Member 9841337254
Supply
Department
15. Mr. Sudama K.C House Member 9841004400
Keeping
Officer
 YEARLY PLAN OF INFECTION CONTROL DEPARTMENT
2078/079
JANU FEBRU APRI AUGUS SEPTE OCT NOVEM
SN MARCH MAY JUNE JULY DECEMBER
ARY ARY L T MBER OBER BER

Conduct regular infection

control and waste
management training for all
staff (as necessary)

Provide Hospital orientation

programme related to
infection prevention toward
new employees and students

Discussion on needle stick

injury
Identify and discussion SSI,
CLABSI, VAP, CAUTI
Hospital Surviellence and its
outbreak

Assess surrounding
environment to reduce
infection through
environmental areas

Supervise and monitor

cleanliness and hand hygiene
practice survey throughout
entire hospital

Cross check for internal store

management
Collect baseline survey on
antibotic staewardship
Point Prevalence Survey
Water culture survey
Monthly meeting
Follow up on IP registerd
book of ICU and OT
Grand Presentation
 Core component 2: Infection prevention and control (IPC)
guidelines
Core component 3: Infection prevention and control (IPC)
education and training
We have infection control link nurse:
An effective way to develop infection control education and operation
support can be through a link system. In large facility the ICN can train
link nurse, these individual have special responsibility for maintaining
good IPC practice and education within their departments. The
infection control link nurse (ICLN) is the link between the ICN and ward
and staff by enabling more effective practice. Sustained, consistent
senior management backing and interest are effective in supporting
such link programs and essential in ensuring their success.

The ICLN responsible for:

*Monitoring hygiene, consistent with policies and nursing practice.
*Monitoring aseptic technique, including hand hygiene and use of
isolation precautions
*Reporting promptly to the attending physician ant evidence of
infection in patients.
*Initiating patient isolation /precautions and ordering culture
specimens from any patient.
*Identifying signs of a communicable disease when the physician is not
available.
*limiting patient exposure to infection from visitor, staff, other
patients, or equipment used for diagnosis or treatment.
*maintaining a safe and adequate supply of water equipment, drugs,
and patient care supplies.
*To act as a role model for colleagues.
 Standard Precaution
Standard precautions are basic level of infection control precautions in the care
of all patients meant to reduce the risk of transmission of blood-borne and other
pathogens from both recognized and unrecognized sources. It is also those
precautions designed to prevent and control the risk of acquiring occupational
infection from both known and unexpected sources in the healthcare setting.
Standard Precautions are recommended for the care delivery to all patients,
regardless of their presumed infection state. It is important when handling
equipment and devices that are contaminated or suspected of contamination, and in
situations with risk of contact with blood, body fluids, secretions and excretions,
without considering the presence or absence of visible blood and non-intact skin
and mucous tissues.
Definition
Standard precautions are meant to reduce the risk of transmission of blood-borne
and other pathogens from both recognized and unrecognized sources (WHO).
Components of Standard precautions
a. Hand hygiene
b. Personal protective equipment (PPE)
c. Respiratory hygiene and cough etiquette
d. Cleaning and Disinfecting (Environmental cleaning and
Patient care equipment)
e. Safe injection practice
f. Safe handling
g. Waste disposal

