Dr.T.V.Rao MD   Dr.T.V.Rao MD   1
A Tribute to    Ignaz Semmelweiss (1818-1865)Ignaz Semmelweiss (1818-1865)   Obstetrician, practised in   Vienna   Studied...
History of infection control andhospital epidemiology in the USA      Pre 1800: Early efforts at wound prophylaxis      18...
Why do we need Infection           Control??Hospitals and clinics are complex institutions where patients go to have their...
What is Nosocomial Infection Any infectionthat is notpresent orincubating at thetime the patientis admitted tothe hospital...
Consequences of Nosocomial        InfectionsAdditional morbidityProlongedhospitalizationLong-term physical,developmental a...
Florence NightingaleIt may seem astrange principle toenunciate as thevery firstrequirement in ahospital that itshould do t...
Links to the Chain of         Infection•   Portal of Entry•   Susceptible Host•   Causative Agent•   Reservoir•   Portal o...
Hospital Infections are Emerging    challenges in Health CareHospital-associated infections represent a seriousand growing...
Modern Hospital Infection          ControlModern hospital infection control programs first began inthe 1950s in England, w...
CHAIN OF INFECTION       Dr.T.V.Rao MD   11
Beginning of AccreditationIn 1969, the JointCommission forAccreditation of Hospitals--later to become the JointCommission ...
CDC Initiates Hospital   Infection Branch                         In 1972, the Hospital                         Infections...
First Data on Infection Control            EfficacyIn 1985, the Study of theEfficacy of NosocomialInfection Control (SENIC...
Committee SuggestedOne infection controlprofessional (ICP) for every250 beds. An effectiveinfection control physician.A pr...
Infection Control Challenges of       Healthcare in 2000 Decreasing reimbursement Increasing emerging infections Increasin...
The nature of infectionsMicro-organisms - bacteria, fungi, viruses,protozoa and wormsMost are harmless [non-pathogenic]Pat...
Modes of spreadTwo sources of infection:  Endogenous or self-infection - organisms which are harmless in one site can be p...
Spread - entry and exit routesNatural orifices - mouth, nose, ear, eye,urethra, vagina, rectumArtificial orifices - such a...
HAI - common bacteriaStaphylococci - wound, respiratory and gastro-intestinal infectionsEscherichia coli - wound and urina...
HAI - common viruses Hepatitis A - infectious hepatitis Hepatitis B - serum hepatitis Human immunodeficiency virus[HIV] - ...
Components of Infection      Control ProgrammeThe important components of the infection control programmeare: Basic measur...
Need For      Control programme?Effective work practices and procedures, such asenvironmental management practices includi...
Developing Infection Control            ProgrammeEvery infection control program should develop a well-defined written pla...
Administrative control measures          Assignment of responsibilities                                   Administrator   ...
Infection control           committeeAn infection control committee provides a forum formultidisciplinary input and cooper...
Prevention of Hospital             Infection-Planning                                   Implemented, monitored LIFECYCLE O...
The Infection Control        TeamConsist of at least aninfection control practitionerwho should be trained forthe purpose;...
Infection Control Committee                Purpose Advisory     Review ideas from infection control team     Review survei...
Infection Control Committee -                  RepresentedCommittee Representatives      Hospital Epidemiologist      Infe...
Identify problems with polices and procedures                Example: Pre- and Post-Operative Care                        ...
Aims of Infection ControlTo review and approve a yearly programme of activityfor surveillance and prevention; to reviewepi...
Education is the Real Strength of Infection Control programmeEducation programs for employees and volunteers areone method...
Minimal Needs to Start   Infection Control Unit1 Organized surveillanceand control activities2. One infection controlpract...
GUIDELINES for Effective    Control of InfectionsHand washing and Hospital Environmental Control* Immunization* Infectious...
GUIDELINES for Effective    Control of Infections* Guidelines for Infection Control in Health Care Personnel* Surgical Sit...
Your Unwashed Hand a Great  Concern to Your Patient           Dr.T.V.Rao MD     37
Hand Washing is the Foundation     of Infection ControlHand washing is the single mostimportant procedure for preventingno...
Hand Washing is the Foundation     of Infection Control                            Hand washing with plain soaps          ...
Hand washing TechniqueFor routine handwashing, a vigorousrubbing together of allsurfaces of lathered handsfor at least 10 ...
Hand washingSingle most effective action to prevent HAI -resident/transient bacteriaCorrect method - ensuring all surfaces...
Hand washing – Areas Missed                           Taylor (1978)                           identified that 89% of      ...
Successful Promotion   in Hand WashingEducationRoutine observation & feedbackEngineering controls     Location of hand bas...
