Infection Control Program Punjab

Standard Operating Procedure: Infection Control Program Punjab

1. Document Control & Revision History

---

2. Executive Summary & Scope

Executive Summary: This document establishes the institutional framework for Infection Prevention and Control (IPC) across all Punjab healthcare facilities. The primary objective is the mitigation of Healthcare-Associated Infections (HAIs) through rigorous adherence to standard precautions, waste management, and sterilization protocols.

Scope: This procedure is mandatory for all clinical and support staff operating within the Punjab Department of Primary and Secondary Healthcare. It encompasses all physical facility zones, clinical wards, operating theaters, and laboratory environments. It aligns with the Punjab Healthcare Commission (PHC) Minimum Service Delivery Standards (MSDS).

---

3. Prerequisites & Tool Requirements

• PPE Requirements: Level 3 surgical masks, N95 respirators (aerosol generating procedures), protective eyewear, nitrile gloves, and fluid-resistant gowns.
• Sanitization Assets: 70% Ethyl Alcohol hand rub, 0.5% Chlorine solution for surface decontamination, and bio-hazardous waste color-coded bags (Yellow: Infectious; Red: Sharps; Black: General).
• System Access: Access to the Electronic Hospital Information Management System (EHIMS) for incident reporting.
• Certifications: Mandatory completion of "Basic IPC Competency" via the Punjab Training Academy or approved equivalent.

---

4. Roles & Responsibilities (RACI Matrix)

---

5. Step-by-Step Operational Procedure

Phase I: Pre-Shift Facility Sanitization

• Verify functionality of hand-hygiene stations (soap, water, alcohol rub).
• Conduct environmental surface wipe-down using hospital-grade disinfectant.
• Confirm segregation of waste bins according to Punjab Environmental Protection Agency (PEPA) standards.

Phase II: Clinical Interaction Protocol

• Perform WHO "5 Moments of Hand Hygiene" before and after every patient contact.
• Don appropriate PPE based on risk assessment of the patient.
• Execute sterile field setup using single-use disposable kits.
• Document all invasive procedures in the Patient Safety Logbook.

Phase III: Post-Procedural Decontamination

• Dispose of sharp instruments in puncture-proof red containers immediately.
• Label infectious waste with facility code, date, and origin department.
• Perform terminal disinfection of clinical surfaces using 0.5% chlorine concentration.

---

6. Quality Assurance & Verification Criteria

• Audit Threshold: Compliance rate must be ≥ 95% across all indicators.
• Acceptance Benchmarks:
  • Zero tolerance for improper sharps disposal.
  • 100% adherence to bio-medical waste segregation.
  • Monthly reporting of HAI occurrences per 1,000 patient days (Target: < 5%).
• Verification: Bi-weekly unannounced floor audits by the IPC Committee.

---

7. Practical Troubleshooting Scenarios

Scenario A: Breach in PPE Supply Chain

• Detection: Stock levels of N95 masks fall below 48-hour reserve capacity.
• Corrective Action: Immediate escalation to the Procurement Officer; transition to "Enhanced Contact Precautions" status (Restricting aerosol-generating procedures until stock replenishment).

Scenario B: Failure of Sterilization Equipment (Autoclave)

• Detection: Biological indicator test failure or pressure gauge fluctuation.
• Corrective Action: Stop use of the unit immediately. Tag equipment as "DO NOT USE." Divert instruments to the Central Sterile Supply Department (CSSD) backup facility; initiate work order for biomedical engineering repair.

Scenario C: Needle-Stick Injury (NSI)

• Detection: Staff exposure reported in the incident log.
• Corrective Action: Apply immediate first aid (wash site with soap/water). Initiate Post-Exposure Prophylaxis (PEP) protocol within 2 hours. Notify the IPC Lead for mandatory incident investigation.