Epidemiology and Risk of Infection in Home Health and Hospice Settings

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Epidemiology and Risk of Infection in Home Health
and Hospice Settings
Module C

• Statewide Program for Infection Control and
  Epidemiology (SPICE)
• UNC School of Medicine

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Objectives

• Discuss the infectious process through review of
  the chain of infection.
• Review methods for controlling transmission of
  infection.
• Describe steps for detecting and controlling
  outbreaks.
• Describe the process for surveillance of
  infections

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Chain of Infection
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Infectious Agent or The Harmful Germ

• Bacteria (MRSA, VRE)
• Viruses (Influenza, Norovirus)
• Fungi (Candida, Aspergillis)
• Parasites (Giardia, pinworms)
• Arthropods (mites)
• Infestations, not infections

Infectious Agent
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Infectious Agent or The Harmful Germ

• Disease Producing Characteristics
• Virulence
• Ability to grow and multiply
• Invasiveness
• Ability to enter tissue
• Pathogenicity
• Ability to cause disease

Infectious Agent
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Reservoir or Hiding Places

• Where germs live, grow, and increase in numbers
• A person
• An animal
• Environment/Fomite

Reservoir
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People as Reservoirs

• Blood
• Skin
• Digestive tract
• Mouth, stomach, intestines
• Respiratory tract
• Nose, throat, lungs
• Urinary tract

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People as Reservoirs
People We Know Who Are Infected
People We Dont Know Who Are Infected
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Portal of Exit or The Way Out
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MODES of transmission

• Contact victim comes in contact with source
• Direct physical contact between source and
  victim
• Indirect victim contacts contaminated inanimate
  objects
• Droplet brief passage of infectious agent
• Airborne airborne phase in disease
  dissemination
• Common vehicle contaminated inanimate vehicle
  serves as the vector for transmission to multiple
  persons.
• Vectorborne - Not associated with healthcare
  transmission

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Portal of Entry or The Way In

• Nose and Mouth
• GI Tract
• Urinary Tract
• Breaks in skin
• Cut, open sore, needlestick

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Susceptible Person

• Age very young or older
• Stress
• Fatigue
• Poor nutrition
• Chronic illnesses
• Not properly vaccinated
• Open cuts, skin breakdown
• Immune suppressive medications

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Knowledge Check

• A disease or condition when harmful germs get
  into the body and cause pathology
• Host
• Infection
• Reservoir
• Portal of exit

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Knowledge Check

• Germs can be spread indirectly through
• Shared medical equipment
• Bloody gauze
• Needlesticks
• A and B only
• All of the above

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Breaking The chain of infection
As long as the chain of infection remains intact,
infection will spread to others.

• Standard Precautions and Transmission-Based
  Precautions

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Elements of Standard Precautions

• Hand hygiene
• Use of personal protective equipment (PPE)
• gowns, gloves, mask, eye protection
• Safe injection practices
• Safe handling of potentially contaminated
  equipment or surfaces
• Respiratory hygiene/cough etiquette

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What is the Best Way to Stop the Spread of
Infection?
Hand Hygiene
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When to Perform Hand Hygiene
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Where Should Hand Hygiene be Performed?
at thePOINT-OF-CARE
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Personal Protective Equipment (PPE)

• Wear gloves for potential contact with blood,
  body fluids, mucous membranes, non-intact skin or
  contaminated equipment.
• Do not wear the same pair of gloves for more than
  one patient
• Do not wash gloves for the purpose of reuse
• Wear a gown to protect skin and clothing during
  procedures or activities where contact with blood
  or body fluids is anticipated.
• Do not wear the same gown for more than one
  patient
• Wear mask and eye protection during procedures
  that are likely to generate splashes or sprays of
  blood or other body fluids.
• Wear a surgical mask when placing a catheter or
  injecting material into the spinal canal or
  subdural space.

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Respiratory Hygiene/Cough Etiquette

• Post signs at entrances.
• Provide tissues and no-touch trash cans for
  disposal in waiting areas.
• Provide hand hygiene product in waiting areas.
• Offer a mask to symptomatic patients.
• Encourage ill patients to sit away from others.

