Dr.T.V.Rao MD 1

Hospital Acquired Infections

Role for Everyone Principles Practice and Prevention

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The very first requirement in

a hospital is that it should do

the sick no harm

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Scientific era continues . . . . .Ignaz Semmelweiss (1818-1865)

• Obstetrician, practised in Vienna

• Studied puerperal (childbed) fever

• Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems

• Reduced maternal mortality by 90%

• Ignored and ridiculed by colleagues

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INFECTION•Definition: Injurious contamination of body or parts of the body by bacteria, viruses, fungi, protozoa and rickettsia or by the toxin that they may produce.

• Infection may be local or generalized and spread throughout the body.

•

our HOSPITALS ARE A BALANCE OF TWO FORCES

Main Sources of Infection• Person to person via hands of health-care providers,

patients, and visitors• Personal clothing and equipment (e.g. Stethoscopes,

flashlights etc.)• Environmental contamination• Airborne transmission• Hospital staff who are carriers • Rare common-source outbreaks

Campaigns to Decrease Infection Rates

•WHO “Clean hands are safer hands” campaign

•Centres for Disease Control and Prevention (CDC) “prevent antimicrobial resistance” campaign in health-care settings

• Institute for Healthcare Improvement (IHI) “5 million lives” campaign• Developing country focus

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Hospital Infection•Hospital infection is also called Nosocomial infection.

• It is the single largest factor that adversely affects both the patient and the hospital

Organization of an infection control programme

• As with all other functions of a health care facility, the ultimate responsibility for prevention and control of infection rests with the health administrator. The hospital administrator/head of hospital should: • Establish an infection control committee which will in turn appoint an infection control team; and provide adequate resources for effective functioning of the infection control programme.

Infection control committee •An infection control committee provides a forum for multidisciplinary input and cooperation, and information sharing. This committee should include wide representation from relevant departments: e.g. management, physicians, other health care workers, clinical microbiology, pharmacy, sterilizing service, maintenance, housekeeping and training services.

Reporting the Matters to whom

?• The committee must have a reporting relationship directly to either administration or the medical staff to promote programme visibility and effectiveness.

The infection control team should:

•A hospital-associated infection prevention manual containing instructions and practices for patient care is an important tool. The manual should be developed and updated by the infection control team and reviewed and approved by the committee. It must be made readily available for health care workers, and updated in a timely fashion.

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Sings of Infection•Once the infectious agent enters the host it begins to proliferate and reacts with the defence mechanisms of the body producing infection symptoms and signs: pain, swelling, redness, functional disorders, rise in temperature and pulse rate and leucocytosis.

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The risk of infection is always present.

• Patient may acquire infection before admission to the hospital = Community acquired infection.

•Patient may get infected inside the hospital = Nosocomial infection.

• It includes infections not present nor incubating at admission, infections that appear more than 48 hours after admission, those acquired in the hospital but appear after discharge also occupational infections among staff.

Cannot autoclave patients

Life is a experience start learningThe TIME IS TICKING

HEALTH CARE ASSOCIATED INFECTION (NOSOCOMIAL)

• Infections that are a result of health care delivery, not present at admission• EXOGENOUS• ENDOGENOUS• IATROGENIC

Refer to Potter & Perry Table 34-2 Pg. 648 (Sites for Causes of HAI’s)

Common Health-Care Associated Infections

•Urinary Tract InfectionSurgical/Traumatic Wound Infection•Respiratory Tract•Bloodstream

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Urinary Catheterization

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Defining a Nosocomial infection• A nosocomial infection (nos-oh-koh-mi-al), also

known as a hospital-acquired infection or HAI, is an infection whose development is favored by a hospital environment, such as one acquired by a patient during a hospital visit or one developing among hospital staff. Such infections include fungal and bacterial infections and are aggravated by the reduced resistance of individual patient

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Leading causes of death 53.9 million from all causes, worldwide

Major Sites of Nosocomial Infections

•Urinary tract infection•Bloodstream infection•Pneumonia (ventilator-associated)

•Surgical site infection

Sources of SSIs• Endogenous: patient’s skin or mucosal flora

• Increased risk with devitalized tissue, fluid collection, edema, larger inocula

• Exogenous• Includes OR environment/instruments, OR air, personnel

• Hematogenous/lymphatic: seeding of surgical site from a distant focus of infection

• May occur days to weeks following the procedure• Most infections occur due to organisms implanted

during the procedure

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When you say Hospital acquired infection

• Infection which was neither present nor incubating at the time of admission

• Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation (Rcn, 1995)

•Also called nosocomial infection

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Sources of Hospital acquired infections

•1.Patients own flora - Endogenous (50%) Autoinfection ( Greatest source of potential danger)2.Environment - Exogenous(15%) (Air-5%; Instruments-10%) 3.Another Patient/Staff - Cross Infection (35%)

Burke J Infection control-a problem for patient safety New Eng Journal of Medicine (February 13, 2003)

Types of Infections

ARE OUR HANDS CLEAN JUST NO

The hands of staff are the commonest vehicles by which microorganisms are transmitted between patients. Hand washing is accepted as the single most important measure in infection

Steps in Hand Washing

What to Use for Hand Washing

Alcoholic hand disinfection is generally used in Europe, while hand washing with medicated soap is more commonly practised in the United States.

