INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES

Policy Type  Clinical  Administrative Issue Date: 1 September 2021

Policy No.: BRFRH/PCI/P – 001 Review Date: NA

Reference Revision No.: NA

PCI 6
Standard Next Review Date: 1 September 2023

1. PURPOSE
1.1 The Birthright fertility by rainbow hospitals takes action to prevent or reduce the risk of
health care-associated infections in patients, employees, visitors and contract workers.
1.2 The hospital takes action to control outbreaks of health care-associated infections when they
are identified.
1.3 Management systems support the infection control process.
1.4 To describe the scope, services and core processes of the Infection Control Program.
1.5 The hospital’s infection control process is designed to lower the risks and to improve the
(proportional) rates or (numerical) trends of epidemiologically significant infections.
1.6 The hospital takes action to control outbreaks of health care-associated infections when they
are identified.
1.7 Management systems support the infection control process.
1.8 To describe the scope, services and core processes of the Infection Control Program.
1.9 The hospital’s infection control process is designed to lower the risks and to improve the
(proportional) rates or (numerical) trends of epidemiologically significant infections.
2. POLICY STATEMENT
2.1 The infection control committee through its chairperson, has the authority to institute any
appropriate control measures and to recommend corrective action within any department,
when this is considered to be a danger to any patient or personnel.
2.2 The ICC has the ultimate authority in the event that there is a question or disagreement in
relation to infection control policies or procedures. Policies are reviewed by ICC team and
approved by management.

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2.3 To facilitate early recognition and complete reporting, the members of the ICC, or the
Infection Control facilitators in the unit has the authority to implement control measures,
and institute any appropriate isolation procedures, if there is reasonable evidence of
potential danger to patients or personnel. When any of these actions are taken, the
physician responsible for the patient will be notified by the Infection Control nurse and to be
reported to ICC.
2.4 The organization uses a coordinated process to reduce the risks of endemic and epidemic
health care-associated infections in patients and health care workers.
2.5 The infection control process is managed by ICC.
2.6 Case findings and identification of demographically important healthcare associated
infections provide surveillance data.
2.7 The hospital reports, when appropriate, information about infections both internally, to
public health agencies and including emerging and re-emerging infections.
2.8 The Medical Director directs that an Infection Control Program be established and that this
policy statement be adopted to ensure the organization has a functioning, coordinated
process in place to reduce the risks of endemic, epidemic and health care-associated
infections in patients and healthcare workers.
2.9 All healthcare providers and each department in partnership with the medical staff are
responsible for the safety, health and well-being of all patients, visitors and hospital staff.
This responsibility may be met by working together to promote safe infection control
practices, observing all rules, regulations, procedural guidelines and striving to improve the
quality of patient care. For those reasons, Birthright fertility By Rainbow hospitals has
established an Infection Control Program, which requires the participation and cooperation
of all personnel.
2.10 To coordinate the infection control activities, infection control management functions are
delegated to the Infection Control Chairperson Infection control nurse, Facilitators, and
Infection control Committee.

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2.11 The Infection Control Chairperson under the direct supervision of the Infection Control
Committee and coordinates with microbiology for priority directed improved patient and
systems outcomes.
2.12 The procedures of the infection control policies document the principles and programs,
which will serve as guidelines for all persons involved in or responsible for providing a safe
and sanitary hospital environment for patients, personnel and visitors.
2.13 The ultimate goal is to prevent, identify and minimize potential risk among patients and
Health Care workers as well as control hospital care-associated infections, actual or
potential. Infection control measures are required both by law and professional standards.
Participation in the Infection Control Program is part of everyone’s job description.
2.14 Programs, policies and procedures described in this manual are in accordance with the
philosophy of the Board and Administration of Birthright by Rainbow hospitals, Hospital
Medical Staff, Health Authority, Joint Commission International Accreditation Standards for
Ambulatory Care, National and international current accepted guidelines - APIC (Association
for Professionals in Infection Control and Epidemiology), WHO (World Health Organization),
CDC (Centers for Disease Control and Prevention) and AORN (Association of Perioperative
Registered Nurses).
3. Scope
3.1 Hospital wide
3.2 The Infection control department is generally staffed Monday till Saturday, day shift hours
(0800 Hrs – 17:30 Hrs). In the absence of the Infection Control Nurse, the Nurse supervisor
or Nurse Manager will respond to immediate infection control concerns. He or she may
consult with the Chairperson Infection control Committee for expert advice.
3.3 Activities performed by the Infection Control Nurse fall within the current infection control
standards and include but not limited to:
3.3.1 Establishing an ongoing laboratory based surveillance of healthcare associated
infections.
3.3.2 Analyzing healthcare associated infection rates.
3.3.3 Benchmarking hospital data with international data.

