IPC Chapter

Infection Prevention and Control (IPC) Training: Comprehensive Foundation

This training program provides a detailed exploration of Infection Prevention and Control (IPC) practices as they are outlined within the NABH (National Accreditation Board for Hospitals & Healthcare Providers) 6th Edition Accreditation Standards for Hospitals – specifically, Chapter 5, dedicated to IPC. This comprehensive training is designed to empower healthcare professionals, administrators, and support staff with the knowledge and tools necessary to contribute to a robust and effective IPC program within their respective healthcare facilities. Mastering these standards is crucial for fostering a safer, cleaner, and healthier environment for patients, visitors, and healthcare workers alike, significantly reducing the incidence of Healthcare-Associated Infections (HAIs) and ensuring optimal patient outcomes.

Defining the Purpose: The Core Intent of an Effective IPC Program

An impactful IPC program extends far beyond simple compliance; it embodies a proactive and systematic approach to safeguarding the healthcare environment. Its principal aims include:

• Proactive Risk Mitigation: The core objective is to establish preemptive strategies and interventions that systematically reduce the risk of infection transmission within the healthcare setting. This includes identifying potential hazards, assessing vulnerabilities, and implementing evidence-based control measures.

• Eliminating the Spread of HAIs: The program is designed to minimize and ultimately eliminate the transmission of HAIs to all stakeholders - patients, visitors, and the essential workforce of healthcare personnel. This requires a multi-faceted approach targeting various routes of transmission and addressing specific infection risks.

• Evidence-Based Practice at the Forefront: The program emphasizes a reliance on the latest scientific research, established best practices, and validated guidelines to inform and guide all prevention and control activities. This includes staying abreast of emerging threats, adapting strategies based on new evidence, and regularly evaluating the effectiveness of existing measures.

• Structured Framework and Comprehensive Documentation: IPC programs are structured in documentation and approach. This involves defining program objectives, assigning responsibilities, establishing workflows, and creating clear, concise, and accessible resources for staff.

• Strategic Resource Allocation and Optimized Accessibility: Adequate resources are pivotal. The intention involves ensuring access to sufficient staffing, specialized equipment, appropriate supplies, and readily available information to effectively implement and maintain all facets of the IPC program.

• Adaptive and Risk-Specific Intervention Measures: An effective IPC program recognizes that risks are not static. The intent includes developing the capacity to respond rapidly to emerging infectious threats, modify strategies based on ongoing surveillance data, and proactively adapt interventions based on real-time needs.

• Antimicrobial Stewardship for Judicious Use: Programs must implement comprehensive antimicrobial stewardship strategies. Key aspects include promoting appropriate use, monitoring patterns of resistance, educating prescribers, and advocating for guidelines that support responsible antimicrobial utilization.

• Data-Driven Insights for Continuous Enhancement: This data is pivotal in identifying trends, evaluating the efficacy of specific interventions, tracking infection rates, and refining strategies for future action. The program prioritizes translating collected information into actionable insights.

• All-Encompassing Scope and Meticulous Attention to Detail: The overall program encompasses a wide spectrum of crucial elements, with each piece crucial in delivering better outcomes.

A Deeper Dive: Comparative Analysis of the NABH Standards (5th vs 6th Editions)

To effectively transition to the NABH 6th Edition, a clear understanding of the modifications from the 5th Edition is imperative. Here's a more granular breakdown of the standards:

• Core Focus of the Standards: Establishing a Baseline: The standards lay out a set of well-defined criteria for developing and maintaining infection prevention and control systems.

• Objective Elements: Tracking key change: A granular assessment of the Objective Elements is also necessary, including items, such as revised document implementation.

Enhancing Understanding: The Utility of the Color Coding System

The document also employs a color-coding system as a useful tool that guides understanding in different segments.

Deciphering the Shifts: Intent-Related Changes from 5th to 6th Edition

The evolution of the NABH standards from the 5th to 6th Edition reflects significant advancements in our understanding of IPC best practices. Understanding the rationale behind these changes is essential for successful implementation:

• The Name Change - A More Inclusive Approach: IPC incorporates many new dimensions, for which programs must align.

• A Focus on Anti-Microbials: By expanding beyond antibiotics, a better focus and indication on all anti-microbial substances is achieved.

By engaging with these fundamental concepts, training participants gain the foundation required to fully grasp and apply the more detailed standards and practices presented in the subsequent modules. This deep-seated understanding promotes a strong culture of infection prevention, leading to a tangible reduction in HAIs and enhanced safety for all within the healthcare environment.

IPC1: Comprehensive and Coordinated Hospital Infection Prevention and Control Program

The cornerstone of any healthcare facility's commitment to patient safety is a robust and well-coordinated Hospital Infection Prevention and Control (IPC) program. This program is not merely a set of protocols, but a living, dynamic system designed to proactively reduce and ideally eliminate the risks of Healthcare-Associated Infections (HAIs) for everyone within the hospital ecosystem – patients, visitors, healthcare providers, and the broader community. The essence of this program lies in its comprehensiveness, encompassing all facets of infection prevention, and its coordinated nature, ensuring seamless integration across all departments and services within the organization. This standard has remained consistent from the 5th to the 6th edition of NABH accreditation, highlighting its fundamental importance.

IPC1a: Documented Infection Prevention and Control Programme

A foundational requirement of an effective IPC program is its formal documentation. The hospital must have a meticulously documented infection prevention and control program manual. This manual serves as the central repository of all policies, procedures, and guidelines related to IPC within the facility. It must be designed with the primary aim of preventing and significantly reducing the risk of healthcare-associated infections within the hospital environment. This documentation is a core objective element, signifying the mandatory system documentation required for accreditation.

The content of this IPC manual should be structured to provide a comprehensive framework for infection control. Key elements to include are:

• Programme Structure: The manual should clearly outline the organizational structure for IPC, including the roles and responsibilities of the infection control committee, the infection control team, and designated personnel such as the Infection Prevention Control Officer (IPCO) and Infection Prevention Control Nurses (IPCNs).

• Overall Aims and Objectives: The manual must articulate the overarching goals of the IPC program. These should be specific, measurable, achievable, relevant, and time-bound (SMART objectives) focusing on the reduction of HAI rates, improvement of patient safety, and creation of a safer environment for all stakeholders.

• Processes, Activities, and Surveillance Procedures: A detailed description of all processes and activities related to IPC is essential. This includes protocols for hand hygiene, standard precautions, transmission-based precautions, disinfection and sterilization, biomedical waste management, and laundry and linen management. Crucially, the manual must define the surveillance procedures used to monitor infection rates, identify trends, and evaluate the effectiveness of control measures.

The documented program must be grounded in evidence-based practices and tailored to the specific context of the hospital. It should be based on several key pillars:

• Organisational Priorities: The IPC program must align with the hospital's strategic goals and priorities, reflecting its commitment to patient safety and quality of care.

• Current Scientific Knowledge: The program should be informed by the latest scientific evidence and best practices in infection prevention and control. This includes staying abreast of emerging pathogens, new technologies, and updated guidelines.

• Guidelines from International/National and Professional Bodies and Statutory Requirements: The IPC program must adhere to relevant guidelines issued by recognized bodies such as the World Health Organization (WHO), Centers for Disease Control and Prevention (CDC), and national health authorities like the Ministry of Health and Family Welfare, Government of India, and National AIDS Control Organisation (NACO). Compliance with all applicable statutory and regulatory requirements is also paramount.

• Periodic Risk Assessment and Setting of Risk Reduction Goals: A crucial element is the incorporation of periodic risk assessments. These assessments help to identify specific infection risks within the hospital and guide the setting of targeted risk reduction goals. These goals, informed by the risk assessments, should drive the direction and focus of the IPC program.

Remember, the written guidance within the IPC manual should be clearly directed at HAI prevention, control, and continuous monitoring. It's also vital to utilize reference documents such as WHO and CDC guidelines, along with national guidelines from NACO and the Ministry of Health and Family Welfare, Government of India, to ensure the program is evidence-based and aligned with best practices.

IPC1b: Identification of High-Risk Activities and Written Guidance

Beyond a general IPC program, the hospital must proactively identify activities within its operations that pose a higher risk of infection transmission. Once these high-risk activities are pinpointed, specific written guidance must be developed and implemented to effectively prevent and manage infections associated with them. This objective element is considered a commitment level, indicating its essential nature for effective IPC.

The identification of these high-risk activities must be based on sound scientific literature and evidence. The key factor driving this identification is the potential risk of transmission of infections to both patients and healthcare providers during these activities.

Examples of high-risk activities that typically require specific written guidance include:

• Performing Aerosol-Generating Procedures: Procedures like intubation, bronchoscopy, nebulizer treatments, and open suctioning have a higher potential for airborne transmission of pathogens and necessitate stringent infection control measures.

• Handling Blood and Body Fluid Spills, Specimens, and Sharps: Activities involving contact with blood and body fluids, especially when sharp instruments are involved, carry risks of bloodborne pathogen transmission. Specific guidance for safe handling, spill management, and sharps disposal is crucial.

• Exposure to Contaminated Medical Devices/Equipment and Biomedical Waste: Improper handling of contaminated medical devices and biomedical waste poses significant infection risks. Procedures for cleaning, disinfection, sterilization, and safe disposal are necessary.

Corresponding to these high-risk activities, a range of high-risk areas within a hospital often require focused attention. These examples of high-risk areas underscore the need for targeted IPC strategies:

• Operation Theatre

• Intensive Care Units (ICUs)

• Bone Marrow Transplantation Units

• Central Sterile Services Department (CSSD)

• Cardiac Catheterization Laboratories (Cath Labs)

• Labour Rooms

• Laboratories

• Blood Banks/Centres

• In-Vitro Fertilization (IVF) Units

For each identified high-risk activity and area, the written guidance should detail the specific precautions, procedures, and protocols to be followed to minimize infection risks. This might include enhanced personal protective equipment (PPE) requirements, specific environmental controls, and specialized cleaning or disinfection protocols.

IPC1c: Annual Review and Update of the Infection Prevention and Control Programme

An effective IPC program is not static; it must be a dynamic and evolving system that adapts to new information, emerging threats, and lessons learned. Therefore, the infection prevention and control program must be reviewed and updated at least once a year. This regular review process, a commitment level element, ensures the program remains relevant, effective, and in line with the latest best practices.

The annual review process should be comprehensive and consider various factors that might necessitate program updates. The update should be based on:

• Newer Literature on Infection Prevention: The IPC team must actively monitor and incorporate new scientific publications, research findings, and updated guidelines related to infection prevention. This ensures the program reflects the most current evidence-based practices.

• Outbreak Prevention Mechanisms: Analyzing past outbreaks, both within the hospital and in the wider community, is critical. The review should identify potential weaknesses in existing mechanisms and incorporate improvements to prevent future outbreaks.

• Infection Trends: Continuous monitoring of infection trends within the hospital is essential. The review should analyze surveillance data to identify any emerging trends, areas of concern, or opportunities for targeted interventions.

• Outcomes of the Audit Processes: Regular audits of IPC practices provide valuable insights into compliance levels and areas needing improvement. The outcomes of these audits should be carefully considered during the annual review to drive necessary program adjustments.

It's important to note that even if the annual review does not identify any specific opportunities for significant program improvement, this outcome itself should be formally documented. This documentation, typically in the minutes of the infection control committee meeting, demonstrates that a review was conducted and confirms the ongoing relevance and appropriateness of the existing program.

IPC1d: Review Based on Infection Control Assessment Tool

To ensure a structured and objective review of the IPC program, the annual review should be based on a validated infection control assessment tool. Utilizing such a tool, an achievement level objective element, provides a standardized framework for evaluating the program's strengths and weaknesses.

The process involves two key steps:

• Use Validated Tool: The hospital must select and consistently use a validated and recognized infection control assessment tool. Examples of such validated tools include:

  • WHO Infection Prevention and Control Assessment Framework at Facility Level: This tool provides a comprehensive framework for assessing IPC programs across various aspects.

  • CDC's Infection Prevention and Control Assessment Tool for Acute Care Hospitals: This tool, specifically designed for acute care settings, offers a detailed assessment of IPC practices.

• Perform Infection Prevention and Control Assessment: The selected validated tool should be systematically applied to assess the hospital's IPC program. This assessment should involve a thorough evaluation of all program components against the criteria defined by the tool.

Using a validated tool ensures a standardized, objective, and comparable assessment of the IPC program over time and potentially across different facilities. It facilitates the identification of specific areas needing improvement and supports the development of targeted action plans.

IPC1e: Multi-disciplinary Infection Control Committee

The coordination of all infection prevention and control activities within the hospital necessitates a dedicated multi-disciplinary infection control committee. This committee, a commitment level objective element, serves as the central coordinating body for all IPC-related matters. Its multi-disciplinary nature is crucial, bringing together diverse expertise to address the complex challenges of infection control.

The composition of the infection control committee should reflect the multi-disciplinary nature of IPC and include representation from key areas within the hospital:

• Hospital Administrator (ensuring administrative support and resource allocation)

• Microbiologist (providing expertise in microbiology and infection epidemiology)

• Physician/Infection Control Specialist (offering clinical and IPC expertise)

• Surgeon (representing surgical aspects of IPC)

• Infection Control Officer (IPCO) (leading the day-to-day IPC activities)

• Infection Control Nurse(s) (IPCNs) (implementing and monitoring IPC practices at the bedside)

• Nursing Manager (Nursing Supervisor) (representing nursing perspectives and operational aspects)

• CSSD, OT, ICU Staff (representing key clinical and support areas with high infection risks)

• Support Services(s) (e.g., Housekeeping, Laundry, Dietary, Engineering – reflecting the broader environmental and support service aspects of IPC)

• Invitees from Various Departments (allowing for inclusion of specific expertise or perspectives as needed)

The responsibilities of the infection control committee are multifaceted and crucial for guiding and overseeing the IPC program:

• Laying down written guidance to guide implementation: The committee is responsible for developing and approving the written policies, procedures, and guidelines that form the basis of the IPC program and guide its implementation across the hospital.

• Establishing risk-reduction goals and measurable objectives: The committee sets the overall direction of the IPC program by establishing annual risk-reduction goals and measurable objectives. These objectives should be reviewed regularly, at least monthly, to track progress and make adjustments as needed.

For effective functioning and accountability, proper documentation of the committee's activities is essential:

• Composition of meeting: Records should be maintained documenting the attendance and roles of committee members at each meeting.

• Frequency of meetings (at least monthly): Documentation should confirm that the committee meets at least monthly, or more frequently if required by circumstances like outbreak situations.

• Minimum quorum required: The committee should establish and adhere to a minimum quorum requirement to ensure meaningful participation and decision-making at meetings.

• Minutes of meeting: Detailed minutes of each meeting, documenting discussions, decisions, and action items, must be recorded and circulated to committee members and relevant stakeholders.

IPC1f: Infection Control Team for Implementation and Coordination

While the committee provides overall direction and oversight, the day-to-day implementation and coordination of IPC activities are the responsibility of a dedicated infection control team. This team, also a commitment level objective element, acts as the operational arm of the IPC program, ensuring that policies and procedures are effectively put into practice throughout the hospital. It's crucial to understand that the committee and the team should be distinct entities. However, to ensure alignment and communication, the infection control team should be represented within the infection control committee.

The responsibilities of the infection control team are focused on the practical aspects of IPC implementation:

• Day-to-day functioning of infection prevention and control programme: The team is responsible for the daily operation of the IPC program, including implementing protocols, monitoring compliance, and responding to emerging issues.

• Supporting surveillance process: The team plays a key role in the hospital's surveillance system, actively collecting, analyzing, and reporting infection data.

• Detecting outbreaks: A critical function of the team is to proactively detect potential outbreaks or clusters of infections through surveillance and promptly initiate investigation and control measures.

• Participating in audit activity and infection prevention and control (on a day-to-day basis): The team actively participates in ongoing audits of IPC practices across the hospital and provides daily support and guidance to staff on infection prevention and control matters.

The staffing of the infection control team must be adequate and appropriate to effectively fulfill its responsibilities. The team's size and composition should be determined based on several factors:

• Organisation's size: Larger hospitals with more beds and departments will require larger teams.

• Level of risk of infection: Hospitals with higher patient acuity, complex procedures, or specialized units may require more specialized and robust teams.

• Programme's complexity: The scope and complexity of the IPC program itself will influence staffing needs.

• Scope of programme: A broader scope of IPC activities, including community outreach or specific programs like antimicrobial stewardship, will require additional staffing resources.

At a minimum, every infection control team should comprise:

• Infection control officer (IPCO): A designated physician with expertise in infection control leadership and oversight.

• Infection control nurse(s) (IPCNs): Registered nurses with specialized training in infection prevention and control, providing frontline implementation and monitoring.

IPC1g: Designated Infection Prevention Control Officer (IPCO)

A designated Infection Prevention Control Officer (IPCO) is a mandatory component of the infection prevention and control team. This designated role, a commitment level objective element, provides crucial clinical leadership and expertise to the IPC program.

The IPCO should be a qualified medical professional, specifically:

• A doctor (Clinical microbiologist/infectious disease specialist): Ideally, the IPCO should be a physician specializing in clinical microbiology or infectious diseases. These specialists possess the in-depth knowledge of infectious agents, epidemiology, and antimicrobial resistance that is essential for effective IPC leadership.

• With knowledge about infection control practices: Regardless of specialization, the IPCO must possess comprehensive knowledge and training in current infection control practices, guidelines, and surveillance methodologies.

In situations where a clinical microbiologist is not available, the note allows for flexibility:

• Note: In absence of microbiologist, a surgeon/physician can be designated as IPCO. A surgeon or other physician with demonstrated interest and training in infection prevention and control can be designated as IPCO if a microbiologist is not available. However, specialized training in IPC is still essential.

The responsibilities of the IPCO are broadly defined as:

• Responsibilities: As defined in manual: The specific responsibilities of the IPCO should be clearly outlined in the hospital's IPC manual. These typically include leading the infection control team, developing and implementing IPC policies and procedures, overseeing surveillance activities, investigating outbreaks, providing expert advice on IPC matters, and reporting to the infection control committee.

IPC1h: Designated Infection Prevention & Control Nurse(s) (IPCNs)

Complementing the role of the IPCO, Infection Prevention & Control Nurse(s) (IPCNs) are essential frontline personnel in the IPC team. This designated role, also a commitment level objective element, provides crucial hands-on implementation, monitoring, and education related to infection prevention and control at the patient level.

The selection and designation of IPCNs should be based on specific criteria:

• Should be designated based on qualification (Registered nurse): IPCNs must be registered nurses with a valid nursing license, reflecting their foundational nursing knowledge and patient care skills.

• Should have undergone additional structured training: Beyond basic nursing qualifications, IPCNs must have completed structured, specialized training in infection prevention and control. This training should equip them with the specific knowledge and skills required for their IPC role.

The responsibilities of IPCNs are broad and encompass key aspects of IPC implementation and monitoring:

• As defined in the manual including: The detailed responsibilities of IPCNs should be clearly defined in the hospital's IPC manual. These responsibilities typically include:

  • Surveillance of HAI and healthcare-associated organisms: Actively participating in surveillance activities to identify and track HAIs and multi-drug resistant organisms within the hospital.

  • Compliance monitoring: Monitoring and auditing staff compliance with established IPC protocols and guidelines, such as hand hygiene, standard precautions, and transmission-based precautions.

  • Education: Providing ongoing education and training to hospital staff on infection prevention and control practices, promoting a culture of safety.

  • Working on outbreaks: Actively participating in outbreak investigations and control efforts, including implementing isolation measures and contact tracing.

  • Documentation: Maintaining accurate records related to surveillance data, compliance monitoring, outbreak investigations, and other IPC activities.

Compliance monitoring is a significant aspect of the IPCN's role and includes the following key areas:

• Hand hygiene practices amongst staff.

• Adherence to transmission-based precautions when indicated.

• Implementation of isolation protocols for patients with infections.

• Appropriate use of infection-specific bundles for prevention of specific HAIs.

• Correct performance of disinfection and sterilisation procedures.

• Use of checklists to monitor and ensure adherence to various IPC protocols.

Regarding the number of IPCNs required, a minimum staffing ratio is recommended:

• Nurses: At a minimum, there should be one dedicated nurse per 250 beds. This ratio provides a benchmark for adequate IPCN staffing levels, recognizing that larger hospitals require more IPCN resources.

• Link nurses who actively participate in infection prevention and control activities should support IPCN(s): To extend the reach of IPC efforts, the involvement of "link nurses" or designated staff champions within various departments who receive additional IPC training and act as local IPC resources is highly beneficial. These link nurses can support IPCNs in promoting compliance and implementing IPC practices within their respective areas.

IPC1i: Information, Education, and Communication (IEC) for the Community

Effective infection prevention and control extends beyond the walls of the hospital and into the community it serves. The organization has a responsibility to implement an information, education, and communication (IEC) program aimed at promoting infection prevention and control activities within the community. This community-focused IEC program, a commitment level objective element, contributes to broader public health and reduces the overall burden of infections.

The IEC program involves a two-pronged approach targeting both the organization and its stakeholders within the community:

• Organisation and stakeholders: The program should involve both internal hospital resources and external community stakeholders.

