Application of engineering controls and work practice control PDF

Application of engineering controls and work practice control (I) &(II) Care of People with Communicable Diseases 1 Learning Objectives After this lecture, you should be able to prevent the following infections. Sharp injury Catheter-associated urinary tract infection (CAUTI)...

Application of engineering controls and work practice control (I) &(II) Care of People with Communicable Diseases 1 Learning Objectives After this lecture, you should be able to prevent the following infections. Sharp injury Catheter-associated urinary tract infection (CAUTI) Intravascular catheter associated infection Ventilator associated pneumonia (VAP) Dialysis units Operation theatre Prevention of surgical site infection Care of People with Communicable Diseases 2 Prevention of sharp injury and mucocutaneous exposure to blood and body fluids Care of People with Communicable Diseases 3  ! ! " ! ! :K#¥En¥ needle stick injery observe case → patient5 4 Ift NG tube Potential activities Dispose of needles attached to tubing IM24 I II culture Manipulate the needle in thebottle client insulinsyringe × hard Recap a needle Use needles or glass equipment to transfer body fluid between containers " " Failto dispose of used needles in puncture-resistant sharps containers anaer microorganism ""enough-spacef o ropen⇐t obe; × Lack proper workstations for procedures using sharps Work quickly / aerobic Bump into a needle, a sharp, or anotherminorganism worker while either person is holding a sharp HKt¥¥ Care of People with Communicable Diseases 4  ! report → postexposed treatment Preventive strategies → A9E Immunization and vaccination HCV and HIV vaccine is currently not available HBV Pre-exposure Post vaccination serological testing antibody if ±wife¥34 , surfaceantigen I t.ake vaccine H¥i¥ Ffr isk riskc a s e f o rhigh Care of People with Communicable Diseases 5 k n owhypo hyper BIG → A c a s e+w e : response  # ## Standard precaution Good hand hygiene 5 moment Proper use of protective barriers T E4E surgical maskf o rT B PPE whenever the contact of blood or body fluid Wear goggles or face shield when splashes of bloody or body fluid Care of People with Communicable Diseases 6  Prevention of sharp injury and mucocutaneous exposure to blood and body fluids Use devices with safety features provided (e.g., retractable needles / lancet) that Avoid recapping needles. If recapping of needles is inevitable, use single hand techniques, e.g., scoop techniques, or needle recapping device ,µfjNk¥d provided Plan for safe handling and disposal before beginning any procedure using sharps Plan' Ask Discard used needles or sharps promptly in appropriate sharps disposal containers H¥Et¥ Care of People with Communicable Diseases 7  ! # " ! 0T ¥17I t LA J PETA Before the beginning of the procedure Ensure that equipment necessary for performing a procedure is available within arms reach Identify the location of the sharps disposal container; if moveable, place it as near the point-of-use as appropriate for immediate disposal of the sharps If the sharp is reusable, determine in advance where it will be placed for safe handling after use. Keep sharps disposal containers securely in safe and upright position so as to prevent them from being toppled over. Care of People with Communicable Diseases 8  lighting nightshift × Adequate lighting and space to perform the procedure × overestimate Well organize working area (e.g. procedure tray) Assess the potential for a patient to be uncooperative, combative, or confused Obtain assistance from other staff or a family member to assist in calming or restraining a patient as necessary communication Inform a patient of what the procedure involves and explain the importance of avoiding any sudden movement that might dislodge the sharps Care of People with Communicable Diseases 9 During a procedure Maintain visual contact with the procedures site and location of the sharp device. Do not hand-pass exposed sharps from one person to another Use a predetermined neutral zone or tray for placing and retrieving used sharps/ verbally announce when sharps are being placed in a neutral zone. https://www.youtube.com/watch?v=PXOJfvye7O0 (03:22-05:12) If the procedure necessitates reusing a needle multiple times on the same patient (e.g., giving local anesthesia), use one-handed technique to recap the needle Care of People with Communicable Diseases 10 After disposal Keep filled sharps disposal containers awaiting final disposal in a secure area Use mechanical device, such as forceps, to assist picking up or handling of any sharps disposed improperly Care of People with Communicable Diseases 11 Care of exposure site Wash needle sticks and cuts with soap and water Report the incident to your supervisor (ward in-charge/ shift in-charge) Immediately seek medical treatment (attend AED for injury on duty (IOD)) for proper wound care and receive the post exposure management. Antiseptics are not necessary as there is no evidence of their efficacy. Care of People with Communicable Diseases 12 CAUTI –Catheter associated urinary tract infection Care of People with Communicable Diseases 13 CAUTI overview Urinary catheter is a commonly used device for different patients in various healthcare settings Their use may put patients at increased risk of urinary tract infection. Indwelling urinary catheter, as a foreign body, allows bacteria to colonize and enter the body The rate of acquisition of bacteriuria is approximately 5% per day with an indwelling urinary catheter The longer the catheter is in place, the greater the n o need→ off risk of developing catheter- associated urinary tract infections (CAUTIs) https://www.youtube.com/watch?v=2iLPfCAMgZs Supra pubic urinary catheter Care of People with Communicable Diseases 14  ! ! ! " # # CAUTI ✓ → cloudy urine infection blood in the urine (haematuria) urinary tinine strong urine odor ] inflammatory sifdsitmfg.m urine leakage aroundoveractive catheter 4 permeable g? bladder meth# pressure, pain, or discomfort in lower back or stomach chills fever NINTH unexplained fatigue 4th I vomiting Care of People with Communicable 15 Diseases  ! # What causes the CAUTI? 