INFECTION PREVENTION AND STANDARD SAFETY MEASURES AND

BIOMEDICAL WASTE MANAGEMENT

DEFINITION:

An infection is the entry and multiplication of an infectious agent in the tissues of host.

CHAIN OF INFECTION:

Development of an infection occurs in a cycle that depends on the presence of all the following
elements:

1. An infectious agent or pathogen.

2. A Reservoir or source for pathogen growth.
3. A Portal of exit from the reservoir.
4. A mode of transmission.
5. A Portal of entry to host.
6. A susceptible host.

INFECTIOUS AGENT:

 Microorganisms include bacteria, virus, fungi and protozoa.

 Microorganisms on the skin may be resident or transient flora.
 Resident organisms are permanent residents of the skin, where they survive and multiply. They are
usually killed by only hand washing with products containing antimicrobial ingredients.

RESERVOIR:

 A reservoir is a place where a pathogen can survive but may or may not multiply.
 The most common reservoir is human body.
 A variety of microorganism lives on the skin and within body cavities, fluid and discharges.
 To thrive from these, organisms require a proper environment, temperature, PH and light.

PORTAL OF EXIT:

 After microorganisms find a site to grow and multiply, they must find a portal of exit if they are to enter
another host and cause disease.

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  It exit by skin and mucous membranes, respiratory tract, urinary tract, gastrointestional tract,
reproductive tract and blood.

MODES OF TRANSMISSION:

 They are many modes for transmission of micro- organisms from the reservoir to the host.
 Certain infectious diseases tend to be transmitted more commonly by specific mode.
 However; the same micro-organisms may be transmitted by more than one route.
 For e.g. herpes zoster by droplet nuclei or by direct contact.

PORTAL OF ENTRY:

 Organisms can enter the body through the same routes they use for exit.
 Eg: when a contaminated needle pierces a client skin organisms enter the body.

SUSCEPTIBLE HOST:

 Susceptibility depends on the individual degree of resistance to pathogen.

 A persons resistance to an infectious agent is enhanced by vaccines or by actually contracting the
disease.

CONTROL MEASURES:

CONTROL OR ELIMINATION OF INFECTIOUS AGENT:

Cleaning, disinfection and sterilization of contaminated object significantly reduce and often eliminate
microorganism.

 Cleaning:
 Cleaning is the removal of all soil from object and surface. Cleaning involves use of water and
mechanical action with detergent.
 When cleaning equipment that is soiled by organic material such as blood, decal matter, this
need applies a mask and protective eyewear and water proof gloves.
 Asepsis:
 Asepsis is the absence of pathogenic microorganism.
 Medical asepsis or clean techniques includes procedures to reduce and prevent spread of
microorganisms.

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  Disinfection:
 It eliminates many or all microorganisms with the exception of bacterial spores.
 Sterilization:
 It is the complete elimination or destruction of all microorganisms including spores steam under
pressure, gas hydrogen peroxide.

CONTROL OR ELIMINATION OF RESERVOIR:

 The nurses should carefully disinfects articles that become contaminated with infectious material.

CONTROL OF PORTAL OF EXIT:

 The nurse follows prevention and control practices to minimize or prevent infection organisms from
exiting the body.
 To control organisms via respiratory tract, the nurse should avoid taking directly into clients faces or
talking, sneezing or coughing directly over surgical wounds or sterile dressing fields.
 A nurse with upper respiratory tract infection should always wear mask while handling the patient and
pay special attention to hand washing.

CONTROL OF TRANSMISSION:

 Effective control of infection requires a nurse to remain aware of the mode of transmission and ways to
control them.
 Sharing bedpans, urinals, basins, eating utensils can easily lead to transmission of infection.
 To prevent transmission - Soiled item and equipment must be kept away from touching the nurses
clothing.
 Dirty linens in the arms should be carried against the uniform.
 Laundry hampers should be replaced before they are overflowing.

Hand Hygiene:

 The most important and most basic technique in preventing and controlling transmission of infection is
hand hygiene.
 Hand hygiene includes using an instant alcohol hand rub antiseptic before and after providing client
care, hand washing with soap and water when hand are visibly soiled and performing a surgical scrub.
 The purpose of hand hygiene is to remove soil and transient organism from the hand and to reduce total
microbial counts over time.

