HAI TYPES BUNDLE APPROACH MANAGEMENT DISINFECTION

1. HAI
HICC
Disinfection
Rashmita Devi
Tutor
College of Nursing

3. Introduction
• Healthcare-associated infection (HCAI) is one of the most common
complications of health care management.
• Leads to increased patients’ morbidity and mortality, length of
hospital stay and the costs associated with hospital stay.
• Effective infection prevention and control is central to providing high
quality health care for patients and a safe working environment for
those that work in healthcare settings.

5. MAJOR HAI TYPES
• Catheter-associated urinary tract infection (CAUTI, 33%)
• Central line-associated bloodstream infection (CLABSI, 13%)
• Ventilator-associated pneumonia (VAP, 15%)
• Surgical site infection (SSI, 31%).

6. Prevention Hospital Acquired
Infections
• Standard Precautions
• Transmission Based Precautions
• Bundle approach for specific HAI

7. Standard Precautions
• In 1996, the CDC established the term “Standard Precautions.”
• This broadened the focus on prevention, applying the principles to all
patients regardless of diagnosis or presumed infection status.
• These guidelines consider the risk of transmission of illness from both
recognized and unrecognized sources.
www.cdc.gov/infectioncontrol/basics/standard-precautions.html

8. What are Standard Precautions?
• Standard Precautions are a set of infection control practices
that healthcare personnel use to reduce transmission of
microorganisms in healthcare settings.
• Standard Precautions protect both healthcare personnel and
patients from contact with infectious agents.
www.cdc.gov/infectioncontrol/basics/standard-precautions.html
National Guidelines for IPC in Healthcare Facilities. MoHFW, GoI, 2020.

9. Components
1. Hand hygiene
2. Personal Protective Equipment
3. Respiratory Hygiene (Cough Etiquette)
4. Ensure appropriate patient placement
5. Cleaning and Disinfection
6. Biomedical Waste Disposal
7. Needle stick and sharps injury prevention
8. Safe Injection Practices

10. Transmission-based precautions
• Transmission-based precautions apply to selected patients based on
a suspected or confirmed clinical syndrome, a specific diagnosis, or
colonization or infection due to epidemiologically important
organisms.
• Implemented along with standard precautions.
• Three major types of transmission-based precautions:
• Airborne
• Droplet
• Contact
https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html

13. What is a care bundle?
• A care bundle identifies a set of key interventions deriving from
evidence-based guidelines that, when implemented together, are
expected to improve health outcomes of patients.

14. Catheter associated urinary tract infection
CAUTIs - most common and account for 35–45% of all HAIs.
Criteria for diagnosis
Patient must meet 1, 2, and 3 below:
1. Patient had an indwelling urinary catheter that had been in place for more than 2
consecutive days in an inpatient location on the date of event
AND
• was either Present for any portion of the calendar day on the date of event† ,
OR
• Removed the day before the date of event‡
2. Patient has at least one of the following signs or symptoms:
• fever (>38.0°C) • suprapubic tenderness* • costovertebral angle pain or tenderness* •
urinary urgency ^ • urinary frequency ^ • dysuria ^
3. Patient has a urine culture with no more than two species of organisms identified, at least
one of which is a bacterium of ≥105 CFU/ml
2024 NHSN Patient Safety Component Manual.

15. Core measures (CAUTI Bundle)
• Insert catheters only for appropriate indications
• Leave catheters in place only as long as needed
• Trained persons insert and maintain catheters
• Aseptic technique and sterile equipment for insertion
• Maintain a closed drainage system
• Maintain unobstructed urine flow
• Hand hygiene and standard (or appropriate isolation) precautions
• Empty when ¾ full and use clean container for each patient
• Secure catheter to leg/abdomen
• Urine samples from sampling port only

16. Supplemental Measures
• Alternatives to indwelling urinary catheterization
• Portable ultrasound devices to reduce unnecessary catheterizations
• Antimicrobial/antiseptic - impregnated catheters
http://www.cdc.gov/hicpac/cauti/001_cauti.html

17. Central line associated bloodstream
infections
• Serious infections that can be associated with high mortality (up to
50% for some microorganisms)
National Guidelines for IPC in Healthcare Facilities. MoHFW, GoI, 2020.

