INFECTION CONTROL POLICY

VARDHAMAN MAHAVIR MEDICAL COLLEGE

&
SAFDARJUNG HOSPITAL

NEW DELHI

CONTRIBUTORS
Created by
Approved by
Date of Creation
Modified on

:
:
:
:

Dr. Rajni Gaind, Dr. Monorama Deb

Medical Superintendent, SJH
September, 2008
August 18, 2010

CONTENTS
Introduction

Hosptial Infection Control Team (HICT) Members

Hospital Guidelines for Prevention And Control of Infections

Surveilance and Reporting of Infection

Disinfection Policy

10

Isolation Policy

12

Investigation of an Outbreak

13

Antimicrobial Policy

15

Annexure 1 Policy on Hospital Waste Management

Annexure 2 Policy on Management of Sharps, Needle Stick Injury & Body Fluids Exposure

INTRODUCTION
Hospital acquired infection is a health hazard. It is important to minimize the risk of spread of
infection to patients and staff in hospital. Good infection control programme reduce patients
morbidity and mortality, length of hospital stay and cost associated with hospital stay. An
infection control policy has been adopted by Safdarjung Hospital.
This policy describes the precautions and control measures that are essential for the prevention
and management of infection through the application of research based knowledge to practices
which include: standard precautions, sterilization and disinfection, waste management, surveillance
and audit.
The following Hospital Infection Control Policies have been formulated and are being practiced
and monitored by the Hospital Infection Control Team (HICT) and Hospital Infection Control
Committee (HICC).
1.

Hospital guidelines for prevention & control of infections

2.

Antimicrobial policy

3.

Surveillance policy

4.

Disinfection policy

5.

Isolation policy

6.

Policy for investigation of an outbreak of infection

The overall aim of this document is to provide evidence based information in the
prevention and control of infection. To fulfill this aim a hospital infection control committee has
been formed that will look after the infection control needs of the hospital. It is relevant to
all staff including doctors, nurses, other clinical professionals and managers working in the
hospital to help to fulfill their professional obligations with regard to both communicable disease
and infection control.
This document will be reviewed and updated by the HICC.
PURPOSE
1.

To maintain standards in infection control measures and minimize hospital acquired

infections in patients and staff.

2.

To define policy and procedure regarding nosocomial infections at VMMC & SJH.

HOSPITAL INFECTION CONTROL TEAM (HICT) MEMBERS

The role of the HICT is to implement the annual programme and policies, and provide infection
control advice on a 24-hour basis. The team is responsible for the following:

Surveillance of infections and monitoring methods of control

Rapid identification and investigation

Giving advice on the management of patients with infection, particularly those in isolation

Providing a staff training programme in infection control and auditing compliance

Preparing the annual infection control programme

Preparing monthly infection control reports

Producing and maintaining up-to-date hospital infection control policies

Assisting different departments across the hospital in their efforts to reduce healthcareassociated infections

of outbreaks or potentially hazardous procedures

The ICT consists of the following members:

Head of the institute

Chairperson

Addl. Medical Superintendent

Member

All heads of Department

Members

Nodal officer HMW

Members

Nursing in charges all patient care units

Members

CPWD Incharge

Members

Infection Control Nurses

Members

HOD Microbiology

Member Secretary

Infection control officer (Senior Microbiologist)

Member

All staff plays an important part in the control of healthcare-associated infections. Staff should
apply the procedures and precautions in all of the HIC policies at all times to ensure safe
practice for themselves and the patient. Good clinical practice can substantially reduce
healthcare acquired infections. Senior staff has managerial responsibility to ensure that all of
their staff follow good infection control practice and comply fully with HIC policies.
Terms and Conditions

Commitment towards Maintenance of Surveillance over hospital acquired infections.

Develop a system for identifying, reporting, analyzing, investigating and controlling hospital
acquired infections.

Develop and implement preventive and corrective programmes in specific situations where
infection hazards exist.

Advice the Medical Superintendent on matters related to the proper use of antibiotics,
develop antibiotic policies and recommend remedial measures when antibiotic resistant
strains are detected.

Review and update hospital infection control policies and procedures from time to time.

Help to provide employee health education regarding matters related to hospital acquired
infections.

Shall meet regularly - once a month and as often as required.

HOSPITAL GUIDELINES FOR PREVENTION AND CONTROL OF INFECTIONS

No.
1.

Topic

Details

Infection control policy

Started in 1998; revised in 2001,
(Ensuring adequate and trained human
March and August 2010.
resources for infection control e.g. a
minimum of one infection control nurse
per 250 beds)
Infection Control committee
(The details of the responsibilities are
enclosed in Annexure -1)

Chairperson: Medical superintendent

Secretary: HOD Microbiology
Members:
Addl. MS, SJH
Heads of all clinical departments
Nursing Superintendent(NS), SJH
Executive Engineer, Civil, CPWD
Executive Engineer, Electrical, CPWD
Store Officer
Infection Control Nurses(ICN) -2
ICO: Microbiologist
ICN: 2 Staff Nurses

Biomedical Waste Management

(BMW) Team

Addl. MS, SJH

MS, SJH
Executive engineer, Civil, CPWD
Executive engineer, Electrical, CPWD
Store Officer
DDA
ICN

2.

Standard precautions

Followed in all health care areas

3.

Hand hygiene guidelines

Strictly observed to be and monitored

4.

Safe injection practices

There is a model Injection Centre in

SJH as a patient safety initiative.

5.

Minimize invasive procedures

Invasive procedures are done when essential.

6.

Patient isolation policy

Isolation policy in place at SJH

7.

Disinfection and sterilization policy

Practiced and monitored regularly.

8.

Antimicrobial policy

Attached as Annexure 1

9.

Safe environment (including

water, air, temperature &
housekeeping) monitoring

Ensured to the best possible extent

under the limited resources.

10.

Maintenance & Cleanliness /

Infrastructure

Housekeeping guidelines followed by

the designated staff

11.

Biomedical Waste Management

(BMWM) guidelines

Practiced as per government regulations,

and waste audit done at monthly intervals.
(Annexure 2)

12.

Training and education of HCW

on HIC Practices, including BMWM
& PEP for HIV &HBV

Conducted by the department of BMWM

on monthly basis, every Pre and post
evaluation tests conducted in the training
program. Certificates issued only if they
achieve 60% marks in the post evaluation
test. (Annexure 3)

13.

Occupational safety guidelines

Additional MS is the designated safety

officer. Hepatitis B and H1N1 immunization
is being done for all at risk, as and
when required.Post exposure prophylaxis
(PEP) for HIV/HBV in place at SSKH &
KSCH. (Annexure 3)

14.

Outbreak investigation policy

All outbreaks are investigated, analyzed

and reported to the Chairperson, and
appropriate measures are taken to control
the outbreaks.

15.

Audits of infection control

Done regularly by the HIC team

SURVEILLANCE AND REPORTING OF INFECTION

Statutory Notifications
All notified by Secretary, Hospital Infection Control Team to the MS of SJH.
Prompt notification and reporting of disease is essential.
The objectives of notification are:
1.

Regulatory obligation by Govt. of India. All notifiable and reportable diseases must be
reported to
concern authorities.

2.

To collect accurate and complete epidemiological information on the disease.

3.

To ensure prompt and appropriate control measures to prevent the spread of infection.
Any patient suffering from a notifiable/reportable disease when detected shall be
communicated to the designated authority immediately.
ACTIVE SURVEILLANCE

Active surveillance of Healthcare associated Infections (HCAI)

The microbiology department shall be responsible for reporting any information about infections
suspected to be hospital acquired on prescribed format to Infection Control Nurse (ICN). The
ICN in consultation with ICO may proceed for investigation of HCAI.
Active surveillance of High Risk Areas
Active surveillance shall be done at least for high risk areas.
High risk areas under various setting include:

Intensive care units

H1N1)

Operation Theatres

Dialysis Unit

(NICU, PICU, ICUs CTVS, CCU, Burns, Trauma, Respiratory,

Burns Unit

Transfusion services unit

Food handlers

Drinking water

CSSD

Operation Theatres
Both surface contamination and air quality will be investigated periodically. Culture swabs and
air sampling plates will be sent from Operation Theatres periodically atleast once in a month.
Fogging of OTs will be done on the basis of these reports and/or clinical procedures carried
out in the operating areas. No routine fogging is recommended. Any civil or engineering works
should invite fogging of OTs.
Parameter

Compliance

Surface swabs

Once in Month

Air Sampling

Once in Month

Disinfectant Monitoring

Once in Month, (In- Use disinfectant method,

Glutaraldehyde monitoring strip)