Successful Promotion can Improve Hand WashingReminders in the workplaceAdministrative sanctions ??Change in hygiene agent ...
Hand Hygiene Techniques           Many Ways1.   Alcohol hand rub2.   Routine hand wash 10-     15 seconds3.   Aseptic proc...
Advantages of Alcoholic Hand           WashRequire less timeCan be strategically placedReadily accessibleMultiple sitesAll...
Antibiotic resistance            Not a new problem - Penicillin in 1944Hospital “superbugs”Methicillin ResistantStaphyloco...
MRSADiscovered in 1981Found on skin and in thenose of 1 in 3 healthypeople - symptomlesscarriersWidespread in hospitalsand...
Hospital Acquired Infections and           ConsequencesIncidence of 10%5,000 deaths per year - direct result of HAI15,000 ...
The nature of infectionMicro-organisms -bacteria, fungi, viruses,protozoa and wormsMost are harmless [non-pathogenic]Patho...
Staff healthRisk of acquiring and transmitting infectionAcquiring infection immunisation cover lesions with waterproof dre...
Waste disposalClinical waste - HIGH risk   potentially/actually contaminated waste including   body fluids and human tissu...
Spillage of body fluidsPPE - disposable gloves, apronSoak up with paper towels, kitchen rollCover area with hypochlorite s...
Standard PrecautionsHand hygieneRespiratory hygiene and cough etiquettePersonal protective equipment (PPE)Based on risk as...
Nosocomial Infections are great concern in     Immune compromised Patients  Immunocompromised patients vary  in their susc...
Strengthen the EpidemiologyEpidemiology is the scientific   process applied to the control of infections in the     health...
Areas of interest to a hospital                 epidemiologist     Surveillance for nosocomial     infection              ...
Areas of interest to a Hospital           EpidemiologistAntibiotic useAntibiotic resistantpathogensMicrobiology supportNat...
What is the role of healthcare            epidemiology?Eliminate or minimize risks to a patient’s  health  organize care t...
Responsibilities of the Infection         Control ProgramSurveillance of nosocomial               Education of hospitalinf...
Key elements of surveillanceDefining as precisely as possible the event to besurveyed (case definition)Collecting the rele...
Areas of interest to a  healthcare epidemiologistSurveillance for                      Employee healthnosocomial infection...
Organizing for Infection        ControlRequires cooperation, understanding andsupport of hospital administration andmedica...
Methods to reduce cost of      Nosocomial InfectionsReduce incidenceReduce morbidityShorten hospital stayReduce costs of t...
Universal infection control           precautionsDevised in US in the 1980’s in response togrowing threat from HIV and hep...
Universal Precautions                IncludeHand washingPersonal protective equipment [PPE]Preventing/managing sharps inju...
Personal protective equipmentPPE when contamination or splashing with blood orbody fluids is anticipatedDisposable glovesP...
Personal protective equipment  PPE when contamination or splashing with blood  or body fluids is anticipated  Disposable g...
Eliminate waste:       Unnecessary microbiologic monitoring  Routine environmental cultures of walls, floors, air,  sinks,...
Practice Aseptic techniquesSepsis - harmful infection by bacteriaAsepsis - prevention of sepsisMinimise risk of introducin...
Antibiotic Prophylaxis in               Surgery     Potentially an important part of surgical wound infection     preventi...
Sharps injuriesPrevention correct disposal in appropriate container avoid re-sheathing needle avoid removing needle discar...
Protecting Yourself fromBlood-Borne Pathogens          Dr.T.V.Rao MD
HIV: 3 Infections per 1,000 Sticks with a                      HIV+ Needle000000000000000000000000000000000000000000000000...
Hepatitis C: 18 Persons per 1,000                Needle-sticks000000000000000000000000000000000000000000000000000000000000...
Hepatitis B is Most Infectious00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000...
Protect Yourself! Get a Hepatitis B Vaccination        and keep your Vaccine Record3 doses of Hepatitis Bvaccine protect m...
Safe Handling of SharpsWear gloves when drawingblood or handling sharps—double glove for surgeryDon’t recap!Don’t bend or ...
Disposal of Sharps: The IdealImmediately afteruse, put sharps in aleak- proof andpuncture-proofcontainerThe container shou...
Sharps Disposal (cont’d)Disposal containers should be placed at all pointsof useDisposal bin should be rigid and should be...
Danger!Open containers ofused needles like thisput staff at risk eachtime they put a handin to pick up oneKeep your ward f...
Remember this Procedure…     When Injures with a NeedleIf a needle pricks you or blood and/or bodyfluidsenter your eye(s) ...
