Infection Control and PatientStaff Safety

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Infection Control and Patient/Staff Safety

• Infection Control
• Jan 2009
• Estimated completion time 15 minutes

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Objectives

• At the conclusion of the lesson you will be able
  to
• Describe the importance of infection control in
  hospitals.
• List measures for preventing/reducing hospital
  infections
• List the categories of infection control
  precautions that healthcare workers use to
  prevent/reduce inrections

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What is a healthcare-associated infection?

• A healthcare associated infection (HAI) is one
  which was not present or incubating when the
  patient was admitted to the hospital, but is
  acquired after admission.
• Urinary tract infections are the most common HAI,
  followed by surgical wound infections, lower
  respiratory tract infections (pneumonia) and skin
  infections.
• Other infections include gastrointestinal
  infections (Clostridium difficile) and
  bloodstream infections.

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Healthcare-associated infections are serious and
affect patient and staff safety

• Over 98,000 people die each year from
  complications of healthcare-associated infections
  (HAIs).
• HAIs also cause suffering, disability and
  increased healthcare costs, which may not be
  reimbursed.
• About 5 of patients develop a HAI.
• Hand hygiene (handwashing or use of an alcohol
  hand rub) can prevent nearly half of preventable
  infections and helps to protect staff from
  infections.
• Other additional infection control measures
  significantly reduce infection risks
• Our goal is to have zero infections!

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Risk Factors for HAIs

• Invasive devices, such as ventilators, foley
  catheters and central lines predispose patients
  to infection.
• Immune system suppression predisposes patients to
  infections with atypical germs (like fungus) that
  usually do not make others sick.
• Antibiotic use predisposes patients to infections
  with antibiotic-resistant germs, fungus, and
  gastrointestinal infections.
• Numbers of at risk patients are increasing
  because of advances in medical therapies,
  antibiotic use, and diagnostic techniques.

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Organisms that cause HAIs

• Any organism which can cause disease is called a
  pathogen
• Pathogens which cause HAIs include
• Staphylococcus
• Pseudomonas, E. coli and other gram negatives
• Clostridium difficile
• Candida
• Some viral agents such as RSV (respiratory
  syncytial virus), and influenza
• Multidrug resistant organisms (MDROs), such as
  MRSA, VRE and ESBLs
• Patients, who are colonized (carriers) of MDROs,
  are a source for spread within the hospital and
  are at risk of developing deadly infections.

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MUSCs Active Surveillance Program

• MUSC has an active surveillance (culturing)
  program to identify patients with MRSA and VRE
  and control the transmission of these pathogens
• Patients colonized or infected with these
  organisms are placed on Contact Precautions and
  are flagged in Oacis
• Rates of MUSC acquisition are tracked and
  analyzed. Please see the next two slides.
• Each one of us can impact our rates and need to
  do all we can to reduce these rates.

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MUSC MRSA Acquisition Rates
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MUSC VRE Acquisition Rates
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How are infections transmitted?
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• Infections do not occur simply because a pathogen
  exists in the environment.
• Example MRSA
• The pathogen must have a reservoir in which it
  grows and lives (e.g., humans serve as a
  reservoir as well as the environment)...
• The portal of exit would be contact with the
  colonized/infected patient or contaminated
  environment
• The mode of transmission would be direct or
  indirect contact, example via hands of healthcare
  workers
• The portal of entry would be via contact with
  another patients non intact skin, mucous
  membranes, contamination of invasive devices,
  such as IV lines, etc
• - A susceptible host is anyone at risk
  for colonization or
• infection with MRSA, i.e. patients with
  invasive devices, non
• intact skin, acutely ill, etc.

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Prevention and Control of HAIs

• The goal of Infection Control is to reduce
  transmission of pathogens from patient to
  patient, from staff to patient, and from patient
  to staff.
• Good infection control practices break the chain
  of infection. Examples
• Hand hygiene and changing gloves between patient
  contacts prevents transmission.
• Removing a foley catheter makes a patient less
  susceptible to HAIs by removing an entry point
  for pathogens.
• Vaccinations (e.g., vaccinations for Hepatitis B,
  influenza, chickenpox, etc.) reduce the number of
  susceptible individuals.

