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  1. 1. PRINCIPLES AND PRACTICES OF ASEPSIS Module E Role of hands and the environment in disease transmission
  2. 2. OBJECTIVES • Describe the principles and practice of asepsis • Understand hand hygiene • Understand the role of the environment in disease transmission
  3. 3. DEFINING ASEPSIS Medical Asepsis Surgical Asepsis Definition Clean Technique Sterile Technique Emphasis Freedom from most pathogenic organisms Freedom from all pathogenic organisms Purpose Reduce transmission of pathogenic organisms from one patient-to -another Prevent introduction of any organism into an open wound or sterile body cavity
  4. 4. MEDICAL ASEPSIS Measures aimed at controlling the number of microorganisms and/or preventing or reducing the transmission of microbes from one person-to-another: Clean Technique • Know what is dirty • Know what is clean • Know what is sterile • Keep the first three conditions separate • Remedy contamination immediately
  5. 5. PRINCIPLES OF MEDICAL ASEPSIS When the body is penetrated, natural barriers such as skin and mucous membranes are bypassed, making the patient susceptible to microbes that might enter. • Perform hand hygiene and put on gloves • When invading sterile areas of the body, maintain the sterility of the body system • When placing an item into a sterile area of the body, make sure the item is sterile
  6. 6. PRINCIPLES OF MEDICAL ASEPSIS Even though skin is an effective barrier against microbial invasion, a patient can become colonized with other microbes if precautions are not taken. • Perform hand hygiene between patient contacts • When handling items that only touch patient’s intact skin, or do not ordinarily touch the patient, make sure item is clean and disinfected (between patients).
  7. 7. PRINCIPLES OF MEDICAL ASEPSIS All body fluids from any patient should be considered contaminated • Body fluids can be the source of infection for the patient and you • Utilize appropriate personal protective equipment (PPE) • When performing patient care, work from cleanest to dirtiest patient area.
  8. 8. PRINCIPLES OF MEDICAL ASEPSIS The healthcare team and the environment can be a source of contamination for the patient • Health care providers (HCP) should be free from disease • Single use items can be a source of contamination • Patients environment should be as clean as possible
  9. 9. Surgery increases the risk of infection! Army Medicine/CC
  10. 10. SURGICAL ASEPSIS Practices designed to render and maintain objects and areas maximally free from microorganisms: Sterile Technique • Know what is sterile • Know what is not sterile • Keep sterile and not sterile items apart • Remedy contamination immediately
  11. 11. PRINCIPLES OF SURGICAL ASEPSIS • The patient should not be the source of contamination • The operating room (OR) team should not be the source of contamination • The surgical scrub should be done meticulously • The OR technique of the surgeon is very important • Recognize potential environmental contamination
  13. 13. REMEDY CONTAMINATION • Every case is considered dirty and the same infection control precautions are taken for all patients • When contamination occurs, address it immediately • Breaks in technique are pointed out and action is taken to eliminate them.
  14. 14. Rutala WA and Weber DJ (2010) Lautenbacch et al.(eds.) in Practical Healthcare Epidemiology
  15. 15. HAND HYGIENE The substance of asepsis iStockphoto
  16. 16. WHAT IS HAND HYGIENE • Handwashing • Antiseptic Handwash • Alcohol-based Hand Rub • Surgical Antisepsis
  17. 17. WHY IS HAND HYGIENE SO IMPORTANT? • Hands are the most common mode of pathogen transmission • Reduces the spread of antimicrobial resistance • Prevents healthcare-associated infections
  18. 18. HAND-BORNE MICROORGANISMS Healthcare providers contaminate their hands with 100-1000 colony-forming units (CFU)of bacteria during “clean” activities (lifting patients, taking vital signs). Pittet D et al. The Lancet Infect Dis 2006
  19. 19. TRANSMISSION OF PATHOGENS ON HANDS FIVE ELEMENTS • Germs are present on patients and surfaces near patients • By direct and indirect contact, patient germs contaminate healthcare provider hands • Germs survive and multiply on healthcare provider hands • Defective hand hygiene results in hands remaining contaminated • Healthcare providers touch/contaminate another patient or surface that will have contact with the patient.
