Fundamentals of Healthcare Professions HCT 101 Topic 6 - Infection Control PDF

Fundamentals of Healthcare Professions HCT 101 Topic 6 - Infection Control Section 3: Danielle Badro, PhD; Associate Professor of Molecular Oncology; College of Healthcare Technologies...

Fundamentals of Healthcare Professions HCT 101 Topic 6 - Infection Control Section 3: Danielle Badro, PhD; Associate Professor of Molecular Oncology; College of Healthcare Technologies [email protected]  Learning Outcomes Understand the importance of infection control practices in maintaining the safety of the health care professional, patients, and others. Identify the five types of microbes and the infectious diseases caused by each type. Describe the chain of infection and identify the methods to break it. Identify preventive procedures included in the standard precautions. Identify situations when handwashing is indicated. Identify the three types of transmission-based precautions and when they may be used. Describe neutropenic precautions and when they would be used. Explain differences between antiseptics, disinfectants, and sterilization. Identify and describe the three major disease risks for health care professionals. Describe how pathogens become drug resistant and the impact this has on health care. Describe measures that will protect health care professional and others from blood-borne pathogens. 2  Importance of infection control in health care 3 Taken from Dakota Mitchell and Lee Haroun 2021, Introduction to Health Care, 5th Edition, Cengage.  The birth of infection control The concept of infection control resulted from multiple observations: o Oliver Wendell Holmes reported in an article published in 1843 that a contagious disease or communicable disease (a disease that may be transmitted either directly or indirectly from one individual to another) might be spread by the contaminated (presence of infectious material) hands of doctors and nurses. o Ignaz Philipp Semmelweis, a Hungarian obstetrician, observed that mortality rates were higher when patients were attended by practitioners who came directly from the morgue or autopsy room without first washing their hands. o Lord Joseph Lister developed in 1864 surgical aseptic technique to prevent contamination of the wound and operative site. 4  Importance of infection control in health care It is essential to have a clear understanding of infection control before entering a health care facility or having contact with a patient. Goal of infection control is to prevent the spread of infectious diseases. An infectious disease is any disease caused by the growth of pathogens, disease-causing microorganisms (germs), in the body. Failure to prevent spread of an infectious disease can cause unnecessary pain, suffering, and death. An infection can be: o Generalized (systemic) – affecting the whole body. o Localized – the area infected will be red, swollen, warm to the touch, and painful. 5  Microbiology Microorganisms are very small, usually one-celled, living plants or animals. They can only be seen with the aid of a microscope. It is easy to forget their significance because their presence is not obvious. Microbiology is the study of microorganisms (derived from the Greek “micros” = small; “bios” = life; and “logy” = the study of). In the 1800s, Louis Pasteur (a French biochemist and physicist) developed the germ theory: specific microorganisms, called bacteria, are the cause of specific diseases in both humans and animals. 6  Microbiology Not all microorganisms are pathogenic (harmful). Many commonly reside on or in the body and are known as normal flora: E.g.: The skin, vagina, and intestines are examples of areas that have normal flora. Some microorganisms of the normal flora are necessary to maintain normal function. E.g.: The bacterium Escherichia coli aids the digestive process in the colon. Other microorganisms of the normal flora have no beneficial role. 7  Microbiology In some cases, bacteria of the normal flora can become pathogenic: o E. coli creates an infection when it invades an area of the body where it is not a part of the normal flora, such as the blood or urine. o When the individual becomes susceptible to an infection due to an alteration in the normal physiological state of the body. Demodex folliculorum What we have on our eyelashes ? Malassezia genus yeast Staphylococcus epidermis 8 Microbiology Types of microbes Microbes are microscopic organisms = microorganisms. They include: Bacteria (prokaryotes) Archaea (prokaryotes) Algae (eukaryotes) Protozoa (eukaryotes, include some parasites) Fungi (eukaryotes) Viruses (acellular) 9 Question 1 True or False: Some, but not all microorganisms cause diseases. This is correct. Most microorganisms do not cause any diseases! 10 Microbiology Types of microbes: Bacteria Singular bacterium; Plural bacteria. It is estimated that each of us carries 1014 bacteria (100 trillion) in and on our bodies. Bacteria are one-celled (unicellular) organisms. Can be either pathogenic or nonpathogenic. Many produce toxins (poisonous substances). Most bacteria require oxygen (aerobic) and grow best in moderate temperatures. When a group of bacteria grows in one place, it is called a colony. Each type of pathogenic bacterium causes certain diseases and conditions. 11  Microbiology Types of microbes: Bacteria – Drug resistance Almost all bacteria can be destroyed with antibiotics. Antibiotics and similar drugs are called antimicrobial agents. However, many infectious organisms the antibiotics are designed to kill have adapted to them, making the drugs less effective = antibiotic resistance: o Drugs have been used very widely and for many years. o Antibiotics have routinely been overused by being prescribed for minor conditions. o Many patients fail to complete, in quantity and/or duration an entire course of antibiotic as prescribed. These two actions create conditions that encourage pathogens to become resistant to antibiotics. Each year in the United States, >2 million people become infected with drug- resistant bacteria; at least 23,000 die as a direct result of these infections. 