NYS-infection control.pdf
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Continuing Education (CEU) course for healthcare professionals. View the course online at wildirismedicaleducation.com for accreditation/approval information, course...
Continuing Education (CEU) course for healthcare professionals. View the course online at wildirismedicaleducation.com for accreditation/approval information, course availability and other details, and to take the test for CE credit. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional healthcare. Contact Hours: 4 Infection Control Training for New York State Healthcare Professionals COPYRIGHT © 2023, WILD IRIS MEDICAL EDUCATION, INC. ALL RIGHTS RESERVED. By Judith Swan, MSN, BSN, AND, Leslie R. Crane, EdD, MSN, RN LEARNING OUTCOME AND OBJECTIVES: Upon completion of this course, you will have increased your knowledge of current, evidence-based information on preventing and controlling the spread of infection. Specific learning objectives to address potential knowledge gaps include: Summarize the principles and practices of infection prevention and control. Describe the modes and mechanisms of the transmission of pathogenic organisms, including the chain of infection. Discuss engineering and work practice controls designed to reduce patient and healthcare worker exposure to infectious materials. Identify barriers and personal protective equipment for protection from exposure to potentially infectious material. Describe the principles and practices for cleaning, disinfection, and sterilization in the healthcare environment. Identify occupational health strategies for preventing the transmission of bloodborne and other pathogens to and from healthcare workers. Recognize suspected sepsis and methods to prevent it. THE NEED FOR INFECTION PREVENTION AND CONTROL PRACTICES Infection control was born in the mid-1800s when Ignaz Semmelweis, a Hungarian obstetrician, demonstrated that handwashing could prevent infection. Semmelweis was director of two wildirismedicaleducation.com 2 Infection Control Training for New York State Healthcare Professionals obstetrical clinics, one staffed by medical students, the other by midwives. Disturbed by the fact that the maternal mortality rate from puerperal (postpartum) fever in the clinic staffed with medical students was almost six times greater than in the clinic staffed by midwives, he set about analyzing the difference and found that medical students often performed dissection prior to assisting with deliveries without washing their hands. Semmelweis came to the conclusion that the medical students performing dissection (which midwives did not do) were carrying some invisible poisonous material on their hands to the women they were assisting in the delivery room, and he instituted a policy requiring medical students to wash their hands in a solution of chlorinated lime prior to assisting in any obstetrical procedure. As a result of this practice, the mortality rate dropped from 18.27% to 1.27% in the medical students’ clinic, and in a period of two months, the death rate dropped to zero (Zoltán, 2023). Later in that same century, Florence Nightingale described the relationship between the diseases that were killing her patients during the Crimean War and the conditions in which they were cared for. Nightingale instituted ways to improve overall hygiene through clean clothing and dressings, bathing, and supplying adequate nutrition. These measures helped prevent contamination and led to reductions in infections and only a 2% mortality rate. Her greatest influence has been on hospital infection control, and many modern healthcare practices (e.g., isolation, ventilation, routine cleaning, and medical and human waste disposal) are attributed to her (Selanders, 2023). Today, we know about pathogenic microorganisms and how they are transmitted, and we have a great deal of knowledge of the principles of infection control. Despite these advances, preventable infections continue to occur. Every year the five most common healthcare-associated infections (HAIs) in U.S. hospitals cost $9.8 billion, with surgical site infections the leader. Healthcare costs from HAIs occur in every medical department, including the intensive care unit (Monegro et al., 2023). Healthcare providers clean their hands less than they should, despite it being known that hand hygiene is the most effective way to prevent HAIs (CDC, 2023a). This discussion indicates that infection control is not just a matter of knowing what is effective but that there is a strong behavioral element involved in the process of carrying out infection control practices. Both factors must be addressed if the absence of HAIs is the goal. To accomplish this, each healthcare worker should have the necessary knowledge, skills, and abilities to implement effective infection control practices, which then may influence their perceptions and provide motivation to change behavior. TERMINOLOGY Healthcare-associated infection (HAI) An HAI is an infection acquired while receiving healthcare in any setting (e.g., hospital, long-term care facility, outpatient clinic, ambulatory setting, assisted living, or home care). These infections occur in patients who do not have infections and are not incubating an infection at the time of entry into the healthcare system but acquire them while receiving treatment for other conditions. Healthcare workers also can be © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 3 Infection Control Training for New York State Healthcare Professionals the recipients of HAIs. Other common terms for HAIs are nosocomial (originating in a hospital) and iatrogenic (caused by medical treatment) (Monegro et al., 2023). Healthcare worker (HCW) Any person who has contact with patients, body fluids, or supplies used for patient care as part of their job. This includes physicians, nurses, occupational therapists, and physical therapists as well as administrative, environmental hygiene, and laboratory staff in medical facilities. HCWs also include interns, volunteers, and paid workers/employees who are involved in any aspect of healthcare in any setting. All HCWs are engaged in enhancing patient health (WHO, 2023a). Outbreak An outbreak is a sudden increase in the occurrence of a particular infectious disease from person to person or from an animal reservoir or other environmental source in a particular place and time. An epidemic is an outbreak in which a disease is actively spreading over a wide geographic area and affecting a high proportion of the population. A pandemic is an epidemic that has spread to multiple countries or regions of the world (WHO, 2023b). Surveillance Surveillance is the continuous, systematic collection, analysis, and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. Monitoring and evaluating the impact of interventions occurs. It can serve as an early warning system for impending public health emergencies, document the impact of an intervention, or track progress toward specific goals (WHO, 2023c). Healthcare-Associated Infections (HAIs) The rate of HAIs is 1 in 31 patients in acute care hospitals and 1 in 43 patients in long-term care facilities (CDC, 2022a). In the United States, the Centers for Disease Control and Prevention (CDC) estimates that HAIs account for an estimated 1.7 million infections and 99,000 associated deaths each year. COMMON TYPES OF HAIs Catheter-associated urinary tract infections (CAUTIs). These infections involve any part of the urinary system, including urethra, bladder, ureters, and kidneys, and result from incorrect insertion, failure to maintain asepsis, and leaving a catheter in place for too long. These make up 32% of all HAIs. Surgical site infections (SSIs). These can involve the skin, tissues, and organs under the skin, or implants such as material inserted or grafted into the body (e.g., prosthetic joints). These constitute 22% of HAIs. Central line–associated bloodstream infections (CLABSIs). These are bloodstream infections unrelated to an infection at another site that develops within 48 hours of central © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 4 Infection Control Training for New York State Healthcare Professionals line placement. Of all HAIs, these are associated with increased care costs and mortality. These and other bloodstream infections add up to 14% of HAIs. Ventilator-associated events (VAEs) or pneumonias (VAPs). These events or pneumonias are caused by a wide variety of pathogens, can be polymicrobial, and can be due to multidrug-resistant organisms. These are 15% of all HAIs in the United States. (Patient CareLink, 2023) The impact of HAIs may be greater when they are due to drug-resistant organisms, which include: Methicillin-resistant Staphylococcus aureus (MRSA). This type of bacteria is resistant to many antibiotics. Clostridioides difficile (C. difficile) (formerly known as Clostridium difficile). When antibiotics are taken, “good” bacteria are destroyed for several months, during which time infection with C. difficile bacteria can cause life-threatening diarrhea. Carbapenem-resistant Enterobacteriaceae (CRE). This family of organisms, which includes Escherichia coli (E. coli) and Klebsiella pneumoniae, has a high level of antibiotic resistance. (Monegro et al., 2023) The improvement in reducing HAIs is mixed, depending on the type of infection being measured. The United States has made significant progress toward the collective goal of eliminating some HAIs and is