• Create information, education and communication messages: The hospital should develop clear, concise, and culturally appropriate IEC materials, messages, and resources tailored for the community. These messages should be designed to raise awareness and promote specific infection prevention practices.

• Conduct infection prevention and control activities: Beyond message dissemination, the hospital should actively conduct community-based infection prevention and control activities. These activities could include workshops, public awareness campaigns, health fairs, and collaborations with community organizations.

Examples of key infection prevention and control activities to promote within the community include:

• Hand hygiene promotion: Emphasizing the importance of regular hand washing with soap and water or using alcohol-based hand rub.

• Appropriate use of antibiotics: Educating the community about the responsible use of antibiotics, combating antibiotic resistance, and discouraging self-medication.

• Use of personal protective equipment: Promoting the appropriate use of masks and other PPE, especially in situations where respiratory infections are prevalent.

IPC1j: Participation in Managing Community Outbreaks

Hospitals have a crucial role to play not only in preventing infections within their own facilities but also in participating in the broader management of community outbreaks. This engagement in community outbreak management, a commitment level objective element, is an extension of the hospital's public health responsibility.

The hospital's participation in managing community outbreaks involves several key aspects:

• Organisation: The hospital itself takes an active role in outbreak management efforts.

• Effective response to community outbreaks: The hospital must have mechanisms and plans in place to effectively respond to community outbreaks, both proactively and reactively.

• External agencies (Including statutory): Collaboration and coordination with external agencies, including statutory health authorities and public health organizations, is essential for effective community outbreak management.

The tasks involved in effectively managing community outbreaks include:

• Communication (Both internally and externally): Establishing clear and timely communication channels, both within the hospital to coordinate internal response efforts and externally with public health agencies and the community to share information and guidance.

• Assigning roles and responsibilities to staff: Clearly defining and assigning specific roles and responsibilities to hospital staff for outbreak response activities, ensuring a coordinated and efficient approach.

• Training staff: Providing staff with necessary training and resources to effectively participate in outbreak management, including recognizing signs of outbreaks, implementing control measures, and communicating with the public.

By actively engaging in these tasks and collaborating with external agencies, hospitals can significantly contribute to the effective management and control of community outbreaks, protecting the health of the wider population.

IPC2: Adequate and Appropriate Resources for Infection Prevention and Control

Section IPC2 of the NABH 6th Edition Accreditation Standards for Hospitals pivots to the critical aspect of resource allocation for a thriving Infection Prevention and Control (IPC) program. While a well-defined program and dedicated personnel are essential (as covered in IPC1), their effectiveness is fundamentally dependent on the availability of adequate and appropriate resources. IPC2 ensures that the hospital provides the necessary infrastructure, supplies, and financial backing to support the IPC program in achieving its objectives. It underscores the principle that IPC is not merely a matter of policy but also requires tangible investment and ongoing resource management. While the overarching standard of IPC2 remains consistent with the 5th edition, specific objective elements and their interpretations have been refined in the 6th edition, emphasizing a more focused approach to resource provision.

IPC2a: Management Commitment and Financial Resources

The bedrock of resource availability for IPC is unwavering management commitment and the tangible manifestation of this commitment through financial resource allocation. IPC2a mandates that hospital management takes active responsibility for making available all resources required for the infection control program. This is a core objective element, highlighted as Commitment Level (Core OE), emphasizing its fundamental nature and the necessity of demonstrable management action. The 6th edition has merged objective elements from the 5th edition (HIC 2a and HIC 2b), streamlining the focus on management responsibility and budgetary support into a single, powerful element.

The availability of resources must be viewed through two critical lenses:

• Availability of resources required (Men and Material): This encompasses both human resources (adequately staffed IPC team, trained personnel across departments) and material resources (supplies, equipment, infrastructure). It signifies that management must ensure that the IPC program is not hampered by shortages in either personnel or essential supplies.

• Continual and Sustained Manner: Resource provision should not be a one-time event but an ongoing, consistent process. Management must ensure a continuous flow of resources to support the IPC program's daily operations and long-term sustainability. This implies proactive planning, regular budget reviews, and responsive adjustments to resource needs.

Financial allocation, a key aspect of management commitment, must be addressed through dedicated budgeting:

• Allocate funds based on: The allocation of funds should be a deliberate and informed process, not arbitrary. It should be based on:

  • Scope of activity: The breadth and depth of the IPC program's activities, including surveillance, training, outbreak investigations, and specific prevention bundles, should dictate the budget size. A more comprehensive program will naturally require a larger budget.

  • Previous year's experience: Analyzing past expenditure patterns, identifying areas of overspending or underspending, and factoring in anticipated changes in program scope or operational needs from the previous year’s experience are crucial for informed budgeting.

A crucial practical step is the establishment of a distinct and identifiable budget line item for IPC:

• Note: The organisation should demarcate separate budget for infection prevention and control activity. Creating a separate, demarcated budget specifically for infection prevention and control activities is not just good financial practice, but it also significantly enhances transparency and accountability. It allows for clear tracking of IPC expenditure, facilitates effective resource management, and reinforces management's commitment to prioritizing IPC. This dedicated budget ensures that IPC funding is not inadvertently diverted to other areas and that resources are readily available when needed.

IPC2b: Personal Protective Equipment, Soaps and Disinfectants

The provision of adequate and appropriate Personal Protective Equipment (PPE), soaps, and disinfectants forms the front line of defense in infection prevention. IPC2b mandates that these essential supplies are not only available but also used correctly. This is classified as a Commitment level objective element, reflecting its crucial role in daily infection control practices. The interpretation of this element has been refined in the 6th edition, likely to emphasize the "used correctly" aspect in addition to mere availability.

The focus on Personal Protective Equipment (PPE) encompasses several critical aspects:

• Personal protective equipment (PPE): PPE serves as a vital barrier protecting healthcare workers from exposure to infectious agents and preventing transmission to patients.

  • Ensure availability at the point of use: PPE must be readily accessible precisely where and when it is needed. This means ensuring adequate stock levels in all patient care areas, procedure rooms, and any location where exposure risks exist. Proximity and ease of access are paramount for consistent PPE use.

  • Maintain adequate inventory: A robust inventory management system is essential to prevent stock-outs and ensure a continuous supply of PPE. This includes forecasting usage, monitoring stock levels, and establishing reliable procurement processes. Adequate inventory prevents delays in accessing PPE which can compromise safety.

Beyond availability, correct utilization of PPE is equally important:

• Staff: Effective PPE use depends on staff understanding the principles of PPE and adhering to established protocols.

  • Use PPE based on the risks involved: PPE selection and usage should be risk-based. Staff must be trained to assess the potential exposure risk associated with each task or patient interaction and choose the appropriate type and combination of PPE accordingly. "One size fits all" approach to PPE is ineffective.

  • Remove PPE after use: Proper doffing (removal) of PPE is as critical as donning (putting on) to prevent self-contamination and further spread of pathogens. Staff must be trained in the correct doffing sequence and practice hand hygiene immediately after removing PPE.

Examples of essential PPE items that must be readily available include:

• Gloves (various types for different procedures and levels of protection)

• Protective eyewear (goggles or face shields to protect mucous membranes of the eyes)

• Masks (surgical masks, N95 respirators depending on the risk of airborne transmission)

• Aprons (fluid-resistant aprons for procedures with risk of splashing)

• Gowns (isolation gowns for procedures with significant risk of contamination)

• Boots/Shoe covers (when indicated to protect footwear from contamination)

• Cap/Hair cover (to prevent hair from contaminating sterile fields or procedures).

IPC2c: Hand Hygiene Facilities in Patient-Care Areas

Hand hygiene is universally recognized as the single most effective measure to prevent healthcare-associated infections. IPC2c specifically emphasizes the provision of adequate and appropriate facilities for hand hygiene in all patient-care areas, accessible to all healthcare providers. This is a Core Objective Element (CO), highlighting the absolute centrality of hand hygiene infrastructure in achieving IPC goals.

The standard differentiates between two primary types of hand hygiene facilities:

• Hand wash facilities: Traditional hand washing with soap and water remains a fundamental hand hygiene practice, especially when hands are visibly soiled.

  • Large washbasins: Washbasins should be of adequate size to allow for comfortable and effective hand washing.

  • Hands-free tap: To prevent re-contamination after hand washing, taps should be hands-free, ideally sensor-operated or foot-operated.

  • Soap: Liquid soap in dispensers should be readily available at each hand wash basin.

  • Facility for drying hands without contamination: A method for drying hands without re-contamination is essential. Options include disposable paper towels or warm air dryers. Cloth towels are generally discouraged in clinical settings due to the risk of pathogen harboring.

Hand rub facilities, using alcohol-based hand rub solutions, are equally important, especially for routine hand hygiene between patient contacts when hands are not visibly soiled:

• Hand rub facilities: Alcohol-based hand rub solutions offer a convenient and highly effective means of hand hygiene, especially in busy clinical settings.

  • Install dispensers at convenient points: Hand rub dispensers should be strategically placed at easily accessible locations throughout patient care areas – at the point of care, near patient bedsides, at entrances and exits of rooms, and other high-traffic areas. Ubiquitous availability encourages frequent hand rub use.

  • Staff can carry their own hand rub dispenser as they move between patient and within facilities: Encouraging staff to carry personal pocket-sized hand rub dispensers enhances their autonomy and ensures hand hygiene is always within reach, especially when moving between patient areas or within facilities where fixed dispensers may be less frequent.

The key message is that hand hygiene facilities, both washbasins and hand rub dispensers, must be ubiquitous and readily accessible in all patient care areas. In every patient care area, the organization's commitment to hand hygiene should be demonstrated by:

• Provide at least one easily accessible washbasin with running water for health care providers: Washbasins with running water, hands-free taps, soap, and hand drying facilities must be conveniently located. "Easily accessible" means proximity and unobstructed access, not requiring staff to walk long distances or navigate cluttered spaces to find a hand washing station.

• Ensure availability of hand rub: Hand rub dispensers must be consistently filled and functional, ensuring a readily available alternative for hand hygiene. Regular checks and refills are crucial to maintain this availability.

IPC2d: Isolation/Barrier Nursing Facilities

Isolation and barrier nursing facilities are critical for preventing the spread of infections from patients with known or suspected contagious conditions. IPC2d mandates the availability of adequate isolation/barrier nursing facilities within the hospital. This is a Commitment level objective element, indicating its importance in controlling transmission of infectious agents.

Effective isolation and barrier nursing require a multi-faceted approach encompassing definition, provision, placement, assurance, and display:

• Define: The hospital must clearly define the conditions and situations where isolation and/or barrier nursing are required. This should be based on established guidelines and the types of infections commonly encountered in the facility. Clear criteria ensure consistent and appropriate implementation of isolation measures.

• Provide: Providing necessary resources is crucial to implement barrier nursing effectively.

  • Necessary resources (For example: Clothing, masks and gloves) to the barrier nursing staff: This includes ensuring that staff caring for isolated patients have readily available access to appropriate PPE such as gowns, gloves, masks (including respirators when indicated), and other barrier attire required for the specific type of isolation (e.g., contact, droplet, airborne). Adequate supply is essential to maintain barrier precautions consistently.

• Place: Appropriate placement of patients requiring isolation is fundamental to preventing transmission.

  • Patients who require isolation (contact, droplet and airborne) in isolation room: Patients requiring isolation should be placed in dedicated isolation rooms. The type of isolation (contact, droplet, airborne) dictates the specific room requirements.

  • Airborne cases in negative pressure rooms: For patients requiring airborne isolation (e.g., tuberculosis, measles, varicella), negative pressure rooms are essential. These rooms are specifically designed to prevent air from flowing out of the room, containing airborne pathogens. Regular monitoring of negative pressure is crucial.

  • Isolation for patients with MRSA / VRE: Patients colonized or infected with multi-drug resistant organisms like MRSA or VRE, often requiring contact isolation, should also be appropriately isolated to prevent cross-transmission.

• Ensure: Maintaining the integrity of isolation measures requires operational diligence.

  • Door(s) to the aisle or other rooms are always closed: Isolation rooms must have functional doors that are kept closed at all times to maintain barrier effectiveness. This is particularly critical for airborne isolation rooms but important for all types of isolation.

• Display: Clear communication and signage are important for reinforcing isolation protocols and informing staff and visitors.

  • Appropriate signage: Isolation rooms should be clearly marked with appropriate signage indicating the type of isolation required (e.g., "Contact Isolation," "Airborne Precautions"). Signage serves as a visual reminder to staff and visitors about necessary precautions.

In summary, Section IPC2 comprehensively addresses the resource dimension of infection prevention and control. It emphasizes management commitment, dedicated budgeting, and the provision of essential supplies and facilities, all of which are indispensable for a successful and effective IPC program that safeguards patients, staff, and the wider healthcare environment.

IPC3: Implementation of Infection Prevention and Control Programme in Clinical Areas

Section IPC3 shifts the focus from program infrastructure and resources to the practical application of the Infection Prevention and Control (IPC) program directly within the clinical environment. It addresses the 'doing' of IPC, ensuring that the policies and procedures established are actively implemented at the point of care, where patient interactions and potential infection risks are highest. This section is about translating the documented program into tangible actions and behaviors by healthcare providers in their daily clinical practice. The overall standard of IPC3 remains consistent with the 5th edition, signifying the continuous importance of effective clinical implementation. However, the interpretation of specific objective elements, like IPC 3a and IPC 3e, have been modified in the 6th edition, likely to reflect evolving best practices and a sharper focus on particular aspects of clinical IPC.

IPC3a: Adherence to Standard Precautions at All Times

IPC3a is a cornerstone of clinical infection prevention, mandating that the organization ensures adherence to standard precautions at all times and in all areas. This objective element, designated as Core Objective (CO), highlights the fundamental and non-negotiable nature of standard precautions in preventing healthcare-associated infections. The interpretation has been modified in the 6th edition, likely to reinforce its pervasive and consistent application.

Standard precautions are a set of basic infection control practices intended to prevent transmission of pathogens from blood and body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. They are considered 'standard' because they should be applied to all patients, regardless of their known or suspected infection status. This approach is based on the principle that infectious agents can be present in any patient, and therefore, routine precautions are essential to minimize transmission risks.

The key aspects of IPC3a are:

• Adhere to standard precautions: This is the core requirement. It means that all healthcare providers, in all roles and departments, must consistently practice standard precautions as defined by established guidelines (e.g., CDC guidelines, WHO guidelines).

• In all areas of the organisation: Standard precautions are not limited to specific high-risk areas like ICUs or operating rooms; they apply universally across the entire healthcare facility, including wards, outpatient clinics, administrative areas, and support services. Infection risks exist everywhere, even in seemingly low-risk settings.

• At all times: Adherence to standard precautions should be continuous and unwavering. It is not a practice to be applied selectively or only when suspicion of infection is high. Routine and consistent application is key to its effectiveness.

The note emphasizes the foundational nature of standard precautions:

• Note: Standard precautions is one of the fundamental tenets of infection prevention and control. This reinforces that standard precautions are not just one element of IPC, but a fundamental pillar upon which all other infection control strategies are built. Without consistent adherence to standard precautions, even the most sophisticated IPC program will be significantly undermined.

Examples of standard precautions include:

• Hand hygiene: Performing hand hygiene (hand washing with soap and water or using alcohol-based hand rub) before and after patient contact, after removing gloves, after contact with body fluids, and after touching potentially contaminated surfaces.

• Use of personal protective equipment (PPE): Wearing gloves when there is a potential for contact with blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin; wearing masks and eye protection when procedures may generate splashes or sprays of body fluids; wearing gowns to protect skin and clothing during procedures where soiling is likely.

• Safe injection practices: Using aseptic technique when administering injections, using single-use vials and syringes, and proper disposal of sharps.

• Respiratory hygiene/cough etiquette: Covering mouth and nose when coughing or sneezing, using tissues and disposing of them properly, performing hand hygiene after contact with respiratory secretions, and separating individuals with respiratory symptoms in waiting areas.

• Safe handling of potentially contaminated equipment or surfaces: Cleaning and disinfecting frequently touched surfaces and equipment, proper handling and disposal of linen and waste.

IPC3b: Adherence to Hand-Hygiene Guidelines

Building upon the foundation of standard precautions, IPC3b specifically focuses on adherence to hand-hygiene guidelines. This objective element is also designated as Core Objective (CO), further underscoring the paramount importance of hand hygiene in preventing infections.

Hand hygiene is not just a component of standard precautions; it is often cited as the single most critical action to reduce the transmission of pathogens in healthcare settings. IPC3b ensures that the organization actively promotes and monitors adherence to established hand hygiene guidelines.

The key elements of IPC3b are:

• Adhere to international/national guidelines: The organization must adopt and implement evidence-based hand hygiene guidelines from recognized international bodies like the World Health Organization (WHO) and national bodies. These guidelines provide detailed recommendations on hand hygiene techniques, timing, and appropriate agents (soap and water vs. alcohol-based hand rub). Adhering to these guidelines ensures practice is aligned with best evidence.

• Display necessary instructions near every hand-washing area: To reinforce proper technique and encourage compliance, clear and concise hand hygiene instructions must be prominently displayed near every hand-washing area. These instructions should outline the recommended steps for hand washing and/or hand rubbing, using visual aids and simple language. Making instructions readily visible serves as a constant reminder and guide.

The note refers to a specific and authoritative resource:

• Note: For more information, refer WHO guidelines on hand hygiene in healthcare (2009). This directs users to the WHO Guidelines on Hand Hygiene in Healthcare (2009), which are a globally recognized and comprehensive resource for evidence-based hand hygiene practices. Using these guidelines as a primary reference ensures alignment with international best practice.

Effective implementation of IPC3b requires a multi-faceted approach:

• Education and Training: Regular and ongoing training for all healthcare providers on proper hand hygiene techniques, indications for hand hygiene, and the importance of hand hygiene in preventing infections.

• Accessibility of Hand Hygiene Facilities: As emphasized in IPC2c, ensuring hand hygiene facilities (both washbasins and hand rub dispensers) are readily available and conveniently located in all patient care areas is crucial.

• Monitoring and Feedback: Implementing a system to monitor hand hygiene compliance through direct observation or indirect methods, and providing regular feedback to staff on their performance.

• Promotion and Reinforcement: Creating a culture of hand hygiene through ongoing promotional campaigns, leadership support, and making hand hygiene a visible priority.

IPC3c: Adherence to Transmission-Based Precautions

While standard precautions are applied to all patients, transmission-based precautions are additional precautions used for patients with known or suspected infections that are spread through specific routes of transmission. IPC3c mandates that the organization ensures adherence to these transmission-based precautions. This objective element is a Commitment level element, signifying its crucial role in controlling specific infection risks.

Transmission-based precautions are designed to interrupt the chain of infection for specific pathogens and routes of transmission. They are used in addition to standard precautions, not as a replacement. The three main categories of transmission-based precautions are:

• Contact Precautions: Used for infections spread by direct or indirect contact (e.g., MRSA, VRE, C. difficile). Involve wearing gloves and gowns upon entry into the patient's room, dedicated patient care equipment, and emphasizing hand hygiene.

• Droplet Precautions: Used for infections spread by large respiratory droplets (e.g., influenza, pertussis, N. meningitidis). Involve wearing a surgical mask when within close proximity of the patient, and patient placement in a single room is preferred.

• Airborne Precautions: Used for infections spread by small airborne particles that can remain suspended in the air (e.g., tuberculosis, measles, varicella). Involve wearing an N95 respirator upon entry into the room, patient placement in a negative pressure room, and limiting patient movement outside the room.

The key elements of IPC3c are:

• Take transmission-based precautions: Healthcare providers must consistently implement the appropriate transmission-based precautions when indicated, based on the patient's diagnosis or suspected infection.

• Follow in all areas of the organisation: Transmission-based precautions are not limited to isolation rooms; they must be followed in all areas of the hospital where patients requiring these precautions are present, including transport, diagnostic areas, and therapy areas.

• Identify and use appropriate PPE: Correctly identifying and utilizing the appropriate personal protective equipment (PPE) is essential for transmission-based precautions. This includes selecting the correct type of mask (surgical mask vs. N95 respirator), gown type, gloves, and eye protection based on the specific transmission route and risk.

The Points to Remember section reinforces the scope:

• Points to Remember: Precautions should be taken for all modes of transmission: This explicitly emphasizes that transmission-based precautions must address all relevant modes of transmission:

  • Airborne

  • Droplet

  • Contact

The note directs users to a valuable resource:

• Note: For more information, refer CDC guidelines. This encourages users to consult CDC guidelines for detailed information on transmission-based precautions, including specific recommendations for various infections and clinical scenarios. CDC guidelines are a widely recognized and authoritative source for these practices.

Successful implementation of IPC3c depends on:

• Accurate Identification of Infections: Prompt and accurate diagnosis of infections requiring transmission-based precautions.

• Clear Policies and Procedures: Well-defined policies and procedures outlining when and how to implement each type of transmission-based precaution.

• Education and Training: Thorough staff training on different types of transmission-based precautions, including proper PPE selection, donning and doffing techniques, and room placement.

• Availability of Resources: Ensuring readily available supplies of appropriate PPE, signage for isolation rooms, and negative pressure rooms when needed.

• Monitoring and Auditing: Regular monitoring of adherence to transmission-based precaution protocols and providing feedback to staff.

