Dana Nguyen, BSN, RN, CICCommunicable Disease

Infection Control PractitionerApril 18, 2017

Objectives

After this workshop, you will be able to:

1.Relate the Chain of Infection to examples of infection transmission.

2.Discuss the most common risk factors associated with infection transmission.

3.Describe the most common evidence-based prevention practices used for specific infection types.

Risk Factors for Transmission

Chain of Infection

Disruption of Transmission

Chain of Infection

Practices to Decrease Risk of Transmission

• Administrative Practices• Surveillance• Employee health• Risk assessments• Product evaluation

• Environmental Services

• Personal Hygiene

• Resident and Caregiver Education

• Healthcare Worker Practices

Precautions to Prevent Transmission of Infectious Agents

There are two tiers of HICPAC/CDC precautions to prevent transmission of infectious agents, Standard Precautions and Transmission-Based Precautions.

Standard Precautions• Standard Precautions are the

minimum infection prevention practices that are intended to be applied to the care of all patients, in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent.

• Implementation of Standard Precautions constitutes the primary strategy for the prevention of healthcare-associated transmission of infectious agents among patients and healthcare personnel.

• These practices are designed to both protect HCP and prevent HCP from spreading infections among patients.

Transmission-Based Precautions• Transmission-Based Precautions are

for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission.

• Since the infecting agent often is not known at the time of admission to a healthcare facility, Transmission-Based Precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or a transmissible infectious etiology is ruled out.

Standard Precautions

Standard Precautions include:

� Hand Hygiene

� Use of Personal Protective Equipment (e.g., gloves, gowns, masks).

� Safe injection practices

� Safe handling of potentially contaminated equipment or surfaces in the patient environment.

� Respiratory Hygiene/Cough Etiquette. Hand Hygiene� Use of Personal Protective Equipment (e.g., gloves, gowns, masks)� Safe Injection Practices� Safe handling of potentially contaminated equipment or surfaces in the patient environment� Respiratory Hygiene/Cough Etiquette.

Hand Hygiene

Hand hygiene (WHO – 5 Moments)Hand hygiene has been cited frequently as the single most important practice to reduce the transmission of infectious agents in healthcare settings and is an essential element of Standard Precautions.

Hand Hygiene (CDC, 2002)� Before direct contact with residents� After contact with blood, body fluids or

excretions, mucous membranes, non-intact skin, or wound dressings

� After contact with resident's intact skin � When moving from a contaminated-body

site to a clean-body site during resident care

� After contact with inanimate objects (including medical equipment) in the immediate vicinity of the resident

� After removing gloves

Personnel Protective EquipmentPPE

• PPE refers to wearable equipment that is intended to protect HCP from exposure to or contact with infectious agents. The selection of PPE is based on the nature of the patient interaction and/or the likely mode(s) of transmission.

• Wear PPE when anticipating contact with blood or body fluids

• Prevent contamination of clothing and skin during the process of removing PPE.

• Hand hygiene is always the final step after removing and disposing of PPE.

• All HCP at the facility should be educated regarding proper selection and use of PPE.

Gloves

� Gloves are used to prevent contamination of healthcare personnel hands when :� anticipating direct contact with

blood or body fluids, mucous membranes, nonintact skin and other potentially infectious material;

� having direct contact with patients who are colonized or infected with pathogens transmitted by the contact route e.g., VRE, MRSA, RSV

� handling or touching visibly or potentially contaminated patient care equipment and environmental surfaces

Isolation Gowns

� Isolation Gowns are used as specified by Standard and Transmission-Based Precautions, to protect the HCW’s arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material.

� The need for and type of isolation gown selected is based on the nature of the patient interaction, including the anticipated degree of contact with infectious material and potential for blood and body fluid penetration of the barrier.

� Isolation gowns are always worn in combination with gloves, and with other PPE when indicated. Gowns are usually the first piece of PPE to be donned. Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed upper body areas are protected.

Face protection: masks, goggles, face shields

Masks are used for three primary purposes in healthcare settings: 1) Placed on healthcare personnel to protect them from contact with infectious material from patients e.g., respiratory secretions and sprays of blood or body fluids, consistent with Standard Precautions and Droplet Precautions.2) Placed on healthcare personnel when engaged in procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a healthcare worker’s mouth or nose.3) Placed on coughing patients to limit potential dissemination of infectious respiratory secretions from the patient to others (i.e., Respiratory Hygiene/Cough Etiquette). Masks may be used in combination with goggles to protect the mouth, nose and eyes, or a face shield may be used instead of a mask and goggles, to provide more complete protection for the face.