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Hand hygiene is the single most important way to
prevent HAIs

• Hands should be washed with antiseptic soap and
  water or decontaminated with alcohol hand rubs
• right before and after caring for a patient
• during patient care if hands become contaminated
• after contact with objects and surfaces in the
  patients immediate vicinity
• after removing gloves
• before handling food or food trays
• before and after eating, after using the toilet

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Aseptic Technique

• Practice of ensuring that bacteria are excluded
  from open sites during surgery, wound dressing,
  blood sampling, and other medical procedures.
  Aseptic technique is a first line of defense
  against infection.
• Use of sterile instruments and supplies and the
  application of principles of asepsis while
  performing invasive procedures are important
  aspects of infection control.
• Examples of aseptic technique include
• - Disinfecting IV ports/valves and capping
  open lines
• - Checking the integrity of sterile
  packages and
• ensuring a color change on the chemical
  indicator
• - Use of a sheathed catheter for closed
  suctioning of ventilated
• patients.

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Standard Precautions

• The first tier of the CDC isolation guidelines
  is Standard Precautions. Since patient
  examination and medical history cannot reliably
  identify every patient with blood borne pathogens
  and other diseases, Standard Precautions apply to
  all patients and all body substances. The risk of
  infection can be minimized if Standard
  Precautions are followed for ALL PATIENTS.

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• Standard Precautions guidelines
• Perform hand hygiene before and after patient
  care, regardless of whether gloves are worn.
  Perform hand hygiene immediately after the gloves
  are removed and between patient contacts.
• Wear gloves when touching blood or any other body
  substance, secretion, or excretion except sweat,
  or when touching contaminated items. Put on clean
  gloves just before touching mucous membranes or
  non-intact skin.
• Take care to prevent needle sticks and other
  injuries when using needles, scalpels, or other
  sharp instruments. Also be careful when handling
  sharps after procedures and when cleaning them.
  Dispose of used needles properly.

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• Use a mouthpiece, resuscitation bag, or other
  ventilation device as an alternative to
  mouth-to-mouth resuscitation. These devices
  should be available for use in areas where the
  need for mouth-to-mouth resuscitation is
  predictable.
• Wear a gown to protect your skin and to prevent
  soiling of your clothing during any patient care
  activity that is likely to generate splashes or
  sprays of blood or body fluids.
• Wear a mask and eye protection or a face shield
  to protect the mucous membranes of your eyes,
  nose, and mouth during any patient care activity
  that is likely to generate splashes or sprays of
  blood or body fluids, including respiratory
  secretions. You should thoroughly wash your hands
  or other skin surfaces immediately after
  accidental exposure to blood or body substances.
  Wear mask and eye protection when working closely
  with a coughing patient.

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• Transmission-Based Precautions
• The second tier of the CDC guidelines is
  transmission-based precautions. There are three
  simple sets of precautions based on likely routes
  of transmission.
• The precautions are designed to prevent airborne,
  droplet, and contact transmission of pathogens.
• These precautions are to be followed when a
  patient is suspected or known to have infection
  or colonization by epidemiologically important
  pathogens (MRSA, VRE, TB, Influenza, etc).
• They are employed on an empiric basis when an
  adult or pediatric patient presents with a
  specific syndrome strongly suggesting that the
  pathogen/disease is present.
• Please refer to Infection Control policies 2-002,
  2-003 and 2-004 for additional information and
  guidance.

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Airborne Precautions

• Airborne precautions are designed to protect
  against the transmission of airborne droplet
  nuclei for illnesses such as measles, chickenpox,
  and tuberculosis. Airborne droplet nuclei are
  smaller than 5 microns in diameter and can remain
  suspended in the air and dispersed widely by air
  currents.

• Airborne precautions include
• Isolation of the patient in a private room with
  monitored negative air pressure. The door to
  the room must remain closed and the patient must
  remain in the room.
• Always wear appropriate respiratory protection
  when you enter the room. For tuberculosis, you
  should wear a respirator mask fit tested to
  your face size. Contact Infection Control if you
  are not sure what type of protection to wear.
• Limit the movement and transport of the patient
  from the room for essential purposes only. If at
  all possible, have the patient wear a surgical or
  procedure mask during transport.

