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Last Updated Aug 2019
Clinical Staff
Annually
Avoid printing this document if possible
Please ensure you read and complete the multiple choice questions at
the end of the Workbook
Please email your answers to [email protected]
You must score 8 correct answers to update your mandatory
training.
If you fail to achieve this, you will be asked to attend the
Infection Prevention Level 2 face to face session offered twice
a month in the lecture theatre.
Infection Prevention Level 2
2
More serious illness
Prolonged stay in a health care facility
Long-term disability
Excess deaths
High additional financial burden
High personal cost on patients and their families
3
Introduction
Good infection control is essential to ensure that people who use Health and Social
Care Services receive safe and effective care. Effective prevention and control of
infection must be part of everyday practice and be applied consistently by
everyone.
Good management and organisational processes are crucial to make sure that high
standards of infection prevention and control are set up and maintained.
As the regulator of Health and Adult Social Care in England, the Care Quality
Commission (CQC) will provide assurance that the care people receive meets
essential levels of quality and safety.
The Health and Social Care Act outlines what hospitals in England need to do to
ensure compliance with the registration requirement for cleanliness and infection
control, and sets out 10 compliance criteria.
1. Systems to manage and monitor the prevention and control of infection.
These systems use risk assessments and consider how susceptible patients
are and any risks that their environment and other patients may pose to them.
2. Provide and maintain a clean and appropriate environment in managed
premises that facilitate good hygiene practices.
3. Provide suitable and accurate information on infections to patients and their
visitors.
4. Provide suitable accurate information on infections to any person concerned
with providing further support or nursing/medical care in a timely fashion.
5. Ensure that people who have/develop an infection are identified promptly and
receive the appropriate treatment and care to reduce the risk of passing on
the infection to other people.
6. Ensure that all staff and those employed to provide care in all settings are fully
involved in the process of preventing and controlling infection.
7. Provide or secure adequate isolation facilities.
8. Secure adequate access to laboratory support as appropriate.
9. Have and adhere to policies designed for the individual’s care and provider
organisations that will help to prevent and control infections.
10. Ensure, so far as reasonably practicable, that care workers are free of and are
protected from exposure to infections that can be caught at work and that all
staff are suitably educated in the prevention and control of infection
associated with the provision of health and social care.
The Health and Social Act 2008
4
Infection Prevention
The term HCAI (Health Care Associated Infection) covers a wide range of infections.
The most well-known include those caused by methicillin resistant Staphylococcus
aureus (MRSA), Methicillin-sensitive Staphylococcus aureus (MSSA), Clostridium
difficile (C.diff) and Escherichia coli (E.coli).
HCAIs cover any infection contracted:
as a direct result of treatment in, or contact with, a health or social care setting
as a direct result of healthcare delivery in the community
as a result of an infection originally acquired outside a healthcare setting (for
example, in the community) and brought into a healthcare setting by patients,
staff or visitors and transmitted to others within that setting (for example,
Norovirus).
Infection prevention and control is a key priority for the NHS, and Public Health
England (PHE) has a responsibility to advise and support the NHS and others in their
efforts to prevent HCAIs and any associated risks to health.
In 2011 and 2016, Airedale hospital took part in the Europe wide point prevalence
survey of hospital acquired infection. Our HCAI rate has dropped from 6.8% to 5.5%
which is excellent news and which shows that staff are ‘adhering to policies,
designed for the individual’s care and provider organisations that will help to
prevent and control infections.’ (Criteria 9)
5
Staphylococcus Aureus
Gram positive skin organism
Methicillin (Flucloxacillin) sensitive staphylococcus aureus (MSSA)
All bloodstream infections reported to PHE. Post infection review for hospital
acquired cases.
Can cause minor skin infections:
(pimples,
impetigo,
boils,
cellulitis,
folliculitis,
abscesses
Can cause life-threatening diseases:
pneumonia
meningitis
osteomyelitis
endocarditis
bacteraemia
Orthopaedic joint infections
Can produce Toxins
Key themes seen:
Staph aureus blood stream infections
Source: unobserved cannulae becoming infected.
Prevention
Good hand hygiene of staff members and patients.
Encourage patients not to touch invasive devices
Check cannulas twice a day for signs of infection
Encouraging patients to wash or shower every day
Ensuring wounds are clean and covered
Wear aprons for changing bed linen
Don’t sit on beds
6
Staphylococcus Aureus
Staphylococcus aureus (S. aureus) is a Gram positive bacterium that commonly
colonises human skin and is carried in the nose, throat, axillae, toe webs and
perineum without causing infection. Once the bacteria gains access to the body, for
example through a cannula site or a surgical procedure, a mild to life-threatening
infection may develop. S. aureus, (whether MSSA or MRSA) is one of the most
common culprits associated with orthopaedic implant infections. Patients with an
Orthopaedic joint, with a S. aureus bacteraemia may go on to develop an implant
infection in around 34% of cases. (Clinical services Journal 2010)
S. aureus can produce toxins which can cause:
Scalded skin syndrome which attacks skin cells, causing them to split causing
large red weeping areas. Paediatrics patients and neonates are more at risk.
Toxic shock syndrome causing hypotension, fever, diarrhoea, skin shedding rash.
