Contents Introduction Spread of infection in Hospital Infection control Practices Environmental Management of Infection Control Decontamination, Sterilization and Disinfection Application of Nursing Process in Infection Control
Introduction Infection may be transferred ◦ patient-to-patient, ◦ patients to staff ◦ staff to patients, ◦ or among-staff. Infection control includes ◦ prevention (via hand hygiene/hand washing, cleaning/disinfection/sterilization, vaccination, surveillance), ◦ monitoring/investigation of demonstrated or suspected spread of infection within a particular health-care setting (surveillance and outbreak investigation), ◦ and management (interruption of outbreaks).
History of Hospital Infection Control Florence Nightingale was the first person to work for infection control in hospital. In 1847 Dr. Ignaz Philip Semmelweis identified that 18% Mortality due to Puerperal Fever. Case control study significance of hand washing was demonstrated. Concept of “nosocomial infection was born.
Background Infection rate in developing countries was 15.5 per 100 patients, compared to “.1 [per 100 patients] in Europe and in the U.S., 4.5- BBC ICU infection - developing countries: 47.9 per 1,000 patient, compared to 13.6 in the U.S. In countries like India and Nepal, hospital infection data not reliably estimated. Surgical infection at BPKIHS -1339 (7.3%) among 18325 total surgeries. Estimates vary from 10 to 30%, the least being about 3% in the best of hospitals Wound sepsis alone affects 20% of post-operative cases
Hospital infection adversely affects the image of hospital. Nosocomial infections : ◦ direct death 1% ◦ Indirectly mortality in 3% 50% of nosocomial infections are preventable.
The main health care related infections are1. Urinary tract infections (catheter-associated)2. Surgical site Infections3. Bloodstream infections (central line-associated)4. Pneumonia (ventilator- associated)
Healthcare-Associated Infections –Numbers and Costs in USA Total HAIs 1.7 million Deaths 99,000 Average additional direct $13.6 cost to hospital billion Overall net hospital cost $8.5 billion Not counted are •Costs to patient/QALY, payer, provider, society, caregiver time/resource •Intangibles such as pain and suffering •Indirect: lost productivity, lost retirement savings and benefits •Decreasing HAIs by 25% would save $148,667 per hospital
InfectiousImmuno - Bacteria, Fungi, AgentSuppresse Virus, Parasitesd, Elderly,Chronicallyill, trauma, Susceptib Sources Humannewborn, s le Hosturgery Beings Animal Inanimate Spread of ObjectMucusMembrane, INFECTION Non intactSkin, GI Sputum,tract, GU Portal of Portal of Emesis,tract, Respi Entry Exit Stool, Blratory Tract ood Mode of Transmis Contact, Vehic sion le, Air borne, Vector borne
3. Infection control practices Additional Standard (Transmission Precautions -Based) Precautions
3.1. Standard Precaution Hand washing Use of personal protective equipment Appropriate handling of patient care equipment and soiled linen Prevention of needlestick/sharp injuries Environmental cleaning and spills- management Appropriate handling of waste
4. Environmental Managementfor Infection Prevention Air, Waste Ventilation Management Vector Water Control Cleaning The Hospital Environment
TYPES OF PATHOGENIC WASTE IN HOSPITAL Radioactive Waste
4.5.2. Color Coding of Container forBio- Medical Wastes Disposal Red Colour: Blood and its product, pad contaminated with body fluid, dressing items, used infusion sets, used catheter set, contaminated cotton roll etc. Human anatomical waste(eg. tissues, organs, body parts etc).
Blue Free from blood contaminated items such as; saline bottle, gauze, pad, I/v set, drugs cover and literature.
Green Fruits cover,kitchen waste, non ca. medicine ampoule, and dry items only.Non con blood taminated items should be kept in green colors container.
Plastic container or cartoon box Sharps items or skin pricking materials Such as: needles, syringes, scalpels, blades, gl ass etc. that may cause puncture and cuts. This includes both used and unused sharps.
Extra bucket or black plastic bag: From the site of operation theatre items such as; body parts, tissues). Orange: Laboratory related items eg. vial,chemical reagents etc.