Hand Hygiene
The hands are the most common vehicle for microbial transmission therefore hand
washing reduces the number of potential infectious agents on the hands. It also an
important means of reducing the incidence of infectious agents in healthcare
facilities. It has been cited frequently as the single most important practice to
reduce the transmission of infectious agents in healthcare settings and is an
essential element of Standard Precautions.” Hand Hygiene includes cleaning hands
with soap and water or alcohol-based hand rub in order to remove germs, also
known as microorganisms. Hand hygiene is a major component of standard
precautions and one of the most effective methods to prevent transmission of
pathogens associated with health care.
 Hand washing (40–60 sec) wet hands and apply soap; rub all surfaces; rinse
hands and dry thoroughly with a single use towel
 Hand rubbing (20–30 sec): apply enough product to cover all areas of the
hands rub hands until dry
Indications of Hand Hygiene
 Before and after any direct patient contact and between patients, whether or
not gloves are worn.
 Immediately after gloves are removed.
 Before handling an invasive device.
 After touching blood, body fluids, secretions, excretions, non-intact skin,
and contaminated items, even if gloves are worn.
 During patient care, when moving from a contaminated to a clean body site
of the patient.
 After contact with inanimate objects in the immediate vicinity of the patient
Five moments of hand hygiene
Moment 1
To protect patient against harmful germs carried on your hands such as
 Holding their hands
 Lifting or transferring
 Clinical examinations
Moment 2
To protect patient against harmful microorganisms, including those already on
patient’s skin such as:
 Wound dressings
 Subcutaneous injections
 Invasive procedure
Moment 3
To protect your colleagues, surroundings from harmful micro-organisms from
patient such as
 Secretion aspirations
 Drawing or manipulating any fluids
 Cleaning of contamination and visibly soiled area or materials
Moment 4
To protect yourself and surrounding from harmful micro-organisms from patient
such as
 Physical examinations
 Taking vital signs
 Caring of a patient
Moment 5
After touching any object in patient immediate surroundings e.g. bed, chair, when
leaving such as
 Changing linens, monitoring alarms, holding bed rails Medical Hand Wash
 Before administering medicine or medical care
 Duration: minimum of 40-60 seconds.
 Steps are based on soap and water hand wash technique and rinse from wrist
to finger tips
Surgical Hand Wash
 Remove rings, watches, and bracelets before beginning to scrub.
 Clean under nails using a nail cleaner under running water.
 When using antimicrobial soap, scrub hands and forearms for 2 to 6 minutes.
Long scrub times (e.g., 10 minutes) are not necessary.
 When using an alcohol-based surgical hand-scrub, prewash hands and
forearms with a non-antimicrobial soap and dry hands and forearms
completely before applying. Allow product to dry thoroughly before
donning sterile gloves.
 Double gloving is advised during invasive procedures that pose an increased
risk of exposure to blood.
The Golden Rules for Hand Hygiene
 Hand hygiene must be performed exactly where you are delivering health
care to patients (at the point of care)
 During health care delivery, REMEMBER 5 MOMENTS of hand hygiene
„My Moments for Hand Hygiene‟ approach.
 To clean your hands, you should prefer hand rubbing with an Alcohol Based
Hand rub (ABHR) if available.
 You should wash your hands with soap and water when visibly soiled.
 You must perform hand hygiene using the appropriate technique and time
duration
“Handy” Tips
 Artificial nails, gel nails or extenders are not to be worn by staff that have
direct patient contact.
 Contaminated surfaces or objects should not be touched after performing
hand hygiene.
 Avoid touching your face, especially your eyes and nose.
 Fingernails should be kept short - no longer than ¼” or 0.635cm long.
 Do not “top up” a partially-used hand hygiene product dispenser.
 If re-usable dispensers are used they must be emptied, washed and dried
prior to being refilled. Hand lotion bottles must not be re-used.
 Include frequently missed areas when performing hand hygiene such as
thumbs, palms, web spaces, under nails and the backs of fingers and hands.
 Use supplied lotions that are compatible with hand hygiene products and
gloves to minimize skin irritation that can occur with frequent hand hygiene.
 Wearing hand and wrist jewelry is not recommended

NEPAL MEDICAL COLLEGE AND TEACHING HOSPITAL

PROCEDURE CHECK LIST OF HAND WASHING
NAME: DESIGINATION:
 WARD: DATE:
[Link] PROCEDURE STEPS YES NO COMMENTS
1. PUSHES UP SLEEVES, REMOVES JEWLLERY AND
WATCHES
2. ADJUSTS WATER TEMPERATURE TO WARM IF
AVAILABLE
3. WETS HANDS AND WRISTS UNDER RUNNING
WATER
4. KEEPING HANDS LOWER THAN WRISTS AND
FOREARMS
5. AVOIDE SPLASHING WATER ONTO CLOTHING
6. AVOIDE TOUCHING INSIDE OF THE SINK
7. APPLIES 3-5 ML LIQUID SOAP/APPLIES SOAP
8. RUBS SOAP OVER ALL SURFACES OF HAND
9. LATHERS ALL SURFACES OF THE HAND AND
FINGER
10. USE SIX STEPS OF MOVEMENTS
11. CLEAN UNDER FINGERNAILS, IF NAILS ARE
DIRTY
12. RINSE THOROUGHLY: MOVES FROM FINGERS
UP FOREARMS
13. DRY WITH PAPER TOWEL
14. TURNS OF FAUCET( TAP) WITH PAPER TOWEL
USING ALCOHAL- BASED HANDRUB
1. IF HAND ARE SOILED, WASHES THEM WITH
SOAP AND WATER
2. APPLIES A SUFFICIENT QUANTITIY OF
ANTISEPTIC SOLUTION TO COVER THE
HANDS AND WRISTS
3. RUBS SOLUTION ON ALL SURFACES OF
FINGERS AND HANDS
4. CONTINUES RUBBING UNTILL HANDS ARE
DRY

RECOMMENDATION: PASS……………………….. NEEDS MORE PRACTICE…………………………..