Protecting Yourself from Blood-Borne            Pathogens (cont’d)Wear gloves                         Dispose of sharps   ...
Prion diseasesPrions [“pree-ons”] - proteinaceous infectious particlesCorrupted form of a normally harmless protein found ...
Prions and surgeryPrions cannot bedestroyed bysterilisationTheoretical risk ofcross infection fromcontaminatedinstruments ...
Wish to be Better Informed Internet               siteshttp://www.icna.co.uk/http://www.nursing-standard.co.uk/http://www....
Resources: Where to get more     information or helpTraining Courses   Society of Hospital Epidemiologists of America (SHE...
Created by Dr.T.V.Rao MD for ‘e’ Learning resources to Medical andParamedical Health Care Workers in      the Developing W...
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INFECTION CONTROL,

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INFECTION CONTROL,

  1. 1. Dr.T.V.Rao MD Dr.T.V.Rao MD 1
  2. 2. A Tribute to Ignaz Semmelweiss (1818-1865)Ignaz Semmelweiss (1818-1865) Obstetrician, practised in Vienna Studied puerperal (childbed) fever Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems Reduced maternal mortality by 90% Ignored and ridiculed by colleagues Dr.T.V.Rao MD 2
  3. 3. History of infection control andhospital epidemiology in the USA Pre 1800: Early efforts at wound prophylaxis 1800-1940: Nightingale, Semmelweis, Lister, Pasteur 1940-1960: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus 1960-1970’s: Documenting need for infection control programs, surveillance begins 1980’s: focus on patient care practices, intensive care units, resistant organisms, HIV 1990’s: Hospital Epidemiology = Infection control, quality improvement and economics 2000’s: ??Healthcare system epidemiologymodified from McGowan, SHEA/CDC/AHA training course Dr.T.V.Rao MD 3
  4. 4. Why do we need Infection Control??Hospitals and clinics are complex institutions where patients go to have their health problems diagnosed and treated But, hospitals, clinics, and medical/surgical interventions introduce risks that may harm a patient’s health Dr.T.V.Rao MD 4
  5. 5. What is Nosocomial Infection Any infectionthat is notpresent orincubating at thetime the patientis admitted tothe hospital Dr.T.V.Rao MD 5
  6. 6. Consequences of Nosocomial InfectionsAdditional morbidityProlongedhospitalizationLong-term physical,developmental andneurological sequelaeIncreased cost ofhospitalizationDeath Dr.T.V.Rao MD 6
  7. 7. Florence NightingaleIt may seem astrange principle toenunciate as thevery firstrequirement in ahospital that itshould do the sickno harm" Dr.T.V.Rao MD 7
  8. 8. Links to the Chain of Infection• Portal of Entry• Susceptible Host• Causative Agent• Reservoir• Portal of Exit• Mode of Transmission Dr.T.V.Rao MD 8
  9. 9. Hospital Infections are Emerging challenges in Health CareHospital-associated infections represent a seriousand growing health problem. The Centers forDisease Control and Prevention (CDC) estimatesthat 2 million people acquire hospital-associatedinfections each year and that 90 000 of thesepatients die as a result of their infections. Avariety of hospital-based strategies aimed atpreventing such infections have been proposed. Dr.T.V.Rao MD 9
  10. 10. Modern Hospital Infection ControlModern hospital infection control programs first began inthe 1950s in England, where the primary focus of theseprograms was to prevent and control hospital-acquiredstaphylococcal outbreaks. In 1968, the American HospitalAssociation published "Infection Control in the Hospital,"the first and only standards available for many years. Atthe same time, the Communicable Disease Center, later tobe renamed the Centers for Disease Control andPrevention (CDC), began the first training coursesspecifically about infection control and surveillance Dr.T.V.Rao MD 10
  11. 11. CHAIN OF INFECTION Dr.T.V.Rao MD 11
  12. 12. Beginning of AccreditationIn 1969, the JointCommission forAccreditation of Hospitals--later to become the JointCommission onAccreditation of HealthcareOrganizations (JCAHO)--first required hospitals tohave organized infectioncontrol committees andisolation facilities. Dr.T.V.Rao MD 12
  13. 13. CDC Initiates Hospital Infection Branch In 1972, the Hospital Infections Branch at the CDC was formed and the Association for Practitioners in Infection Control was organized. By the close of the decade, the first CDC guidelines were written to answer frequently asked questions and establish consistent practice. Dr.T.V.Rao MD 13
  14. 14. First Data on Infection Control EfficacyIn 1985, the Study of theEfficacy of NosocomialInfection Control (SENIC)project was published,validating the cost-benefit ofinfection control programs.Data collected in 1970 and1976-1977 suggested thatone-third of all nosocomialinfections could beprevented Dr.T.V.Rao MD 14