Enterotoxin causes acute sudden onset gastroenteritis, when food is contaminated
with S. Aureus, by interfering with electrolyte imbalance in the gut.
Panton-Valentine Leukocidin (PVL) is a toxin that destroys white blood cells and
causes extensive tissue necrosis and severe infection. It is carried by < 2% of
isolates of S. aureus, (See Management of PVL associated Staphylococcus aureus
infections (PVL-SA) Guideline on Aireshare)
Preventing the spread of infection
Therefore good hand hygiene of both staff members and patients is needed to
prevent transferring the germ around the ward/ hospital.
Staff should wear clean clothes or uniforms daily.
Staff should wear an apron for changing bed linen to prevent skin cells
getting on their uniform and should dispose of used linen straight into a linen
skip at the bed side, to prevent skin cells from becoming airborne. Hand gel
should be applied between beds.
Staff should cover any cuts or abrasion with waterproof plasters to prevent
themselves from getting wound infections from germs found in the hospital
7
environment. (Contamination injury)
Staff and visitors should not sit on patients beds to prevent the transfer of
organisms to or from the patient.
Methicillin (Flucloxacillin) resistant
Staphylococcus Aureus (MRSA)
Rising numbers of mupirocin resistance
Screening Programme (Acute and some elective patients)
Management of cases/expectations
All bloodstream infections reported to PHE
Post infections reported to PHE
Post infection review for Hospital Acquired Cases
Staphylococcus aureus that are resistant to Flucloxacillin are called MRSA as
Methicillin was the previous antibiotic used before Flucloxacillin came on the market.
MRSA can vary in resistance to other antibiotics. Our bacteraemia (or blood stream
infection) target is Zero MRSA Blood stream infections.
Screening Programme
All acute admissions to hospital get screened for MRSA and some elective
patients. This is due to a DoH study that found that only 1% of elective admissions
were MRSA colonised. The exceptions are patients coming for elective orthopaedic
operations, pacemaker insertion and breast reconstruction surgery as the surgery is
considered a high risk of infection.
8
Mupirocin resistant
Since January 2017 we have seen a large increase in Mupirocin (Bactroban)
resistant MRSAs. This is partly due to the germ becoming more resistant and the lab
using more sensitive testing equipment that picks up more cases than we would
through the agar plate method that was previously used. When the germ is resistant
to Mupirocin (Bactroban) we have a second line treatment that should be used.
Management of cases/expectations
If a patient is found to be colonised from a nasal screen or infected from a
swab/sample, they should be isolated (gold standard) or nursed in a bay with other
low risk patients who have no wounds, catheters or cannulas. The patient is
prescribed 5 days of nasal antibiotic cream and 5 days of antiseptic body wash
which supresses the MRSA present on the skin and allows healthy skin flora to take
its place.
(NB: Naseptin (used for pregnant mums) nasal cream is a 10day course.)
The MRSA patient information leaflet explains how to correctly apply the
suppression. Medical staff will decide treatment of any positive swab (e.g. wound) or
sample (e.g. urine) with the microbiologist. The MRSA carepathway (Infection
prevention Aireshare page) informs you of all the necessary actions that are needed
to prevent further spread of infection whilst caring for the patient.
Post Infection Reviews
Any MRSA blood stream infection will have a post infection review (PIR), where
nursing and medical staff meet to look at how the patient got the infection, whether it
was preventable or unpreventable and lessons learned.
MRSA Alert symbol!
The yellow IC triangle symbol above the patients name on the SystmOne ward board
identifies that the patient as having a history of MRSA colonisation or infection. For
more information, see MRSA Management Guideline’ on AireShare.
9
MRSA Screening
Patient groups to be screened:
All adult general acute admissions
Patients admitted to/attending high risk areas as per individual departmental
protocols
Elective orthopaedic, pacemaker insertion and breast implant patients at pre-
assessment.
MRSA colonistion suppression to be started on:
Patients found to be MRSA positive on
screening
All patients admitted from a
nursing/residential home
All acute orthopeadic patients on admission if
over 65 years of age
Please remember to screen any invasive device that the patient has
insitu on admission for MRSA, aswell as their nasal screen. MRSA
may be colonising these sites (as it is a skin organism) but may
precede to cause an infection if staff are not aware.
10
Winning the Battle Against MRSA
Invasive devices can be an entry point
for infection.
Preventing a Catheter associated urine infection
Urinary catheters bypass the body’s natural defence of the flushing action of urine.
They are frequently responsible for hospital acquired urinary tract infections and are the most common source of bloodstream infections here at Airedale.
Germs can enter the urinary tract due either to poor aseptic technique on insertion, as a result of contamination by staff members’ hands during handling of the device, poor personal hygiene of the patient, lack of post insertion
11
catheter care or simply the catheter bag touching the floor thus allowing germs access to the device.
Please ensure that the Urinary Catheter
Monitoring Bundle is correctly filled in
daily. It also conatins
Monitoring peripheral cannulae/central lines
for signs of infection
12
Peripheral Vascular Catheter (PVC)
Infection
There are four possible pathways leading to peripheral vascular catheter (PVC)
infection.
