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Title: PREVENTION OF INFECTION IN THE HOSPITAL SETTING


1
PREVENTION OF INFECTION IN THE HOSPITAL SETTING
2
  • Coming together is a beginning, keeping together
    is a process, working together is a SUCCESS.
    Henry Ford

3
Learning Objectives
  • To understand the importance and implications of
    Prevention of Infection in the Hospital Setting
  • To understand how Infection in the Hospital
    Setting can be prevented
  • Consider Infrastructure, Education,
    Policies/procedures, Audit, Surveillance,
    Outbreak Management,Antimicrobial Policy,
    Occupational Health, Risk Management and Outcome
    Indicators in understanding the above

4
Contents of Lecture
  • Infrastructure (environment, ventilation,
    facilities)
  • Education
  • Surveillance/Audit
  • Infection control policy/procedures ( e.g
    transmission precautions, evidence based)
  • Antimicrobial policy
  • Occupational Health policy
  • Infection Control indicators
  • Possible problem areas

5
Infection Control
  • SENIC project (Study on the Efficacy of
    Nosocomial Infection Control) established the
    scientific basis of efficacy of infection control
    programmes (Haley Am J Epidemiol 1985 121
    182-205).
  • 32 of blood-stream, respiratory, urinary tract,
    and wound infections could be prevented by high
    intensity infection surveillance and control
    programmes

6
Consequences of HAI
  • U.S.
  • 2 million infections/year
  • 90,000 deaths
  • 4.5 billion dollars in excess healthcare costs
  • MMWR 199241783-7
  • U.K.
  • Estimated to cost 1 billion/year in 1995
  • PHLS 1999
  • 5000 deaths/year

MOST IMPORTANTLY HAI IMPACT ON THE MORBIDITY AND
MORTALITY FOR THE PATIENT
7
Extent of the problem
  • About 10 of patients in hospital have a
    hospital-acquired infection
  • Emmerson AM, Enstone JE, Griffin M et al. J
    Hosp Inf 1996 32 175-190.
  • U.S data 5.7 nosocomial infections per 100
    admissions in 1975-6
  • 42 UTI
  • 24 surgical wound infections
  • 10 pneumonia
  • 5 bacteraemias
  • Haley et al.Am J Epidemiol. 1985
    Feb121(2)159-67

8
Problem Areas
  • Increasingly complex patients with increased
    susceptibility to infection
  • Increasing use of invasive devices
  • Increasing problem of antimicrobial resistance
  • New threats re-emergence of old threats
  • SARS, influenza
  • MDR-TB
  • Agents of bioterrorism anthrax, smallpox

9
  • Overcrowding
  • Frequent patient movement
  • Inability to separate elective and emergency
    admissions
  • Understaffing
  • Inadequate facilities e.g isolation rooms

10
Environment
  • Consider Patient factors-Increased susceptibility
  • Immunosuppressed
  • Immunodepressed
  • Burns/Large open wound
  • Premature neonates
  • ICU and those with invasive devised

11
Destroying physical barriers
Deleted pictures
  • Intravascular devices
  • a gateway into the patients bloodstream

12
Foreign bodies
Endocarditis on an artificial valve
Deleted pictures
Foreign material used in fracture fixation -
relative non-pathogens e.g. Staphylococcus
epidermidis are frequent causes of infection in
this setting
13
Destroying physical barriers - 2
Deleted pictures
Skin integrity disrupted in this burn - caused by
a hot-water bottle in a bed-ridden patient
14
Environmental Items
  • Floors/walls/ceilings ( consider dealing with
    spills)
  • Furniture/fittings
  • Beds/pillows/mattresses
  • Linen
  • Infant incubators-consider manufactors
    instructions
  • Baths/Showers/Sinks/ footpedal bins
  • Drains/Toilets/toilet seats
  • Additional equipment e.g Hydrotherapy pools

15
Consider Prevention
16
Environmental items
  • Cleaning equipment
  • Floor scrubbers, must be amendable to cleaning
  • Mops- wet , cleaning on hotwash and dried
    throughly, colour code mops for different area
    used e.g high risk area as opposed to toliet
  • Vaccuum cleaners, must have a filter on the
    exhaust , protocol for changing , person in charge

