Hospital infection control(Indicators)

1. HOSPITAL INFECTION
CONTROL(INDICATORS)
DR JAYANT BALANI
CONSULTANT MICROBIOLOGIST(MBBS,MD))
DHARAMSHILA HOSPITAL &RESEARCH CENTRE,
NEW DELHI

2. OVERVIEW OF INFECTION CONTROL PROGRAMME
• GOAL
• POLICY
• SURVELLANCE PROGRAM
• TRAINING PROGRAME
• DATA SLIDES
• SPECIFIC GOALS SET FOR INFECTION CONTROL
• PROCESS OUTCOME MEASURES
• HURDLES /PROBLEMS/ROOT CAUSE ANALYSISS
• ANTIBIOTIC POLICY
• ANNEXURSES

3. INFECTION CONTROL
PROGRAMME
• GOAL
• TO REDUCE THE INCIDENCE OF HOSPITAL ACQUIRED
INFECTIONS,CATER TO PATIENT AND HEALTHCARE
WORKER SAFETY

4. DHARAMSHILA HOSPITAL & RESEARCH CENTRE
VASUNDHRA ENCLAVE, DELHI –110096
INFECTION CONTROL GOALS FOR 2012-2013
• TO INCREASE THE HAND HYIEGENE COMPLIANCE TO 70% .
• TO FORMULATE AUDIT DOCUMENTS IN BIOMEDICALWASTE MANAGEMENT ,
KITCHEN, CSSD, LAUNDARY.
• TO IMPLEMENT BUNDLE APPROACH IN VAP,CUATI, CRBSI.
• TO ENSURE RUNNING OF INFECTION CONTROL SURVEILLANCE PROGRAM AS PER
SCHEDULE.
DT:1/4/2012

5. POLICY FOR H.I.C
• PROCEDURE LABORATORY BASED WARD SURVEILLANCE
AND SELECTED CONTIUNING SURVEILLANCE(IC..U)
COMPONENTS
• MULTIDISCILIPLINARY INFECTION CONTROL COMMITTEE
AND INFECTION CONTROL TEAM TO MONITOR HOSPITAL
INFECTION CONTROL

6. ESSENTIALS OF INFECTION CONTROL PROGRAMME
INFECTION CONTROL MANUAL
– UPDATED ANNUALLY
INFECTION CONTROL COMMITTEE
– MEETING QUATERLY
– MEMBERS
NAME DESIGNATION IN ORGANIZATION DESIGNATION IN COMMITTEE
• DR. JAYANT BALANI DEPT. OF MICROBIOLOGY CHAIRMAN
• DR. V.R. MINOCHA DEPT. OF SURGERY MEMBER
• DR. PRAVEEN TIWARI DEPT. OF MEDICINE MEMBER
• DR. PREETI MISHRA DEPT. OF ANAESTHESIA MEMBER
• MRS. S.KUMRA NURSING SUPT. MEMBER
• MRS. RENUKA ICN MEMBER
FUNCTIONS
• DEVELOPS & REVIEWS INFECTION CONTROL POLICIES AND PROCEDURES
• DESIGNS AND DETERMINES THE TYPE OF SURVEILLANCE AND REPORTING PROGRAME
• ANALYSES THE INFECTION CONTROL SURVIELLENCE DATA.
• ENSURE THAT CORRECTIVE ACTION AND CONTROL MEASURES ARE TAKEN IN THE EVENT OF
OUTBREAKS
• MONITORS FUNCTIONAL COMPLIANCE WITH INFECTION CONTROL POLICIES AND PROCEDURES.
• DEVELOPS EDUCATIONAL PROGRAM ABOUT INFECTION CONTROL POLICIES AND PRACTICES FOR
HOSPITAL STAFF.

7. POLICY FOR H.I.C
1. BUDGETARY ALLOCATION AND AMOUNT OF 14,87,463 SPENT
ON INFECTION CONTROL PROGRAMME.
SPENDING
DISINFE
CTANTS
P.P.E
TYPE SPENDING
DISINFECTANTS 4,63172
PPERSONAL
PROTECTIVE
EQUIPMENT
7,79,291
SURVEILLANCE
CULTURES
2,45,000

8. POLICY FOR H.I.C
2. REGULAR TRAINING FOR INFECTION CONTROL
PRACTICES.
A)STAFF B)MEDICAL STAFF C)PATIENT
D)FAMILY

9. TRAINING SHEET
TOPICS STAFF MEDICAL
STAFF
PATIENT FAMILY
Educate patients/families about
central line associated
bloodstream infection prevention
prior to insertion of a central
venous catheter
X X X X
Educate LIP, staff regarding
surgical site infections and
importance of prevention at hire
and annually when involved in
these procedure or care of patients
X X X X
Educate patients/families who are
undergoing a surgical procedure
about surgical site infection
prevention
X X X X