4.5.3.Laundry Handle all linen with minimum agitation. Place soiled/contaminated linen in impervious bags for transportation. Disinfect by using hot water and/or bleach (use heavy-duty gloves, eye protection and masks to protect against splashes). Wash linen in hot water (70 C to 80 C) and detergent, rinse and dry preferably in a dryer or in the sun.
Wash woollen blankets in warm water and dry in the sun. Bed Cover: Change weekly or whenever soiled and on discharge. Bed sheet: Change on alternate day or whenever soiled and on discharge. Mattresses and pillows: Cover with inpervious plastic. They can be cleaned by wiping with a housekeeping disinfectant- detergent. Blood stained linen: Soak in 1% sodium hypochloride for 30 min. and send to laundry.
Decontamination, Sterilization,Disinfection 5.1. Decontamination Decontamination of medical equipment involves the destruction or removal of any organisms present in order to prevent them infecting other patients or hospital staff.
Sterilization Sterilization is the destruction of all micro-organisms.1. Autoclave (Steam Under Pressure)2. Flamming3. Chemical Sterilization i. Glutaraldehyde ii. Alcohol iii. Formalin4. Gas Sterlization i. Ethylene Oxide5. Iradiation
5.2.2. Sterilization Method AvailableIn BPKIHS Autoclaving: 4 machine in CSSD, 1 not functioning 2% Glutaraldehyde solution : as necessity in each ward Gas sterilization by formalin tablet in OT for suction pipe, cautry wire, tip etc.
5.2.2. Storage of Sterile Equipment Keep the storage area clean, dry, dust-free and lint-free. Control temperature and humidity (approximate temperature 240C and relative humidity <70%) when possible. Packs and containers with sterile (or high-level disinfected) items should be stored 20–25 cm (8–10 inches) off the floor, 45–50 cm (18–20 inches) from the ceiling and 15–20 cm (6–8 inches) from an outside wall. Do not use cardboard boxes for storage. Date and rotate the supplies (first in/first out). Change the cydex solution in each 28th day
Disinfection Disinfection removes micro-organisms without complete sterilization.
5.3.2. Selection of disinfectant There is no single ideal disinfectant. Glutaraldehyde is the generally the most appropriate chemical disinfectant that will provide high level disinfection.
5.3.3.Common Disinfectants Used ForEnvironmental Cleaning In HospitalsDisinfectant Recommende Precautionss d UseSodium Decontamination of - Should be used in wellHypochloride material ventilated areas. contaminated with -Protective clothing required blood and body fluids while handling and using undiluted. - Do not mix with strong acids to avoid release of chlorine gas. - Corrosive to metalsBleaching Powder Toilet/ bathrooms Same as Sodium Hypochloride
Alcohol Smooth Metal - Flammable, toxic, to be used in(70%): Ethyl Surfaces well ventilated area, avoidAlcohol, Meth tabletops and inhalation.ylated spirit other surfaces - Keep away from heat source, where bleach can electrical equipment, flames, hot not be used surfaces. - allow it to dry completely, particularly when using diathermy as it can cause diathermy burn.Carbolic Acid Floor mopping, - toxic(Phenol) cleaning OT room, Contaminated bed, furniture etcPhenyle, Lysol Black Phenyle is - Poisonous used in cleaning toilet and bathroom. White phenyl is used in routine
5.3.4. Common AntisepticAntisep Recommended Precautiontics UseChlorhex Antiseptic for skin - Inactivated by soapidine and mucous and organic matter.combine membranes, - Relatively non toxic.d with preoperative skin - Do not allow contactalcohol preparation, with brain meninges,or disinfection of the eye or middle ear.detergent hands
Quaternary Antiseptic for - Relatively non toxic.Ammonium cleaning dirty - Dilution are likely to get wounds contaminated and grow gramCompound: negative bacteria, hence:eg. Dettol - Use in correct dilution and only pour enough solution for single patient use. - Discard any solution that is left over single use.Povidine In BPKIHS, 7.5% + detergent combination isIodine recommended to use in pre-operative hand(Betadine) wash and part preparation.5%, 7.5% and 7.5% solution is recommended for wound10% dressing .