INSTRUCTOR:

Personal Protective Equipment (PPE)

Personal protective equipment (PPE) refers to wearable equipment that is designed
to protect from exposure to or contact with infectious agents. PPE that is
appropriate for various types of patient interactions and effectively covers personal
clothing and skin likely to be soiled with blood, saliva, or other potentially
infectious materials should be available. These include gloves, face masks,
protective eye wear, face shields, and protective clothing (e.g., reusable or
disposable gown, jacket, laboratory coat).
 Use of gloves in situations involving possible contact with blood or body
fluids, mucous membranes, non-intact skin (e.g., exposed skin that is
chapped, abraded, or with dermatitis)
 Use of protective clothing to protect skin and clothing during procedures or
activities where contact with blood or body fluids is anticipated.
 Use of mouth, nose, and eye protection during procedures that are likely to
generate splashes or sprays of blood or other body fluids
 Do not wear the same pair of gloves for the care of more than one patient.
 Do not wash gloves. Gloves cannot be reused.
 Perform hand hygiene immediately after removing gloves
 Remove PPE before leaving the work area
 Nepal Medical College (Pvt.) Ltd., Teaching Hospital
Attarkhel, Jorpati
PPE checklist of Donning
Name:
SN CRITERIA YES NO

1 Ensure that all the equipment’s are available

(boots, shoe cover, N95 respirator, goggles,
impermeable coverall, plastic apron, 2 pairs latex
gloves, alcohol based hand rub or soap and water)
2 Wear your first layer clothes (comfortable duty
clothes)
3 Wear plastic or rubber boots
4 Remove watch, jewelries and contents of pocket
5 Secure your hair
6 Inspect PPE items prior to putting on (good
working condition)
7 Wash your hand with soap and water (completely
follow 6 steps of hand washing)
8 Put on half shoe covers
9 Hand wash with alcohol based sanitizer
10 Put inner gloves
11 Put on cover-all /gown (make sure that large
enough to free movement)
12 Zip up cover-all
13 Make sure that the cuffs of inner gloves are tucked
under sleeve of cover-all/gown
14 Put on N95 respirator

Cup the respirator in your hand with the nosepiece

at fingertips
 Position the mask under your chin with nosepiece
up

Pull the bottom strap over your head and position

it around the neck, below the ears

Pull the top strap over your head and position

above the ear

Mold the nosepiece using two finger of each hand

to the shape of your nose

Perform seal check

15 Wear surgical mask (cover all part of N95) and fix
it
16 Wear surgical cap and goggles

17 Put on hood ( make sure that the hood covers all of

hair, ear and neck with no skin expose
18 Put on face shield
19 Put outer gloves over sleeves of cover-all
20 Let the observer check the worn PPE (make sure
all parts of skin are covered even while moving) if
worn change it
21 Observer ask to do extend arms, wrist, waist and
do his/her range of motion
20 Ready to enter in working area
 Nepal Medical College (Pvt.) Ltd., Teaching Hospital
Attarkhel, Jorpati
PPE checklist of Doffing
Isolation Area
Name:
SN CRITERIA YES NO

1 PPE should be taken off in a designated PPE

removal area

Ensure that all the equipment’s are available (dust

bin with lid and leak proof plastic bag, alcohol
based hand rub
2 Minimize touching the healthcare worker during
doffing
3 Inspect PPE for visible contamination or tears by
slowly movement (observer should be carefully
monitor him/her)
4 Disinfect outer gloves by using alcohol based hand
rub
5 In case of visible contamination seen use 1%
bleach solution or alcohol based hand rub for
decontamination to wipe it off
6 Disinfect outer gloves by using alcohol based rub
if you done step no. 5 otherwise skip this step
7 Disinfect outer gloves and remove it without
contaminating inner gloves
8 Inspect and disinfect inner gloves