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3.3.4 Educating healthcare workers regarding Infection control principles.
3.3.5 Identifying areas of Infection Control risks and opportunities for performance
improvement and facilitating performance improvement projects with concerned
parties.
3.3.6 Overseeing infection related issues relevant to employee health.
3.3.7 Carrying outbreak investigations when an outbreak is identified.
3.3.8 Proposing appropriate policies and procedures are in place to prevent healthcare
associated infections in patients, staff, visitors, and to ensure proper clean hospital
environment.
3.3.9 Performing continuous surveillance for Healthcare-associated infections, to identify
these infections and decrease their magnitude.
3.3.10 Performing improvement projects based on the surveillance results.
3.3.11 Continuous education on Infection Control principles to hospital staff.
3.3.12 Writing and periodically revising policies that are relevant to prevention and control
of infection in the hospital.
4. Responsibility
4.1 All healthcare workers are required to:
4.1.1 Comply with prevention and control of infection policies
4.1.2 Attend orientation program for infection control for newly joined staff.
4.1.3 Review with their supervisor or incharge the current infection control practices prior
to commencing any work in their area.
4.1.4 Participate in annual in-service mandatory infection control continuous education
program.
4.1.5 Be evaluated for job performance with respect to infection prevention and control
practices based on assigned duties.
5. Definition and Abbreviations
5.1 ICC –Infection Control Committee
5.2 ICN – Infection Control Nurse
5.3 BRFRH: Birthright Fertility by Rainbow hospitals.

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6. Procedure
6.1 Major functions or services, significant activities or procedures.
6.1.1 Focused Surveillance & Monitoring of all identified or suspected patients with
healthcare associated infections (includes data collection and analysis, prevention
and control)
6.1.2 Case finding or collection or analysis of data by:
 Laboratory (culture or sensitivity) reports:
 Review of patient’s file and surveillance forms for Healthcare associated
infections.
 Discussion with the doctor or nurse supervisor
 In cases of identified healthcare associated infection and or outbreak of
infection in the unit of BRFRH, the following measures are implemented:
o Matter is discussed with the attending doctor, nurse supervisor of the unit
and the concerned infection control facilitator of the unit.
o Investigation & surveillance of the cases.
o Immediate isolation of the infected cases.
6.1.3 All staff are instructed to observe, apply or adhere to the implementation of
infection control accepted practices according to BRFRH Infection control policy and
procedures e.g :
- Proper hand washing technique
- Isolation precautions
- Proper disposal of sharps
- Proper waste disposal
- Proper storage & handling of soiled or contaminated linen
- Appropriate use of personal protective equipment
o All staff should observe and apply the principle of asepsis (medical or surgical
asepsis) for any invasive, diagnostic and therapeutic procedures such as:
- Insertion of IV or central lines
- Catheterization

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- Wound dressing
- Intubation
- Endotracheal suctioning
o Strict adherence to control visitors especially in high-risk areas like IVF Unit.
o Staff are advised to apply or observe proper isolation precautions and
technique:
- Standard precautions
- Transmission based precautions (as to contact, airborne, droplet)
- Educate patients, families and visitors when allowed.
6.2. Functions related to Environment
Screening of patient’s environment is done when necessary and right after
outbreak which includes:

 Procedure room including bed, bedside cupboard, countertops, trolley tops,

door knobs, sink & water tap handles.
 Hospital equipment or machines
 Medications trolley or intravenous fluids pumps
 Articles, equipment contaminated with faeces which may harbor the
infecting or contaminating organism
 Cleaning and disinfecting of equipment especially one that is shared
between patients.
 Coordination with the housekeeping service department for the cleaning
and disinfection of the unit.
6.3 Investigation of outbreaks of infectious diseases
6.3.1 The ICC review or collaborate with the infection control nurse and concerned health
care workers to identify, investigate and control any event of identified outbreak as
and when necessary.
6.3.2 When an outbreak of an infectious disease had been identified, the ICC meets to
evaluate the situation. A root cause analysis is performed.

