Introduction to Infection Control

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Introduction to Infection Control

• Marian McDonald, RN, MSN, CIC
• Infection Control at YOUR Service Consulting

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Welcome!

• This talk is an introductory overview.
• It is OK to be a beginner.
• You do NOT need to know everything to start.
• You do need to know enough to keep your patients
  and yourselves safe.
• That is not too difficult and is our focus today.
• These are skills you will use every single day
  you work as a nurse, no matter where you work.
• At the end we will review the parts that you
  really need to get today. You will have more
  chances to learn some of the details.
• We will leave time for questions.

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Objectives

• Who does Infection Control protect?
• What is the weakest link in the chain of
  infection?
• What is the most important procedure to prevent
  spread of infection?
• Which kind of hand hygiene is better for routine
  use?
• What kind of patients need Standard Precautions?

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The purpose of Infection Control is to protect
EVERYONE in the hospital from catching a new
infection they did not already have.

• The patients always come first, because they are
  already compromised by being sick.
• We take many actions to protect staff from
  infection (that means you and your co-workers!)
• We even work to protect visitors and the flower
  delivery folks!
• We dont want ANYONE to catch a new infection!

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Healthcare-associated infections (HAIs)

• New infections not present or incubating at the
  time of admission are called healthcare-associated
  infections or HAIs.
• They used to be called nosocomial infections.

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We will be talking a lot about GERMS!

• Germs is a non-scientific term which is very
  useful.
• Germs include bacteria, viruses, fungi, and
  protozoans.
• These types of organisms are different in many
  ways, but they are transmitted in similar ways.
• To prevent new infections, we must prevent
  transmission of all kinds of germs!

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The Chain of Infection
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Infectious agent

• These are the germs.
• Can we get rid of them? Some yes, but not all.
• Actions we take to eliminate germs include
• Sterilizing surgical instruments
• Cleaning reusable equipment such as commodes.
• Safe food handling practices
• Telling sick people to stay home

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Reservoir

• Reservoirs are where the germs live and grow.
• Reservoirs are generally WET. As a rule,
  anything that stays wet is germy!
• The most important reservoirs in the hospital are
  PEOPLE.
• Sick people with infections
• Well people with their normal flora (mouth, etc.)
• We cant get rid of
• the most important reservoirs!

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Portal of exit

• This is the way the germs get out of the
  reservoir.
• This is usually a break in the skin, a natural
  orifice, or a body fluid.
• We cant do much about most portals of exit, but
  we can
• Cover a draining wound with a bandage.
• Do hand hygiene after contact with any body fluid.

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Means of transmission

• Very few germs can fly.
• Almost all have to be CARRIED from one place to
  another.
• The main means of transmission are
• The HANDS if the caregivers
• THINGS that move from patient to patient.
• The means of transmission is the only link in the
  chain of transmission that you can actually
  eliminate!

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Portal of entry

• No kind of germ in the world can make you sick
  until they get INSIDE your body.
• They cannot go through intact skin, so they have
  to find a HOLE (the portal of entry!)
• Keep anything germy away from any hole in your
  patient.
• Keep anything germy away from any hole in
  yourself!
• Take good care of your skin to prevent holes!

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Susceptible host

• Can we eliminate susceptible hosts? Yes,
  partially, by vaccination or natural disease that
  causes immunity.
• We can also reduce susceptibility by keeping our
  resistance up.
• However, no one is immune to all disease, so
  everyone, patients and staff, is a susceptible
  host.

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One of the MAIN POINTS of this talk

• The weakest link in the chain of transmission is
  the means of transmission.
• Most of the efforts of Infection Control are
  aimed at NOT CARRYING GERMS from the reservoir to
  the susceptible host!
• The reservoir and the susceptible host may be the
  same person!

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This is why hand hygiene is still the single most
important procedure for preventing the spread of
infection!
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How to save lives

• Read the name band!
• Wash your hands!

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What is hand hygiene?

• Hand hygiene includes
• washing with soap and water
• De-germing hands with alcohol-based hand
  sanitizers.
• So which one is better?

