INFECTION CONTROL COMMITTEE

Healthcare-associated infection (HCAI) is one of the most common complications of health care management.
It is a serious health hazard as it leads to increased patients’ morbidity and mortality, length of hospital stay and
the costs associated with hospital stay. As a general timeline, infections occurring more than 48 hours after
admission are usually considered HCAI. (WHO)

HCAI is also known as hospital acquired infections or nosocomial infections Effective infection prevention and
control is central to providing high quality health care for patients and a safe working environment for those that
work in healthcare settings.

POLICIES FOR EFFECTIVE INFECTION CONTROL SHOULD BE IN PLACE IN ALL HEALTH

CARE SETTINGS.

 Guidelines for prevention & control of infections

 Antimicrobial use guidelines
 HCAI Surveillance guidelines
 Disinfection
 Guidelines for patient Isolation
 Investigation of an outbreak of infection

INFECTION CONTROL PROGRAMME Infection control programme is required in every health care set
up to assist the health care workers in the provision of quality health care for the well being and safety of
patients and health care workers.The Infection control Programme has the following objectives:

 To minimize the risk of infection to patients, health care workers and visitors.
 To formulate local guidelines and standard operating procedures (SOPs) for prevention and control of infection.
 To educate and train health care workers.
 To recommend antimicrobial policy for the hospital and formulate antimicrobial stewardship programme.
 To ensure implementation and monitoring of the programme.
 To Conduct outbreak investigations, Environmental Surveillance activities (Air / Water Samples)
 To Ensure compliance to Biomedical Waste disposal
INFECTION CONTROL COMMITTEE:

The Committee is an integral component of the patient safety programme of the health care facility, and is
responsible for establishing and maintaining infection prevention and control, its monitoring, surveillance,
reporting, research and education. This committee should include wide representation from all relevant
disciplines or departments in the facility.
RESPONSIBILITIES OF THE HOSPITAL INFECTION PREVENTION AND CONTROL
COMMITTEE

1. Formulating Hospital Infection Prevention and Control Policy. It should be reviewed and updated once a
year.

2. Analysis of the surveillance data for health care associated infections (including identifying common sources
and routes of entry of infections) on a monthly basis and identifying at-risk patients and taking appropriate
actions and implementing recommendations where necessary.

3. Reviewing the levels of HAI and their trends regularly and compare the rates of infections with other health
set ups wherever feasible.

4. Verifying the effectiveness of the recommendations implemented for infection prevention and control.

5. Assessing on an ongoing basis whether recommended precautions are being adhered to, i.e., hand washing,
decontamination, disinfection and sterilization through audits and quality control activities of infection
prevention and control.

6. Planning and conducting ongoing training programmes in order to ensure that all members of staff are
sensitized to measures to prevent the transmission of infections.

7. Investigating the spread of infection outbreaks in collaboration with medical, nursing and other staff.

INFECTION CONTROL MEETINGS:

Periodic meetings at least once in a month of Infection Control Committee shall take place and documented
with clear action points and responsibility to implement on the medical/nursing/operational personnel. A review
of last minutes and implementation shall be a part of the next meeting.

STRUCTURE

 Chairperson: Head of the Institute (preferably) OR hospital administrator

 Infection Control officer (Medical Microbiologist/ID physician/physician)-secretary of
committee
 Members: Representation from Management/Administration (Dean/Director of Hospital;
Nursing Services; Medical Services; Operations)
 Relevant Medical Faculties
 Support Services: (OT/CSSD, House-keeping/Sanitation, Engineering, Pharmacologist, Store
Officer / Materials Department)
 Infection Control Nurse (s)
 INFECTION CONTROL OFFICER:

Infection control officer is usually a medical microbiologist or a medical epidemiologist or any other physician.
Infection control officer may be the member secretary of HICC and is responsible for day-to-day activities of
infection prevention and control.

