Fundamentals Test 2

Bacteria Need

Food, Oxygen, Water, Temp, pH, Light

Regulatory Agencies

CDC Occupational Safety and Health Administration

CDC

CDC) responsible for developing safe guidelines to help prevent and control the spread of infectious diseases

Applying PPE

Don PPE from the Bottom Up with your hands up in the air Gown Mask or respirator Goggles or Face Shield

Pouring Sterile Solutions

Inside contents and inside of bottle cap are considered sterile. The bottle cap may be placed on a clean surface with the sterile side up Before pouring the solution into a container, pour a small amount(1-2mL) into a disposable cap or waste receptacle Pour slowly to avoid splashing Hold the bottle outside the edge of the sterile field Outside of bottle is not sterile

Psychological Implications of Isolation

Loneliness: Normal social relationships are disrupted Depression & anxiety Less satisfied w/ care Feel rejected Altered body image: Unclean, rejected, guilty, feel "different" Sensory deprivation Teaching: Teaching Teach patient & family about the disease/condition The purposes of isolation Steps for each specific precaution Hand hygiene Barrier protection How organisms are transmitted

Applying Sterile Gloves

Open gloving: See Skill 28-5 View video Closed gloving: See Skill 28-4

Body System Defenses

Organs

Removing PPE

Remove PPE in Alphabetical order Gloves Goggles or Face Shield Gown Mask of Respirator

Method or Mode of Transmission

This is how the pathogens can travel or get from place to place The #1 way a harmful germ travels from place to place is by our hands. Carry germs on our hands from out body and body secretions, wounds, stool, vomit and carry them to someone or to an object and then someone else touches that object. Hand washing is the Number One way to stop the transmission of infections. So with our hands we are spreading Mos by what is called contact transmission. Contact transmission Contact- this is the most frequent means of transmitting infections in healthcare facilities. Can be by direct or indirect. Again*Contact transmission of infectious organisms on the hands of caregivers is the most frequent mode of transmission of infection in healthcare facilities. One way germs can travel is by Direct contact involves body surface-to-body surface contact causing the physical transfer of organisms between an infected or colonized person and a susceptible host without a contaminated intermediate person or object.. HCP to patient during such Activities such as bathing, dressing changes and inserting invasive devices. Patient to patient. Germs can travel in body fluids such as blood, sputum, pus, wound drainage, saliva, stool, vomit. Contact with skin that has a rash, cuts or scratches, splash or spray to the mucous membranes Indirect contact - Involves the transfer of an infectious agent thru a contaminated intermediate object or person. occurs when a susceptible host is exposed to a contaminated object (This could be your hands, your stethoscope, your clothing and things such as shared patient devices such as multipatient BP cuffs, thermometers, glucose monitoring devices), shared toys in a pediatric setting, needles, or inadequately cleaned surgical instruments. Vehicle Transmission- involves the transfer or microorganisms by way of vehicles, or contaminated items that pathogens, Ex. Food carrying salmonella, water carrying Legionella, blood can carry hepatitis, drugs can carry bacteria from contaminated infusion supplies. Contaminated Blood, food, water, inanimate objects are vehicles of transmission. Droplet Transmission- According to CDC, droplet transmission is technically a form of contact transmission., and some infectious agents can be transmitted by the droplet route by both direct and indirect contact routes. But in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the resp tract of the infectious individual to susceptible mucosal surfaces of the recipient., generally over short distances and necessitating facial protection. As far as the distance, according to cdc document that distance is currently unresolved. Although pathogens that are transmitted by the droplet have not been transmitted thru the air at long distances in contrast to airborne transmission. Historically the area of defined risk has been a distance of < or equal to 3 feet. Around the patient. Some studies in 2003 suggested that smallpox and SARS could reach persons located 6 feet or more from the source. Droplet vs droplet nuclei- this is regarding the size occurs when mucous membranes of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, or talking. Droplets are body fluids. Droplets do not remain suspended in the air for very long and seldom travel more than 3 feet. Thus transmission IS NOT via the airborne route. Some examples- flu, rhinovirus, SARS, group a strep, Neisseria meningitis. Airborne Transmission- Examples Tuberculosis, aspergillus, measles , chicken pox and POSSIBLY smallpox. Airborne occurs when find particles are suspended in the air for a long time or when dust particles contain pathogens. Air currents disperse organisms, which can be inhaled by or deposited on the skin of a susceptible host. Special air handling and ventilations systems called airborne infection isolation rooms (AIIRs) are needed to contain and remove the infectious agent. Vehicle borne- this would be the transmission of infection from sources other than an infectious individual and includes common environmental surfaces or vehicles such as contaminated food or water, or medications-in particular referring to IV medications. Vectorborne Transmission- Vectors are non human carriers that transmit organisms from 1 host to another and can be biologic or mechanical. Biologic vectors- are living creatures that carry pathogens, such as rats, insects, or birds. Transmission by biologic vectors is of great concern in tropical areas where mosquitoes transmit diseases such as malaria. Ticks. Biting flies. Mites. The term vector refers to any arthropod that transmits a disease thru feeding activity. Mosquitoes, ticks, and lice, are nonhuman carriers that transmit organisms from 1 hots to another by injected salivary fluid when a human bite occurs. Mechanical vectors- inanimate objects that are contaminated with infected body fluids. Central line catheters and ventilators, shared needles and syringes by drug abusers, are examples of mechanical vectors. Contact - Direct & Indirect Direct: body surface to body surface contact Droplet -Influenza, Pneumonia Airborne -Tuberculosis Vehicle-borne -Contaminated items, water, drugs, blood, food Vector-borne -External mechanical transfer (flies), internal transmission between vector & host- parasites (mosquito, tick, flea)

Hand-washing

When hands are visibly dirty When hands are soiled with blood or body fluids Before eating & After using the toilet If exposed to spore-forming organisms (C. Diff

Chapter 28- Infection Prevention and Control Infection

invasion of a susep. host by pathogens or microorganisms resulting in disease

Hand Hygiene

is the most important technique to use in preventing and controlling transmission of infection Don't forget, however, about your stethoscope, BP cuff, bedside commode, can be a source of transmission

Transmission-Based Precautions

Airborne, droplet, and contact type precautions

Stages of Infection

Incubation Period The time between the pathogens entrance into the host and when symptoms appear Prodromal Stage Time from onset of nonspecific to more specific symptoms. A period of non-specific symptoms such as nausea, fatigue, fever, aches, and pains to more specific symptoms. Acute Stage of Illness Specific symptoms appear May be able to diagnose with certain lab tests Convalescence Stage This stage completes the progress of an infection, acute symptoms disappear, the body systems return to normal Teacher's Notes: Incubation period-the time between the pathogens entrance into the host and when symptoms appear, this can vary depending on the number of organisms absorbed, the time they require to grow and multiply, their virulence, the hosts resistance. Why important- Transmission Rubella is spread from person to person via airborne transmission or droplets shed from the respiratory secretions of infected persons. Rubella may be transmitted by persons with subclinical or asymptomatic cases (up to 50% of all rubella virus infections). Rubella is only moderately contagious. The disease is most contagious when the rash first appears, but virus may be shed from 7 days before to 5-7 days or more after rash onset. Infants with CRS shed large quantities of virus from body secretions for up to 1 year and can therefore transmit rubella to persons caring for them who are susceptible to the disease. Acquired Rubella The incubation period of rubella is 14 days, with a range of 12 to 23 days. Symptoms are often mild, and up to 50% of infections may be subclinical or unapparent. Congenital Rubella Syndrome Prevention of CRS is the main objective of rubella vaccination programs in the United States. A rubella epidemic in the United States in 1964-1965 resulted in 12.5 million cases of rubella infection and about 20,000 newborns with CRS. The estimated cost of the epidemic was $840 million. This does not include the emotional toll on the families involved. Infection with rubella virus is most severe in early gestation. The virus may affect all organs and cause a variety of congenital defects. Infection may lead to fetal death, spontaneous abortion, or premature delivery. The severity of the effects of rubella virus on the fetus depends largely on the time of gestation at which infection occurs. As many as 85% of infants infected in the first trimester of pregnancy will be found to be affected if followed after birth. While fetal infection may occur throughout pregnancy, defects are rare when infection occurs after the 20th week of gestation. The overall risk of defects during the third trimester is probably no greater than that associated with uncomplicated pregnancies. Congenital infection with rubella virus can affect virtually all organ systems. Deafness is the most common and often the sole manifestation of congenital rubella infection, especially after the fourth month of gestation. Eye defects, may occur. Cardiac defects are possible. Neurologic abnormalities, including microcephaly and mental retardation, Prodromal Stage- the onset of symptoms, will be non-specific such as nausea, fever, fatigue, aches and pains Acute phase or Stage of Illness- this is when specific symptoms appear, depending on the pathogen there is a cluster of usual symptoms and often able to diagnose using laboratory tests Convalescence Stage - recovery, completes the progress of an illness, body systems return to normal, appetite returns, antibodies begin to appear in the blood

