THE IMPORTANCE OF INFECTION CONTROL IN PATIENT CARE

THE IMPORTANCE OF INFECTION CONTROL IN PATIENT CARE

Dr. Satti M. SalehChief of Infectious Diseases DepartmentCBAHI SIT Member Medical Director MGH

PEARLS OF WISDOM

QUALITY OF CARE IS AS IMPORTANT AS QUALITY OF TREATMENT

IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure, Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health CareAssociated Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting from Falls

International Patient Safety GoalsIPSG

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PATIENT SAFETYAn Organisation with a memory

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THE PARADIGM OF STRUCTURE , PROCESS & OUTCOME

THE RELATIONSHIP BETWEEN STRUCTURE , PROCESS & OUTCOME IS A CAUSAL RELATIONSHIP DONABEDIAN

STRUCTURE

PROCESS

OUTCOME

ARRANGEMENT OF PARTS OF CARE SYSTEM OR ELEMENT OF CARE

CLINICALCARE DELIVERYADMINISTRATIVE

REFERES TO RESULTS OF CARE (ADVERSE OR BENIFICIAL )

CLINICALFUNCTIONA PECEIVED

LEADS TO

LEADS TO

Infection Control Programme Structure

1) INFECTION CONTROL UNIT :- IndependentIPP's all patient care areasInfection control policy standard

2) CURRENT SCIENTIFIC KNOWLEDGE

3) ICP : FULL TIME

4) QUALIFIED PERSONNEL

5) IC MANUAL

6) CONTINUE EDUCATION. Infection Control Personnel Staff Orientation Staff Continuous Education

7) IC COMMITTEE

GOAL FOR HOSPITAL INFECTION PREVENTION &CONTROL PROGRAMMS

PROTECT THE PATIENT . PROTECT HCWS VISITORS &OTHERS IN THE

HEALTHCARE ENVIRONMENT

ACCOMPLISH PREVIOUS GOALS ,WHEREVER POSSIBLE , IN A COST EFFECTIVE MANNER

Definition Of HCAI

INFECTION OCCURRING DURING OR AS A RESULT OF HOSPITALIZATION

WHICH THE PATIENT NEITHER HAVING NOR INCUBATING AT THE TIME OF ADMISSION.

Importance

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INCREASE PROBLEMS DUE TO :-

1-ADVANCE TECHNOLOGY2-OVERCROWDING 3-POOR RESOURCES 4- USES OF ANTIBIOTICS 5-INCREASE INVASIVE PROCEDURES 6-IMUNOSUPRESSION 7-SHORTAGE OF TRAINED STAFF

MISCONCEPTIONS

1-IC IS EXPENSIVE 2-DIFFICULT TO IMPLEMENT 3-NO RISK TO STAFF 4-BLOOD BORN PATHOGENS 5-SCREENING IN EMERGENCY6-SCREEING IS COSTLY

!!?

Surveillance Program

CONTINUOUS OR PERIODIC.DIRECTED TO ALL INFECTIONS OR TARGETED SITES / DEVICES.ALL NEED TO BE SUPPLEMENTED BY MICROBIOLOGY LABORATORY BASED SYSTEMS.TECHNIQUES: REVIEW ANTIBIOTIC RECORDS. PATIENT / NURSING CARE RECORDS MICROBIOLOGY RESULTS AUGMENT BY AFTER ICU FOLLOW UP. AUTOPSY REPORTS

Surveillance

Pearson EducationCopyright 2005

Phlebotomy Handbook: Blood Collection Essentials, Seventh EditionDiana Garza Kathleen Becan-McBride

INFECTION CONTROL PROGRAM CLOSELY MONITORS THE FOLLOWING:PATIENTS AT HIGH RISK OF INFECTION.PATIENTS WITH ALREADY ACQUIRED INFECTIONS.PERSONNEL/PATIENTS EXPOSED TO COMMUNICABLE DISEASES, CONTAMINATED EQUIPMENT, OR HAZARDOUS REAGENTS.PATIENTS IN CERTAIN AREAS OF THE HOSPITAL OR IN CERTAIN ROOMS.PATIENTS IN AMBULATORY SETTINGS: HOME OR LONG-TERM CARE FACILITIES. SURVEILLANCE IS ALSO INVOLVED IN CLASSIFYING INFECTIONS ACCORDING TO PREVALENCE RATES AND MONITORING EMPLOYEE HEALTH INCLUDING SCREENING FOR DISEASES AND OFFERING IMMUNIZATIONS.

