Module 2 Medical Asepsis / Infection Control

INFECTION Definition An infection is the result of an interaction between a susceptible hose and an infectious agent (bacteria, viruses, fungi, parasites) a clinical syndrome caused by the invasion and multiplication of a pathogen in the body.

Infections are: Localized Systemic

Course of Infection The course of an infection can be divided into four major phases: 1. Incubation 2. Prodromal 2. Period of Clinical illness 3. Convalescence

Transmission of Infections Health Care institutions can present a danger in infectious disease transmission Nosocomial infection - a hospital-acquired infection Iatrogenic infection – a direct result of treatments The health care system itself is another factor in infectious disease transmission. The public has a right to expect that the risk for acquiring an infection during hospitalization be minimal, however controlling hospital-acquired infections is a major health care problem. A nosocomial infection is one that a patient acquires while in a health care facility. The infections can be simple and uncomplicated, or major and life threatening. Patients are at risk for nosocomial infection because they often have weakened immune systems and because the health care facility contains patients and equipment that harbor infection. An Iatrogenic infection is the direct result of treatments.

Transmission of Infections Goal 4 of the National Patient Safety Goals (NPSG’s) is directed toward infection related sentinel events: “Preventing health-care associated infections”. Health care-associated infections are a serious problem and health care workers need to strive toward preventing the occurrence. When the transmission of infection is not properly controlled, a sentinel event could result. A sentinel event is an unexpected occurrence that leads to serious injury or death. Not all infections result in sentinel events, but health-care related infections are a serious problem. “In the United States, health care-associated infections occur in about one tenth of hospitalized patients, and about 90,000 patients die of such infections each year. Health care-associated infections are preventable.” (www.jointcommission.org).   To promote prevention of infection and control infection related sentinel events, the Joint Commission established a National Patient Safety Goals (NPSG’s) directly related to infection control. One goal is relevant to infection-related sentinel events: “Preventing health-care associated infections”. “The requirement of this goal is to decrease cases of unanticipated death or major permanent loss of functions associated with a health care-associated infection” (www.jointcommission.org).

Primary Defenses Against Infection 1. Skin and mucous membrane 2. Respiratory system 3. Gastrointestinal system 4. Circulatory system

Secondary Defenses Against Infection Inflammatory response Local reaction to an infectious agent Serves to localize, destroy, dilute, neutralize, remove a pathogen Signs – redness, heat, swelling and pain 2. Immune response Immunity is a measure of a person’ s ability to fight disease by forming immunoglobulins ( antibodies formed against invading antigens), or producing interferon.

Portal of exit from Reservoir Chain of Infection Source of infection Infectious agent Host Susceptibility Reservoir Portal of Entry to susceptible host Portal of exit from Reservoir Mode of transmission http://www.d.umn.edu/ehso/training/idp1.html

Components of the Infection Cycle Infectious agent—bacteria, viruses, fungi Reservoir—natural habitat of the organism Portal of exit—point of escape for the organism Means of transmission—direct contact, indirect contact, airborne route Portal of entry—point at which organisms enter a new host Susceptible host—must overcome resistance mounted by host’s defenses

Link 1 – Source of Infection /Pathogenic Organism What is the type of organism – virus, bacteria, fungi, parasites, etc. Level of virulence Number of organisms

Factors Affecting an Organism’s Potential to Produce Disease Number of organisms Virulence Competence of person’s immune system Length and intimacy of contact between person and microorganism

Question Which of the following is the most significant and commonly found infection-causing agent in healthcare institutions? A. Bacteria B. Fungi C. Viruses D. Mold

Answer Answer: A. Bacteria Rationale: Bacteria are the most significant infection- causing agents in the healthcare system. Bacteria can be categorized by shape, by their reaction to the Gram stain, or according to their need for oxygen. Fungi (molds and yeasts) can cause infection and are present in the air, soil, and water. Viruses cause infections including the common cold, and do not respond to antibiotics.

Link 2 - Possible Reservoirs for Microorganisms Other humans Animals Soil Food, water, milk Inanimate objects

Question Which one of the following infections or diseases may be spread by touching a contaminated inanimate article? A. Rabies B. Giardia C. E. coli D. Influenza

Answer Answer: D. Influenza Rationale: Influenza may be spread if a person touches a contaminated article and then touches his eyes or nose. The reservoir for rabies is animals; for Giardia, water; and for E. coli, water or food.

