Chapter 5: Preventing infection

Learning objectives Discuss infection prevention, including the types of infections Describe the chain of infection Explain why the elderly are at a higher risk for infection Explain standard precautions Discuss hand hygiene, including when to wash hands Discuss the use of personal protective equipment (PPE) in facilities List the guidelines for handling equipment and linen Explain how to handle spills Explain transmission-based precautions Discuss bloodborne pathogens Explain OSHA’s bloodborne pathogens standard Discuss tuberculosis, including infection prevention guidelines Discuss MRSA, VRE, and C. difficile List the employer and employee responsibilities for infection prevention

Infection prevention Infection prevention Microorganism/microbe Infections Pathogens Localized infection Systemic infection Healthcare-associated infection (HAI) Signs and symptoms of localized infections Signs and symptoms of systemic infections Preventing infection is so important for both resident safety and NA safety. Infection prevention is a set of methods practiced in healthcare facilities to prevent and control the spread of disease. Microorganisms, or microbes, are living things or organisms that are so small that they can be seen only under a microscope. Microorganisms may cause infection, the state resulting from pathogens invading the body and multiplying. The microorganisms that cause infection and disease are called pathogens. If an infection is limited to a specific location in the body and has local symptoms, it is called a localized infection. An infection that is in the bloodstream and is spread throughout the body, causing general symptoms, it is referred to as a systemic infection. Healthcare-associated infections (HAI) are infections acquired within a healthcare setting during the delivery of medical care. It is important to observe and report the following signs and symptoms of localized infections: • Pain • Redness • Pus • Swelling • Drainage (fluid from a wound or cavity) • Heat It is important to observe and report the following signs and symptoms of systemic infections: • Fever • Body aches • Chills • Nausea, vomiting • Weakness • Headache • Mental confusion • Drop in blood pressure

The chain of infection Chain of infection Causative agent Reservoir Portal of exit Mode of transmission Direct contact Indirect contact Portal of entry Mucous membranes Susceptible host Infectious Medical asepsis Surgical asepsis The chain of infection is a way of describing how disease is transmitted from one living being to another. There are 6 links to the chain. The first is a causative agent, which is a pathogenic microorganism that causes disease. A reservoir is a place where a pathogen lives and grows. A portal of exit is any body opening on an infected person that allows pathogens to leave. The mode of transmission is the method of describing how a pathogen travels. Transmission can be through either direct or indirect contact. Direct contact is a way of transmitting pathogens through touching the infected person or his or her secretions. Indirect contact is a way of transmitting pathogens from touching something contaminated by the infected person. The pathogen must then enter another host through a portal of entry which is any body opening on an uninfected person that allows pathogens to enter. Mucous membranes, the membranes that line body cavities that open to the outside of the body, are common portals of entry into the body. There must be a susceptible host, an uninfected person who could get sick. Infectious diseases are contagious diseases. Healthcare workers practice medical and surgical asepsis to avoid transmission, or spread, of illnesses. Medical asepsis refers to practices, such as handwashing, that reduce, remove, and control the spread of microorganisms. Surgical asepsis is the state of being free of all microorganisms and is also called sterile technique. Remember: If even one link in the chain of infection is broken, the spread of infection is stopped. Handwashing is the most effective means of preventing the spread of infection.

Why the elderly are at a higher risk for infection Malnutrition Dehydration Factors that place the elderly at higher risk for infection The elderly are at increased risk for infection. Two of the reasons for this are malnutrition and dehydration. Malnutrition is poor nutrition due to improper diet. Dehydration is a serious condition resulting from inadequate fluid in the body. Other reasons why the elderly are at a higher risk for infection include: Weakened immune systems Decreased circulation Slow wound healing Limited Mobility Hospitalization Difficulty swallowing Incontinence Feediing tubes and other tubing Infections are more dangerous for the elderly because even a simple infection can lead to a life threatening one. The elderly also take longer to recover from an infection. For these reasons, it is important that NAs practice infection control.

