Infection Control and Healthcare-Associated Infections

Infection Control: An Overview

• Infection control aims to identify and minimize the risk of infections.
• This includes preventing the development and spread of infections.

Healthcare-Associated Infections (HAIs)

• HAIs, also known as "nosocomial" infections, are defined by the World Health Organization (WHO).
• HAIs are infections acquired in a hospital by a patient admitted for a reason other than that infection.
• Can also refer to an infection occurring in a patient in a healthcare facility.
• The infection was not present or incubating at the time of admission.

Preventing HAIs

• Strategies involve identifying the types of HAIs.
• Focus on infections patients would not have acquired outside of the hospital.
• Common HAIs include:
  • CAUTI: Catheter-Associated Urinary Tract Infections
  • CLABSI: Central Line-Associated Bloodstream Infections
  • VAP: Ventilator-Associated Pneumonia
  • SSI: Surgical Site Infections
• HAIs increase the patient's length of stay, costing the institution.
• These costs are incurred, as hospitals don't get reimbursed for the treatments due to the HAI.

Specific HAIs and Prevention

• Urinary Tract Infections (UTIs) are the most frequent HAIs.
• Account for roughly 35% of all HAIs.
• Prevention of catheter-associated UTIs:
  • Avoid catheter use.
  • Assess the need for a catheter every shift.
  • Follow nurse-driven Foley catheter removal protocols.
  • Keep Foley bags off the floor, below the bladder, and empty.
  • Secure tubing to the leg to prevent tension.
  • Provide good perineal care every shift, as needed.
• Surgical Site Infections (SSIs) account for ~20% of all HAIs.
  • Pre-op antibiotics can help prevent them.
• Bloodstream infections linked to intravascular devices account for ~15% of HAIs.
  • Prevent with CLABSIs prevention.
  • Asses for the need for central lines every shift.
  • Assess insertion site and change dressing if loose or soiled.
• Pneumonia associated with ventilators accounts for ~15% of HAIs.
  • Prevent with VAP guidelines.
  • Head of bead positioned at 30 degrees.
  • Provide oral care every 4 hours.
  • Consider a Sedation Vacation when appropriate.

Financial Implications

• The Centers for Medicare and Medicaid Services (CMS) stopped paying for costs related to three common hospital-acquired infections.
• The infections include catheter-associated infections, infections in the blood, and chest incision infections after open-heart surgery.

Impacts of HAIs

• HAIs can negatively impact patients.
• The impact includes increased suffering.
• Can also cause permanent disability, death and prolonged hospital stays.
• HAIs increase the need for a higher level of care and overall costs.

Chain of Transmission

• Infections require a number of factors to manifest for transmission.
• Includes an infectious agent and a susceptible host.
• Also requires a reservoir where microorganism can live and reproduce.
• Requires portals of exit and entry for the infectious agent.
• And lastly, modes of transmission are required for spread.

Breaking the Chain of Infection

• Healthcare workers (HCW) can help to break the chain of infection
• Proper hand hygiene and wearing gloves.
• Maintaining clean rooms and disinfected surfaces.
• Providing proper care and maintenance of medical devices.
• Ensuring patients have proper personal hygiene.
• Ensures any cuts/wounds covered.
• Isolation when necessary.
• Limiting use of unnecessary antibiotics.
• Ensuring proper waste disposal.

Reservoirs

• Reservoirs are places where pathogens live and multiply.
• Reservoirs include beings like humans, animals, and insects.
• Reservoirs can also be nonliving, such as food, floors, equipment, and contaminated water.

Portals of Exit/Entry

• Pathogens can exit or enter through various pathways.
• Included are skin and mucous membranes, respiratory tract (sneezing, coughing), urinary tract, gastrointestinal tract (diarrhea), reproductive tract, and blood.

Antibiotic-Resistant Microorganisms

• A major problem rises from the overuse and inappropriate use of antibiotics.
• This overuse results in antibiotic resistant microorganisms.
• These microorganisms are resistant to multiple antibiotics.
• Results in fewer treatment options.
• Require the addition of isolation precautions.
• This includes MRSA, VRE, and MDR TB
• Must utilize solutions like more appropriate antibiotic use, and infection control and prevention.

Modes of Transmission

• Contact transmission can be direct (touching, kissing, sexual contact) or indirect (contact with fomites).
• Droplet transmission occurs through sneezing.