safer now than it was in years past. Cases of C. difficile decreased by 50% between 2015 and 2021. Other HAIs saw a 7%–21% reduction in in the same time period (CDC, 2021a). However, increases were documented for MRSA at 14%, VAEs at 12%, SSI-hysterectomy at 11%, CLABSIs at 7%, and CAUTIs at 5% between 2020 and 2021 (CDC, 2022c). The presence of the COVID-19 virus also contributed to an unusual increase in infection rates. This new virus brought patients with existing central lines and urinary catheters into the hospital and/or caused newly immunocompromised patients to acquire these tubes as well as endotracheal tubes while hospitalized. HAIs IN OUTPATIENT SETTINGS Increasingly, healthcare delivery, including complex procedures, is being shifted to outpatient (ambulatory) settings. These settings often have limited capacity for oversight and infection control compared to hospital-based settings. Because patients with HAIs, including those caused by antibiotic-resistant organisms, often move between various types of healthcare facilities, prevention efforts must expand across the continuum of care. Examples of outpatient settings include: Medical group practices © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 5 Infection Control Training for New York State Healthcare Professionals Clinics at hospitals or other facilities Surgery centers Imaging centers Mental health centers Lab centers Physical therapy and rehabilitation facilities Chemotherapy and radiation therapy centers Dialysis centers Birthing centers Hospice homes Home care Surveillance for infection in outpatient or ambulatory settings is inherently difficult, as detecting infections among outpatients typically requires retrospective reviews of medical records and/or prospective audits. However, intelligent information technology may serve as a meaningful tool. Such automated systems can be used to perform prospective surveillance for infections following outpatient procedures, such as a reference database designed to document SSIs in ambulatory surgery and linking institutional databases to detect bloodstream infections (Anderson & Kanafani, 2020; AHRQ, 2023). ACCREDITATION FOR AMBULATORY HEALTHCARE FACILITIES The Centers for Medicare and Medicaid Services has granted several organizations, along with itself, the authority to determine whether or not ambulatory healthcare facilities are in compliance with Medicare’s conditions for coverage and to provide accreditation for them. While there is no federal requirement for accreditation, some states and private payers require it. Organizations granted authority to accredit include: Accreditation Association for Ambulatory Health Care Accreditation Commission for Health Care, Inc. American Osteopathic Association/Healthcare Facilities Accreditation Program Center for Improvement in Healthcare Quality Community Health Accreditation Partner DNV GL-Healthcare National Dialysis Accreditation Commission The Compliance Team © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 6 Infection Control Training for New York State Healthcare Professionals The Joint Commission (CMS, 2020) HAIs IN LONG-TERM CARE FACILITIES Long-term care settings include nursing homes, skilled nursing facilities, and assisted living facilities. Over 4 million Americans are admitted to or live in nursing homes and skilled nursing facilities each year, and nearly 1 million live in assisted living facilities. While reporting is limited, the CDC (2020) provides the following data about infections in these facilities: 1 to 3 million serious infections occur each year. Infections include urinary tract infections, diarrheal diseases, antibiotic-resistant staph infections, and many others. Infections are a major cause of hospitalization and death. As many as 380,000 people die of infections in long-term care facilities every year. Development of Infection Control and Prevention Standards and Guidelines Standards and guidelines are designed to proactively prevent the spread of infection in healthcare settings. The development of these standards and guidelines came about through the collaborative efforts of the Centers for Disease Control and Prevention, the Joint Commission, the World Health Organization, and the Occupational Safety and Health Administration. Significant infection control challenges include: SARS-CoV-2 (COVID-19) SARS-CoV-1 (severe acute respiratory syndrome) HIV infection Lyme disease Escherichia coli Hantavirus Dengue fever West Nile virus Zika virus © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 7 Infection Control Training for New York State Healthcare Professionals Reemerging infectious diseases include: Tuberculosis Pertussis Influenza Pneumococcal disease Malaria Cholera Gonorrhea Standards and guidelines for these and other infectious diseases include vaccinations, emergency medications, preventive care, and information learned about the possible risks to avoid or to prepare for when traveling (Johns Hopkins, 2023). New York State Infection Control Requirements Title 10, part 92, chapter 785, of the Official Compilation of Codes, Rules, and Regulations of New York established a requirement that certain healthcare professionals licensed in New York State must receive approved training in infection control and barrier precautions every four years unless otherwise exempted. NEW YORK STATE PROFESSIONS REQUIRING INFECTION CONTROL TRAINING Dental hygienists Dentists Licensed Practical Nurses Registered Professional Nurses Medical residents Medical students Optometrists Physicians Physician assistants Physician assistant students Podiatrists Specialist assistants © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 8 Infection Control Training for New York State Healthcare Professionals The goal of New York State’s mandate is to: Assure that licensed, registered, or certified health professionals understand how bloodborne pathogens may be transmitted in the work environment from patient to healthcare worker, healthcare worker to patient, and patient to patient Apply current scientifically accepted infection prevention and control principles as appropriate for the specific work environment Minimize opportunity for transmission of pathogens to patients and healthcare workers Familiarize professionals with the law requiring this training and the professional misconduct charges that may result from failure to comply with the law CORE ELEMENTS OF NEW YORK STATE INFECTION CONTROL TRAINING Element I Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor the performance of those ancillary personnel for whom the professional is responsible. Element II Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control Element III Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings Element IV Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with potentially infectious material Element V Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfection, and sterilization Element VI Prevention and control of infectious or communicable diseases in healthcare workers Element VII Sepsis awareness and education (NYSDOH & NYSED, 2018) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 9 Infection Control Training for New York State Healthcare Professionals This course explores each of the seven elements in detail, covering the basic principles of infection control and evidence-based infection control practices. INFECTION CONTROL PRINCIPLES AND PRACTICES ELEMENT I Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control and to oversee and monitor the performance of those ancillary personnel for whom the professional is responsible. Infection control practices can stop the spread of infection in healthcare settings. Title 10, part 92 (Health), of the Official Compilation of Codes, Rules, and Regulations of New York, and the Rules of the Board of Regents, Part 29.2(a)(13), identify professionals who must receive infection control training, and defines unprofessional conduct in the area of infection prevention and control as the failure to use scientifically accepted infection control practices to prevent transmission of disease pathogens as appropriate to each profession, including: Cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces Utilization of personal protective equipment (PPE) Use of covers for contamination-prone equipment Safe handling of sharp instruments (“sharps”) The National Institute for Occupational Safety and Health is the federal agency that provides scientifically sound infection control recommendations. Other professional organizations and accrediting agencies that provide guidelines, standards, and recommended practices for infection prevention and control in healthcare settings include: The Joint Commission American Hospital Association Association for Professionals in Infection Control and Epidemiology Society for Healthcare Epidemiology of America Centers for Disease Control and Prevention Det Norske Veritas Healthcare, Inc. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 10 Infection Control Training for New York State Healthcare Professionals Consequences for Unprofessional Conduct The consequences of failure to follow accepted standards of infection prevention and control include: Increased risk of adverse health outcomes for patients and healthcare workers Charges of professional misconduct Patients, family members, or coworkers can file charges against a healthcare professional through their institution or directly to the New York State Department of Health, Office of Health Systems Management, which will investigate the complaint. Depending on the severity of misconduct, outcomes may include: Disciplinary action Revocation of professional license Professional liability To be in compliance in order to avoid charges of unprofessional conduct, designated healthcare professionals must: Participate in required infection prevention and control training Adhere to accepted principles and practices of infection prevention and control MODES AND MECHANISMS OF PATHOGEN TRANSMISSION: THE CHAIN OF INFECTION ELEMENT II Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control Epidemiology involves knowing how disease spreads and how it can be controlled. Infection can only spread when conditions are right. This set of conditions is referred to as the chain of infection, which consists of six links. When all the links are connected, infection spreads. Infection control and prevention training provides the knowledge and skills that healthcare professionals can use to break the links in the chain and prevent the occurrence of new infections. Thus, understanding the chain of infection is at the foundation of infection prevention (Infection Prevention and You, 2023). © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 11 Infection Control Training for New York State Healthcare Professionals The six links in the chain of infection. (Source: Wild Iris Medical Education, Inc.) CHAIN OF INFECTION Link Examples 1. Pathogen: Microorganisms capable of causing disease or Bacteria illness Fungi Parasites Prions 2. Reservoir: Places in which infectious agents live, grow, and People reproduce Water Food 3. Portal of exit: Ways in which an infectious agent leaves the Blood reservoir Secretions Excretions Skin 4. Transmission: Ways in which the infectious agent is spread Physical contact from reservoir to susceptible host Droplets Airborne 5. Portal of entry: Ways in which the infectious agent enters the Mucous membrane susceptible host © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 12 Infection Control Training for New York State Healthcare Professionals Respiratory system Digestive system Broken skin 6. Susceptible host: Individuals with traits that affect their Persons with: susceptibility and severity of disease Immune deficiency Diabetes Burns Surgery Age (Potter et al., 2023) Pathogens A pathogen is any biological agent that can cause disease or illness in its host. Bacteria are single-celled organisms present everywhere, some of which can cause disease. Viruses are intracellular parasites, that is, they can only reproduce inside a living cell. Fungi are prevalent throughout the world, but only a few cause disease in healthy people. Prions are a form of infectious protein. Like viruses, prions are not considered living. Protozoa are single-celled microorganisms that are larger than bacteria. Helminths include roundworms, tapeworms, and flukes. (OSU, 2020; CDC, 2022b) Reservoirs The next link in the chain of infection is the reservoir, the usual “habitat” in which the infectious agent (pathogen) lives and multiplies. It is defined as any person, animal, arthropod, plant, soil, substance, or combination of these on which the pathogen depends primarily for survival and where it reproduces itself in such a way that it can be transmitted to a susceptible host. A reservoir, however, is not the same thing as the “source.” For example, in typhoid fever, the reservoir may be a person with the infection, but the source of infection may be the feces or urine of those who are infected or contaminated food, milk, or water (Potter et al., 2023). © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 13 Infection Control Training for New York State Healthcare Professionals HUMAN RESERVOIRS The most important reservoir of infection for humans is other humans, and humans are also the most important reservoir for HAIs. The nose (nostrils, nares) may harbor bacteria and viruses. The skin is another natural reservoir for yeast and bacteria, and both healthcare workers and patients may carry pathogenic MRSA and Staphylococcus on their skin. The gastrointestinal tract is a reservoir for many different types of organisms, including viruses, bacteria, bacterial spores, and parasites. People who are sick can release microbes into the environment through infected body fluids and substances. For example, sneezing releases influenza virus in secretions from the respiratory tract. Coughing releases tuberculosis bacteria from the lungs. Diarrhea releases C. difficile and many pathogens from the bowel. Exudates from skin lesions release Staphylococcus in pus from boils or herpesvirus from fluid in sores around the mouth, hands, or other body areas. Two types of human or animal reservoirs are generally recognized. These are (1) symptomatic persons who have a disease (cases) and (2) carriers who are asymptomatic and can still transmit the disease. Carriers are individuals who have been colonized by a pathogen. Colonization is the presence of a microorganism on or in a host with growth and multiplication of the organism but no clinical expression or immune response from the host. There are five types of carriers: Healthy or passive carrier: A person exposed to and harboring a pathogen but who has not become ill or has no symptoms Active carrier: A person exposed to and harboring a pathogen who may or may not exhibit signs and symptoms of infection Incubatory carrier: A person exposed to and harboring a pathogen in the beginning stages of the disease (e.g., the incubation period for HIV can last for many years before symptoms occur, but the person is able to transmit HIV to others during that time period) Intermittent carrier: A person exposed to and harboring a pathogen who can spread the disease in different places or at different intervals Convalescent carrier: A person who harbors the pathogen and, although in the recovery phase, is still infectious (Merrill, 2021) The important point to remember is that infectious agents are transmitted every day from people who are sick as well as from those who appear to be healthy. In fact, those individuals who are carriers may present more risk for disease transmission than those who are sick because: They are not aware of their infection. Their contacts are not aware of their infection. Their activities are not restricted by illness. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 14 Infection Control Training for New York State Healthcare Professionals They do not have symptoms and, therefore, do not seek treatment. Possible outcomes of exposure to an infectious agent. (Source: Wild Iris Medical Education, Inc.) * The term carrier state is used to describe the presence of a microorganism on or in a host with growth and multiplication of the organism but no clinical expression or immune response from the host. ANIMAL/INSECT RESERVOIRS Animal reservoirs transmit infectious diseases from animal to animal, with humans as incidental hosts. An infectious disease caused by a pathogen transmitted from birds, rodents, reptiles, amphibians, insects, and other domestic and wild animals is called a zoonosis. A common way for these pathogens to spread is via a vector, usually a bite from a mosquito, mite, or tick. Examples of zoonoses include: Rabies (from bats, skunks, raccoons, and other mammals, transmitted directly through a bite) SARS (believed to originate from horseshoe bats that transmitted the virus to small mammals called civets, which are trapped and eaten, exposing humans to blood or organs during butchering or food preparation; now capable of being transmitted from human to human in respiratory secretions) Lyme disease (from deer mice to deer ticks to humans) Bubonic plague (from rats or prairie dogs to fleas to humans) West Nile virus (from birds to mosquito to humans) Zika (primarily from the Aedes aegypti mosquito to domestic animals and humans) Scabies (mites transmitted from humans to humans) (Merrill, 2021) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 15 Infection Control Training for New York State Healthcare Professionals ENVIRONMENTAL RESERVOIRS Environmental reservoirs are certain environmental conditions or substances (e.g., food, feces, decaying organic matter) that are conducive to the growth of pathogens. Pathogens may survive in such a reservoir but may or may not multiply or cause disease. These reservoirs can include soil, water, and air, as well as inanimate objects, referred to as fomites, that convey infection because they have been contaminated by pathogenic organisms. Examples include facial tissues, doorknobs, telephones, bed linens, toilet seats, and clothing. Environmental reservoirs in healthcare facilities can include: Contaminated medical devices (e.g., central venous catheters, urinary catheters, endoscopes, surgical instruments, ventilators, needles/sharps) Contaminated water sources Contaminated medications Air from heating, ventilation, or air conditioning systems Hospital textiles (e.g., linens, privacy curtains) Patient care equipment (blood pressure cuffs, gloves) (Potter et al., 2023) Portal of Exit The portal of exit is the route (or routes) by which a pathogen leaves the reservoir. PORTALS OF EXIT FROM THE HUMAN BODY Portal How the Pathogen Infectious Diseases Exits Respiratory tract Coughing, sneezing Influenza, tuberculosis, common cold, SARS, COVID-19 Skin Draining skin lesions or Scabies, staph infection, MRSA wounds Blood Insect bite, needles, HIV/AIDS, hepatitis B, hepatitis C syringes Digestive tract