12  Microbiology Types of microbes: Bacteria – Drug resistance The Centers for Disease Control and Prevention (CDC) is the United States’ leading science-based organization that protects the public’s health. It lists antibiotic-resistant microorganisms by threat level. Two of these drug-resistant organisms commonly encountered in health care are methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin- resistant Enterococcus (VRE): o Treatment is available but is very expensive. o Can have severe side effects, such as liver, kidney, and hearing damage. o These infections occur most frequently in elderly patients who are more susceptible to the side effects and already have weakened resistance → often result in death. 13  Microbiology Types of microbes: Bacteria – Drug resistance Another organism that poses immediate public health threat requiring urgent and aggressive action is Clostridium difficile. Infections most often occur in people who have had both recent medical care and antibiotics. C. difficile causes life-threatening diarrhea. Although resistance to the antibiotics used to treat C. difficile is not yet a problem, the bacteria spread rapidly because they are naturally resistant to many drugs used to treat other infections. An estimated $1 billion in excess medical costs occur per year as a result of this infection. 14 Question 2 List some of the factors that contributed to the antibiotic resistance problem. Unnecessary and excessive use of drugs. Abusive use of antibiotics. Misuse of antibiotics. Use of antibiotics in livestock. 15  Microbiology Types of microbes: Bacteria – Spore formation Some bacteria form spores – sporulation. Spores are a thick capsule that the bacterium creates for self-protection. Spores are created when life-supporting conditions are not favorable and are referred to as the “resting stage.” Spores are extremely difficult to kill - can lay dormant for months or even years. In this stage, bacteria are still alive but inactive and very resistant to heat, drying, and the action of disinfectants. When supportive conditions return, the bacteria become active again – it is the process of germination. Extremely high temperatures, such as that reached by steam, must be used for sterilization to ensure that all spores are killed. 16  Microbiology Types of microbes: Protozoa They are unicellular. Plentiful in the environment; reside in and on the body. Seek locations that provide nutrients, warmth, and moisture; some of the 45,000 identified types of protozoa are constantly present in the intestines and on the skin and mucous membranes of the nose and throat. Also found in decayed materials, water contaminated with sewage waste, food washed in contaminated water or handled by unwashed hands, bird and animal feces, and insect bites. 17  Microbiology Types of microbes: Protozoa Some of the most common diseases caused by the pathogenic protozoa include the following: o Dysentery: intestinal infection resulting in abdominal pain, cramping, and diarrhea. Caused by Giardia lamblia. Commonly referred to as “traveler’s diarrhea.” Acquired through contaminated water or food; diagnosed by examination of the feces. o Trichomoniasis: sexually transmitted genital infection. o Toxoplasmosis: of particular significance in pregnant women because it can pass to the unborn child and result in death, blindness, or mental retardation. Found in the feces of birds and animals. o Pneumocystis pneumonia: caused by a nonpathogenic protozoan that affects patients with weakened immune systems; common cause of death among AIDS patients. o Malaria: parasite attacks red blood cells; characterized by periodic (every 48-72 hours) chills, fever, and sweats. Parasite is acquired through the bite of a specific kind of mosquito or through a blood transfusion. 18  Microbiology Intestinal protozoan Entamoeba coli. 19  Microbiology Types of microbes: Fungi Singular is fungus. Constitute a Kingdom of their own; are neither plant nor animal. Two forms of fungi are potential pathogens: yeast and mold. o Yeasts are one-celled and molds are multicelled organisms o Both are present everywhere Fungi cannot produce their own nutrients. Some use live and others use dead organic materials for nutrients. Fungi thrive in warm, moist, dark conditions. Many yeasts and molds are nonpathogenic. The antibiotic penicillin is produced from a mold. 20  Microbiology Types of microbes: Fungi Fungi can become pathogenic when the right conditions exist → opportunistic infection. Fungal infections (mycoses) can range from annoying to life-threatening: o Some fungi cause chronic infections. o Superficial, or cutaneous, infections - infections of the skin, nails or mucous membranes. E.g.: fungi that cause ringworm, athlete’s foot, and infections of the skin, hair follicles, and scalp. o Subcutaneous (under the skin) infections - diagnosis often delayed because associated bacterial colonization may be mistaken for the primary infectious agent. Treatment with systemic antibiotics o Deep infections - usually caused by direct inoculation of fungus into deep soft tissues (including organs). o Systemic infections - most serious of the fungal infections. Treatment requires medications that are toxic to humans → close monitoring. E.g.: histoplasmosis (a respiratory disease) o Infections that go beyond the cutaneous level are always difficult, if not impossible, to treat or cure. 21  Microbiology Types of microbes: Fungi Fungi can cause food spoilage. It produces fuzzy or dark moldy spots on spoiled bread, fruits, and vegetables. The smell of mold is “musty”. There are also commercial uses of fungi; yeast in making of wine from grapes and beer from malt and creating the carbon dioxide necessary for dough to rise. Molds are also responsible for the flavor of Roquefort and Camembert cheeses. 22  Microbiology Types of microbes: Viruses Viruses are the smallest of the microbes. They are visible under the electron microscope. Viruses are acellular. They can only live inside another living organisms; they are referred to as obligate intracellular parasites. > 300 viruses have been identified. Some are harmless, but others can cause infections that result in the common cold, influenza (flu), pneumonia, chickenpox, croup, hepatitis B, acquired immunodeficiency syndrome (AIDS), measles, mumps, herpes, warts, and polio. 