18. CLABSI Bundle
1. Insertion Bundle:
- Maximal sterile barrier precautions
- Skin cleaning with alcohol-based chlorhexidine
- Avoidance of the femoral vein for central venous access in
adult patients; use of subclavian rather than jugular veins.
- Dedicated staff for central line insertion, and competency
training/assessment.
- Standardized insertion packs.
- Availability of insertion guidelines
- Use of ultrasound guidance for insertion of internal jugular
lines.

19. 2. CLABSI Maintenance Bundle:
- Daily review of central line necessity.
- Prompt removal of unnecessary lines.
- Disinfection prior to manipulation of the line.
- Daily chlorhexidine washes (in ICU, patients > 2 months).
- Disinfect catheter hubs, ports, connectors, etc., before using the
catheter.
- Ensure appropriate nurse-
to-patient ratio in ICU (1:2 or 1:1).

20. Continued..
72-96
72-96
72-96
72-96
72-96

21. Ventilator-associated pneumonia
Pneumonia is one of the most serious of HAIs.
Ventilator-associated pneumonia (VAP) is the most important
infection in patients on ventilators in intensive care units.
National Guidelines for IPC in Healthcare Facilities. MoHFW, GoI, 2020.

22. Risk factors
• Invasive devices bypassing natural defences as in mechanical
ventilation, intubation, tracheostomy, enteral feeding
• Existing pulmonary, neurological disease
• Decreased clearance of respiratory secretions due to coma, sedation,
etc.
• Medications such as antibiotics, antacids, immunosuppressive agents
and chemotherapy
• Extremes of age
• Coronary bypass surgery
• Abdominal surgery

23. VAP Prevention Bundle
• Elevation of the head of the bed to between 30°-45°
• Use of subglottic secretion drainage
• Oral hygiene with chlorhexidine
• Daily sedative interruption and daily assessment of
readiness to extubate
• Peptic ulcer disease prophylaxis
• Deep venous thrombosis prophylaxis if not
contraindicated
• Initiation of safe enteral nutrition within 24-48 hours of
ICU admission

24. •Use sterile water to fill bubbling humidifiers.
•A HME should be changed when it malfunctions mechanically or
becomes visibly soiled.
• An HME that is in use on a patient should not be routinely
changed more often than every 48 hours.
•The breathing circuit attached to an HME while it is in use on a
patient should not be changed routinely (in the absence of gross
contamination or malfunction).
CDC and HICPAC Release Updated Guidelines on the Prevention of
Health-Care–Associated Pneumonia

25. IV. Surgical-site infection
• The incidence of surgical-site infections (SSIs) varies from 0.5% to 15%
• Surgical site infections (SSIs) occur near or at the incision site
and/or deeper underlying tissue spaces and organs within 30
days of a surgical procedure (or up to 90 days for implanted
prosthetics).
National Guidelines for IPC in Healthcare Facilities. MoHFW,
GoI, 2020 CDC Guidelines 2018.

26. Risk factors

27. SSI prevention bundle
• Administer preoperative antimicrobial agents only when indicated
• Avoid removing hair from the operative site; don't use razors
• Perioperative glycemic control ( target levels less than 200 mg/dL)
• Perioperative normothermia
• General anesthesia with endotracheal intubation, administer
increased FIO2 during surgery and after extubation in the immediate
postoperative period.
• Bathe (full body) with soap or an antiseptic agent on at least the night
before the operative day.
• Use an alcohol-containing skin prep agent unless there are
contraindications

28. C. difficile prevention Bundle
• Isolate all CDI patients in a single room with hand washing sink and a
designated toilet until they are at least 48 hours symptom free.
• Review the patient’s antibiotic regimen - stop inappropriate
antibiotics.
• Check that all HCWs remove PPE (gloves and aprons) immediately
after each contact with CDI patient and their environment.
• Ensure that HCWs perform hand hygiene with liquid soap and water
immediately after removal of PPE.
• Check that the CDI patient’s immediate environment has been
disinfected with a sporicidal disinfectant

29. HOSPITAL INFECTION CONTROL COMMITTEE(HICC)
• The Committee is an integral component of the patient safety programme
of the health care facility
Structure
• Chairperson: Head of the Institute (preferably)
• Member Secretary: Senior Microbiologist
• Members: Representation from Management/Administration
(Dean/Director of Hospital; Nursing Services; Medical Services; Operations)
• Relevant Medical Faculties
• Support Services: (OT/CSSD, Housekeeping/Sanitation, Engineering,
Pharmacologist, Store Officer / Materials Department)
• Infection Control Nurse (s)
• Infection Control officer
AIIMS Infection Control Manual 2020