Feces, saliva Hepatitis A, cholera, salmonella infection, parasites, typhoid Genitourinary tract Urine, semen, vaginal HIV/AIDS, herpes, cytomegalovirus secretions Placenta Mother to fetus Herpes, malaria, rubella (Potter et al., 2023) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 16 Infection Control Training for New York State Healthcare Professionals Modes of Transmission For an organism to travel from one person to another or from one place in the body to another it must have a way of getting there, or a mode of transmission. For any single agent, there are many different means by which it can be transmitted. The modes of HAI transmission include: Contact transmission, the most important and frequent mode of HAI transmission, is divided into three subgroups: direct contact, indirect contact, and droplet. Direct contact transmission involves skin-to-skin direct contact and the physical transfer of pathogens between a susceptible host and an infected or colonized person. Examples include scabies, sexually transmitted diseases, mononucleosis, and MRSA. Direct contact can include: o Childbirth o Medical procedures o Injections of drugs o Airborne-propelled a short distance (3–6 feet) via droplets, coughing, or sneezing, and deposited on the host’s conjunctivae, nasal mucosa, or mouth o Transfusion (blood) o Transplacental Indirect contact transmission occurs by: o Vehicle transmission involves contact of a susceptible host with a contaminated inanimate object (fomite), such as food, water, medications, contaminated instruments, patient-care equipment, needles, dressings, gloves, or hands. Contaminated hands are often responsible for transmission of HAIs. o Vector-borne transmission usually refers to insects; however, a vector can be any living creature that transmits an infectious agent to humans. Vector-borne transmission is not a common source of HAIs. o Airborne, long-distance transmission involves generation of aerosolized particles from droplet nuclei that remain infectious when suspended in air over long distances and time. Aerosolized particles may also be generated from biological waste products. (Ather et al., 2020) The mode of transmission is the weakest link in the chain of infection, and it is the only link that healthcare providers can hope to eliminate entirely. Therefore, a great many infection control efforts are aimed at avoiding carrying pathogens from the reservoir to the susceptible host. Because people touch so many things with their hands, hand hygiene is still the single most important strategy for preventing the spread of infection. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 17 Infection Control Training for New York State Healthcare Professionals HIGH-RISK SETTINGS FOR INFECTION TRANSMISSION Every area of the healthcare facility and every type of patient care holds the potential for exposure to pathogens, but some settings and practices present greater risk than others. High-risk settings include: Intensive care units Burn units Pediatric units and newborn nurseries Operating rooms Long-term care facilities Transmission risks within the various healthcare settings are influenced by the characteristics of the population (e.g., immunocompromised patients, exposure to indwelling devices and procedures), intensity of care, exposure to environmental sources, length of stay, and interaction among and between other patients as well as healthcare providers. Portals of Entry The term portal of entry refers to the anatomical route or routes by which a pathogen gains entry into a susceptible host. The portal of entry is often the same as the portal of exit from the reservoir. PORTALS OF ENTRY TO THE HUMAN BODY Portal How the Pathogen Enters Infectious Diseases Skin Conjunctivae, hair follicles, sweat Hookworm, tinea pedis, herpes ducts, cuts, nicks, abrasions, simplex, folliculitis, sepsis punctures, insect bites Respiratory tract Inhalation Influenza, tuberculosis, common cold, coronaviruses Gastrointestinal Food, drink, contaminated fingers Diarrheal illnesses, salmonella tract infection, gastric and duodenal ulcers, gastroenteritis Genitourinary Skin or mucous membrane of Cystitis, gonorrhea, chlamydia, tract penis, vagina, cervix, urethra, genital herpes, HPV, HIV/AIDS external genitalia Across placenta Vascular access Zika, rubella, syphilis to fetus Medical and surgical procedures often introduce new portals or facilitate the entry of pathogens. Examples include IV catheters, surgical wounds, urinary catheters, endotracheal tubes, and percutaneous injuries. Healthcare workers may develop dermatitis from frequent handwashing or allergy to latex gloves. They may receive needlestick injuries that allow pathogens access to their © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 18 Infection Control Training for New York State Healthcare Professionals bloodstream. Any invasive procedure may facilitate entry of pathogens into the host (Potter et al., 2023). INVASIVE DEVICES An invasive device provides a portal of entry for pathogens. It is a device that, in whole or part, penetrates inside the body either through a body orifice or through the body surface. Examples include: Vascular access devices Urinary catheters Wound drains Gastrostomy tubes Endotracheal or tracheostomy tubes Fracture fixation devices Traction pins Dental implants Joint prostheses Cardiac pacemakers Mammary implants Mechanical heart values Penile implants Susceptible Host The final link in the chain of infection is the susceptible host. In healthcare settings, susceptible hosts abound. Susceptibility to infections depends on genetic or constitutional factors, physiologic and immunological condition of the host, and virulence of the pathogen. Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system, and the presence or absence of an invasive device. HOST NATURAL BARRIERS There are many natural barriers against the penetration of pathogens into the human host. They are categorized as physical, mechanical, chemical, and cellular. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 19 Infection Control Training for New York State Healthcare Professionals Lines of Defense The first line of defense against the entry of pathogens includes physical, mechanical, and chemical barriers, which are considered functions of innate (natural or inborn) immunity. Physical barriers (or anatomical barriers) include the skin and associated accessories, such as nails and hair within the nose. Mechanical barriers include intact skin and mucous membranes. Coughing, sneezing, urinating, defecating, and vomiting are also mechanical barriers. Chemical barriers include tears, perspiration, sebum (oily substance produced by the skin), mucus, saliva, and gastrointestinal secretions. Tears contain active enzymes that attack bacteria. Mucus in the respiratory tract traps pathogens and contains enzymes that serve as antibiotics. The gastrointestinal tract contains various chemicals, including acid in the stomach. The second line of defense comes into play when pathogens make it past the first line. Cellular defensive processes include: Phagocytes. Two types of white blood cells, macrophages and neutrophils, destroy and ingest pathogens that enter the body. Inflammation. Several types of white blood cells flood a localized area that has been invaded by pathogens, allowing for the removal of damaged and dead cells and beginning the repair process. Fever. Elevated temperature inhibits the growth of and is even lethal to some bacteria and viruses; it also facilitates the host’s immune response and increases the rate of tissue repair. The third line of defense against invading pathogens is the immune system response, which involves lymphocytes. T cells send out an alarm and cause white blood cells to divide and multiply. B cells secrete antibodies that stick to antigens on the surface of pathogens and destroy them. Memory T and B cells store information about the invading pathogen to be used against a future invasion. (InformedHealth.org, 2020) The protective antibodies resulting from this process can be the result of: Past infection Vaccination or toxoid © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 20 Infection Control Training for New York State Healthcare Professionals Transmission through the placenta from mother to child Administration of antitoxin or immunoglobulin Factors Affecting a Host’s Natural Barriers Several important factors affect a host’s susceptibility to infection: Age. The very young and the very old are more susceptible to infection. The older adult often has comorbid conditions such as diabetes, renal insufficiency, or a decrease in immune function, and the young do not as yet have an immune system as efficient as that of adults. Genetics. Genetic background causes variations in innate immunity, e.g., Alaska Natives, Native Americans, and Asians are more susceptible to tuberculosis than persons of other races/ethnicities. Stress level. Stress increases the release of cortisol from the adrenal cortex, causing a suppression of the inflammatory response, which facilitates infection. Nutritional status. The function of the cells that make up the first, second, and third lines of defense are dependent upon specific nutrients without which the system weakens. Current medical therapy. Patients undergoing chemotherapy or radiation are more susceptible to infections since these agents also destroy cells that make up the immune system. Transplant patients on immunosuppressant medications to prevent