CHAIN OF INFECTION

Organism

Source

Mode ofTransmission

Host

NEW ISOLATION PRECAUTIONS, 1996

STANDARDAND TRANSMISSION BASED PRECAUTIONS

A-ESSENTIAL STANDARD PRECAUTIONS

1- HAND HYGIENE.2- PPE . TECHNIQUES 3- ASEPTIC4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.

HAND HYGIENE

. HAND HYGIENE IS THE SINGLE MOST IMPORTANT PRACTICE TO REDUCE THE TRANSMISSION OR INFECTIOUS AGENTS IN HEALTHCARE SETTINGS .. THE TERM HAND HYGIENE INCLUDES : HAND WASHING WITH EITHER PLAIN OR ANTISEPTIC CONTAINING SOAP AND WATER . USE OF ALCOHOL-BASED PRODUCTS ( GELS, RINSES, FOAMS) CONTAINING AN EMOLLIENT THAT DO NOT REQUIRE THE USE OF WATER.

RATIONALE

TRANSIENT FLORA (Contaminating or non colonizing)Attached to the superficial layer of skin.Microbes isolated from skin not consistently present in majority of persons associated with HCAI .

RESIDENT FLORAAttached to deeper layer of the skin persistently isolated from skin of most persons (cons, diphtheriods )

TYPE OF HAND HYGIENE

Intensity of contact .Degree of contamination .Susceptibility of patient to infection .Prove dure to be performed .

HAND HYGIENE

In the absence of visible soiling of hands, approved alcohol-based products for hand disinfection are preferred over hand washing with water and antimicrobial or plain soap because of their superior microbiocidal activity, reduced drying of the skin, and convenience.

HAND HYGIENE

In observational studies of opportunities for hand washing in health care workers in U.S.A The overall compliance was 40% (range 5 81%) .Compliance was highest among nurses and lowest among physicians, in intensive care units, and when required intensity of care was greater .

HAND WASHING STUDY IN RIYADH MEDICAL COMPLEX-GENERAL HOSPITAL

Overall frequency of hand washing .23.7% after patient contact .6.7% before patient contact .

HAND WASHING

Health care infection control practices advisory committee (HICPAC) former recommendationsPlain soap and water was recommended for routine hand washing.Antimicrobial soaps (e.g. : chlorhexidine) was recommended for :Patients under contact precautions .During instances of epidemic or hyperendemic spread of infections.

A-ESSENTIAL STANDARD PRECAUTIONS

1- HAND HYGIENE.

2-Personal Protective Equipment (PPE) . 3- ASEPTIC TECHNIQUES4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.

What are Personal Protective Equipment (PPE)?

Items specified for protection of many parts of body (to reduce risks to the health and safety of HCWs, and to minimize risks of cross infection between patients, staff, visitors) e.g. gloves, masks, respirators, goggles, specialized clothing (aprons & gowns)

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Personal = each person has it rather than protective equipment; mask is a personal protective equipment. A high efficiency ventilation systems is protective equipment that protects more than one person at once. Protective - to protect youEquipment - disposable supplies and

Common PPEs

GlovesAprons and gowns Face, mouth, nose, eye ProtectionFoot protectionHead coverings

Evidence shows hand washing prevents infections, but does PPE?

If health workers currently use PPE that doesnt mean it is effective.

One role of Infection Control Staff is to assess the changing risks and practices.Stop practices that are ineffective, expensive.Help institute cost-effectiveness practices of proven efficacy.

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Group one: What do you think use of hats prevents?

What do you think use of shoe barriers prevents?

Group three: What do you think think gloves do?

Group four: are gloves sterilized to protect the patient or protect the staff?

Are personal head scarves a form of personal protective equipment?

Last reminder

Dont assume current PPE use is effectiveAssess where and how employees are getting exposed to body fluids and harmful exposures. Assess how patients are getting disease from staff Select PPE that rationally protects patients and staff. Measure costs.

