1

Infection Control Training

New York State Department of Health

State Education Department

2001 Syllabus Revised July 2007, November 2008

Developed by Robin Haag, RNC, MA

Infection Control Director, Coney Island Hospital

Presented by Barbara A. Smith, MPA, CIC

St. Luke’s Roosevelt Medical Center 1

Background

• Chapter 786 of the Laws of 1992

established a requirement that certain health

care professionals licensed in NYS receive

training on infection control and barrier

precautions by July 1994 and every four

years thereafter unless otherwise exempted

2

Statute Applies To:

• Dental hygienists

• Dentists

• Licensed practical

nurses

• Optometrists

• Physicians

• Physician assistants

• Podiatrists

• Registered

professional nurses

• Specialist assistants

• New as of 11/08

– Medical & PA students

3

Documentation

• Submit certification of training to

hospital/facility that maintains credentials

for granting professional privileges to

practice

• If not employed by a State regulated facility

submit form to NYSDOH attesting to

completion of required training

4

Goals of Infection Control Training

• Assure the understanding of how bloodborne pathogens

(BBP) may be transmitted in the work environment : – patient to healthcare worker: hepatitis B

Occupational cases of HBV in HCWNIOSH- Worker Health Chart book - 2004 5

Transmission in the Workplace

– Healthcare worker to patient : NEW YORK CITY – 3/15/07

15, 2007

– patient to patient: Hepatitis C – NY and Nevada

Acute Hepatitis C Virus Infections

Attributed to Unsafe Injection Practices

at an Endoscopy Clinic --- Nevada, 2007

May 16, 2008/ 57(19);513-517

HEALTH DEPARTMENT AND ST. BARNABAS HOSPITAL NOTIFY PATIENTS OF POTENTIAL

TUBERCULOSIS EXPOSURE Mothers, Babies, Patients, and Staff who Were in the Maternity,

Neonatal, or Psychiatric Units at St. Barnabas Hospital in the Bronx from November 1, 2006 –

January 24, 2007 May Have Been Exposed and Should be Screened Immediately

2

•NYC – Sept ’08

•2 women rec’d epidural – S. salivarius meningitis

•Ohio - May ’09

•3 women rec’d epidural- S. salivarius meningitis

•One fatal

6

Bacterial Meningitis After Intrapartum Spinal

Anesthesia --New York and Ohio, 2008- 2009 MMWR January 29, 2010 / 59(03)

7

Goals Continued:

• Apply current scientifically accepted infection

control principles, as appropriate for the specific

work environment

• Minimize opportunity for transmission of

pathogens to patients and healthcare workers

• Familiarize professionals with the law requiring

this training and the professional misconduct

charges that may be applicable for not complying

with the law.

8

New York State Public Health Law

• Section 2819 enacted in 2005

• Effective January 1, 2007

• Mandates reporting of:

– Central Line Associated Blood Stream Infections in ICUs

– Coronary Artery Bypass Surgical Infections

– Colon Surgical Site Infections

– Hip Replacements Surgical Site Infections

– C. difficile

9

MDRO Guidelines

• Management of Multidrug-Resistant Organisms in

Healthcare Settings, 2006. Jane D. Siegel, MD; Emily

Rhinehart, RN MPH CIC; Marguerite Jackson, PhD; Linda Chiarello,

RN MS; the HICPAC

• JCAHO expectation

• Designed to:

– halt the rising rates of drug-resistant infections

10

MRSA Guidelines

• Guide to the Elimination of MRSA Transmission

in Hospital Settings. March 2007

• www.apic.org

– Click on implementation guide

– Risk assessments

– Surveillance cultures

– Contact isolation

• Pending NYS legislation

– Reporting all MRSA infections

11

3

Six Core Elements

• Element I

The responsibility to adhere

to scientifically accepted

principles and practices of

infection control and to

monitor the performance

of those for whom the

professional is responsible

• Element II

Modes and mechanisms of

transmission of pathogenic

organisms in the

healthcare setting and

strategies for prevention

and control

12

Elements continued

• Element III

Use of engineering and work

practice controls to reduce

the opportunity for patient

and healthcare worker

contact with potentially

infectious material for

bloodborne pathogens.

• Element IV

Selection and use of barriers

and/or personal protective

equipment for preventing

patient healthcare worker

contact with potentially

infectious material

13

Final 2 Elements

• Element V

Creation and maintenance of

a safe environment for

patient care through

application of infection

control principles and

practices for cleaning,

disinfection, and

sterilization

• Element VI

Prevention and management

of infectious or

communicable diseases in

healthcare workers

14 15

Element I

• The responsibility to adhere to scientifically

accepted principles and practices of

infection control and to monitor the

performance of those for whom the

professional is responsible

16

Learning Objectives

• Recognize the benefit to patients and HCWs of

adhering to scientifically accepted principles and

practices of IC

• Recognize the professional’s responsibility to

adhere to scientifically accepted IC practices and

consequences of failing to comply

• Recognize the professional’s responsibility to

monitor IC practices of those for whom she/he is

responsible and intervene as necessary for

compliance and safety

17

Source of Standards

• NYS Education Department, Board of

Regents, Section 29.2 (A) (13) defines

unprofessional conduct as “failure to use

scientifically accepted infection prevention

techniques.”