23  Microbiology Types of microbes: Viruses Viruses multiply rapidly and are easily transmitted by blood and other body secretions. Are resistant to many disinfectants. Not killed by antibiotics ➔ Viral infections can be extremely difficult to treat. Electron micrographs of herpes simplex viruses. 24 Question 3 Name a common feature and a difference between bacteria and protozoa. The are both unicellular Bacteria are prokaryotes, while protozoa are eukaryotes 25  Chain of Infection Model for explaining how infectious diseases occur and are transmitted. It consists of six elements that must be present for an infection to develop: 1. Infectious agent: pathogen must be present. 2. Reservoir host: pathogen must have a place to live and grow; the human body, contaminated water/food, animals, insects, and dead or decaying organic material. o Carriers: humans or animals that can transmit the pathogen but have no outward signs of the disease; may not even be aware that they are spreading an infectious disease. 3. Portal of exit: pathogen must be able to escape from the reservoir host; blood, urine, feces, breaks in the skin, wound drainage, and body secretions such as saliva, mucus, and reproductive fluids. 4. Route of transmission: pathogen leaves host through portal of exit, must be transmitted to a new host; air, food, insects (biological vectors), direct contact with an infected person. 5. Portal of entry: pathogen must enter the new host; mouth, nostrils, skin. 6. Susceptible host: an individual who is invaded by a large number of pathogens or does not have adequate resistance to the pathogen. 26  Chain of Infection Breaking at least one link stops the infectious disease! Examples of health care practices and procedures that impact the cycle are included. 27  Defense Mechanisms If the body’s immune defense mechanisms are intact and strong, the individual can resist the microorganism and not become ill. The body relies on a multitude of natural defense mechanisms including: o Cilia in the respiratory tract - catch and move pathogens out of the body. o Coughing and sneezing - propel pathogens outward. o Tears - contain chemicals to kill bacteria. o Hydrochloric acid in the stomach - destroys pathogens. o Mucous membranes of the respiratory, reproductive, and digestive systems - serve to trap pathogens. o Rise in body temperature (fever) to a level that kills microorganisms. o Production of additional leukocytes (white blood cells), which have the specific function of destroying pathogens. 28 Transmission of disease in the health care setting: Scope of the problem Nosocomial infection refers to an unintended infection that occurs while a patient is receiving health care. Also termed healthcare-associated infections (HAIs). HAIs can be prevented by consistently following standard precautions and transmission-based precautions outlined by the CDC Over the past 25 years, the rate of nosocomial infections per 1000 patient days has increased 36%. The CDC states that handwashing is the single most important procedure for preventing health care-acquired infections. 29 Transmission of disease in the health care setting: Scope of the problem An industrial/occupational illness is a disease acquired by an employee while at work. Industrial illnesses in the health care are preventable if the health care professional follows standard precautions. Needlestick injuries - a main cause of exposure or industrial injury that may lead to an industrial illness (could be fatal). Safer equipment is available, and more devices are continually being developed. 30  Regulatory Agencies Two very important regulatory agencies are responsible for developing the guidelines to safeguard health care professionals, their patients, and the public. The Centers for Disease Control and Prevention (CDC): o Government agency that is part of the U.S. Department of Health and Human Services. o Studies the causes and distribution of diseases (epidemiology) → formulates safety guidelines to help prevent and control the spread of infectious diseases. o Other major tasks include the licensing of clinical laboratories, maintenance of laboratory reference centers for microorganisms, and operation of extensive disease research programs. The Occupational Safety and Health Administration (OSHA): o Government agency that is under the Department of Labor. o Two main functions: to establish minimum health and safety standards for the workplace and to enforce those standards. o It is the “watchdog” of employee safety and has the authority to conduct onsite inspections to verify compliance with its standards. o Requires employers to have an exposure control plan and provide hepatitis B vaccines to employees with occupational exposure risk. 31  Standard Precautions Standard precautions are infection control practices that are used to prevent the transmission of infections. Because it is impossible to know which pathogens a patient may carry, standard precautions should be applied at all times during patient care regardless of infection status. These precautions have been developed by the CDC. They prevent contact with potentially infectious body fluids. These fluids include: o All body fluids, secretions, and excretions except sweat, regardless of whether or not they contain visible blood o Blood o Nonintact skin o Mucous membranes o Any unidentified body fluids 32 Standard precautions 1. Appropriate hand hygiene. 2. Use of personal protective equipment (e.g., gloves, gowns, masks, eyewear) whenever infectious material exposure may occur. 3. Respiratory hygiene/cough etiquette. 4. Proper handling and cleaning of environment, equipment, and devices. 5. Safe handling of textile and laundry. 6. Sharps safety. 7. Appropriate patient placement. 8. Safe Injection practices and lumbar punctures. 33 Standard precautions 1- Handwashing Good handwashing is the most effective in preventing the spread of microorganisms. Remember! You must wash hands between tasks and procedures on the same patient if there is the possibility of cross- contaminating different body sites. Clean hands are caring hands. 