Infection Control

Navaz Clement
Manager Housekeeping
Aravind Eye Care System

In order to provide better and safer hospital facilities for its patients and personnel, the Health Care Institution has to adopt a programme of infection control involving all sections of the Health Care Centre.

A satisfactory infection control programme requires the co-operation of all personnel involved with patients. Any break in technique or lapse in discipline on the part of one person can render the efforts of a number of conscientious individuals ineffective. It is only through co-operative efforts of every member of the staff that nonsocomial infections can be prevented.

Nonsocomial infections are defined as infections acquired during or as a result of hospitalization. The patients neither have these infections nor are incubating these infections on admission. Generally a patient who develops an infection after 48 hours of hospitalization is considered to have nosocomial infection. However, nonsocomial infection may not manifest as disease immediately and may manifest as disease only after discharge.

Objectives of an infection control programme:

  1. To develop written policies and procedures for standards of cleanliness, sanitation and asepsis in the hospital
  2. To interpret uphold and implement the hospital infection control policies and procedures in specific situations.
  3. To provide surveillance for nonsocomial infections
  4. To review and analyse data on infections that occur, in order to take corrective steps
  5. To develop a mechanism to supervise infection control measures in all phases of hospital activities
  6. To ensure continuing education of employees on infection control aspects
Several surveys of infections in developed countries have shown that occupationally acquired infections are greatest among some categories of health care workers (HCW) such as medical and technical staff, attenders and cleaners, while such risk is low among secretarial staff. This is essentially because of their coming into contact with pathogens or infected specimens.

The most effective method of preventing occupationally acquired infections is adopting safe working practices. Based on the risk assessment of the staff, specific protection may be recommended. The assessment takes into account the pathogens they may be exposed to, the local epidemiology of the disease, the nature of specimens/infective material handled the frequency of exposure/contact with potentially infected material or patient. Staff considered to be at risk should be offered specific protection, including immunization.

Safety education must be given at the time of employment. A video on universal precautions should be screened and the employee should secure a certain score on a questionnaire that follows. All staff should be informed of the need to report exposure to blood or potentially infectious body fluids to the duty doctor without any delay. Other health and safety education should also be carried out as appropriate.

Rules of universal precautions:
  • Consider all patients potentially infectious
  • Assume all blood and body fluids and tissue contaminated with blood borne pathogens
  • Assume all unsterile needles and other sharps are similarly contaminated.
What does one need to do?
  1. Hand washing: Hands should be washed if contaminated with blood or body fluids and after removing the gloves.
  2. All HCWs should routinely use appropriate barrier precautions when exposure to blood or potentially infected body fluids is anticipated. These include:
    • Use of gloves for contact with blood, potentially infectious body fluids, mucous membranes or non-intact skin in ALL patients. Gloves should also be used for handling items or surfaces soiled with blood or body fluids and for performing venipuncture or other vascular access procedures. Gloves should be removed before leaving the patients bedside.
    • Masks and protective eyewear should be used for procedures likely to generate droplets of body fluids or blood that could lead to contamination of eyes, nose, or mouth.
    • Appropriate protective clothing such as gowns, aprons, surgical caps, and impervious shoes should be worn if there is a risk of exposure. The type and characteristics of the attire worn will depend on the task and degree of exposure anticipated. All protective clothing and equipment must be properly discarded or decontaminated before leaving the work area.
  3. Proper disposal of needles and sharps: Needles and sharps are the commonest mode of transmission of blood borne pathogens to HCWs. Precautions should be taken to prevent injuries by sharp instruments, especially hollow bore needles that have been used for venipuncture or other vascular access procedures.
    • Needles should not be recapped, bent or broken by hand. Disposal needles and other sharps should be disposed immediately after use into puncture resistant containers which should be located at the site of the procedure.
    • If a needle has to be removed from a syringe, use forceps or do it with utmost care.
    • Do not overfill a sharps container.
  4. Disinfection of instruments: Re-use instruments, tubings, etc. only after decontamination and sterilization. Do not touch the equipment with soiled gloves or gloves used for patient care. Surfaces of large equipment should be disinfected with 1:100 dilution of sodium hypochlorite or an approved disinfectant. Heavily soiled equipment may require additional cleaning with detergent and water. Gloves must be worn while cleaning the equipment
  5. Waste Disposal : Non plastic items soiled with blood, bloody drainage, or potentially infected material must be placed in the yellow biohazard plastic bags. Items that may tear the bag must not be put into the bag. Excreta, blood or body fluids must be emptied down the drain with adequate amount of water.
  6. Linen: Linen soiled with blood or potentially infectious body fluid must be soaked in Lysol for 60 minutes, placed in a leak proof bag and sent to the laundry.
  7. Spill clean up: Cover spills of blood or body fluids with Dakins solution or 1:10 to 1:100 dilution of freshly prepared sodium hypochlorite or household bleach for 10 minutes. Then mop dry. A second decontamination may be done if required. Was the area with detergent and water. Gloves must be worn during cleanup and decontamination procedures.
Disinfection and Sterilization:
Sterilization is defined as a process where all microbes are removed from a defined object, inclusive of bacterial endospores. Disinfection is a process where most microbes are removed from a defined object or surface, except bacterial endispores. Certain chemicals are capable of sterilizing an object if exposed for long periods of time, and serve as disinfectants at shorter exposure time. However, a common practice is to call all chemical agents as disinfectants a misnomer.