  20. 20. HAND HYGIENE COMPLIANCE IS LOW Author Year Sector Compliance Preston 1981 General Wards ICU 16% 30% Albert 1981 ICU ICU 41% 28% Larson 1983 Hospital-wide 45% Donowitz 1987 Neonatal ICU 30 Graham 1990 ICU 32 Dubbert 1990 ICU 81 Pettinger 1991 Surgical ICU 51 Larson 1992 Neonatal Unit 29 Doebbeling 1992 ICU 40 Zimakoff 1993 ICU 40 Meengs 1994 Emergency Room 32 Pittet 1999 Hospital-wide 48 <40% Pittet and Boyce. Lancet Infectious Diseases 2001
  21. 21. REASONS FOR NONCOMPLIANCE • Inaccessible hand hygiene supplies • Skin irritation • Too busy • Glove use • Didn’t think about it • Lacked knowledge
  22. 22. WHEN TO PERFORM HAND HYGIENE The 5 Moments Consensus recommendations CDC Guidelines on Hand Hygiene in healthcare, 2002 1. Before touching a patient • Before and after touching the patient 2. Before clean / aseptic procedure • Before donning sterile gloves for central venous catheter insertion; also for insertion of other invasive devices that do not require a surgical procedure using sterile gloves • If moving from a contaminated body site to another body site during care of the same patient 3. After body fluid exposure risk • After contact with body fluids or excretions, mucous membrane, non-intact skin or wound dressing • If moving from a contaminated body site to another body site during care of the same patient • After removing gloves 4. After touching a patient • Before and after touching the patient • After removing gloves 5. After touching patient surroundin gs • After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient • After removing gloves
  23. 23. HOW TO HAND RUB To effectively reduce the growth of germs on hands, hand rubbing must be performed by following all of the illustrated steps. This takes only 20–30 seconds! /HAND_RUBBING.pdf credit: WHO
  24. 24. To effectively reduce the growth of germs on hands, handwashing must last at least 15 seconds and should be performed by following all of the illustrated steps. HAND_WASHING.pdf HOW TO HAND WASH credit: WHO
  25. 25. HAND RUBBING VS HANDWASHING 0 15sec 30sec 1 min 2 min 3 min 4 min 6 5 4 3 2 1 0 Bacterial contamination (mean log 10 reduction) Handwashing Handrubbing Hand rubbing is: • more effective • faster • better tolerated Pittet and Boyce. Lancet Infectious Diseases 2001
  26. 26. SUMMARY OF HAND HYGIENE Hand hygiene must be performed exactly where you are delivering healthcare to patients (at the point-of-care). During healthcare delivery, there are 5 moments (indications) when it is essential that you perform hand hygiene. To clean your hands, you should prefer hand rubbing with an alcohol-based formulation, if available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better tolerated. You should wash your hands with soap and water when visibly soiled. You must perform hand hygiene using the appropriate technique and time duration.
  27. 27. Rutala WA and Weber DJ (2010) Lautenbacch et al.(eds.) in Practical Healthcare Epidemiology
  28. 28. DEFINITIONS Spaulding Classification of Surfaces: 1. Critical – Objects which enter normally sterile tissue or the vascular system and require sterilization 2. Semi-Critical – Objects that contact mucous membranes or non-intact skin and require high- level disinfection 3. Non-Critical – Objects that contact intact skin but not mucous membranes, and require low or intermediate-level disinfection
  29. 29. DISINFECTION LEVELS High – inactivates vegetative bacteria, mycobacteria, fungi, and viruses but not necessarily high numbers of bacterial spores Intermediate – destroys vegetative bacteria, most fungi, and most viruses; inactivates Mycobacterium tuberculosis Low - destroys most vegetative bacteria, some fungi, and some viruses. Does not inactivate Mycobacterium tuberculosis
  30. 30. CATEGORIES OF ENVIRONMENTAL SURFACES Clinical Contact Surfaces • Exam tables, counter tops, BP cuffs, thermometers • Frequent contact with healthcare providers’ hands • More likely contaminated Housekeeping Surfaces • Floors, walls, windows, side rails, over-bed table • No direct contact with patients or devices • Risk of disease transmission
  31. 31. SURVIVAL OF PATHOGENS ON SURFACES Pathogen Survival MRSA 7 days – 7 months VRE 5 days – 4 months Acinetobacter 3 days -5 months C. difficile (spores) 5 months Norovirus 12 – 28 days HIV Minutes to hours HBV 7 days HCV 16 hours – 4 days Kramer A, et al (2006). BMC Infect Dis; 6:130; CDC