Disinfection

: Refers to chemical or physical processes used to reduce the numbers(many or all) of microorganisms on an inanimate object's surface, does not destroy spores. * Do not use disinfectants on your skin. Surface Disinfection High-level Disinfection (endoscopes, bronchoscopes) Disinfection involves using a chemical or wet pasteurization . (alcohol, chlorine, gutaraldehydes, H202, phenols) Glutaraldehydes are caustic & toxic to tissue and are a potential health risk Teacher's Notes: A disinfectant is a chemical preparation, such as phenol or iodine compounds, used on inanimate objects. Disinfectants are frequently caustic and toxic to tissues. An antiseptic is a chemical preparation used on skin or tissue. Sterilization is a process that destroys all microorganism including spores and viruses.

Types of Aseptic Technique

Aseptic techniques are practices/procedures that help reduce the risk of infection -Medical -Surgical

HEP B and C

Hepatitis B and C are the infections most commonly transmitted by contaminated needles Healthcare personnel are at risk for occupational exposure to bloodborne patho - gens, including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Exposures occur through needlesticks or cuts from other sharp instruments contaminated with an infected patient's blood or through contact of the eye, nose, mouth, or skin with a patient's blood. Important factors that influence the overall risk for occupational exposures to bloodborne pathogens include the number of infected individuals in the patient population and the type and number of blood contacts. Most exposures do not result in infection. Following a specific exposure, the risk of infection may vary with factors such as these: The pathogen involved The type of exposure The amount of blood involved in the exposure The amount of virus in the patient's blood at the time of exposure Healthcare personnel who have received hepatitis B vaccine and developed immunity to the virus are at virtually no risk for infection. For a susceptible person, the risk from a single needlestick or cut exposure to HBV-infected blood ranges from 6-30% and depends on the hepatitis B e antigen (HBeAg) status of the source individual. Hepatitis B surface antigen (HBsAg)-positive individual - also who are HBeAg positive have more virus in their blood and are more likely to transmit HBV than those who are HBeAg negative. While there is a risk for HBV infection from exposures of mucous membranes or nonintact skin, there is no known risk for HBV infection from exposure to intact skin. 2 HCV The average risk for infection after a needlestick or cut exposure to HCV- infected blood is approximately 1.8%. The risk following a blood exposure to the eye, nose or mouth is unknown, but is believed to be very small; however, HCV infection from blood splash to the eye has been reported. There also has been a report of HCV transmission that may have resulted from exposure to nonintact skin, but no known risk from exposure to intact skin. HIV The average risk of HIV infection after a needlestick or cut exposure to HlV-infected blood is 0.3% (i.e., three-tenths of one percent, or about 1 in 300). Stated another way, 99.7% of needlestick/cut exposures do not lead to infection. The risk after exposure of the eye, nose, or mouth to HIV-infected blood is estimated to be, on average, 0.1% (1 in 1,000). The risk after exposure of non-intact skin to HlV-infected blood is estimated to be less than 0.1%. A small amount of blood on intact skin probably poses no risk at all. There have been no documented cases of HIV transmission due to an exposure involving a small amount of blood on intact skin (a few drops of blood on skin for a short period of time). How many healthcare personnel have been infected with blood- borne pathogens? HBV The annual number of occupational infections has decreased 95% since hepatitis B vaccine became available in 1982, from >10,000 in 1983 to <400 in 2001 (CDC, unpublished data). HCV There are no exact estimates on the number of healthcare personnel occupation - ally infected with HCV. However, studies have shown that 1% of hospital healthcare personnel have evidence of HCV infection (about 3% of the U.S. population has evidence of infection). The number of these workers who may have been infected through an occupational exposure is unknown. HIV 3 As of December 2001, CDC had received reports of 57 documented cases and 138 possible cases of occupationally acquired HIV infection among healthcare personnel in the United States since reporting began in 1985.

Asepsis

Asepsis is the absence of pathogenic/disease-causing microorganisms.

Preparation of a Sterile Field

Clean, dry work area above waist level Inspect supplies for package integrity and sterility Perform hand hygiene Apply PPE Must open sterile packages without contaminating the contents When performing sterile procedures you need a sterile work area- a sterile field is an area free of microorganisms & prepared for sterile items Inner surface of wrapper is considered sterile Cannot be delegated to NAP-Surgical Tech

Age and Culture

Communication with patients can be improved and patient care enhanced if health care providers can bridge the divide between the culture of medicine and the beliefs and practices that make up patients' value systems. These may be based on ethnic heritage, nationality of family origin, age, religion, sexual orientation, disability, or socioeconomic status..

Transmission Based Precautions

Contact Used for direct and indirect contact with patients and their environment Droplet Diseases that are transmitted by large droplets expelled into the air & travel from 3-6 feet from the patient Airborne Diseases that are transmitted by smaller droplets wh/ remain in the air for longer periods of time Protective Environment Requires a Specialized room with positive air flow Teacher's Notes: CDC became active and involved in developing and recommending infection control practices and procedures for hospitals. Updated their guidelines for transmission based precautions in 2007. Transmission based Precautions- are used in addition to standard precautions for patients w/ suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes. New in the 2007 guidelines is a directive to don PPE when entering the room of a patient on contact or droplet precautions. Previously PPE was only required when the nurse was delivering care within 3 feet of the patientcare used when the route of transmission is not completely interrupted using standard precautions alone. Some diseases, such as SARS, have multiple routes of transmission and therefore may require more than one TBP category. When highly transmissible or significant pathogens have been identified, additional isolation may be required to prevent the spread of infection. Depending on the organism and its mode of transmission, Airborne precautions, Droplet or Contact Precautions may be instituted. There are 3 categories of TBP Contact- When pt's are infected w/ significant organisms (ef MDRO's) need extra care to prevent transmission, and Contact transmission are instituted. Used in the presence of wound drainage that is not being contained, fecal incontinence, intended to prevent transmission of infectious agents which are spread by direct OR indirect contact with the patient or the patients environment. Used with organisms that can be transmitted by hand- or skin-to-skin contact, such as during pt care activities or when touching the patients environmental surfaces or care items. don PPE upon room entry and dispose before exiting the room Patient is in a private room or w/ someone who is infected with the same organism. Gloves upon entering the room, change when exposed to possible infectious material and remove before leaving the room. Use gowns and other protective barriers when contamination is likely When indicated- wound infx or abscess, that the dressing does not adequately contain drainage or no dressing in place, Bronchiolitis (mask according to SP), C diff, congenital Rotavirus, Hepatitis A in incontinent or diapers, impetigo, lice, MDROs, polio, RSV, scabies, rubella Droplet- Use these for a pt with an infx that is spread by lg particle droplets. Indicated for pertussis, influenza, adenovirus, rhinovirus, strep (for the first 24 ours of antx tx). used for microorganisms transmitted by larger particle droplets wh/ disperse into air currents droplet precautions are intended to prevent transmission pathogens spread thru close resp or mm contact with resp secretions. These pathogens do not remain infectious over long distances, special air handling and ventilation are not required.. Person must be in a private room or with a person who is infected with the same microorganism. An AIIR (airborne infection isolation room) -negative pressure is not required. Use masks when within 3 feet of the patient. Visitors should stay 3 feet from pt as well, Patient should wear a mask when outside the room. Airborne- use for patients who have infxs that spread thru the air such as TB, Varicella, rubeola and ? SARS, airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air-used to protect against micro organisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents. Patient should be cared for in an AIIR (airborne infection isolation room) -negative pressure, certain number of air exchanges, air goes directly to outside or it is recirculated thru HEPA filtration. is not required. . Healthcare personnel should wear an N95 respirator mask for when entering room, do not transport pt out of room unless necessary make sure patient wears a surgical mask when transported out of the room. Keep patient door closed, Used in measles (rubeola), varicella A&C, TB and possibly SARS-. Special N95 mask required and it is put on BEFORE entering the rooms You are not to care for or enter patient rooms on airborne precautions