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Hand Hygiene

• If you can SEE dirt on your hands, whether blood,
  body fluid, or dirt from the ground,
• WASH HANDS WITH SOAP AND WATER!
• Wet hands before applying soap.
• Use FRICTION on all surfaces
• For 15 seconds. (row, row, row your boat TWICE!)
• Water temperature should be comfortable.
• Washing with soap and water physically removes
  the dirt from your hands.
• (It does NOT kill germs!)

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Hand Hygiene

• If your hands LOOK clean and just need to be
  de-germed,
• an ALCOHOL-based HAND HYGIENE PRODUCT is
  PREFERRED!
• They are better 3 ways
• They DO kill most germs (including viruses).
• They leave skin condition better.
• They are quicker and easier to use!

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Hand Hygiene

• A couple of notes on how to use the alcohol
  products right
• Use the alcohol products on DRY skin only.
• Do use a hand hygiene product and not plain
  alcohol. Plain alcohol evaporates too fast and
  there is not enough contact time to kill the
  germs.
• Use one squirt of alcohol gel or foam, and rub
  until hands are completely dry! Do not wipe off
  with a paper towel!

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Hand Hygiene

• There is no need for an antimicrobial soap, since
  the alcohol product is your antimicrobial.
• If you get into something really terrible, first
  wash with soap and water, dry your hands, then
  use the alcohol gel. That is the best hand
  hygiene possible, since you are getting the germs
  by two different methods!

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WHEN should you do Hand Hygiene? (Part 1)

• When you first come on duty.
•    Before and after every patient contact,
  including touching intact skin.
• (You can count one hand hygiene for both if you
  do not touch anything else!)   
• Before any clean or invasive procedure.
• Before putting on sterile gloves.
•     After you remove gloves, every time!
•     After contact with any body fluids, INCLUDING
  YOUR OWN! (Coughing, sneezing, blowing your
  nose)
• When leaving an isolation room.

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When should you do Hand Hygiene? (Part 2)

• Going from a dirtier to a cleaner part of the
  patient. (Dont carry germs)
• Any time hands feel or look dirty.
• After contact with contaminated things or
  environments, such as charts.
• After handling used equipment or linen.
• After using the bathroom.
• Before contact with any portal of entry, your
  patients or your own.
• Before and after eating.
• When going off duty.

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Lets review the basics!
Means of transmission
Reservoirs There are lots of germy places in the
hospital, mostly patients and staff.
Susceptible hosts Everyone can catch
something, patients and staff
That is WHY hand hygiene is the single most
important procedure for preventing the spread of
infection!
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What is infection?

• Germs are present.
• They are invading tissue and causing tissue
  damage.
• Tissue damage causes symptoms.
• The infection is a reservoir for spread of
  infection.
• Infections produce greater NUMBERS of germs than
  colonization.

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What is colonization?

• Germs are present.
• They are NOT invading tissue and causing tissue
  damage.
• There are NO symptoms.
• The germs are still a reservoir for spread of
  infection.
• Numbers of germs shed are fewer than with
  infection.

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What is an unknown carrier?

• An unknown carrier has an infection which has not
  been diagnosed.
• There may or may not be symptoms.
• This is why we stay out of the body fluids of ALL
  patients, because we never know who might be an
  unknown carrier of what!
• That sounds pretty scary, but you will see that
  it is easier that you think.
• Most nurses you know do seem to be pretty
  healthy, dont they?

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Where do the germs come from?

• Endogenous flora the patients own germs they
  come in with. Includes their normal flora (their
  good germs) and any pathogens (bad germs) they
  may be carrying.
• Exogenous flora germs the patient did NOT bring
  in with them, that came to them from outside
  themselves.
• Either kind can cause healthcare-associated
  infections (HAIs).

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Standard Precautions

• Use Standard Precautions in the care of ALL
  patients!
• Standard Precautions used to be called Universal
  Precautions or Body Substance Precautions.
• Standard Precautions protect both staff and
  patients from infection.
• Standard Precautions are required by both good
  science and by LAW!