  32. 32. SELECT, MIX, AND USE DISINFECTANTS CORRECTLY • Right product • Right dilution • Right preparation – not before low level disinfection • Right application method • Right contact time • Wear appropriate PPE (gloves, gown, mask, eye protection)
  33. 33. LIQUID DISINFECTANTS Disinfectant Agent Use Concentration Ethyl or isopropyl alcohol 70% - 90% Chlorine (bleach) 100 ppm Phenolic UD Iodophor UD Quaternary ammonium compound (QUAT) UD Improved/Accelerated hydrogen peroxide 0.5%, 1.4% UD = Manufacturer’s recommended use dilution
  34. 34. CLEANING RECOMMENDATIONS Clean and disinfect surfaces using correct technique • Clean to dirty • Prevent contamination of solutions • Don’t use dried out wipes • Physical removal of soil (elbow grease) • Contact time • Correct type of cleaning materials
  35. 35. THOROUGHNESS OF CLEANING Mean = 32% Carling P, et al. APIC, 2012
  36. 36. OTHER ENVIRONMENTAL ISSUES Blood and Body Fluid Spills • Promptly clean and decontaminate • Use appropriate PPE • Clean spills with dilute bleach solution (1:10 or 1:100) or an EPA-registered hospital disinfectant with a TB or HIV/HBV kill claim.
  37. 37. REFERENCES • CDC Guidelines for Hand Hygiene in Healthcare Settings – Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC Hand Hygiene Task Force. MMWR October 25, 2002, 51(RR-16). • CDC Guidelines for Environmental Infection Control in Health-care Facilities, HICPAC, MMWR June 6, 2003, 52(RR-10).

Editor's Notes

  • Welcome to Module E, Principles and Practices of Asepsis
  • There are three main objectives for the this module.

    Describe the principles and practices of aspesis

    Understand hand hygiene

    Understand the role of the environment in disease transmission
  • Asepsis is the condition of being free from disease producing microorganisms. Aseptic technique refers to all those procedures that reduce or eliminate pathogens and their actions or minimize their areas of existence. There are two types of asepsis, Medical and Surgical.
    Medical asepsis, also referred to as clean technique, is used during most routine patient care activities and non-surgical procedures. With medical asepsis, emphasis is placed on removing most of the pathogenic organisms to reduce transmission from one patient to another.
    Conversely, surgical asepsis, also called sterile technique, is used only during surgical procedures. Unlike medical asepsis, the goal of surgical asepsis is to ideally remove all pathogenic organisms and prevent the introduction of any organism into a normal sterile body site.
  • Medical asepsis is based on several measures with the goal of controlling the number of microorganisms, not making things sterile. To achieve medical asepsis we must understand what is dirty, what is clean, what is sterile, how to keep these things separate, and how to remedy any contamination that might occur. When approaching each patient care activity, consider the following principles as a framework to guide your practice.
  • When performing invasive procedures, like placing an IV or giving an injection, one of the bodies’ first lines of defense against invading microorganisms is bypassed: the skin. When we bypass the skin, we increase the susceptibility of the patient to invading microorganisms. For example, when placing an IV into the patient’s bloodstream (which is a sterile system) we perform hand hygiene and put on gloves to prevent our normal body flora from contaminating the insertion site. Next we decontaminate the patient’s skin using an antiseptic. This reduces the level of microbial burden at the insertion site so microbes are not carried through the skin during the insertion. Finally, we use a sterile IV catheter and sterile solutions so we do not introduce any additional microbes into the bloodstream.
  • The second principle of asepsis is focused on preventing the transfer of microorganisms from one patient to another via healthcare provider hands and shared equipment. All of us are colonized with many different types of bacteria, some helpful and some potentially pathogenic. When we fail to take the opportunity to perform hand hygiene between patients or clean and disinfect shared patient equipment like blood pressure cuffs between patients, we are creating opportunities for cross contamination that can introduce new, harmful microbes to patients.
