I. MEDICAL ASEPSIS

HAND HYGIENE- hand hygiene is the most effective way to help prevent the spread of organisms- applies to either hand washing with plain soap and water, use of antiseptic handrubs including alcohol-

based products, or surgical hand antisepsis- important to clean hands promptly: when they are visibly soiled, after each contact with contaminated

materials, after removing gloves

1. BACTERIAL FLORA ON HANDS a. Types

i. Transient Bacteria- normally picked up by the hands in the usual activities of daily living- relatively few in number and type on clean and exposed areas of the skin- attached loosely, usually in grease, fats, and dirt (found in greater numbers under the

fingernails)- pathogenic and nonpathogenic can be removed with relative ease by washing the hands

thoroughly and frequently- may adjust to environment when present in large numbers and over a long period of time

become resident

ii. Resident Bacteria- normally found in creases in the skin (relatively stable in number and type)- cling tenaciously to the skin by adhesion and absorption, requiring considerable friction

with a brush for removal- less susceptible to antiseptics

2. CLEANSING AGENTS a. Types

i. Nonantimicrobial Agents- soaps and detergents (bar, liquid, leaflet, and powdered)- considered adequate for routine mechanical cleansing of the hands and removal of most

transient microorganisms- lower surface tension and act as emulsifying agents

ii. Antimicrobial Agents - can kill bacteria or suppress their growth- recommended in any setting where the risk for infection is high- alcohol-based handrubs are more effective in reducing bacterial counts, thus reducing

nosocomial spread of disease- alcohol-based handrubs have an alcohol concentration between 60% and 90%- available as foam, gel, or lotions- save time - do not require a sink - easily available in patient care areas

Disadvantages: can cause skin irritation and dryness which defeats the purpose of the product in decreasing the number of surface organisms because damaged skin harbors organisms and is more difficult to clean adequately- alcohol-based handrubs containing emollients address these concerns- lotions, applied after patient care, may also be used to soothe damaged

skin (oil-based lotions may adversely affect the integrity of latex gloves)

3. RECOMMENDED TECHNIQUES - if hands are visibly soiled or contaminated with blood or body fluids, washing with soap and water is

required

- if hands are not visibly soiled, an alcohol-based handrub can be used- effective Handwashing requires at least a 15-second scrub with plain soap or disinfectant and

warm water- visibly soiled need a longer scrub

- recommended all jewelry (where bacteria tend to accumulate) except wedding bands be removed- rings also increase the likelihood that gloves may tear when donned

- nails are to be kept short, with close attention to the area beneath the fingernails- polish doesn’t appear to increase numbers of microorganisms as long as it’s not chipped- clear polish is preferable to color- artificial nails are not recommended because they harbor more bacteria than natural nails,

place the wearer at risk for developing a fungal infection in the nail bed and are associated with less vigorous scrubbing in the nail area

- wearing gloves does not eliminate the need for proper hand hygiene- warmth and moisture inside gloves create an ideal environment for bacteria to multiply

- gloving does not guarantee complete protection from infectious organisms- provides a barrier but are not impenetrable

ACTION RATIONALE1. Stand in front of sink – Don’t allow clothes to touch sink during washing

Clothing may carry contamination from place to place

2. Remove jewelry Microorganisms may accumulate in settings3. Use warm water and medium force Water splashed will contaminate clothing. Warm water is

more comfortable, has less tendency to open pores and remove oils from skin. Organisms can lodge in rough, broken areas of chapped skin

4. Keep hands lower than elbows Water should flow from the cleaner (forearms) toward contaminated (hands)

5. Apply washing agent (if using bar, rinse soap again and return to soap dish)

Rinsing bar soap removes lather than may contain microorganisms

6. With firm rubbing and circular motions, wash hands, up to at least 1” above the hands (Continue for at least 15 sec.)

Friction helps loosen dirt / organismsLength of washing is determined by degree of contamination