9 Remove face shield by lift back of strap and

slightly lean forward ( avoid touching outer area)
10 Disinfect inner gloves
11 Put off hood by outside ( grasp back side only)
12 Disinfect inner gloves
13 Wear off surgical cap and goggles by lift back of
strap in back site (if you wear)
14 Find the zip and carefully un-zip not touch inner
side of cover-all
15 After touching zip disinfect gloves
16 Before rolling down turn inside out
17 Avoid touching outside of cover-all
18 Rolling out gown from inner to outer
19 Disinfect the gloves
20 Wear off shoe cover one by one from dirty area
and Placed your foot in clean area slowly and
carefully
21 Discard shoe cover in clean area dust bin
22 Disinfect the gloves
23 Wear off surgical mask (slightly lean forward) and
discard it
24 Disinfect the gloves and remove it properly
25 Disinfect the hands (6 steps) with alcohol base rub
26 Leave the isolation area
27 Perform hand hygiene with alcohol based hand rub
28 Remove N95 mask and placed in paper bag

29 Change your shoes

30 Hand wash with soap and water
 Sharps Safety
Most percutaneous injuries (e.g., needle stick, cut with a sharp object)
among DHCP involve burs, needles, and other sharp instruments. sharps
injuries continue to occur and pose the risk of blood borne pathogen
transmission to DHCP and patients. Most exposures in dentistry are
preventable; therefore, each dental practice should have policies and
procedures available addressing sharps safety
 Consider sharp items (e.g., needles, scalers, burs, lab knives, and
wires) that are contaminated with patient blood and saliva as
potentially infective and establish engineering controls and work
practices to prevent injuries.
 Do not recap used needles by using both hands or any other technique
that involves directing the point of a needle toward any part of the
body.
 Use either a one-handed scoop technique or a mechanical device
designed for holding the needle cap when recapping needles (e.g.,
between multiple injections and before removing from a non-
disposable aspirating syringe).
 Place used disposable syringes and needles, scalpel blades, and other
sharp items in appropriate puncture-resistant containers located as
close as possible to the area where the items are used
NEPAL MEDICAL COLLEGE TEACHING HOSPITAL
PRACTICE GUIDELINES ON NEEDILE PRICK INJURIES WHILE WORKING

NEEDLE OR SHARP WHEN THE BLOOD OR WHEN BLOOD OR SECRETIONS

CONTAMINATED BLOOD SECRETIONS OF PATIENTS FROM THE MOUTH OF THE
INJURIES CONTACT WITH EYES PATIENT

WIPE OFF THE RINSE WITH PLENTY OF WATER OR EYE RINSE WITH CLEAN WATER
BLOOD WASH

RINSE WITH CLEAN WATER INFORM WARD

AND SOAP SISTER/INCHARGE

REPORT INFECTION
CONTROL NURSE TO
ACKNOWLEDGE
  CONTACT/CONSULT IMMEDIATELY AT ER
ON DUTY DOCTOR OR SENIOR DOCTOR
 WRITE A REPORT OF AN ACCIDENT

IF NOT KNOWN CASE OF HIV

COUNSELLING TO INJURED STAFF (PHYSICIAN
INFORM TO ATTENDING DOCTOR TO ASK THE PATIENT FOR
PROVIDES KNOWLEDGE ABOUT THE DISEASE AND
BLOOD CHECKING FOR ANTI-HIV, HBsAg AND ANTI-HCV
CONDUCT AFTER AN ACCIDENT)

1. HBSAG-NEGETIVE PATIENT: - DO NOT HAVE TO

BLOOD DRAW FROM INJURED STAFF IMMEDIATELY DO ANYTHING
TO CHECK FOR HIV, HCV, RFT, LFT AND CBC, OR
PHYSICIAN ORDERED 2. HBsAg – POSITIVE PATIENT
 IF THE STAFF HAD NOT RECEIVED THE VACCINE
SHOULD BE GIVE HBIG AND HBV VACCINE (IF
ANTI HBV <10 IU/ML)
IN CASE OF KNOWN HIV PATIENT  IF THE STAFF HAS BEEN VACCINATED BEFORE
CONSIDER TO USE HIV ANTIRETROVIRAL DRUGS ALREADY HAVE IMMUNITY: - DO NOT HAVE TO
IMMEDIATELY OR WITHIN 2 HRS IN CASE THAT DO ANYTHING:
DESERVES AND CONTINUTY OF CARE BY A BLOOD 3. NO IMMUNITY, GIVE INJECTION HBIG AND START
CHECK FOR ANTI- HIV ACCORDING TO THE DISCRETION INJECTION HBV VACCINE
OF THE PHYSICIAN