17
Environment
  • Deleted pictures

18
Environmental additional items
  • Toys
  • Telephones- clean on a regular basis, but hands
    should be decontaminated before use
  • Flowers/plants- Risk assessment

19
Environment
  • Evidence that a clean environment reduces HAI
  • Norovirus
  • Indirect transmission occurs
  • Cleaning is a key infection control measure
  • C. difficile
  • Extensive environmental contamination
  • MRSA
  • Evidence that improved cleaning may assist in
    termination of outbreaks
  • VRE
  • Extensive environmental contamination has been
    described

20
Ventilation
  • Prevention of spread of airborne pathogens (
    airborne precautions)
  • Positive pressure isolation
  • Negative pressure isolation
  • Special considerations for Operating Theatre

21
Ventilation
  • Negative pressure isolation
  • HEPA filtered air
  • At least 6 exchanges of air/ hour
  • Air should not be recirculated into system and
    external exhaust should be away from intake air
    system
  • Particle Filter Respirator masks for those
    entering
  • Indicated for Infectious mycobacterium
    tuberculosis, measles, dissemeinated zoster,
    varicella ( ideally those immune should deal with
    the patient with measles etc)

22
Ventilation-Operating Theatre
  • Operating theatres- purpose to prevent bacteria
    settling in the wound (HTM 2025)
  • People are constantly sheeding dead skin(squames)
    around 15 um, rate of shedding increases with
    movement, some of these may carry bacteria
  • Filtration
  • Differential air pressures, filtered clean air to
    critical areas to less critical
  • Commissioning of theatres smoke test, casella
    air counts, structure , maintaince system, rates
  • Ultraclean theatres required for eye surgery etc,
    unidirectional flow

23
Operating theatre-Commisioning
  • Deleted pictures

24
Ward Air Sampling- Which Unit may be of concern?
  • Deleted pictures

25
Water Systems and Prevention of Legionellosis
26
Hospital Water Sytems
Deleted pictures
27
Legionnaires Disease
  • The management of Legionnaires Disease in
    Ireland
  • Scientific Advisory Committee Legionnaires
    Disease sub-committee National Disease
    Surveillance Centre Guidelines for Control
  • http//www.HPSC.ie

28
Legionnaires Disease
  • American Legion convention
  • 221 ill and 34 died
  • Mystery Illness
  • Legionella species 65 serotypes
  • Legionella Pneumophilia serogroup 1 accounts for
    71 notified to CDC

Deleted pictures
29
Natural History
  • 20-45º C favors growth
  • Do not multiply below 20 ºC and will not survive
    above 60 ºC
  • Dormant and multiply when temperature suitable
  • Nutrients to multiply derived from algae, amoebae
    and other bacteria
  • Sediment, Sludge , Scale, Biofilms

30
Water Systems
  • Drinking water disinfectants , free Cl-, kills
    free floating coliforms but penetrates poorly
    into biofilm
  • Legionella is further shieled by the amoebae it
    parasitises
  • Cl-, does not reach distal sites in water
    distribution systems
  • Dissipates quickly in heated water or removed in
    water filtering in Spapools
  • So Require design of water systems,
    Hyperchlorination and Temperature control of water

31
Legionnaires Disease
Cluster/Outbreak 2 or more , Single source lt 6
mts
Linked 2 or more Single source gt 6 mts lt 2 yrs
Sporadic Single Case
32
POTENTIAL SOURCES
  • Hot/Cold Water Systems
  • Cooling Towers
  • Evaporative condensers
  • Respiratory Equipment
  • Spa pools, Natural pools, Thermal springs
  • Fountains/Sprinklers
  • Humidifiers for food display cabinets
  • Water cooling machine tools
  • Vechicle washes
  • Ultrasonic misting machine

In common combination of High Temperature and
Potential for Aerosol Formation
33
TRANSMISSION
  • Respiratory Inhalation of aerosol ,
    microaspiration of water containing legionella
    species
  • The smaller the aerosol more dangerous (
    1-5um)
  • No person to person Transmission