1. Contamination upon insertion 2. The drainage bag may not be emptied often enough 3. Bacteria from a bowel movement may get on the catheter F)closeE 1 bag 4. Urine in the catheter bag may flow backward into the bladder & it 5. The catheter may not be regularly cleaned IIs→ the Care of People with Communicable Diseases 16  The most frequent pathogens associated with CAUTI (combining both ASB and SUTI) in hospitals reporting to NHSN between 2006- 2007 were : 1 1 1 Escherichia coli (21.4%) Candida spp (21.0%) Enterococcus spp (14.9%) Pseudomonas aeruginosa (10.0%) Klebsiella pneumoniae(7.7%), and Enterobacter spp (4.1%). A smaller proportion was caused by other gram-negative bacteria and Staphylococcus. Care of People with Communicable Diseases 17 CAUTI Education, Training and Competence Assessment Educate staff on the preventive measures of catheter-associated urinary tract infections (CAUTIs) in the orientation program and the in-service refresher training Ensure health care personnel, who involve in urinary catheter care, are trained and competent to perform the procedure with aseptic technique Keep an updated written Standard Operating Procedures (SOP) on urinary catheter care Provide clear instruction to patients and carers on proper care of urinary catheter and drainage system Twoo : #FIFTYo f ffoley → bladder s c a n Care of People with Communicable Diseases 19 CAUTI # F¥f¥¥tt Avoid Unnecessary Urinary Catheterization Limit the use of indwelling urinary catheter to patients with strong clinical indication and that the benefits outweigh the risks of CAUTI and its complications - It#EEK Do not use indwelling urinary catheter for the following purposes:  as a means to obtain urine specimen when the patient can void voluntarily, e. use “cath once” instead  as a substitute for nursing care in incontinent patients or terminally ill patient, i.e. may consider to use external catheter https://www.youtube.com/watch?v=LKlviGOZIn8 Care of People with Communicable Diseases 21  CAUTI Evidence has shown that use of bedside ultrasound to assess post-voiding residual volume can prevent a significant proportion of patients from unnecessary catheterization Efforts should be initiated to train doctors and nurses to use bedside ultrasound ¥¥IAtExH#the https://www.youtube.com/watch?v=UOhbMih33fY (female) https://www.youtube.com/watch?v=Z6ASnzmBXwE (male) Care of People with Communicable Diseases 22 CAUTI w e a r gloves Shorten the Duration of Indwelling Urinary Catheterization Establish a system to ensure the urinary catheter is removed promptly when it is no longer indicated Document the indication clearly Assess and document the indication for continuous urinary catheterization on daily basis Renewal order is required for continuous catheter use and must be documented in the patient’s record Care of People with Communicable Diseases 23 CAUTI Proper Hand Hygiene and Using of Gloves Perform hand hygiene immediately before and after urinary catheter care Wear gloves when there is potential risk of body fluid contamination Change gloves between patients to prevent cross-infection Care of People with Communicable Diseases 24 CAUTI Aseptic Urinary Catheter Insertion Ensure the catheter is inserted by trained and competent persons Maintain aseptic technique for catheter insertion Use sterile equipment and supplies: use single-use packet of sterile lubricant jelly, sterile urinary catheter, sterile bloodclot gloves and sterile drape Use appropriate antiseptic solution to clean the peri-EEK DF r n o. urethral skin thoroughly before insertion normalF r I.l-14 ¥¥&#Di fn o contraindication#n'¥ E Minimize the risk of urethral trauma. Use the smallest possible size, good drainage urinary catheter unless otherwise clinically indicated Ensure the catheter is always firmly secured to prevent in-and-out movement (stablise the catheter on inner thigh or lower abdomen) and urethral traction, i.e. never hang the urine bag on the bedside rail X Care of People with Communicable Diseases 25  CAUTI Maintain Unobstructed Urine Flow Prevent kinking or sagging of the urinary catheter to ensure unobstructed flow of urine Prevent retrograde flow of urine from collection bag to the bladder Keep the drainage bag below the level of bladder. The outlet should never rest on the floor Clamp the drainage tube before raising the drainage bag above bladder level Do not allow the drainage bag to be overfilled Care of People with Communicable Diseases 26  CAUTI Maintain a Sterile and Closed Urinary Drainage System Minimize opening and manipulating the catheter and the drainage system. Do not re-use the drainage bag Aceptic Care of People with Communicable Diseases 27  Use a designated urine-collecting container for each patient during emptying the drainage bag Disinfect the outlet of the drainage bag with alcohol before and after each opening Prevent the outlet of drainage bag from touching the collecting container while emptying Perform hand hygiene and wear clean gloves for the procedure. Gloves should be removed and hand hygiene should be performed immediately afterwards Disinfect the container and keep it dry after each use https://www.youtube.com/watch?v=XPyR9HU-nb4 Care of People with Communicable Diseases 28 Changing of urinary bag: Change the urinary drainage bag in line with manufacturer’s recommendation and when the urinary catheter is changed or the bag leaks ¥ supplyw HE A. Follow manufacturer’s recommendation on changing of catheter valve (not available in HK) Disinfect (by alcohol swab/wipe) the catheter-tubing junction before disconnecting the drainage system Care of People with Communicable Diseases 29 CAUTI Good Meatal Care Use soap and water for the daily cleansing of the meatal area to maintain good catheter-urethral interface hygiene Keep peri-urethal area clean and dry Remove gross debris from the catheter tubing during bathing or showering Additional cleansing is indicated for patients with diarrhoea or incontinence Care of People with Communicable Diseases 30 CAUTI Aseptic Urine Specimen Collection Apply aseptic technique; perform hand hygiene and wear clean gloves for the procedure To collect small volume urine sample or urine for culture:  Disinfect the sampling port or distal end* of the urinary catheter with appropriate disinfectant (70% alcohol) and allow time (>30 seconds) for the disinfectant to work before puncture.  