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6.3.3 Results are disseminated to the units involved, link nurses, medical director and Chief
executive officer.
6.3.4 A quality improvement project if necessary will be developed using the FOCUS – PDCA
tool.
6.3.5 Monitoring to ensure that improvement is effective.
6.4 Functions related to health care workers
6.4.1 Available vaccine in BRFRH for free for all healthcare workers: Hepatitis B – (Genevac
B) and Flu vaccine, Covid 19 vaccine.
6.4.2 Management of staff who come positive with multi-drug resistant organisms isolated
from culture reports, until a negative culture report is obtained.
6.4.3 Screening of Health Care Workers especially those who are assigned in high-risk areas
such as procedure room, andrology and embryology lab including new recruits and
catering staff for carriage of pathogens when there is suspicion of cross –infection.
 Referral to specialist of any health care worker with positive culture report for
appropriate treatment.
 Temporary relocation to the ward of any health care worker assigned in high risk
areas to other area or mandatory leave whichever is applicable.
 Notification of any health care workers who may require vaccination or
immunization upon advice of the specialist:
6.5 Administrative Functions
6.5.1 Monitor or evaluate implementation and compliance of the BRFRH infection control
policy & procedures.
6.5.2 Assist in the planning, improvement and development of services and facilities in the
hospital on issues which are relevant to infection control.
6.5.3 Participate in the review or revision of infection control policies and procedures.
6.5.4 Prepare monthly or annually health care-acquired infection surveillance and infection
control activity report.

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6.5.5 The Infection control team should perform an annual risk assessment and Action plan
to be prearranged accordingly. (Refer Annexure 1 for Infection control annual risk
assessment)
6.5.6 Attend infection control committee meetings.
6.6 Advisory Functions
6.6.1 Monitor and advise on specific areas of hygiene and infection control, e.g.,
Andrology lab, Procedure room, Biomedical waste storage area.
6.6.2 Identify potential infection control hazards and suggest appropriate action to relevant
personnel.
6.6.3 Liaise with other hospital department to solve or rectify infection control issues.
6.6.4 Conduct training for all staff on infection control principles, practices and policies.
6.7 Education
6.7.1 Participate in formal (In-Service) and informal teaching program for nurses and
other health care workers
6.7.2 Conduct orientation to newly appointed staff about principles on prevention and
control of infection. Educate patient and family.
6.7.3 Attend lectures, seminars related to infection control.
6.7.4 Keep updated with recent advances on infection control issues.

6.8 Infection Control committee (ICC)

6.8.1 The members of the Infection control Committee include
 Chair: Consultant Microbiologist
 Facilitator: Infection Control Nurse
 Members:
o General Manager
o Medical Director
o Anesthesia –HOD
o Hospital Administrator
o HOD – IVF

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o Quality Manager
o Maintenance – HOD
o House-keeping Supervisor
o Obstetrics & Gynecology- HOD
o OT Incharge
o Nursing Manager
o Pharmacist
6.8.2 Frequency of meetings
The Infection Control Committee shall meet once in two months.
New members will be recommended by ICC and will be inducted on approval by the
Medical Director.
6.8.3 The ICC carries out the following functions:
 Develops infection control policies and procedures in BRFRH.
 The ICC acts as a source of expertise on matters relating to infection control.
 Ensures that corrective action and control measures are taken in the event of
outbreaks of infection.
 Reviews reports of infections, infection control policies, and procedures.
 Monitors functional compliance with infection control policies and procedures.
 Develops educational program about infection control policies and practices for unit
staff.
 Reviews unit’s infection control policies and procedures manual every two years.
 Designs and determines the type of surveillance and reporting programs.
 Assigns responsibility to an individual or a department to carry out actions or
recommendations.
 Ensures that rules of asepsis and sanitation are being followed throughout the units.
 Develops rules of handling and reporting of infectious cases and in the event of
outbreaks of infection.