10. TRAINING SHEET
TOPICS STAFF MEDICAL
STAFF
PATIENT FAMILY
Policy regarding reprocessing of
single-use devices (IC 221.5)
X X
Hand hygiene guidelines X X X X
Educate LIP, staff regarding HAI, MDRO
and prevention strategies at hire and
annually
X X X X
Educate patients/families who are
infected or colonized with an MDRO
about HAI prevention strategies
X X X X
Educate LIP, staff regarding central line
associated infections CLABSI and
prevention strategies at hire and
annually when involved in these
procedure or care of patients
X X X X
Educate patients/families about central
line associated bloodstream infection
X X X X

11. TRAINING SHEET
TOPICS STAFF MEDICAL
STAFF
PATIENT FAMILY
Methods for communicating
responsibilities about preventing and
controlling infection
X X X X
Method to communicate emerging
infections that could cause influ
X X X X
Processing medical equipment,
devices, and supplies cleaning and
low level disinfection (IC 221.1
X X
Performing intermediate and high-
level disinfection and sterilization of
medical equipment, devices and
supplies as applicable (IC 221.2
X X
Appropriate disposal of medical
equipment, devices and supplies (IC
X X

12. POLICYFOR H.I.C
4. COMPLIANCE WITH I.P.C PROCEDURES PART OF PERFORMANCE
EVALUATION FOR STAFF.
5 ESTABLISHING ROLE MODELS FOR EMPLOYEES BY ENCOURAGEMENT
OF STAFF FOLLOWING GOOD INFECTION CONTROL PRACTICES.
6.COMMUNICATION WITH HEALTH DEPARTMENT,DELHI GOVT.
PROVIDING FEEDBACK ABOUT COMMUNICABLE INFECTIONS.
7 BENCHMARKING OF HOSPITAL DATA WITH N.H.S.N

13. POLICY FOR H.I.C
8. ADRESSING ISSUES RELATED TO HEALTHCARE WORKER SAFETY-
NEEDLE STICK INJURY,VACCINATION OF STAFF,BIOMEDICAL
WASTE MANAGEMENT.
9. MONITORING USE OF ANTIBIOTICS IN HOSPITAL AND
ENCOURAGING GOOD ANTIBIOTIC PRACTICES.
10. REGALAR AUDITS IIN FOLLOWING AREAS AS MEASURE OF
PROCESS OUTCOME

14. POLICYFOR H.I.C
• ANTIBIOTIC PRESCRIBING AUDIT
• SURGICAL SITE AUDIT
• LAUNDARY AND HOUSEKEEPING AUDIT
• KITCHEN AUDIT
• ISOLATION ROOM AUDIT
• C.S.S.D AUDIT.
• ENDOSCOPE REPROCESSING AUDIT

15. SURVEILLANCE PROTOCOL

16. (A) AIR CULTURE
REPORT
RESULT REMARK CORRECTIVE
ACTION
REPEAT
CULTURE
REMARK
O.T. 1
1 Week
2. Week
3.Week
4. Week
O.T. 2
1 Week
2. Week
3.Week
4. Week
O.T. 3
1 Week
2. Week
3.Week
4. Week
O.T. 4
1 Week
2. Week
3.Week
4. Week
HDU (monthly)
ICU (monthly)
MONTHLY SURVEILLANCE PRLOTOCOL

17. B) SWAB C/S RESULT REMARK CORRECTIVE
ACTION
REPEAT
CULTURE
REMARK
1.Anesthesia
2. Sodalime jar
3. Suction machine E
4. Suction machine C
5. Suction machine
BIPAP
6. Breathing Bag
7.Curtain Room No.
8. Curtain Room No
9. Curtain Room No
10. Door knob Room
No.
11. Door knob Room
No.
12. Door knob Room
No.
13. Keyboard area
14. Keyboard area
MONTHLY SURVEILLANCE PROTOCOL

18. (C) Biological indicator RESULT REMARK CORRECTIVE
ACTION
REPEAT
CULTURE
REMARK
1. C.S.S.D
1 week
2. week
3. week
4. week
2. T.S.S.U. (monthly)
(D)DIALYSIS UNIT
1. R.O. Water (monthly)
2. Dialysis fluid
(monthly)
(F) WATER TESTING
(WATER COLLERS)
1. Water cooler No.
2. Water cooler No.
3. Water cooler No.
4. Water cooler No.
(G) KITCHEN STAFF
1. Sputum for AFB stain
2. Stool Routine and
C/S
MONTHLY SURVEILLANCE PROTOCOL