Disinfectants can be classified according to their ability to destroy these categories of microorganisms. The agent which destroys only vegetative bacteria is termed a low level disinfectant. If the agent is capable of rendering myco-bacteria non-viable it is termed as intermediate level disinfectant. It is a safe assumption that all the other categories of microbes which are classified more susceptible are also destroyed if efficacy against myco- bacteria can be demonstrated. High level disinfection is in other words sterilization wherein all microbial life is destroyed inclusive of endospores.

Housekeeping and Infection Control:
The following procedures need to be followed by the Housekeeping Department in order to maintain a zero percent infection rate in the hospital:
  1. The floor should be cleaned at least 4 times in 24 hours. Detergents and copious amount of water should be used during one cleaning. Lysol or any other equivalent disinfectant may be used to mop the floor for the remaining times.
  2. The walls are to be washed with a brush, using detergent and water once a week
  3. High dusting should be done once a week with a wet mop
  4. Fans and lights should be cleaned with soap and water once a month. This should be handled by the electrical department
  5. All work surfaces are to be disinfected by wiping with 7% Lysol and then cleaned with detergent and water twice a day.
  6. Cupboards, shelves, beds, lockers, IV stands, stools and other fixtures are to be cleaned with detergent and water once a week
  7. Curtains should be changed once a month or whenever soiled. These curtains are to be sent for regular laundering. In certain high risk areas such as the ICU and transplant units more frequent changes are required.
  8. Patients cot is to be cleaned every week with detergent and water. 7% Lysol is to be used when soiled with blood or body fluids. In the isolation ward, cleaning is to be done daily.
  9. Store rooms should be mopped once a day and high dusted once a week.
  10. The floor of bathrooms is to be cleaned with a broom and detergents once a day. For disinfection 7% Lysol can be used.
  11. Toilets are cleaned with a brush using a detergent twice a day. Disinfection may be done using 7% Lysol. A stain removing liquid can be used once a month to remove stains.
  12. Wash basins are to be cleaned with vim powder every morning and with the stain removing liquid once a month
  13. Regular AC maintenance is a must. The AC section should draw up a protocol for this.
Patient Linen:
  • Bed linen is to be changed once in 2 days and whenever soiled with blood and body fluids
  • Patients gown is to be changed every day and whenever soiled with blood and body fluids
  • Dry dirty linen is to be sent to the laundry for regular wash
  • Linen soiled with blood or body fluids and all linen used by patients diagnosed to have HIV, HBV, and MRSA is to be decontaminated in the ward by soaking in 7% Lysol for at least 1 hour and then sent to the laundry.
Rubber goods: Rubber goods are to be cleaned with soap and water, disinfected with 7% Lysol, dried in the sun, powdered, rolled and stored.

Thermometer solution: Separate thermometers are recommended in intensive care units, nurseries and transplant units. In areas where a common thermometer is used, it is disinfected between patients by immersing it in thermometer solution (containing alcohol) for 5 minutes. After disinfection, the thermometer is washed and kept dry or immersed in alcohol. Empty the water from the container when not in use, and keep it dry. The thermometer solution should be changed once in three days. The date of change of the thermometer solution should be written on n adhesive tape which is stuck to the tray.

Miscellaneous items: K basins, bed pans, urinals, etc. are to be cleaned with vim powder and water and disinfected with 7% Lysol.

Metal buckets are to be cleaned with vim powder every week. Dustbins are to be cleaned with detergent and water every morning and then with dettol solution.

Housekeeping in the Isolation Ward:

Before admission:
The admitting physician should inform the sister in charge of Isolation Ward at least one hour prior to admission, mentioning the diagnosis, sex and the general state of the patient.