Standard precautions Occupational Safety and Health Administration (OSHA) Centers for Disease Control and Prevention (CDC) Isolate Standard Precautions Body fluids There are two agencies that have guidelines and laws regarding infection control and prevention. The first is the Occupational Safety and Health Administration (OSHA). This is a federal government agency that makes rules to protect workers from hazards on the job. The Centers for Disease Control and Prevention (CDC) is a government agency under the Department of Health and Human Services (HHS) that issues information to protect the health of individuals and communities. In 1996, the CDC updated the recommendations for infection control to a two-tiered system: Standard Precautions and Transmission-based precautions. Standard precautions are methods of infection prevention in which all blood, body fluids, non-intact skin, and mucous membranes are treated as if they were infected with an infectious disease. Transmission-based precautions isolate patients who have contagious diseases. This means they are kept separate from other patients. Because it is impossible to tell from looking at a person whether he or she has an infectious disease, NAs should protect themselves from body fluids (any fluid that it wet and not their own) by practicing standard precautions. The CDC defines body fluids as including the following substances: Saliva Sputum (mucus coughed up) Urine Feces Semen Vaginal secretions Pus or other wound drainage Vomit Standard precautions include the following measures; Wash hands Wear gloves Remove gloves immediately when finished with a procedure Immediately wash skin surfaces Wear a disposable gown Wear a mask and goggles Wear gloves when handling sharp objects (like needles) Never attempt to recap needles or sharps Avoid nicks and cuts Bag all contaminated supplies Clearly label body fluids Dispose of contaminated waste properly

Hand hygiene Hand hygiene Antimicrobial When to wash your hands Because NAs use their hands for much of their work they come into contact with microorganisms constantly. The most common way for healthcare-associated infections to spread is via the hands of healthcare workers. Handwashing is the most important thing NAs can do to prevent the spread of disease. Hand hygiene is washing hands with either plain or antiseptic soap and water or using alcohol-based hand rubs. While alcohol-based hand cleansers can be used in some circumstances, hands that are visibly soiled should be washed using plain or antimicrobial soap and water. Antimicrobial agents destroys, resists, or prevents the development of pathogens. NAs should wash their hands at the following times: When first arriving at work Any time they are visibly soiled Before, between, and after all resident contact Before putting on gloves and after removing gloves After contact with body fluids, mucous membranes, non-intact skin, or wound dressings After handling contaminated items After contact with objects in resident’s room Before and after touching meal trays or handling food Before and after feeding residents Before getting clean linen Before and after using the toilet After touching the garbage or trash After picking up things from the floor After blowing nose or sneezing into hand Before and after eating After smoking After touching areas on the body Before and after applying makeup After any contact with pets/pet care items Before leaving the facility Remember: Handwashing is the single most important thing a NA can do to prevent the spread of disease.

SKILL: Hand Hygiene Equipment: soap, paper towels 1. Turn on water at sink. Keep your clothes dry, because moisture breeds bacteria. Wet hands and wrists thoroughly. 3. Apply soap to your hands. Keep your hands lower than your elbows and your fingertips down. Rub hands together and fingers between each other to create a lather. Lather all surfaces of wrists, fingers, and hands, using friction for at least 20 seconds. Friction helps clean. 5. Clean your nails by rubbing them in the palm of your other hand.

Skill: Hand Hygiene (Cont.) 6. Being careful not to touch the sink, rinse thoroughly under running water. Rinse all surfaces of your hands and wrists. Run water down from wrists to fingertips. Do not run water over unwashed arms down to clean hands. 7. Use a clean, dry paper towel to dry all surfaces of your hands, wrists, and fingers. Do not wipe towel on unwashed forearms and then wipe clean hands. Dispose of paper towel into waste container without touching the container. If your hands touch the sink or wastebasket, start over. 8. Use a clean, dry paper towel to turn off the faucet then dispose of paper towel into waste container. Do not contaminate your hands by touching the surface of the sink or faucet.

