11/18/2018 INFECTION CONTROL Annual Review

Topics: OSHA Standards Isolation Review Multiply Resistant Organisms Emerging Pathogens JCAHO Patient Safety Goal #7 Bioterrorism 11/18/2018

OSHA STANDARDS Bloodborne Pathogens Tuberculosis 11/18/2018

Bloodborne Pathogens Hepatitis B Hepatitis C HIV 11/18/2018

Sharps Safety Devices Required by OSHA Designed to prevent needlestick and sharps exposures May include retractable needles, re-sheathing devices, or cover shields Selection of devices is partly based on input from the user. 11/18/2018

Sharps Safety Always wear gloves when handling sharps. Never bend, break or recap a needle. Activate the safety feature before disposal. Dispose of sharps into an approved container immediately, as close to the point of use as possible. Never force items into the container. EMS should replace the liner when 3/4 of the way full. 11/18/2018

Types of Exposures Blood-to-blood contact through a sharps or needlestick injury Splash exposure to mucous membrane or non-intact skin 11/18/2018

Exposure Protocol Immediately wash affected area with soap and water. Notify your supervisor and report to Employee Health ASAP. Off tours and weekends: Urgent Care (WP) Nursing Supervisor (BV). If known source, patient will be tested for HBV, HCV and HIV (informed consent required). 11/18/2018

Post-Exposure Prophylaxis Employee Health will evaluate the level of risk and determine the need for post-exposure prophylactic medication (PEP). If employee is not immune to HBV, a dose of vaccine or hepatitis B immune globulin may be appropriate. No PEP is indicated for Hepatitis C exposure. Must follow-up with Employee Health. 11/18/2018

Tuberculosis 11/18/2018

High-risk Groups HIV+ History of IV drug use Close contacts of a person with active TB Homeless people Residents of long-term care facilities, shelters, mental institutions, prisons Chest x-ray consistent with TB Immigrants or people born in high-prevalence areas 11/18/2018

Medical Factors Increasing the Risk of Active TB Diabetes Mellitus Silicosis >10% below ideal body weight Chronic renal failure Immunosuppressive therapy Hematologic disorders Other malignancies 11/18/2018

Symptoms of TB Fever and chills Night sweats Loss of appetite Unexplained weight loss Productive cough Bloody sputum Elevated WBC count 11/18/2018

How is TB Transmitted? Usually a pulmonary disease, transmitted through the air by tiny particles called droplet nuclei. Can be spread when a person with active disease coughs, sings, sneezes, laughs, etc. Healthcare workers are at higher risk due to possible exposure to sick patients. Appropriate isolation precautions must be followed. 11/18/2018

Airborne Isolation -TB Known or suspected cases should be placed in a negative pressure room. HCW must verify negative pressure Some outpatient areas have portable HEPA filter fans to be used prior to transfer. Respiratory Hygiene and Cough Etiquette: Instruct patient to cover his/her cough, or wear surgical mask. Employee must wear N-95 Particulate Respirator (fit-testing required by OHSU) 11/18/2018

TB Screening PPD skin test is the preferred method of screening. Required annually of all Medical Center employees. Required upon admission and annually for all long-term care patients. RNs must be trained to administer and interpret PPDs within the VA. 11/18/2018

Latent TB vs. Active TB A positive PPD skin test indicates that there was an exposure to TB at one time. Most cases of latent (inactive) TB never progress to active disease, but the skin test usually remains positive for life. Prophylactic treatment may prevent active TB from ever developing. 11/18/2018

Influenza Flu season is October through March. Vaccination is strongly recommended. No risk of getting the flu from the flu shot. Available for patients 10/15/03 Available for employees 11/1/03 Refer to Flu Plan in public drive. 11/18/2018

Isolation Precautions Standard Precautions - Use for all patients. All body fluids/substances considered potentially infectious. Use appropriate personal protective equipment (PPE). 11/18/2018