• Part 92 of Title 10 (Health) of the Official

Compilation of Codes, Rules and

regulations of New York

• Statements of relevant professional and

national organizations

4

18

NYS DOH Mandates

• Infection control training for health professionals

• Enforcement of infection control standards in licensed health facilities

• Protection of HCWs from exposure to infection as per OSHA

• Processes and procedures to evaluate infected HCWs

• Policies to protect confidentiality of HCWs

• Policies for prevention and transmission within a facility

19

Implication of Professional

Conduct Standards

• Professional responsibility to adhere to

infection control standards

• Professional responsibility for monitoring

others

20

Monitoring Compliance of

Regulations

• New York State Public Health Law Article 28

inspections

• JCAHO Surveys and other accreditation bodies

– Patient Safety Goals

• OSHA and PESH inspections

• Inter-agency sharing of findings

• Penalties and fines for failure to comply with

standards

Consequences of Failing to Apply IC

Standards

• Increase risk of

adverse health

outcomes for patients

and healthcare

workers

• Subject to charges of

professional misconduct if

managers: – fail to report misconduct

– fail to conduct complaint

investigation

• Possible outcomes – professional liability

– disciplinary action

– revocation of professional

license

21

22

Methods of Compliance

• Participation in required infection control

training

• Adherence to accepted principles and

practices of infection control

23

Element II

• Modes and mechanisms of transmission of

pathogenic organisms in the healthcare

setting and strategies for prevention and

control

5

24

Learning Objectives

• Describe how pathogenic organisms may be

spread in healthcare settings

• Identify the factors which influence the

outcome exposure

• List the strategies for preventing

transmission of pathogenic organisms

• Describe how infection control concepts are

applied in professional practice

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Definitions

• Pathogen or Infectious Agent

– A biological agent capable of causing disease

• Transmission

– Any mechanism by which a pathogen is spread

by a source or reservoir to a person

• Susceptible Host

– A person or animal lacking effective resistance

to a particular infectious agent

Definitions continued

• Reservoir

– Any person, animal, arthopod, soil or substance (or

combination of these) in which an infectious agent

normally lives and multiplies, on which it depends

primarily for survival, and where it reproduces itself in

such manner that it can be transmitted to a susceptible

host

26 27

Definitions continued

Common Vehicle

– Contaminated material, product, or substance

that serves as an intermediate means by which

an infectious agent is transported to two or

more susceptible hosts

28

The Chain of Infection

• An epidemiological model that describes

the transmission of pathogenic organisms

• A circle of links, each representing a

component in the cycle

• Each link must be present and in sequential

order for an infection to occur

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Pathogen

Mode of

Transmission

The Chain of Infection

Transmission requires 6 elements

infectious agent (pathogen)

a source (reservoir)

a portal of exit

a mode of transmission

a portal of entry receptive to the agent

a susceptible host

6

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Presence of a Pathogen

• Bacteria

• Viruses

• Fungi

• Parasites (protozoa and helminths)

• Prions

– small proteinaceous particles

– resists inactivation procedures

Reservoirs

• Animate

– Human reservoirs may

be symptomatic of

infection or may be

non- symptomatic

carriers

• Inanimate

– Objects (fomites) may

also be reservoirs for

infection

• Contaminated

equipment or supplies

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Portals of Exit

• Mechanism by which pathogens leave the

reservoir

• Allows for the pathogen to be transmitted to

a susceptible host

– drainage of blood and other body substances

– coughing, sneezing respiratory / oral secretions

– draining lesions

– feces

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Modes of Pathogen Transmission • Direct contact with the source

– Airborne (TB)

– Droplet spread (Meningitis)

• Direct physical contact

– or indirect contact with a fomite

• Common vehicle by an intermediate means of transmission

to multiple susceptible hosts

– Food borne pathogens (E Coli)

• Vectorborne transmission through a pathogen carrying

organism

– Insects (Malaria, WNV, Lyme Disease)

34

Portals of Entry

• Sites and mechanisms by which pathogens

are introduced to a susceptible host

• Susceptible host

– lacks effective resistance to infectious agent

– entry sites (mucous membranes, non-intact

skin, gastrointestinal, respiratory, gentourinary

tracts)

– mechanism of introduction (percutaneous

injury, vascular access, other invasive devices,

surgical incision)

35

Host Factors that Influence the

Outcome of Exposures

• Natural barriers – intact skin

– respiratory cilia

– gastric acid

– tears

– normal flora

• Extremes of age

• Underlying pathology

• Nutrition

• Lifestyle

• Invasive procedures or

devices

• Medication (steroids,

chemotherapy, antibiotics)

• Immune System

– inflammatory response

– humoral immunity

– cell-mediated

immunity

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36

Agent Factors that Influence the

Outcome of Exposures

• Agent Factors

– Infectivity

– Pathogenicity

– Virulence

– Size of inoculum: How big

– Route and site of exposure: Entry

– Duration of exposure: Time

37

Environmental Factors that

Influence the Outcome of

Exposures

• Contamination of environment

• Contamination of equipment

• Guideline for Environmental Infection Control in Health-Care Facilities. – MMWR. June 2003

– Recommendations of the Advisory Committee on Immunization Practices (ACIP)

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How We Break The Links

• Eliminate the agent by reducing the number of organisms

– Sterilization / Disinfection

• Remove the means of transmission

– Cleaning Blood Spills Properly

• Limit the susceptibility of the host

– Wearing a PFR 95 Particulate Respirator

39

Prevention Strategies

• Standard Precautions

– Consider all patients to be potentially infected

with a bloodborne pathogen (BBP)

• Non BPP

– Early identification

– Prompt isolation

– Appropriate treatment

40

Hand Hygiene

• The single most important measure in breaking the

chain of infection

• Compliance is poor

• CDC Guidelines

– Guideline for hand hygiene in health-care settings:

recommendations of the Healthcare Infection Control

Practices Advisory Committee and the

HICPAC/SHEA/APIC/IDSA Hand Hygiene Task

Force. MMWR. 2002;51(RR-16):1-44.

41

8

42

Hand Flora

• Resident Flora

– AKA colonizing flora

– Can be isolated on hands of most people

– Not readily removed by mechanical friction

• Transient Flora

– AKA contaminating or non-colonizing flora

– Readily transmitted unless removed by hand

hygiene

43

44

Selection Of Products

• Antiseptic soaps

• Scrubs

• Waterless hand sanitizers

• Selection of product based on: – Desired characteristics

• Rapidity of flora reduction, persistence of action, absorption, spectrum

– Staff acceptance

– Where product will be used

– Cost

– Safety and efficacy

– Potential contamination of soaps

45

Antimicrobial Products

• Use where invasive procedures are performed

• Use in special care units

• Use in areas where patients have resistant organisms

• CHG: Chlorhexadine gluconate – Remains active for 6 hrs on skin

– Neutralized by hand creams

• PCMX: Para-chloro meta-xylenol – Less active than CHG

– Neutralized by hand creams

• Iodophor – Slightly less effective than CHG

– Inactivated by organic material

• Triclosan: Dichlorophenoxyl – Absorbed through intact skin

– Commonly used in commercial soaps

46

Antimicrobials continued

• Waterless Alcohol Based hand sanitizers

– 60 - 70% alcohol solutions kill 99% of most

common organisms including MRSA,

Acinetobacter and VRE

– Emollients reduce dryness

– Takes less than 30 seconds to use

– Can be carried in pockets or wall mounted

– Use where non-anti-microbial soaps are used

47

Non-Antimicrobial Soap

• Standard hand soap

– No antimicrobial activity

– Use in visitors areas

– Use in bathrooms

– Use in conjunction with hand sanitizers

– Bar soap must be placed on racks that permit drainage

• Organisms collect in pools of water and then become reservoirs for soap.