NOTE: IF TREATMENT IS REQUIRED SEND INJURED STAFF TO TEKU/TEACHING

HOSPITAL WITH OFFICIAL LETTER AND A COPY OF INCIDENT RECORD FORM.
 NEPAL MEDICAL COLLEGE [Link], TEACHING
HOSPITAL
ATTERKHEL, JORPATI
INCIDENT/INJURY/NEAR MISS REPORT FORM

INJURED PERSONS DETAIL REPORTING PERSON DETAIL

NAME:- SEX:- NAME:- SEX:-
DATE OF BIRTH:- DATE OF BIRTH:-
STAFF STUDENT VISITOR STAFF STUDENT VISITOR
OCCUPATION:- OCCUPATION:-
WARD:- WORK PHONE:- WARD:- WORK PHONE:-
MOBILE NO. MOBILE NO.
EMAIL:- EMAIL:-
HOME ADDRESS:- HOME ADDRESS:-
SIGNATURE SIGNATURE
DATE:- DATE:-
INCIDENT DETAILS
INCIDENT INJURY NEAR MISS ILLNESS/DISEASE DATE OF OCCURRENCE TIME:-
DESCRIPTION OF HOW THE INCIDENT OCCURRED, AND ANY INJURY RECEIVED (INFORMATION ON
PROTECTIVE GARMENTS WORN, LENGTH OF EXPOSURE, WETHER IT WAS A SHARP INJURY OR BODY
FLUID EXPOSURE: SITE AND LOCATION ON THE BODY)

WITNESS 1 WITNESS 2
SOURCE PATIENT DETAILS
NAME: AGE/SEX:
ADDRESS:

SECTION – B

NOTIFIED SAFETY AND HEALTH REPRESENTATIVE

NAME: AGE: TIME:
ADDRESS: PHONE NO.
SIGNATURE:
NOTIFIED SUPERVISER/MANAGER
NAME: AGE: TIME:
ADDRESS: PHONE NO:
SIGNATURE:

SECTION C
 DETAILS OF INJURY
EXPOSURE TYPE:
INTACT SKIN NOSE(MUCOSA) NON INTACT SKIN
MOUTH(MUCOSA) EYES(CONJUNCTIVA)
IS THE SOURCE A KNOWN POSITIVE FOR HIV/ HEPATITIS B /HCV? YES NO
UNKNOWN
SOURCE PATIENT TESTED AFTER INCIDENCE HIV/HBV/HCV? YES NO
UNKNOWN
IS THE INJURED KNOWN FOR HIV/HBV/HCV? YES NO
UNKNOWN
THE INJURED TESTED FOR HIV/HBV/HCV AFTER INJURY? YES NO
UNKNOWN

SECTION D

FOLLOW UP ACTION
WHAT FIRST AID TREATMENT WAS PROVIDED AND BY WHOM?

HAVE YOU PREVIOUSLY BEEN VACCINATED AGAINST HEPATITIS B? YES

NO

SECTION E

RECOMMENDATIONS TO PREVENT RECCURENCE OF THIS HAZARD:

SECTION F

DOCTOR FOLLOW UP
No follow up required: follow up required: vaccination: prophylactic
treatment:
Date: Date:
Doctors Name:
Signature: Date:
Disinfection of Patient-Care Items and Devices
 Cleaning and Disinfection
The healthcare environment can become easily contaminated with pathogens. The
potential for contamination exists in every area of the hospital or other healthcare
facility. Contaminated patient-care equipment (wet or soiled dressings), invasive
devices that were used in diagnosis and treatment (surgical instruments or
endoscopes), and environmental surfaces (doorknobs,
floors, toilets) can act as vehicles for the transmission of infection to healthcare
workers and/or patients.
 Decontamination is the combination process (including cleaning,
disinfection and sterilization) of removing or neutralizing contaminants that
have accumulated on personnel and equipment
WHO consists of following steps in decontamination;

 Cleaning
 Disinfection
 Inspection
 Packaging
 Sterilization
 Storage
 Transport of sterile items
 Use
 Transportation of contaminated items
Level of Decontamination
a) Cleaning: is first step of decontamination. Cleaning means to get rid of
visible dirt which helps to reduce the pathogen load while removing organic
and inorganic residues. It has 2 type of cleaning Manual cleaning which
requires detergents or enzymes with friction (rubbing, brushing, flushing) to
remove soil. Mechanical cleaning where we use mechanical equipment
(washer disinfectors, ultrasonic cleaner and cart washers) to improve
cleaning effectiveness, increase productivity and promote employee safety.