A-ESSENTIAL STANDARD PRECAUTIONS

1- HAND HYGIENE.2- PPE ASEPTIC TECHNIQUES 3-

4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.

ASEPSIS (ASEPTIC TECHNIQUE)

REFERS TO PRCEDURES PERFORMED UNDER STERILE CONDITIONDEFINED AS A SET OF SPECIFIC PRACTICES & PROCEDURES PERFORMED UNDER CAREFULLY CONTROLLED CONDITIONS WITH THE GOALOF MINIMIZING CONTAMINATION BY PATHOGENS e.g. DRAIN REMOVAL & CARE RESPIRATORY SUCTION

A-ESSENTIAL STANDARD PRECAUTIONS

1- HAND HYGIENE.2- PPE ASEPTICTECHNIQUES 3-

4- REPROCESSING OFINSTRUMENT /STERILE SERVICES

5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.

REPROCESSING OF REUSABLE INSTRUMENTS

CLEANED & MAINTAINED ACCORDING TO MANIFACTURER INSTRUCTIONSSINGLE USE DEVICES DISCARDED AFTER ONE PATIENTDEVICES FLOW FROM HIGH CONTAMINATION TO STERILE AREADEVICES STORED IN A MANNER TO PROTECT FROM DAMAGE

A-ESSENTIAL STANDARD PRECAUTIONS

1- HAND HYGIENE.2- PPE . 3- ASEPTICTECHNIQUES4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING.

6- PROPER SHARPS &WASTE DISPOSAL.

5- ENVIROMENTAL CLEANING

SURFACE CLEANED & DISINFECTEDCLEANERS & DISINFECTANTS ARE USED IN ACCORDANCE WITH MANIFACTIORER INSTRUCTIONS.

A-ESSENTIAL STANDARD PRECAUTIONS

1- HAND HYGIENE.2- PPE . TECHNIQUES 3- ASEPTIC4- REPROCESSING OF INSTRUMENT /STERILE SERVICES 5- ENVIROMENTAL CLEANING. 6- PROPER SHARPS &WASTE DISPOSAL.

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Factors which increase risk of infection

Deep injury.Visible blood on the device.High viral titer.Artery or vein device.Combined factors.Un-immunized against hepatitis B.No post exposure prophylaxis with Zidovidine (prophylaxis decrease risk by 80%).

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Risk of Transmission of Blood born Infection

Occupational Exposure

Risk of Transmission

Hepatitis B Virus

2-40%

Hepatitis C Virus

2.7-10%

HIV

0.3% (1 in 300 chance of infection)

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Hazards of Needle stick injuries

Hepatitis B and C.HIV.Brucellosis.Malaria.S. aureus and S. pyogenes.Toxoplasmosis.Tuberculosis.

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How can needle stick injuries be prevented

Employee training.Recommended guidelines. Safe recapping procedures.Effective disposal systems.Surveillance programs.Improved equipment design.

B-Transmission-Based Precautions

Three categories of Transmission-based Precautions : Contact Precautions . Droplet Precautions . Airborne Precautions .

Contact transmission

Examples of organisms spread by contact:Multi-drug-resistant organisms in the gastrointestinal tract, sputum, or wounds (MRSA, MDR Gram ve, VRE).Clostridium difficile.Herpes simplex virus (mucocutaneous).Scabies.

Contact precautions. Wash hands with antimicrobial soap before leaving the patient's room .. Minimize risk or environmental contamination during patient transport (e.g. patient can be placed in a gown ).. Patients care devices ( e.g. thermometer , BP cuffs , stethoscopes ) should be dedicated to use for a single patient if possible , otherwise, they should be rigorously cleansed and disinfected before use for other patients .

Contact precautions. Private room preferred; cohorting allowed if necessary .. The door of the room may remain open .. Gloves : - upon entering room . - change gloves after contact with contaminated secretions . - should be removed before leaving the room .. Gown: - if clothing may come into contact with the patient or environmental surfaces . - should be removed before leaving the room .

DROPLET TRANSMISSION

Respiratory droplets are large particles (>5 micron) expelled during :- - Coughing .- Sneezing .Talking.During procedures such as suctioning and bronchoscope .Droplets travel < 1,5 meter from the source patient .Example :Neisseria meningitides .Haemophilus influenza type b ( invasive ) .Streptococcus pyogenes (group A Streptococcus) . Mycoplasma pneumonia .