34 Standard precautions 1- Handwashing Examples of appropriate times to do handwashing are as follows: o When coming on duty. o When taking a break or leaving work. o Between patient contacts. o Before applying and immediately upon removing gloves. o Before and after touching your face in any way (manipulating contact lenses, applying lip balm, blowing your nose, coughing, sneezing). o After contact with anything considered contaminated (picking up items from the floor, touching equipment or environmental surfaces that may be contaminated, handling soiled linens). o Before touching any items considered clean, such as a patient’s food or drink. o Before and after eating, drinking, or using the restroom. 35 Watch this video carefully to learn how to perform handwashing. The content of this video is detailed on the next slide. Reference: Chapter 4 Aseptic Technique - Nursing Skills - NCBI Bookshelf (nih.gov) 36 37 Standard precautions 1- Handwashing Health care facilities will often have waterless handwashing foams, gels, or lotions available. These products contain alcohol as the antiseptic and a moisturizer to prevent drying of the skin. Can be used between patients when hands are not visibly soiled and when there has been no contact with blood or body fluids. Enough product should be applied to all surfaces of the hands, fingers, nails, and wrists for it to take about 15 seconds of rubbing for the hands to feel dry. Always read carefully the manufacturer’s instructions of use. 38 Standard precautions 1- Handwashing Many microorganisms are normal flora; always present on the body (E.g., staphylococci occur naturally on the hands). But when transferred to a wound site, they can cause pus-producing infections. Two types of normal flora are found on the hands: o Transient flora: whether pathogenic or nonpathogenic, are picked up during our activities of daily living and are easily removed from the hands with frequent and thorough handwashing. o Resident flora: are constantly present, considerable scrubbing is required to remove these deeply imbedded microbes. Transient flora can be completely removed, and resident flora diminished with diligent handwashing. In individuals who do not maintain proper hygiene, transient flora becomes resident flora → person becomes a carrier of that organism. 39 Standard precautions 2- Personal protective equipment (PPE) PPE includes gloves, masks, protective eyewear, gowns, and caps. To be effective, these must be properly used in all situations that have the potential to infect the health care professional. OSHA requires the use of PPE to reduce employee exposure to infectious hazards in the health care environment. Employers are required to determine what hazards exist and to implement a PPE program to address these hazards. This program should address: o The hazards present; o The selection, maintenance, and use of PPE; o The training of employees; o and monitoring of the program to ensure its ongoing effectiveness. 40 Watch this video carefully to learn how to apply and remove personal protective equipment (PPE). Reference: Chapter 4 Aseptic Technique - Nursing Skills - NCBI Bookshelf (nih.gov) 41 Standard precautions 2- Personal protective equipment (PPE) 2.1- Gloves Wear clean, nonsterile gloves when you touch, or have the potential of coming in contact with blood, body fluids, secretions, excretions, or contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Gloves should be changed between tasks and procedures on the same patient if there is contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient. After gloves are removed, wash your hands immediately to avoid transferring of microorganisms to other patients or environments. 42  Safely removing gloves. Non-sterile gloves. 43 44 Standard precautions 2- Personal protective equipment (PPE) 2.2- Mask, eye protection, face shield Wear a mask and eye protection or a face shield to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. 45 Standard precautions 2- Personal protective equipment (PPE) 2.3- Gown Used during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Wear a clean, nonsterile gown to protect the skin and to prevent soiling clothing. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as possible and wash your hands to avoid transfer of microorganisms to other patients or environments. 46 Guidelines for applying and removing the gown. Applying the gown. Removing the gown. 47 Guidelines for applying and removing PPE when working in contaminated areas. 48 Standard precautions 3- Respiratory Hygiene/Cough Etiquette Respiratory hygiene is targeted at patients, accompanying family members and friends, and health care workers with undiagnosed transmissible respiratory infections. It applies to any person with signs of illness, including cough, congestion, rhinorrhea, or increased production of respiratory secretions when entering a health care facility. The elements of respiratory hygiene include the following: 49 Standard precautions 3- Respiratory Hygiene/Cough Etiquette Health care personnel are advised to: Wear a mask and use hand hygiene when examining and caring for patients with signs and symptoms of a respiratory infection. Health care personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients. If this is not possible, then a mask should be worn while providing patient care. Spatial separation, ideally greater than 3 feet (~1 meter), of persons with respiratory infections in common waiting areas when possible. 50 Standard precautions 4- Proper handling and cleaning of environment, patient care equipment, and devices Care equipment can become soiled with blood, body fluids, secretions, and excretions. Handle them in a manner that prevents: o Skin and mucous membrane exposures o Contamination of clothing o Transfer of microorganisms to other patients and environments. Reusable equipment must be cleaned and reprocessed appropriately when used for the care of another patient. Single-use items must be discarded properly. 