First: Migration of microbes down the catheter tract i.e. through the ‘wound’
created to insert the catheter. These microbes may be from the patient’s skin, or
contaminated disinfection or the healthcare worker’s hands. The process may
happen on insertion if the catheter is contaminated and then introduced into the
patient or via microbiologic migration at any time while the catheter is in situ. The
insertion of a PVC provides a portal or entry for bacteria to cross from an unsterile
external environment to the normally sterile blood.
Second: The second route is via the catheter hub, which can become
contaminated by healthcare workers’ or patients’ skin flora during connection of
fluids, medicine administration or during extraction of blood. Nishikawa reported that
bacterial contamination was more common in the hub area than indwelling catheter
segments, and the hub seems an important risk in post-insertion care, in addition
to adequate aseptic technique on catheter insertion (Nishikawa et al, 2010; Zingg
and Pittet, 2009)
Third: The third route is for catheters to be contaminated directly by bacteria
circulating in the bloodstream. That is, the patient has an existing bloodstream
infection and microbes are able to attach to the catheter as they pass by the device.
Fourth: The fourth is that of contaminated infusate which may occur at the
manufacturing stage (intrinsic) or during manipulation by healthcare workers
(extrinsic). Research confirms that infusates other than water, including heparin,
have great potential to form crystals in the intraluminal surface of PVCs, which can
induce bacterial attachment and colonisation. (Nishikawa et al, 2010).
13
A microbial attachment on the PVC surface is likely to be followed by biofilm
development and maturation and dispersion of microbial cells from the biofilm into
blood stream. The most frequently isolated bacteria from PVCs are coagulase-
negative staphylococci and staphylococcus aureus. These bacteria can originate
from the skin flora of the patient or the hands of healthcare workers and then reach
the patient’s tissues and organs via the blood, causing serious infections and
high mortality rates. Thus the infectious route for these organisms is likely skin-
bloodstream; i.e. the bacteria enter the bloodstream through PVC wounds in the skin
and cause subsequent infection in other organs.
The next most common pathogens for PVC related infections are Gram-negative
bacilli such as E. coli. These microorganisms are generally acquired from the
hospital environment. (Infection risks associated with Peripheral vascular catheters,
Zhang et al 1016)
Ensure the point of insertion is visible under the dressing
allowing staff to check for sign of phlebitis. Ensure that the
dressing is dated with the insertion date and the Visual Infusion
Phlebitis (VIP) score and cannula care plan is completed with
the name of the person who inserted the cannula. Observations
of the cannula site should take place twice a day. If any signs of
phlebitis are observed, then the guide below should be followed.
Please ensure that AFFs are completed for any phlebitis that
scores 2 or above.
The new VIP chart for 2018 has an
observation panel on the back. This is
so that staff can monitor any areas of
phlebitis post cannula removal.
14
Phlebitis Score
15
Clostridium difficile (C.diff)
Often C.diff patients present with confusion, dehydration, acute kidney injury (AKI)
due to profuse diarrhoea and possibly even a fall due to dizziness. A stool sample
should be sent to rule out colitis caused by C.diff in these patients.
16
C.diff is an anaerobic germ which means it thrives in the gut where no oxygen is
present but dies when exposed to oxygen. It overcomes this by being able to form a
spore, where it wraps itself in a protective layer and lies dormant in the environment,
waiting to be picked up on hands and ingested (eaten!). Getting patients to:
Wash their hands with soap and water after opening their bowels will
remove any C.diff spores present, thus preventing them from being left in the
environment.
Wash their hands before eating will prevent them from ingesting any
spores picked up from the environment
Communicating with Ward Domestics or Ward Supervisor (x4102)
Communicate to the Ward Domestics or Ward Supervisor:
if a patient has been using the communal toilets on the ward
whilst having diarrhoea so that the toilets can be cleaned with
Tristel fuse and spores removed from the environment
17
which side rooms contain infected patients so that they can be cleaned twice
daily with Tristel fuse.
Infection prevention- It is important to physically separate the symptomatic
patient from other vulnerable patients in order to prevent the spread of Clostridium
difficile. They should remain isolated in a single room until 48 hours free of
symptoms. Please see the Clostridium Management Guideline for advice on
treatment options or speak to the Microbiologist. The patient’s side room should
ideally have its own toilet and the side room door should remain closed where
possible, due to airborne dispersal of spores. The side room should be cleaned
twice a day with Tristel fuse and the commode should be cleaned after each
use. Allocate where possible specific equipment for the infected patient e.g.
moving and handling slings, wash bowl, single patient use blood pressure cuff and
tourniquet. These must be decontaminated after use.
Contact precautions- Non-sterile disposable gloves and plastic aprons should be
put on outside the patient’s room and worn when in contact with the patient, with any
body fluids or their environment. Before leaving the sideroom, gloves should be
removed first (without contaminating your hands); then your apron (breaking the neck
strap first and then your hands must be thoroughly washed with warm water and
liquid soap and dried with paper towels. Hygienic hand rub must not be used as an
alternative as this has no effect on Clostridium difficile spores.
18
Winning the Battle against C.difficile
Please ensure all staff know
that commodes should only
be cleaned with Tristel Fuse.
This is the only solution that
kills C.difficile.
Detergent wipes should
NEVER be used or even
stored in the sluice.