https://www.youtube.com/watch?v=0xT5mfWrW_I Inner lock Inner slip 0 \ takesample Care of People with Communicable Diseases 31 Intravascular catheter related infection Care of People with Communicable Diseases 32 General aspects https://www.youtube.com/watch?v=8YrK0_KIdsM Hand hygiene Aseptic technique 70% alcohol for peripheral line insertion Chlorhexidine based preparation is preferred for central line insertion Care of People with Communicable Diseases 33 Catheter and site care Use sterile gauze or transparent dressings to cover the catheter site The choice of materials of transparent dressings should prefer increased durability, improved security of the catheter, visibility of the wound site, provision of an effective barrier to micro-organisms or increase the rate of evaporation of fluid A gauze dressing is preferred if the site is bleeding, oozing Change dressings at least weekly or when clinically indicated (removal or replacement of catheter; damp, loosened or visibly soiled dressings) Secure the catheter after insertion Do not apply topical antibiotic ointment or creams to the catheter insertion site except for dialysis catheters + i s antibioticoilmentpveve currency Remove the catheter when it is no longer used nt.ve o f H¥¥¥h¥ In#12M¥ → off inflammatory i n ve i n Care of People with Communicable Diseases 34  # " higher standard Care of specific catheters Central venous catheter (CVC), including peripheral central venous catheter , hemodialysis and pulmonary catheters. 5 key components Hand hygiene Maximal barrier precautions 2% i n70%alcohol Optimal catheter site selection, with jugular vein subclavian vein as the preferred site for non-tunneled catheters Daily review of line necessity, with prompt removal of unnecessary lines. ¥4 + infection rate it Care of People with Communicable Diseases 35  Use maximal sterile barrier precautions (including the use of cap, mask, sterile gloves, sterile gown and one large sterile drape) for insertion of central line Minimal numbers of ports and lumens of central venous catheters essential for infectionr a t e management of patients should be used 4 port 9 Replace gauze dressing every 2 days and transparent dressing every 7 days for short-term CVC. The risk of catheter dislodging should be weighed for changing of dressing in paediatric patients Routine replacement of intravascular catheters is not necessary if they are functioning and have no evidence of causing local or systemic (pink) complications Prepare skin with antiseptic chlorhexidine 2% in 70% isopropyl alcohol which has been proven to provide better skin antisepsis than other antiseptic agents such as povidine-iodine solutions "F * Care of People with Communicable Diseases 36 Intravascular catheter related infection Use ultrasound guidance to place central venous catheters (if this technology is available) to reduce the number of cannulation attempts and mechanical complications. https://www.youtube.com/watch?v=5dIyh0kqKCs Care of People with Communicable Diseases 37  × clean HEY, ✓ DVT Peripheral Catheters and Midline Catheters In adults, use an upper-extremity site for catheter insertion Observe the catheter insertion site daily No need to replace short, peripheral venous catheter more frequently than every 72 -96 hours in adult Remove when no longer indicated, but if sites for venous access are limited, catheter can be maintained for longer period but close monitoring of insertion site is necessary. Leave the catheter in place until the therapy is completed. Care of People with Communicable Diseases 38  ¥¥Hk Remove the peripheral intravascular catheter if there is sign of phlebitis or malfunctioning Flush the peripheral intravascular lock or needle free device with normal saline for maintaining the patency and lowering the overall catheter-related complications though they are not necessarily infection related https://www.youtube.com/watch?v=AFn9-VyGslA Care of People with Communicable Diseases 39 Maintenance of administration sets Replace administration sets including extension tubing, add-on devices no more frequently than every 96 hours, unless Catheter Associated Blood Stream Infections (CABSI) is suspected or EH4E confirmed, but at least every 7 days. 4 - 7 Replace administration sets transfusing blood, blood products or lipid containing solutions after administration or within 24 hours Disinfect IV injection port, stopcocks, needleless intravascular device or heparin-block with 70% alcohol, 2% Chlorhexidine in alcohol preparation before access IV injection port: there have been reports of higher infection rate associated with the use of stopcocks. When stopcocks are to be used, cap all stopcocks when not in use https://www.youtube.com/watch?v=_S8JfTbZbdk Care of People with Communicable Diseases 40 Care of Infusate, IV Medication and Admixture lipid - containing solution Complete lipid-containing solutions within 24 hours of hanging the solution. Use single-dose vial of parenteral additive and medication as far as possible. Do not combine the leftover content of single-use vials for later use Disinfect diaphragm of the multidose vials with 70% alcohol before insertion. Do not use any parenteral fluid that has visible turbidity, containing particulate matter or container with leaks or cracks https://www.youtube.com/watch?v=gyHhpPeioes Care of People with Communicable Diseases 41  Needless intravascular catheter system Wipe the access port with an appropriate antiseptic and accessing the port only with sterile devices to minimize the risk of contamination Replace caps or the needleless system no more frequently than at 72- hour Replace needleless components at least as frequently as the administration set and ensure the components are compatible to minimize the leaks and breaks in the system Care of People with Communicable Diseases 42  Intravascular catheter related infection Promptly remove any intravascular catheter that is no longer essential When adherence to aseptic technique cannot be ensured (i.e catheters inserted during a medical emergency), replace the catheter as soon as possible, i.e, within 48 hours Scrub the hub with alcohol pad limit I V a c c e s s ftp.ff-ff infection signo f → otherwise × o f f Care of People with Communicable Diseases 43 Ventilator-associated pneumonia (VAP) Care of People with