rejection are also more susceptible, as are patients taking corticosteroids. Preexisting disease. Patients with chronic diseases such as diabetes or AIDS are more susceptible. Sex. Anatomical differences of the genitourinary tract allow bacteria to more easily traverse the shorter female urethra to reach the bladder. (JoVE, 2023) INFECTIOUS AGENT FACTORS It is only when a pathogen has been successful in establishing a site of infection in the host that disease occurs, and little damage will result if the pathogen is unable to spread to other parts of the body. There are a number of factors that are important in this process. Specific to the pathogen itself are its: Infectivity, or the ability of an infectious agent to invade and replicate in a host Pathogenicity, or the capacity of the agent to cause disease Virulence, or the extent of disease that the pathogen can cause © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 21 Infection Control Training for New York State Healthcare Professionals Another important factor includes the number of organisms that are transferred to the host (the inoculum). Some organisms require only a few to cause disease, while others require many. The route of exposure, or the portal of entry of the pathogen, also influences the ability to cause infection, as does the duration, or amount of time the host is exposed to the pathogenic reservoir. ENVIRONMENTAL FACTORS Environmental factors are those extrinsic elements that affect the infectious agent and the opportunity for exposure. In a healthcare setting, these factors involve contamination of the environment and equipment. Environmental contamination involves inanimate objects (fomites) such as air, water, food supply, floors, and surfaces around patients. Proper sanitation prevents the spread of infectious organisms from the environment to patients. Contamination of equipment occurs when it is not cleaned and disinfected between patients. Equipment that has been contaminated can spread infectious agents from patient to patient. METHODS FOR PREVENTING THE SPREAD OF PATHOGENS IN HEALTHCARE SETTINGS Preventing the spread of pathogens involves breaking one of the links in the chain of infection, and the link most amenable to actions by healthcare workers is mode of transmission. Standard Precautions One of the most effective infection control practices is Standard Precautions. Standard Precautions are a set of infection control practices used to prevent transmission of pathogens and are based on the concept that all blood, body fluids, nonintact skin (including rashes), and mucous membranes may contain transmissible pathogens. Standard Precautions are implemented for all patient-care settings and include: Performing hand hygiene Using personal protective equipment (PPE) whenever there is an expectation of possible exposure to infectious material Following respiratory hygiene/cough etiquette principles Ensuring appropriate patient placement Proper handling and proper cleaning and disinfecting of patient-care equipment and instruments or devices Cleaning and disinfecting the environment appropriately © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 22 Infection Control Training for New York State Healthcare Professionals Handling textiles and laundry carefully Following safe injection practices Wearing a surgical mask when performing lumbar punctures Ensuring healthcare worker safety, including handling of needles and other sharps (Potter et al., 2023; CDC, 2016) BLOOD AND OTHER POTENTIALLY INFECTIOUS MATERIALS (OPIM) All occupational exposures to blood or other potentially infectious materials place healthcare providers at risk for infection with bloodborne pathogens. Standard Precautions are designed to eliminate exposure to blood and other potentially infectious materials. The Occupational Safety and Health Administration (OSHA) defines blood as: Human blood Human blood components Products made from human blood OPIM include: Semen Vaginal secretions Cerebrospinal fluid Synovial fluid Pleural fluid Pericardial fluid Peritoneal fluid Amniotic fluid Saliva in dental procedures Any body fluids that are visibly contaminated with blood All body fluids in situations where it is difficult or impossible to differentiate between them Any unfixed tissue or organ (other than intact skin) from a human (living or dead) Hepatitis B- and HIV-containing cell, tissue, or organ cultures, and HBV- or HIV- containing culture medium or other solutions Blood, organs, or other tissues from experimental animals infected with HBV or HIV (OSHA, 2023a) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 23 Infection Control Training for New York State Healthcare Professionals HAND HYGIENE Hand hygiene is the single most important practice to reduce transmission of infectious agents and means cleaning hands by using handwashing with soap and water, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. During delivery of healthcare, the CDC (2021c) advises healthcare workers to avoid unnecessary touching of surfaces in close proximity to the patient and requires performance of hand hygiene in accordance with the recommendations described below. Wash hands with soap and water: When hands are visibly soiled After caring for a person with known or infectious diarrhea After known or suspected exposure to spores (e.g., B. anthracis, C. difficile outbreaks) Unless hands are visibly soiled, an alcohol-based hand sanitizer is the method of choice for hand hygiene. Alcohol-based hand rubs come in gel, rinse, wipe, and foam form. They are less drying and have superior microbicidal activity in comparison to soap and water. Indications include: Immediately before having direct contact with a patient’s intact skin (e.g., taking a pulse) Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices Before moving from work on a soiled body site to a clean body site on the same patient After touching a patient or the patient’s immediate environment After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressing After contact with inanimate objects in the immediate vicinity of the patient, including medical equipment Before donning gloves Immediately after glove removal Skin and Nails The CDC offers the following recommendations to maintain hand skin health: Use lotions and creams to prevent and decrease healthcare provider skin dryness related to frequent hand hygiene. Use only hand lotions approved by the healthcare facility so as to avoid interfering with hand sanitizing products. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 24 Infection Control Training for New York State Healthcare Professionals Recommendations regarding fingernails state: Healthcare providers should not wear artificial fingernails or extensions when having direct contact with patients at high risk (e.g., those in the intensive care unit or operating room). Pathogens can live under artificial fingernails both before and after use of an alcohol-based hand sanitizer and handwashing. Keep natural nail tips less than 1/4 inch long. (CDC, 2021c) Studies regarding the issue of wearing nail polish remain inconclusive. Some studies have shown that more pathogens are present on the skin underneath rings than comparable areas of skin on fingers without rings. Rings may also increase the risk of glove tears. Wearing a simple finger band and unchipped nail polish may be acceptable, although removal of all rings and wearing no nail polish may be the safest prevention option. However, further studies are needed to determine if wearing rings results in an increased spread of pathogens (CDC, 2021c). FINGERNAIL HYGIENE Keep nails short, and trim them often. Scrub the underside of nails with soap and water (or a nail brush) every time they are washed. Clean any nail grooming tools before use. In commercial settings such as nail salons, sterilize nail grooming tools before use. Avoid biting or chewing nails. Avoid cutting cuticles, as they act as barriers to prevent infection. Never rip or bite a hangnail. Instead, clip it with a clean, sanitized nail trimmer. (CDC, 2022d) Hand Cleansing Techniques Both the CDC and the World Health Organization provide guidelines in the techniques of handwashing as well as hand rub cleansing using an alcohol hand sanitizer. Handwashing requires 15 to 20 seconds to be effective (about as long as it takes to sing “Happy Birthday” twice). © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 25 Infection Control Training for New York State Healthcare Professionals Technique for handwashing with soap and water (WHO, 2020): © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 26 Infection Control Training for New York State Healthcare Professionals Technique for applying hand sanitizer correctly (CDC, 2023a): Sanitizers can quickly reduce the number of germs on hands in many situations. However: Sanitizers do not remove all types of germs. Hand sanitizers may not be as effective when hands are visibly dirty or greasy. Hand sanitizers might not remove harmful chemicals from hands, such as pesticides and heavy metals. (CDC, 2023a) Surgical Hand Antisepsis Performing surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand sanitizer with persistent activity is recommended before donning sterile gloves when performing surgical procedures. Remove rings, watches, and bracelets before beginning to scrub. Clean under nails using a nail cleaner under running water. When using antimicrobial soap, scrub hands and forearms for 2–6 minutes. Long scrub times (e.g., 10 minutes) are not necessary. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions. When using an alcohol-based surgical hand scrub, prewash hands and forearms with a nonantimicrobial soap and dry hands and forearms completely before donning sterile gloves. Double gloving is advised during invasive procedures that pose an increased risk of exposure to blood. (CDC, 2021c) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 27 Infection Control Training for New York State Healthcare Professionals GLOVES The CDC recommendations state that gloves should be worn according to Standard Precautions, as described below: Make sure that gloves fit properly before performing any tasks. Wear disposable medical examination gloves when providing direct patient care. Wear disposable medical examination gloves or reusable utility gloves for cleaning the environment or medical equipment. Wear gloves whenever it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, nonintact skin, potentially contaminated skin, or contaminated equipment could occur. Wearing gloves is not a substitute for hand hygiene. Prior to a task that requires gloves, perform hand hygiene before donning them and before touching the patient or the patient environment. Change gloves and perform hand hygiene during patient care if: o Gloves become damaged o Gloves become visibly soiled with blood or body fluids following a task o Moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs Never wear the same pair of gloves in the care of more than one patient. Do not touch the face when wearing gloves. Do not wear gloves in the halls, except as approved by facility. Perform hand hygiene immediately after removing gloves. (CDC, 2021c) EYE PROTECTION, MASKS, FACE SHIELDS, AND GOWNS Appropriate barriers include personal protective equipment used alone or in combination to protect the mucous membranes, airway, skin, and clothing from contact with infectious materials. These barriers include eye protection, face masks, and gowns. Wear eye protection (goggles and face shields) whenever there is a potential of a splash or spray of blood, respiratory secretions, or other body fluids. Personal eyeglasses and contact lenses are not considered adequate eye protection. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task to be performed. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 28 Infection Control Training for New York State Healthcare Professionals Wear a mask to protect patients from exposure to infectious agents carried in the mouth or nose of healthcare personnel. Wear a mask when placing a catheter or injecting material into the spinal canal or subdural space, or to perform intrathecal chemotherapy. Wear a fluid-resistant, nonsterile gown to protect skin and clothing during procedures or activities where contact with blood or body fluids is anticipated. Wear a new gown for the care of each individual patient. Don a gown prior to direct patient contact that may generate splashes or sprays of blood, body fluids, secretions, and excretions. Remove a gown and perform hand hygiene before leaving the patient’s environment. Do not reuse gowns, even for repeated contacts with the same patient. (Potter et al., 2023) RESPIRATORY HYGIENE/COUGH ETIQUETTE To prevent transmission of all respiratory infections in healthcare settings, Standard Precautions require that the following infection control measures be implemented at the point of initial encounter with patients or accompanying individuals who have signs and symptoms of respiratory infection: Educate healthcare workers on the importance of source-control methods to contain respiratory secretions, especially during outbreaks of respiratory illness such as influenza, measles, or coronavirus. Post signs at entrances and in strategic places, such as elevators and cafeterias, in both ambulatory and inpatient settings, in languages appropriate to the population served, with instructions to patients and other persons on cough etiquette. Make the following supplies readily available: o Tissues o No-touch waste containers o Hand hygiene supplies and instructions (alcohol-based hand rub, sinks when available) For patients with signs and symptoms of respiratory infection, offer a mask to contain their secretions. Separate patients with symptoms of respiratory infection from the general patient population by 6 feet. For healthcare workers, wear a surgical or procedural mask whenever in close proximity to a patient with signs or symptoms of respiratory infection. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 29 Infection Control Training for New York State Healthcare Professionals (LabCE, 2023) When coughing: Cover the mouth and nose when coughing and/or sneezing with a tissue; if no tissue is available, cough or sneeze into the elbow, not the hands. Immediately dispose of the tissue into the nearest waste container. Perform hand hygiene after coughing, sneezing, or using a facial tissue. (LabCE, 2023) PATIENT-CARE EQUIPMENT AND INSTRUMENTS/DEVICES The following policies and procedures are recommended for containing, transporting, and handling patient-care equipment and instruments/devices that may be contaminated with blood or body fluids. Meticulously clean patient-care items with water and detergent or with water and enzymatic cleaners before high-level disinfection or sterilization procedures. Remove visible organic residue (e.g., blood and tissue) and inorganic salts with appropriate effective cleaning agents. Clean medical devices as soon as practical after use to avoid soiled materials drying onto the instruments. Dried or baked materials make the removal process more difficult and disinfection or sterilization less effective or ineffective. Wear PPE, such as gloves and gown, according to the level of expected contamination when handling patient-care equipment and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids. Progressively stronger substances are used to clean or disinfect medical instruments and devices depending on the equipment to be cleaned or the microorganisms to be eradicated. These can include: Intermediate disinfectants that are a chemical germicide, kill some viruses and bacteria, and can be used on medical devices that are visibly soiled or on intact skin High-level disinfectants that kill all living organisms and some spores Sterilization with extreme heat or chemicals (Cumming, 2020) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 30 Infection Control Training for New York State Healthcare Professionals CARE OF THE ENVIRONMENT Policies and procedures for keeping the environment clean include using facility-approved disinfectants to clean patient equipment and to clean high-touch surfaces on a more frequent schedule, including: Bed rails IV poles Sink handles Bedside tables Counters where medications and supplies are prepared Edges of privacy curtains Patient-monitoring equipment (keyboards, control panels) Transport equipment (wheelchair handles) Call bells Doorknobs Light switches Surfaces in and around toilets in patients’ rooms Spills of blood or other potentially infectious materials must be promptly cleaned and decontaminated following proper procedures and using protective gloves and other personal protective equipment appropriate for the task (ACSQHC, 2021). In facilities providing healthcare to pediatric patients or that have waiting areas with child play toys, policies and procedures for cleaning and disinfecting toys at regular intervals should follow these principles: Select play toys that can easily be cleaned and disinfected and avoid use of stuffed, furry toys if they will be shared. Clean and disinfect large stationary toys (e.g., climbing equipment) at least weekly and whenever visibly soiled. If toys are likely to be put in the mouth, rinse with water after disinfection; alternatively, wash in a dishwasher. When a toy requires cleaning and disinfection, do so immediately or store in a designated, labeled container separate from toys that are clean and ready for use. Clean and scrub with soap and water. Sanitize using a weaker bleach solution (bleach diluted in water) or spray to reduce the number of germs on a surface. Disinfect with stronger bleach solutions to remove germs and completely clean surfaces. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 31 Infection Control Training for New York State Healthcare Professionals Include multiuse electronic equipment in environmental cleaning and disinfection policies, especially those items used by patients, those used during delivery of patient care, and mobile devices that are moved in and out of patient rooms frequently (CDC, 2023b). TEXTILES AND LAUNDRY Recommendations include: Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons. Bag or otherwise contain contaminated textiles and fabrics at the point of use. Use lead-resistant containment for textiles and fabrics contaminated with blood or body substances. If laundry chutes are used, ensure they are properly designed, maintained, and used so as to minimize dispersion of aerosols from contaminated laundry. (CDC, 2023f; Decker, 2022) PATIENT PLACEMENT Include the potential for transmission of infectious agents in patient-placement decisions. Place patients who pose a risk for transmission to others in a single-patient room when available (e.g., those with uncontained secretions, excretions, or wound drainage; infants with suspected viral respiratory or gastrointestinal infections). Determine patient placement based on the following principles: o Route(s) of transmission of known or suspected pathogen o Risk factors for transmission in the infected patient o Risk factors for adverse outcomes resulting from an HAI in other patients in the area or room being considered for patient placement o Availability of single-patient rooms o Patient options for room sharing (e.g., placing together [cohorting] patients with the same infection) (CDC, 2023c) SAFE INJECTION PRACTICES The following recommendations apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems. Use aseptic technique to avoid contamination of sterile injection equipment. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 32 Infection Control Training for New York State Healthcare Professionals Do not administer medications from a syringe to multiple patients. Needles, cannulas, and syringes are single-patient-use items; they should not be reused to access a medication or solution that might be used for a subsequent patient. Use fluid infusion and administration sets (i.e., intravenous bags, tubing, and connectors) for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula to be contaminated after it has entered an IV bag or administration set. Use single-dose vials for parental medications whenever possible. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. If multidose vials must be used, use only a sterile needle/cannula and syringe to access them. Do not keep multidose vials in immediate patient-care areas; store as recommended by the manufacturer and discard if sterility is compromised. Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients. (CDC, 2023c) (See also “Sharps- and Injection-Related Practices and Controls” later in this course.) INFECTION CONTROL PRACTICES FOR LUMBAR PUNCTURE PROCEDURES Healthcare workers should wear a surgical mask when placing a catheter or injecting material into the epidural or subdural spaces to prevent infection caused by the transfer through normal breathing or coughing of oral flora to the central nervous system of the patient during the procedure (CDC, 2023c; Johnson & Sexton, 2023). Transmission-Based Precautions In addition to Standard Precautions, which are used with all patients, patients with documented or suspected infection or colonization with highly transmissible or epidemiologically important pathogens require additional precautions known as transmission-based precautions. The duration of these precautions is to be extended for immunosuppressed patients with viral infections due to prolonged shedding of viral agents that may be transmitted to others. There are three types of transmission-based precautions: Contact, Droplet, and Airborne. CONTACT PRECAUTIONS Contact Precautions are designed to minimize transmission of organisms that are easily spread by contact with hands or objects. Conditions requiring Contact Precautions may include: Enteric infections (C. difficile, E. coli) Viral infections (rhinovirus, COVID-19) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 33 Infection Control Training for New York State Healthcare Professionals Scabies Impetigo Enteric infections Noncontained abscesses or decubitus ulcers (S. aureus, Group A Streptococcus) (Anderson, 2020) CDC Contact Precautions are summarized below. Patient Placement In acute care hospitals, place the patient in a single-patient room when available. When a single-patient room is not available: Prioritize patients with conditions that may facilitate transmission (e.g., stool incontinence) for single-patient-room placement. Place together in the same room (cohort) patients who are infected or colonized with the same pathogen and are suitable roommates. If necessary to place the patient in a room with a patient who is not infected or colonized with the same pathogen: o Avoid placement in rooms with patients whose conditions increase risk of adverse outcome or may facilitate transmission (e.g., immunocompromised, open wounds, or have anticipated prolonged lengths of stay). o Ensure physical separation of greater than 6 feet. Draw privacy curtain between beds. o Change protective attire and perform hand hygiene between contacts with patients in the same room. In long-term care and other residential settings, make decisions about placement on a case- by-case basis, balancing risk to other patients in the room, presence of risk factors increasing likelihood of transmission, and potential adverse psychological impact on infected or colonized patients. In ambulatory settings, place patients in an examination room or cubicle as soon as possible (CDC, 2023c). Use of Personal Protective Equipment Don gloves upon entry into the room or cubicle. Wear gloves whenever touching the patient’s intact skin or surfaces and articles in close proximity to the patient. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 34 Infection Control Training for New York State Healthcare Professionals Wear a gown when anticipating clothing will have direct contact with the patient or potentially contaminated environmental surfaces or equipment in close proximity to the patient. Don a gown upon entry and remove and perform hand hygiene before leaving the patient- care area. After removal of gown, ensure clothing and skin do not contact environmental surfaces in the patient-care area. Patient Transport In acute care hospitals and long-term care and other residential settings, limit transport and movement of patients outside of the room to medically necessary purposes. If necessary to transport or move, ensure infected or colonized areas of the patient’s body are contained and covered. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting. Don clean PPE to handle the patient at the transport destination. Patient-Care Equipment and Instruments/Devices Handle equipment and instruments/devices according to Standard Precautions. In acute care hospitals, long-term care, and other residential settings, use disposable equipment (e.g., blood pressure cuffs) or implement patient-dedicated use. If common use is unavoidable, clean and disinfect before use on another patient. Limit the amount of nondisposable patient-care equipment brought into the patient’s home. Whenever possible, leave equipment in the home until discharge from home services. o If noncritical equipment (e.g., stethoscope) cannot remain, clean and disinfect items before taking them from the home using a low- to intermediate-level disinfectant. Alternatively, place in a plastic bag for transport and later cleaning and disinfection. o In ambulatory settings, place contaminated reusable noncritical patient-care equipment in a plastic bag for transport to a soiled utility area for reprocessing. Ensure that rooms of patients are prioritized for frequent cleaning and disinfection (at least daily), with a focus on frequently touched surfaces (e.g., bed rails, over-bed table, bedside commode, lavatory, doorknobs) and equipment in the immediate vicinity of the patient. (CDC, 2023c; WDHS, 2023) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 35 Infection Control Training for New York State Healthcare Professionals DROPLET PRECAUTIONS Droplet Precautions are designed to prevent transmission of diseases easily spread by large- particle droplets (>5 microns in size) produced when the patient coughs, sneezes, or talks, or during the performance of procedures. Conditions requiring Droplet Precautions may include: Neisseria meningitidis infection Mycoplasma pneumoniae infection Pertussis (whooping cough) (Bordetella pertussis) Influenza Rubella Mumps Adenovirus infection Parvovirus B19 infection Rhinovirus infection Certain coronavirus infections (e.g., MERS-CoV, SARS-CoV, and SARS-CoV-2) (Anderson, 2020) CDC Droplet Precautions are summarized below. Patient Placement In acute care hospitals, place the patient in a single-patient room when available. When a single room is not available: Prioritize patients who have excessive cough and sputum production for single-room placement. Place together in the same room (cohort) patients who are infected with the same pathogen. If necessary to place a patient in a room with another patient who does not have the same infection: o Avoid placing in the same room with patients who have conditions that may increase risk of adverse outcome or may facilitate transmission (e.g., those who are immunocompromised or have anticipated prolonged lengths of stay). o Ensure patients are physically separated greater than 6 feet and draw a privacy curtain between beds to minimize close contact. o Change protective attire and perform hand hygiene between contact with patients in the same room, regardless of whether one patient or both patients are on Droplet Precautions. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 36 Infection Control Training for New York State Healthcare Professionals In long-term care and other residential settings, make decisions on a case-by-case basis following consideration of infection risks to other patients in the room and available alternatives. In ambulatory settings, place patients in an examination room or cubicle as soon as possible. Instruct all patients to follow respiratory hygiene/cough etiquette. Use of Personal Protective Equipment Wear a mask upon entry into the patient room or cubicle. Patient Transport In acute care hospitals, long-term care facilities, and other residential settings, limit transport and movement outside the room to medically necessary purposes. If transporting or moving is necessary, instruct the patient to wear a mask and follow respiratory hygiene/cough etiquette. No mask is required for persons transporting patients. (CDC, 2023c) AIRBORNE PRECAUTIONS Airborne Precautions are designed to prevent transmission of small particles of respiratory secretions that contain infectious microbes over time and long distances. Airborne Precautions are the only type that requires a negative-pressure airborne infection isolation room (AIIR) with door kept closed and use of an N95 respirator. Conditions requiring Airborne Precautions may include: Tuberculosis Varicella Measles Smallpox Certain coronavirus infections (e.g., MERS-CoV, SARS-CoV, and SARS-CoV-2) Ebola (Anderson, 2020) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 37 Infection Control Training for New York State Healthcare Professionals CDC Airborne Precautions are summarized below. Patient Placement In acute care hospitals and long-term care settings, place patients in an AIIR that has been constructed in accordance with current guidelines. Keep the AIIR door closed except for entry and exit. When an AIIR is not available, transfer patient to a facility that has an available AIIR. In the event of an outbreak or exposure involving large numbers of patients requiring Airborne Precautions: o Consult infection control professionals. o Cohort patients presumed to have the same infection in areas away from other patients. o Use temporary portable solutions (e.g., exhaust fan) to create negative pressure in the converted environment, and discharge air directly to the outside or through HEPA filters before it is introduced to other air spaces. In ambulatory settings: o Develop a system (e.g., signage, triage) to identify patients requiring Airborne Precautions. o Place in an AIIR as soon as possible. If not available, put a surgical mask on the patient, instruct in respiratory hygiene/cough etiquette, and place in an examination room. Once the patient leaves, the room should remain vacant for about 1 hour to allow full exchange of air. o Instruct patients to wear a surgical mask and observe respiratory hygiene/cough etiquette. Once in an AIIR, mask may be removed. Restrict susceptible healthcare personnel from entering rooms of patients known to have measles (rubeola), varicella (chicken pox), disseminate zoster, or smallpox if other immune healthcare personnel are available. Respiratory protection is recommended for all healthcare personnel, vaccinated and unvaccinated. Use of Personal Protective Equipment Wear a fit-tested NIOSH-approved N95 or higher-level respirator personal mask when entering the room or home of a patient with known or confirmed infectious pulmonary tuberculosis and when procedures for treating tuberculosis skin lesions are performed that would aerosolize viable organisms. It is essential to wear medical gloves while removing an N95 respirator personal mask. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 38 Infection Control Training for New York State Healthcare Professionals Patient Transport In acute care hospitals, long-term care, and other residential settings, limit transport and movement outside of the room to medically necessary purposes. If transport or movement is necessary, instruct patients to wear a surgical mask and observe respiratory hygiene/cough etiquette. Cover infectious skin lesions. Transporting healthcare personnel do not need to wear a mask or respirator during transport if patient is wearing a mask and infectious skin lesions are covered. Exposure Management Healthcare workers are encouraged to be vaccinated against common childhood illnesses to prevent outbreaks in vulnerable populations such as neonates. Annual influenza vaccination reduces the incidence of institutional outbreaks. Healthcare workers should receive periodic boosters against pertussis. Immunize or provide appropriate immune globulin to susceptible persons as soon as possible following unprotected exposure to a patient with measles, varicella, or smallpox. (CDC, 2023c) Infection Prevention and Control Practices for COVID-19 The CDC and OSHA recommend using additional infection prevention and control practices along with Standard and transmission-based precautions when caring for patients with suspected or confirmed SARS-CoV-2 or COVID-19 infection. The infectious period includes the time between 2 days before symptoms started until 10 days after symptoms stop or a 5-day negative test; or on day 5 or later with no fever without the help of a fever-reducing medication. Recommended prevention and control practices include, but are not limited to: Implement telehealth and nursing-directed triage protocols. Screen and triage everyone entering a healthcare facility for signs and symptoms of COVID-19. Perform screening assessments of all admitted patients on a daily basis. Implement universal source control measures (face coverings or face mask) for everyone in a healthcare facility working with infected patients. Ensure all healthcare personnel wear eye protection in addition to a face mask during patient-care encounters to ensure protection, where indicated and per current facility policy. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 39 Infection Control Training for New York State Healthcare Professionals Encourage physical distancing (6 feet) between people wherever possible. Limit visitors to only those essential for patients’ physical and emotional well-being and care. Quarantine an infected employee and allow their return to the workplace only when cleared according to the above restrictions. Give notice to employees of any incidences of possible close exposure to another person who possibly has COVID-19. Maximize the amount of outside air whenever possible. Aerosolizing procedures, which may promote the spread of potentially infectious material, should be considered as to risks and benefits whenever possible. (OSHA, 2023b) Due to the rapidly growing body of knowledge concerning SARS-CoV-2 infection, it is recommended that all healthcare professionals review the most recent infection control guidelines provided by the CDC. (See also “Resources” at the end of this course.) ENGINEERING AND WORK PRACTICE CONTROLS ELEMENT III Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings In addition to the precautions described above, other practices and controls can be employed to prevent and control infection. These include: Engineering controls Work practice controls Environmental controls Types of Practices and Controls Engineering controls are measures that protect workers by removing hazardous conditions or by placing a barrier between the worker and the hazard. Examples include: Sharps disposal containers Self-sheathing needles Sharps with engineered sharps injury protections © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 40 Infection Control Training for New York State Healthcare Professionals Needleless systems According to the Occupational Safety and Health Administration (OSHA, 2020b), engineering controls shall be examined and maintained or replaced on a regular schedule to ensure their effectiveness. ENGINEERING CONTROL DEVICE EXAMPLES Retractable needle. Self-resheathing needle. Resheathing disposable scalpel. Phlebotomy needle with hinged shield as an add-on safety feature. (Image sources: OSHA.) © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 41 Infection Control Training for New York State Healthcare Professionals Work practice controls reduce the likelihood of exposure to pathogens by changing the way a task is performed, such as: Practices for handling and disposing of contaminated sharps Handling specimens Handling laundry Cleaning contaminated surfaces and items Performing hand hygiene (CDC, 2023c; OSHA, 2023a) Environmental controls help prevent the transmission of infection by reducing the concentration of pathogens in the environment. Such measures include but are not limited to: Appropriate ventilation (including air filtration systems) Environmental cleaning (housekeeping) Cleaning and disinfecting strategies (including food service areas) Cleaning, disinfection, and sterilization of patient-care equipment Proper linen and laundry management Disposal of regulated medical waste (CDC, 2023c) Sharps- and Injection-Related Practices and Controls Engineering, work practice, and environmental controls have all been developed to prevent and control the spread of infection related to the use of needles and other sharps in the healthcare setting. SHARPS HANDLING OSHA requirements for handling sharps state that contaminated sharps are needles, blades (such as scalpels), scissors, and other medical instruments and objects that can puncture the skin. Contaminated sharps must be properly disposed of immediately or as soon as possible in containers that are closable, puncture resistant, leakproof on the sides and bottom, and color- coded or labeled with a biohazard symbol. Discard needle/syringe units without attempting to recap the needle whenever possible. If a needle must be recapped, never use both hands. Use the single-hand “scoop” method by placing the cap on a horizontal surface, gently sliding the needle into the cap with the same hand, tipping the needle up to allow the cap to slide down over the needle, and securing the cap over the needle with the same hand. © 2023 WILD IRIS MEDICAL EDUCATION, INC. wildirismedicaleducation.com 42 Infection Control Training for New York State Healthcare Professionals Never break or shear needles. To move or pick up needles, use a mechanical device or tool, such as forceps, plier