7. Use fingernails of other hand or clean orangewood stick to clean under fingernails

Area under nails has a high microorganism count

8. Rinse thoroughly & pat hands dry using paper towels and discarding immediately without touching other clean hand

Drying and patting the skin well prevents chapping

9. Use lotion, if desired Avoid oil-based lotions – they deteriorate gloves

CONTROL VIA STERILIZATION AND DISINFECTION- cleansing, disinfection, and sterilization help to break the cycle of infection and prevent disease- items, such as pitchers, water glasses, and plastic basins, may be used repeatedly but by one patient only,

then discarded or sent home with the patient on discharge

disinfection – destroys all pathogenic organisms except spores- can be used when prepping the skin for a procedure or cleaning a piece of equipment that does not

enter a sterile body part

sterilization – process in which all microorganisms, including spores, are destroyed- performed on equipment that is entering a sterile portion of the body

1. FACTORS FOR METHOD SELECTION a. Nature of organisms present – supplies, linens, and equipment in a healthcare setting should be

treated as if the patient were infectiousb. Number of organisms present – the more present, the longer it takes to destroy themc. Type of equipment – equipment with small lumens, crevices, or joints require special care

- articles that may be damaged by various sterilization and disinfection methods require special handling

d. Intended use of equipment – medical or surgical asepsis influences the preparation and cleaninge. Available means for sterilization and disinfection – choice of chemical or physical means depends on

nature and number of organism, type and intended use of equipment, availability and practicality of the means

f. Time – failure to follow recommended time periods is grossly negligent

2. CLEANING OF SUPPLIES AND EQUIPMENT - wear waterproof gloves at all times- rinse the article first with cold running water to remove organic material- wash the articles, after rinsing them, in warm water that contains detergent or soap- use brush with stiff bristles to clean thoroughly- rinse and dry thoroughly- prepare the cleaned equipment for sterilization and disinfection- consider the brush, gloves, sink / basin highly contaminated and treat or discard accordingly

**Home Care Considerations – after thorough cleaning, some items may be disinfected by placing them in boiling water or using common household disinfectants such as bleach, isopropyl alcohol (70%) or acetic acid (white vinegar)

3. METHODS Physical:a. Steam – higher temperature caused by higher pressure destroys organisms (ex. autoclaving)

- most plastic and rubber devices are damaged by autoclavingb. Boiling Water – simple, inexpensive – frequently used in homes – boil item for at least 10 minutes

- spores and some viruses are not destroyed by boilingc. Dry Heat – alternative sterilization method for home – used for metal items – 350º heated oven for 2

hrs. or more- insufficient to destroy all microorganisms – not used in healthcare agencies

d. Radiation – used for pharmaceuticals, foods, plastics, and other heat-sensitive items- items must be directly exposed to ultraviolet radiation on all surfaces – poses risk to personnel

Chemical:a. Ethylene Oxide Gas – destroys microorganisms and spores (gases released with items in autoclave)

- precautions necessary because gas is toxic to humansb. Chemical Solutions – generally used for instruments and equipment disinfection and housekeeping

disinfection- chlorines, sodium hypochlorite (household bleach), betadine and alcohol are used- method does not destroy all spores and may cause corrosion on metal

PERSONAL PROTECTIVE EQUIPMENT (PPE) AND SUPPLIES

A. TRANSMISSION-BASED PRECAUTIONS AND BARRIER TECHNIQUES FOR INFECTION PREVENTION AND CONTROL- transfer of pathogens from person to person can be decreased by limiting the dissemination of

pathogens

- most practical way to accomplish is through the use of barriers that prevent common vehicles from transmitting the pathogens

B. PERSONAL PROTECTIVE EQUIPMENT AND SUPPLIES- check physician’s order for type of precautions and review precautions in Infection-Control Manual

- mode of transmission or organism determines type and degree of precautions- plan nursing activities and gather necessary equipment before entering patient’s room- provide instruction about precautions to patient, family members, and visitors