Communicable 44 Diseases  n¥424k¥ Ventilator-associated pneumonia (VAP) - overview Ventilator-associated pneumonia (VAP) is a term used to describe pneumonia (lung infection) that develops in a patient who has been on mechanical ventilation for more than 48 hours. → 4h11A t UA P = A ventilator is a machine that is used to help a patient breathe by giving oxygen through a tube placed in a patient’s mouth or nose, or through a hole in the front of the neck. Increased cost of care Increased mortality Care of People with Communicable Diseases 45 Ventilator-associated pneumonia (VAP) –overview (cont’d) Increased length of stay Increased patient care intensity for staff critical Higher facility resource utilization levels Substantially increased healthcare costs Care of People with Communicable Diseases 47  VAP-Clinical manifestation AS 7¥ FEE New or progressive infiltrates, consolidation, cavitations, or pleural Wm¥¥ effusion on chest radiographic examination and ¥¥ at least one of the following:  new onset of purulent sputum or change in character of sputum  increased temperature >38 degree Celsius  increased or decreased white blood cell count CBC  organisms cultured from blood  isolation of an etiologic agent from a specimen obtained by bronchial brushing or biopsy ¥E¥Ei¥u Care of People with Communicable Diseases 48  VAP prevention Infrastructure Establish VAP improvement team and develop a protocol for prevention Promote use of noninvasive ventilation "house ETHIIITY.ie/ sangwmtotptes.me sesFhe Establish adequate professional manpower to facilitate quality care invasive mechanical ventilation non-invasive Care of People with Communicable Diseases 49 VAP prevention Staff training Staff orientation and refreshment program Adequate coaching and supervision Educate acute care doctor on non-invasive ventilator strategies invasive off → non-invasive → Care of People with Communicable Diseases 50  VAP prevention Shorten the duration of intubation and invasive ventilation Care of People with Communicable 51 Diseases  VAP prevention Shorten the duration of intubation and invasive ventilation FH5E, musades relaxing ② 44ft Avoid continuous use of paralytics as far as possible as paralytics may prolong the duration of ventilation and increase the incidence of VAP t¥¥¥¥ ①I t t Ensure appropriate dosage of sedation or narcotics is prescribed. Consider use of sedation scale to avoid over-sedation Interrupt or lighten sedations daily at an appropriate time to assess patient’s readiness for extubation Wean patient off invasive ventilation as soon as possible Prevent unplanned extubation, e.g. patient self-extubation Care of People with Communicable Diseases 52 VAP prevention Basic principles on preventing contamination Apply appropriate infection precautions to prevent patients from exposure to potential nosocomial pathogens Practice of standard precaution should be observed Perform hand hygiene before and after performing respiratory care such as, manipulation of ventilator circuits or tracheal tube Wear clean gloves when contact with respiratory secretions is anticipated. Gloves should be changed between patients Care of People with Communicable Diseases 53 VAP prevention Tracheal tube intubation Maintain aseptic technique in the whole intubation procedure. Mask and gloves should be worn. Insert endotracheal tube via oral route when there is no contraindication. Compared with nasal-tracheal intubation, orotracheal intubation is associated with low risk of sinusitis and VAP > 1¥ Care of People with Communicable Diseases 54 VAP prevention Perform tracheal suction properly Perform suction only when indicated. Avoid routine suction. p m The depth of suction catheter insertion should be measured beforehand. Care should be taken to suction pressure to avoid damaging the respiratory mucosa. Perform suction with aseptic technique. The type of suction systems, open or closed, makes no difference in the incidence of VAP The advantage of closed suction method is that there is no dissemination of aerosols. Care of People with Communicable Diseases 55 VAP prevention When open tracheal suction method is used: Use a sterile, single-use suction catheter. Perform hand hygiene before wearing gloves It is preferable to use sterile gloves than clean gloves for endotracheal suction IF clean gloves are used, ensure the sterility of inserted part of suction catheter is maintained When a suction catheter is blocked by secretions, it is preferable to discard it and use a new suction catheter https://www.youtube.com/watch?v=HHrNk4sJUqQ Care of People with Communicable Diseases 56 VAP prevention dailyTIE When closed suction method is used: Wear clean gloves Change the in-line suction catheter following manufacturer’s recommendation or when the suction catheter is visibly soiled. htt o t e com atch v oeh F )system = close section × ¥ 1 aerosol Care of People with Communicable Diseases 57 VAP prevention Care of the respiratory care equipment Ensure the policies and practices for disinfection, sterilization, and maintenance of respiratory equipment are aligned with evidence-based standards. Disposable (usually) Care of People with Communicable Diseases 58 VAP prevention Develop maintenance care incorporated with infection control principles: Allocate individualized respiratory equipment for each patient as far as possible Provide a new set of disposable or high level disinfected ventilator tubing for each patient Change ventilator tubing when it is visibly soiled Use sterile water to fill the humidifier of ventilator. It is an acceptable option to set up a closed water-refilling system to minimize manipulation of the humidifier system Change suction collection canisters and tubing between patients Care of People with Communicable Diseases 59  VAP prevention Handle and store disinfected respiratory equipment or sterile items properly to preserve its sterility Check the expiry date and inspect the package of sterile respiratory items before use Dude Ensure the disinfected respiratory ① sputum , equipment (e.g. nebulizer) is not re- trapk¥2× active contaminated during rinsing process. Sterile water should be used Care of People with Communicable Diseases 60 VAP prevention Prevent condensate from ventilator circuits drain toward the patients Position the ventilator’s