Lecture By : Dr. Satti M. Saleh Chief of Infectious Diseases Department CBAHI SIT Member Medical Director MGH

1. THE IMPORTANCE OF INFECTION CONTROL
IN PATIENT CARE
Dr. Satti M. Saleh
Chief of Infectious Diseases Department
CBAHI SIT Member
Medical Director MGH

2. PEARLS OF WISDOM
QUALITY OF CARE
IS
AS IMPORTANT AS
QUALITY OF TREATMENT

3. International Patient Safety Goals
IPSG
 IPSG.1 Identify Patients Correctly
 IPSG.2 Improve Effective Communication
 IPSG.3 Improve the Safety of High-Alert Medications
 IPSG.4 Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
 IPSG.5 Reduce the Risk of Health Care–
Associated Infections
 IPSG.6 Reduce the Risk of Patient Harm Resulting from
Falls

4. PATIENT SAFETY
An Organisation with a memory
21/01/2013

5. THE PARADIGM OF STRUCTURE , PROCESS & OUTCOME
 THE RELATIONSHIP BETWEEN STRUCTURE , PROCESS &
OUTCOME IS A CAUSAL RELATIONSHIP “DONABEDIAN “
ARRANGEMENT OF
PARTS OF CARE STRUCTURE
SYSTEM OR
ELEMENT OF CARE
LEADS TO
CLINICAL
CARE DELIVERY PROCESS
ADMINISTRATIVE
LEADS TO
REFERES TO
•CLINICAL
RESULTS OF CARE
OUTCOME •FUNCTIONA
(ADVERSE OR
•PECEIVED
BENIFICIAL )

6. Infection Control Programme Structure
1) INFECTION CONTROL UNIT :-
 Independent
IPP's all patient care areas
Infection control policy standard
2) CURRENT SCIENTIFIC KNOWLEDGE
3) ICP : FULL TIME
4) QUALIFIED PERSONNEL
5) IC MANUAL
6) CONTINUE EDUCATION.
 InfectionControl Personnel
 Staff Orientation
 Staff Continuous Education
7) IC COMMITTEE

7. GOAL FOR HOSPITAL INFECTION
PREVENTION &CONTROL PROGRAMMS
 PROTECT THE PATIENT .
 PROTECT HCWS VISITORS &OTHERS IN THE
 HEALTHCARE ENVIRONMENT
 ACCOMPLISH PREVIOUS GOALS
,WHEREVER POSSIBLE , IN A COST
EFFECTIVE MANNER

8. Definition
Of HCAI

9.  INFECTION OCCURRING DURING
OR AS A RESULT OF
HOSPITALIZATION
WHICH THE PATIENT NEITHER

HAVING NOR INCUBATING AT THE
TIME OF ADMISSION.

10. Importance

11. INCREASE PROBLEMS DUE TO :-
1-ADVANCE TECHNOLOGY
2-OVERCROWDING
3-POOR RESOURCES
4- USES OF ANTIBIOTICS
5-INCREASE INVASIVE
PROCEDURES
6-IMUNOSUPRESSION
7-SHORTAGE OF TRAINED STAFF

12. MISCONCEPTIONS ?
1-IC IS EXPENSIVE
2-DIFFICULT TO IMPLEMENT
3-NO RISK TO STAFF
4-BLOOD BORN PATHOGENS
5-SCREENING IN EMERGENCY
6-SCREEING IS COSTLY

13. Surveillance Program
 CONTINUOUS OR PERIODIC.
 DIRECTED TO ALL INFECTIONS OR TARGETED
SITES / DEVICES.
 ALL NEED TO BE SUPPLEMENTED BY
MICROBIOLOGY LABORATORY BASED SYSTEMS.
 TECHNIQUES:
 REVIEW ANTIBIOTIC RECORDS.
 PATIENT / NURSING CARE RECORDS
 MICROBIOLOGY RESULTS
 AUGMENT BY AFTER ICU FOLLOW UP.
 AUTOPSY REPORTS