IPC3d: Adherence to Safe Injection and Infusion Practices

IPC3d focuses on a critical area of patient safety: adherence to safe injection and infusion practices. This objective element, designated as Core Objective (CO), highlights the importance of preventing infections associated with invasive procedures like injections and infusions.

Unsafe injection and infusion practices can lead to the transmission of bloodborne pathogens (e.g., hepatitis B, hepatitis C, HIV) and other infections. IPC3d aims to minimize these risks through consistent adherence to safe practices.

The core message is visually represented by the image:

• ONE NEEDLE, ONE SYRINGE, ONLY ONE TIME. This powerful visual encapsulates the fundamental principle of safe injection practices. It means that needles and syringes are strictly single-use, never to be reused on another patient or even to access multiple doses from a single-dose vial.

Key aspects of safe injection and infusion practices embedded in IPC3d include:

• Aseptic technique: Using aseptic technique for preparation and administration of injectable medications, including hand hygiene, disinfection of vial stoppers, and avoiding contamination of needles and syringes.

• Single-dose vials for single patient use: Using single-dose vials whenever possible and discarding any unused portion. Multi-dose vials should be used cautiously and only when necessary, with strict adherence to manufacturer's instructions for use and expiration dating after opening.

• Needle and syringe safety: Utilizing safety-engineered needles and syringes whenever possible to prevent needle-stick injuries, and proper disposal of sharps in designated sharps containers.

• Proper IV infusion practices: Using aseptic technique for insertion and maintenance of intravenous catheters, appropriate disinfection of catheter hubs, and timely replacement of IV catheters and administration sets according to established guidelines.

• Medication preparation in clean environment: Preparing injectable medications in a clean and designated area, minimizing potential contamination.

The note provides a valuable resource:

• Note: For more information, refer WHO best practices for injections and related procedures toolkit. This directs users to the WHO's "Best Practices for Injections and Related Procedures Toolkit," a comprehensive resource that details evidence-based recommendations for safe injection and infusion practices across various settings. Using this toolkit as a reference helps ensure the hospital’s practices align with global best practices.

Implementation of IPC3d effectively requires:

• Policies and Procedures: Clear policies and procedures on safe injection and infusion practices, based on evidence-based guidelines.

• Training and Competency: Comprehensive training for all healthcare providers who administer injections or infusions, ensuring competency in aseptic technique and safe practices.

• Availability of Safe Supplies: Providing readily available supplies of single-use needles and syringes, safety-engineered devices, sharps containers, and appropriate disinfectants.

• Monitoring and Auditing: Regular monitoring of adherence to safe injection and infusion practices and providing feedback to staff to improve compliance.

IPC3e: Appropriate Antimicrobial Usage Policy

IPC3e moves into the realm of antimicrobial stewardship, focusing on the establishment and documentation of an appropriate antimicrobial usage policy. This objective element, designated as Commitment level (C), recognizes the critical importance of responsible antimicrobial use to combat antimicrobial resistance (AMR). The interpretation has been modified in the 6th edition, likely to emphasize the shift from 'antibiotics' to 'antimicrobials' and to reflect the broader scope of antimicrobial stewardship.

The rise of antimicrobial resistance is a global health threat. Inappropriate antimicrobial use is a major driver of resistance. IPC3e aims to promote rational and evidence-based antimicrobial prescribing within the hospital through a structured policy. The scope has broadened from focusing solely on antibiotics to encompassing antimicrobials, reflecting the need to manage resistance to antifungal, antiviral, and other antimicrobial agents as well.

The policy development process should consider several key factors based on clinical conditions:

• Based on the clinical conditions, identify: The policy should be clinically driven and tailored to the specific infectious disease landscape and patient population of the hospital.

  • Type of antimicrobial agent. For example: Antibiotics, anti-fungal agents, anti-viral agents: The policy must address the usage of various types of antimicrobial agents, not just antibiotics, but also antifungals and antivirals, reflecting the need for stewardship across all classes of antimicrobials.

  • Method of administration. For example: Monotherapy vs combination therapy: The policy should guide decisions regarding the route of administration (oral, intravenous, etc.) and whether monotherapy or combination therapy is more appropriate for different infections, based on evidence and local resistance patterns.

  • Approach to be used. For example: Escalation or de-escalation of therapy: The policy should address strategies like antibiotic escalation (starting with narrow-spectrum and broadening if needed) and de-escalation (narrowing therapy once culture results are available and clinical improvement occurs) to optimize antimicrobial use and minimize broad-spectrum antibiotic pressure.

  • Dose and duration of antimicrobial therapy: The policy should promote evidence-based dosing and duration of therapy for common infections, avoiding unnecessarily high doses or prolonged courses, which can increase the risk of resistance and adverse effects.

Furthermore, the policy development and implementation should include:

• Develop a system to monitor antimicrobial susceptibility (based on culture sensitivity): Establishing a robust system to monitor local antimicrobial susceptibility patterns through regular analysis of culture and sensitivity data is critical. This data informs the development of empirical treatment guidelines and helps track emerging resistance.

• Refer to national and international guidelines from professional societies while framing antimicrobial policy: The policy should be informed by and aligned with national and international guidelines from professional societies and expert bodies in infectious diseases and antimicrobial stewardship. This ensures the policy is evidence-based and reflects best practices.

The Points to Remember section further elaborates on key aspects:

• Points to Remember: Organisation: These points pertain to organizational considerations for effective antimicrobial usage policy.

  • It is preferable to have standardised methodology for antibiotic susceptibility testing: Standardizing laboratory methods for antibiotic susceptibility testing ensures consistency and comparability of results across the hospital, which is crucial for accurate surveillance and policy development.

• Antimicrobial usage policy: These points are specific to the content and implementation of the antimicrobial usage policy.

  • It should identify list of restricted antimicrobial agents, if any: The policy should clearly identify any restricted antimicrobial agents that require pre-authorization or have specific prescribing guidelines. Restricting certain broad-spectrum or high-risk antibiotics can be a valuable stewardship strategy.

  • it also considers introducing audit & formulary restrictions: The policy should consider incorporating audit and feedback mechanisms to monitor antimicrobial prescribing practices and identify areas for improvement. Formulary restrictions can also be used to limit access to certain antimicrobials or promote preferred agents.

  • It should be reviewed periodically (at least every year) for continuing applicability: The antimicrobial usage policy is not static; it needs to be reviewed and updated at least annually, or more frequently if needed, to reflect changes in local resistance patterns, new antimicrobial agents, and updated guidelines.

Further guidance is provided on resources for policy development:

• Refer national and international guidelines: These are specific examples of guidelines to consult.

  • To develop antibiotic policy: Step-by-step approach for development and implementation of hospital antibiotic policy and standard treatment guidelines (2011) by WHO: The WHO's step-by-step guide provides a structured framework for developing and implementing a comprehensive hospital antibiotic policy and standard treatment guidelines.

  • While framing antimicrobial usage policy: Ministry of Health's National Treatment Guidelines for Antimicrobial Use in Infectious Diseases and Indian Council of Medical Research's Treatment Guidelines for Antimicrobial Use in Common Syndromes: These national guidelines (from India in this example) provide regionally relevant recommendations for antimicrobial use that should be considered in policy development.

  • The restricted antimicrobials shall adhere to WHO's AWaRe classification: The WHO's AWaRe (Access, Watch, Reserve) classification of antibiotics provides a framework for categorizing antibiotics based on their risk of promoting resistance and should be considered when defining restricted agents and stewardship strategies.

IPC3f: Implementation of Antimicrobial Stewardship Program

Building upon the policy framework of IPC3e, IPC3f mandates the implementation of an antimicrobial stewardship program and the active monitoring of antimicrobial agent use. This objective element is also designated as Core Objective (CO), emphasizing that having a policy is not enough; active implementation and monitoring are essential to achieve real-world impact on antimicrobial use and resistance.

An antimicrobial stewardship program is a structured and systematic approach to optimize antimicrobial use, improve patient outcomes, reduce antimicrobial resistance, and minimize adverse consequences of antimicrobial use. IPC3f calls for a program, implying a comprehensive and proactive approach, not just isolated interventions.

Key components of implementing an effective antimicrobial stewardship program, as implied by IPC3f, include:

• Prescribe antimicrobial agents (Based on organisation's policy): Prescribing practices should be guided by the hospital's antimicrobial usage policy (developed in IPC3e). This means promoting adherence to treatment guidelines, encouraging appropriate antimicrobial selection, dosing, and duration, and discouraging inappropriate use.

• Implement mechanism for ordering restricted antimicrobial agents: If the policy includes restricted antimicrobials, a clear mechanism for ordering these agents must be implemented. This may involve pre-authorization requirements, infectious disease specialist consultation, or other strategies to ensure appropriate use of these restricted agents.

• Inform deviations to the concerned clinicians: A system to monitor and identify deviations from the antimicrobial usage policy is crucial. When deviations are identified (e.g., inappropriate antibiotic selection, prolonged duration of therapy), concerned clinicians should be informed and provided with feedback and education to improve future prescribing.

• Perform CAPA (Corrective and Preventive Action): Data from antimicrobial use monitoring and audits should be analyzed to identify trends and areas for improvement. Corrective and preventive actions (CAPA) should be implemented to address identified issues, such as revising treatment guidelines, providing targeted education, or implementing new stewardship interventions.

• Document actions taken: All stewardship activities, including monitoring data, feedback provided to clinicians, CAPA implemented, and outcomes, should be documented. Documentation provides a record of stewardship efforts, facilitates tracking progress, and supports accountability.

The notes expand on the underlying principles and aims of stewardship:

• Note: The organisation should have a mechanism for monitoring appropriate use of restricted antimicrobial agents: This reinforces the importance of specifically monitoring the use of restricted antimicrobials to ensure they are being used judiciously and in accordance with policy.

• Note: Organization creates awareness amongst healthcare providers and community for AMR & rational use of antimicrobials: Stewardship extends beyond just clinicians and policies; it requires fostering a culture of responsible antimicrobial use. Raising awareness about antimicrobial resistance (AMR) and promoting the rational use of antimicrobials amongst healthcare providers and the community is a crucial element of a successful program. This broader awareness contributes to long-term behavior change and improved antimicrobial use practices.

The program itself should be guided by core principles:

• Guide: Efforts for improving appropriate and necessary antibiotic use: The overarching goal of the stewardship program is to improve the appropriateness and necessity of antibiotic (and antimicrobial) use. This means ensuring antibiotics are used only when needed, selecting the right antibiotic for the infection, at the correct dose, for the optimal duration, and via the most appropriate route of administration.

• Include: Leadership, commitment, accountability, drug expertise, action, tracking, reporting and education: Effective stewardship requires a multi-faceted approach encompassing:

  • Leadership commitment: Strong leadership support from hospital administration and clinical leaders is essential to prioritize and resource stewardship efforts.

  • Accountability: Clearly defined roles and responsibilities for stewardship activities and accountability for antimicrobial prescribing practices.

  • Drug expertise: Involvement of pharmacists and infectious disease specialists with expertise in antimicrobial therapy is crucial to provide clinical guidance and support stewardship interventions.

  • Action: Implementing a range of stewardship interventions, such as prospective audit and feedback, pre-authorization, formulary restriction, and guideline development.

  • Tracking: Establishing systems to track antimicrobial use, resistance patterns, and outcomes of stewardship interventions.

  • Reporting: Regular reporting of stewardship data to relevant stakeholders, including hospital administration, clinicians, and infection control committee.

  • Education: Ongoing education and training for healthcare providers on antimicrobial stewardship principles, best prescribing practices, and local resistance data.

By implementing IPC3 comprehensively, hospitals ensure that the principles of infection prevention and control are not just theoretical concepts but are actively and consistently put into practice across all clinical areas, protecting patients and staff from the risks of healthcare-associated infections and contributing to the fight against antimicrobial resistance.

IPC4: Implementation of the Infection Prevention and Control Programme in Support Services

Section IPC4 of the NABH 6th Edition standards broadens the scope of Infection Prevention and Control (IPC) beyond direct patient care areas, emphasizing its critical implementation within support services. Hospitals are complex ecosystems where infection risks can originate and propagate not only from clinical activities but also from seemingly ancillary services. IPC4 recognizes that effective IPC requires a holistic approach, extending its principles and practices to support departments that, while not directly involved in patient treatment, significantly impact the overall hospital environment and infection risk. This section ensures that support services are integrated into the IPC program, contributing proactively to a safer healthcare setting. The standard for IPC4 has been modified in the 6th edition, and objective element IPC 4d is also modified, suggesting a refined emphasis or updated requirements within this domain.

IPC4a: Appropriate Engineering Controls to Prevent Infections

IPC4a focuses on the crucial role of engineering controls in preventing infections within the hospital environment. This objective element, a Commitment level (C) requirement, highlights that physical infrastructure and engineering systems are not passive elements, but rather active components of an effective IPC program. Engineering controls are designed to eliminate or reduce hazards at the source, providing a more sustainable and less error-prone approach to infection prevention compared to solely relying on administrative controls or personal protective equipment.

The standard addresses engineering controls across several key areas:

• Hospital setting: This refers to the fundamental design and layout of hospital spaces to minimize infection risks from the outset.

  • Design of patient care areas (One-two metres spacing between beds): The physical spacing between patient beds in care areas is a crucial engineering control. Maintaining a minimum of one to two meters spacing, where feasible, helps to reduce droplet and contact transmission of infections between patients. Adequate spacing promotes better air circulation and reduces the likelihood of direct contact or contaminated droplet deposition between beds.

  • Design of operating rooms: Operating rooms (OTs) require specialized engineering controls due to the invasive nature of surgical procedures. This includes considerations like laminar airflow systems, controlled air pressure gradients, and appropriate materials and finishes that facilitate cleaning and disinfection. OT design aims to minimize airborne contamination and create a sterile environment for surgery.

• Air quality checks: Maintaining good air quality within the hospital, particularly in critical areas, is essential for preventing airborne infections.

  • Maintenance of AC plant and equipment: Regular and scheduled maintenance of air conditioning (AC) plants and associated equipment is crucial. This includes cleaning, inspection, and repair to ensure optimal functionality and prevent the AC system from becoming a source of contamination itself. Poorly maintained AC systems can harbor and disseminate pathogens.

  • Cleaning AC ducts/filters and air handling units: AC ducts, filters, and air handling units can accumulate dust, mold, and other contaminants over time. Regular cleaning and replacement of filters are essential to maintain air quality and prevent the recirculation of contaminated air. Specific protocols for cleaning and filter replacement should be in place.

  • Cleaning/replacement of filters: Filters in AC systems act as the primary barrier to remove airborne particles. Regular replacement, according to manufacturer's recommendations and hospital protocols, is vital for maintaining filter efficiency. Clogged or overdue filters lose their effectiveness and can even become sources of contamination.

  • Prevention of fungal colonisation: Humidity and moisture in AC systems can promote fungal growth. Engineering controls should include measures to control humidity levels and prevent condensation within ducts and units, minimizing the risk of fungal colonization and subsequent airborne fungal infections. Regular inspections and appropriate biocides, where necessary, are important.

• Water management: Water systems in hospitals can be a source of waterborne pathogens like Legionella and Pseudomonas. Effective water management is a key engineering control.

  • Water supply sources: The source of hospital water supply (municipal, well, etc.) and its treatment processes need to be understood and monitored. Appropriate water treatment and disinfection at the source are fundamental.

  • System of supply: The entire water distribution system within the hospital, including piping, storage tanks, and fixtures, needs to be designed and maintained to minimize stagnation, biofilm formation, and dead legs, all of which can promote microbial growth. Regular flushing and temperature control are important.

  • Testing for water quality: Regular testing of hospital water for bacterial counts, Legionella, and other relevant waterborne pathogens is essential to verify the effectiveness of water management measures and identify potential contamination issues early. A defined water quality monitoring plan should be in place.

The note directs users to specific guidance:

• Note: For more information, refer NABH guidelines on OT air-conditioning. This indicates that NABH provides specific guidelines related to air-conditioning systems in operating theatres, reflecting the heightened importance of air quality in these critical areas. These guidelines should be consulted for detailed requirements and best practices.

IPC4b: Plan to Reduce the Risk of Infection during Construction and Renovation

Hospital construction and renovation projects, while necessary for facility upgrades and expansion, can significantly disrupt the hospital environment and increase the risk of infections if not properly managed. IPC4b mandates that the organization designs and implements a plan to reduce the risk of infection during construction and renovation projects. This is a Commitment level (C) requirement, emphasizing the proactive approach needed to mitigate these risks.

Construction and renovation activities can generate dust, debris, and disrupt air and water systems, potentially exposing patients and staff to increased infection hazards, especially airborne fungal spores like Aspergillus. A well-structured Infection Control Risk Assessment (ICRA) plan is essential to manage these risks effectively.

The standard breaks down the implementation into two core phases:

• Design: The planning phase of construction and renovation projects must incorporate infection control considerations from the outset.

  • Use a validated tool to identify risk of infection. For example: Infection control risk assessment (ICRA) tool: Before any construction or renovation work begins, a comprehensive Infection Control Risk Assessment (ICRA) must be conducted. This ICRA should utilize a validated tool to systematically identify and evaluate potential infection risks associated with the project, considering factors like the type of construction, location within the hospital, patient population in the area, and potential disruptions to essential services. Several validated ICRA tools are available, and selecting an appropriate one is crucial.

• Implement: Following the risk assessment, specific infection prevention and control measures must be implemented throughout the construction and renovation process.

  • Infection prevention and control measures: Based on the ICRA findings, a detailed plan of infection prevention and control measures must be developed and rigorously implemented. These measures are tailored to the specific risks identified and may include:

    • Containment: Establishing physical barriers (e.g., plastic sheeting, temporary walls) to contain dust and debris within the construction zone and prevent its spread to patient care areas.

    • Air handling: Managing air flow to prevent contaminated air from construction areas from entering patient areas. This may involve using negative air machines and sealing off ventilation systems.

    • Dust control: Implementing dust control measures such as wet mopping, HEPA filtration vacuums, and surface cleaning within and around the construction zone.

    • Traffic control: Managing traffic flow of construction workers, materials, and equipment to minimize disruption and potential contamination pathways.

    • Hand hygiene and PPE: Ensuring construction workers adhere to hand hygiene protocols and use appropriate PPE, such as masks and respirators.

    • Water management: Preventing water contamination related to construction activities, especially if plumbing systems are affected.

    • Waste management: Properly managing and disposing of construction waste to minimize dust and contamination.

    • Monitoring: Regularly monitoring air quality, dust levels, and compliance with infection control measures throughout the project duration.

The note emphasizes collaboration:

• Note: Any renovation work (For example: Architectural segregation, traffic flow and use of materials) should be planned with the infection control team. This underscores the critical importance of involving the infection control team early in the planning stages of any renovation or construction project. The infection control team's expertise is essential for conducting the ICRA, developing the IPC plan, and providing ongoing oversight throughout the project. Architectural decisions, traffic flow patterns, and material choices can all have significant IPC implications, and proactive consultation with the IPC team is crucial.

IPC4c: Adherence to Housekeeping Procedures

IPC4c focuses on the fundamental role of housekeeping procedures in maintaining a clean and safe hospital environment. This is a Core Objective (CO) requirement, emphasizing that consistent and effective housekeeping is not merely an aesthetic concern, but a cornerstone of infection prevention. Effective housekeeping removes visible dirt and dust, reduces microbial load on surfaces, and helps to break the chain of infection.

The standard addresses housekeeping procedures across several dimensions:

• All levels: Housekeeping procedures must be applied comprehensively across all areas of the hospital.

  • Address different areas of the organisation. For example: Wards, OT and public areas including toilets and corridors: Housekeeping is not limited to patient rooms and clinical areas; it must encompass all areas of the hospital, including wards, operating theatres (OTs), public areas like waiting rooms and corridors, and even non-clinical areas. Consistent cleanliness across the entire facility contributes to a safer overall environment.

• Cleaning: The core function of housekeeping is effective cleaning.

  • Cleaning: Regularly clean to remove visible dirt and dust in the environment and all surfaces. Cleaning must be performed regularly and effectively to remove visible dirt, dust, and organic matter from the environment and all surfaces. Regularity of cleaning is determined by risk stratification.

  • For example: Fixtures, fomites, furniture, furnishings and equipment: Cleaning must target all types of surfaces, including fixtures (sinks, toilets), fomites (door handles, light switches), furniture, furnishings, and medical equipment that is not subject to sterilization or high-level disinfection. Consistent cleaning of these surfaces reduces the reservoir of potential pathogens.

• Frequency of cleaning: Cleaning frequency should be risk-based.

  • Frequency of cleaning: Use risk stratification matrix to determine frequency: A risk stratification matrix should be used to determine appropriate cleaning frequencies for different areas based on their level of contamination risk. High-touch surfaces in high-risk areas (e.g., ICUs, patient rooms) require more frequent cleaning than low-touch surfaces in low-risk areas (e.g., administrative offices). Risk-based cleaning optimizes resource allocation and targets cleaning efforts where they are most needed.

• Physical environment: Categorizing the physical environment based on risk is essential for tailoring housekeeping protocols.

