infection prevention and safety measures

05/03/2023 MN1st Year Chanak (6th Batch) 1

Welcome to Seminar

Infection Prevention and Safety Measures

Chanak TrikhatriMN 6th Batch

05/03/2023 2

“It may seem a strange principle

to enunciate as the very first requirement of a hospital

that it do the sick no harm”

(Florence Nightingale, Notes on Hospitals, 1863)


• Concepts of infection prevention and safety measures • Chain of infection • healthcare-associated infections and safety measures• Development of infection prevention guideline• Component of Standard Precaution and Transmission

based Precaution and Safety Measures • Challenges of healthcare-associated infections.• Illustrate nurses Role In infection prevention and safety

measures

Highlights of the Seminar

05/03/2023 4MN1st Year Chanak (6th Batch)

HistoryPeriod Events

Hippocrates (460-370 BC)

Suppuration and pus was not a natural component in the healing process

Sumerians The wound was cleansed with beer and then bandaged with a cloth soaked in wine and turpentine.

Middle age Earliest Europeans hospitals no resemblance to modern hospitals. Lack of space and shifts were ordered for patients and occasionally more than one patients in beds. Hospitals called “pest houses.”

19th century (1865)

Germ theory by Louis Pasteur, and its subsequent application to surgical sterility by Joseph Lister

Koch’s postulates, 1890

The germ theory and Semmelweis’ theory of transmission from patient to patient were considered plausible


History Contd….

Period Events Middle 1800s Ignaz Phillip Semmelweis

Ignaz Phillip Semmelweis and Nightingale introduced sanitation and hygienic practices into the hospital.

19th century Surgery almost always followed by infection, 60% of limb amputations resulted in fatal infection

1950s North America and the UK.

Modern infection control and practiced due to hospital outbreaks of staphylococcus aureus

1990s Emergence of Vancomycin resistant Enterococci.--- Advancement brought new challenges like catheter,

blood stream infection and ventilator associated pneumonia.

2000 on ward Increase number of susceptible patients as a result of survival to immune modifying disease or effect of therapy


Definition of an Infection

• The entry and development or multiplication of an agent in the body of man or animals (Park, 2015).

• Entry of a harmful microbe into the body and its multiplication in the tissues / bloodstream (Wilson, 2001).

• Invasion of the body by a pathogenic microorganism (Bergquist and Pogosian, 2000)


Def. Contd….

The presence of viable multiplying microorganisms in the

tissues of a host, or in body cavities in which such

organisms are not usually found in normal course. The

term implies the presence of a host response (in contrast

to colonization where there is no host response), which

may actually be responsible for many unwanted effect of

infection (Thomas, 2007).


Chain of Infection:

Source or Reservoir

Mode of Transmission

Susceptible Host

(Park, 2015) 05/03/2023 9MN1st Year Chanak (6th Batch)

Causative Agent Microorganisms

Infectious agent microorganisms (bacteria, viruses, fungus, parasite)

• Resident:- normally reside on the skin in stable numbers

• Transient:- attach loosely to the skin by contact with another easily removed by hand washing


ReservoirA reservoir is defined as “any person, animal, arthropod, plant, soil or substance (or combination of these) in which as infectious agent lives and multiplies, on which it depends primary for survival and where it reproduces itself in such manner that it can be transmitted to a susceptible host.” Three types of reservoir are;

1) Human reservoir

2) Animal reservoir

3) Reservoir in non-living things (Park, 2015).


Portal of ExitAs part of the chain of infection, the path by which the causative agent gets out of the reservoir. In a person, this is often by a body fluid (Park, 2015).

Mode of Transmission Communicable diseases may be transmitted from the

reservoir or source of infection to a susceptible individual in many different ways, depending upon the infectious agent, portal of entry and the local ecological conditions (Park, 2015). Direct, Indirect


Portal of Entry:

• As part of the chain of infection, the path by which the causative agent gets into a susceptible host.

• Nose, mouth, eyes, rectum, genitals and other mucous membranes, cuts, abrasions or breaks in the skin

Susceptible Host• Anyone whose resistance to disease decreases

• Reasons for lowered resistance: age, existing illnesses, fatigue and stress


Types of infection

1. Community Acquired

2. Hospital Acquired

a. Nosocomial Infection

b. Opportunistic Infection

c. Iatrogenic Infection

d. Cross Infection05/03/2023 14MN1st Year Chanak (6th Batch)

1. Community Acquired

An infection contracted outside of a health care setting or

an infection present on admission. Community acquired

infections are often distinguished from nosocomial by the

types of organisms (Medical Dictionary, 2009). In contrast

to nosocomial (hospital acquired) infection.


Prevention Modalities • Primordial Prevention: inhibit the emergence of risk

factors

• Primary Prevention: the action taken prior to the onset of disease

• Secondary Prevention: action which halts the progress of a disease at its incipient stage and prevents complications

• Tertiary Prevention: prevention are disability limitation, and rehabilitation


2. Hospital-acquired infection (HAI)

Hospital-acquired infection (HAI) is an infection that is contracted from the environment or staff of a healthcare facility. Infection is spread to the susceptible patient in the clinical setting by a number of means; health care staff, contaminated equipment, bed linens, or air droplets (CDC, 2014).


Contd…

• Exogenous:– from an outside source, staff, other patients, environment, equipment (Iatrogenic, Nosocomial Infection)

• Endogenous:– self infection from the patient (Oppotunistic Infection)


Semmelwish Investigation• In 1846 there was differential mortality of childbed fever

between 2 obstetrics wards 1 & 2 at University of Geneva.

• Then Pathologist doing post mortem died of similar illness having nicked his hand with scalpel, conclusion from infectious materials.

• Hospital staff and students were subsequently ordered to wash their hands

• Mortality rate dropped from 11.4% to 1.3% in ward 1- decline of 89%.

• Hand washing also ordered for ward 2, rate declined by 52%.


Nosocomial Infections

Nosocomial infection is an infection originated in a patient while in a hospital or other health care facility. It denotes a new disorder associated with being in hospital. (Park, 2015).

An infection occurring in a hospitalized patient, 72 hours or more after admission. Also includes infections directly related to a previous hospitalization (Capital Health, 2010).


Contd..

• At least 5% of hospitalized patients each year in the U.S. develop nosocomial infections many are preventable (CDC, 2014a).

• About 5.6 million HCWs and related occupations are at risk of occupational exposure to bloodborne pathogens, including HIV, HBV, HCV, and others (OSHA, 2014).


