Infection prevention and safety measures

2/4/2016 MN1st Year Chanak (6th 1

Infection Prevention and
Safety Measures
Chanak Trikhatri
MN 6th Batch
2/4/2016 2

“It may seem a strange principle
to enunciate as the very first requirement
of a hospital
that it do the sick no harm”
(Florence Nightingale, Notes on Hospitals,
1863)

• Concepts of infection prevention and safety measures
• Chain of infection
• healthcare-associated infections and safety measures
• Development of infection prevention guideline
• Component of Standard Precaution and Transmission
based Precaution and Safety Measures
• Challenges of healthcare-associated infections.
• Illustrate nurses Role In infection prevention and safety
measures
Highlights of the Seminar
2/4/2016 4MN1st Year Chanak (6th

History
Period Events
Hippocrates (460-
370 BC)
Suppuration and pus was not a natural component in the
healing process
Sumerians The wound was cleansed with beer and then bandaged with
a cloth soaked in wine and turpentine.
Middle age Earliest Europeans hospitals no resemblance to modern
hospitals. Lack of space and shifts were ordered for patients
and occasionally more than one patients in beds. Hospitals
called “pest houses.”
19th century
(1865)
Germ theory by Louis Pasteur, and its subsequent
application to surgical sterility by Joseph Lister
Koch’s
postulates, 1890
The germ theory and Semmelweis’ theory of transmission
from patient to patient were considered plausible

History Contd….
Period Events
Middle 1800s Ignaz
Phillip Semmelweis
Ignaz Phillip Semmelweis and Nightingale introduced
sanitation and hygienic practices into the hospital.
19th century Surgery almost always followed by infection, 60% of limb
amputations resulted in fatal infection
1950s North America
and the UK.
Modern infection control and practiced due to hospital
outbreaks of staphylococcus aureus
1990s Emergence of Vancomycin resistant Enterococci.
--- Advancement brought new challenges like catheter,
blood stream infection and ventilator associated
pneumonia.
2000 on ward Increase number of susceptible patients as a result of
survival to immune modifying disease or effect of therapy

Definition of an Infection
• The entry and development or multiplication of an agent
in the body of man or animals (Park, 2015).
• Entry of a harmful microbe into the body and its
multiplication in the tissues / bloodstream (Wilson, 2001).
• Invasion of the body by a pathogenic microorganism
(Bergquist and Pogosian, 2000)

Def. Contd….
The presence of viable multiplying microorganisms in the
tissues of a host, or in body cavities in which such
organisms are not usually found in normal course. The
term implies the presence of a host response (in contrast
to colonization where there is no host response), which
may actually be responsible for many unwanted effect of
infection (Thomas, 2007).

Chain of Infection:
Source or
Reservoir
Mode of
Transmission
Susceptible
Host
(Park, 2015)

Causative Agent Microorganisms
Infectious agent microorganisms (bacteria,
viruses, fungus, parasite)
• Resident:- normally reside on the skin in
stable numbers
• Transient:- attach loosely to the skin by
contact with another easily removed by
hand washing

Reservoir
A reservoir is defined as “any person, animal, arthropod,
plant, soil or substance (or combination of these) in
which as infectious agent lives and multiplies, on which it
depends primary for survival and where it reproduces
itself in such manner that it can be transmitted to a
susceptible host.” Three types of reservoir are;
1) Human reservoir
2) Animal reservoir
3) Reservoir in non-living things (Park, 2015).

Portal of Exit
As part of the chain of infection, the path by which the
causative agent gets out of the reservoir. In a person, this is
often by a body fluid (Park, 2015).
Mode of Transmission
Communicable diseases may be transmitted from the
reservoir or source of infection to a susceptible individual in
many different ways, depending upon the infectious agent,
portal of entry and the local ecological conditions (Park,
2015). Direct, Indirect

Portal of Entry:
• As part of the chain of infection, the path by which the
causative agent gets into a susceptible host.
• Nose, mouth, eyes, rectum, genitals and other mucous
membranes, cuts, abrasions or breaks in the skin
Susceptible Host
• Anyone whose resistance to disease decreases
• Reasons for lowered resistance: age, existing illnesses,
fatigue and stress

Types of infection
1. Community Acquired
2. Hospital Acquired
a. Nosocomial Infection
b. Opportunistic Infection
c. Iatrogenic Infection
d. Cross Infection

1. Community Acquired
An infection contracted outside of a health care setting or
an infection present on admission. Community acquired
infections are often distinguished from nosocomial by the
types of organisms (Medical Dictionary, 2009). In contrast
to nosocomial (hospital acquired) infection.

Prevention Modalities
• Primordial Prevention: inhibit the emergence of risk
factors
• Primary Prevention: the action taken prior to the onset of
disease
• Secondary Prevention: action which halts the progress of
a disease at its incipient stage and prevents
complications
• Tertiary Prevention: prevention are disability limitation,
and rehabilitation

2. Hospital-acquired infection (HAI)
Hospital-acquired infection (HAI) is an infection that is
contracted from the environment or staff of a healthcare
facility. Infection is spread to the susceptible patient in the
clinical setting by a number of means; health care staff,
contaminated equipment, bed linens, or air droplets (CDC,
2014).

Contd…
• Exogenous:– from an outside source, staff, other
patients, environment, equipment (Iatrogenic,
Nosocomial Infection)
• Endogenous:– self infection from the patient
(Oppotunistic Infection)

Semmelwish Investigation
• In 1846 there was differential mortality of childbed fever
between 2 obstetrics wards 1 & 2 at University of Geneva.
• Then Pathologist doing post mortem died of similar illness
having nicked his hand with scalpel, conclusion from
infectious materials.
• Hospital staff and students were subsequently ordered to
wash their hands
• Mortality rate dropped from 11.4% to 1.3% in ward 1- decline
of 89%.
• Hand washing also ordered for ward 2, rate declined by 52%.