  • Physical environment: Divide into several areas based on risk of transmitting microorganisms: The hospital environment should be divided into distinct areas based on their potential risk of transmitting microorganisms. This categorization guides the selection of appropriate cleaning methods, disinfectants, and frequencies.

The Points to Remember section elaborates on criteria for risk classification and uniform policy:

• Points to Remember: Criteria for classifying physical environment: These criteria help in objectively classifying areas based on risk.

  • Number of footfalls: Areas with higher foot traffic (e.g., corridors, waiting rooms) tend to have higher levels of surface contamination and may require more frequent cleaning.

  • Type of activity performed. For example: Clinical vs. non-clinical: Clinical areas where patient care is provided (wards, ICUs, procedure rooms) have a higher risk of contamination than non-clinical areas (offices, storage rooms) and require more stringent cleaning protocols.

  • Probability of being exposed to body fluids. For example: OT or lab: Areas with a higher probability of exposure to body fluids (e.g., operating theatres, laboratories, emergency departments) have the highest risk of contamination and require the most rigorous cleaning and disinfection procedures.

• Identify common disinfectants: Proper disinfectant selection and usage are critical for effective housekeeping.

  • Identify common disinfectants: Select appropriate disinfectant, establish its dilution protocols and compile its usage in appropriate situation: The hospital should identify common disinfectants appropriate for use in healthcare settings. For each disinfectant, clear dilution protocols must be established and strictly followed to ensure efficacy. A compilation of disinfectant usage guidelines for different situations (routine cleaning, blood spills, etc.) should be readily available to housekeeping staff.

• Terminal cleaning: Terminal cleaning is a more thorough cleaning process performed after a patient is discharged or transferred from a room.

  • Terminal cleaning: Follow appropriate protocols for terminal cleaning, blood and body fluid clean up and cleaning isolation rooms: Standardized protocols for terminal cleaning, blood and body fluid spill clean-up, and cleaning of isolation rooms are essential. These protocols should specify cleaning agents, procedures, and PPE requirements for housekeeping staff.

• Points to remember: It is preferable that organisation follows uniform housekeeping policy across different departments: While cleaning frequencies and specific procedures may vary based on risk stratification, a uniform overarching housekeeping policy across all departments is desirable. This ensures consistency in standards, training, and accountability throughout the hospital.

• Points to remember: Do not dust inside clinical areas: Traditional dusting methods using dry cloths can actually disperse dust and microorganisms into the air. "Dusting" in clinical areas should be performed using damp cloths or microfiber cloths to trap dust rather than spreading it.

The note directs users to key resources:

• Note: For more information, refer CDC Guideline for Disinfection and Sterilisation in Healthcare Facilities, 2008 and Swachhta Guidelines for Public Health Facilities. This points to two authoritative resources: the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008) and Swachhta Guidelines for Public Health Facilities (relevant in the Indian context). These guidelines provide detailed recommendations on cleaning, disinfection, and sterilization procedures in healthcare settings.

IPC4d: Biomedical Waste (BMW) is Handled Appropriately and Safely

IPC4d addresses the critical issue of Biomedical Waste (BMW) management. This is a Core Objective (CO) requirement, underscoring the importance of safe and compliant BMW handling to protect patients, staff, and the environment from the hazards associated with medical waste. The objective element is modified in the 6th edition, likely reflecting updated regulations or a refined emphasis on specific aspects of BMW management.

Biomedical waste, if not handled properly, can pose significant risks of infection transmission, sharps injuries, and environmental contamination. IPC4d ensures a comprehensive and compliant BMW management system.

The standard outlines key steps in BMW handling:

• Handle: Safe handling of BMW begins with appropriate personal protection.

  • Handle: Wear appropriate PPE: All personnel handling biomedical waste must wear appropriate Personal Protective Equipment (PPE), including gloves, masks, eye protection, and gowns, to protect themselves from exposure to infectious materials and sharps injuries. PPE selection should be based on the type of waste being handled.

• Segregate: Waste segregation at the point of generation is fundamental to effective BMW management.

  • Segregate: BMW in patient-care areas: Biomedical waste must be segregated from general waste at the point of generation, which is primarily in patient-care areas. This segregation must be done immediately and not delayed. Proper segregation is the first step in compliant and safe BMW handling.

• Collect: Segregated BMW must be collected in designated containers according to color-coding and container specifications.

  • Collect: In different colour-coded bags and containers (as per statutory provisions): BMW must be collected in different colour-coded bags and rigid containers, as mandated by statutory regulations and guidelines (e.g., Bio-medical Waste Management Rules in India). Color-coding is essential for visual identification and proper subsequent handling of different categories of BMW. Containers must also meet specific standards for leak-proofness and puncture-resistance, especially for sharps.

• Store: Collected BMW must be stored safely and in compliance with regulations while awaiting collection and disposal.

  • Store: In accordance with statutory provisions: Storage of BMW must be in accordance with statutory provisions. This includes designated storage areas, temperature control if required, security measures to prevent unauthorized access, and time limits for storage before collection. Compliance with storage regulations is crucial to prevent environmental contamination and public health risks.

• Dispose: Final disposal of BMW must be through authorized channels and methods.

  • Dispose: Handover BMW to authorised vendor for transport to the site of treatment and disposal: Hospital BMW must be handed over to authorized vendors or agencies that are licensed and equipped to transport, treat, and dispose of BMW in a compliant and environmentally sound manner. The hospital remains responsible for ensuring the vendor is authorized and follows proper disposal procedures.

The image and note further clarify key aspects:

• Image: The image depicts examples of BMW categories and corresponding color-coded containers. It visually reinforces the segregation and color-coding principles. Categories shown include:

  • General Waste (Green)

  • Infected Plastics (Red)

  • Infected Waste (Yellow)

  • Cytotoxic Waste (Yellow with black cytotoxic symbol)

  • Glassware (Blue/White translucent)

  • Sharps (White puncture-proof container)
    This visual aid is helpful for training staff on proper BMW segregation.

• Note: The members of the infection control committee/team should monitor BMW management process. The infection control committee or team has a critical oversight role in BMW management. They are responsible for monitoring all aspects of the BMW management process, from segregation at source to final disposal, to ensure compliance with regulations and effective risk mitigation. Regular audits and inspections of BMW handling practices are essential.

IPC4e: Adherence to Laundry and Linen Management Processes

IPC4e focuses on the often-overlooked but important area of laundry and linen management. This is a Commitment level (C) requirement, recognizing that improper linen handling can contribute to the spread of infections within hospitals. Contaminated linen can harbor microorganisms and serve as a vehicle for transmission if not managed effectively.

The standard addresses linen management across its entire cycle:

• Handling soiled linen: Safe handling of soiled linen is crucial to prevent cross-contamination and exposure risks.

  • Handling soiled linen: Implement defined process in patient care units, during transport to laundry and inside laundry: A clearly defined process for handling soiled linen must be implemented and followed consistently in patient care units, during transport to the laundry facility, and within the laundry facility itself. This process should address:

    • Safe collection: Collecting soiled linen in designated, leak-proof, and appropriately labeled bags or containers at the point of use. Avoidance of sorting or pre-rinsing in patient care areas is crucial.

    • Minimize handling: Minimizing manual handling of soiled linen to reduce aerosolization of microorganisms and contact exposure.

    • Transport procedures: Secure and covered transport of soiled linen to prevent spills and environmental contamination.

    • Laundry worker protection: Providing laundry workers with appropriate PPE and training on safe handling procedures.

• Storage and distribution of clean linen: Maintaining the cleanliness of processed linen is just as important as properly handling soiled linen.

  • Storage and distribution of clean linen: Keep clean and dirty linen separately: Strict segregation of clean and dirty linen is paramount throughout the laundry cycle, from collection to storage and distribution. Clean linen storage areas must be physically separate from soiled linen handling and processing areas to prevent cross-contamination.

  • Compile the storage and distribution process done within the organisation: The entire process of clean linen storage and distribution within the hospital, from the laundry facility to patient care areas, must be documented and standardized. This includes defining storage conditions, transport methods, and handling procedures to maintain linen cleanliness.

• Changing linen: Proper procedures for changing patient linen also contribute to IPC.

  • Changing linen: Implement documentation regarding change of linen: Implementing a system to document linen changes, particularly for isolation patients or specific infection control interventions, can be important for tracking compliance and monitoring effectiveness. Documentation may include frequency of linen changes, type of linen used, and any specific handling precautions taken.

The Points to Remember section addresses laundry options:

• Points to Remember: Laundry:

  • Can be in-house or outsourced: Hospitals may choose to have an in-house laundry facility or outsource laundry services to external providers. Both options are viable, but regardless of the model, IPC principles must be maintained.

  • Outsourced laundry: Establish adequate measures to prevent and control infections: If laundry services are outsourced, the hospital retains responsibility for ensuring the outsourced laundry adheres to adequate infection prevention and control measures. This may involve requiring the laundry to meet specific standards, conducting audits of the laundry facility, and having a clear contractual agreement outlining IPC requirements.

IPC4f: Adherence to Kitchen Sanitation and Food-Handling Issues

IPC4f focuses on kitchen sanitation and food-handling practices, recognizing that foodborne illnesses and contamination can be a significant source of hospital-acquired infections, particularly in vulnerable patient populations. This is a Commitment level (C) requirement, highlighting the importance of maintaining high standards of hygiene in dietary services.

The standard addresses food safety from staff to storage and distribution:

• Staff: Staff involved in food preparation and handling are a critical link in food safety.

  • Staff: Screen kitchen workers and food handlers: Screening kitchen workers and food handlers for communicable illnesses (e.g., gastrointestinal infections, skin infections) is important to prevent them from becoming a source of contamination. This may involve pre-employment screening and ongoing health monitoring.

  • Prepare, handle, store and distribute food in a safe and hygienic manner: All aspects of food handling, from preparation to distribution, must be performed in a safe and hygienic manner. This includes following food safety guidelines for hand hygiene, food preparation techniques, temperature control, and prevention of cross-contamination.

• Dietary services: The design and operation of dietary services are crucial for preventing foodborne risks.

  • Dietary services: Can be either in-house or outsourced: Similar to laundry services, dietary services can be in-house or outsourced. In either case, the hospital is responsible for ensuring food safety standards are met.

  • Provide separate food preparation area: A dedicated and physically separate food preparation area, distinct from other kitchen activities and potential contamination sources, is essential. This area should be designed for hygienic food preparation with appropriate surfaces, equipment, and cleaning protocols.

  • Design in a manner that prevents criss-cross of traffic: The kitchen layout should be designed to prevent "criss-cross" traffic patterns that could lead to contamination. Raw food preparation areas should be separate from cooked food areas, and clean and dirty pathways should be clearly defined to minimize cross-contamination risks.

  • Perform all activities in a sequence: Food preparation activities should be performed in a logical sequence to minimize the risk of cross-contamination. This typically involves separating raw and cooked food handling, ensuring proper cleaning and disinfection between steps, and following a flow from raw ingredients to finished dishes.

  • Implement kitchen sanitation measures to prevent risk of cross-contamination: Comprehensive kitchen sanitation measures must be implemented to prevent cross-contamination. This includes regular cleaning and disinfection of surfaces and equipment, proper hand hygiene practices for staff, and procedures to separate raw and cooked food handling.

• Storage/refrigeration: Proper food storage, particularly refrigeration, is essential for preventing bacterial growth and food spoilage.

  • Storage/refrigeration: Provide and maintain dedicated food storage/ refrigeration area to ensure food preservation: Adequate and dedicated food storage and refrigeration facilities must be provided and maintained to ensure proper food preservation. Temperature monitoring and control within refrigeration units are essential.

  • Store food products off the floor: Food products should be stored off the floor, using shelving or pallets, to prevent contamination from floor surfaces and facilitate cleaning and pest control.

  • Ensure flies and insects do not come in contact with prepared/stored food: Measures to prevent flies and insects from accessing prepared or stored food are essential. This includes proper screening, pest control measures, and appropriate food covering or storage containers.

  • Store cleaning supplies in a separate location away from food: Cleaning supplies and chemicals should be stored in a designated location separate from food storage areas to prevent chemical contamination of food.

• Distribution: Safe food distribution is the final step in ensuring food safety reaches patients.

  • Distribution: Use temperature appropriate food service trolleys to distribute food to patients: Temperature-controlled food service trolleys, capable of maintaining food at safe temperatures (hot food hot, cold food cold), must be used to distribute food to patients. This is crucial to prevent bacterial growth during transport and maintain food safety until consumption.

The Points to Remember section emphasizes overarching organizational responsibility:

• Points to Remember: Organisation:

  • It should ensure that hygienic conditions are followed throughout the process. And, this is applicable even if the activities are outsourced: Regardless of whether dietary services are in-house or outsourced, the hospital retains ultimate responsibility for ensuring hygienic conditions are maintained throughout the entire food preparation and distribution process. This includes oversight of outsourced vendors and contractual agreements that clearly define food safety responsibilities.

  • It should adhere to statutory requirements and national and international guidelines: Food safety practices must adhere to all applicable statutory requirements, food safety regulations, and relevant national and international guidelines for food handling and hygiene in healthcare settings. Staying current with these requirements is essential for compliance and patient safety.

By diligently implementing IPC4 across all support services, hospitals create a safer and more infection-resistant environment, demonstrating a commitment to holistic infection prevention that extends beyond direct patient care activities.

IPC5: Actions to Prevent Healthcare Associated Infections (HAI) in Patients

Section IPC5 marks a critical transition from establishing the infrastructure and programs for Infection Prevention and Control (IPC) to actively implementing specific strategies to prevent Healthcare-Associated Infections (HAIs) directly in patients. This section is action-oriented, focusing on targeted interventions to reduce the incidence of key HAIs that pose significant risks to patient safety and outcomes. IPC5 emphasizes a proactive, evidence-based approach, moving beyond general precautions to implement specific bundles of care and preventative measures for common HAI types. The overall standard for IPC5 has been modified in the 6th edition, and objective element IPC 5c is also modified, suggesting an updated focus or refinement in the specific HAI prevention strategies.

IPC5a: Action to Prevent Catheter-Associated Urinary Tract Infections (CAUTI)

IPC5a specifically addresses the prevention of catheter-associated urinary tract infections (CAUTIs), the most common type of HAI globally. This objective element, designated as Commitment level (C), underscores the importance of targeted interventions to reduce CAUTI rates. CAUTIs are often preventable through diligent adherence to evidence-based practices.

The standard mandates a two-pronged approach to CAUTI prevention:

• Adhere to basic principles of infection prevention (Standard precautions and transmission-based precautions): The foundation of CAUTI prevention, as with all HAIs, lies in consistent adherence to basic infection prevention principles. This includes rigorous application of standard precautions, particularly hand hygiene before and after catheter insertion and manipulation, and appropriate use of transmission-based precautions if the patient has a known or suspected infection. These fundamental practices create a baseline of infection control that must be consistently applied.

• Develop care bundle to prevent catheter-associated urinary tract infections: Beyond basic precautions, a specific CAUTI prevention care bundle must be developed and implemented. Care bundles are sets of evidence-based practices that, when implemented together reliably, have been shown to significantly improve patient outcomes and reduce HAI rates. A CAUTI bundle typically includes elements addressing the entire lifecycle of urinary catheter use.

A comprehensive CAUTI prevention care bundle often includes the following key components:

• Appropriate Indication for Catheterization: Strict criteria for urinary catheter insertion should be established and followed. Catheters should only be inserted when medically necessary and not for routine convenience. Regular assessment of ongoing catheter necessity and prompt removal when no longer indicated is crucial.

• Aseptic Insertion Technique: Urinary catheter insertion must be performed using strict aseptic technique. This includes proper hand hygiene, sterile gloves, sterile drapes, antiseptic skin preparation (e.g., chlorhexidine), and sterile lubricant. Maintaining sterility during insertion is paramount to prevent introducing pathogens into the urinary tract.

• Closed Drainage System: Maintaining a closed urinary drainage system is essential to prevent ascending infection. The drainage system should remain intact and unobstructed, with the collection bag positioned below the level of the bladder to promote gravity drainage and prevent reflux.

• Catheter Maintenance: Proper catheter maintenance is vital to reduce infection risks over time. This includes:

  • Securing the catheter appropriately to prevent movement and urethral traction.

  • Regular periurethral hygiene with soap and water, as needed.

  • Avoiding routine catheter irrigation unless clinically indicated for obstruction.

  • Maintaining unobstructed urine flow and promptly addressing any blockage.

  • Emptying the drainage bag regularly, using aseptic technique, and preventing drainage spigot contact with contaminated surfaces.

• Staff Education and Training: Ongoing education and training for all staff involved in urinary catheter insertion, maintenance, and management is essential to ensure consistent adherence to bundle elements. Education should cover proper techniques, indications, and the importance of CAUTI prevention.

• Surveillance and Feedback: Implementing a surveillance system to monitor CAUTI rates, track catheter utilization, and identify areas for improvement. Regular feedback of surveillance data to clinical staff helps drive continuous quality improvement in CAUTI prevention efforts.

The note directs users to authoritative guidelines:

• Note: For more information, refer CDC/WHO/SHEA guidelines. This encourages users to consult guidelines from the CDC, WHO, and the Society for Healthcare Epidemiology of America (SHEA). These organizations provide widely respected and evidence-based guidelines for CAUTI prevention, offering detailed recommendations and best practices for each element of a CAUTI prevention program.

IPC5b: Action to Prevent Ventilator-Associated Pneumonia (VAP)

IPC5b focuses on the prevention of ventilator-associated pneumonia (VAP), a serious and potentially life-threatening HAI that occurs in patients requiring mechanical ventilation. This objective element, also designated as Commitment level (C), highlights the importance of specific interventions to reduce VAP incidence in ventilated patients. VAP significantly increases morbidity, mortality, and hospital length of stay.

Similar to CAUTI, the standard advocates a dual approach to VAP prevention:

• Adhere to basic principles of infection prevention (Standard precautions and transmission-based precautions): Again, consistent adherence to standard precautions and transmission-based precautions forms the essential foundation for VAP prevention. Hand hygiene before and after contact with the ventilator circuit or patient's respiratory secretions, and appropriate PPE use are crucial.

• Develop care bundle to prevent ventilator-associated pneumonia: A specific VAP prevention care bundle must be developed and rigorously implemented. VAP bundles are sets of evidence-based interventions that, when consistently applied, significantly reduce VAP rates.

A comprehensive VAP prevention care bundle typically includes the following key elements:

• Elevation of Head of Bed (HOB): Maintaining the patient's head of bed elevated to at least 30-45 degrees, unless medically contraindicated, helps to reduce aspiration of gastric contents into the lower respiratory tract.

• Oral Care with Chlorhexidine (or other antiseptic): Regular oral care with chlorhexidine (or another antiseptic agent as per hospital policy) helps to reduce oropharyngeal colonization with pathogenic bacteria, a major source of VAP pathogens.

• Subglottic Secretion Drainage (for patients with cuffed endotracheal tubes): Using endotracheal tubes with subglottic secretion drainage ports helps to remove accumulated secretions above the cuff, reducing the risk of aspiration into the lower airways.

• Ventilator Circuit Management: Proper management of the ventilator circuit includes:

  • Avoiding routine ventilator circuit changes unless visibly soiled or malfunctioning.

  • Condensate management: Draining condensate that accumulates in the ventilator circuit regularly and discarding it appropriately, preventing it from flowing back into the patient's airway.

  • Closed suction system: Using closed suction systems for airway suctioning to minimize environmental contamination and maintain a closed respiratory system.

• Early Mobilization and Weaning from Mechanical Ventilation: Early mobilization and active efforts to wean patients from mechanical ventilation as soon as medically appropriate reduces the duration of mechanical ventilation, a primary risk factor for VAP.

• Pulmonary Hygiene (e.g., Chest Physiotherapy, Suctioning as needed): Promoting pulmonary hygiene through techniques like chest physiotherapy, postural drainage, and suctioning as needed, helps to clear airway secretions and reduce the risk of aspiration and pneumonia.

• Staff Education and Training: Ongoing education and training for all staff involved in the care of mechanically ventilated patients is essential to ensure consistent implementation of all VAP bundle elements.

• Surveillance and Feedback: Implementing a surveillance system to monitor VAP rates, ventilator utilization, and adherence to bundle elements. Regular feedback of surveillance data to clinical teams drives continuous quality improvement in VAP prevention.

The note again directs users to authoritative guidelines:

• Note: For more information, refer CDC/WHO/SHEA guidelines. Similar to CAUTI, users are directed to consult guidelines from the CDC, WHO, and SHEA for detailed, evidence-based recommendations on VAP prevention bundles and best practices. These guidelines provide comprehensive information to guide the development and implementation of effective VAP prevention programs.

IPC5c: Action to Prevent Central Line Associated Blood Stream Infections (CLABSI)

IPC5c targets the prevention of central line-associated bloodstream infections (CLABSIs), a serious and often life-threatening HAI associated with central venous catheters. This objective element, also a Commitment level (C) requirement, emphasizes the critical need for targeted strategies to reduce CLABSI rates. CLABSIs are associated with significant morbidity, mortality, and increased healthcare costs. The objective element is modified in the 6th edition, likely reflecting updated best practices or renewed emphasis on specific aspects of CLABSI prevention.