  15. 15. Committee SuggestedOne infection controlprofessional (ICP) for every250 beds. An effectiveinfection control physician.A program reportinginfection rates back to thesurgeon and those clinicallyinvolved with the infection.An organized hospital-widesurveillance system. Dr.T.V.Rao MD 15
  16. 16. Infection Control Challenges of Healthcare in 2000 Decreasing reimbursement Increasing emerging infections Increasing resistant organisms Increasing drug costs Institute of Medicine Report--healthcare-associated infections Nursing shortage OSHA safety legislation Multiple benchmark systems FDA legislation on reuse of single-use devices Dr.T.V.Rao MD 16
  17. 17. The nature of infectionsMicro-organisms - bacteria, fungi, viruses,protozoa and wormsMost are harmless [non-pathogenic]Pathogenic organisms can cause infectionInfection exists when pathogenicorganisms enter the body, reproduce andcause disease Dr.T.V.Rao MD 17
  18. 18. Modes of spreadTwo sources of infection: Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment Dr.T.V.Rao MD 18 (Peto, 1998)
  19. 19. Spread - entry and exit routesNatural orifices - mouth, nose, ear, eye,urethra, vagina, rectumArtificial orifices - such as tracheostomy,ileostomy, colostomyMucous membranes - which line most naturaland artificial orificesSkin breaks - either as a result of accidentaldamage or deliberate inoculation/incision (May,2000) Dr.T.V.Rao MD 19
  20. 20. HAI - common bacteriaStaphylococci - wound, respiratory and gastro-intestinal infectionsEscherichia coli - wound and urinary tractinfectionsSalmonella - food poisoningStreptococci - wound, throat and urinary tractinfectionsProteus - wound and urinary tract infections(Peto, 1998) Dr.T.V.Rao MD 20
  21. 21. HAI - common viruses Hepatitis A - infectious hepatitis Hepatitis B - serum hepatitis Human immunodeficiency virus[HIV] - acquired immunodeficiencysyndrome [AIDS] (Peto, 1998) Dr.T.V.Rao MD 21
  22. 22. Components of Infection Control ProgrammeThe important components of the infection control programmeare: Basic measures for infection control, i.e. standard andadditional precautions; education and training of health careworkers; protection of health care workers, e.g.immunization; identification of hazards and minimizing risks; routine practices essential to infection control such as aseptictechniques, use of single use devices, reprocessing ofinstruments and equipment, antibiotic usage, management ofblood/body fluid exposure, handling and use of blood andblood products, sound management of medical waste; Dr.T.V.Rao MD 22
  23. 23. Need For Control programme?Effective work practices and procedures, such asenvironmental management practices includingmanagement of hospital/clinical waste, supportservices (e.g., food, linen), use of therapeuticdevices; surveillance; incident monitoring;outbreak investigation; infection control inspecific situations; and research. Dr.T.V.Rao MD 23
  24. 24. Developing Infection Control ProgrammeEvery infection control program should develop a well-defined written plan outlining the organizationalphilosophy regarding infection prevention and control.The plan should take into account the goals, missionstatement, and an assessment of the infection controlprogram. It should include a statement of authority, andshould review patient demographics including geographiclocations of patients served by the healthcare system Dr.T.V.Rao MD 24
  25. 25. Administrative control measures Assignment of responsibilities Administrator Infection control nurse/Engineer Chief doctors/ Head nurses Personnel Responsibility on implementing, monitoring, enforcing, evaluating, and revisinginfection control programs on a routine basis MD Dr.T.V.Rao including linkage to TB diagnostics 25 and other communicable Infections
  26. 26. Infection control committeeAn infection control committee provides a forum formultidisciplinary input and cooperation, and informationsharing. This committee should include widerepresentation from relevant departments: e.g.management, physicians, other health care workers,clinical microbiology, pharmacy, sterilizing service,maintenance, housekeeping and training services. Thecommittee must have a reporting relationship directly toeither administration or the medical staff to promoteprogramme visibility and effectiveness. Dr.T.V.Rao MD 26
  27. 27. Prevention of Hospital Infection-Planning Implemented, monitored LIFECYCLE OF IC PLAN and enforced IC plan Educated and trained Develop HCW to ensure good work practices Counselling andEvaluate Revise screening HCW Implement periodically Evaluated and revised plan 4 times Dr.T.V.Rao MD 27