Nosocomial Infections
Nosocomial infection is an infection originated in a
patient while in a hospital or other health care
facility. It denotes a new disorder associated with
being in hospital. (Park, 2015).
An infection occurring in a hospitalized patient, 72 hours
or more after admission. Also includes infections directly
related to a previous hospitalization (Capital Health,
2010).

Contd..
• At least 5% of hospitalized patients each year in the U.S.
develop nosocomial infections many are preventable
(CDC, 2014a).
• About 5.6 million HCWs and related occupations are at
risk of occupational exposure to bloodborne pathogens,
including HIV, HBV, HCV, and others (OSHA, 2014).

Contd…
• In 2011, over 700,000 HAIs occurred in U.S. hospitals,
with 75,000 patients dying from complications of HAIs
(CDC, 2014a).
• About 380,000 people die of infections acquired in long-
term care facilities each year (CDC, 2014b).
• In England, more than 100,000 cases of HAIs lead to
over 5,000 deaths occur annually.

Contd…
• Out of every 100 hospitalized patients at any given time,
7 in developed and 10 in developing countries will
acquire HAIs. Hundreds of millions of patients are
affected by this worldwide each year (WHO, 2014).
• Globally it is estimated that 142,000 people died in 2013
from adverse effects of medical treatment up from
94,000 in 1990.
• Eastern Mediterranean and South-East Asia Regions
11.8 and 10.0%, respectively (Sah, M.K., et. al., 2012).

Research: Nosocomial Bacterial Infection
and antimicrobial Resistant Pattern in a
Tertiary care Hospital in Nepal
Prevalence of bacteria causing nosocomial infection was
(34.4%, 310). Out of 310 specimens, urine 122 (39.30%),
sputum 78(25.2%), pus 78(25.2%), endotracheal
secreation 24 (7.7%) and blood 8(2.6%). The most
common isolates were Escherichia coli followed by
Acinetobacter species, Klebsiella pneumonia and
Staphylococcus aureus (Sah, M.K., et. al., 2012).

Common Microbes
Gram-negative bacteria:
• Pseudomonas aeruginosa
• Staphylococcus aureus
• Aeromonas hydrophilia
• Acinetobacter calcoaceticus
• Legionella pneumophila
Mycobacteria:
• Mycobacterium xenopi
• Mycobacterium chelonae
• Mycobacterium avium-intracellularae

Contd…

Iatrogenic Infection
Resulting from the activity of a health care provider or
institution or said of any adverse condition in a patient
resulting from treatment by a physician, nurse, allied
health professional or medical instruments and procedures
(Park, 2015).

Opportunistic infection
Infection by an organism that does not ordinarily
cause disease but becomes pathogenic under
certain circumstances, as when the patient is
immunocompromised. An infection caused by
normally nonpathogenic organisms in a host
whose resistance has been decreased (Perry, and
Potter, 2007).

Count of Normal Flora
Normal human skin is colonized with bacteria
• On the scalp1 x 106 (CFUs)/cm2
• In the axilla 5 x 105 CFUs/cm2
• Abdomen 4 x 104 CFUs/cm2
• On forearm 1 x 104 CFUs/cm.
• Faeces contain approximately 1013 bacteria per gram.
• Medical personnel have ranged from 3.9 x 104 to 4.6 x
106
• The hands of HCWs colonized with pathogenic flora
(e.g., S. aureus), gram- negative bacilli, or yeast.

Cross Infection
Cross infection transmitted between one patient to
another patients infected with different pathogenic
microorganisms (Perry, and Potter, 2007).

Rationale and Significance
• Enough knowledge and protocol but increasing
rate of the infection
• And about the medical risk and error
• Low compliance rate and adherence of health
care worker
• New advancement and facts less
implementation

Infection Prevention
Measures practiced by healthcare personnel
intended to prevent spread, transmission and
acquisition of infection between clients, health
care professional to the client, from instrument,
and client to health care worker in the healthcare
setting (Park, 2015).

IP….. contd…
Largely depends on placing barriers between a
susceptible host (person lacking effective natural
or acquired protection) and the microorganisms.
Protective barriers are physical, mechanical or
chemical processes that help prevent the spread
of infectious microorganisms from (CDC, 2007).

Cost Estimation
• CDC 2014, report estimated the annual medical costs of
HAIs to U.S. hospitals between $28 and $45 billion
dollars.
• In England are estimated to cost £1 billion a year.
• In Mexico, the annual cost approaches $ 1.5 billion.

History of Infection Prevention
Year Infection Prevention
1877,1910 Separates facilities, Antisepsis and disinfections ... etc
1985 Universal Precautions: (guidelines for protecting healthcare
worker because the emergence of HIV & other bloodborne
pathogens)
1987 Body Substance Isolation: ( focused on protecting patients and
health personnel from all moist body fluids not just blood: semen,
vaginal secretions, wound drainage, sputum, saliva etc
1996 Standard Precaution: Two level approach:
•Standard Precautions which apply to all clients and patients
attending healthcare facilities
•Transmission-based Precautions which apply only to hospitalized
patients
2007 Isolation Precautions (new pathogens; SARS, Avian Influenzae
H5N1, H1N1)

Fundamental Principles of Infection
Prevention (CDC guideline 1996)
Guideline of infection prevention develop on 1996
and revised in 2007
1. Standard Precaution
2. Transmission Based Precaution

Definitions of Standard Precautions
• Placing a physical, mechanical or chemical barrier
between microorganisms and an individual
• Consider every person (patient or staff) as
potentially infectious and susceptible to infection.
• Wash hands the most important procedure for
preventing cross- contamination (person to person
or contaminated object to person), (OSHA, 2011a.).