The standard continues to emphasize the dual approach:

• Adhere to basic principles of infection prevention (Standard precautions and transmission-based precautions): As with CAUTI and VAP, consistent adherence to standard precautions and transmission-based precautions forms the foundation for CLABSI prevention. Hand hygiene before and after central line insertion and manipulation, and appropriate PPE are essential.

• Develop care bundle to prevent central line associated blood stream infections: A specific CLABSI prevention care bundle must be developed and implemented. CLABSI bundles are evidence-based sets of interventions that, when consistently applied, significantly reduce CLABSI rates.

A comprehensive CLABSI prevention care bundle typically includes the following key components, often referred to as the "maximal barrier precautions" bundle:

• Hand Hygiene: Rigorous hand hygiene immediately before central line insertion. This should be performed using either soap and water or alcohol-based hand rub.

• Maximal Barrier Precautions: Utilizing maximal sterile barrier precautions during central line insertion. This includes:

  • Sterile gloves.

  • Sterile gown.

  • Cap.

  • Mask.

  • Large sterile drape covering the entire patient from head to toe.

• Chlorhexidine Skin Antisepsis: Using chlorhexidine-based antiseptic for skin preparation at the insertion site, as chlorhexidine has been shown to be more effective than povidone-iodine in reducing CLABSI risk. Allowing adequate drying time for the antiseptic is crucial.

• Optimal Catheter Site Selection: Selecting the optimal insertion site to minimize infection risk, generally preferring subclavian veins over internal jugular or femoral veins in adults, when clinically appropriate. Avoiding femoral vein sites in adults is often emphasized if other sites are feasible.

• Daily Review of Line Necessity and Prompt Removal: Daily assessment of the ongoing necessity of the central line and prompt removal as soon as it is no longer clinically indicated. Reducing the duration of central line catheterization is a primary strategy to lower CLABSI risk.

• Catheter Site Care: Proper catheter site care and maintenance is essential. This includes:

  • Transparent semipermeable dressing for site coverage, allowing for visualization.

  • Dressing changes at recommended intervals or when the dressing becomes soiled, loose, or damp.

  • Using sterile technique for dressing changes.

  • Avoiding routine antimicrobial ointment application to the insertion site.

• Staff Education and Training: Ongoing education and training for all staff involved in central line insertion and maintenance is crucial to ensure consistent adherence to bundle elements. Training should include proper techniques, indications, and the importance of CLABSI prevention.

• Surveillance and Feedback: Implementing a surveillance system to monitor CLABSI rates, central line utilization, and adherence to bundle elements. Regular feedback of surveillance data to clinical teams drives continuous quality improvement in CLABSI prevention.

The note again points to authoritative guidance:

• Note: For more information, refer CDC/WHO/SHEA guidelines. Users are again directed to guidelines from the CDC, WHO, and SHEA, which provide detailed and evidence-based recommendations for CLABSI prevention bundles and best practices. These guidelines are essential resources for developing and implementing effective CLABSI prevention programs.

IPC5d: Action to Prevent Surgical Site Infections (SSI)

IPC5d focuses on preventing surgical site infections (SSIs), infections that occur in the area of a surgical incision. This objective element, also a Commitment level (C) requirement, highlights the importance of targeted measures to minimize SSI risk, as SSIs are a significant cause of postoperative morbidity, prolonged hospitalization, and increased healthcare costs.

For SSI prevention, the standard similarly emphasizes a bundled approach:

• Adhere to basic principles of infection prevention (Standard precautions and transmission-based precautions): As with all HAIs, consistent application of standard precautions and transmission-based precautions is foundational. Hand hygiene for the surgical team, appropriate surgical attire, and environmental controls in the operating room all contribute to SSI prevention.

• Develop care bundle for pre-op, intra-op and post-op measures: A comprehensive SSI prevention care bundle must be developed and implemented. Importantly, SSI prevention bundles address measures across the entire perioperative period: pre-operative, intra-operative, and post-operative phases. Effective SSI prevention requires a continuum of care approach.

A comprehensive SSI prevention care bundle typically includes elements in each phase:

• Pre-operative Measures:

  • Patient Skin Preparation: Pre-operative showering or bathing with soap or antiseptic soap (e.g., chlorhexidine). Clipping hair at the surgical site, if needed, rather than shaving, and clipping close to the time of surgery.

  • Antimicrobial Prophylaxis: Administering prophylactic antibiotics, when indicated based on the type of surgery and risk factors, timed appropriately (typically within 60 minutes prior to incision) to achieve adequate tissue levels at the time of incision. Selecting appropriate antibiotics based on surgical site and likely pathogens.

  • Glycemic Control: Optimizing glycemic control in patients with diabetes, both pre-operatively and post-operatively, as hyperglycemia increases SSI risk.

  • Smoking Cessation: Encouraging smoking cessation in patients who smoke, as smoking impairs wound healing and increases SSI risk.

  • Nasal Decolonization for Staphylococcus aureus (in some settings/patient populations): Pre-operative nasal decolonization with mupirocin may be considered in some settings, particularly for high-risk surgeries or in hospitals with high rates of S. aureus SSIs.

• Intra-operative Measures:

  • Surgical Site Skin Preparation: Performing surgical site skin preparation with an appropriate antiseptic solution (e.g., chlorhexidine or povidone-iodine) using a standardized technique and allowing adequate drying time before incision.

  • Surgical Hand Antisepsis: Surgical team members performing surgical hand antisepsis using either a surgical scrub with an antimicrobial soap and water, or an alcohol-based hand rub with persistent activity, before donning sterile gloves.

  • Maintenance of Normothermia: Maintaining patient normothermia (normal body temperature) throughout the perioperative period, as hypothermia impairs wound healing and increases SSI risk.

  • Wound Irrigation (when indicated): Using appropriate wound irrigation solutions (e.g., normal saline) during surgery when indicated to remove debris and reduce bacterial contamination.

  • Minimizing Surgical Time: Minimizing the duration of surgery, as prolonged surgical time increases SSI risk.

  • Appropriate Surgical Technique: Employing meticulous surgical technique to minimize tissue trauma, optimize tissue perfusion, and ensure proper wound closure.

• Post-operative Measures:

  • Surgical Site Dressing: Applying sterile dressings to surgical incisions in the immediate post-operative period. Choosing appropriate dressing types and managing dressings as per protocol.

  • Wound Care: Providing appropriate post-operative wound care instructions to patients upon discharge.

  • Surgical Site Surveillance: Implementing a system for post-discharge surgical site surveillance to identify SSIs that may present after hospital discharge.

  • Patient Education: Educating patients about SSI prevention measures, signs and symptoms of SSI, and when to seek medical attention post-operatively.

• Staff Education and Training: Ongoing education and training for all surgical team members and perioperative staff is essential to ensure consistent implementation of all SSI bundle elements across all phases of care.

• Surveillance and Feedback: Implementing a surveillance system to monitor SSI rates, surgical procedure types, and adherence to bundle elements. Regular feedback of surveillance data to surgical teams drives continuous quality improvement in SSI prevention.

The note directs users to key resources:

• Note: For more information, refer CDC/WHO/SHEA guidelines. Users are again directed to guidelines from the CDC, WHO, and SHEA, which provide comprehensive, evidence-based recommendations for SSI prevention bundles and best practices. These guidelines are essential resources for developing and implementing effective SSI prevention programs across the perioperative continuum.

By implementing IPC5 diligently and focusing on these key HAI prevention strategies, hospitals actively work to reduce the burden of preventable infections in patients, improving patient safety, quality of care, and overall healthcare outcomes.

IPC6: Surveillance to Capture and Monitor Infection Prevention and Control Data

Section IPC6 of the NABH 6th Edition Accreditation Standards shifts the focus to the vital process of surveillance within the Infection Prevention and Control (IPC) program. Surveillance is not merely about data collection; it's about strategically capturing, systematically monitoring, and intelligently analyzing infection-related data to understand infection risks, trends, and the effectiveness of control measures. IPC6 emphasizes a data-driven approach to IPC, where decisions and improvements are guided by robust and reliable information. The overall standard of IPC6 remains unchanged from the 5th edition, signifying the enduring importance of surveillance as a cornerstone of effective IPC. However, objective element IPC 6f is modified in the 6th edition, possibly reflecting updated methodologies or a refined emphasis on specific surveillance activities.

IPC6a: Scope of Surveillance – Tracking and Analysing Infection Risks, Rates and Trends

IPC6a defines the essential scope of a robust surveillance system. It mandates that the surveillance incorporates tracking and, crucially, analysing infection risks, rates, and trends within the hospital. This objective element is designated as Core Objective (CO), underscoring the fundamental role of comprehensive and analytical surveillance in effective IPC.

Effective surveillance, as outlined in IPC6a, is a multi-step process:

• Use a judicious mix of active and passive surveillance: The surveillance system should employ a combination of both active and passive surveillance methods.

  • Active surveillance: This involves proactively searching for cases of infection, typically by regularly reviewing patient charts, laboratory data, and conducting active case finding. Active surveillance is more resource-intensive but can be more sensitive in detecting infections, especially in high-risk areas or for specific pathogens.

  • Passive surveillance: This relies on routine reporting of infections by healthcare providers to the IPC team. Passive surveillance is less resource-intensive but may underreport infections, particularly milder cases or those not routinely tested. A balanced approach using both methods is often optimal.

• Lay down parameters that need to be captured: Clearly defining the specific parameters to be captured during surveillance is essential for focused and relevant data collection. These parameters should align with the hospital's IPC objectives and the types of infections being targeted for prevention. Examples of parameters include:

  • Type of infection (e.g., CAUTI, VAP, CLABSI, SSI)

  • Causative organism (identified through culture)

  • Location of infection (ward, unit)

  • Patient demographics (age, risk factors)

  • Antimicrobial susceptibility patterns (for identified organisms)

• Collect surveillance data: Implementing a systematic process for collecting the defined surveillance data is critical. This may involve using standardized data collection forms (paper or electronic), integrating with electronic health records (EHRs), and training staff on data collection procedures. Data should be collected consistently and accurately.

• Consolidate into annual report: Surveillance data collected throughout the year should be consolidated into a comprehensive annual report. This report serves as a summary of infection trends, rates, and risk factors for the hospital. It becomes a key document for reviewing program effectiveness and planning future interventions.

• Analyse data: Data collection is only the first step; data analysis is crucial to derive meaningful insights. The annual report should include in-depth analysis of the collected data to identify:

  • Trends in infection rates over time (increasing, decreasing, stable)

  • High-risk areas or patient populations

  • Common causative organisms and their susceptibility patterns

  • Potential outbreaks or clusters of infections

  • Effectiveness of existing IPC interventions

• Take suitable steps based on analysis: The ultimate goal of surveillance data analysis is to inform action. Based on the findings of the data analysis, the hospital must take suitable steps to:

  • Refine existing IPC strategies

  • Implement new interventions to address identified problems

  • Target specific areas or patient populations with focused prevention efforts

  • Evaluate the impact of implemented changes on infection rates

The "Points to Remember" section provides practical guidance on data collection and analysis:

• Points to Remember: Collection of surveillance data:

  • Is an ongoing process: Data collection is not a one-time activity but a continuous, ongoing process integrated into routine hospital operations. Consistent data collection over time is essential to detect trends and monitor the long-term impact of IPC efforts.

  • It should be done at regular intervals (maybe monthly): Data collection and preliminary analysis should be performed at regular intervals, ideally monthly, to allow for timely identification of emerging trends or potential problems. Monthly analysis allows for quicker response compared to solely relying on an annual report.

• Points to Remember: Data analysis:

  • Simple calculation of infected patients (numerator): Provides little information which is difficult to interpret: Simply counting the number of infected patients (numerator data alone) provides limited actionable information. It doesn't account for the size of the patient population at risk (denominator) or other confounding factors. Crude numbers alone are difficult to interpret and compare over time or across units.

  • Risk factor analysis: Requires information for both infected and non-infected patients to calculate infection and risk-adjusted rates: Meaningful data analysis requires a risk factor analysis. This involves collecting data not only on infected patients (numerator) but also on a comparable group of non-infected patients (denominator) at risk for the same infection. This allows for calculation of infection rates (infections per 1000 patient-days or 100 procedures) and risk-adjusted rates, which account for differences in patient populations and allow for more accurate comparisons and trend analysis. Risk-adjusted rates provide a more nuanced and interpretable picture of infection burden.

IPC6b: Verification of Data by the Infection Control Team

IPC6b emphasizes the importance of data quality through data verification. It mandates that verification of surveillance data is done regularly by the infection control team. This objective element is a Commitment level (C) requirement, highlighting the need to ensure the accuracy and reliability of surveillance data. Reliable data is the foundation for sound decision-making in IPC.

Data verification aims to identify and correct errors or inconsistencies in the collected surveillance data. IPC6b offers two approaches to data verification:

• Verify all data: Ideally, all collected surveillance data should be verified for accuracy and completeness. This involves reviewing data entries, comparing data with source documents (e.g., patient charts, lab reports), and resolving any discrepancies. Verifying all data provides the highest level of data quality but can be resource-intensive.

• OR Use random sampling: If verifying all data is not feasible due to resource constraints, a random sampling approach can be used. This involves selecting a statistically representative sample of data records for verification. While less comprehensive than verifying all data, random sampling can still provide a reasonable level of confidence in data accuracy, particularly if the sample size is appropriately determined.

The note offers an important exemption to verification:

• Note: If data is collected by the infection prevention & control team, then verification is not necessary. If the infection prevention and control team itself is directly involved in data collection, and robust data collection protocols and quality control measures are in place, then a separate, formal verification process may not be necessary. The IPC team's direct involvement and quality processes serve as inherent verification. However, this assumes a high level of data collection rigor by the IPC team.

IPC6c: Surveillance Directed Towards Identified High-Risk Activities

IPC6c emphasizes targeted surveillance, mandating that surveillance is directed towards the identified high-risk activities. This objective element is a Commitment level (C) requirement, reflecting the need to focus surveillance efforts where infection risks are highest, as identified in IPC1b. Targeted surveillance is more efficient and effective than broad, unfocused data collection.

The core principle is that surveillance efforts should be strategically directed towards areas and activities within the hospital known to pose a higher risk of infection transmission. This aligns with the principle of risk-based IPC.

IPC6c outlines key aspects:

• Surveillance: The surveillance system must be designed to specifically monitor infection risks and outcomes associated with identified high-risk activities.

  • Provide evidence for surveillance of high-risk activities: The hospital must be able to demonstrate that surveillance activities are in fact being conducted for the identified high-risk activities. This evidence might include surveillance protocols, data collection forms specific to high-risk activities, and reports showing data collected and analyzed for these activities.

  • Define frequency and mode of surveillance: The frequency and mode of surveillance should be defined and appropriate for each high-risk activity. Frequency might be continuous, daily, weekly, or monthly, depending on the nature of the risk and the rate of events. Mode refers to the methods used for surveillance (active chart review, automated data extraction from EHRs, etc.). The frequency and mode should be justified based on the specific risks.

• Surveillance system: The overall surveillance system itself must be robust and appropriate for the identified high-risk activities.

  • Ensure appropriateness: The surveillance system must be appropriate for detecting and monitoring the specific infections or risks associated with the high-risk activities. For example, surveillance for surgical site infections is different from surveillance for ventilator-associated pneumonia, and the methods and data collected need to be tailored.

  • Adhere to national/international guidelines: Surveillance methodologies and case definitions should adhere to recognized national and international guidelines and standards. This ensures data comparability and alignment with best practices in surveillance.

The "Points to Remember" section gives concrete examples of areas where targeted surveillance of high-risk activities is particularly relevant:

• Points to Remember: Surveillance activities should be done in following areas:

  • Demolition: Construction and demolition activities, as highlighted in IPC4b, are high-risk for airborne fungal infections (e.g., Aspergillus). Targeted surveillance of air quality and monitoring for fungal infections in susceptible patients in areas near demolition is important.

  • Construction: Similar to demolition, ongoing construction activities pose infection risks. Surveillance for construction-related infections, environmental monitoring, and adherence to ICRA measures are crucial.

  • Repairs: Even routine repair work can disrupt infrastructure and potentially increase infection risks, albeit typically to a lesser extent than major construction. Surveillance may be focused on monitoring for water quality issues after plumbing repairs or air quality concerns after HVAC repairs.

IPC6d: Surveillance Includes Monitoring Compliance with Hand-Hygiene Guidelines

IPC6d emphasizes the critical importance of hand hygiene compliance monitoring within the overall surveillance system. It mandates that surveillance includes monitoring compliance with hand-hygiene guidelines. This objective element is designated as Core Objective (CO), again highlighting the foundational role of hand hygiene in IPC and the need for active monitoring to ensure adherence.

Hand hygiene is universally recognized as the single most effective measure to prevent HAIs. However, simply providing hand hygiene facilities and guidelines is insufficient; active monitoring of compliance and feedback are essential to drive sustained improvement in hand hygiene practices.

IPC6d outlines key aspects of hand hygiene compliance monitoring:

• Choose appropriate sample size: When conducting hand hygiene observations, it's important to choose an appropriate sample size of observations to ensure representative and reliable data. The sample size should be large enough to provide a reasonable estimate of overall compliance rates. Statistical methods can be used to determine appropriate sample sizes.

• Monitor all categories of staff (Involved in direct patient care): Hand hygiene compliance monitoring should include all categories of staff involved in direct patient care. This includes physicians, nurses, nursing assistants, therapists, and any other healthcare workers who have direct patient contact. Compliance rates may vary across staff categories, and monitoring should provide a comprehensive picture.

The "Points to Remember" section provides practical guidance on frequency and feedback:

• Points to Remember:

  • Monitor at a minimum of once every month: Hand hygiene compliance monitoring should be performed at least monthly to provide regular feedback and track trends over time. More frequent monitoring may be beneficial, especially initially or after implementation of new interventions. Monthly frequency provides a balance between resource use and timely feedback.

  • Share compliance levels with the relevant staff: Crucially, the results of hand hygiene compliance monitoring should be shared with relevant staff, including individuals, teams, and departments. Feedback should be timely, specific, and constructive. Sharing compliance data creates transparency, raises awareness, and motivates improvement. Benchmarking compliance rates against targets and previous performance can be effective.

The note points to a valuable tool:

• Note: For more information, refer WHO's Observation Form. This directs users to the WHO's Hand Hygiene Observation Form, a standardized tool for conducting direct observation of hand hygiene practices. Using a standardized form ensures consistency in observation methods and data collection. The WHO observation form is widely recognized and validated.

IPC6e: Surveillance Includes Mechanisms to Capture Occurrence of Multi-Drug-Resistant Organisms (MDROs)

IPC6e highlights the growing threat of antimicrobial resistance and mandates that surveillance includes mechanisms to capture the occurrence of multi-drug-resistant organisms (MDROs). This objective element, designated as Achievement level (A), recognizes the importance of actively monitoring and tracking MDROs to implement targeted control measures and prevent their spread. MDROs pose significant challenges for treatment and patient safety.

Surveillance for MDROs is critical for:

• Understanding local epidemiology: Knowing the types and prevalence of MDROs circulating within the hospital and community is essential for guiding empirical therapy and implementing effective infection control strategies.

• Detecting outbreaks: Surveillance can help to detect outbreaks or clusters of MDRO infections, allowing for prompt investigation and control measures to prevent further spread.

• Monitoring effectiveness of control measures: Surveillance data allows for tracking the impact of interventions aimed at controlling MDROs, such as antibiotic stewardship programs and enhanced infection control practices.

IPC6e emphasizes capturing the:

• Occurrence: The surveillance system must be designed to capture the occurrence of MDRO infections and/or colonization. This involves actively looking for MDROs through laboratory data, microbiology reports, and potentially targeted screening in high-risk units or patient populations.

• Monitor: The data on MDRO occurrence must be actively monitored over time to identify trends, detect increases in resistance, and evaluate the impact of control efforts. Ongoing monitoring is essential to adapt IPC strategies to evolving resistance patterns.

• Spread: While not explicitly stated, effective MDRO surveillance also aims to understand the potential spread of MDROs within the hospital. This might involve tracking patient movements, identifying potential transmission pathways, and investigating links between MDRO cases.

The "Points to Remember" section provides examples of key MDROs to focus on:

• Points to Remember: Examples of multi-drug resistant organisms (MDROs):

  • Methicillin-resistant staphylococcus aureus (MRSA): MRSA is a common and significant MDRO that is often targeted for surveillance and control efforts.

  • Multi-drug resistant gram-negative bacteria: Gram-negative bacteria resistant to multiple classes of antibiotics, such as carbapenem-resistant Enterobacteriaceae (CRE), are a growing concern. Surveillance should include tracking resistance patterns in key gram-negative pathogens.

  • Vancomycin-resistant enterococci (VRE): VRE is another important MDRO, particularly in certain patient populations (e.g., transplant recipients, ICU patients). VRE surveillance is often targeted in specific units or patient groups at higher risk.

IPC6f: Surveillance Includes Monitoring the Effectiveness of Housekeeping Services

IPC6f focuses on evaluating the effectiveness of housekeeping services through surveillance. It mandates that surveillance includes monitoring the effectiveness of housekeeping services. This objective element is designated as Core Objective (CO), emphasizing that housekeeping is not just a routine support service, but a critical component of IPC, and its effectiveness must be actively monitored and verified. Effective housekeeping contributes significantly to reducing environmental contamination and preventing infections.