Schedule may be changed to increased frequency in case of suspected increase in infection

rate from OTs.
Sampling of in-use disinfectants: 1ml of sample of in-use disinfectants, hand wash agents are
sent to microbiology laboratory in a sterile container once a month preferably when other
sampling (Air and surface) is being carried out.
Records are kept with nursing incharge OT and the results produced in HICC meetings. In case
of unacceptable results, decisions on corrective measures are taken by HICC.
Intensive care units
Monitoring of device associated infections needs to be done on regular basis. The basic
indicators required ventilator associated pneumonia (VAP), catheter linked blood stream infections
(CLBSI) and catheter associated urinary tract infections (CAUTI). VAP, CLBSI and CAUTI
episodes are monitored
Regular active surveillance is recommended through the emergence /clustering of positive
cultures cases or similar clinical case clustering.
In case of surveillance following surveillance specimens must be collected:
Surveillance samples:

Clinical Material
o Central line tips with blood culture
o ET tube secretions for microscopy and culture
o Urine samples from catheterized patients
o Others
Environmental Sampling
o
o
o
o
o
o
o
o

Water samples from humidifiers

Sampling of drugs prepared for patients
Ventilators
Walls
Floors
Suction tubing
Disinfectants on dressing trolleys
Others

Surveillance clinical samples are sent to microbiology lab on basis of clinical data or microbiological
reports. Analyses of data are presented at the subsequent HICC meeting. Records are
maintained by ICO. At our hospital the surveillance is carried out once in every two weeks for
each area mentioned above (clinical and environmental sampling). The data will be presented
in HICC meetings.
Transfusion services unit
Environmental sampling shall be done once in a week. Blood component bags FFP and
platelets shall be screened for contamination, as and when required. The record will be maintained
by blood bank officer and chairman/Secretary HICC and presented in HICC meetings.
Wards
No active surveillance is required for routine non-ICU patient care units. Active surveillance
is recommended whenever clustering of positive cultures from cases are seen in the laboratory.
Sampling should be done in consultation with ICN under guidance of microbiologist.
Food handlers
Screening of food handlers is recommended every four month. Samples include stool samples
for ova, cyst and cultures for typhoid carriers. Records to be maintained by the dietician and
ICN.

Drinking Water
Bacteriological surveillance is to be done monthly. Potable water testing is routinely carried out
for bacterial cultures in laboratory from all patient care units, hospital kitchen, canteens and
hostels once in a month.
Centralised Sterilised Supplies Department
Air and surface sterility is monitored from sterile zone. Bowie Dick test and use of biological
indicators for steam sterilisation is carried out. Disinfectant screening is also done. Records
to be kept by CSSD.
PASSIVE SURVEILLANCE
Reporting of hospital acquired infections
Passive Clinical Reporting
It will be mandatory for clinicians to fill the prescribed form for every admitted patient and the
form may be sent to Infection Control Nurse (ICN).
Passive Microbiological Reporting
In an event of clustering of cases passive surveillance is initiated. Respective clinicians are
informed about the suspected clustering and surveillance specimens are collected. The report
thus generated from the study is sent to the concerned physicians and surgeons. This is being
done regularly.
HAND HYGIENE

Training and compliance needs to be monitored. Availability of hand rubs, Soaps hand
towels and water should be ensured. Foot operated and wall mounted dispensing stations
are required. Hand hygiene training programme for doctors, nursing staff, students and
housekeeping staff is done regularly once a month for each category of staff. Hand
hygiene compliance is not yet initiated.
MULTIDISCIPLINARY CONTINUING EDUCATION PROGRAMME

Continuous education programme is conducted on regular basis for all categories of staff
ensuring each staff attends the programme at least once in three months.
DISINFECTION POLICY
DISINFECTION
Disinfection is a process where most microbes are removed from defined object or surface,
except spores.
Disinfectants can be classified according to their ability to destroy different categories
of micro-organisms:

High Level disinfectants

Intermediate Level disinfectant : alcohols, chlorine compounds, hydrogen peroxide,

chlorhexidene, glutaraldehyde(short term exposure)

: glutaraldehyde 2%, ethylene oxide

Low level disinfectants

: benzalkonium chloride, some soaps

GENERAL GUIDELINES FOR DISINFECTION:

Critical instruments/equipments (that are those penetrating skin or mucous membrane) should
undergo sterilisation before and after use. e.g. surgical instruments.

10

Semi-critical instruments /equipments (that are those in contact with intact mucous membrane
without penetration) should undergo high level disinfection before use and intermediate level
disinfection after use. e.g. endotracheal tubes
Non-critical instruments /equipments (that are those in contact with intact skin and no contact
with mucous membrane) require only intermediate or low level disinfection before and after use.
e.g. ECG electrodes
Disinfectants that are in use
Glutaraldehyde:
Can be used up to 14 days after activation,
Contact time

- For disinfection

15-30 minutes

- For sterilization

8-10 hours

Sterilium :
Contains 2-propanol, 1-propanol, macetronium ethyl sulphate
Contact time for patient care hand wash : 1.5 ml for 30 seconds
Contact time for surgical hand wash : 9 ml for 3 minutes
Ecoshield :
Contains stabilized hydrogen peroxide 11% w/v with 0.01% w/v, diluted silver nitrate
solution.
For surface disinfection: 10% v/v solution in de-ionized water with contact time of 60
minutes.
For fumigation: 1 litre of 20% v/v solution /1000 cu ft of space in 60 minutes.
Bacillocid :
Contains chemically bound formaldehyde, glutaraldehyde and benzalkonium chloride.
Used as surface disinfectant at 2% solution in operation theatres and at 0.5% in wards and
dressing rooms.
Sprayed onto wet surfaces with a low pressure sprayer and allowed to dry slowly.
Betadine:
Iodophor .This is a high level disinfectant. Used for surgical hand scrub, skin disinfection.
Tincture Iodine:
For part preparation in operation theatres and blood specimen collection.
Sodium Hypochlorite:
Used for containing blood spills at 10%, disinfecting counter tops and other hard surfaces at
1 %.
Used in laboratory for decontamination of waste from equipment and glassware at 5%.
Alcohol (70%) :
Used for disinfection of non-disposable patient care items in/out- patient departments and also
in laboratory for cleaning of microscope lenses and surfaces of critical work surfaces.
ALDEHYDE
Glutaraldehyde may be used in places like the endoscopy unit, cardiac catheterization labs.
Formaldehyde is used for fumigation.

11

Endoscopes - cleaning and disinfection

1.

Mechanical cleaning : This is the most important step. Flush the air/water channel for 1015 seconds to eject any blood or mucus. Aspirate detergent through the biopsy/suction
channel to remove gross debris. Use a cleaning brush suitable for the instrument and
channel size to brush through the suction channel.

2.

Disinfection : The endoscope and all internal channels should be soaked in 2% glutaraldehyde
for 20 minutes.

3.

Rinsing : Following disinfection, rinse the instrument internally and externally to remove
all traces of disinfectant.

4.

Drying : Dry the endoscope externally. Flush air through each channel.
STEAM STERILIZATION

Microbiological indicators are used once a week: namely spores of Bacillus stearothermophilus
for steam sterilizers and Bacillus subtilis for ethylene oxide. Vials are removed from sterilizers
and sent to microbiology laboratory where they are incubated at relevant temperatures for 48
hours. Report is sent to ICN.
An expiry date is given for sterile articles based on the packing material used.
FOGGING :
Eco-shield is used for fogging using Fog spraying machine.
Operation theatres are fogged once a week and if necessary such as in case of a septic wound
being drained.
Other patient care areas regular fogging not recommended.
Necessary decision is taken by in charge of concerned patient care area.
FLOOR MOPPING
General cleaning by plain soap and water in non-critical care areas.
In critical care areas generous mopping using wet cloth by 0.5% Sodium Hypochlorite solution.
BEDDING AND BLANKET
Impermeable covers, mattresses should be mopped with 0.1% Sodium hypochlorite solution or
spirit.
Blanket may be sent for laundry or dry cleaning.
Monitoring of biomedical waste management practices
ICN shall take daily rounds in pre-formatted round sheet and will look into the biomedical waste
management of various hospital areas.
Bedside teaching by ICNs will be undertaken.
ISOLATION POLICY
Aim :

To prevent the transmission of pathogenic microorganisms within the healthcare

setting

The patients of following disease categories should be treated under isolation.

Severe influenza cases, SARS, Open case of tuberculosis, Anthrax, C. diphtheriae,

Pertussis, Pneumonic plague, Chicken pox, and patients suffering from multidrug resistant
pathogens/MRSA.

12

The isolation of the patient would be done taking following into consideration:
(1)

Separate ward/room/area is designated for keeping the patient.

(2)

Isolation wards/area has double door entry with a separate changing room with
availability of Personal Protective Equipment (PPE) and disinfectants and a hand
washing area providing negative pressure with adequate air changes (6-12/hour) and
HEPA filtered air in case of patients suffering from respiratory pathogens.