 Responsibilities of Infection Control Officer-

 Prepare guidelines for infection control practices.
 Initiates hospital infection surveillance activities and analyzes the surveillance data.
 Provide trends of HAI to the different patient care units.
 Analyze and report data regarding organisms isolated and their resistance pattern (antibiograms).
 Monitor rational use of antimicrobials.
 Investigate the outbreak, if any and advise about control measures.
 Organize regular educational and training activities for HCWs.
 Organize IPCC meeting regularly

Infection control responsibility of different stakeholders

 Role of Hospital Administration

The administration and/or medical management of the hospital must provide leadership by supporting the
hospital infection programme and has important role in formulating infection prevention and control activities.
For this, the head of the hospital should establish a hospital infection control committee (HICC).HICC should
appoint Infection control Team (ICT) for carrying out the day to day activities as formulated by the HICC.
 Responsibilities of the Hospital administrator-
 Establish a multidisciplinary Infection Control Committee.
 Identify appropriate resources for the programme to monitor infections and apply the most appropriate
methods for preventing infection.
 Ensure availability of appropriate infrastructure, financial and human resources.
 Periodically review the status of nosocomial infections and effectiveness of interventions to contain
them.
 Promote educational and training activities for all categories of staff.
 Ensure implementation of nosocomial infection surveillance system.
 Ensure availability of safe food and drinking water.
 Role of the physician
Physicians have unique responsibilities for the prevention and control of hospital infections:
 By providing direct patient care using practices which minimize infection
 By following appropriate practice of hygiene (e.g. hand washing, isolation)
 Serving on the Infection Control Committee
 Supporting the infection control team.
 Specifically, physicians are responsible for:
 Protecting their own patients from other infected patients and from hospital staff who may be infected
 Complying with the practices approved by the Infection Control Committee
 Obtaining appropriate microbiological specimens when an infection is present or suspected
 Notifying cases of hospital-acquired infection to the team, as well as the admission of infected patients
 Complying with the recommendations of the Antimicrobial Use Committee regarding the use of antibiotics &
complying with the antibiotic policy.
 Advising patients, visitors and staff on techniques to prevent the transmission of infection.
 Instituting appropriate treatment for any infections they themselves have, and taking steps to prevent such
infections being transmitted to other individuals, especially patients.
 Role of the microbiologist :-
The microbiologist is responsible for:
 Handling patient and staff specimens to maximize the likelihood of a microbiological diagnosis.
 Developing guidelines for appropriate collection, transport, and handling of specimens.
 Developing guidelines for appropriate collection, transport and handling of specimens.
 Ensuring safe laboratory practices to prevent infections among laboratory staff.
 Rapidly diagnose infections, identify pathogens and perform antimicrobial susceptibility testing of isolated
pathogens following standard methods.
 Timely communication of results to the Infection Control Committee.
 Analyze and report antimicrobial resistance pattern of relevant pathogens in different units and in different
specimens.
 Analyze and report hospital infection rates and trends over a period of time.
 Monitoring sterilization, disinfection and the environment where necessary.
 Conducts epidemiological typing to trace sources and reservoirs of infection during outbreaks and whenever
necessary.
 Role of the hospital pharmacist: -
Pharmacist should be an active member of the hospital antibiotic stewardship program. The hospital pharmacist
is responsible for:
 Obtaining, storing and distributing pharmaceutical preparations using practices which limit potential
transmission of infectious agents to patients.
 Dispensing anti-infectious drugs and maintaining relevant records (potency, incompatibility, conditions of
storage and deterioration).
 Obtaining and storing vaccines or sera, and making them available as appropriate.
 Maintaining records of antibiotics distributed to the medical departments.
 Providing the Antimicrobial Use Committee and Infection Control Committee with summary reports and trends
of antimicrobial use.
 Infection Control Nurse (ICN) :
A full time senior nursing staff should be appointed as ICN and to support her adequate full time or part time
nursing. The duties of the ICN are primarily associated with ensuring the practice of infection control measures
by healthcare workers. Thus the ICN is the link between the HICC and the wards/ICUs etc. in identifying
problems and implementing solutions.
Responsibilities of infection Control Nurse –
 The ICN conducts Infection control rounds daily and tracks all positive culture cases and maintains the
surveillance data.
 The ICN is involved in education and training of HCWs under the supervision of infection control officer.
 Ensures compliance to hospital’s BMW policy.
 Maintains data of Sharps/Needle stick injuries and Post–exposure prophylaxis.
Initiates and ensure proper immunization for Hepatitis B Virus (Immunoglobulin use if needed after exposure,
and HBsAg vaccine), annual influenza immunization for the staff especially in high risk areas and typhoid
vaccination of kitchen workers.
 In consultation with microbiologist/physician (Member HICC) in case of suspected exposure of any hospital
worker.
 Role of the nursing staff: -
Implementation of patient care practices for infection control is the role of the nursing staff. Nurses should be
familiar with practices to prevent the occurrence and spread of infection, and maintain appropriate practices for
all patients throughout the duration of their hospital stay.
The senior nursing administrator is responsible for:
 Participating in the meetings of Infection Control Committee.
 Promoting the development and improvement of nursing techniques, and ongoing review of aseptic nursing
policies, with approval by the Infection Control Committee.
 Developing training programmes for members of the nursing staff.
 Supervising the implementation of techniques for the prevention of infections in specialized areas such as the
operating suite, the intensive care unit, the maternity unit and newborns.
 Monitoring of nursing adherence to policies.
 Documentation, reliable reporting and maintenance of records of cases suspected to be suffering from HAI, as
per records from ward cases notes, laboratory reports and information collected in routine visits and discussions
with staff.
 Empowering nurse-in charge for implementation, monitoring and adherence to IPC practices.
 The nurse in charge of a ward is responsible for:
 Maintaining hygiene, consistent with hospital policies and good nursing practice on the ward.
 Monitoring aseptic techniques, including hand washing and use of isolation.
 Reporting promptly to the attending physician any evidence of infection in patients under the nurse’s care.
 Initiating patient isolation and ordering culture specimens from any patient showing signs of a communicable
disease, when the physician is not immediately available.
 Limiting patient exposure to infections from visitors, hospital staff, other patients, or equipment used for
diagnosis or treatment.
 Maintaining a safe and adequate supply of ward equipment, drugs and patient care supplies.
 Identifying nosocomial infections.
 Participating in training of personnel.
 Participating in outbreak investigation.
HOW DOES THE INFECTION CONTROL COMMITTEE PREVENT AND CONTROL INFECTION?
The Infection Control Committee uses several tools to ensure patient and employee
safety. They include the following:

Planning: Successful prevention and control of infection requires careful

planning. The Infection Control Committee is actively involved with the planning and
implementation of new procedures that pose a potential infection control risk.

Monitoring: The Infection Control Committee also monitors infectious processes

within the healthcare facility. They track nosocomial infections and incidents that have
the potential to cause infections. They review infection control statistics from the
facility in an effort to minimize risk, identify problem areas, and implement corrective
actions.

When infections do occur, the committee undertakes epidemiological investigations to

determine the cause of the problem and recommends the necessary education or changes in
protocols.

Evaluating: Along with monitoring specific incidents, the Infection Control

Committee also looks at the bigger picture as it continually strives to improve processes
within the facility. This is demonstrated by the regular review of infection control
procedures for all departments. The committee may also be called upon to evaluate
practices and provide input regarding products and protocols.
Updating: Perhaps one of the biggest challenges that all Infection Control
Committees face is keeping current. The Infection Control Committee's
purpose is to provide guidance and leadership through these changes. By keeping current, they can assist the
committee as it works to manage its facility's
infection control policy.

Educating: Finally, as an integral part of its leadership, the committee must

take an active role in staff education. That role may be a hands-on approach or it may be
an advisory role in partnership with the facility's education department. However it
functions, the committee must set direction for staff education and validation of that
education. Educational roles should focus on creating awareness of
infection control and developing the appropriate skills necessary to function effectively
on the job.