Introduction and Overview

Infection Control Training Course

By
Rehmat Ullah
Nursing Director, MTI KTH, Peshawar

MTI, Khyber Teaching Hospital, Peshawar

Overview/Introduction MTI KTH, Peshawar
A. History of Hospital
 A state-of-the-art tertiary care teaching Hospital located in
Peshawar, Pakistan
 formerly Hayat Shaheed Teaching Hospital, was
established in 1976 as a training and biomedical research
facility
 The present capacity of beds is 1300
 Khyber Medical College, the first medical school of the
province, came into existence in February, 1954
 Khyber College of Dentistry as department of Dentistry was
created in 1964
 School of Nursing Khyber Teaching Hospital also works as
an allied institution with KTH for training of student nurses
since inception of the institution

MTI, Khyber Teaching Hospital, Peshawar

 VISION

To become a role model & leader in

patient care, medical education,
research and community interaction.

MTI, Khyber Teaching Hospital, Peshawar

 Infection control Training

Infection control is important for safety of both

patients and the workers because infections
can:
Increase the Lengthen the stay for the patients

Increase the hospital cost/patient cost

Can cause more pain and suffering to the

patients and may even lead to death

Expose the workers to many germs that may

cause illness to them and their family if they get

infections from the hospital.
MTI, Khyber Teaching Hospital, Peshawar
 Goals & Objectives of the Program

 Assure that licensed, registered, or certified health

professionals understand how bloodborne
pathogens may be transmitted in the work
environment: patient to healthcare worker,
healthcare worker to patient, and patient to patient
 Apply current scientifically accepted infection
prevention and control principles as appropriate for
the specific work environment.
 Minimize opportunity for transmission of pathogens
to patients and healthcare workers.

MTI, Khyber Teaching Hospital, Peshawar

Course Structure

 is based on training contents created by Joint

Commission International (JCI) presents in-depth
knowledge through three comprehensive
modules
1. Module 1: Basic Science and Principles
2. Module 2: Applications in Care Settings
3. Module 3: Special Infection Prevention Issues,
Leadership, and Patient Safety

MTI, Khyber Teaching Hospital, Peshawar

Introduction to Course

 Duration Of Course
 There will be a minimum of 2.5 months.
 Stand Alone Modules
 Each module is offered as a Competence Certificate
Short Course.
 Evaluation
 The outcome will be evaluated by successfully
completing a written exam, practical work and clinical
projects.

MTI, Khyber Teaching Hospital, Peshawar

Presentation

Hours
Lectures 14 hours
Practical/Clinical work and monitoring 32 hours
04 Reflective writing on clinical learning 20 hours
Clinical writing 80 hours

MTI, Khyber Teaching Hospital, Peshawar

 INFECTION PREVENTION AND CONTROL
PROGRAM SCHEDULE 2019
Date & Day 0830 - 1030 Am 10:45 - 12: 00 12-1400
Thursday Characteristics and functions of an IPC program Basic Microbiology Concepts Patient Care Processes To Prevent Infections
25/07/2019 (Mr. Rehmat Ullah) (Mr. Noor Rehman) (AP. Dr. Asghar )

Thursday Epidemiology and Statistics for IPC Barrier Precautions and Isolation Methods of Cleaning, Disinfection, and
01/08/2019 (Mr. Hidayat Ullah/Mr. Rehmat Ullah ) (Mst. Nazia Gul/ Mr. Asmat Pasha) Sterilization
(Mr. Noor Rehman)
Thursday Infectious diseases and health care-associated infections Prevention of Infections Caused by Multi-resistant IPC Clinical Monitoring and Hand hygiene
08/08/2019 (HAIs) Organisms assessment
(AP. Dr. Hamza Ali Khan) (AP. Dr. Awais Naeem) (Facilities Visits)
(Mst. Nazia Gul, Mr. Asmat Pasha & Mst. Zuhra)