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 Develops educational programs to ensure that the hospital staffs are aware of their
roles and responsibilities in the prevention and control of infections. (Refer Annexure
-2 for annual Training Calendar)
 Assigns responsibility to an individual or a department to carry out actions or
recommendations.
6.8.4 Responsibilities Regarding the ICC
 Medical Director approves and notifies the Chair, ICC, of the names of the members of
the ICC and their alternates.
 Department Heads recommends facilitators from their departments to the ICC and
notifies the ICC of any change of facilitators or alternates.
 Chair, ICC
o Convenes meeting of the ICC not less than bimonthly; more often if necessary.
o If an urgent matter arises, assembles as many members of the ICC as possible, but
not less than the following:
- Him/herself.
- Infection Control Nurse.
- The chief of the concerned department service.
- Any other directly concerned with the matter.
 Infection Control Chairperson
o Maintains copies of the minutes of meetings, reports, worksheets, and other data.
o Maintains a list of names of the members of the ICC and their alternatives.
o Distributes pertinent information to members of the ICC.
o Coordinates infection control activities throughout the Hospital.
o Reports surveillance and control activities at each ICC meeting.
o Receives and reviews all reports of infections and infection potential among patients
and healthcare personnel.
o Directs resolution of identified or potential problems.
o Recommends corrective action to resolve problems.

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o Conducts prospective prevalence studies periodically to evaluate the effectiveness of
surveillance system.
o Identifies and promptly reports epidemiological variations in levels of infections to
the ICC, and implements his/her recommendations for prevention and control.
o Inspects environment and observes personnel activities for the purpose of
eliminating possible infection hazards and to evaluate compliance with standards set
by the ICC.
o Collaborates with all disciplines and departments to develop and update area-
specific policies and procedures pertinent to infection control and makes
recommendations to the ICC regarding proposed additions and modifications to such
policies and procedures.
o Disseminates information regarding infection control and implements infection
control measures recommended by the ICC.
o Compiles data regarding antibiotic usage as a part of surveillance.
o Notifies designated medical and administrative staff members of all reportable
communicable diseases.
o Compiles data on patients with Healthcare Associated Infections.
Infection Control Nurse (ICN):

 Works as a clinical supervisor by ensuring all the established policies are practiced
 Hand washing procedures, use of hand rub, care of vascular access, universal precautions,
urinary catheterization, terminal cleaning, disinfection and follow-up to needle stick injuries
 Works as an investigator along with the infection control committee to track down outbreaks,
evaluates equipment to detect risk leading to infection hazards
 Works as an educator by participating in informal and formal teaching programmes for nurses
and other healthcare workers
 Attends appropriate courses and workshops
 Ensures adequate isolation precautions based on the reports of microbiology specially about
nosocomial strains

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 e.g: MRSA, MDRO etc.
 Perform surgical site infection surveillance for clean and selected clean contaminated,
contaminated and dirty cases
 Perform surveillance related activities once in a month in IVF unit.
 Conduct water surveillance -
 Potable water biochemical analysis once in 3 months and microbiological analysis once
every month.
 RO water of Hand washing internal surveillance by microbiology once every month
 Ensures pre-exposure prophylaxis to all healthcare workers
 Ensures annual health check-up
Purpose and scope for ICC Chair and Infection control Nurses

o Working with clinical and non- clinical staff on all aspects of infection control,
including porters, domestics, catering, and estates staff.
o Education and training related to infection control.
o Audit and surveillance.
o Development of policies and guidelines.
o Outbreak management.
o Advice on decontamination of the environment and equipment.
o Expert advice as required.
o Visiting all wards to answer questions from staff, patients, and the public about
prevention and control of infection issues.
o The Infection control team is responsible for day-to-day infection control activities
within the BRFRH, recommending means to minimize potential infections and taking
action to prevent and control infections.

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7. Annexure
7.1. Annual Infection control risk assessment and plan template

Infection Control Risk Assessment

Risk/Impact (Health, Financial, Current Systems/

EVENT Probability of Occurrence
Legal, Regulatory) Preparedness
Expected

Seriousg

Clinical

Clinical

Good

Solid
Fair
Poor
Likely

Threatinin
Life

Length of
Loss

Moderate
Never

Prolonged

Stay

Minimal
Maybe

4 3 2 1 Rare 0 4 3 2 1 0 4 3 2 1

Influenza (H1N1) 3 0 2 5
Pelvic or Abdomen TB 1 1 2 6
Chickenpox 1 1 1 3
Covid 19 3 3 1 7
emeging and reemerging
1 1 1 3
infection
Others: Outbreak 2 2 2 6
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Potential Device-Associated
Infections (HAIs)
Others: MDRO 1 2 1 4
catheter - Associated
Infections
Vaginal probes 1 1 2 4
Catheters (COOKS,ISPERM) 1 1 2 4