humidifier below the bed level to prevent condensation from draining toward the patients. Drain the condensate from ventilator tubing to water traps periodically Always drain ventilator tubing and remove oral secretion before repositioning patient HEY I clear Care of People with Communicable 61 Diseases  ¥ suction VAP prevention # off other secretion 1417 5¥ Prevent leakage of subglottic secretion into the lower airway Maintain the tracheal tube cuff pressure adequately to prevent the leakage of secretion into the lower airway If chec k Ensure oral and subglottic secretion is cleared before tracheal cuff deflation suction first Consider use of subglottic drainage endotracheal tube and tracheostomy tube for selected eligible patients Care of People with Communicable Diseases 62  VAP prevention Prevent aspiration Place the ventilated patient in semi-upright position between 30 and 45 degrees, especially during feeding and transport, unless there is contraindication Verify the gastric tube is in proper position every time before feeding Adjust the rate of tube feeding carefully according to individual’s tolerance to prevent gastric over-distention Consider use of gastrostomy tube feeding for long-term ventilated patient as it is associated with lower risk of aspiration 74TH Adjust the heated humidifier setting to provide optimum airway humidification. The inspired gas should be warmed to achieve physiological body temperature of 37°C and physiological humidity Care of People with Communicable Diseases 63  $ ! VAP prevention Proper humidification of the inspired gas – HME (Heat and Moisture exchanger) Though there is no significant difference in the incidences of VAP in patients among the HME and humidifier However, HME can be considered an acceptable option because it is easier to use, and it can save manpower and thus reduce the healthcare cost Make sure the patient has no contraindications when using heat moist exchanger Change an HME when it becomes visibly soiled Do] ARDSc a s e hard Care of People with Communicable Diseases 64 VAP prevention 1¥11 → § bacteria ✓oral c a r e Provide oral care to ventilated patients Include oral care as a part of standard ventilator care protocol. Poor oral hygiene may increase the risk of VAP Implementation of oral care can be facilitated with oral care kits Consider use of antiseptic oral rinse such as 0.12% Aq. Chlorhexidine at set interval × allergyt o asprineX I I I.I I I Care of People with Communicable Diseases 65 Infection control in Dialysis Unit (腎臟透析中心) AMR operation theater Care of People with Communicable 66 Diseases NC17 renal failure  ¥u opposite direction , 4 f i trationale artery4h 1. 2. 3. v e i n1 1 Care of People with Communicable Diseases  ttCwminH% Peritoneal Dialysis tH t test HE 1¥ warm? 711L 1 0m i n Diffusion. ~ x vo r te x - n o w a s t eproduct 2. 5-10 minutes for 2-3L 1. 3. 10-20 minutes d isc Andy * ¥44 : ' 2-31%111-4 4 ① claim-4% pt ft time#filter w a s t e ②flush4 ¥ ③a s k Care of People with Communicable Diseases ④ 44stop441¥ → ¥7174 Ultra bag flush That " APD Hk * locka l lthings pie"E → ¥4ufc→µ Infection in Dialysis Unit Infection related to hemodialysis (洗血) system Infection related to vascular access Infection unique to dialysis unit - aqueous environment Care of People with Communicable Diseases 70 Preventing Bloodstream Infections in Outpatient Hemodialysis Patients https://www.youtube.com/watch?v=_0zhY0JMGCA oppositdirection e 4 titrationr a t e Care of People with Communicable 71 Diseases Bacterial growth in water used for HD Depends on: The source of water The water treatment system The distribution system The dialysis machine The disinfection method Care of People with Communicable Diseases 72 Water Treatment System Disinfection of dialysis systems can be done by using sodium hypochlorite 1% , 4% formaldehyde, hydrogen perioxide…etc Sample of source water obtained and cultured at least monthly Care of People with Communicable Diseases 73  " Infection related to vascular access Migration of patient’s own skin flora on the outer catheter surface Contamination of the catheter connector Lumen contamination during dialysis Common bacteria: staphylococcus aureus (AV fisula); and coagulase-negative staphylococci (with catheter) infection AVE A t graff artery← vein prevent N¥Io m Care of People with Communicable Diseases 74  bothI#vein just k¥1171 P¥MRsAk¥ I v blood clot Prevention ""¥ " " " HEHE 9 blood * : *. i t dexitsi.i flow tbIwd ×#antibiotic oiemmT e 1 rejection flow Do not use antimicrobial prophylaxis before insertion or during the use of the catheter artyconnect Not routinely replacing the catheter * withve i n Use sterile technique during the catheter insertion akoa.iq. only Atf AV Use the catheter solely for HD unless there is no other alternative e.g. no blood drawing xbpl.LV access Restrict catheter manipulation and dressing changes to trained personnel Disinfect skin before catheter insertion (by doctor) ✓ Ask j inni Replace catheter site dressing at each dialysis session or if damp, loose or Xffficathertax Care of People with Communicable Diseases 75 Measures to prevent vascular access related infection *A#t b The AV fistula is preferred over graft or catheter for hemodialysis Tunneled cuffed catheter is preferred as a temporary access or as a permanent access Appropriate disinfection of the vascular access prior to cannulation Apply aseptic technique, perform hand hygiene, implement maximal barrier precautions and best disinfect the site with 2% alcoholic chlorhexidine C vc Performed by trained personnel, hand hygiene, put on appropriate PPE and sterile dressing, secure catheter, keep dressing clean and dry Educate the patient on the proper access care Care of People with Communicable Diseases 76 HEYheartI T ← Hemodialysis associated infection Catheter- related bloodstream infection varies by catheter type, frequency of manipulation and patient-related factors ✓vaccine HBV HCV HIV Care of People with Communicable Diseases 78 Prevention Screen the HBV, HCV and HIV serological status to all patients before accepting in dialysis unit (baseline) Ongoing screening of patients at regular interval (yearly) Isolate HBsAg positive patient in a separate room with a dedicated machine and other equipment carrier € 2At-EPHIE Vaccinate all