Series: Understanding MSDS for Category II-C Hospitals | Post 44 of 61
Standard 22 (COP-5) | Indicators 85 and 86 | RED: 85 | YELLOW: 86
The Dressing Room Was Busy
In the spring, the dressing room at a 15-bed hospital in Jhang saw more wound infections than anyone could remember. Six patients came back within a month with red, discharging wounds after caesarean sections and hernia repairs. Samina, the head nurse, counted them on her fingers when Dr. Tariq Mehmood, the medical superintendent, asked.
No one could say which surgeon, which operation or which of the two theatres they came from. There was no register. The OT had a ceiling fan, the floor was swept with a broom between cases, and nobody recorded the temperature or humidity. The infection control committee had met twice in the year, and its minutes did not mention the theatres.
When the PHC assessor asked for evidence of surgical quality monitoring and surgical site infection rates, there was nothing to show.
What Indicator 85 Requires
The indicator reads: The surgical quality assurance program including surveillance of the operation theatre environment is followed for surgical services.
The assessor reviews documents such as minutes of surgical department meetings to confirm that quality indicators of surgical care are defined and monitored. The evidence reviewed includes infection control surveillance, medical equipment maintenance and cleaning of theatres between cases. Results must be documented, presented in the relevant committee meetings and minuted.
The manual lists the surveillance activities:
- Daily monitoring of humidity and temperature, at least three times a day at regular intervals by designated staff
- At least monthly monitoring of pressure differential
- At least six-monthly checks of filter integrity
- Medical equipment maintenance, with electro-medical equipment cleaned and disinfected after use
- Monitoring of the efficacy of OT cleaning and disinfection
It also gives practical rules. Floors are cleaned with a vacuum or a mop kept dry, never a broom. Ceiling fans are not used because they spread aerosols. Only the people needed for a procedure enter. Between cases, tables and equipment are cleaned with detergent and disinfectant, blood spills are treated with chlorine, and waste is not allowed to accumulate. At the end of the day, surfaces and handles are cleaned, floors washed with detergent and warm water, and final mopping done with a disinfectant such as phenol 1:10. Routine bacteriological testing is not required and is done only after modification of a theatre or an unexplained rise in infection.
What Indicator 86 Requires
The indicator reads: The surveillance program also includes monitoring of surgical site infection rates.
This evidence is expected in the minutes of the infection control committee. The assessor looks for SSI rates that are specific to the surgeon, the procedure and the room, since aggregate rates without categories are of little use. The assessor also looks at the action taken and whether it reduced infection. The manual describes SSI as the second most common hospital-acquired infection and asks that every case be documented, with daily follow-up, for review by a designated surgical site infection surveillance committee.
How They Are Scored
Indicator 85 (RED):
- Fully met: evidence that quality indicators of surgical care, including OT safety and cleanliness, are monitored and evaluated.
- Not met: no such monitoring or evaluation.
Indicator 86 (YELLOW):
- Fully met: SSI data segregated by surgeon, procedure and room, with remedial measures initiated.
- Partially met: SSI data only in aggregate, without specific analysis or corrective measures.
- Not met: no SSI data, or no corrective measures.
What Dr. Tariq Changed
The ceiling fan was removed and the broom replaced with a mop and a vacuum cleaner. A wall chart in each theatre now records temperature and humidity at 8 a.m., 1 p.m. and 6 p.m., signed by the OT technician. A monthly line records the pressure check, and a six-monthly line the filter check. A cleaning checklist covers between cases and end of day.
Samina opened an SSI register. Each surgical patient is entered with the date, surgeon, procedure and theatre, and the wound is recorded at each follow-up visit. At month end she works out the rate for each surgeon, each procedure and each room.
The infection control committee now meets monthly. The OT logs and SSI rates are presented and the decisions are minuted. The first analysis showed most infections came from one theatre, where the autoclave log had gaps. The autoclave was serviced and the cleaning schedule tightened, and the next quarter’s rate fell.
At reassessment, the assessor read the minutes, checked the logs and saw the analysis. Both indicators were fully met.
A Quick Self-Check
- Are OT temperature and humidity recorded at least three times a day?
- Are monthly pressure checks and six-monthly filter checks documented?
- Is there a written cleaning checklist for between cases and end of day, with no broom or ceiling fan in use?
- Are SSI rates calculated separately for each surgeon, procedure and room?
- Do committee minutes record the findings and the corrective action taken?
Prepare Your Hospital Before the Assessor Arrives
Register as a UPMED member to access ready-to-use OT temperature and humidity charts, SSI registers, cleaning checklists and the full MSDS toolkit for Category II-C hospitals. View membership plans and join today.
About this series: Educational content on MSDS compliance for Category II-C hospitals under the Punjab Healthcare Commission, based on the PHC MSDS Reference Manual for Cat II-C Health Care Establishments, 2017.