Infection Prevention and Control Standard

Operating Procedure(SOP)

Rumbek State Hospital

Fisseha Eshete Woldeyes

RN,BSC and MPH

July 2015

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Contents Introduction .................................................................................................................................................. 4

Current problem ....................................................................................................................................... 4

Purpose: ........................................................................................................................................................ 5

Objectives of the infection prevention and control SOP: ............................................................................. 5

Scope: ............................................................................................................................................................ 5

Responsibilities: ............................................................................................................................................ 6

Formation of Hospital infection control committee (HICC) ...................................................................... 6

Role and responsibility of the Hospital infection control committee (HICC)............................................ 6

Role and responsibility of Management staff: .......................................................................................... 6

Role and responsibility Support Staff (cleaners and Admin Staffs of the Hospital) ................................. 6

Role and responsibility of technical Staff .................................................................................................. 7

Definitions ..................................................................................................................................................... 7

Segregation of wastes ................................................................................................................................... 9

Collection Treatment and Disposal of Various Categories of Waste in the Hospital ............................... 9

Personnel Safety and Universal Precautions .............................................................................................. 10

Universal Precaution Instruction ................................................................................................................ 11

................................................................................................................................................................ 11

Protocols for Gloves ................................................................................................................................ 12

Safe Handling of Sharps .......................................................................................................................... 12

Protocols for Masks ................................................................................................................................ 12

Infection prevention program within a hospital: ........................................................................................ 13

Infection prevention Checklist to assesses departments and units ....................................................... 15

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Acronyms

HICC: Hospital infection control committee

IP: Infection prevention

HCW: Hospital Health Care Waste

HCWM: Hospital Health Care Waste Management

PPE: personal protective Equipment’s

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Introduction

The main purpose of infection prevention (IP) is to demonstrate a hospital’s commitment to the

Well-being of patients and staff, this commitment demonstrates the desire to provide quality

standard of care and cleanliness within the clinical setting, assuring that every patient and staff

Member within hospital is afforded his/her right to a clean and safe environment.

A hospital that adheres to standards of infection prevention is assured of protecting the right of a

patient to a clean environment, especially when one is immuno-compromised. Moreover,

Hospitals must ensure that the safety of employees, patients, and visitors is upheld by preventing

acquisition and transmission of infections. With high standards for infection prevention, a health

system is able to promote high standard for patient care.

Health-care waste should be considered as a reservoir of pathogenic microorganisms, which can

cause contamination and give rise to infection. If waste is inadequately managed, these micro

organisms can be transmitted by direct contact, in the air, or by a variety of vectors. Infectious

waste contributes in this way to the risk of nosocomial infections, putting the health of hospital

personnel, and patients, at risk.

Current problem

The current experience of Rumbek State hospital is to a high risk of infection for both patient,

patient families, and hospital staff alike. The essential problems that exist include:

1. Lack of consistent running water for use in patient care and hospital sanitation,

2. Lack of infection prevention protective materials

3. Lack of deep pit for sharp waste disposal

4. Improper Hospital waste management

5. Lack of surveillance and monitoring system for infections.

Why haven’t the hospitals implemented infection prevention programs? The answers to this

question are the same for most healthcare facilities and are as follows:

Lack of management commitment,

“Not My Job” attitude among staff,

No formal leadership,

Lack of funding for supplies and other resources,

Lack of labor resources,

No training,

Lack of motivation

Poor understanding of benefits of IP.

Overcoming these barriers to implementation is essential

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Purpose:

To provide safety for patient and employee within the hospital environment through an infection

Control program.

Objectives of the infection prevention and control SOP:

To develop procedures and standards for cleanliness, sanitation and asepsis in the

hospital.

To interpret, uphold and implement the hospital infection control policies and procedures

in specific situations.

To review and analyze infections, those occur, in order to take corrective steps.

To develop preventive measures designed to control, prevent or minimize the risk of

nosocomial infections.

