1. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Chapter 4 Principles of Infection Prevention and Control

2. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Learning Objectives Define health care  associated infections and state how often they occur. Describe why infection prevention is important in respiratory care. Identify and describe the three elements that must be present for transmission of infection within a health care setting. 2

3. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Learning Objectives (cont.) List the factors associated with an increased risk of a patient acquiring a nosocomial infection. State the three major routes for transmission of human sources of pathogens in the health care environment. Describe strategies to control the spread of infection in the hospital. Describe how to select and apply chemical disinfectants for processing respiratory care equipment. 3

4. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Learning Objectives (cont.) Describe equipment handling procedures that help prevent the spread of pathogens. State when and to use general barrier measures during patient care. Describe surveillance with regard to infection control. 4

5. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Infection Control Introduction  Hospital-acquired infections (HAIs) account for 1.7 million infections & 99,000 excess deaths annually  About 5% of patients admitted develop an HAI  About 25% of mechanically ventilated patients develop pneumonia, & 30% (of those 25%) will die 5

6. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Infection Control (cont.) Infection control procedures aim to:  Eliminate the sources of infectious agents  Create barriers to their transmission  Monitor the effectiveness of control All health care workers must take responsibility & follow procedures carefully Infection prevention is an ongoing responsibility of all respiratory therapists 6

7. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 7 Infection control procedures aim to do the all of the following except? A.Monitor the effectiveness of control measures B.Eliminate the sources of infectious agents C.Restrain infectious patients D.Create barriers to disease transmission

8. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Spread of Infection 3 elements must be present for infection to spread:  Source of pathogens  Susceptible host  Route of transmission 8

9. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Spread of Infection 9

10. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Spread of Infection (cont.) Susceptible hosts Resistance to infection varies greatly from one person to next Host factors increasing chance of infection are:  Poorly controlled diabetes  Increased age  Chemotherapy  Placement of tubes & catheters 10

11. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Spread of Infection (cont.) Sources of infectious agents:  Humans are primary source  Inanimate objects (e.g., contaminated medical equipment) can spread infection  Individuals in hospital capable of being source include: Workers Visitors Patients 11

12. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 12 Host factors that increase the chance of infection are all of the following,except? A.Poorly controlled diabetes B.COPD C.HIV positive D.Normal white blood cell count

13. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Spread of Infection (cont.) Nosocomial Infections acquired in hospital Most nosocomial pneumonias occur in patients having chest or abdominal surgery Patients with history of chronic obstructive pulmonary disease (COPD), cigarette smoking, or obesity & those with advanced age have greatest risk for nosocomial pneumonia following major surgery Patients with artificial airways or immuno- compromised are at higher risk of acquiring nosocomial infections 13

14. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 14 All of the following population are at risk for nosocomial infections except: A.Post-op bariatric patients B.COPD patients C.Patients with impaired swallowing D.Diabetic patients

15. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Modes of Transmission 15

16. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Infection Prevention Strategies Decreasing host susceptibility:  Immunizations & chemoprophylaxis  Most HAIs from ventilator associated pneumonia (VAP), catheter related bloodstream infections, & catheter associated UTIs  Limit use of devices associated w/ HAIs & assure proper placement & maintainence  Prevention bundles: use of multiple evidence-based best practices to prevent device related infection Eliminating source of pathogens 16

17. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 17 What is the most effective way to decrease host susceptibility to infection regarding the use of medical devices? A.Discontinue the device immediately when no longer needed B.Get an second opinion regarding the medical device C.Change the device daily D.Keep the patient on the medical device until they are ready to be discharged

18. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Infection Prevention Strategies (cont.) Interrupting routes of transmission  Special equipment handling  Barrier/isolation precautions using both standard & transmission based precautions  Disposable equipment Infection prevention programs identify & categorize HAIs & provide guidance to break chain of events Infection prevention programs endorse prevention by assuring that caregivers have appropriate time, equipment, & training to provide best possible care 18

19. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Infection Prevention Strategies (cont.) 19

20. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Infection Prevention Strategies (cont.) 20

21. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Eliminating Source of Pathogens General sanitation measures:  Help to keep overall environment clean  Aim to reduce number of pathogens to safe level  Environmental control of air & water complements efforts Specialized equipment processing:  to decontaminate equipment capable of spreading infection  involves cleaning, disinfection, & sterilization 21

22. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Preventing Transmission of Infectious Agents Standard Precautions: combine major features of Universal Precautions & Body Substance Isolation To be applied to patients in all health care settings, all the time Standard precautions apply to: –Blood –All body fluids –Nonintact skin –Mucous membranes 22

23. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Preventing Transmission of Infectious Agents (cont.) Personal Protective Equipment (PPE) must be worn at all times  Gloves: must be sterile whenever performing invasive procedures  Masks: protect mucosal surfaces against splashes or sprays but should not be confused w/ particulate respirators  N-95 or higher-level respirator: intended for diseases that could be airborne transmitted  Gowns: provide barrier protection & can prevent contamination of clothing & exposed body areas 23

24. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Preventing Transmission of Infectious Agents (cont.) Respiratory Hygiene/cough etiquette:  Education of patients & employees  Posted signs  Source control measures (covering mouth/nose, or using surgical mask)  Hand hygiene  Spatial separation (at least 3 feet of space) 24

25. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Expanded Precautions Transmission Based Precaution: patients who are known/suspected to be infected w/ pathogens requiring additional control measures to prevent transmission Contact precautions:  Intended to reduce risk of transmission by direct or indirect contact  Proper use of gowns & gloves  Most commonly employed to decrease spread of multidrug resistant organisms, such as Clostridium difficile 25

26. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Expanded Precautions (cont.) Droplet precautions (see Box 4-5)  To prevent form of contact transmission that occurs when droplets are propelled short distances, such as influenza  Generated w/ coughing, sneezing, suctioning, bronchoscopy, & cough induction  Surgical mask must be worn 26

27. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Expanded Precautions (cont.) Airborne infection isolation (see Box 4-7)  Isolation techniques intended to reduce risk of selected infectious agents transmitted by “small droplets” of aerosol particles, such as M. tuberculosis  Use of N-95 respirator  Room must be negative pressured, 2 air exchanges per hour, & use HEPA filters 27

28. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 28 Expanded Precautions (cont.)

29. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Expanded Precautions (cont.) Protective environment  Specialized engineering approach to protect highly immunocomprised patients  Used w/ allogeneic stem cell transplant patient  Includes: HEPA filtration of incoming air, directed room air flow, positive room air pressure relative to corridor, well-sealed rooms to prevent infiltration of outside air, ventilation to provide 12 or more air changes per hour 29

30. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Expanded Precautions (cont.) Patient placement & transport  Single occupancy room ideal  Cohorting: grouping patients w/ same infection  Limit transport of patients w/ contagious diseases  During transport: patient needs to wear appropriate barrier protection (masks, gowns, impervious dressings) consistent w/ route & risk for transmission 30

31. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Disinfection & Sterilization Cleaning  Cleaning is first step in all equipment processing  Involves removing dirt & organic material  Failure to clean equipment properly can render all subsequent processing efforts ineffective  Soaps & detergents need to be used  Non-critical items, such as commodes, intravenous pumps, & ventilator surfaces, must be thoroughly cleaned & disinfected before use w/ another patient 31

32. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Disinfection & Sterilization (cont.) Disinfection  Disinfection destroys vegetative form of all pathogens except bacterial spores  Disinfection can involve either chemical or physical methods  Pasteurization is most common physical method 32

33. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Disinfection & Sterilization (cont.) Chemical Disinfection  Chemical disinfection involves application of chemical solutions to contaminated equipment or surfaces  Equipment must be immersed in solution for set period of time  Many chemical methods used to disinfect respiratory care equipment  Labels should be read carefully & instructions properly followed during use 33

34. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Sterilization Destroys all microorganisms Can be achieved w/ physical & chemical approaches Steam sterilization is most common & easiest Low-temperature sterilization technologies include ethylene oxide: colorless & toxic gas Medical devices contacting with sterile body tissues or fluids are critical items & should be sterile before use 34

35. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Sterilization 35

36. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Sterilization 36

37. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 37 Which one of the following equipment requires to be “sterilized” ? A.ventilator B.stethoscope C.bronchoscope D.oxygen therapy device

38. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Equipment Handling Procedures Include:  Maintenance of in-use equipment  Processing of reusable equipment  Application of one-patient–use disposables  Fluid & medication precautions Respiratory care equipment that can spread pathogens include: nebulizers, ventilator circuits, bag-valve-mask devices (BVMs; manual resuscitators), & suction equipment Oxygen therapy & pulmonary function equipment are also implicated as potential sources of nosocomial infections 38

39. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Equipment Handling Procedures (cont.) Nebulizers  Large-volume nebulizers are often problem  Small-volume nebulizers can also produce bacterial aerosols Ventilators and Circuits  Circuits pose greatest risk for infection  High-efficiency particulate air/aerosol (HEPA) filters help reduce endotracheal tube contamination 39

40. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Equipment Handling Procedures (cont.) 40

41. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 41 Equipment Handling Procedures (cont.)

42. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Equipment Handling Disposable Equipment Important alternative to continually reprocessing equipment 3 major issues 1.Cost 2.Quality 3.Reuse (raises significant safety concerns) 42

43. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. 43 What does a room that is on airborne isolation need to have? A.no windows B.HEPA filters C.a disposable ventilator D.positive pressure air

44. Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Surveillance  Ongoing process of monitoring patients & personnel for acquisition of infection  Infection control committee establishes surveillance policies & infection control expert administers them  Common for infection prevention programs to oversee hand hygiene & standard precautions adherence observations 44