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  Contaminated hand are a prime cause of cross infection.
 for eg a nurse caring for a client who has excessive pulmonary secretion assist the client reporting
mucus and disposes of the tissue in a bedside container.
 The use of alcohol-based waterless antiseptics is recommended by the CDC to improve hand hygiene
practices, protect health care worker hand and reduce transmission of pathogens to client and personnel
in healthcare setting.
 Emollients are added to alcohol based antiseptics to prevent drying of the skin.

The CDC (2009) Recommends the Following

1. Wash hands with plain soap or antimicrobial soap & water when hands are visibly dirty.

2. If hands are not visibly soiled, use an alcohol based waterless antiseptics agent.

A. After contact with a client intact skin.

B. When moving from a contaminated body site during client care, after contact.

C. With inanimate object in the immediate vicinity of the client.

D. Before caring for clients with severe neutropenia or other forms of severe immune
suppression.

E. Before inserting indwelling urinary catheters or other invasive devices.

F. After removing gloves.

Steps of Hand Washing:

o Palm to palm
o Right palm over left dorsum and left palm over right dorsum
o Palm to palm, fingers interlaced
o Backs of fingers to opposing palms with fingers interlocked
o Rotational rubbing of right thumb clasped in left palm, then vice versa
o Rotational rubbing backwards and forwards with clasped fingers of hand in left palm then vice versa.

CONTROL OF PORTAL OF ENTRY:

 Maintaining the integrity of skin and mucous membrance reduces the chances of microorganisms
reaching a host.
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  The clients skin should be well lubricated by using lotion.
 Immobilized and delibitated clients are particularly to skin break down. Dry and wrinkle free skin also
reduces the chances of skin break down. .Turning and positioning are needed before the clients skin
become reddened.
 Meticulous and frequent perineal care is especially important in older adult women who wear disposable
continent pads.
 The nurse may care for clients with closed drainage system that collect wound drainage, bile or other
body fluids. Drainage receptacles should only be opened when it is necessary to discard or measure the
volume of drainage.

PREVENTION OF THE SUSCEPTIBLE HOST:

 A client’s resistance to infection improves as the nurse protects normal body defence against infection.
 The nurse also protects himself or herself and others through the use of isolation precautions.
1. Isolation precaution:
 Isolation and barrier precautions include the appropriate use of gloves, gowns, mask, eyewear and other
appropriate devices or clothing.
 Barrier precautions is indicated for use with all the clients because every client has the potential to
transmit infection via blood and blood fluids and the risk for the infection transmission can be unknown.
 Use of personal respiratory protective devices capable of filtration of 95% efficiency when entering the
isolation room.
 Use of masks by the client when out of the room.
 The nurse should wash hands before and after handling of the clients in isolation.
 Contaminated supplies and equipment should be disposed of in a manner that prevents spread of
microorganisms to other persons.

Psychological implications of isolation:

 When a client requires isolation in a private room , a sense of loneliness may develop because social
relationship becomes disturbed.
 The client and family should be taught to wash hands, use barrier protection if appropriate. It is also
important to explain how infectious organisms can be transmitted so that the clients understands the
difference between contaminated and clean objects.

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2. Protective environment:

 Private rooms used for isolation may have negative pressure airflow to prevent infection particles from
flowing out of the room with positive pressure airflow that are used for highly susceptible clients.
 The isolation room or adjoining entrance room should contain hand hygiene, bathing and toilet
facilities.
 Impervious receptacles prevent transmission of microorganisms by preventive seepage and soiling of
the outside surface.
 The devices should not used on other clients unless they are first adequately cleaned and disinfected.

3. Specimen collection:

 Body fluids and secretions suspected from containing infectious microorganisms are collected for
culture and sensitivity test.
 All the specimen containers should be sealed tightly to prevent spoilage and contamination of the
outside of container.

4. Routine cleaning:

 Microorganisms may be present on walls, gloves and table tops in the rooms occupied by people with or
without infections.
 Promptly clean surfaces whenever they are visibly spoiled.

5. Surgical asepsis:

 Like medical asepsis, surgical asepsis is used to prevent infection.

 It is necessary to prevent exposing the client to all living microorganisms .
 The goal is to prevent contamination.