susceptible patient against hepatitis B Care of People with Communicable Diseases 80 Universal precaution PPE gloves × recapx Staff must wear fluid impermeable garment Gloves are to be used when there is a potential for exposure to blood or body fluid Gloves must be changed and hand hygiene between patient Protective eyewear and face shield for potential body fluid / blood splashing procedure No recapping of contaminated needles Care of People with Communicable Diseases 81 Peritoneal dialysis (洗肚) associated infection Exit site (Tenckhoff site) Peritonitis – staphylococcus aureus is the most frequent pathogen associated with infections in PD patients 1 ex i t s i t e ✓ r e c o m m e n d → ¥ I f AFE#¥E¥ am - ent Care of People with Communicable Diseases 82  # i Infection control Preventing exit site infection + infect r a t e A double cuff peritoneal catheter is preferred (evidence-based) e x i t site microorganis Avoid fresh water swimming, tub bath and public pools m Put on dressings when the exit site is likely to get directly or wet Albine I v benefitt o i m m u n e secure Enhance nutrition sysen → HEHE rat 4 e ①× - ② Care of People with Communicable Diseases 83 General exit site catheter 11 sit e Change of catheter dressing using aseptic technique Keep the exit site dry until well healed Cleanse exit site with 0.05% chlorhexidine or 0.9% normal saline daily doctor prescription Secure the catheter to prevent trauma to the exit site and traction on the cuffs Care of People with Communicable Diseases 84 Operating theatre (OT) Care of People with Communicable Diseases 85 Ventilation and environment in OT Buffer zone before the entry into the operating room Outer Zone Main access corridor, transfer area, changing facilities, reception area Clean/Semi restricted zone Corridor, recovery room, rest area Restricted zone Operation room, scrub sinks ¥1 sterile Reception Care of People with Communicable Diseases 86 Ventilation THEI' and environment in OT tt¥ XhE¥ × junction × microorganism Seamless wall and ceiling Sliding instead of swinging door should be used – not to disturb of laminar flow OT wall and ceiling spray with antibacterial paints Introduce the air at the ceiling and exhaust air near the floor https://www.youtube.com/watch?v=zvNEdUk5k0Q Care of People with Communicable Diseases 87 Ventilation high low and environment in OT pressure → pressure Positive pressure ventilation for operating rooms Maintain pressure gradient i.e. high to low From operating suite to the corridors Periodical checking HEPA air filter (high efficiency particulate air) At least 15 air changes per hour A-I I R : 12 Humidity at 30-60% Temperature 20-23C Care of People with Communicable Diseases 88  Surgical Attire and Drapes Wear surgical mask to fully cover mouth and nose Wear cap to fully cover head and face hair Surgical gowns and drapes should be sterile waterresistant and resistant to liquid penetration and Pate remain effective barriers when get wetted sink Scrubbed surgical team members should wear masks, caps, sterile gowns and gloves https://www.youtube.com/watch?v=MpwMnjQR41Y Care of People with Communicable Diseases 90 Operating suite Other personnel in the operating theatre should wear surgical masks Use sterile surgical drapes to create a barrier between the surgical field and the environment or potential source of bacteria Change surgical gowns and scrub suit if visibly soiled or penetrated by blood or body fluids Shoe covers are not necessary for prevention of surgical site infection Care of People with Communicable Diseases 91  Sterilization of Surgical Instruments All surgical instruments, especially those with long and narrow lumens, must be clean and decontaminated adequately before sterilization Theatre Sterile Supplies Unit (TSSU) process Heat resistant surgical instruments should receive steam sterilization. Heat sensitive instruments can use low temperature sterilization technology (not greater than 60°C), such as hydrogen peroxide plasma and ethylene oxide sterilization Laparoscopes, arthroscopes, cystoscopes and other scopes that enter normally sterile tissue should ideally be sterilized. When it is not feasible, they should at least be treated with high level disinfection after thorough cleansing Sterilitation i.t o o % disinfection : 99.99% Care of People with Communicable Diseases 92 Asepsis The principle of aseptic technique should be complied during operations, when inserting intravascular devices, administration of medication, or placing anaesthetic devices Sterile surgical instruments, medications and solutions should be assembled just prior to use Care of People with Communicable 93 Diseases Prevention of surgical site infection (SSI) Care of People with Communicable Diseases 94 Overview -SSI Surgical site infection (SSI) is the second most common health care- associated infection Surgical site infection accounts for 14% to 16% of hospital-acquired infections Reported surgical site infection rates ranged from 0.5% to 13%, depending on the type of surgery and patient characteristics Applying strategies for the prevention of surgical site infection help to reduce surgical patients’ morbidity, mortality and length of stay, and save cost for the healthcare institutions Care of People with Communicable Diseases 95  G U Thinfected fluid i n pus infected 1 inflammatory Preparation of Surgical Patients: Eradicate or control all infections remote to the surgical site before elective surgery whenever possible H 'Stix Screen patients for presence of hyper-glycaemia and implement protocol to adequately control the serum blood glucose level (less than 11.1mmol/L) peri-operatively and during the first 48 hours post-op) Educate the patients about the increased risk of smoking on postoperative surgical site infection and encourage patients to stop smoking or taking any tobacco consumption at least 30 days before the operation Maintain normo-thermia (core temperature of 36-38oC) peri-operatively in colorectal surgery patients + infection r a t e Ata, Ata, A., Lee, J., Bestle, S. L., Desemone, J., & Stain, S. C. (2010). Postoperative hyperglycemia and surgical site infection in general surgery patients. Archives of surgery, 145(9), 858-864. Care of People with Communicable Diseases 96 Preoperative Care of the Operation Site