Asepsis in NICU LSD 2013

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Asepsis in NICU LSD 2013

  1. 1. Newborn Week 2013 Quality issues and Accreditation of newborn healthcare delivery systems
  2. 2. Dr L S Deshmukh MD,DNB,DM(Neonatology) Professor, In charge (Neonatology) GMC, Aurangabad
  3. 3. Introduction Nosocomial infections : * * * * In hospital acquired Higher mortality rate Longer hospitalization Increased cost
  4. 4. NICU ATTACK
  5. 5. Sources of nosocomial infection      Personnel Other sources Fomites – equipments Environment Invasive procedures
  6. 6. Risk factors for nosocomial infections  Intravenous catheters and other invasive procedures  Ventilation / suctioning  Medications  Overcrowding  Understaffing  Prolonged hospital stay  Contaminated enteral feed  Health care workers  Colonization by pathogenic organisms  Other neonates with infection
  7. 7. Nosocomial infections HCWs get their hands contaminated during  – – – – – – – – Taking a patient‟s blood Examination / Recording TPR / BP Assisting patients for mobility Inserting Catheters / Invasive devices contact with a patient‟s clothes / bed linen Performing procedures Wound-dressing Inanimate objects - bed rails / bedside tables / I.V. pumps
  8. 8. sepsis – Disaster Weeks of hard work + Sleepless nights + Carefully calibrated fluids + Meticulous titrated ventilator settings Inadequate asepsis = Nothing (Zero) Nosocomial infections ~ nightmare
  9. 9. Asepsis - Definition Absence of germs / pathogens Two types of techniques : - Medical (Clean) - Surgical (Sterile)
  10. 10. Definition of Terms Hand hygiene – A general term that applies to either handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis. Hand washing – Washing hands with plain soap and water. Plain soap – Refers to detergents that do not contain antimicrobial agents or contain low concentrations. Antimicrobial soap – Soap containing an antiseptic agent.
  11. 11. Definition of Terms  Antiseptic agents – Antimicrobial substances that are applied to the skin to reduce the number of microbial flora. e.g. alcohols, chlorhexidine, iodine etc.  Antiseptic hand wash – Washing hands with water and soap containing an antiseptic agent.  Alcohol-based hand rub – An alcoholcontaining preparation designed for application to the hands for reducing the number of viable micro-organisms on the hands.
  12. 12. Five parts of asepsis Practices that prevent entry of microbes into the nursery environment II. Practices that prevent proliferation of microbes in nursery. III. Practices that prevent spread of microbes between babies. IV. Practices that protect that newborn from developing infections. V. Practices that enable better asepsis & administration. I.
  13. 13. Fight against Macro-organisms
  14. 14. Fight against Micro-organisms
  15. 15. I- Practices that prevent entry of microbes into the nursery environment  Maintain a clean environment outside the nursery.  Entry restrictions  Hand washing - Single most important intervention  Gowns/masks/slippers  Air changes : - 12 air changes - 0.5 µ bacterial filters - ? Roll of exhaust fans Contd….
  16. 16. I- Practices that prevent entry of microbes in to the nursery environment Entry restrictions - Only Mothers Allowed - No Entry of infected infants Regulated entry - Personnel of nursery - Personnel of allied services
  17. 17. II – Practices that prevent proliferation of microbes in nursery Good house – keeping practices - Floors - Refrigerators - Bins
  18. 18. II – Practices that prevent proliferation of microbes in nursery Decontamination of equipments : Imp - Incubators & open care systems - Ventilators (change tubing daily) - Resuscitation bags & kits (have sufficient Nos.) - Laryngoscopes - Disposable Procedure sets (LP /Taps/ ExTx) Develop “ Disposable Culture”
  19. 19. III – Practices that prevent spread of microbes between babies  In addition to Hand washing & “Disposable culture“  Prevention of overcrowding - At least 4-6 ft. space in between - Avoid overcrowding  Adequate Staffing : - Tertiary care, 1:1 ratio - 1:2 for cohorted babies - 1:3 for noninfectious, treated babies. - 1:4 for stable babies  Prohibit stock solutions  Fomites – Files/stethoscope/Exam.tools/pens/cups/ telephone  Laminar flow – for mixing / reconst. Drugs / TPN
  20. 20. IV – Practices that protect newborn from developing infections Breast milk Involvement of mother Early discharge Eye and cord care Skin care ( position / probes / emollients ) * Handling IV fluids & drugs * * * * * Contd…
  21. 21. IV – Practices that protect newborn from developing infections * Handling invasive lines & tubes - Peripheral IV lines (Change every 72 hrs.) - Central lines (surgical scrub must) * Do not keep, if not necessary - Peripheral IV lines a minute more - IV infusion for an hour more - Central line a day more
  22. 22. IV – Practices that protect newborn from developing infections  Minimize handling & breach of barriers - Noninvasive monitoring - Clubbing together rounds  Aseptic precautions during procedures - Universal precautions - IV lines ( assess frequently) - Endotracheal intubation & suctioning - Chest tube insertion/LP/Ex transfusion. - Central lines insertions ( maintain sanctity)
  23. 23. Iatrogensis
  24. 24. V – Practices that enable better asepsis  Environmental surveillance - At least every month.  Record of positive cultures - Analyze data regularly - Develop antibiotic policy  Motivating staff- Most Important - Sweeper to consultant / In-charge - Regular meetings