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Droplet Precautions

• Droplet precautions are designed to protect
  against the transmission of infectious droplets
  larger than 5 microns (such as mycoplasma
  pneumonia, pertussis, mumps, and influenza).
  Patients with these illnesses tend to generate
  infectious droplets while sneezing, coughing, or
  talking.

• Droplet precautions include
• Keeping the patient in a private room. The door
  may remain open.
• You should wear a mask when you enter the room.
• You should also wear a mask when examining or
  transporting a patient who is suspected to have
  an illness requiring droplet precautions.
• Limit the movement and transport of the patient
  from the room for essential purposes only. If at
  all possible, have the patient wear a surgical or
  procedure mask during transport.

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CONTACT PRECAUTIONS

• Contact Precautions are designed to halt the
  transmission of pathogens which may be spread by
  direct contact with the patient, contaminated
  equipment, or the patients environment. Contact
  Precautions are designed for different types of
  infections which may survive for extended periods
  in the environment (e.g., C diff, MRSA, VRE,).

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CONTACT PRECAUTIONS

• The patient is placed into a private room
  whenever possible. Cohorting patients with the
  same organism may be done if needed and under the
  guidance of Infection Control.
• A GOWN AND GLOVES MUST BE WORN BY ALL ENTERING
  THE ROOM! THIS INCLUDES VISITORS. Dietary staff
  that are delivering trays are required to wear
  gloves, not gowns.
• When providing care, change gloves after contact
  with any infective material such as wound
  drainage.
• Remove the gown and gloves and perform hand
  hygiene before leaving the room (take care not to
  touch any potentially infectious items or
  surfaces on the way out).
• Dedicate the use of non-critical patient-care
  equipment to a single patient. If use of common
  equipment is unavoidable, adequately clean and
  disinfect it before use with other patients.
• The door may be left open and in most cases,
  patients can go for tests and/or therapy off the
  unit. For patient transport, wear gown and
  gloves to enter the room and prepare patient for
  transport. Use only clean linen, dont pull linen
  from patients bed. Remove gown/gloves , wash
  hands and don clean gown and gloves.

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REMEMBER -

• Place patients into the precautions indicated as
  described in the Infection Control Manual
  (policies 2-002, 2-003 and 2-004)or call
  Infection Control.
• Isolated patients must have a blank Precautions
  sticker on the outside of their chart. A second
  Precautions sticker goes on the inside of the
  chart so other departments will know the correct
  precautions to follow. Place chart into a plastic
  bag for transport.
• To facilitate proper control and management of
  patients notify other departments of precautions
  by phone or request whenever possible.
• Report exposure to infectious illness to employee
  health. Post exposure testing and prophylaxis may
  be necessary to prevent infection.

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Prevention of Specific Infections

• Bundles are groupings of best practices with
  respect to a disease process that individually
  improve care, but when applied together result in
  substantially greater improvement.
• When all measures in a bundle are practiced
  consistently by all staff, infection rates are
  significantly reduced
• CLABSI and VAP are serious infections and have
  attributable mortality rates of 4-20 and up to
  50 respectively.
• Bundles for VAP (ventilator associated pneumonia)
  and CLABSI (central line assoc bloodstream
  infection) have been implemented.
• All staff, nursing, physicians, radiology,
  respiratory therapy, etc., must practice
  excellent ventilator and IV line care.

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Central Line Bundle

• Hand Hygiene for Insertion/All Line Care
• Maximal Barrier Precautions Upon
  Insertion-Sterile gown/gloves, also cap/mask
• Chlorhexidine Skin Antisepsis
• Optimal Catheter Site Selection, Subclavian Vein
  Preferred Site for Non-Tunneled Catheters in
  adults
• Daily Review of Line Necessity with Prompt
  Removal of Unnecessary Lines
• Monitor compliance, call Break Scrub
• Insertion must be recorded on CVL Procedure
  Checklist

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Think Outside the Bundle

• For All IV Lines
• IV Line Assessment
• Each shift, assess for patency, site condition
  and dressing patency
• If the IV line was placed in a true clinical
  emergency, the line is to be changed after 24
  hours
• IV Line Care
• - Hand Hygiene
• Change transparent dressings every 7 days, those
  you cannot visualize the site i.e. gauze
  dressing, change every 24 hours
• Change tubing and caps/valves every 72 hours
• Cleanse caps prior to tubing change, IVP
  medication or flushing with alcohol or
  CHG/alcohol swab. Use friction and allow to dry
  for 30 seconds!