Personal Protective Equipment Gloves Gowns Masks Goggles Face Shield 11/18/2018

PPE - Gloves Wear gloves when contact with blood/body fluids, mucous membranes, or non-intact skin could occur. Change gloves when moving from a contaminated body site to a clean body site. Remove gloves after caring for a patient. Decontaminate your hands after gloves are removed! 11/18/2018

PPE - cont. Don PPE prior to patient contact Remove PPE at point of use, before leaving the area Observe proper technique to prevent contamination DECONTAMINATE hands after PPE removal 11/18/2018

Isolation Precautions Transmission - Based Precautions Airborne - TB, Chickenpox Droplet - MRSA pneumonia Contact - VRE, C. Difficile 11/18/2018

Contact Precautions Private room or cohort when possible. Private or designated bathroom. Wear gloves when entering room; other PPE as needed. Clean and disinfect all equipment before use with another patient. Hang stop sign outside door. 11/18/2018

Multiply Resistant Organisms MRSA VRE C. Difficile Other resistant organisms 11/18/2018

MRO-cont. Contact isolation - private room or cohort if necessary. Be aware of environmental contamination Target antibiotic therapy 11/18/2018

11/18/2018 At your hospital, what percentage of Staph aureus isolates are resistant to methicillin? <5% 15% 20% 30% >50% You can personalize this slide to an organism-drug combination that is a problem at your institution. 11/18/2018

Colonized or Infected: What is the Difference? 11/18/2018 Colonized or Infected: What is the Difference? People who carry bacteria without evidence of infection (fever, increased white blood cell count) are colonized If an infection develops, it is usually from bacteria that colonize patients Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers People who carry bacteria without evidence of infection are colonized. If an infection develops, it is usually from bacteria that colonize patients. Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers. ~ Bacteria can be transmitted even if the patient is not infected ~ 11/18/2018

The Iceberg Effect Infected Colonized 11/18/2018 The Iceberg Effect Infected Colonized This iceberg graphically represents colonization versus infection. Those patients that are infected with an organism represent just the “tip of the iceberg” of patients that are colonized or infected. Just because a patient is not infected, or showing signs of infection, does not mean that they do not carry organisms that could be transferred to another patient if proper hand hygiene and other infection control precautions are not taken. 11/18/2018

Vancomycin-Resistant Enterococcus (VRE) Most often associated with antibiotic use. Colonization is asymptomatic. Diagnosis can only be made with a VRE culture. Requires contact isolation and weekly specimens until there are three consecutive negative cultures. History of VRE-isolate on admission . No treatment for colonization. 11/18/2018

Recovery of VRE from Hands and Environmental Surfaces 11/18/2018 Recovery of VRE from Hands and Environmental Surfaces Up to 41% of healthcare worker’s hands sampled (after patient care and before hand hygiene) were positive for VRE1 VRE were recovered from a number of environmental surfaces in patient rooms VRE survived on a countertop for up to 7 days2 Many patients in the hospital acquire Vancomycin-Resistant Enterococci (VRE) from another patient, potentially via the hands of healthcare workers. In epidemiologic investigations of contamination of the hands of healthcare workers with VRE, up to 41% of hands sampled were positive for VRE. VRE has been recovered from a number of environmental surfaces in patient rooms, including patient and healthcare worker gowns, door handles, cabinets, floors, blood pressure cuffs, bed rails, urinals, bedpans, and toilet seats. In one study, VRE survived on a countertop for up to 7 days. 1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065. 2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581. 11/18/2018

The Inanimate Environment Can Facilitate Transmission 11/18/2018 The Inanimate Environment Can Facilitate Transmission X represents VRE culture positive sites In one study, hands of 131 healthcare workers (HCWs) were cultured before, and hands and gloves after, routine care. A mean of 56% of body sites and 17% of environmental sites were VRE positive. After touching the patient and environment, 75% of ungloved HCWs hands and 9% of gloved HCWs hands were contaminated with VRE. After touching only the environment, 21% of ungloved and 0 gloved HCWs hands were contaminated. The inanimate environment plays a role in facilitating transmission of organisms. ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. 11/18/2018