19. DISINFECTANTS

20. O PURPOSE ITEM NAME GENERIC NAME BRAND PACK SIZE NET
RATE/PCS
CONSUMPTION
Apr 11 to Jan
12 (10
months)
TOTAL PURCHASE IN Rs.
CARBOLISATION/
FLOOR AND
SURFACE
DISINFACTANT
PHENOL IP CARBOLIC ACID AGGRAWAL 400 GM 147.60 95 14022.00
FUMIGATION MICROGEN D-
125
MICROGEN 1 LTR 285.60 23 6568.80
INSTRUMENT
CLEANING
NEODISHER-LM2 ELDER 1 LTR 1239.75 39 48350.25
SURGICAL HAND
WASH / SCRUB
CHLOREHEXIDINE CHLORHEXIDINE
GLUCONATE
SOLUTION IP
RAMAN AND
WEIL
500 ML 170.57 246 41960.22
STERIMAX BIOSHIELD 500 ML 182.50 200 bottle 36500.00
DISINFECTANT IN
INFECTED CASE
SODIUM
HYPOCHLORITE
2%
SODIUM
HYPOCHLORITE
MERCK 5 LTR 396.90 165 65488.50
PHENOL IP CARBOLIC ACID AGGRAWAL 400 GM 0 0 0.00
PREPERATION OF
PRE-OPERATIVE
SITE AND SKIN
CLEANING.
BETADINE
SOLUTION
POVIDONE
IODINE IP 5%
WIN
MEDICARE
1 LTR 236.25 355 83868.75
DENATURE SPIRIT 20 LTR 101.25
per ltr.
400 ltr 40500.00
ANTISEPTIC ACEPTIK CHLORHEXIDINE
GLUCONATE
SOLUTION IP,
ISOPROPYL
ALCOHOL IP
RAMAN AND
WEIL
1 LTR 168.00 30 5040.00
RUST REMOVER NEODISHER-IR PHOSPHORIC
ACID
ELDER 1 LTR 1721.25 10 17212.50
CHITTLE FORCEPS TRIDEX 28LL TORRELL 5 LTR 549.00 36 19764.00
DISINFECTANT
FOR EQUIPMENTS
TUBINGS AND
SCOPES
KORSOLEX GLUTARALDEHYD
E
RAMAN AND
WEIL
500 ML 448.9 184 82597.60

21. DATA SLIDES

22. 0
50
100
150
200
250
Pseudomonas…
Klebsiellasp.
E.coli
Acinetobacter
Candidasp.
Citrobatersp.
Enterococcus…
S.aureus
Proteussp.
Enterobacter
Total isolates
H.A.I Isolates
TYPE OF ISOLATES

23. H.A.I INDICATORS
TYPE JAN FEB MAR APR MAY JUN JULY AUG SEP. OCT. NOV. DEC.
C.R.B.S.I
(I.C.U)
1.1 2.9 0.6 1.17 0.8 0.44 0.6 0 0.5 0 0 0
C.U.A.T.I
(I.C.U)
5.3 6.8 5.3 3.3 4 3.5 3.3 0 1.9 0 6.8 3.9
C.A.U.T.I
WARDS
4,.9 5.1 4.3 2.1 2.1 2.2 2.3 0 .8 1.1 2.3 2.1
S.S.I 6.4 5 5.7 6.6 13.5 11.1 8.1 7 9.5 10 14.5 8.5
VAP
(I.C.U)
0 0 90.9
*1
case
0 0 0 0 0 0 0 0 0