1. GLOVES - not a substitute for good hand hygiene- worn only once then discarded appropriately

- if worn with gown, draw glove cuffs over gown sleeves- if worn with gown, untie waist strings (considered contaminated) of gown before removing

gloves- hands are thoroughly decontaminated with meticulous hand hygiene- each patient interaction requires a clean pair of gloves- activities such as turning a patient, feeding a patient, taking vital signs, and changing IV fluid bags

do not require gloves as long as the potential contact with body fluids is not present- while wearing gloves never: leave the patient’s room (unless transporting a contaminated item

or a patient requiring transmission-based precautions)write in a patient’s chartuse the computer keyboard or telephone in the nurses’ station

- being exposed to body fluids and blood and handling many surgical instruments are both factors contributing to glove failure

a. Latex Allergy – sensitivity reactions can range from local skin reactions to urticaria (hives) to systemic anaphylaxis (an exaggerated allergic reaction that can result in death)- cornstarch powder or talc used to make gloves easier to put on is a major causative factor

-powder particles may be inhaled, be absorbed into skin or mucous membranes or enter the bloodstream

- nitrile gloves (synthetic material that resembles latex but has not latex protein) tear easily but provide an alternative to latex

- latex safe environment involves removal or covering of any natural latex rubber items, such as wall mounted blood pressure cuffs, sharps containers, injection port caps on IV tubing, and urinary catheters

- always ask whether patients have experienced any unusual signs or symptoms when blowing up balloons, using latex condoms, or wearing rubbing gloves for dishwashing or cleaning

2. GOWNS - usually worn to prevent soiling of healthcare worker’s clothing by the patient’s blood and body fluids- provide barrier protection and are donned immediately before entering a patient’s room- worn only once and then discarded appropriately- if gown becomes heavily soiled or moistened with blood or body fluids when caring for a patient,

remove it, perform thorough hand hygiene and put on a clean gown- neck strings are considered clean

- gown that is not visibly soiled requires no particular technique for removal

3. MASKS - help prevent wearer from inhaling large-particle aerosols, which usually travel short distances

(about 3 ft) and small-particle droplet nuclei, which can remain suspended in air and travel longer distances

- discourage wearer from touching the eyes, nose, and mouth, limiting contact with mucous membranes

- worn only once and never lowered around the neck and then brought back over the mouth and nose for reuse

- high-efficiency particulate air (HEPA) filter respirator or N95 respirator certified by NIOSH must be worn when entering room of patient with known or suspected tuberculosis- these respirators filter inspired air (surgical masks filter only expired air)- N95 respirator fits more comfortably against the face and costs considerably less than the

HEPA filter respirators- elastic straps provide more protection and a better fit than the ties on regular surgical masks

4. PROTECTIVE EYEWEAR - goggles or face shield- must be available whenever there is a risk of contaminating the mucous membranes of the eyes

ex. while suctioning a tracheostomy or assisting in an invasive procedure

5. OTHER SUPPLIES AND PROCEDURES - used equipment may be disposed of after use or, if reusable, bagged and sent to a central cleaning

area, and sterilized or disinfected- use of paper trays and plastic eating utensils does not prevent transmission of pathogens and is no

longer recommended- combined hot water and detergent used in commercial dishwashers sufficiently decontaminates

dishes, glasses, and utensils- when collecting a specimen, take care to prevent the outside of the container from becoming

contaminated- place all laboratory specimens in plastic bags and seal to prevent leakage during transport- bag marked “BIOHAZARDS” is used to dispose of trash containing liquid or semi-liquid

blood or other potentially infective material (OPIM)

SPECIALIZED INFECTION-CONTROL PRECAUTIONSisolation – protective procedure that limits the spread of infectious diseases among hospitalized patients,

hospital personnel, and visitors

CDC recommends that healthcare workers use gloves, gowns, masks, and protective eyewear when exposure to blood or body fluids is likely and that all patients should be considered potentially infected- blood, semen, vaginal secretions, breast milk, cerebrospinal, synovial, pleural, peritoneal, pericardial, and

amniotic fluids are included

Body substance isolation precautions consider all body substances potentially infectious regardless of person’s diagnosis, advocating the consistent use of barriers whenever healthcare personnel have contact with moist body substances, mucous membranes and nonintact skin- include not only blood and blood-tinged fluids but also feces, urine, wound drainage, oral secretions,

vomitus, and any other body substances- varicella (chickenpox), influenza, and pulmonary tuberculosis are examples of airborne diseases that

require a private room with a door closed and a “Stop Sign Alert”- mask use depends on the organism and visitor’s immune status

