Precautions to Prevent Transmission of Infectious Agents Among Patients and Personnel: Isolation Patricia Lynch, RN, MBA
Purpose of Isolation Systems:  Reduce Cross-transmission ONLY <ul><li>Sterilization and disinfection reduce risk from inst...
Fundamental Controversy: Traditional Isolation or generic Precautions <ul><li>Traditional Isolation: Control transmission ...
Problems with Traditional Isolation <ul><li>1. Diagnosis is usually delayed </li></ul><ul><li>2. Fails to protect suscepti...
Laboratory Screening Before Precautions <ul><li>Good for low frequency events especially if hard to recognize clinically B...
Laboratory Screening Before Precautions <ul><li>Bad example: Blood + for HIV, HBV, or HCV before blood precautions begun <...
Barrier Precautions Reduce Bi-Directional Transmission <ul><li>Generic precautions: Precautions must be used for all activ...
Isolation Systems Direct: <ul><li>When to wear/change gloves </li></ul><ul><li>When to wear/change gowns </li></ul><ul><li...
Factors that Affect Risk for Nosocomial Infections <ul><li>Size of inoculum and virulence </li></ul><ul><li>Duration and i...
Cross-transmission:  Sources for Organisms <ul><li>Moist body sites and substances </li></ul><ul><li>Articles soiled with ...
Cross-transmission: Role of Articles, Surfaces <ul><li>C. difficile  on an adult  medical unit: </li></ul><ul><li>23%  acq...
Infection Risk Increases : <ul><li>When new organisms become established. </li></ul><ul><li>This is the basis for isolatio...
Studies of Generic Barrier Precautions for Patient Protection <ul><li>Clean gloves just before mucous membrane, non-intact...
Studies of Generic Barrier Precautions for Patient Protection <ul><li>Gown and gloves: RSV transmission.  LeClaire .  NEJM...
Importance of Gowns <ul><li>Unlikely to play a major role for patients or personnel  </li></ul><ul><li>In 2 pediatric stud...
Ineffective Risk  Reduction Strategies
Generic Precautions for Health Care Worker Protection <ul><li>Research proves risk for blood exposure is decreased by gene...
Select Generic Precautions When: <ul><li>Unrecognized cases are common (what is the shape of the iceberg?) </li></ul><ul><...
Icebergs for Some Diseases  <ul><li>Hepatitis B: 2/3 cases clinically inapparent </li></ul><ul><li>HIV, multi-drug resista...
Potential Advantages of Generic Precautions <ul><li>More consistent than diagnosis-based </li></ul><ul><li>Independent of ...
Elements of Generic Precautions  Proven  to be Effective: SP <ul><li>1. Wear sterile gloves for normally sterile body site...
Elements of Generic Precautions  Proven  to be Effective: SP <ul><li>3.  Wear gloves for contact with any moist body subst...
Elements of Generic Precautions  Likely  to be Effective: SP <ul><li>1. Alcohol handrub or antimicrobial handwash in high ...
Elements of Generic Precautions  Likely  to be Effective <ul><li>3. Clean & disinfect surfaces that patients and staff han...
Elements of Generic Precautions  Likely  to be Effective <ul><li>5. Bag all soiled trash & linen to prevent leakage </li><...
Compliance with Precautions <ul><li>Must be measured & reinforced as often as necessary </li></ul><ul><li>Is most effectiv...
Occupational Bloodborne Diseases <ul><li>Comply with generic precautions </li></ul><ul><li>Immunize for HBV </li></ul><ul>...
What Additional Precautions for  Airborne Communicable Diseases? <ul><li>High index of suspicion </li></ul><ul><li>Respira...
Airborne Communicable Diseases <ul><li>Screen all patients & visitors for cough, systemic viral infections </li></ul><ul><...
New CDC Draft Guideline <ul><li>CDC &quot;The Draft Guideline for Isolation Precautions: Preventing Transmission of Infect...