  28. 28. The Infection Control TeamConsist of at least aninfection control practitionerwho should be trained forthe purpose; carry out thesurveillance programme;develop and disseminateinfection control policies;monitor and manage criticalincidents; coordinate andconduct training activities. Dr.T.V.Rao MD 28
  29. 29. Infection Control Committee Purpose Advisory Review ideas from infection control team Review surveillance data Expert resource Help understand hospital systems and policies Decision making Review and approve policies and surveillance plans Policies binding throughout hospital Education Help disseminate information and influence others29 Dr.T.V.Rao MD
  30. 30. Infection Control Committee - RepresentedCommittee Representatives Hospital Epidemiologist Infection Control Practitioners Administrator Ward, ICU and Operating room Nurses Medicine/Surgery/Obstetrics/Pediatrics Central Sterilization Hospital Engineer Microbiologist Pharmacist 30 Dr.T.V.Rao MD
  31. 31. Identify problems with polices and procedures Example: Pre- and Post-Operative Care create your protocols Problem Recommendation Area Skin shaved the night Eliminate shaving of skin the before surgery night before surgery Inappropriate peri-op Single dose peri-op antibiotic antibiotic prophylaxis prophylaxis guidelines Instruments used for Use individual sterile packs of dressing changes wound care instruments submerged disinfectant Use small containers of Large containers of antiseptics; clean and dry antiseptics, no routine for containers before refilling cleaning and refilling31 Dr.T.V.Rao MD
  32. 32. Aims of Infection ControlTo review and approve a yearly programme of activityfor surveillance and prevention; to reviewepidemiological surveillance data and identify areas forintervention; to assess and promote improved practice atall levels of the health facility; to ensure appropriate stafftraining in infection control and safety management,provision of safety materials such as personal protectiveequipment and products; and training of health workers. Dr.T.V.Rao MD 32
  33. 33. Education is the Real Strength of Infection Control programmeEducation programs for employees and volunteers areone method to ensure competent infection controlpractices. It is a unique challenge since employeesrepresent a wide range of expertise and educationalbackground. The ICP must become knowledgeable inadult education principles and use educational tools andtechniques that will motivate and sustain behavioralchange. Much has been written about the education ofhealthcare workers (HCWs). Dr.T.V.Rao MD 33
  34. 34. Minimal Needs to Start Infection Control Unit1 Organized surveillanceand control activities2. One infection controlpractitioner for every majorHealth Facility.3. A Trained HospitalEpidemiologist4. A system for reportingsurgical wound infectionrates and other infectionback to the practicingsurgeons and physicians. Dr.T.V.Rao MD 34
  35. 35. GUIDELINES for Effective Control of InfectionsHand washing and Hospital Environmental Control* Immunization* Infectious Diseases Control* Intravascular Device-Related Infections and its control* Isolation Precautions* Long-Term Care Facilities Dr.T.V.Rao MD 35
  36. 36. GUIDELINES for Effective Control of Infections* Guidelines for Infection Control in Health Care Personnel* Surgical Site Infections Control* Urinary Tract and Respiratory Tract Infections Control* Ordering and Preparing Guidelines appropriately* Home care* Hospital Construction* Sterilization / Disinfection Dr.T.V.Rao MD 36
  37. 37. Your Unwashed Hand a Great Concern to Your Patient Dr.T.V.Rao MD 37
  38. 38. Hand Washing is the Foundation of Infection ControlHand washing is the single mostimportant procedure for preventingnosocomial infections. Handwashing is defined as a vigorous,brief rubbing together of all surfacesof lathered hands, followed byrinsing under a stream of water.Although various products areavailable, hand washing can beclassified simply by the nature of theproducts used:plain soapdetergentsAntimicrobial containing products Dr.T.V.Rao MD 38
  39. 39. Hand Washing is the Foundation of Infection Control Hand washing with plain soaps or detergents (in bar, granule, leaflet or liquid form) suspends microorganisms and allows them to be rinsed off; this process is often referred to as mechanical removal of microorganisms. In addition, hand washing with antimicrobial containing products kills or inhibits the growth of microorganisms; this process is often referred to as chemical removal of microorganisms. Dr.T.V.Rao MD 39