34
Risk Factors
  • gt 50 years
  • Male
  • Cig Smokers
  • Chronic underlying Disease
  • With/without Immunodeficiency
  • Incubation Period 2-10
  • Days
  • Attack rates in Outbreak lt 5, 102 104 /L
    and sporadic 104 106 /L
  • So Risk depends on
  • Individual susceptibility
  • Degree of Intensity of Exposure ( amt. Of
    legionella, size of aerosol etc)
  • Length of Exposure

35
Hospital INFECTION-Legionnaires Disease
  • Case Defintion Definite, Probably, Possible
  • Hospitals at risk those caring for
    immunocompromised patients
  • Hospital size may be importantgt 200 beds 31 of 32
    outbreaks in US
  • Mostly linked to Legionella colonising hot water
    system ( also cooling towers near ventilation
    intake, respiratory equipment cleaned with
    unsterile water, Ice machines, aspiration of
    contaminated water etc)

36
Recommendations for Control
  • Staff Education
  • Surveillance
  • Interrupting Transmission e.g Nebuliser equipment
    and Water distribution systems
  • Sampling
  • Sites
  • 1Litre in sterile containers containing
    sufficient sodium thiosulphate to neutralise any
    Cl- or oxidising biocide
  • Measure Temperature

37
Guidelines
  • Responsible named person for Legionella control
  • Kept hot water hot at all times 50-60ºC .
  • Keep cold water cold at all times. Maintained at
    temperatures below 25ºC
  • Run all taps and showers in rooms for a few
    minutes daily, even if room is unoccupied

38
Guidelines
  • Keep all showers, showerheads and taps clean and
    free from scale
  • Clean and Disinfect cooling towers used in air
    conditioning systems regularly every 3 months
  • Clean and disinfect heat exchangers( calorifiers)
    regularly- once a year
  • Disinfect the hot water system with high level (
    50 ppm) chlorine for 2-4 hours after work on heat
    exchangers

39
Guidelines
  • Clean and disinfect all water filters regularly-
    every one to three months
  • Inspect storage tanks, cooling towers and visible
    pipe work monthly. Ensure all coverings are
    intact and firmly in place
  • Ensure that system modifications or new
    installations do not create pipework with
    intermittent or no water flow

40
Emergency Control Measures
  • Precautionary Shock Heating ( min 5 mins each
    water outlet 65º C)-Disinfection, disabling
  • Hyperchlorination ( gt 10 PPM) of cooling
    tower on 3 occasions including mechanical cleaning
  • Cleaning of tanks, shower heads, water heaters
    and circulation of 5 ppm free Cl- through water
    system for min. 3 hours
  • Storage tanks and pipework temp below 20ºC

41
Waste Segretation/Disposal
  • Black Bags-non-clinical waste e.g paper
  • Yellow bags-Clinical waste not containing sharps
  • Yellow rigid sharps bin/box for sharps disposal
  • Contaminated linen alginate bags
  • Each hospital may have separate colour scheme

SJH
42
Deleted pictures
43
Food
  • Cook Chill System
  • HACCP(critical control point) analysis
  • Microbiolgical Testing of Food

44
Cook-Chill system
  • Deleted pictures

45
Facilities
  • Ideally lass than 100 occupancy allows for
    cleaning and maintaince
  • In the U.K 50 of New Hospitals will be isolation
    rooms
  • Lower rates of MRSA acquistion in countries that
    have hospitals with lt90 bed occupancy

46
1. Policies and Procedures
  • Based on scientific evidence-Evidence-based
  • Practical
  • Easily audited
  • Regularly reviewed

47
Examples
  • Policies/Procedures in Infection Control Manual
  • SJH 016-Safe Disposal of Sharps etc covered in
    Hand Hygiene Practical

48
Dealing with blood spillage
49
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50
Policy for dealing with blood and body fluid
spillages
  • Put on plastic apron and non-sterile disposable
    gloves
  • Use masks and visors if splashing in the nose,
    eye and mouth are likely to occur
  • Cover the spill with disposable paper towels to
    absorb liquid . Discard into clean yellow
    infectious waste bag
  • Avoiding contamination of the outside of the new
    bag.
  • Wipe up excess spillages with disposable paper
    towel and place into yellow infectious waste bag