(3)

Central air conditioning and use of desert air coolers is not permitted.

(4)

Adequate distancing between patient beds (3-6 feet) to be ensured.

(5)

Overcrowding to be avoided in isolation ward/area.

(6)

Unauthorised Visitors entry is to be prohibited.

(7)

Nobody is allowed to enter the ward without donning adequate PPE.

(8)

As far as possible dedicated health care staff to be posted for isolation ward.

(9)

Regular daily cleaning and proper disinfection of isolation wards to be done at least
twice a day. in addition, special attention should be given to cleaning and disinfecting
frequently touched surfaces to prevent aerosolisation. Damp sweeping/wet mopping
to be performed.

(10) Standard precautions which include barrier nursing to be followed with special stress
on hand hygiene using soap water and alcoholic hand rubs (Preferably foot operated)
and the procedures should be adequately displayed for the same.
(11) Appropriate use of PPE should be strictly adhered to e.g. use of face masks,
N95 masks, gloves, gowns, aprons , shoe covers, head covers etc as per the
requirement (The procedures of donning/undonning of PPE will be displayed).
(12) Sharing of equipments among the patients to be avoided, if unavoidable, ensure that
reusable equipments are disinfected before use on other subjects(Equipments like
Thermometer, Nebulisers ,Stethoscopes, BP apparatus cuff to be dedicated for each
patient).
(13) All the equipments coming in contact with the patient should be disinfected.
(14) Use of mobile phones by healthcare staff to be avoided inside the isolation area.
(15) Appropriate waste disposal facilities to be available in the isolation area, All waste
to be treated as infectious and should be segregated and disinfected before removal
from the isolation area.
(16) All paper work/record keeping should be done outside the isolation area.
(17) Sample collection to be done using appropriate PPE, following standard work precautions.
Sample to be packaged/transported in triple packaging.
(18) Used linen to be handled as little as possible with minimum agitation and should be
transported in closed containers and should be labelled as infectious before sending
to laundry for washing.
(19) Regular training on PPE, standard precautions and other infection control for the
healthcare workers and providers shall be under taken.
INVESTIGATION OF AN OUTBREAK
The occurrence of two or more similar cases relating to place and time is identified as a cluster
or an outbreak and needs investigation to discover the route of transmission of infection, and
possible sources of infection in order to apply measures to prevent further spread. If the cases
occur in steadily increasing numbers and are separated by an interval approximating the
incubation period, the spread of the disease is probably due to person to person spread. On
the other hand if a large number of cases occur following a shared exposure e.g. an operation,
it is termed a common source outbreak, implying a common source for the occurrence of the
disease.

13

Epidemiological methods
The investigation of an outbreak may require expert epidemiological advice on procedures.
Formulation of a hypothesis regarding source and spread is made before undertaking microbiological
investigations in order that the most appropriate specimens are collected.
Steps to be taken to investigate an outbreak
Step 1

Recognition of the outbreak. Is there an increase in the number of cases of a particular

infection or a rise in prevalence of an organism? Such findings indicate a possible outbreak.

Preliminary investigation must begin by developing a case definition, identifying the site,
pathogen and affected population. Define the outbreak in time, person and place.

Determination of the magnitude of the problem and if immediate control measures are
required. If so general control measures such as isolation or cohorting of infected cases;
strict hand washing and asepsis should be immediately applied.

Verification of the diagnosis. Each case should be reviewed to meet the definition.

Confirmation that an outbreak exists by comparing the present rate of occurrence with
the endemic rate should be made.

Step 2

The appropriate departments, personnel and the hospital administration should be notified
and involved.

Step 3

Additional cases must be searched for by examining the clinical and microbiological ecords.

Line listing for every case, patient details, place and time of occurrence and infection
details should be developed.

An epidemic curve based on place and time of occurrence should be developed, the date
analyzed, the common features of the cases e.g. age, sex, exposure to various risk
factors, underlying diseases etc. should be identified.

A hypothesis based on literature search and the features common to the cases; should
be formulated about suspected causes of the outbreak.

Microbiological investigations depending upon the suspected epidemiology of the causative

organism should be carried out. This will include (a) microbial culture of cases, carriers
and environments (b) epidemiological typing of the isolates to identify clonal relatedness.

The hypothesis should be tested by reviewing additional cases in a case control study,
cohort study, and microbiological study.

Step 4

Specific control measures should be implemented as soon as the cause of outbreak is

identified.

Monitoring for further cases and effectiveness of control measures should be done.

A report should be prepared for presentation to the HICC, departments involved in the
outbreak and administration.

Immediate control measures

Control measures should be initiated during the process of investigation. An intensive review
of infection control measures should be made and general control measures initiated at once.
General measures include:

Strict hand washing

Intensification of environmental cleaning and hygiene
Adherence to aseptic protocols
Strengthening of disinfection and sterilization

14

Microbiological Study
Microbiological study is planned depending upon the known epidemiology of the infection
problem. The study is carried out to identify possible sources and routes of transmission.
The investigation may include cultures from other body sites of the patient, other patients, staff
and environment. Careful selection of specimens to be cultured is essential to obtain meaningful
data.
Specific control measures
Specific control measures are instituted on the basis of nature of agent and characteristics of
the high-risk group and the possible sources. These measures may include :

Identification and elimination of the contaminated product

Modification of nursing procedures

Identification and treatment of carriers

Rectification of lapse in

clinical technique or procedure

Evaluation of efficacy of control measures

The efficacy of control measures should be evaluated by a continued follow-up of cases

after the outbreak, clinically as well as microbiologically. Control measures are effective
if cases cease to occur or return to the endemic level.

The outbreak will be documented and the records should be kept with HICC and should be
presented in HICC meeting.
ANTIMICROBIAL POLICY
The annual antibiogram is released from the microbiology department. Antibiotic susceptibility
tests is analyzed regularly on a quarterly basis and the common resistance patterns of the
bacterial isolates are reported and discussed in the HICC meetings and the antibiotic policy is
reviewed accordingly. Present Antibiotic policy is published as separate document
Antibiotic policy is prepared in consultation with respective clinical departments
Antibiotic policy shall be prepared using following general principles:
1.

Data is analyzed on a quarterly basis as per hospital records)

(a) Common etiological agents as per
(i)

site of infection

(ii)

age groups

(iii) patient location outdoor (OPD), indoor (wards & critical care areas)
(b) Antibiogram data as per
(i)

site of infection

(ii)

age groups

(iii) patient location outdoor (OPD), indoor (wards & critical care areas)
(c) Unusually resistant organisms to be confirmed and submitted for further characterization
to National Centre for Disease Control (NCDC) for
2.

Standard treatment guidelines [categorization of patients as per age and Community

acquired infections (CAI) / Health care associated infections (HCAI)]
(a) Guidelines for empirical antimicrobial therapy as per common clinical syndrome
(i)

Adults & older children

1.

Blood Stream Infections (BSI)

2.

Meningitis

3.

UTI

15

4.

Pneumonia
(a) Community Acquired Pneumonia (CAP)
(b) Ventilator Associated Pneumonia (VAP)

5.

GIT Infections

6.

Conjunctivitis

7.

Otitis Media

8.

Tonsilltitis / Pharyngitis

9.

Skin and Soft Tissue Infection (SSTI)

10. Genitali Infections

11. Osteomyelitis
(ii)

Neonates (special conditions)

1.

Sepsis

2.

Meningitis

(iii) Infants & Small Children (special conditions)

1.

Meningitis

2.

Sepsis

3.

Pneumonia

(b) Classification of Antimicrobials into first line, second line and reserve group of drugs
(c) Chemoprophylaxis
(i)

Pre-operative antimicrobials

(ii)

Other invasive procedures

(iii) Special high risk groups e.g. Prophylaxis for rheumatic fever, splenectomy
patients, immuno-compromised patients
(d)
4.

Special clinical syndromes (e.g. STIs as per government guidelines)

Prescription auditing (not being done at present; will be initiated in collaboration with the
department of Pharmacology) as per
(i)

age groups

(ii) patient location outdoor (OPD), indoor (wards & critical care areas)
5.

Quarterly and annual review of surveillance data generated from antibiograms (done) &
prescription auditing (planned).

6.

Education and training for all infection control activities being coordinated by the department
of Microbiology, in collaboration with the Hospital Infection Control Committee.

16

Annexure-1

Policy on
Hospital Waste Management

10.5.10

Dr. K.T. Bhowmik, Dr Sunita Singal,

Department of HWM

17

ACKNOWLEDGE
We would like to place on record, that valuable contributions were made by *Dr K S
Beghotia, in the preparation of the policy. He performed an exchaustive review of the draft,
which helped in the finalization of this policy document.
Our special thanks are also due, to Mr. Ajay Wadhwa Sanitary superintendent, for his
inputs and unstinted support throughout the preparation of this document.
Dr. Sunita Singal,
Nodal Officer
Department of HWM, VMMC & Safdarjung Hospital

*Dr K S Baghotia is State Programme Officer, Govt. of Delhi, Directorate of Health Service,
F-17, Karkadooma, Delhi-110032

18

CONTENTS
TOPIC

SUB-TOPIC

1.