Cough Etiquette

Cover your nose/mouth with a tissue when you cough, and promptly dispose of the contaminated tissue. Place a surgical mask on a patient if it does not compromise respiratory function or is applicable; this may not be feasible in pediatric populations. Perform hand hygiene after contact with contaminated respiratory secretions Maintain spatial separation greater than 3 feet from persons with respiratory infection Teacher's Notes: To control organisms exiting via the respiratory tract, cover your mouth or nose when coughing or sneezing. Teach patients, health care staff, patient's families, and visitors respiratory hygiene or cough etiquette. The elements of a respiratory hygiene or cough etiquette are listed here.

Basic Principles of Medical Asepsis

Hand hygiene Keep soiled items and equipment from touching clothing Do not put soiled bed linens or any other items on the floor (floor is grossly contaminated) Do not shake linens (dust and lint can be a vehicle for microorganisms) Clean from areas of least soiling to greater soiling Avoid splashing any liquids such as bath water Dispose of soiled or used items directly into appropriate containers Wear hair up and shampoo hair regularly, keep fingernails short and free of broken cuticles, avoid wearing rings

The CDC Recommends the following

Handwashing Alcohol-based waterless antiseptic agent

Applying PPE

How are you going to remember the correct order? Raise your hands up and dress from the bottom up. Applying PPE 1. Perform hand hygiene- clean hands reduce the number of MOs that could be transferred if gloves were to accidentally puncture or tear 2. Gown - we will practice this in lab, tie at neck and waist 3. Mask covering the nose and mouth will prevent exposure to airborne and droplet modes of transmission. 4. Goggles- if splash is anticipated put on goggles or a face shield, some mask come with face shield attached already 5. Gloves- don gloves last so that the cuffs of the gloves fit over the cuffs of the gown, want them to cover the cuff to provide impenetrable seal from MOs

Hep C

If the source patient is positive for Hep C the employees is tested for a baseline 4 weeks post exposure an HCV-RNA test should be offered If post exposure test is positive employee starts treatment *there is no prophylactic treatment for HCV after exposure Early treatment for infection can prevent chronic infection

Focus on the Older Adult

Immune senescence- age related decline in immune system function Decreased ability to produce lymphocytes to combat challenges to the immune system Increase in production of autoantibodies after age 70 Bereavement, depression and poor social support can lead to suppressed immunity Changes in the skin, urinary tract and lungs lead to increased risk Risks associated w/ developing a HAI -Poor nutrition -Unintentional weight loss -Low serum albumin levels

Chain of Infection

Infectious Agent of Pathogen Reservoir of Source Portal of Exit from Reservoir Means of Method or Transmission Portal of Entry (to the Susceptible Host) Susceptible Host

Normal Flora

Microorganisms Maintain a balance with other microorganisms to prevent infection Normal body flora do not normally cause disease when residing in their usual area of the body Help to resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms.

Age Related considerations in Preventing the Transmission of Infectious Diseases

Newborn and Infants -Immune system not fully operational until about 6 months old Antibodies passed to infant from placenta and breast milk Toddler and preschooler -By age 3 or 4 years the immune system has matured to level similar to an adult Child and adolescent -Mature immune system Exposure through school, sports and group activities Adolescents and exposure to STDs Adult and Older Adult -Immunity to many diseases is established by adulthood Chronic diseases Aging diminishes defenses to microbial invasion Teacher's Notes: Newborns and Infants- prevention of infection in the newborn begins during pregnancy. Maternal infections can be transmitted to the fetus during pregnancy and cause congenital anomalies or fetal death. Exposure is most dangerous very early in pregnancy when the mother may not even realize she is pregnant -all women of childbearing age should be up to date on immunizations and avoid exposure to contagious diseases The most frequent mode of transmission of organisms to the infant is from direct contact with the skin and hands of caregivers and to a lesser extent contaminated formula Handwashing is the single most important means for preventing hospital associated infections in the newborn Immunizations Immune system not fully operational until about 6 months of age, prior to that the infants resistance is from the antibodies passed by way of the placenta and breast milk Toddlers and Preschoolers- normal behaviour at this age fosters transmission of microorganisms. Usually not potty trained at this age. Usually have poor personal hygiene at this age. Play on the floor. Put objects in their mouth. Exposed to groups of children. School Age Children and Adolescents- Child- communicable diseases are prevalent as children enter school and organized play the incidence of many infections decrease during school years- immunizations and more mature immune systems. Adolescence brings new elements of exposure. Injuries are more frequent. Incidence of STDs and mononucleosis rise. Respiratory infections and viral diseases are common because of group activities in close quarters. Adults and Older Adults- infections of injury and STDs continues, travel, travel to foreign countries. Surgical procedures. Expired immunizations. Chronic illnesses. Older adults- the immune system may be impaired. Aging < non specific and specific defenses to microbial invasion. Metabolism and repair of body cells and tissues decrease. WBC counts do not always respond to infection, there is a decreased inflammatory response and body temp may not be elevated in response to infection. The ability to wall off and limit the spread of infection is <.

Defenses Against Infection

Normal Flora Body Systems Defenses Inflammation Teacher's Notes: •Normal flora: microorganisms that reside in the body. [Where are these floras located? Floras are located in the skin, saliva, oral mucosa, and intestinal walls.] •Refer to the pharmacology course students have taken. Recall that use of broad-spectrum antibiotics for the treatment of infection may eliminate or change normal flora, leading to a superinfection. •A number of body organ systems have unique defenses against infection. For example, the airways are lined with moist mucous membranes and cilia, which rhythmically beat to move mucus or cellular debris up to the pharynx to be expelled through swallowing. [See Table 28-2 on text p. 402 Normal Defense Mechanisms Against Infection for more examples.] The inflammatory response is a protective cellular and vascular reaction that neutralizes pathogens and repairs body cells. It delivers fluid, blood products, and nutrients to an injured area. The accumulation of fluid appears as localized swelling (edema). •The process neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues. Signs and symptoms usually include fever, leukocytosis, malaise, anorexia, nausea, vomiting, and lymph node enlargement. •Leukocytosis, or an increase in circulating white blood cells (WBCs), is the body's response to WBCs leaving blood vessels. Phagocytosis is the process of destroying and absorbing bacteria-Neutrophils & Monocytes. •Inflammatory exudate is the accumulation of fluid, dead tissues, and WBCs that forms at the site of infection. The lymph system usually carries this fluid away. Exudate may be serous (clear, like plasma), sanguineous (containing red blood cells), or purulent (containing WBCs and bacteria). •Tissue repair occurs when tissue cells undergo an injury. Damaged cells are replaced with healthy new cells. If an inflammation is chronic, tissues will be replaced with granulation tissues, which is not as strong as normal tissue and will leave a scar.

