Guidelines for INFECTION CONTROL POLICY - Safdarjung Hospital

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ANNEXURE-I (PERFORMA)RECORD OF SHARPS/NEEDLE STICK INJURY/BLOOD, BODY FLUID EXPOSUREName of HCW: Age: Sex : M/FDepartment: Category of HCW: Regd.no. :HISTORY OF INJURY:Date of InjuryDate of reporting to casualty:How the injury was sustained (while performing which procedure)_______________________________________________________________________________Nature and source of injury : Needle prick/ Sharp cut/Laceration/Splash of FluidsHepatitis B Immunization status of HCW & source :Exposed HCWVaccinated – Yes/No:Incompletely vaccinated 1 :Unvaccinated:Previous H/O infection with HB 2SourceUnknown/unavailable for testingUnknown/but available for testingKnown HBsAg- PositiveKnown HBsAg-NegativeHIV status of ‘Source’ : Negative/Positive/UnknownAction taken in Casualty :1. Help.B vaccination initiated : Yes/No.2. HBIG : Yes/No If yes, indication:3. TT: 4. Anti Retro Treatment 5. Any otherInvestigation advised to HCW in Casualty :Haemogram, LFT, KFT, HBsAg, HIV(if consent is given).Refer to ART clinic, R.no.557 for all above investigations and further follow-up.Investigation of source patient, if available:HIVHBsAGRemarks if any.Signatue of CMO/Nodal Officer on duty (Casualty)1. Received only 1 or 2 doses of Hep.B vaccine2. Persons who have previously been infected with HB are immune to reinfection and donot require postexposure prophylaxisDept. of Medicine & Dept. of Hosp. Waste Management, SJH.38
ANNEXURE-IIRECOMMENDED POSTEXPOSURE PROPHYLAXIS FOR EXPOSURE TO HEPATITIS B VIRUSVaccination TREATMENT TREATMENT TREATMENTstatus of exposedworkersSource Source Source 2Hbs Ag Positive HBsAg Unknown or notnegativeavailable fortesting1. Unvaccinated HBIG x 1 and Initiate HB Initiate HBinitiate HB vaccine vaccine vaccineseriesseries2. Previouslyvaccinated• Serum anti-body No treatment No treatment No treatmenttitre known > bodymiu• Serum anti-body HBIG + 1 dose of No treatment 1 dose of HBtitre unknown or Hep.B vaccine< 10 miu3. Incomplete HBIG + Initiate Initiatevaccination 1 vaccination vaccination vaccination1Received only 1 or 2 doses of Hepatitis B vaccine2If source High risk treat as HbsAG positive.* Persons who wave previously been infected with HBV are immune to reinfection and donot require postexposure prophylaxis* HBsAg-Hepatitis B surface antigen* HBIG- Hepatitis B immune globulin; dose 0.06 ml/kg intramuscularly.RECOMMENDED POSTEXPOSURE PROPHYLAXIS FOR EXPOSURE TO HIV(Emergency dose to be given in Casualty)- Tablet Zidovudine 300mg + Lamivudine 150 mg.(Duovir) 1 Tab. BD+- Tablet. Indinavir 800mg. 1 Tab.BDPlease see attached annexure III and copy of NACO Guildelines for Post ExposureProphylaxis for Occupational Exposure(PEP) to HIV/AIDS(Annexure IV)Dep. of Medicine & Dept. of Hosp. Waste Management, SJH39
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 and 30: MERCURY SPILL MANAGEMENT :If accide
Page 31 and 32: FUTURE PROPOSAL FOR DISPOSAL OF RAD
Page 33 and 34: Minimization (ofwaste)MonitoringOn-
Page 35 and 36: PERFORMA OF BIOMEDICAL WASTE MANAGE
Page 37: ANNEXURE-2PROTOCOL FOR MANAGEMENT O
Page 41: Step-II : Determine the HIV STATUS

Guidelines for INFECTION CONTROL POLICY - Safdarjung Hospital

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