inf control fundamentals

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Hospital InfectionHospital Infection Control Control

FundamentalsFundamentals

Department of NursingDepartment of Nursing

Induction Program for NursesInduction Program for Nurses



³««the very first requirement in a

hospital is that it should do the sick

no harm"

Florence Nightingale



First, do no Harm To Err is Human

The paradox



Why do we need infectionWhy do we need infection

control in hospital?control in hospital?Patients go to hospitals for diagnosis andPatients go to hospitals for diagnosis and

treatmenttreatment

But,But,

interventions/treatmentinterventions/treatment introduce risksintroduce risksthat may harm a patient¶s healththat may harm a patient¶s health



Healthcare Associated InfectionsHealthcare Associated Infections

(HAI)(HAI)

NNosocomial infections:osocomial infections:

Any infection that is not present or Any infection that is not present or incubating at the time the patient isincubating at the time the patient is

admitted to the hospital.admitted to the hospital.



Additional morbidity Additional morbidity

Prolonged hospitalizationProlonged hospitalization LongLong--term physical, developmentalterm physical, developmental

and neurological sequelaeand neurological sequelae

Increased cost of hospitalizationIncreased cost of hospitalization DeathDeath

Consequences of HAIConsequences of HAI



Ignaz Philipp Semmelweis

(1818 ± 1865)

Semmelweis was a Hungarian

obstetrician who worked to identify

the cause of puerperal sepsis.

Semmelweis compared mortality rates

among obstetrical patients in two

Viennese clinics. He identified high

mortality rates in the first clinic were

caused by the transfer of livingorganisms on caregivers hands.

The first clinic was staffed by medical

students and physicians whose hands

became contaminated while

performing autopsies. The second

clinic, with significantly lower

mortality rate, was staffed by

midwives who did not perform

autopsies.



Semmelweis implemented a program which

required medical students to wash their hands in

liquid chlorine after performing autopsies. Themortality rate of women declined from 18% to 2%

in only 5 Months.

Unfortunately, Semmelweis was unable to convince

his colleagues of the importance of handwashing.

Most of the medical community ignored hisfindings. Semmelweis was committed to a

sanitorium. He died at the age of 47.



The Disease Triangle

Host (patient/ HCW)

Agent

(Bacteria, Viruses, Fungi,)

Environment

( Air, water, fomites, Equipments,

practices)



Infection control Risk assessmentInfection control Risk assessment

Riskassociated

with patients

care

Risk associatedwith Employee

Risk assoc withEquipment &

construction



Risk associated with patient care

I/V devices

Ventilators

Scopes Instruments & CSSD

Placement of patients

Practices & Procedures



Infection Control CommitteeInfection Control Committee

Committee RepresentativesCommittee Representatives

± ± MicrobiologistMicrobiologist

± ± Hospital EpidemiologistHospital Epidemiologist

± ± Infection Control PractitionersInfection Control Practitioners

± ± Administrator Administrator

± ± Ward, ICU and Operating room NursesWard, ICU and Operating room Nurses

± ±Medicine/Surgery/Obstetrics/PediatricsMedicine/Surgery/Obstetrics/Pediatrics

± ± Central SterilizationCentral Sterilization

± ± Hospital Engineer Hospital Engineer

± ± PharmacistPharmacist



Infection control TeamInfection control Team

Infection ControlInfection Control

NurseNurse

(Dipali Dumbre)(Dipali Dumbre)

Infection ControlInfection Control

Doctor Doctor

One ICN per 250 beds : SENIC study, CDC



Hand hygiene

compliance

Surgical Site

Infections

Catheter Related

Urinary tractinfections

No of CR UTI per 1000 folley¶s catheter daysNo of CR UTI per 1000 folley¶s catheter days

No of SSI per 1000 casesNo of SSI per 1000 cases

Infection Control Indicators

Central Line

Associated Blood

stream Infections

Ventilator

Associated

Pneumonia

R adiologically +ve pneumonia cases per

R adiologically +ve pneumonia cases per 1000 ventilator days1000 ventilator days

No of hand hygiene opportunities availed per No of hand hygiene opportunities availed per

100 hand hygiene opportunities that presented 100 hand hygiene opportunities that presented

to the HCW to the HCW

CLABSI cases per 1000 central line daysCLABSI cases per 1000 central line days



Standard PrecautionsStandard Precautions

Applies toApplies to ALLALL patients regardless of patients regardless of

their diagnosis or presumed infectiontheir diagnosis or presumed infection

statusstatus

Applies to all body fluids, secretions,Applies to all body fluids, secretions,

and excretions (except sweat)and excretions (except sweat)

Applies to nonApplies to non--intact skin and mucousintact skin and mucousmembranesmembranes



Components:Components:

± ± Hand HygieneHand Hygiene

± ± Use of Personal Protective Equipment (PPE)Use of Personal Protective Equipment (PPE)

((Gloves, Gowns, Masks, Goggles for Eye Protection)Gloves, Gowns, Masks, Goggles for Eye Protection)

± ± Transmission Based PrecautionsTransmission Based Precautions

(Airborne precaution, droplet protection, contact precaution)(Airborne precaution, droplet protection, contact precaution)

± ± Biomedical Waste Management includingBiomedical Waste Management includingsharp disposalsharp disposal

± ± Prevention & management of exposuresPrevention & management of exposures




Tranmission of healthcare associated pathogensTranmission of healthcare associated pathogensmost often occurs via contaminated hands of most often occurs via contaminated hands of HCWHCW

Compliance by HCWs to recommended HH practicesCompliance by HCWs to recommended HH practices

are unacceptably low in hospitals.are unacceptably low in hospitals.

Hand HygieneHand Hygiene



Hand HygieneHand Hygiene

Hand Hygiene is the simplest and most costHand Hygiene is the simplest and most cost

effective practice for control of HAIeffective practice for control of HAI

Measured high on priority grid for hospitalsMeasured high on priority grid for hospitals

55thth

goal of International Patient Safety Goalsgoal of International Patient Safety Goals



DefinitionsDefinitions

Hand hygieneHand hygiene ± ± Performing handwashing, antiseptic handwash, alcoholPerforming handwashing, antiseptic handwash, alcohol--

based handrub, surgical hand hygiene/antisepsisbased handrub, surgical hand hygiene/antisepsis

HandwashingHandwashing

± ± Washing hands with plain soap and water Washing hands with plain soap and water

Antiseptic handwash Antiseptic handwash

± ± Washing hands with water and soap or other detergentsWashing hands with water and soap or other detergentscontaining an antiseptic agentcontaining an antiseptic agent

Alcohol Alcohol--based handrubbased handrub ± ± Rubbing hands with an alcoholRubbing hands with an alcohol--containing preparationcontaining preparation

Surgical hand hygiene/antisepsisSurgical hand hygiene/antisepsis

± ± Handwashing or using an alcoholHandwashing or using an alcohol--based handrub beforebased handrub beforeoperations by surgical personneloperations by surgical personnel

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002 ; vol. 51, no. RR-16.



Recommended Hand HygieneRecommended Hand HygieneTechniqueTechnique

HandrubsHandrubs

± ± Apply to palm of one hand, rub hands Apply to palm of one hand, rub hands

together covering all surfaces until drytogether covering all surfaces until dry ± ± Volume: based on manufacturer Volume: based on manufacturer

HandwashingHandwashing

± ± Wet hands with water, apply soap, rubWet hands with water, apply soap, rubhands together for at least 15 secondshands together for at least 15 seconds

± ± Rinse and dry with disposable towelRinse and dry with disposable towel

± ± Use towel to turn off tapUse towel to turn off tap

Guideline for Hand Hygiene in Health-care Settings. MM W R 2002 ; vol. 51, no. RR-16.



When to wash handsWhen to wash hands

BEFOREBEFORE

Starting workStarting work

Leaving work areas Leaving work areas

Performing invasive Performing invasivetechniquestechniques

Donning gloves Donning gloves

Caring for a susceptible Caring for a susceptiblepatientpatient

Entering and leaving Entering and leavingisolation roomsisolation rooms

Preparing or handling food Preparing or handling food

BEFORE AND AFTER

Touching wounds anddressings

Giving medication

Touching urinary cathetersand IV lines

Emptying urinary drainagebags



When to wash handsWhen to wash hands

AFTER Personal contamination ± using the toilet, blowing

or wiping the nose Contact with blood and body fluids

Touching contaminated objects eg. suction bottles,specimen pots, bedpans, urinals

Caring for patients with specific organisms such

as MRSA and other multi-resistant organisms Removing Gloves

Making Beds

Handling contaminated laundry and waste

BETWEEN

Contact between different patients



Alcohol Alcohol--Based HandrubsBased Handrubs:: What benefits doWhat benefits dothey provide?they provide?