Personal Protective Equipment (PPE) Don Doff Gowns In order to practice Standard Precautions, NAs must wear personal protective equipment (PPE) to protect themselves from serious workplace injuries or illnesses resulting from contact with workplace hazards. PPE is equipment that helps protect employees from serious workplace injuries or illnesses resulting from contact with workplace hazards. PPE includes gloves, gowns, masks, goggles, and face shields. To don PPE means to put it on and to doff means to remove. You will don gloves prior to helping a resident brush his dentures and you will doff your gloves once you are finished. PPE must be worn when a caregiver might come into contact with body fluids, mucous membranes, or open wounds. This includes wearing gowns, masks, goggles, and face shields any time splashing or spraying of body fluids or blood could occur. We will now talk in more detail about the types of PPE.

Skill: donning a Gown 1. Wash your hands. 2. Open the gown. Hold out in front of you and allow gown to open/unfold. Do not shake it. Facing the back opening of the gown, place your arms through each sleeve. 3. Fasten the neck opening. 4. Reaching behind you, pull the gown until it completely covers your clothing. Secure gown at waist. 5. Use a gown only once and then remove and discard it. If gown becomes wet or soiled during care, remove it. Check your clothing, and put on a new gown. OSHA requires non-permeable gowns—gowns that liquids cannot penetrate—when working in a bloody situation. 6. Put on your gloves after putting on gown. The cuffs of gloves should overlap the cuffs of the gown. 7. When removing a gown, remove and discard gloves properly (see procedure later in the chapter). Unfasten gown at neck and waist. Remove the gown without touching the outside of gown. Roll the dirty side in, while holding gown away from your body. Dispose of gown properly and wash your hands. Gowns protect exposed skin and prevent soiling of clothing. Gowns should fully cover the torso and the sleeves should fit snugly.

Skill: donning mask and goggles 1. Wash your hands. 2. Pick up the mask by top strings or elastic strap. Do not touch the mask where it touches your face. 3. Pull elastic strap over your head, or if mask has strings, tie top strings first, then bottom strings. Do not wear a mask hanging from only the bottom tie or strap. Masks must always be dry or they must be replaced. 4. Pinch the metal strip at the top of the mask (if part of the mask) tightly around your nose so that it feels snug. 5. Put on the goggles over your eyes or eyeglasses. Use the headband to secure them to your head. Make sure they are on snugly. 6. Put on gloves after putting on mask and goggles. Masks are worn when the resident has a respiratory illness. Masks should fully cover the nose and mouth and should fit snugly. It is important to change masks between residents. Goggles should fit snugly over eyes or eyeglasses.

Skill: donning gloves 1. Wash your hands. 2. If you are right-handed, slide one glove on your left hand (reverse if left-handed). 3. Using your gloved hand, slide the other hand into the second glove. 4. Interlace fingers to smooth out folds and create a comfortable fit. 5. Carefully look for tears, holes, or discolored spots. Replace the glove if needed. 6. If wearing a gown, pull the cuff of the gloves over the sleeves of the gown. Gloves must be worn if the NA might touch blood or any body fluid. This includes during mouth care or care of any body fluid and during perineal care (care of genitals and anal care). Gloves must also be worn when providing personal care on non-intact skin, when providing personal care if the NA has cuts on hands, when shaving residents, when disposing of soiled linens, gowns, dressings, and pads, and when touching contaminated surfaces or equipment. Gloves must be changed immediately before contact with mucous membranes or broken skin and if gloves become soiled, worn, or damaged.

Skill: doffing gloves 1. Touch only the outside of one glove. With one gloved hand, grasp the other glove at the palm and pull the glove off. 2. With the fingertips of your gloved hand, hold the glove you just removed. With your ungloved hand, slip two fingers underneath cuff of the remaining glove at wrist. Do not touch any part of the outside of glove. 3. Pull down, turning this glove inside out and over the first glove as you remove it. 4. You should now be holding one glove from its clean inner side and the other glove should be inside it. 5. Drop both gloves into the proper container without contaminating yourself. 6. Wash your hands. Gloves should be removed after use, before caring for another resident, and before touching non-contaminated items or surfaces.