Thursday Patient care practices for preventing device- and Outbreak investigation methods and application HAIs in hospital, clinical, and support
22/08/2019 procedure-associated infections (Mr. Abbas/ Mr. Hidayat Ullah) services
(Mr. Asmat Pasha/ Mst. Uzma) (Facilities Visits)
(Mst. Nazia Gul, Mr. Asmat Pasha & Mst. Zuhra)

Thursday Environmental Infection Risks And Prevention IPC during facility construction & renovation Infection issues for specialty and ambulatory
29/08/2019 Strategies (Mr. Rehmat Ullah/ Mst. Nihayat Usman) settings
(Mr. Rehmat Ullah/ Mr. Asmat Pasha ) (Facilities Visits)
(Mst. Nazia Gul, Mr. Asmat Pasha & Mst. Zuhra)

Thursday Preparation for infectious disease emergencies and Sepsis Awareness and Education Infection prevention for selected hospital
05/09/2019 disasters Employee health and IPC services
(AP. Dr. Awais Naeem/ Mr. RehmatUllah) (Dr. Aleena Badshah) (Facilities Visits)
(Mst. Nazia Gul, Mr. Asmat Pasha & Mst. Zuhra)

Thursday Quality improvement methods and performance (Facilities Visits)

12/09/2019 measures & Advanced Leadership Strategies (Mst. Nazia Gul, Mr. Asmat Pasha & Mst. Zuhra)
(Mr. RehmatUllah)

Written Exam & Project Presentation

MTI, Khyber Teaching Hospital, Peshawar

The Reflective Writing

 The Gibbs reflective writing cycle shall be used for clinical practice reflection
 Description
 What Happened?
 Feelings
 What were you thinking and feeling?
 Evaluation
 What was good and bad about the experience?
 Analysis
 What sense can you make of the situation?
 Conclusion
 What else could you have done?
 Action Plan
 If it arose again what would you do?

MTI, Khyber Teaching Hospital, Peshawar

PROJECT GUIDELINES

 Participants are required to implement a project that brings about a

significant change in their organizations. They will be required to apply
the learning of concepts and knowledge from the Training Program they
went through.
 The project should have the following characteristics:
 Have a clear objective.
 Specify what the outputs should be and each output must be SMART
(specific, measurable, achievable, realistic and time bound).
 There must be at least two clear outputs.
 The approach to the change must be documented.
 Be a new project based on the learning from the training program and the
project must specify how the learning was applied in the project. The
project can be an existing project which has an expanded scope to bring
about a change expected from this assignment.

MTI, Khyber Teaching Hospital, Peshawar

Infection Control and Prevention Program in
MTI KTH, Peshawar

MTI, Khyber Teaching Hospital, Peshawar

 HOSPITAL INFECTION CONTROL
PROGRAM
 Infection Control is a core part of a healthcare
organisation’s (MTI-KTH) clinical governance and
patient safety programmes.

 SCOPE
 The scope of this program extends to all areas of the
MTI-KTH, Peshawar.

MTI, Khyber Teaching Hospital, Peshawar

 HOSPITAL INFECTION CONTROL
PROGRAM
 SCOPE
 The scope of this program extends to all areas of the MTI-
KTH, Peshawar.
 GOAL:
1. To prevent or minimize the potential for infections to patients
and family as well as to staff
2. To provide safety for patient, family and employee,
Surveillance of infection rates, outbreaks and implementation
of control measures
3. To Identify and rectification of flaws in infection control
practices
4. To ensure compliance with best practices and regulations in
infection control.