- body substance isolation precautions also provide a consistent approach to soiled linen, trash disposal, and laboratory specimens

STANDARD PRECAUTIONS – precautions used in the care of all hospitalized individuals regardless of their diagnosis or possible infection status

- apply to blood, all body fluids, secretions, and excretions except sweat (whether or not blood is present or visible), nonintact skin and mucous membranes

Techniques: wear clean nonsterile gloves and PPEavoid recapping needleshandle patient care equipment that is soiled with blood or identified body fluids, secretions,

and excretions carefullyuse adequate environmental controlsreview room assignments carefully

TRANSMISSION-BASED PRECAUTIONS – precautions used in addition to standard precautions for patients in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet or contact routes- encompass all the diseases or conditions previously listed- recognizes that a disease may have multiple routes of transmission

Techniques: in addition to standard precautionsAirborne – for infections spread through the air

- place patient in private room that has monitored negative air pressure- use respiratory protection- transport patient out of room only when necessary and with a surgical mask on the patient- consult CDC Guidelines for additional preventions regarding tuberculosis

Droplet – for infections spread by large-particle droplets- use private room (door may remain open)- wear a mask when within 3 ft. of patient- transport patient out of room only when necessary and with a surgical mask on the patient- keep visitors 3 ft. from infected person

Contact – for infections spread by direct or indirect contact- use private room- wear gloves- wear gown if contact with infectious agent is likely- limit movement of patient out of room- avoid sharing patient-care equipment (blood pressure cuff, stethoscope, thermometer, etc)

SPECIAL SITUATIONS Methicillin Resistant Staphylococcus Aureus (MRSA)Vancomycin Resistant Enterococcus (VRE)

- use standard and transmission-based (particularly contact) precautions- avoid wearing rings, bracelets, or watches

Immunosuppressed Patients – more often than not become infected by organisms harbored in their own bodies rather than pathogens present in the environment or transmitted from other people- provide a healthy healthcare provider- restrict visits from friends and family who have colds or contagious illnesses- avoid standing collection of water in the room

II. SURGICAL ASEPSIS-procedures that involve the insertion of a urinary catheter, sterile dressing changes, or preparing an

injectable medication are examples of surgical asepsis techniques- object is considered sterile when all microorganisms, including pathogens and spores, have been

destroyed- observing medical asepsis, areas are considered contaminated if they bear or are suspected of

bearing pathogens- observing surgical asepsis, areas are considered contaminated if they are touched by any object

that is not also sterile- effectiveness of both depends on faithful and conscientious practice by those carrying them out

OPENING A STERILE PACKAGE AND PREPARING A STERILE FIELD- sterile packages may be opened on a flat surface or while held in the hands

1. POURING STERILE SOLUTIONS - most solutions are considered sterile for 24 hours after they are opened- when pouring from a bottle, grasp the bottle so that the label is in the palm of your hand

(prevents any liquid from running over the label and making it illegible)- if pouring from a bottle that has been previously used, “lip” it by pouring a small amount out into a

waste receptacle to “clean” the rim of the bottle

2. ADDING STERILE SUPPLIES TO A STERILE FIELD - sterile gloves are donned in a way that allows only the inside of the gloves to come in contact with

the hands- after gloves are on, only sterile items may be handled with the sterile-gloved hands

3. POSITIONING A STERILE DRAPE - sterile drape, which ideally is waterproof, may be used to extend the sterile working area- using sterile gloves allows the nurse to handle the entire drape surface

- for protection when positioning, fold the upper edges of the drape over the sterile gloved hands- when sterile gloves are not worn, the nurse can touch only the outer 1” of the drape

- use caution when shaking the drape open so as not to touch one’s clothing or an unsterile object- holding the drape by the 1” upper edge, position the drape over the desired area- do not reach over the drape

PREVENTING NOSOCOMIAL INFECTIONSnosocomial – hospital acquired infection

- infection results while the patient is receiving healthcare and source is either exogenous or endogenous