Surgical hand asepsis/surgical scrub

Nurses with active skin infections, open lesions/cuts, or respiratory infections should be excluded from the surgical team Surgical hand asepsis: Remove rings, bracelet & watches Nails-short, clean, & health; no artificial nails; Natural nails < ¼" Scrub from fingertips to 2" above elbows, optimum duration is unclear. Traditional time in the U.S. is 5 minutes- policies vary between time of scrub vs. number of strokes Keep hands above elbows at all tines Rinse thoroughly under running water keeping hands above elbows at all times Clean under nails Scrub hands and fingers first, then forearms Dry hands first then forearms, use reverse side of towel or new towel for other hand Optional additional Brushless antiseptic hand rub

Surgical Asepsis Principles

Only sterile objects may be placed on a sterile field Only sterile objects may touch another sterile object Avoid moisture (a wet field is contaminated) Sterile objects should be held above waist level Avoid coughing, talking, sneezing, or reaching over a sterile field Never turn your back on a sterile field When in doubt, throw it out- sterile items are packaged in paper or plastic and impervious to microorganism as long as they are dry and intact- if opened, soiled or ever been wet it is no longer sterile A sterile object of field out of the range of vision or an object held below a person's waist is contaminated A sterile object/ field becomes contaminated by prolonged exposure to air When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated The edges of a sterile field or container are considered to be contaminated (2.5 cm (1") border)

Isolation

Psychological implications Specimen collection- Box 28-14 Wound specimen Blood specimen Stool specimen Urine specimen Bagging of trash or linen To prevent accidental exposure of personnel & contamination of the environment Patient transport Pt on droplet or airborne precautions should only leave their rooms for essential purposes- procedures or surgery and wear a mask when leaving room Notify personnel in the receiving dept. of the type of isolation precautions the patient needs Clean equipment after patient use

Sterilization

Refers to the complete destruction of all microorganisms, including spores Pressurized steam, Ethylene oxide (TEO) gas, chemicals ETO is a potential health risk to staff using this agent and exposure must be monitored

Droplet Precautions

STREPTOCOCCAL PHARYNGITIS PERTUSSIS/ PNEUMONIA INFLUENZA DIPTHERIA EPIGLOTTIS RUBELLA MUMPS/MENINGITIS/MYCOPLASMA/ MENINGOCOCCAL ADENOVIRUS/ +CONTACT Use for patients with an infection that is spread by large particle droplets such as rubella, mumps, diphtheria, adenovirus infection in infants and young children Use a private room Door may remain open Wear PPE upon entry into the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patients environment Transport patient out of room only when necessary and place a surgical mask on the patient if possible Keep visitors 3 feet from the infected person

Currect CDC Guidelines

Teacher's Notes: Standard Precautions are used on all patients regardless of their infection status They reduce the risk of blood borne pathogen transmission Reduced the risk of disease transmission from body substances They are based on the principle that all blood, body fluids, secretion, excretions except sweat, non intact skin, and mm may contain transmissible infectious agents. SP include a group of infection prevention practices that apply to ALL patients, regardless of suspected or confirmed infection status, in any setting in which all healthcare is delivered. Standard Precautions:used in care of all patients to prevent and control infection and its spread Apply to contact w/ blood, body fluids, secretions, excretions (except sweat), non-intact skin, mucous membranes Transmission-based precautions- are used in addition to standard precautions for patients with suspected infection *Include Airborne, Droplet, Contact precautions

Labs

The clinical microbiology laboratory is an essential component of an effective infection control program

Basic Principles of Isolation

Thorough hand hygiene before entering & leaving Dispose of contaminated supplies & equipment in a way that prevents spread of microorganisms to others Apply knowledge of the disease process & the mode of infection transmission when using protective barriers Protect all persons who may be exposed during transport of patient outside of their room

Goggle/face shields

Use to protect HCW from splashes, sprays and respiratory droplets Personal eyeglasses or contact lenses are NOT considered adequate eye protection Protection for the eyes, nose and mouth using a mask and goggles, or face shield alone, is necessary when it is likely that there will be a splash or spray of respiratory secretions or other body fluids as defined in Standard Precautions Disposable or non-disposable face shields may be used as an alternative to goggles Compared with goggles, a face shield can provide protection to other facial areas in addition to the eyes

Protective

Used for highly susceptible immunocompromised patients. Ex-organ transplant; allogeneic hemopoietic stem cell transplant (HSCT) Requires: Positive airflow with rate >12 air exchanges/hour with all air filtered through a HEPA filter Patients are not allowed dried or fresh flowers or potted plants It has been advised that patients wear an N95 mask when outside the protected environment.

Inflammation

Vascular & cellular responses Exudates (serous, sanguineous, or purulent) Tissue repair Signs of local inflammation and infection are identical

OSHA

handling and disposal of blood and body fluids that potentially pose a risk for the transmission of blood borne pathogens Safe handling of needles/sharps OSHA and CDC publish rules, regulations, and guidelines to protect employees in the workplace. The OSHA regulations and CDC guidelines are incorporated into the policies and procedures of health care institutions and are part of regularly scheduled staff education programs. *Employee Health

Medical asepsis

includes all procedures and practices that reduce the number, growth, transmission and spread of pathogens. Goal is limiting the number, growth and transmission of microorganisms. Clean technique In Medical Asepsis objects referred to as clean NOT sterile Reduces or inhibits the number and growth of microorganisms Practices- They include handwashing, bathing, cleaning the environment, gloving, gowning, wearing a mask, hair and shoe covers, disinfecting articles and use of antiseptics Medical Asepsis or Clean technique includes all measures aimed at reducing the number or spread of microorganisms Hand hygiene Barrier Techniques/PPE (Personal Protective Equipment) Gloves to prevent direct contact with blood or body fluids. Routine cleaning of the environment Routine Environmental Cleaning Medical Asepsis- refer to measures aimed at reducing the number or spread of microorganisms Recommend hand hygiene, handwashing with soap and water, alcohol based hand cleanser Hand hygiene- most effective way to prevent the spread of infectious agents, includes washing with plain soap and water, use of antiseptic handrubs or surgical hand antisepsis Clean technique Disinfection: the process of eliminating pathogenic organisms on an inanimate object with the exception of spores Disinfectant- a chemical substance that is used for disinfecting only an inanimate object (phenol, chlorine). Antiseptic solution- a substance that is used on person's skin to inhibit the growth and activity of microorganisms, but not necessarily to destroy them Bactericidal- a chemical that KILLS microorganisms Bacteriostatic- an agent that prevents bacterial multiplication but does NOT kill all forms of the organism Sterilization- this refers to the complete destruction of ALL microorganisms INCLUDING spores.

Cleaning, disinfection, and Sterilizatoin

proper cleaning, disinfection & sterilization significantly reduce & often eliminate microorganisms

Isolation Precautions Isolation

techniques to prevent or limit the spread of infection In 1995 CDC introduced a two-tiered system of isolation precautions

Cleaning

the removal of all soil from objects & surfaces

Indication Safety Guidelines from CDC

■ Never administer medications from the same syringe to more than one patient, even if the needle is changed. ■ After a syringe or needle has been used to enter or connect to a patient's IV it is contaminated and should not be used on another patient or to enter a medication vial. ■ Never enter a vial with a used syringe or needle. ■ Never use medications packaged as single-dose vials for more than one patient. ■ Assign medications packaged as multi-dose vials to a single patient whenever possible. ■ Do not use bags or bottles of intravenous solution as a common source of supply for more than one patient.