Antibiotic Resistant Organisms

• The usual bacteria suspects for multidrug-resistant organisms (MDROs) include:
• MRSA
• CRE
• Enterobacteriaceae
• C. difficile
• Staphylococcus aureus
• Pseudomonas
• Enterococcus

Antibiotic Resistant Continued

• Residents with an indwelling catheter are more likely to have one of these MDROs.
• Clostridium difficile spores can survive on Environmental Surfaces for > 1 yr.
• Survival of Vancomycin-resistant Enterococci (VRE) ranges from 5 days – 4 months.
• Methicillin-resistant Staphylococcus aureus (MRSA) has survival time of 7 days – 7 months.
• Hepatitis B virus (HBV) survives > 1 week.
• Human immunodeficiency virus (HIV) survives for 3 – 4 days.

Nursing Diagnosis for Infection

• Nursing diagnoses for infection include Risk for Infection.
• Impaired Nutritional Status: Deficient Food Intake.
• Impaired Oral Mucous Membrane, Social Isolation, and Impaired Tissue Integrity.

Nursing Process for Infection: Planning

• Goals often include the prevention of further exposure to infectious organisms.
• Also controlling infection to reduce the extent and maintaining resistance.
• Verbalizing understanding of infection prevention and control is key.
• A care plan involves priorities for each diagnosis and promotes teamwork.
• This requires collaboration with patients and interprofessional teams.

Nursing Process: Implementation

• Health promotion such as nutrition, hygiene, immunization and adequate rest and exercise are important.
• Include also acute care.
  • Eliminating the infectious organism.
  • Supporting the patient's defenses.

Hand Washing Guidelines

• Wash for at least 20 seconds in a nonsurgical setting and 2 to 6 minutes in surgical settings.
• Remove jewelry and clean beneath fingernails.
• Employ a bactericidal solution or water if visibly soiled.
• Use warm water, friction, and apply soap to wet hands.
• Rinse soap and towel or hand dry.
• Scrub soiled hands with a cleansing brush or sponge.

CDC Hand Hygiene Guidelines

• Maintain short, natural nails (no longer than 0.25 inch).
• Avoid artificial nails or and chipped nail polish.
• Wash hands with antimicrobial soap and water if visibly soiled.
• Wash after caring for Clostridium difficile patients.
• Perform hand hygiene before and after patient contact, including after glove removal.
• An alcohol handrub can be used.

Standard Precautions

• Guidelines that intend to prevent exposure to blood, body fluids, secretions, excretions.
• This excludes sweat.
• Also for broken skin, or mucous membranes.
• The intent is to assume that body fluids from any patient can be infectious.
• Standard precautions should be used on every patient.
• Use PPE when needed.
• CDC guidelines require category-specific isolation in addition to Standard Precautions when a patient is known or suspected to have an infection.
• It’s good practice to have protective barriers for all potential contact with bodily fluids.
• That includes blood, secretions, and mucous membranes.
• These precautions operate under the assumption that each patient is potentially infectious and contagious.

When to Wear Gowns

• Gowns are indicated when expecting contact of clothing or exposed skin.
• Includes contact with blood or body fluids, secretions, or excretions
• Procedures likely to generate splashes, sprays or droplets, such as catheter insertion.
• Includes emptying urine collection bags.
• Needed with non-intact skin, such as large wounds, rashes, or burns.
• Handling fluid containers likely to leak, splash or spill, such as bedside commodes, bedpans, or urinals.

Glove Use: Putting On and Taking Off

• The outside of gloves are contaminated during use.
• Removal process:
  • Grasp outside of glove with opposite gloved hand.
  • Peel off.
  • Hold removed glove in gloved hand.
  • Slide fingers of ungloved hand under remaining glove.

Gown Use: Putting On and Taking Off

• The outside of gowns are contaminated during use.
• Putting on:
  • Gown should be first before gloves.
  • Then fasten at back of neck and waist.
• Removal process:
  • Remove gloves first.
  • Unfasten neck, then waist ties.
  • Remove gown using a peeling motion, to turn it inside out.
  • Hold removed gown away from body, roll into a bundle and discard in room.

Transmission-Based Precautions

• Use these specific practices in addition to standard precautions when standard precautions are not enough.
• These practices depend on the way organisms spread in health care settings.
• Contact Precautions are when there is exposure to "touching/oozing".
• Droplet Precautions are when there is exposure to "sneezing, dripping".
• Airborne Precautions are when there is exposure to "coughing".

Contact Precautions

• Prevent transmission of infectious pathogens spread by direct or indirect contact with a resident.
• Indicated when a resident has uncontained excessive wound drainage, fecal incontinence, or infection.
• MDROs or epidemiological significant organisms, like MRSA, VRE, CRE, C. difficile and scabies, also require these precautions.
• Don’t share non-critical equipment like stethoscopes and thermometers.
• If equipment is in contact in isolation, then disinfect before utilizing on another patient.
• Place a patient on airborne, contact, or droplet precautions in a private room.

