Maureen Spencer, RN, M.Ed., CIC Infection Control Coordinator Healthcare Associated Infections (HAI) and the Infection Control Precaution Manual Update Maureen Spencer, RN, M.Ed., CIC Infection Control Coordinator

Elements of Performance for IC.3.10 Standard IC.3.10 Based on risks, the hospital establishes priorities and sets goals for preventing the development of health care-associated infections within the hospital. Rationale for IC.3.10 The risks of HAIs within a hospital are many, while resources are limited. An effective IC program requires a thoughtful prioritization of the most important risks to be addressed. Priorities and goals related to the identified risks guide the choice and design of strategies for infection prevention and control in a hospital. These priorities and goals provide a framework for evaluating the strategies.

Elements of Performance for IC.3.10 1. Priorities are established and goals related to preventing the acquisition and transmission of potentially infectious agents are developed, based on the risks identified. These goals include but are not limited to the following: 2. Limiting unprotected exposure to pathogens throughout the hospital 3. Enhancing hand hygiene 4. Minimizing the risk of transmission of infections associated with the use of procedures, medical equipment, and medical devices

Centers for Disease Control (CDC) Definitions of HAI Surgical Site Infection (SSI) Urinary Tract Infection  Pneumonia Bacteremia (primary) Gastrointestinal System Infection Cardiovascular System Infection Other Other infections include skin infection (other than incisional wound infection), lower respiratory tract infection (excluding pneumonia), eye, ear nose, throat, and mouth infection.

Risk Factors and Surgical Infections The strength of the association between potential risk factor, or the composite risk index, and a patient’s risk of developing a SSI was summarized by Culver, et al. SSI rates ranged from 1.5 SSI’s per 100 operations for patients with none of the risk factors, to a high of 13.0 for patients with all 3 risk factors present. The presence of each additional risk factor nearly doubles the SSI risk . Patients who develop surgical site infections are sixty percent more likely to spend time in an ICU, five times more likely to be readmitted to the hospital And have twice the incidence of mortality

Significant Changes - 2004 New Hand Hygiene Policy MRSA – changed to 3 negative cultures from nares obtained on three separate days VRE – changed to 3 negative rectal/stool cultures obtained 3 separate days New Precaution Signage Elimination of Contact “C” for Clostridium difficile and Contact “V” for VRE. Both are included in the category of Contact Precautions. Droplet Precautions includes Sudden Acute Respiratory Syndrome (SARS)                Revised - Employee Health Program, Blood & Body Fluid Exposure, Pregnant Workers and Communicable Diseases

Categories of Precautions Techniques depend on the mode of transmission Modes of Transmission: Direct contact with blood and bodily fluids (HIV, HBV) Indirect contact with contaminated items and patient care equipment and the environment (MRSA, VRE) Droplet nuclei (Influenza) Airborne route (TB) Vector (West Nile Virus)

Categories of Precaution Techniques Standard Contact Droplet Airborne

Precautions are used for both colonized and infected patients Colonization: The complex process of new organisms becoming a part of the endogenous flora of an area of the body with no signs of active infection Infection: The presence of signs and symptoms of a host/pathogen response (fever, drainage, cough, purulence, inflammation, etc.)

Standard Precautions Applies to everyone Hand washing Gloves, masks and gowns when deemed necessary to protect you Cleaning patient care equipment between patient use Environmental controls Careful handling of linen Appropriate patient placement

Precaution Materials *Precaution Gowns *Vinyl Gloves *Masks *N95 Respirators *Private Room *Precaution Cart *Signage – new Red signs *Dedicated Equipment (stethoscope, sphgmanometer, commodes) *Cal Stat Alcohol Hand Rub *Red Bags for Infectious Waste Disposal

Contact Precautions Contact - MRSA, VRE, C.Difficile, Abscess, Cellulitis, Herpes Zoster, Impetigo, Staph aureus wound infections, Streptococcus wound infections - Significant fecal incontinence No longer Contact V and Contact C

Contact Precautions Techniques Gloves for EVERYONE entering the room – including physicians, visitors, family members

Contact Precautions Gown if you will touch or be close to the patient’s bed (within 3 feet of the bed) Mask is only indicated if you are likely to be sprayed or splashed during irrigation or suctioning

Contact Precautions Techniques Inside the Room: Covered linen hamper Red lined trash container Cal Stat Alcohol Hand Rub Stethoscope and Blood Pressure Equipment Disposable Thermometers Red Bags for disposal of contaminated dressings and items used in patient care

MRSA contamination in precaution rooms Ref: Boyce, Infec Cont Hosp Epid 1977 70% of rooms had environmental contamination when the patient was colonized or infected 42% of nurses’ gloves cultured were contaminated after touching environmental surfaces WITHOUT touching the patient! Ref: Boyce, et. Al. SHEA 1998 Abstract Results: 14 (40%) of 35 HCWs gowns were culture + for MRSA on exiting room. Clothing underneath was negative. 11 (69%) of 16 HCWs wearing freshly laundered lab coats had detectable contamination. 3 of 11 developed positive hand cx after touching the coat.