  • The third principle of asepsis is recognizing that any body fluid is potentially contaminated. This means that if it is wet and not yours you should use the appropriate personal protective equipment (PPE) and perform hand hygiene after handling potentially contaminated fluids, and when performing patient care activities. Remove gloves and perform hand hygiene between dirty and clean patient care activities. For example, follow a wound dressing change with glove removal and hand hygiene before performing an injection on the same patient. By doing so, you can feel confident that you have not introduced any more microbes at the injection site.
  • The final principle of asepsis is that healthcare providers and the environment can also be a source of contamination. Healthcare providers can reduce their opportunities of transmitting disease by staying up to date on vaccinations, maintaining good personal hygiene, and performing hand hygiene appropriately.
    Additionally, single use items can be a source of contamination if they are reused on another patient. For example, many sterile solutions used for irrigation do not have bacteriostatic or bacteriocidal compounds that prevent growth of microbes once they have been opened. Because of this, any excess fluid left in the bottle should be discarded - not stored for later use. It is important that you read the labels and follow manufacturers’ instructions for use.
    The environment is also a potential source of contamination for the patient. If surfaces and shared patient equipment are not cleaned appropriately, they can be a source of cross-transmission. The role of the environment is discussed later in this section.
  • Now that we have reviewed medical asepsis, let’s move on to surgical asepsis. More stringent requirements are used during surgery because the risk of infection increases during surgery.
  • Measures that keep and maintain objects and areas maximally free of microorganisms so that normally sterile body sites are not contaminated are the basis of surgical asepsis. Understanding which equipment and areas are sterile, and which are not, and keeping these two separate so as not to introduce contamination is critical to achieving surgical asepsis.
  • While in the surgical environment, there are several principles which help maintain a sterile environment. First, the patient should not be a source of contamination. The skin around the surgical site is meticulously cleaned using a chemical antiseptic, like chlorhexadine alcohol solution, and all other areas of skin are covered by a sterile drape.
    Similarly, operating room personnel should not be a source for contamination. Sterile operating room personnel (those working in the sterile field) should perform a surgical hand scrub, gown and glove, and only contact sterile items. Unsterile operating room personnel should only contact unsterile items and should not have direct contact with sterile operating room personnel.
  • What is sterile in the operating room? Gowns are sterile in front from chest high level to the operative level. A sterile healthcare provider should keep hands in sight and at or above waist level at all times and should avoid direct contact with non-sterile personnel or equipment. Similarly, non-sterile personnel should avoid contact with sterile personnel and items, and stay at least one foot beyond the sterile field. Sterile areas should also be kept continuously in view, and sterile personnel should not turn their back to the sterile field. All items used within the sterile field must be sterile. Articles of doubtful sterility should be considered non-sterile. Tables are sterile only at the operative level.
    Contamination occurs when sterile gowns and drapes are permeated, when non-sterile items are brought into the sterile field, and when sterile personnel drop their hands or body below the level of the table.
  • Once there has been a breach in sterility, it is important that the contamination is recognized quickly and steps are taken to remedy the situation promptly.
  • Two of the primary practices of aseptic technique are appropriate hand hygiene and disinfection of surfaces and shared equipment. This diagram demonstrates how both hands and the environment play a role in the transmission of disease between two patients. The left side of the diagram shows transmission by the hands of the healthcare provider and the right side shows transmission by environmental surfaces and shared equipment. We are first going to cover hand hygiene followed later by environmental disinfection. We will cover high-level disinfection and sterilization in later modules.
  • Hand hygiene is a general term that applies to routine hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis.
  • Hand hygiene substantially reduces potential pathogens on the hands and is considered a primary measure for reducing the risk of transmitting organisms to patients and health care personnel. Hospital-based studies have shown that noncompliance with performing hand hygiene is associated with health care-associated infections, the spread of multi-drug resistant organisms, and has been a major contributor to outbreaks. Studies have shown that the prevalence of health care-associated infections decreases as hand hygiene measures improve.
