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15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er

Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

Controlling Nosocomial Infections The Dr L H Hiranandani Hospital Experience


Uday Tewary*with inputs from V M P Thomas**, Suvin Shetty***, Sheena Binu****
*AGM Pharmacy, **General Manager Operations & Projects, ***Consultant Pathologist, ****Infection Control Nurse Dr L H Hiranandani Hospital, India
Abstract: Dr L H Hiranandani hospital manages a vibrant and effective infection control program. The hospital infection control committee (HICC) has a multidisciplinary constitution. The surveillance of nosocomial infections is the foundation for organizing and maintaining an infection control programme. Hence, the infection control data collected and analysed include surgical site infections, catheter-related bloodstream infections, urinary tract infections and ventilator-associated infections. The analysis involves comparing the data with the national and international benchmarks. The isolated microorganisms in the clinical specimens and their antibiogram are discussed to assess the trends and prevalence of antibiotic resistance and emergence of multidrug resistant bug. The measures taken after analysis help in taking corrective actions to reduce the average length of stay of patients and associated morbidity and mortality. The infection control programme has helped to preempt any outbreaks in the high dependency areas of the hospital. It has also reduced the overall stay of the patient in hospital as evinced by a decreasing Average Length of Stay (ALOS), there by decreasing cost of treatment to the patient and a faster turnover for the hospital a win win situation for all.

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

Controlling Nosocomial Infections The Dr L H Hiranandani Hospital Experience


Uday Tewary*with inputs from V M P Thomas**, Suvin Shetty***, Sheena Binu****
*AGM Pharmacy, **General Manager Operations & Projects, ***Consultant Pathologist, ****Infection Control Nurse Dr L H Hiranandani Hospital, India
Summary Dr L H Hiranandani hospital has a vibrant hospital infection control committee, which has effectively implemented the hospital infection control programme. The surveillance of nosocomial infection is the foundation for organizing and maintaining an infection control programme. Hence, the infection control data collected and analysed include catheter-related bloodstream infections (CRBSI), catheter associated urinary tract infections (UTI) and ventilator-associated pneumonia (VAP) The analysis involves comparing the data with the national and international benchmarks. The isolated microorganisms in the clinical specimens and their antibiogram are discussed to assess the trends and prevalence of antibiotic resistance and emergence of multidrug resistant bug. The measures taken after analysis help in taking corrective actions to reduce the average length of stay of patients and associated morbidity and mortality. Introduction A nosocomial infection also called hospital acquired infection can be defined as: An infection acquired in hospital by a patient who was admitted for a reason other than that infection (1). A more complete definition would be An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility (2). 2

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

The term healthcare associated infection is now widely used instead of the traditional nosocomial infections and is defined by the CDC as a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent(s) or its toxin(s). There must be no evidence that the infection was present or incubating at the time of admission to the acute care setting. Hospital acquired infections are a world wide phenomenon. Patient care is provided in settings ranging from small health care providers with only basic facilities to sophisticated highly equipped clinics and large university hospital with state of the art technology. Despite progress in public health and hospital care, infections continue to develop in hospitalized patients and also in hospital staff. Factors promoting infection among hospitalized patients include decreased immunity among patients; the increasing variety of medical procedures and invasive techniques creating potential routes of infection; and the transmission of drugresistant bacteria among crowded hospital populations, where poor infection control practices may facilitate transmission. Nosocomial infections occur worldwide and affect both developed and poor countries. Infections acquired in health care settings are among the major causes of death and increased morbidity among hospitalized patients. There is a significant burden both for the patient and public health. A prevalence survey conducted under the auspices of WHO in 55 hospitals of 14 countries representing 4 WHO Regions (Europe, Eastern Mediterranean, South-East Asia and Western Pacific) showed an average of 8.7% of hospital patients had nosocomial infections. At any time, over 1.4 million people worldwide suffer from infectious complications acquired in hospital (3). The highest frequencies of nosocomial infections were reported from hospitals in the Eastern Mediterranean and South-East Asia Regions (11.8 and 10.0% respectively), with a prevalence of 7.7 and 9.0% respectively in the European and Western Pacific Regions (4). The most frequent nosocomial infections are infections of surgical wounds, urinary tract infections and lower respiratory tract infections. The WHO studies, and others, have also shown that the highest prevalence of nosocomial infections occurs in intensive care units and in acute surgical and orthopaedic wards. Infection rates are higher among patients with increased susceptibility because of old age, underlying disease, or chemotherapy.