C. Diff

• Alcohol based hand sanitizer doesn't kill.
• In response, soap and water wash should be utilized.

Droplet Precautions

• Intended to prevent transmission of pathogens through close respiratory or mucous membrane contact.
• Don a face mask, but not an N-95 respirator, before entering patient room.
• 3 feet of Special separation is required.
• Place face mask on patient for transport outside of room.

Airborne Precautions

• Prevent transmission of infectious agents during air suspension.
• These pathogens include measles, chickenpox, and TB.
• Patient requires airborne isolation infection room (AIIR):
• Single-patient room equipped with special air handling and ventilation, which meets regulatory guidelines.
• The air is exhausted directly to the outside or recirculated through a HEPA filtration system.
• Door MUST remain closed.

Airborne Isolation

• Components include a negative pressure isolation room alongside a closed doors.
• fit-tested N95 respirator is required, or PAPR.
• Hand washing.

Reverse Isolation

• Protects a patient from infectious organisms that might be carried by others.
• Used for patients with leukemia, and after receiving immunosuppressive medication, bone marrow transplant, and neutropenia.
• Preventative steps including strict hand washing, requiring masks and restricting live plants or fresh flowers.
• No fresh fruit, and private room.

Glove Use: Dos and Don'ts

• Important to work from "clean to dirty," and limit opportunities for "touch contamination."
• Don't touch your face or adjust PPE with contaminated gloves.
• Don't touch environmental surfaces.
• Change gloves during use if torn and after use on each patient.
• Discard in an appropriate receptacle and never wash or reuse disposable gloves.

Face Protection

• Masks protect nose and mouth and must fully cover and prevent fluid penetration.
• Goggles protect eyes must fit snuggly, especially as personal glasses are not substitute for goggles.
• Look for antifog.
• Face shields protect the entire face.
• Face shields should cover forehead and extend below chin.

Areas of PPE

• Contaminated is the outside front is likely to have come with contact of bodily fluids.
• Clean is inside.
• Also, the outside back, which is not likely to have come into contact with fluid.

Where to Remove PPE

• At the doorway, before leaving patient's room or in the anteroom.
• Remove respirator outside the room only after the door has been closed.
• Hand hygiene facilities must be available (sink or alcohol-based hand rub).

Respiratory Etiquette to Prevent Transmission

• Cover your cough or sneeze.
• Deposit tissues directly into the trash.
• Clean hands after use of tissues or cough/sneeze.
• Offer tissues or mask to others with coughing or sneezing and remind them to clean their hands.

Sharps Safety

• Prepare to use the device the moment the sharp is first opened.
• Take precautions while using sharps during use, cleanup, and disposal.
• Engage active injury-prevention safety features on equipment.
• Never hand off or leave needles or sharps.
• Activate engineering safety features.

Cleaning Up Sharps Safely

• Clean-up and dispose safely:
• Keep hands behind sharps at all times.
• Never put hands or fingers into sharps container.
• Control both tubing and device disposal, as attached tubing can recoil and lead to injury.

Disposing Cleanly Continued.

• Look for container inspection and no overfilling.
• Replace container when no more than ¾ full.
• Use appropriate PPE such as gloves.
• Use appropriate measures for one-handed scoop technique.

Best Practices

• Do not recap needles or disassemble sharps by hand.
• Use safety syringes and needle-less systems when possible.
• Immediately dispose of sharps in a sharps container.

Exposure Response & Reporting

• Wash area after exposure.
• Notify supervisor immediately.
• Fill out appropriate forms.
• See health care professional within 1-2 hours.

Infectious Medical Waste

• Minimize the potential for spread from the setting to the general public.
• Includes waste capable of producing an infectious disease.
• Contamination usually involves pathogenic activity not routinely available in the average environment.
• For medical waste to be considered infectious, organism is required in significant quantity such that it has virulence to transmit disease.

Types of Infectious Waste

• Blood and blood products, excluding those which are absorbed.
• Sharps which have been contaminated through use.
• Isolation wastes.
• Include also wastes and unfixed pathological tissues, as well as those that are liquid.
• Also any potentially infections bodily fluids are other potential material.

Non-Infectious Medical Waste

• Includes used personal hygiene products, fixed pathological tissues and uncontaminated medical tubing/devices.

Liquid Infectious Medical Waste Disposal

• Liquid infectious medical waste refers to contents of suction canisters.
• There are a few approaches to proper disposal.
• Placing material directly in the Biohazardous waste.
• Pouring into a sanitary sewer, Solidifying using an approved disinfectant, and discarding into the solid waste.
• For an exposure incident: Wash exposed area with soap and water.
• Follow additional steps: irrigate eyes, report the action, and file proper documentation.