Contd…

• In 2011, over 700,000 HAIs occurred in U.S. hospitals, with 75,000 patients dying from complications of HAIs (CDC, 2014a).

• About 380,000 people die of infections acquired in long-term care facilities each year (CDC, 2014b).

• In England, more than 100,000 cases of HAIs lead to over 5,000 deaths occur annually.


Contd…• Out of every 100 hospitalized patients at any given time,

7 in developed and 10 in developing countries will acquire HAIs. Hundreds of millions of patients are affected by this worldwide each year (WHO, 2014).

• Globally it is estimated that 142,000 people died in 2013 from adverse effects of medical treatment up from 94,000 in 1990.

• Eastern Mediterranean and South-East Asia Regions 11.8 and 10.0%, respectively (Sah, M.K., et. al., 2012).


Research: Nosocomial Bacterial Infection and antimicrobial Resistant Pattern in a

Tertiary care Hospital in Nepal

Prevalence of bacteria causing nosocomial infection was (34.4%, 310). Out of 310 specimens, urine 122 (39.30%), sputum 78(25.2%), pus 78(25.2%), endotracheal secreation 24 (7.7%) and blood 8(2.6%). The most common isolates were Escherichia coli followed by Acinetobacter species, Klebsiella pneumonia and Staphylococcus aureus (Sah, M.K., et. al., 2012).


Common Microbes

Gram-negative bacteria: • Pseudomonas aeruginosa • Staphylococcus aureus • Aeromonas hydrophilia • Acinetobacter calcoaceticus • Legionella pneumophila Mycobacteria: • Mycobacterium xenopi • Mycobacterium chelonae • Mycobacterium avium-intracellularae


Contd…


Iatrogenic Infection

Resulting from the activity of a health care provider or

institution or said of any adverse condition in a patient

resulting from treatment by a physician, nurse, allied

health professional or medical instruments and procedures

(Park, 2015).


Opportunistic infection

Infection by an organism that does not ordinarily cause disease but becomes pathogenic under certain circumstances, as when the patient is immunocompromised. An infection caused by normally nonpathogenic organisms in a host whose resistance has been decreased (Perry, and Potter, 2007).


Count of Normal FloraNormal human skin is colonized with bacteria

• On the scalp1 x 106 (CFUs)/cm2

• In the axilla 5 x 105 CFUs/cm2

• Abdomen 4 x 104 CFUs/cm2

• On forearm 1 x 104 CFUs/cm.

• Faeces contain approximately 1013 bacteria per gram.

• Medical personnel have ranged from 3.9 x 104 to 4.6 x 106

• The hands of HCWs colonized with pathogenic flora (e.g., S. aureus), gram- negative bacilli, or yeast.


Cross Infection

Cross infection transmitted between one patient to another patients infected with different pathogenic microorganisms (Perry, and Potter, 2007).


Rationale and Significance

• Enough knowledge and protocol but increasing rate of the infection

• And about the medical risk and error

• Low compliance rate and adherence of health care worker

• New advancement and facts less implementation


Infection Prevention

Measures practiced by healthcare personnel intended to prevent spread, transmission and acquisition of infection between clients, health care professional to the client, from instrument, and client to health care worker in the healthcare setting (Park, 2015).


IP….. contd…

Largely depends on placing barriers between a

susceptible host (person lacking effective natural

or acquired protection) and the microorganisms.

Protective barriers are physical, mechanical or

chemical processes that help prevent the spread

of infectious microorganisms from (CDC, 2007).


Cost Estimation

• CDC 2014, report estimated the annual medical costs of HAIs to U.S. hospitals between $28 and $45 billion dollars.

• In England are estimated to cost £1 billion a year.

• In Mexico, the annual cost approaches $ 1.5 billion.


History of Infection Prevention Year Infection Prevention

1877,1910 Separates facilities, Antisepsis and disinfections ... etc1985 Universal Precautions: (guidelines for protecting healthcare

worker because the emergence of HIV & other bloodborne pathogens)

1987 Body Substance Isolation: ( focused on protecting patients and health personnel from all moist body fluids not just blood: semen, vaginal secretions, wound drainage, sputum, saliva etc

1996 Standard Precaution: Two level approach:•Standard Precautions which apply to all clients and patients attending healthcare facilities•Transmission-based Precautions which apply only to hospitalized patients

2007 Isolation Precautions (new pathogens; SARS, Avian Influenzae H5N1, H1N1)

Fundamental Principles of Infection Prevention (CDC guideline 1996)

Guideline of infection prevention develop on 1996

and revised in 2007

1. Standard Precaution

2. Transmission Based Precaution


Definitions of Standard Precautions

• Placing a physical, mechanical or chemical barrier between microorganisms and an individual

• Consider every person (patient or staff) as potentially infectious and susceptible to infection.

• Wash hands the most important procedure for preventing cross- contamination (person to person or contaminated object to person), (OSHA, 2011a.).


1. Standard Precautions

I. Hand Hygiene

II. Personal Protective Equipment

III. Respiratory Hygiene

IV. Safe Injection Practice

V. Cleaning and Disinfections

VI. Safe Handling Sharp

VII. Waste Management

VIII. Linen or Laundry Management

IX. Spill Management

X. Pre and Post Prophylaxis

XI. Immunization


I. Hand Hygiene

• Hand washing is the most important way to reduce the spread of infections in health care setting.

• Reduces the number of infectious microorganisms on hands

• Reduces client sickness and death caused by infections (Perry, and Potter, 2007).


Hand Hygiene Eighty percent of common infections are spread by hands (BC Center for Disease Control, Hand Hygiene and Queensland Health, 2015).

Thorough hand washing with adequate quantities of water and soap removes more than 90% of the transient (i.e. superficial) flora, including all or most contaminants (WHO, 2014).


Research: Hand Hygiene for the Prevention of Nosocomial Infections

Results• Hygienic hand disinfection has better antimicrobial efficacy before

and after manual contact with patients.

• The hands should be washed, rather than disinfected, only when they are visibly soiled.

• Compliance can be improved by training, by placing hand-rub dispensers at the sites where they are needed, ConclusionsImproved compliance in hand hygiene, with proper use of alcohol-based hand rubs, can reduce the nosocomial infection rate by as much as 40%. (Kampf, Löffler, and Gastmeier, 2009)


The Global Public-Private Partnership for Hand washing

• Two major illnesses that transmitted by hands are diarrhea and pneumonia.

• Together, diarrhea and pneumonia kill 1.7 million children anuually (WHO, 2014).

