Infection Prevention

1
Infection Prevention Control Core Competencies
for HCWs

• Dr. Donna Moralejo
• Novice ICP Day
• June 2008

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Overview

• IPC Core Competencies for HCWs
• Why we need them/benefits
• How they were developed
• Details of the competencies
• Areas for action by ICPs

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Background The SARS outbreak

• 21 of 8098 SARS cases were in front line workers
  who cared for SARS pts
• Many HCWs became infected because they
• Failed to adequately/appropriately use routine
  practices like hand hygiene and PPE
• Frequently contaminated themselves when removing
  PPE

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SARS Raised Qs

• What do HCWs need to know to protect themselves
  and pts?
• Knowledge, skills (PPE, HW), other
• Do they know it?
• How can we get them to know it?
• Need to answer 1 first before sorting out the
  rest!

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Its not all about SARS though

• Influenza
• Seasonal, pandemic
• Other respiratory infections
• C. difficile, norovirus, other GI infections
• Surgical Site Infections
• Other HCAI

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Core Competency Development

• CHICA-Canada set out to develop a set of common
  core competencies in IPC that
• Applies to all HCWs involved with pt care
• Allows them to work safely
• Prevents transmission of organisms in their
  setting (institution)
• Education Committee coordinated project

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Methods (Nov 2004-May 2005)

• Round 1 Asked Chapters to id competencies
• Round 2 Compiled list sent for feedback from
  individuals and groups (n 78 respondents)
• Categorized by major topic 7 topics
• Interlinked
• Final list of 36 Core Competencies identified by
  at least 80 were included
• 100 consensus on 6 of 7 topics

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7 Areas of Core Competencies

• Basic Microbiology (6)
• Hand Hygiene (4)
• Routine Practices Transmission-based
  Precautions (4)
• Personal Protective Equipment (4)
• Personal Safety (8)
• Sterilization Disinfection (3)
• Critical Assessment Skills (7)

36 items total
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Competencies are Interlinked

• Basic microbiology is essential for understanding
  hand hygiene, PPE, critical assessment
• HH and PPE are essential for Routine Practices
  and Personal Safety
• Critical thinking applies to all

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Benefits of Achieving Core Competencies in HCW

• Provide HCW with
• Tools for assessing/acting on a situation
• Confidence in IPC measures used
• Ability to use IPC measures correctly
• Reduce work related stress/fear of exposure,
• Reduce actual exposure (daily, emergency)

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Benefits of Articulating Core Competencies for
HCW

• Can use to specify learning objectives and
  relevant learning strategies
• Can identify where each is best learnt and who is
  responsible
• Basic education vs. continuing education
• IPC vs NSD vs self vs admin vs
• Platform for adding occupation-specific
  competencies

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What Can ICPs do?

• Focus on education
• Formal, informal
• Base sessions on core competencies
• Share them with managers, staff
• Emphasize principles, skills practice and
  discussion of application to different scenarios
  relevant to audience
• Not just info sharing, rules

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Key Challenge

• We already have basic and continuing education on
  IPC
• So what do we need to do more of or do
  differently?

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7 Core Competencies/Action

• Basic Microbiology (6)
• Hand Hygiene (4)
• Routine Practices Transmission-based
  Precautions (4)
• Personal Protective Equipment (4)
• Personal Safety (8)
• Sterilization Disinfection (3)
• Critical Assessment Skills (7)

36 items total
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1. Basic Microbiology

• Understands basic microbiology and how infections
  can be transmitted in health care settings

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Basic Microbiology

• Chain of infection agent, transmission, host
• All microbes are not the same (bacteria, virus,
  etc)
• Pathogenic vs normal flora
• Routes of transmission (contact,
  droplet,airborne)
• Recognize susceptible person
• Id reportable/Notifiable Diseases
• Define ARO local protocols
• Describe Respiratory Etiquette, importance

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Chain of Infection

• Infectious agent
• Transmission
• Susceptible host

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The Chain of Infection
Portal of exit
Portal of entry
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Routes of Transmission

• Direct contact (skin-to-skin, mucous membrane to
  mucous membrane)
• Indirect (via intermediate surface, local)
• Vehicle borne inanimate object
• Blankets, food, water, blood
• Vector borne live intermediate
• Mosquitos, tse-tse
• Airborne vs Droplet