Require less timeRequire less time

More effective for standardMore effective for standard

handwashing than soaphandwashing than soap More accessible than sinksMore accessible than sinks

Reduce bacterial counts onReduce bacterial counts on

handshands

Improve skin conditionImprove skin condition

Residual effectResidual effect



Efficacy of Hand Hygiene Preparations inEfficacy of Hand Hygiene Preparations inKilling BacteriaKilling Bacteria

Good Better Best

Plain Soap Antimicrobialsoap

Alcohol-basedhandrub



RingsRings

Skin underneath rings isSkin underneath rings isheavily colonized withheavily colonized withbacteriabacteria

The number of The number of microorganismsmicroorganismsincreases with theincreases with the

number of rings wornnumber of rings worn



Wrist Watches and BraceletsWrist Watches and Bracelets

Wrist watches andWrist watches and

bracelets should bebracelets should be

removed before handremoved before handhygiene practiceshygiene practices



Fingernails, Nail technology andFingernails, Nail technology and

Nail PolishNail Polish

Do not wear artificialDo not wear artificialfingernailsfingernails

Keep nails tips less than ¼Keep nails tips less than ¼--inch longinch long



HOSPI AL IDE HAND HYGEINE COMPLIANCE

0

10

20

30

40

50

60

70

RR ICU CCU NTU CARDIAC SANGVI CANCER SR WARD

JULY

AUGUST

SEP

OCTOBER

NOVEMBER

DECEMBER

HOSPI AL IDE MON HLY HAND HYGEINE DA A FROM JULY O DEC 09HOSPI AL IDE MON HLY HAND HYGEINE DA A FROM JULY O DEC 09

DEPDEP JULYJULY AUGUSAUGUS SEPSEP OC OBEROC OBER NOVEMBERNOVEMBER DECEMBERDECEMBER

RR RR 30.530.5 40.240.2 60.060.0 42.542.5 43.543.5 3939

ICUICU 2929 39.739.7 57.057.0 45.345.3 48.448.4 42.742.7

CCUCCU 30.230.2 39.739.7 48.848.8 44.444.4 37.337.3 42.142.1

N UN U 27.327.3 54.254.2 52.152.1 53.553.5 46.246.2 4040

CARDIACCARDIAC 35.335.3 54.154.1 50.450.4 41.341.3 41.241.2 37.137.1

SANGVISANGVI 24.424.4 54.954.9 53.753.7 46.746.7 38.338.3 33.333.3

CANCERCANCER 30.730.7 46.746.7 48.448.4 44.744.7 49.549.5 4141

SR ARDSR ARD 41.341.3 5050 59.559.5 43.343.3 43.943.9 45.545.5

AVERAGEAVERAGE 30.30%30.30% 47.50%47.50% 54.20%54.20% 44%44% 43.243.2 40.240.2



If this cat can do this«If this cat can do this«

Y ou can tell anyone to decontaminate

their hands!



Personal Protective EquipmentPersonal Protective Equipment

GlovesGloves

Mask, Goggles, Face ShieldMask, Goggles, Face Shield

GownGown OvershoesOvershoes



GlovingGloving

Wear gloves when contact with blood or Wear gloves when contact with blood or other potentially infectious materialsother potentially infectious materials

Remove gloves after caring for a patientRemove gloves after caring for a patient

Do not wear the same pair of gloves for theDo not wear the same pair of gloves for thecare of more than one patientcare of more than one patient

Do not wash glovesDo not wash gloves

Do not do anything else with gloved handDo not do anything else with gloved hand(writing in file, handling mobile)(writing in file, handling mobile)

Guideline for Hand Hygiene in Health-care Settings. MM W R 2002 ; vol. 51, no. RR-16.



Sharp Injury protectionSharp Injury protection

Reusable sharps require proper handlingReusable sharps require proper handling(mechanical means) and decontamination(mechanical means) and decontamination

Do notDo not RECAPRECAP needlesneedles

Retractable needlesRetractable needles

Needleless systemsNeedleless systems



Do not put in mouth.

Do not squeeze, allow free bleeding.

Wash hands with soap and water.

HCW sustaining needle stick injury/Splash

Go to Casualty and Inform Nursing

Supervisor / ICN

Casualty initiates Incident formBaseline serum sample of HCW source patient (if

available) to be sent for lab evaluations for HIV/HBV

Follow up treatment regimen within 2 hrs of the

injury

If source patient is

HIV + ve start post

exposure prophylaxis

immediately


HbsAg + ve start

treatment as per

protocol in the

CASUALT

If source patient is HIV ±

ve then the HCW must

repeat blood test after 3

months


HbsAg ± ve

If HCW vaccinated for HBV

Check antibody titre.

a. IF < 10 IU/ml give

Inj immunoglobulien

b. Revaccinated with

Full course.

Repeat blood test after 3 months.

Give Counseling

If HCW vaccinated

Give counseling

If source is

UNKNOWN then

If HCW vaccinated for HBV and

antibody titer

If > 10 IU/ ml

a. HCW protected.

b. Give counseling.

If HCW not vaccinated

And

Vaccinate for HBV

Full course i.e.0, 1, and

6



Infectious spill ManagementInfectious spill Management

Segregate/cohort the area of spill.Segregate/cohort the area of spill.

Put 10% solution of Sodium HypochloritePut 10% solution of Sodium Hypochlorite(Medichlor) over the spill.(Medichlor) over the spill.

Put a thick folded tissue paper on it.Put a thick folded tissue paper on it.