  25. 25. Hand Hygiene Historical perspective : oUse of antiseptics – 19th century oLiquid chloride solution, 1825 oIgnaz Semmelweis, 1846 Use of chlorine solution – Decreased mortality (First evidence) In 1961, US Public Health services recommended hand washing for health personnel
  26. 26. Normal Bacterial Skin Flora » Normal human skin – colonized with bacteria. Total bacterial count – 3.9x104 to 4.6x106 Transient Vs Resident flora’ » Transient flora – Superficial layers Easily removed with washing Usually acquired through patient contact / infected source Usual cause of nosocomial infection » Resident flora : - More deeper - Not easily removed - May be pathogenic
  27. 27. Purpose of Handwashing * Removal all dirt and debris * Reduce cross contamination from microbes * Interrupt the fecal – oral route of infection. * Reduce risk of hands acting as vectors * Breaks a link in a chain of infections. * Increase the image of cleanliness of Health Care Personnel.
  28. 28. Indications for hand washing  Hands are visibly dirty or contaminated  Before having direct contact with patients  Before donning sterile gloves  Before doing procedures  After handling contaminated body fluids
  29. 29. Types of hand wash Routine / social Procedural (antiseptic) Surgical hand scrub „Time‟ method / „stroke count‟ method  Details must be followed  Recommended time  First - 2 min, then 30 sec.    
  30. 30. Hand Rub Selection of hand hygiene agents  Must provide efficacious hand hygiene with low irritancy potential.  Maximize acceptance by HCWs  Should not be costly.  Must have adequate information from manufacturers.  Friendly dispenser systems
  31. 31. Criteria for selection of disinfectant  Broad spectrum of action  Rapid action  Ability to suppress microbial re-growth for a prolonged period of time.  Non-irritating to the skin  Non allergenic  Effective after the first use  Visually and aesthetically acceptable  Cost effective
  32. 32. Types of chemical disinfectants * Phenolics (environmental disinfectants) - Black and white fluids - Active against a wide range of bacteria - e.g. Cresol & LYSOL * Chloroxylenols (non irritant) - e.g. Dettol, Ibcol - High concentrations are required (2.5 – 5.0%) * Chlorine releasing agents (Cheap) - Effective disinfectants - Rapidly effective against viruses, fungi, bacteria & spores. - Should be prepared daily - e.g. Sterite, Chloros, Presept Contd….
  33. 33. Types of chemical disinfectants • • • • • • • Iodine or Idophors - For hand disinfection or surgical scrub - e.g. tincture of iodine, povidone iodine (betadine) Aldehydes - e.g. Glutaraldehyde (Cidex), Formaldehyde (Formalin) - Nondamaging to metal, plastics, or rubber - Useful for heat sensitive items. Alcohols - e.g. ethyl alcohol 70% (ethanol), isopropranol - Rapid disinfection - Cheap Chlorhexidine - Skin antiseptic, used for procedures - Costlier Quaternary ammonium compounds Hydrogen peroxide and related compounds Ethylene oxide gas
  34. 34. Recommended disinfectants * A chlorine releasing agent (virus – contaminated material) * Phenolic disinfectant (for routine use) * Hypochlorides and other chlorine releasing agents (baths, toilets, wash basins) * Glutaraldehyde – immersible metal objects
  35. 35. Performance Indicators for Hand Hygiene » Periodically monitor and record adherence » Provide feed back » Monitor the volume of antiseptic use / soap / towels » Monitor adherence to policies » During outbreaks, total assessment.
  36. 36. Risk factors for poor hand hygiene practices    Physician status Higher work load Handwashing agents cause irritation and dryness  Sinks are inconveniently located/shortage of sinks  Lack of soap, water and towels  Often too busy/ insufficient time  Overcrowding  Lack of guidelines / protocols Needs - “ Behavioral Change “
  37. 37. Optimal NICU design  Adequate space (80-100 sq. ft. for Level III)  Minimum 6 ft. distance between incubators / warmers  Facilities for hand wash  Foot or elbow operated taps  Air circulation facility
  38. 38. Fumigation  No additional benefit, provided excellent house keeping and asepsis  Mostly done routinely  Periodically / following epidemic  During low occupancy  Spraying may be used
  39. 39. Fumigation
  40. 40. Waste Disposal
  41. 41. Isolation of neonates * Open wounds or skin lesions 0r acute gastroenteritis * Strict hand washing * Use of individual equipment * Use of disposable * Maintain optimum distance
  42. 42. Nursery Outbreaks  Cluster of infection with same pathogens  Common source • Contaminated equipments (Thermometers,Ventilators,Stetho) • Environmental reservoirs • Lapses in hand washing – Most IMP. “neonatologist‟s nightmare”
  43. 43. Nursery Outbreaks Lessons  Be vigilant to detect an increased incidence of common organisms  Adopt a systematic approach  Be prepared to be surprised
  44. 44. Infection control and prevention “best practices.”  staffing,  spacing,  cohorting,  auditing cleaning effectiveness,  auditing hand hygiene,  frequent microbiologic screening
  45. 45. Without commitment from everybody involved in care, Infection Control becomes a “BIG JOKE”
  46. 46. CONCLUSIONS • Hand washing & common sense are the best disinfectants. • Mother is the best nurse of the baby. • Breast milk is the best antidote. • “MININMAL HANDLING” is the key. • Conscious, determined efforts & health education is our moral responsibility.

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