  • All of us have bacteria on our hands, even after performing hand hygiene. These bacteria are normal resident bacteria that generally reside in deeper layers of skin and are not likely to be removed during routine hand hygiene and are less likely to be associated with healthcare-acquired infections. When we provide patient care or have contact with the immediate patient environment, we pick up transient, potentially pathogenic microorganisms on our hands. In the study cited above, the researchers found that healthcare providers contaminate their hands with an additional 100 to 1000 bacteria during clean activities like taking vital signs. By performing appropriate hand hygiene, we remove these transient microorganisms so they cannot be transmitted to other patients.
  • In the study sited above, the researchers found that healthcare providers contaminate their hands with an additional 100-1000 CFU of bacteria during clean activities like taking vital signs. By performing appropriate hand hygiene, we remove these transient microorganisms so they cannot be transmitted to other patients.
  • Transmission of health care-associated pathogens from one patient to another via healthcare provider hands requires five sequential steps:
    1. Organisms are present on the patient’s skin, or have been shed onto inanimate objects immediately surrounding the patient;
    2. Organisms must be transferred to the hands of the healthcare provider;
    3. Organisms must be capable of surviving for at least several minutes on the healthcare provider’s hands;
    4. Hand washing or hand antisepsis by the healthcare provider must be inadequate or entirely omitted, or the agent used for hand hygiene
    inappropriate; and
    5. The contaminated hand or hands of the caregiver must come into direct contact with another patient or with an inanimate object that will come into direct contact with the patient.
  • Adherence of healthcare providers to recommended hand hygiene procedures has been reported with great variation, and in some cases is unacceptably poor. A meta-analysis of 34 studies of hand hygiene practices of healthcare providers found, across all studies, there was average hand hygiene compliance rate of 40%.
  • Some of the most frequent reasons given for the lack of hand hygiene were:
    products were inaccessible,
    the products caused skin irritation,
    healthcare providers were too busy and it interfered with patient care,
    they were wearing gloves and felt hands were not contaminated,
    they just didn’t think about it, and
    they lacked the knowledge of when and how to perform hand hygiene.
  • This table demonstrates the correspondence between the WHO 5 Moments of Hand Hygiene and the CDC Guidelines on Hand Hygiene.
  • The use of an alcohol based hand rub is preferential to hand washing when hands are not visibly soiled. You should not use alcohol based hand rubs after providing care to patients with diarrhea. Review the steps for hand rubbing shown here.
  • Hand washing with antiseptic soap and water should be used when hands are visibly soiled and after providing care patients with diarrhea. Review the steps for hand washing shown here.
  • Why is hand rubbing with an alcohol-based hand sanitizer preferred over hand hygiene with antiseptic soap and water? When compared side by side using 15-30 seconds of use, hand rubbing was significantly more efficient in reducing hand bacterial contamination.
  • In summary, hand hygiene should occur where care is delivered. Healthcare providers should know the indications for when to perform hand hygiene. Caregivers should preferentially choose to use an alcohol based hand rub over and hand washing, unless their hands are visibly soiled or they provided care to a patient with diarrhea. Healthcare providers should use the correct technique and duration.
  • In addition to hand hygiene, one of the most important concepts to understand is the role of the environment in disease transmission in healthcare settings. Patients colonized or infected with epidemiologically important pathogens shed these microorganisms into the environment and contaminate surfaces and shared patient equipment in their immediate surroundings. This pathway can be disrupted by adequately and thoroughly disinfecting the contaminated surfaces. Failure to do so poses a risk for transmission of infection.
  • The Spaulding classification scheme is used to classify surfaces and objects in healthcare based on the intended use and type of disinfection they require. Critical objects are items that enter normally sterile tissue, like surgical instruments, and require sterilization; semi-critical objects are items, like endoscopes, which have contact with mucous membranes and non-intact skin and require high-level disinfection; and finally, we have non-critical objects, like exam tables and blood pressure cuffs, which are in contact with intact skin and require only low-level disinfection.
  • There are three levels of disinfection: High, Intermediate, and Low. High level disinfection kills all microorganisms except for small numbers of bacterial spores. Intermediate level disinfection kills all non-spore forming bacteria including Mycobacterium tuberculosis, as well as most fungi and viruses. Low level disinfection also kills most microorganisms, with the exception of spores and Mycobacterium tuberculosis.