Diarrhea

• Each day 2,195 children die from diarrhea. Review of more than 40 studies found that hand washing with soap can prevent 4 out of every 10 cases of diarrhea (WHO, 2014).


Contd…Pneumonia and Acute Respiratory Infections

• Evidence suggests that washing hands with soap after defecation and before eating could cut the respiratory infection rate by about 21-25 percent (WHO, 2014).

• A study in Pakistan found that handwashing with soap reduced the number of pneumonia related infections in children under 5 by more than 50 percent.

• Ebola: Handwashing with soap is an important component of Ebola infection protection.

• Skin & Eye Infections: Studies have shown that handwashing reduces the skin eye infections (WHO, 2014).


The Three Kind of Hand Washing Type 1 (with soap and running water)• Removes transient microorganism and soil.

Type 2( with antiseptic and running water)• Removes transient microorganism and soil, kills or inhibits

resident microorganism and appropriate before invasive procedures

Type 3 ( alcohol handrub)• Kills or inhibits transient and resident microorganism, but does

not remove microorganism and soil (Perry, and Potter, 2007).


47

Seven Steps of Hand Washing

(Raffles Medical Group, 2010).

Rub palm together Rub back side of both hands Interlace fingers and rub hands

Interlock the finger and rub the back of fingers of both hands

Rub thumbs by rotating manner area in between index finger

Rub fingertips on palm for both hands

Rub both wrists in a rotating manner rinse and dry thoroughly

Apply soap all over two hands

05/03/2023 MN1st Year Chanak (6th Batch)

Research: Hand hygiene and aseptic techniques during routine anesthetic care -

observations in the operating room

• The aim of this study was to explore the indications and occurrence of hand hygiene opportunities and the adherence to hand hygiene.

Results

• A total of 2,393 opportunities for hand hygiene was recorded revealed overall adherence of 8.1%.

Conclusions

• Evidence for low adherence to hand hygiene guidelines. The study concluded that strategy should include education and practical training to carry out hand hygiene and aseptic techniques and use gloves correctly (Veronika, et. al, 2014)


Research: Systematic review of studies on compliance with hand hygiene guidelines in hospital care.

The mean compliance rate of (ICU) and general wards is 40%, and the lowest compliance rates among physicians (Erasmus, 2010).

Factors associated with non-adherence are high workload, insufficient time, inaccessibility of HH products, skin irritation, HH not being a prioritized task, forgetfulness, lack of scientific information and skepticism concerning the importance of HH.


Your 5 moments for HAND HYGIENE


II. Personal Protective Equipment:

51

Face mask / eye protection:protect mucous membranes of the eyes, nose and mouth during procedures

Gloves:Touching mucous membrane and non-intact skin and performing sterile procedures

Gown:Prevent soiling of clothing and skin during procedures that are likely to generate splashes of blood, body fluids, secretions or excretions


Cap:During sterile technique to prevent infection

Footwear:If contact with blood or body fluids may occur

Sequence of Putting on PPE (“Donning”)


Sequence of Taking off PPE (“Doffing”)


III. Respiratory Hygiene

Respiratory hygiene is a relatively new concept introduced after the SARS outbreak in 2003, comprising vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting. It is directed to patients and family members with signs of respiratory illness such as cough, congestion, or increased respiratory secretion (CDC, 2007).


Respiratory Hygiene


• Education regarding how respiratory illnesses spread

and prevention practices including “cover your cough”

• Availability and use of tissues and hand hygiene products

• Use of mask for person who is coughing

• Spatial separation of the person with a respiratory illness

• At least 1 metre (3 feet) away from others in common

waiting areas (WHO, 2007)

N95 Respirator

*Image courtesy of: CDC Image Library


IV. Safe Injection Practice

• Safe injection practices are intended to prevent

transmission of infectious diseases between individuals

and to prevent injuries such as needle sticks

• In developing countries 16 thousand million injections

used each year. 90%, for therapeutic purposes while 5 to

10% are given for preventive services, including

immunization and family planning (WHO, 2014).


Safe Injection Practice• According to a study conducted in Western region of

Nepal (DoHS, 2013), 70% of clinical staff and 63% of non-clinical staff reported a needle stick injury (NSI) or other sharps injury at some time.

• Around 385,000 needlesticks and other sharps related injuries are sustained by hospital HCWs annually (CDC, 2013).

• Nearly 15% of needle stick injuries occur during or after disposal (CDC, 2014).


Safe Injection Practices Include• Aseptic technique

• Using a single syringe and fluid infusion sets only once

• Using single-dose vials when possible

• If multi-dose vials must be used, then use & store them according to manufacturer's recommendation


Safe Injection Practices: Fingerstick Devices

Single-use devices• Disposable• Prevent reuse through an auto-

disabling feature• Appropriate for settings where

assisted monitoring of blood glucose is performed

Single-Use Fingerstick DeviceSource: CDC


Contd…

Reusable devices• Often resemble a pen (“penlet”) not appropriate

due to

• Failure to clean and disinfect properly

• Links to multiple outbreaks of hepatitis B

• Risk for occupational needlestick

• Only appropriate for people who do not require assistance with blood glucose monitoring (BGM)


Reusable Fingerstick DeviceSource: CDC

Needle Stick Injury Prevention

• Over 80% of needle stick injuries can be prevented with the use of safer needle devices.

• Worker education and work practice controls can reduce injuries by 90% ( WHO, 2014).


AntisepticInhibits the growth of pathogenic and disease causing bacteria. Antiseptic are used in living beings for humans and living cells

• Antibacterial – (antimicrobial)

– Bacteriocidal - kill bacteria

– Bacteriostatic - suppresses their growth


V. Cleaning and Disinfection

Antiseptic • 60 - 90% alcohol (Ethyl, isopropyl or “methylated spirit”)

• 4% chlorhexidine gluconate (Hibitane®, Hibiscrub®, Hibiclens®)

• Chlorhexidine gluconate and cetrimide, in various concentrations (Savlon®)

• 3% iodine aqueous iodine and alcohol containing (tincture of iodine) products, 7.5 – 10%

• Iodophors, various concentrations (Betadine® or Wescodyne®

• 0.5 – 4% chloroxylenol (Para-chloro-metaxylenol or “PCMX) various concentrations (Dettol®)


Clean

Activities that remove, or reduce, the amount of dirt and/or microbes. Thorough cleaning will remove more than 90% of visible dirt. Cleaning process depends essentially on mechanical action. There must be policies specifying the frequency of cleaning and cleaning agents used for walls, floors, windows, beds, curtains, screens, fixtures, furniture, baths and toilets, and all reused medical devices (WHO, 2002).