- 5th leading cause of death in acute care settings

exogenous – causative organism is acquired from other people

endogenous – causative organism comes from microbial life harbored in the person

iatrogenic – infection comes from treatment or diagnostic procedure

A. INVASIVE MEDICAL DEVICES- urinary tract infections, pneumonia, and bloodstream infections are the three most common

sources for nosocomial infections- hemodynamic monitoring lines, hemodialysis equipment, and respiratory equipment are also examples

- patients receiving mechanical ventilation are especially at risk for nosocomial pneumonia- hands of the healthcare worker are the most significant means for transmission - surgical wounds are also a common site for infections to develop- increasing use of biomedical equipment is often cited as a causative factor

B. ANTIBIOTIC RESISTANT ORGANISMS- indiscriminate use of broad-spectrum antibiotics has allowed once-susceptible bacteria to develop

defenses against antibiotics- Methicillin Resistant Staphylococcus Aureus (MRSA), Vancomycin Resistant Enterococcus (VRE),

Vancomycin Intermediate Resistant S. Aureus (VISA) are examples- linezolid (Zyvox) is effective against the deadliest enterococcal pathogens and provides an

alternative if vancomycin resistance develops- administered IV or orally

- culture of a wound, blood, or other body fluids can identify the specific organism present- sensitivity test determines which antibiotic is most effective against the organism

C. STRATEGIES TO PROTECT THE PATIENT- MRSA and VRE are most often transmitted by the hands of the healthcare providers

- can also be spread through patient contact with a contaminated surface, such as side rails or overbed table

- VRE lives much longer in the environment and is more likely to spread

Strategies instituting constant surveillancehaving written infection-prevention practices for all personnelusing practices to promote and keep patients in the best possible physical condition

(meet nutritional needs, fluids, rest, oxygen, and physical and psychologicalcomfort and security)

MEETING NEEDS OF PATIENTS REQUIRING INFECTION-CONTROL PRECAUTIONS- sensory deprivation and loss of self-esteem may occur with patients regarding the use of transmission-

based precautions- emphasize: precautions are temporary

precautions and PPE protect the patient, caregiver, and other patientsproper hand hygiene before and after visiting the patientcontinued explanations about procedures and continued updates on progress

- MUST document health teaching about barrier precautions in patient’s plan of care

ACCIDENTAL EXPOSURE REPORTING- nurses are accountable for their own safety

- any needlestick injury or accidental exposure to blood or body fluids must be reported immediately so that appropriate interventions can be used

- failure to report may result in personal jeopardy as well as loss of compensation if an infection develops

Plan of Action: washing exposed area immediatelyreporting incident to appropriate person and completing incident reportreporting the source and nature of exposureconsenting to initial baseline blood test with follow up testingconsenting to postexposure prophylaxisawaiting blood test resultsattending counseling session regarding safe practices

TEACHING ABOUT INFECTION CONTROL- patients need to be aware of techniques that prevent spread of infection

- medical asepsis techniques are appropriate for most procedures at home, except self-injections and venous catheter care

Home Practices: washing hands before preparing food and before eatingpreparing foods at temps. high enough to ensure safe eatingusing care with cutting boards and utensils – thorough cleaning before and after

handling raw meatkeeping food refrigerated, especially those containing mayonnaisewashing raw fruits and vegetables using pasteurized milk and fruit juiceswashing hands after using the restroomusing individual personal care items (washcloths, towels, toothbrushes, etc.)

Public Practices: wash hands after using any public restroomuse paper towels or hot-air dryers in restroomsuse individually wrapped drinking strawsuse tongs to lift food from common service trays

Community Practices: use sterilized combs and brushes in barber and beauty shopsperform exam of food handlers for evidence of disease

CDC – Center for Disease Control

APIC – Association for Professionals in Infection Control and Epidemiology

OSHA – Occupational Safety and Health Administration

NIOSH – National Institute for Occupational Safety and Health

JCAHO – Joint Commission on Accreditation of Healthcare Organizations

HICPAC – Hospital Infection Control Practices Advisory Committee