Infection Control in the Hospital Setting

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Infection Control in the Hospital Setting

• Vickie Brown, RN, MPH, CIC
• Associate Director
• Hospital Epidemiology
• UNC Health Care

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Hospital Epidemiology

• Infection Preventionists
• Becky Brooks, RN, CIC
• Tina Adams, RN
• Brenda Featherstone, RN
• Lisa Teal, RN
• Kirk Huslage, RN, MPH

• Director
• William Rutala, PhD, MPH
• Medical Director
• David Weber, MD, MPH
• Public Health Epidemiologist
• Emily Sickbert-Bennett, MS

Location 1st Floor, West Wing, Memorial
Hospital Office Hours Monday Friday 730 AM to
4 PM Phone [phone]
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Infection Control Resources

• Infection Control Policies on Hospital Intranet
• http//intranet.unchealthcare.org/hospitaldepartme
  nts/infection/policies
• Infection Control on call pager available 24/7
  216-6652

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PURPOSES OF EPIDEMIOLOGY

• To plan and evaluate interventions and prevention
  strategies more effectively by knowing
• The distribution of disease
• Its determinants in person, place, and time

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CHAIN OF INFECTION

• Infection requires a chain of events
• The role of the hospital epidemiologist/infection
  control is to understand this chain and the most
  efficient means of interrupting transmission

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CHAIN OF INFECTION

• Causative agent
• Susceptible host
  Reservoir
• Inoculating dose
  Portal of exit
• 
  
• Portal of entry
  Environmental
• 
  survival
• Mode of transmission

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SOURCES OF PATHOGENS

• People
• Endogenous Normal flora or reactivation
• Exogenous People (staff, visitors) or
  environment
• Animals
• Arthropods (insects)
• Environment

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Normal Skin Micro-Flora
Numbers of bacteria that colonize different parts
of the body

• Numbers per square centimeter of skin surface
  (cfu/cm2).

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ICU Setting Multiple Sources of Pathogens
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Basic Modes of Transmission

• Contact-victim contact with source
• Direct-physical contact between source (e.g.,
  MRSA on medical students hands) and victim
  (patient medical student is examining)
• Indirect-victim contacts contaminated inanimate
  object (e.g., ultrasound probe contaminated with
  MRSA or VRE)
• Droplet-infectious droplets deposited on mucous
  membranes of the nose or mouth
• Airborne-airborne phase in disease dissemination
• Vectorborne-not a significant source in US
  healthcare facilities

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• Isolation Precautions to Prevent the
  Transmission of Infections to Patients and
  Personnel

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STANDARD PRECAUTIONS

• Hand hygiene Before and after each patient
  contact after gloves removed
• Gloves When touching contaminated items (blood,
  body fluids, secretions, excretions).
• If it is wet and not yours, wear gloves!
• Mask, eye protection, face shield whenever
  splashes or sprays of body fluids possible
• Gown Whenever splashes or sprays of body fluids
  possible

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• Personal Protective Equipment (PPE)
• Gloves
• Gown
• Mask
• Eyewear

Wear your personal protective equipment correctly!
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AIRBORNE PRECAUTIONS

• Used for patients with known or suspected
  diseases transmitted by airborne droplet nuclei
  (lt5 microns)
• Private room
• Negative air pressure in relation to the corridor
• gt6 air exchanges per hour
• Direct discharge of air to the outside
• Personnel Respiratory protection required
• N-95 respirator
• Limit transport of patient to essential purposes

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AIRBORNE PRECAUTIONS

• Representative pathogens
• M. tuberculosis
• Varicella
• Zoster
• Measles

HCWs required to wear a respirator to enter room
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SPECIAL AIRBORNE PRECAUTIONS

• Used for patients with known or suspected
  diseases transmitted by airborne droplet nuclei
  and contact
• Private room (must meet airborne isolation
  guidelines)
• Personnel Respiratory protection required
• N-95 respirator
• Eye protection Shield or goggles
• Gowns and gloves when entering room
• Limit transport of patient to essential purposes

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SPECIAL AIRBORNE PRECAUTIONS

• Representative pathogens
• Avian influenza
• Monkey pox
• SARS Co-V
• Smallpox
• Viral hemorrhagic fever (e.g., Ebola, Lassa)

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DROPLET PRECAUTIONS

• Used for diseases spread
• via large droplets (gt5 microns)
• Private room
• Special air handling not required
• Personnel
• Surgical mask upon entering room

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DROPLET PRECAUTIONS

• Representative pathogens
• Invasive N. meningitidis
• RSV
• Bordetella pertussis
• Rubella
• Mumps
• Group A streptococcal pharyngitis
• Influenza

H1NI Precautions
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CONTACT PRECAUTIONS

• Used for pathogens that
• can easily be transmitted by
• contact with patient and/or items
• in the patients environment
• Private room
• Gloves and gown when entering room
• Careful hand hygiene

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Representative Pathogens

• Methicillin-resistant S. aureus (MRSA)
• Vancomycin-resistant enterococcus (VRE)
• C. difficile
• Norovirus
• Multiply-drug resistant (MDR) gram negative rods
  (e.g., B. cepacia, P. aeruginosa, Acinetobacter)