51
Policy for dealing with blood and body fluid
spillages
  • Apply a chlorine based solution, strength 10,000
    ppm(part per million) and soak for 10 minutes
    (Klorsept 87 , 1 tablet / 500mls water)
  • Ensure a wet floor sign is in place.
  • Mop up any excess solution. If applied to chrome
    or metal surfaces wash area with detergent and
    water.
  • Remove aprons and gloves and discard into yellow
    waste bag. Tie securely.
  • Wash hands

52
Policy for dealing with blood and body fluid
spillages
  • Klorsept 87 is Sodium dichloroisocyanurate
    freshly prepared daily
  • 1 tablet Klorsept 87 / 500mls water

53
Effective Infection Control Team
  • Deleted pictures

54
2. Audit
  • Key component of infection control
  • Defined as systematic review of
    care/policies/procedures against explicit
    criteria and the implementation of change

55
3. Education
  • Organised educational training programme
  • HCW acquisition of SARS was significantly
    associated with
  • Amount of PPE perceived to be inadequate
  • Having lt2 h infection control training
  • Not understanding infection control procedures
  • Lau et al. Emer Infect Dis 200410.

56
Prevention of Infections
  • Hepatitis B , 1995 800 healthcare workers
    infected in the US, IN 1983 17,000 , 95 decline
    due to universal precautions and vaccination

57
GUIDELINES ON STANDARD PRECAUTIONS
  • Standard Precautions describe the guidelines
    which are designed to protect patients and
    healthcare workers from contact with infectious
    body fluids. Bloodborne viruses of concern are
    Hepatits C, Hepatitis B/D and HIV.
  • The most serious risk is associated with infected
    blood, while tears, saliva and urine are
    considered less hazardous due to lower level of
    infectious agent present in these fluids

58
GUIDELINES ON STANDARD PRECAUTIONS
  • It is not possible to identify every potentially
    infectious person, therefore it is prudent to
    adopt Universal precautions (Standard
    Precautions)

59
Principles of Standard Precautions
  • Avoid contact with body fluids at all times
  • Avoid cuts, abrasions and puncture wounds
  • Cover existing cuts and abrasions with a water
    proof dressing
  • Avoid contamination of personal clothing with
    body fluids
  • Protect mucus membranes, eyes and mouth from
    splashes with body fluids

60
Principles of Standard Precautions
  • Regular handwashing and good hygiene practices
    are vital
  • Dispose of waste and linen contaminated with
    blood or body fluids correctly
  • Decontaminate all items soiled with blood and or
    body fluids correctly
  • Remember Hands, mucous membranes, eyes, clothes
    and Protection Gloves, masks, Goggles/visors,
    Aprons
  • Avoid recapping of needles and always dispose of
    sharps safely

61
Personal Protective Clothing and its use covered
previously
62
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63
Deleted pictures
Foot pedal bin
64
  • Deleted pictures

65
HAND HYGIENE
GUIDELINES FOR HAND HYGIENE IN IRISH HEALTHCARE
SETTING 2004 http//www.ndsc.ie/Publications/Hand
HygieneGuidelines/ See handout Copies in the
Library
66
Why wash your hands?
Handwashing is one of the most important
procedures in preventing the spread of disease
67
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68
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69
Hands should be washed
- Before commencement of duty - Before handling
food - Before attending patients - Before
entering protective isolation rooms - Before
performing non-touch or aseptic techniques
70
- After visiting the toilet - After removing
gloves - After any microbial contamination -
After handling contaminated linen and
infectious waste -After patient contact
71
Resident Micro-organisms (normal flora) Resident
micro-organisms are normally found on the hands
e.g. CNS. They are deep-seated within the
epidermis and are not easily removed. Transient
Organisms Transient micro-organisms e.g. MRSA and
E. Coli are located on the surface of the skin.
Direct contact with people or equipment all
result in the transfer of these micro-organisms
to and from the hands with ease. They are
easily removed with handwashing and the risk of
cross infection is then immediately reduced.
72
Contact spread of resistant pathogens via HCW
hands
  • MRSA
  • VRE
  • Pan-resistant Acinetobacter spp.
  • Others