51 Standard precautions 4- Proper handling and cleaning of environment, patient care equipment, and devices Frequently touched surfaces, especially those closest to the patient are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces, and equipment in close proximity to the patient) Procedures must be followed and consistently performed for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces. 52 Standard precautions 5- Textiles and Laundry Textiles can become soiled with blood, body fluids, secretions, and excretions, and may be contaminated with pathogenic microorganisms. However, the risk of disease transmission is negligible if they are handled, transported, and laundered in a safe manner. Handle, transport, and process these in a manner that prevents: o Skin and mucous membrane exposures. o Contamination of your clothing. o Transfer of microorganisms to other patients and environments. 53 Standard precautions 5- Textiles and Laundry Key principles for handling soiled laundry are as follows: o Do not shake items or handle them in any way that may aerosolize infectious agents. o Avoid contact of one’s body and personal clothing with the soiled items being handled. o Place soiled items in a laundry bag or designated bin in the patient’s room before transporting to a laundry area. o When laundry chutes are used, they must be maintained to minimize dispersion of aerosols from contaminated items. 54 Standard precautions 6- Sharps and blood-borne pathogens Injuries due to needles and other sharps have been associated with transmission of blood-borne pathogens (BBP), including hepatitis B, hepatitis C, and HIV to health care personnel. Measures to handle needles and other sharp devices aim to prevent injury to the user and to others who may encounter the device during or after a procedure. The Bloodborne Pathogens Standard is a regulation that prescribes safeguards to protect workers against health hazards related to blood-borne pathogens. All needles and sharp objects should be discarded immediately in a puncture- resistant sharp container. 55 Standard precautions 6- Sharps and blood-borne pathogens Injuries can occur when using sharp instruments or devices including needles, scalpels: o During the use; o When handling sharp instruments after procedures; o When cleaning used instruments; o When disposing of used needles. When performing procedures that include sharps, dispose of these items immediately in appropriate puncture- resistant containers. All needles and sharp objects should be discarded immediately in a puncture- These should be located as close as practical to the area in resistant sharp container. which the items are used. 56 When a sharps disposal container is about three- quarters full, follow agency policy for proper disposal of the container. Sharps Disposal Containers 57 Standard precautions 6- Sharps and blood-borne pathogens The following additional precautions must be followed when using needles: o Never recap used needles. There may be an exception to this rule: either the one- hand “scoop” technique (see next slide) or a mechanical device designed for holding the needle sheath. o Do not remove used needles from disposable syringes by hand. o Do not bend, break, or otherwise manipulate used needles by hand. 58 Remember! Recapping needles is dangerous and should be avoided when possible. Recapping a needle using the one-hand scoop technique. Reference: Chapter 4 Aseptic Technique - Nursing Skills - NCBI Bookshelf (nih.gov) 59 Standard precautions 7- Appropriate patient placement Patients with infections who contaminate the environment or who do not assist in maintaining appropriate hygiene or environmental control should be placed in a private room. If room not available, consult with infection control professionals for other alternatives. In addition to appropriate patient placement, care using transmission-based precautions must be used when indicated (see slides 64-72). 60 Standard precautions 8- Safe injection and lumbar puncture practices Healthcare providers must strictly adhere to safe injection practices during patient care. These include the following practices: o Never administer medications from the same syringe to more than one patient, even if the needle is changed. o Do not enter a vial with a used syringe or needle. o Medications packaged as single-use vials never be used for more than one patient. o Medications packaged as multi-use vials be assigned to a single patient whenever possible. o Bags or bottles of intravenous solution not be used as a common source of supply for more than one patient. o Absolute adherence to proper infection control practices be maintained during the preparation and administration of injected medications. 61  Transmission precautions Transmission precautions must be used in addition to standard precautions, either singularly or in combination. May be combined for diseases that have multiple routes of transmission. The CDC recommends the use one or more of transmission-based precautions: o Airborne precautions o Droplet precautions o Contact precautions Some hospitals prefer to protect the patient’s privacy and post a note stating that one must report to the nurse’s station prior to entry into the room (next slide). 62 Transmission Precautions 63 Transmission precautions 1- Airborne precautions 64 Transmission precautions 2- Droplet precautions 65 Transmission precautions 3- Contact precautions 66  Transmission precautions Placing a patient on transmission precautions often presents certain disadvantages to the hospital, patients, personnel, and visitors; o Patient is placed in a private room unless it is shared with another patient with the same disease. o May require specialized equipment and environmental modifications that add to the cost of hospitalization. o Frequent visits by care givers inconvenient → more difficult for personnel to give prompt and frequent care. o Using a multipatient room for one patient uses valuable space that otherwise might accommodate several patients. o Forced solitude may be psychologically harmful to the patient, especially to children and confused patients. 67  Transmission precautions Proper disposal of hazardous waste (contaminated materials) is crucial. In isolation rooms, there are specially marked hazardous waste containers for trash and for linen. Double-bagging technique is used to remove contaminated items from the room: o Take the contaminated bag from the isolation room (whit appropriate PPE on). o Slip it into another bag held by a coworker outside the isolation room - coworker does not touch the contaminated bag, and the health care professional in the room does not touch the clean bag. o Bags are labeled according to the facility policy to alert other personnel to the need for special handling. 