Clean contd…

Zone A: no patient contact. Normal domestic cleaning (e.g. administration, library).

Zone B: care of patients who are not infected, and not highly susceptible.

Zone C: infected patients (isolation wards). Clean with a detergent/disinfectant solution, with separate cleaning equipment for each room.

Zone D: highly-susceptible patients OT, delivery rooms, ICU, NICU, and haemodialysis units. Clean using a detergent/disinfectant solution and separate cleaning equipment. 05/03/2023 MN1st Year Chanak (6th Batch) 66

67

Destroys all pathogenic organism except spores. The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms, such as bacterial endospores, on inanimate objects and equipments (WHO, 2002).

Disinfection


Disinfection with hot water

Articles Temperature Time

Sanitary Equipment

800 C 45-60 sec

Cooking Utensils 800 C 1 min

Linen 700 C 950 C

25 min 10 min


Types of Disinfection• High level disinfection (critical) :- destroy all

microorganisms, with the exception of heavy contamination by bacterial spores.

• Intermediate disinfection (semi-critical) :- inactivates Mycobacterium tuberculosis, vegetative bacteria, most viruses and most fungi, but does not necessarily kill bacterial spores.

• Low-level disinfection (non-critical) :- kill most bacteria, some viruses and some fungi, but cannot be relied on for killing more resistant bacteria (Perry, and Potter, 2007).


SterilizationThe process by which all microorganisms including spores are destroyed. The use of a physical, radiation or chemical process to destroy all microbial life, including highly resistant bacterial spores. It is never absolute; by definition, it reduces the number of microorganisms by a factor of more than 106 (i.e. more than 99.9999% of microorganisms are killed) (CDC, 2014)


Principal Sterilization Methods

Thermal sterilization

• Wet sterilization: exposure to steam saturated with water at 121 °C for 30 minutes, or 134 °C for 13 minutes in an autoclave; (134 °C for 18 minutes for prions).

• Dry sterilization: exposure to 160 °C for 120 minutes, or 170 °C for 60 minutes; this sterilization process is often considered less reliable


Principal…Contd…

Chemical Sterilization

• Ethylene oxide and formaldehyde for sterilization

• Peracetic acid is widely used in the United States and some other countries in automatic processing systems. (WHO, 2002)


Practice of Fumigation

In the 1960s, the use of chemical fumigation for control of microbial contamination in hospitals was thought to be an effective adjunct to environmental cleaning of hospital isolation rooms and other critical areas.(Friedman, H., Volin, E., & Laumann, D., 1968).

The same fumigant inadvertently entered a room through a sewer pipe, killing an infant and sickening the parents. Adverse effects are carcinogenic effect, pungent environment, damage the surfaces of the equipment (Langard, S., Rognum, T., Flotterod, O., & Skaug, V., 1996) Potential for the gas or vapor to escape through breaks, plumbing fixtures, or ventilation ducts.


Sterilization of Operation Theatres: Newer Methods to Replace Fumigation

Bacillocidrasant:- A newer and effective compound in environmental decontamination with very good cost/benefit ratio, good material compatibility, excellent cleaning properties and virtually no residues. It has the advantage of being a Formaldehyde-free disinfectant cleaner with low use concentration. Asepsis within 30 to 60 minutes no need to close OT for 24 hour (William, 2008)

Virkon: is gaining importance as non-Aldehyde compound. Virkon is proved to be a safe virucidal, bactericidal, fungicidal, mycobactericidal and non-toxic compound. It contains oxone (potassium peroxymonosulphate), sodium dodecylbenzenesulfonate, sulphamic acid; and inorganic buffers (Hernndez, A., et al., 2000).


Aseptic Technique

Aseptic technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens. Aseptic technique means without sepsis (Perry, and Potter, 2007).


Contd….

• Medical Asepsis :- clean technique-reduces the number of pathogens. Clean technique; procedures used to reduce & prevent spread of microorganisms

• Practices used to “confine a specific microorganism to a specific area, limiting the number, growth and transmission of microorganisms” (Kozier, Erb et al, 2004, p.744).


Contd…

Surgical Asepsis: – Sterile technique practices used to render and keep objects and areas free from organisms. Sterile technique; procedures used to eliminate microorganisms Sterilization Practices destroy all forms microorganisms


Principle of maintaining asepsis • Creation of sterile field using sterile equipment

• All items in a sterile field must be sterile

• Sterile packages or fields are opened or created as close as possible to time of actual use

• Moist areas are not considered sterile

• Only areas that can be seen by the clinician are considered sterile (i.e., the back of the clinician is not sterile).


• Gowns are considered sterile only in the front, from chest to waist and from the hands to slightly above the elbow

• Tables are considered sterile only at or above the level of the table.

• Nonsterile items should not cross above a sterile field.

• There should be no talking, laughing, coughing, or sneezing across a sterile field


Principle of maintaining asepsis cont..

Principle of maintaining asepsis cont..

• Personnel with colds should avoid working while ill or apply a double mask

• Edges of sterile areas or fields (generally the outer inch) are not considered sterile

• When in doubt about sterility, discard the potentially contaminated item and begin again

• A safe space or margin of safety is maintained between sterile and nonsterile objects and areas

• Tears in sterile packs and expired sterilization dates are considered breaks in sterility (Perry, and Potter, 2007).


When Should Apply the Aseptic Technique

• Wound care

• drain removal and drain care

• intravascular procedures

• vaginal exams during labor

• insertion of urinary catheters

• respiratory suction

• Injection technique

• Collection of blood specimens


VI. Safe Handling of sharp

A hypodermic needle, suture needle, blade, scissors, forceps can be a potentially lethal instrument. Vein puncture for example, is one of the most dangerous procedures a health care worker can perform if it results in a needle prick injury.


Preventing Sharps Injuries cont..• Preparation:

– Assemble all equipment required for the procedure.

– Minimize distractions.

• Equipment:

– Equipment should be used strictly according to protocols and only for the purpose for which it was designed.

– Choose the safest equipment.


• Technique:

– Perform the procedure slowly and carefully

– Minimize the handling of sharp instruments. The less they are handled the less chances of needle prick injuries occurring

– The needle must be properly recapped; the sheath must not be held in the fingers; either a single-handed technique, forceps or a suitable protective guard designed for the purpose, must be used if needed.

Preventing Sharps Injuries cont..


