HOSPITAL ASSOCIATED INFECTIONS ROLE OF RESIDENT DOCTORS

1. HOSPITAL ASSOCIATED INFECTIONS
ROLE OF RESIDENT DOCTORS
Dr.T.V.Rao MD

2. PREVENTING INFECTION
IN THE HOSPITAL

3. Vision:
•Vision: to provide the safest healthcare
system in the world through creating a zero
tolerance approach to avoidable infections,
and delivering safe, effective and person
centred care through continued
improvement in the prevention and control
of Healthcare Associated Infections.

4. Learning Objectives
1. Recognize patient safety as an important
nursing responsibility in global health care
systems.
2. Apply required knowledge in preventing
and/or minimizing infection.
3. Perform appropriate behaviors required to
prevent health care associated infections.
4. Demonstrate required competence to
provide patients with safe care.

5. Cannot autoclave patients

6. Introduction to Patient Safety:
Background
•Adverse medical events are widespread and
preventable (Emanuel et al., 2008) .
•Much unnecessary harm is caused by health-
care errors and system failures.
• Ex. 1: Hospital acquired infections from poor
hand-washing.
• Ex. 2: Complications from administering the
wrong medication.

7. Global Infection Problems
According to WHO (2005),
• On average, 8.7% of hospital patients suffer health
care-associated infections (HAI).
• In developed countries: 5-10%
• In developing countries:
• Risk of HAI: 2-20 times higher
• HAI may affect more than 25% of patients
• At any one time, over 1.4 million people
worldwide suffer from infections acquired while in
hospital.

8. Health Care-Associated Infections (HAI)
According to WHO:
•HAI is also called “nosocomial”.
•HAI is defined as:
• an infection acquired in hospital by a patient
who was admitted for a reason other than that
infection.
• an infection occurring in a patient in a hospital
or other health-care facility in whom the
infection was not present or incubating at the
time of admission.

9. What is Hospital Acquired
Infections
•Any infection that
is not present or
incubating at the
time the patient is
admitted to the
hospital
Dr.T.V.Rao MD' TMC Kollam Kerala 9

10. What is Infection Control?
•Identifying and reducing the risk of infections
developing or spreading
6/7/2015 Dr.T.V.Rao MD @Health Care 10

11. Lets now put the “Spotlight” on
Infection control in Our
Hospitals

12. Impression of my Hand Showing the Growth of
Bacteria

13. Why Everyone Concerned with Hospital
Infections
•The Centers for
Disease Control (CDC)
estimates that 2
million U.S. patients a
year acquire hospital-
related infections.
Dr.T.V.Rao MD' TMC Kollam Kerala 13

14. Impacts of Health Care-Associated
Infections (HAI)
HAI can:
•Increase patients’ suffering.
•Lead to permanent disability.
•Lead to death.
•Prolong hospital stay.
•Increase need for a higher level of care.
•Increase the costs to patients and hospitals.

15. Impact of Nosocomial Infections
They lead to functional disability and emotional stress
to the patient.
They lead to disabling conditions that reduce the
quality of life.
They are one of the leading causes of death.
The increased economic costs are high: Increased
length of hospital stay (SSI - 8.2 days), extra
investigations, extra use of drugs and extra health care
by doctors and nurses.
6/7/2015 Dr.T.V.Rao MD @Health Care 15

16. Frequency of Nosocomial Infection
 Nosocomial infections occur worldwide.
 The incidence is about 5-8% of hospitalized
patients, 1/3 of which is preventable.
 The highest frequencies are in East
Mediterranean and South-East Asia.
 A high frequency of N.I. is evidence of poor
quality health service delivered.
6/7/2015 Dr.T.V.Rao MD @Health Care 16

17. Nosocomial infections can spread to Community
Organisms causing N.I.
can be transmitted to the
community through
discharged patients, staff
and visitors. If organisms
are multi-resistant they
may cause significant
disease in the
community.6/7/2015 Dr.T.V.Rao MD @Health Care 17

18. HAI - common bacteria
• Staphylococci - wound, respiratory and
gastro-intestinal infections
• Escherichia coli - wound and urinary tract
infections
• Salmonella - food poisoning
• Streptococci - wound, throat and urinary
tract infections
• Proteus - wound and urinary tract
infections (Peto, 1998)
• C.difficle an emerging pathogen
Dr.T.V.Rao MD' TMC Kollam Kerala 18