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Precautions to Prevent Transmission of Infectious Agents Among Patients and Personnel: Isolation

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Precautions to Prevent Transmission of Infectious Agents Among Patients and Personnel: Isolation

  1. 1. Precautions to Prevent Transmission of Infectious Agents Among Patients and Personnel: Isolation Patricia Lynch, RN, MBA
  2. 2. Purpose of Isolation Systems: Reduce Cross-transmission ONLY <ul><li>Sterilization and disinfection reduce risk from instruments </li></ul><ul><li>Housekeeping reduces organisms on surfaces </li></ul><ul><li>Food & water hygiene </li></ul>
  3. 3. Fundamental Controversy: Traditional Isolation or generic Precautions <ul><li>Traditional Isolation: Control transmission from recognized infection sites (quarantine) </li></ul><ul><li>Generic precautions: use only precautions that are effective but use them for EVERYONE </li></ul>
  4. 4. Problems with Traditional Isolation <ul><li>1. Diagnosis is usually delayed </li></ul><ul><li>2. Fails to protect susceptible sites (mucous membranes, non-intact skin of all patients) </li></ul><ul><li>3. De-emphasizes generic precautions </li></ul><ul><li>4. Hospitals AMPLIFY transmission </li></ul>
  5. 5. Laboratory Screening Before Precautions <ul><li>Good for low frequency events especially if hard to recognize clinically BUT </li></ul><ul><li>Delayed precautions result </li></ul><ul><li>Very expensive </li></ul><ul><li>Good example: Screening for CJ Disease before any organs used for transplant </li></ul>
  6. 6. Laboratory Screening Before Precautions <ul><li>Bad example: Blood + for HIV, HBV, or HCV before blood precautions begun </li></ul><ul><li>1. High prevalence in some hospitals makes delay risky </li></ul><ul><li>2. MRSA in many populations: high prevalence </li></ul>
  7. 7. Barrier Precautions Reduce Bi-Directional Transmission <ul><li>Generic precautions: Precautions must be used for all activities with risk for transmission, not solely infected cases. </li></ul><ul><li>Documented by research </li></ul>
  8. 8. Isolation Systems Direct: <ul><li>When to wear/change gloves </li></ul><ul><li>When to wear/change gowns </li></ul><ul><li>When to wear/change masks </li></ul><ul><li>Who may enter the room </li></ul><ul><li>Roommate selection </li></ul>
  9. 9. Factors that Affect Risk for Nosocomial Infections <ul><li>Size of inoculum and virulence </li></ul><ul><li>Duration and intimacy of contact </li></ul><ul><li>Host defenses </li></ul><ul><li>Risk is greatest when these factors overlap </li></ul>
  10. 10. Cross-transmission: Sources for Organisms <ul><li>Moist body sites and substances </li></ul><ul><li>Articles soiled with moist body substances (MBS) </li></ul><ul><li>Hands that have touched MBS, then touched mucous membranes or non-intact skin </li></ul>
  11. 11. Cross-transmission: Role of Articles, Surfaces <ul><li>C. difficile on an adult medical unit: </li></ul><ul><li>23% acquired C. d within days </li></ul><ul><li>C. d persisted on hands, surfaces </li></ul><ul><li>New admissions acquired C.d in rooms of discharged patients McFarland. NEJM 1989:204-10. </li></ul>
  12. 12. Infection Risk Increases : <ul><li>When new organisms become established. </li></ul><ul><li>This is the basis for isolation in hospitals: prevention of new colonization. </li></ul><ul><li>Burke. Ann Surg 1977:377 </li></ul>
  13. 13. Studies of Generic Barrier Precautions for Patient Protection <ul><li>Clean gloves just before mucous membrane, non-intact skin: infections and colonization decreased. Lynch. AJIC 1990:1-12 </li></ul><ul><li>Clean gloves & gown: febrile days, colonization, infection decreased. Klein. NEJM 1989:1714-21. </li></ul>
  14. 14. Studies of Generic Barrier Precautions for Patient Protection <ul><li>Gown and gloves: RSV transmission. LeClaire . NEJM 1987:329-34 </li></ul><ul><li>Gloves: C. difficile outbreak ended. Johnson. AJM 1990:137-40. </li></ul>