All of the above organisms can survive on
environmental surfaces for long periods of time
and can be transiently carried on hands.
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Bloodborne Pathogens
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UNC Hospital Employees
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BLOODBORNE PATHOGENSTRANSMITTED BY NEEDLESTICKS

• Ebola virus infection
• Herpes simplex I
• Leptospirosis
• Malaria
• Marburg VHF
• Mycobacterium marinum
• Mycoplasma caviae infection
• Rocky Mountain spotted fever
• Syphilis
• Toxoplasmosis
• Tuberculosis
• Varicella zoster
• West Nile

• Big 3
• Hepatitis B
• Hepatitis C
• HIV
• Others
• Argentinean VHF (Junín virus)
• Blastomycosis
• Brucellosis
• Corynebacterium diphtheria
• Cryptococcus
• Dengue
• Diphtheria

Tarantola A, et al. AJIC 200634367-75
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Campus Health

• Blood/body fluid exposure reporting 966-6561
• After hours, weekends call Health Link 966-2281
• Additional Information Exposure Control Plan for
  Bloodborne Pathogens attachment 12 55-58.
• http//intranet.unchealthcare.org/hospitaldepartme
  nts/infection/policies/Ecpbbp.pdf

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Other Communicable Diseases with Risk of
Occupational Exposure

• Tuberculosis
• Varicella zoster
• Pertussis
• Influenza
• Meningococcal Meningitis
• Parvo Virus-B19

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UNC OHS EVALUATIONS, 2007-08
Disease 2007 Index Cases 2007 Staff Screened 2007 Infected 2008 Index Cases 2008 Staff Screened 2008 Infected
Tuberculosis 9 38 1 4 14 0
Pertussis 4 11 0 5 19 0
Varicella 1 0 0 0 0 0
Zoster 3 0 0 0 0 0
Syphilis 5 9 0 6 9 0
N. meningitidis 1 49 0 3 16 0
Hepatitis B 2 2 0 2 2 0
Hepatitis C 27 27 0 39 39 1
HIV 12 0 0 10 10 0
All blood 269 269 0 314 314 1
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• Health Care Associated Infections
• (HAIs)

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Impact of HAIs

• 2002 data from CDC National Nosocomial Infections
  Surveillance Systems
• Estimated number of HAIs 1.7 million
• Estimated number of deaths associated with the
  HAI98,987
• Pneumonia 35,967
• Bloodstream 30,665
• Urinary tract 13,088
• Surgical site 8,205
• Other sites 11,062

Klevens RM. Public Health Rep. 2007, 122(2)160-6
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Economic Costs of HAIs

• Overall annual direct medical costs range from
  28.4 to 33.8 billion (adjusted to 2007
  dollars).

http//www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper
.pdf
Scott DR, CDC, March 2009
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COST ESTIMATES FOR SPECIFIC HEALTHCARE-ASSOCIATED
INFECTIONS
HAI type Weight-Adjusted Cost per HAI Mean SE Range of Published Estimates of Cost per HAI
VAP 25,072 4,132 8,682-31,316
BSI 23,242 5,184 6,908-37,260
SSI 10,443 3,249 2,527-29,367
CA-UTI 758 41 728-810
(2005 dollars)
Anderson DJ, et al. ICHE 200728767-773
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UNC HOSPITALSSELECTED HAIs AND ESTIMATED COST
HAI type UNC Cases, 2008 Estimated Cost
VAP 82 2,055,904
BSI 231 5,368,902
SSI 335 3,498,405
CA-UTI 339 256,962
Total 987 11,180,173
Total cost estimated by multiplying number of
cases at UNC Hospitals by mean cost derived from
Duke meta-analysis
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• What is the most effective and simplest method
  to protect your health and to help prevent HAIs?

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UNC Hospitals Intensive Care Units Hand
Hygiene Compliance (), 2003-2008

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Hand Hygiene Methods

• Soap and water
• Hand washing with antimicrobial soap (e.g.CHG)
  and water for 15 seconds
• Alcohol-based handrubs (e.g. Alcare) when
• Hands are not visibly soiled, or
• Hand washing facilities are not available in
  patient rooms
• Use soap and water when
• Patient known or suspected to have C. difficile
  disease or norovirus infection (alcohol not
  effective against spores or nonenveloped viruses)

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Indications for Handwashing and Hand Antisepsis

• Before having direct contact with patients.
• Before donning sterile gloves for sterile/aseptic
  procedures (e.g., central venous catheter
  placement)
• After glove removal
• After patient contact
• After contact with a contaminated instrument or
  surface

- Artificial nails and nail extenders are
prohibited for direct patient care providers.
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In Review

• Infections can be transmitted in the hospital
  setting via contact, droplet, or airborne spread
• Adherence to Isolation Precautions prevents
  transmission of disease to you and to other
  persons
• Appropriate use of PPE and safe handling of sharp
  devices can reduce your risk of exposure to
  bloodborne pathogens
• Hand hygiene reduces the risk of transmission of
  pathogenic organisms
• Questions related to infection prevention and
  control contact Hospital Epidemiology _at_ 6-1638
  and after hours on pager 216-6652

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Thank You!
I don't see the glass as half-empty or
half-full. I see it as a glass somebody else has
already put their lousy germs on. Maxine