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Process of Infection

• Microbe enters body
• Microbe multiplies in tissue (bacteria) or in
  cell (viruses)
• Bacterial toxins damage cells
• Physical damage
• Hosts inflammatory and immune responses destroy
  microbe
• SS from IR, inflammation, loss of function

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Risk of Infection if

• Infection occurs if
• microbes gtgt defenses
• Need exposure to/ entry of
  microbe
• Risk increases with
• Number of microbes (microbial load)
• Virulence of microbes
• Host susceptibility

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Discussion for Understanding

• Colonization vs. Infection
• Colonization organism grows and multiplies
  without tissue changes
• Infection damage/change to tissue
• Exposure ? Transmission ? Infection
• All airborne may be transmitted by droplet but
  not vice versa!
• Splashes/sprays travel through air so airborne
  BUT transmission is via droplet route, not
  airborne

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From the School of Photographic Arts and
Sciences, Rochester Institute of Technology
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Breaking the Chain of Infection
Portal of exit
Portal of entry
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Infection Prevention Control

• Interrupt chain of infection at any point no
  infection!
• Eliminate infectious agent
• Drugs, disinfectant, remove reservoir
• Disrupt transmission
• HH, masks, gowns etc, mosquito/vector control
• Cough etiquette
• Decrease host susceptibility
• Vaccines, good nutrition, good skin integrity

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Eg 1 Chain of Infection
Person with cold Susceptible person

• Coughs/sneezes on someone directly
• Coughs on hand and deposits virus on doorknob

• Droplets land directly on mucous membranes
• Picks up virus on hands when opens doors and then
  touches own mucous. membranes

Outline the chain of Infection. How can the
chain be broken?
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2. Hand Hygiene

• Understands the importance of hand hygiene/ hand
  washing
• Best method of preventing transmission
• Id when necessary to perform
• Steps to proper hand hygiene
• Demonstrate
• Hand washing
• Use of alcohol based hand rub

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WHOs 5 moments for HH

• Before patient contact
• Before aseptic task
• After body fluid exposure risk
• After patient contact
• After contact with patient surroundings

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How to Perform HH
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Discussion for Understanding

• Compare indications in RPAP Guidelines with the
  WHOs five moments
• Discuss examples of each moment
• Discuss why the emphasis on alcohol based hand
  rub
• Advantages/disadvantages
• Discuss when to wear gloves and link between HH
  and gloves

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Demonstrate and Practice!

Dirty Hands Hand Washing
Clean Hands
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Why dont HCWs perform HH?
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Lots of Reasons

• Irritation and dryness 
• No sinks or inconveniently located
• Lack of soap, paper, towel 
• Often too busy or insufficient time 
• Patient needs take priority 
• HH interferes with HCW/pt relationship 
• Low risk of acquiring infection from pts 
• No need if wearing gloves
• Lack of knowledge of guidelines
• Not thinking about it, forgetfulness 
• No role model
• Skeptic about the value of hand hygiene 
• Disagree with recommendations 

Unclear from research re what will work to
improve HH
Whats their reason? What can they do about it?
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3. Routine Practices Transmission-Based
Precautions

• Understands the activities of Routine Practices
  Standard Precautions
• Understands Additional Transmission-based
  Precautions
• Why and when they are used
• Assesses need based on activities
• Adapts for practice setting

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4. Personal Protective Equipment

• Knows and selects appropriate/required PPE for
  specific activities, clinical presentations and
  specific diseases relevant for their jobs
• Demonstrates appropriate use for PPE
• Donning and removing gloves, gowns, protective
  glasses, face shield, etc
• Use of NIOSH mask

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RPAP

• Routine Practices
• Assess need based on patient care activities
• Minimal practice standard
• Key to preventing transmission
• Additional Precautions
• Route of transmission determines precaution
  category
• Can operate a negative pressure room

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• Antibiotic Resistant Organisms (AROs)
• VRE, MRSA, Clostridium difficile

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Respirator Placement

• Fit Check
• Quickly inhale/exhale
• Should feel mask move under hands
• If not, reposition it

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Cap Placement

• Ensure cap covers all hair

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Protective Goggles
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Isolation Gown