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Standard Precautions

• Standard Precautions are used to care for ALL
  patients so that we use the right precautions
  with both known cases and unknown carriers of
  diseases carried in blood and body fluids.
• They are all you need to care for a patient known
  to have hepatitis B, hepatitis C, or HIV.
• We must do Standard Precautions right with EVERY
  patient so we are protected from the unknown
  carriers of those diseases.

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Universal Precautions and Standard Precautions

• Universal Precautions started first and were
  designed to protect employees.
• They are required by OSHA federal law!
• They focus on bloodborne viruses, HBV, HCV, HIV.
• Stay out of blood and OPIM, which includes semen,
  vaginal secretions, cerebrospinal fluid, synovial
  fluid, pleural fluid, pericardial fluid,
  peritoneal fluid, amniotic fluid, saliva in
  dental procedures, any body fluid that is visibly
  contaminated with blood, and all body fluids in
  situations where it is difficult or impossible to
  differentiate between body fluids.
• Standard Precautions is the current term from the
  CDC, designed to protect patients and workers.
• If it is wet and not yours, stay out of it! Any
  body fluid probably carries germs!

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How to do Standard PrecautionsPart 1 all about
GLOVES

• Use good hand hygiene, of course!
• Use gloves for contact with body fluids,
  non-intact skin (this includes rashes), mucous
  membranes, used equipment, linen, and trash.
• Change gloves if they become heavily soiled, or
  if you must go from a dirtier area to a cleaner
  one. (Dont carry germs!)
• NEVER touch the second patient with the same pair
  of gloves!
• Do not wear gloves in the hall unless you can say
  why you are wearing them.
• Dont soil the environment with dirty gloves!

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How to do Standard PrecautionsPart 2 OTHER
STUFF , NOT gloves

• Use a gown any time your clothing may be soiled.
• Use a mask AND eye protection if you may be
  splashed. (Your glasses do NOT meet OSHA!)
• Know where to find the personal protective
  equipment (PPE) you will need.
• Dont recap sharps unless you absolutely must,
  and use a one-handed technique if you must.
• Discard used sharps into a sharps box
  immediately.
• Be sure to activate safety sharps before discard.
  
• Be sure you learn how to use each type of safety
  sharp before you use it!

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OSHA Bloodborne Pathogens Standard

• Federal and state LAW require many of the basics
  of Infection Control.
• Bloodborne pathogens are organisms in blood which
  can cause disease. The main ones are hepatitis
  B, hepatitis C, and HIV.
• They can be transmitted by needlesticks, body
  fluid contact with mucous membranes, such as eyes
  or mouth, or body fluid contact with broken skin.
• Most patients with these infections have NO
  symptoms!
• The Biohazard Symbol identifies some contaminated
  items, but many items are contaminated which
  dont show the symbol.
• It also REQUIRES the use of red bags, hepatitis
  vaccine, and follow-up after exposures.

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BIOHAZARD
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Exposure to body fluids

• Exposures include needlestick, face splash, and
  blood on broken skin.
• Avoid exposure! Be very careful! Use PPE!
• If you have an exposure, first wash, then tell
  your instructor.
• The source patient will be tested for HBV, HCV,
  and HIV.

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So what DOES go into a red bag?

• Blood or liquids which cannot be emptied must go
  into a red bag for special handling.
• Different facilities have different policies.
• Different states have different policies.
• Find out where the red bag container is.
• Do not throw things into red bag trash unless
  they need to go it, since it costs up to 80 times
  as much as regular trash!

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Aerosol-Transmissible Diseases (ATD) Standard

• NEW California law went into effect 2009.
• Specifies actions to protect workers from any
  disease requiring Airborne or Droplet
  Precautions.
• Use precautions with any patient with symptoms of
  a respiratory infection, such as cough, sore
  throat, or runny nose.
• You will get workplace-specific information from
  your employers.

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Respiratory Hygieneis part of the new ATD
Standard

• Wear a mask (surgical or isolation mask) when
  caring for any patient with symptoms of a
  respiratory infection, until it is clear that the
  cause of the symptoms does not require those
  precautions.
• Use eye protection with the mask if you may be
  splashed.
• Do not wear eye protection without a mask!
• In ambulatory care sites, assist patients with
  respiratory symptoms to cover coughs with tissues
  or wear a mask themselves and to do hand hygiene
  before being seen.