19
The Challenge to Reduce Gram
Negative Infections
The previous Secretary of State for Health launched an
ambitious challenge to reduce healthcare associated Gram-
negative (E.coli, Klebsiella and pseudomonas) bloodstream
infection by 50% by 2021. Gram-negative bloodstream infection
is believed to have contributed to approximately 5,500 NHS
patient deaths in 2015.
Enterobacteriaceae are a large family of Gram-negative bacteria
that includes many of the more familiar pathogens (germs that
cause disease), such as Salmonella, Escherichia coli (or E. coli),
Yersinia pestis (causes plague), Klebsiella and Shigella, Proteus,
Enterobacter, Serratia, and Citrobacter. E. coli is a part of all human and animal gut
flora and can be picked up from animals, other humans or through the food chain in
uncooked food.
,
20
Ingesting E.coli causes no symptoms (unless the germ produces a toxin as in E.coli
157) as the body does not recognise E.coli as a pathogen. Gut flora are readily
shared among family members, in prisons, hospitals, music festivals, anywhere
where hand hygiene is poor and the environment is contaminated with these germs.
Trying to achieve this target set by the Secretary of State for Health is likely to be a
far harder challenge than previous targets to reduce MRSA blood stream
infections (BSI) and C. difficile, and the evidence base around which to develop
preventive strategies is presently rather thin. Also, there are no accepted
decolonization treatments for people colonized with Gram-negative bacteria.
Consequently, the infection control strategies that have been successful in
preventing MRSA BSI cannot be expected to work for blood stream infections
caused by Gram-negative bacteria. Several guidelines have been published on the
prevention and control of multidrug-resistant Gram-negative bacteria; however, there
are no guidelines that consider the prevention and control of blood stream infections
caused by non-resistant Gram-negative bacteria within healthcare settings. (Journal
of Hospital Infection, March 2018).
E.coli bacteraemia or blood stream
infections
21
Sources of E.coli bloodstream infections
A total of 40,580 cases of E. coli bacteraemia
were reported by NHS trusts in England between
1 April 2016 and 31 March 2017. These have
been rising year by year; since the year 2000 but
numbers of hospital acquired cases (48hrs after
admission) have stayed consistent each year at
between 20-23%. The majority of cases are
community acquired, found in elderly people and
occurred primarily through a urinary tract infection
that likely originated from their own bowel flora.
A sentinel surveillance study in England
looking at risk factors associated with E. coli
Bacteraemia found that approximately half of
the community-onset cases has some sort of
healthcare intervention in the four weeks prior
to the bacteraemia onset.
2016/2017 AGH had 132 E.coli bacteraemia; 15 cases were hospital acquired. It is the above 20-23% of hospital acquired cases that we need to reduce.
So how can we do this?
Ensure our patients drink plenty of fluid to aid the natural flushing effect of urine washing bacteria out of the bladder. Dehydrated patients are more prone to urinary tract infections.
Ensure that incontinent patients with pads are checked regularly and are thoroughly cleaned after each episode of incontinence.
Advise patients not to touch their line dressings or urinary catheters unless
their hands are clean and they have been shown what to do.
22
Criteria for Urine Specimens (Midstream and Catheter) in
Suspected Urinary Tract Infections (UTI)
Preventing Urinary Catheter associated Urinary
Tract Infection
Key recommendations
Patient self-care: Wherever possible the patient must be taught to care for their
own urinary catheter. This will help to prevent the risk of infection and will give the
patient autonomy. When performing catheter care the nurse must always wear
gloves (non- sterile) and wear a disposable apron.
All urinary catheters should be secured to the patient’s leg by a retaining strap;
this is to prevent the catheter from sliding up and down the urethra. This could lead
to trauma of the urethra, bladder neck and glans of the penis. It also prevents
accidental disconnection or removal.
Cleaning the catheter: Using soap and water to clean the catheter is sufficient. This
can be done in the shower or bath. Daily bathing should be encouraged (Pratt et al
(2001). A disposable wipe can be used to clean the catheter, away from the urethra.
Talcum powder or antiperspirants/perfumes are not to be used around the catheter.
The glans of the penis can be cleaned using a disposable wipe with soap and water.
23
The foreskin, retracted for cleaning, must be replaced to prevent a paraphimosis.
Make sure the male patients are aware of this so that they can prevent this from
happening.
Infection prevention: A ‘closed system’ is where the catheter stays attached to the
leg bag/ valve. The only time the system is broken is when the leg bag/ valve is
changed (every 7 days). Attaching a night bag does not break the system.
Maintaining a sterile, continuously closed system is essential to the prevention of
catheter associated infection. Modern closed systems have significantly reduced the
incidence of bacteraemia. Breaches in the closed system, such as unnecessary
emptying of the urinary drainage bag or taking a urine sample, will increase the
risk of catheter related infection and should be kept to a minimum (Pellowe 2005).
The bag should be emptied before it is three quarters full.
Catheter bags must not be allowed to touch the floor.
They should be secured to the patient’s leg or set on a
specifically designed catheter stand. Bacteria can travel
up the catheter system and enter the body causing
infection. The drainage bag must be kept below the level
of the patient’s bladder at all times, (or emptied before a
procedure i.e. turning or physiotherapy). It is essential to always wear
gloves/apron and wash hands before and after contact with the catheter bag as it is
likely to be contaminated with germs from the urine itself.