1. Standard Precautions
I. Hand Hygiene
II. Personal Protective Equipment
III. Respiratory Hygiene
IV. Safe Injection Practice
V. Cleaning and Disinfections
VI. Safe Handling Sharp
VII. Waste Management
VIII. Linen or Laundry Management
IX. Spill Management
X. Pre and Post Prophylaxis
XI. Immunization

I. Hand Hygiene
• Hand washing is the most important way to reduce
the spread of infections in health care setting.
• Reduces the number of infectious microorganisms
on hands
• Reduces client sickness and death caused by
infections (Perry, and Potter, 2007).

Hand Hygiene
Eighty percent of common infections are spread by
hands (BC Center for Disease Control, Hand Hygiene
and Queensland Health, 2015).
Thorough hand washing with adequate quantities of
water and soap removes more than 90% of the transient
(i.e. superficial) flora, including all or most contaminants
(WHO, 2014).

Research: Hand Hygiene for the
Prevention of Nosocomial Infections
Results
• Hygienic hand disinfection has better antimicrobial efficacy before
and after manual contact with patients.
• The hands should be washed, rather than disinfected, only when
they are visibly soiled.
• Compliance can be improved by training, by placing hand-rub
dispensers at the sites where they are needed,
Conclusions
Improved compliance in hand hygiene, with proper use of alcohol-
based hand rubs, can reduce the nosocomial infection rate by as
much as 40%. (Kampf, Löffler, and Gastmeier, 2009)

The Global Public-Private
Partnership for Hand washing
• Two major illnesses that transmitted by hands are
diarrhea and pneumonia.
• Together, diarrhea and pneumonia kill 1.7 million
children anuually (WHO, 2014).
Diarrhea
• Each day 2,195 children die from diarrhea. Review of
more than 40 studies found that hand washing with soap
can prevent 4 out of every 10 cases of diarrhea (WHO,
2014).

Contd…
Pneumonia and Acute Respiratory Infections
• Evidence suggests that washing hands with soap after defecation
and before eating could cut the respiratory infection rate by about
21-25 percent (WHO, 2014).
• A study in Pakistan found that handwashing with soap reduced the
number of pneumonia related infections in children under 5 by more
than 50 percent.
• Ebola: Handwashing with soap is an important component of Ebola
infection protection.
• Skin & Eye Infections: Studies have shown that handwashing
reduces the skin eye infections (WHO, 2014).

The Three Kind of Hand Washing
Type 1 (with soap and running water)
• Removes transient microorganism and soil.
Type 2( with antiseptic and running water)
• Removes transient microorganism and soil, kills or inhibits
resident microorganism and appropriate before invasive
procedures
Type 3 ( alcohol handrub)
• Kills or inhibits transient and resident microorganism, but does
not remove microorganism and soil (Perry, and Potter,
2007).

47
Seven Steps of Hand Washing
(Raffles Medical Group, 2010).
Rub palm together Rub back side of both hands Interlace fingers and rub hands
Interlock the finger and rub the
back of fingers of both hands
Rub thumbs by rotating manner
area in between index finger
Rub fingertips on palm for both hands
Rub both wrists in a rotating
manner rinse and dry thoroughly
Apply soap all over two hands
2/4/2016 MN1st Year Chanak (6th

Research: Hand hygiene and aseptic
techniques during routine anesthetic care -
observations in the operating room
• The aim of this study was to explore the indications and
occurrence of hand hygiene opportunities and the adherence
to hand hygiene.
Results
• A total of 2,393 opportunities for hand hygiene was recorded
revealed overall adherence of 8.1%.
Conclusions
• Evidence for low adherence to hand hygiene guidelines. The
study concluded that strategy should include education and
practical training to carry out hand hygiene and aseptic
techniques and use gloves correctly (Veronika, et. al, 2014)

Research: Systematic review of studies on compliance
with hand hygiene guidelines in hospital care.
The mean compliance rate of (ICU) and general wards is
40%, and the lowest compliance rates among physicians
(Erasmus, 2010).
Factors associated with non-adherence are high workload,
insufficient time, inaccessibility of HH products, skin
irritation, HH not being a prioritized task, forgetfulness, lack
of scientific information and skepticism concerning the
importance of HH.

Your 5 moments for HAND HYGIENE

II. Personal Protective Equipment:
51
Face mask / eye protection:
protect mucous
membranes of the eyes,
nose and mouth during
procedures
Gloves:
Touching mucous
membrane and non-
intact skin and
performing sterile
procedures
Gown:
Prevent soiling of
clothing and skin
during procedures that
are likely to generate
splashes of blood,
body fluids, secretions
or excretions
Cap:
During sterile technique
to prevent infection
Footwear:
If contact with blood or
body fluids may occur

Sequence of Putting on PPE (“Donning”)

Sequence of Taking off PPE (“Doffing”)

III. Respiratory Hygiene
Respiratory hygiene is a relatively new concept
introduced after the SARS outbreak in 2003,
comprising vigilance and prompt implementation of
infection control measures at the first point of
encounter within a healthcare setting. It is directed to
patients and family members with signs of respiratory
illness such as cough, congestion, or increased
respiratory secretion (CDC, 2007).

Respiratory Hygiene
• Education regarding how respiratory illnesses spread
and prevention practices including “cover your cough”
• Availability and use of tissues and hand hygiene
products
• Use of mask for person who is coughing
• Spatial separation of the person with a respiratory illness
• At least 1 metre (3 feet) away from others in common
waiting areas (WHO, 2007)

N95 Respirator
*Image courtesy of: CDC Image Library

IV. Safe Injection Practice
• Safe injection practices are intended to prevent
transmission of infectious diseases between individuals
and to prevent injuries such as needle sticks
• In developing countries 16 thousand million injections
used each year. 90%, for therapeutic purposes while 5 to
10% are given for preventive services, including
immunization and family planning (WHO, 2014).