Lab - Associated Infections

Sperm wash 1 1 1 3
Semen Analysis 1 1 1 3
Sperm freezing 1 1 1 3
Sperm
1 1 2 4
chromatinedispersiontest
Embryo freezing 1 1 2 4
Intracytoplasmic sperm
1 1 2 4
injection
Procedure-Associated
Infections (SSI)
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Intra uterine insemination 2 1 2 5
Oocyte retreval 2 1 2 5
Embryo transfer 2 1 2 5

TESA 2 1 2 5
Infection Control Precautions
Hand Hygiene Compliance 4 4 2 10
Biomedical waste
4 3 2 9
management
Use of aseptic technique 2 2 1 6
PPE Compliance 3 1 1 5
Isolation Procedure
Use of isolation Technique
2 1 2 5
when required

Occupational Health &

Safety

Immunizations for Vaccine-

2 2 3 7
Preventable Viruses

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Staff Exposure to Needlestick
1 1 1 3
Injury
Risk of Unknown Level of
Communicable Disease 2 2 1 5
among Employees

Environment

Infection from Inadequate

2 2 2 6
Sterilization
Contamination/Infection
1 1 2 4
from Pharmacy
Infection/Accidents related
1 1 2 4
to Construction/Renovation
Poor Infection Control
Practices in Laundry 2 1 2 5
department
Poor Infection Control
1 2 2 5
Practices with regards to

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Waste Disposal
Problems with
2 2 3 7
Cleaning/Disinfectants

Others

Educational Activities for

3 2 2 7
BRFRH Staff
Programs for BRFRH 3 2 2 7
Antibiogram 1 2 1 4

Risk =_>=8

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Annexure 2. Action Plan

Event Goal Strategies Implimentation

Responsible Person Methods of evaluating
effectiveness
covid 19 Adherence to covid 19 *training and Education, ICO/ICN/HIC Link Reviewing the audit
Specific recommendations for Adherence to usage of nurses data. Evaluation and
improving practices and PPE`s feedback.
To reduce the risk of infection Adherence to hand
to healthcare personnel, the hygiene practices
population, and the
Hand Hygiene Adherence to Hand hygiene Training and Education ICO/ICN/HIC Link review audit report for
complainces prcatices Regular Audits nurses Improvement
Specific recommendations for Reminder in workplace opportunities and trends
improving practices and evaluation and Feedback .Circulate evaluation
reducing the transmission of report to the team
Needle Stick Injury
Report and investigate all *Placing particular focus ICO/ICN/HIC Link Reviewing the
sharps injuries, identifying on processes, medical nurses facility’s Exposure
trends or patterns of sharps waste container control plan annually,
injury occurrence and positioning and training including the evaluation
completing thorough analysis of staff. of sharps containers
with the participation of the *Where possible, with proven safety
injured staff implement a hands-free
sharps passing technique
* Creating a “no blame,
no shame” culture to
Pandemic/Epi Controlled separation *Patient placement and ICO/ICN/HIC Link Reviewing the facility`s
demic between patients, visitors, isolation nurses/Medical admin pandemic plan annualy.
and staff, based upon specific *separate emergency Providing the ability to
illnesses and their related entrances for suspected convert existing hospital
level of contagion /infected patients spaces—during a
*Training and education pandemic—into patient
Biomedical To reduce the risk of damage Proper segregation of ICO/ICN/HIC Link Update and improve
waste to healthcare personnel, the biomedical waste nurses waste management
management population, and the * Training and education system as per the
environment; for all Healthcare workers government noms.
* Regular audits

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Annexure 3. Annual Training Calendar