To develop a mechanism to supervise infection control measures in all phases of hospital

Activities

Scope:

Health care risk waste generated from health care facilities can pose risks to patients, health care

workers and visitors and / or the environment when handled, packaged, and/or disposed of

inappropriately. Standards to control and minimize these risks

Current practice of waste Management in Rumbek Hospital

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Responsibilities:

Formation of Hospital infection control committee (HICC)

Members of HICC committee

Head Nurse of the hospital(Chairman)

Nurse services specialist(IMC)( secretory)

Laboratory Head of the hospital

Pharmacy Head of the hospital

Bio medical waste technician (IMC)

Cleaners Head of the hospital

Role and responsibility of the Hospital infection control committee (HICC)

The HICC will supervise the implementation of the hospital infection control programme.

To ensure the proper conduct of sterilization and disinfection practices

Ensure that the Bi Medical waste management is being carried out.

Conduct Internal Surveillance of Hospital acquired infections.

Develop and implement preventive and corrective Programmes in specific situations

where infection hazards exist.

Advice the Medical Officers on matters related to the proper use of antibiotics

Review and update hospital infection control procedures from time to time.

Help provide employee training regarding matters related to hospital acquired infections.

Role and responsibility of Management staff:

Obtain and be familiar with national waste management policies and guidelines.

Ensure staff is trained on the infection prevention proper procedures.

Budget for adequate supply of HCWM products and activities.

Advocate for staff health and safety.

Follow waste management policies and procedures.

Practice safe operating procedures and wear appropriate personal protective Equipments

Follow color-coded waste segregation system.

Notify Support Staff when Health Care waste (HCW) containers are ¾ full for collection

and replacement.

Know color-coding system and use it correctly.

Role and responsibility Support Staff (cleaners and Admin Staffs of the

Hospital)

Place appropriate Health Care waste (HCW) containers at designated locations.

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Know color-coding system and use it correctly.

Practice safe operating procedures

Wear appropriate personal protective Equipment’s (PPE).

Collect correctly filled (no more than ¾) Health Care Wastes (HCW) containers.

Ensure a clean and orderly environment at the facility.

Supply needs, report stock outs.

Role and responsibility of technical Staff

Follow waste management policies and procedures.

Practice safe operating procedures and wear appropriate PPE.

Ensure adequate supply of HCWM products.

Follow color-coded waste segregation system.

Notify Support Staff when HCW containers are no more than ¾ full.

Definitions

Anatomical Waste: (also often referred to as pathological waste) consists of tissues, organs,

body parts, blood and bodily fluids from patients, human fetuses and animal carcasses, but

excludes teeth and hair.

Biohazard Symbol: This symbol is required on the side of all infectious and sharp

waste containers cleaning removal of contamination from an item to the extent necessary for the

further processing or for the intended use.

Clinical Staff: This includes all staff involved in and related to the observation and treatment of

actual patients rather than theoretical or laboratory studies.

National Health Care Waste Management Standard Operating Procedures

Chemical Waste: consists of discarded solid, liquid, and gaseous products that contain

dangerous or polluting chemicals, for example from diagnostic and experimental work and from

cleaning, housekeeping and disinfecting procedures.

Chemical waste from health care may be hazardous or nonhazardous. Example: pharmaceutical

waste, cytotoxic / genotoxic waste and radioactive waste.

Color-coding System: A system for relating the contents of packaging / containers by using

Different colors

Containerization Often used interchangeably with the word packaging. Refers to the materials

used to wrap and safely contain the relevant waste streams to prevent exposure during transport

till final disposal.

Examples: rigid plastic containers, flexible plastic bags, lined fibre-board box sets, etc.

Contaminated: State of having been actually or potentially in contact with a contaminant.

Examples: pollutant, radioactivity, chemical, blood, etc.

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Decontamination: Process or mode of action to reduce contamination to a safe level

Decontamination Area: Area of a health care facility designated for collection, retention, and

cleaning of soiled and/or contaminated items.

Hazard Intrinsic: potential property or ability of any agent, equipment, material, or Process to

cause harm

Health Care Risk Waste: All waste generated by health care establishments, research facilities,

and laboratories that could pose a health risk to health workers, the public, or the environment.

Identification: The process of visually recognizing relevant health care waste streams at the

Point of generation.

