This chapter reviews two skills and one procedure: hand hygiene, caring for patients under isolation precautions, and caring for patients with multidrug-resistant organisms (MDRO) and Clostridium difficile.
Hand hygiene practices are major principles of infection control and are essential to safe patient care.
Patients in all health care settings are at risk of becoming colonized or infected as a result of an impaired immune response, exposure to increased numbers of pathogenic organisms, and performance of invasive procedures.
Know a patient’s susceptibility to infection. Age, nutritional status, stress, disease processes, and forms of medical therapy place patients at risk.
Health care–associated infections (HAIs) result from delivery of health services in a health care setting and were not present at the time of admission.
A hospital is one of the most likely settings for acquiring an HAI because staff, patients, and environmental factors support a high population of pathogens that are resistant to antibiotics.
Health care workers transmit many HAIs by direct contact during delivery of care.
Although protecting patients from HAIs is an obvious priority, nurses are also at risk because of contact with infectious materials or exposure to a communicable disease.
The presence of a pathogen does not mean that an infection will occur.
Infection occurs in a cycle, often referred to as the chain of infection, which depends on the presence of all six elements [Discuss each.]
[Shown is Figure 9-1: Chain of infection.]
An infection develops if this chain remains intact.
Use infection control practices to break an element of the chain so as not to transmit infection.
[Review with students Table 9-1, Breaking the Chain of Infection.]
[Ask students: what are some examples of medical asepsis practices? Discuss: hand hygiene, barrier techniques, routine environmental cleaning, washing hands before preparing food.]
Medical asepsis, or clean technique, includes procedures that reduce the number of organisms and prevent their transfer.
Principles of hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis. These principles are common in the health care and home environment, as in the case of washing hands before preparing food.
[Ask students: what are some examples of invasive procedures that require sterile technique? Discuss: insertion of a central line or an indwelling urinary catheter.]
Techniques for maintaining surgical asepsis are more rigid than those performed under medical asepsis.
Correct answer: B
Rationale: The nursing assistive personnel (NAP) is incorrect in saying that hand hygiene does not need to be performed before she assists the nurse. Although she may not touch the patient, she is still participating in patient care. Hand hygiene is performed by all caregivers.
Nurses are responsible for educating patients and their families about infection control, including information concerning signs and symptoms of infection, modes of transmission, and methods of prevention, knowledge of the infectious process, disease transmission, and critical thinking skills associated with use of aseptic techniques and barrier protection is essential.
Infection can require isolation. This may lead to loneliness or changes in self-concept or body image.
Know cultural views and preferences of your patients. When a patient from another culture requires isolation, use caution to be sure that the patient and family understand the therapeutic purpose of isolation.
Bundled interventions, such as ongoing education, reminders (e.g., posters), administrative support, wall mounted alcohol dispensers, pocket size bottles, improve hand hygiene practices.
Recent research shows that handwashing with plain soap sometimes results in paradoxical increases in bacterial counts on the skin.
Alcohol-based products are more effective than soap or antiseptic soaps for standard handwashing or hand antisepsis.
Brisk alcohol-based rinses or gels containing emollients cause substantially less skin irritation and dryness than plain or antimicrobial soaps.
Soap and water is still necessary for hand hygiene if hands are visibly soiled, or when the clinician is caring for patients infected with C. difficile.
Correct answer: C
Rationale: Keeping nails short will limit collection of bacteria under the nails.
[Ask students: what are some of the factors that influence a patient’s susceptibility to infection? Discuss: age, nutritional status, stress, disease processes, and forms of medical therapy can place patients at risk.]
Always know a patient’s susceptibility to infection. Age, nutritional status, stress, disease processes, and forms of medical therapy can place patients at risk.
[What are some ways to encourage patients to cover their mouth and nose when coughing and sneezing?]
Recognize the elements of the chain of infection and initiate measures to prevent its onset and spread.
Health care workers should not wear artificial nails and extenders because of bacterial buildup.
Fingernails should not be longer than 0.625 cm in length and nail polish should not be chipped. There are no recommendations regarding nail polish color (Cook, 2011).
Consistently incorporate the basic principles of medical asepsis into patient care.
Ensure that patients, family members, and health care workers follow “cough hygiene practices” and cover their mouth and nose when coughing or sneezing, use tissues to contain respiratory secretions, dispose of tissues in the waste receptacle, and wash their hands.
Use clean gloves when you anticipate contact with body fluids, nonintact skin, or mucous membranes when there is a risk of drainage.
[Ask students to discuss how they would approach a co-worker who is not following safety guidelines.]
Hand hygiene is a general term that applies to handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.
Handwashing refers to washing hands with plain soap and water.
An antiseptic hand wash is defined as washing hands with water and soap or other detergents containing an antiseptic agent.
An antiseptic hand rub means applying an antiseptic hand rub product to all surfaces of the hands to reduce the numbers of microorganisms present.
Surgical hand antisepsis is the use of an antiseptic hand wash or antiseptic hand rub before surgery by surgical personnel to eliminate transient and to reduce resident hand flora.
Antiseptic detergent preparations often have persistent antimicrobial activity.
[Ask students: what do you think the compliance rate is for hand hygiene among health care workers? Discuss: Longtin et al. (2011) found that hand hygiene compliance among health care workers had an overall compliance rate below 40%. Ask students: what do you think are the consequences of not using proper hand hygiene?]
Hand hygiene is a critical responsibility of all health care workers.
[Discuss the guidelines for hand hygiene presented on the slide.]
Examples of spore-forming organisms are Clostridium difficile and Bacillus anthracis.
