Second core IC measure -Standard precautions are used for all patients regardless of their diagnoses to ensure protection of the health care worker and the patient. -For certain highly transmissible or epidemiologically important pathogens, transmission-based precautions are used in addition to standard precautions. -Contact, droplet, and airborne precautions are meant to block the different routes of transmission that we discussed earlier. -Since the infecting agent often is not known at the time of admission to a health care facility, transmission-based precautions are used empirically , according to the clinical syndrome and the likely etiologic agent at time, and then modified when the pathogen is identified or a transmissible infectious disease etiology is ruled out. -These infection control principles are also used for laboratory and procedure-specific safety.
Standard precautions are intended to be applied to the care of all patients in all health care settings, regardless of the suspected or confirmed presence of an infectious agent. The main elements of standard precautions include: Hand hygiene Respiratory hygiene and cough etiquette have been added to standard precautions to control transmission of respiratory infections. Use of personal protective equipment (PPE) based on risk assessment to avoid direct contact with patient's blood, body fluids, secretions and non-intact skin Prevention of needle sticks/sharps injuries and Cleaning and disinfection of the environment and equipment
Droplet Precautions are used in addition to Standard Precautions to provide protection to clinicians and others protection from infections spread by large droplets generated by coughs and sneezes, such as Neisseria meningitidis , and pertussis Critical additional protection measures under Droplet Precautions are: the use of a medical/ procedural mask (by HCWs) when within a meter of a patient Physically maintaining distance between the infected patient and other persons by a distance of at least one meter from all other persons, Limit patient movement. If a patient has to leave the area, the patient should wear a medical mask, if tolerated, for the duration of their time away.
Contact Precautions are used for protection against contact (i.e., hand contamination or self-contact) with large droplets The key elements of Contact Precautions for patients suspected or confirmed of having a disease spread by droplets or some common respiratory pathogens are: Using clean, non sterile gloves for all episodes of direct patient contact Changing the gloves after each patient contact Use a gown (disposable or re-washable) for each patient contact and disposing of it as either waste or laundry depending on its type, after each episode Use dedicated specific equipment (preferable single-use) for a single patient and clean and disinfect shared equipment between patient uses. HCWs should avoid contact with their face, eyes or mouth when their ungloved or gloved hands may be contaminated Limit patient movement outside of their designated room Limiting patient contact with other well patients Putting the patient in a single room or in a room only with other patients with the same diagnosis or with similar risk factors Contact Transmission Persons infected with some common respiratory pathogens can spread their disease by either contaminating their own hands, the hands of a healthcare worker or an environmental surface. Hands can transmit these diseases when they have contact with contaminated surfaces followed by contact with either another body surface such as the conjunctival or nasal mucosa or an intermediate object.
Airborne Transmission Airborne precautions are used for protection against inhalation of tiny infectious droplet nuclei, In addition to standard precautions Use a particulate respirator when entering the patient isolation room. PERFORM SEAL CHECK BEFORE EACH USE! Place the patient in adequately ventilated room (≥ 12 air changes per hour) Limit patient movement and ensure that the patient wears a medical mask if outside their room. Airborne precautions should also be performed during the performance of any aerosol-generating procedures associated with pathogen transmission (e.g., endotracheal intubation, bronchoscopy)
Hand hygiene is the cornerstone of infection control Hand hygiene should be performed: before direct contact with a patient after any direct contact with a patient and before contact with the next patient before performing invasive procedures after contact with blood, body fluids, secretions and excretions after contact with items known or considered likely to be contaminated with blood, body fluids, secretions and excretions, including respiratory secretions immediately after removing gloves and other protective equipment between certain procedures on the same patient where soiling of hands is likely, to avoid cross-contamination of body sites before preparing, handling, serving or eating food and before feeding a patient. Patients, care givers and visitors should be instructed in proper hand hygiene.