5.3.5. Method of Diluting Chlorine SolutionProduct Chlorine How to dilute to How to dilute How to dilute Available 0.5% to 1% to 2%Sodium 3.5% 1 part bleach to 6 1 part bleach 1part ofHypochlor parts of water to 2.5 parts bleach to 0.7ite- liquid water parts of waterbleachSodium 5% 1 part bleach to 9 1 part bleach 1 part bleachHypochlor parts of water to 4 parts of to 1.5 parts ofite- liquid water waterBeaching 34% 14gm powderPowder in 1liter waterChloramin 25% 20gm to 1Litre of 40gm to 1 80gm to 1 lte Powder water litre of water of water(Virex)
5.3.6. Disinfection of Linen and EquipmentsEquipments Standard Procedure In BPKIHS According to WHO ProtocalFurniture, Clean with detergent and Cleaning bybed, IV water and wipe dry. If detergent and water.stand, wheel contaminated or use by In OT wiped by 2%chair, fan and infected patient wipe by 1% carbolic acid.light etc sodium hypochloride or 70% alcohol.
Mattress and Clean with If contaminatedPillows detergent and with blood and(always cover with water in between body fluid wipeplastic bag) patients and as with or 1% sodium required. hypochloride. If contaminated with blood and body fluid wipe with 70% alcohol or 1% sodium hypochloride.
Telephone Disinfect with 70% alcohol daily.Dressing trolley Clean with detergent and water and wipe dry. Disinfect with 70% alcohol daily.
Ventilator, Clean machine with detergent and water, drySuction and disinfect with 70% alcohol.Equipment and Mask and suction tube should be used forMask single use. AMBU bag after use send for Sterilization to CSSD.Soiled patient Clean with detergent and water. If notcare equipment, washable wipe with 1% sodium hypochloritestethoscope, or 70% alcohol.blood pressureapparatusThermometer Clean with 70 % alcohol, store dry
5.3.7. Cleaning ofEnvironmental SurfaceArea Recommended by WHO In BPKIHS ProtocalFloor Damp mopping with Dry sweeping detergent and water followed by and some disinfectant wet mopping twice in each shift. by 2% carbolic acid.
Spilling of - Cover with the absorbent likeblood and cotton, wool, gauze, paper, towelbody fluid etc. - Pour liberally 1% sodium hypochloride/ bleaching powder solution (14gm/lt) - Allow to stand for 30 min. Clean with carbolic acid.
Walls and Curtains If visibly soiled clean with detergent and water.Toilet and commode Clean with detergent and water and wipe with 2% carbolic acid.
In BPKIHS Protocol•Floor is cleaned with detergent and water•Mopping by 2% Carbolic acid•Seal the room with adhesive tape•For each 1000 cu feet of space place 500 ml of formalin and1000 ml of water in an electric boiler with a safety cut out anda time switch. Switch on the boiler.•Open the room after 24 hr, let some time to evaporate thevapour.•Ammonia gas is used to help the easy evaporation
Mooping of OT table and surrounding after everycase is with 2% carbolic acid.Bacillocid special: Recommended use at all JighRisk areas.Spray 2% solution over all exposed surfaces with asprayer allowing 60 min. after sealing all doors andwindows.
Preparation of 2% Carbolic AcidsolutionCarbolic Available To make 2%Acid concentration solution add 20(Phenol) = 100% ml of carbolic acid in 980 ml of water (aprrox.1 litre)
Application of Nursing Process inInfection Control and Prevention: I. Nursing Assessment 1. Client’s susceptibility to infection ◦ Age, nutritional status, stress level, associated disease like diabetes mellitus. 2. Cleanliness of ward environment ◦ Linen ◦ Ventilation ◦ Water supply ◦ Floor ◦ Health of staff ◦ Patient’s clothing and personal Hygiene etc.
Decontamination, Disinfection and Sterilization Procedure Dressing Hand washing IV insertion Catheterization etc.