Gowns

Are worn to protect the HCW's arms & body and to prevent contamination of clothing with blood, body fluids and other potentially infectious material To be worn at all times with Contact Precautions Standard Precautions- to be worn only if contact w/ blood or body fluid is anticipated Need to cover arms & body front from neck to mid-thigh or below Remove before leaving patient room & carefully to minimize contamination of hands and uniform

Susceptible Host

A person who is susceptible to an infection A compromised host is a person at increased risk Susceptibility depends on the individual's degree of resistance Age Nutritional status Presence of chronic disease Trauma Smoking Lack of Immunizations Host- a susceptible host is a person whose body defense mechanism, when exposed, cannot withstand the invasion of pathogens. Any person who is at risk for infection. They do not have an infection at the time but are at risk . A compromised host is a person at increased risk. Body has numerous defense mechanisms. When infectious disease occurs in a human, the agent of infection has overcome the body's ability to resist infection. Factors that increase susceptibility to infection include: 1. Age 2. Heredity 3. The nature, number and duration of physical and emotional stressors. 4. Nutritional status 5. Certain medical therapies and medications predispose a person to infection 6. Lack of immunizations

Reservoir

A place where the agent can survive, multiply, and wait for a host; it's the natural habitat of the organism -Humans -Animals -Environment Carriers- people who carry or harbor pathogens but are asymptomatic, have nor symptoms

Factors that influence infection prevention & control

Age and Culture Nutritional Status -A ↓ in protein & nutrients ↓ the body's defense against infection and impairs wound healing Surgery, Illnesses such as burns and febrile conditions ↑ protein requirements Stress- the body responds to both emotional &physical stress by the general adaptation syndrome (3 Stages) Alarm Stage- ↑ basal metabolism rate as the body uses energy stores Adrenocorticotropic hormone ↑ glucose levels and ↓ anti-inflammatory response thru the release of cortisone If stress continues ↑ cortisone levels cause a decreased resistance to infection & exhaustion and the body has no resistance to invading organisms Treatments/Conditions that compromise the immune system Disease Process -Certain conditions compromise a host by weakening the host's defenses against infectious organisms (Leukemia, AIDS, lymphoma, aplastic anemia) Chronic Diseases (DM , MS, COPD, Cancer) Teacher's Notes Multiple factors influence a patient's susceptibility to infection. It is important to understand how each of these factors alone or in combination increases this risk. •Throughout life, susceptibility to infection changes. An infant has immature defenses against infection. The young or middle-aged adult has refined defenses against infection. In older adults, immune response declines, particular cell-mediated immunity. •A patient's nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. (This is discussed in greater detail in Chapter 48.) •The body responds to emotional or physical stress by the general adaptation syndrome (discussed in detail in Chapter 37). If stress continues or becomes intense, elevated cortisone levels result in decreased resistance to infection. •If a patient has a condition or a disease that compromises the patient's ability to fight off infection, he or she becomes more susceptible. [What conditions can you think of that would make a patient more susceptible to infection?] •For example, AIDS compromises the immune system, and bronchitis impairs the lungs' defense system by impairing ciliary action and thickening mucus. Patients with burns are susceptible owing to damage to the skin surface.

Hand Hygiene

Alcohol Hand Antiseptic Handwashing - Do not wear artificial nails or extenders when performing patient care -Keep natural nails clean, well manicured at inch long, and free of nail gels and acrylic products

Infectious Causing Agent

Any micro-organism that is capable of producing an agent Bacteria Virus Fungi Parasites

How do we Break the Chain?

Breaking at least one link stops the spread of infectious disease 1. The infectious agent -early recognition of s/s of infection and rapid, accurate identification of organisms 2. Reservoir Medical asepsis, standard precautions, good employee health, environmental sanitation, disinfectant/sterilization 3. Portal of exit from host Medical asepsis, PPE, hand washing, control of excretions and secretions, trash and waste disposal, standard precautions 4. Route of transmission -standard precautions, hand washing, sterilization, medical asepsis, air flow control, food handling, transmission based precautions 5. Portal of entry- wound care, catheter care, medical asepsis, and standard precautions, 6. Susceptible host- treat the underlying disease and recognize the high risk patient How do we break the Chain? Continued... Hand hygiene Standard Precautions Transmission Based Precautions Personal Protective Equipment Medical Asepsis Surgical Asepsis Isolate infected individuals Cover cuts and open sores Dispose of soiled items appropriately Take care with raw foods Wash pets on a regular basis

Alcohol-based waterless antiseptic agent

Can be used If hands are not visibly soiled for routine decontamination of hands Before, after, & between patient contact After contact with body fluids or excretions, mucous membranes, non intact skin, wound dressings When moving from a contaminated to a clean body site After contact with inanimate surfaces or objects in patient's rooms Before caring for patients w/ severe neutropenia or immune suppression Before applying sterile gloves & after removing gloves Teacher's Notes: Instruct patients and visitors about the proper technique and times for hand hygiene. Teaching hand hygiene is particularly important if health care is to continue at home. Patients need to wash their hands before eating or handling food; after handling contaminated equipment, linen, or organic material; and after elimination. Encourage visitors to wash their hands before eating or handling food; after coming in contact with infected patients; and after handling contaminated equipment, patient furniture, or organic material

Cultural Considerations in Preventing the Transmission of Infectious diseases

Concepts of personal hygiene and infections control develop early in an individual and are greatly influenced by family, community, and the culture of origin. Hygiene practices can vary widely within the same culture and different groups living in the same country or area. The World Health Organization (WHO) recommends taking all cultural and religious beliefs into consideration when both interacting with patients and families and when considering goals and plans for patient education Teacher's Notes Concepts of personal hygiene and infections control develop early in an individual and are greatly influenced by family, community, and the culture or origin, hygiene practices can vary widely within the same culture and different groups living in the same country or area. WHO created a task force to look at religious and cultural aspects of hand hygiene. WHO Guidelines on Hand Hygiene in Health Care 2009 Examples: Buddhism- wash hands after each meal and wash the hands of the deceased Hinduism- wash hands after prayer, after any unclean act such as toileting, before and after meals Islam- wash hands before prayers 5 times a day, before and after any meals, after toileting, after touching anything soiled (dog, shoes, cadaver) Judaism- wash first thing in the morning, before and after meals, after toileting

Scientific Knowledge Base

Disease or infection results only if pathogens multiply and alter normal tissue function. Some infectious diseases such as viral meningitis and pneumonia have low or no risk for transmission. Colonization: MRSA in nares, growing in warm places- underarms, groin; Smokers colonized with haemophilus infuenzae

Airborne

Diseases that are transmitted by smaller droplets that remain infectious over long distances in the air for longer periods of time Microorganisms carried in this manner may be dispersed over long distances by air currents Requires: Negative airflow to prevent infectious particles from flowing out of room to other rooms and air handling system. Air is not returned to the inside ventilation system. It is filtered through a HEPA filter & sent directly outside or recirculated through HEPA filtration before return N95 mask/respirator must be worn at all times & donned prior to entry

Performing Sterille Procedures

Donning and removing caps, masks, and eyewear Opening sterile packages Opening a sterile item on a flat surface Opening a sterile item while holding it Preparing a sterile field Pouring sterile solutions Surgical scrub Applying sterile gloves Donning a sterile gown Teacher's Notes Assemble all of the equipment that will be needed before a procedure. Have a few extra supplies available in case objects accidentally become contaminated. Do not leave a sterile area. Before a sterile procedure, explain each step so the patient can cooperate fully. If an object becomes contaminated during the procedure, do not hesitate to discard it immediately. Wear a surgical mask and eyewear without a cap for any sterile procedures on a general nursing unit. Sterile items such as syringes, gauze dressings, or catheters are packaged in paper or plastic containers and are impervious to microorganisms as long as they are dry and intact. Commercially packaged items are usually designed so you only have to tear away or separate the paper or plastic cover. To open a small sterile item, hold the package in your nondominant hand while opening the top flap and pulling it away from you. When performing sterile procedures, you need a sterile work area that provides room for handling and placing sterile items. You prepare the sterile field by using the inner surface of a sterile wrapper as the work surface, or by using a sterile drape or dressing tray. A bottle containing a sterile solution is sterile on the inside and contaminated on the outside; the neck of the bottle is also contaminated, but the inside of the bottle cap is considered sterile. Nurses working in operating rooms perform surgical hand antisepsis to decrease and suppress the growth of skin microorganisms in case of glove tears. Sterile gloves are an additional barrier to bacterial transfer. Nurses wear sterile gowns when assisting at the sterile field in the operating room, delivery room, and special treatment areas.

Surgical Asepsis or Sterile Technique.