• Each health care worker who uses sharp instruments is responsible for their management and disposal

• Dispose of all the sharp instruments used during the procedure immediately, carefully and appropriately

• The sharps container never be overfilled and dispose after ¾ filled up the container.

• The sharp container must be securely sealed with a lid before disposal. Use utility glove during disposing the sharps.

Preventing Sharps Injuries cont..


Needle Stick Safety Law

Effective in 1991 and revised in 2000, requires employers to protect healthcare workers from exposure to HIV and hepatitis B and C virus

Employers must:

• Develop a written exposure control plan

• Implement standard precautions

• Provide personal protective equipment for example, gloves and face shields e.t.c.

• Use engineering controls for example safety devices05/03/2023 86MN1st Year Chanak (6th Batch)

Reporting

Every health care facility, including, general practices and dental surgeries, must have an Occupational Exposure Policy so that staff members know the reporting mechanism of their workplace, and the steps to follow in the event of a needle prick injury. All needle prick injuries must be reported.


VII. Waste Management

• Hospital waste is “Any waste which is generated in the diagnosis, treatment or immunization of human beings or animals or in research” in a hospital.

• Hospital waste is a potential reservoir of pathogenic micro organisms and requires appropriate safe and reliable handling. The main risk associated with infection is sharps contaminated with blood.


Principles Of Waste Management Steps in the management of hospital waste :

Generation

Segregation/separation

Collection

Transportation

Storage

Treatment

Final disposal (WHO, 2007)


VIII. Linen and Laundry Management

• Although soiled linen may harbor large numbers of pathogenic microorganisms, the risk of actual disease transmission from soiled linen is negligible.

• Dirty linen often contains a significant number of microbes (104–108 bacteria per 100 cm2 of soiled bed sheets), mostly Gram-negative rods and bacilli (Blaser, et al. 1984).


Soiled Linen and Laundry• All soiled linen should be bagged or placed in containers

at the location where it was used and should not be sorted or rinsed in the location of use.

• Linen heavily contaminated with blood or other body fluids should be bagged and transported in a manner that will prevent leakage.

• Soiled linen is generally sorted in the laundry before washing.

• Gloves and other appropriate protective apparel should be worn by laundry personnel while sorting soiled linen.


Washing • Walter and Schillinger suggested that levels of microbes

on laundered fabrics of 20 colony forming units 100 cm2 or less per are equal to complete pathogen removal (Walter, and Schillinger, 1975).

• While Christian et al proposed that a 106–107 reduction in viable counts is effective. Nonetheless, regular assessment of the microbial levels on laundered linen is unnecessary unless laundry- related outbreaks occur. (Christian, Manchest, and Mellor, 1983).


Contd….

Commercial laundry facilities often use water temperatures of at least 71°C for minimum 25 mins and 50-150 ppm of chlorine bleach to remove significant quantities of microorganisms from grossly contaminated linen(CDC, 2011).


Management of the Clean Linen

Storing Clean Linen

• Keep clean linen in clean, closed storage areas.

• Use physical barriers to separate folding and storage rooms from soiled areas.

• Keep shelves clean.

• Handle stored linen as little as possible.


Contd…Transportation of Clean Linen

• Clean and soiled linen should be transported separately.

• Containers or carts used to transport soiled linen should be thoroughly cleaned before used to transport clean linen.

• Clean linen must be wrapped or covered during transport to avoid contamination.


Contd…Distribution of Clean Linen

• Protect clean linen until it is distributed for use.

• Do not leave extra linen in patients’ rooms.

• Handle clean linen as little as possible.

• Avoid shaking clean linen, it releases dust and lint into the room.

• Clean soiled mattresses before putting clean linen on them.


IX. Spill Management

Small Spills: spots or drops of blood and other small spills up to 10cm diameter.

• Wipe the area immediately with paper towelling

• Clean with warm water and detergent followed by rinsing

• Dry the area (as wet areas attract contaminants)

• A sanitizer (e.g. alcohol wipe) can be used on the area after cleaning.


Contd…Large Spills: spots greater than 10 cm diameter. • Wash carefully into the sewerage system using copious

amounts of water, taking care to avoid splashes

• Clean the area with mop and bucket of warm water and detergent

• Clean the bucket and mop thoroughly after use using warm soapy water and store dry.

Carpet • contain and clean with warm water and detergent

• do not use disinfectant. Professional carpet cleaning/steam cleaning may be required (CDC, 2007).


Spill Management contd…Equipment • Equipment (mop, bucket and cleaning agents) is to be

readily available in a location known to all.

• A portable ‘spills kit’ can be made up to manage likely spills for the area/activity e.g.

Basic Principles:

• Assume all blood and body substances are potentially infectious and cover cuts, maintain hand hygiene and use appropriate PPE.


Spill Management contd…

• Cover the spill, to prevent the generation of splashes and aerosols from the spilled substance –

– e.g. granular formulation such as vomit control

– use a scraper and pan to remove the absorbed material

• Clean the area thoroughly, rinse and dry.

• Clean non-disposable cleaning equipment thoroughly after use, rinse and store dry.


X. Post Exposure Prophylaxis• Post exposure prophylaxis is intended to protect the

health care workers from different infection which could be acquired while performing medical procedures (e.g. needle stick injury, blood splash on mucosa, blood and body fluid)

• Expose with HIV cases -PEP should be started as soon as possible within72 hours the course will be for 28 days.


Risk of transmission of infection following HIV Hepatitis B Hepatitis C occupational

exposure

HIV, 0.3%(Cardo et al., and Bell, 1997) HB 18–30% (Pruuss-Ustun et al., 2005) HC 1.8% (Puro et al., 2010)

Waste handlers were infected by tuberculosis (TB) at a medical waste-processing facility in Morton, Washington, in the United States of America, as a result of exposure to healthcare waste.


Pre Exposure Prophylaxis

Pre-exposure vaccination (immunization) for HBV In healthcare settings, immunization against HBV must be provided to health workers who perform tasks involving contact with potentially infectious blood or other bodily fluids. The risk of acquiring HBV is far greater than that of HIV or Hepatitis C.


Contd…• If contact with Hepatitis B and C cases PEP (immunoglobin) should

be started as soon as possible within 72 hours.

• If a person contact with rabies disease, anti rabies vaccine should be provided within 72 hours after exposure.