Clostridium Difficile (C. Diff.) Also associated with recent exposure to antibiotics. Symptoms usually include diarrhea and abdominal cramping. Recommended treatment is oral metronidazole (Flagyl) x10 days. Requires contact isolation until symptoms resolve (usually within a few days of treatment). 11/18/2018

Emerging Pathogens SARS West Nile Smallpox Monkeypox To be announced….. WWW.CDC.GOV 11/18/2018

JCAHO Patient Safety Goal #7 Reduce the Risk of Health Care-Acquired Infections CDC Hand Hygiene Guidelines Sentinel Events Related to Infections 11/18/2018

CDC Guideline for Hand Hygiene in Health-Care Settings Published in October 2002 Provides recommendations for hand hygiene among healthcare workers Addresses alcohol-based hand rubs (gel, foam, etc.) 11/18/2018

“Hand washing is generally considered to be the most important measure in preventing the spread of infection.” “Hands should be washed before significant contact with any patient and after activities likely to cause contamination.” 11/18/2018

So Why All the Fuss About Hand Hygiene? 11/18/2018 So Why All the Fuss About Hand Hygiene? Most common mode of transmission of pathogens is via hands! Infections acquired in healthcare Spread of antimicrobial resistance Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings. Hand hygiene reduces the incidence of healthcare associated infections. CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection. More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections. 11/18/2018

Definitions Hand hygiene Handwashing Antiseptic handwash 11/18/2018 Definitions Hand hygiene Performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis Handwashing Washing hands with plain soap and water Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub Rubbing hands with an alcohol-containing preparation Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis. Handwashing refers to washing hands with plain soap and water. Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts. Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent. Alcohol-based handrub refers to the alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms. Surgical hand hygiene/antisepsis refers to an antiseptic handwash or antiseptic handrub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora. Antiseptic detergent preparations often have persistent antimicrobial activity. 11/18/2018 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Definitions Hand decontamination Surgical hand hygiene/antisepsis 11/18/2018 Definitions Hand decontamination Performing handwashing using antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis Surgical hand hygiene/antisepsis Use antiseptic handwash or an alcohol-based handrub with persistance before operations by surgical personnel Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis. Handwashing refers to washing hands with plain soap and water. Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts. Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent. Alcohol-based handrub refers to the alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms. Surgical hand hygiene/antisepsis refers to an antiseptic handwash or antiseptic handrub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora. Antiseptic detergent preparations often have persistent antimicrobial activity. 11/18/2018 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Indications for Hand Hygiene 11/18/2018 Indications for Hand Hygiene When hands are visibly dirty, contaminated, or soiled, wash with non-antimicrobial soap and follow with decontamination using alcohol-based handrub if situation dictates; or use antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands. Healthcare workers should wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use an alcohol-based handrub when hands are not visibly soiled to reduce bacterial counts. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. 11/18/2018

Specific Indications for Hand Decontamination 11/18/2018 Before: Patient contact Donning gloves when inserting a CVC Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery Hand hygiene is indicated before: patient contact, donning gloves when inserting a central venous catheter (CVC), and inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery. Hand hygiene is also indicated after contact with a patient’s intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves. Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. 11/18/2018

Specific Indications for Hand Decontamination 11/18/2018 After: Contact with a patient’s skin Contact with body fluids or excretions, non-intact skin, wound dressings Contact with the environment/equipment in patient room/area Removing gloves Hand hygiene is indicated before: patient contact, donning gloves when inserting a central venous catheter (CVC), and inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery. Hand hygiene is also indicated after contact with a patient’s intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves. Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. 11/18/2018

Efficacy of Hand Hygiene Preparations in Killing Bacteria 11/18/2018 Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best. Antimicrobial soap Plain Soap Alcohol-based handrub 11/18/2018

Alcohol-Based Hand Rubs Require less time Can be strategically placed Readily accessible Multiple sites All patient care areas 11/18/2018