Eliminates all organisms, both pathogenic and non-pathogenic, including spores. Practices that keep an area or objects free from all microorganisms, non pathogenic and pathogenic, including spores and viruses. Practices that destroy all microorganisms and spores. Surgical asepsis is used for procedures involving the sterile areas of the body and would include inserting a urinary catheter Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. Surgical asepsis is used during procedures that require intentional perforation of the patient's skin such as insertion of IV catheters or central lines; when the integrity of the skin is broken as a result of trauma, surgical incision, or burns; and during procedures that involve insertion of catheters or surgical instruments into sterile body cavities, such as insertion of a urinary catheter. Frequently you place sterile objects on a sterile towel, drape, or tray. Because the edge of the drape touches an unsterile surface such as a table or bed linen, a 1-inch border around the drape is considered contaminated. Because surgical asepsis requires exact techniques, you need to have the patient's cooperation. Explain how you will perform a procedure and what the patient can do to avoid contaminating sterile items Sterile technique- the Purpose: to prevent the introduction of microorganisms from the environment to the patient. When is sterile technique or surgical asepsis used? -surgical procedures -All procedures that invade the bloodstream -procedures that cause a break in skin or mucous membranes (IM injections) -selected dressing changes and wound care -procedures involving insertion of catheters or devices into sterile body cavities (foley catheters) -care for selected high risk people or groups (transplant patients, burn patients, immunosuppressed patients An item is deemed sterile when all organisms and spores are destroyed. Items are clearly labeled as sterile, packaging must not be torn, punctured, wet or outdated

Gloves

GLOVES ARE A BARRIER AND ARE NOT IMPENETRABLE Gloves are not a substitute for hand hygiene Wear gloves when touching blood, body fluids, secretions and excretions, and items containing these body substances, mucous membranes and non intact skin Hand hygiene prior to donning gloves and after removal Warmth and moisture inside gloves can promote growth of microorganisms Some care activities may necessitate changing gloves more than once Gloves should always be changed prior to moving from a contaminated task to a clean one Do not leave the patient's room wearing gloves Do not use the computer keyboard or touch your phone while wearing gloves Perform hand hygiene touching your phone Double gloving is recommended when being exposed to blood or body fluids

PPE Personal Protective Equipment

Gloves Gown Mask Goggles or Face Shield Teacher's Notes The use of barriers, aka PPE, is important in preventing the spread of infections. Gloves should be worn whenever there could be contact with the patients body secretions. When do you wear gloves? Private rooms are used to < the chance of transmission of infection by all routes. PPE or Personal protective equipment. This is equipment that prevents the transfer of pathogens from one person to another. Masks and respirators- Mask- prevents transmission of infectious organisms thru the air. The wearer is protected from inhaling large particle droplets and small particle droplets. Lg particle droplets are transmitted by close contact and usually travel only a short distance, up to 3 feet. Small particle droplets, remain suspended in the air and may travel farther. Masks lose their effectiveness if they are wet or worn for long periods. Must also be changed after caring for each patient. Respirators- use them to filter inspired air vs exhaled air as with the mask, disposable particulate respirators, N95 or higher level, are indicated when pat has, or is suspected of having, contagious airborne diseases such as tuberculosis. Look like masks but fit the face more tightly and are able to filter out particles or organisms as small as 1 micron. Should be individually fitted to ensure a tight seal. Gowns- to be worn when the caregivers clothing is likely to be soiled by infected material. To be used only once, change when they become moist. Wear during any procedure that is likely to cause body fluid splashes or sprays When appropriate for the procedure or activity Caps and Shoe coverings- Gloves- help protect from acquiring infective organisms on the hands. They reduce the likelihood that personnel will transmit their own of other patient microbial flora from their hands to patients. -Wear clean non sterile gloves when direct contact with moist body substances is anticipated. Perform hand hygiene before and after gloving Change and discard gloves between patients or when they become torn or grossly soiled Do not wash and reuse gloves Googles or Face Shields- to be used when splashing is likely (wound irrigation, respiratory secretions, blood splatter) Googles protect the mucous membranes of the eyes. (Example suctioning a trach, assisting with an invasive procedure that may result in splattering of blood or other body fluid) a Face shield protects the eyes, mouth, nose and facial area. Personal eyewear is never a substitute. BOX 18-3 and Table 18-2 on pp 373 Standard Precautions and Transmission based precautions

Airborne Precautions

MY MEASLES CHICKEN CHICKEN POX/ + CONTACT HEZ HERPES ZOSTER/ + CONTACT TB TUBERCULOSIS Teacher Notes: Use for patients who have infections that spread thru the air such as TB, varicella, rubeola and possible sars Put pt in private room with monitored negative air pressure, 6-12 air changes per hour, and appropriate discharge of air Keep door closed Keep patient in the room Wear a mask or respirator when entering patient room with known of suspected TB. If pt has known or suspected rubeola or varicella resp protection should be worn unless person entering room is immune to these diseases Transport pt out of room only when necessary and place a surgical mask on the patient if possible Consult cdc guidelines for additional prevention strategies for TB

Healthcare-Associated Infections Continued

HAI- this term encompasses infections contracted in all healthcare settings whereas Nosocomial refers only to hospital acquired infection Risk factors in the development of HAIs are environment, therapeutic regimen and Pt resistance There are 5 types of HAIs that account for 61% of cases. These numbers are from 2009 Catheter associated Urinary tract infections (CA-UTIs)- 26% Surgical site infections (SSIs)- 17% Clostridium difficile associated disease (CDAD) 10% Central line associated bloodstream infections (CLA-BSI) 5% Ventilator associated pneumonia (VAP) 3% Results Surveys were conducted in 183 hospitals. Of 11,282 patients, 452 had 1 or more health care-associated infections (4.0%; 95% confidence interval, 3.7 to 4.4). Of 504 such infections, the most common types were pneumonia (21.8%), surgical-site infections (21.8%), and gastrointestinal infections (17.1%). Clostridium difficile was the most commonly reported pathogen (causing 12.1% of health care-associated infections). Device-associated infections (i.e., central-catheter-associated bloodstream infection, catheter-associated urinary tract infection, and ventilator-associated pneumonia), which have traditionally been the focus of programs to prevent health care-associated infections, accounted for 25.6% of such infections. We estimated that there were 648,000 patients with 721,800 health care-associated infections in U.S. acute care hospitals in 2011.

Standard Precautions

Hand hygiene Use of Gloves Gown Mask Eye protection, or face shield depending on the anticipated exposure Safe injection practices Respiratory/ Cough etiquette Masks for insertion of epidural catheters or injection into spinal or epidural spaces. Teacher's Notes: Standard Precautions are used in the care of ALL hospitalized individuals regardless of their diagnosis or possible infections status. These precautions apply to blood, all body fluids, secretions and excretions except sweat, non intact skin, and mucous membranes. New additions here are Resp Hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing hi risk prolonged procedures involving spinal cord punctures. Standard precautions include hand hygiene, use of loves, gown, mask eye protection or face shield depending on the anticipated exposure and safe injection practices. Also equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents (ie war gloves for direct contact, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another person) The application of SD is based on the nature of the HCW patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some things such as performing an IV insertion, only gloves may be needed and with others such as intubation use of gloves, gown and face shield or mask and goggles is necessary SPs are also intended to protect patients by ensuring that HC Personnel do not carry infectious agents to patients on their hands and equipment during pt care Respiratory Etiquette and masks for insertion of epidural catheters or epidural injections are new elements of SP. Resp/cough was added after the widespread SARS outbreaks in 2003. this includes that HCPs are advised to observe droplet precautions, wear a mask, and perform hand hygiene when examining and caring for a pt with s/s of a respiratory infection.