MTI, Khyber Teaching Hospital, Peshawar

 SPECIFIC OBJECTIVES OF
INFECTION CONTROL PROGRAM
 To develop written policies, procedures and standards for cleanliness, sanitation and
asepsis in the hospital.
 To interpret, uphold and implement the hospital infection control policies and procedures
in specific situations.
 To provide surveillance for different types of infections.
 To review and analyze infections, those occur, in order to take corrective steps.
 To develop preventive measures designed to control, prevent or minimize the risk of
nosocomial infections.
 To develop a mechanism to supervise infection control measures in all phases of
hospital activities.
 Review and update hospital infection control policies and procedures from time to time.
 Advice the Medical Director on matters related to the proper use of antibiotics, develop
antibiotic policies and recommend remedial measures when antibiotic resistant strains
are detected.
 Help to provide employee health education regarding matters related to HCAIs.

MTI, Khyber Teaching Hospital, Peshawar

OVERSIGHT AND RESPONSIBILITY
FOR INFECTION CONTROL
 The Medical Director (MD) is ultimately
responsible for the infection control program.
 The MD as chairman of clinical executive board
(CEB) delegates this function to chairman ICC and
Infection Control Committee.

MTI, Khyber Teaching Hospital, Peshawar

Infection Control Committee (ICC)
 an integral component of the patient safety programme of
the health care facility,
 is responsible for establishing and maintaining
infection prevention and control, its monitoring,
surveillance, reporting, research and education.
 This committee has been granted the authority to
implement any measures necessary to prevent and control
the spread of infection and to conduct any studies in this
connection.
 All departments will facilitate in the effective functioning of
this committee.
 The committee will report to the Clinical Executive Board,
quarterly.

MTI, Khyber Teaching Hospital, Peshawar

Structure of the committee
 Chairperson: Head of the Infection Disease
 Member: Senior Microbiologist/Pathologist
 Member: Head Anesthesia and OT/ Manager OT
 Member /Secretary. Infection Control Nurse
 Members: Representation from Management/
Administration (Deans, Medical Director Hospital
Director, Nursing Director)
 Relevant Medical Faculties
 Support Services: (OT/CSSD, Housekeeping/
Sanitation, Engineering, Pharmacologist, Store Officer
/ Materials Department)
MTI, Khyber Teaching Hospital, Peshawar
Infection Control Committee (ICC)

 MEETING SCHEDULE
 Once every quarters, or more as required by the
chairman ICC.
 REPORTING AND COORDINATION
 The ICC will submit meeting minutes to ICC members,
MD, HD & ND.
 The committee shall report and submit quarterly
Infection Control Report to the Medical Director as
Chairman CEB.

MTI, Khyber Teaching Hospital, Peshawar

Responsibilities of the Infection
Control Team
 Develop a manual of policies and procedures for
aseptic, isolation and antiseptic techniques
 Carry out targeted surveillance of HCAIs, data
analysis for presentation in ICC meeting and take
corrective steps
 Advise staff on all aspects of infection control and
maintain a safe environment for patients and staff
 Supervise and monitor cleanliness and hygienic
practices
 Oversee sterilization and disinfection and monitor the
use and quality control of disinfectants

MTI, Khyber Teaching Hospital, Peshawar

Responsibilities of the Infection
Control Team
 Advise management of at risk patients and supervision of
isolation procedures
 Investigate outbreaks of infection and take corrective measures
for control and prevention of outbreak
 Waste management
 Provide relevant information on infection problems to
management.
 Assist in training of all new employees as to the importance of
infection control and the relevant policies and procedures
 Organize regular training programme for the staff to ensure
implementation of infection control practices
 Audit infection control procedures and antimicrobial usage –
Monitors Health care workers safety Programme

MTI, Khyber Teaching Hospital, Peshawar

Infection Control Nurse
 Responsibility is delegated to the infection control
Nurse (ICN) to carry out daily functions of the
infection control program.
 These functions include data management, policy
and procedure development, education, employee
health coordination, quality improvement,
consulting and investigating potential out breaks.
 The ICN is administratively part of the nursing
department/ division and reports to the infection
control committee for professional oversight and
direction.
MTI, Khyber Teaching Hospital, Peshawar
NURSING PROCEDURE FOR INFECTION
CONTROL SERVICES