IPC6f outlines a structured approach to monitoring housekeeping effectiveness:

• Define periodicity of monitoring: Establish a defined schedule or frequency for monitoring housekeeping effectiveness. This might be daily, weekly, or monthly, depending on the risk level of the area and the resources available. Regular, scheduled monitoring ensures consistent oversight.

• Identify desired outcome parameters: Clearly define the outcome parameters that will be used to assess housekeeping effectiveness. These parameters should be measurable and relevant to infection prevention. Examples include:

  • Visual cleanliness (absence of visible dirt, dust, spills)

  • Objective measures of surface contamination (e.g., ATP bioluminescence assays, surface culture sampling - used judiciously, see note below)

  • Compliance with cleaning checklists and protocols

  • Patient and staff feedback on cleanliness

• Capture effectiveness (Do not just verify if the activity has been done as per defined frequency): Monitoring should go beyond simply verifying that cleaning activities are being performed as per the schedule. It should focus on capturing the effectiveness of those activities in achieving desired outcomes. This means assessing whether cleaning is actually achieving the intended level of cleanliness and reducing contamination, not just whether cleaning schedules are being followed. Process monitoring alone is insufficient; outcome monitoring is key.

The "Points to Remember" section provides practical guidance:

• Points to Remember:

  • Monitor effectiveness of housekeeping services regularly: Housekeeping effectiveness monitoring should be performed regularly, according to the defined periodicity. Consistent monitoring allows for tracking performance over time and identifying areas needing improvement.

  • Monitor both in-house and outsourced housekeeping activities: If housekeeping services are outsourced, monitoring of effectiveness is equally important as for in-house services. The hospital retains responsibility for ensuring housekeeping standards are met, regardless of service provision model.

  • Use checklist to capture data: Using a standardized checklist to document observations during housekeeping effectiveness monitoring ensures consistency and completeness of data collection. Checklists can cover visual cleanliness, procedural adherence, and other defined outcome parameters.

  • This need NOT mean routine environmental sampling: Routine environmental sampling (e.g., surface cultures) is generally not recommended for routine monitoring of housekeeping effectiveness. Visual assessment, checklists, and ATP bioluminescence assays are typically sufficient for routine monitoring. Routine environmental sampling is resource-intensive, may not be reliably indicative of infection risk, and its interpretation can be complex.

The note clarifies the limited role of fumigation/fogging:

• Note: Periodic fumigation is not recommended and Fogging is recommended only: This emphasizes that routine, periodic fumigation or fogging for housekeeping purposes is not generally recommended in healthcare settings. Fogging or fumigation is a more intensive disinfection method and should be reserved for specific, justifiable situations, not routine housekeeping. Permitted situations include:

  • 1. Commissioning new OT: Initial disinfection of a newly constructed operating theatre before first use.

  • 2. Modification / renovation of OT: Disinfection after significant modification or renovation of an operating theatre.

  • 3. Significance increase in SSI with evidence of evolvement of environment: In rare situations, when there is a significant and unexplained increase in surgical site infections and there is strong evidence implicating environmental contamination as a contributing factor, fogging or fumigation may be considered, but only after thorough investigation and as part of a targeted response. Even in these cases, it should be used judiciously and not as a substitute for routine cleaning and disinfection.

IPC6g: Feedback Regarding Surveillance Data to Appropriate Health Care Provider

IPC6g emphasizes the crucial step of providing feedback on surveillance data. It mandates that feedback regarding surveillance data is provided regularly to the appropriate health care provider. This objective element is a Commitment level (C) requirement, highlighting that surveillance data is not useful unless it is effectively communicated and used to inform practice changes. Feedback loops are essential for data-driven improvement in IPC.

Surveillance data, once collected and analyzed, needs to be communicated back to those who can use it to improve IPC practices at the point of care. Feedback loops close the loop in the surveillance cycle and drive action.

IPC6g outlines key aspects:

• Provide feedback on: The feedback provided should include relevant and actionable information. Examples of data to feedback include:

  • Adherence rates: Feedback on hand hygiene compliance rates, adherence to isolation precautions, or other process measures. Feedback on compliance helps staff understand their performance relative to expectations and benchmarks.

  • Healthcare associated infection (HAI) rates: Reporting HAI rates (e.g., CAUTI rate, CLABSI rate) for specific units, services, or the hospital as a whole. Rate feedback provides outcome data and allows for tracking progress towards reduction goals.

  • Trends and opportunities for improvement: Feedback should highlight trends in infection rates and identify specific areas or practices where improvements are needed. Constructive feedback focuses on solutions and opportunities for positive change.

  • Data from other surveillance activities: Feedback can also include data from other surveillance activities, such as MDRO prevalence, housekeeping effectiveness monitoring, or antibiotic usage data, as relevant to different healthcare providers and departments.

• Appropriate health care provider: Feedback should be targeted to the appropriate healthcare providers or teams who are in a position to act on the information. This means tailoring feedback to specific roles, units, or departments. For example, hand hygiene compliance feedback is relevant to all clinical staff, while surgical site infection data is particularly relevant to surgical teams.

The note suggests a practical communication method:

• Note: Specific inputs can be provided to reduce HAI rate in the form of a bulletin/newsletter. Using a bulletin or newsletter is suggested as a practical way to disseminate surveillance data and provide specific inputs to reduce HAI rates to a broader audience of healthcare providers. Bulletins or newsletters can be used to share:

  • Summary of key surveillance findings

  • Trends in infection rates

  • Areas for improvement

  • Success stories or best practices

  • Updates on IPC policies and procedures

  • Educational messages related to IPC

IPC6h: Identification and Action to Control Outbreaks of Infections

IPC6h focuses on the critical aspect of outbreak detection and response. It mandates that the organization identifies and takes appropriate action to control outbreaks of infections. This objective element is a Commitment level (C) requirement, highlighting the essential role of outbreak management in protecting patients and staff from widespread infections.

Outbreaks represent a significant threat to patient safety and hospital operations. Prompt detection and effective control measures are essential to minimize the impact of outbreaks.

IPC6h outlines a three-pronged approach to outbreak management:

• Early identification of outbreak: Use surveillance: Early identification is paramount for effective outbreak control. The surveillance system (as detailed in IPC6a-f) is the primary mechanism for detecting potential outbreaks or clusters of infections. Rapid signal detection from surveillance data is critical.

• Define what constitutes an outbreak: Have baseline rate: To effectively identify outbreaks, the hospital must have a clear definition of what constitutes an "outbreak." This requires establishing baseline infection rates for different types of infections and patient populations. An outbreak is typically defined as an increase in the observed number of cases of an infection above the established baseline rate. Having baseline data allows for statistically meaningful detection of increases.

• Handle an outbreak: Adhere to written guidance: Once an outbreak is suspected or confirmed, the hospital must have written guidance or protocols in place to guide outbreak investigation and control measures. These written protocols ensure a standardized and coordinated response.

Written guidance for outbreak management should typically include:

• Outbreak Investigation Protocol: Steps for initiating an outbreak investigation, including defining the case definition, confirming cases, and gathering epidemiological data (time, place, person).

• Line Listing and Case Identification: Procedures for creating a line list of cases and actively searching for additional cases within the affected area or patient population.

• Environmental Assessment and Sampling (if indicated): Guidelines for environmental assessment and sampling if an environmental source of infection is suspected.

• Control Measures: Detailed protocols for implementing appropriate control measures, which may include:

  • Enhanced infection control practices (hand hygiene, isolation, cohorting)

  • Environmental cleaning and disinfection

  • Source control measures (e.g., removing contaminated products)

  • Antimicrobial management strategies (if relevant)

  • Patient and staff cohorting or isolation

  • Closure of affected areas (if necessary)

• Communication Plan: Procedures for communication within the hospital (staff, administration), with public health authorities, and potentially with patients and the public, as needed.

• Documentation: Requirements for documenting all aspects of the outbreak investigation and control efforts, including findings, interventions implemented, and outcomes.

IPC6i: Surveillance Data Analysis and Corrective and Preventive Actions (CAPA)

IPC6i emphasizes the continuous quality improvement cycle in IPC. It mandates that surveillance data is analysed, and appropriate corrective and preventive actions are taken. This objective element is a Commitment level (C) requirement, highlighting that surveillance is not just about identifying problems, but about using data to drive positive change and prevent future infections. Data analysis must lead to action.

IPC6i underscores the role of the Hospital Infection Control Committee in driving this improvement cycle:

• Hospital infection control committee: The Infection Control Committee (as detailed in IPC1e) plays a central role in overseeing the analysis of surveillance data and guiding the implementation of corrective and preventive actions.

• Analyse surveillance data: The committee is responsible for regularly reviewing and analyzing surveillance data (annual report and more frequent interim data), as outlined in IPC6a. This analysis identifies trends, problem areas, and opportunities for improvement.

• Take CAPA (Corrective and Preventive Action): Based on the data analysis, the committee must identify and implement appropriate corrective and preventive actions (CAPA).

  • Corrective actions: Actions taken to address existing problems or deviations from expected performance. Examples include: revising a policy, providing targeted education, implementing new control measures in a specific unit.

  • Preventive actions: Proactive actions taken to prevent problems from occurring in the future or to prevent recurrence of existing problems. Examples include: strengthening a process, implementing a new training program hospital-wide, enhancing environmental controls.

• Prevent recurrence of infection: The ultimate goal of CAPA is to prevent the recurrence of infections and to continuously improve IPC practices to reduce HAI rates. CAPA is an iterative process, with actions implemented, monitored, and adjusted based on ongoing surveillance data.

By comprehensively implementing IPC6, hospitals establish a robust and data-driven surveillance system that is not just a data collection exercise, but an active engine for continuous improvement in infection prevention and control, ultimately contributing to a safer healthcare environment for all.

IPC7: Infection Prevention Measures Include Sterilisation and/or Disinfection of Instruments, Equipment and Devices

Section IPC7 of the NABH 6th Edition Accreditation Standards for Hospitals addresses a core pillar of infection prevention: the processes of sterilisation and disinfection. This section emphasizes that infection prevention is not solely reliant on hand hygiene or isolation; the proper reprocessing of instruments, equipment, and devices used in patient care is equally crucial. IPC7 ensures that hospitals have robust systems in place to clean, disinfect, and sterilise items effectively, thereby breaking the chain of infection and preventing patient exposure to contaminated medical devices. The overall standard for IPC7 remains consistent with the 5th edition, reaffirming the enduring importance of these reprocessing procedures. However, objective element IPC 7e has been modified in the 6th edition, likely to reflect updated requirements or a sharper focus on specific aspects within sterilisation processes.

IPC7a: Adequate Space and Appropriate Zoning for Sterilisation Activities

IPC7a focuses on the physical infrastructure required for effective sterilisation services. It mandates that the organisation provides adequate space and appropriate zoning specifically for sterilisation activities. This objective element, categorised as Commitment level (C), underscores that a well-designed physical environment is a prerequisite for a safe and efficient Central Sterile Services Department (CSSD). Proper space and zoning are not merely about convenience; they are fundamental to preventing cross-contamination and ensuring the integrity of the sterilisation process.

A well-designed CSSD is crucial for preventing the re-contamination of instruments after sterilisation and ensuring a unidirectional workflow. This sub-section highlights several key aspects of space and zoning within the CSSD:

• Suitable Location: The CSSD should be located in a suitable area within the hospital. This implies several considerations:

  • Accessibility: It should be easily accessible for the transportation of both soiled and sterile items from various clinical areas, especially the operating theatres and procedural units, which are major users of sterile supplies.

  • Traffic Flow: It should be located away from general hospital traffic and areas with high pedestrian movement to minimise the risk of external contamination.

  • Proximity to User Units: Ideally, it should be in close proximity to major user departments like the operating theatre complex to ensure timely and efficient delivery of sterile supplies and to reduce transportation distances and associated risks.

• Proper Layout (Unidirectional flow and zoning): The internal layout of the CSSD must be designed to facilitate a unidirectional workflow. This is a critical principle to prevent cross-contamination between soiled and sterile items. Unidirectional flow means that items progress through the CSSD in a single direction, from soiled to clean to sterile, without backtracking or crossing paths. This is achieved through physical zoning:

  • Zoning: The CSSD should be divided into distinct zones, each dedicated to a specific stage in the reprocessing cycle. These zones are typically:

    • Soiled Zone (Receiving and Decontamination Area): This is the area where soiled instruments and equipment are received from clinical areas. It is designated for sorting, pre-cleaning, and initial decontamination processes. This zone should be physically separated and maintained under negative pressure to contain potential contaminants.

    • Clean Zone (Preparation and Packaging Area): After decontamination, items move to the clean zone for inspection, assembly, and packaging. This zone should be physically separated from the soiled zone and maintained as a cleaner environment, often with positive air pressure compared to the soiled zone.

    • Sterile Zone (Sterilisation and Storage Area): This zone houses the sterilisers and is used for the final sterilisation process. It also includes areas for the short-term and long-term storage of sterilised items before they are issued. This zone should be the cleanest, maintained under positive pressure relative to the clean zone, and with restricted access to prevent contamination of sterile goods.

• Separation of clean and dirty area: Physical separation between clean and dirty areas is a fundamental principle of CSSD design and operation. This separation can be achieved through:

  • Physical Barriers: Walls, partitions, or doors effectively separate the soiled zone from the clean and sterile zones, preventing airflow and movement of personnel and equipment between zones without proper transitions.

  • Spatial Separation: Even within zones, adequate spatial separation between different activities (e.g., cleaning and packaging within the clean zone) should be maintained to minimise cross-contamination.

• Sufficient Space: The CSSD must have sufficient space to accommodate all required equipment, workflow processes, and personnel comfortably and safely. Adequate space is needed for:

  • Equipment: Space for decontamination equipment (e.g., washer-disinfectors), sterilisers (steam, low-temperature), packaging equipment, storage racks, and trolleys.

  • Workflow: Adequate space for smooth and efficient workflow within each zone, allowing for unimpeded movement of items and personnel through the reprocessing cycle.

  • Personnel: Sufficient space for staff to work safely and comfortably, including space for workstations, movement, and donning/doffing of personal protective equipment (PPE).

  • Future Expansion: Considering potential future expansion needs during the initial design phase is prudent to avoid space constraints later.

The illustration in the material visually reinforces the concept of zoning and unidirectional flow within a CSSD, depicting the progression of items through the Soiled Zone, Clean Zone, and Sterile Zone, separated by "Barriers." It also highlights the concept of controlled airflow, with negative pressure in the Soiled Zone and positive pressure in the Clean and Sterile Zones to further control contamination.

The note directs users to authoritative guidelines:

• Note: For more information, refer Hospital Infection Society India (HISI) and WHO guidelines. This encourages users to consult guidelines from the Hospital Infection Society India (HISI) and the World Health Organization (WHO). These organisations provide comprehensive guidance on CSSD design, layout, zoning, equipment, and operational practices, serving as valuable resources for hospitals in establishing or upgrading their sterilisation facilities. These guidelines offer detailed recommendations based on best practices and international standards.

IPC7b: Cleaning, packing, disinfection and/or sterilisation, storing and the issue of items is done as per the written guidance.

IPC7b outlines the essential steps in the reprocessing cycle of medical devices and emphasizes the critical importance of performing each step according to established written guidance. This objective element, categorised as Core Objective (CO), highlights that a standardised, documented, and consistently followed process is crucial for ensuring the safety and effectiveness of sterilisation and disinfection. Variability and deviations from established procedures can compromise reprocessing outcomes and increase infection risks.

This sub-section breaks down the key stages in the reprocessing cycle, all of which must be governed by written guidance:

• Clean used items in CSSD (If done in patient care areas, take infection prevention measures): The first and most fundamental step is cleaning. All reusable medical devices must be thoroughly cleaned before undergoing disinfection or sterilisation. Cleaning removes gross soil, organic matter (blood, tissue), and reduces bioburden. This step is typically performed in the CSSD's decontamination area, but in some situations, initial cleaning or pre-treatment may need to occur at the point of use in patient care areas.

  • CSSD Cleaning: Ideally, cleaning should be centralised in the CSSD's decontamination area, equipped with washer-disinfectors and ultrasonic cleaners to ensure standardised and effective cleaning.

  • Point-of-Care Cleaning (with IPC measures): If initial cleaning or pre-treatment (e.g., enzymatic spray application to prevent drying of soil) is performed in patient care areas, strict infection prevention measures must be in place to protect healthcare workers and prevent environmental contamination. These measures include appropriate PPE, designated cleaning areas, and proper handling and transport of soiled items to the CSSD.

  • Written Guidance: The written guidance must detail specific cleaning procedures for different types of medical devices, including manual cleaning protocols (e.g., brushing, enzymatic detergents), automated cleaning procedures (washer-disinfector cycles), and quality control measures to verify cleanliness.

• Prepare and pack items using appropriate material: After cleaning and inspection, items are prepared and packaged for sterilisation. Proper packaging is essential to maintain sterility after sterilisation and until the point of use.

  • Preparation: This may involve assembling multi-part instruments, ensuring items are positioned correctly within trays for optimal sterilant penetration.

  • Packaging: Items must be packaged in appropriate sterilisation packaging materials that are compatible with the sterilisation method being used (e.g., steam-sterilisation pouches, wraps, rigid containers). Packaging materials must maintain a sterile barrier, allow sterilant penetration, and be durable enough to withstand handling.

  • Written Guidance: The written guidance must specify the types of packaging materials to be used for different items and sterilisation methods, proper packaging techniques, and labelling requirements (e.g., item identification, load number, date of sterilisation, expiry date).

• Determine level of disinfection (High/Intermediate/Low) based on Spaulding's classification: Not all medical devices require sterilisation; some can be safely reprocessed with disinfection. Spaulding's classification (detailed later in the material) is a critical framework for determining the appropriate level of reprocessing based on the risk of infection associated with device use.

  • Spaulding Classification: This system categorises medical devices into critical, semi-critical, and non-critical based on their risk of infection transmission.

  • Level of Disinfection: Based on Spaulding's classification, the appropriate level of reprocessing is determined:

    • Critical Devices: Require sterilisation as they enter sterile tissues or the bloodstream.

    • Semi-critical Devices: Require high-level disinfection as they come into contact with mucous membranes or non-intact skin.

    • Non-critical Devices: Require low-level or intermediate-level disinfection as they come into contact with intact skin.

  • Written Guidance: The written guidance must clearly outline Spaulding's classification system, categorise common medical devices within the hospital based on this classification, and specify the minimum level of reprocessing (sterilisation or disinfection level) required for each category of device.

• Disinfect/sterilise items as per written guidance: Once cleaned, packaged, and the required reprocessing level determined, items undergo disinfection or sterilisation. This step is critical for rendering items safe for reuse.

  • Sterilisation Methods: Common sterilisation methods include steam sterilisation (autoclaving), ethylene oxide gas sterilisation, and low-temperature sterilisation methods (e.g., hydrogen peroxide plasma). The choice of sterilisation method depends on the device material, heat sensitivity, and hospital resources.

  • Disinfection Methods: High-level disinfection methods include liquid chemical disinfectants (e.g., glutaraldehyde, ortho-phthalaldehyde, high-level hydrogen peroxide). Intermediate and low-level disinfection methods are also available for non-critical and some semi-critical items, depending on the context.

  • Written Guidance: The written guidance must detail specific disinfection and sterilisation procedures for each method used in the CSSD. This includes parameters like sterilisation cycles (temperature, pressure, time), disinfectant concentrations and contact times, loading instructions for sterilisers, and quality control measures (e.g., validation testing).

• Store sterilised/disinfected items appropriately across organisation (not just in CSSD): Maintaining the sterility or disinfection level of reprocessed items after they leave the CSSD is crucial. Proper storage and handling are essential to prevent contamination during storage and transportation.

  • Sterile Storage: Sterilised items must be stored in designated sterile storage areas within the CSSD and in user departments (e.g., operating theatre sterile supply rooms). Storage areas must be clean, dry, well-ventilated, and protected from dust, moisture, and physical damage. Stock rotation (first-in, first-out) should be implemented.

  • Disinfected Item Storage: High-level disinfected items may require specific storage conditions to maintain their disinfection level, depending on the disinfectant used. Storage areas should be clean and dry.

  • Transportation: Transport of sterile and disinfected items from the CSSD to user departments must be done in a manner that maintains sterility and prevents contamination. Using covered trolleys or containers is recommended.

  • Written Guidance: The written guidance must specify requirements for sterile and disinfected item storage areas (temperature, humidity, cleanliness), storage procedures, transport protocols, and handling guidelines for sterile and disinfected items in user departments.

• Determine expiry date of sterilised items. (Based on packing material used and mode of sterilisation.) and shelf life monitored: Sterility is event-related, meaning sterility is maintained as long as the packaging integrity is not compromised. However, in practice, expiry dates are often assigned to sterilised items based on the type of packaging material and sterilisation method used. Shelf life monitoring is also important.

  • Expiry Dating: Hospitals often assign practical expiry dates based on packaging type and sterilisation method, considering factors like typical storage conditions and handling within the facility. These expiry dates are generally shorter than the theoretical event-related sterility.

