RT15A Egan's Ch 4 infection prevention and control

cough hygiene etiquette

1) education of health care personnel, patients, and vistors 2) posted sings in language appropriate to the population served with instructions for patients and accompanying family members or friends 3) source control measure (covering the mouth and nose with a tissue when coughing or placing a surgical mask on a coughing person when possible) 4) hand hygiene after contact with respiratory secretions 5) spatial separation (>=3 feet from persons with respiratory infections in common waiting areas).

what estimated percentage of hospitalized patients develop a HAI?

4%

Droplet Transmission

A form transmission via respiratory droplets Respiratory droplets are generated when an infected individual discharges large contaminated liquid droplets into the air by coughing, sneezing, or talking Ø Usually ≤3 feet through the air Ø Also generated during procedures such as suctioning, bronchoscopy, and cough induction

Infection Prevention Strategies: Maintaining a Healthy Workforce

A sick health care worker not only has difficulty executing assignments but could also serve as a source of infection for vulnerable patients Employee immunization and chemoprophylaxis Occupational Safety and Health Administration (OSHA)

PVAP is present if:

An IVAC has been identified in a patient with positive culture results meeting specific threshold values Ø Or purulent respiratory secretions and a positive culture result that does have sufficient growth to meet the threshold values.

Disposable Equipment

An important alternative to reprocessing equipment continually is employing singlepatient-use disposable devices Three major issues are involved in using disposable devices: Ø Cost Ø Quality Ø Reuse Handling contaminate articles and equipment

Bronchoscope Reprocessing

Bronchoscopes routinely become contaminated with high levels of organisms during a procedure Ø Because of the body cavities in which they are used Ø The most common reasons for transmission include failure to adhere to recommended cleaning and disinfection procedures, failure of automated endoscope reprocessors, and flaws in design

What special guidelines exist in regard to cough-inducing and aerosol-generating procedures for patients with active tuberculosis?

Cough-inducing procedures should not be performed on TB patients unless absolutely necessary and can be performed with the proper precautions. Procedures should be performed in an isolation room with the door closed, in special booths, or enclosures. Patients must be instructed to cover their mouth and nose when coughing. Before the room can be used by another patient, enough time must pass to allow 99% of the air to be contaminate free.

Infection Prevention Strategies: Creating a Safe Culture

Creation by leadership Ø At all levels Ø A shared commitment to patient and health care worker safety Ø The responsibility of each individual health care worker Ø Each person is empowered and willing to speak up and "stop the line" Ø Comprehensive Unit-Based Safety Program (CUSP) Ø Support of best practices

the difference between droplet vs airborne transmission

Droplets are expelled into the air from sneezing, coughing, or talking but eventually fall out of suspension due to gravity. Airborne transmission occurs when small evaporated droplets containing infections microbes are able to remain suspended in the air and travel far distances and can infect others at any time if the droplets are breathed in.

what are three general barrier methods to prevent exposure to organisms?

Gloves, Gown, Mask

agencies for best practice infection prevention recommendations

Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease Control and Prevention (CDC)

Sources of Infections Agents

Humans are primary source Ø Patients, personnel, or visitors Inanimate objects Ø Contaminated medical equipment, linen medications Patients quickly contaminate their local hospital environment People Ø Via endogenous flora

Equipment -Handling Procedures (1 of 2)

Include: Ø Maintenance of in -use equipment Ø Processing of reusable equipment Ø Application of one-patient-use disposables Ø Fluid and medication precautions Respiratory care equipment that can spread pathogens include: nebulizers, ventilator circuits, bag -valve -mask devices (BVMs, or manual resuscitators), and suction equipment Oxygen therapy and pulmonary function equipment are also implicated as potential sources of nosocomial infections

Airborne infection isolation

Isolation techniques intended to reduce risk of selected infectious agents transmitted by "small droplets" of aerosol particles, such as M. tuberculosis Ø Use of N-95 respirator Ø Room must be negative pressured, have two air exchanges per hour, and use HEPA filters

Transport of Infected Patients

Limit the transport of patients with contagious disease When transport occurs: Ø The patient needs to wear appropriate barrier protection Ø If manually ventilating during the transport of a patient on respiratory precautions, ensure that a filter is placed on the expiratory side of the manual resuscitator device

Airborne Transmission

Occurs via the spread of airborne droplet nuclei These are small particles (≤5 µm) of evaporated droplets containing infectious microorganisms Can remain suspended in air for long periods Can travel further distances than droplets Special air handling and ventilation/respiratory protection is required to help prevent airborne transmission

why do postoperative patients have an increased risk of infection?