  40. 40. Hand washing TechniqueFor routine handwashing, a vigorousrubbing together of allsurfaces of lathered handsfor at least 10 seconds,followed by thoroughrinsing under a stream ofwater, is recommended. Dr.T.V.Rao MD 40
  41. 41. Hand washingSingle most effective action to prevent HAI -resident/transient bacteriaCorrect method - ensuring all surfaces are cleaned - moreimportant than agent used or length of time takenNo recommended frequency - should be determined byintended/completed actionsResearch indicates: poor techniques - not all surfaces cleaned frequency diminishes with workload/distance poor compliance with guidelines/training Dr.T.V.Rao MD 41
  42. 42. Hand washing – Areas Missed Taylor (1978) identified that 89% of the hand surface was missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs. Dr.T.V.Rao MD 42
  43. 43. Successful Promotion in Hand WashingEducationRoutine observation & feedbackEngineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs availablePatient education(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and HospitalEpidemiology. Vol. 21 No. 6 Page 381) Dr.T.V.Rao MD 43
  44. 44. Successful Promotion can Improve Hand WashingReminders in the workplaceAdministrative sanctions ??Change in hygiene agent (not in Winter)Promote and facilitate skin careAvoid understaffing and excessiveworkload Dr.T.V.Rao MD 44
  45. 45. Hand Hygiene Techniques Many Ways1. Alcohol hand rub2. Routine hand wash 10- 15 seconds3. Aseptic procedures 1 minute4. Surgical wash 3-5 minutes Dr.T.V.Rao MD 45
  46. 46. Advantages of Alcoholic Hand WashRequire less timeCan be strategically placedReadily accessibleMultiple sitesAll patient care areasActs fasterExcellent bactericidalactivityLess irritating (??)Sustained improvement Dr.T.V.Rao MD 46
  47. 47. Antibiotic resistance Not a new problem - Penicillin in 1944Hospital “superbugs”Methicillin ResistantStaphylococcus Aureus[MRSA]VancomycinIntermediateStaphylococcus Aureus[VISA]Tuberculosis - antibioticresistant an EmergingGlobal Concern Dr.T.V.Rao MD 47
  48. 48. MRSADiscovered in 1981Found on skin and in thenose of 1 in 3 healthypeople - symptomlesscarriersWidespread in hospitalsand communityResistant to mostantibioticsWhen fatal - often due tosepticaemia Dr.T.V.Rao MD 48
  49. 49. Hospital Acquired Infections and ConsequencesIncidence of 10%5,000 deaths per year - direct result of HAI15,000 deaths per year linked to HAIDelayed discharge from hospitalExpensive to treat [£3,500 extra]Cost to NHS - £1 billion per yearEffective hand washing is the most effective preventativemeasureDirty wards and re-use of disposable equipment also blamed Dr.T.V.Rao MD 49
  50. 50. The nature of infectionMicro-organisms -bacteria, fungi, viruses,protozoa and wormsMost are harmless [non-pathogenic]Pathogenic organisms cancause infectionInfection exists whenpathogenic organismsenter the body, reproduceand cause disease Dr.T.V.Rao MD 50
  51. 51. Staff healthRisk of acquiring and transmitting infectionAcquiring infection immunisation cover lesions with waterproof dressings restrict non-immune/pregnant staffTransmitting infection advice when suffering infectionReport accidents/untoward incidentsFollow local policy (May, 2000) Dr.T.V.Rao MD 51
  52. 52. Waste disposalClinical waste - HIGH risk potentially/actually contaminated waste including body fluids and human tissue yellow plastic sack, tied prior to incinerationHousehold waste - LOW risk paper towels, packaging, dead flowers, other waste which is not dangerously contaminated black plastic sack, tied prior to incinerationFollow local policy (May, 2000) Dr.T.V.Rao MD 52
  53. 53. Spillage of body fluidsPPE - disposable gloves, apronSoak up with paper towels, kitchen rollCover area with hypochlorite solution e.g.,Milton, for several minutesClean area with warm water and detergent,then dryTreat waste as clinical waste - yellow plasticsackFollow local policy (May, 2000) Dr.T.V.Rao MD 53
  54. 54. Standard PrecautionsHand hygieneRespiratory hygiene and cough etiquettePersonal protective equipment (PPE)Based on risk assessment to avoid contact with blood, body fluids, excretions, secretionsSafe injection practicesEnvironmental controlPatient placement Dr.T.V.Rao MD 54
  55. 55. Nosocomial Infections are great concern in Immune compromised Patients Immunocompromised patients vary in their susceptibility to nosocomial infections, depending on the severity and duration of immunosuppression. Use of the two tiered system essential to break the “Chain of Infection”. Dr.T.V.Rao MD 55
  56. 56. Strengthen the EpidemiologyEpidemiology is the scientific process applied to the control of infections in the healthcare setting. Dr.T.V.Rao MD 56