• An Antiretroviral Therapy (ART) (zidovudine (AZT), lamivudine (3TC), and indinavir) double therapy for low risk Zidovudine (ZDV) + Lamivudine (3TC) OR Tenofovir + Emtricibine (TRUVADA)

• Triple therapy for high risk ZDV + 3TC + Efavirenz (EFV) OR replace Efavirence with Rotanovir®/Lopinavir (LPV) in pregnancy replace Efavirenz with Aluvia (WHO, 2007)


Outcome

• Post-exposure prophylaxis can reduce the risk of HIV transmission by 80%.

• Risk of developing disease 30% in hepatitis B, 3-10% in hepatitis C if not vaccinated (WHO & ILO, 2007).


XI. Immunization

• Health care workers may be exposed to certain infections in the course of their work.

• Vaccines are available to provide some protection to workers in a healthcare setting.

• Before exposure, first responders (health personnel) may receive vaccinations for different diseases, e.g. hepatitis B, influenza, measles, mumps, rubella, tetanus, diphtheria and pertusis etc


Immunizations for Healthcare Workers

Since 1981 the CDC has recommended healthcare workers receive influenza vaccination, and the coverage among healthcare workers during the 2013–14 flu season was 75.2%. Coverage was highest (97.8%) among healthcare personnel working in settings in which flu vaccination was a requirement for employment (CDC, 2014e).


Contd…

Federal OSHA law requires that that all employees whose jobs involve participation in tasks or activities with potential exposure to blood/OPIM be offered hepatitis B vaccination. The vaccination is free, safe, and highly protective. This vaccine is given in three doses. Serologic testing after vaccination (to verify that the vaccination was effective) is recommended.


05/03/2023 MN1st Year Chanak (6th Batch) 109(CDC, 2011c, 2010).

2. Transmission Based Precaution

I. Contact precautions

II. Droplet precautions

III. Airborne precautions (CDC, 2007, Gardner, 1996 and Siegel et al., 2007).

(Including standard precautions)

• Isolation Precautions (CDC, 2007)


Transmission Based Precaution

Contact, Droplet, and Airborne Precautions are transmission-based precautions that should be applied when a specific infectious agent is known or suspected to be present in a patient. Each transmission-based precaution is used in conjunction with Standard Precautions (CDC, 2007).



Sneezing may produce as many as 40 000 droplets between 0.5–12 μm in diameter that may be expelled at speeds up to 100 m/s (Cole & Cook, 1998; Tang et al., 2006).

Coughing may produce up to 3000 droplet nuclei, about the same number as talking for five minutes (Cole & Cook, 1998; Tang et al., 2006).

Transmission – Based Precautions

Airborne Precautions: spread of microbes on small droplet nuclei through the air (< 5 microns).

(ie) Measles; Chicken Pox; TB

Droplet Precautions: large particle droplets

(> 5 microns); which transmit 3 feet in air.

(ie) Mumps; Pertussis; Influenza; SARS

Contact Precautions: for prevention of disease transmitted by either direct / or indirect, contact.

(ie) Impetigo, Scabies, Herpes Zoster, C Difficile.

Airborne Precautions

Air Borne Diseases among Inpatients FY 2070/71. Among

patients the Pneumonia, Organism unspecified patients

were reported highest among the Air Borne disease with a

total patients of 9,558 were affected and 113 patients were

reported dead (DoHS, Annual Report 2070/71).


Isolation PrecautionSeparation is critically important when using isolation precautions because, as Florence Nightingale observed, many infectious diseases spread mainly through direct contact when patients are near to one another (Gardner, 1996).


Isolation

• Isolation refers to various measures taken to prevent contagious diseases from being spread from a patient to other patients, health care workers, and visitors, or from others to a particular patient.

• Isolation is most commonly used when a patient has a viral illness (CDC, 2007).


Types of Isolation

CDC (Centers for Disease Control and prevention) isolation precaution. It includes;

• Category specific Isolation precaution

• Disease specific Isolation precaution

• Universal blood and body fluid precaution


Category of Specific Isolation Precaution

• Strict isolation: - It includes strict hand washing, private room, gown, mask, proper disposal of contaminated items.

• Contact isolation: - It includes private room, gown, mask as needed, gloves, proper disposal of contaminated items and hand washing.

• Respiratory isolation: - It concludes private room, mask, gown and gloves as needed, proper disposal of contaminated articles.


Disease Specific Isolation Precaution

• Tuberculosis isolation:- Same as respiratory isolation. It also includes cleaning and disinfecting the articles.

• Enteric precaution:- It is maintained through private room if hygiene is poor, gown and gloves as needed, hand washing, disposal of contaminated articles. Same as strict isolation.

• Drainage/Secretion precaution:- It concludes gown and gloves as necessary, hand washing, disposal of contaminated articles. Same as enteric/strict isolation.


Blood and Body Fluid Precaution

• Blood and body fluid precaution:- Same as secretion precaution in puncture proof container for disposal.

• Reverse Isolation (Protective Isolation):- Is used to prevent contact between potentially pathogenic organisms and uninfected person who have seriously impaired resistance (CDC, 2007)


Definition of safety The condition of being safe from undergoing or causing hurt, injury, or loss. ‘The avoidance, prevention and amelioration of adverse outcomes or injuries stemming from the process of healthcare.’ (Vincent, 2010)

• S - Sense the error

• A - Act to prevent it

• F - Follow the safety guideline

• E - Enquire into accidents and death

• T - Take appropriate remedial measures

• Y - Your responsibility


IOM, USA (2014)

• 1 in 10 patient encounter adverse effect

• Due medical error injury 1 in 25

• Kills about 44000 to 98000

• Billion dollar each year in USA

• 66 % Errors done by patient

• 16% Staff

• 14% Both

• 4 % Accidents due to electrical mechanical


Incidence

The study report set out for the first time the annual figures for known reported harm 400 people known to have died seriously injured from events involving medical devices; nearly 10,000 people known to have experienced adverse reactions to drugs (NHS, 2000)


Safety Measures:Definition

Safety measures is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient and HCWs safety is also an attribute of health care systems, it minimizes the incidence and impact and maximizes recovery from, hazardious and adverse events (Emanuel et al., 2008) . All the measures intended to protect patient and HCWs is safety measures.