Pre-requisites for Isolation:
  • A source of running water should be available at the entrance of each room to facilitate hand washing.
  • The mattress and pillow should have an impervious cover such as mackintosh so that it can easily be damp dusted.
  • Clean gowns should always be available
  • Separate urinals, bed pans and thermometers are to be used for each patient
  • A bin lined with appropriate colour coded plastic cover should be available in each room for disposal of medical waste.
  • Rooms should be isolated according to disease conditions and should be well lit.
Cleaning Procedure for Isolation Ward:
  1. Linen should be stripped from the bed taking care not to shake the linen during this action. The linen should then be soaked in 7% Lysol solution before being sent to the laundry
  2. All other articles like IV stands, and furniture should be cleaned with detergent and disinfected with 7% Lysol solution
  3. Walls should be cleaned with detergent and disinfected with 7% Lysol
  4. The bathrooms should be cleaned with detergent and disinfected with 7% Lysol
At Discharge (terminal disinfection):
  • Keep an ultra-violet light in the room facing each direction for half an hour in a 2 bedded room and 1 hour in a 4 bedded room
  • The pillows and mattress are to be cleaned with detergent , disinfected with 7% Lysol and dried in sunlight for 24 hours
  • Bed sheets, curtains, gowns and dusters must be removed, soaked in 7% Lysol for one hour and then sent to the laundry
  • After disinfection, wash the room, walls, windows, doors, bathrooms, sink and furniture with soap solution after doing thorough high dusting in that cubicle.
  • Soaked bed pan, urinal, kidney basin in Lysol solution for one hour, wash with detergent and dry it under sunlight.
  • Bath basins, multi-bin, bucket, jugs, mugs are washed with solution and dried in sunlight
  • Rubber sheets are to be cleaned with Lysol, dried, powdered and replaced
  • Soak the thermometer tray and its contents in 7% Lysol after cleaning. Utensils used by the patient are washed, boiled and replaced.
Housekeeping in the Operation Theatre:
Theatre complex should be absolutely clean at all times. Dust should not accumulate at any region in the theatre.

Soap solution is recommended for cleaning floors and other surfaces. Operating rooms(ORs) are cleaned daily and the entire theatre complex is cleaned thoroughly once a week.

Before the start of the first case:
Wipe all furniture, equipment, room lights, suction points, OR table, surgical light reflectors, other light fittings, slabs with soap solution. This should be completed at least one hour before the surgery.

After each case:
  • Linen and Gloves Gather all soiled linen and towels in the receptacles provided. Take them to the service corridor (behind the theatre) and place them in trolleys to be taken for sorting. The dirty linen is then sent to the laundry. Use gloves while handling soiled linen.
  • Instruments Used instruments are cleaned immediately by the scrub nurse and the attender. Reusable sharps are decontaminated in Lysol / hypochlorite and then washed in the room adjacent to the respective OR by scrubbing with a brush, liquid soap and vim. They are then sent for sterilization in the TSSU. In the septic theatre alone the instruments are sent in the instrument tray for autoclaving. Once disinfected, they are taken back to the same instrument cleaning area for a manual wash described earlier. They are then packed and re-autoclaved before use.
  • Environment Wipe used equipment, furniture, OR table, etc. with detergent and water. If there is a blood spill, disinfect with sodium hypochlorite before wiping.
    Empty and clean suction bottles and tubing with disinfectant.
After the last case
The same procedure as mentioned above is followed and in addition, the following are carried out.
  • Wipe overhead lights, cabinets, waste receptacles, equipment, furniture with a detergent
  • Wash floor and wet mop with liquid soap and then remove water and wet mop with a disinfectant solution.
  • Clean the storage shelves, scrub and clean sluice room.
Weekly cleaning procedure:
  • Remove all portable equipment
  • Damp wipe lights and other fixture with detergent
  • Clean doors, hinges, facings, glass inserts, and rinse with a cloth moistened with detergent.
  • Wipe down walls with clean cloth mop with detergent
  • Scrub floor using detergent and water
  • Stainless steel surfaces clean with detergent, rinse and clean with warm water
  • Replace portable equipment: clean wheel castors by rolling across toweling saturated with detergent.
  • Wash (clean) and dry all furniture and equipment. (OR table, suction holders, foot and sitting stools, Mayo stands, IV poles, basin stands, X-ray view boxes, hamper stands, all tables in the room, hoses to oxygen tank, kick buckets and holder, and wall cupboards)
  • After washing floors, allow disinfectant solution to remain on the floor for 5 minutes to ensure destruction of bacteria.
  • Do not remove or disturb delicate equipment
  • While wiping cabinets, see to it that the solution does not get inside and contaminate sterile supplies.
  • Operating rooms and scrub rooms should never be dry dusted
Maintenance and repairs:
  • Machinery and equipment should be checked, cleaned and repaired routinely on Sundays
  • Urgent repairs should be carried out at the end of the days list
  • Air conditioners and suction points should be checked, cleaned and repaired on a weekly basis.
  • Preventive maintenance on all theatre equipment is to be carried out every Saturday, and major work to be done at least once a year.
(taken from Hospital Infection Control Manual , Hospital Infection Control Committee Christian Medical College, Vellore)