Infectious Waste: This is waste that may have been in contact with human blood or bodily fluid

and may have the ability to spread disease.

Examples: gauze, cotton, dressings, laboratory cultures, IV fluid lines, blood bags, gloves,

anatomical waste, surgical instruments and pharmaceutical waste.

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Segregation of wastes

Segregation is the process of separating different categories of waste at the point of generation,

keeping them isolated from each other for specific reasons and in suitably designed labeled and

color-coded packaging for visual identification

Collection Treatment and Disposal of Various Categories of Waste in the Hospital

Segregation, Treatment and Disposal Options

Color

Coding

Type of Container Waste Category Treatment and Disposal

Options

Yellow Plastic bucket / Bag Organic wastes (Fluid,

Water, Urine, Blood,

Placenta, Vomit)

Deep Burial

Blue Plastic bucket /Bag

Plastic, Syringe, Needle

cap, papers cottons etc….

Incineration

White/

Translucent

Puncture Proof

Translucent

Container

Sharps Waste

(Needles, Lancets, Broken

glass)

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Personnel Safety and Universal Precautions

In a hospital setting personnel protection should be considered as the utmost priority. The

principle of universal precautions is to provide a barrier between the HCW and the patient’s

body substance when they have to come in close proximity. Blood, cerebrospinal fluid, synovial

fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, salival in dental procedures,

semen, vaginal secretions, any body fluid that is visibly contaminated with blood; any unfixed

tissue or organ from a human ; HIV containing culture medium or other solutions; blood or other

tissues infected with HIV or hepatitis B, C or non A non B are considered as the source of

potential infection ,for which following Precautions and instructions should be followed:

Barrier Use of Barrier

Hand washing Hand washing Before and after patient contact after using gloves,

immediately after contact with blood and care workers who have

exudative lesions or weeping dermatitis should refrain from all

patient care activities that involve direct contact and from

handling patient care equipment.

Masks and other protective

equipment such as face

shields and goggles

When one is likely to be splashed in the face with infective

material, which may lead to contamination of the eyes, nose or

mouth.

Gloves When direct contact with blood and body fluids, mucous

membranes non-intact skin surfaces or infectious material is

anticipated when performing vascular access or other invasive

procedures and when handling specimens, cultures, or tissues that

are visibly contaminated with blood or other infectious material. .

Hands must be washed each time gloves are removed.

Those with non intact skin must wear gloves when indirect

handling of infectious material is a possibility.

Protective clothing Gowns,

lab coats, caps, hoods,

shoe

covers, boots, or other such

paraphernalia.

When the HCW is likely to be soiled by the splattering of

infectious material.

These must be removed and discarded properly immediately after

use.

Handling Needles and

small

sharps

Never recap or bend the needles unless by using an instrument or

by no touch technique.

Dispose of used needles and disposable small sharps in puncture

proof containers that are located as close to the area of use as

possible.

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Universal Precaution Instruction

Blood, body fluids, synovial fluids and tissue of all patients are considered potentially infectious

and therefore should be handled accordingly. This is also called as standard precautions.

Wash hands before and after all patient/specimen contact

Handle blood of all patients as potentially infectious

Always use gloves for contact with blood/body fluids

Place used syringes in puncture proof containers

Do not recap or manipulate needles

Wear protective eye-wear and masks if splash/splatter of blood/body fluids is possible

e.g. During oral surgery, bronchoscopy etc.

Wear gowns and aprons when splash with blood/body fluids is expected

Lab staff should not use mouth pipette

Wear masks while examination and Rx of TB patients

When there is any breach in skin, seal it with strongly water proof adhesive tape

Pic:1 Hand Hygiene techniques

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Protocols for Gloves

Use of Disposable gloves to be ensured

In high risk cases; double gloving should be done; routine cases single

Gloves should be changed if duration of procedure/operation is > 3 hours

Any pair of gloves can be used for total time of 3 hours

Between patients; gloved hands should be disinfected for at least 30 seconds

Surgical hygienic hand (w) should be done before and after use of gloves

Check gloves for gross defects before putting on Cover cuts with waterproof dressing

before gloving

Discard gloves immediately on suspicion of puncture Protocols for Masks Masks are

mandatory for infections patients’ esp. airborne infection

Ideally masks should be disposable; if not cotton masks can be used

Masks should fit properly and cover both mouth and nose.