24. CLABSI(TEMP)
0
1
2
3
4
5
6
7
8
Jul-12 Aug-
12
Sep-12 Oct-12 Nov-
12
Dec-12
N.H.S.N DHARAM HOSP. I.N.I.C.C
CENTRAL LINE ASSOCIATED BLOOD
STREAM INFECTION(CLABSI
TEMP.LINE)
0
2
4
6
8
Jan-12 Feb-12 Mar
12
Apr-12 May-
12
Jun-12
N.H.S.N DHARAM HOSP. I.N.I.C.C
CLABSI(PERM)
0
1
2
3
4
5
6
7
8
Jul-12 Aug-
12
Sep-
12
Oct-12 Nov-
12
Dec-
12
N.H.S.N DHARAM HOSP. I.N.I.C.C
CENTRAL LINE ASSOCAITED
BLOODSTREAM INFECTION(CLABSI
PERM)
0
2
4
6
8
Jan-12 Feb-12 Mar 12 Apr-12 May-12 Jun-12
N.H.S.N DHARAM HOSP. I.N.I.C.C
CATHETER ASSOCIATED URINARY
TRACT INFECTION(CAUTI)
0
1
2
3
4
5
6
7
Jan-12 Feb-12 Mar
12
Apr-12 May-
12
Jun-12
N.H.S.N DHARAM HOSP. I.N.I.C.C
CAUTI
0
1
2
3
4
5
6
7
Jul-12 Aug-
12
Sep-
12
Oct-12 Nov-
12
Dec-
12
N.H.S.N DHARAM HOSP. I.N.I.C.C
VENTILATOR ASSOCIATED
PNEUMONIA(VAP)
0
5
10
15
20
25
30
Jan-12 Feb-12 Mar
12
Apr-12 May-
12
Jun-12
N.H.S.N DHARAM HOSP. I.N.I.C.CVAP
0
2
4
6
8
10
12
14
16
Jul-12 Aug-
12
Sep-
12
Oct-
12
Nov-
12
Dec-
12
N.H.S.N DHARAM HOSP. I.N.I.C.C
DHARAMSHILA HOSPITAL HAI RATES 2012
NHSN-NATIONAL HEALTHCARE SAFETY NETWORK,CDC,ATLANTA
*INICC-INTERNATIONAL INFECTION CONTROL CONSORTIUM(INCLUDES DATA FROM ASIAN,EUROPEAN COUNTRIES)
SURGICAL SITE INFECTION(CLEAN)
0
0.5
1
1.5
2
2.5
Jan-12 Feb-12 Mar
12
Apr-12 May-
12
Jun-12
N.H.S.N DHARAM HOSP.
SURGICAL SITE INFECTION
(CLEAN)
0
5
10
15
Jul-12 Aug-
12
Sep-
12
Oct-
12
Nov-
12
Dec-
12
N.H.S.N DHARAM HOSP.
SURGICAL SITE
INFECTION(CONTAMINATED)
0
2
4
6
8
10
12
14
16
Jan-12 Feb-12 Mar
12
Apr-12 May-
12
Jun-12
N.H.S.N DHARAM HOSP.
SURGICAL SITE
INFECTION(CONTAMINATED)
0
2
4
6
8
10
Jul-12 Aug-
12
Sep-
12
Oct-
12
Nov-
12
Dec-
12
N.H.S.N DHARAM HOSP.

25. )
36813 32507 0.88
36813 5589 .02

26. BENCHMARKING DATA

27. CATEGORY DHARAMSHILA
HOSPITAL
I.N.I.C.C
2004-2009
MEAN
(95%c.i)
U.S
N.H.S.N
2006-2008
Mean
95%c.i
CRBSI 0.67 6.8 1.5
C.A.U.T.I 3.675 7.1 3.1
V.A.P 7.5 18.4 1.9
S.S.I 8.32 15

28. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
73.6
57.8
5.2
18.4
44.7
63.1
15.7
44.7
13.110.513.1
5.2
15.7
26
47.3
84.2
10.5
63.168.4
18.4
31.536.8
5.22.62.6
52.655.2
99
23.6
0
20
40
60
80
100
120
Pseudomonas

29. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
33.7
12.1
2.76.74 4
29.7
14.8
22.9
81
5.4
0.8
16.2
6.7
12.1
18.9
5.48.1
2.7
21.6
68.9
1.3
10.814.8
1.3
52.7
1.3
28.3
55.4
0
10
20
30
40
50
60
70
80
90
Klebsiella

30. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
22.2
11.1
4440
2.2
13.315.5
42.2
6.6
31.1
40
93.3
6.6
20
26.6
6.68.8
17.7
4.4112.22.2
28.8
91.1
11.1
22.2
40
53.3
60
68.8
0
20
40
60
80
100
E. Coli

31. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
40
20
40
20 20
10
50
30
40
90
10.1
30 30
10 10
40
0
40
50
10
40
30
50
40
60
0
10
20
30
40
50
60
70
80
90
100
Acinetobacter

32. DHRAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
39.6
13
26
8.6 13 8.6
39.1
1317.3
86.9
8.6
30.4
1317.317.3
8.6
30.4
65.2
8.6
30.4
52.147.8
65.2
0
10
20
30
40
50
60
70
80
90
100
Amikacin
Azyreonam
Amoxycillin/Sulb…
Ceftazidime/tazo…
Ceftazidime
cephalothin
Cefoperazone/Su…
Ciprofloxacin
Ceftriaxone/Sulb…
Colistin
Co-trimoxazole
Cefepime/tazoba…
Cefoperazone
Cefoperazone/ta…
cefotaxime
Cefuroxime
Gentamicin
Imipenem
Moxiflox
Netilmicin
Polymyxin
Piperacillin/tazo…
Tigicycline
Citrobacter

33. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
55.5
33.3
22.2
11.1
22.2
11.1
22.222.2
11.1
66.6
11.1
22.222.222.2
33.3
0
44.4
100
22.2
33.3
44.4
77.7
66.6
0
20
40
60
80
100
120
Amikacin
Amoxycillin/Sulb…
amp
Ceftazidime/tazo…
Ceftazidime
cephalothin
Cefoperazone/Su…
Ciprofloxacin
Ceftriaxone/Sulb…
Colistin
Co-trimoxazole
Cefepime/tazoba…
Cefoperazone
Cefoperazone/ta…
cefotaxime
Cefuroxime
Gentamicin
Imipenem
Moxiflox
Netilmicin
Polymyxin
Piperacillin/tazo…
Tigicycline
Enterobacter

34. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
83.3
50
33.3
16.6
33.3
66.6
16.6
83.3
100
33.333.3
13.3
50 50 50
83.3
16.6
50
83.3
66.6
16.616.6
83.3
50
0
20
40
60
80
100
120
Proteus

35. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
0 0 0 0 0 0 0 0 0 0
78.9
31.531.5
78.9
68.4
15.7
47.3
26.3
10.5
26.3
5.2
42.1
52.6
94.7
78.9
52.652
10.5
31.5
57.8
15.9
78.9
100
0
20
40
60
80
100
120
Amikacin
Amoxicillin/clav…
Ampicillin
Chloramphenicol
Clindamycin
Ceftazidime/taz…
cephalothin
Ciprofloxacin
Cefuroxime
Co-trimoxazole
Doxicycline
Erythromycin
Gentamicin
Linizolid
Imipenem
Moxiflox
Nitrofurantoin
Oflox
Oxacillin
Tetracycline
Tigicycline
Teicoplanin
Vancomycin
Staphylococcus

36. DHARAMSHILA HOSPITAL AND RESEARCH
CENTRE
ANTIBIOTIC SENSITIVITY PROFILE
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
33.3
5
16.616.6
33.3
83.3
33.3
16.6
83.383.3
0
10
20
30
40
50
60
70
80
90
Entrococus

37. A BLOOODSTREAMINFECTIONS(ANTIBIOTIC SUSEBTIBILTY)IWARDS)
DHARAMSHILA HOSPITAL
Most Common Pathogens1 Prevalence % Antibiotic Sensitivity (%)
Escherichia coli 42.80% Polymyxin (99%) tigecyclin (95%) Colistin (93.3%) Imipenem (91.1%)
Cefoperazone/tazoactam (76.9%)
Cefoperazone/Subactam(71.4%)Amikacin (71.1%)
Klebsiella pneumoniae 33.30% Polymyxin (98.6%) Colistin (81%) Imipenem (68.9%) tigcycline (55.4%)
Amikacin (33.7%) cefoperazone sulbactam (29.7%) Ceftriaxone
sulbactam (22.97%)
Pseudomonas sp. 11%% Polymyxin(99%) Colistin (90.6%), Gentamycin (76.6%) Amikacin
(73.6%), Imipenem (70.5%), Cefoperazone/taobacter (66.6%)
piperacillin (63.3%)
Acinetobacter sp. 4.70% Polymyxin(99%) Colistin (90%), tigcycline (60%) Imipenem(50%)
cefoperazone sulbactam (50%) Moxiflox(40%) Gentamycin (40%)
A BLOOODSTREAMINFECTIONS(ANTIBIOTIC SUSEBTIBILTY)I.C.U
DHARAMSHILA HOSPITAL
Most Common Pathogens Prevalence % Antibiotic Sensitivity Blood (%)
Klebsiella pneumoniae 52.00% Polymyxin (98.6%) Colistin (81%) Imipenem (68.9%) tigecyclin (55.4%)
Amikacin (33.7%) cefoperazone sulbactam (29.7%) Ceftriaxone
sulbactam (22.97%)
Escherichia coli 16.00% Polymyxin (99%) tigecyclin (95%) Colistin (93.3%) Imipenem (91.1%)
Cefoperazone/tazoactam (76.9%)
Cefoperazone/Subactam(71.4%)Amikacin (71.1%)
Enterobacter sp. 16.00% tigecyclin(95%) Imipenem (90%) Colistin (85.7%), Polymyxin (80%)
piperacillin taxobactum (77.7%) Cefeperazone/tazobactam (66.6%)
Staphylococcus aureus 16.00% Vancomycin (100%) Tigicycline (100%) Linizolid (94.7%) Teicoplanin
(83.3%)Amikacin (81.2%) Chloromphenicol (78.9%) Imipenem (76%)
TOTAL 100.00%