* Masks should not be confused with particulate respirators that are used to prevent inhalation of small particles that may contain infectious transmitted v ia the airborne route as described below.

Safe Injection PracticesInjection safety practices are intended to prevent transmission of infectious diseases between one patient and another, or between a patient and healthcare provider during preparation and administration of parenteral medications.

Implementation of the OSHA Bloodborne Pathogens Standard has helped increase the protection of HCP from blood exposure and sharps injuries, but there is room for improvement in outpatient settings. For example, efforts to increase uptake of hepatitis B vaccination and implementation of safety devices that are designed to decrease risks of sharps injury are needed.

Unsafe practices that have led to patient harm incl ude: 1). Use of a single syringe, with or without the same needle, to administer medication to multiple patients.

2). Reinsertion of a used syringe, with or without the same needle, into a medication vial or solution container (e.g., saline bag) to obtain additional medication for a single patient and then using that vial or solution container for subsequent patients.

3). Preparation of medications in close proximity to contaminated supplies or equipment.

4). Failure to wear a facemask (e.g., surgical mask) when placing a catheter or injecting material into the epidural or subdural space (e.g., during myelogram, epidural or spinal anesthesia).

Environment� Safe handling of potentially contaminated

equipment or surfaces in the patient environment.

� Cleaning and disinfecting non-critical surfaces in patient-care areas are part of Standard Precautions. In general, these procedures do not need to be changed for patients on Transmission-Based Precautions.

� The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient).

� The frequency or intensity of cleaning may need to change based on the patient’s level of hygiene and the degree of environmental contamination and for certain for infectious agents whose reservoir is the intestinal tract

Transmission - Based Precautions

Appendix A – 2007 HICPAC Guideline for Isolation Pre cautions

Transmission -Based Precautions

Contact Precautions• MRSA, VRE, C. difficile, diarrhea of

unknown etiology, draining wounds, gastroenteritis

• Personal protective equipment– Gloves– Gowns

• Resident isolation– Limit isolation to period of active,

symptomatic disease– Balance with psychosocial/safety

needs

• Environmental services

• Equipment and medical devices– Disposable– Clean and disinfect between residents– Handle contaminated equipment with

standard precautions

Transmission -Based Precautions

Droplet Precautions• Influenza, pertussis,

Streptococcal pneumonia, viral respiratory illnesses

• Resident isolation or mask

• Personal protective equipment– Surgical mask upon entry

into the room

• Visitor notification

Control MDROs

In your facility:� Type, number, and rate of MDROs

� Vulnerable residents/at risk patients

� Antimicrobial utilization

� Know your colonized vs. infected residents

� Strict adherence to HAND HYGIENE and Standard Precautions

Questions

Action / Next Steps

• Review HICPAC Guideline

• Review your policies:

• Hand hygiene

• Standard precautions

• Transmission-based precautions

Source DocumentsAll evidence-based recommendations for prevention of healthcare-associated infections from CDC/HICPAC can be found at the following site: http://www.cdc.gov/hicpac/pubs.html

Guidelines available at this webpage include:

• 2008 Guideline for Disinfection, and Sterilization in Healthcare Facilities http://www.cdc.gov/hicpac/Disinfection_Sterilization/1_sumIntroMethTerms.html

• Guidelines for Environmental Infection Control in Healthcare Facilities http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm

• Guideline for Hand Hygiene in Healthcare Settingshttp://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

• 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settingshttp://www.cdc.gov/hicpac/2007IP/2007ip_ExecSummary.html

• Management of Multi-drug Resistant Organisms in Healthcare Settings, 2006http://www.cdc.gov/hicpac/mdro/mdro_toc.html

• Influenza Vaccination of Health-Care Personnel, 2006http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm

• Guideline for Infection Control in Healthcare Personnel 1998http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf

Key Links for Additional Information:� CDC Website on Healthcare-associated infections: www.cdc.gov/hai� CDC Website on Hand Hygiene in Healthcare facilities: www.cdc.gov/handhygiene� CDC Website on Injection Safety: www.cdc.gov/injectionsafety� CDC’s One & Only Campaign: www.oneandonlycampaign.org