Remove hair only when it interferes with the operation. Perform hair removal immediately before surgery and preferably with a clipper Razors are not recommended. BUT controversial Educate and assist patients in taking shower wash or bath at least the night before the operation Preoperative showers reduce the skin’s microbial colony counts but studies did not show reduction in SSI rates Chlorhexidine is a more effective skin disinfectant and repeated applications with this agent may be indicated for cardiac thoracic and orthopaedic surgical patients with known MRSA in hospitals and units where there is a high incidence of postoperative wound infections by MRSA Inspect and clean gross contamination of skin at and around site Care of People with Communicable Diseases 97  ¥EE¥b X Care of People with Communicable Diseases 98 Preoperative Surgical Hand Preparation of Surgical Team Nails should be kept short. Artificial fingernails are prohibited. Rings, wrist-watch and bracelets should be removed before surgical hand preparation The design of sinks should reduce risk of splashes handwashing If hands are visibly soiled, wash hands with plain soap before performing surgical hand preparation. Debris from underneath fingernails should also be removed Care of People with Communicable Diseases 99 When using alcohol-based surgical handrub product, follow the manufacturer’s instructions and observe the following guidance: Apply alcohol-based product on dry hands only Use sufficient amount of product to keep hands and forearms wet throughout the procedure hands and forearms should be allowed to dry thoroughly before donning sterile gloves Do not combine surgical hand antimicrobial soap with alcohol-based surgical handrub sequentially Care of People with Communicable Diseases 100  # In Antimicrobial Prophylaxis Administer surgical antimicrobial prophylaxis as indicated, such as in some operations classified preoperatively as clean surgical wounds and clean- contaminated surgical wounds skin preparation Operations classified as contaminated or dirty surgical wounds are frequently receiving therapeutic antimicrobial agents preoperatively to treat related infections e.g. stab wound, gun shot wound, traumatic wound etc. They areFL4X not a¥hHtt surgical 4441 H regarded as surgical antimicrobial prophylaxis O n c a l l4 4411orderET1H = EH ¥T I K4 4 Relatively narrow spectrum antibiotics, such as Cefazolin and Cefuroxime are preferred in'€EE¥%%i ttp t On DO NOT use Vancomycin as a routine surgical antimicrobial n¥#medicine ¥IhOTEtt prophylaxis HE ×-f¥HthA Care of People with Communicable Diseases 101  # Postoperative Incision Site Care EH7open Cover the primarily closed clean surgical wound with sterile dressing and keep it intact for 24-48 hours postoperatively. If excess oozing is noted, the k¥3 active bleeding I I dressing should be replaced * call doctor¥ → call doctor f prescripti doi n cleanwound × chlorhexidine. → on Use normal saline to cleanse and remove surface bacteria and discharge from wound Perform hand hygiene before and after touching the surgical site or changing dressing Teach the patients and their carers how to care and monitor the incision site, signs and symptoms of surgical site infection and to report if any problems occur ptttnt.TT#nEEwumd Care of People with Communicable Diseases 102  * '¥414HERE#ZETA-MDR0 1 I E Antimicrobial resistance (AMR) is a broader term that encompasses resistance to drugs to treat infections caused by pathogens including bacteria, viruses, fungi and parasites. While all are significant to human health, the discussion will focus on resistance in bacteria that present an urgent or serious threat to public health It is estimated by the Organisation for Economic Co- operation and Development (OECD) that about 700,000 deaths may be caused each year by AMR globally. Morbidity and mortality caused by these strains of microorganisms are estimated to be two to three times those of the non-resistant strains Care of People with Communicable Diseases 103  # " " # " # " Action plan measure At Eh prevention 44E tdata :L Key Area 1: Strengthen knowledge through surveillance and research Objective 1: Enhance the existing antimicrobial resistance surveillance system antibiotic under One Health for Hong Kong man Hm Objective 2: Maintain laboratory capacity to support surveillance g. activities in both human and animal sectors Objective 3: Monitor antimicrobial use in humans and animals 4h54 nf¥antibiotic f : pt request ' I Iantibiotic ' Care of People with Communicable Diseases 104  # "¥ → Higa, / Iggy Key Area 2: Optimise use of antimicrobials in humans and animals Objective 4: Strengthen regulation on over-the-counter purchase of prescription-only antimicrobials Objective 5: Implement and enhance training in prescribing antimicrobials through Antibiotic Stewardship Programme in human health sector non-specific U R 7 2,E÷← 4 IF Objective 6: Monitor compliance with antimicrobial prescription guidelines of human health practitioners Objective 7: Ensure proper use of antimicrobials in animals Care of People with Communicable Diseases 105  infection control Key Area 3: Reduce incidence of infection through effective sanitation, hygiene and preventive measures Objective 8: Strengthen infection prevention and control measures in healthcare settings (Promotional activities on hand hygiene, e.g. annual Hand Hygiene Day, proper use of personal protective equipment and isolation of infectious cases etc.) Objective 9: Strengthen infection control training for healthcare workers (Acquire up-to-date knowledge, recognize the importance of infection control) Objective 10: Develop and strengthen infection prevention and control programmes in veterinary settings and along food supply chain Objective 11: Develop and strengthen surveillance and interventions to combat antimicrobial resistance in food Objective 12: Enhance vaccination uptake Care of People with Communicable Diseases 106  Key Area 4: Improve awareness and understanding of antimicrobial resistance through effective communication, education and training Objective 13: Raise awareness of antimicrobial resistance among general public, students and target population Objective 14: Engage patients in adopting infection control measures and proper use of antimicrobials