Respiratory hygiene and cough etiquette have been added to standard precautions to control transmission of respiratory infections . Education of health workers, patients and visitors Source control measures (e.g., cover cough to prevent dissemination of infectious droplets) Hand hygiene Spatial separation (> 1 meter) of persons with acute febrile respiratory symptoms
PPE has been used by HCWs since at least the 14 th century Although most doctors left plague-affected areas during the time of the “Black Death,” those who remained often donned PPE that consisted of: a hat to indicate that the wearer was a doctor a mask to protect the face crystal eyes to protect the eyes of the wearer beak stuffed with spices or herbs to purify the air leather gloves a waxed gown full length boots a wooden stick to push away patients who got too close
All of the PPE listed here prevent contact with the infectious agent, or body fluid that may contain the infectious agent , by creating a barrier between the worker and the infectious material. Gloves, protect the hands, gowns or aprons protect the skin and/or clothing, masks and respirators protect the mouth and nose, goggles protect the eyes, and face shields protect the entire face. The respirator, has been designed to also protect the respiratory tract from airborne transmission of infectious agents. We’ll discuss this in more detail later. Goggles – protect eyes Face shields – protect face, mouth, nose, and eyes
ASSESS THE RISK of exposure to body substances or contaminated surfaces BEFORE any health care activity. Select PPE based on the assessment of risk: The effectiveness of PPE is dependent on adequate and regular supplies, adequate staff training, proper hand hygiene, and in particular, appropriate human behaviour.
ASSESS THE RISK of exposure to body substances or contaminated surfaces BEFORE any health care activity. Select PPE based on the assessment of risk: As discussed earlier, contact precautions are used for infections spread by direct or indirect contact. Protection measures to prevent contact transmission include the use of disposable gowns and gloves Protection measures to prevent droplet transmission include the use of a medical/ procedural mask when within one meter of a patient. A particulate respirator should be used when entering the room of a patient with an airborne disease to protect against airborne transmission
Assess patients for placement based on their epidemiological and clinical clues for ARDs of potential concern as well as the recommended precautions (including standard precautions) for their suspected or confirmed causative agent. Patient placement will also depend on what facilities are available. Ideally, infectious patients with droplet or airborne diseases should be isolated from other patients so that others are not exposed to the infectious droplets generated by the infectious patients. In settings where isolation facilities do not exist, separate wards, areas, or rooms should be established for infectious patients. Only allow patients with epidemiological and clinical information suggestive of a similar diagnosis to share rooms. Patients should be spatially separated by at least 1 meter.
Ideally, infectious patients with droplet or airborne diseases should be isolated from other patients so that other patients are not exposed to the infectious droplets that they generate This slide shows the ventilation system that might be used if a negative pressure isolation room is not available. Air flows into the room from the outdoors, and flows back out of the room to the outdoors. There should be a door that can be kept closed. If multiple patients are cohorted in the same room, beds should be kept at least one meter apart.
DEFINITIONS• INFECTION is invasion and multiplication of microorganisms in a host, with an associated host response (e.g. fever, pain, edema, purulent drainage).• Infection may be local or generalized.• Infections may require antibiotic treatment.• Infection is preceded by colonization.• COLONIZATION, whereby microorganisms are present in the host but do not invade or cause an associated host response, is distinct from infection. No treatment is needed.
RISK OF INFECTION• The risk of infection is always present.• Patient may acquire infection before admission to a hospital known as Community acquired infection.• Patient may get infection inside the hospital known as Nosocomial Infection/ Healthcare Associated Infections (HAIs).
HEALTHCARE ASSOCIATED INFECTIONS (HAIS)• These includes infections which are Not present nor incubating at admission. That appear more than 48 hours after admission. Those acquired in the hospital but appear after discharge. Occupational infections among staff as a result of Needle Stick Injury / exposure to blood & body fluids e.g. HBV, HCV & HIV.
PREVALENCE OF HAIs• Developed countries• In developed countries, even with sophisticated treatments and technologies, HAI continues to account for complications in 5-10% of admissions to acute-care hospitals.• For example, in the U.S. alone there are at least 80,000 fatalities each year (about 200 deaths/day) from HAI. (WHO 2013)
PREVALENCE OF HAIs• Developing countries• The impact of HAI is far greater than developed countries, the prevalence studies report hospital-wide infection rates usually higher than 15%. (WHO 2013)• In these countries, over 4000 children die of HAI every day.• Approximately half of all patients admitted to neonatal intensive care units acquire an infection, and over half of them die.