Link 3 - Common Portals of Exit Respiratory Gastrointestinal Genitourinary tracts Breaks in skin Blood and tissue

Link 4– Mode of Transmission Direct contact Droplets Vectors Airborne

Link 5 – Portal of entry to Host Eyes Mucous membranes Respiratory tract Placenta Breaks in the host barriers

Link 6 – Characteristics of the Host Lack of effective resistance Changes in host defense Tissue destruction

Factors Affecting Host Susceptibility Intact skin and mucous membranes Normal pH levels Body’s white blood cells Age, sex, race, hereditary factors Immunization, natural or acquired Fatigue, climate, nutritional and general health status Stress Use of invasive or indwelling medical devises

Factors Predisposing Patients to Nosocomial Infections Use of invasive medical devices Antibiotic-resistant organisms developed in hospitals

Measures to Reduce Incidence of Nosocomial Infections Constant surveillance by infection-control committees and nurse epidemiologists Written infection-prevention practices for all agency personnel Hand hygiene recommendations Infection control precaution techniques Keeping patient in best possible physical condition

Stages of Infection Incubation period—organisms growing and multiplying Prodromal stage—person is most infectious, vague and nonspecific signs of disease Full stage of illness—presence of specific signs and symptoms of disease Convalescent period—recovery from the infection

Question In which of the following stages of infection is the patient most contagious? A. Incubation period B. Prodromal stage C. Full stage of illness D. Convalescent period

Answer Answer: B. Prodromal stage Rationale: The patient is most infectious during the prodromal stage when early signs and symptoms of the disease are present but are often vague and nonspecific. During this stage, the patient often does not realize he or she is contagious and spreads the infection.

Body’s Defense Against Infection Body’s Normal flora Inflammatory response Immune Response

What are some examples of a Nursing Diagnosis? Risk for Infection RT: Chronic disease Altered immune response Effects of medication Altered skin integrity Lack of proper immunization

Planning / Goals The patient will: 1. demonstrate effective hand hygiene 2. identify the signs of infection 3. maintain adequate nutrition 4. demonstrate proper disposal of soiled articles.

Intervention

Infection Control Although it is impossible to ensure that the patient’s environment is free of microorganisms, there are many steps that a nurse can take to reduce the spread of microorganisms and thus promote safety for both the patient and the healthcare personnel. Maintaining the patients safety is of utmost importance!! One of the most important actions that a nurse can do is assist in preventing the spread of infectious microorganisms. Who is susceptible for acquiring an infection? The nurse who is exposed to many patients (patient to nurse); nurse to patient. What do you know about the patient’s resistance to infections??, nurse to co-worker,( telephone, B/P machine), patient to patient. Although it is impossible to ensure that the patients environment is free of microorganisms, there are many steps that a nurse can take to reduce the spread of microorganisms and thus promote safety for the patient and staff.

National Patient Safety Goal Reduce the risk of health care–associated infections. According to the Centers for Disease Control and Prevention, each year, millions of people acquire an infection while receiving care, treatment, and services in a health care organization. Consequently, health care-associated infections (HAIs) are a patient safety issue affecting all types of health care organizations.

Quality and Safety Education in Nursing (QSEN) The goal of QSEN is to address the challenge of preparing future nurses with the knowledge, skills and attitudes (KSA) necessary to continuously improve the quality and safety of the healthcare systems in which they work. They have 6 competencies and Safety is one of the main competencies.

Safety – Infection Control Infection control measures used in the hospital include: Medical Asepsis Standard Precautions Isolation Precautions Although it is impossible to ensure that the patient’s environment is free of microorganisms, there are many steps that a nurse can take to reduce the spread of microorganisms and thus promote safety for both the patient and the staff.   Infection control measures used in the hospital include: 1. Medical Asepsis 2. Standard Precautions 3. Isolation Precautions

Infection Control -- Medical Asepsis Definition: Practices designed to reduce the numbers of pathogenic microorganisms and limit their growth and transmission in the patient’s environment Medical asepsis, or clean technique, refers to practices designed to reduce the numbers of pathogenic microorganisms and limit their growth and transmission in the patient’s environment.

Why Practice Medical Asepsis Helps the patient fight a current infection and prevent its spread. Prevents the patient from being re-infected by the same pathogen. Prevents the patient from being infected with a new pathogen. 4. Prevents health care professionals and visitors who come in contact with the patient from being infected.

Helps decrease the chance of the patient acquiring a nosocomial infection. The infections can be simple and uncomplicated, or major and life threatening. Patients are at risk for nosocomial infection because they often have weakened immune systems and because the health care facility contains patients and equipment that harbor infection. The desired result is: to reduce the transmission of the microorganisms from one person to another. Or from one person to an object

Medical Asepsis – Hand Hygiene The first line of defense in medical asepsis is hand hygiene. Proper hand-hygiene is considered the single most effective way to stop the spread of microorganisms and preventing infection. Although the most effective preventive method of decreasing hospital acquired infections is hand washing, it is used inconsistently and sometimes is done inadequately. Both the Joint Commission and the Quality and Safety Education for Nurses (QSEN) project funded by the Robert Wood Johnson Foundation (RWJF) are striving to address the challenge of preparing future nurses with the knowledge, skills and attitudes necessary to continuously improve the quality and safety of the healthcare systems in which they work. One of the ways to accomplish this goal is to perform hand washing effectively.