Lab Coats, Stethoscopes, Otoscopes, Gloves, Gowns, Pagers, Cell Phones – contamination with Staph aureus, MRSA and VRE Infect Control Hosp Epidemiol. 2001 Sep;22(9):560-4. Contamination of gowns, gloves, and stethoscopes with vancomycin-resistant enterococci. Zachary KC, Bayne PS, Morrison VJ, Ford DS, Silver LC, Hooper DC. Infectious Disease Division Massachusetts General Hospital, Boston RESULTS: VRE were isolated from at least 1 examiner site (gloves, gowns, or stethoscope) in 33 (67%) of 49 cases. Gloves were contaminated in 63%, gowns in 37%, and stethoscopes in 31%.   J Hosp Infect. 2001 Aug;48 Suppl A:S64-8. Stethoscopes and otoscopes--a potential vector of infection? Cohen HA, Amir J, Matalon A, Mayan R, Beni S, Barzilai A. RESULTS: All the stethoscopes and 90% of the otoscope handles were colonized by microorganisms. Staphylococci were isolated from 85.4% of the stethoscopes and 83.3% of the otoscopes, with 54.5% and 45.2% respectively being S. Aureus. Methicillin-resistant S. aureus were found in four each of the stethoscopes (7.3%) and otoscopes (9.5%) Docs' Cell Phones May Spread Hospital Infections - screened 124 hospital personnel for the germ Acinetobacter baumannii - 12 percent of healthcare providers' cell phones were contaminated with the bug not only on phones but also on 24 percent of the hands of the people tested, who included 71 physicians and 53 nurses. Infect Control Hosp Epidemiol. 2002 May;23(5):274-6. Bacterial contamination of hospital pagers. Singh D, Kaur H, Gardner WG, Treen LB. Microorganisms were isolated from all pagers; 21% yielded Staphylococcus aureus, of which 14% were methicillin resistant. Cleaning with alcohol reduced the total colony count by an average of 94%.

Infect Control Hosp Epidemiol. 2003 May;24(5):362-86 Society of Hospital Epidemiologist of America guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and enterococcus. CONCLUSION: Active surveillance cultures are essential to identify the reservoir for spread of MRSA and VRE infections and make control possible using the CDC's long-recommended contact precautions.

Discontinuation of Precautions for MRSA Three negative surveillance cultures from nares obtained on separate days Patient must be off mupirocin and antibiotic therapy for MRSA One negative cultures from original site of infection (urine, wound, g-tube, sputum, etc.)

Discontinuation of Precautions for VRE Three negative surveillance cultures from rectal/stool specimen obtained on separate days Patient must be off antibiotic therapy for VRE One negative cultures from original site of infection (urine, wound, g-tube, sputum, etc.)

Droplet Precautions Influenza Meningitis - Hemophilus Meningococcemia Mumps Pertussis Rubella SARS

Droplet Precautions Private Room (does not have to be a negative pressure room) Masks for all entering the room

Airborne Precautions Pulmonary Tuberculosis Sputum AFP Positive Chickenpox Disseminated Herpes Zoster Measles

Airborne Precautions Negative Pressure Isolation Room created with the negative air filtration unit ordered from Facilities – checked by Facilities while in use ICU – Room 8 - is first room of choice then 519 if ICU bed unavailable N95 Respirator Door must be kept closed When transporting patient – place a surgical mask on during transport

DIRECT TRANSMISSION FROM HANDS MOST COMMON WAY DISEASE IS TRANSMITTED

Most Important Control Measure HAND HYGIENE Wash hands several times a shift – especially if you have had gloves on for more than 20 minutes – organisms multiply every 20 minutes

Use Cal Stat Alcohol Based Hand Rub

Hand Cultures – before and after the use of Cal Stat

Environmental Disinfection INTERMEDIATE LEVEL DISINFECTION STAT III TB disinfectant must be used in all Contact Precaution rooms to clean bedside equipment and environmental surfaces. PDI Sani Cloths are used for all other low level disinfection – they are bactericidal, virucidal, tuberculocidal (but will not disinfect Clostridium difficile)

In Summary….. Healthcare-associated infections are a major problem in hospitals Infection control measures, such as precaution techniques and hand hygiene have been shown to prevent the spread of nosocomial infections Follow department-specific infection control policies and procedures Report any problems immediately and…………