[Ask students: when do you think it would be a good time to use an alcohol-based hand rub? Discuss.]
Before and after having direct contact with patients
Before applying sterile gloves and inserting an invasive device such as an indwelling urinary catheter or a peripheral vascular catheter
After having contact with body fluids or excretions, mucous membranes, and nonintact skin
After having contact with wound dressings (if hands are not visibly soiled)
When moving from a contaminated body site to a clean body site during patient care
After having contact with inanimate objects (e.g., medical equipment) in the immediate vicinity of a patient
After removing gloves
Correct answer: A
Rationale: Alcohol-based hand sanitizers have been shown to reduce infection in a variety of settings from intensive care units to long-term care facilities. Alcohol-based rinses or gels containing emollients cause substantially less skin irritation and dryness than plain or antimicrobial soaps.
[Discuss ways to remember hand hygiene throughout the workday.]
Teaching
Instruct patient and family caregiver on proper techniques and situations for hand hygiene.
When patients are educated about the risks for infection, they play an important role in improving hand hygiene compliance in health care settings by reminding visitors and health care workers to perform hand hygiene.
Gerontological
Hand hygiene by staff attending older adults is of utmost importance and should be an ongoing continuing education requirement.
Evaluate patient and primary caregiver to determine their understanding of the transmission of microorganisms and their ability and motivation to perform hand hygiene correctly.
Evaluate hand hygiene facilities in the home to determine the possibility of contamination, proximity of the facilities to the patient, and the patient’s ability to maintain supplies and equipment.
When a patient has a known or suspected source of colonization or infection, health care workers follow specific infection prevention and control practices to reduce the risk of cross-contamination to other patients.
Standard precautions require you to wear clean gloves before coming in contact with mucous membranes, nonintact skin, blood, body fluids, or other infectious material.
You wear clean gloves routinely when performing a variety of procedures (e.g., nasogastric tube insertion).
Masks are worn when there is a risk of splash during a procedure or when certain sterile procedures such as changing a central line dressing are performed.
Protective eyewear and masks become important when there is a risk for splash of blood or other body fluids to the eyes or mouth.
[Ask students: when should you wear gloves, masks, or protective eyewear when tending to a patient? Discuss: you wear gloves routinely when performing a variety of procedures (e.g., nasogastric tube insertion). Masks are worn when there is a risk of splash during a procedure, or when certain sterile procedures such as changing a central line dressing are performed. Protective eyewear and masks become important when there is risk for splash of blood or other body fluids to the eyes or mouth.]
The Hospital Infection Control Practices Advisory Committee (HICPAC) of the CDC published revised guidelines for isolation precautions (2009). The guidelines contain recommendations for respiratory hygiene/cough etiquette as part of standard precautions.
[Review with students Box 9-1, Special Tuberculosis Precautions.]
[Review with students Box 9-2, Centers for Disease Control and Prevention Isolation Guidelines.]
Cough etiquette is explained in Box 7-2.
Table 9-2 discusses airborne, droplet, contact, and protective environment. Infection/condition and barrier protection are also included.
The three types of transmission-based precautions—airborne, droplet, and contact—may be combined for diseases that have multiple routes of transmission (e.g., chickenpox). When used either singly or in combination, you use them in addition to standard precautions.
[Using the different categories, discuss with students which type of barrier protection is needed and the rationale for it.]
The task of caring for patients on isolation precautions can be delegated to NAP. However, the nurse must assess the patient’s status and isolation indications.
The nurse instructs NAP to:
Reason patient is on isolation precautions.
Precautions about bringing equipment into the patient’s room.
Special precautions regarding individual patient needs such as transportation to diagnostic tests.
[Ask students: what are some concerns that patients may have about isolation? How can you address these concerns?]
Pediatric
Strange environment adds to the confusion that a child feels during isolation.
Preschoolers are unable to understand cause-effect relationship for isolation.
Older children may be able to understand cause but still fantasize.
An example of a simple explanation is, “You need to be in this room to help you get better.”
Show all barriers to a child.
Actively involve parents in any explanations.
The nurse lets the child see her face before applying the mask, so the child does not become frightened.
Gerontological
Isolation can be a particular concern for older adults, especially those who have signs and symptoms of confusion or depression. Many times, patients become more confused when they are confronted with a nurse using barrier precautions, or when they are left in a room with the door closed. Nurses must assess the need for closing the door (negative-airflow room) along with the safety of the patient and additional safety measures that may need to be taken.
Assess older adults for signs of depression such as loss of appetite or decrease in verbal communications. If necessary, report to the health care team for appropriate interventions.
Home care
Although isolation precautions followed in the hospital are not directly applicable to home care, caregivers should be aware of potential sources of contamination in the home.
Multidrug-resistant organisms (MDROs) include methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).
In recent reports, MRSA caused upward of 19% of health care–associated bloodstream infections.
Clostridium difficile infection is one of the most common and costly HAIs:
In most instances, patient susceptibility to C. difficile infection requires prior treatment with antibiotics.
Unlike MRSA and VRE, C. difficile is difficult to eliminate from the environment because it is a spore-forming organism, meaning that it can remain on surfaces in its dormant state for long periods.
[Ask students: what is the most common way for patients to get one of these infections? Discuss: no matter which MDRO is involved, the most common means of transmission is by way of a health care worker’s hands. To reduce the risk of cross-contamination among patients, use contact precautions in addition to standard precautions when caring for these patients.]
Assessment of a patient’s status and the type of care required cannot be delegated to NAP.
Basic care procedures performed using contact precautions can be delegated to NAP.