Definition…contd…

The World Health Organization (WHO) Conceptual Framework for the International Classification for Patient Safety (ICPS) activities or measures taken by an individual or a health care organization to prevent, remedy or mitigate the occurrence or reoccurrence of a real or potential (patient) safety event (WHO, World Alliance for Patient Safety 2009)


Safety For


People

Patient

HCW

Visitors

Place

Fire

Infrastructure

Mechanical/Electrical

Property

Assets

Stores

Equipment

Safety Issue• Adverse Health Care Event: event arise from care

• Error: Failure to complete the plan

• Health Care Near Miss: failure to prevent injury and compensating

• Adverse Drug Reaction: noxious drug

• Medication Error: inappropriate medication, harm during medication

• Sentinel Error: surgery wrong body part, wrong patient patient receive wrong medicaiton


Safety measure

Environmental safety

Medical Safety

Surgical Safety

Electrical SafetyEquipment Installation Safety

Blood safety

Sanitation IPC and BMW

Laboratory Safety


Environmental Safety • Enough light • Proper ventilation, exhaust fan• Stairs with hand rails• Window door• Slip preventing floors• Fire extinguishers and fire alarms • Prevent noise pollution• Heavy and fixed beds and bed screen• Safe wheel chairs and trolleys • No water logging in bathrooms • Call bell system for patients • Traffic control/ crowd control• Smell and order


Medical Safety• 10s rights of medication administration

• Illegible writing prescription by doctors

• Drip sets, air bubbles, over hydration, drip speeds

• Oxygen flow check empty gas cylinders

• Proper hand taking and hand over during shift change

• Radiation Protection Techniques


Surgical Safety

• Ensure aseptic technique

• Consent of the patient in writing

• Proper identification or patient and part to be operated

• Pre anesthetic check up

• Anesthetic safety

• Ensure no foreign body left inside

• Safety measures from ward to OT


Equipment Installation Safety

• Regular check up of equipments

• Proper earthing to avoid shock

• Regular maintenance and repair

• Training of nurses and technical staff

• Orientation and training of new devices and equipment


Laboratory safety

• Personal Protective Equipment (PPE) • Eating in the Lab and Food Storage • Close Laboratary door• Avoid needle prick • Measures radiology and radiotherapy• Biomedical waste disposal• Chemical Spills • Housekeeping • Hand Washing • Fume Hoods 05/03/2023 MN1st Year Chanak (6th Batch) 136

Electrical Safety

• Safety fuses with each equipment

• No loose wires or connection

• Properly plugged and fixed

• If short circuit call electrician

• Electricity back up battery/ generator

• Use of UPS

• Recognize hazards


Research

Ramnarayan, et. Al. (2006) examined the impact of a web based diagnostic reminder system on clinicians’ decisions in an acute paediatric setting during assessments that were characterized by diagnostic uncertainty. The mean count of diagnostic errors of omission decreased significantly, and the mean diagnostic quality score increased. The number of irrelevant diagnoses increased from 0.7 to 1.4, but did not result in a corresponding increase in the number of irrelevant or deleterious tests and treatments.


Challenges to Implementation of Infection Prevention Guideline

In Nepal• Lack of supervision and monitoring of government policy

Sense of accountability • Unavailability of resources and new technologies • High workload, errors and system failures repeated• Health care service is granted commercial business • Most of events not reported, defensiveness and secrecy• Blame culture “alive and well”• Detection systems in their infancy• Limited understanding of causes and measurements

impact• Action on known risk is very slow05/03/2023 MN1st Year Chanak (6th Batch) 139

Challenges…Contd….. International

• Lack of health care epidemiologists data managers and statisticians in infection control team with their expertise and experience of its leaders.

• The scope of antimicrobial resistant organisms broadens as patients needs become complex.

• Infection control programs which is limited with in hospital walls


Challenges…Contd…..

• Recent literature has highlighted the role that long-term acute-care hospitals play in HAIs. Given that long term care facilities have been implicated as the source of regional outbreaks of MDR organisms.

• Needs will broaden not only in the developed world but also in developing countries, where technology is growing and health care is modernizing, increasing the opportunities for HAIs.


Multidisciplinary Approach

Multidisciplinary infection control committee must be organized, comprising (but not limited to):

• A senior physician to provide leadership

• A clinical microbiologist

• Hospital hygiene and infection control Officer

• An infection-control nurse

• An antibiotic specialist

• A director of environmental services.


Applicable Nursing TheoryBetty Neuman System Model (1972)


Flexible Line of Defense

Normal Line of Defense

Line of Resistance

144

Physical environment

Psychological environment Social Environment

Patient condition & nature

communicationAdvice and variety

Mortality dataPrevention of disease

AirLightNoiseWater

BeddingDrainage

DietCleanlinessVentilation

Nightingale Environmental Theory

The Role Nursing Staff • Participating in the infection control committee

• Promoting the development and improvement of nursing techniques,

• Ongoing review of IP and safety measures nursing policies

• Developing training programs for members of the nursing staff

• Supervising the implementation of techniques for the prevention of infections and practice in specialized areas

• Monitoring of nursing adherence to policies. 05/03/2023 MN1st Year Chanak (6th Batch) 145

The Role Nursing Staff … contd..• Monitoring aseptic techniques, including handwashing

and use of isolation

• Reporting promptly to the attending physician any evidence of infection in patients under the nurse’s care

• Initiating patient isolation and ordering culture specimens

• Limiting exposure to infections, hazard and risk

• Maintaining a safe and adequate supply of ward equipment, drugs and patient care supplies.


The Role Nursing Staff … contd..• Identifying nosocomial infections, type of infection and

infecting organism

• Participating in training of personnel

• Surveillance of hospital infections

• Participating in outbreak investigation

• Ensuring compliance with local and national regulations

• Providing expert consultative advice


Infection Prevention Training (Annual Report (2013/14)


Program Activities Year Targets Achieve %TOT on Infection Prevention

2070/2071 20 0 0

District Level Training (Infection Prevention, (HFOMC, Basic FCHV)

2071/2072 According to district

Research: Attitudes towards infection prevention and control; an interview study with nursing students and nurse mentors

• Qualitative study from one large university and one large NHS Trust North of England.

• Results Nursing students negative attitude towards IPC and factors additional workload burden. Mentors identified more positive attitudes within their areas and organization, but their comments did not always reflect this. Mentors were more of the opinion that staff attitudes could affect student practice and learning than were students.


Recommendation• Evidence based practice by providing professional training.• Reinforcement programs and attitude stimulating. • Awareness of right based approach in health care services.• Management and Staffs need to identifying barriers to good IP

and safety measures practice and ways to overcome these.• Health care epidemiologists data managers and statisticians

should be involved in infection prevention committee • Proper documentation should be done, manage and keep

properly • Regular monitoring and surveillance should be done


Summary

Infection prevention and safety measure definitions and components. Some research on implementation infection prevention safety measures guideline coverage and lacking. Nurses role on infection prevention and safety measures recommendation for lacking.