38. COMPARISON OF ANTIMICROBIAL RESISTANCE RATES IN THE ICUS OF DHARAMSHILA HOSPITAL VS THE INTERNATIONAL
NASOCOMIAL INFECTIONS CONTROL CONSORTIUM.
PATHOGEN
ANTIMICROBIAL
NO, OF PATHOGENIC
ISOLATED TESTED
POOLED(DHARAMSH
ILA HOSPITAL)
RESISTANCE
PERCENTAGE%
NO, OF PATHOGENIC
ISOLATED TESTED
POOLED(I.N.I.C.C)
RESISTANCE
PERCENTAGE
Staphylococus aures
OXA 67 31.50% 646 84.40%
Enterococcus Faecalis
VAN 26 15.10% 98 5.10%
Pseudomonas aeruginosa
FQS 149 53.30% 285 42.10%
PIP or TZP 149 35.30% 589 36.20%
AMK 149 27.70% 278 27.70%
IPM or MEM 149 42.20% 217 47.20%
FEP 149 100.00% 2 100.00%
Klebsiella pneumoniae
CRO or CAZ 227 76.30% 447 76.30%
IPM, MEM or ETP 227 42.10% 508 7.90%
Acinetobacter baumsnnii
IPM or MEM 36 50.00% 667 55.30%
Esherichia coli
CRO or CAZ 180 82.00% 171 66.70%
IPM, MEM or ETP 180 15.00% 182 4.40%
FQs 180 82.00% 133 53.40%

39. Months Number of patient
less than 5 days
Number of
patient more
than 5 Days
Total Patient Total
Ventilation
days
January 8 Nil 8 9
February 9 Nil 9 11
March 10 Nil 10 10
April 11 2+1 12 34
May 17 Nil 17 37
June 7 2 9 26
July 16 2 17 28
VENTILALATOR PATIENTS DATA

40. Month Average period of
catheterization
CUATI
Average
period of
catheterizatio
n non - CUA.
T - I
Average
period of
central line
days CRBSI
patient
Average
period of
central line
days Non
CRBSI patient
January 6.9 8.1 20.4 51
Februar
y
7.9 8.6 24.7 28.7
March 7.2 27 24.7 28
April 4.7 20 24.8 41.5
May 7.78 8.5 32.5 37.5
June 7.3 11.5 28.4 12
August 7.1 28 37.4 32
POSITIVE/NEGATIVE H.A.I DATA

41. • AVERAGE PERIOD OF CATHERISATION 8 DAYS
• AVERAGE PERIOD OF CATHERISATION WITH CUATI 19 DAYS
• AVERAGE EXTRA DAYS WITH CAUTI 11 DAYS
• AVERAGE CENTRAL LINE DAYS WITHOUT CRBSI 32 DAYS
• AVERAGE CENTRAL LINE DAYS WITH CRBSI 38 DAYS
• EXTRA DAYS ASSOCIATED WITH CRBSI 6 DAYS
• NO. OF PATIENTS VENTILATED <5 DAYS 86%
• NO. OF PATIENTS VENTILATED >5 DAYS 14%

42. CRUDE MORTALITY RATES
WITH HAI/WITHOUT HAI
NO.
DEATHS
NO.
PATIENTS
POOLED CRUDE
MORTALITY%
95%
C.I
CRUDE MORTALITY RATE
OF PATIENTS WITHOUT
DA-HAI
264 6294 4
CRUDE MORTALITY RATE
OF PATIENTS WITH
C.L.A.B
4 1126 0.35
CRUDE EXCESS MORTALITY
RATE OF PATIENTS C.L.A.B
4 1126 _3.65
CRUDE MORTALITY RATE
OF PATIENTS C.A.U..IT
7 910 .76
CRUDE EXCESS
MORATLITY RATE OF
PATIENTS C.A.U.T.I
7 910 _3.24
CRUDE MORTALITY RATE
OF PATIENTS V.A.P
1 160 .63
CRUDE EXCESS MORTALITY
RATE v.a.p
1 160 _3.35

43. 5
LENGTH OF STAY
WITH HAI/WITHOUT HAI
LOS,
TOTAL
DAYS
NO.
PATIENTS
AVERAGE
LOS,DAYS
95% C.I
LOS OF PATIENTS
WITHOUT DA-HAI
36813 6294 5.8
LOS OF PATIENTS WITH
CLAB
32,507 1126 28.86
EXTRA LOS OF PATIENTS
WITH CLAB
32,507 1126 23
LOS OF PATIENTS WITH
CAUTI
5589 910 6.14
EXTRA LOS OF PATIENTS
WITH CAUTI
5589 910 0.4
LOS OF PATIENTS WITH
VAP
258 160 1.6
EXTRA LOS OF PATIENTS
WITH VAP
258 160 _4.2