TRAINING CALENDAR -2022

MONTH WEEK 1 WEEK 2 WEEK 3 WEEK 4
JANUAR HAND Nursi 03.01.2 ISOLATION Nursi 10.01.2 Aseptic Nursi 17.01.2 CLEANING house 24.01.2
Y HYGIENE ng 022 PRACTICES ng 022 Non Touch ng 022 PROTOCOLS keeping 022
staff staff Technique staff
USES OF hous 05.01.2 COMMUNIC Nursi 12.01.2 BIOMEDIC hous 19.01.2 STERILIZATI Nursing 27.01.2
PPE e 022 ABLE ng 022 AL WASTE e 022 ON AND staff 022
keepi DISEASE staff MANAGE keepi DISINFECTIO
ng MENT ng N
FEBRUA ISOLATION nursi 02.02.2 HAND front 07.02.2 HAND nursi 14.02.2 HAND security 21.02.2
RY PRACTICES ng 022 HYGIENE office 022 HYGIENE ng 022 HYGIENE 022
staff staff
NEEDLE doct 03.02.2 CARE Nursi 09.02.2 USES OF doct 17.02.2 SURGICAL doctors 23.02.2
STICK ors 022 BUNDLES ng 022 PPE ors 022 SITE 022
INJURY staff INFECTION

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MARCH HAND doct 2.03.20 HAND lab 07.03.2 ISOLATION doct 14.03.2 HEALTHCAR doctors 21.03.2
HYGIENE ors 22 HYGIENE tech 022 PRACTICES ors 022 E 022
ASSOCIATED
INFECTION
NEEDLE Nursi 04.03.2 BIOMEDICA lab 09.03.2 NEEDLE Nursi 16.03.2 CLEANING Nursing 23.03.2
STICK ng 022 L WASTE tech 022 STICK ng 022 PROTOCOLS staff 022
INJURY staff MANAGEM INJURY staff
ENT
APRIL SPILLAGE Nursi 04.04.2 Aseptic Non lab 11.04.2 STERILIZAT Nursi 18.04.2 MULTIVIAL Nursing 25.04.2
MANAGEM ng 022 Touch tech 022 ION AND ng 022 POLICY staff 022
ENT staff Technique DISINFECTI staff
ON
BLOOD AND Nursi 06.04.2 CARE Nursi 13.04.2 HEALTHCA Nursi 20.04.2 SAFE Nursing 26.04.2
BODY FLUID ng 022 BUNDLES ng 022 RE ng 022 INFUSION staff 022
EXPOSURE staff staff ASSOCIAT staff PRACTICES
ED
INFECTION

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MAY NEEDLE hous 04.05.2 CARE doct 10.05.2 CLEANING hous 16.05.2 BIOMEDICAL front 23.05.2
STICK e 022 BUNDLES ors 022 PROTOCO e 022 WASTE office 022
INJURY keepi LS keepi MANAGEME
ng ng NT
CLEANING hous 05.05.2 Aseptic Non doct 12.05.2 STERILIZAT doct 18.05.2 USES OF PPE doctors 25.05.2
PROTOCOLS e 022 Touch ors 022 ION AND ors 022 022
keepi Technique DISINFECTI
ng ON
JUNE COMMUNIC Nursi 06.06.2 USES OF hous 13.06.2 NEEDLE Nursi 21.06.2 Healthcare- Nursing 27.06.2
ABLE ng 022 PPE e 022 STICK ng 022 associated staff 022
DISEASE staff keepi INJURY staff Infections
ng
COMMUNIC Nursi 07.06.2 ISOLATION Nursi 15.06.2 SAFE Nursi 23.06.2 HAND mainten 28.06.2
ABLE ng 022 PRACTICES ng 022 INFUSION ng 022 HYGIENE ance 022
DISEASE staff staff PRACTICES staff
JULY HAND hous 04.07.2 ISOLATION doct 11.07.2 Aseptic doct 18.07.2 CLEANING lab tech 25.07.2
HYGIENE e 022 PRACTICES ors 022 Non Touch ors 022 PROTOCOLS 022
keepi Technique

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ng

USES OF doct 06.07.2 COMMUNIC doct 13.07.2 BIOMEDIC doct 20.07.2 STERILIZATI doctors 27.07.2
PPE ors 022 ABLE ors 022 AL WASTE ors 022 ON AND 022
DISEASE MANAGE DISINFECTIO
MENT N
AUGUST ISOLATION doct 01.08.2 HAND doct 09.08.2 HAND doct 16.08.2 Aseptic Non doctors 22.08.2
PRACTICES ors 022 HYGIENE ors 022 HYGIENE ors 022 Touch 022
Technique
NEEDLE doct 03.08.2 CARE Nursi 10.08.2 USES OF doct 17.08.2 SURGICAL doctors 24.08.2
STICK ors 022 BUNDLES ng 022 PPE ors 022 SITE 022
INJURY staff INFECTION
SEPTEM NEEDLE Nursi 07.09.2 BIOMEDICA Nursi 14.09.2 NEEDLE Nursi 21.09.2 CLEANING Nursing 06.10.2
BER STICK ng 022 L WASTE ng 022 STICK ng 022 PROTOCOLS staff 022
INJURY staff MANAGEM staff INJURY staff
ENT