Isolation and Isolation Precautions

Health care facilities are required to have the capability of isolating patients. Isolation practices may prevent personnel and patients from acquiring infections and from transmission of microorganisms to other persons. Barrier precautions include the appropriate use of personal protective equipment (PPE) such as gowns, gloves, masks, eyewear, and other protective devices or clothing. A patient in isolation is subject to sensory deprivation because of the restricted environment. .Regardless of the type of isolation system, follow these basic principles: • Use thorough hand hygiene before entering and leaving the room of a patient in isolation. • Dispose of contaminated supplies and equipment in a manner that prevents spread of microorganisms to other persons as indicated by the mode of transmission of the organism. • Apply knowledge of a disease process and the mode of infection transmission when using protective barriers. • Protect all persons who might be exposed during transport of a patient outside the isolation room. An infection prevention and control professional—a valuable resource for assisting nurses in controlling HAIs—monitors the incidence of infection within an institution and provides educational and consulting services Isolation is the separation and restriction of movement of ill persons with contagious diseases. Standard precautions The first and most important tier Isolation precautions: Based on the mode of transmission of a disease Airborne Droplet Contact Protective environment

Healthcare Associated Infections (HAI)

Healthcare Associated Infections (HAI) Exogenous Microorganisms found outside the individual (Salmonella, Clostridium tetani, Aspergillus-do not exist as normal flora) Endogenous Overgrowth of natural flora ( staph, enterococci, yeast, strep) Often due to broad spectrum antibiotics Microorganisms normally found in one body site move to another Iatrogenic Result from a diagnostic or therapeutic procedure Teacher's Notes: Exogenous-from the hospital environment Endogenous-from the patient themselves Iatrogenic-received from an invasive procedure A HAI is a term that encompasses infections contracted in all healthcare settings and is often used in place of the more commonly known term, nosocomial infection, why/ refers only to hospital acquired infections. Iatrogenic infection is a type of HAI that results from a diagnostic or therapeutic procedure. For example, procedures such as bronchoscopy and treatment with broad-spectrum antibiotics have been shown to increase the risk for certain infections. •Health care-associated infections may be exogenous or endogenous. An exogenous infection comes from microorganisms found outside the individual such as Salmonella. They do not exist as normal floras. Endogenous infection occurs when part of the patient's flora becomes altered and an overgrowth results, as with streptococci. This often happens when a patient receives broad-spectrum antibiotics. Shorter hospital stays > increased reliance on outpatient facilities such as surgery centers, dialysis clinics, outpatient infusion centers, extended care facilities and rehab facilities. Movement thru the healthcare system increases the opportunity for cross contamination among facilities. Exogenous- Exogenous infections come from sources outside of the patient's own body A Compromised host plays a role in the occurrence of exogenous infection, however the presence within hospitals of pathogens that are particularly capable of infecting individuals in possession of the above risk factors also play a role Many of these pathogens possess antibiotic resistance Such hospital-specific pathogens can be found incorporated among the normal flora of staff or on fomites Much effort in a medical setting must be put forth to not only reduce patient contact with these pathogens but also to prevent these pathogens from becoming endemic to the hospital (e.g., passed around from patient to patient or found integrated in the normal flora of staff) Endogenous-Endogenous infections are ones caused by opportunistic pathogens that come from a patient's own normal bacterial flora. Bacterial flora is endogenous bacteria, which is defined as bacteria that naturally reside in a closed system.[Disease can occur when microbes included in normal bacteria flora enter a sterile area of the body such as the brain or muscle. This is considered an endogenous infection. A prime example of this is when the residential bacterium E. coli of the GI tract enters the urinary tract This causes a urinary tract infection Iatrogenic- an iatrogenic illness results from treatment, in this instance a nosocomial infection or HAI http://www.mansfield.ohio-state.edu/~sabedon/black15.htm

Hep B

Hepatitis B Health care employers are required to make Hep B vaccine series available to all employees who may have occupational exposures prior to providing patient care at no cost. Vaccine to be made available w/in 10 days of assignment. Titer 1-2 months following series is available If exposed no treatment is required if there is a positive blood titer on file.

Droplet

Historically, the area of defined risk has been a distance of < 3 feet around the patient and is based on epidemiologic and simulated studies Using this distance for donning masks has been effective in preventing transmission of infectious agents via the droplet route. However experimental studies with smallpox and investigations during the global SARS outbreaks of 2003 suggest that droplets from patients with these two infections could reach persons located 6 feet or more from their source. It Is likely that the distance droplets travel depends on the velocity and mechanism By which respiratory droplets are propelled from the source, the density of respiratory secretions, environmental factors such as temperature and humidity, and the ability of the pathogen to maintain infectivity over that distance. Thus, a distance of < 3 feet around the patient is best viewed as an example of what is meant by "a short distance from a patient and should not be used as the sole criterion for deciding when a mask should be donned to protect from droplet exposure. Based on these considerations, it may be prudent to don a mask when within 6 to 10 feet of the patient or upon entry into the patient's room, especially when exposure to emerging or highly virulent pathogens is likely

Exposure to HIV

If the patient is positive for HIV infection a viral load study should be performed If the exposure meets the CDC criteria for HIV prophylactic treatment it should be started as soon as possible, preferably within 24 hours after exposure All medical evaluation & procedures, including the vaccine & vaccination series and evaluation after exposure (prophylaxis) are made available at no cost to at-risk employees

Body System Defenses: Inflammation

Inflammation-cellular response of the body to injury, infection, irritation -Fluid, blood products & nutrients to the site of injury -Neutralizes & eliminates pathogens or necrotic tissue -Localized vs. Systemic -Physical agents, chemical agents, microorganisms will trigger the inflammatory response The Inflammatory Response includes: -Vascular & Cellular Responses -Inflammatory Exudate -Tissue repair Teacher's Notes: Each organ stem has unique defenses against infection that are physiologically suited to its specific structure and function Example- Airways are lined with moist mucous membranes and cilia Inflammation- the cellular response to injury, infection or irritation. It is a protective vascular reaction that delivers FLUID, BLOOD PRODUCTS AND NUTRIENTS to the area of injury. The process neutralizes and eliminates pathogens or dead (necrotic) tissue and establishes a means of repairing body cells and tissues. LOCALIZED- s/s include swelling, redness, heat, pain or tenderness and loss of function in the affected body part SYSTEMIC- fever, leukocytosis, malaise, anorexia, N/V, lymphadenopathy, organ failure Physical Agents, Chemical Agents, or Microorganisms trigger the Inflammatory Response. Physical Agents- mechanical trauma, temperature extremes, radiation Chemical- external and internal irritants such as poisons, gastric acid Microorganisms- example-pertussis Vascular and cellular responses- acute inflammation is an immediate response to cellular injury. Rapid vasodilation occurs, allowing more blood near the location of the injury. The > in the local blood flow causes the redness and localized warmth at the site of inflammation. Edema- the accumulation of fluid appears as localized swelling/edema. Another sign of inflammation is pain. The swelling of inflamed tissues > pressure on nerve endings Cellular response of inflammation involves white blood cells (WBCs) arriving at the site- wbcs pass thru blood vessels and into the tissues. INFLAMMATORY EXUDATE- accumulation of fluid and dead tissue cells and WBCs forms an exudate at the site of inflammation. Exudate can be- Serous (clear, like plasma) Sanguineous (containing RBCs) Purulent (containing WBCs and bacteria) Tissue Repair- when there is injury to tissue cells, healing involves the defensive, reconstructive and maturative stages. Damaged cells are eventually replace w/ healthy new cells.

Contact

MDROs (MRSA/VRE) RESPIRATORY INFECTION (INFLUENZA) SKIN INFECTION (IMPETIGO) WOUND INFECTION ENTERIC&EYE INFECTIONS (C.DIFF/CONJUNCTIVITIS) HERPES SIMPLEX/HEMORRHAGIC FEVER IMPETIGO PEDICULOSIS (LICE) SCABIES/STREPTOCOCCUS/STAPHYLOCOCCUS Healthcare personnel caring for patients on Contact Precautions wear a GOWN and Gloves for ALL interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (C. difficile, noroviruses, VRE) Use for patients infected or colonized by a MDRO Place pt in private room Wear PPE whenever you enter the room for all interactions that may involve contact with the patient and potentially contaminated areas in the patients environment Change gloves after having contact wit infective material Remove PPE before leaving the patient environments and wash hands with an antimicrobial or waterless antiseptic agent Limit movement of the patient out of the room Avoid sharing patient care equipment

Employee Health

Monitoring and counseling of personnel Transmissible diseases Significant exposure-percutaneous injuries: gloves Work restriction Healthcare workers with AIDS Waste disposal

Contact Precautions

Most common mode of transmission CP are intended to prevent transmission of infectious agents spread by direct and indirect contact with the patient or the patients environment. Contact precautions used for patients infected or colonized with DMROs. Contact precautions also apply where the presence of excessive wound drainage, fecal incontinence or other discharges from the body suggest a > potential for extensive environmental contamination and risk of transmission. HCP caring for a patient on contact precautions wear a GOWN & Gloves for ALL interactions that may involve contact with the patient or potentially contaminated areas in the patients environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens Direct Contact: Microorganisms are transferred from 1 infected person to another person without a contaminated intermediate object or person Care & handling of contaminated body fluids Ex: blood or body fluids such as wound drainage from an infected patient enters through a break in the HCW's skin or thru contact with a mucous membrane Indirect Contact: Transfer of an infectious agent through a contaminated intermediate object Ex: surgical instruments, patient care items, hands, toys

Surgical Asepsis Principles ONLY_________ objects can touch a ________ field! Avoid______________. ________objects should be held above__________. Avoid _____________________ over a sterile field. Never turn ___________________on a sterile field. When in doubt, ______________________________.

