1

DR. J. R. DHAR. SUB DIVISIONAL

HOSPITAL, BONGAON
STANDARD OPERATING PROCEDURES
INFECTION CONTROL
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Standard Operating
SOP /BNG/2018/
Procedures

Date of issue-

01.04.2018
Document name- Date of implementation-

DR. J.R. DHAR. SUB

INFECTION CONTROL 01.04.2018
DIVISIONAL
Version -
HOSPITAL, BONGAON

One

CONTROL OF THE MANUAL -

The holder of the copy of this SOP is responsible for maintaining it in good and safe
condition and in a readily identifiable and retrievable state. The holder of the copy of this
SOP shall maintain it in current status by inserting latest amendments as and when the
amended versions are received. Assistant Superintendent and Facility level Quality Manager
is responsible for issuing the amended copies to the copyholders. And the copyholder should
acknowledge the same and he/she should return the obsolete copies to the office. The
amendment sheet, is to be updated (as and when amendments received) and is to be referred
for details of amendments issued. The SOP is reviewed once a year and is to be updated as
relevant to the hospital policies and procedures. Review and amendment can happen also as
corrective actions to the non-conformities raised during the self-assessment or assessment
audits.
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Name of hospital Dr. J.R. Dhar Sub Divisional Hospital,

Telephone number of hospital 03215-255776

Office of the Superintendent, Sub-division

Address ( Official) for correspondence Hospital P.O- Bongaon , District-North 24
Parganas

email address bongaonsdh@[Link]

Name of Superintendent Dr. Sankar Prasad Mahata

Telephone number of Superintendent 9732838150

Name of Nursing Superintendent [Link] Biswas

Telephone number of Nursing

9836632342
Superintendent

Name/s of Asst Super Mr. Saptarshi Chowdhury

Telephone number of Asst. Superintendent 9836991193

Name/s of Facility level Quality Manager Mr. Dilip Kumar Bain

Telephone number of FLQM 9733958651

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Approved by-

Name Designation Signature

Dr. Sankar Prasad Mahata Superintendent

Mr. Saptarshi Chowdhury Asst. Superintendent

Mr. Dilip Kumar Bain Facility level Quality

Manager

Finally Approved and authenticated by-

Name Designation Signature

Dr. Sankar Prasad Mahata Superintendent

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1. Purpose:
The purpose of this procedure is to develop a system for managing: Infection Control
2. Procedure:
Para Measurab Activity Responsibility Ref document/
no. le Record
Elements
(ME) as
per NQAP
Standard
Guidelines

Area of Concern – Cleanliness of Circulation Area

Hand Hygiene
1 D1.1 Sink and running Infection Kayakalp
water was available at point of use. Control Implementatio
Washbasin with functional tap, Committee, n Guideline
soap and running water was available Infection
at all points of use including nursing Control Nurse,
stations, OPD Superintendent
clinics, OT, labour room etc. , Asst.
Superintendent
and Facility
Level Quality
Manager
2 D1.2 Hand Washing Instructions are Infection
displayed. Hand washing instructions Control
are displayed at all points of use Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
3 D1.3 Staffs are adhered to 6 steps of Hand Infection
washing. Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
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Level Quality
Manager
4 D1.4 Alcohol Based handrub is available Infection
and in regular supply. Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
5 D1.5 Staff is aware of when to hand wash Infection
Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Personal Protective Equipment (PPE)
6 D2.1 Staff uses gloves during Infection
examination, and while conducting Control
procedures Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
7 D2.2 Staff uses mask and head caps in Infection
patient care and procedure areas Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
8 D2.3 The housekeeping staff and waste Infection
handlers uses heavy duty gloves and Control
gum boots Committee,
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Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
9 D2.4 Protective attire e.g. Infection
Apron is used by the doctor and Control
nurses, lab coat by Committee,
the lab technicians, gown in OT, etc. Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
10 D2.5 Staff have adequate Infection
supply of personal protective Control
equipment. Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Personal Protective Practices
11 D3.1 The staff is aware of use of gloves, Infection
when to Control
use (occasion) and its type. Committee,
The Staff also know difference Infection
between clean &sterilized gloves and Control Nurse,
when to use Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
12 D3.2 Staff know correct method of wearing Infection
and removing gloves Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
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and Facility
Level Quality
Manager
13 D3.3 Staff knows correct method of Infection
wearing mask Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
14 D3.4 Disposable gloves and mask are Infection
not re-used. Reusable Gloves and Control
mask are Committee,
used after adequate sterilization. Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
15 D3.5 The Staff is aware of five Infection
Standard Precautions Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Decontamination and Cleaning of Instruments
16 D4.1 Staff knows how to make Chlorine Infection
solution from Bleaching powder and Control
Hypochlorite solution Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
17 D4.2 Decontamination Infection
of operating and Surface examination Control
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table, dressing tables etc. by chlorine Committee,