  • There are two categories of environmental surfaces. Clinical contact surfaces have a high potential for direct contamination from patient secretions, especially during procedures that generate spray or splatter. These surfaces also have frequent contact with the contaminated hands of healthcare providers and patients. These surfaces can become a reservoir for contamination of instruments, patient care devices, and healthcare provider bare or gloved hands.
  • Once epidemiologically important pathogens are on surfaces, many can live for quite some time. According to numerous studies published in the literature, many of these pathogens can live from days to several months on dry surfaces. The human immunodeficiency virus does not survive well outside of the host, while hepatitis C virus can survive for up to 4 days, and hepatitis B virus can survive up to a week on a surface.
  • When approaching the task of disinfection, it is important that you always select the right product for the right microbe. For instance, after providing care to a patient you suspect of having C. difficile or norovirus, clean environmental surfaces with a dilute bleach solution that is able to inactivate these germs. When using a disinfectant product that requires mixing or dilution, the process must be repeatedly accurate and monitored.
    Be sure to prepare the surface appropriately. In some instances, there may be heavy soiling of a surface (like a blood spill) that needs to be removed so that the disinfectant can have direct, full contact with the surface. Use a disposable wipe or microfiber cloth to apply the disinfectant to the surface with enough moisture to allow the surface to remain wet for at least 1 minute, and according to manufacturer’s instructions for use.
    Finally, it is important that healthcare providers utilize the appropriate personal protective equipment (PPE) when disinfecting surfaces.
  • These are examples of commonly used disinfectants in healthcare. A quaternary ammonium compound is the most commonly used product, but there are new products on the market including an improved hydrogen peroxide, a very robust disinfectant that has the fastest contact time to kill many different pathogens, including a claim against norovirus. Most of these preparations come in ready to use forms that do not require any additional mixing or dilution.
  • When cleaning a patient area or room it is important to use the correct technique. Here are some considerations:
    Cleaning and disinfecting of surfaces should move from clean to dirty to avoid possible contamination of surfaces that may not be soiled.
    To avoid contaminating cleaning and disinfecting solutions, a cleaning cloth should never be re-dipped into the clean solution. Rather, the used cloth should be discarded and a new cloth obtained to adequately remove pathogens from surfaces. The same is true for disposable wipes.
    If the cloth does not provide a minimum wet time of one minute, a new wipe should be obtained.
    Nothing can replace good old-fashioned elbow grease to physically remove the bioburden from the surface being cleaned.
    Personnel performing the cleaning and disinfection should know what the contact time is for the disinfectants. Follow the manufacturer’s recommendation for the area that can be cleaned per wipe. Centers for Medicare and Medicaid Services (CMS) surveyors and accrediting organizations place heavy emphasis on this during surveys, and personnel should be able state the contact time of the disinfectant they are using and know what the institutional policy and expectation is for this practice.
    Make sure that you are using the correct type of cleaning materials. If you have an item that has to be cleaned in a certain way per manufacturer instructions (e.g. with a special cloth or disinfectant), make sure that it is available and part of the cleaning process.
  • In addition to correct technique, it is also important that all of the surfaces in the room are adequately cleaned. The Environmental Hygiene Study group has tracked the thoroughness of cleaning. Across all healthcare settings representing over 110,000 objects, an average of 32% of the surfaces in rooms are cleaned. It is important that daily and post-discharge cleaning are monitored and feedback is given to the personnel performing the cleaning to ensure that all surfaces are cleaned thoroughly.
  • Another important process to know and understand is how to clean-up blood and body fluid spills. OSHA requires, as part of the bloodborne pathogen standard, that there be a formalized process for remediating these spills. The first step is to clean and decontaminate the area promptly. If the spill contains large amounts of blood or body fluids (e.g. >10 ml), first apply a 1:10 dilute bleach solution to the area, followed by cleaning the visible matter with a disposable absorbent material. Once the visible contamination has been removed, the area should be decontaminated using a dilute bleach solution of either a 1:10 or 1:100 concentration, or an EPA-registered hospital disinfectant labeled as tuberculocidal or with specific label claims against HIV and hepatitis B. All articles used to clean-up the spill should be disposed of in the appropriate, labeled containers.
  • The following references were used in the preparation of this module.
    Congratulations, you have completed this module, and may continue to the next module.