PREVENTION OF INFECTION IN THE HOSPITAL SETTING

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

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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

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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

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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

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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
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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

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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

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

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Environment

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

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Destroying physical barriers
Deleted pictures

• Intravascular devices
• a gateway into the patients bloodstream

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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
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Destroying physical barriers - 2
Deleted pictures
Skin integrity disrupted in this burn - caused by
a hot-water bottle in a bed-ridden patient
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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

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Consider Prevention
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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

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Environment

• Deleted pictures

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Environmental additional items

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

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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

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Ventilation

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

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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)

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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

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Operating theatre-Commisioning

• Deleted pictures

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Ward Air Sampling- Which Unit may be of concern?

• Deleted pictures

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Water Systems and Prevention of Legionellosis
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Hospital Water Sytems
Deleted pictures
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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

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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
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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

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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

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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
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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
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TRANSMISSION

• Respiratory Inhalation of aerosol ,
  microaspiration of water containing legionella
  species
• The smaller the aerosol more dangerous (
  1-5um)
• No person to person Transmission

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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

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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)

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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

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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

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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

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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

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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

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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
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Deleted pictures
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Food

• Cook Chill System
• HACCP(critical control point) analysis
• Microbiolgical Testing of Food

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Cook-Chill system

• Deleted pictures

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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

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1. Policies and Procedures

• Based on scientific evidence-Evidence-based
• Practical
• Easily audited
• Regularly reviewed

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Examples

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

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Dealing with blood spillage
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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

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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

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Policy for dealing with blood and body fluid
spillages

• Klorsept 87 is Sodium dichloroisocyanurate
  freshly prepared daily
• 1 tablet Klorsept 87 / 500mls water

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Effective Infection Control Team

• Deleted pictures

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2. Audit

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

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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.

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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

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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

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GUIDELINES ON STANDARD PRECAUTIONS

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

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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

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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

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Personal Protective Clothing and its use covered
previously
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Deleted pictures
Foot pedal bin
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• Deleted pictures

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HAND HYGIENE
GUIDELINES FOR HAND HYGIENE IN IRISH HEALTHCARE
SETTING 2004 http//www.ndsc.ie/Publications/Hand
HygieneGuidelines/ See handout Copies in the
Library
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Why wash your hands?
Handwashing is one of the most important
procedures in preventing the spread of disease
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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
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- After visiting the toilet - After removing
gloves - After any microbial contamination -
After handling contaminated linen and
infectious waste -After patient contact
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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.
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Contact spread of resistant pathogens via HCW
hands

• MRSA
• VRE
• Pan-resistant Acinetobacter spp.
• Others

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Deleted pictures
U.S. Army Camp Hospital No. 45, Aix-Les-Bains,
France, Influenza Ward No. 1, 1918
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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)

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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.

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

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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

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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

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• 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

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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

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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.

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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
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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.

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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

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Process Control- Example Decontamination of
Endoscope
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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.

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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

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Process

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

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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

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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

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Antimicrobial Policy see previouslecture
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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

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Deleted pictures
What preventative strategies can be put in place?
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Resistance to Antibiotics
No antibiotic no selection for resistant
organisms
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Resistance to Antibiotics
antibiotic selects for resistant organisms
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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

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Occupational Health Policy

• Vaccination
• Education
• Risk Assessment ,PEP and follow-up
• Standard Precautions

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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

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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

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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

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

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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

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Nothing but Healing Hands