Isolation of Infected case Standard Precaution Availability of Personnel Protective Equipment eg. Gloves, mask, gown etc. Stock of sterile items Waste disposal Adherence of health personnel to IP guideline Familiarity of staff about IP guidelines
II. Nursing Diagnosis1. Risk for infection related to Improper technique while inserting cannula Using same syringes, cannula, IV set for prolonged time Failure to recognize early sign of infection and infiltration Indwelling catheter Unsterile technique while inserting catheter Touching the connection tubing with contaminated hands Back flow of urine from the tubing and uro bag. Failure to follow aseptic technique during change of dressing Contamination of opened wound with soiled linen, cloths and hands Cross infection with other patient or health personnel. Transmission of disease from patient to patient, patient to staff and staff to staff.
Knowledge deficit among nursing and cleaning staff about the procedure of making disinfect solution of different concentration Risk for impair skin integrity Social Isolation
III. Nursing Goal Prevention of exposure to infectious organism. Controlling and reducing the extent of infection Maintaining resistance to infection Educating the clients and family about infection control technique.
Expected Outcome The overall goal of IP program is the reduction of nosocomial infection in the ward Client will remain free of infection as evidenced by Client will remain afebrile Client will develop no signs and symptoms of local infection (eg. Remain free of cough, purulent drainage from wound or normal body opening) Client will become knowledgeable of infection risk. Client will identify routine to follow in the hospital as well as in hospital that reduce transmission of micro organism. Client will identify signs and symptoms to report health care provider indicating infection.
IV. Nursing Intervention Monitor client’s body temperature routinely, inspect oral cavity for lesions, inspect urethral and vaginal orifice for drainage or discharge, assess IV assess site for sign of infection and observe the client for evidence of cough. Practice hand hygiene routinely before caring for client, between clients, and before any invasive procedure. Supervision and education of cleaning staff in preparation of solution for floor mopping, carbolization, decontamination etc. Use aseptic technique perfoming all surgical procedure like dressing, catheterization, ET tube suctioning etc.
Use aseptic technique while inserting IV cannula, change cannula, IV set in 72 hrs, Change labeled syringe for IV injection in every 24 hours. Teach the patients’ relative about the way of emptying urobag. Provide catheter care to the patient. Change foley’s catheter in every 7 days. Follow standard precautions. Provide education to the patient and relatives about importance and process of deep breathing and coughing.
Proper disposal of waste in color coded bucket, monitor and supervise the use by all staff, patients and patient’s relatives. Controlling of visitors. Change dressing that become wet and soiled. Adequate supplies of clean and sterile gloves, gown, mask, detergent, disinfectants should be there in the ward. Monitoring of use of antibiotics. Change Gltutareldehyde solution in every 28th days
Monitoring of the shelf life of sterile equipment, if not used Take Home Message within 7 days send to CSSD for resterilization without reopening the pack. Supervise the cleaning of equipment like AMBU bag, mask, O2 mask, tubing, Nebulizer set etc. Wipe the thermometer with 70%alcohol after using each patient. Send periodic culture of different sites like dressing, treatment trolley, cydex container, tap water etc. Appropriate use of isolation procedure for infected case. Maintain the ventilation of the ward. Stay healthy, take nutritious food. Use available protective device and also encourage others to use.
Person to Contact if anyconfusion about Infection Control
References1. Deb M. hospital-acquired Infections: Guidelines for Control, BP Koirala Institute of Health Sciences, Dharan, Nepal.2. Wenzel, Brewer, Butzler. A Guide to Infection Control in the Hospital. International Society of Infection Control. Hamilton. Ontario. BC Decker Inc; 2nd Edition; 2002.3. Sakarkar BM. Principles of Hospital Administration and Planning.New Delhi. Jaypee Brothers Medical Publishers P. Ltd; first Edition; 1998.4. WHO. Practical Guidelines for Infection Control in Health care Facilities. WHO; 2003.5. WHO. A manual on Infection Control in Health Facilities. WHO Regional Office for South East Asia. New Delhi; 1990.6. Hospital Infection Society. Department of Health, England. Third Prevalence Survey in HCAI in England. Wilington House. Waterloo Road. London 2006.7. Poudyal P.Simkhada P. Bruce J. Infection control knowledge, attitude and practice among Nepalese health care workers. American Journal of Infection Control; October 2008; 36(8) : 595-597.8. Potter PA, Perry AG. Fundamental of Nursing. St. Louis. Missouri. Mosby; 6th Edition; 2005