44. MULTIDRUG RESISTANT ORGANISIMS(M.D.R.O)

45. ORGANISI
N
TYPE
NO.OF CASES
LOCATION
TOTAL
DAYS
RATE=NO.
CASES/
TOTAL
PATIENT
DAYS
X100
MDR
PSEUDOMON
AS
ICU 1 598 0.16
WARD 4 9839 0.04
MDR
KLEBSIELLA
ICU 6 598 1.0
WARDS 10 9839 0.10
MDR
AINETOBACT
ER
ICU 3 598 0.5
WARDS 0 9839 0
MDR TOTAL ICU 16 598 2.6
WARDS 17 9839 0.17

46. ORGANISI
N
TYPE
NO.OF CASES TOTAL
DAYS
RATE=NO.
CASES/
TOTAL
PATIENT
DAYS
X100
M,R,S,A ICU 1 598 0.16%
WARDS 4 9839 0.04%
E,S,B.L ICU 1 598 0.16%
WARDS 3 9839 0.03%

47. NEEDLE STICK INJURY DATA
NEEDLE STICK
INJURY
HANDLIN
G B,M,W
SURGICAL
PROCEDU
RES
WITHDRA
WING
BLOOD
16 02
02

48. ANTIBIOTIC AUDIT DATA

49. SURGICAL SITE AUDIT DATA

50. HAND HYIEGINE COMPLIANCE
0
20
40
60
80
HAND WASH
HAND RUB

51. HAND RUB AVAILIBILITY DATA
0
2
4
6
Category
1
Category
2
Category
3
Category
4
Series 1
Series 1

53. 2/2/2011OR-I Medi Solution Pseudomonas 2/11/2011No Growth
2/9/2011ICU-Meddis Solution Pseomonas 2/11/2011No growth
3/7/2011OT-I Air Culture
25 Colonies of
GNB 3/9/2011No growth
4/4/2011OR-I Breathing Bag 7 Colonies of GPC 4/7/2011No growth
4/11/2011Dialysis Water Coliforms grown 4/18/2011No growth
7/18/2011
CSSD-Biological
indicator Positive 7/20/2011No growth
8/1/2011OR-I Sodalime Jar Stephalococcus 8/5/2011No growth
8/26/20113rd Floor- Water Coliforms grown 8/29/2011No growth
9/3/20114th Floor Water Coliforms grown 9/10/2011No growth
11/7/2011OR-II Breathing Bag MRSA 11/10/2011No growth
11/29/201
1ICU Air culture
> 35 colonies of
GPC 12/6/2011No growth
11/29/201
1Hdu Air culture
> 35 colonies of
GPC 12/3/2011No growth
12/10/201
12nd-D- Water Coliforms grown 2/14/2011No growth
12/10/201

54. DHARAMSHILA HOSPITAL & RESEARCH CENT .
VASUNDHRA ENCLAVE, DELHI –110096
• INFECTION CONTROL GOALS FOR 2013-2014
•
• TO INCREASE THE HAND HYIEGENE COMPLIANCE TO 90%
• TO DECREASE THE INCIDENCE OF NEEDLE STICK INJURIES AMONG HEALTHCARE
STAFF PARTICULARLY HOUSEKEEPING STAFF.
• TO DECREASE THE INCIDENCE OF INFECTIONS IN TEMPORARY CENTRAL LINE AS IT IS
NOT MEETING INICC BENCHMARK.
• TO ENSURE RUNNING OF INFECTION CONTROL SURVEILLANCE PROGRAM AS PER
SCHEDULE.
•
• DT. 1/4/2013