6. Performing sterile procedures:

 All the equipment that will be needed should be assembled before a procedure.
 Before the sterile procedure, each step should be explained so that the client can co-operate fully , if any
object becomes contaminated during the procedure, then the nurse should not hesitate to discard it
immediately.

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7. Gloving:

 Sterile gloves are frequently packaged in a paper peel back outer package.
 Inside this is usually another paper package that contains two gloves marked ‘right and left’.
 The gloves can be put on by using open method or a closed method.
 Open method is used for routine sterile procedures and closed methods is used for operationg room.
 When the procedures are completed, then immediately remove the gloves, consider it contaminated and
make every effort to protect your bare skin and clothing from touching them and dispose it immediately.

Personal protective equipment:

 Goggles
 N-95 mask
 Triple layer mask
 Gown
 Shoe covers
 Gloves

INFECTIOUS PROCESS:

 If the infection is localizes, proper care to control the spread and minimize the illness.
 The client may experience localized symptoms such as pain and tenderness at the wound site.
 The nurse is responsible for properly admininstering the antibiotics and monitoring the response to drug
therapy.

COURSE OF INFECTION BY STAGE:

 Incubation period:
Interval between entrance of pathogen into the body and appearance of first signs or symptoms.
Eg: common cold 1-2days, chickenpox 2-3weeks.
 Prodromal stage:
Interval from onset of nonspecific signs and symptoms to more specific symptoms.
Eg: malaise, low grade fever, fatigue.
 Illness stage:
Interval when client manifest signs and symptoms specific to type of infection.
Eg: common cold manifested by sore throat

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  Convalescence:
Interval when acute symptoms of infection disappear .
Eg: length of recovery depends on severity infection and clients general state of health.

INFECTION RISK:

The risk of probability that infection will occur is influenced by:

 Competence of individual immune system.

 The quantity of infectious agent
 The agent virulence
 The duration and the intimacy of contact between individual and microorganism.

NOSOCOMIAL INFECTIONS:

Nosocomial infection is an infection that is not present or incubating when a patient is admitted to a
hospital. This is also known as hospital acquiring infection.

SITES AND CAUSES OF NOSOCOMIAL INFECTION:

1. Urinary tract:
 Insertion of urinary catheter
 Improper specimen collection techniques
2. Surgical and traumatic wounds:
 Improper skin preparation before surgery
 Use of contaminated antiseptic solutions
3. Respiratory tract:
 Failure to use aseptic techniques while suctioning airway
 Improper disposal of mucosal secretion
4. Blood stream:
 Contamination of IV fluids by tubing or needle changes
 Improper care of needle insertion site.

NURSING PROCESS IN INFECTION CONTROL:

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 1. ASSESSMENT:
 The nurse assess the clients defence mechanism, suspectibility and knowledge of infection.
 By knowing the factors of susceptibility or risk of infection, the nurse is better able to plan preventive
therapy that includes aseptic techniques.

Risk factors for infection:

Inadequate primary defences:

 Broken skin or mucosa

 Traumatized tissue
 Altered peristalsis
 Reduced mobility

Inadequate secondary defences

 Reduced Hb level
 Suppression of WBC
 Suppressed inflammatory response
 Low WBC count

Clients susceptibility:

Many factors influence suspectibility to infection. The nurse gathers information about each factor through the
clients and family history.

These factors are:

Age :

 Throughout the life span, susceptibility to infection changes.

 infant has immature defenses against infection.
 Breastfeeding infants have greater immunity than bottle feeding infants.
 The young or middle age adult has refined defences against infection.
 Defences against infection may change with ageing.

Nutritional status:

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  Reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces the body’s
defences against infection and impairs wound healing.

Stress:

 The body responds to emotional or physical stress by general adaptation syndrome.

 If stress continued or become intense, then elevated cortisone levels results in used resistance to
infection.

Heredity:

 Certain hereditary conditions impair an individuals response to infection.

 Eg: gammaglobuinemia is a rare inherited or acquired characterized by the absence of serum antibiodies.

Disease process:

 Clients with disease of the immune system are of particular risk for infection.
 Victim of chronic disease such as diabetes mellitus and multiple sclerosis are also more susceptible to
infection because of general debilitation and nutrition impairment.
 Burn client have a very high susceptibility to infection because of the damage to skin surfaces.

Medical therapy:

 Some drugs and medical therapies compromise immunity to infection.