Multi-Resistant Enterobacteriaceae (E.coli
Klebsiella and Pseudomonas)
40, 580 cases of E.coli bacteraemia
Often multi-resistant through ESBL enzyme production Now becoming resistant to Carbapenems (Meropenem)
There are a number of different ways that germs can be resistant. One of these
ways is by producing an enzyme called a beta-lactamase that breaks down the
beta-lactam antibiotic family, making it ineffective.
The green IC triangle symbol above the patients name on the SystmOne ward board
identifies that the patient as having a history of ESBL colonisation or infection. For
more information, see Multi-resistant Organism Management Guideline’ on
Aireshare.
IC
ESBLs
24
In 1980, the 3rd generation cephalosporin antibiotic family were introduced
(Cefotaxime is one of them) as they had an ‘extended
spectrum of activity’ or greater ability to destroy
resistant gram negative bacteria. By 1985, bacteria were
found to be producing a beta-lactamase enzyme that was
resistant to this new antibiotic family. They were then
named ‘Extended Spectrum Beta-Lactamases’ or
ESBLs.
ESBL producing E.coli, Klebsiella are commonly seen in
urinary tract infections but can cause a variety of other
infections. The source of the infection is mainly from the
patient’s own gut flora when it is transferred accidently to other parts of their body,
such as the bladder. These resistant germs get in the gut either through the food
chain or being picked up on hands from the contaminated environment and then
eating with unwashed hands.
In those countries with level 3 treatment of sewage, such as the UK, sewage
treatment removes E. coli from drinking water (see Yorkshire water website) but
a recent study from the Midlands has shown that significant numbers of ESBL
producing E. coli in treated effluent are discharged into water courses, where they
may then be acquired by people during recreational activity in what appears to be a
perfectly clean river, and also by livestock, which may explain the acquisition by dairy
herds of ESBL gene CTX-M 14 and 15, the two most prevalent types in humans.
( Multidrug-resistant Gram-negative bacteria: a product of globalization:Journal of
Hospital Infection 2015).
Gaze and colleagues measured the presence of third-generation cephalosporin-
resistant (ESBL) E. coli in seawater surrounding England and Wales. 11 of 97
sea water samples were found to contain CTX-M ESBL E. coli. While the
percentage of ESBL E. coli in bathing waters was low, water users are at risk of
ingesting these antibiotic resistant bacteria. (Healio infectious disease, March 31 2015).
The Institute of Soil, Water and Environmental Sciences in Israel, performed a
study where E. coli were added into the hydroponic growing medium of maize
plants and 48hrs later detected E.coli in the shoot of the plant. This is the first
study to demonstrate internalization of E. coli via the root in monocotyledonous
plants.
25
A study by the London school of Hygiene & Tropical Medicine in 2011, found that 1
in 6 mobile phones grew E.coli from the unwashed hands of their users.
A number of studies have found that these resistant germs may spread extensively
amongst family members in the home. (The British Infection Society 2010.) We have seen this in Airedale, where we tested a family (with their permission) of a
5 month old child with a history of multiple ESBL UTI infections. We found that the
whole family were gut colonised with the same resistant E.coli. Likewise a study
by Rooney et al. (2009) found that nursing homes can act as a reservoir of ESBL E.
coli. So how do we look after these patients?
Winning the Battle against Resistant
Enterobacteriacea isolation?
26
Continent of urine or faeces? - Continent patients pose little risk of infection as the
germs pass down the toilet and if good hand hygiene is performed, germs are not
carried on the hands.
Incontinent patients pose a risk of infection as the germ can spread into the
environment or onto staff members’ hands, thus the need for isolation.
Colonised or Infected?- As we learned earlier, germs can colonise the bladder of
elderly patients and cause asymptomatic bacteriuria, therefore staff must observe
for clinical symptoms of infection rather than just relying on the MSU result.
Catheterised patients can have resistant bacteria living in the residual volume of
urine that remains in the bladder or even in biofilms in the catheter itself.
Hand hygiene– needed by both the patient and staff members is important to
prevent carrying the germ on their hands and potentially transferring it on to others.
Patient education- Informing and educating patients puts them at the centre of
their care.
Cleaning contaminated equipment- Any equipment used by the patient must
be cleaned effectively with Tristel fuse and allowed to dry before use by
another patient to prevent onward transmission of the germ. Use the ’I am clean’
labels to assure others you’ve cleaned it.
Cleaning contaminated environment– A research study recovered ESBL
producing bacteria in the plug-holes of hospital hand wash sinks (also where
pseudomonas is found), around the sinks themselves and on toilet floors. The
predominant germs recovered were Klebsiella which have the ability to survive in the
environment by producing a biofilm whereas E. coli cannot. ‘ESBL-producing Gram
negative organisms in the health care environment’ Journal of Hospital infection
2016 If incontinence care is performed by staff and the water from the wash bowl is
poured down the hand wash sink, it contaminates the sink and the plughole.
Also the wash- bowl itself will need cleaning and be allowed to dry upside down
before storing.
