Abstract of Dissertation

Agency : Nosocomial Infection, Hospital Associated Infection, Gap Analysis

Objective : 1. To compare the standards given for HIC chapter of NABH and determine the present status of the hospital. 2. To make Action plan to fulfil the gap areas. 3. To see the impact of the intervention through the Action plan.

Background : J.B.M.M Civil Hospital, Amritsar is 150 bedded hospital and has applied for Pre assessment of NABH . The score in the self assessment of NABH shows that score for the HIC chapter is quiet less than required. Work in this respect was required so Gap Analysis for the HIC chapter of NABH according to the standards was done. Aim of the study was to firstly bring out the present situation and gap areas, then on the basis of the findings make an action plan to fulfill those gaps.

Methodology : Study Design – Experimental Study (Intervention non clinical) Location of Study – Civil Hospital, Amritsar, Punjab. Data Collection Primary Data: - NABH Checklist for HIC Chapter. Scoring pattern:- Scoring of each objective element will be based upon following criteria: 10 = Compliance 5 = Partial Compliance 0 = Non compliance NA = Not applicable 103 Secondary Data: The records in reference to the Hospital Infection Conrol in the hospital were checked and monitored as per NABH requirement of data. Tools Used Checklist will be prepared according to the 9 standards of Hospital Infection Control chapter, based on that checklist NABH gap analysis will be done. All observations were made in 2 parts: 1. Bring out the current situation of the hospital related to Hospital Infection Control. 2. Comparison in respect to the NABH standards. Assessment will be done by following ways: • Direct Observation • Document Review • Discussion with the hospital staff • Discussion with the patients

Findings : Initially present situation and gap areas were identified based on NABH checklist for HIC chapter and average score was calculated. On the basis of these findings an Action Plan was developed for 3 months in order to fulfill those gaps. Then at the end of 3 months again self assessment was done to see the impact of intervention in terms of average score. Results of the above analysis suggested that initially the average score for HIC chapter came out to be 1 and then after implementation of the Action Plan it was observed that the score rose to 6.5 at the end of 3 months.

Recommendations : Improvement in score is there but still works needs to be done to achieve full compliance. Suggestions have been given so that implementation can be done to achieve full compliance for this chapter before Pre assessment.

A clean hospital environment is essential for the health and well being of patients, staff and visitors. More than 10% of patients admitted to hospital acquire infections. Nosocomial Infection is that which develops in the patients after more than 48 hours of hospitalization. To reduce the risk of HAI, hospital Infection control program is there. The main aim of the infection control program is to lower the risk of an infection during the period of hospitalization. The hospitals undergoing Quality Control with the help of Accreditation such as NABH are doing this program to reduce the rate of infection.