Hospital 0481 2592001  
Casualty 2592475


In order to provide better and safer hospital practices for the patients and personnel in MCH Kottayam, we have a strong infection control team since December 2017. This team is functioning according to the of the National guidelines.


HICC Meeting

HICC has the Hospital superintendent as the chairman and HOD Microbiology as the member secretary. HICC meeting is conducted every 2 months and discussions are made regarding infection prevention and control practices, preventive and corrective actions taken in each areas and evaluating the outcomes timely.

Link Nurses System

For the implementation and monitoring of infection control practices,  link nurse from each areas are appointed . We are selected and trained nurses from all the areas of our institution. Along with senior nursing officers they carry out infection control activities in their respective areas. They do the surveillance activities, monitoring and communicate all the relevant information to the infection control team. Meeting of Link nurse and SNOs are conducting every month. Monthly reports are presenting and needed corrections were given.

Activities of infection control team includes:

    • Hand hygiene auditing: Hand hygiene was the area initially concentrated. We have given adequate training on hand hygiene to all categories of staffs. Posters of hand hygiene displayed in all areas. Availability of hand rub ensured in all areas. Software based hand hygiene auditing started in all ICUs from July 2019 onwards. 51 nurses from different ICUs were trained in doing software based hand hygiene auditing in coordination with our Microbiology department. It was discontinued from Covid pandemic period. Now we are doing paper based hand hygiene auditing.
    • Biomedical waste management: All categories of staffs were trained in BMWM in coordination with IMAGE. Updated posters of BMWM are displayed in all areas. Colors coded and bar coded bags are issued in all areas. Segregation at the point of origin has ensured with continuous supervision and training, there by mixing of waste is reduced now. Puncture proof containers were used for collecting sharps at initial stage. In order to provide puncture proof container in all areas of hospital, request is given and processed already. Now closed trolleys are used for transporting waste to the final segregation area. Centralized waste collection extended to all areas .Biomedical waste are kept separately and sent to KEIL within 24 hrs. Food waste is sending to our biogas plant and general waste to MCF.
    • Infection control Audit: Prepared a checklist with 50 checkpoints includes all standard precautions and it is conducted on monthly basis on all hospital areas and scoring will be done and will be presented in HICC and Link nurses meeting. The score between 80-100 will be in the Green Zone,60-80 yellow zone and <60 will be in the Red Zone
    • HCAI SURVEILLANCE: New bundle care forms are designed in 2019 and implemented in ICUs after giving adequate training to the staff. Bundle adherence rate and HCAI rates are calculated monthly and presented in Link nurse meeting and corrective measures taken accordingly.
    • ENVIRONMENTAL SURVEILLANCE: It is regularly done in Operation theatres and ICUs.
    • NEEDLE STICK INJURY REPORTING SYSTEM: Appropriate reporting and follow up of needle stick injury is ongoing based on the current policy.
    • MDRO Surveillance: Tracking all cases of MDROs done in coordination with Microbiology department and corrective and preventive actions were taken.
    • Water Quality Testing: Water quality testing of common water source and RO water plant
  3.   STERILE PRACTICES: Adequate training given to the staff nurses in IV therapy, Injection & infusion practices and other sterile practices by CNEU. Auxiliary staffs are also trained. Special procedure trays are designed for each area.
    • CSSD: Endure adequate supply of sterile items. Extra stock of sterile supplies kept there to meet any emergencies. The use of Cidex and Formaline chambers are now reduced by the increased days of ETO sterilization.
    • LAUNDRY: We are now concentrating on strengthening of laundry services.
    • Check lists: The checklists we are distributed and collecting data from different area are:
      • Cleaning check lists
        • OPD cleaning checklist
        • Toilet cleaning checklist
        • Ward cleaning schedule checklist
        • High touch surface cleaning checklist
        • Lift cleaning checklist
        • Equipment cleaning
      • Other check lists
        • Biomedical audit form
        • Oxygen cylinder checklist
        • Needle stick injury incident report
        • Needle stick injury Performa
        • Fridge temperature chart
        • HCAI surveillance forms
        • SSI root cause analysis checklist
  4. Daily monitoring of day to day activities: Daily monitoring of activities done in all areas of the hospital by taking daily rounds in a scheduled manner.
  5. Worked for accreditation process
    • LAQSHYA and MBFHI accreditation process carried out and achieved with scores of 88% and 97.26% respectively.

Activities Includes

  • Preparation of HIC Manual
  • Implementation of Standard and transmission based precautions and its monitoring
  • Preparation of checklist and its implementation
  • Training of staff


Biomedical waste management
Hand Hygiene
Cleaning practices

Government Medical College

Kerala Pin-686008
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Last Updated on 12-06-2023
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