Proper order for donning and doffing ppE Wash hands Put on gown Put on mask Put on goggles or face shield Put on gloves Doffing Remove and discard the gloves Remove goggles or face shield Remove and discard gown Remove and discard mask Wash hands The proper order for donning PPE, after handwahsing, is gown, mask, goggles or face shield, and finally gloves. Pretend you are going to a fancy dinner and you need to get ready. First, you’d shower (wash your hands). Then, you’d get dressed in your evening gown or suit (gown), you’d put on your lipstick or shave (mask), then you’d put on your sun glasses prior to going outside (goggles/face shield), and finally, you’d use your hands to steer your car (gloves). The proper order for doffing PPE is to remove and discard the gloves, remove goggles/face shield, remove and discard the gown, remove and discard the mask, and wash your hands. You have just arrived home from your evening out. First, you’d park your car in the garage (gloves), then you’d take off your sunglasses (you are cool enough to wear your sunglasses at night and you have come inside from the outdoors), then you’d take off your dress or suit (gown), and remove the lipstick and wash your face. You’d probably use the bathroom prior to going to bed and would need to wash your hands. It is important for NAs to don and doff PPE in this order to prevent the spread of infection.

Guidelines for handling equipment and linen Clean Dirty Disinfection Sterilization Disposable Guidelines regarding equipment, linen, and clothing In order to understand how to properly handle equipment and linen, there are a few terms we must understand first. An object is called clean if it has not been contaminated with pathogens. An object is dirty has been contaminated with pathogens. Disinfection is a process that kills pathogens. Disinfection doesn’t kill all pathogens, but reduces the pathogen count to a level that is considered not infectious. We disinfect equipment like blood pressure cuffs and stethoscopes between patients. Sterilization is a measure that destroys all microorganisms, including pathogens. This includes those that form spores. Some items are only used once or for one patient, and are then discarded. These items are disposable. NAs should follow these guidelines regarding equipment, linen, and clothing: Prevent skin/mucous membrane contact Prevent contamination of clothing Prevent transfer of disease to other residents or environments Do not use reusable equipment until it has been cleaned properly Dispose of all single-use equipment properly Clean and disinfectant all environmental surfaces, beds, bedrails, bedside equipment, and all frequently touched surfaces (such as doorknobs and call lights). Handle, transport, and process soiled linens and clothing in a way that prevents skin and mucous membrane exposure, contamination of clothing (hold linen away from uniform), and transfer of disease to other residents and environments Bag soiled linen at point of origin Sort soiled linen away from resident care areas Place wet linen in leak-proof bags

How to handle spills Guidelines for cleaning spills involving blood, body fluids, or glass NAs should follow these guidelines for cleaning spills involving blood, body fluids, or glass: Put on gloves (industrial strength) Use proper product to absorb spill Scoop up absorbed spill and dispose of it in designated container Apply disinfectant Use proper cleaning solution Use tools, never hands, to pick up glass Properly bag waste Remember: It is important to absorb a spill and remove the fluid before treating the area with disinfectant. If the spilled fluid is not absorbed and removed first, it may neutralize the disinfectant on contact.

Transmission-based precautions Multidrug-resistant organism (MDROs) Transmission-based precautions are methods of infection prevention used when caring for persons who are infected or suspected of being infected with a disease. Some patients in transmission-based precautions have multidrug-resistant organisms (MDROs). MDROs are microorganisms – mostly bacteria – that are resistant to one or more antimicrobial agents that are commonly used for treatment. Remember: Transmission-based precautions are always used in addition to Standard Precautions. We will now look at the different types of transmission-based precautions.

Airborne Diseases Airborne diseases spread when pathogens are transmitted through the air after being expelled. The pathogens can remain floating for some time. The following illnesses are caused by airborne pathogens: Tuberculosis (TB) Measles Chicken pox The following precautions can help prevent the spread of airborne diseases: Using a face mask Wearing a gown Handwashing Proper ventilation