19. HAI - common viruses
•Hepatitis A - infectious
hepatitis
•Hepatitis B - serum hepatitis
•Human immunodeficiency virus
[HIV] - acquired
immunodeficiency syndrome
[AIDS] (Peto, 1998)
Dr.T.V.Rao MD' TMC Kollam Kerala 19

20. Required Skills
• Apply universal precautions*
• Use personal protection methods
• Know what to do if exposed
• Encourage others to use universal precautions
• Report breaks in technique that increase patient
risks
• Observe patients for signs and symptoms of infection

21. Main Sources of Infection
• Person to person via hands of health-care providers, patients,
and visitors
• Personal clothing and equipment (e.g. Stethoscopes,
flashlights etc.)
• Environmental contamination
• Airborne transmission
• Hospital staff who are carriers
• Rare common-source outbreaks

22. Campaigns to Decrease Infection Rates
•WHO “Clean hands are safer hands”
campaign
•Centers for Disease Control and Prevention
(CDC) “prevent antimicrobial resistance”
campaign in health-care settings
•Institute for Healthcare Improvement (IHI)
“5 million lives” campaign
•Developing country focus

23. Antibiotic Resistant Microorganisms
normal flora too can cause Infections
Problem exists because of overuse and
inappropriate use
Resistant to multiple antibiotics
Reduced options for treatment
Require isolation precautions
Examples: MRSA, VRE, MDR TB
Solutions: more appropriate antibiotic use,
better infection control and prevention
6/7/2015 Dr.T.V.Rao MD @Health Care 23

24. 24
Leading causes of death
53.9 million from all causes, worldwide

25. Incidence of Healthcare associated infections
•Lack of reliable data affects estimates on the burden-
millions worldwide every year
•No health-care facility, no country, no health-care
system in the world is free of this problem
• Developed world: 5–10% patients
• Developing countries: risk is at least 2 times
higher and can exceed 25%
• ICU - 30% patients; attributable mortality as high
as 44%
25

26. Main Routes for infections
• Urinary tract infections (UTI)
• Catheter-associated UTIs are the most frequent,
accounting for about 35% of all HAI.
• Surgical infections: about 20% of all HAI
• Bloodstream infections associated with the use of
an intravascular device: about 15% of all HAI
• Pneumonia associated with ventilators: about15%
of HAI

28. Burke J Infection control-a problem for patient safety New Eng Journal
of Medicine (February 13, 2003)
Types of Infections

29. Infection control in developing countries
 None/inadequate Infection Control infrastructure
 Lack of strategic direction at national/local level
 Lack of resources/financial governance
 Well-organized, effective infection control programmes are confined to
academic institutions, well-funded government and private hospitals
 Smaller hospitals in urban areas and hospitals in rural centres have less
resources
 None or inadequate infection control programme
 Lack of Microbiology Laboratory supports
 Availability of antimicrobial agents, hand hygiene products and hand washing facilities,
Personal Protective Equipment and sterile goods
29

30. 30
NO COST MEASURES
Good infection control practices
• Aseptic technique for all sterile procedures
• Remove indwelling devices when no longer needed
• Isolation of patient with communicable diseases/multi-resistant
organism
• Avoid unnecessary Per Vaginal (PV) examination in women in
labour
• Placing mechanically ventilated patients in a semi-recumbent
position
• Minimize number of people in operating theatre
Damani NN. Journal of Hospital infection 2007; 65(S1): 151-154.

31. We Doctors and Nurses Have a Great role
•Staff nurses play an important
role in risk reduction by paying
careful attention to hand
hygiene, by ensuring careful
administration of prescribed
antibiotics, and by following
procedures to reduce the risks
associated with patient care
devices.

32. Standard precautions
•Treating all patients in the health care
facility with the same basic level of
“standard” precautions involves work
practices that are essential to providea
high level of protection to patients,
health care workers and visitors.

33. Nosocomial Infections Cost
The cost varies according to the type and
severity of these infections.
An estimated 1 to 4 extra days for a
urinary tract infection, 7 – 8 days for a
surgical site infection, 7 – 21 days for a
blood stream infection, and 7 – 30 days for
pneumonia.
The CDC has recently reported that US$5
billion are added to US health costs every
year as a result of NI.
6/7/2015 Dr.T.V.Rao MD @Health Care 33

34. Include the following:
•Hand washing and antisepsis (hand hygiene);
use of personal protective equipment when
handling blood, body substances, excretions and
secretions; appropriate handling of patient care
equipment and soiled linen; prevention of
needle stick/sharp injuries; environmental
cleaning and spills-management; and
appropriate handling of waste.

35. . METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
• refers to S. aureus organisms
that are resistant to methicillin
• 1940- PENICILLIN was
discovered
• Soon after penicillin was
introduced, S. aureus became
all but universally penicillin
resistant

36. 36
Neonatal sepsis among NICU
(University Hospital in Egypt)
•Increase rates of early
onset neonatal sepsis
among infants in ICU
•Mortality rates : 55%
•All infants placed on IV
fluids and antibiotics
Yassin S. et al 5th IFIC Congress Malta, 2003

37. 37
Effect of hand washing on child health
Randomised controlled trial in Karachi, Pakistan.
Hand washing with soap and water
Children under age of 5 years
• 50% lower incidence of pneumonia
Children under age of 15 years
• 53% lower incidence of diarrhoea
• 34% lower incidence of impetigo
Luby SP et al. Lancet 2005; 366: 225-33.

38. Importance of Education
•Educate patients and families/visitors
about clean hands and infection
transmission.
•Ensure patients on precautions have same
standard of care as others:
• frequency of entering the room
• monitoring vital signs

39. Breaking the Chain
How to prevent the spread of Infection

40. How the Infections Spread
• Pathogens can be transmitted to a host from a reservoir four main
ways;
1.By direct contact; exchange of body fluid especially during sexual
intercourse
2.By an object; people handle contaminate objects then touch face,
nose, eyes, etc…
3.Through the air; person coughs or sneezes spreading droplets which
are then inhaled
4.By a vector; insects such as mosquitos, ticks spread pathogens
between hosts or reservoirs

41. CONTROL
•Control is best achieved by
1.intensifying cleaning,
2.using Contact Precautions for infected patients
3.stressing glove use
4.hand hygiene for all care workers.

42. CDC RECOMMENDATION
1. Intensified environmental
cleaning using 1:10 bleach :
water solution
2. Equipment cleaned whenever
visibly soiled
3. Items close to the patient
should be cleaned daily
4. IV poles should be cleaned
when the patient is
discharged.

43. Five moments for hand hygiene
•Before patient contact
•Before an aseptic task
•After body fluid exposure even if wearing
gloves!
•After patient contact
•After contact with patient surroundings

44. How should you wash your hands?
4 Rinse your hands
well under clean,
running water.
5Dry your hands
using a clean towel
or air dry them.

45. Hand washing reduces spread of
Microbes
We can take to reduce the
spread of diarrheal and
respiratory illness so you can
stay healthy. Regular
Handwashing, particularly
before and after certain
activities, is one of the best
ways to remove germs, avoid
getting sick, and prevent the
spread of germs to others.

46. Isolation Precautions

47. Need For Protection

48. Protecting Whom?
• Protecting:
• Ourselves
• Patient
• Other patients
• Other staff
• Our families

49. Elements of Standard Precautions
1. hand hygiene
2. use of gloves and other barriers
(eg, mask, eye protection, face
shield, gown),
3. handling of patient care
equipment and linen
4. environmental control
5. prevention of injury from sharps
devices
6. patient placement.

50. Hand Hygiene
• hands should be washed
with soap and water
• antimicrobial agents (eg,
chlorhexidine gluconate,
iodophors, chloroxylenol,
triclosan) may be used.

51. Hand Hygiene
• Effective hand washing
requires at least 20 seconds
of vigorous scrubbing with
special attention to the
area around nail beds and
between fingers, where
there is high bacterial
burden.

52. Universal Precautions
• CDC (Centers for Disease
Control) in 1987:
• All patients be regarded
as potentially infective
(HIV & Hepatitis…)
• that all patients are
colonized or infected
with microorganisms,
whether or not there
are signs or symptoms

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54. 54
Important Conclusions
•Nosocomial transmission of pathogenic
bacteria creates a major health burden
•Multifaceted interventions are needed
for high level control: proper hand
hygiene is the cornerstone of prevention
efforts
•Isolation of patients may place them at
risk for errors of omission
6/7/2015 Dr.T.V.Rao MD @Health Care

55. I washed my Hands Are You ?

56. Challenging Issues
• Issues that will continue to
impact infection control
programs into the new
millennium are a challenging
combination of clinical
factors and increasing cost
to treat infections, and
financial impact of
implementing new
government regulations .
Dr.T.V.Rao MD' TMC Kollam Kerala 56

57. Can We Gift Flowers to Patients ?

58. 58
Conclusions
• Identify unsafe, unnecessary and ineffective infection
control practices
• Divert resources to apply basic evidence based practice
in Infection control
• Implement simple & effective solutions according to
local need and resources which are achievable and
affordable
Simple measures do save lives !