To ensure all interventions are in place to prevent further spread of infection,
please follow the Multi- resistant Organism Care pathway that can be found on the
Infection prevention Aireshare page or in the Multi-resistant Organism
guideline.
IC
ESBLs
27
Carbapenemase Producing Enterobacteriaceae
(CPE)
Thanksfully, we have always been able to treat serious (ESBL) infections with an
antibiotic called Meropenem (one of the Carbapenem family) which is our ‘last line
of defence’ when it comes to antibiotics. Gram negatice bacteria have now been
found to produce an enzyme or carbaoenemase that also breaks down Meropenem,
making it resistant (in some cases to all, or nearly all) antibiotics. A number of
countries across Europe have seen large numbes of these infections (Greece
being the highest).
28
To identify these patients, the question above has been added to the Triage
questions in Emergency Departments (EDs) and in the admission documentation
at ‘door ways’ to the hospital.
London and Mancester hospitals have had outbreaks with these resistant germs.
Patients that are identified are isolated and are required to have 3 negative stool
samples for CPE before they can be nursed on the open bay. Patients that have a
history of CPE have this symbol above their name on the ward board.
The orange IC triangle symbol above the patients name on the SystmOne
ward board identifies that the patient as having a history of CPE
colonisation or infection. For more information, see Multi-resistant
Organism Management Guideline’ on Aireshare
Suspected CPE Risk
Early isolation and detection
Isolate in a single room (ensuite if possible) and reinforce strict isolation
standard precautions
Screening is either 3x rectal swabs or faeces samples on alternate days.
If all 3 screens are negative – discontinue
If any screens positive – continue for duration of stay
29
Pseudomonas Aeruginosa Risks
Often multi-resistant to a number of antibiotics
Common cause of urinary tract infections/pneumonia
Often associated with contaminated water and live in moist environments
around the sink
CPE producing P.Aeruginosa was isolated in a sink drain. Patients closest to
the sink were infected with the same germ. Water
flowing directly into the plug hole may have caused
aerosols across the ward. (Aspeland et al).
Hand wash sinks should not be used for anything
other than hand washing!
Safe water in healthcare premsises – DOH
30
Antimicrobial Guidance
Antimicrobial use (AMU) is a key driver of animicrobial resistance (AMR);
understanding the indications, dose used and adherence to guidelines is
important in reducing anitbiotic consumption.
Antimicrobials: a Balancing Act
Antibiotic use is a balancing act of risks and
benefits
Use the Start smart:Then focus guide (below)
The right drug, according to local guidance
Within an hour of presentation for IVs
Then focused to the safest, most appropriate choice
Every use of an antibiotic risks increasing resistance rates
31
32
Infective dose: As little as 10 to 100 virions are required to infect a
host
One single episode of vomiting may generate 300,000 to 3 milliion
infectious doses
Environmental swabbing has shown contamination of common
touch surfaces such as door handles, soap dispensers, patient
equipment, toilet seats and telephone.
Tristel fuse is recommended for environmental decontamination.
Ring Infection Prevention Immediately
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Standard Precautions
Hand hygiene
Maintain skin integrity
Personal Protective Equipment (PPE)
Blood/body substance spillage
Sharps safety
Safe handling of clinical waste
Decontamination of equipment
Decontamination of environment
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Hand Hygiene
It is important to recognise that the hands of
health care staff will always carry bacteria, be
it their own bacteria or those that have
attached as a result of acitivities (e.g.
handling equipment, touching surfaces or
patients). Remember, the greatest concentration of micro organisms are found
beneath your finger nails.
Although it is not possible to sterilise your hands, the number of bacteria present can
be reduced significantly through good hand hygience practice.
Situations that pose the greatest risks include, but are not limited to:
Before patient contact
Before contact with a susceptible patient site (such as an invasive device or
wound)
Before an aseptic task
After exposure to body fluids (blood, vomit, faeces, urine and so on)
After glove removal
After patient contact
After contact with the patient’s immediate environment.
To support compliance with hand hygience in the workplace, health
care workers should meet the following standards while working:
Keep nails short, clean and polish free
Avoid wearing wrist watches and jewellry
Avoid wearing rings with ridges or stones. (A plain wedding
band is acceptable)
Do not wear artifical nails or nail extensions
Cover any cuts and abrasions with a waterproof dressing
Wear short sleeves or roll up sleeves prior to hand hygience
Report any skin conditions affecting hands (for example, psoriasis or
dermatities) to Employee Health and Wellbeing for advice.
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Intact Skin Protects You
Wet hands transfer micro-organisms more effectively than dry ones, and inadequately dried hands can also be prone to developing skin damage.
Disposable paper hand towels should be used to ensure hands are dried thoroughly. Fabric towels are not suitable for use in health care facilities as these quickly become contaminated with micro-organisms.
Applying liquid soap directly to dry hands can irritate and dry out the skin making it painful to wash Therefore, always wet hands first.
Using moisturiser as you start work, before breaks and as you leave will protect and maintain the skin integrity.
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Personal Protective Equipmement (PPE)
A selection of PPE must be based on an assessment of the risk of transmission of
micro-organisms to the patient or carer, and the risk of contamination of the
healthcare practitioner’s clothing and skin by the patient’s blood, secretions or
excretion. The risk assessment should include:
Who is at risk
Whether sterile or non sterile gloves should be worn
Exposure to blood or body fluids
Contact with non-intact skin or mucus membranes
Exposure to hazadous substances.