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Transmission-based Precautions

• Certain conditions (syndromes) require triage and
  additional attention
• Diarrhea (C. difficile, norovirus)
• Febrile respiratory illness (influenza)
• Febrile rash (chickenpox/shingles, measles)
• Early detection is important

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Contact Precautions

• Put on gloves before direct contact with patient
  or immediate environment.
• Use gown for contact with
• Uncontrolled secretions
• Pressure ulcers
• Draining wounds
• Limit amount of non-disposable patient care
  equipment brought into home.
• Place contaminated re-usable noncritical patient
  care equipment in plastic bag for transport.
• Clean horizontal surfaces and equipment with
  Environmental Protection Agency (EPA)-registered
  disinfectant

• Stool Incontinence
• Ostomy tubes or bags

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Droplet Precautions

• Instruct patient to follow respiratory
  hygiene/cough etiquette.
• HCP should wear surgical mask upon entry to room.
• Have patient wear a mask when outside the home.
• Disinfect all horizontal surfaces and equipment
  using a Environmental Protection Agency
  (EPA)-registered disinfectant.

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Airborne Precautions

• Have system in place to identify patients with
  known or suspected airborne spread infections.
• Instruct patient to follow respiratory
  hygiene/cough etiquette.
• If tolerated, patient can wear surgical mask
  while in the home to prevent dispersion of
  microorganism.
• Educate family regarding the contagious nature of
  the disease.
• Protect vulnerable household members
  (immunocompromised, lt4 yrs old)
• For TB, HCP must wear fit-tested N-95 respirator
  upon entry.
• For Chickenpox and Measles, susceptible staff
  should wear a surgical mask.
• Clean horizontal surfaces and equipment with
  EPA-registered disinfectant.

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Precautions in the home

• Caregivers should wash hands with soap and water
  after contact with infected or colonized person
  and before leaving home
• Use disposable towels to dry hands
• Do not share personal care items with infected
  person
• Disposable gloves should be worn if contact with
  body fluids is possible. Wash hands following
  removal
• Change linens and wash on a routine basis
• Clean environment routinely and when visibly
  soiled with body fluids

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Knowledge Check

• What is the single most effective way to prevent
  the spread of infections?
• Using PPE
• Cleaning patient care equipment
• Hand Hygiene
• Coughing into the crook of elbow or tissue

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Outbreak Investigation
Outbreak occurrence of more cases of disease
than normally expected within a specific
place or group of people over a given period of
time.
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Definitions

• Endemic the usual presence of disease within a
  geographic area
• Epidemic (Outbreak) an excess over the usual or
  expected occurrence of disease within a
  geographic area
• Pandemic epidemics that affected several
  countries or continents (e.g., AIDS, pandemic
  influenza, SARS)

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Outbreaks Steps

• Verify diagnosis
• Establish case definition
• Review for cases case search
• Create a line listing
• Make an epi-curve

• Develop hypothesis
• Test hypothesis
• Implement control measures
• Evaluate control measures
• Disseminate information

a chart showing the number of persons who became
ill each day
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Suspected OutbreakKnow Who to Call for
Assistance

• Facility Risk Manager
• Local Health Department first OR
• State Public Health Department
• (Raleigh 919-733-3419)
• Infection Control Assistance Statewide Program
  for Infection Control and Epidemiology (SPICE),
  spice_at_unc.edu, 919-966-3242

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Knowledge Check

• Who should be notified of a suspected or known
  communicable disease outbreak?
• Risk Management
• Administration/Director
• Local Health Department
• All of the above

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Surveillance of Infections
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Purpose

• Assess safety and quality of patient care
• Monitor infection trends
• Improve care and prevent healthcare-acquired
  infections
• Assist with identifying conditions that may be
  reportable to public health department

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Developing a surveillance program

• Assessment of population served and services
  provided
• Review of existing infection data

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Published Rates of Home Care-Acquired Infection
Rates
Author (Date of pub) Catheter Associated UTIs (per 1000 catheter days Central Line Associated Bloodstream infections (per 1000 catheter days)
Missouri Home Care Alliance (2004) 3.9 0.82
Gorski (2004) -- 0.77
Moureau (2002) -- 0.19
Long (2002) 4.4 --
Leuhm (1999) 2.79 0.54
Weber (2009) 2.2 1.24
APIC Infection Control in Home Care and Hospice
(2nd ed.), 2006 Weber DJ, et al. ICHE
2009301022-1024
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The surveillance Plan

• Defines the scope of the data gathering
• Should focus on frequently occurring infections,
  high-risk infections, and infections where
  interventions are likely to result in prevention
• Must specify minimum data to be collected, the
  data collectors and methodology

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Surveillance Definitions

• February 2008, APIC-HICPAC published surveillance
  definitions for Home Health and Hospice.
• Definitions should be used consistently

http//apic.org/Resource_/TinyMceFileManager/Pract
ice_Guidance/HH-Surv-Def.pdf