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Could this patient have TB???

• Only ACTIVE TB is contagious (not latent).
• Active TB has SYMPTOMS
• Cough that lasts more than 3 weeks
• Unexplained weight loss or loss of appetite
• Night sweats
• Bloody sputum

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Could this patient have TB???

• Groups at higher risk to have TB include
• Foreign born persons from areas with high
  incidence of TB, such as Africa, Asia, Eastern
  Europe, Latin America and Russia
• Residents and employees of congregate care
  facilities at higher risk, including prisons
• Medically underserved populations.
• The patient most likely to transmit TB is the
  patient who has NOT BEEN DIAGNOSED AND ISOLATED!

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Identifying people with active TB

• Screening for TB infection, which may be latent,
  is often done by a TB skin test, but false
  negatives can occur if the person is immune
  compromised.
• People with active TB are likely to have an
  abnormal chest X-ray.
• Diagnosis is by microscope examination of sputum.
• DO NOT WAIT FOR A FIRM DIAGNOSIS! Get an order
  to isolate as soon as TB is suspected!

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CDC has 4 kinds of isolation,but only 3
isolation signs!

• Standard Precautions are used with ALL patients,
  and no sign is placed on the door.
• These 3 will have a sign on the door and they
  will need a private room.
• Airborne Precautions
• Droplet Precautions
• Contact Precautions

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Airborne PrecautionsPart 1

• Use Airborne Precautions for patients who may
  have TB, chickenpox, disseminated zoster,
  measles, SARS, or smallpox.
• Patients with chickenpox are not usually admitted
  to the hospital, but they may be admitted for
  ANOTHER REASON!
• Most patients in Airborne Precautions are having
  TB ruled out, and most of them DO rule out.
  There is not much TB around here, but there is
  some.
• TB is NOT super-contagious!

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Airborne PrecautionsPart 2

• This is the ONLY kind of isolation which requires
  use of a negative pressure room.
• The room sucks!
• This is the ONLY kind of isolation which requires
  use of an N-95 respirator. Do not refer to it
  as a TB mask.
• Keep the door to the room CLOSED to maintain
  negative pressure. IMPORTANT POINT!
• For patients with chickenpox, disseminated
  zoster, or measles, only IMMUNE STAFF should
  enter the room, if possible.
• If the patient must come out of the room, put a
  regular mask on him/her. Do not put an N-95 on
  the patient!

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Droplet Precautions

• DROPLET PRECAUTIONS are used for patients with
  respiratory infections which have not yet been
  diagnosed, also with seasonal INFLUENZA,
  pertussis (whooping cough) some kinds of
  meningitis, and others.
• Wear a surgical or isolation mask (NOT an N-95
  respirator) to enter the room.

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PANDEMIC INFLUENZA

• Last years H1N1 pandemic has been declared over.
• It is now considered part of seasonal influenza,
  and a droplet mask is enough.
• In any future pandemic, expect guidance to
  change, sometimes often, as the science evolves.
• Do diagnose and ISOLATE patients with either
  pandemic or seasonal influenza.

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Contact Precautions

• Contact Precautions are used for infections which
  are easily spread by hands or things.
• Think of these germs as being sticky.
• Hand hygiene is the critical key to
  preventing spread of these germs!

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Contact Precautions

• Contact Precautions are used in some (but not
  all) facilities for patients with
• MRSA Methicillin-Resistant Staph aureus, a
  skin germ
• VRE Vancomycin-resistant Enterococcus, a poop
  germ
• C diff Clostridium difficile, another poop germ
• Norovirus another poop germ!
• And a number of less common infections.

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To do Contact Precautions

• Wear gown and gloves for ALL interactions that
  may involve contact with the patient or
  potentially contaminated areas in the patients
  environment. (This is a 2007 change from earlier
  recommendations which did not require a gown
  every time.)
• Patient care equipment (stethoscopes,
  thermometers, etc.) should NOT BE SHARED! You
  should find that equipment already in the room
  for that patient only.
• Equipment which must be brought out of the room
  must be WIPED DOWN with disinfectant. Most
  places have disinfectant wipes which are handy
  for that.
• Masks are not needed except as required by
  Standard Precautions.

