Transcript Document 7149489

PREVENTION OF INFECTION
IN THE HOSPITAL SETTING
• Coming together is a beginning, keeping
together is a process, working together is
a SUCCESS.
Henry Ford
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
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
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
Consequences of HAI
• U.S.
– 2 million infections/year
– 90,000 deaths
– $4.5 billion dollars in excess healthcare costs
MMWR 1992;41:783-7
• 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
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 Feb;121(2):159-67
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
• Overcrowding
– Frequent patient movement
– Inability to separate elective and emergency
admissions
• Understaffing
• Inadequate facilities e.g isolation rooms
Environment
• Consider Patient factors-Increased
susceptibility
• Immunosuppressed
• Immunodepressed
• Burns/Large open wound
• Premature neonates
• ICU and those with invasive devised
Destroying physical barriers
Deleted pictures
Intravascular devices
• a gateway into the patient’s bloodstream
Endocarditis on an artificial valve
Foreign bodies
Deleted pictures
Foreign material used in fracture fixation - relative non-pathogens e.g.
Staphylococcus epidermidis are frequent causes of infection in this setting
Destroying physical barriers - 2
Deleted pictures
Skin integrity disrupted in this burn - caused by
a hot-water bottle in a bed-ridden patient
Environmental Items
• Floors/walls/ceilings ( consider dealing with
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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
Consider Prevention
Environmental items
• Cleaning equipment
- Floor scrubbers, must be amendable to cleaning
- Mops- wet , cleaning on hotwash and dried
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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
Environment
• Deleted pictures
Environmental additional items
• Toys
• Telephones- clean on a regular basis, but
hands should be decontaminated before
use
• Flowers/plants- Risk assessment
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
Ventilation
• Prevention of spread of airborne
pathogens ( airborne precautions)
• Positive pressure isolation
• Negative pressure isolation
• Special considerations for Operating
Theatre
Ventilation
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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)
Ventilation-Operating Theatre
• Operating theatres- purpose to prevent bacteria
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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
Operating theatre-Commisioning
• Deleted pictures
Ward Air Sampling- Which Unit may
be of concern?
• Deleted pictures
Water Systems and Prevention
of Legionellosis
Hospital Water Sytems
Deleted pictures
Legionnaire`s Disease
• The management of Legionnaire`s
Disease in Ireland
• Scientific Advisory Committee
Legionnaire`s Disease subcommittee National Disease
Surveillance Centre – Guidelines for
Control
http://www.HPSC.ie
Legionnaire`s Disease
• American Legion
Deleted pictures
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convention
221 ill and 34 died
Mystery Illness
Legionella species 65
serotypes
Legionella
Pneumophilia
serogroup 1 accounts
for 71% notified to
CDC
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
Water Systems
• Drinking water disinfectants , free Cl-,
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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
Legionnaire`s Disease
Sporadic
Single Case
Cluster/Outbreak
2 or more ,
Single source
< 6 mts
Linked
2 or more
Single source
> 6 mts < 2 yrs
POTENTIAL SOURCES
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Hot/Cold Water Systems
Cooling Towers
Evaporative condensers
Respiratory Equipment
Spa pools, Natural pools,
Thermal springs
• Fountains/Sprinklers
• Humidifiers for food
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display cabinets
Water cooling
machine tools
Vechicle washes
Ultrasonic misting
machine
In common combination of High Temperature and Potential for
Aerosol Formation
TRANSMISSION
• Respiratory: Inhalation of aerosol ,
microaspiration of water containing
legionella species
• The smaller the aerosol more
dangerous
( 1-5um)
• No person to person Transmission
Risk Factors
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> 50 years
Male
Cig Smokers
Chronic underlying
Disease
• With/without
Immunodeficiency
• Incubation Period 210
Days
Attack rates in Outbreak
< 5%, 102 –104 /L and
sporadic 104 –106 /L
• So Risk depends
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on:
Individual
susceptibility
Degree of Intensity
of Exposure ( amt.