73
Deleted pictures
U.S. Army Camp Hospital No. 45, Aix-Les-Bains,
France, Influenza Ward No. 1, 1918
74
Hand washing Evidence -base
  • Major reduction in postpartum mortality when
    routine hand washing introduced. (Semmelweis
    1861)
  • Important risk factors for non compliance were
    high work load and being a physician. (Pittet
    et. al. 2000)
  • Alcohol based hand rub use associated with a
    steady reduction in nosocomial infection rate
    over a 4 year period
  • Another key feature was active involvement of
    hospital management in promoting hand hygeine.
    (Pittet et. al. 2000)

75
Pittet et al. Effectiveness of a hospital-wide
programme to improve compliance with hand
hygiene. Lancet 2000 356 1307-1312
  • Interventions
  • A multidisciplinary project team
  • Priority from senior hospital management
  • Posters emphasising the importance of hand
    washing, particularly disinfecting.
  • Distribution of individual bottles of
    alcohol-based chlorhexidine solution
  • Funding
  • A series of educational sessions in individual
    medical departments.
  • Feedback from results of surveys and hospital
    infection through hospital newsletters.

76
  • Overall nosocomial infection rates decreased from
    a prevalence of 16.9 to 9.9 (plt0.04)

77
Impact of hand hygiene on infection rates
  • Year Author Setting Impact on Infection Rates
  • 1977 Casewell adult ICU Klebsiella decreased
  • 1982 Maki adult ICU decreased HAI rates
  • 1984 Massanari adult ICU decreased HAI rates
  • 1990 Simmons adult ICU no effect
  • 1992 Doebbeling adult ICU decreased with one
    versus another hand hygiene product
  • 1994 Webster NICU MRSA eliminated
  • 1995 Zafar nursery MRSA eliminated
  • 1999 Pittet hospital MRSA decreased

78
5. Surveillance
  • the on-going, systematic collection, analysis,
    interpretation and dissemination of data
    regarding a health-related event for action to
    reduce morbidity and mortality and to improve
    health
  • Single most important factor in prevention of
    nosocomial infections
  • Hospitals with active surveillance programmes
    have significantly less nosocomial infection
    rates

79
  • Identify patient groups/types of infection
  • Ensure completeness of data collection
  • Post-discharge surveillance
  • Must
  • Use standardised, objective definitions
  • Validate the data
  • Adjust for risk
  • Produce reports/feedback

80
Catheter Associated Blood stream infection
(CABSI)
  • Less strict definition
  • Expressed as a rate using Catheter days as
    denominator
  • Rates usually higher than CRBSI as definition
    is less specific

81
CRBSI / CABSI Surveillance Project in SJH.
Aims of Project
  • To determine the catheter-related and
    catheter-associated bloodstream infection rate
    within the hospital.
  • To audit all aspects of central and peripheral
    line care including insertion, maintenance, drug
    administration, dressing changes, TPN
    administration, line removal and documentation.
  • To conduct educational sessions to inform staff
    involved in line care of the line infection rates
    and audit findings and to educate and update
    staff where needs are identified.
  • To reduce patient morbidity, mortality,
    hospital stay and hospital costs.

82
CRBSI / CABSI Surveillance Project in SJH.
Project started 09/05/2005 Duration to date
38 weeks Weeks 1 2 Surveillance forms
developed Database to collect and analyse
data tested
83
Future of the Project
  • Continuous CRBSI surveillance to monitor changes
    in rate over time.
  • IV Steering Group to oversee the implementation
    and maintenance of a quality assured service
    related to all aspects of IV practice.
  • This will include
  • Education programme.
  • To address findings of audit .
  • Re audit to evaluate education provided.

84
PROCESSES
  • All processes need to be quality control, quality
    assurance, accreditation
  • New product evaluation
  • Step by step procedure defined
  • Quality indictators of process
  • Manufactors guidelines e.g single use adhered to
  • Risk Management and Sterivigilance

85
Process Control- Example Decontamination of
Endoscope
86
Process Example- Decontamination
  • Decontaminaton is the process which removes or
    destroys contamination and thereby prevent
    microorganisms or other contaminants reaching a
    susceptible site in sufficient numbers to
    initiate infection or some other harmful
    response. It included cleaning, disinfection and
    sterilization.