Safe Injection Practice
• According to a study conducted in Western region of
Nepal (DoHS, 2013), 70% of clinical staff and 63% of
non-clinical staff reported a needle stick injury (NSI) or
other sharps injury at some time.
• Around 385,000 needlesticks and other sharps related
injuries are sustained by hospital HCWs annually (CDC,
2013).
• Nearly 15% of needle stick injuries occur during or after
disposal (CDC, 2014).

Safe Injection Practices Include
• Aseptic technique
• Using a single syringe and fluid infusion
sets only once
• Using single-dose vials when possible
• If multi-dose vials must be used, then use
& store them according to manufacturer's
recommendation

Safe Injection Practices: Fingerstick Devices
Single-use devices
• Disposable
• Prevent reuse through an auto-
disabling feature
• Appropriate for settings where
assisted monitoring
of blood glucose is performed
Single-Use Fingerstick Device
Source: CDC

Contd…
Reusable devices
• Often resemble a pen (“penlet”) not appropriate
due to
• Failure to clean and disinfect properly
• Links to multiple outbreaks of hepatitis B
• Risk for occupational needlestick
• Only appropriate for people who do not require
assistance with blood glucose monitoring
(BGM)
Reusable Fingerstick Device
Source: CDC

Needle Stick Injury Prevention
• Over 80% of needle stick injuries can be prevented with
the use of safer needle devices.
• Worker education and work practice controls can reduce
injuries by 90% ( WHO, 2014).

Antiseptic
Inhibits the growth of pathogenic and disease
causing bacteria. Antiseptic are used in living
beings for humans and living cells
• Antibacterial – (antimicrobial)
– Bacteriocidal - kill bacteria
– Bacteriostatic - suppresses their growth
V. Cleaning and Disinfection

Antiseptic
• 60 - 90% alcohol (Ethyl, isopropyl or “methylated spirit”)
• 4% chlorhexidine gluconate (Hibitane®, Hibiscrub®, Hibiclens®)
• Chlorhexidine gluconate and cetrimide, in various concentrations
(Savlon®)
• 3% iodine aqueous iodine and alcohol containing (tincture of iodine)
products, 7.5 – 10%
• Iodophors, various concentrations (Betadine® or Wescodyne®
• 0.5 – 4% chloroxylenol (Para-chloro-metaxylenol or “PCMX) various
concentrations (Dettol®)

Clean
Activities that remove, or reduce, the amount of dirt and/or
microbes. Thorough cleaning will remove more than 90% of
visible dirt. Cleaning process depends essentially on
mechanical action. There must be policies specifying the
frequency of cleaning and cleaning agents used for walls,
floors, windows, beds, curtains, screens, fixtures, furniture,
baths and toilets, and all reused medical devices (WHO,
2002).

Clean contd…
Zone A: no patient contact. Normal domestic cleaning (e.g.
administration, library).
Zone B: care of patients who are not infected, and not highly
susceptible.
Zone C: infected patients (isolation wards). Clean with a
detergent/disinfectant solution, with separate cleaning equipment for
each room.
Zone D: highly-susceptible patients OT, delivery rooms, ICU, NICU, and
haemodialysis units. Clean using a detergent/disinfectant solution and
separate cleaning equipment.

67
Destroys all pathogenic organism except
spores. The use of a chemical procedure that
eliminates virtually all recognized pathogenic
microorganisms but not necessarily all microbial
forms, such as bacterial endospores, on
inanimate objects and equipments (WHO,
2002).
Disinfection

Disinfection with hot water
Articles Temperature Time
Sanitary
Equipment
800 C 45-60 sec
Cooking Utensils 800 C 1 min
Linen 700 C
950 C
25 min
10 min

Types of Disinfection
• High level disinfection (critical) :- destroy all
microorganisms, with the exception of heavy contamination by
bacterial spores.
• Intermediate disinfection (semi-critical) :- inactivates
Mycobacterium tuberculosis, vegetative bacteria, most viruses
and most fungi, but does not necessarily kill bacterial spores.
• Low-level disinfection (non-critical) :- kill most bacteria,
some viruses and some fungi, but cannot be relied on for
killing more resistant bacteria (Perry, and Potter, 2007).

Sterilization
The process by which all microorganisms including spores
are destroyed. The use of a physical, radiation or chemical
process to destroy all microbial life, including highly
resistant bacterial spores. It is never absolute; by definition,
it reduces the number of microorganisms by a factor of
more than 106 (i.e. more than 99.9999% of microorganisms
are killed) (CDC, 2014)

Principal Sterilization Methods
Thermal sterilization
• Wet sterilization: exposure to steam saturated with water
at 121 °C for 30 minutes, or 134 °C for 13 minutes in
an autoclave; (134 °C for 18 minutes for prions).
• Dry sterilization: exposure to 160 °C for 120 minutes, or
170 °C for 60 minutes; this sterilization process is often
considered less reliable

Principal…Contd…
Chemical Sterilization
• Ethylene oxide and formaldehyde for sterilization
• Peracetic acid is widely used in the United States and
some other countries in automatic processing
systems. (WHO, 2002)

Practice of Fumigation
In the 1960s, the use of chemical fumigation for control of microbial
contamination in hospitals was thought to be an effective adjunct to
environmental cleaning of hospital isolation rooms and other critical
areas.(Friedman, H., Volin, E., & Laumann, D., 1968).
The same fumigant inadvertently entered a room through a sewer pipe,
killing an infant and sickening the parents. Adverse effects are
carcinogenic effect, pungent environment, damage the surfaces of the
equipment (Langard, S., Rognum, T., Flotterod, O., & Skaug, V., 1996)
Potential for the gas or vapor to escape through breaks, plumbing
fixtures, or ventilation ducts.