• Long sleeved isolation gown
• Ties must be tied
• At neck waist level

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Gloves

• Ensure gloves are pulled over gown cuffs

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A brief Hx of RPAP

• Universal Precautions 1988
• Applied to those body fluids associated with
  blood-borne pathogens, namely, hepatitis B virus,
  hepatitis C virus, and HIV
• Standard Precautions mid-1990s
• Applied to all body fluids
• Routine Practices 1999
• All settings, all patients
• Eastern Health moving to RP

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Pyramid and Iceberg of Disease
Explain in terms of examples they can relate to!
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Practice SkillsGive Feedback
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Teach Risk Assessment and Action
Is there potential for exposure to secretions/
blood via cough or sneeze?
No
Yes
Protect mucous membranes with mask and eye gear
Teach pt cough etiquette
HH to protect hands
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Discuss Risk Assessment

• What it is and how to do it
• Using context-specific examples
• Pros and cons (vs. rote action)
• Is overestimating risk (and increasing use of
  PPE) better than underestimating risk and
  under-use?
• Different consequences, e.g., workload, using up
  supplies, reduced care to pts, fear, social
  isolation

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Apply! Eg 2 Pt has norovirus

• What precautions are required and why?
• If doc steps into room to tell pt something
• If nurse brings in medication and leaves it on
  bedside table
• If nurse helps pt take the medication
• If LPN does morning care and vital signs
• If PCA empties bedpan
• If housekeeping cleans bedside area

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5. Personal Safety

• Knows how to appropriately manage sharps, and
  blood and body fluid spills
• Recognizes appropriate first aid activities for
  exposure
• Understands the role of vaccines in preventing
  certain infections
• Knows where to get info on conditions that
  require absence from work or work restrictions

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6. Sterilization and Disinfection

• Recognizes that reusable equipment that has been
  in contact with a pt should be cleaned and
  reprocessed before use for another pt.
• Appreciates difference between clean, disinfected
  and sterile items
• Knows difference between regular and biohazard
  wastes

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7. Critical Assessment Skills
Varies by HCW type

• Knowledge r/t access of infection control
  resources (IPC manual)
• Id high risk pts and how to manage them
• Demonstrate problem solving and critical thinking
  when presented with infection control studies and
  situations
• Id clusters of illnesses (Epi principles)

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Critical Assessment Skills (contd)

• Implement protocols as directed by the IPC
• Be a leader/role model to other HCW, pts and
  visitors by adhering to IPC principles
• Demonstrate work practices that reduce risk of
  infection (immunization, not coming to work sick)

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Overview

• IPC Core Competencies for HCWs
• Why we need them/benefits
• How they were developed
• Details of the competencies
• Areas for action by ICPs

54
What Can ICPs do?

• Focus on education, both formal and informal
• Base sessions on core competencies
• Share them with managers, staff
• Get learners involved!
• Emphasize principles, skills practice, discussion
  and application to different scenarios relevant
  to audience
• Do not just share info, rules

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What Do ICPs Need?

• Knowledge of the core competencies
• A good understanding of IPC principles and
  guidelines, and how to apply them
• Able to assess and understand different learners
  needs and create examples to engage them
• Tools, e.g., scenarios, teaching resources
• We need to evaluate what works and share
• Time

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Time Theres Never Enough!

• Demand sufficient time/resources for education
• Balance education with other duties
• Restructure education sessions so have time to
  practice, discuss and apply
• Accept may need to cover fewer items but will
  cover them very well!
• Build in follow up in practice area

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Its Not Just Up To ICPs

• Up to individuals
• HCWs, IPC depts, schools, Cont. Ed., admin,
  institutions, regions
• ICPs, Educators, Admin, staff share
  responsibility
• Assess local/individual needs
• Develop or access resources
• Implement strategies in systematic way

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Conclusion

• Core competencies for HCWs are available
• Core Competencies will get us moving in the same
  direction toward same goals
• Learn them and implement strategies to achieve
  them
• Rethink how you conduct your education
• Focus on linking understanding and
  context-appropriate action
• Need to share resources and communicate needs,
  strategies, successes and failures

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Key reference

• Infection Prevention and Control Core
  Competencies for HCW a consensus document
• EA Henderson and CHICA-Canada Education Committee
  and members of CHICA-Canada Chapters
• Canadian Journal of Infection Control Spring
  2006 21(1) pp 62-67.

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Thank you! Any Questions?