68  Transmission precautions Neutropenic precautions Precautions ordered for patients who are very susceptible to infections. Precautions are meant to protect the patient from infections brought in by people or other sources, rather than protecting the health care professional and visitors from patient infections. Also called reverse isolation. Commonly seen with an oncology patient who has a repressed immune system secondary to the cancer treatment (i.e., chemotherapy, radiation). A sign can be posted on the patient’s door. 69  Transmission precautions Neutropenic precautions The general guidelines, in addition to standard precautions, are as follows: o Patient is placed in a private room. o No one who has an infection should enter the room. o No visitors who have infections or recent exposure to communicable diseases or vaccinations are allowed to enter the room. o No unwashed fresh fruit or vegetables, raw eggs, or yogurt may be eaten. o No flowers or plants are allowed in the room. o Sources of stagnant water (e.g., denture cups, irrigating containers) should be avoided. 70  Aseptic Technique (Medical Asepsis) In addition to using standard precautions and transmission-based precautions, aseptic technique (also called medical asepsis) is used during routine care or procedures (not surgeries!). It is the purposeful reduction of pathogens to prevent the transfer of microorganisms from one person or object to another during a medical procedure. It is used, for example, when administering parenteral medication or performing urinary catheterization uses aseptic technique. When performed properly, aseptic technique prevents contamination and transfer of pathogens to the patient from caregiver hands, surfaces, and equipment. 71  Aseptic Technique (Medical Asepsis) The word “aseptic” literally means an absence of disease-causing microbes and pathogens. In the clinical setting, aseptic technique refers to the purposeful prevention of microbe contamination from one person or object to another. These potentially infectious, microscopic organisms can be present in the environment, on an instrument, in liquids, on skin surfaces, or within a wound. 72  Sterile Technique (Surgical Asepsis) Sterile technique, or surgical asepsis includes procedures to completely eliminate the presence of pathogens from objects and areas. There is often misunderstanding between the terms aseptic technique and sterile technique in the health care setting. In the most simplistic terms, asepsis is creating a protective barrier from pathogens, whereas sterile technique is a purposeful attack on microorganisms. Sterile technique is the standard of care for surgical procedures, invasive wound management, and central line care. Sterile technique requires a combination of meticulous hand washing, creation of a sterile field, using long-lasting antimicrobial cleansing agents such as betadine, donning sterile gloves, and using sterile devices and instruments. 73  Sterile Technique (Surgical Asepsis) It is a group of principles and related procedures that eliminate the presence of pathogens from objects and areas (let’s be cautious about the term “eliminate”!). Sterile field: an area that has been designated as free of microorganisms. E.g.: a sterile towel placed on a clean, dry surface; towel now represents a sterile field. Many health care procedures require the use of sterile fields. It is essential that contaminants NOT be brought into the field through actions such as touching it, allowing it to become wet, reaching across it, or talking directly over the surface. The goal of asepsis is to eliminate infection, not achieve sterility! 74  Sterile Technique (Surgical Asepsis) Sterile technique relies on the use of sterilized materials and items. Sterilized items, such as instruments and surgical gloves, come in sealed packages. Must be opened and handled properly to avoid contamination. Always check for expiration dates of any sterilized items. When using sterile gloves, apply them in a way that prevents them from being contaminated (see video on next slide). 75  Applying and removing sterile gloves. Reference: Chapter 4 Aseptic Technique - Nursing Skills - NCBI Bookshelf (nih.gov) 76  Sterile Technique (Surgical Asepsis) Procedure for applying sterile gloves while preventing them from being contaminated. 77 Sterile Technique (Surgical Asepsis) Procedure for applying sterile gloves while preventing them from being contaminated. 78  Prevention through asepsis: breaking the chain of infection The most important concept to remember is that breaking at least one link stops the infectious disease. Practices and techniques used daily by health care professionals are designed to break the chain. The six elements of the chain are often summarized into three components: 1. Source of infecting microorganisms (elements 1 and 2 - infectious agent and reservoir host - both involve the source of infection). 2. Means of transmission for the microorganism (elements 3, 4, and 5 - portal of exit, route of transmission, and portal of entry - all affect transmission). 3. Susceptible host (element 6 - susceptible host - is unchanged in this summarized format). 79  Prevention through asepsis: breaking the chain of infection Health care professional can have an impact on the three components: 1. Decreasing the source of microorganisms: - Perform proper handwashing. - Decontaminate surfaces and equipment (antiseptics, disinfectants, sterilization). - Avoid contact with patients and others when harboring infectious microorganisms (E.g., a sneeze can propel microorganisms for many feet). 2. Preventing the transmission of microorganisms: - Wear personal protective equipment (PPE, includes caps, gloves, gowns, masks, booties, and eye protection. - Follow isolation procedures when working with highly contagious patients. 3. Maximizing the resistance of the host: - Provide good hygiene. - Ensure proper nutrition and fluid intake. - Decrease stressors that weaken the immune response. 