Sterilization of Operation Theatres:
Newer Methods to Replace Fumigation
Bacillocidrasant:- A newer and effective compound in environmental
decontamination with very good cost/benefit ratio, good material
compatibility, excellent cleaning properties and virtually no residues. It
has the advantage of being a Formaldehyde-free disinfectant cleaner
with low use concentration. Asepsis within 30 to 60 minutes no need to
close OT for 24 hour (William, 2008)
Virkon: is gaining importance as non-Aldehyde compound. Virkon is
proved to be a safe virucidal, bactericidal, fungicidal, mycobactericidal
and non-toxic compound. It contains oxone (potassium
peroxymonosulphate), sodium dodecylbenzenesulfonate, sulphamic
acid; and inorganic buffers (Hernndez, A., et al., 2000).

Aseptic Technique
Aseptic technique is a set of specific practices
and procedures performed under carefully
controlled conditions with the goal of minimizing
contamination by pathogens. Aseptic technique
means without sepsis (Perry, and Potter, 2007).

Contd….
• Medical Asepsis :- clean technique-reduces the
number of pathogens. Clean technique; procedures
used to reduce & prevent spread of microorganisms
• Practices used to “confine a specific microorganism to
a specific area, limiting the number, growth and
transmission of microorganisms” (Kozier, Erb et al,
2004, p.744).

Contd…
Surgical Asepsis: – Sterile technique practices used to render
and keep objects and areas free from organisms. Sterile
technique; procedures used to eliminate microorganisms
Sterilization Practices destroy all forms microorganisms

Principle of maintaining asepsis
• Creation of sterile field using sterile equipment
• All items in a sterile field must be sterile
• Sterile packages or fields are opened or created as close
as possible to time of actual use
• Moist areas are not considered sterile
• Only areas that can be seen by the clinician are
considered sterile (i.e., the back of the clinician is not
sterile).

• Gowns are considered sterile only in the front,
from chest to waist and from the hands to
slightly above the elbow
• Tables are considered sterile only at or above
the level of the table.
• Nonsterile items should not cross above a sterile
field.
• There should be no talking, laughing, coughing,
or sneezing across a sterile field
cont..

cont..
• Personnel with colds should avoid working while ill or
apply a double mask
• Edges of sterile areas or fields (generally the outer inch)
are not considered sterile
• When in doubt about sterility, discard the potentially
contaminated item and begin again
• A safe space or margin of safety is maintained between
sterile and nonsterile objects and areas
• Tears in sterile packs and expired sterilization dates are
considered breaks in sterility (Perry, and Potter, 2007).

When Should Apply the Aseptic
Technique
• Wound care
• drain removal and drain care
• intravascular procedures
• vaginal exams during labor
• insertion of urinary catheters
• respiratory suction
• Injection technique
• Collection of blood specimens

VI. Safe Handling of sharp
A hypodermic needle, suture needle, blade,
scissors, forceps can be a potentially lethal
instrument. Vein puncture for example, is one of
the most dangerous procedures a health care
worker can perform if it results in a needle prick
injury.

Preventing Sharps Injuries cont..
• Preparation:
– Assemble all equipment required for the procedure.
– Minimize distractions.
• Equipment:
– Equipment should be used strictly according to
protocols and only for the purpose for which it was
designed.
– Choose the safest equipment.

• Technique:
– Perform the procedure slowly and carefully
– Minimize the handling of sharp instruments. The less
they are handled the less chances of needle prick
injuries occurring
– The needle must be properly recapped; the sheath
must not be held in the fingers; either a single-handed
technique, forceps or a suitable protective guard
designed for the purpose, must be used if
needed.

• Each health care worker who uses sharp instruments is
responsible for their management and disposal
• Dispose of all the sharp instruments used during the
procedure immediately, carefully and appropriately
• The sharps container never be overfilled and dispose
after ¾ filled up the container.
• The sharp container must be securely sealed with a lid
before disposal. Use utility glove during disposing the
sharps.

Needle Stick Safety Law
Effective in 1991 and revised in 2000, requires employers to
protect healthcare workers from exposure to HIV and hepatitis B
and C virus
Employers must:
• Develop a written exposure control plan
• Implement standard precautions
• Provide personal protective equipment for example, gloves
and face shields e.t.c.
• Use engineering controls for example safety devices

Reporting
Every health care facility, including, general practices
and dental surgeries, must have an Occupational
Exposure Policy so that staff members know the
reporting mechanism of their workplace, and the steps to
follow in the event of a needle prick injury. All needle
prick injuries must be reported.

VII. Waste Management
• Hospital waste is “Any waste which is generated in
the diagnosis, treatment or immunization of human
beings or animals or in research” in a hospital.
• Hospital waste is a potential reservoir of pathogenic
micro organisms and requires appropriate safe and
reliable handling. The main risk associated with
infection is sharps contaminated with blood.

Principles Of Waste Management
Steps in the management of hospital waste :
Generation
Segregation/separation
Collection
Transportation
Storage
Treatment
Final disposal (WHO, 2007)

VIII. Linen and Laundry Management
• Although soiled linen may harbor large numbers of
pathogenic microorganisms, the risk of actual disease
transmission from soiled linen is negligible.
• Dirty linen often contains a significant number of
microbes (104–108 bacteria per 100 cm2 of soiled bed
sheets), mostly Gram-negative rods and bacilli (Blaser,
et al. 1984).

Soiled Linen and Laundry
• All soiled linen should be bagged or placed in containers
at the location where it was used and should not be
sorted or rinsed in the location of use.
• Linen heavily contaminated with blood or other body
fluids should be bagged and transported in a manner
that will prevent leakage.
• Soiled linen is generally sorted in the laundry before
washing.
• Gloves and other appropriate protective apparel should
be worn by laundry personnel while sorting soiled linen.

Washing
• Walter and Schillinger suggested that levels of microbes
on laundered fabrics of 20 colony forming units 100 cm2
or less per are equal to complete pathogen removal
(Walter, and Schillinger, 1975).
• While Christian et al proposed that a 106–107 reduction
in viable counts is effective. Nonetheless, regular
assessment of the microbial levels on laundered linen is
unnecessary unless laundry- related outbreaks occur.
(Christian, Manchest, and Mellor, 1983).