14. Surveillance
 INFECTION CONTROL PROGRAM CLOSELY MONITORS THE
FOLLOWING:
PATIENTS AT HIGH RISK OF INFECTION.
PATIENTS WITH ALREADY ACQUIRED INFECTIONS.
PERSONNEL/PATIENTS EXPOSED TO COMMUNICABLE
DISEASES, CONTAMINATED EQUIPMENT, OR
HAZARDOUS REAGENTS.
PATIENTS IN CERTAIN AREAS OF THE HOSPITAL OR IN
CERTAIN ROOMS.
PATIENTS IN AMBULATORY SETTINGS: HOME OR LONG-TERM
CARE FACILITIES.
 SURVEILLANCE IS ALSO INVOLVED IN CLASSIFYING INFECTIONS
ACCORDING TO PREVALENCE RATES AND MONITORING
EMPLOYEE HEALTH INCLUDING SCREENING FOR DISEASES
AND OFFERING IMMUNIZATIONS.
Phlebotomy Handbook: Blood
Collection Essentials, Seventh Edition Pearson Education
Diana Garza • Kathleen Becan-McBride Copyright 2005

15. CHAIN OF INFECTION
Organism
Source
Mode of
Transmission
Host

16. NEW ISOLATION PRECAUTIONS, 1996
‘’ STANDARD’’
AND
‘’ TRANSMISSION – BASED
PRECAUTIONS’’

17. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE .
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE
DISPOSAL.

18. HAND HYGIENE
. HAND HYGIENE IS THE SINGLE MOST
IMPORTANT PRACTICE TO REDUCE THE
TRANSMISSION OR INFECTIOUS AGENTS IN
HEALTHCARE SETTINGS .
.THE TERM “HAND HYGIENE” INCLUDES :
 HAND WASHING WITH EITHER PLAIN OR ANTISEPTIC
CONTAINING SOAP AND WATER .
 USE OF ALCOHOL-BASED PRODUCTS ( GELS,
RINSES, FOAMS) CONTAINING AN EMOLLIENT
THAT DO NOT REQUIRE THE USE OF WATER.

19. RATIONALE
TRANSIENT FLORA (Contaminating or non –
colonizing)
 Attached to the superficial layer of skin.
 Microbes isolated from skin not consistently
present in majority of persons associated with
HCAI .
RESIDENT FLORA
 Attached to deeper layer of the skin
persistently isolated from skin of most persons
(cons, diphtheriods )

21. TYPE OF HAND HYGIENE
1) Intensity of contact .
2) Degree of contamination .
3) Susceptibility of patient to infection .
4) Prove dure to be performed .

23. HAND HYGIENE
 In the absence of visible soiling of hands,
approved alcohol-based products for hand
disinfection are preferred over hand
washing with water and antimicrobial or
plain soap because of their superior
microbiocidal activity, reduced drying of
the skin, and convenience.

24. HAND HYGIENE
 In observational studies of opportunities for
hand washing in health care workers in U.S.A
 The overall compliance was 40% (range 5 –
81%) .
 Compliance was highest among nurses and
lowest among physicians, in intensive care
units, and when required intensity of care was
greater .

25. HAND WASHING STUDY IN RIYADH
MEDICAL COMPLEX-GENERAL
HOSPITAL
 Overall frequency of hand washing .
 23.7% after patient contact .
 6.7% before patient contact .

26. HAND WASHING
Health care infection control practices
advisory committee (HICPAC) former
recommendations
 Plain soap and water was recommended for
routine hand washing.
 Antimicrobial soaps (e.g. : chlorhexidine) was
recommended for :
- Patients under contact precautions .
- During instances of epidemic or hyperendemic
spread of infections.

27. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2-Personal Protective
Equipment (PPE)
.
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE DISPOSAL.

28. What are Personal Protective
Equipment (PPE)?
 Items specified for
protection of many parts
of body (to reduce risks to
the health and safety of
HCWs, and to minimize
risks of cross infection
between patients, staff,
visitors) e.g. gloves,
masks, respirators,
goggles, specialized
clothing (aprons & gowns)

29. Common PPEs
 Gloves
 Aprons and gowns
 Face, mouth, nose, eye Protection
 Foot protection
 Head coverings

30. Evidence shows hand washing
prevents infections, but does PPE?
 If health workers currently use PPE that
doesn’t mean it is effective.
 One role of Infection Control Staff is to
assess the changing risks and practices.
◦ Stop practices that are ineffective, expensive.
◦ Help institute cost-effectiveness practices of
proven efficacy.

31. Last reminder
 Don’t assume current PPE use is effective
 Assess where and how employees are getting
exposed to body fluids and harmful exposures.
Assess how patients are getting disease from
staff
 Select PPE that rationally protects patients
and staff.
 Measure costs.

32. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE
DISPOSAL.