HAIs INFECTION SITESBlood stream & Urinary tract infections are most common (30-40%), these are associated with an central line or umbilical catheter / with an indwelling urinary catheter or instrumentation.Ventilator Associated Pneumonia ( VAP) and Surgical Site infections (SSI) are the next (about 15% each).Than comes bacteraemia (5%).Other sites includes gastrointestinal tract, intravenous site infections and skin infections.
MICROBIAL AGENTS1. Commensal bacteria: found as normal flora of healthy humans they prevent pathogenic bacterial colonization of mouth, skin, colon, vagina etc.2. Pathogenic bacteria: have great virulence and causes infection.3. Viruses:4. Parasites:5. Fungi:
PATIENT SUSCEPTIBILITYAge: Infancy and old age has decreased resistance to infection.Immune status: Patients with chronic diseases as malignancy, leukemia, diabetes mellitus, renal failure or AIDS have increased susceptibility to infection.Immunosuppressive drugs or irradiation
ENVIRONMENTAL FACTORS Healthcare settings are environment where both infected and infection susceptible patients are present. Patients may get infection due to crowding within hospital or due to frequent transfers between deferent units. Microbial flora may contaminate hospital furniture, rooms, devices and other materials which if come in contact with susceptible patients cause infection.
ROUTE OF HAIsEndogenous infection:When normal patient flora change to pathogenic bacteria because of change of normal habitat, damage of skin and inappropriate antibiotic use.About 50% of HAIs Are caused by this way.Exogenous cross-infection:Mainly through hands of healthcare workers, visitors, patients.
ROUTE OF HAIsExogenous environmental infections:several types of micro-organisms survive well in the hospital environment (hospital flora): On linen, equipment and supplies In water supply and food. In fine dust and as droplet nuclei.Invasive procedures:Increase risk of infection e.g. urinary catheters, I.V. lines, inhalation therapy, surgery.Inappropriate use of antibiotics.Treating colonization with antibiotic.
CHAIN OF INFECTION Portal ofQuant Routes of entry into Susceptibity of Virule transmission le nce hostpatho host
AIM OF INFECTION CONTROL• Disease transmission can be prevented by breaking one or more of the links in the chain of transmission.• Basic infection control measures based on reducing the risk of transmission of pathogens from a known or unknown source.
BASICS OF INFECTION CONTROLPrevention of HAIs is the responsibility of all individuals and services providers of the healthcare setting. To practice good asepsis, one should know: what is dirty, what is clean, what is sterile and how to keep them separate. Hospital Infection Control policies & procedures are applied to prevent spread of infection in hospital.
INFECTION CONTROL PROGRAM• A comprehensive, effective and supported program is essential for reducing infection risk and increasing hospital safety.• It includes surveillance, preventive activities and staff training.• Hospital ICP should be based on: 1) Preventive efforts keeping in mind patients and staff safety. 2) Support of senior management and provision of sufficient resources. 3) Development of an yearly work plan to assess and promote all infection control health care activities.
Hospi t a l Pr o gr a mI n f e ct io n Conr t o l Team I n f e ct i o n c o ntr o l commi t e e I n f e ct io n cont r o l manual
INFECTION CONTROL TEAM• The optimal structure varies with hospitals types, needs and resources but ideally ICT should compose of ICD & ICNs with a separate office. According to WHO one ICN for 250 beds.• Hospital can appoint public health specialist or epidemiologist or infectious disease specialist, microbiologist to work as Infection Control Director (ICD).• Infection control nurse (ICN), having experience in infection control issues.
INFECTION CONTROL COMMITTEE It is a multidisciplinary committee responsible for monitoring IC program policy implementation and recommendation for corrective actions. It includes representatives from different concerned hospital departments and management, and they should meet monthly. It establishes standards for patient care, reviews and assesses IC reports and identifies areas of intervention.
INFECTION CONTROL MANUALEvery Hospital should have a Infection Prevention & Control manual (ICM) having instructions and recommended practices for patient care.IC manual should be developed and updated every two years by the infection control team.It should be reviewed and approved by infection control committee and distributed to all units for reference.