The Objectives of Waste Management Policy

INTRODUCTION

PAGE NO.

Strategies of Waste Management

Hospital Waste Management Committee & Its

Function
2.

PRACTICES IN THE

Policy on Segregation of Wastes

PATIENT-CARE

Bins and Liners

AREAS/CLINICAL

Disinfection and Mutilation

AREAS

Labeling, Collection, Storage and Recording of

Waste in the Clinical Areas

Transportation
3.

TREATMENT

Equipment
Maintenance of Equipment:

11

Storage, Quantification and Treatment of the

Waste Storage Site
4,

FINAL DISPOSAL

Disposal of non sharps

Disposal of Sharps:
Recycling Policy:

13

Record Keeping and Reporting of Data

5.

MANAGEMENT OF

Liquid and chemical waste management

WASTE FROM

Laboratories, Blood Bank

SPECIAL AREAS:

RNTCP Laboratory
Mercury and Lead Waste

14

Disposal of Radioactive waste Disposal of

Radioisotope/Nuclear Waste
E-Waste:
Effluent Treatment Plant
6.

SAFETY ISSUES AND PPE & Vaccination of the Health Care Workers
OTHER PROTOCOLS

Liquid spill management

Mercury Spill Management

17

Sharps Injury Management

7.

TRAINING

Induction and refresher training

19

8.

MONITORING AND

Monitoring, supervision and Evaluation

20

SUPERVISION
9.

FUTURE

BACK-UP for Treatment of waste

PROPOSALS

Refresher Training of the Staff

Public Awareness/IEC Material

21

Composting of Kitchen and Horticulture waste

10. ABBREVIATIONS

Abbreviations/Glossary

22

Proforma Samples

27

GLOSSY
11. ANNEXURES

19

1. INTRODUCTION
All over the world, the modern hospitals and Healthcare institutions use a wide variety
of drugs chemicals, radioactive substances, and perform a variety of investigations and surgical
procedures. The advent of state of art sophisticated newer technologies, the disposables i.e.,
syringes gloves and other devices all of which ultimately become part of the hospital waste.
This has brought in tis wake, risks of unauthorized and illegal reuse/misuse of these devices
and an enormous increase in the quantum of waste from hospitals.
The Ministry of Environment and Forests, Govt. of India notified the Bio-Medical Waste
(Management and Handling) Rules on 27th July, 1998; under the provisions of Environment Act
1986. These rules have been framed to regulate the disposal of various categories of Bio-Medical
Waste as envisaged therein; so as to ensure the safety of the staff, patients, public and the
environment.
In order toe comply with the BMW Rules safdarjung hospitals has set up requisite biomedical waste treatment facilities incinerator, microwave system for the treatment of waste and
all other requisite arrangements as per guidelines o.
THE OBJECTIVES OF WASTE MANAGEMENT POLICY:
The Bio-Medical Waste Management policy of Safdarjang hospitals has been drafted to meet
the following broad objectives:(i)

Provide a system of management of potentially infectious and hazardous waste as per

guidelines and recommendations of Biomedical Wastes (Management and Handling Rules)
1998.

(ii)

Identifying, defining & classifying the various categories of waste being generated in the
hospitals.

(iii)

Segregation of various categories of waste in separate color coded containers at the site
of generation, so that each category is treated in a suitable manner to render it harmless.

(iv)

Disinfection/decontamination of infected items at the site of generation immediately after

use.

(v)

Onsite appropriate treatment technology to be used depending upon the category of

waste.

(vi)

Creating a system where all categories and personnel are responsible as well as accountable
for proper waste management.

(vii) Environment and patient friendly safety norms.

STRATEGIES OF WASTE MANAGEMENT :
Following strategies will be adopted to meet the broad objectives of the Bio-Medical Waste
Management in Safdarjung hospital :
1)

A system will be established of management of potentially infectious and hazardous as

per guidelines and recommendations of Biomedical Wastes (Management and Handling
Rules) 1998.

2)

Waste will be classifying the various categories being generated in the hospital.

3)

Use of separate color coded containers for Segregation of various categories of waste
at the point of generation,

4)

Disinfection/decontamination of infected items at the site generation immediately after

use.

5)

Onsite appropriate treatment technology will be used depending upon the category of
waste.

6)

Establishing a system where all categories of personnel perceive responsible as well as

accountable for proper waste management.

7)

Adoption of Environment and patient friendly safety norms.

20

HOSPITAL WASTE MANAGEMENT COMMITTEE AND ITS FUNCTION

A hospital Waste Management Committee, has been formed which function under the Chairmanship
of the Medical Superintendent. It is a broad based committee with representative from various
clinical departments, including Medical store, sanitation, Nursing and engineering Depts. The
committee holds meetings periodically.
Function of the Committee :

Implementation of the Bio-Medical Waste (Management and Handlings) Rules published

in gazette of India of 27th July, 1988; under the provisions of Environment Act 1986
in the hospital.

Monitor and ensure effective, hospital waste management in the Hospital.

Organize proper and timely; training program for all categories of workers.

Responsible for ensuring good waste management practices and waste minimization.

AUTHORISATION : The hospital has been authorized for generation, collection and treatment
of the Bio medical waste as per rule.
2. PRACTICES IN THE PATIENT-CARE AREAS/CLINICAL AREAS :
POLICY ON SEGREGATION OF WASTE :
The hospital should ensure that clinical and general wastes is segregated at source and placed
in color coded plastic bags and containers prior to collection and disposal at the site generation
in all patient care areas/clinical areas. There is no mixing of waste.
Yellow, Blue and Black colored bags are used for segregation*.

Segregation is the responsibility of the generator of wastes i.e. the doctors, nurses or
paramedical personnel.
Segregation is done for each of the following:

Infectious non sharps

Infectious sharp

Disposable plastic items

Glass

General waste

Paper/ cardboards

Cytotoxic/radiological/radioactive

Microbiological/pathological wastes

*Read bags contain Cadmium which gives toxic emissions if incinerated hence not used in SJH.

21

Biomedical Waste Management Segregation Chart

Yellow Bag (one)
Category 1,2, 3,6

Items

Non Infected

contaminated
with blood or
body fluid, Blood
bags and blood
transfusion set
(non-PVC),
Cotton swabs,
body tissues,
body parts,
organ tissues,
Micorobiology and
Biotechnical
waste without
chemical
treatment

I/V Bottles-1
Give a nick,
Collect, tie
when 3/4ths
full and send
for disposal.

Black
Bag (one)
Category
5,9,10
Infected
General and
household
Syringes-2
Gloves-3
1/V sets -4
type of
waste
Destroy/cut the After
Catheters
paper, peels
hub with needle Clipping
tubings, Ryles leftover
syringes
and
tube, Suction food
destroyer,
disinfecton
tubes,
disinfect in
Collect
urobes,
bleach solution for disposals Oxygen Mask All expired/
(1%, for 30
when
etc, give a
medicines,
minutes).
3/4th full.
nick
incineration
Collect and
Collect and
Ash and
send for final
send for
solid
disposal when
disposal when chemicals
3/4 full.
3/4the full.
sent to
Puncture proof
secured
Container
landfill
Destroyed
Needles, Scalpel
Blades, Other
Metal Sharps

NB: No PVC material should be placed in yellow bag.

Any material treated with hypo-chlorite solution should never be sent for incineration

22

Color-coded bags & Category wise Treatment

Color Coding

Type of Container-1

Treatment option as per

Waste Category
Yellow Bags

Schedule 1

Cat. 1, Cat. 2 and Cat. 3,

Incineration

Cat. 6.
Blue Bags

Cat. 4, Cat. 7.

Black Bags

Cat. 5 and Cat. 9 and

Chemical Treatment Microwaving

and shredding
Disposal in municipal landfill

Cat. 10. (solid)

SEPARATE PUNCTURE PROOF CONTAINERS
Separate Puncture proof Containers are used i.e., one for each of following:

Metallic sharps in a container with hypochlorite solution and

Glass vials, broken glass.