Contd….
Commercial laundry facilities often use water
temperatures of at least 71°C for minimum 25
mins and 50-150 ppm of chlorine bleach to remove
significant quantities of microorganisms from
grossly contaminated linen(CDC, 2011).

Management of the Clean Linen
Storing Clean Linen
• Keep clean linen in clean, closed storage areas.
• Use physical barriers to separate folding and
storage rooms from soiled areas.
• Keep shelves clean.
• Handle stored linen as little as possible.

Contd…
Transportation of Clean Linen
• Clean and soiled linen should be transported
separately.
• Containers or carts used to transport soiled linen
should be thoroughly cleaned before used to
transport clean linen.
• Clean linen must be wrapped or covered during
transport to avoid contamination.

Contd…
Distribution of Clean Linen
• Protect clean linen until it is distributed for use.
• Do not leave extra linen in patients’ rooms.
• Handle clean linen as little as possible.
• Avoid shaking clean linen, it releases dust and lint into
the room.
• Clean soiled mattresses before putting clean linen on
them.

IX. Spill Management
Small Spills: spots or drops of blood and other small
spills up to 10cm diameter.
• Wipe the area immediately with paper towelling
• Clean with warm water and detergent followed by rinsing
• Dry the area (as wet areas attract contaminants)
• A sanitizer (e.g. alcohol wipe) can be used on the area
after cleaning.

Contd…
Large Spills: spots greater than 10 cm diameter.
• Wash carefully into the sewerage system using copious
amounts of water, taking care to avoid splashes
• Clean the area with mop and bucket of warm water and
detergent
• Clean the bucket and mop thoroughly after use using
warm soapy water and store dry.
Carpet
• contain and clean with warm water and detergent
• do not use disinfectant. Professional carpet
cleaning/steam cleaning may be required (CDC, 2007).

Spill Management contd…
Equipment
• Equipment (mop, bucket and cleaning agents) is to be
readily available in a location known to all.
• A portable ‘spills kit’ can be made up to manage likely
spills for the area/activity e.g.
Basic Principles:
• Assume all blood and body substances are potentially
infectious and cover cuts, maintain hand hygiene and
use appropriate PPE.

Spill Management contd…
• Cover the spill, to prevent the generation of splashes and
aerosols from the spilled substance –
– e.g. granular formulation such as vomit control
– use a scraper and pan to remove the absorbed material
• Clean the area thoroughly, rinse and dry.
• Clean non-disposable cleaning equipment thoroughly after use,
rinse and store dry.

X. Post Exposure Prophylaxis
• Post exposure prophylaxis is intended to protect the
health care workers from different infection which could
be acquired while performing medical procedures (e.g.
needle stick injury, blood splash on mucosa, blood and
body fluid)
• Expose with HIV cases -PEP should be started as soon
as possible within72 hours the course will be for 28 days.

Risk of transmission of infection following
HIV Hepatitis B Hepatitis C occupational
exposure
HIV, 0.3%(Cardo et al., and Bell, 1997) HB 18–30%
(Pruuss-Ustün et al., 2005) HC 1.8% (Puro et al., 2010)
Waste handlers were infected by tuberculosis (TB) at a
medical waste-processing facility in Morton, Washington, in
the United States of America, as a result of exposure to
healthcare waste.

Pre Exposure Prophylaxis
Pre-exposure vaccination (immunization) for HBV
In healthcare settings, immunization against HBV
must be provided to health workers who perform
tasks involving contact with potentially infectious
blood or other bodily fluids. The risk of acquiring
HBV is far greater than that of HIV or Hepatitis C.

Contd…
• If contact with Hepatitis B and C cases PEP (immunoglobin) should
be started as soon as possible within 72 hours.
• If a person contact with rabies disease, anti rabies vaccine should
be provided within 72 hours after exposure.
• An Antiretroviral Therapy (ART) (zidovudine (AZT), lamivudine
(3TC), and indinavir) double therapy for low risk Zidovudine (ZDV) +
Lamivudine (3TC) OR Tenofovir + Emtricibine (TRUVADA)
• Triple therapy for high risk ZDV + 3TC + Efavirenz (EFV) OR
replace Efavirence with Rotanovir®/Lopinavir (LPV) in pregnancy
replace Efavirenz with Aluvia (WHO, 2007)

Outcome
• Post-exposure prophylaxis can reduce the risk of
HIV transmission by 80%.
• Risk of developing disease 30% in hepatitis B, 3-
10% in hepatitis C if not vaccinated (WHO &
ILO, 2007).

XI. Immunization
• Health care workers may be exposed to certain
infections in the course of their work.
• Vaccines are available to provide some protection to
workers in a healthcare setting.
• Before exposure, first responders (health personnel)
may receive vaccinations for different diseases, e.g.
hepatitis B, influenza, measles, mumps, rubella, tetanus,
diphtheria and pertusis etc

Immunizations for Healthcare Workers
Since 1981 the CDC has recommended healthcare
workers receive influenza vaccination, and the coverage
among healthcare workers during the 2013–14 flu season
was 75.2%. Coverage was highest (97.8%) among
healthcare personnel working in settings in which flu
vaccination was a requirement for employment (CDC,
2014e).

Contd…
Federal OSHA law requires that that all employees whose
jobs involve participation in tasks or activities with potential
exposure to blood/OPIM be offered hepatitis B vaccination.
The vaccination is free, safe, and highly protective. This
vaccine is given in three doses. Serologic testing after
vaccination (to verify that the vaccination was effective) is
recommended.

(CDC, 2011c, 2010).