  57. 57. Areas of interest to a hospital epidemiologist Surveillance for nosocomial infection Employee health bloodstream infections Disinfection and pneumonia sterilization urinary tract infections Hospital engineering and surgical wound infections environment Patterns of transmission of water supply nosocomial infections air filtration Outbreak investigation Isolation precautions Reviewing policies and procedures for patient Evaluation of exposures care57 Dr.T.V.Rao MD
  58. 58. Areas of interest to a Hospital EpidemiologistAntibiotic useAntibiotic resistantpathogensMicrobiology supportNational regulations oninfection controlInfection controlcommitteeQuantitative methods inepidemiology Dr.T.V.Rao MD 58
  59. 59. What is the role of healthcare epidemiology?Eliminate or minimize risks to a patient’s health organize care to minimize risk eliminate risk factors work around risk factors develop improved policies and procedures educate physicians and nurses regarding risks study risk factors to learn more about them and how to eliminate them Dr.T.V.Rao MD 59
  60. 60. Responsibilities of the Infection Control ProgramSurveillance of nosocomial Education of hospitalinfections staff on infectionOutbreak investigation controlDevelop written policies for Ongoing review of allisolation of patients aseptic, isolation andDevelop written policies to sanitation techniquesreduce risk from patient care Eliminate wasteful orpractices unnecessary practicesCooperation with occupationalhealth Dr.T.V.Rao MD 60
  61. 61. Key elements of surveillanceDefining as precisely as possible the event to besurveyed (case definition)Collecting the relevant data in a systematic, valid wayConsolidating the data into meaningful arrangementsAnalyzing and interpreting the dataUsing the information to bring about change61 adapted from R. Haley Dr.T.V.Rao MD
  62. 62. Areas of interest to a healthcare epidemiologistSurveillance for Employee healthnosocomial infection Disinfection andPatterns of transmission sterilizationof nosocomial infections Hospital engineering andOutbreak investigation environmentIsolation precautions water supplyEvaluation of exposures air filtration Reviewing policies and procedures for patient care Dr.T.V.Rao MD 62
  63. 63. Organizing for Infection ControlRequires cooperation, understanding andsupport of hospital administration andmedical/surgical/nursing leadershipThere is no simple formula: Every facility is different Every facility’s problems are different Every facility’s personnel are differentThe facility must develop its own uniqueprogram Dr.T.V.Rao MD 63
  64. 64. Methods to reduce cost of Nosocomial InfectionsReduce incidenceReduce morbidityShorten hospital stayReduce costs of treating infectionsReduce costs of preventative measuresStop ineffective control measures64 Dr.T.V.Rao MD
  65. 65. Universal infection control precautionsDevised in US in the 1980’s in response togrowing threat from HIV and hepatitis BNot confined to HIV and hepatitis BTreat ALL patients as a potential bio-hazardAdopt universal routine safe infection controlpractices to protect patients, self andcolleagues from infection Dr.T.V.Rao MD 65
  66. 66. Universal Precautions IncludeHand washingPersonal protective equipment [PPE]Preventing/managing sharps injuriesAseptic techniqueIsolationStaff healthLinen handling and disposalWaste disposalSpillages of body fluidsEnvironmental cleaningRisk management/assessment Dr.T.V.Rao MD 66
  67. 67. Personal protective equipmentPPE when contamination or splashing with blood orbody fluids is anticipatedDisposable glovesPlastic apronsFace masksSafety glasses, goggles, visorsHead protectionFoot protectionFluid repellent gowns (May, 2000) Dr.T.V.Rao MD 67
  68. 68. Personal protective equipment PPE when contamination or splashing with blood or body fluids is anticipated Disposable gloves Plastic aprons Face masks Safety glasses, goggles, visors Head protection Foot protection Fluid repellent gowns (May, 2000) Dr.T.V.Rao MD 68
  69. 69. Eliminate waste: Unnecessary microbiologic monitoring Routine environmental cultures of walls, floors, air, sinks, or other hospital surfaces Routine cultures of healthcare workers nose and hands Clinical cultures which are not available to clinicians in time to help with decision makingAlso: Failure to generate annual summary of culture data to provide clinicians with data for empirical selection of antibiotics 69 Dr.T.V.Rao MD
  70. 70. Practice Aseptic techniquesSepsis - harmful infection by bacteriaAsepsis - prevention of sepsisMinimise risk of introducing pathogenicmicro-organisms into susceptible sitesPrevent transfer of potential pathogensfrom contaminated site to other sites,patients or staffFollow local policy (May, 2000) Dr.T.V.Rao MD 70