Only STERILE objects can touch a STERILE field. Avoid moisture Sterile objects should be held above the waist. Avoid coughing, talking, sneezing, or reaching Never turn YOUR BACK on a sterile field. When in doubt, CONSIDER THE OBJECT UNSTERILE Table 18-3 Principles of Surgical Asepsis Moisture causes contamination-handle liquids carefully near sterile fields to prevent splashing and place wet objects on sterile, water-impermeable surfaces, such as sterile basins. *Microorganisms travel more easily thru moist environments. When a sterile surface becomes moist, microorganisms many be transmitted from an unsterile surface by capillary action. Never assume that an object is sterile. Check to see that it is labeled as sterile. Always check the packages integrity. Check the expiration date. If any doubt consider it unsterile. *Any package that is torn, punctured or moist or out of date cannot be considered sterile. Always face the sterile field *The area defined as sterile is the field. Objects that are out of the line of vision may be inadvertently contaminated Sterile articles may touch only sterile articles or surfaces if they are to maintain their sterility *Anything considered unsterile may transfer microorganisms to the sterile object it touches. An object used on an unsterile surface must be used once and then discarded. Sterile equipment or areas must be kept above the waist and on top of the sterile field. Drapes hanging over the edge of the table are NOT considered sterile. *Waist level is the limit of good visual field. Prevent unnecessary traffic and air currents around the sterile area. Close doors. Unfold drapes or wrappers slowly. Do not sneeze, cough or talk excessively over the sterile field. Do not reach across sterile fields. *Microorganisms cannot be completely excluded from the air even with the best filtration and airflow designs. Masks do not contain all organisms expelled from the oral or nasal cavities and become moist more quickly from talking. Open unused sterile items are no longer sterile A person who is considered sterile who becomes contaminated must reestablish sterility. *If a scrubbed person leaves the area of the sterile field, they must go through the procedure of rescrubbing, gowning and gloving. Surgical technique is a team effort. All objects used in a sterile technique must be sterile Sterile objects become un sterile when touched by unsterile objects Sterile items that are out of vision or below the waist level are considered unsterile Sterile objects can become unsterile by prolonged exposure to airborne microorganisms Fluids flow in the direction of gravity Moisture that passes thru a sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action The edges of a sterile field are considered unsterile The skin cannot be sterilized and is unsterile

KNOW NORMALS and INDICATION OR INFECTION

PPT SLIDE on 28

Portal of Exit

Portal of exit provides a means for the microorganism to leave the source. Any opening on an infected persons body that lets harmful germs escape from the reservoir, such as the nose, mouth, eyes, GI tract and the skin. Just a way for the little bugger to get out and spread the joy. Before an infection can establish itself in a host the microorganism must leave the reservoir. Portals of exit include the nose and mouth (harmful germs can leave in mucous droplets and saliva and spit) GI Tract can allow harmful germs to leave in stool and vomit Skin can allow harmful germs to leave thru direct contact or in blood,pus,or other liquids that come from inside of the body Examples- Sputum, emesis, stool, urine, blood, wound drainage, genital secretions all permit microorganisms to exit the source. Animal discharge or blood organisms carried by mosquitoes also can provide a means of escape. The route by which an infectious agent leaves the reservoir to a susceptible host Respiratory Tract Gastrointestinal Tract Genitourinary Tract Urine is normally sterile (UTI) Skin & Mucous Membranes Break in skin integrity Blood Blood is normally sterile (Hepatitis, HIV, Bacteria) Transplacental (mother→ fetus)

Standard Precautions for Isolation

Precautions designed to care for all patients in health care facilities regardless of their diagnosis or presumed infectiousness

Healthcare-Associated Infections

Previously called nosocomial infections or health care acquired infections Affect patients in a hospital or other health-care facility and are not present or incubating at the time of admission. Infections acquired by patients in hospital or facility but appearing after discharge. Occupational infections among staff Most frequent adverse event in healthcare delivery worldwide Result from delivery of health services in a health care facility from Invasive procedures- such as IV catheters, urinary catheters Antibiotic administration Presence of multidrug resistant organisms (MDROs) Breaks in infection/prevention and control activities Teacher's Notes Health care-associated infection (HAI) can occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities. Invasive procedures, medical therapies, long hospitalization, and contact with health care personnel increase a hospitalized patient's risk for acquiring a health care-associated infection. •Patients who develop HAIs, such as the elderly, are usually more susceptible to infection. •Meticulous hand hygiene practices, use of chlorhexidine washes, and other advances in intensive care unit (ICU) infection prevention help to prevent these infections. [See Box 28-4 on text p 404 Focus on Older Adults for additional discussion.] •Health care-associated infection significantly increases the costs of health care.

Masks

Primary Purpose: HCWs wear to protect them from contact with infectious material from patients respiratory secretions, sprays of blood or body fluids Wear: During procedures requiring sterile technique to protect patients from exposure to infectious agents carried in a HCW's mouth or nose Patient on Droplet or Airborne precautions When you anticipate splashing or spraying of body fluids into the face Place on coughing patients to limit potential spreading of infectious respiratory secretions from the patient to others * If the mask becomes moist change as soon as possible

Removing PPE

Removing PPE Remain inside patient room to remove PPE. Removing PPE outside the room risks transmission to others 1. Remove gloves- removing gloves first safeguards against contamination of your race or eyes while removing mask and goggles or you neck when you are removing the gown 2. Hand hygiene 3. Remove goggles or face shield 4. Remove gown 5. Remove mask- according to CDC, masks should be removed last to prevent respiratory transmission of infection. The front of the mask is considered contaminated. Remove the bottom tie first to prevent the mask from falling and contaminating your clothing 6. Hand hygiene

Signs of Infection

Systemic/Generalized: Fever Increased heart rate and respiratory rate Loss of energy Anorexia, nausea Vomiting Enlarged lymph nodes Localized: Erythema(redness) Edema Pain or tenderness Heat Possible loss of function Sepsis is a term that means poisoning of tissues, often used to describe serious infections Sepsis. It is a severe systemic inflammatory response to a documented or suspected infection. Sepsis can progress to septic shock, with hypotension and a high mortality rate if not detected early Septicemia- transport of an infection (or its products) throughout the body by the blood Infectious disease- refers to the pathologic events that result from the invasion and multiplication of microorganisms in a host When the patient is referred to as septic, it means that he or she is displaying the manifestations of a systemic inflammatory state caused by widespread microbial destruction of tissues. This condition, called systemic inflammatory response syndrome (SIRS), is often accompanied by high fevers, tachycardia, hypotension, and leukocytosis.

Portal of Entry

Where the infectious agent enters the body -Respiratory Tract -Gastrointestinal Tract -Genitourinary Tract -Skin and Mucous Membranes -Blood Any body opening on a person who does not have an infection that allows the organism to enter into the body. The portal of entry permits the organism to entrance into the host. A susceptible host is a person whose own body defense mechanisms, when exposed, cannot withstand the invasion of pathogens. Pathogens can enter thru body orifices such as the mouth, nose, ears, eyes, vagina, rectum, urethra Breaks in the skin or mucous membranes increase opportunities Central venous catheters, feeding tubes, drains Before a person can become infected microorganisms must enter the body. The skin is a barrier to infectious agents; however, any break in the skin can readily serve as a portal of entry.

Asymptomatic

Without clinical signs & symptoms

Symptomatic

if pathogens multiply and cause clinical signs and symptoms