Hic 1 & 2

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Policy

 There should be a documented infection control programme which aims at preventing


& reducing the risk of healthcare associated infection. This document should identify
high risk areas & procedures
 There should be a multi-disciplinary Hospital Infection Control Committee consist of
MS, Deputy MS, Infection control doctor, Infection control nurses, Microbiologist,
HODs of Paediatric Oncology, Surgical Oncology, Medical Oncology,
Anesthesiology, Transfusion Medicine, Clinical Lab, Dietician, Biomedical Engineer,
Chief Nursing Officer, HOD Engineering Division, Controller of Finance, Purchase
Officer, & Nurse In- charge of OT, CSSD, CVAD , laundry & housekeeping, NABH
Coordinator.
 There should be a hospital infection control team consisting of MS, infection control
doctor, dedicated infection control nurses and microbiologist for day to day
functioning of infection control program.
 The infection control team should be responsible for surveillance process, detect
outbreaks, participate in audit activity, day to day infection prevention & control
within the hospital.
 There should be three designated and qualified infection control nurses for this
activity. The surveillance system should be based on WHO criteria & it should define
the frequency & mode of surveillance.
 The equipment cleaning & sterilization practices in each area should be mentioned.
 As a part of the infection control programme, the organization should develop a
system for monitoring the drug susceptibility & accordingly develop its antibiotic
policy. This antibiotic policy must be reviewed once in a year by the committee.
 The committee should also control the linen & laundry activities, kitchen sanitation,
mortuary & engineering work to prevent infection.
 The infection control manual must be updated once in a year based on its trends &
outcomes of the audit processes.

Responsibility
MS/ HIC committee/ HIC team

Procedure
 Infection control program should be documented in the form of Hospital Infection
control manual. It is the responsibility the HIC committee to review & update the
manual once in a year/ or whenever required
 The manual should list all the high risk areas & procedures
 The infection control committee should be formulated & all the committee members
must meet once in a month to discuss the issues and take corrective & preventive
action.
 The hospital infection control team should collect the necessary data required for the
HIC committee and implement the decisions/ corrective & preventive action taken by
the committee
 The designated & qualified infection control nurses should be responsible for all the
HIC activities.
 The frequency & mode of surveillance in each area should be mentioned in the HIC
manual.
 Equipment cleaning & sterilization practices of ward, OT, ICU & CSSD should be
mentioned in this manual.(Refer HIC/ CSSD manual)
 The microbiologist should develop an antibiogram & based on that the antibiotic
policy needs to be developed by experts in various clinical speciality. The committee
can refer WHO reference document “Global strategy for containment of antimicrobial
resistance”.
 The linen & laundry manual should clearly state washing protocols for different
categories of linen including blankets. (Refer Linen & Laundry services manual).
 The hospital adheres to kitchen sanitation and food-handling issues
 Issues such as air conditioning plant & equipment maintenance, cleaning of AC ducts,
AHUs, replacement of filters, replacement / repair of plumbing, water supply sources
& testing of water quality must be documented in the maintenance division.
 The organization adheres to safe injection and infusion practices

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