CARDBOARD BOXES

Paper/cardboards

others

BINS AND LINERS :

The container comprises of an inner bag of color depending on the type of waste, and should
match the chosen outer container is a plastic bin with handles, and of a size which will depend
on the amount of waste generated. The inner polythene bag should be leak proof, and should
fit into the container with one-fourth of the polythene bag turned over the rim.
LINERS/PLASTIC BAGS: MATERIALS USED:
Biodegradable plastic bags of 3 colors yellow, and black are used, to line the same colored
bins with the specifications ad guidelines of BMW Rules:

Gauze 225 (55 microns) if low density

Gauze-100 (25 microns), if high density

Yellow and Blue bags are marked with Biohazard symbol and hospital logo.
Black bags Hospital logo and name.
BINS :
Containment of waste : An optimum number of easy to use, Standard, uniform, covered, footoperated bins of 3 colors i.e., yellow, blue and black, of appropriate size would be placed at
identified places in all clinical areas.
DISINFECTION OF BINS :
Chemical disinfection of the waste bins using hypochlorite solution should be done frequently
at a separate washing facility in the hospital.
DISINFECTION AND MUTILATION OF SHARPS :
In order to render them harmless to waste handlers a Pre-Treatment of the infectious waste
generated in the patient-care areas is required, prior to transportation for onsite treatment and
disposal. It is required for the following infectious items;

Syringes

Needles

Catheters, I/V sets, gloves

23

To ensure the disinfection/pretreatment of the waste without at the site of generation, the
following guidelines/advisory is followed in all areas:1.

Use of needle destroyer the needles and then the same is put into the puncture proof
container containing hypochlorite solution.

2.

After use, the nozzle of Syringes is to be cut with the needle destroyer. Draw some bleach
solution into the syringe or separate the piston and barrel, and place it in the container
with a sieve having 1% hypochlorite solution for 30 minutes. After 30 minutes the syringe
are placed in the blue bags by lifting the inner sieve.

3.

In the gloves are clipped immediately after use by the dedicated pair of scissors placed
in the area to prevent reuse and the dipped in 1% hypochlorite solution in a bucket for
30 minutes for disinfection. After disinfection they should be placed in a blue bag.

4.

All plastic items IV bottles, urobags, brains etc. are given a nick putting in blue bag. Each
bag is labeled and securely tied when three-fourths full.

COLLECTION STORAGE, LABELING, AND RECORDING OF WASTE

All the biomedical waste is labeled as waste type, site of generation, date of generation before
transportation from the generation site. Waste is stored in the areas of generation at an identified
safe area, for an interim period after which it is transported for onsite treatment and final
disposal. During this period it is the responsibility of the waste. No untreated bio-medical waste
shall be kept stored beyond a period of 48 hours.
Collection si done
-

Daily from all areas

Done twice daily or more frequently form labor rooms/ OTs

Label is filled up by staff on duty and given to waste collectors

Each patient care area has been provided with the waste receipt book to record the quantity/
number of yellow and blue gabs handed over the HCW. All the staff are required to duly full
in the waste book color wise mentioning the number and size of bags handed over and sign
the slip for further record.
TRANSPORTATION :
Hospital waste is transported in securely tied bags from the site of generation to the treatment
facility (incinerator premises) through designated route, on dedicated, color coded, covered and
leak proof wheel barrows/Trolleys. At the waste treatment premises verification of the number/
size of the bags is done for each trolley by the sanitation staff for recording and quantification
before disposal.
Chemical disinfection of the trolleys using hypochlorite solution is being at the waste storage
site.
3. TREATMENT FACILITIES :
EQUIPMENT :
Safdarjung hospital has the following Equipment for in-house treatment of waste:
1.

Incinerator : 3 units of incinerator were installed in 1994 having chimney height of

30 meters each, capacity 150-175 kg/hr. Only one is equipped with APCD and is in
use.

2.

Microwave : Microwave with a capacity of 60 Litres per cycle is available at the waste
site. All the infectious plastic waste is disinfected in Microwave.

3.

Shredder Machine : One indigenous type and one Bometic shredder machine is
installed in 1998. It is used to shred plastic and PVC materials such as I.V. bottles,
disposable syringes, IV tubing etc. after they have been micro waved at the site of
generation

24

MAINTENANCE OF EQUIPMENT
Maintenance of Incinerators is done by CPWD Electrical Engineers. The operator posted by
CPWD is maintaining the record of the operations of incinerator, temperature of the incinerator
chambers and hours of operation of the incinerator as per CPCB requirements. The parameters
are recorded everyday, manually at present under supervision of junior Engineer CPWD
(Electrical) and Sanitary Supervisor (S. S) and are available for inspection any time.
OPERATING PARAMETERS OF EQUIPMENT :
The incinerator and microwave operate as per parameters give by BMW Guidelines. Culture of
the treated waste is periodically performed and monitored.
STORAGE AT THE MAIN WASTE STORAGE SITE :
There is adequate space to store the wastes transported from various clinical areas while awaiting
final treatment and disposal. In the storage areas, wastes are stacked with clear distinction as
per the color coding of the waste. There is warning signboard prominently placed at the entrance.
Adequate security and guarded gate is provided at the facility to prevent unauthorized access
to the site by humans and livestock. The premise has provision for locking. The site has
sufficient electricity and water supply. There is adequate open space for municipal trucks to
have easy access for collection.
QUANTIFICATION :
Counting of bags and verifying with the labels from each area is done at the collection site
by the staff posted there. The yellow bags containing the infectious waste are counted and
the number is confirmed from the receipt from each area. After this the weighing of all yellow/
blue is done. The data is recorded and maintained area-wise/Department-wise.
TREATMENT :
After this all the Yellow bags are directly sent for incineration. Ash from the incinerator
is collected in black bags and kept along with the general waste. The waste is non toxic and
non infectious, and is taken by civic authorities.
The blue bags containing disposable plastic (Syringes, IV canulas and bottles) are duly
verified in number from the receipt at the site. The infected plastics and gloves are then put
in the microwave for disinfection/treatment.
After treatment, in the microwave all plastics are shredded in the shredding machine. After
shredding the granular plastic is stored in blue bags till final disposal. These bags should be
labeled as with Cytotoxic symbol. There should be a separate storage facility for untreated and
treated waste.
4. FINAL DISPOSAL
DISPOSAL OF NON SHARPS:
Black bags containing expired/discarded medicines along with ash from the incinerator are taken
away by the NDMC truck for disposal to a secured landfill everyday.
Blue bags:
The shredded material so obtained from the shredded is placed and stored in blue bags. It is
then sold for recycling to Govt. authorized vendors every fortnight or earlier if required.
DISPOSAL OF SHARPS :
All metallic sharps are received in puncture-proof containers.
Deep pits for sharps have been made in a safe areas as per guidelines of BMW. Currently
fourth pit is in use. All sharps are poured in the pits after weighing and recording. Encapsulation
option of disposal of sharps will be started after fourth pit is full.

25

RECYCLING POLICY :
The hospital follows the principle of reducing, and favors policy of recycling
All disinfected and shredded plastics, gloves, glass, cardboard etc. are sold to Govt. approved
vendors/Kabariwalas at Govt. approved rates.
RECORD KEEPING AND REPORTING OF DATA :
Maintenance of the records :
The following records are being maintaining by the HWM Dept. :
i) Incinerator parameters
ii) Microwave parameters.
iii) Each patient care area has been provided with the waste Receipt book. All the staff
are requested to duly fill up the waste book code wise with nos. of beg and sign
the slip for further record.
iv) Quantity of infectious waste received from various areas
v ) Quantity of plastic waste
vi) Quantity of waste sold to vendor
vii) Annual reports
viii) Monthly reports
ix) Authorization from DPCC,
x) Consent to establish
xi) Recyclable waste
xii) Sharps Injury register.
xiii) Immunization register
xiv) Miscellaneous correspondence liaison with other department DPCC etc.
The monthly and annual reports are sent to MOHFW and the requisite information is provided
to CPCB/DPCC whenever required.
5. MANAGEMENT OF WASTE FROM SPECIAL AREAS :
LIQUID AND CHEMICAL WASTES MANAGEMENT :
Chemical disinfection of the liquid waste, at the areas of generation e.g., Labor rooms, OTs,
labs etc is done. These liquid wastes should be disinfected by chemical treatment using at least
1% sodium hypochlorite solution for a contact period of 30 Minutes and them discharged into
drains/sewers where it is taken care of by the principle of dilution and dispersal.
LABORATORIES, BLOOD BANK :

The blood sample glass vials, plastic vials etc. from all he laboratories is chemically
disinfected in the respective labs. The discarded disinfected vials are packed in blue
plastic bag for final disposal.

The Microbiology cultures plates/dishes, stalks are locally autoclaved before transporting
to the waste premises for final disposal.

The discarded blood bags are brought by a responsible staff member, (Doctor or
technician) double packed in yellow bags and sealed. At the incinerator premises the
sealed bag is weighed for record purpose and then incinerated in the presence of
both the blood bank technician and the incinerator operator. Both of them sign and
record the same.

DISCARDED MEDICINES AND CYTOTOXIC DRUGS:

The discarded medicines and cytotoxic drugs, which need to the disposed, should
be certified by Head of the concerned department, put in a yellow bag, tied and
sealed.