9

48

Hand Washing Instructions

• Wet hands with warm

water

• Apply soap

• Lather hands well

• Vigorously rub

together all hand

surfaces for 10 - 15

seconds

• Thoroughly rinse

hands under a stream

of water

• Completely dry hands

with a clean paper

towel

• Use a clean dry paper

tower to turn off the

faucet

49

50

Hand Sanitizing Instructions

• Hold one hand under dispenser spout and press

• the lever once or twice with your other hand

• Use enough alcohol to wet all surfaces of your hands

• Spread the alcohol thoroughly over your hands and

fingers

• Rub your hands together until the alcohol is dry

• Do Not rinse with water

• Do Not use a source of electricity or flame until dry

• Do Not drink!

51

ABHR really works!

52

Fingernails

• Natural Nails

• No artificial fingernails or extenders

– For direct care providers with patients at high

risk for infection (OR, ICU, Transplant)

– Hospital policy

• No chipped nail polish

• ¼ inch beyond fingertip

53

Control of Transmission Routes

• Standard precautions for all patients

• Use of appropriate barriers

• Sterilization or disinfection of patient care

equipment

• Isolation/cohorting communicable

individuals – Who is in the next bed?

“If you’re in a two, three or four-bedded

room, each time you get a new roommate

your risk of acquiring these serious

infections increases by 10 per cent,” says

Dr. Zoutman

10

54

Standard Precautions

• Apply to ALL patients

• Use Personal Protective Equipment (PPE)

• Wear gloves before touching:

– body fluids

– mucous membranes

– non-intact skin

• Change gloves between patients

• Wash hands after removing gloves

55

Transmission Based Precautions

• Guideline for Isolation Precautions: Preventing

Transmission of Infectious Agents in Healthcare Settings, June 2007, Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the

Healthcare Infection Control Practices Advisory Committee, 2007

• Isolation based on route of transmission

• Airborne precautions

• Droplet precautions

• Contact precautions

• Protective isolation

Airborne Precautions

• Use for:

– TB

– Varicella (with contact)

– Measles

– Variola

– SARS

– Avian flu

56 57

Airborne Pathogens

Prevention and Control Early Identification of Suspect Cases

– Triage and separate possibly infectious individuals from others

– Respiratory Etiquette

• Signage

• Instruct patient to wear surgical mask

• Instruct patient to cover mouth with tissue

• when coughing or sneezing

• Garbage cans

• Hand sanitizer availability

58

Airborne Pathogens continued

• Engineering Controls to Prevent Transmission

– Negative Pressure Isolation Rooms

• Air currents prevented from entering corridor

• Monitor effectiveness of negative pressure

– Air Exchanges

• New Construction: 12 per hour

• Old Construction: 6 per hour

– Alarms and Physical Testing

• Smoke or tissue tests

• Logs

HEPA filtration

UV irradiation 59

Airborne Pathogens continued

• Personal Protective Equipment (Element IV)

• Special Considerations

– Operating suites

• all have positive pressure

• air flows from room into the corridor

– Procedures associated with transmission of

extrapulmonary TB

– Limit transportation of potentially infectious

patients

11

60

Droplet Precautions

• Standard procedure mask required when within 3 - 6 feet of the patient

• Private room

• Use for:

– Pneumonic Plague

– Influenza

– Rubella

– Adenovirus

– Meningococcal meningitis

– Pertussis 61

Contact Precautions

• Gloves for contact with infective material

• Change gloves when contaminated

• Gowns for close contact with patient

• May or may not require a private room

• Patients with like organisms and sites

may be cohorted

• Used for resistant organisms, Scabies, C Difficile

Respiratory etiquette

Necessary because unable to identify all infectious sources immediately

and consistently

Implemented at first point of contact and in conjunction with standard

precautions

• 1. Visual alerts to patients to report symptoms of

respiratory illness.

• 2. Respiratory hygiene

– Cover your mouth and nose with a tissue when

coughing or sneezing

– Use the nearest waste receptacle to dispose of the tissue

after use.

– Perform hand hygiene after having contact with

respiratory secretions.

• 3. Masking and separation of patients with

respiratory symptoms.

Key components

Resources: http://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm

Cover your cough multiple

languages

Symptoms alert

65

Environmental Control Measures

• Environmental cleaning

• Appropriate ventilation

• Waste management

• Linen and laundry management

12

66

Additional Controls

• Support and Protection of the Host

– Vaccination

– Pre and post exposure prophylaxis

– Protecting skin and immune system integrity

• Training and Education of HCWs

67

Element III

• Use of engineering and work practice

controls to reduce the opportunity for

patient and healthcare worker contact with

potentially infectious material for

bloodborne pathogens.

68

Learning Objectives

• Define “engineering controls” and “work”

practice controls”

• Describe specific practices and settings

which increase the opportunity for exposure

to healthcare workers and patients

• Identify where engineering or work practice

controls can be utilized to prevent exposure

69

Definitions

• Engineering Controls

– Equipment, devices or instruments that remove

or isolate a hazard

• Work Practice Controls

– Controls that reduce or eliminate the

likelihood of exposure by altering the manner

in which a task is performed

• Personal Protective Equipment (PPE)