30. FUNCTIONSOF INFECTION CONTROL NURSES
• Regular visits to all wards and high risk units to monitor infection control
practices.
• Monitoring and supervision infection control of staffs
• Recording details of patients with healthcare associated infections
• Collection of samples from different areas of the hospital for monitoring
disinfection, sterilization and air quality and sending them to the lab.
• Daily visit to microbiology laboratory to ascertain results of samples
collected for surveillance and to liaise between microbiology department
and clinical departments.
• Compilation ward wise statistics for HCAI
• Training and education
AIIMS Infection Control Manual 2020

31. Components Of
Hospital Infection Control Program
• There are three main components of Hospital Infection Control
Program
Preventive
Measures
Training Surveillance

32. Preventive Measures
Standard Precautions.
Isolation Precautions /
Transmission Based
Precautions.
Immunization of Health
Care Workers (HCWs).
Sterilization,
disinfection and
decontamination of
medical instruments
and environment.
Bundle care approach
for certain procedures.
Appropriate use of
Personal Protective
Equipment (PPE).
Antimicrobial
stewardship program.
Use of single use
devices.
Spill management.
Reporting and
Management of
accidental injuries by
sharps.
Hospital Bio Medical
Waste Management.
Environmental
Management Practices.

33. Surveillance
• Surveillance is the on-going, systematic collection, analysis, and
interpretation of health data essential to the planning,
implementation, and evaluation of public health practice, closely
integrated with the timely dissemination of these data to those, who
need to know, so that action can be taken in order to reduce
morbidity and mortality improve health.
Surveillance is a data driven process including collection, analysis, timely
dissemination, implementation and evaluation of right data, in the right format, in
right hands, at right time, at right place.

34. Surveillance Activities
Surveillance
Passive
Laboratory Based
(Alert Organism)
Ward Based
(Alert Condition)
Medical Records
Active
Prevalence of
HAI
Incidence of HAI
Infection Control
Practices (Audits)
Reporting by individual outside of Infection Control Team To Detect
BACTERIA
1. MRSA
2. VRE
VIRUSES
1. Hepatitis B or C
2. HIV
Chicken pox
Mumps, measles
Whooping cough
Swine Flu
Typhoid
High risk areas :
• Operation theatres
• Intensive care units
• HDU
• Dialysis unit
• CSSD
• Blood bank
• Drinking water facilities
• Hand Hygiene
• Monitoring Disinfectants
• Care Bundles
• Environmental Cleaning
• CSSD Protocol

35. Case study
• A 73 year old man admitted in the ICU since four days developed
fever , supra pubic tenderness. Urine culture revealed
E.Coli,count105/mL. He has been on urinary catheterization since the
day of admission
• What is the clinical diagnosis?

36. Case Scenario
• During a routine rounds ICN of the concerned area ‘X’
observed that after intubation, the concerned staff dipped all
the used resuscitation articles like LS blades etc in the
disinfectant solution ‘Y’. AMBU Bag was floating in the solution
and when ICN questioned the concerned staff regarding the
inadequate quantity of the solution, the staff replied -“I will
top up the disinfectant solution Madam ’’.
• Resuscitation articles- Device Classification as per Spaulding??
• Disinfectant solution ‘Y’??- Minimum inactivation level of
disinfectant??
• Assume that you are the concerned ICN of the area ‘X’. Any comments on
the statement of the staff: “I will top up the disinfectant solution
Madam ” ? & observation like – floating AMBU bag in the
solution ?

38. Disinfection
• The process of destroying all pathogenic microorganisms But not
necessarily all bacterial spores on inanimate objects
• It can refer to the action of antiseptics as well as disinfectants
• Disinfectants -Chemical agents that are used to kill
microorganisms

39. Types Of Disinfectants
• High level disinfectants: 2% gluteraldehyde, stabilized hydrogen peroxide
and 1% sodium hypochlorite solution (10,000 ppm of Cl )
• Destroys all vegetative bacteria, most bacterial spores, fungi, viruses
including entero viruses and Mycobacterium tuberculosis, except some
bacterial spores.
• Intermediate level disinfectants: 0.1% sodium hypochlorite solution
(1,000 ppm of Cl ), ethyl or isopropyl alcohol (70%), iodophores and
phenolic solution
• Destroys vegetative bacteria, Mycobacterium tuberculosis, most viruses
and fungi but not bacterial spores.
• Low level disinfectants: Quaternary ammonium compounds e.g.
Benzylkonium chloride,
• Destroys most vegetative bacteria, fungi and enveloped virus e.g. HIV, but
they will not kill bacterial spores, mycobacteria and non-enveloped virus
like enteroviruses