Classification of medical device

According to Earl H. Spaulding
1. Critical items: it includes surgical instruments, sutures, cardiac and urinary
catheter, implants, ultrasound probes, sharp instruments like needles,
 diathermy cautery, sponges etc. These are must be sterile because it enters
sterile tissue or contact with vascular system.
2. Semi critical items: It includes respiratory therapy equipment (face mask,
ET tube, oral and nasal airway and Yankeur’s suction), some endoscope,
Laryngoscope and its blades, spatulas, cystoscopies, bronchoscopes,
colonoscopies, gastroscopies and sigmoidoscopies. These kind of items
come into contact with non-intact skin and mucous member and do not cross
blood barrier. They require high level disinfection, although they may also
be sterilized
3. Noncritical Items: it comes only with intact skin. Intermediate or low level
disinfection is adequate. E.g. Bp cuff and stethoscope, crutches, pulse
oximeter probes, ECG cables, thermometer, blood warmers, bedpan, urinals,
IV stand, exterior of anesthetic machine and monitor, bedside table, bed
rails, furniture, floors, table, station etc.

b) Disinfection -is a process that kills or destroys many microorganisms on the

inanimate object. It usually does not kill spores. If sterilization is not
available, High level of disinfection is the only acceptable alternative.
Level of disinfection
 High level disinfection: Kill bacteria, virus, fungi, mycobacterium
tuberculosis and some but not necessarily all endospores. It is used for
processing instruments and other items that are semi critical. Ortho-
phthaldehyde, Glutaraldehyde, formaldehyde, peracetic acid,
hydrogen peroxide
 Intermediate level disinfection: kills some bacteria, some virus,
fungi, and mycobacterium tuberculosis. They are not effective against
resistant bacteria spores. Chlorine, iodophors, phenolic and alcohol
belongs to this group
 Low level disinfection: kills most vegetative bacteria, fungi and lipid
enveloped viruses but do not kill spores or non-lipid viruses. They are
less active against Mycobacterium tuberculosis and pseudomonas
(gram negative rods). This kind of disinfectant only used to wipe
down that items which only contact with intact skin or for
environmental surface disinfection e.g. Alcohol
 Dressing checklist

PATIENT NAME: AGE/SEX: IP NO.

DATE:
DEPARTMENT: DIAGNOSIS: OPERATIVE PROCEDURE:

S.N DESCRIPTION YES NO REMARKS

1. Proper hand washing
2. The surface of dressing trolley disinfect with 75% alcohol and
allowed to dry
3. Trolley laid up with sterile wound dressing pack and approved
antiseptic solution bottles
4. A disposable biohazard bag for soiled dressing attached at the side of
the trolley
5. Disposable gown, face mask and eye goggles (if splash is
anticipated)are worn and trolley taken to patient side.
6. Hands disinfected and clean non sterile gloves
7. The wound outer dressing is removed just immediately prior to
dressing procedure and not earlier. It is disposed in biohazard bag
8. The gloves removed and hands disinfected with alcohol rub
9. The corner of the sterile inner dressing set opened immediately before
dressing and sterile field formed.
10. The antiseptic solution poured in the dressing set
11. Hands disinfected, and sterile gloves worn
12. The inner wound dressing removed with sterile forceps, and disposed
in biohazard bag.
13 Wound assessed for signs of infection
14. The wound cleaned and wiped using sterile forceps and cotton swab.
(From the less contaminated area to the most contaminated area in
one direction)
15. The wound covered with sterile dressing, using another sterile forceps
16. Sterile field is maintained and non-touch technique is maintained
throughout the procedure.
17. The forceps, soiled material and the protective equipment discarded
in biohazard bag
18. All non- contaminated materials and packing discarded in the
domestic waste (blue bag).
19. The surface of the trolley disinfected
20. Hands washed and dried.
Core component 4: Health care- associated infection (HAI) surveillance
Core component 5: Multimodal strategies for implementation of IPC
intervention