Alcohol-Based Hand Foam 11/18/2018 Alcohol-Based Hand Foam Dispense a golf ball-sized amount of foam, covering all surfaces of both hands, and rub in until dry. Preferred method of hand hygiene when hands are not visibly soiled. Before any invasive surgical procedure First wash – 5 minutes Subsequent washes – 3 minutes using an antimicrobial skin cleaner containing 4% chlorhexidine or povidone-iodine Surgical wash Before any nonsurgical procedures that require aseptic technique (such as inserting IV catheters) One minute using an antimicrobial soap or skin cleanser Aseptic procedures Before eating or smoking. After going to the toilet Before significant patient contact Before injection, venepuncture Before and after routine use of gloves After handling items soiled with blood or body substances 10 – 15 seconds using a neutral pH soap Routine hand wash 11/18/2018 Non-water cleansers or antiseptic products such as alcohol-based hand rubs or foam may be used when hand washing facilities are inadequate or in emergency situations where there may be insufficient time and/or facilities. If hands are visibly soiled a source of water should be sought. Hands should be washed as soon as an appropriate facilities become available. Add Notes Here:

Time Spent Cleansing Hands: one nurse per 8 hour shift 11/18/2018 Time Spent Cleansing Hands: one nurse per 8 hour shift Hand washing with soap and water: 56 minutes Based on seven (60 second) handwashing episodes per hour Alcohol-based handrub: 18 minutes Based on seven (20 second) handrub episodes per hour The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis. More rapid access to hand hygiene materials could help improve adherence. Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often. ~ Alcohol-based handrubs reduce time needed for hand disinfection ~ 11/18/2018 Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.

Summary Alcohol-Based Handrubs: What benefits do they provide? 11/18/2018 Summary Alcohol-Based Handrubs: What benefits do they provide? Require less time More effective for standard handwashing than soap More accessible than sinks Reduce bacterial counts on hands Improve skin condition In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster. In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition. 11/18/2018

Hand Washing (15 seconds of friction) 11/18/2018 Hand Washing (15 seconds of friction) Non-antimicrobial lotion soap: Use only to wash if hands are soiled or visbly dirty. FOLLOW WITH ALCOHOL-BASED HANDRUB IF HANDS NEED TO BE DECONTAMINATED! Antimicrobial soap: Use to decontaminate hands, clean hands when visibly soiled, and when caring for a patient with Clostridium difficile Before any invasive surgical procedure First wash – 5 minutes Subsequent washes – 3 minutes using an antimicrobial skin cleaner containing 4% chlorhexidine or povidone-iodine Surgical wash Before any nonsurgical procedures that require aseptic technique (such as inserting IV catheters) One minute using an antimicrobial soap or skin cleanser Aseptic procedures Before eating or smoking. After going to the toilet Before significant patient contact Before injection, venepuncture Before and after routine use of gloves After handling items soiled with blood or body substances 10 – 15 seconds using a neutral pH soap Routine hand wash 11/18/2018 Non-water cleansers or antiseptic products such as alcohol-based hand rubs or foam may be used when hand washing facilities are inadequate or in emergency situations where there may be insufficient time and/or facilities. If hands are visibly soiled a source of water should be sought. Hands should be washed as soon as an appropriate facilities become available. Add Notes Here:

Repeat procedures until hands are clean 11/18/2018 Routine Hand Wash Note: Hand and wrist jewellery including plain weddings bands should not be worn, as these are likely to increase the presence of gram negative bacilli Nails should be short and clean and artificial nails should be discouraged as they contribute to increased bacterial counts. Wet hands thoroughly with warm running water. Keep hands lower than elbows and apply soap. Use friction to clean between fingers, palms, backs of hands and wrists. 4. Rinse hands under running water until all soap is gone. DO NOT TOUCH TAPS WITH CLEAN HANDS – IF ELBOW OR FOOT CONTROLS ARE NOT AVAILABLE, USE PAPER TOWEL TO TURN TAPS OFF. 5. Pat hands dry with a clean, single use towel. A neutral soap should be used for routine handwashing. If liquid soap is dispensed from reusable containers, these must be cleaned when empty and dried before refilling with fresh soap – refilling soap containers is a potential source of infection. Where possible single use soap containers or bladders should be used. HANDWASH SOLUTIONS SHOULD NEVER BE TOPPED UP Scrub brushes should not be used for routine handwashing because they can cause abrasion of the skin, and may be a source of infection. Add Notes Here: 11/18/2018 Repeat procedures until hands are clean

