Guidelines for INFECTION CONTROL POLICY - Safdarjung Hospital

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8. MONITORING AND SUPERVISIONA Monitoring Team which includes Nodal officers, Nursing Sisters, Technicians and Sanitationstaff is responsible for supervision of segregation practices in the specific area, allocated tothem. The Nursing Sister in charge of the area is expected is take a round of the area everydayand record the findings in the observations Daily observation Performa attached herewith(Annexure II). This Performa is displayed/available in each clinical area. The DNS of each zoneensure proper compliance of Daily monitoring of waste management practices in the clinicalareas by the ANS/Nursing Sister.The technicians of Laboratories and O Ts will be responsible, for the are of their workAny adversity should be reported to are Nodal Officer, who will take appropriate action and ifrequired intimate the same to the higher authorities. The Area Nodal officers will take periodicround of their area, record using ‘Monitoring Performa’ (Annexure ‘III’) and address any issues.They may also take appropriate action, and inform the respective HODs, and HWM Committee.All the Sanitary Inspectors as well as Health Inspectors will be responsible for the wastemanagement practices in the area already allocated to them for supervision of sanitation.Regular rounds are taken by CMO, Nodal Officer of HWM. The observation reports of thefindings are sent to the respective HOD for remedial action through Medical Superintended.Surprise rounds are also being taken by Addl. MS & MS from time to time in the patient careareas. The random checking of the waste receipts, bags for segregation of waste are beingdone at the waste storage site, as a part of audit and any deficiencies / observation are sentto the HOD for remedial action.9. FUTURE PROPOSALS :BACK-UP EQUIPMENT FOR TREATMENT OF WASTE:- Backup for Microwave and shredder to be procured..- Alternative options of ‘Encapsulation’/outsourcing for disposal of metallic sharps, soas to discontinue making any more ‘pits’ or outsourcing for disposal of metallicsharps- Autoclave/Hydroclave- Installation of ETP- ‘OUTSOURCING OF WASTE’‘SHARPS INJURY’ (NEEDLE STICK INJURY)A specific protocol for prevention of risks of Hepatitis B to HCW of our hospital due to Sharpsinjury (NSI) is being worked out.PATIENT AND ATTENDANT EDUCATION AND AWARENESS :At the time of admission to hospital a briefing regarding the segregation policy of the hospitalshould be given by the Staff nurses and the same is reinforced everyday. Al leaflet of ’Do’s& Don’ts’ will be prepared and given to all attendants of patients at the time of admission.PUBLIC AWARENESS/IEC ACTIVITIES :In order to involve the public and seek co-operation, it is essential to generate awareness byall possible means. This can be achieved through IEC activities. This would help to keep thehospital clean. Public redress system of the hospital can also be used to propagate the samemessage.Posters in the working clinical areas to serve as reminders of segregation protocols will beprepared, and distributed in the whole to be displayed at the prominent points.30
FUTURE PROPOSAL FOR DISPOSAL OF RADIOSOTOPE/NUCLEAR WASTE• The immediate plan is to construct two separate tanks for liquid radioactive wastematerial. First one is filled and then sealed for a period of 10 half life of the radioactivematerial put into it. During this period the radio active waste is stored is second tank.By the second tank becomes full, the first completes 10 half lives and comes to thelevel of background radioactivity. This waste is discarded safely in sewer system.This becomes a continuous process.COMPOSTING OF KITCHEN AND HORTICULTURE WASTE :It is proposed to generate manure by composting waste from kitchen, horticulture and disinfecteddiscarded blood. Four pits for the same can be made in identified areas. For fifteen days thewaste can be put in one pit, in the second pit for the next 15 days and so on. It Compostinggenerally takes 45-60 days, and the manure is ready.BIOFUEL, BIOGAS (BIO-CNG, BIO-PNG) and manure production from General wet/kitchenwaste, using BARC developed Technology may also be considered if feasible.As & when a new, heavy duty shredding machine is produced by the hospital or outsourcingis decided, instead of four only 2 blue plastic bags will be used for segregation of plasticwaste, one for infectious plastic and 2nd for non-infectious plastic. The current shredders donot take up mixed plastic items for shredding.10. ABBREVIATIONS AND GLOSSARY OF TERMS:ANSAssistant Nursing SuperintendentAPCDAir Pollution Control DeviceBMWBio-medical WasteCat.CategoryCMEContinuing Medical EducationCMOChief Medical BoardCPCBCentral Pollution Control BoardDMSDeputy Medical SuperintendentDNSDeputy Nursing SuperintendentDPCCDelhi Pollution Control CommitteeHCF(s)Health-care facility (facilities)HCWHealth-Care Waste. HCW is made up of HCRW and HCGW.HCWHealth Care WorkerHCWMHealth-care Waste ManagementHIVHuman Immunodeficiency VirusHODHead of the DepartmentHWMHospital Waste managementMSMedical superintendentOPDsOut Patient DepartmentPPEPersonal Protective EquipmentRNTCPRevised National Tuberculosis Control ProgrammeAir pollution The presence of a material or substance in the air which may beharmful to either the natural or human environment, which includesnay material present in sufficient concentrations for a sufficienttime, and a number of circumstance, to interfere significantly withthe comfort, health or welfare of persons or with the full use andenjoyment of property.31
Page 2 and 3: CONTRIBUTORSCreated by : Dr. Rajni
Page 5 and 6: HOSPITAL INFECTION CONTROL TEAM (HI
Page 7 and 8: 12. Training and education of HCW C
Page 9 and 10: Schedule may be changed to increase
Page 11 and 12: Semi-critical instruments /equipmen
Page 13 and 14: • The isolation of the patient wo
Page 15 and 16: Microbiological StudyMicrobiologica
Page 17 and 18: Annexure-1Policy on‘Hospital Wast
Page 19 and 20: CONTENTSTOPIC SUB-TOPIC PAGE NO.1.
Page 21 and 22: HOSPITAL WASTE MANAGEMENT COMMITTEE
Page 23 and 24: Color-coded bags & Category wise Tr
Page 25 and 26: MAINTENANCE OF EQUIPMENTMaintenance
Page 27 and 28: • Labelled as with ‘Cytotoxic
Page 29: MERCURY SPILL MANAGEMENT :If accide
Page 33 and 34: Minimization (ofwaste)MonitoringOn-
Page 35 and 36: PERFORMA OF BIOMEDICAL WASTE MANAGE
Page 37 and 38: ANNEXURE-2PROTOCOL FOR MANAGEMENT O
Page 39 and 40: ANNEXURE-IIRECOMMENDED POSTEXPOSURE
Page 41: Step-II : Determine the HIV STATUS

Guidelines for INFECTION CONTROL POLICY - Safdarjung Hospital

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