Standard Operating Procedure for Hand Hygiene and Infection Control Procedures in BA/BE Studies
| Department | BA-BE Studies |
|---|---|
| SOP No. | SOP/BA-BE/130/2025 |
| Supersedes | SOP/BA-BE/130/2022 |
| Page No. | Page 1 of 8 |
| Issue Date | 17/04/2025 |
| Effective Date | 20/04/2025 |
| Review Date | 17/04/2026 |
1. Purpose
To outline the procedures for hand hygiene and infection control to be followed by all clinical personnel involved in BA/BE studies to minimize risk of cross-contamination, maintain aseptic conditions, and protect both subjects and staff.
2. Scope
This SOP applies to all healthcare providers, laboratory staff, nursing personnel, volunteers, and ancillary
3. Responsibilities
- Clinical Investigator: Ensures overall adherence to hygiene protocols and infection prevention.
- Nursing Staff: Comply with hand hygiene during dosing, sampling, and subject handling activities.
- Housekeeping Staff: Maintain daily disinfection routines and proper waste segregation.
- Quality Assurance (QA): Conducts periodic audits of hand hygiene compliance and documents observations.
4. Accountability
The Facility-in-Charge or Clinical Operations Manager is accountable for ensuring the implementation of hand hygiene policies, availability of sanitation infrastructure, and staff training.
5. Procedure
5.1 Hand Hygiene Protocol
- All staff must perform hand hygiene:
- Before and after direct contact with study subjects
- Before performing any aseptic procedure (e.g., blood collection)
- After exposure to bodily fluids or contaminated surfaces
- Before donning and after removing gloves
- Acceptable methods:
- Handwashing with antimicrobial soap and water (minimum 20 seconds)
- Use of 70% alcohol-based hand rubs (ABHR) when hands are not visibly soiled
- Use designated hand hygiene stations at entry/exit points of clinical and sampling areas.
5.2 PPE and Gowning Requirements
- Clinical staff must wear:
- Clean lab coats or scrub suits
- Disposable gloves (changed between each subject)
- Face masks when performing close-contact procedures
- Use Annexure-1: PPE Gowning Checklist before entering sampling or dosing areas.
5.3 Environmental Disinfection
- High-touch surfaces (e.g., bedrails, dosing chairs, doorknobs) to be disinfected:
- Twice daily and after each sampling session
- Use freshly prepared 1% sodium hypochlorite or hospital-grade disinfectants.
- Document cleaning using Annexure-2: Disinfection Record Log.
5.4 Infection Control in Sampling and Dosing
- Use sterile, single-use supplies (needles, vacutainers, alcohol swabs).
- Label samples in a clean zone, separate from blood collection sites.
- Dispose sharps immediately in puncture-proof containers.
5.5 Volunteer Education and Monitoring
- Educate volunteers during screening and admission about:
- Hand hygiene stations
- Respiratory etiquette
- Reporting of symptoms or illness
- Provide access to hand rubs and tissues near volunteer beds and common areas.
5.6 Compliance Monitoring and Training
- Train all staff annually on hand hygiene and infection control procedures.
- Use Annexure-3: Staff Training Attendance Log for documentation.
- QA to conduct monthly hand hygiene audits using Annexure-4: Compliance Observation Checklist.
6. Abbreviations
- BA: Bioavailability
- BE: Bioequivalence
- PPE: Personal Protective Equipment
- QA: Quality Assurance
- ABHR: Alcohol-Based Hand Rub
7. Documents
- PPE Gowning Checklist – Annexure-1
- Disinfection Record Log – Annexure-2
- Staff Training Attendance Log – Annexure-3
- Compliance Observation Checklist – Annexure-4
8. References
- WHO Guidelines on Hand Hygiene in Healthcare
- CDC Infection Control Guidelines
- ICH E6(R2) – Good Clinical Practice
9. SOP Version
Version: 2.0
10. Approval Section
| Prepared By | Checked By | Approved By | |
|---|---|---|---|
| Signature | |||
| Date | |||
| Name | |||
| Designation | |||
| Department |
11. Annexures
Annexure-1: PPE Gowning Checklist
| Date | Staff Name | Gown | Mask | Gloves | Compliant |
|---|---|---|---|---|---|
| 16/04/2025 | Sunita Reddy | Yes | Yes | Yes | Yes |
Annexure-2: Disinfection Record Log
| Date | Area | Disinfectant Used | Time | Done By |
|---|---|---|---|---|
| 16/04/2025 | Dosing Room | 1% NaOCl | 08:00 AM | Ajay Verma |
Annexure-3: Staff Training Attendance Log
| Name | Department | Date Trained | Trainer | Signature |
|---|---|---|---|---|
| Meena Joshi | Clinical | 14/04/2025 | QA Officer | Signed |
Annexure-4: Compliance Observation Checklist
| Observer | Date | Area Observed | Hand Hygiene Compliance (%) | Remarks |
|---|---|---|---|---|
| QA Team | 15/04/2025 | Sample Collection | 95% | 2 missed entries |
Revision History:
| Revision Date | Revision No. | Details | Reason | Approved By |
|---|---|---|---|---|
| 05/01/2022 | 1.0 | Initial Release | GCP Compliance | QA Head |
| 17/04/2025 | 2.0 | Expanded sections on PPE and audit procedures | Post-pandemic SOP upgrade | QA Head |