Can a Fashion Statement Harm the Patient? 11/18/2018 Can a Fashion Statement Harm the Patient? ARTIFICIAL Studies have shown that hospital personnel with artificial nails harbor more potential pathogens both before and after handwashing than personnel with natural nails. Artificial nails contribute to nail changes that can increase the risk of colonization and transmission of organisms from HCWs to patients. Natural nail tips should be kept to ¼ inch in length. POLISHED NATURAL Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for high risk patients (ICU, OR) 11/18/2018 Edel et. al, Nursing Research 1998: 47;54-59

Artificial Nails Associated with outbreaks in healthcare due to bacterial and fungal contamination. Artificial nails are prohibited in high-risk areas; strongly discouraged for anyone providing patient care. No chipped nail polish. Natural nails should be kept less than 1/4 inch long. 11/18/2018

What is the Story on Moisturizers and Lotions? 11/18/2018 What is the Story on Moisturizers and Lotions? ONLY USE facility-approved and supplied lotions Because: Some lotions may make medicated soaps less effective Some lotions cause breakdown of latex gloves Lotions can become contaminated with bacteria if dispensers are refilled This slide provides an opportunity for the healthcare facility to insert a picture of the lotions used at their facility. ~ Do not refill lotion bottles ~ 11/18/2018

Surveillance Activities Line-related bacteremias Ventilator-associated pneumonia Surgical wound infections Resistant organisms- C. difficile UTIs in nursing home 11/18/2018

Surveillance- cont. Notify Infection Control of any increased incidence of infections. If you are sick, report to Employee Health before coming to work. Report to Infection Control any adverse patient outcomes related to infection. 11/18/2018

Sentinel Event All cases of unanticipated death or permanent loss of function associated with a health care-acquired infection. Notify Infection Control if you are aware of any cases. 11/18/2018

Bioterrorism 11/18/2018

All employees should be aware of the Hospital Bioterrorism Plan. 11/18/2018

Significant agents of bioterrorism Anthrax Smallpox Plague Tularemia Viral Hemorrhagic Fevers Botulism 11/18/2018

Anthrax Caused by bacillus anthracis bacteria May cause inhalational, cutaneous or gastrointestinal disease. Transmitted by inhaling or handling spores, but not transmitted person-to-person. Antibiotic treatment is necessary. 11/18/2018

Smallpox Caused by variola virus Last case identified in 1977; declared eradicated in 1980. Person-to-person transmission through contact or airborne route is likely. Smallpox vaccine is available, but only to be used if there is an identified risk. Treatment is supportive care. 11/18/2018

Smallpox Vaccine Made with vaccinia virus, another orthopox virus similar to variola. Causes the body to produce antibodies which protect against all orthopox viruses. This is a live virus vaccine, so the vaccination site must be cared for to prevent the virus from spreading. Many contraindications. 11/18/2018

Plague Bacterial infection that causes bubonic or pneumonic disease. Most commonly transmitted through infected fleas or infected animal tissues. Antibiotic treatment effective when administered early. 11/18/2018

Early recognition is the key! Fortunately, most illnesses caused by potential bioterrorist agents are treatable when promptly diagnosed. Early recognition is the key! 11/18/2018

When you suspect bioterrorist activity, immediately call the VA Police by dialing 2222! 11/18/2018

For more information on bioterrorism, see the Bioterrorism Module located on the public drive in the Infection Control Education folder. http://www.cdc.gov 11/18/2018

Questions? Contact Infection Control Wade Park: ext 4791/4792 Brecksville: ext 6571 11/18/2018