87
Categories of Infection Risk to patient treatment
of equipment
  • High Risk- Items in close contact with break in
    the skin or mucous membranes or introduced into a
    sterile body cavity Sterilization required
  • Intermediate risk- Items in contact with intact
    mucous membranes Disinfection or Sterilization
    required

88
Process
  • From Purchasing to decomissioning
  • Clearly outline
  • Quality control
  • Quality assurance
  • Accreditation
  • All involves documentation and monitoring

89
Process Example- Decontamination of Endoscopes
  • Good Cleaning is essential
  • -removes potentially infectious microorganisms
  • -removes organic material
  • -soil that may protect microorganisms
  • -soil that may inactivate disinfectants

90
Selection of Endoscope washer disinfectors
  • This should throughly clean all instrument
    surfaces and lumens
  • This should disinfect instruments with an
    effective non-damaging disinfectant at use
    concentration and temperature
  • This should remove irritant disinfectant residues
    with sterile or bacteria free water
  • It should have a self disinfecting facility
  • Contain of remove all toxic vapour emissions
  • Produce a print out for cycle validation and
    instrument traceability
  • Monitor Rinse water microbiologically

91
Antimicrobial Policy see previouslecture
92
Transmission of antibiotic resistance
  • Mutation - random genetic change
  • Incidence of mutations 1 bacterium in 10 million
  • One bacterium can produce 1 billion progeny in 10
    hours
  • Antibiotics select mutant strains from patients
    flora
  • modify flora to resistant
    strains or species
  • Transfer between bacteria of resistant genes via
    plasmids or transposons, bacteriophages or naked
    DNA
  • Spread of resistant strains between patients -
    via contaminated hands or equipment
  • Also importance of prudent use of antibiotics
    following Hospital Antimicrobial Policy advised

93
Deleted pictures
What preventative strategies can be put in place?
94
Resistance to Antibiotics
No antibiotic no selection for resistant
organisms
95
Resistance to Antibiotics
antibiotic selects for resistant organisms
96
MRSA CONTROL
  • Reduce antimicrobial use, reduce selection
  • Reduce MRSA Reservoir and potential for spread by
  • -Ward closures/cohort, Decolonisation, early
    discharge
  • Infection Control Measures to prevent spread
  • -PROMOTE HAND HYGIENE
  • -Effective isolation measures
  • -Screening

97
Occupational Health Policy
  • Vaccination
  • Education
  • Risk Assessment ,PEP and follow-up
  • Standard Precautions

98
Infection Control Indicators
  • Control Assurance Standards for Infection
    Control- capable of showing improvement in
    infection control and/or providing early warning
    of risk are used at all levels of organisation
    including review of the efficacy and usefulness
    of indicator

99
Indicators may be
  • Structure Indicators -or compliance indicators
    with national/local guidelines
  • Process Indicators- how people in an organisation
    follow internal rules and guidelines e.g audit
    of hand hygiene compliance
  • Outcome Indicators- link a risk indicator to the
    progress of patients
  • Surrogate indicator- relates action to effects

100
Examples of Indicators
  • Structure-
  • Process-
  • Outcome- Healthcare associated Infections,
    Surgical site infection following clean surgery,
  • Alert organisms
  • -MRSA colonisation
  • -C.difficile diarrhoea
  • -Gentamicin resistant GNBs
  • -Penicillin resistant pneumococcus
  • -Actinebacter in ITUs
  • Surrogate
  • -Length of Hospital stay, Use of oral vancomycin
    etc

101
  • See link
  • http//www.bms.jhmi.edu/CFI/inside/studies/CFI_IH_
    CaseStudy_CatheterRelatedBloodstreamInfections

102
Contents of Lecture
  • Infrastructure (environment, ventilation,
    facilities)
  • Education
  • Surveillance/Audit
  • Infection control policy/procedures ( e.g
    transmission precautions, evidence based)
  • Antimicrobial policy
  • Occupational Health policy
  • Infection Control indicators
  • Possible problem areas

103
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