41. Classification Of Hospital Areas Into Risk
Categories
High
• Intensive &
frequent C &
D with HLD
• Routinely
monitored
• OTs, ICUs,
CSSD, ED, HD
unit Moderate
• Regular &
frequent C &
D with spot
cleaning with
HLD
• Weekly &
daily
monitoring
• Medical
wards, lab
areas, laundry
services
Low
• Regular &
frequent C & D
with spot
cleaning in btw
with MLD to
LLD
• Fortnightly &
daily
monitoring
• Administrative
areas, offices,
stores etc.,

42. A.Zone 1: Protective area
B.Zone 2: Clean area
C. Zone 3: Sterile area
D. Zone 4: Disposal area

43. ZONE 1: THE PROTECTIVE AREA
• Includes Reception area, waiting area, Trolley Bay and
Changing rooms
• Act as the central control point (front desk)
• To monitor the entrance of patients, personnel, and
materials
• Traffic is not limited

44. ZONE 2: THE CLEAN AREA
• In OT : Includes Scrub sink area, pre-operative
area, post-operative area
• In ICU and general wards : Includes the area
around patient's bed. central nursing station,
nursing and doctor's station/computer
area/immediate investigation area like ABG
analysis/ drug trolleys.
• From here, one must exit to protective zone only
after removing the surgical attire and shoe
covers

45. ZONE 3: THE STERILE AREA
• In OT: Operating rooms (OR)
• In ICUs:

46. Continued..
• Team members must wear hospital laundered surgical scrub attire
• Head and facial hair to be covered
• Bare below elbows (BBE) policy to be followed –
• No religious forearm covering sleeves, no finger rings, bangles, other
ornaments or bands in forearm and hands (below elbow).
• In case of religious Hijab, or turban, either hospital provided
headgear (non-ornamental prototype hijab headgear) must be worn
and discarded before leaving, or sterile cloth drape provided from
hospital to be worn over and above the hijab or turban.

47. Zone 4: Disposal area
• • Dirty utility area
• • Disposal area

48. SIGNAGE FOR DEMARCATION OF ZONE
• FROM PROTECTIVE
AREA (ZONE 1) TO
CLEAN AREA (ZONE 2)
• A broad yellow line
on the floor should be
there to demarcate
between protective
and clean area

49. Continued..
• FROM CLEAN AREA (ZONE 2) TO
STERILE AREA (ZONE 3)
• A broad red line on the floor
should be there to demarcate
between clean area and sterile
area

50. Continued..
• FROM CLEAN AREA (ZONE 2)
TO DISPOSAL AREA (ZONE 4)
• A broad black line on the
floor should be there to
demarcate between clean
area and disposal area

51. General Principles while Using a Hospital Disinfectant
• It is most important that an item or surface be free from
visible soil and other items that might interfere with the action
of the disinfectant
• A hospital approved disinfectant may be used for equipment
that only touches intact skin
• It is important that the disinfectant be used according to the
manufacturer’s instructions for dilution and contact time

52. Continued..
• Minimise the contamination levels of the disinfectant solution
and equipment used for cleaning.
Ensuring proper dilution of the disinfectant,
Preparing the disinfectant fresh before use,
Frequently changing the disinfectant solution
not dipping a soiled cloth into the disinfectant solution
(i.e., no ‘double-dipping’)

53. Continued..
• Personal protective equipment should be worn appropriate
to the product(s) used
• There should be a quality monitoring system in place to
ensure the efficacy of the disinfectant over time
• (Vendors may also be asked to provide a quality test
certificate for each batch for hospital records)

54. Various disinfectants and uses
Disinfectant Purpose Contact
time
7% Lysol
Benzalkonium chloride
solution (80%) and 2.5%
w/w deionised water,
Lauryl alcohol ethoxylate
Floor surface toilet Cleaning
(non-ICU area)
10
minutes
0.5% Bacillocid Extra
Ethylenedioxy
dimethanol,
Glutaradehyde
Floor surface toilet cleaning in
ICU
5 minutes
1% Hypochlorite
** Daily preparation-
discard after 24
hrs.
Suction jar, suction tubes,
ventilator circuits, oxygen
mask, nasal prongs. Blood &
body fluid stained instruments
15
minutes