– Equipment or clothing worn to reduce the

exposure to hazards

70

High Risk Practices and

Procedures

• Percutaneous Exposures

– Injury through

handling/disassembly/disposal/reprocessing of

needles and other sharps

• manipulating needles and other sharps by hand

• recapping using a two-handed technique

• removing scalpel blades

71

High Risk Practices and Procedures continued

Procedures in which there is opportunity for

injury, particularly where there is poor

visualization

• blind suturing

• non-dominant hand opposing next to a sharp

• bone spicules or metal fragments

• passing sharp instruments

13

72

High Risk Practices and Procedures continued

• Mucous membrane and non-intact skin

exposures

– Direct contact with blood or body fluid

• contaminated hand in contact with eyes, nose

or mouth

• open skin lesions on hands/dermatitis

– Splashes or sprays of blood or body fluid

• irrigation/suctioning

73

High Risk Practices and

Procedures continued

• Parenteral Exposures

– Injection with infectious material

– Infusion of contaminated blood products or

fluids

– Multidose vials

74

Evaluation/Surveillance of

Exposure Incidents

• Identification of those at risk for exposure

(who)

• Identification of devices causing exposure

(what)

– Devices with higher disease transmission risk

(hollow bore)

– Devices with higher injury rates (butterflies

recoil action)

– Devices by name brand 75

Evaluation/Surveillance of

Exposure Incidents continued

• Identification of areas/settings where

exposures are occurring

• Circumstances by which exposures are

occurring

• Identify trends and hazards for the purpose

of minimizing future exposures

76

Engineering Controls Which

Eliminate or Isolate the Hazard

• Use safer devices whenever possible to

prevent sharps injuries – proper evaluation and selection of safer devices

– passive vs. active safety devices

– mechanisms that provide continuous protection immediately

– integrated safety equipment vs. accessory devices

http://www.healthsystem.virginia.edu/internet/EP

INet/safetydevice.cfm

77

Engineering Controls continued

• Proper education and training on safer devices

• Eliminating the traditional or non-safety

alternative whenever possible

• Puncture resistant containers for transport and

disposal of needles and other sharps

– NIOSH guidelines for selecting containers

– Location and accessibility

• Splatter shields on medical equipment with risk

prone procedures

– Locking centrifuge lids

14

78

Work Practice Controls

• General Practices

– Handwashing

– Prompt cleaning of blood and body fluid spills

with appropriate disinfectant

– Proper disposal/handling of blood and body

fluid, including contaminated patient care items

– Use of personal protective equipment (PPE)

• Element IV

79

Work Practice Controls continued

• Percutaneous Exposures

– Avoiding unnecessary use of needles and other

sharps

– Using care in handling/disposal of needles and

other sharps

• No recapping unless absolutely medically necessary

and then only using one-hand technique or safety

device

• Passing sharps by use of designated “safe zones”

• Disassembling sharp equipment with forceps or

other devices

80

Work Practice Controls continued

• Modifying Procedures to Avoid Injury

– Using forceps, suture holder or other

instruments for suturing

– Not holding tissue with fingers when suturing

or cutting

– Not leaving sharps on a field

– Cleaning up after yourself

– Checking linen for sharps/trash before disposal

– Asking for assistance with procedures 81

Work Practice Controls continued

• Appropriate Use of Safety Devices

– Attend the inservice

– Always activate the safety feature

– Never circumvent the safety feature

– Give the safer device a chance

• learning curve

82

Safe injection practices

Pathogens can be present in sufficient quantities to produce infection in the absence of visible blood

Unsafe injection practices have resulted in:

• Transmission of bloodborne viruses, including hepatitis B and C viruses to patients;

• Notification of thousands of patients of possible exposure to bloodborne pathogens

• Referral of providers to licensing boards for disciplinary action; and

• Malpractice suits filed by patients.

83

Acute Hepatitis C Virus Infections Attributed

to Unsafe Injection Practices at an Endoscopy

Clinic --- Nevada, 2007 MMWR 5/16/2008

15

84

MMWR 5/2008 continued

85

Highlights of safe injection practice

• Medications should be drawn up in a designated "clean" area

• If a medication vial has already been opened, the rubber septum should be disinfected with alcohol prior to piercing it.

• Never leave a needle or “spikes” inserted into a medication vial septum or IV bag/bottle for multiple uses

• Never administer medications from the same syringe to more than one patient, even if the needle is changed

• Never use bags or bottles of intravenous solution as a common source of supply for more than one patient.

Safe Injection Practices Coalition

www.oneandonlycampaign.org

Nineteen of 67 ASCs that were evaluated

in this study administered injections or

handled medications in an unsafe

manner, primarily through the use of

single-dose vials for more than one

patient.

Infection Control Assessment of

Ambulatory Surgical Centers” and

authored by Melissa K. Schaefer, M.D.

JAMA June , 2010

87

Element IV

• Selection and use of barriers and/or

personal protective equipment for

preventing patient healthcare worker

contact with potentially infectious material.

88

Learning Objectives

• Describe circumstances requiring use of

barriers and PPE to prevent patient or HCW

contact with potentially infectious material

• Identify specific barriers or PPE for patients

and HCW protection from exposure to

potentially infectious material

89

Definitions

• Personal Protective Equipment (PPE)

– Specialized clothing or equipment worn by a

HCW for protection against a hazard

• Barrier

– A material object that separates a person from a

hazard

16

90

Selection Criteria

• Selection of PPE

– Wide variety of PPE available

– Selection of equipment is situation based

– Dependent on type and amount of contact

91

Glove Selection

• Sterile

– Barrier device to reduce transmission of

infection to the patient

– For procedures involving direct contact with

sterile body parts

• Surgery

– For procedures requiring the entry of sterile

devices into sterile areas

• Foley Catheter and Central Line Insertions

92

Glove Selection continued • Non-sterile Gloves for:

– procedures having contact with patient’s body

fluids, mucous membranes or non-intact skin

– decontaminating equipment

– cleaning the environment

– removing medical waste

• Material • latex

• vinyl

• Nitrile

• rubber (utility)

93

Types of PPE/Barriers

Selection Criteria

• Allergies

– Latex allergy in personnel or patients

• Select hypo-allergenic/ non-latex gloves

• Must be made available

– Powder

• Powderless gloves available for powder allergy

• Powderless gloves reduce release of latex into

environment

94

Glove Basics

• Wear for potential contact with

– body fluids or fluid contaminated items

– mucous membranes

– non-intact skin

• Remove immediately after need to wear

• Hand hygiene immediately after removing

• Double gloving for procedures with large quantities of blood

• Don’t wear gloves unnecessarily

– Moist skin: conducive to bacterial growth

• Gloves develop microscopic holes

95

Cover Garb

• Types

– gowns

– aprons

– lab coats

• Characteristics

– impervious: Fluid will not soak through to skin

– fluid resistant: If saturated, fluid can soak

through

– permeable: Protect against small splashes, will

soak through

17

96

When To Wear Cover Garb

• When there is a risk that clothing, arms or legs

may be contaminated with body fluids

• Use impervious gowns when there may be an

exposure to large quantities of body fluid (OR,

Trauma ER)

• Wear a fluid resistant gown when less fluids are

expected (linen removal, dental procedures)

• Wear a lab coat when minimal exposure is

expected (drawing blood)

• Wear a sterile gown during to protect the patient

during procedures 97

Masks

• Fluid shield: impervious to fluids

• Surgical: lightweight, not fluid resistant

• Particulate respirators:

– HEPA filtration to less than 5 microns.