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

The various factors influencing the development of nosocomial infections include: a. Microbial agent factors i. Resistance to antimicrobial agents ii. Intrinsic virulence iii. Amount (inoculum) of infective material b. Patient susceptibility factors like i. Age ii. Immune status iii. Underlying disease iv. Diagnostic and therapeutic interventions c. Environmental factors like i. Crowded conditions within the hospital ii. Frequent transfers of patients from one unit to another iii. Concentration of patients highly susceptible to infection in one area Dr L H Hiranandani Hospital is a 130 bed multi specialty tertiary care hospital located at the suburb of Powai in Mumbai. Spread over 210,000 square feet it has an unmatched bed to space ratio of 1:1600. The hospital is only five years old but within this short period of time it has made a name for itself in the healthcare scenario of the country. It is an ISO: 9000 certified organization and the first in Mumbai and Western India to be accredited by the National Accreditation Board for Hospitals and healthcare providers (NABH), the winner of the Ramkrishna Bajaj National Quality Award (Indian award using the Malcolm Baldrige model) in 2008 and the only Indian hospital to win an award at the International Asia Pacific Quality Organization. In the subsequent paragraphs we would deal with the various strategies implemented by the hospital to have a firm control over healthcare associated infection rates.

Hospital Infection Control Programme at Dr L H Hiranandani Hospital Environmental factors: The design considerations itself took cognizance of the requirements of minimizing hospital infections and thus reducing the morbidity and mortality. The various factors which has been considered include 1. Building: The building has a bed to space ratio of 1:1600 thus providing adequate spatial segregation of patients, thereby eliminating the factor of overcrowding. 2. Zoning of hospital into various areas based on the risk of acquiring infections. These include: Low-risk areas: e.g. administrative sections and physiotherapy 4

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009. Moderate-risk areas: e.g. regular patient units, High-risk-areas: e.g. isolation unit, intensive care units and very-high-risk areas: e.g. operating rooms. 3. Traffic flow: adequate consideration has been taken to the flow of patients, staff and materials so as to prevent crisscrossing to the extent possible. In areas like the critical care and the operating rooms the flow of clean and dirty traffic is segregated. Material like food and biomedical waste is segregated in protected containers so that there is no contamination, even when the material is sent to the biomedical waste disposal area. Not only is there spatial segregation, but temporal segregation is also ensured by moving biomedical waste at laid down time. 4. Material: the choice of construction material has been made based on the requirement of each area. Thus the operating rooms and intensive care areas have vinyl flooring with polyurethane paint on the walls for ease of cleaning. Special attention has been given to the coving of corners and the cold soldering of joints. 5. Ventilation: The hospital follows the American Society of Heating Refrigeration and Air conditioning Engineers (ASHRAE) standards. Thus each operating room has a separate air handling unit (AHU) with three stage filtration including high efficiency particulate air (HEPA) filters with sufficient air changes and laminar air flow, the critical care areas like the intensive care, intensive cardiac care and the neonatal intensive care units also have separate air handling units. There are designated areas with positive air pressure for immunologically compromised patients and in the operating rooms. Isolation areas for infective cases are at a negative pressure. 6. Potable water is supplied by the Mumbai Municipal Corporation. Even this water is tested periodically for chlorine content, chemical analysis and for bacterial contamination. Raw water used in dialysis department is tested every day for pH, total dissolved solids and Chlorine. 7. Food: Food borne infection is prevented by meticulous attention to the sourcing, storage, preparation and distribution of food. The food is cooked in house. Multiple levels of checks are in place. The kitchen has been designed so as to separate the clean and dirty area. Periodic medical examination of cooks and food handlers are also carried out. Daily check of personnel hygiene of these staff is carried out. Protective clothing is used in the kitchen and by the food handlers.

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009. 8. Waste: Waste is segregated at the point of generation into different colour coded containers / bins as laid down by the Gazette of India notification on Biomedical Waste Management. Sharps are destroyed and collected at source and disposed of into earmarked containers made of high density plastic. The following standard precautions are used while treating all patients 1. Washing of hands promptly after contact with infective material 2. Use of no touch technique wherever possible 3. Wearing gloves when in contact with blood, body fluids, secretions, excretions, mucous membranes and contaminated items 4. Washing hands immediately after removing gloves 5. Handling all sharps with extreme care 6. Cleaning up spills of infective material promptly 7. Ensuring that patient-care equipment, supplies and linen contaminated with infective material is either discarded, or disinfected or sterilized between each patient use 8. Ensuring appropriate waste handling 9. Proper handling of soiled linen 10. Use of hand sanitizers before and after contact with a patient.