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Personal Protective Equipmement (PPE)
Aprons: Disposable plastic aprons must be worn
when it is likely that body substance will soil
clothing. Plastic aprons must be worn during all
close patient contact including bed making.
Plastic aprons afford more protection to
uniforms/own cloths than cloth gowns because they
are water repellant, impervious to microial
contamination and can prevent the transmission of
micro organisms from uniforms/clothes to patients.
Plastic aprons must be worn as single use items for one procedure or episode of
patient care and then discarded and disposed of as clinical waste.
Gloves: There are two main indications for the use of
gloves in preventing healthcare associated infection, to
protect the hands from contamination with organic matter
and micro organisms and to reduce the risks of
transmission of micro-organisms to both patients and
staff.
A risk assessment should be made of the type of procedure to be undertaken and
the related risks to the patient and health care worker in order to establish whether
gloves should be worn.
Gloves should be worn as single use items. They should be put on immediately
before an episode of patient care and removed as soon as the activitity is completed.
Gloves must be changed between caring for different patients, or between different
carers for the same patient. Gloves must be disposed of as clinical waste and
hands decontaminated, ideally by washing with soap and water. Hand gel should
never be applied to gloves.
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Personal Protective Equipmement (PPE)
Eye/Mouth Protection: Should be worn
where there is a risk of blood or body fluids
splashing into the mouth or eyes. This is to
protect you from acquiring a blood borne virus or
a bacterial infection. A surgical mask is
waterproof and will prevent this from happening.
Goggles over spectacles or visors will protect your
eyes from spashes. If you receive a spash to your eye, use saline to gently irrigate
your eye, washing from the inner side of your eye (closest to your nose) allowing the
saline to flow over your eye. If you receive a splash to your mouth or broken skin,
rinse/cleanse thoroughly with water and then contact Infection Prevention via the
switchboard. When this happens, it is called a contamination issue. Surgical masks
should be worn when caring for patients with Flu but changed to an FFp3 Respirator
when performing aerosol generating procedures.
FFP3 Respirators: are designed to
protect the wearers from breathing in small
airborne particles which might contain viruses or
Tuberculosis. Staff need to perform a Fit check
before carrying out any procedures. Please see
Flu Guidance on Infection Prevention’s Aireshare
page on how to perform a fit check. If a sucessful
fit check cannot be achieved, remove and refit
the respirator. If you still cannot obtain a
sucessful fit check, try the cone shape respirators. If a sucessful fit check cannot be
achieved, please contact Infection Prevention. FFp3 Respirators should be worn
when performing aerosol generating procedures with patients suspected of having
Flu or worn when in contact with a patient with suspected or known Mycobacterium
Tuberculosis.
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Safe Handling of Spillages
Blood Spillage
(Hep B, C &HIV risk)
Clean spillages promptly
Soak up fluid with paper towels &
discard in orange bag
Disinfect the area using
Hypochlorite solution 10, 000ppm
Body Fluid Spillage
Clean spillage promptly
Soak up fluid with paper towels & discard in
orange bag
Disinfect the are using Tristel fuse 1,000ppm
Deal with any blood/body fluid spllage immediately.
Blood Spillage: Wear PPE to protect your hands and uniform (and a surgical
mask if there is a risk of spashing). Use paper towels to absorb the fluid, then clean
with hot water and detergent followed by 10,000ppm hypochlorite solution. Ensure a
window is opened as the chlorine smell is very strong.
Urine, faeces and vomit: Wear PPE (gloves and apron) and use paper towels to
absorb the fluid. Clean with hot water and detergent followed by 1,000ppm
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hypochlorite solution or an agent that contains both: e.g. Tristel fuse. Dispose of the
paper towels in a clinical waste bag.
Sharps Safety
Safe disposal of contaminated sharps
This is classified as healthcare waste and must be disposed of
in a rigid sharps container that complies with UN3291 and
BS7329 standards. Refer to Prevention and Management of
contamination Injuries Policies on Aireshare.Ensure that
sharps bin lids are firmly clicked down on assembling and the
label is completed. When sharps containers are ¾ full they must
be closed securely and the person closing must complete and
sign the label on the container. The bin must be placed for collection in the clinical
waste area and must not be placed inside a clinical waste bag,When a sharps bin is
not in use, pull the lid half way across (see picture). This is called ‘temporary closure’
and will prevent sharps from falling out of the bin if it is accidently dropped.
Tips for prevention of sharps injuries:
Never re-sheath needles
Use safety devices where possible
Always use point of use sharpes bin
Do not overfill sharps bin
Do not use sharps bin for objects other than sharps
Disposing of needle and syringe as a unit reduces risk
of injury
Wearing gloves can remove up to 80% of blood from
a needle in the event of an injury
Make sure lighting and space to perform the
procedure is adequate
If a sharps bin is full Do not use it. Close it up and start a new one. This is the
responsibility of all clinical staff.