– Required by OSHA for Airborne Precautions

– Require an annual fit test

98

Masks continued

• Fluid splashes to the face may enter through

the eyes

• Face Shields

– provide full facial protection by a transparent

shield that covers from chin to forehead

• sometimes combined with a face mask

• Eye Protection

– goggles

• afford more protection than glasses

• designed with side pieces to cover all entry points of

the eye

– safety glasses

99

PPE and Barriers continued

• Shoe Covers

– Essentially aesthetic

• minimal risk of pathogen transmission from

surgeon’s shoes

– Use when shoes are expected to become grossly

contaminated by body fluids

• orthopedic surgery

• Head Covers

– Protect patient from surgical team member’s

hair

100

Choosing PPE and Barriers

• Selection based on reasonably anticipated

interaction

– Blood or body fluid splash or drainage?

– Volume of contact?

– Respiratory droplets or airborne pathogens?

• Surgical masks for droplets when within 3 feet of

patient

• Particulate respirators for airborne organisms that

stay suspended in the air

101

Choosing PPE and Barriers For

the Patient’s Protection

• Sterile barriers for invasive procedures

• Masks for the prevention of droplet

contamination

• Head covers

• Gloves

18

102

Element V

• Creation and maintenance of a safe

environment for patient care through

application of infection control principles

and practices for cleaning, disinfection, and

sterilization

103

Learning Objectives

• Recognize importance of correct application

of reprocessing methods for assuring the

safety and integrity patient care equipment

• Identify the individual’s professional

responsibility for maintaining a safe patient

care environment

• Recognize strategies for effective pre-

cleaning, chemical disinfection and

sterilization of instruments and devices

104

Definitions

• Contamination

– The presence of microorganisms on inanimate objects (surgical

instruments) or in substances (water, food, milk)

• Cleaning

– The removal of all foreign material (dirt, fluids, organic debris)

from objects

• Decontamination

– Process of removing disease-producing microorganisms and

rendering the object safe for handling

• Disinfection

– Process that results in the elimination of many or all pathogenic

microorganisms on inanimate objects with the exception of

bacterial endospores

105

Definitions continued

Sterilization – Process that completely eliminates or destroys all forms of microbial life

High Level Disinfection – Kills bacteria, mycobacteria (TB), fungi, viruses and some bacterial

spores.

Intermediate Level Disinfection – Kills bacteria, mycobacteria (TB), most fungi and most viruses. Does not

kill resistant bacterial spores.

Low Level Disinfection – Kills most bacteria, some fungi and some viruses.

– Will not kill bacterial spores, MTb, and is less active against some gram

negative rods (pseudomonas)

106

Potential For Contamination

• Degree of frequency of hand contact

• Potential for contamination with body

substances or environmental sources of

microorganisms

• Level of contamination

– Types of microorganisms

– Number of microorganisms

• Potential for cross-contamination

107

Potential For Contamination

• Type of device, equipment or

environmental surface

– External contamination

• surface

– Internal contamination

• channels

– Composition of the device, equipment,

environmental surface being contaminated

• Manufacturer’s recommendations

19

108

Contributing Factors to

Contamination

• Inadequate cleaning

– most important step in disinfection or

sterilization

– Physically eliminates many microbes

– Organic matter prevents surface exposure to

disinfectant or sterilant

– Residual detergent may inactivate disinfectant

or sterilant: rinse well

109

Contributing Factors to

Contamination cont.

• Contamination of disinfectant or rinse

solutions

• Improper storage and handling

• Failure to reprocess or dispose of equipment

between patients

• FDA reprocessing standards for single use

devices (SUDs)

110

Efficacy of Disinfection/Sterilization

Influencing Factors

• Cleaning of the object

• Organic and inorganic load present

• Type and level of microbial contamination

• Concentration of and exposure time to

disinfectant/sterilant used

• Nature of object

• Temperature and relative humidity

111

Reprocessing Points That Can Compromise

Equipment/Device Integrity

• Handling and cleaning contaminated items

– internal and external surfaces

• endoscopy equipment

– right chemical or process

– timing

• right amount of time

• rinse/pre-soak

– immediate transport for reprocessing

112

Cleaning Methods

• Manual

– Soaking (i.e.: Glutaraldehyde, OPA)

• Mechanical (Automated)

– Reduces employee contact with potentially

infectious material or equipment

• Washer-sterilizer: Item immersed and agitated

in detergent bath. Usually put through a steam heat

cycle to sterilize.

• Ultrasonic cleaner: Sonic waves produce tiny

bubbles from gas nuclei. Imploding bubbles

dissolve organic material from equipment surface.

113

EH Spaulding’s Principles

• How an object will be disinfected depends on the object’s intended use.

