Transcript Infection Control in the Hospital Setting Vickie Brown, RN, MPH, CIC

Infection Control in the Hospital Setting
Vickie Brown, RN, MPH, CIC
Associate Director
Hospital Epidemiology
UNC Health Care
Hospital Epidemiology
Director
William Rutala, PhD, MPH
Medical Director
David Weber, MD, MPH
Public Health Epidemiologist
Emily Sickbert-Bennett, MS
Infection Preventionists
Becky Brooks, RN, CIC
Tina Adams, RN
Brenda Featherstone, RN
Lisa Teal, RN
Kirk Huslage, RN, MPH
Location: 1st Floor, West Wing, Memorial Hospital
Office Hours: Monday – Friday 7:30 AM to 4 PM
Phone: 966-1638
Infection Control Resources
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Infection Control Policies on Hospital Intranet
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http://intranet.unchealthcare.org/hospitaldepartments/infection
/policies
Infection Control on call pager available 24/7: 216-6652
PURPOSES OF EPIDEMIOLOGY
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To plan and evaluate interventions and prevention
strategies more effectively by knowing:
 The distribution of disease
 Its determinants in person, place, and time
CHAIN OF INFECTION
Infection requires a “chain” of events
 The role of the hospital epidemiologist/infection control
is to understand this chain and the most efficient
means of interrupting transmission
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CHAIN OF INFECTION
Causative agent
Susceptible host
Reservoir
Inoculating dose
Portal of exit
Portal of entry
Environmental
survival
Mode of transmission
SOURCES OF PATHOGENS
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People
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Endogenous: Normal flora or reactivation
Exogenous: People (staff, visitors) or environment
Animals
Arthropods (insects)
Environment
Normal Skin Micro-Flora
Numbers of bacteria that colonize different parts of the body
Numbers per square centimeter of skin surface (cfu/cm2).
ICU Setting: Multiple Sources of Pathogens
Basic Modes of Transmission
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Contact-victim contact with source
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Direct-physical contact between source (e.g., MRSA on medical
student’s hands) and victim (patient medical student is examining)
Indirect-victim contacts contaminated inanimate object (e.g.,
ultrasound probe contaminated with MRSA or VRE)
Droplet-infectious droplets deposited on mucous membranes
of the nose or mouth
Airborne-airborne phase in disease dissemination
Vectorborne-not a significant source in US healthcare facilities
Isolation Precautions to Prevent the Transmission
of Infections to Patients and Personnel
STANDARD PRECAUTIONS
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Hand hygiene: Before and after each patient contact & after
gloves removed
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Gloves: When touching contaminated items (blood, body fluids,
secretions, excretions).
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If it is wet and not yours, wear gloves!
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Mask, eye protection, face shield: whenever splashes or sprays
of body fluids possible
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Gown: Whenever splashes or sprays of body fluids possible
Personal Protective Equipment (PPE)
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Gloves
Gown
Mask
Eyewear
Wear your personal protective equipment
correctly!
AIRBORNE PRECAUTIONS
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Used for patients with known or suspected diseases
transmitted by airborne droplet nuclei (<5 microns)
Private room
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Negative air pressure in relation to the corridor
>6 air exchanges per hour
Direct discharge of air to the outside
Personnel: Respiratory protection required
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N-95 respirator
Limit transport of patient to essential purposes
AIRBORNE PRECAUTIONS
Representative pathogens
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M. tuberculosis
Varicella
Zoster
Measles
HCWs required to wear a
respirator to enter room
SPECIAL AIRBORNE PRECAUTIONS
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Used for patients with known or suspected diseases
transmitted by airborne droplet nuclei and contact
Private room (must meet airborne isolation guidelines)
Personnel: Respiratory protection required
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N-95 respirator
Eye protection: Shield or goggles
Gowns and gloves when entering room
Limit transport of patient to essential purposes
SPECIAL AIRBORNE PRECAUTIONS
Representative pathogens
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Avian influenza
Monkey pox
SARS Co-V
Smallpox
Viral hemorrhagic fever (e.g., Ebola,
Lassa)
DROPLET PRECAUTIONS
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Used for diseases spread
via large droplets (>5 microns)
Private room
Special air handling not required
Personnel
Surgical mask upon entering room
DROPLET PRECAUTIONS
Representative pathogens
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Invasive N. meningitidis
RSV
Bordetella pertussis
Rubella
Mumps
Group A streptococcal pharyngitis
Influenza
H1NI Precautions
CONTACT PRECAUTIONS
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Used for pathogens that
can easily be transmitted by
contact with patient and/or items
in the patient’s environment
Private room
 Gloves and gown when entering room
 Careful hand hygiene
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Representative Pathogens
Methicillin-resistant S. aureus (MRSA)
 Vancomycin-resistant enterococcus (VRE)
 C. difficile
 Norovirus
 Multiply-drug resistant (MDR) gram negative rods (e.g.,
B. cepacia, P. aeruginosa, Acinetobacter)
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All of the above organisms can survive on environmental surfaces for
long periods of time and can be transiently carried on hands.