DROPLET PRECAUTIONS

Private room preferred; cohorting allowed if necessary.Special air handling and ventilation are unnecessary .The door of the room may remain open .Wear a mask when within 1 meter of the patient .Mask the patient during transport .

AIRBORNE TRANSMISSION

Airborne spreads upon aerosolization of small particles (=< 5 micron) of the infectious agent that can then travel over long distances through the air .Most common nosocomial pathogens transmitted by this route :Mycobacterium tuberculosis .Varicella-zoster virus (chickenpox) .Measles .Smallpox.? SARS .

AIRBORNE PRECAUTIONS

Place the patient in a negative pressure room with at least 6 12 air exchanges per hour .Room exhaust must be appropriately discharged outdoors or passed through a HEPA ( high efficiency particulate aerator ) filter before recirculation within the hospital .The door of the room should be kept closed .

Precautions Needed for Cases

Condition Type DurationPulmonary TB S+A Till sputum NegativeChicken Pox S+A Till rash crusted M-meningitis S+D 24 HrsHIV S Duration of stay

Clinical Syndromes: Empiric precautions as per clinical presentation

COMMUNICABLE DISEASE

Staff awarenessMeasures toward patient's diagnosis, isolation disinfection etc.Notification Class I, Class II

EMPLOYEE HEALTH

Staff health clinicPhysical examinationScreeningVaccinationPost exposure management*Blood, body fluids*Needle stick injury*Vaccine-Staff accommodationVaccine preventable disease

SUPPORT SERVICES

a) CSSDb) House Keepingc) Mortuary & PostmortemWritten policy disinfection & cleaning morgue temperature (2-8) logged dailyd) KitchenEnvironment & function Food container Food protection PPE Staff health & screening Written policye)LaundryLinen management Laundry structure & functionf)Haemodialysis Staff knowledge-PPE Standard precaution Structure Patient Medical Records (Screen Vaccination) Staff Medical Record-Haemodialysis water dialysate Water treatment -Written policyg) Operating Room Structure Traffic Control Pressure gradient & air cycle Cleaning Written policy

STERILIZATION

STERILIZATION OF REUSABLE INSTRUMENTS &DEVICES STERILIZATION

PROCESS OF ELIMENATING (REMOVING)OR KILING MICROBIAL ORGANISMS PRESENTING ON THE SURFACE OR IN FLUID OR MEDIAMETHODS:-HEATIRRADIATIONCHEMICALHIGH PRESSURERADIATION

DISINFECTION

THE PROCESS OR ACT OF DISTROYING PATHOGENIC MICRO-ORGANISMS OR MAKING THEM INERT (SOME CERTAIN BACTERIA SPORES MAY SURVIVE)COULD BE CHEMICAL OR BY HEAT

HIGH LEVEL DISINFECTION OF REUSABLE DEVICES

CLEANING

REMOVAL OF VISIBLE SOIL FROM OBJECT & SURFACESITS A FORM OF DECONTAMINATION

OUTBREAK INVESTIGATION

OUTBREAKS ARE RECOGNIZED BY:-PRACTITIONERPATIENT &PATIENT FAMILYPUBLIC HEALTH SURVEILLANCELOCAL DATD-MEDIA

OUTBREAK INVESTIGATION

REASONS TO INVESTIGATE :-PREVENT ADDITIONAL CASESPREVENT FUTURE CASES OUTBREAKLEARN ABOUT NEW DISEASESLEARN SOMETHING NEW ABOUT OLD DISEASESREASSURE THE PUBLICECONOMIC &SOCIAL REASONS

OUTBREAK INVESTIGATION

CONDUCTING AN OUTBREAK INVESTIGATION:-CASE INVESTIGATIONCAUSE INVESTIGATIONCONTROL MEASURES SHOULD BE DONE EARLYCONDUCT ANALYTIC STUDY IF NECESSARYCONCLUSIONSCONTINUE SURVEILLANCECOMMUNICATE FINDINGS eg. EPIDEMIOLOGICAL,CLINICAL,FORENSIC INVESTIGATION

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