Operations that break the protective skin layer can introduce infection into the body. Postoperative patients may have an ineffective cough due to pain or may not be able to take a deep breath which may lead to stagnant mucus which can grow bacteria. The immune system is compromised because of medication or antibiotics, and is focused on repair of surgical wounds. The breathing may be shallow due to anesthesia which impair mucus clearance and proper lung inflation.

what are important concerns when working with TB patients?

Possible transmission to health care workers. The patient may become agitated and want to leave so security may need to be called to prevent health risk to others.

Surveillance for HospitalAcquired Infections (1 of 2)

Surveillance Ø An ongoing process of monitoring patients and health care personnel for acquisition of infection, colonization of pathogens, or bot Infection control committee establishes surveillance policies, and infection control expert administers them Common for infection prevention programs to oversee hand hygiene and standard precautions adherence observations

Susceptible Hosts

Susceptibility and resistance to infection vary greatly Host factors increasing chance of infection are: Ø Poorly controlled diabetes mellitus Ø Extremes of ages Ø Underlying acquired (human immunodeficiency virus [HIV] infection) Ø Iatrogenic • Chemotherapy • Placement of tubes and catheters

Contact Transmission

The most common route of transmission Divided into two subgroups: Ø Direct • Occurs less frequently than indirect contact in the health care environment Ø Indirect • Most frequent mode of transmission • Involves transfer of a pathogen through a contaminated intermediate object or person • Fomites

Modes of Transmission

The three major routes for transmission of human pathogens in the health care environment are: Ø Contact (direct and indirect) Ø Droplets Ø Airborne

what kind of precautions should be taken to prevent the spread of TB infection once these patients are admitted?

They should be in a negative pressure isolation rooms with frequent indoor and outdoor air changes with HEPA air filters, that direct air to the outside, to prevent airborne particles from traveling through hospital.

when transporting TB patients out of the emergency department, what action should you take?

You should have them wear a specialized mask that prevents airborne transmission of TB particles.

by what route does tuberculosis spread?

airborne

mask

airborne- during procedures that could produce splashes of bodily fluids

ventilator-associated events (VAEs)

broken down into three tiers: Ø Ventilator-associated condition (VAC) Ø Infection-related ventilator-associated complication (IVAC) Ø Possible VAP (PVAP)

Gloves

contact with bodily fluids or mucous membranes

transmission-based precautions

contact, droplet, airborne

contact

contaminated equipment, unwashed hands

droplet

coughing, sneezing, talking, suctioning, bronchoscopy

sterilization

death of all microorganisms; complete destruction of all forms of microbial life; Ø Destroys all microorganisms Ø Can be achieved with physical and chemical approaches

disinfection

death of pathogenic microorganisms; inactivation of most pathogenic organisms excluding spores; destroys vegetative form of all pathogens except bacterial spores Ø Disinfection can involve either chemical or physical methods Ø Pasteurization is most common physical method

gown

droplet- during procedures to prevent contamination of clothing with bodily fluids

what are three ways to disrupt the route of transmission during contact?

have all staff and visitors wash hands frequently, have everyone wear gloves, separate the infected babies from the uninfected babies

About 4% of patients admitted develop a

health care - associated infection

high level disinfection

inactivation of all microorganisms except bacterial spores (with sufficient exposure times, spores may also be destroyed)

intermediate level disinfection

inactivation of all vegetative bacteria, most viruses, most fungi, and M. tuberculosis without destruction of bacterial spores

low level disinfection

inactivation of most bacteria, some viruses and fungi, without destruction of resistant microorganisms such as Mycobacterium tuberculosis or bacterial spores

fomites

inanimate objects that help transfer pathogens

nosocomial

infections acquired in the hospital

what is a healthcare-associated infection (HAI)?