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BIOMEDICA hous 10.09.2 USES OF Nursi 16.09.2 SAFE doct 23.09.2 OCCUPATIO doctors 8.10.20
L WASTE e 022 PPE ng 022 INFUSION ors 022 NAL 22
MANAGEM keepi staff PRACTICES EXPOSURE
ENT ng
OCTOBE SPILLAGE hous 03.10.2 Aseptic Non Nursi 10.10.2 STERILIZAT lab 17.10.2 MULTIVIAL Nursing 25.10.2
R MANAGEM e 022 Touch ng 022 ION AND tech 022 POLICY staff 022
ENT keepi Technique staff DISINFECTI
ng ON
BLOOD AND Nursi 06.10.2 CARE doct 12.10.2 HEALTHCA lab 18.10.2 SAFE Nursing 27.10.2
BODY FLUID ng 022 BUNDLES ors 022 RE tech 022 INFUSION staff 022
EXPOSURE staff ASSOCIAT PRACTICES
ED
INFECTION
NOVEM STANDARD Nursi 04.11.2 SSI CARE Nursi 10.11.2 STERILIZAT Nursi 16.11.2 Aseptic Non Nursing 23.11.2
BER PRECAUTIO ng 022 BUNDLE ng 022 ION AND ng 022 Touch staff 022
NS staff staff DISINFECTI staff Technique
ON

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
SPILLAGE doct 05.11.2 HAND front 12.11.2 HEALTHCA doct 18.11.2 HAND doctors 26.11.2
MANAGEM ors 022 HYGIENE office 022 RE ors 022 HYGIENE 022
ENT ASSOCIAT
ED
INFECTION
DECEM SPILLAGE Nursi 06.12.2 ISOLATION Nursi 14.12.2 SAFE Nursi 21.12.2 BLOOD AND Nursing 28.12.2
BER MANAGEM ng 022 PRACTICES ng 022 INFUSION ng 022 BODY FLUID staff 022
ENT staff staff PRACTICES staff EXPOSURE
BLOOD AND doct 09.12.2 BIOMEDICA Nursi 16.12.2 MULTIVIA doct 23.12.2 ENVIRONME house 29.12.2
BODY FLUID ors 022 L WASTE ng 022 L POLICY ors 022 NTAL keeping 022
EXPOSURE MANAGEM staff CLEANING
ENT

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
8. References
9.1 APIC(Association for Professionals in Infection Control and Epidemiology) textbook 4th Edition
9.2 WHO (World Health Organization)

9.3 CDC (Centers for Disease Control and Prevention)

9.4 Joint Commission International. Management of Information & Accreditation for Ambulatory Care. 4th Edition, USA. Joint Commission
Resources, 2019.

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10 Amendment history
Explanation of change Page/s
Version Date of revision
(compared to previous version) affected

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
11 Approval Sheet

Prepared by Date:

Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Reviewed by

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Name Signature
Designation
Approved by

Annual Infection Control Plan-Template

11.1. PHASES
Probability, Risk or Impact and Current system scale
(For identified risk analysis)
Scale 1 2 3 4 5
Probability
Never Rare Maybe Likely Expected
( scores from 1 -5)
Risk or Impact Minimal Moderate Prolonged length of Temporary loss of Loss of life

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
(scores from 1-5) clinical/financial clinical/financial stay function limb/function
Current System
Solid Good Fair Poor None
(scores from 1 to 5)

11.1.1. Each identified risk was prioritized and scored in terms of: Likelihood, Severity and System preparedness
Likelihood, Severity and System preparedness scale
(For identified risk prioritization)

Scale 1 2 3 4 5
Likelihood
Never Rare Maybe Likely Expected
( scores from 1 -5)
Severity
Minimal Negligible Marginal Critical Catastrophic
(scores from 1-5)
System preparedness
Strongly well Moderately Preparedness level
(scores from 1 to 5) Fairly strong Preparedness level is poor
prepared prepared is weak

11.2. Scores given by consensus after group discussion and experts’ feedback.
11.3. In preparation for the last meeting, risks and scores were recorded by Infection Control nurse.