Droplet diseases spread when pathogens are transmitted through droplets in the air. The droplets normally do not travel more than three feet, but they may travel further. The following illnesses are examples: Mumps Influenza The following precautions can help prevent the spread of droplet diseases: Using a face mask Covering nose and mouth when sneezing or coughing Handwashing The CDC recommends the following measures (part of Standard Precautions) to prevent the transmission of respiratory illnesses in healthcare settings: Alerts should be posted instructing patients and visitors to inform staff of respiratory symptoms and to practice respiratory hygiene/cough etiquette, which includes Cover noses/mouths with a tissue when coughing or sneezing Dispose of used tissues in nearest waste container after use Wash hands after contact with respiratory secretions or contaminated objects Healthcare facilities must make these items available to staff, patients, and visitors: Tissues and no-touch receptacles for disposal Conveniently located hand rub dispensers and handwashing supplies During times of increased respiratory infections, masks should be offered to anyone who is coughing and coughing people encouraged to sit at least three feet away from others. Healthcare personnel should observe droplet precautions, in addition to Standard Precautions, when interacting with a patient with symptoms of a respiratory infection.

Contact Diseases Contact diseases can be spread when an uninfected person comes into contact with the skin, wound, or infection of an infected person. The following illnesses are spread by contact: Conjunctivitis (pink eye) Clostridium difficile (C. diff) Lice Scabies The following precautions can help prevent the spread of contact diseases: Using PPE Washing hands with antimicrobial soap Not touching infected surfaces without gloves Not touching uninfected surfaces with contaminated gloves Not sharing towels, linens, and clothing Using disposable equipment when possible

Guidelines for isolation precautions When isolation precautions are required, the NA should remember these points: • Transmission-Based Precautions always used in addition to Standard Precautions • Nurses will set up the isolation unit. • Use PPE as instructed. Do not wear PPE outside resident’s room, and perform hand hygiene following removal of PPE. • Do not share equipment between residents. • Wear proper PPE when serving food and drink. • Follow Standard Precautions in dealing with body waste removal. • Wear proper PPE required to take specimen. • Reassure residents that the disease, not the person, is being isolated.

Bloodborne pathogens and diseases Human Immunodeficiency Virus (HIV) Hepatitis Jaundice How bloodborne diseases may be transmitted Bloodborne pathogens are microorganisms found in human blood, body fluid, draining wounds, and mucous membranes that can cause infection and disease in humans. Two common bloodborne pathogens are the human immunodeficiency virus (HIV) and hepatitis. HIV is the virus that attacks the body’s immune system and gradually disables it, eventually causing AIDS. Hepatitis is inflammation of the liver caused by certain virus, as well as other factors including alcohol abuse, some medications, and trauma. Hepatitis and other liver diseases can cause jaundice, a condition in which the skin, whites of the eyes, and mucous membranes appear yellow. Bloodborne diseases may be transmitted in the following ways: • Infected blood • Infected semen or vaginal secretions contacting mucous membranes • Sexual contact • Needle sharing • Infected mothers • Contact with infected blood or certain other body fluids in healthcare setting Remember: It is safe to touch and spend time with residents who have bloodborne diseases. Residents with these illnesses need the same thoughtful, personal attention NAs give to all their residents.

Osha’s bloodborne pathogens standard Exposure control plan Significant exposure Guidelines employers must follow OSHA has set standards for special procedures that must be followed in healthcare facilities. The Bloodborne Pathogens Standard is federal law that requires that healthcare facilities protect employees from bloodborne health hazards. The Bloodborne Pathogens Standard designates the following as a significant exposure: • Needle stick • Mucous membrane contact • Cut from an object containing potentially infectious body fluid • Contact with non-intact skin Employers must take the following steps to protect employees from bloodborne pathogens: • Maintain a written exposure control plan (a plan designed to eliminate or reduce employee exposure to infectious material) • Provide proper PPE • Provide biohazard containers for disposal of sharps and other infected waste • Offer free hepatitis B vaccine to employees • Affix warning labels to waste containers, refrigerators, and freezers that contain potentially infectious material • Keep a log of injuries from contaminated sharps • Provide in-service training on the Bloodborne Pathogens Standard