80  Antiseptics, disinfectants, and sterilization Multiple chemical agents and physical methods are used to inhibit the growth of or destroy microorganisms: o If the method used only inhibits the growth of the microorganism, the action is described as bacteriostatic. o If the method results in the microorganisms being killed, the action is bacteriocidal or germicidal. 81  Antiseptics, disinfectants, and sterilization The methods used can be broken into the following three categories: o Antiseptics: Are only bacteriostatic; mild enough to be used on the skin. E.g.: cleaning with a 70% isopropyl alcohol wipe before giving an injection. o Disinfectants: Agents or methods that destroy most bacteria and viruses; used for cleaning instruments that do not penetrate the skin and for cleaning the environment (e.g., floors, bathroom, equipment). Chemical agents are frequently used as disinfectants. If instruments are soaked for 20 to 30 minutes in alcohol, it acts as a disinfectant. Physical disinfectant methods include boiling instruments in water. o Sterilization: Agents or methods that destroy all microorganisms, including viruses and spores; most common method used is the autoclave - sterilizes by pressurized steam. E.g.: chemical agents, gas, radiation, and dry or moist heat under pressure. 82  Antiseptics, disinfectants, and sterilization The most frequently used sterilization methods in health care are: o Steam sterilization using a device called autoclave (see next slide). o Flash sterilization: it uses steam and high pressure; however, the duration of the procedure is much shorter compared to autoclaving. Disadvantages: absence of protective packaging following sterilization, possibility for contamination of processed items during transportation to the operating rooms, and the sterilization cycle parameters (i.e., time, temperature, pressure) are minimal. o Low-temperature sterilization technologies or ethylene-oxide “gas” sterilization: ethylene oxide (ETO) has been widely used as a low-temperature sterilant since the 1950s. It has been the most commonly used process for sterilizing temperature- and moisture-sensitive medical devices and supplies in healthcare institutions in the United States. Safety issues since gas is toxic. 83  Antiseptics, disinfectants, and sterilization The size of an autoclave can vary from a small unit for a medical office to a large unit for a hospital. Use at a temperature of 121ᵒC and a pressure of 15 psi (103kPa or 1.02 atm) 84  Thinking it through 1 Frank Gello is very excited about his new position as a surgical technologist at the local hospital, although he is somewhat intimidated by the person who is orienting him and is anxious to complete his training and work more independently. As they set up for the next surgery, his preceptor positions himself on the opposite side of the sterile field. As Frank opens the sterile instruments to place them on the sterile field, his preceptor talks him through the procedure and on several occasions, he reaches across impatiently to move Frank’s placement of the instruments. Frank also knows that he should check all of the packaging on the instruments for integrity to ensure sterility has been maintained, but his preceptor abruptly states “I have already done that. Don’t waste my time. Keep going as the surgeon is arriving in a few minutes.” 1. Does this scenario refer to medical or surgical asepsis? What is the difference between medical and surgical asepsis? 2. Were any of the aseptic principles broken? If so, what are they? 3. Should Frank perform a double-check on the packaging to verify the integrity of the sterility of the instruments even if his preceptor states he has already performed that check? 85  Thinking it through 2 Monica Stokes is a volunteer at a local extended care facility. Her duties include pushing a cart with books around to the patients’ rooms to ask if they would like to borrow a library book. When she enters Mr. Haskin’s room, the nurse asks her if she would please take the dirty linens and place them in the linen basket down the hall. She is new and unclear if this is one of her duties, but also desires to be helpful, and surely the nurse would not ask her if it were not appropriate. So, she picks up the linens from the floor, carries them close to her, and places them in the linen basket. She notices some stains on her clothes, so she goes to the sink and rinses them off with cold water in the hope there will be no permanent stain. She then returns to her duties of distributing books to patients. 1. Was it appropriate for the nurse to ask the volunteer to assist with the linens? 2. Are all the links present in the chain of infection? 3. What breaks in standard precautions can you identify? 86  The Risks Certain diseases pose special risks to the health care professional. These include: o Hepatitis B virus (HBV) – a blood-borne pathogen. o Human immunodeficiency virus (HIV) – a blood-borne pathogen. o Tuberculosis (TB) - an airborne-transmitted disease. o Drug-resistant infections. The term blood-borne is used to identify pathogenic microbes that are spread through contact with blood. Blood-borne infections can also be transmitted through contact with nonintact skin, mucous membranes, secretions, excretions, or any moist body fluid except sweat. 87  The Risks Hepatitis B Major infectious blood-borne occupational hazard for health care professionals. HBV can be spread via several routes: o Parenteral: Blood transfusion, needle sharing by intravenous (IV) drug users, needlestick, or other sharp instruments. o Mucous membranes: Blood contamination of the eye or mouth. o Sexual contact. o Perinatal: From infected mother to newborn infant. The infected liver, in its attempt to destroy the hepatitis virus, causes an inflammation and subsequent destruction of liver cells. Symptoms: jaundice (yellowing of the eyes and skin), dark urine, fatigue, loss of appetite, nausea, abdominal pain, and sometimes joint pain, rash, and fever. 