• Critical – Objects which enter normally sterile tissue or the vascular system

or through which blood flows should be sterile

• Semicritical – Objects that touch mucous membranes or skin that is

not intact require high level disinfection

• Noncritical – Objects that touch only intact skin require low level disinfection

20

Resistance of Microorganisms

Low Level Disinfection

LIPID VIRUSES Hepatitis A, B Herpes Simplex HIV

High Level Disinfection

Intermediate Level Disinfection

BACTERIAL SPORES Clostridium difficile Clostridium perfringens Cryptosporidium

MYCOBACTERIUM Mycobacterium tuberculosis Mycobacterium chelonae

NONLIPID VIRUSES poliovirus -- polio rhinovirus – common cold

FUNGI Candida albincans – thrush Aspergillus Trichophyton fungus – Athlete’s Foot

VEGETATIVE BACTERIA Pseudomanas,sp. Salmonella, sp. Staphylococcus spp. Escherichia coli – E coli MRSA

Sterilization

PRIONS (Creutzfeld-Jakob Disease) Prion processing Critical items Semi critical Non critical

Sterilization High Level Disinfection Intermediate & Low level

Disinfectants

Steam under pressure

Dry heat

If heat labile, low

temperature

sterilization process

Ethylene oxide gas

Plasma sterilization

Prolonged contact

with liquid agents

Glutaraldehyde

Hydrogen Peroxide

Peracetic acid

Wet pasteurization

Sodium hypochlorite

Phenolic Solutions

Alcohols

Chlorine Sodium

Hypochlorite

Iodophors

Quaternary Ammonium

Compounds

Methods of reprocessing

116

Critical Devices

• Enter sterile tissue or the vascular system

– Surgical instruments (scalpels)

– Dental instruments

– Needles & syringes

– Implants

– Urinary catheters

– Pacing electrodes

– Vascular guidewires

117

Methods of Sterilization

• Methods of sterilization

– Steam under pressure

– Dry heat

– If heat labile, low temperature sterilization

process

– Ethylene oxide gas (ETO)

– Plasma sterilization

– Prolonged contact with liquid sterilization

agents

118

Steam Sterilization • Steam produced under pressure

• Specific temperature to eliminate microbes

• Process exposes to 100% humidity

• Sterilizers range in sizes from tabletop to

large industrial chambers

• Gravity and vacuum sterilizers

• Advantages: highly effective, rapid heating

penetrate textiles, low cost, & non toxic

• Disadvantages: equipment must be heat and

moisture resistant

119

Dry Heat Sterilization

• Temperature ranges from 121° - 171° C

• Gravity or mechanical convection

• Advantages: non corrosive, low cost,

suitable for powders and glass

• Disadvantages: Uneven penetration, long

exposure time required, not suitable for

rubber or some fabrics due to temperature

21

120

Plasma Sterilization

• Gas plasma created in vacuum chamber through

radio waves and hydrogen peroxide

• Free elements generated that eliminate all

microorganisms and spores

• Marketed as STERRAD by J&J

• Advantages: highly sporicidal, non corrosive,

good for heat and moisture resistant items

• Disadvantages: Requires special packing

material, doesn’t penetrate foreign material,

unable to enter small and long lumens

121

Ethylene Oxide Gas

• Chamber filled with Ethylene Oxide (ETO)

• Gas inhibits microorganism’s metabolism

• Must comply with EPA standards for safe

exhaust of gas

• Advantages: Very effective, safe for heat

sensitive items

• Disadvantages: Toxic gas, special

ventilation required

122

Peracetic Acid (Cidex PA)

• Submerge instruments in peracetic acid liquid or

in a computerized processing unit

• Connectors direct fluid through lumens Marked as

Steris system by Steris

• Advantages: rapid cycle, fully automated,

decomposes into water, hydrogen peroxide and

acetic acid, effective in presence of organic matter,

can be used without Steris

• Disadvantages: For immersible items only,

inactivated by blood, unstable when diluted,

corrosive

123

Ortho-phthaladehyde (Cidex-OPA )

• Liquid disinfectant/sterilant

• Advantages: 12 – 20 minute process, no

activation, not a known irritant to eyes or

nasal passages, no special ventilation

• Disadvantages: Cost, stains protein gray

(including skin)

124

Glutaraldehyde (Cidex)

• Excellent high level disinfectant /sterilant

• Advantages: Active in the presence of

organic matter, compatible with lensed

instruments

• Disadvantages: Toxic and caustic, requires

copious rinsing, requires special ventilation

125

Hydrogen Peroxide

• Can be used to achieve disinfection or

sterilization

• Environmentally friendly

• Advantages: Decomposes into hydrogen

and water

• Disadvantages: Oxidizing may be harmful

to scopes, copious rinsing required

22

126

Semi-Critical Devices

• Touches mucous membranes or non-intact skin

• Require cleaning and high level disinfection

• Use for: – Vaginal sonography probes

– Diaphragm fitting rings

– Flexible endoscopes

– Themometers

– Tonometers

– Laryngoscopes

– Anesthesia/respiratory equipment

127

Methods of Reprocessing

Semi-Critical Items

• High Level Disinfection (HLD)

– Glutaraldehyde

– Hydrogen Peroxide

– Peracetic acid

– Wet pasteurization (HLD with hot water)

• anesthesia/respiratory equipment

– Sodium hypochlorite (household bleach)

128

Non-Critical Devices

• Touch intact skin

• Require cleaning and low level disinfection

• Examples: – BP cuffs

– Stethescopes

– EKG leads

– Crutches

– Furniture

– Mattresses

– Walls

– Floors

The Inanimate Environment

Can Facilitate Transmission

Green X’s show areas of contamination in a patient’s room

Pathogen HCW Hand

Contamination

Persistence

(Hands)

Persistence

(Environmental)

Acinetobacter 3-15 % >150 min 3 days-5 mo

C. difficile 14-59 % ? 24 h (vegetative

cells), up to 5 mo

(spores)

Klebsiella spp. 17% 2 h 2 h-30 mo

MRSA Up to 16.9 % ? 4 wk-7 mo

(* 1 yr in dust)

VRE Up to 41% 60 min 5 days-4 mo

Adapted from Kampf G, Kramer A. Clinical Microbiology Reviews (2004) 17:863-893

*JH Wagenvoort, W Sluijsmans, RJ Penders, Better environmental survival of outbreak

vs sporadic MRSA isolates. , J Hosp Infect 45 (2000), pp. 231–234

131

Intermediate & Low level

Disinfectants

Alcohol

– Requires wet contact for 5 minutes

– Evaporation may diminish disinfection

– Flammable

– Inactivated by organic matter

– Damaging to lensed instruments

– Uses: thermometers, external surfaces of

equipment, skin antisepsis

23

132

Intermediate & Low level

Disinfectants

Chlorine Sodium Hypochlorite

• Must dilute to be effective

– Dilution determines level of disinfection

• Corrosive to metals

• Cannot combine with detergents

• Inactivated by organic matter

• Uses: disinfect dialysis equipment, hydrotherapy tanks,

CPR mannequins, toilets, blood spills

133

Intermediate & Low level

Disinfectants

Iodophors (Iodine Based)