MTI, Khyber Teaching Hospital, Peshawar

1. EDUCATION OF HEALTHCARE WORKERS
2. VACCINATION
3. ENVIRONMENTAL TESTING
4. SURVEILLANCE ON HOSPITAL ACQUIRED
INFECTIONS
5. ISOLATION OF INFECTIOUS PATIENTS
6. HAND HYGIENE AUDIT
7. NEEDLE STICK INJURIES
8. COMMUNICATION
9. OTHER ACTIVITIES

MTI, Khyber Teaching Hospital, Peshawar

EDUCATION OF HEALTHCARE
WORKERS
 This refers to the process of education of all health
care workers (doctors, nurses, allied)
 New joiner’s orientation session
 Infection control workshop for nurses
 sessions as a part of other programme of nurses
 Need base session with other health care worker (CSSD, OR
& Endoscopy etc.)
 Dissemination of IC&P updates
 Unit based in- service sessions
 prevention and control strategies and trends sharing
 Educational records of session

MTI, Khyber Teaching Hospital, Peshawar

VACCINATION

 vaccination against Hepatitis B

 Typhoid vaccination
 Flu vaccinations

MTI, Khyber Teaching Hospital, Peshawar

ENVIRONMENTAL TESTING

 The process of checking hospital facilities like

food, drinking water and air culture sampling
testing to make sure that the environment, food
and drinking water is safe for consumers.

MTI, Khyber Teaching Hospital, Peshawar

SURVEILLANCE ON HOSPITAL
ACQUIRED INFECTIONS
 Identification of patients as per standard
definitions for;
 Ventilator Associated Pneumonia,
 Central Line Associated Blood Stream Infection,
 Cather Associate Urinary Tract Infections,
 Bed sore,
 Surgical Site infection in Critical Care Areas

MTI, Khyber Teaching Hospital, Peshawar

ISOLATION OF INFECTIOUS
PATIENTS
 This process refers to nurse the patient in
separate room who has contagious
disease/infections like C. Diff, MRSA, Scabies,
VRE, TB, Measles, Chicken pox and others which
may spread through contact, droplet and airborne
route

MTI, Khyber Teaching Hospital, Peshawar

HAND HYGIENE AUDIT

 Hand Hygiene facilities are checked by infection

control nurses and infection control link-liners.
 Data collection by all departmental link-liner and
infection control nurse/s
 Data is analyzed by ICN, presented in ICC, CEB,
NAB, & HQI session
 Report is forwarded to all concerned head of
departments by Infection Control Nurse/s’

MTI, Khyber Teaching Hospital, Peshawar

NEEDLE STICK INJURIES

 All health care workers who get a needle stick

injury must report
 After blood results Risk Assessment is being
carried out by ICN as:
 Review of Lab reports & consult with ID physician if
needed
 Recommends follow up if required
 Reports in ICC and all concerned departments.
 Infection Control keeps the record of all NSI

MTI, Khyber Teaching Hospital, Peshawar

COMMUNICATION

 The common used ways of communication are:

 E: mails across the facility through infection control team.
 Infection Control Committee meeting
 Clinical rounds and report by ICN/S’
 Infection Control updates are being shared Clinical Executive
Board Meeting by chairman of the committee and Nursing
Advisory Board Meeting by Infection Control Nurse
 In hospital operation committee meeting by Nurse Manager
Risk Management in the presence of all HODs’/designee.
 Department infection control link linear

MTI, Khyber Teaching Hospital, Peshawar

OTHER ACTIVITIES

 Participation in annual divisional/Departmental

audit.
 Monthly risk management and infection control
clinical round.
 Monthly infection control rounds of other high risk
areas (pharmacy, pathology, etc.).
 Participates for hospital facility round.
 Education of externals, if any.

MTI, Khyber Teaching Hospital, Peshawar

 THANKS

Questions

MTI, Khyber Teaching Hospital, Peshawar