We developed some form for hospital acquired infections which include

CAUTI, CLABSI, VAP, SSI. In addition, we have been recorded
daily inpatient culture surveillance and visit to the field for
comparison in between report and clinical features of patient, its
sensitivity pattern, isolation if required, provide awareness to related
ward. Periodically swab culture done in hospital surrounding. We
have checklist of dressing, hand hygiene (according to WHO),
catheter care, cvp care.
We monitor cleanliness of environment, quality of devices (cannula), bed
space, update of sterility in instruments, disinfectant, laundry, safe
injection practice, sterilization, Donning and doffing, waste
segregation etc

NEPAL MEDICAL COLLEGE AND TEACHING HOSPITAL

Attarkhel, Jorpati- KTM
SSI Format
Date: ………………
Patient IP No: ………….
Hospital No: …………….
Name: ………………
Age/ Sex: ……………
Ward: …………
Date of Admission: ……………. Unit:
Surgical Intervention
Date of Operation: Starting Time: Ending Time:
Operative Procedure: Reason for OT:
Surgeon: Anesthesia: Anesthesia time:
Assistant: Assistant: Anesthesia type:
Lap / Open: Scrub nurse: ASA Gr.
Elective: Pre. Hb: Post Hb :
Emergency: Blood loss during OT:
Surgical Site Infection
Infection date:
Infection Site:
Wound Class:
1. Superficial incisional
2. Deep incisional
 OR
a. Clean Contaminated Infected
b. Contaminated Wound
c. Dirty Wound
Detected during Admission Post- discharge OPD
Secondary Septicemia:
Re- intervention: Y N (indicate Y only if re-intervention is related to SSI) Date:
Re- admission: Y N (indicate Y only if readmission is related to SSI or Secondary septicemia)
Culture taken: Y Type of specimen: WD (wound drainage Fluid), WS (wound swab)
Microorganism Name: Other:
Sensitivity Pattern
Fever Pattern:
Patient Follow up Blood Group
Date of discharge Treatment Procedure: Dressing/sitz bath/ pericare/perilight
Status at discharge-imp Visitor Phone no.
Medicine used:
Prophylaxis A/B After OT After organism seen
1.
2.
3.

Nepal Medical College and Teaching Pvt. Ltd

Attarkhel, Jorpati-KTM
CAUTI FORM
Date: ………………
Patient IP No: ……………
Hospital No: ……………
Name: …………….
Age/ Sex: …………….
Ward: ………………….. Bed No: ……………
Date of Admission: ………………………
Diagnosis: ……………………….
Clinical History of Chronic Disease:
1. Diabetes 4. Tuberculosis
2. Hyper/ Hypotension 5. Renal Failure
3. Hyper/ Hypothyroidism 6. Others……………………….
Previous History of Catheterization: If Yes … ……………….. No
Current Cause of Catheter insertion:
Types of Catheter used: Foleys other (specify)…………
Date of Catheterization: Duration of Catheterization:
Removal date of Catheterization
Procedure done by: Name:…………………………………………… Designation: …………………………
Area……………………………… Time…………………………….
Blood culture before catheterization:
Symptoms of UTI: …………………………………………
Symptoms start from: ………………….(in Hours)
Culture taken: Yes (date:…………) / No Bacteria count in colony forming unit (CFU): ………………..
Micro-organism Name: 1.
2.
Antibiotic Susceptibility Pattern:
Medicine Used:
Antibiotic during Admission Antibiotic change after catheterization After organism seen

Discharge Status About Catheter: If present (specify types)……………… removed

NEPAL MEDICAL COLLEGE AND TEACHING HOSPITAL

ATTERKHEL, JORPATI
VENTILATER ASSOCIATED PNEUMONIA
DATE: …………………...
PATIENT IP NO.……………………………...
HOSPITAL NO……………………………
NAME: ………………………………...
AGE/SEX: ……………………….
WARD: ………………………… BED NO ……………………
DATE OF ADMISSION: …………………………...
DIAGNOSIS: ……………………………...............
REASON OF ICU ADMISSION: ……………………
INTUBATION DATE: …………………………………...
DATE OF R/O PNEUMONIA: ………………………
INVESTIGATION
BLOOD CULTURE………………………
ORGANISM: ……………………………….
SENSITIVITY: ………………………………
SECRETION FROM ET TUBE: …………………...
ORGANISM: ………………………....................
SENSITIVITY: ………………………………………….
ET TUBE TIP CULTURE: ………………………….
ORGANISM: …………………………………………..
SENSITIVITY: …………………………………………
MEDICINE USED: …………………………………..