  • Shelf Life Monitoring: Regular monitoring of stored sterile packages for integrity breaches (tears, punctures, moisture damage) is crucial. Packages with compromised integrity should be considered non-sterile and reprocessed.

  • Written Guidance: The written guidance should specify the hospital's policy on expiry dating for sterilised items, based on packaging material and sterilisation method. It should also outline procedures for shelf life monitoring, including frequency of inspections and actions to be taken for compromised packages.

The "Points to Remember" section highlights key considerations:

• Points to Remember:

  • The written guidance should be in consonance with national and/or international guidelines: The hospital's written guidance for reprocessing medical devices must be aligned with established national and international guidelines and standards for sterilisation and disinfection (e.g., CDC guidelines, WHO guidelines, professional body guidelines like AAMI in the US or HTM in the UK). Adherence to these guidelines ensures that the hospital's practices are evidence-based and reflect best practices.

  • Flash sterilisation should be done in exceptional situations when there is insufficient time to sterilise an item using the preferable method: Flash sterilisation (also known as immediate-use steam sterilisation - IUSS) is a rapid sterilisation cycle used for items needed urgently and when there is not sufficient time for standard sterilisation cycles. Flash sterilisation should be reserved for exceptional situations and should not be used routinely. The written guidance should clearly define the circumstances under which flash sterilisation is permitted, the specific cycle parameters to be used, and any additional precautions necessary when using flash sterilisation, as flash-sterilised items are typically not packaged for long-term storage and should be used immediately. The preferable method is always standard sterilisation with appropriate packaging for maintaining sterility.

IPC7c: Reprocessing of instruments, equipment and devices are done as per written guidance.

IPC7c focuses specifically on the reprocessing of reusable instruments, equipment, and devices and reiterates the critical importance of following written guidance for these processes. This objective element, categorised as Commitment level (C), reinforces that safe reuse of medical devices depends on meticulous adherence to validated and documented reprocessing procedures.

This sub-section addresses two key aspects of reprocessing reusable devices:

• Identify Re-usable single-use instruments, equipment and devices: A crucial first step is to clearly identify which medical devices are intended for single-use only and which are designed for reuse. Single-use devices are designed, validated, and labelled by manufacturers for one-time use only and are not intended to be reprocessed and reused. Reprocessing single-use devices is generally discouraged and may be associated with safety and efficacy concerns. However, in specific situations, and under stringent regulatory frameworks, some single-use devices may be reprocessed and reused if properly validated and approved.

  • Identification Process: The hospital must have a system in place to clearly identify and segregate single-use devices from reusable devices at the point of use. Device labelling and hospital policies should clearly indicate single-use status.

  • Exceptional Reprocessing (if permitted): If the hospital engages in reprocessing of certain single-use devices (which is often not recommended and subject to strict regulations), it must have robust, validated, and documented procedures in place for this, ensuring patient safety and device efficacy are not compromised. This is a complex and regulated area, often requiring specific regulatory approvals and validation data.

  • Written Guidance: The written guidance must clearly list medical devices that are designated as single-use within the hospital and specify that these devices are not to be reprocessed for reuse unless there is a very specific, validated, and approved process in place for a particular device type (which is uncommon and generally discouraged).

• Define and monitor Number of re-uses and Process of re-use: For devices that are intended for reuse, the hospital must define and monitor the number of times they are reprocessed and the entire reprocessing process itself. This is especially relevant for certain types of complex reusable devices where device degradation or wear and tear with repeated reprocessing may be a concern.

  • Number of Re-uses: For some devices, the manufacturer may specify a maximum number of safe reuses. The hospital must adhere to these manufacturer's recommendations or establish its own evidence-based limits if manufacturer guidance is lacking. Tracking the number of reuses for certain devices may be necessary.

  • Process of Re-use: The entire reprocessing process for reusable devices, from cleaning to sterilisation, must be rigorously defined in written guidance and consistently followed. This includes specific procedures, equipment, parameters, and quality control measures for each step of reprocessing.

  • Monitoring Compliance: The hospital must monitor compliance with the defined reprocessing procedures to ensure that reusable devices are consistently reprocessed according to the established protocols.

  • Note: The patient should be informed of the same: In situations where reusable devices are being reprocessed and reused (particularly if there are concerns about single-use devices being reprocessed under specific circumstances), ethical considerations require that patients be informed about this practice, especially if there are any potential risks or concerns. Transparency and patient consent are important ethical principles.

The "Points to Remember" section highlights crucial aspects of written guidance:

• Points to Remember: Written guidance:

  • It should be adhered for cleaning, disinfection or sterilisation of re-usable items: The written guidance for reprocessing reusable medical devices is not optional; it must be strictly adhered to for every reprocessing cycle. Consistent adherence is the foundation of safe reuse.

  • It should be in consonance with available good practices: The written guidance should be based on and aligned with available good practices, evidence-based recommendations, and guidelines from reputable sources (e.g., CDC, WHO, professional organisations). Using recognised good practices ensures that the hospital's reprocessing procedures are robust and effective.

IPC7d: Regular validation tests for sterilisation are carried out and documented.

IPC7d emphasizes the critical importance of regular validation testing to ensure the ongoing effectiveness of sterilisation processes. It mandates that regular validation tests for sterilisation are carried out and documented. This objective element, categorised as Commitment level (C), underscores that sterilisation is not simply a process of running a cycle; it requires ongoing monitoring and verification to confirm that sterilisation is actually being achieved consistently and reliably. Validation testing is essential for quality assurance and patient safety.

Validation testing involves using specific tests to monitor different aspects of the sterilisation process and confirm that sterilisation parameters are being met and that sterilisation is actually being achieved. IPC7d highlights three key types of validation tests that should be performed:

• Physical Validation: Physical tests monitor the physical parameters of the sterilisation process, such as temperature, pressure, and time, within the steriliser chamber. These tests confirm that the steriliser is functioning correctly and delivering the programmed cycle parameters.

  • When should it be done? Daily: Physical validation tests should be performed daily, typically at the beginning of each day of steriliser operation, and ideally with each load.

  • How can it be done? Maintaining temperature, pressure and time-record chart: Physical validation is done by monitoring and recording the temperature, pressure, and cycle time displayed by the steriliser’s monitoring systems during each cycle. These readings are typically recorded on a chart recorder or electronically logged to provide a permanent record of each cycle's physical parameters. This documentation serves as evidence of physical parameter compliance.

• Chemical Validation: Chemical indicators are used to monitor the sterilant penetration into packages and to visually verify that items have been exposed to the sterilisation process. They provide a quick, visual indication of process exposure but do not confirm sterility itself.

  • When should it be done? Daily: Chemical indicators should be used with each sterilisation load, and checked after each cycle.

  • How can it be done? Using test strips: Chemical indicators are available as test strips, tapes, or integrated indicators that are placed inside sterilisation packages or within the steriliser load. These indicators change colour when exposed to the sterilisation process (e.g., heat, steam, sterilant), providing a visual confirmation of process exposure. Different types of chemical indicators (Class 1-6) provide varying levels of process monitoring, and the appropriate type should be selected based on the sterilisation method and type of load.

• Biological Validation: Biological indicators (BIs) are the gold standard for sterilisation validation. BIs contain highly resistant bacterial spores (e.g., Geobacillus stearothermophilus for steam sterilisation, Bacillus atrophaeus for ethylene oxide). After sterilisation, BIs are incubated to determine if spores have been killed. A negative BI result (no spore growth) indicates that the sterilisation cycle was effective in killing a high challenge of resistant spores, providing a high level of assurance of sterility.

  • When should it be done? At least weekly: Biological validation tests should be performed at least weekly for each steriliser and each type of sterilisation cycle routinely used. More frequent BI testing may be indicated in certain situations, such as after steriliser repairs or malfunctions, when introducing new devices or packaging, or for implantable devices.

  • How can it be done? Bacteriologic: Biological validation is a bacteriologic test. BIs are placed within sterilisation packages (representing a "worst-case" location for sterilant penetration) and run through a standard sterilisation cycle. After the cycle, the BIs are retrieved and incubated under optimal growth conditions for a specified period. The incubated BIs are then examined for spore growth. Spore growth indicates sterilisation failure, while no growth indicates sterilisation success for that cycle. Control BIs (not sterilised) are also incubated to confirm spore viability.

In addition to routine validation tests, Engineering Validations are also mentioned:

• Engineering validations: These are more comprehensive tests performed periodically to verify the overall performance and functionality of the steriliser itself, beyond routine cycle monitoring. Examples include:

  • Bowie-Dick Tape test: This test is specifically for pre-vacuum steam sterilisers to assess the efficiency of air removal from the steriliser chamber and prevent air entrapment, which can hinder steam penetration and sterilisation. It is typically performed daily for pre-vacuum sterilisers.

  • Leak rate test: This test is also for pre-vacuum steam sterilisers to check for vacuum leaks in the steriliser chamber, which can compromise the vacuum and affect air removal and sterilisation effectiveness. Leak rate testing is typically performed periodically (e.g., weekly or monthly) as per steriliser manufacturer's recommendations.

The "Point to Remember" section highlights documentation:

• Point to Remember: Each load should have unique number and content description. Proper documentation of each sterilisation load is essential for traceability and recall purposes. Each sterilisation load should be assigned a unique load number, and a record should be kept detailing the contents of the load (items sterilised), cycle parameters, validation test results (physical, chemical, biological), and the operator. This documentation is vital for tracking sterilisation history and facilitating recall if a sterilisation failure is identified.

The note directs users to further guidance:

• Note: For more information, refer CDC Guideline for Disinfection and Sterilisation in Healthcare Facilities, 2008. This encourages users to consult the CDC Guideline for Disinfection and Sterilization in Healthcare Facilities (2008), a comprehensive and authoritative resource for detailed information on sterilisation validation testing, types of indicators, frequency of testing, and interpretation of results. This guideline provides in-depth guidance on best practices for sterilisation validation in healthcare settings.

IPC7e: The established recall procedure is implemented when a breakdown in the sterilisation system is identified.

IPC7e focuses on the critical response when a sterilisation system breakdown or failure is identified. It mandates that an established recall procedure is implemented when a breakdown in the sterilisation system is identified. This objective element, categorised as Commitment level (C), underscores the absolute necessity of having a robust recall plan and activating it promptly and effectively in the event of a sterilisation failure. A failure in sterilisation can have serious patient safety implications, and a rapid and well-executed recall is essential to mitigate potential harm.

A breakdown in the sterilisation system can be identified through various means:

• Validation Test Failure: A failed biological indicator test, a failed chemical indicator test, or a deviation from acceptable physical parameters during cycle monitoring can all indicate a sterilisation failure.

• Equipment Malfunction: Steriliser equipment malfunction, alarms, or error messages during a cycle may signal a potential sterilisation problem.

• Process Deviation: Any deviation from established sterilisation procedures, such as incorrect loading, packaging errors, or cycle parameter deviations, can raise concerns about sterilisation effectiveness.

Upon identification of a sterilisation system breakdown, a rapid and systematic recall procedure must be implemented. IPC7e highlights two key aspects of a recall procedure:

• Adhere to written guidance for withdrawal of such items: The hospital must have a pre-established written recall procedure that outlines the steps to be taken in the event of a sterilisation failure. This written guidance ensures a standardized and efficient response. The recall procedure should specify:

  • Notification procedures: Who needs to be notified immediately (CSSD supervisor, infection control team, relevant clinical departments, hospital administration).

  • Scope of recall: Determining the scope of the recall - which sterilisation loads, which dates/time periods, which specific items are affected based on the identified breakdown.

  • Item identification: Procedures for rapidly identifying and locating potentially affected items that have been issued from the CSSD. Load numbers, date/time stamps, and item tracking systems are crucial for this step.

  • Withdrawal process: Step-by-step instructions for withdrawing potentially non-sterile items from circulation, including from user departments, procedure trays, and any point of use.

  • Quarantine and segregation: Procedures for quarantining and segregating recalled items to prevent accidental reuse.

  • Reprocessing decisions: Decision-making process for determining whether recalled items can be reprocessed (after steriliser repair) or if they must be discarded.

  • Documentation: Requirements for documenting all steps taken during the recall process, including notifications, item identification, withdrawal actions, and final disposition of recalled items.

• Have a batch-processing system with date and machine number for effective recall: A robust batch-processing and tracking system is essential for enabling an effective recall. This system should include:

  • Batch Processing: Sterilisation should be performed in batches or loads, with each load assigned a unique identifier (load number).

  • Date and Machine Number: Each load record must include the date and time of sterilisation and the specific steriliser machine used.

  • Content Documentation: Ideally, load records should also document the contents of each load (types and quantities of items sterilised).

  • Traceability: The tracking system should enable traceability of sterilised items from the steriliser to the point of use. This can be achieved through barcode scanning, electronic tracking systems, or manual logbooks.

  • Effective Recall: A well-maintained batch-processing and tracking system is the foundation for a rapid and effective recall, allowing for quick identification and withdrawal of potentially affected items should a sterilisation failure occur.

The note emphasizes proactive monitoring of sterilisation procedures:

• Note: The organisation should regularly monitor the sterilisation procedure. Proactive and ongoing monitoring of the entire sterilisation procedure, not just validation testing after the fact, is crucial for preventing breakdowns and ensuring consistent sterilisation effectiveness. Regular monitoring includes:

  • Routine steriliser maintenance and preventive maintenance schedules.

  • Daily checks of steriliser function and physical parameters.

  • Regular review of sterilisation records and validation data.

  • Staff training and competency assessments.

  • Audits of CSSD procedures and practices.

By implementing IPC7 comprehensively, hospitals establish a robust and reliable system for sterilisation and disinfection, minimizing the risk of infection transmission from contaminated medical devices and contributing significantly to patient safety.

IPC8: Actions to Prevent or Reduce Healthcare Associated Infections in its Staff

Section IPC8 of the NABH 6th Edition Accreditation Standards shifts the focus from patient safety to the critical aspect of staff safety, specifically addressing actions the organisation must take to prevent or reduce healthcare-associated infections (HAIs) in its own staff. This section acknowledges that healthcare providers themselves are also at risk of acquiring infections in the workplace and emphasizes the organisation's responsibility to implement occupational health and safety practices to protect its workforce. IPC8 underscores that a safe working environment is not only ethically imperative but also crucial for maintaining a healthy and productive healthcare workforce, which in turn directly benefits patient care. The overall standard of IPC8 remains consistent with the 5th edition, signifying the continuous importance of staff protection in IPC programs. However, objective element IPC 8a has been modified in the 6th edition, suggesting a refined focus or updated requirements within the domain of occupational health and safety for staff.

IPC8a: Implementation of Occupational Health and Safety Practices

IPC8a sets the overarching requirement for the organization: to implement occupational health and safety practices aimed at reducing the risk of transmitting microorganisms among healthcare providers. This objective element, a Commitment level (C) requirement, highlights that staff safety is not just a matter of individual responsibility but a systematic organizational obligation requiring proactive measures. Occupational health and safety practices are essential for creating a safer working environment and reducing the incidence of work-related infections among staff.

IPC8a outlines a sequence of key steps to achieve this:

• Provide adequate resources: The foundation of occupational health and safety is providing adequate resources to support these practices. This includes:

  • Personnel: Designating staff responsible for occupational health, such as occupational health nurses or physicians, and ensuring adequate staffing levels for these services.

  • Equipment and supplies: Providing necessary equipment and supplies for occupational safety, including sufficient quantities of personal protective equipment (PPE) (gloves, masks, gowns, eye protection), hand hygiene facilities (hand rub, soap and water), sharps containers, and safety-engineered devices.

  • Training materials and programs: Developing and delivering comprehensive training programs on occupational health and safety practices, including infection prevention, safe work procedures, and management of exposures.

  • Vaccines and prophylaxis: Providing access to recommended vaccines (e.g., hepatitis B vaccine, influenza vaccine) and post-exposure prophylaxis (PEP) for bloodborne pathogen exposures.

  • Policies and procedures: Developing and implementing clear written policies and procedures for occupational health and safety, including infection prevention, exposure management, work restrictions, and immunisation.

• Adhere to standard precautions: Just as standard precautions are fundamental for patient safety, they are equally crucial for staff safety. Healthcare providers must consistently adhere to standard precautions in all their patient interactions and work activities. This includes:

  • Hand hygiene: Performing hand hygiene diligently before and after patient contact, after removing gloves, and after touching potentially contaminated surfaces.

  • Appropriate PPE use: Using PPE consistently and correctly whenever there is a risk of exposure to blood, body fluids, secretions, excretions, non-intact skin, or mucous membranes.

  • Safe injection practices: Adhering to safe injection practices, including using single-use needles and syringes and proper sharps disposal, to prevent needle stick injuries and bloodborne pathogen exposures.

  • Respiratory hygiene/cough etiquette: Practicing respiratory hygiene and cough etiquette to prevent the spread of respiratory infections among staff and patients.

  • Safe handling of sharps and waste: Handling sharps and biomedical waste safely and disposing of them properly to minimise exposure risks.

• Perform pre-employment health screening: Pre-employment health screening is a proactive measure to assess the health status of new employees and identify any pre-existing conditions that might increase their risk of occupational infections or pose a risk to patients. Pre-employment screening may include:

  • Medical history and physical examination.

  • Review of immunisation history and vaccination status.

  • Screening for tuberculosis (TB) risk factors and TB testing (e.g., tuberculin skin test or interferon-gamma release assay).

  • Screening for other relevant infectious diseases based on local epidemiology and job roles.

  • Baseline health assessment to monitor for occupational health issues over time.

• Capture immunisation status: Capturing and maintaining records of staff immunisation status is essential for occupational health management. This includes:

  • Documentation of received vaccinations, particularly hepatitis B vaccine, influenza vaccine, measles, mumps, rubella, varicella, and other vaccines recommended for healthcare workers based on risk assessment and local guidelines.

  • Regularly updating immunisation records and offering recommended vaccinations to staff.

  • Tracking staff immunisation rates to identify gaps and improve coverage.

  • Using immunisation records to manage potential exposures and outbreaks.

By implementing these sequential steps, organizations can create a systematic and effective approach to occupational health and safety, specifically focused on preventing the transmission of microorganisms and protecting the health of their healthcare providers.

IPC8b: Implementation of an Immunisation Policy for its Staff

IPC8b drills down into the specifics of immunisation, mandating the implementation of an immunisation policy for hospital staff. This objective element, also a Commitment level (C) requirement, underscores that a proactive immunisation program is a core component of occupational health and safety for healthcare workers. Immunisation is a highly effective strategy for preventing vaccine-preventable diseases and protecting both staff and patients.

IPC8b specifically highlights two key aspects of an immunisation policy:

• Immunisation: The policy must address specific immunisations recommended for healthcare workers.

  • Hepatitis B vaccination: Hepatitis B vaccination is a cornerstone of healthcare worker immunisation programs due to the occupational risk of exposure to blood and body fluids and the potential for hepatitis B virus transmission. The policy must mandate offering hepatitis B vaccination to all staff involved in direct patient care. This typically involves a series of vaccine doses and post-vaccination serological testing to confirm immunity.

  • Other relevant immunisation: Beyond hepatitis B, the immunisation policy must address other relevant immunisations based on risk assessment, local epidemiology, and national/international recommendations. This may include:

    • Influenza vaccination: Annual influenza vaccination is strongly recommended for healthcare workers to reduce influenza transmission to vulnerable patients and protect staff health.

    • Measles, Mumps, Rubella (MMR) vaccination: Ensuring staff have immunity to measles, mumps, and rubella, especially those working with paediatric or pregnant patient populations.

    • Varicella (chickenpox) vaccination: Ensuring staff are immune to varicella, particularly important for those working in settings where varicella exposure is likely (e.g., paediatric units).

    • Pertussis (whooping cough) vaccination: Tdap (tetanus, diphtheria, acellular pertussis) vaccine, including the pertussis component, is recommended for healthcare workers, especially those who may have contact with infants, to prevent pertussis transmission.

    • Other vaccines as indicated by risk assessment and local guidelines (e.g., meningococcal vaccine in specific settings).

• Immunisation policy: The immunisation policy itself must be well-defined and practical.

  • Immunise staff involved in direct patient care: The policy must explicitly mandate offering immunisation to all staff who are involved in direct patient care, as these individuals are at highest risk of occupational exposure to infectious agents and of transmitting infections to patients.

  • Provide as per risk and in accordance with applicable statutory requirements: The policy should be risk-based, meaning that specific immunisation recommendations may vary based on job roles, potential exposures, and individual risk factors. The policy must also be compliant with all applicable statutory requirements and regulations related to healthcare worker immunisation in the specific jurisdiction.

The note emphasises the evidence-based nature of the immunisation policy:

• Note: The organisation's immunisation policy should be provided in consonance with available evidence. The immunisation policy must be grounded in available scientific evidence and best practices. This means that the policy should be based on recommendations from reputable sources like the Advisory Committee on Immunization Practices (ACIP) in the US, the National Immunisation Advisory Committee (NIVAC) in India (or equivalent national bodies), the WHO, and other evidence-based guidelines. Regular review and updating of the policy based on new evidence and changing recommendations is essential.