55. INFECTION CONTROL GAP ANALYSIS

56. Area/Issue/
Topic/Standard
Current Status Desired Status Gap
(Describe)
Action Plan
And Evaluation
Incomplete
implementation of CDC
Hand Hygiene (HH)
Guideline (NPSG
01.07.01)
Only 80% of units and
services are following
CDC HH Guideline and
hospital policy.
Full implementation of required
elements upto level 0f 90%
10% of units and
services are not
following CDC HH
Guideline and hospital
policy.
Develop proactive
implementation plan.
Make a leadership priority.
Workplace reminders like
posters,screen savers.
Evaluate existing hand
hygiene compliance.
Provide feedback to staff
monthly .
Central line-associated
bloodstream infections
(temporary CLABSIs in
medical ICU are very
high compared to INICC
CLABSI in medical ICU
at 75th percentile of
INICC benchmark.
Reduce CLABSI s to 50
percentile
INICC benchmark or lower.
Processes to prevent
CLABSIs are not
flowed consistently
among staff.
Reinforce use of the BSI
bundle.Monitoring insertion
practices for CLABSI and
documenting the same.
Evaluate the bundle
processes and the outcomes
and report to leadership and
ICC monthly.
Needlesticks in
employees increasing
(particularly
housekeeping staff)
The incidence of
needlesticks among
environmental services
(ES) staff is 30%
Analysis shows that
greatest risk is during
changing of needle
containers.
Reduce needle sticks in ES staff
.
Process for emptying
sharp containers is
faulty
Sharp containers
disposal schedule is
not adhered to.
Switch to puncture proof
containers for sharp storage
and disposal.
Reinforce disposal schedule
and enhance d coordination
between housekeeping staff
and nurses.
Training for housekeeping
staff in sharp disposal, use of
PPE.
Display ongoing data to show
number of weeks without
needle sticks.
Revaluate needle stick injuries

57. INFECTION CONTROL RISK
ANALYSIS

58. PROBABILITY OF
OCCURRENCE
PATIENT EFFECT
INTENSITY OF
ORGANIZATION’S
RESPONSE NEEDED
TO ADDRESS THE
RISK
ORGANIZATION
PREPAREDNESS
TO ADDRESS
SUCH A RISK AT
THIS TIME
RISK
LEVEL
High
(3)
Med
(2)
Low
(1)
None
(0)
Life
Threa
t (3)
Perm
Harm
(2)
T
e
m
p
H
a
r
m
(
1
)
None (0)
High
(3)
Med
(2)
Low
(1)
Non
e (0)
Poor
(3)
Fair
(2)
Good
(1)
Geography and
Community
High Risk Patients
1. Surgical
2. ICU
3. NICU
4. Oncology
1. Dialysis
1. Transplant
1. Antibiotic
resistance,
multi- drug
resistant
organism.
INFECTION CONTROL RISK ASSESSMENT

59. BARRIERS OUTCOMES MEASURES
STAFF ATTRITION DECLINE IN INFECTION
CONTROL PRACTICES
TEACHING,BETTER H.R
INITIATIVES
BUDGETARY
ALLOCATION H.I.C
REDUCED SPENDIND ON
H.I.C
TAKING/RESULTS TO
HOSPITAL
ADMINISTRATORS
OVERPRESCIBING
OF ANTIBIOTICS
INCREASED
COSTS,INCREASE
INCIDENCO OF M.D.R.O
FEEDBACK BY
QUARTERLY
ANTIBIOGRAMS,LOCAL
ANTIBIOTIC REGIME FOR I
.C.U/WARDS,REGALAR
ANTIBIOTIC AUDITS,

60. • EDUCATION REGULAR FEEDBACK PROVIDED TO
DOCTORS NURSING STAFF ABOUT
HOSPITAL ANTIBIOGRAMS
• FORMULARY
RESTRICTION
ANTIOTIC RESTRICTION FORM BEING
USED FOR RESERVE ANTIBIOTICS
TEIGYCYCLINE,TEICOPLANIN,VANCOMY
CIN AND LINEZOLID
• INTRAVENOUS TO
ORAL SWITCH
BEING MONITORED BY REGULAR
ANTIBIOTIC AUDITS
• COMPUTERISED ORDER
ENTRY
COMPUTERISED ORDER ENTRY IN
PHARMACY
• AUTOMATIC STOP
ORDERS
NOT IMPLEMANTED

61. •INCORPORATION OF
GUIDELINES
LOCAL DATA OF I.C.U AND
WARDS USED TO FORMULATE
EMPIRIC POLICY FOR
AREAS.DATA RELEASED IN
INFECTION CONTROL
BULLETIN.
•EXTENDED INFUSION OF
BETA LACTUM
ANTIBIOTICS
BEING DONE FOR M.D.R
PATIENTS

62. INITIATIVES FOR INFECTION CONTROL/PROJECTS
UNDERWAY
• COLOUR CODING OF CLEANING ARTICLES AND PATIENT
EQUIPMENT ZONEWISE E.G. I.C.U/WARDS/OPD/DIAGNOSTICS
• INCORPORATION OF SELECTIVE ANTIBIOTIC REPORTING IN LAB
SOFTWARE .
• NEW REGIMES/EXTENDED ZONE INFUSIONS TO TACKLE WITH
MDRO ORGANISIMS.
• AUTOMATION OF LAB EQUIPMENT FOE FASTER DETECTION
AND SURVEILLANCE
• PRE MRSA SWABS FOR HIGH RISK PATIENTS/NEUTROPENIC
PATIENTS