26

Labelled as with Cytotoxic

Weighed, and weight should be written over it

Send for incineration through 2 responsible staff members from the ward, who will
get it incinerated in the presence of Sanitary Inspector.

After incineration all three staff members will record the same and duly put their
signatures on the document.

A copy of the same may be sent to M.S. for information

MERCURY AND LEAD WASTE, DENTAL OPDs :

Our hospital has stopped purchase of mercury-based BP Instrument and Thermometers and
their use is being phased out. The mercury waste generated is contained, awaiting appropriate
disposal options e.g., handing over to Govt. approved vendors. Similarly the Lead waste is also
being contained awaiting suitable and safe disposal options.
Mercury amalgum fillings are not being used in dental fillings are present.
DISPOSAL OF BIOMEDICAL WASTE GENERATED IN THE RNTCP LABORATORY (DOTS
CENTRE)
Sputum cups and broom sticks : The use of cups made from biodegradable poly propylene
poyethylene will be encouraged. The lids will be removed from used cups. Then the cups and
lids will be placed in the disinfectant 5% Phenol provided by the RNTPCP or hypochlorite solution
overnight. The broom sticks will be placed in the separate container having similar disinfectant.
Next the cups, lids and broomsticks will be autoclaved provided to the RNTTCP Centre. The
autoclaved cups and lids will be sent for shredding and further disposal in blue bags. The
chemically disinfected and autoclaved broomsticks can be disposed of as general waste. The
left over fluid after chemical disinfection will be drained in hospital drainage.
Used slides: The slides will be disinfected by immersion in 5% Phenol for a minimum of 30
minutes. After that it is disposed of with other hospital sharps. Breaking of slides is not
recommended. The used chemical solution will be drained away in the hospital drain.
WASTE FROM RADIOLOGY :
The fixer and developer and contained and then sold periodically to Govt. authorized vendor
for recycling.
DISPOSAL OF RADIOACTIVE WASTE
The department of radiotherapy is not generating Radio-Active waste for disposal. The department
uses sealed sources. The depleted sources are sent back to BARC by the Authorized Agents
of equipment concerned.
DISPOSAL OF RADIOISOTOPE/NUCLEAR WASTE
1.

The hospital is authorized by the competent authority, i.e. Atomic Energy Regulatory
Board of India, Mumbai 400094 vides letter no. AERB/RSD/RIA-Auth/DL-07/2009/
3166 dated March 17, 2009.

2.

At present we are using RIA / IRMA kits which contain radioactive 125-lodine. The
above authorization is for the procurement and use of the radioactive material in our
department. It also specifies the numbers of kits which we can use per months.

3.

After use, the radioactive material is disposed into the sewerage system in the
hospital. The quantity disposed by per day is much less than the maximum limit
on total discharge per day.

E-WASTE :
Electronic WasteSome called E-Waste. A term loosely applied to consumer and business
electronic equipment that is near or at the end of its useful life. It includes, computers, computer

27

peripherals, telephones, answering machines, radios, stereo equipment, tape players/recorders,

phonographs, video cassette players/recorders, compact disc players/recorders, calculators, and
some appliances. Certain components of some electronic products contain materials that render
them hazardous, depending on their condition and density. Nonfunctioning CRTs (cathode ray
tubes) from television and monitors are considered as hazardous. Therefore, nonfunctioning
CRTs from television and monitors are banned from the trash. All electronic waste will be
contained in the area of use. E-waste recyclers authorized by Central Pollution Control Board
will be contacted for collection and final disposal of E-waste.
As per guidelines issued by DGHs, a clause for Buy back policy may be included at the time
of tendering for purchase of electronic Equipment for minimization of E-waste.
EFFLUENT TREATMENT PLANT :
The design and operation of wastewater treatment system for hospital is a. These liquid
effluents, directly rejected in the network drainage of laboratories, and other clinical areas of
the hospital, can contribute under certain physico-chemical conditions to the presence of the
virus in the urban sewer network and in the wastewater treatment plant. Hospital wastewater
reveals the presence of molecules chlorinated in high concentrations and in a punctual way the
presence of heavy metals such as mercury and sliver. DPCC has issued notice that 500 or
more bedded hospitals should install the ETP in their hospitals. ETP of Safdarjang Hospital is
under process and is likely to be functional shortly.
6. SAFETY ISSUES AND OTHER PROTOCOLS
PPE & VACCINATION OF THE HEALTH CARE WORKERS:
All waste handlers have been provided with Masks, Caps, Gum Boots, Gloves, and Disposable
apron which they are expected to wear while dealing with the waste. All health care workers are
vaccinated against Hepatitis B and tetanus.
DEALING WITH SPILLAGE :
Liquid spill management :
For small volume spills:

Cover spills of infected or potentially infected material on the floor with paper towel/
blotting paper/news paper. Pour 5% Phenol or freshly prepared 5% hypochlorite
solution.

Leave for 30 minutes for contact

Then it wipe with gauze or cloth with gloved hands.

The gauze or cloth used to wipe is to be considered as noninfectious waste and

discarded in general waste.

For large volume spills:

Wear gloves.

Mop with absorbent cotton/gauze and discard it to infectious waste bin

Cover spills of infected or potentially infected material on the floor with paper towel/
blotting paper/news paper. Pour 5% Phenol or freshly prepared 5% hypochlorite
solution.

Allow it for 30 min contact period.

Wipe thoroughly with gloved hands using cotton or gauze and treat the gauze as soon
infectious waste and dispose accordingly.

NB : Any material treated wit hypo-chlorite solution should never be sent for incineration

28

MERCURY SPILL MANAGEMENT :

If accidental spill of mercury occurs it is to be collected in a special manner as follows :

Spilled mercury should be collected with a mercury spill kit- containing nitrile gloves,
N-95 face mask, 2 pieces of cardboards, 2 plastic containers, cello tape, and
flashlight.

Do not touch mercury.

Remove all jewelry, wear gloves, masks.

Use flashlight to locate and cardboards to bring mercury beads together.

Collect with an eyedropper of a syringe and carefully place it or contain in a bottle

containing water.

Any remaining beads of mercury should be picked up with a sticky tape and place
in the plastic bag, properly labeled.

The bottle should be sealed with a tape, labeled as hazardous waste and securely
stored inside another plastic container; awaiting final disposal to Govt. nominated or
authorized mercury dealers.

After mercury has been recovered the spill area should be covered with calcium
sulfide or sodium thiosulfate to neutralize it.

Reporting formats will be used to report and register any mercury spills/leakages.

SHARPS INJURY MANAGEMENT

The commonest cause of injury while handling the waste is inappropriate segregation wherein
sharp waste is deposited in containers meant for non sharp waste. When sharp injury occurs
following procedures is to be followed.
(i)

Stop the procedure immediately and wash the wound with soap and water, encourage
bleeding the apply antiseptic.

(ii)

Immediately report to Nodal officer in Casualty for First aid and emergency
treatment or any other action and follow-up advice, if required. PEP is provided is
casualty round the clock as per MOHFW guidelines.

(iii)

Retention, if possible of the item and details of its source for identification of
possible infection.

(iv)

Investigation, determination and implementation of remedial measures.

(v)

Recording of Sharp injury: Needle Sticks/ Sharp injury should be recorded as per
the Performa provided by BMW Guidelines. (Annexure I). This Performa is available
in casually.

Training needs of different categories of persons are identified and training is provided
regularly, as well as informally onsite during inspection or supervisory rounds. The objectives
of training are to increase awareness, improve practices, change attitudes and monitor the
system.
INDUCTION TRAINING OF THE NEWLY RECRUITED STAFF:
Induction Training is provided to each of the fresh new employee, involved in patient-care
service in the hospitals, whether a Doctor, a Nurse a Technician or a Group D staff. It is a
pre-requisite for the release of first salary.
REFRESHER TRAINING OF ALL THE STAFF MEMBERS OF VMMC & SJH:
A regular training of the staff CMEs, Workshops, are the essential part to maintain the Hospital
Waste Management (HWM) at the best. It is necessary to conduct the regular refresher training
of all the staff members of the hospital. The Department of HWM organizes Regular Training,
every month and it has become a permanent feature. A training calender for all categories
of staffs of the hospitals has been prepared.