Pr o gr a m Com ponentsSur v eil a nce Pr e vent iv e Act iv it ie s St a f Tr a in in g
NOSOCOMIAL INFECTION SURVEILLANCE• The term surveillance implies to regular analysis of observational data aiming at the reduction of HAIs rate and their costs.• HAIs rate of a hospital is an indicator for quality of service & safety of patient care.• Surveillance is done to monitor HAIs rate, which is essential to identify problems and to evaluate infection control activities.
TYPES OF SURVEILLANCE• Active surveillance (Prevalence and incidence studies).• Targeted surveillance (site, unit, priority-oriented target).• Requirements For Surveillance• Trained investigators.• Standardized methodology.• Risk- adjusted rates for comparisons.
ORGANIZATION FOR SURVEILLANCE D a t a c o lle c t io n a n d a n a ly s is W a r d a c t iv ity L a b o r a t o r y r e p o r ts D a t a e le m e n t s & a n a ly s is d e v ic e s o r p r o c e d u r e s c u lt u r e & s e n s it iv ity p a t ie n t d a t a & in f e c t io n f e v e r & in f . s ig n s r e s is t a n c e p a t t e r n s p o p u la t io n & r is k s a n t ib io t ic s & c h a r ts s e r o lo g ic t e s t s c o m p u t e r iz a t io n o f d a ta F e e d b a c k & d i s s e m e n a ti o np ro m p t, re l e v e n t to ta rg e t g ro u p M e e tin g s & d is s c u s s i o n s D is s e m e n a tio n b y c o m m itte e
Core Infection Control Measures inHealth Care Settings
CORE INFECTION CONTROL MEASURES IN HEALTH CARE SETTINGS● Early recognition and reporting of HAIs.● Infection control precautions.● Hand hygiene: Use of hand wash & alcohol- based hand rub.● Personal Protective Equipment PPE: Like gloves, gowns, masks/respirators, eye protection.● Patient accommodation.● Environmental cleaning and waste disposal.● Occupational health management.
INFECTION CONTROL PRECAUTIONS • Standard Precautions – Should be applied for ALL patients • Transmission-based Precautions* – Contact – Droplet – Airborne*Transmission-based precautions are often used empirically, according to the clinical syndrome and the likely etiological agent
STANDARD PRECAUTIONS•Hand hygiene.•Respiratory hygiene/cough etiquette.•Use of personal protective equipment (PPE).•Prevention of needle sticks/sharps injuries.•Cleaning and disinfection of the environment and equipment.
DROPLET PRECAUTIONS• Use for protection against respiratory pathogens transmitted by large droplets• In addition to Standard Precautions: – Use a surgical/medical mask – Maintain a distance ≥ 1 meter between infectious patient and others. – Place patient in a single room or cohort with similar patients. – Limit patient movement.
CONTACT PRECAUTIONS• Use for protection against infections which spread by contact• In addition to Standard Precautions: – Use non-sterile, clean, disposable gloves, gown, apron (only if gown is not impermeable) – Use disposable or dedicated reusable equipment (which must be cleaned and disinfected before use on other patients) – Limit patient contact with non-infected persons – Place patient in a single room or cohort with similar patients
AIRBORNE PRECAUTIONS• Use for protection against inhalation of tiny infectious droplet nuclei• In addition to Standard Precautions: – Use particulate respirator /N 95 mask – Place the patient in adequately ventilated room (≥ 12 air changes per hour) – Limit patient movement• Use airborne precautions during performing of any aerosol-generating procedures associated with risk pathogen transmission like bone cutting, dental procedures.
HAND HYGIENE IS THE CORNERSTONE OF INFECTION CONTROL WHO Five Moments of Hand Hygiene
TYPES OF HAND HYGIENE• Routine Hand wash with plain soap & water is the mechanical removal of soil and transient bacteria (for 40-60 sec).• Aseptic hand wash is removal & destruction of transient flora using anti-microbial soap & water (for 40-60 sec).• When hands are visibly soiled do wash hands with soap and water.• Alcohol hand rub 2cc gel is use (for 15-20 sec).• Use alcohol-based hand rub when hands are not visibly soiled.• Surgical hand scrub: removal / destruction of transient flora and reduction of resident flora using anti-microbial soap with effective rubbing (for least 3-5 min).