solution Infection
or Disinfectant like carbolic acid is Control Nurse,
done after every procedures Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
18 D4.3 Decontamination Infection
of instruments are done with 0.5% Control
chlorine solution for 10 minutes after Committee,
use Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
19 D4.4 Instruments are cleaned thoroughly Infection
with water and soap before Control
sterilization Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
20 D4.5 Adequate Infection
Contact Time for Control
Decontamination of instruments (10 Committee,
Minutes) is given Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Disinfection & Sterilization of Instruments
21 D5.1 Staff is awared of recommended Infection
temperature, duration and pressure for Control
autoclaving instruments Instruments - Committee,
121 Infection
degree C, 15 Pound Pressure for 20 Control Nurse,
Minutes Superintendent
(30 Minutes if wrapped) Linen - 121 , Asst.
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C, 15 Pound for 30 Minutes Superintendent

and Facility
Level Quality
Manager
22 D5.2 Staff is aware of process of High Infection
Level disinfection using Boiling or Control
Chlorine Committee,
Solution Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
23 D5.3 Signal Locks are used for Sterilization. Infection
Autoclaving records are kept for use Control
of sterilization indicators (signal Loc) Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
24 D5.4 Chemical Sterilization of instruments Infection
are done Control
as per protocol. Committee,
Staff know the protocol for Infection
sterilization of laparoscope soaking it Control Nurse,
in 2% Glutaraldehyde solution for 10 Superintendent
Hours , Asst.
Superintendent
and Facility
Level Quality
Manager
25 D5.5 Sterility of autoclaved pack is Infection
maintained during storage. Autoclaved Control
instruments are kept in Committee,
the clean area. Their expiry date is Infection
mentioned on the package. Control Nurse,
Instruments are not used later once Superintendent
instrument pack has been opened. , Asst.
Superintendent
and Facility
Level Quality
Manager
Spill Management
26 D6.1 Staff is aware of Infection
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how manage small spills. Control

Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
27 D6.2 Spill management Kit is available Infection
Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
28 D6.3 Staff are trained for spill management Infection
Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
29 D6.4 Spill Management protocols are Infection
displayed at points of use Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
30 D6.5 Staff is aware of Infection
management of large spills Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
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Superintendent
and Facility
Level Quality
Manager
Isolation and Barrier Nursing
31 D7.1 Isolation ward is available in the Infection
hospital Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
32 D7.2 Infectious patients are not mixed with Infection
general patients. Infectious patients are Control
admitted in Committee,
infectious ward only Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
33 D7.3 A distance of 3.5 Foot is maintained Infection
between Control
two beds in wards Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
34 D7.4 External foot wear are not allowed in Infection
labour Control
room, OT,ICU, Burn ward, SNCU, Committee,
etc. Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
35 D7.5 Visitors are not allowed in critical Infection
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areas like OT, ICU,SNCU, Burn Control

Ward, etc. Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Infection Control Program
36 D8.1 Infection Control Infection
Committee is Control
constituted and Committee,
functional in the Infection
Hospital and regular meetings are Control Nurse,
conducted at the facility. Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
37 D8.2 Facility have the practice of daily Infection
monitoring of infection control Control
practice like hand hygiene and Committee,
personal protection. Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
38 D8.3 Antibiotic Policy is implemented at Infection
the [Link] hospital has Control
documented Anti Committee,
biotic policy and doctors are aware of Infection
it. Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
39 D8.4 Hospital staff have been immunized Infection
against Control
Hepatitis B Committee,
Infection
Control Nurse,
Superintendent
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, Asst.
Superintendent
and Facility
Level Quality
Manager
40 D8.5 Regular Medical check- ups of food Infection
handlers and housekeeping staff is Control
done. Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Hospital Acquired Infection Surveillance
41 D9.1 Regular microbiological Infection
surveillance of Critical areas like OT, Control
Labour Committee,
room, ICU, SNCU etc. are done Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
42 D9.2 Hospital measures Infection
Surgical Site Infection Rates. Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
43 D9.3 Hospital measures Device Related Infection
HAI rates. Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
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44 D9.4 Hospital measures Blood Related and Infection

Respiratory Tract HAI Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
45 D9.5 Hospital takes Corrective Action on Infection
occurrence of HAIs Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
Environment Control
46 D10.1 Positive pressure is maintained in Infection
OT Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
47 D10.2 Maintenance of air exchanges in OT Infection
and ICU is done. Air conditioner is Control
available Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
48 D10.3 Zoning of OT in protective, clean, Infection
sterile and disposal zones is done Control
Committee,
Infection
Control Nurse,
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Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
49 D10.4 OT and Labour room are carbolized Infection
daily Control
Committee,
Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager
50 D10.5 General and patient traffic are Infection
segregated in Hospitals Control
There is no criss cross between Committee,
general and patient traffic. Infection
Control Nurse,
Superintendent
, Asst.
Superintendent
and Facility
Level Quality
Manager

3. Records:
Sl. No. Name of Records
01 Stock Record of PPE
02 Autoclave register including signal lock
03 Spill Management Training register
04 Infection Control Committee formation notice and register
05 Infection control meeting register with Infection Control Nurse
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06 Medical Check up of staff Register

07 Swab Culture report
08 Hospital Acquired Infection record
09 Fumigation record