  71. 71. Antibiotic Prophylaxis in Surgery Potentially an important part of surgical wound infection prevention May also be a significant expense for the hospital What is the cost-benefit of prophylactic antibiotics? What is cost of wound infection? In money? In suffering? How effective is prophylaxis? How much can we spend to prevent a case of wound infection ?71 Dr.T.V.Rao MD
  72. 72. Sharps injuriesPrevention correct disposal in appropriate container avoid re-sheathing needle avoid removing needle discard syringes as single unit avoid over-filling sharps containerManagement follow local policy for sharps injury (May, 2000) Dr.T.V.Rao MD 72
  73. 73. Protecting Yourself fromBlood-Borne Pathogens Dr.T.V.Rao MD
  74. 74. HIV: 3 Infections per 1,000 Sticks with a HIV+ Needle000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 Dr.T.V.Rao MD
  75. 75. Hepatitis C: 18 Persons per 1,000 Needle-sticks000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 Dr.T.V.Rao MD
  76. 76. Hepatitis B is Most Infectious0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 Dr.T.V.Rao MD
  77. 77. Protect Yourself! Get a Hepatitis B Vaccination and keep your Vaccine Record3 doses of Hepatitis Bvaccine protect mostpeople for a lifetime inMajority of IndivuaslsBut HCW blood banks,and dialysis shouldfollow the updatedInstructionsThe next dose at thisfacility will be given on Dr.T.V.Rao MD Slide 77
  78. 78. Safe Handling of SharpsWear gloves when drawingblood or handling sharps—double glove for surgeryDon’t recap!Don’t bend or break needlesNever place used sharps ontables, beds, furniturePut used sharpsimmediately into a sharpscontainer Dr.T.V.Rao MD 78
  79. 79. Disposal of Sharps: The IdealImmediately afteruse, put sharps in aleak- proof andpuncture-proofcontainerThe container shouldbe within arm’slength
  80. 80. Sharps Disposal (cont’d)Disposal containers should be placed at all pointsof useDisposal bin should be rigid and should be leak andpuncture proofSeparate sharps from other waste so laundry workers orwaste disposal staff do not get needlesticksEmpty sharps containers when they are ¾ full Dr.T.V.Rao MD Slide 80
  81. 81. Danger!Open containers ofused needles like thisput staff at risk eachtime they put a handin to pick up oneKeep your ward freeof used sharps
  82. 82. Remember this Procedure… When Injures with a NeedleIf a needle pricks you or blood and/or bodyfluidsenter your eye(s) or mouth Wash wounds with soap and water Flush eyes and mouth with water Check the patient record to see if the patient is HIV+, HIV- , or untested Check patient record for Hepatitis B or C infection Call the medical duty officer immediately Dr.T.V.Rao MD Slide 82
  83. 83. Protecting Yourself from Blood-Borne Pathogens (cont’d)Wear gloves Dispose of sharps immediately after use toDon’t recap needles minimise handling thatComplete 3 doses of increases risk ofHep B vaccine needlesticksEliminate Substitute safer devicesunnecessary injections or tools whenever possible Report needlesticks Dr.T.V.Rao MD Slide 83
  84. 84. Prion diseasesPrions [“pree-ons”] - proteinaceous infectious particlesCorrupted form of a normally harmless protein found inmammals and birdsCauses fatal neurodegenerative diseases of animals andhumansAnimals: scrapie - sheep, bovine spongiformencephalopathy [BSE or Mad Cow Disease]Humans: Creutzfeldt-Jakob disease [CJD]Prions found in blood, tonsil and appendix tissue Dr.T.V.Rao MD 84
  85. 85. Prions and surgeryPrions cannot bedestroyed bysterilisationTheoretical risk ofcross infection fromcontaminatedinstruments andblood transfusion Dr.T.V.Rao MD 85
  86. 86. Wish to be Better Informed Internet siteshttp://www.icna.co.uk/http://www.nursing-standard.co.uk/http://www.medscape.com/http://www.anes.uab.edu/medhist.htmhttp://www.shef.ac.uk/~nhcon/http://medweb.bham.ac.uk/nursing/http://www.healthcentre.org.uk/hc/library/default.htm Dr.T.V.Rao MD 86
  87. 87. Resources: Where to get more information or helpTraining Courses Society of Hospital Epidemiologists of America (SHEA) Association of Professionals in Infection Control (APIC) National courses and congressesBooks Textbooks: Bennett and Brachman - Wenzel - Mayhall APIC Curriculum and Guidelines CDC GuidelinesJournals Infection Control and Hospital Epidemiology Journal of Hospital Infections American Journal of Infection ControlConsulting services National: CDC, Ministry of Health Colleagues Dr.T.V.Rao MD 87
  88. 88. Created by Dr.T.V.Rao MD for ‘e’ Learning resources to Medical andParamedical Health Care Workers in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD 88
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