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
11.4. Risks arranged in descending order as per scores.
11.5. Code no is assigned and to all identified and arranged risks to facilitate identification of risks priority.
11.6. The first vital seven identified risk were identified.
11.7. The identified vital risks represent the highest priority risks as the focus of the Infection Control plan for the year of 2021.
11.8. A new ICRA shall be defined and prepared in December 2021-January 2022.
12. IDENTIFYING INFECTION CONTROL RISK BY CATEGORY

Category Identified Risk

Patient related risks SSI due to undiagnosed infection before surgery

Peripheral line associated cellulitis or blood stream infection
Lack of patient education
Patient with infectious diseases
Patient colonized with MDRO Outbreak
Staff related risks Hand hygiene poor compliance
Proper follow of universal precautions/PPE
Lack of staff education
Lack of preventive measures including droplet precautions, Contact precautions and
Airborne precautions
New and Current hired staff are not oriented to the INH infection control policies &

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
procedures
Lack of B/BF exposure management plan
Lack of staff immunization
Risk of needle stick/ sharps injury
Environment related risks Lack of sterilizer monitoring
Failure to identify construction risks
Geographical risks including Exposure to MERS Corona/other respiratory illness
epidemiological significant micro- Risk of exposure to TB
organisms and emerging & re-emerging Preparation of hospital for global communicable disease
diseases
Waste disposal non-compliance
Others Lack of Equipment’s cleaning (include used for patients)
Lack of compliance to waste management

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
13. NTIFIED RISK ANALYSIS

Program Probability/Likelihood RP
Risk - Impact/ Severity Current Systems
Components N
Exp Likel Maybe Rar Neve Loss of Temp Prolonge Moder Minima Non Poo Fai Goo Solid
ect y e r life/lim loss of d ate l e r r d
ed b/ functio length of clinical clinical/
functio n stay / Financi
n Financ al
ial

SSI due to
undiagnosed
infection before
surgery
Hand hygiene
poor
compliance

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
Lack of staff
Education
Lack of patient
Education
Proper follow of
Universal
precautions/PPE
Lack of
Airborne
precautions
Lack of
Droplet
precautions
Lack of
Contact
precautions
New hired and
current staff are
not oriented to

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
the INH infection
control
policies &
procedures
Lack of B/BF
exposure
management
plan
Risk of exposure
to
TB
Exposure to
MERS Corona
/other
respiratory
illness
Preparation of
hospital for
global

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 INFECTION CONTROL PROGRAM, TEAM AND RESPONSIBILITIES
communicable
disease
SSI-Surgical Site
Infections
PLABSI-
Peripheral line
associated blood
stream infection
Multidrug
Resistant
organisms
Infectious
disease
Outbreak
Sentinel Event
Lack of staff
immunization
Risk of needle
stick/ sharps

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injury

Lack of
sterilizer
monitoring
Failure to
identify
construction
risks
Equipment’s and
instruments
cleaning and
disinfecting
outside (CSSD)
Lack of
compliance
to waste
management
Total Risk Priority Number (RPN) 77
3

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14. SEVEN VITAL IDENTIFIED RISK

Code Identified risks

1. Preparation of hospital for global communicable disease
2. SSI- Surgical Site Infection
3. New and current hired staff are not oriented to the INH infection control policies &
procedures
4. Proper follow of Universal precautions/PPE
5. Lack of compliance to waste management
6. Hand hygiene poor compliance
7. Lack of patient education

15. INFECTION CONTROL PLAN BASED ON RISK ASSESSMENT

INFECTION CONTROL ACTION PLAN FOR 2022

Priority area Goal(s) Measurable Objectives Strategies/ Method of Responsibility
(Risks) / Interventions Evaluation/
and Performance and Time-
Indicator frame

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13.0 APPENDICES:
13.1. Document Control

NAME DESIGNATION SIGNATURE DATE

20/08/2021
PREPARED BY: Sis Nimisha Infection Control Nurse

30/08/2021
REVIEWED BY: Dr. Ranganathan Iyer HOD Microbiologist

30/08/2021
APPROVED BY: Dr.Prashanth.K Group Medical Director

13.2. Revision History

# Revision Date Change made by Reason for change Clause added/

deleted

13.3. Review History

Review Revision Reviewed by Signature Approved by Signature Next

Date Review

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