 Adrenal corticosteroids prescribed for several conditions are inflammatory drugs that cause protein
break down and impair the inflammatory response against infection.
 Cancer clients receiving radiotherapy are also risk for infection.

Clients with infection:

 A client with infection may have a variety of health problems.

 The nurse assesses that how the infection affects the clients and family needs.

2. NURSING DIAGNOSIS:

 It may be necessary for the nurse to validate data.

 The diagnosis must have the appropriate etiological factors for the nurse to establish an appropriate and
well through out plan.
 For eg: minimizing the risk for infection related to broken skin requires good hygiene measures and
wound care.
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  Nursing intervention depends on the accuracy of the diagnosis and the ability to meet the clients needs.

2. PLANNING:

 Interventions are selected in collaboration with the client, the family and others in the health care team.
 The nurse directs care in the acute care setting and may involve the dietician or respiratory therapist in
assisting with in strategies on procedure that needs to be followed after discharge.
 Common goals of care include the following:
 Preventing exposure to infectious organisms
 Controlling or reducing the extent of infection
 Maintaining resistance to infection.

3. IMPLEMENTATION:

 By recognizing and assessing a clients risk factors and implementing appropriate measures , the nurse
can reduce the risk for infection.
 Health promotion:
 Eliminating reservoirs of infection, controlling portals of exit and entry, avoiding action
that transmits microorganisms prevent bacteria from finding new sites in which to grow.
 Proper use of sterile supplies, barrier protection and proper hand hygiene are examples of
methods that the nurse may use to control the spread of microorganisms.
 Acute care measures:
 Treatment includes eliminating the infection organism and supporting client’s defences.
 Identifying causative organisms by collecting specimens of body fluids.
 After identifying causative agents the physician prescribes treatment the nurse
administers antibiotics and other treatments.

4. EVALUATION:

 To evaluate whether the client has achieved the expect outcome and has remained free of
infection.
 Maintain high standard of medical and surgical asepsis and constantly monitor the client for sign
on infection.

BIOMEDICAL WASTE MANAGEMENT:

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DEFINITION:

Biomedical waste is the waste that is generated during:

 Diagnosis, treatment or prevention of a disease.

 Biomedical research
 Production and testing of biochemicals.

SOURCES OF BIOMEDICAL WASTE:

1. Hospital and health care centers:

 Government hospitals
 Private hospitals and nursing homes
 Vaccinating centers( Govt and private)
2. Clinic / offices:
 Private Nursing Clinics
 Dental clinics
 Special clinics
3. Medical research centers and laboratories:
 Medical research and training establishments
 Diagnostic laboratories
4. Animals institutions:
 Animal homes
 Veterinary institutes
 Slaughter houses
5. Blood banks and collection centers or donation camps.

6. Biotechnological institutes and production units:

 Biomedical waste can also be generated at home, if health care is being provided to a patient.

RISK GROPUS:

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  Direct care givers, Nurses , Doctor
 Support service staff technicians, lab assistants, radiographers, etc
 Hospital caretaker staff: caretakers, ward boys, ayahs, sweepers, etc
 Workers of waste disposal management, incinerator operators, transporters, rag pickers, etc
 Patient and visitors

SAFE DISPOSAL METHODS OF BIOMEDICAL WASTE:

Disposal of biomedical waste includes three stages:

 Collection and segregation

 Transportation and storage
 Disposal techniques

Colour coding:

Colour coding Type of container Waste category Treatment

Yellow Plastic bags Cat. 1, Cat. 2, and Cat. 3, Incineration/deep burial

Cat. 6.

Red Disinfected Cat. 3, Cat. 6, Cat.7 Autoclaving/Microwaving/

container/ Chemical Treatment
plastic bags

Blue/White Plastic Cat. 4, Cat. 7. Autoclaving/Microwaving/

translucent bag/puncture Chemical Treatment and
proof Container destruction/shredding

Black Plastic bag Cat. 5 and Cat. 9 and Cat. Disposal in secured landfill
10. (solid)

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CATEGORIES OF BIOMEDICAL WASTE:

Option Waste Category Treatment & Disposal

Category No. 1 Human Anatomical Waste Incineration / deep burial

Category No. 2 Animal Waste Incineration / deep burial

Category No. 3 Microbiology & Biotechnology Waste Local autoclaving / microwaving /

incineration

Category No. 4 Waste Sharps Disinfection by chemical treatment/ autoclaving/

microwaving and mutilation/shredding

Category No. 5 Discarded Medicines and incineration / destruction and drugs disposal in
secured landfills
Cytoxic drugs

Category No. 6 Solid Waste Incineration / autoclaving / microwaving

Category No. 7 Solid Waste Disinfection by chemical treatment/

autoclaving/microwaving and
mutilation/shredding

Category No. 8 Liquid Waste Disinfection by chemical treatment and

discharge into drains

Category No. 9 Incineration Ash Disposal in municipal landfill

Category No. 10 Chemical Waste Chemical treatment and discharge into drains for
liquids and secured land for solids

Collection and segregation:

 Hospital waste should be collected at the site of generation only.

 Segregation aims to keep the harmful and infected material separate from the harmless and non-
contagious waste.
 For this purpose, use of specially coloured dustbin and plastic bag is mandatory.

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Procedures and facts should be kept in mind during the collection and segregation of biomedical waste: -

1. Bins and bags should bear the symbol of biomedical hazards.

2. Never mix infectious waste with non-infectious waste.

3. Needles should be destroyed with a needle cutter. Manual mutilation of sharps should never be tried as it may
cause injury. All other sharps must be strongly disinfected (chemically) before they are shredded or finally
disposed off.

4. All sharps should be kept in puncture, proof box and properly labelled.

5. Disposable Items (syringes, IV bottles, catheters, rubber gloves etc.) should be undertaken only when they
have been Mutilated (cut) and chemically disinfected dipping in 1% hypochlorite solution for 30minutes).

6. Waste should not spill outside. Non infections waste can be dealt with as normal household waste and does
not require any special treatment.

Transportation and Storage:

Ideally as soon as a bag is full, it should be tied, labelled and sent to the site of final disposal. Temporarily
stored at a central area in the hospital and from there it may be sent in bulk to the site of final disposal once or
twice a day.

Important precautions regarding transportation and storage are:

 Before taking the bag away, ensure that it is properly tied and labelled and there is no possibility of
spillage.
 Persons handling the waste bags should not touch the items of public use.
 A covered, bio hazard symbolized hand cart may be used to transport the waste to the central storage
area of the hospital.
 Do not throw the bags haphazardly as this may tear and the waste may spill out.
 A full-time person should be posted at the central site of storage for regular receiving and dispatching
the waste.
 Unauthorized people should not enter in the storage area.
 As per rules, bio medical waste cannot be stored for more than 24 to 48 hours.
 There will be no chemical pre-treatment before incineration. Chlorinated plastics shall not be
incinerated.
 Chemical treatment using at least 1% hypochlorine solution.

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Disposal Techniques:

1. Chemical Disinfection:

 Solid waste as plastic, rubber and metallic item, IV sets, blood bags, gloves, catheters, urobag, syringe,
needles etc. must be disinfected before they are sent for final disposal (landfill).
 Chemical disinfection is also most appropriate method to treat, the liquid waste such as blood, urine,
stools or hospital sewage.

2. Thermal Measures (wet and dry)

i. Autoclave (Wet thermal treatment):

 It is effective method of sterilization for microbiology and biotechnology waste.

 But it cannot be used for human anatomical waste or animal carcasses. Also, it is not effective for
pharmaceutical or chemical waste.

ii. Hydroclave (Dry thermal treatment):

 In this method, shredded infectious waste is exposed to high temperature, high pressure steam like
autoclaving.
 It dries 80% liquid of waste and waste is reduced to 20-30% in weight. Adequately trained operators or
technicians are needed for its operation.

3. Microwave Irradiation

 This technique is also effective (like autoclave or hydroclave) in sterilizing the Infected disposable
waste.
 Most microorganism are destroyed by the action of microwaves.

4. Incineration

 Incineration is a high temperature dry oxidation process that reduces organic, incombustible matter.
 It also reduces the volume and weight of the waste.
 It is usually related to the waste that cannot be reused, recycled or disposed off by a landfill treatment.

Generally three kinds of incinerators are used:

i. Single chamber furnaces: These are simple and cheapest units.