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Neutropenia (or Protective) Precautions

• The CDC does not give specific details for
  Neutropenia Precautions since the evidence is
  weak that they help.
• Their purpose is to protect the severely
  immune-compromised patient from exogenous flora.
• The greatest risk to these patients is from
  endogenous flora.
• Some facilities do still use them.
• Refer to facility policy for specific details.

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Isolation policies vary!

• CDC Guidelines for Infection Control are
  guidelines, NOT regulations.
• Hospital policies for isolation vary!
• Be sure to find out the details of what your
  facility expects.
• Answers to many questions are often right on the
  isolation sign.
• Know how to find the Infection Control Manual for
  details. It is usually online!

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Should this patient be isolated?

• They have a cough and weight loss - could be TB.
• They have respiratory symptoms - could be
  influenza.
• They have a rash - could be chickenpox or
  measles.
• They have a draining wound, especially if the
  drainage is not contained.
• Dementia may cause uncontained body substances
  and the need for isolation.
• They have diarrhea - could be C diff or
  norovirus.
• Sick poop? Think isolation and soap and water!

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What do I need to know about MRSA?

• Ordinary Staph aureus is very common. One of
  every 3 people is a carrier.
• Ordinary Staph aureus is an invasive germ which
  can cause serious, even fatal infections.
• Methicillin-resistant Staph aureus is resistant
  to most (but not all) antibiotics.
• In most facilities, EVERY patient known to have
  MRSA will be on Contact Precautions.
• Patients with MRSA in their SPUTUM (NOT just
  their nose) will be on Droplet Precautions TOO.

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MRSA has become MUCH more common in the
community!

• It may start out looking like a spider bite, and
  it can spread through a family or an athletic
  group.
• Good hygiene, especially hand hygiene, stops
  spread.
• Forest and field take care of your good germs!

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Emotional impact of isolation

• Isolation can have a profound psychological
  impact on the patient and their family,
  especially if it is prolonged.
• They treat me like a leper!
• Depression can impact recovery from the
  underlying disease.
• Be sure to treat the patient with full respect
  and extra TLC!

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Vector-borne diseases

• Vector-borne diseases are spread by arthropods
  such as mosquitoes or ticks.
• Examples include West Nile Virus, which we all
  know is spread by mosquitoes, and Lyme disease,
  which is spread by ticks.
• There is not an isolation category for this means
  of transmission, since we do not expect to find
  arthropods in hospitals.

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How to protect your patients from HAIs

• There are 4 main kinds of HAI-
• Bloodstream infections Change IV sites and
  maintain them per policy. Get the IV out ASAP.
• Surgical site infections Meticulous sterile
  technique is used in the OR. Maintain surgical
  dressings dry and intact.
• Pneumonia Help your patient to turn, cough, and
  deep breathe. Get your patient up and walking as
  ordered. Give pain medicine as needed to help
  them cough. Do frequent oral care. Prevent
  aspiration. Keep the head of the bed up.
• Urinary tract infections Get the foley cath out
  ASAP!
• HAIs can KILL!

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Host defenses

• Skin keeps the germs out unless there are
  holes!
• Mucous membranes same as skin.
• Cilia sweep germs out of our lungs.
• Cleansing flow fluids clean systems that open
  to the outside, and infections result if the flow
  is blocked.
• Normal flora the good germs crowd out the bad
  ones.
• Stomach acids kill most of the germs on our
  food.
• White blood cells (WBCs) swallow up germs.
• Antibodies attack invaders we have met before.

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Tubes and foreign bodies

• Tubes in the patient can lead to infection
  because
• They bypass normal host defenses
• Germs can live on them by creating biofilm.
• Ask for an order to get the tubes out as soon as
  they are no longer needed!
• Foreign bodies, such as artificial joints, heart
  valves, or implanted devices can lead to
  infection because germs can live on them by
  creating biofilm.