33. ASEPSIS (ASEPTIC TECHNIQUE)
 REFERS TO PRCEDURES PERFORMED
UNDER STERILE CONDITION
 DEFINED AS A SET OF SPECIFIC PRACTICES
& PROCEDURES PERFORMED UNDER
CAREFULLY CONTROLLED CONDITIONS
WITH THE GOALOF MINIMIZING
CONTAMINATION BY PATHOGENS
 e.g. DRAIN REMOVAL & CARE
 RESPIRATORY SUCTION

34. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE
3- ASEPTICTECHNIQUES
4- REPROCESSING OFINSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE DISPOSAL.

35. REPROCESSING OF REUSABLE INSTRUMENTS
 CLEANED & MAINTAINED ACCORDING
TO MANIFACTURER INSTRUCTIONS
 SINGLE USE DEVICES DISCARDED
AFTER ONE PATIENT
 DEVICES FLOW FROM HIGH
CONTAMINATION TO STERILE AREA
 DEVICES STORED IN A MANNER TO
PROTECT FROM DAMAGE

36. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE .
3- ASEPTICTECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE
DISPOSAL.

37. 5- ENVIROMENTAL CLEANING
 SURFACE CLEANED & DISINFECTED
 CLEANERS & DISINFECTANTS ARE
USED IN ACCORDANCE WITH
MANIFACTIORER INSTRUCTIONS.

38. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE .
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE DISPOSAL.

39. Factors which increase risk of
infection
 Deep injury.
 Visible blood on the device.
 High viral titer.
 Artery or vein device.
 Combined factors.
 Un-immunized against hepatitis B.
 No post exposure prophylaxis with Zidovidine
(prophylaxis decrease risk by 80%).
1/21/2013 39

40. Risk of Transmission of
Blood born Infection
Occupational Risk of
Exposure Transmission
Hepatitis B Virus 2-40%
Hepatitis C Virus 2.7-10%
HIV 0.3% (1 in 300
chance of infection)
1/21/2013 40

41. Hazards of Needle stick injuries
 Hepatitis B and C.
 HIV.
 Brucellosis.
 Malaria.
 S. aureus and S. pyogenes.
 Toxoplasmosis.
 Tuberculosis.
1/21/2013 41

42. How can needle stick injuries be
prevented
 Employee training.
 Recommended guidelines.
 Safe recapping procedures.
 Effective disposal systems.
 Surveillance programs.
 Improved equipment design.
1/21/2013 42

43. B-Transmission-Based
Precautions
 Three categories of Transmission-
based Precautions :
 Contact Precautions .
 Droplet Precautions .
 Airborne Precautions .

44. Contact transmission
 Examples of organisms spread by contact:
 Multi-drug-resistant organisms in the
gastrointestinal tract, sputum, or wounds
(MRSA, MDR Gram –ve, VRE).
 Clostridium difficile.
 Herpes simplex virus (mucocutaneous).
 Scabies.

45. Contact precautions
. Wash hands with antimicrobial soap before leaving
the patient's room .
. Minimize risk or environmental contamination
during patient transport (e.g. patient can be
placed in a gown ).
. Patient’s care devices ( e.g. thermometer , BP
cuffs , stethoscopes ) should be dedicated to use
for a single patient if possible , otherwise, they
should be rigorously cleansed and disinfected
before use for other patients .

46. Contact precautions
. Private room preferred; cohorting allowed if necessary .
. The door of the room may remain open .
. Gloves :
- upon entering room .
- change gloves after contact with contaminated secretions .
- should be removed before leaving the room .
. Gown:
- if clothing may come into contact with the patient or environmental
surfaces .
- should be removed before leaving the room .

47. DROPLET TRANSMISSION
 Respiratory droplets are large particles (>5 micron) expelled
during :-
- Coughing .
- Sneezing .
- Talking.
- During procedures such as suctioning and bronchoscope .
 Droplets travel < 1,5 meter from the source patient .
 Example :
• Neisseria meningitides .
• Haemophilus influenza type b ( invasive ) .
• Streptococcus pyogenes (group A Streptococcus) .
• Mycoplasma pneumonia .

48. DROPLET PRECAUTIONS
 Private room preferred; cohorting allowed if
necessary.
 Special air handling and ventilation are
unnecessary .
 The door of the room may remain open .
 Wear a mask when within 1 meter of the
patient .
 Mask the patient during transport .