CSSD: The Central Sterile Supply Department (CSSD) carries out the procurement, packing, cleaning, sterilization and supply of all sterile equipment and stores. Laid down procedures are there for ensuring proper sterilization including running of test samples with each load as well as tests for bacterial cultures from different areas. The clean and non clean areas are strictly segregated.

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

Surveillance: Microbiological surveillance for bacterial growth of the high risk areas is done in the following manner: 1. OTs Fortnightly 2. NICU - Monthly 3. ICU - Monthly 4. Labour room - Monthly 5. Dialysis - Monthly 6. CSSD Fortnightly

Figure 1 Surveillance Results OT & CSSD Swab Culture Jan 08 till date Average per month Year OT CSSD

Tested Positive Tested Positive 2008 2009 (upto April) 13 0.4 2 0 13 1.3 2 0.08

Whenever a surveillance culture shows growth the area is washed down, the operating room / CSSD is cleaned thoroughly, and a repeat surveillance is done. The operating room is made operational only after the next swab culture is shown to be sterile.

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

I.

URINARY CATHETER ASSOCIATED URINARY TRACT INFECTION:

The hospital carries out a surveillance of all patients on Urinary catheter for the development of UTI. The hospital follows the CDC guidelines for defining UTI (6). Thus 1. Patient has at least 1 of the following signs or symptoms with no other recognized cause: fever (>=380C), urgency, frequency, dysuria, or suprapubic tenderness and patient has a positive urine culture, that is, >=105 microorganisms per cc of urine with no more than 2 species of microorganisms.

2. Patient has at least 2 of the following signs or symptoms with no other recognized cause: fever (>=380C), urgency, frequency, dysuria, or suprapubic tenderness and at least 1 of the following a. positive dipstick for leukocyte esterase and/ or nitrate b. pyuria (urine specimen with >=10 white blood cell [WBC]/mm3 or >=3 WBC/high power field of unspun urine) c. organisms seen on Grams stain of unspun urine d. at least 2 urine cultures with repeated isolation of the same uro-pathogen (gram negative bacteria or Staphylococcus saprophyticus) with >=102 colonies/mL in nonvoided specimens e. >=105 colonies/mL of a single uropathogen (gram-negative bacteria or S saprophyticus) in a patient being treated with an effective antimicrobial agent for a urinary tract infection f. physician diagnosis of a urinary tract infection g. physician institutes appropriate therapy for a urinary tract infection.

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

3. Patient =<1 year of age has at least 1 of the following signs or symptoms with no other recognized cause: fever (>38OC rectal), hypothermia (<370C rectal), apnea, bradycardia, dysuria, lethargy, or vomiting and patient has a positive urine culture, that is, >=10 microorganisms per cc of urine with no more than two species of microorganisms. 4. Patient =<1 year of age has at least 1 of the following signs or symptoms with no other recognized cause: fever (>=380C), hypothermia (<370C rectal), apnea, bradycardia, dysuria, lethargy, or vomiting and at least 1 of the following: a. positive dipstick for leukocyte esterase and/ or nitrate b. pyuria (urine specimen with >=10 WBC/mm or >=3 WBC/high-power field of unspun urine) c. organisms seen on Grams stain of unspun urine d. at least 2 urine cultures with repeated isolation of the same uropathogen (gram negative bacteria or S saprophyticus) with >=10 colonies/mL in nonvoided specimens e. >=10 colonies/mL of a single uropathogen (gram-negative bacteria or S saprophyticus) in a patient being treated with an effective antimicrobial agent for a urinary tract infection f. physician diagnosis of a urinary tract infection g. physician institutes appropriate therapy for a urinary tract infection.
5 2 3 5

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

Figure 2 Incidence rate of catheter associated UTI Average per month


YEAR ADMISSIONS IN HOSPITAL PATIENTS ON CATHETER CATHETER DAYS NO.OF UTI UTI PER 1000 CATHETER DAYS

2007 2008 2009 (Upto April)

552 577 506

119 116 118

351 373 342

3.5 1.8 2.0

10.16 4.97 5.74

The above rates are comparable to the International Nosocomial Infection Control Consortium (INICC) report data summary which gives a rate of 6 per 1000 catheter days for hospital acquired UTI. (7) Figure 3 Incidence rate of catheter associated UTI compared with INICC Rate

UTI per 1000 Catheter Days


14.00 12.00 10.00 Rate 8.00 6.00 4.00 2.00 0.00 Nov 07 Jan 08 Mar 08 May 08 Jul 08 Sep 08 Nov 08 Jan 09 Mar 09 Months UTI cases per 1000 Catheter days INICC Rate

10

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

II.

CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION:

Similarly the hospital carries out a surveillance of all central line patients admitted. Again CDC guidelines are followed to define the cases. Figure 4 Incidence rate of CRBSI Average per month
YEAR ADMISSIONS IN HOSPITAL NO.OF CENTRAL LINES CENTRAL LINE DAYS NO. OF CRBSI CASES CRBSI cases per 1000 Central line days

2007 2008 2009 (Upto April)

552 577 506

25 28 23

145 174 198

0.5 0.5 0

3.46 2.70 0

The above rates are comparable to the International Nosocomial Infection Control Consortium (INICC) report data summary which gives a rate of 9 per 1000 line days for central line infection rates. (7)

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15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009. Figure 4 Incidence rate of CRBSI compared to NNIC rates

CRBSI Rates comparison with INICC


20.00 15.00 Rate 10.00 5.00 0.00 Nov 07 Jan 08 Mar 08May 08 Jul 08 Sep 08 Nov 08 Jan 09 Mar 09 Month CRBSI cases per 1000 Central line days
III. VENTILATOR ASSOCIATED PNEUMONIA (VAP):

INICC Rate

The hospital also tracks the incidence of ventilator associated pneumonia. VAP cases are defined as per the CDC guidelines. The incidence rates are comparable to international standards. Figure 5 Incidence rate of VAP Average per month
YEAR ADMISSIONS IN ICU N O. OF VENTILATED PATIENTS VENTILATOR Days NO.OF VAP VAP cases per 1000 Ventilator days

2007 2008 2009 (Upto April)

103 114 104

12 10 9

50 50 41

3.0 0.5 0

46 7 0

The above rates are comparable to the International Nosocomial Infection Control Consortium (INICC) report data summary which gives a rate of 20 per 1000 ventilator days for ventilator associated pneumonia rates (7). 12

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

Figure 6 Incidence rate of VAP compared to INICC rates

VAP Comparison with INICC Rates


70.00 60.00 Rate50.00 40.00 30.00 20.00 10.00 0.00 Nov 07 Jan 08 Mar 08 May 08 Jul 08 Sep 08 Nov 08 Jan 09 Mar 09 Month INICC Rate

VAP cases per 1000 Ventilator days

Surveillance of multidrug resistant organisms: The hospital carries out a surveillance of multi drug resistant organisms from the cultures found positive. The data for the years 2008 & 2009 have been shown in the Figure 7 below. Figure 7 Multidrug resistant organisms MDRO ESBL E coli & Klebsiella spp MBL Pseudomonas spp MRSA (clinical specimens) Vanco-resistant Enterococci LHHH data Comparator (2008 2009) 26.3% 19.8% 32% 10% 20.6% 21.1% 59.6% 28.5%

* NNIS System Report, ICUs data; 2004 13

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009.

The above figures indicate that MRSA is still not the scourge it is in the west. The hospital carries out active surveillance for MRSA cases by subjecting all patients transferred in from other hospitals, patients coming from abroad and clinically suspect cases to MRSA screening test. In addition staff exposed to MRSA patients and randomly those involved in patient care are also randomly surveyed to detect asymptomatic carriers. Those found positive are treated with suitable antibiotics and followed up till they are negative.

Antibiotic policy: Based on the sensitivity pattern, the hospital has a laid down antibiotic policy for various clinical conditions. All treating doctors are expected to adhere to the antibiotic policy. The antibiotic policy is revised regularly based on the antibiotic sensitivity pattern and feedback received from clinicians. Discussions are also held on antibiotic usage and streamlining as also the possibility of taking a decision on Antibiotic holiday in case of over usage of any antibiotic.

