Infection Control DR - Rammish
Infection Control DR - Rammish
Infection Control DR - Rammish
DR.RAMMISH.R,
CHIEF CIVIL SURGEON,
DISTRICT QUALITY NODAL OFFICER,
NATIONAL ASSESSOR,
O/O JDHS, RAMNAD
Assessment of Infection
Control Practices
AREA OF CONCERN F
Standards: 6
Measurable Elements: 21
Infection Control
Program
ME F1.1
Infection
The facility has functional infection control
Control General/ Administration
committee.
Committee
ME F1.5
Infection
The facility has established procedures for regular
Control All Departments
monitoring of infection control practices.
Monitoring
Policy level in
ME F1.6 The facility has defined and established antibiotic
Antibiotic
General/Admin.
Policy policy. Practices all patient
care departments
Standard The facility has infection control Program and procedures in place
F1
for prevention and measurement of hospital associated infection.
Review Records –
Attendance & Minutes of meetings of ICC to known
frequency and agenda
Records of microbial surveillance and HAI
Immunization and Medical Checkup Records of Staff
Infection control practice monitoring Records
Documented Antibiotic Policy & Records of
Antimicrobial Resistance if Any
CRITERIA FOR SURVEILLANCE OF HAI
Standard The facility has defined and Implemented procedures for ensuring
F2
ME-3 hand hygiene practices and antisepsis
Check for
Washbasins are available at the at/nearby service areas. Staff do not
have to walk much for hand washing facility
Running water is available at the wash basin
Availability of elbow operated taps(OT,LR, SNCU)
Soap is available with washbasin
A poster depicting steps of hand washing and when to hand wash is
displayed at hand washing area
Alcohol base hand rub is available for the staff
Availability of antiseptics Betadine, Sevlon etc.
Standard The facility has defined and Implemented procedures for ensuring
F2 hand hygiene practices and antisepsis
Ask Staff
Whether supply of water ,soap & Hand rub is regular and they having
no difficulty in availing hand washing facilities
Ask any staff to demonstrate the Six Steps of Hand washing
Ask staff about when they hand wash
Ask staff about practices of antisepsis and Asepsis eg. Cleaning of skin
with antiseptic before procedure like insertion of cannula or catheter
Area commonly missed during Hand washing
Standard The facility ensures standard practices and materials for Personal
F3
protection.
(ME:2)
ME F3.1
The facility ensures adequate personal protection
Personal
Protection
All Departments
Equipment as per requirements
Equipment
ME F3.2
Personal The facility staff adheres to standard personal
Protection All Departments
Practices protection practices.
The facility ensures standard practices and materials for Personal
Standard
F3 protection.
Check for
Availability of personal protective equipment like Gloves,
Gown, Mask, head cap, shoes , lab coat etc.
Check staff is using these PPE when required
Check there is no reuse of disposable items happening
Check whether
Sterilization records being maintained.
Autoclaving Indicators are beings used.
Where sterilized items are kept?
How linen is collected from wards and whether some processing of
infected linen done on patient care areas.
Autoclave
15lbs/In2 Chemical soak
pressure in Chemical
Boiling Soak in
121ºC, Glutaraldehyde Lid on 20
(2%) for 10-24 Glutaraldehyde
(250ºF) minutes
hrs, Rinse with (2%) for 20
20 min/30
sterile water min. Rinse with
min
Normal saline
Dr.Rammish
FLASH STERILIZATION
Dr.Rammish
ETHYLENE OXIDE (ETO)
Dr.Rammish
GLUTERALDEHYDE (2%)
Dr.Rammish
GAMMA IRRADIATION
Dr.Rammish
VALIDATION OF STERILIZATION
CHEMICAL INDICATORS
Signoloc tapes
Bowie-Dick tapes
BIOLOGICAL INDICATORS
Spore strips/vials impregnated with spores of bacillus
steriothermophillus.
Strips are inserted in the cold compartment of autoclave, which is the
lowest part of the chamber.
TRACEABILITY OF STERILIZED PACK
BG010210
Date and time of sterilization
Date and time of expiry
ME F5.2
Disinfectant The facility ensures availability of standard materials for cleaning All Departments
Materials
and disinfection of patient care areas.
ME F5.3 The facility ensures standard practices are followed for the All departments with
Environment & Special focus on
Cleaning cleaning and disinfection of patient care areas.
High Risk Areas
Standard Physical layout and environmental control of the patient care areas
F5 ensures infection prevention
ME F5.5
The facility ensures segregation infectious patients All patient Care Area
Isolation
ME F5.6 The facility ensures air quality of high risk area SNCU, ICU,OT Unit,
Air Quality Lab & PP Unit
Standard Physical layout and environmental control of the patient care areas
F5 ensures infection prevention
Check whether
Check layout of department and organization of processes ensures
unidirectional flow and no criss- cross between sterile and infected
items
Check for availability of cleaning solutions/Disinfectants used for
cleaning purpose
Observe infectious patients are not admitted with other patients
There is provision of equipment for maintain positive/negative
pressure as per requirement
External foot wears are not allowed in critical areas like Labour room ,
OT & SNCU
Standard Physical layout and environmental control of the patient care areas
F5 ensures infection prevention
ME F6.2
Sharps The facility ensures management of sharps as per guidelines All Departments
Management
ME F6.3
The facility ensures transportation and disposal of waste as
Transportation General
and disposal per guidelines administration
Bio Medical Waste Management
Rules 2016
(Amendment 2018 and 2019)
YELLOW CATEGORY: Soiled waste
ED
P I R
EX
RED CATEGORY: Contaminated recyclable plastics
BLUE CATEGORY: Glass sharps
WHITE Category: Metal sharps