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Prevention and Management of
Contamination Injuries
First Aid Treatment (Bleed)
Wash the wound
Inform Infection Prevention
Team
Inform Employee Health and
Wellbeing (EHWB)
Complete documentation
Appropriate blood
specimens will be recommended
Ensure you dispose of your waste correctly
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Decontamination of Equipment
One study showed that frequently touched articles in the
patients’ environment such as cardiac monitors, infusion
pumps and bed rails were grossly contaminated with micro
organisms. Any piece of equipment that is used by or on a
patient should be cleaned before being used on another
patient. Therefore, members of staff need to be aware of
their individual responsiblitiy for practising and promoting
decontamination of reusable medical devices to ensure the
safety of the patient, themselves and the environment.
Equipment such as commodes need to be decontaminated
with the correct cleaning solution. Three patients had the
same strain of Clostridium difficile on one ward. The commodes were swabbed and
the same strain of Clostridium difficile spores were found. The
commodes had been cleaned with detergent wipes which do not remove
C.diff spores instead of Tristel fuse which kill C.diff spores. Refer to:
Medical Devices:Process for Decontamination, Cleaning and Disinfection.
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Safe disposal of linen contaminated with body
substances
Linen skips should be taken to the bedside and
used linen should be carefully placed in them, to
prevent dispersal of skin cells and micro
organisms into the air, to then settle in the
environment. Hand gel should be applied after
handling used linen and before handling clean
linen to prevent the spread of skin cells.Aprons
should be worn for bed making.
Linen heavily contaminated with body
substances must be placed into a water soluble
bag to protect laundry staff from avoidable risk. When handling soiled linen, gloves
and apron must be worn.
The Clinical environment
A dirty or contaminated clinical environment is one of the factors that may
contribute to HCAIs. Exposure to environmental contamination with spores of C.difficile is one example of occasions when the environment contributes to the development of infection. Many micro-organisms can be identified from the patient’s environment and these usually reflect bacteria carried by patients or staff ( in the case of S.aureus). Contact with the immediate patient of a contaminated environmenr by the hands of staff can also be a route for transmission of micro organisms. High standards of cleanliness will help to reduce the risk of cross-infection and are aesthetically pleasing to patients and the public .
Mattress Checks
After a patient has been discharged, please unzip the mattress cover. If staining is present on either the underside of the cover or on the mattress core then please follow and complete a mattress audit form (can be found on the Aireshare Infection prevention page). Please attach the form to the mattress and ask porters to swap it or a clean mattress. The dirty mattress needs taking by porters to
the dirty mattress store on ward 11.
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Clinical Workbook Level 2- Questions
All the answers to the questions below are found in this workbook. Please write your
answers on this sheet and email to the Infection Prevention group email address:
You will need to get 8 answers correct to complete your update. The questions
will be marked and your record will be updated by the Training dept. If you do not
achieve the pass rate you will need to attend an Infection Prevention session in
the lecture theatre. You will be contacted by email.
1. Which one of the following is not one of the 10 compliance criteria from
the Health and social care act?
a) Provide a clean and appropriate environment.
b) Provide accurate information on infections to patients and visitors.
c) To screen patients for MRSA on admission.
d) To provide adequate isolation facilities.
2. Why should used linen be handled carefully and put into a skip at the
bedside when changing bed linen?
a) Prevents skill cells from becoming airborne.
b) More time efficient.
c) Prevents skin cells getting on your uniform
d) So staff do not need to wear gloves
3. What does this symbol mean?
a) History of CPE colonisation or infection
b) History of CDI colonisation or infection
c) History of MRSA colonisation or infection
d) History of ESBL colonisation or infection
4. The hub (injectable bung) of the cannula should be cleaned with a Sani-
cloth wipe for a minimum of:
a) 5 seconds and allowed to dry
b) 15 seconds and allowed to dry
c) 30seconds and allowed to dry
d) 60 seconds and allowed to dry
5. Contact Precautions- What is the correct order for removing PPE when
leaving a side room?
a) Apron/gloves/ hand wash
b) Gloves/apron/ hand wash
c) Either/ hand wash
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Clinical Workbook Level 2- Questions (Cont)
6. Looking after patients with ESBLs. The source of their infection is
mainly from where?
a) The Patients pet
b) The Patients family
c) The Patients own gut flora
d) The Patients Urine
7. If a patient has been in a hospital abroad in the last 12 months you
should….?
a) Isolate them in a side room and take 3 urine samples
b) Isolate them in a side room and take 3 sputum samples
c) Isolate them in a side room and take 3 stool samples/ rectal swabs
8. When is hygienic hand gel not effective?
a) After contact with a patient suspected of having clostridium difficile
b) After an aseptic technique
c) Before patient contact
d) When leaving the ward
9. How would you clean up a blood spillage?
a) Clean spillage promptly/ soak up fluid with paper towels and place in
an orange bag/disinfect the area with hypochlorite solution 10000ppm
b) Clean spillage promptly/ soak up fluid with paper towels and place in
an orange bag/disinfect the area with Tristel fuse
c) Clean spillage promptly/ soak up fluid with paper towels and place in
an orange bag/disinfect the area with a sani-cloth wipe
10. What shouldn’t you do if you have had a needle stick injury?
a) Encourage the wound to bleed by squeezing the wound.
b) Suck the wound
c) Inform Infection prevention immediately
d) Complete an AEF