Of legionella, size
of aerosol etc)
Length of Exposure
Hospital INFECTIONLegionnaire`s Disease
• Case Defintion: Definite, Probably,
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Possible
Hospitals at risk those caring for
immunocompromised patients
Hospital size may be important> 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)
Recommendations for
Control
• Staff Education
• Surveillance
• Interrupting
Transmission e.g
Nebuliser
equipment and
Water distribution
systems
• Sampling:
• Sites
• 1Litre in sterile
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containers containing
sufficient sodium
thiosulphate to
neutralise any Cl- or
oxidising biocide
Measure Temperature
Guidelines
• Responsible named person for Legionella
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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
Guidelines
• Keep all showers, showerheads and taps
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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
Guidelines
• Clean and disinfect all water filters
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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
Emergency Control
Measures
• Precautionary Shock
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Heating ( min 5 mins
each water outlet
65º C)-Disinfection,
disabling
Hyperchlorination
( > 10 PPM) of cooling
tower on 3 occasions
including mechanical
cleaning
• Cleaning of tanks,
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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
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
Deleted pictures
Food
• Cook –Chill System
• HACCP(critical control point) analysis
• Microbiolgical Testing of Food
Cook-Chill system
• Deleted pictures
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 <90%
bed occupancy
Examples
• Policies/Procedures in Infection Control
Manual
• SJH 016-Safe Disposal of Sharps etc
covered in Hand Hygiene Practical
Dealing with blood spillage
Policy for dealing with blood
and body fluid spillages
• Put on plastic apron and non-sterile
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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
Policy for dealing with blood
and body fluid spillages
• Apply a chlorine based solution, strength
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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
Policy for dealing with blood
and body fluid spillages
• Klorsept 87 is Sodium
dichloroisocyanurate freshly
prepared daily
1 tablet Klorsept 87 / 500mls water
Effective Infection Control Team
• Deleted pictures
3. Education
• Organised educational training programme
• HCW acquisition of SARS was significantly
associated with
– Amount of PPE perceived to be inadequate
– Having <2 h infection control training
– Not understanding infection control procedures
Lau et al. Emer Infect Dis 2004;10.
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
GUIDELINES ON STANDARD
PRECAUTIONS
• Standard Precautions describe the
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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
GUIDELINES ON STANDARD
PRECAUTIONS
• It is not possible to identify every
potentially infectious person,
therefore it is prudent to adopt
“Universal precautions” (Standard
Precautions)
Principles of Standard
Precautions
• Avoid contact with body fluids at all times
• Avoid cuts, abrasions and puncture
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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
Principles of Standard
Precautions
• Regular handwashing and good hygiene
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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
Personal Protective Clothing
and its use covered previously
Deleted pictures
Foot pedal bin
• Deleted pictures
HAND HYGIENE
GUIDELINES FOR HAND HYGIENE IN IRISH
HEALTHCARE SETTING 2004
http://www.ndsc.ie/Publications/HandHygieneGuidelines/
See handout
Copies in the Library
Why wash your hands?
Handwashing is one of the most
important procedures in preventing
the spread of disease
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
- After visiting the toilet
- After removing gloves
- After any microbial contamination
- After handling contaminated linen and
infectious waste
-After patient contact
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.
Contact spread of resistant
pathogens via HCW hands
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MRSA
VRE
Pan-resistant Acinetobacter spp.
Others
Deleted pictures
U.S. Army Camp Hospital No. 45, Aix-Les-Bains,
France, Influenza Ward No. 1, 1918
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
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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)
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.
• Overall nosocomial infection rates decreased
from a prevalence of 16.9% to 9.9% (p<0.04)
5. Surveillance
• ‘the on-going, systematic collection, analysis,
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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
• 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
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
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.
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
Future of the Project
• Continuous CRBSI surveillance to monitor changes
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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.
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
Process Control- Example
Decontamination of Endoscope
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.
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
Process
• From Purchasing to decomissioning
• Clearly outline
• Quality control
• Quality assurance
• Accreditation
• All involves documentation and monitoring
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
Selection of Endoscope washer
disinfectors
• This should throughly clean all instrument surfaces and
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lumens
This should disinfect instruments with an effective nondamaging 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
Antimicrobial Policy see previous
lecture
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
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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
Deleted pictures
What preventative strategies can be put in place?
Resistance to Antibiotics
No antibiotic – no selection for resistant organisms
sensitive
resistant
Resistance to Antibiotics
antibiotic – selects for resistant organisms
sensitive
resistant
MRSA CONTROL
• Reduce antimicrobial use, reduce selection
• Reduce MRSA Reservoir and potential for spread
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by
-Ward closures/cohort, Decolonisation, early
discharge
Infection Control Measures to prevent spread
-PROMOTE HAND HYGIENE
-Effective isolation measures
-Screening
Occupational Health Policy
• Vaccination
• Education
• Risk Assessment ,PEP and follow-up
• Standard Precautions
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
Indicators may be
• Structure Indicators -or compliance indicators
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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
Examples of Indicators
• Structure• Process• Outcome- Healthcare associated Infections,
Surgical site infection following clean surgery,
Alert organisms
-MRSA colonisation
-C.difficile diarrhoea
-Gentamicin resistant GNB`s
-Penicillin resistant pneumococcus
-Actinebacter in ITU`s
• Surrogate –
-Length of Hospital stay, Use of oral vancomycin
• See link
• http://www.bms.jhmi.edu/CFI/inside/studi
es/CFI_IH_CaseStudy_CatheterRelatedBlo
odstreamInfections
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
Nothing but Healing Hands