Nursing Policy: Prevention of Healthcare-Associated Infections (HAIs) – Focus on Standard Precautions

Policy Number: AKUH-N/NURS-PS-002 Effective Date: August 1, 2025 Review Date: August 1, 2027 Approved By: Hospital Infection Control Committee, Chief Nursing Officer, Medical Director

1. Specific Patient Safety Initiative

This policy outlines the standardized procedures for the Prevention of Healthcare-Associated Infections (HAIs), with a primary focus on the consistent application of Standard Precautions. Standard Precautions are a set of infection control practices that apply to the care of all patients in any healthcare setting, regardless of suspected or confirmed infection status. They are based on the principle that all blood, body fluids (excluding sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents.

2. Purpose of the Policy

The purpose of this policy is to establish clear guidelines for all nursing staff at Aga Khan University Hospital, Nairobi (AKUH, N) regarding the consistent application of Standard Precautions. This ensures a safe environment for patients, visitors, and healthcare personnel by minimizing the risk of transmission of healthcare-associated infections (HAIs), thereby improving patient outcomes and maintaining the hospital’s commitment to quality care.

3. Policy Objective

The primary objective of this policy is to significantly reduce the incidence of preventable Healthcare-Associated Infections (HAIs) through the rigorous and consistent application of Standard Precautions by all nursing staff.

Desired Metrics/Outcomes:

• Reduction in Key HAIs: Achieve a 25% reduction in the incidence rate of hospital-acquired bloodstream infections (BSI) and catheter-associated urinary tract infections (CAUTI) within 12 months of full policy implementation.
• Improvement in Hand Hygiene Compliance: Achieve and maintain a ≥ 90% hand hygiene compliance rate among nursing staff, as measured by direct observation audits, within 6 months.
• Appropriate Use of Personal Protective Equipment (PPE): Achieve a ≥ 95% compliance rate for the correct donning and doffing of appropriate PPE for indicated patient care activities, as measured by direct observation audits.