49. AIRBORNE TRANSMISSION
 Airborne spreads upon aerosolization of small particles
(=< 5 micron) of the infectious agent that can then
travel over long distances through the air .
 Most common nosocomial pathogens transmitted by
this route :
- Mycobacterium tuberculosis .
- Varicella-zoster virus (chickenpox) .
- Measles .
- Smallpox.
- ? SARS .

50. AIRBORNE PRECAUTIONS
 Place the patient in a negative pressure room
with at least 6 – 12 air exchanges per hour .
 Room exhaust must be appropriately
discharged outdoors or passed through a
HEPA ( high – efficiency particulate aerator )
filter before recirculation within the hospital .
 The door of the room should be kept closed .

51. Precautions Needed for Cases
Condition Type Duration
 Pulmonary TB S+A Till sputum Negative
 Chicken Pox S+A Till rash crusted
 M-meningitis S+D 24 Hrs
 HIV S Duration of stay
Clinical Syndromes:
Empiric precautions as per clinical presentation

57. COMMUNICABLE
DISEASE

58.  Staffawareness
 Measures toward patient's
diagnosis, isolation disinfection
etc.
 Notification
◦ Class I, Class II

59. EMPLOYEE HEALTH

60.  Staff health clinic
 Physical examination
 Screening
 Vaccination
 Post exposure management
◦ *Blood, body fluids
◦ *Needle stick injury
◦ *Vaccine
 -Staff accommodation
 Vaccine preventable disease

61. SUPPORT SERVICES

62. a) CSSD
b) House Keeping
c) Mortuary & Postmortem
Written policy disinfection & cleaning morgue temperature (2-8) logged daily
d) Kitchen
Environment & function Food container Food protection PPE Staff health & screening Written policy
e)Laundry
Linen management Laundry structure & function
f)Haemodialysis Staff knowledge
-PPE Standard precaution Structure Patient Medical Records (Screen Vaccination) Staff Medical
Record
-Haemodialysis water dialysate Water treatment -Written policy
g) Operating Room
Structure Traffic Control Pressure gradient & air cycle Cleaning Written policy

63. STERILIZATION

64. STERILIZATION OF REUSABLE INSTRUMENTS
&DEVICES
STERILIZATION
 PROCESS OF ELIMENATING
(REMOVING)OR KILING MICROBIAL
ORGANISMS PRESENTING ON THE
SURFACE OR IN FLUID OR MEDIA
 METHODS:-
◦ HEAT
◦ IRRADIATION
◦ CHEMICAL
◦ HIGH PRESSURE
◦ RADIATION

65. DISINFECTION
 THE PROCESS OR ACT OF
DISTROYING PATHOGENIC MICRO-
ORGANISMS OR MAKING THEM
INERT (SOME CERTAIN BACTERIA
SPORES MAY SURVIVE)
 COULD BE CHEMICAL OR BY HEAT

66. HIGH LEVEL
DISINFECTION OF
REUSABLE DEVICES

67. CLEANING
 REMOVAL OF VISIBLE SOIL FROM
OBJECT & SURFACES
 IT’S A FORM OF DECONTAMINATION

68. OUTBREAK INVESTIGATION
 OUTBREAKS ARE RECOGNIZED BY:-
◦ PRACTITIONER
◦ PATIENT &PATIENT FAMILY
◦ PUBLIC HEALTH SURVEILLANCE
◦ LOCAL DATD-MEDIA

69. OUTBREAK INVESTIGATION
 REASONS TO INVESTIGATE :-
◦ PREVENT ADDITIONAL CASES
◦ PREVENT FUTURE CASES OUTBREAK
◦ LEARN ABOUT NEW DISEASES
◦ LEARN SOMETHING NEW ABOUT OLD
DISEASES
◦ REASSURE THE PUBLIC
◦ ECONOMIC &SOCIAL REASONS

70. OUTBREAK INVESTIGATION
 CONDUCTING AN OUTBREAK
INVESTIGATION:-
◦ CASE INVESTIGATION
◦ CAUSE INVESTIGATION
◦ CONTROL MEASURES SHOULD BE DONE
EARLY
◦ CONDUCT ANALYTIC STUDY IF NECESSARY
◦ CONCLUSIONS
◦ CONTINUE SURVEILLANCE
◦ COMMUNICATE FINDINGS eg.
EPIDEMIOLOGICAL,CLINICAL,FORENSIC
INVESTIGATION