29

8. MONITORING AND SUPERVISION

A Monitoring Team which includes Nodal officers, Nursing Sisters, Technicians and Sanitation
staff is responsible for supervision of segregation practices in the specific area, allocated to
them. The Nursing Sister in charge of the area is expected is take a round of the area everyday
and record the findings in the observations Daily observation Performa attached herewith
(Annexure II). This Performa is displayed/available in each clinical area. The DNS of each zone
ensure proper compliance of Daily monitoring of waste management practices in the clinical
areas by the ANS/Nursing Sister.
The technicians of Laboratories and O Ts will be responsible, for the are of their work
Any adversity should be reported to are Nodal Officer, who will take appropriate action and if
required intimate the same to the higher authorities. The Area Nodal officers will take periodic
round of their area, record using Monitoring Performa (Annexure III) and address any issues.
They may also take appropriate action, and inform the respective HODs, and HWM Committee.
All the Sanitary Inspectors as well as Health Inspectors will be responsible for the waste
management practices in the area already allocated to them for supervision of sanitation.
Regular rounds are taken by CMO, Nodal Officer of HWM. The observation reports of the
findings are sent to the respective HOD for remedial action through Medical Superintended.
Surprise rounds are also being taken by Addl. MS & MS from time to time in the patient care
areas. The random checking of the waste receipts, bags for segregation of waste are being
done at the waste storage site, as a part of audit and any deficiencies / observation are sent
to the HOD for remedial action.
9. FUTURE PROPOSALS :
BACK-UP EQUIPMENT FOR TREATMENT OF WASTE:
-

Backup for Microwave and shredder to be procured..

Alternative options of Encapsulation/outsourcing for disposal of metallic sharps, so

as to discontinue making any more pits or outsourcing for disposal of metallic
sharps

Autoclave/Hydroclave

Installation of ETP

OUTSOURCING OF WASTE

SHARPS INJURY (NEEDLE STICK INJURY)

A specific protocol for prevention of risks of Hepatitis B to HCW of our hospital due to Sharps
injury (NSI) is being worked out.
PATIENT AND ATTENDANT EDUCATION AND AWARENESS :
At the time of admission to hospital a briefing regarding the segregation policy of the hospital
should be given by the Staff nurses and the same is reinforced everyday. Al leaflet of Dos
& Donts will be prepared and given to all attendants of patients at the time of admission.
PUBLIC AWARENESS/IEC ACTIVITIES :
In order to involve the public and seek co-operation, it is essential to generate awareness by
all possible means. This can be achieved through IEC activities. This would help to keep the
hospital clean. Public redress system of the hospital can also be used to propagate the same
message.
Posters in the working clinical areas to serve as reminders of segregation protocols will be
prepared, and distributed in the whole to be displayed at the prominent points.

30

FUTURE PROPOSAL FOR DISPOSAL OF RADIOSOTOPE/NUCLEAR WASTE

The immediate plan is to construct two separate tanks for liquid radioactive waste
material. First one is filled and then sealed for a period of 10 half life of the radioactive
material put into it. During this period the radio active waste is stored is second tank.
By the second tank becomes full, the first completes 10 half lives and comes to the
level of background radioactivity. This waste is discarded safely in sewer system.
This becomes a continuous process.

COMPOSTING OF KITCHEN AND HORTICULTURE WASTE :

It is proposed to generate manure by composting waste from kitchen, horticulture and disinfected
discarded blood. Four pits for the same can be made in identified areas. For fifteen days the
waste can be put in one pit, in the second pit for the next 15 days and so on. It Composting
generally takes 45-60 days, and the manure is ready.
BIOFUEL, BIOGAS (BIO-CNG, BIO-PNG) and manure production from General wet/kitchen
waste, using BARC developed Technology may also be considered if feasible.

As & when a new, heavy duty shredding machine is produced by the hospital or outsourcing
is decided, instead of four only 2 blue plastic bags will be used for segregation of plastic
waste, one for infectious plastic and 2nd for non-infectious plastic. The current shredders do
not take up mixed plastic items for shredding.
10. ABBREVIATIONS AND GLOSSARY OF TERMS:
ANS

Assistant Nursing Superintendent

APCD

Air Pollution Control Device

BMW

Bio-medical Waste

Cat.

Category

CME

Continuing Medical Education

CMO

Chief Medical Board

CPCB

Central Pollution Control Board

DMS

Deputy Medical Superintendent

DNS

Deputy Nursing Superintendent

DPCC

Delhi Pollution Control Committee

HCF(s)

Health-care facility (facilities)

HCW

Health-Care Waste. HCW is made up of HCRW and HCGW.

HCW

Health Care Worker

HCWM

Health-care Waste Management

HIV

Human Immunodeficiency Virus

HOD

Head of the Department

HWM

Hospital Waste management

MS

Medical superintendent

OPDs

Out Patient Department

PPE

Personal Protective Equipment

RNTCP

Revised National Tuberculosis Control Programme

Air pollution

The presence of a material or substance in the air which may be

harmful to either the natural or human environment, which includes
nay material present in sufficient concentrations for a sufficient
time, and a number of circumstance, to interfere significantly with
the comfort, health or welfare of persons or with the full use and
enjoyment of property.

31

Anatomic waste

Consisting of recognizable body parts

Biomedical and

solid or liquid waste arising form health-care (medical) activities

health-care waste

such as diagnosis, monitoring, treatment, prevention of disease or

alleviation of handicap in human or animals, including related research,
performed under the supervision of a medical practitioner or veterinary
surgeon or another person authorized by virtue of this professional
qualifications

Chemical waste

Consisting of/or containing chemical substances.

Collection

the act of removing accumulated containerized solid waste from the

generating source. Private collection of solid and liquid waste by
individuals or companies from residential, commercial, health facility
or industrial premises. The arrangements for the service are made
directly between the owner or occupier of the premises and the
collector

Container

vessel in which waste is placed for handling, transportation. storage

and/or eventual disposal. The waste container is a component of the
waste package.

Decontamination

the process of reducing or eliminating the presence of harmful

substances such as infectious agents so as to reduce the likelihood
of disease transmission from those substances

Disinfectant

chemical agent that is able to reduce the viability of micro-organisms

Disposal

Intentional burial, deposit, discharge, dumping, placing or release of

nay waste material into or on any air, land or water.

Exposure

the amount of radiation or pollutant present in a particular environment

(i.e. human, natural) which represent a potential health threat to the
living organisms in that environment

Cytotoxic waste

cytotoxic/Genotoxic waste is highly hazardous and may have

mutagenic, terato-genic, or carcinogenic properties. It raises serious
safety problems, both inside hospitals and after disposal, and
should be given special attention. Genotoxic waste may include
certain cytostatic (antineoplastic) drugs. These powerful drugs have
specific destructive action on action cells (often used in chemotherapy
of cancer).

HIV/AIDS

HIV (Human Immuno-deficiency Virus) is the virus that causes

AIDS (Acquired Immune Deficiency Syndrome). Over time, infection
with HIV can weaken the immune system to the point that the
system has difficulty fighting off certain infections that in turn can
lead to death.

Incineration

discarded materials from health-care activities on humans or animals

which have the potential of transmitting infectious agents to humans.
These include discarded materials or equipment form the diagnosis,
treatment and prevention of disease, assessment of health status
or identification purposes, that have been in contact with blood and
its derivatives, tissues, tissue fluids, or wastes from infection
isolation wards.

Infectious health-

exposure to radiation of wavelengths shorter than those of visible

light (gamma, x-ray or ultraviolet) for medical purpose, the destruction
of bacteria in milk or other foodstuffs or initiation of polymerization
of monomers or vulcanization of rubber.

Irradiation

the application of activities such as waste reduction, reuse and

recycling care waste to minimize the amount of waste that requires
disposal.

32

Minimization (of
waste)

Periodic or continuous surveillance or testing to determine the level

of compliance with statutory requirements and/or pollutant levels in
various media or in humans, animals and other living things.

Monitoring

a clinical and related waste treatment, storage or disposal facility

that is located on the generating site

On-site facility

consisting of/or containing pharmaceuticals

Pharmaceutical

consists of containers (full or empty) with pressurized liquid, gas or

powdered materials.

Pressurized

material contaminated with a radioisotope which arises from the

medical

containers

or research use of radionuclides. It may be in a solid, liquid or

gaseous form

Radioactive waste

a term embracing the recovery and reuse of scrape or waste

material for manufacturing or other purposes.

Recycling

Probability that a hazard will cause harm and the severity of that
harm

Risk

characterized by the controlled and organized deposit of wastes

which is then covered regularly (daily) by the staff present on site.
Appropriate engineering preparations of the site and a favorable
geological setting (providing an insolation of wastes from the
environment) are required

Sanitary landfill

the control of all the factors in the physical environment that

exercise or can exercise a deleterious effect on human physical
development, health and survival.

Segregation

sharps are a subcategory of infectious health-care waste and

include objects that are sharp and can cause injuries

Sharps

a process used to reach a state of free of viable micro-organisms.

Note that in a sterilization process, the nature of microbiological
death or reduction is described by an experiment function. Therefor,
the number of micro-organisms that survive a sterillization process
can be expressed in terms of probability. While the probability may
be reduced to a very low number, it can never be reduced to zero.