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Aseptic technique

• Aseptic technique is the use of sterile items.
• It is both a knowledge base AND a motor skill.
• Items which enter sterile spaces (bloodstream,
  brain, or muscle tissue, for example) must be
  sterile.
• An item is either sterile or not sterile. There
  is no gray area.
• Only sterile things may touch sterile things or
  areas.
• If a sterile item or area is touched by an
  unsterile item, the once-sterile item or area has
  been contaminated and is no longer sterile.
• Aseptic technique can be done with non-sterile
  gloves or bare hands when we simply do not touch
  the sterile area. We do this routinely when we
  give injections or start IVs, for example.
• Aseptic technique is sometimes called surgical
  asepsis.

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Clean and dirty

• Clean and dirty are relative terms.
• You must always ask compared to what?
• The patients chart is _______ .
• Always work from clean to dirty to avoid carrying
  germs.
• Clean technique uses non-sterile gloves, and is
  used for mouth care, for example.
• Clean technique is sometimes referred to as
  medical asepsis.

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Disinfection

• Critical items which enter sterile spaces must
  be sterile. Sterilization kills all microbial
  life.
• Semicritical Items which touch intact mucous
  membranes must receive high-level disinfection.
  It kills all microbial life except spores.
• Non-critical Items which touch intact skin must
  be clean, such as washed with soap and water,
  which removes most pathogenic bacteria.
• High-level disinfection products used to clean
  patient care equipment which touches mucous
  membranes.
• Low-level disinfection products used to clean
  the hospital environment or items which touch
  intact skin.
• Be sure you use
• the right product for the purpose!

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What patients are at higher risk?

• The patient who is already seriously ill.
• The patient who is bed-bound.
• The patient with tubes in.
• The patient with holes in their skin.
• The patient whose breathing is compromised.
• The patient with immune compromise, such as low
  WBC count, HIV, renal failure or diabetes.

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Putting Infection Prevention to work for your
patient!

• Know what to do to protect every patient you care
  for!
• Use the CDC Guidelines to protect them!
• Teach the patient and their family what THEY can
  do to prevent infection!
• Include infection prevention in the care plan of
  every patient, especially those at higher risk.
• Identify patients at higher risk, and take extra
  care to protect them!
• Be sure the entire team takes extra care for them!

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Infection Control is a fast-moving field!

• The basics do not change, but the science and
  regulations do!
• We have even changed the name from Infection
  Control to Infection Prevention, which is really
  what we are doing!
• Recent changes include
• ATD Standard and Respiratory Hygiene
• No artificial nails on bedside staff.
• Dont think you learned it once in school and it
  will never change!

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Its getting more strict

• due to MRSA, the Patient Safety movement and
• LOTS of new regulations,
• both state and federal!
• Know your Infection Preventionist as your friend,
  resource, and ally!

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Teamwork and accountability

• The whole care team must work together to protect
  the patient!
• Be sure the patient and family are on the team!
• Each unit is accountable
• for its own practice.
• Learn your units policy for holding others
  accountable. What do YOU do if you see someone
  else fail to do hand hygiene?

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Lets quickly review the syllabus objectives

• Define healthcare-associated infections, client
  risk factors, and appropriate nursing
  interventions to decrease incidence of HAIs.
• Define aseptic technique (surgical asepsis) and
  clean technique (medical asepsis).
• Analyze each link of the chain of infection and
  nursing actions to interrupt each link.
• Explain why hand hygiene is the most important
  single procedure for preventing spread of
  infection.

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More syllabus objectives

• Explain the rationale for Standard Precautions
• Describe the categories of transmission-based
  precautions currently recommended by the CDC.
• Discuss the psychological impact of precautions,
  such as for MRSA, on the client.
• Identify clients most at risk for acquiring an
  infection

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Objectives

• Who does Infection Control protect?
• What is the weakest link in the chain of
  infection?
• What is the most important procedure to prevent
  spread of infection?
• Which kind of hand hygiene is better for routine
  use?
• What kind of patients need Standard Precautions?

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Got brain overload?

• Lets review what you really do need to know now,
  and then we can take your questions.