Objective 15: Include AMR and related topics in school curricula and continuous training of human health and veterinary professionals nar row Key Area 5: Promote research on antimicrobial resistance spawn o f antibiotic Objective 16: Promote research on innovative technology and medical science Objective 17: Promote research on behavioural science and psychology Objective 18: Promote research on health and economic burden Objective 19: Promote research on the contribution of environment to the burden of AMR overseas stakeholders raise problem Key Area 6: Strengthen partnerships and foster engagement of relevant stakeholders Objective 20 Strengthen international partnerships and regional collaboration Objective 21 Inform public policy and facilitate stakeholder engagement Care of People with Communicable 107 Diseases  risk4 Va n t i n e : complication4 symptom 6 chance I  $ " " % 3- 2¥#syste m 7 -common update guild lines f o r doc tor infection# Jh ¥ centre h o m ef o relderly resendital wellW0K animal, f a r m× TENTHantibiotict o animals 'torspa.IE" a Methicillin-resistant staphylococcus aureus -MRSA and community acquired (CA)- MRSA 108  ! # Hospital Acquired Methicillin- resistant Staphylococcus Aureus HA-MRSA Staphylococcus aureus One of the most frequent bacterial pathogens Superficial infection: skin, and soft tissue infection Hospital: causes catheter-related infections group resistant ¥71 14 Methicillin-resistant Staphylococcus Aureus (MRSA) Methicillin  Introduced in 1961  Hospital acquired (HA)-MRSA was reported less than 1 year and cephalosporins ① Resistant to penicillinase resistant penicillins (e.g. methicillin, oxacillin, cloxacillin) enzymes distorybetalectom Nowadays, nosocomial pathogens throughout the world 109 Care of People with Communicable Diseases 109 Community acquired (CA)-MRSA Community Acquired (CA)-MRSA In 1982, MRSA was first reported outside hospital in Detroit In 2004, first reported in HK Carries less resistance genes as compared with HA-MRSA Cause deep infection: septic arthritis, osteomyelitis, pyomyostitis community Definition of CA-MRSA people with no history of the following risk factors within one year MRSA infection or colonization Hospitalization or surgery Permanent indwelling catheters or percutaneous medical devices Residence in a long term care facility Dialysis 110 Care of People with Communicable Diseases 110  ! ! Local Epidemiology Co1m1munity-asso,c iated methiicillin resistant Staphylococcus aureus infection CA-MRSA Infection 2007 173 6 916 300 2.5 Data not available 2008 282 6 957 800 4.1i Data not available 2009 368 6 972 800 5.3 Data not available 2010 495 7 024 200 7.0 Data not available 20 11 624 7 071 600 8.8 Data not available 2012 815 7150 100 11.4 Data not available 2013 990 7178 900 13.8 Data not available 2014 997 7 229 500 13.8 6 (0.60) 2015 1046 7 291 300 14.3 6 (0.57) 2016 1167 7 336 600 15.9 4 (0.34) 2017 1258 7 391 700 17.0 5 (0.40) 2018 1218 7 451 000 16.3 7 (0.57) 2019 1236 7 507 400 16.5 4 (0.32) 2020 810 7 481 800 10.8 7 (0.86) 2021 582 7 413 100 7.8 1 (0.17) 2022 416 7 346 1003 5.7 3 (0.72) Edit It 111  " Distinctive features of CA-MRSA Panton-Valentine Leukocidin (PVL) gene all CA-MRSA strains possess the gene allows the production of a necrotizing cytotoxin(capable of destroying human leukocytes and causing significant tissue damage) responsible for the invasiveness and virulence of the organism Exotoxinhkf.fi & Clinical Manifestation 98.4% skin and soft tissue infections danny Endo , present as boils, abscesses, or cellulitis - HK¥E¥yiµ less commonly, bacteremia surgical site infections high mortality hemorrhagic necrotizing pneumonias necrotizing fasciitis E¥ Ett¥ 112 Care of People with Communicable Diseases 112 Three-level of management & Preventive measures of HA-MRSA in healthcare settings Administrative controls Use of personal Environmental protective controls equipment 113 Care of People with Communicable Diseases 113 Management & Preventive Measures for HA- MRSA in Healthcare Settings Administrative control: 1. Assigning responsibility for MRSA infection control 2. Conducting a MRSA risk assessment 3. Developing and instituting a written MRSA infection-control plan 4. Ensuring the timely availability of recommended laboratory to the ordering physician; 5. Implementing effective work practices for the management 6. Ensuring proper cleaning and sterilization or disinfection 7. Training and educating health-care workers (HCWs) regarding MRSA 8. Performing surveillance for multidrug-resistant organisms incidence 114 Care of People with Communicable Diseases 114 Infection Control Precautions of HA-MRSA Environmental control Placed “contact precautions” and single room Cleaning and disinfection Wound covered → × contamination e n v Patient to clean hands Personal protective equipment Hand Hygiene Wear gowns and gloves when caring patient with MRSA Masks are not needed 115 Care of People with Communicable 115 Diseases References Ata, A., Lee, J., Bestle, S. L., Desemone, J., & Stain, S. C. (2010). Postoperative hyperglycemia and surgical site infection in general surgery patients. Archives of surgery, 145(9), 858-864 CHP (2007). Environmental control: Ventilation. Retrieved from http://www.chp.gov.hk/files/pdf/ventilation_advanced_draft.pdf CHP (2009) Prevention of sharps injury and mucocutaneous exposure to blood and body fluids. Retrieved from http://www.chp.gov.hk/files/pdf/prevention_of_sharps_injury_and_mucocutaneous_exposure_to_blood_and_body_flui ds.pdf CHP (2009) Recommendations on Prevention of Surgical Site Infection. Retrieved from http://www.chp.gov.hk/files/pdf/recommendations_on_prevention_of_ssi.pdf CHP (2010). Recommendations on prevention of intravascular catheter associated bloodstream infection. Retrieved from http://www.chp.gov.hk/files/pdf/recommendations_on_prevention_of_intravascular_catheter_associated_bloodstream _infection_r.pdf CHP (2010) Recommendations on prevention of catheter-associated urinary tract infection. Retrieved from http://www.chp.gov.hk/files/pdf/Recommendations_on_prevention_of_CAUTI.pdf CHP (2010) recommendations on prevention of ventilator associated pneumonia. Retrieved from http://www.chp.gov.hk/files/pdf/Recommendations_on_prevention_of_VAP.pdf Care of People with Communicable 116 Diseases