infections that occur in the hospital during treatment

airborne

infectious evaporated droplets suspended in the air, e.g. Tb, measles, SARS

Glutaraldehyde

is the best choice for high-level disinfection of semicritical respiratory care equipment

what should the RT do to help lower the risk of a nosocomial infection when using heated aerosol systems?

label the equipment with the date and time it was started use an aseptic technique during initial setup

what respiratory care equipment has the greatest potential to spread infection?

large volume nebulizers

what should be worn during any procedure that can generate splashes or sprays of bodily fluids?

masks and goggles

steam sterilization

most common and easiest Ø Low-temperature sterilization technologies include ethylene oxide: colorless and toxic gas Ø Medical devices contacting sterile body tissues or fluids are critical items and should be sterile before use

aerosol transmission

obligate, preferential, opportunistic

infection Prevention (IP) program

organizes and coordinates efforts to decrease HAIs, responsible for reducing risks for HAIs, protecting patients, employees, and visitors, provides guidance to break the chain of events leading to HAIs

cleaning

removal of all foreign material (soil, organic material) from objects first step in all equipment processing Ø Involves removing dirt and organic material Ø Failure to clean equipment properly can render all subsequent processing efforts ineffective Ø Soaps and detergents need to be used Ø Noncritical items, such as commodes, intravenous pumps, and ventilator surfaces, must be thoroughly cleaned and disinfected before use with another patient

what are vaccinations the help decrease HAI transmission?

rubella, measles, varicella, hepatitis B, pertussis, influenza

CDC guidelines on hand cleaning

scrub hands thoroughly with warm soap and water for at least 20 sec. frequently throughout the day and especially before and after contact with a patient or contact with hospital equipment. Alcohol based hand sanitizer is an alternative to hand washing but does not eliminate all pathogens.

what should be done with TB patients if there are no private rooms with airborne precautions available?

separate patients by at least 3 ft

what are three elements required for infections to develop?

source route a susceptible host

what type of water should be placed in the nebulizer?

sterile distilled water

what should always be used for tracheal suctioning and filling nebulizers and humidifiers?

sterile fluids

what is the most common source of S. aureus organisms?

the skin of health care workers and visitors

why is knowledge regarding HAIs important to our profession?

to prevent the spread of infections that affect the lungs and could be fatal

standard precautions

universal method of protection for health workers; the simplest level of infection control The primary strategy for the prevention of health care-associated transmission of infections Health care worker should employ personal protective equipment (PPE) Ø Various barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents Hand hygiene Gloves Mouth, eye protection, face shields Respiratory protection Gowns Patient care equipment Occupational health and blood-borne pathogens Patient placement

what is the maximum duration of time that ventilator circuits can be used safely?

unknown

the best way to prevent infection spread in ICU is

wash hands after (and before) every patient contact

An IVAC is considered present if:

Ø A VAC has been identified and there is an elevated temperature or WBC and new antibiotics have been started and administered for 4 or more days

Three elements must be present for transmission of infection within a health care setting:

Ø A source (or reservoir) of pathogens Ø A route of transmission for the pathogen Ø A susceptible host

Methods that kill bacteria

Ø Bactericidal

Methods and techniques that inhibit the growth of bacteria

Ø Bacteriostatic

Most hospitals perform surveillance for device-related infections:

Ø Central line-associated bloodstream infections (CLABSI) Ø Catheter-associated urinary tract infections (CAUTI) Ø VAPs • The VAP surveillance definition has significant limitations Ø Surveillance is performed to look for ventilator-associated events (VAE)

chemical disinfection

Ø Chemical disinfection involves application of chemical solutions to contaminated equipment or surfaces Ø Equipment must be immersed in solution for set period of time Ø Many chemical methods used to disinfect respiratory care equipment Ø Labels should be read carefully and instructions properly followed during use

equipment handling procedures: ventilators and circuits

Ø Circuits pose greatest risk for infection Ø High-efficiency particulate air/aerosol (HEPA) filters help reduce endotracheal tube contamination