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ii. Double chamber pyrolytic incinerators; most suitable and commonly used process for health care waste is
first pyrolytic chamber, waste is destroyed through an oxygen deficient, medium temp. Combustion process
(800°C), this produces solid ashes and gases. In the second chamber (Post combustion) gases are burnt at a
high temperature (900-1200°C) using an excess of air to minimize smoke and odours.

iii. Rotary- Kiln: It comprises a rotating oven and a post combustion chamber. It is specially used to burn
chemical wastes - (including cytotoxic drugs and pharmaceuticals).

Wastes to be incinerated

 Human materials (body parts, blood and body fluids).

 Animal wastes.
 Laboratory wastes.
 Dressing material.

Wastes not to be incinerated

 Pressurized gas containers.

 Large amount of reactive chemical waste.
 Radiographic/photographic waste.
 Halogenated plastics such as PVC (Poly vinyl chloride).
 Waste with high mercury or cadmium (such as thermometers, used batteries etc).
 Sealed ampoules/ampoules containing heavy metals.

5. Inertization

 In this process, cement and other substances are mixed with waste before disposal.
 Mixing of cement etc reduces the risk of migrating toxic substances into surface water or ground water.
 After making homogeneous mixture, cubes are prepared at site, then transported to final disposal site.

6. Landfill

It is quite effective, provided practiced appropriately a sanitary landfill observing certain rules can be acceptable
choice for disposal of biomedical waste, particularly in developing Countries like India.

Some guidelines for sanitary landfill are

 Site away from the residential areas or water Sources.

 Easy transportation facilities.
 Constant supervision.

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Health Care Waste Management Improvement Interventions Specifications and Results: A
Systematic Review and Meta-Analysis
Ali Ashtari ,Jafar Sadegh Tabrizi , Ramin
Rezapour , Mohammad Rashidian Maleki ,
Saber Azami-Aghdash
Abstract

Background:

Given the importance of proper management of Health Care Waste Management (HCWM),
comprehensive information on interventions in this field is necessary. Therefore, we aimed to systematically
review and meta-analysis of characteristics and results of interventions in the field of HCWM.

Methods:

The required data were gathered through searching the keywords such as waste management, biomedical
waste, hospitals waste, health care waste, infectious waste, medical waste, Waste Disposal Facilities, Garbage,
Waste Disposal Facilities, Hazardous Waste Sites in PubMed, Scopus, EMBASE, Google scholar, Cochrane
library, Science Direct, web of knowledge, SID and MagIran and hand searching in journals, reference by
reference, and search in Gray literatures between 2000 and 2019. CMA software: 2 (Comprehensive Meta-
Analysis) was used to perform the meta-analysis.

Results:

Twenty-seven interventions were evaluated. Most of the studies were conducted after 2010, in the form
of pre and post study, without control group, and in hospital. Interventions were divided into two categories:
educational interventions (19 studies) and multifaceted managerial interventions (8 studies). The most studied
outcome (in 11 studies) was KAP (knowledge, attitude and practice). The mean standard difference of
interventions on KAP was estimated 3.04 (2.54-3.54) which was significant statistically (P<0.05). Also,
interventions were considerably effective in improving the indicators of waste production amount, waste
management costs and overall waste management performance.

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SUMMARY:

So far we have discussed about the definition, chain of infection, control measures, infectious process,
nosocomial infection, sites and causes of nosocomial infection, nursing process in infection control, biomedical
waste management and safe disposal methods of biomedical waste management.

CONCLUSION:

Here, I conclude my topic , I hope that the students may gain knowledge regarding definition, chain of
infection, control measures, infectious process, nosocomial infection, sites and causes of nosocomial infection,
nursing process in infection control, biomedical waste management and safe disposal methods of biomedical
waste management

BIBLIOGRAPHY:

BOOK REFERENCE:

 Samata Soni, Textbook of Advance Nursing Practice, first edition, Jaypee publication, page no:416-426,
514-521.
 Shabeer.P. basher, A concise Textbook of Advanced Nursing Practice, second edition, emmess
publications, page no: 323-335
 Taylor, fundamentals of nursing, 8th edition, south Asian edition, page no: 530-556

NET REFERENCE:

 www.Slideshare.com
 http://www.scribed.com
 http://www.tnmcnair.com

JOURNAL REFERENCE:

 www.pubmed.com
 www.scribd.com
 www.proquest.com

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