• Relatively non-toxic and non-irritating

• Excellent detergent action

• May stain fabrics, plastic an other synthetics

• Inactivated by organic material

• Not suitable for hard surface disinfection

• Uses: Disinfect thermometers, hydrotherapy tanks

134

Intermediate & Low level

Disinfectants

Phenolic Solutions

• Leave residue film on environmental surfaces

• May cause skin irritation

• Affected by organic matter

• Corrosive to rubber and plastic

• Never use in a nursery setting

– Cause hyperbilrubinemia

• Uses: environmental cleaning

135

Low level Disinfectants

Quaternary Ammonium Compounds

• Good detergents

• Good germicides

• Affected by organic matter

• Uses: environmental cleaning (floors, walls,

furniture)

136

Reprocessing Summary

• Choose reprocessing method based on:

– Desired level of antimicrobial activity

• High, intermediate or low

– Manufacturer’s recommendations

• Heat/pressure/temperature tolerance, time

– Effectiveness of process

• Surface, channels, immersible, stability of product

137

Sterilization Process Summary

• Selection and use of sterilization methods

– compatibility with equipment components and

materials

– heat and pressure tolerance

– time requirements for reprocessing

– temperature requirements for reprocessing

24

138

Process Monitoring

• Monitoring the sterilization process

– biologic monitors

– indicator strips

– pressure, temperature gauges

• Post-sterilization handling and storage

– package integrity

– shelf-life or event related sterility criteria

139

Event Related Sterility

• Based on concept that specific events, not

time, causes contamination

• Event is an incident that compromises

package integrity

– wetness

– holes or tears

– dropped on floor

– improperly transported

– improperly stored

140

Storing Sterile Items

• Limited access areas

• Closed cabinets

• Clean, dry and dust free

• 65° - 72° degrees F

• Relative humidity of 35 – 50 %

• 18 - 20 inches below ceiling

• 6 - 2 inches from walls

141

Equipment Users

• Must Know:

– Basic concepts and principles of cleaning,

disinfection and sterilization

– Appropriate application of safe practices for

handling devices and equipment

142

Reprocessing Managers/Workers

• Must Know:

– Core concepts of cleaning, disinfection and sterilization

– Appropriate application of safe practices for handling devices and equipment

– Residual Effect/Toxicity

– Antibacterial residual

– Staff/patient toxicity

– Monitoring exposures

– Abatement procedures

– Ease of Use

– Need for special equipment

– Training requirements

– FDA rules for reuse of SUDs

– Cost

143

Element VI

• Prevention and management of infectious or

communicable diseases in healthcare

workers

• 5/2010 – OSHA issued RFI re: workpalce

exposure to air, droplet contact routes – all

HC settings

25

144

Learning Objectives

• Recognize the role of occupational health

strategies in protecting healthcare workers and

patients

• Recognize non-specific disease findings which

should prompt evaluation of healthcare workers

• Identify strategies for preventing BBP and other

communicable diseases in HCWs

• Identify resources for evaluation of HCWs

infected with HIV, HBV, and/or HCV

145

Definitions

• Infectious Disease

– A clinically manifest disease of

man resulting from infection

• Communicable Disease

– An illness due to a specific infectious agent

which arises through transmission of that agent

from an infected person, animal, or inanimate

reservoir to a susceptible host

• Occupational Health Strategies

– A set of activities intended to assess, prevent,

and control infections

146

Pre-Employment & Periodic

Health Assessments

• Prevent the HCW from transmitting

diseases to patients and co-workers

• Protect HCWs from acquiring

communicable diseases at work

• Annual health assessments

• Follow-up for potential communicable

diseases

147

Immunization/Screening Program

• Rubella

• Measles

• Varicella

• Hepatitis B

• Influenza

• Any other additional/mandated

requirements - Pertussis

148

Recommended Immunizations

• Recommended Adult Immunization Schedule---United States

• Mandated immunizations for school

• Foreign born HCWs

• If immunization or serologic evidence of immunity cannot be established, vaccination for these diseases is strongly recommended

149

Boosters

• Tetanus

– 0.5 ml every 10 years

• Diphtheria and Polio boosters

– recommended for travel where diseases prevail

• Pertussis

– Tdap

26

In 2010, 9,143 cases of pertussis (including ten infant deaths) were

reported throughout California. This is the most cases reported in

63 years when 9,394 cases were reported in 1947.

In Michigan, an increase in pertussis was first observed in 2008. In

2010 there were 1,564 cases. In 2009 there were 902 cases reported.

In 2008 there were 315 cases reported.

In Ohio, in 2010, there were 964 cases reported by Columbus and

Franklin Counties. This is the most cases reported in 25 years.

Outbreaks of pertussis-not uncommon

• The ACIP recommends that all healthcare personnel

(HCP), regardless of age, should receive a single dose of

Tdap as soon as feasible if they have not previously

received Tdap and regardless of the time since last Td

dose.•

• Hospitals and ambulatory-care facilities should provide

Tdap for HCP and use approaches that maximize

vaccination rates (e.g., education about the benefits of

vaccination, convenient access, and the provision of Tdap

at no charge).