IPC8c: Implementation of Work Restrictions for Health Care Providers with Transmissible Infections

IPC8c addresses the important issue of managing healthcare providers who themselves develop transmissible infections. It mandates the implementation of work restrictions for healthcare providers with transmissible infections. This objective element, an Achievement level (A) requirement, reflects the ethical responsibility to protect both patients and staff by preventing the transmission of infections from infected healthcare workers. Balancing staff well-being with patient safety is a key consideration in this area.

IPC8c outlines a balanced approach to managing staff with transmissible infections:

• Limit role and responsibilities of infected staff: Work restrictions may involve temporarily limiting the role and responsibilities of infected staff to minimize the risk of transmission to patients and colleagues. The specific restrictions should be tailored to the type of infection, the mode of transmission, the staff member's job duties, and the patient population they typically interact with. Restrictions may include:

  • Avoiding direct patient contact, especially with high-risk patients (e.g., immunocompromised patients, infants).

  • Limiting participation in aerosol-generating procedures if the infection is respiratory and airborne.

  • Restricting work in specific units or areas (e.g., ICUs, operating rooms) if the infection poses a heightened risk to vulnerable patients in those settings.

  • Modifying job duties to tasks that do not involve direct patient care or exposure risks.

• Encourage them to report illness or exposures: Creating a culture of trust and support where staff feel comfortable reporting illnesses or potential exposures is crucial. Staff should be encouraged to report symptoms of transmissible infections promptly, without fear of reprisal. Open reporting is essential for early detection and preventing further transmission.

• Do not penalise infected staff: It is critical to avoid penalising staff for reporting illnesses or exposures. Penalizing staff for reporting illness can create a disincentive to report, leading to underreporting and increased risks of transmission. The focus should be on supporting staff health and protecting patients, not on punitive measures. Work restriction policies should be supportive and non-punitive, focusing on facilitating staff recovery and preventing further transmission.

The "Points to Remember" section provides examples of transmissible infections that may warrant work restrictions:

• Points to Remember: Examples of transmissible infections: These are examples of infections that are commonly considered when implementing work restrictions for healthcare workers.

  • Acute conjunctivitis (pink eye): Highly contagious and easily spread through contact. Work restriction may be considered for staff involved in direct patient care until symptoms resolve.

  • Chickenpox (varicella): Highly contagious, especially airborne spread. Work restriction is crucial for staff who are not immune to varicella and develop chickenpox, especially to protect susceptible patients (pregnant women, immunocompromised individuals).

  • Acute respiratory infections (e.g., influenza, pertussis): Spread through droplets and contact. Work restriction may be recommended during periods of acute illness to prevent transmission, especially to vulnerable patients.

  • Smear-positive case of tuberculosis: Active pulmonary tuberculosis with positive sputum smears is highly contagious. Work restriction is mandatory for staff with active smear-positive TB until they are deemed non-infectious by public health authorities and have completed appropriate treatment.

The specific work restriction policy should be tailored to the hospital setting, patient population, and local epidemiology, and should be developed in consultation with occupational health experts and the infection control team.

IPC8d: Implementation of Measures for Blood and Body Fluid Exposure Prevention

IPC8d focuses on a very specific but significant occupational hazard for healthcare workers: blood and body fluid exposures. It mandates the implementation of measures for blood and body fluid exposure prevention. This objective element, a Commitment level (C) requirement, highlights the need to proactively minimize the risk of percutaneous (needle stick) injuries and mucocutaneous exposures to blood and body fluids, which are major routes of transmission for bloodborne pathogens like hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).

IPC8d emphasizes a layered approach to exposure prevention:

• Use appropriate personnel protective equipment: Consistent and correct use of appropriate personnel protective equipment (PPE) is a primary barrier to blood and body fluid exposures. This includes:

  • Gloves: Wearing gloves whenever there is a risk of contact with blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin. Proper glove selection and use are crucial.

  • Eye protection (goggles or face shields): Wearing eye protection when procedures may generate splashes or sprays of blood or body fluids to protect mucous membranes of the eyes.

  • Masks: Wearing masks (and face shields if needed) to protect mucous membranes of the nose and mouth from splashes or sprays.

  • Gowns: Wearing gowns to protect skin and clothing during procedures where soiling with blood or body fluids is likely.

• Provide needle devices with safety features: Implementing safety-engineered needle devices is a crucial engineering control measure to reduce needle stick injuries. Safety-engineered devices incorporate features that shield or retract the needle after use, minimizing the risk of accidental needlesticks. Examples include:

  • Retractable needles.

  • Needle shields that automatically cover the needle.

  • Blunt suture needles (where clinically appropriate).

  • Needleless intravenous access systems.

  • Safety lancets for finger or heel sticks.

The note promotes elimination of needle devices where possible:

• Note: The organisation should eliminate use of needle devices whenever safe and effective alternatives are available. A key principle of exposure prevention is to eliminate the hazard whenever feasible. Organizations should actively seek and implement safe and effective alternatives to needle devices whenever possible. Examples include:

  • Oral medications instead of injections, when clinically appropriate.

  • Needleless intravenous medication administration systems.

  • Non-invasive monitoring methods.

IPC8e: Appropriate Post-Exposure Prophylaxis is Provided to All Staff Members Concerned

IPC8e addresses the crucial post-exposure management of staff who experience blood and body fluid exposures. It mandates that appropriate post-exposure prophylaxis (PEP) is provided to all staff members concerned. This objective element, also a Commitment level (C) requirement, emphasizes the organisation's responsibility to have systems in place to promptly assess, manage, and provide PEP when occupational exposures to bloodborne pathogens occur. PEP can significantly reduce the risk of infection after exposure.

IPC8e focuses on key aspects of post-exposure management:

• Provide PEP for hepatitis B and HIV exposure: The policy must explicitly address providing post-exposure prophylaxis (PEP) for exposures to hepatitis B virus (HBV) and human immunodeficiency virus (HIV), as these are significant occupational risks.

  • Hepatitis B PEP: This typically involves hepatitis B immunoglobulin (HBIG) and/or hepatitis B vaccine, depending on the source patient's HBV status and the exposed staff member's HBV vaccine status and response.

  • HIV PEP: HIV PEP involves antiretroviral medications started as soon as possible after exposure (ideally within hours) and continued for a recommended duration. HIV PEP regimens and guidelines are regularly updated based on evidence.

• Adhere to national and/or international guidelines: Post-exposure management protocols and PEP regimens must be aligned with current national and international guidelines. These guidelines provide evidence-based recommendations on risk assessment, PEP initiation, medication regimens, monitoring, and follow-up after bloodborne pathogen exposures. Guidelines from the CDC, WHO, and national health authorities should be consulted.

• Maintain records of PEP provided: Accurate records of all occupational exposures and PEP provided must be maintained. These records are important for:

  • Individual staff member’s medical history and follow-up.

  • Tracking exposure trends and identifying areas for prevention improvement.

  • Legal and regulatory compliance.

  • Occupational health program evaluation.

The "Points to Remember" section highlights key aspects of PEP management:

• Points to Remember:

  • Infection Prevention & control nurse is in-charge of documentation: The Infection Prevention and Control Nurse (IPCN) often plays a key role in managing occupational exposures and PEP, including documentation, follow-up, and coordination of care.

  • Example of PEP: PEP for needle stick injury: The example of PEP for needle stick injury illustrates a common scenario where PEP is indicated. However, PEP protocols also apply to other types of blood and body fluid exposures, such as mucocutaneous exposures.

By implementing IPC8 comprehensively, organizations create a healthcare environment where the safety and well-being of their staff are prioritized, leading to a healthier workforce, reduced occupational infections, and a stronger overall commitment to patient safety and quality care.

Based on the provided NABH 6th Edition Chapter 5: Infection Prevention & Control (IPC) presentation, here's a list of policies and procedures that are typically implied or explicitly mentioned as being required against each standard. This is not an exhaustive list and the specific policies and procedures may vary based on your hospital's specific context and risk assessment.

IPC1: The organisation has a comprehensive and coordinated Hospital Infection Prevention and Control (HIC) programme aimed at reducing/eliminating risks to patients, visitors, providers of care and community.

• Policies:

  • Hospital Infection Prevention and Control (IPC) Programme Manual Policy: This overarching policy establishes the framework for the entire IPC program, including its objectives, scope, organizational structure, and review process.

  • Policy on Documentation of the IPC Programme: Ensuring all aspects of the IPC program are documented, including policies, procedures, guidelines, minutes of meetings, surveillance data, etc.

  • Policy on Periodic Risk Assessment for Infection Prevention & Control: Mandating regular risk assessments to identify and address infection risks within the hospital.

  • Policy on Annual Review and Update of the IPC Programme: Setting a formal process for annual review and updates of the IPC program based on evidence, trends, and audit outcomes.

  • Policy on the Multi-Disciplinary Infection Control Committee: Establishing the committee's composition, responsibilities, meeting frequency, documentation (minutes), and quorum.

  • Policy on the Infection Control Team: Defining the team's responsibilities in implementing the IPC program, staffing requirements based on hospital size and risk, and reporting structure.

  • Policy on Community Infection Prevention and Control Education: Outlining the organisation's approach to providing information, education, and communication about IPC to the community.

  • Policy on Participation in Community Outbreak Management: Defining the hospital's role and responsibilities in managing community outbreaks, including communication and coordination with external agencies.

• Procedures:

  • Procedure for High-Risk Activity Identification and Guidance Development: A process to identify high-risk activities (e.g., aerosol-generating procedures, handling sharps) and develop specific written guidance for each.

  • Procedure for Conducting Annual IPC Programme Review: A structured procedure for performing the annual review, including utilizing validated assessment tools.

  • Procedure for Conducting Infection Control Risk Assessment (ICRA): For various areas and activities, including construction and renovation.

  • Procedure for Managing Community Outbreaks: A step-by-step procedure outlining the hospital's response to community outbreaks, including communication, role assignment, and staff training.

IPC2: The organisation provides adequate and appropriate resources for infection prevention and control.

• Policies:

  • Policy on Resource Allocation for Infection Prevention and Control: Ensuring adequate financial and human resources are allocated to support the IPC program continually.

  • Policy on Procurement and Maintenance of Personal Protective Equipment (PPE): Ensuring availability of appropriate PPE at the point of use and maintaining adequate inventory.

  • Policy on Provision and Maintenance of Hand Hygiene Facilities: Ensuring accessibility and proper functioning of hand wash basins and hand rub dispensers in all patient care areas.

  • Policy on Provision and Maintenance of Isolation/Barrier Nursing Facilities: Ensuring availability of isolation rooms, negative pressure rooms, signage, and necessary resources for barrier nursing.

• Procedures:

  • Procedure for Budgeting and Financial Allocation for IPC: A procedure to demarcate and manage a separate budget for IPC activities.

  • Procedure for PPE Inventory Management and Stock Replenishment: To maintain adequate PPE supplies.

  • Procedure for Regular Maintenance and Functionality Checks of Hand Hygiene Facilities: Ensuring washbasins and dispensers are working correctly.

  • Procedure for Setting up and Maintaining Isolation/Barrier Nursing Areas: Including protocols for room preparation, signage, and resource provision for staff.

IPC3: The organisation implements the infection prevention and control programme in clinical areas.

• Policies:

  • Policy on Adherence to Standard Precautions: Mandating the consistent application of standard precautions by all healthcare providers at all times in all areas.

  • Policy on Adherence to Hand Hygiene Guidelines: Promoting and enforcing adherence to international/national hand hygiene guidelines.

  • Policy on Adherence to Transmission-Based Precautions: Defining when and how to implement contact, droplet, and airborne precautions.

  • Policy on Safe Injection and Infusion Practices: Outlining guidelines for aseptic technique, single-use vials/syringes, and safe infusion practices.

  • Antimicrobial Usage Policy: Establishing guidelines for appropriate antimicrobial agent selection, dosage, duration, route of administration, and promoting antimicrobial stewardship.

• Procedures:

  • Procedure for Standard Precautions Implementation: Detailed steps for implementing each element of standard precautions (hand hygiene, PPE, etc.).

  • Procedure for Hand Hygiene Technique: Step-by-step instructions for proper hand washing and hand rubbing techniques.

  • Procedure for Implementing Transmission-Based Precautions: Detailed procedures for contact, droplet, and airborne precautions, including PPE use, patient placement, and environmental controls.

  • Procedure for Safe Injection and Infusion Administration: Step-by-step guidance on performing injections and infusions safely, emphasizing aseptic technique.

  • Procedure for Antimicrobial Stewardship Program: Outlining the process for antimicrobial stewardship interventions, order review, feedback, and CAPA implementation.

  • Procedure for Monitoring Antimicrobial Susceptibility: Regularly monitoring and analyzing antimicrobial susceptibility data.

IPC4: The organisation implements the infection prevention and control programme in support services.

• Policies:

  • Policy on Engineering Controls for Infection Prevention: Addressing air quality checks, water management, and hospital setting design to prevent infections.

  • Policy on Infection Control During Construction and Renovation: Mandating risk assessment and implementation of control measures during construction and renovation.

  • Housekeeping Procedures Policy: Defining cleaning frequencies, methods, and agents for different areas of the hospital based on risk stratification.

  • Biomedical Waste (BMW) Management Policy: Outlining procedures for handling, segregation, collection, storage, and disposal of BMW, ensuring compliance with statutory regulations.

  • Laundry and Linen Management Policy: Establishing procedures for handling soiled linen, storage and distribution of clean linen, and documentation of linen changes.

  • Kitchen Sanitation and Food Handling Policy: Defining standards for kitchen hygiene, food handling practices, storage/refrigeration, and distribution to prevent foodborne illnesses.

• Procedures:

  • Procedure for Maintenance of AC Plant and Equipment, and Cleaning of Ducts/Filters: Regular maintenance and cleaning schedules.

  • Infection Control Risk Assessment (ICRA) Procedure for Construction and Renovation: Step-by-step process for conducting ICRA.

  • Procedure for Housekeeping in Different Areas of the Hospital: Specific cleaning protocols based on risk stratification for various areas.

  • Procedure for Handling Biomedical Waste (BMW): Step-by-step guide for staff on proper BMW handling from generation to disposal.

  • Procedure for Laundry and Linen Handling: Detailed procedures for each stage of linen management.

  • Procedure for Kitchen Sanitation and Food Handling: Covering all aspects from staff hygiene to food storage and distribution, ensuring safe practices.

IPC5: The organisation takes actions to prevent healthcare associated infections (HAI) in patients.

• Policies:

  • Policy on Prevention of Catheter-Associated Urinary Tract Infections (CAUTI): Outlining strategies and care bundles to prevent CAUTI.

  • Policy on Prevention of Ventilator-Associated Pneumonia (VAP): Outlining strategies and care bundles to prevent VAP.

  • Policy on Prevention of Central Line Associated Blood Stream Infections (CLABSI): Outlining strategies and care bundles to prevent CLABSI.

  • Policy on Prevention of Surgical Site Infections (SSI): Outlining strategies and care bundles to prevent SSI in pre-op, intra-op, and post-op phases.

• Procedures:

  • CAUTI Prevention Care Bundle Implementation Procedure: Step-by-step guide for implementing and auditing the CAUTI prevention bundle.

  • VAP Prevention Care Bundle Implementation Procedure: Step-by-step guide for implementing and auditing the VAP prevention bundle.

  • CLABSI Prevention Care Bundle Implementation Procedure: Step-by-step guide for implementing and auditing the CLABSI prevention bundle.

  • SSI Prevention Care Bundle Implementation Procedure: Step-by-step guide for implementing and auditing the SSI prevention bundle across the perioperative period.

IPC6: The organisation performs surveillance to capture and monitor infection prevention and control data.

• Policies:

  • Policy on Infection Prevention and Control Surveillance System: Establishing the scope, methodology (active and passive), parameters to be captured, and reporting mechanisms for the surveillance system.

  • Policy on Data Verification for IPC Surveillance: Ensuring data accuracy and reliability through verification procedures.

  • Policy on Targeted Surveillance of High-Risk Activities: Directing surveillance efforts towards identified high-risk areas and activities.

  • Policy on Hand Hygiene Compliance Monitoring: Establishing methods, frequency, and reporting of hand hygiene compliance monitoring.

  • Policy on Surveillance of Multi-Drug Resistant Organisms (MDROs): Defining mechanisms to capture and monitor MDRO occurrence and spread.

  • Policy on Monitoring Effectiveness of Housekeeping Services: Establishing methods and parameters for monitoring housekeeping effectiveness.

  • Policy on Feedback Mechanism for Surveillance Data: Ensuring regular feedback of surveillance data to relevant healthcare providers.

  • Outbreak Management Policy: Defining triggers, procedures for investigation, control measures, and communication during outbreaks.

  • Policy on Corrective and Preventive Actions (CAPA) based on Surveillance Data: Establishing a process to analyze surveillance data and implement CAPA for continuous improvement.

• Procedures:

  • Procedure for Active Surveillance for HAIs: Step-by-step guide for active case finding and data collection.

  • Procedure for Data Collection, Analysis, and Reporting for IPC Surveillance: Standardizing data collection, analysis methods, and reporting formats for surveillance.

  • Procedure for Data Verification for IPC Surveillance: Outlining steps for data verification (e.g., random sampling).

  • Procedure for Hand Hygiene Compliance Monitoring and Data Reporting: Step-by-step guide for conducting hand hygiene observations, data collection, and reporting.

  • Procedure for Outbreak Investigation and Control: Detailed steps for outbreak investigation, case finding, implementation of control measures, and communication.

  • Procedure for Implementing CAPA based on Surveillance Data Analysis: Step-by-step process for identifying CAPA, implementing actions, and monitoring effectiveness.

IPC7: Infection prevention measures include sterilisation and/or disinfection of instruments, equipment and devices.

• Policies:

  • Policy on Central Sterile Services Department (CSSD) Zoning and Space Management: Defining requirements for CSSD location, layout, zoning, and space adequacy.

  • Policy on Reprocessing of Medical Devices (Cleaning, Disinfection, Sterilisation, Storage, Issue): Establishing comprehensive guidelines for all stages of medical device reprocessing.

  • Policy on Spaulding's Classification for Reprocessing Levels: Defining Spaulding's classification and its application to determining appropriate reprocessing levels.

  • Policy on Sterilisation Validation and Quality Control: Mandating regular validation tests, documentation, and quality control measures for sterilisation processes.

  • Policy on Recall Procedure for Sterilisation Failures: Establishing a step-by-step recall process in case of a sterilisation system breakdown.

  • Policy on Reprocessing of Reusable Single-Use Devices (if applicable and permitted): If engaging in this practice, a strict and validated policy is required.

• Procedures:

  • Procedure for CSSD Workflow (Soiled to Sterile): Detailed steps for unidirectional workflow within the CSSD.

  • Procedure for Cleaning Medical Devices (Manual and Automated): Step-by-step guides for cleaning different types of instruments and equipment.

  • Procedure for Packaging Medical Devices for Sterilisation: Detailed instructions on proper packaging techniques and materials.

  • Procedure for Operating Sterilisation Equipment (Steam, Low Temperature etc.): Step-by-step operational procedures for each type of sterilizer used, including loading and cycle parameters.

  • Procedure for Disinfection of Medical Devices (High, Intermediate, Low Level): Detailed procedures for using different disinfectants and achieving various levels of disinfection.

  • Procedure for Storage of Sterile and Disinfected Items: Defining storage conditions, shelf-life, and handling protocols.

  • Procedure for Routine Sterilisation Validation Testing (Physical, Chemical, Biological): Step-by-step guidance on performing and documenting validation tests.

  • Procedure for Implementing Recall of Potentially Non-Sterile Items: Detailed steps for initiating and executing a recall procedure.

IPC8: The organisation takes action to prevent or reduce healthcare associated infections in its staff.

• Policies:

  • Occupational Health and Safety Policy for Infection Prevention: Establishing a framework for occupational health and safety practices to reduce infection risks for staff.

  • Immunisation Policy for Healthcare Workers: Mandating and facilitating immunisation against vaccine-preventable diseases for staff.

  • Work Restriction Policy for Healthcare Providers with Transmissible Infections: Defining guidelines for work restrictions to prevent infection transmission from infected staff.

  • Blood and Body Fluid Exposure Prevention Policy: Outlining measures to prevent percutaneous and mucocutaneous exposures to blood and body fluids.

  • Post-Exposure Prophylaxis (PEP) Policy for Bloodborne Pathogens: Establishing procedures for assessment, management, and provision of PEP after bloodborne pathogen exposures.

• Procedures:

  • Procedure for Pre-Employment Health Screening of Healthcare Workers: Step-by-step process for conducting health screenings.

  • Procedure for Managing Staff Immunisation Program: Outlining how immunisations are offered, tracked, and recorded.

  • Procedure for Implementing Work Restrictions for Staff with Transmissible Infections: Step-by-step guidance on assessing risk, determining restrictions, and managing staff return to work.

  • Procedure for Management of Blood and Body Fluid Exposures: Step-by-step guide for immediate actions, risk assessment, reporting, PEP initiation, and follow-up after exposures.

  • Procedure for Providing Post-Exposure Prophylaxis (PEP): Detailed protocol for accessing, administering, and documenting PEP for HBV and HIV exposures.

Remember, this list provides a comprehensive starting point. You should tailor and adapt these policies and procedures to the specific needs and risks of your hospital, in consultation with your infection control team and relevant stakeholders. Regularly review and update these documents to ensure they remain current and effective.