Tuberculosis and infection prevention guidelines Tuberculosis (TB) Latent TB infection TB disease Multidrug-resistant TB (MDR-TB) Resistant Signs and symptoms of TB Guidelines for caring for residents with TB Tuberculosis (TB) is a highly contagious lung disease caused by a bacterium that is carried on mucous droplets suspended in the air. There are several types of TB. Latent TB infection is a type of tuberculosis in which the person carries the disease but does not show symptoms and cannot infect others. When a person shows symptoms of the disease and can spread TB to others, the person has TB disease. Finally, multidrug-resistant TB (MDR-TB) is a type of tuberculosis that can develop when a person with TB disease does not take all the prescribed medication. Resistant, in this case, means that drugs will no longer work to kill the TB bacteria. NAs should be familiar with these signs and symptoms of TB disease: Fatigue Loss of appetite Weight loss Slight fever and chills Night sweats Prolonged coughing Coughing up blood Chest pain Shortness of breath Trouble breathing When caring for residents with tuberculosis, NAs should follow these guidelines: • Follow Standard Precautions and Airborne Precautions. • Wear PPE as instructed. • Handle sputum or phlegm carefully. • Ensure proper ventilation. • If resident is in AIIR isolation room, open and close door slowly. • Follow isolation procedures if ordered. • Help resident remember to take medications.

MRSA, VRE, and C. Difficile MRSA (methicillin-resistant Staphylococcus aureus) Hospital-associated Community-associated Vancomycin-resistant enterococcus (VRE) Clostridium difficile (C. diff, C. difficile) Methicillin-resistant Staphylococcus aureus (MRSA) is an infection caused by specific bacterial that have become resistant to many antibiotics. MRSA can be hospital-associated (acquired in the hospital setting) or community-associated (infections in people who have not been recently hospitalized). MRSA can be spread by direct and indirect contact. Handwashing is the single most important measure to control the spread of MRSA. Vancomycin-resistant enterococcus (VRE) are bacteria (enterococci) that have developed resistance to antibiotics as a result of being exposed to vancomycin (an antibiotic). VRE can be spread by direct and indirect contact. Prevention of VRE is very important, and proper handwashing is an important part of prevention. Clostridium difficile (C. diff, C. difficile) is a bacterial illness that can cause diarrhea and colitis. It is spread by direct contact with spores in feces that are difficult to kill and when intestinal flora is altered due to enemas, nasogastric tube, GI tract surgery, or overuse of antibiotics. Proper handwashing and proper handling of wastes can help prevent C. Difficile. Soap and water must be used each time hand hygiene is performed. Disinfecting surfaces and limiting antibiotic use can also help. Stapylococcus aureus

Employer and employee responsibilities for infection prevention Employer’s responsibilities regarding infection prevention Both employers and employees have a responsibility for infection prevention. The following are an employer’s responsibilities regarding infection prevention: • Establish procedures and exposure control plan. • Provide in-service education. • Have written procedures for exposures. • Provide proper PPE. • Provide HBV vaccination. The following are an employee’s responsibilities regarding infection prevention: • Follow Standard Precautions. • Follow facility’s policies and procedures. • Follow care plans and assignments. • Use PPE. • Take advantage of free hepatitis B vaccine. • Report any exposure immediately. • Participate in education programs.

Review Infection prevention The chain of infection Why the elderly are at higher risk for infection Standard precautions Hand Hygiene Personal Protective Equipment (PPE) Guidelines for handling equipment and linen Handling spills Transmission-based precautions Bloodborne pathogens and diseases OSHA’s bloodborne pathogens standard Tuberculosis and infection prevention guidelines MRSA, VRE, and C. Difficile Employer and employee responsibilities for infection prevention In this chapter, we discussed infection prevention and the chain of infection. Why the elderly are at higher risk for infection was outlined. Standard precautions were defined, including hand hygiene and the use of personal protective equipment. Guidelines for handling equipment and linen as well as for handling spills were provided. Transmission-based precautions were described. Bloodborne pathogens and diseases were explained and OSHA’s bloodborne pathogens standard was discussed. Infectious diseases, including TB, MRSA, VRE, and C. Difficile were discussed. Employer and employee responsibilities for infection prevention were defined.