2. Transmission Based Precaution
I. Contact precautions
II. Droplet precautions
III. Airborne precautions (CDC, 2007, Gardner, 1996
and Siegel et al., 2007).
(Including standard precautions)
• Isolation Precautions (CDC, 2007)

Transmission Based Precaution
Contact, Droplet, and Airborne Precautions are
transmission-based precautions that should be applied
when a specific infectious agent is known or suspected
to be present in a patient. Each transmission-based
precaution is used in conjunction with Standard
Precautions (CDC, 2007).

Sneezing may produce as
many as 40 000 droplets
between 0.5–12 μm in diameter
that may be expelled at speeds
up to 100 m/s (Cole & Cook,
1998; Tang et al., 2006).
Coughing may produce up to
3000 droplet nuclei, about the
same number as talking for five
minutes (Cole & Cook, 1998;
Tang et al., 2006).

Transmission – Based Precautions
Airborne Precautions: spread of microbes on small droplet
nuclei through the air (< 5 microns).
(ie) Measles; Chicken Pox; TB
Droplet Precautions: large particle droplets
(> 5 microns); which transmit 3 feet in air.
(ie) Mumps; Pertussis; Influenza; SARS
Contact Precautions: for prevention of disease transmitted
by either direct / or indirect, contact.
(ie) Impetigo, Scabies, Herpes Zoster, C Difficile.

Airborne Precautions
Air Borne Diseases among Inpatients FY 2070/71. Among
patients the Pneumonia, Organism unspecified patients
were reported highest among the Air Borne disease with a
total patients of 9,558 were affected and 113 patients were
reported dead (DoHS, Annual Report 2070/71).

Isolation Precaution
Separation is critically important when using
isolation precautions because, as Florence
Nightingale observed, many infectious diseases
spread mainly through direct contact when patients
are near to one another (Gardner, 1996).

Isolation
• Isolation refers to various measures taken to
prevent contagious diseases from being spread
from a patient to other patients, health care
workers, and visitors, or from others to a
particular patient.
• Isolation is most commonly used when a patient
has a viral illness (CDC, 2007).

Types of Isolation
CDC (Centers for Disease Control and
prevention) isolation precaution. It includes;
• Category specific Isolation precaution
• Disease specific Isolation precaution
• Universal blood and body fluid precaution

Category of Specific Isolation Precaution
• Strict isolation: - It includes strict hand washing, private
room, gown, mask, proper disposal of contaminated
items.
• Contact isolation: - It includes private room, gown,
mask as needed, gloves, proper disposal of
contaminated items and hand washing.
• Respiratory isolation: - It concludes private room,
mask, gown and gloves as needed, proper disposal of
contaminated articles.

Disease Specific Isolation Precaution
• Tuberculosis isolation:- Same as respiratory isolation.
It also includes cleaning and disinfecting the articles.
• Enteric precaution:- It is maintained through private
room if hygiene is poor, gown and gloves as needed,
hand washing, disposal of contaminated articles. Same
as strict isolation.
• Drainage/Secretion precaution:- It concludes gown
and gloves as necessary, hand washing, disposal of
contaminated articles. Same as enteric/strict isolation.

Blood and Body Fluid Precaution
• Blood and body fluid precaution:- Same as secretion
precaution in puncture proof container for disposal.
• Reverse Isolation (Protective Isolation):- Is used to
prevent contact between potentially pathogenic
organisms and uninfected person who have seriously
impaired resistance (CDC, 2007)

Definition of safety
The condition of being safe from undergoing or causing
hurt, injury, or loss. ‘The avoidance, prevention and
amelioration of adverse outcomes or injuries stemming
from the process of healthcare.’ (Vincent, 2010)
• S - Sense the error
• A - Act to prevent it
• F - Follow the safety guideline
• E - Enquire into accidents and death
• T - Take appropriate remedial measures
• Y - Your responsibility

IOM, USA (2014)
• 1 in 10 patient encounter adverse effect
• Due medical error injury 1 in 25
• Kills about 44000 to 98000
• Billion dollar each year in USA
• 66 % Errors done by patient
• 16% Staff
• 14% Both
• 4 % Accidents due to electrical mechanical

Incidence
The study report set out for the first time the
annual figures for known reported harm 400
people known to have died seriously injured from
events involving medical devices; nearly 10,000
people known to have experienced adverse
reactions to drugs (NHS, 2000)

Safety Measures:
Definition
Safety measures is a discipline in the health care sector
that applies safety science methods toward the goal of
achieving a trustworthy system of health care delivery.
Patient and HCWs safety is also an attribute of health
care systems, it minimizes the incidence and impact and
maximizes recovery from, hazardious and adverse events
(Emanuel et al., 2008) . All the measures intended to
protect patient and HCWs is safety measures.

Definition…contd…
The World Health Organization (WHO) Conceptual
Framework for the International Classification for
Patient Safety (ICPS) activities or measures taken by
an individual or a health care organization to prevent,
remedy or mitigate the occurrence or reoccurrence of a
real or potential (patient) safety event (WHO, World
Alliance for Patient Safety 2009)

Safety For
People
Patient
HCW
Visitors
Place
Fire
Infrastructure
Mechanical/Electrical
Property
Assets
Stores
Equipment

Safety Issue
• Adverse Health Care Event: event arise from care
• Error: Failure to complete the plan
• Health Care Near Miss: failure to prevent injury and
compensating
• Adverse Drug Reaction: noxious drug
• Medication Error: inappropriate medication, harm
during medication
• Sentinel Error: surgery wrong body part, wrong patient
patient receive wrong medicaiton

Safety
measure
Environ
mental
safety
Medical
Safety
Surgical
Safety
Electrical
Safety
Equipment
Installation
Safety
Blood
safety
Sanitation
IPC and
BMW
Laboratory
Safety

Environmental Safety
• Enough light
• Proper ventilation, exhaust fan
• Stairs with hand rails
• Window door
• Slip preventing floors
• Fire extinguishers and fire alarms
• Prevent noise pollution
• Heavy and fixed beds and bed screen
• Safe wheel chairs and trolleys
• No water logging in bathrooms
• Call bell system for patients
• Traffic control/ crowd control
• Smell and order