  15. 15. Importance of Gowns <ul><li>Unlikely to play a major role for patients or personnel </li></ul><ul><li>In 2 pediatric studies, gowns, masks, caps did not decrease colonization or infection; Donowitz. Pediatrics 1986:35-8. Haque. J Hosp Inf 1989:159-62. </li></ul>
  16. 16. Ineffective Risk Reduction Strategies
  17. 17. Generic Precautions for Health Care Worker Protection <ul><li>Research proves risk for blood exposure is decreased by generic precautions. Beekman; Wong, others </li></ul><ul><li>Barrier precautions+sharp instrument safety: 15-fold decline in clinical HBV in health care workers. Osterholm. JAMA 1985:3207-10 </li></ul>
  18. 18. Select Generic Precautions When: <ul><li>Unrecognized cases are common (what is the shape of the iceberg?) </li></ul><ul><li>Lab results take longer than 3 days </li></ul><ul><li>Patients are moved frequently </li></ul><ul><li>There are many high risk patients </li></ul>
  19. 19. Icebergs for Some Diseases <ul><li>Hepatitis B: 2/3 cases clinically inapparent </li></ul><ul><li>HIV, multi-drug resistant enteric organisms: >90% of cases inapparent </li></ul><ul><li>Measles: only 10% clinically inapparent; all before diagnosis </li></ul>
  20. 20. Potential Advantages of Generic Precautions <ul><li>More consistent than diagnosis-based </li></ul><ul><li>Independent of lab, delayed diagnosis </li></ul><ul><li>Protection for susceptible sites </li></ul><ul><li>Decreases knowledge burden </li></ul>
  21. 21. Elements of Generic Precautions Proven to be Effective: SP <ul><li>1. Wear sterile gloves for normally sterile body sites </li></ul><ul><li>2. Wear clean gloves for contact with MM, NIS </li></ul>
  22. 22. Elements of Generic Precautions Proven to be Effective: SP <ul><li>3. Wear gloves for contact with any moist body substance </li></ul><ul><li>4. Cover gown, mask, eyewear or other barriers before MBS contact </li></ul>
  23. 23. Elements of Generic Precautions Likely to be Effective: SP <ul><li>1. Alcohol handrub or antimicrobial handwash in high risk areas </li></ul><ul><li>2. Private room for patients who soil the environment with moist body substances: diarrhea, lesion drainage, respiratory secretions </li></ul>
  24. 24. Elements of Generic Precautions Likely to be Effective <ul><li>3. Clean & disinfect surfaces that patients and staff handle frequently </li></ul><ul><li>4. Clean & disinfect immediately articles and surfaces soiled with MBS </li></ul>
  25. 25. Elements of Generic Precautions Likely to be Effective <ul><li>5. Bag all soiled trash & linen to prevent leakage </li></ul><ul><li>6. Careful roommate selection & patient placement </li></ul><ul><li>7. Cough etiquette </li></ul>
  26. 26. Compliance with Precautions <ul><li>Must be measured & reinforced as often as necessary </li></ul><ul><li>Is most effective when accompanied by departmental outcome measures </li></ul>
  27. 27. Occupational Bloodborne Diseases <ul><li>Comply with generic precautions </li></ul><ul><li>Immunize for HBV </li></ul><ul><li>Surveillance for blood exposures in all departments; focused studies in high risk areas; prevention strategies from data </li></ul>
  28. 28. What Additional Precautions for Airborne Communicable Diseases? <ul><li>High index of suspicion </li></ul><ul><li>Respiratory etiquette for all patients, personnel & visitors </li></ul><ul><li>Controlled air, immune personnel, high-efficiency masks & respirators when needed </li></ul>
  29. 29. Airborne Communicable Diseases <ul><li>Screen all patients & visitors for cough, systemic viral infections </li></ul><ul><li>Educate personnel about transmission risk </li></ul><ul><li>Change social etiquette to “Cover completely all coughs” </li></ul>
  30. 30. New CDC Draft Guideline <ul><li>CDC &quot;The Draft Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2004&quot; www.cdc.gov </li></ul><ul><li>4 years, 8 drafts, 730 references, 200 pages. </li></ul>

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