Masks should be changed after every proc/surgery lasting > 20 minutes

Cotton masks should be disinfected with liquid bleach before washing and reuse7 Safe

Handling Of Sharps

Pass syringes and needles in a tray, cut it with electric /manual needle cutlers after

Safe Handling of Sharps

Pass syringes and needles in a tray, cut it with electric /manual needle cutlers after use

Put needle and syringes in a puncture proof white container, containing 2% hypochlorite

solution

Remove cap of needle near the site of use

Pick up open needle from tray/drum with forceps

Destroy syringes by burning their tips/cutters not available

Never pass syringe and needle on directly to next person

Do not bent/or break used needle with hands

Never test the fineness of the needle’s tip before use with bare or gloved hand

Never pick up open needle by hand, and never dispose it off by breaking it with

hammer/stone

Always dispose of your own sharps, into a Sharp pit

During exposure-prone procedure, the risk of injury should be minimized by ensuring

that the operator has the best possible visibility, e.g. by positioning the patient, adjusting

good light source and controlling bleeding

Protocols for Masks

Masks are mandatory for infections patients’ esp. airborne infection deally masks should be

disposable; if not cotton masks can be used

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Masks should fit properly and cover both mouth and nose.

Masks should be changed after every proc/surgery lasting > 20 minutes Cotton masks should be

disinfected with liquid bleach before washing and reuse

Infection prevention program within a hospital:

1. Access to clean running water in all patient areas: This will ensure the feasibility and

maintenance of infection prevention in Rumbek hospital. It will also assist with

preventing environmental threats such as cholera outbreaks that can potentially occur

within a hospital lacking a clean water source.

2. Ward Sinks: It is important that each ward within a hospital have a properly functioning

sink with plumbing at the minimum, there should be a sink in each ward

3. Items for clinical care: The following items must be readily available for use by every

hospital staff member. They include:

A) Required for each sink site:

• Liquid soap

• Paper towels

B) Available to all hospital staff per each patient contact:

• Latex gloves

• Personal protective equipment (robes, gowns, protective eyewear, masks, etc.)

• Surgical gloves

C) Soaps and supplies for staff hand-hygiene:

• Alcohol based hand-rub

• Soap

• Paper towels (or hand towels)

• Rubbing alcohol

4. Disinfection and cleaning of medical instruments: In the absence of an autoclave, the

following items must be available and functioning to ensure proper cleaning of the

hospital’s medical instruments:

0.5% chlorine solution (diluted bleach),

Pressure cooker (ideal method),

Commercial boiler or steamer (an alternative method)

High temperature oven for heat tolerant items.

5. Environmental cleanliness: To ensure proper cleanliness of the hospital facility and

associated supplies, the following items should be purchased, installed, and utilized

following a regular schedule:

Laundry washers,

Laundry dryers,

Detergent with bleach,

Disinfectant sprays,

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Mops and dustpans, and

Disinfectants and cleaning solutions.

6. Waste management: Ensuring the safe and effective disposal of all hospital waste is

extremely important and should be handled with great care. Assigning hospital staff

accordingly to ensure disposal occurs regularly is essential.

The following items should be purchased by the hospital to ensure that waste is disposed

of properly.

Small plastic garbage bin: Each clinical area should have its own bin labeled (in

the local language) for disposal of hazardous/infectious waste.

Large garbage bin: At least two for each clinical site should be used for disposing

of all other waste (labeled in the local language as non infectious waste).

Plastic garbage bags: Used to properly contain all disposed waste.

Sterilization of medical instruments: If a pressure cooker is not present, medical

instruments, including surgical gloves, should be washed and then steamed using

a commercial rice cooker.

4) Isolating infectious patients: Designated patient areas for infectious patients

should be assigned to limit the possibility of transmission of infectious agents.

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Infection prevention Checklist to assesses departments and units

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