Bloodborne Pathogens
UNC Hospital Employees
Blood Exposure Trends, 1999-2008
Number of Exposures
300
250
200
150
100
50
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Y ears
Percutaneous/Lacerations
Mucous Membrane/Non-Intact Skin
Bite/Scratch
BLOODBORNE PATHOGENS
TRANSMITTED BY NEEDLESTICKS
Big 3
 Hepatitis B
 Hepatitis C
 HIV
Others
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Argentinean VHF (Junín virus)
Blastomycosis
Brucellosis
Corynebacterium diphtheria
Cryptococcus
Dengue
Diphtheria
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Ebola virus infection
Herpes simplex I
Leptospirosis
Malaria
Marburg VHF
Mycobacterium marinum
Mycoplasma caviae infection
Rocky Mountain spotted fever
Syphilis
Toxoplasmosis
Tuberculosis
Varicella zoster
West Nile
Tarantola A, et al. AJIC 2006;34:367-75
Campus Health
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Blood/body fluid exposure reporting: 966-6561
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After hours, weekends call Health Link: 966-2281
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Additional Information: Exposure Control Plan for
Bloodborne Pathogens; attachment 12: 55-58.
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http://intranet.unchealthcare.org/hospitaldepartments/infection/
policies/Ecpbbp.pdf
Other Communicable Diseases with Risk of Occupational
Exposure
Tuberculosis
 Varicella zoster
 Pertussis
 Influenza
 Meningococcal Meningitis
 Parvo Virus-B19
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UNC OHS EVALUATIONS, 2007-08
Disease
Tuberculosis
Pertussis
Varicella
Zoster
Syphilis
N. meningitidis
Hepatitis B
Hepatitis C
HIV
All blood
2007 Index
Cases
2007
Staff
Screened
9
4
1
3
5
1
2
27
38
11
0
0
9
49
2
27
12
269
0
269
2007
Infected
1
0
0
0
0
0
0
0
2008
Index
Cases
4
5
0
0
6
3
2
39
2008
Staff
Screened
14
19
0
0
9
16
2
39
0
0
10
314
10
314
2008
Infected
0
0
0
0
0
0
0
1
0
1
Health Care Associated Infections
(HAIs)
Impact of HAIs
2002 data from CDC National Nosocomial Infections Surveillance Systems
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Estimated number of HAIs: 1.7 million
Estimated number of deaths associated with the HAI:98,987
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Pneumonia:
Bloodstream:
Urinary tract:
Surgical site:
Other sites:
35,967
30,665
13,088
8,205
11,062
Klevens RM. Public Health Rep. 2007, 122(2):160-6
Economic Costs of HAIs
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Overall annual direct medical costs range from $28.4 to
$33.8 billion (adjusted to 2007 dollars).
http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
Scott DR, CDC, March 2009
COST ESTIMATES FOR SPECIFIC
HEALTHCARE-ASSOCIATED INFECTIONS
HAI type
VAP
BSI
Weight-Adjusted Cost per HAI
Mean + SE
25,072 + 4,132
23,242 + 5,184
SSI
CA-UTI
10,443 + 3,249
758 + 41
Range of Published Estimates
of Cost per HAI
8,682-31,316
6,908-37,260
2,527-29,367
728-810
(2005 dollars)
Anderson DJ, et al. ICHE 2007;28:767-773
UNC HOSPITALS
SELECTED HAIs AND ESTIMATED COST
HAI type
UNC Cases, 2008
Estimated Cost
VAP
82
2,055,904
BSI
231
5,368,902
SSI
335
3,498,405
CA-UTI
339
256,962
Total
987
11,180,173
Total cost estimated by multiplying number of cases at UNC Hospitals by
mean cost derived from Duke meta-analysis
What is the most effective and simplest method to
protect your health and to help prevent HAIs?
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% Compliance
UNC Hospitals Intensive Care Units:
Hand Hygiene Compliance (%), 2003-2008
100
90
80
70
60
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40
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20
10
Hand Hygiene: Methods
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Soap and water
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Alcohol-based handrubs (e.g. Alcare) when…
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Hand washing with antimicrobial soap (e.g.CHG) and water for 15
seconds
Hands are not visibly soiled, or
Hand washing facilities are not available in patient rooms
Use soap and water when…
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Patient known or suspected to have C. difficile disease or norovirus
infection (alcohol not effective against spores or nonenveloped
viruses)
Indications for Handwashing and Hand
Antisepsis
Before having direct contact with patients.
 Before donning sterile gloves for sterile/aseptic
procedures (e.g., central venous catheter placement)
 After glove removal
 After patient contact
 After contact with a contaminated instrument or
surface
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- Artificial nails and nail extenders are prohibited for direct patient
care providers.
In Review
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Infections can be transmitted in the hospital setting via contact, droplet, or
airborne spread
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Adherence to Isolation Precautions prevents transmission of disease to
you and to other persons
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Appropriate use of PPE and safe handling of sharp devices can reduce
your risk of exposure to bloodborne pathogens
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Hand hygiene reduces the risk of transmission of pathogenic organisms
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Questions related to infection prevention and control: contact Hospital
Epidemiology @ 6-1638 and after hours on pager 216-6652
Thank You!
“I don't see the glass as half-empty or half-full.
I see it as a glass somebody else has already put
their lousy germs on.”
Maxine