Allow to stay for 20 min.Allow to stay for 20 min.

Wear gloves.Wear gloves.

Collect with scoop and put into yellow bag.Collect with scoop and put into yellow bag.

Wipe the floor with medichlor.Wipe the floor with medichlor.



PREVENTION

IS PRIMARY!

Protect patients« protect heal t hc are personnel «

promote qual ity heal t hc are!



TransmissionTransmission--Based PrecautionsBased Precautions

Used in addition to Standard PrecautionsUsed in addition to Standard Precautions

for Specified Patientsfor Specified Patients

Designed for the Care of SpecifiedDesigned for the Care of Specified

PatientsPatients

Infections spread by: airborne,Infections spread by: airborne,droplet, or contact transmissiondroplet, or contact transmission



Airborne TransmissionAirborne Transmission

For infectious agents with droplet nuclei < 5For infectious agents with droplet nuclei < 5

micronsmicrons

Examples: TExamples: Tuberculosis, Measles, H1N1uberculosis, Measles, H1N1 Precaution ExamplesPrecaution Examples

± ± Isolation rooms under negative pressureIsolation rooms under negative pressure

± ± N95 maskN95 mask



Droplet TransmissionDroplet Transmission

For infectious agents with droplet nuclei >For infectious agents with droplet nuclei >

5 microns5 microns

Examples: Pertussis, MeningococcalExamples: Pertussis, Meningococcalmeningitis, Tuberculosismeningitis, Tuberculosis

Precaution Examples:Precaution Examples:

± ± Private roomPrivate room ± ± Mask if within 3¶ of patientMask if within 3¶ of patient



Contact PrecautionsContact Precautions

For protection against skinFor protection against skin--toto--skin contact andskin contact and

physical transfer of microorganisms to a hostphysical transfer of microorganisms to a host

from a sourcefrom a source

Precaution Examples:Precaution Examples:

± ± Private roomPrivate room

± ± HandwashingHandwashing

± ± Glove changesGlove changes

ExamplesExamples

± ± ScabiesScabies

± ± MRSA, VREMRSA, VRE



Safe Work PracticesSafe Work Practices

Keep hands away from faceKeep hands away from face

Work from clean to dirtyWork from clean to dirty

Limit surfaces touchedLimit surfaces touched Change when torn or heavilyChange when torn or heavily

contaminatedcontaminated

Comply with hand hygieneComply with hand hygiene



Education/Motivation ProgramsEducation/Motivation Programs

Monitor healthcare workers (HCWs)Monitor healthcare workers (HCWs)adherence with recommended hand hygieneadherence with recommended hand hygienepractices and give feedbackpractices and give feedback

Implement a multidisciplinary program toImplement a multidisciplinary program toimprove adherence to recommendedimprove adherence to recommendedpracticespractices

Encourage patients and their families toEncourage patients and their families toremind HCWs to practice hand hygieneremind HCWs to practice hand hygiene

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002 ;

vol. 51, no. RR-16.



Healthcare Associatrd InfectionHealthcare Associatrd Infection


Components:Components:

± ± Hand HygieneHand Hygiene

± ± Use of Personal Protective Equipment (PPE)

Use of Personal Protective Equipment (PPE)((Gloves, Gowns, Masks, Goggles for Eye Protection)Gloves, Gowns, Masks, Goggles for Eye Protection)

± ± Transmission Based PrecautionsTransmission Based Precautions

(Airborne precaution, droplet protection, contact precaution)(Airborne precaution, droplet protection, contact precaution)

± ± Biomedical Waste Management including sharpBiomedical Waste Management including sharp

disposaldisposal

± ± Prevention & management of exposuresPrevention & management of exposures

SummarySummary



ResourcesResourcesWhere to get more information or helpWhere to get more information or help

Training CoursesTraining Courses ± ± Society of Hospital Epidemiologists of America (SHEA)Society of Hospital Epidemiologists of America (SHEA)

± ± Association of Professionals in Infection Control (APIC)Association of Professionals in Infection Control (APIC)

± ± National courses and congressesNational courses and congresses

BooksBooks ± ± Textbooks: Bennett and BrachmanTextbooks: Bennett and Brachman -- WenzelWenzel -- MayhallMayhall

± ± APIC Curriculum and GuidelinesAPIC Curriculum and Guidelines

± ± CDC GuidelinesCDC Guidelines

JournalsJournals ± ± Infection Control and Hospital EpidemiologyInfection Control and Hospital Epidemiology

± ± Journal of Hospital InfectionsJournal of Hospital Infections

± ± American Journal of Infection ControlAmerican Journal of Infection Control

Consulting servicesConsulting services ± ± National: CDC, Ministry of HealthNational: CDC, Ministry of Health

± ± ColleaguesColleagues



Thank you

inf control fundamentals

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