Tdap in healthcare personnel

January 27, 2010

CONFIRMED CASE OF MEASLES IN

NASSAU COUNTY Uniondale, NY

The Nassau County Department of Health today

announced that a case of measles has been

confirmed in a 12 month old child who resides in

Nassau County. The child recently traveled

internationally to a location with known measles

152

www.nassaucountyny.gov/agencies/Health/NewsRelease/2010/01272010.html

153

Hepatitis B Vaccine

• OSHA Bloodborne Pathogen Standard

requires:

– Offering to HCWs at no charge

– For employees at risk for exposures to blood

and body fluids which may contain blood

– If refused, employee must sign a statement

acknowledging potential consequences

– Employees may request vaccination at future

date during employment

154

Influenza

• Up to 20 % or more of the population becomes infected with the flu each season

• Viral shedding occurs before symptoms

• Some people are so mildly sick they don’t realize they are sharing their flu virus

• Prevention and Control of Seasonal Influenza with Vaccines – MMWR Recommendations and Reports

27

Cumulative percentages of health-care personnel* who

received seasonal influenza vaccine, influenza A (H1N1)

2009 monovalent vaccine, or both United States, August 2009--January 2010†

Fundamental Elements to Prevent Influenza

Transmission

• administration of influenza vaccine

• implementation of respiratory hygiene and cough

etiquette

• appropriate management of ill HCP

• adherence to infection control precautions

– Standard precautions for all patient-care activities

– Droplet – separate patient & HCP use mask

– Upgrade for aerosol-generating procedures

• implementing environmental and engineering

infection control measures

2010-11 Influenza Prevention & Control Recommendations

• All persons aged 6 months and older should be vaccinated annually

If limited supply, vaccination efforts should focus on :

• aged 6 months--4 years (59 months)

• aged 50 years and older

• have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal,

hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus);

• immunosuppressed (medications or by human immunodeficiency virus)

• will be pregnant during the influenza season

• aged 6 months--18 years and receiving long-term aspirin therapy and who therefore might be

at risk for experiencing Reye syndrome after influenza virus infection;

• residents of nursing homes and other chronic-care facilities;

• American Indians/Alaska Natives

• morbidly obese

• health-care personnel

• household contacts and caregivers of – children aged younger than 5 years, esp. younger than 6 months NYS requirement to offer vaccine to caregivers of

NICU babies

– adults aged 50 years and older, with particular emphasis on vaccinating contacts of children aged younger than 6

months

– persons with medical conditions that put them at higher risk for severe complications from influenza.

161

28

162

Varicella Vaccine

• Prevention of Varicella

– MMWR June 22, 2007/ Vol.56/ No. RR-4.

– Recommendations of the Advisory Committee on Immunization

Practices (ACIP) 2007

• Available for children and adults in the USA

• Varicella titers drawn for those who are unsure of

history

• If susceptible to varicella, the vaccine should be

offered

• HCWs refusing immunization sign

acknowledgment of potential consequences

• Re-offered an annual physical exam 163

Tuberculosis Screening

• QuantiFeron Gold: blood test

• 2 step TST (PPD) placed at time of hire

• Annual screening thereafter

• Semi-annual screening for high risk employees

• Exposures referred for follow-up

• TST conversions tracked and trended annually

• Positive TST HCWs screened for signs and

symptoms of active disease: bloody sputum,

weight loss, night sweats

164

Symptoms Requiring Immediate

Medical Evaluation

• Fever

• Cough

• Rash

• Vesicular lesions

• Draining wounds

• Vomiting

• Diarrhea

165

Management of Exposures

• Prompt evaluation and treatment as needed

• Limiting contact with susceptibles

• Furlough until non-infectious

• Prophylaxis if indicated

166

Exposure Prophylaxis

• Diphtheria: Contact with respiratory

secretions

– Penicillin, Erythromycin, Td vaccine

• Hepatitis A: Contact with feces

– Immune globulin within 2 weeks

• Hepatitis B: Contact with infected blood

or body fluid via needlestick, splash to eyes,

non-intact skin, or mucous membrane

– Hepatitis B Immune Globulin

– Hepatitis B Vaccine

167

Hepatitis B

• 6 -30% risk of seroconversion

• Conversion risk influenced by source’s viral

titer

• Correlation with presence of hepatitis B

antigen

• 10% HBV infections become chronic

• CDC prophylaxis recommendations based

on exposed persons immunization status

– Detailed CDC recommendation

29

168

Hepatitis C

• 1 - 10 % seroconversion rate post exposure

• Estimated 4 million Americans infected

• 60 -70 % have no symptoms

• 80 % develop chronic liver disease

• No recommended post-exposure treatment

• Following exposure, HCWs should be

tested for HCV antibodies (anti-HCV) or

PCR at baseline, 4 weeks, 6 and 12 months

• Source patient should be tested if possible

169

HIV

• 0.3% risk of seroconversion from needlestick

• 0.09% risk from mucous membrane exposure

• Old data

– 56 HCWs infections since 1985

– 138 “possible” occupational transmissions

• Percutaneous injury associated with 89%

transmissions

170

HIV PEP

• NYS guidelines more aggressive than CDC

• Maximally suppress any limited viral

replication with HAART

– Highly active anti-retroviral therapy

• Assess exposure within 2 hours

– percutaneous exposure

– bite with blood in source’s mouth

– splash to mucous membrane or non-intact skin

– source patient’s HIV status or risk factors

– confidential consented HIV testing of source

171

HIV PEP cont.

• Initiate Pep within 2 hours of exposure, no

longer than 36 hours

• HAART (2 nucleoside analogues with

either a PI or NNRTI) for four weeks

• Baseline CBC, liver enzymes, Hep B & C

serologies

• Confidential HIV baseline within 72 hours

and at 6, 12 and 26 (52 weeks option)

172

BBP Source is a HCW

• Professional obligation to inform patients or

other HCWs

• Post exposure management must be offered

to exposed

• Evaluation of HCWs compliance with IC

Standards

• Assessment of HCWs physical health status

and cognitive function

• Ethical panel for evaluation when needed

www.cdc.gov/HAI/settings/outpatient/checklist/outpat

ient-care-checklist-observations.html

Ten point checklist

1. Hand hygiene

2. Use of PPE

3. Injection safety

4. Point of care testing

5. Environmental cleaning

6. Reprocessing of instruments

7. Sterilization of instruments

8. High level disinfection of

instruments

9. Policies

10.Training

30

Hope You Learned Something

New Today

Special thanks to my colleague- Robin Haag

Barbara A. Smith basmith@chpnet.org

Resources

• APIC www.apic.org

• CDC www.cdc.gov

• Institute for Healthcare Improvement www.ihi.org

• SHEA www.shea-online.org

• TJC www.jointcommission.org

• AHRQ www.ahrq.gov

• CMS Hospitalcompare.hhs.gov

• New York State - search for HAI report

• ADVANCE http://nursing.advanceweb.com

– Look for infection control center

• Articles, references, blogs and quizzes

• Barbara A. Smith, basmithRN@gmail.com