Roles and Responsibilities
A. Infection Surveillance
- Conduct surveillance for healthcare-associated infections, including:
- Catheter-associated urinary tract infection (CAUTI).
- Central line-associated bloodstream infection (CLABSI).
- Ventilator-associated pneumonia (VAP).
- Surgical site infection (SSI).
- Collect, validate, analyse and maintain infection surveillance data.
- Monitor infection rates per 1,000 device-days and surgical site infection rates using approved definitions.
- Identify infection trends, clusters and potential outbreaks.
- Prepare monthly, quarterly and annual infection control reports.
B. Hand Hygiene Monitoring
- Conduct regular hand hygiene audits in all clinical and patient-care areas.
- Monitor compliance with the WHO Five Moments for Hand Hygiene.
- Ensure availability of alcohol-based hand rub, soap and handwashing facilities.
- Provide feedback to staff and arrange corrective training where compliance is low.
C. Isolation and Transmission-Based Precautions
- Ensure appropriate isolation of patients with suspected or confirmed transmissible infections.
- Monitor implementation of contact, droplet and airborne precautions.
- Check availability and correct use of personal protective equipment (PPE).
- Educate staff, patients and attendants regarding isolation precautions.
D. Infection Control Audits
- Conduct scheduled and surprise rounds in:
- Intensive Care Units (ICUs).
- Operation theatres and recovery rooms.
- Emergency and inpatient wards.
- Dialysis units and procedure rooms.
- Labour room and neonatal care units.
- CSSD, laboratory, laundry and housekeeping areas.
- Audit hand hygiene, aseptic techniques, biomedical waste segregation, environmental cleaning and device-care practices.
- Document non-compliance and follow up on corrective and preventive actions (CAPA).
E. Staff Training and Education
- Conduct induction training for newly recruited employees.
- Provide regular training on hand hygiene, PPE, standard precautions, isolation, needle-stick injury prevention and biomedical waste management.
- Maintain attendance sheets, training records and competency assessments.
- Conduct awareness programmes for doctors, nurses, housekeeping staff, technicians and other healthcare workers.
F. Biomedical Waste Management
- Monitor segregation of biomedical waste at the point of generation.
- Check colour-coded bins, bags, labels, barcoding and waste transportation practices according to applicable rules.
- Ensure appropriate handling of sharps and contaminated materials.
- Coordinate with the biomedical waste management team and authorised waste disposal agency.
- Report incidents and arrange corrective action.
G. Sterilization and Disinfection
- Monitor cleaning, disinfection and sterilization practices in patient-care areas.
- Audit CSSD processes, including instrument cleaning, packaging, sterilization cycles and traceability.
- Review chemical and biological indicator records according to policy.
- Monitor high-level disinfection of reusable medical devices where applicable.
- Coordinate with CSSD and concerned departments to investigate sterilization failures.
H. Needle-Stick Injury and Occupational Exposure
- Ensure immediate reporting and documentation of needle-stick injuries and blood/body-fluid exposures.
- Facilitate prompt risk assessment and referral for post-exposure management according to hospital protocol.
- Monitor follow-up and maintain confidential records.
- Investigate contributing factors and recommend preventive measures.
I. Outbreak Investigation
- Immediately report suspected outbreaks or unusual infection clusters to the designated authority.
- Assist with case identification, line listing, specimen coordination and epidemiological investigation.
- Implement additional precautions as directed by the outbreak response team.
- Monitor compliance with control measures and document the investigation.
J. Documentation and Quality Compliance
- Maintain the following records:
- Infection surveillance registers and databases.
- Hand hygiene and infection control audit reports.
- Isolation and outbreak records.
- Staff training and competency records.
- Needle-stick injury and exposure records.
- CSSD and environmental cleaning audit reports.
- CAPA records and infection control committee minutes.
- Support NABH assessments, internal audits, quality indicators and accreditation-related documentation.
- Review and update IPC policies, SOPs and checklists with the authorised team.