A competent and active infection control committee is an essential component of the infection prevention and control program by authorizing and directing the activities of the Infection Control Team, communicating policy, surveillance, monitoring, educational and problem resolution issues and information to all the clinical and non-clinical departments, and acting as liaison between the management and departmental heads.
Table of Contents
- 1 Scope
- 2 Constitution of committee
- 3 Quorum
- 4 Frequency of meeting
- 5 Selection of members
- 6 Responsibilities
- 7 Role of Chairperson
- 8 Agenda
- 9 Minutes
- 10 Decision making
- 11 Infection control team
- 12 Composition of infection control team
- 13 Who should be trained for the purpose?
- 14 Functions of infection control team
- 15 Records to be maintained
Applicable to all the polciie and procedures coming under infection control protocols and polcies
Constitution of committee
As per guidelines, an infection control committee is a multidisciplinary committee, which is composed of members from all departments.
- Consultant Microbiologist Infection Control Officer
- Infection Control Nurse (Secretary)
- Intensivist (Chairperson)
- Surgical Oncologist
- IC chapter Champion
- Nursing Head
- Deputy Nursing Manager
- OT Manager
- Quality Manager
- Clinical Assistant
- Executive Medical Services
- Housekeeping in charge
- CSSD Incharge
- Canteen Head
- Maintenance Incharge
- Invitees based on agenda point – Dietician / Canteen In-charge, QI Team Member, Bio Medical Eng.
The chairman shall have the authority to invite any non member to attend the meeting, if it is deemed fit in relation to any matter being/ or to be deliberated by the committee.
The minimum quorum for passing any resolution in the committee should be 50% of the members present in the committee with chairperson being mandatory.
Frequency of meeting
Members of the committee meet once in two months.
Selection of members
- Chairperson Selected by the chairman of Apex Committee
- Secretary Selected by the chair person, he or she is also a member of the committee
- Members Selected by the chair person
- Identification of hazards and high risk area and to prepare surveillance programme to minimize the risk of infection to patients, staff and visitors
- To develop a structure for identifying, reporting, analyzing, investigating and controlling hospital acquired infections.
- To develop and implement preventive and corrective programmes in specific situations where infection hazards exist.
- Define nosocomial infections for surveillance purposes; to establish the criteria for early identification and reporting of HAI, minimize the risk of infection to patients, staff and visitors, to determine the prevalence rates of defined infections
- To review and approve a yearly programme of activity for surveillance and prevention;
- To review epidemiological surveillance data and identify areas for intervention
- To develop written policies defining the specific indications for patient isolation requirements.
- The committee reviews infection surveillance data, infection risks, recommends policies to appropriate medical staff committees, hospital administration, and hospital personnel.
- The committee develops, recommends, reviews and updates policies from time to time.
- Departmental heads or representatives have line responsibility for implementation of policies
- Ensure that facilities are available to the hospital personnel to maintain good infection control practices.
- Establish Standards for the procedures or systems used for identifying the infectious organisms within the hospital.
- Maintain an ongoing educational programme for all hospital personnel in the use of such standards.
- Establish objectives for the hospital in areas of Infection control measures by identifying problems and framing time bound action plan.
- Monitor health of health care providers and others working in the hospital in collaboration with the Infection control committee, to prevent spread of infections from them to patients.
- Monitor the rational use of antibiotics.
- Monitor the use of disinfectants, sterilization practices and cleaning practices etc.
Role of Chairperson
- Acts as a liaison between the hospital infection control committee members and the hospital administration.
- Receives all the safety audit reports and information pertaining to hospital infection control, initiate necessary action based on the reports.
- Initiate surveillance programmes in the hospital.
- Keep oneself abreast with the recent developments in the field.
- Role of secretary (Member Secretary)
- Prepare the agenda for the next meeting
- Submission for approval of agenda by the chairperson
- Inform the committee members regarding the next meeting at least 2 days before the meeting
- The minutes of meeting shall be prepared by the secretary
- Get the approval of minutes by the chairperson
- Circulate the agenda approved by the chair person to the members and the concerned persons
- To maintain all records ( as per list) related to the committee
- Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting signature from all the concerned members
- Agendas for the meeting shall be prepared by the secretary in consultation with the chair person and signed by the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2 days before the scheduled meeting.
- A meeting shall be called even by an oral / telephone communication in case of an emergency meeting. A justification for the emergency meeting has to be given.
- Shall be prepared by secretary
- MoM is send to the chairperson for the approval within three days of the meeting
- After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the meeting to all the committee members and the person concerned for implementation
- A copy of the agenda and minutes of every meeting shall be sent to the quality manager by the member secretary
A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed and based on the outcome of it the committee will decide on that issue.
The decision of the committee will be finally taken by a majority vote and that shall be implemented.
Infection control team
The policies and procedures put forward by the Infection Control Committee are implemented by the Infection Control Team. The infection control team is responsible for the day-to-day activities of the infection control programme.
Composition of infection control team
- Infection Control Officer
- Infection Control Nurses
Who should be trained for the purpose?
- To carry out the surveillance programme
- To disseminate infection control policies
- To Monitor and manage critical incidents
- To Coordinate and conduct training activities.
Functions of infection control team
- To provide an Infection Control Manual at each essential area of hospital.
- To maintain Surveillance over hospital acquired infections.
- To analyze interpret and disseminate data arising out of surveillance and reporting to recommend remedial measures and to ensure follow up action.
- To assess, monitor and conducts Infection control round at all levels of the health facility with help of common & area specific checklist and to promote improved practice which helps to maintain a safe environment for patients and staff.
- To establish the ongoing evaluation and review of all aseptic, isolation, and sanitation techniques employed in the hospital. Such techniques shall be defined in written policies and procedures.
- To ensure the proper conduct of sterilization and disinfection practices and to ensure that the, central services, housekeeping, laundry, engineering and maintenance, food sanitation, and waste management are in conformity with the hospital infection control policies. The necessary procedures shall be evaluated to revise periodically.
- To act upon recommendations related to infection control, received from the administration departments, services and other hospital committees.
- To maintain log registers/ sheet of infected patients, causes of infections, type of organisms with culture details,
- To check, study and maintain log of the swab & report sent by various departments like O.T., ICU, etc.
- To implement preventive and corrective programme in specific situations where infection hazards exist.
- Protection of health care workers, e.g. Immunization;
- To monitor routine practices essential to infection control such as aseptic techniques, use of single use devices, reprocessing of instruments and equipment, antibiotic usage, management of blood/body fluid exposure, handling and use of blood and blood products, sound management of medical waste;
- To ensure provision of safety materials such as personal protective equipment and products
- Incident reporting and monitoring
- To investigate outbreaks of infection and take corrective measures.
- To guide the scope and content of the Employee health program.
- To identify the roles and responsibilities of key personnel involved in the prevention and control of infection
- To ensure that hospital infection control protocols are made aware to the employees concerning their own areas.
- To educate, train and promote health care workers for basic measures of infection control, i.e. Standard and additional precautions
- To help in the education and the orientation of all new employees as to the importance of infection control and the relevant policies and procedures.
- To conduct surprise checks to evaluate the implementation of the policies.
- To ensure and monitor adherence to Bio medical Waste Management
Records to be maintained
- List and details of all members
- The TOR of the committee
- Copy of all agendas, minutes of all meeting
- Attendance sheet
- Copy of any other correspondence to the committee members or non-members
- Copy of any study conducted for the sake of the committee