Sterllization

the placement of waste isolation, environment and health protection

and human control (e.g. monitoring for radioactivity, limitation of
access) are provided. This is done with the intention that the waste
will be subsequently retrieved for treatment and conditioning and/
or disposal (or clearance of radioactive waste)

Storage

any method, technique or process for altering the biological, chemical

or physical characteristics or waste to reduce the hazards it presents
and facilitate, or reduce the costs of, disposal. The basic treatment
objective include volume reduction, disinfection, neutralization or
other change of composition to reduce hazards, including removal
or radionuclides from radioactive waste

Waste management all the activities-administrative and operational - involved in the

handling, treatment, conditioning, storage, transportation and disposal
of waste

33

11. ANNEXURES :
Recording of Sharp Injury:
Needle Stick/Sharp injury should be recorded as per the following protocol.
Needle Stick/Sharp Injury Protocol
Name of H.V.W.

Section of H.C.W.

Employment No.

History of Injury
Date of Needle Stick/ Sharp Injury

Date of Reporting To Casualty

Site & Depth of Injury

Nature of Injury: Needle Prick/ Sharp Cut/ Laceration/ Splash of Fluids/ Splattered Glass
History of Hepatitis B Immunization:
Date : Intradermal/ Intramuscular
Anti HBs Titer (Date of Test)
HBsAg

Yes/No

HIV

Yes/No

Action Taken in Casualty

Hep. B. Vaccination
HBsAg

Yes/No

HBsAg

Yes/No

Tetanus Toxoid

Yes/No.

Source of injury (if available)

Serum sent for : (report to be entered in follow: up visit)
HIV
HbsAg

34

PERFORMA OF BIOMEDICAL WASTE MANAGEMENT

SAFDARJUNG HOSPITAL, NEW DELHI - 110029
Ward No.
Date

MONTH :
Working

Sharp

Proper segregation in

Hypochlor

Any

Signa-

condition

Cont

different bags

Ite.

Remar

ture of

of the

ainer

solution

ks

ANS

Needle

Yellow

Blue

Destroyer

Black

Nursing
Sister

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.

35

Annexure : III
OFFICE OF THE PRINCIPAL & MEDICAL SUPERINTENDENT
VMMC & SAFDARJUNG HOSPITAL NEW DELHI - 110029
No. CMO (HWM)/Inspetion/200

Dated :

MONITORING/ROUND RECORD
During various inspections conducted in your __________________________________ on
_______________________ following deficiencies as regard the implementation of Bio Medical
Waste Management and handling Rules 1998, were found.
1.
2.
3.
4.
Sister-In-charge is directed to take effective steps immediately to correct.

(Area Nodal officer/Chief Medical Officer)

Hospital Waste Management
Copy to :
1. Head of Dept. for necessary action
2. DNS/ANS
3. Copy for information to Addl Medical Superintendent

36

ANNEXURE-2

PROTOCOL FOR MANAGEMENT OF

SHARPS/NEEDLESTICK INJURY/
BLOOD BODY
FLUID EXPOSURE.

Dept. of Machine & Dept. of Hospital Waste Management

Safdarjung Hospital
New Delhi

37

ANNEXURE-I (PERFORMA)
RECORD OF SHARPS/NEEDLE STICK INJURY/BLOOD, BODY FLUID EXPOSURE
Name of HCW:
Department:

Age:

Sex : M/F

Category of HCW:

Regd.no. :

HISTORY OF INJURY:
Date of Injury

Date of reporting to casualty:

How the injury was sustained (while performing which procedure)

_______________________________________________________________________________
Nature and source of injury : Needle prick/ Sharp cut/Laceration/Splash of Fluids
Hepatitis B Immunization status of HCW & source :
Exposed HCW

Source

Vaccinated Yes/No:

Unknown/unavailable for testing

Incompletely vaccinated1:

Unknown/but available for testing

Unvaccinated:

Known HBsAg- Positive

Previous H/O infection with HB2

Known HBsAg-Negative

HIV status of Source : Negative/Positive/Unknown

Action taken in Casualty :
1. Help.B vaccination initiated : Yes/No.
2. HBIG : Yes/No

If yes, indication:

3. TT:

4. Anti Retro Treatment

5. Any other

Investigation advised to HCW in Casualty :

Haemogram, LFT, KFT, HBsAg, HIV(if consent is given).
Refer to ART clinic, R.no.557 for all above investigations and further follow-up.
Investigation of source patient, if available:
HIV
HBsAG
Remarks if any.
Signatue of CMO/Nodal Officer on duty (Casualty)
1.

Received only 1 or 2 doses of Hep.B vaccine

2.

Persons who have previously been infected with HB are immune to reinfection and do
not require postexposure prophylaxis

Dept. of Medicine & Dept. of Hosp. Waste Management, SJH.

38

ANNEXURE-II
RECOMMENDED POSTEXPOSURE PROPHYLAXIS FOR EXPOSURE TO HEPATITIS B VIRUS
Vaccination
status of exposed
workers

TREATMENT

TREATMENT

TREATMENT

Source
Hbs Ag Positive

Source
HBsAg
negative

Source 2
Unknown or not
available for

HBIG x 1 and

Initiate HB

Initiate HB

initiate HB vaccine

vaccine

vaccine

series

series

No treatment

No treatment

No treatment

HBIG + 1 dose of

No treatment

1 dose of HB

testing
1. Unvaccinated

2. Previously
vaccinated
Serum anti-body
titre known > body
miu
Serum anti-body
titre unknown or

Hep.B

vaccine

< 10 miu
3. Incomplete

HBIG +

Initiate

Initiate

vaccination 1

vaccination

vaccination

vaccination

Received only 1 or 2 doses of Hepatitis B vaccine

If source High risk treat as HbsAG positive.

* Persons who wave previously been infected with HBV are immune to reinfection and do
not require postexposure prophylaxis
* HBsAg-Hepatitis B surface antigen
* HBIG- Hepatitis B immune globulin; dose 0.06 ml/kg intramuscularly.
RECOMMENDED POSTEXPOSURE PROPHYLAXIS FOR EXPOSURE TO HIV
(Emergency dose to be given in Casualty)
-

Tablet Zidovudine 300mg + Lamivudine 150 mg.(Duovir) 1 Tab. BD

+

Tablet. Indinavir 800mg. 1 Tab.BD

Please see attached annexure III and copy of NACO Guildelines for Post Exposure
Prophylaxis for Occupational Exposure(PEP) to HIV/AIDS(Annexure IV)
Dep. of Medicine & Dept. of Hosp. Waste Management, SJH

39

ANNEXURE-III

THREE STEPS TO HIV POST-EXPOSURE PROPHYLAXIS (PEP)

AFTER OCCUPATIONAL EXPOSURE
Step-I : Determine the exposure code (EC)

Is source material blood bloody fuid, semen/vaginal fuild or

other normally sterile fluid or tissue ?

Yes

No PEP
Required

No

What type of
exposure occurred ?

Mucous members or skin

integrity compromised
(e.g. Dermatitis, open
would)

Percutaneouse exposure :
Severity

Intack Skin

No PEP

Severity

Volume

Small :
Few Drops

EC 1

Less severe :
Solid needle,
scratch

Large : Major
splash & / or
long duration

EC 2

EC 2

Of source

40

More severe : Large

bore hollow needle
deep puncture,
visible blood, needle
used in blood vessel

EC 3

Step-II : Determine the HIV STATUS Code (HIV SC)

What is the HIV status of the exposure source ?

HIV Negative

HIV Positive

Status unknown

No PEP

Low titre exposure :

Asymptomatic and
High CD4 count

High titre exposure :

Advanced AIDS,
primary HIV, high
viral load or low CD4

HIV SC

HIV SC

Status unknown

HIV SC
unkonown

Step 3 : Determine Post-Exposure Prophylaxis(PEP) Recommendation

EC

HIV SC

PEP

Consider basic

Recommend basic regimen

Recommend expanded regimen

1 or 2

Recommend expanded regimen

1,2,3,

Unknown

If exposure setting suggests risks of HIV

Exposure, consider basic regimen

Basic Regimen : Zidovucine (AZT)-600 in divided doses (300 mg) twice a day or 200 mg (thrice
a day) for 4 weeks + Lamiondine (3TC)- 150 mg twice a day for 4 weeks.
Expanded Regimen : Basic regimen + Indinavir-800 mg thrice a day. or any other protease
inhibitor.
Pregnancy and PEP
Based on limited information, anti retroviral therapy taken during 2nd and 3rd trimester of
pregnancy has not caused serious side effects in mother and infants. There is very little
information on the safety in the 1sr trimester. If the HCW is pregnant a time of exposure to
HIV, the designated authority or physician must be consulted about the use of the drugs and
PEP.

Dept. of Medicine & Dept. of Hesp. Waste Management, SJH

41