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VAP Bundle
- Hand Hygiene - Head of Bed Elevation 30
- 45 degrees, 15 30 degrees for
neonates - Oral Care Q4hrs (Q 6hrs for
neonates), teeth brushed Q12 - Deep
Vein Thrombosis Prophylaxis (as
appropriate for pediatrics.) - Stress Ulcer
Prophylaxis (as appropriate for
pediatrics) - Sedation Management Daily
Wake Up (not for pediatric pts.) -
Spontaneous Breathing Trial (as appropriate
for pediatrics)
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VAP/Pneumonia-Additional Measures

• Provide oral suctioning and deep suctioning. Use
  separate tubing and device set-ups for
  endotracheal suctioning and oral suctioning
• Encourage coughing and deep breathing for non
  ventilated patients
• Ambulate and turn patients as possible

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Surgical Site Infection (SSI) Prevention

• 2 to 5 of surgical patients will develop SSI
• SSI increases length of stay by7.5 days on
  average and adds costs of 2600 to 27,000 per
  case
• Measures to Reduce SSI Include
• - Preoperative antiseptic bathing. This is
  hospital policy,
• C-139.
• - Identifying and treating infections prior
  to surgery,
• such as UTI. Notify MD when infection
  present.
• - Appropriate antibiotic selection and
  administration.
• Antibiotics should be given within an hour
  of incision.
• Discontinue antibiotics after surgery
  within 24 hours of
• surgery.

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Measures to Reduce SSI (contd)

• - Appropriate hair removal. Dont remove hair
  at all or
• use clippers, no shaving
• - Maintain appropriate peri and postoperative
  glucose
• levels and normal body temperature during
  surgery
• - Perform appropriate surgical scrub, no
  artificial nails
• and natural nails should be no more than ¼
  in. long
• - Perform a thorough prep of the operative
  site
• - Avoid flash sterilization of surgical
  instruments
• - Limit traffic in and out of ORs, keep doors
  closed
• during procedures
• - Keep scrubs clean, if leaving the hospital
  or traveling
• to a dirty area of the hospital, put on
  clean scrubs on return to OR

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UTI Prevention

• Most healthcare acquired UTIs are related to
  foley catheters-avoid catheter placement if at
  all possible-remove catheters as soon as possible
• Use strict aseptic technique for foley
  insertion-sterile field, prep with pick ups,
  dont contaminate catheter
• Bag below level of patient
• Proper technique for specimen collection
• Foley Care twice a day and with incontinent care

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C Diff

• All patients with diarrhea/testing for C diff are
  placed on Contact Prec
• Use Dispatch for environmental/equipment cleaning
• Soap and water hand hygiene followed by alcohol
• Three negatives before d/c of precautions
• If pt is positive, two months of prec from last
  positive
• Pts are flagged, consult with IC upon readmission

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ADDITIONAL CONCERNS

• Keep clean separate from dirty
• Follow appropriate cleaning and disinfecting
  procedures
• Stethoscopes (no fabric covers)
• Multi-use patient equipment
• Multi-use diagnostic equipment
• Toys and other distraction devices
• Lab coats and jackets must be kept clean but are
  NOT sterile!

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Conclusion

• Infection Control is crucial for patient safety.
• Infection control in the hospital is the
  responsibility of every person working in
  healthcare. Consistent and conscientious
  practice of infection control principles can
  prevent unnecessary suffering. Effective
  communication about the presence of infectious
  diseases and following hospital policies are
  essential to the hospital's effort to protect
  patients, staff, and others in the acute-care
  environment.
• All employees are urged to report poor practices
  which might harm patients or staff. Report to
  manager or to Infection Control Dept.
• The safety of our patients and staff depends on
  all of us.

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Congratulations!

• You have completed the lesson. Please complete
  test now.