Infections can be categorized by where they originate

Ø Community onset: Those that develop outside the hospital Ø Hospital-onset or nosocomial: Those that develop in the hospital

elements of cough etiquette

Ø Education of health care personnel, patients, and visitors Ø Posted signs in language appropriate to the population served with instructions for patients and accompanying family members or friends Ø Source control measures (covering the mouth and nose with a tissue when coughing or placing a surgical mask on a coughing person when possible) Ø Hand hygiene after contact with respiratory secretions Ø Spatial separation (≥3 feet from persons with respiratory infections in common waiting areas).

Standard infection prevention procedures always include efforts to:

Ø Eliminate pathogens Ø Recommended practices for cleaning and disinfecting noncritical surfaces in patient care areas

sources of infection not involving person-to-person transmission

Ø Exposure to pathogens in contaminated food, water, or medications (e.g., heparin solution) Ø Vector-borne transmission of infectious diseases from insects and rats and other vermin occurs (less significant in U.S. health care facilities)

two major categories of infection prevention

Ø General sanitation measures Ø Specialized equipment processing

Health care-associated infection (HAI)

Ø Infections that develop in a patient during the course of medical treatment

reprocessing reusable equipment: factors to consider

Ø Information found in equipment manufacturer's instructions for use Ø Infection risk (critical, semi-critical, non-critical) Ø Material and equipment configuration Ø Available hospital reprocessing resources Ø Relative cost (labor and materials)

equipment handling procedures: nebulizers

Ø Large-volume nebulizers are often a problem Ø Small-volume nebulizers can also produce bacterial aerosols

Low -Temperature Sterilization Technologies

Ø Less than <60 ° C Ø ETO, hydrogen peroxide gas plasma, ozone, vaporized hydrogen peroxide, and peracetic acid

opportunistic transmission

Ø Microorganisms that cause disease through other routes—droplet or contact—but under certain environmental conditions may be transmitted via airborne transmission Ø An example of this is SARS transmission via an aerosol plume that originated from sewage in the Amoy Gardens housing complex

Preferential transmission:

Ø Natural infection results from transmission through multiple routes, but airborne transmission predominates Ø Measles is an example of preferential airborne transmission

Immediate Use Sterilization

Ø Previously referred to as flash sterilization Ø Item is placed in an open tray or a specially designed container to allow for rapid penetration of steam Ø Not recommended as a routine method of sterilization

Protective environment

Ø Specialized engineering approach to protect highly immunocomprised patients Ø Used with allogeneic stem cell transplant patient Ø Includes: HEPA filtration of incoming air, directed room air flow, positive room air pressure relative to corridor, well-sealed rooms to prevent infiltration of outside air, ventilation to provide 12 or more air changes per hour, strategies to reduce dust, and prohibition of dried and fresh flowers and potted plants in rooms

Methods that destroy spores

Ø Sporicida

Prevention bundles

Ø The use of multiple different evidence-based best practices to prevent device-related infection Ø Have been shown to decrease the incidence of HAIs significantly

Obligate transmission:

Ø Under natural conditions, disease occurs after transmission of the microorganism only through airborne (droplet nuclei) aerosols Ø An example of obligate transmission is tuberculosis

A large percentage of HAIs are device-related infections including

Ø Ventilator-associated pneumonia (VAP) Ø Catheter-related bloodstream infection Ø Catheter-associated urinary tract infection

Methods that destroy viruses

Ø Virocidal

VAE surveillance starts with the identification of a VAC defined as:

Ø an increase in the daily minimum positive end expiratory pressure (PEEP) Ø Or daily minimum fraction of inspired oxygen (FiO2) for 2 calendar days or longer after a period of stability

Droplet precautions

• Employed for patients with presumed or confirmed infection with organisms known to be transmitted by respiratory droplets

contact precautions

• Intended to reduce the risk for transmission by direct or indirect contact with the patient or the patient's environment