88  The Risks Hepatitis B Prevention in health care settings are focused on the: o Administration of hepatitis B vaccine. o Use of PPE. o Prevention of puncture injuries. o Disinfection and sterilization of equipment and surfaces. OSHA mandates that employers provide hepatitis B vaccine for all employees who have an occupational exposure risk. o HepB vaccines are given in three doses over a six-month period. o Induce protective antibody levels in 85% to 97% of healthy adults. o Immunization can be verified through a blood test. o An employee has the right to refuse the hepatitis B vaccine - employee must sign a form stating his or her refusal; releases the facility from responsibility. 89  The Risks Hepatitis B and other types of Hepatitis viruses Hepatitis B is the most common hepatitis virus. Health care professional must have knowledge of other hepatitis viruses: o Hepatitis A (HAV) and hepatitis E (HEV) are transmitted by the fecal-oral route. o Hepatitis B, hepatitis C (HCV), and hepatitis D (HDV) are transmitted by blood and body fluids. 90 The Risks Hepatitis B and other types of Hepatitis viruses People can become infected with HBV from: Having sex with an infected partner Sharing needles, syringes, or drug preparation equipment Mother to child during childbirth Coming in contact with blood or open sores of an infected person Needle sticks or sharp instrument exposures Sharing items (such as razors and toothbrushes) with an infected person HBV is not spread through: Food or water Sharing eating utensils Breastfeeding Hugging, kissing, and hand-holding Coughing and sneezing 91  The Risks Human Immunodeficiency Virus (HIV) HIV virus causes AIDS (acquired immune deficiency syndrome). Virus destroys cells in the host’s immune system. Individuals infected are said to be HIV positive. This is not the same as having AIDS, which means that the immune system has become weakened. Common signs and symptoms of AIDS: weakness, chronic fever, night sweats, swelling of the lymph nodes, weight loss, and diarrhea. There is no vaccine against AIDS and no known cure; goal is to prolong life. Most HIV positive persons eventually develop AIDS and die because of an opportunistic infection. o Most common deadly opportunistic infection in AIDS patients is Pneumocystis carinii. 92  The Risks To become infected with HIV, a person must come into direct contact with certain body fluids from a person with HIV who has a detectable viral load. These fluids are: Blood Semen and pre-seminal fluid Rectal fluids Vaginal fluids Breast milk Important 93  The Risks Tuberculosis (TB) TB is caused by the bacterium Mycobacterium tuberculosis, an airborne pathogen. Requires the use of special PPE; special masks fitted to avoid inhaling the tiny droplets that carry the pathogen through the air. TB bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. People nearby may breathe in these bacteria and become infected. TB is not spread by: o Shaking someone’s hand. o Sharing food or drink. o Touching bed linens or toilet seats. o Sharing toothbrushes. o Kissing 94  The Risks Tuberculosis (TB) Medications must be taken for at least six months. Failure to complete the full length of treatment has allowed certain strains of the bacterium to develop resistance to the drugs. Remains one of the most common infections in the world (one third of the world’s population is infected with TB). Is the leading killer of HIV positive people. Signs and symptoms: lethargy, fever, night sweats, cough, weight loss, blood-tinged sputum, chest pain, and shortness of breath. 95  The Risks Tuberculosis (TB) The screening test for TB is: o A skin test (tuberculin test); a positive test result indicates that the person has or had an exposure to the pathogen. o A chest X-ray and other tests will determine if active disease is present. TB primarily affects the lungs; can affect the kidney, spine, and brain. Patients with suspected TB are placed in isolation for 2-3 weeks during which time antibiotic treatment is given. Two TB-related conditions exist: o Latent TB infection: TB bacteria live in the body without making the person sick. If TB bacteria become active in the body and multiply (sometimes years after becoming infected) → the person will become sick. o Active TB disease: bacteria become active if the immune system cannot stop them from growing. 96  The Risks Tuberculosis (TB) 97  The Risks Other infectious organisms 98  Reporting accidental exposure When a health care is injured or has an accident that involves exposure to blood or body fluids, the following steps should be undertaken: Step 1: Wash immediately and thoroughly the wound site or infection site. Skin must be washed with warm water and soap. Eye or mucous membranes must be rinsed with normal saline. Step 2: Report the incident to the supervisor. Step 3: Complete a written incident or injury report according to facility or agency requirements. Prompt reporting allows for evaluation, appropriate treatment (if indicated), and follow up of any problems resulting from the exposure. Failure to report an incident can result in negative health consequences for the health care professional and others, as well as the need to take time off from work to recover. 99  Reporting accidental exposure OSHA regulations require every facility to have an exposure control plan. This plan has many components and must include: o Predetermination of employee exposure risk to blood-borne pathogens. o Description of how employees at risk will be protected. o Training and annual retraining and testing requirements for employees. o Policies and procedures to be followed if exposure does occur. o Actions to be taken immediately upon exposure. o Time frames for reporting. o To whom the incident must be reported. o Form(s) to complete and information that must be included, such as how exposure occurred and the name of the patient. 10 0  Reporting accidental exposure This plan has many components and must include (cont’): o Recommended procedure for evaluating the risk and outcome of the exposure. For example, a baseline blood test would be run on the health care professional and then repeated at specified intervals, the patient’s blood would be drawn to determine HBV and HIV status, and postexposure treatment would begin if indicated. Blood draws and treatments require the consent of the involved individual. o Plan for counseling and information on safe practices to protect self and others 10 1