Average length of Stay (ALOS): Right from inception the hospital has been process driven. The various SOPs were formulated while the hospital was still under construction. These were modified over a period of time to improve operational efficiency. The hospital has been tracking its average length of stay from the very beginning. Currently the average length of stay in the hospital is 2.75 which is outstanding by any standards for a multispecialty tertiary care hospital of this size. A low ALOS is due to multiple factors. An important factor being a low rate of complications; this in turn could be due to the low nosocomial infection rate. The following figure tries to correlate the ALOS to the nosocomial infections (catheter related UTI, CRBSI and VAP rates). The correlation is not too evident as the infection rates are available since 2007 only. At this stage the ALOS was 3.19. Further reduction in the ALOS would be very difficult for a hospital of our size. The figure below tries to graphically correlate the ALOS to the hospital infection rates. VAP has been correlated to rate per 100 as the rate per thousand goes out of scale of the graph.

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15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009. Figure 8 Comparison of ALOS & infection rates (INF)

ALOS & INF RATES


12.0 10.0 RATES 8.0 6.0 4.0 2.0 0.0 2004 2005 2006 2007 2008 2009 YEARS ALOS UTI CRBSI VAP

The Hospital Infection Control Committee (HICC): All this would not have been possible without the yeoman efforts of the hospital infection control committee and especially that of the infection control nurse. The committee is headed by the Senior Consultant in Pathology, the senior Intensivist, the Infection Control Nurse (ICN), the in charge of the CSSD, the senior Surgeon, the senior Physician,. In addition the quarterly meetings of the committee are attended by the CEO and other management staff. The committee has not only set policies and procedures at all levels, but has also ensured that it is implemented. There is a very strong stress right from the induction level, when all staff is sensitized to the requirements of infection control. The infection control nurse carries out rounds, where it is ensured that the policies are being implemented. The nursing team has been motivated to not only adhere to these procedures but to also ensure that it is followed by others especially the doctors. This has resulted in a paradigm shift in the ownership of the various processes in the hospital. The stress laid on hand hygiene has paid rich dividends, in decreasing incidence of all forms of infections. The insistence on proper disposal of sharps has drastically reduced the incidence of needle stick injuries. The surveillance of swabs in the OT and the CSSD have reduced the incidence of nosocomial infection. In a short period of time, despite the hospital occupancy being high we have been able to achieve decreasing trends in the infection rates. The HICC has now started monitoring surgical site infections also. These are still early days for meaningful trends to set in. 15

15 CONFERENCIA DE LA ORGANIZACION ASIA PACIFICO DE CALIDAD XXXVII CONGRESO NACIONAL DE CONTROL DE CALIDAD 28 Convencin Nacional de Crculos de Calidad 1er Foro Asia Pacfico de Trabajo en Equipo ISO9000 18o Foro Internacional de IMECCA sobre la ISO 9000 ISO14001 11o Foro Internacional de IMECCA sobre la ISO 14000 OHSAS18000 3er Foro Internacional de IMECCA sobre la OHSAS 18000 Cd. de Mxico, octubre 7 al 10 del 2009. Conclusions Dr L H Hiranandani Hospital has an effective Nosocomial Infection Control Programme. The Hospital Infection Control Committee is the monitoring and the implementing body and has strong institutional support across the board. The infection control programme is based on following practical guidelines as enunciated by the WHO and the CDC and includes building design parameters, surveillance and adherence to laid down policies and procedures with regards to antibiotic usage, biomedical waste management and control and treatment of multidrug resistant organism. There is strong emphasis on simple methods like hand hygiene. The hospital actively tracks catheter associated UTI, central line related blood stream infections and ventilator associated pneumonias. These are comparable and surpass international data from the INNIC. One of the factors responsible for a low ALOS is the low incidence of complications, the major cause of which is nosocomial infection. A correlation has been made between the nosocomial infections rates and the average length of stay. References 1. Ducel G et al. Guide pratique pour la lutte contre linfection hospitalire. WHO/BAC/79.1. 2. Benenson AS. Control of communicable diseases manual, 16th edition. Washington, American Public Health Association, 1995. 3. Tikhomirov E. WHO Programme for the Control of Hospital Infections. Chemiotherapia, 1987, 3:148 151. 4. Mayon-White RT et al. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect, 1988, 11 (Supplement A):4348. 5. Ducel G et al. Prevention of Hospital Acquired Infections A practical guide (2nd edition) WHO/CDS/CSR/EPH/2002.12 6. Teresa C. Horan, et al CDC/NHSN surveillance definition of health careassociated infection and criteria for specific types of infections in the acute care setting. Am. J. Infect. Control. 2008;36:309-32 7. Victor D. Rosenthal, Dennis G. Maki, Ajita Mehta, et al. International Nosocomial Infection Control Consortium (INICC) Report, Data Summary for 2002- 2007, American Journal of Infection Control- In Press, 2008

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