Proper Hand Hygiene Assures: Reduction in the number of pathogens on the hands

Safety Check Prior to Hand washing Assess that the fingernails are short Highest concentration of organisms on the hands are found UNDER THE NAILS. Jewelry should be removed, especially rings with stones. Wedding bands may be worn sometimes. Skin is free of lesions If the skin should have a small lesion, bandage the area then double glove.

When Should You Wash Your Hands ? At the start of each shift After sneezing or coughing After using the bathroom After handling contaminated items Before and after giving patient care and between patients. After handling body excretions- even with gloves on

Before and after performing any treatments After removing gloves At the end of each shift before leaving the health facility

WASH YOUR HANDS !

Guidelines and Principles Hand-washing is one of the most effective methods of preventing the spread of bacteria. Usually 15 seconds should be allowed to wash the hands Clean from the cleanest area to the dirtiest area wrist Finger tips

Guidelines and Principles Medical Asepsis These 3 are necessary to remove microorganisms Do not touch the sink when washing hands – stand away Keep clean items separate from dirty ones. Turn off water with a dry paper towel – wet acts as a wick. 1. Friction 3. Cleansing Agent 2. Running Water

Guidelines and Principles Medical Asepsis Jewelry makes it difficult to adequately cleanse the hands. It is best to not wear jewelry in the clinical setting. Wedding bands are acceptable sometimes. If using hand lotion—allow hands to dry about 30 minutes before applying. Do NOT apply hand lotion immediately after washing hands.

Alcohol Based Handrubs Alcohol-based hand rubs (foam or gel) kill more effectively and more quickly than handwashing with soap and water. They are less damaging to skin than soap and water, resulting in less dryness and irritation. They require less time than handwashing with soap and water. Bottles/dispensers can be placed at the point of care so they are more accessible.

How to use Handrubs HAND RUB (foam and gel) Apply to palm of one hand (the amount used depends on specific hand rub product). Rub hands together, covering all surfaces, focusing in particular on the fingertips and fingernails, until dry. Use enough rub to require at least 15 seconds to dry.

Alcohol based handwash ALCOHOL-BASED HAND RUBS ARE MORE EFFECTIVE IN KILLING BACTERIA THAN SOAP AND WATER. Alcohol-based hand rubs (foam or gel) kill more effectively and more quickly than handwashing with soap and water. They are less damaging to skin than soap and water, resulting in less dryness and irritation. They require less time than hand washing with soap and water. Bottles/dispensers can be placed at the point of care so they are more accessible.

Infection Control Standard Precautions – Tier 1 Standard Precautions are: Those precautions designed for the care of all patients in hospitals regardless of their diagnosis or presumed infection status. Standard Precautions are a set of guidelines developed by the Centers for Disease Control and Prevention (CDC) for preventing contact with potentially infectious blood or body fluids that may harbor diseases regardless of whether or not they contain visible blood.   The CDC spent several years researching, improving, and developing recommendations to protect health care providers, patients, and their visitors from infectious diseases. This intensive period of research resulted in Standard Precautions, a set of infection control guidelines that should now be utilized by all health care professionals for all patients.

Standard Precautions Set of guidelines developed by the Centers for Disease Control and Prevention (CDC) for preventing contact with potentially infectious blood or body fluids that may harbor diseases regardless of whether or not they contain visible blood

Standard Precautions are used for: All body fluids, secretions and excretions regardless of whether or not they contain visible blood Sputum, saliva Urine Feces Nasal secretions, tears Vomitus Spinal fluid/ cerebrospinal fluid Synovial, pleural, peritoneal , pericardial, amniotic fluid All moist body surfaces, mucus membranes Blood

Standard Precautions Used for all patient’s, not just those with known infections These precautions should be implemented whenever contact with potentially infectious material is anticipated. Used to protect the caregiver.

Components of Standard Precautions – Tier 1 Hand Hygiene Personal Protective Devices Gloves Mask, Eye Protection, Face Shield, Gown Respiratory Hygiene/ Cough Etiquette Avoid recapping of needles; dispose of sharp objects appropriately Handle Patient-care equipment appropriately Use adequate Environment controls Review room assignments

Hand Hygiene Hands must be washed after patient contact regardless of the use of gloves. Even if you wear gloves, wash your hands Gloved hands cannot be effectively washed.