Gloves is not substitute hand washing, it must be done before putting on gloves and after their removal.
RESPIRATORY HYGIENE AND COUGH ETIQUETTE• Part of standard precautions.• Education of health care workers, patients and visitors.• Source control measures ( cover mouth to prevent dissemination of infectious droplets)• Proform Hand hygiene• Spatial separation (> 1 meter) of persons with acute febrile respiratory symptoms.
PERSONAL PROTECTIVE EQUIPMENT Courtesy of K. Harriman
TYPES OF PPE USED IN HEALTHCARE Gloves – protect hands Gowns/aprons – protect skin and/or clothing Masks and respirators– protect mouth/nose – Respirators /N95 mask – protect respiratory tract from airborne infectious agents Goggles – protect eyes Face shields – protect face, mouth, nose, and
PPE FOR STANDARD PRECAUTIONS Based on Risk Assessment• IF direct contact with blood & body fluids, secretions, excretions, mucous membranes, non-intact skin – Gloves – Gown – Mask• IF there is the risk of spills onto the body and/or face – Gloves – Gown – Face protection (mask plus eye protection goggle or visor; face shield) – Booties
PPE FOR TRANSMISSION-BASED PRECAUTIONS• Used in addition to Standard Precautions• Contact Precautions + – Gloves – Gown• Droplet Precautions – Surgical/Medical mask• Airborne Precautions – Particulate respirator/ N95 mask
PATIENT ACCOMMODATION●Separate wards, areas or establish rooms for infectious patients where isolation facilities do not exist.●Separate patients by at least 1 meter●Isolate patients with droplet or airborne spread diseases from other patients.●Only patients with epidemiological and clinical information suggestive of a similar diagnosis should share rooms.
PATIENT ACCOMMODATION:NATURAL VENTILATION ROOM 1 meter
SHARP PRECAUTIONSNeedle stick and sharp injuries carry the risk of blood born infections e.g. AIDS, HCV,HBV and others.Sharp injuries must be reported and notified so that treatment & post exposure prophylaxis can possible.Reusable sharps must be handled with care to avoid injury during procedure.Never recap needles, if necessary use one hand scoop method.Dispose used needles and other sharps immediately in puncture resistant boxes (sharp container ).Sharp Containers: must be easily accessible and at eye level, must not be overfilled, labeled or color coded.
SHARPONE HAND SCOOP CONTAINERMETHOD OF RECAPPING
HANDLING OF CONTAMINATED MATERIAL• Cleaning of Blood/Body Fluid spills: a- wear gloves gown mask. b- wipe-up the spill with paper towel. c- apply disinfectant Clorox for 2 to 10 minutes.• Cleaning & decontamination of equipment: Protective barriers must be worn like gloves.• Handling & processing lab specimens: Must be placed in strong plastic bags with biohazard label.• Handling and processing linen: Soiled linen must be handled with barrier precautions like gloves & mask and sent to laundry in coded bags in designated trolleys.
ENVIRONMENTAL DECONTAMINATION• Cleaning MUST precede decontamination• Disinfectant ineffective if any organic matter is present.• Use mechanical force – Scrubbing – Brushing – Flush with water• Wipe nonporous surfaces with sponge or wet cloth – Allow to dry• Use fresh diluted Clorox/bleach daily! 100 ml Clorox into 900ml water
WASTE DISPOSAL• Handling and processing infectious waste:a. Waste must be placed in color coded, leakage proof bags, collected with barrier precautions like gloves.b. Contaminated waste incinerated or better autoclaved prior to disposal in a landfill according to local
PATIENT PROTECTION• Corrective measures before major procedure, vaccination, antibiotics prophylaxis, proper use of antibiotics.• Isolation precautions.• Limiting endogenous risk.
STAFF HEALTH PROMOTION & EDUCATION• HCW are at risk of acquiring infection, they can also transmit infection to patients and other employee.• Employee health history must be reviewed, immunizations recommendations must be carried out.• Release from work if sick (Work restriction)• Occupation injury must be notified.• Continuous education to improve practice, better performance of new techniques.