Medical Safety
• 10s rights of medication administration
• Illegible writing prescription by doctors
• Drip sets, air bubbles, over hydration, drip speeds
• Oxygen flow check empty gas cylinders
• Proper hand taking and hand over during shift change
• Radiation Protection Techniques

Surgical Safety
• Ensure aseptic technique
• Consent of the patient in writing
• Proper identification or patient and part to be operated
• Pre anesthetic check up
• Anesthetic safety
• Ensure no foreign body left inside
• Safety measures from ward to OT

Equipment Installation Safety
• Regular check up of equipments
• Proper earthing to avoid shock
• Regular maintenance and repair
• Training of nurses and technical staff
• Orientation and training of new devices and
equipment

Laboratory safety
• Personal Protective Equipment (PPE)
• Eating in the Lab and Food Storage
• Close Laboratary door
• Avoid needle prick
• Measures radiology and radiotherapy
• Biomedical waste disposal
• Chemical Spills
• Housekeeping
• Hand Washing
• Fume Hoods

Electrical Safety
• Safety fuses with each equipment
• No loose wires or connection
• Properly plugged and fixed
• If short circuit call electrician
• Electricity back up battery/ generator
• Use of UPS
• Recognize hazards

Research
Ramnarayan, et. Al. (2006) examined the impact of a web based
diagnostic reminder system on clinicians’ decisions in an acute
paediatric setting during assessments that were characterized by
diagnostic uncertainty. The mean count of diagnostic errors of
omission decreased significantly, and the mean diagnostic
quality score increased. The number of irrelevant diagnoses
increased from 0.7 to 1.4, but did not result in a corresponding
increase in the number of irrelevant or deleterious tests and
treatments.

Challenges to Implementation of
Infection Prevention Guideline
In Nepal
• Lack of supervision and monitoring of government policy
Sense of accountability
• Unavailability of resources and new technologies
• High workload, errors and system failures repeated
• Health care service is granted commercial business
• Most of events not reported, defensiveness and secrecy
• Blame culture “alive and well”
• Detection systems in their infancy
• Limited understanding of causes and measurements
impact
• Action on known risk is very slow

Challenges…Contd…..
International
• Lack of health care epidemiologists data managers and
statisticians in infection control team with their expertise
and experience of its leaders.
• The scope of antimicrobial resistant organisms broadens
as patients needs become complex.
• Infection control programs which is limited with in
hospital walls

Challenges…Contd…..
• Recent literature has highlighted the role that long-term
acute-care hospitals play in HAIs. Given that long term
care facilities have been implicated as the source of
regional outbreaks of MDR organisms.
• Needs will broaden not only in the developed world but
also in developing countries, where technology is
growing and health care is modernizing, increasing the
opportunities for HAIs.

Multidisciplinary Approach
Multidisciplinary infection control committee must be organized,
comprising (but not limited to):
• A senior physician to provide leadership
• A clinical microbiologist
• Hospital hygiene and infection control Officer
• An infection-control nurse
• An antibiotic specialist
• A director of environmental services.

Applicable Nursing Theory
Betty Neuman System Model (1972)
Flexible Line of Defense
Normal Line of Defense
Line of Resistance

Physical environment
Psychological environment Social Environment
Patient condition & nature
communication
Advice and variety
Mortality data
Prevention of disease
Air
Light
Noise
Water
Bedding
Drainage
Diet
Cleanliness
Ventilation
144
Nightingale Environmental Theory

The Role Nursing Staff
• Participating in the infection control committee
• Promoting the development and improvement of nursing
techniques,
• Ongoing review of IP and safety measures nursing
policies
• Developing training programs for members of the
nursing staff
• Supervising the implementation of techniques for the
prevention of infections and practice in specialized areas
• Monitoring of nursing adherence to policies.

The Role Nursing Staff … contd..
• Monitoring aseptic techniques, including handwashing
and use of isolation
• Reporting promptly to the attending physician any
evidence of infection in patients under the nurse’s care
• Initiating patient isolation and ordering culture specimens
• Limiting exposure to infections, hazard and risk
• Maintaining a safe and adequate supply of ward
equipment, drugs and patient care supplies.

The Role Nursing Staff … contd..
• Identifying nosocomial infections, type of infection and
infecting organism
• Participating in training of personnel
• Surveillance of hospital infections
• Participating in outbreak investigation
• Ensuring compliance with local and national
regulations
• Providing expert consultative advice

Infection Prevention Training
(Annual Report (2013/14)
Program Activities Year Targets Achieve %
TOT on Infection
Prevention
2070/2071 20 0 0
District Level
Training (Infection
Prevention,
(HFOMC, Basic
FCHV)
2071/2072 According
to district

Research: Attitudes towards infection
prevention and control; an interview study
with nursing students and nurse mentors
• Qualitative study from one large university and one large NHS
Trust North of England.
• Results Nursing students negative attitude towards IPC and
factors additional workload burden. Mentors identified more
positive attitudes within their areas and organization, but their
comments did not always reflect this. Mentors were more of the
opinion that staff attitudes could affect student practice and
learning than were students.

Recommendation
• Evidence based practice by providing professional training.
• Reinforcement programs and attitude stimulating.
• Awareness of right based approach in health care services.
• Management and Staffs need to identifying barriers to good IP
and safety measures practice and ways to overcome these.
• Health care epidemiologists data managers and statisticians
should be involved in infection prevention committee
• Proper documentation should be done, manage and keep
properly
• Regular monitoring and surveillance should be done

Summary
Infection prevention and safety measure definitions
and components. Some research on
implementation infection prevention safety
measures guideline coverage and lacking. Nurses
role on infection prevention and safety measures
recommendation for lacking.

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