Reference Aiello, A.E., Coulborn, R.M., Perez, V., and Larson, E.L. (2008). Effect of Hand Hygiene

on Infectious Disease Risk in the Community Setting: A Meta-Analysis. Am J Public Health. 8(8): 1372–1381.

Allegranzi, B., et. Al. (2011). Burden of Endemic Health-Care-Associated Infection in Developing Countries: Systematic Review and Meta Analysis. The Lancet. 377(9761): 228-241.

Bergquist, L.M. and Pogosian, B. (2000). Microbiology Principles and Health Science Application. Philadelphia: W.B. Saunders.

Blaser, M.J., Smith, P.F., Cody, H.J., et al. (1984). Killing of fabric-associated bacteraemia in hospital laundry by low-temperature killing. J Infect Dis.

Burke, J. P. (2003). Infection control: A problem for patient safety. The New England Journal of Medicine, 348, p. 651-656.


Reference Central for Disease Control and Prevention, (CDC).(2013). Diarrhea: Common Illness,

Global Killer. U.S.: Department of Health and Human Services, CDC.

CDC (2001). Update: Investigation of bioterrorism-related anthrax and interim guidelines for exposure management and antimicrobial therapy, October 2001. MMWR Morb.Mortal.Wkly.Rep., 50, 909-919.

CDC (2003). Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC) (Rep. No. MMWR 2003; 52 (No. RR-10)). Atlanta: Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention (CDC). (2002). Guideline for Hand Hygiene in Health-Care Settings. U.S.: Department of Health and Human Services, CDC.


Reference Centers for Disease Control and Prevention (CDC). (2000). Core Curriculum on Tuberculosis, What the Clinician Should Know, (4thEd.). US :Dept. of Health and Human Services.

Centers for Disease Control and Prevention, (CDC). (1985). Recommendations for preventing transmission of infection with human T-lymphotropic virus type III/lymphadenopathy-associated virus in the workplace. MMWR 34(45): 681(686): 691–695.

Christian, R.R., Manchest, J.T., and Mellor, M.T. (1983). Bacteriological quality of fabrics washed at lower than standard temperatures in a hospital laundry facility.

Appl Environ Microbiol.

Curtis, V., and Cairncross, S. (2003). Effect of washing hands with soap on diarrhoea risk in the community: A systematic review. The Lancet Infectious

Diseases. 3(5): 275-281.


Reference Emanuel, L., et. al, (2008). What exactly is patient safety? Advances in Patient Safety,

Vol. 1: Assessment. Retrieved on Dec 15, 2015, from, http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi? book=aps2v1&part=advances-emanuel-berwick_110

Freeman, M.C., et. al. (2013). Hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Medicine and International Health 19(8): 906-16.

Friedman, H., Volin, E., & Laumann, D. (1968). Terminal disinfection in hospitals with quaternary ammonium compounds by use of a spray-fog technique.

Appl.Microbiol., 16, 223-227.

Gardner, J. (1996). Centers for Disease Control: guideline for isolation precautions in hospitals. American Journal of Infection Control, 24 :2–52.


Reference Langard, S., Rognum, T., Flotterod, O., & Skaug, V. (1996). Fatal accident resulting from

methyl bromide poisoning after fumigation of a neighboring house; leakage through sewage pipes. J Appl.Toxicol., 16, 445-448.

Luby, S. P., et al. (2005). Effect of handwashing on child health: A randomised controlled trial. The Lancet, 366(9481): 225-233.

Majorin, F., Freeman, M.C., Barnard, S., Routray, P., Boisson, S., and Clasen, T., (2014). Child Feces Disposal Practices in Rural Orissa: A Cross Sectional Study. PLoS One.

MoHP. (2014). Health Care Waste Management Guideline. Kathimandu.

Mosby’s, (2009). Medical Dictionary (9th ed). Elsevier.

National Audit Office, (2009). Reducing healthcare associated infections in hospitals in England. Infection prevention and control NICE quality standard 61 NICE.


Reference NHS England (2011). English national point of prevalence survey on healthcare-associated infections and antimicrobial use, 2011: preliminary data.

NHS. (2000). An organisation with a memory: Report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer.

Park, K. (2015). Park’s Textbook of Preventive and Social Medicine (23rd ed). M/s Banarsidas Bhanot: India.

Potter, P.A. and Perry, A.G.(2007). “Basic Nursing: Essentials For Practice” (6 th ed.). India: Elsevie.

Public Health England (February 2014) Healthcare associated infections.

Sah, M.K., et. Al. (2012). Nosocomial Bacterial Infection and antimicrobial Resistant Pattern in a Tertiary care Hospital in Nepal. Kathmandu: Institute of Medicine.


Reference Siegel, J.D., et. al. (2007). guideline for isolation precautions: preventing transmission of

infectious agents in healthcare settings. Public Health Service, US Department of Health and Human Services, Centers for Disease Control and Prevention (2007). Retrieved on Dec 15, 2015, from, http:// www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.

Thomas, P.A.(2007). Clinical Microbiology. India, Hyderabad: Orient Longman Pvt. Ltd

UNICEF. (2013). Committing to Child Survival: A Promise Renewed Progress Report. Published UNICEF.

Vincent, C. (2010) Patient safety. (2nd ed.). Chichester: John Wiley and Sons.

Ward, D.J. (2012). Attitudes towards infection prevention and control: an interview study with nursing students and nurse mentors. Manchester, UK: University of Manchester.

Walter, W.G., and Schillinger, J.E. (1975). Bacterial survival in laundered fabrics. Appl Environ Microbiol.


Reference WHO/CDS/CSR/EPH. (2002). Prevention of hospital-acquired infections: A practical

guide (2nd ed.). World Health Organization. Retrieved on Dec 12, 2015, from, http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html

WHO/UNICEF (2015). Water, sanitation and hygiene in health care facilities: Status in low- and middle-income countries and way forward.

World Health Organization. (2014). 10 facts on patient safety. World Health Organization. http://www.who.int/features/factfiles/patient_safety/en/

World Health Organization. (2010). WHO Patient Safety Curriculum Guide for Medical Schools.

World Health Organization. (2010). Topic 9: Minimizing infection through improved infection control.World Health Organization. (2010). WHO Patient Safety Curriculum Guide for Medical Schools.

World Health Organization. (2010). Topic 1: What is patient safety?


Be healthy to make people healthy!!!! Thank You