Personal Protective Equipment PPE

Gloves Gloves can be used to avoid direct contact with infectious material Wear gloves to handle: Blood Body fluids Secretions, Excretions Contaminated items Change gloves before preceding to the next task, or touching non-contaminated items even on the same patient. Made of vinyl or latex -- vinyl are used if allergy to latex is present.

Mask, Eye Protection, Face Shield, Gown Masks provide barrier protection against splashes and sprays, and airborne droplets Masks come in various types depending on their permeability to airborne particles. Eye goggles or glasses and face shields provide barrier protection against splashes and sprays. Gown – should be water impermeable to provide barrier protection

Infection Control Patient-Care Equipment Handle equipment in a manner that prevents personal skin and mucous membrane exposure and cross contamination to other patient’s. Reusable equipment must be cleaned/ disinfected and reprocessed before using it in the care of another patient.

Environment Each hospital, clinic has procedures for care, cleaning, and disinfection of environmental surfaces. Spills of blood or body fluids need to be handled with special procedures.

Linen Handled in a way to prevent contamination of skin, mucous membranes, and clothing. Fold soiled linen with contaminated area to the inside. Do not shake. Hold away from body and place in appropriate bag and dispose of properly.

Sharp Objects Place all sharp objects in a puncture-proof container. Do not re-cap needles Immediately discard after use. Do not attempt to bend or break a needle before discarding. Throw away the whole thing.

Transmission-based guidelines Tier 2 Isolation precautions are utilized when: patients have a greater susceptibility to infection than others A patient or patient’s body fluids are a carrier of microorganisms that can easily be transmitted to other patients, family members, or health care workers.

Isolation Precaution Categories In addition to standard precautions, the CDC recommends three categories of transmission-based precautions. They include: 1. Airborne precautions 2. Droplet precautions 3. Contact precautions The fourth type of isolation is protective isolation.

Airborne Precautions Used when the organism is capable of remaining in the air for prolonged periods of time and can be transported in the air . Most common organisms are: Tuberculosis Chicken pox Measles Must wear a special particulate filter mask

A private negative air pressure room is used for patients needing airborne precautions. Negative air pressure rooms are used for patients needing airborne precautions Bring air into the room from the hallway and have a separate exhaust system. Outside the room is isolation cart that contains supplies needed to care for the patient and protects persons entering the room.

Caring for the patient in airborne isolation Personal Care - **Remember it is the disease that is being isolated, not the patient. Place linens in proper contaminated –waste container, and soiled paper towels in an isolation waste container. Food Service – disposable paper trays and disposable dishes that are discarded in proper isolation waste container. Do not put tray back on the food cart. Contaminated articles – according to agency policy, usually double bagged or color-coded waste bags to indicate contaminated waste.

Airborne Isolation All patients on airborne precautions should wear surgical masks when leaving the negative air pressure room for x-rays, tests, or procedures.

Droplet Precautions Organisms that can be spread by large- particle droplets. Examples of organisms include: Influenza Cold Meningitis Mumps Pertussis

Droplet Precautions Single rooms are preferable Patients with same disease can share the same room Standard surgical masks and gloves must be worn for anyone entering the patients room. Gloves should be worn anytime handling tissues or items contaminated with the respiratory secretions Keep visitors 3 feet from the infected patient.

Contact Precautions Purpose is to prevent the transmission of disease by direct or indirect contact Direct contact involves: Touching Bathing Skin-to-skin contact Indirect contact involves: Contact with inanimate objects – doorknobs, light switches, tabletops, telephones Examples of diseases are: staph, herpes, diphtheria, and many others

Contact Precautions Contact precautions include use of barrier precautions such as gloves and impermeable gowns to prevent direct contact with infectious organism Used: With patients who are infected by a multi-drug resistant organism (MDRO) For patient with diarrhea When coming into contact with draining wounds Patients with acquired antibiotic resistance infections

Contact Precautions Place the patient in a private room if possible Wear PPE when entering the room for all interactions that may involve contact with the patient or contaminated areas in the patient’s environment Remove PPE before leaving the room and perform hand hygiene Avoid sharing patient-care equipment

Critical Thinking - Ask Yourself You have gone in Mr. A.’s room to perform a dressing change. What type of isolation is he in? What equipment would you use? A. Gloves only B. Gloves and gown C. Gloves, gown, and mask

Protective / Strict Isolation Used with patients who are immunocompromised such as: Chemotherapy AIDS Organ transplants

Review: Match the Following: __ Influenza __ Diarrhea __ Tuberculosis __ AIDS __ Chicken pox __ Draining wound __ Chemotherapy pt’s A. Airborne B. Droplet C. Contact D. Protective / Strict

Review: Mrs. B. is on airborne isolation. What specific equipment is used in airborne isolation that is not used in other types of isolation?

Review: When would the nurse apply goggles or a face mask?