What is the Best Soap to wash Hands

Alcohol-based hand rubs are more effective against most bacteria and many viruses than either medicated or non-medicated soaps

CAN I USE THE ALCHOOL HAND WASH

Require less time to use

Result in a significantly greater reduction in bacterial numbers than soap and water in many clinical situations

Cause less irritation to the skin

Can be made readily accessible to HCWs

Are more cost effective

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Three Levels of Infection ControlSanitization – cleaning

and scrubbing instruments and equipment to remove contaminated materials and microorganisms

Disinfection – second level used on instruments and equipments that come in contact with intact mucous membrane

Sterilization – complete destruction of all microorganisms-pathogenic, beneficial, and harmless- surface of instrument

and equipment

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Sanitization Methods

Collecting instruments – place in container with water and neutral pH detergent until you can get to them.

Use utility gloves always and mask, eye protection and protective clothing if blood, body fluids or tissue are present

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Standard Precautions•Apply standard precautions to all patients regardless of their diagnosis, and to all contaminated equipments and materials.

•Use judgment in determining which protective barriers are necessary.

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Scope of Infection Control • Aiming at preventing spread of infection:

• Standard precautions: these measures must be applied during every patient care, during exposure to any potentially infected material or body fluids as blood and others.

• Components:• A. Hand washing.• B. Barrier precautions.• C. Sharp disposal.• D. Handling of contaminated material

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1st principale of infection prevention

at least 35-50% of all healthcare-associated infections are asociated with only 5 patient care practices:

•Use and care of urinary catheters

• Use and care of vascular access lines• Therapy and support of pulmonary functions• Surveillance of surgical procedures• Hand hygiene and standard precautions

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Healthcare-Associated Urinary Tract Infection

• Urinary tract infection (UTI) causes ~ 40% of hospital-acquired infections

• Most infections due to urinary catheters

• 25% of inpatients are catheterized

• Leads to increased morbidity and costs

Nurses should be Familiar INTERVENTIONS• ISOLATION PRECAUTIONS

• HYPERTHERMIA INTERVENTION• ELIMINATE UNDERLYING CAUSE• FEVER MANAGEMENT

• HEALTH TEACHING• ANTIBIOTIC THERAPY• PSYCHOSOCIAL SUPPORT• HEALTH CARE RESOURCES

Read Manuals on Isolation Precautions

• CDC and OSHA Guidelines on

1. Contact

2. Droplet

3. Airborne

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Why Hand Washing

Impression of my Hand Showing the Growth of Bacteria

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HAND WASHING• Proper hand washing is the single

most important way to prevent and reduce infections

• Wash and rinse hands for 15 seconds, using a dry paper towel to turn off faucet

• Alcohol based hand wash is also available in all patient care areas

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Hands should be washed:•Before and after patient contact•Before putting on gloves and after taking them off

•After touching blood and body substances (or contaminated patient-care equipment), broken skin, or mucous membranes (even if you wear gloves)

•Between different procedures on the same patient

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HAND WASHINGHand washing is the single most effective precaution for prevention of infection transmission between patients and staff.

Hand washing with plain soap is mechanical removal of soil and transient bacteria (for 10- 15 sec.)

Hand antisepsis is removal & destroy of transient flora using anti-microbial soap or alcohol based hand rub (for 60 sec.)

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Methods in Hand Washing • Surgical hand scrub: removal or destruction of transient flora and reduction of

resident flora using anti-microbial soap or alcohol based detergent with effective rubbing (for least 2-3 min)

• Our hands and fingers are our best friends but still could be our enemies if they carry infective organisms and transmit them to our bodies and to those whom we care for.

•Sinks & soap must be found in every patient care room. Doctors, nurses must comply to hand washing policy.

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Children too are at Risk from Hospital Infections.

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Hand Hygiene TechniquesMany Ways

1. Alcohol hand rub

2. Routine hand wash 10-15 seconds

3. Aseptic procedures 1 minute

4. Surgical wash 3-5 minutes

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Risk Reduction: Antimicrobial Pre-Operative Shower

Chlorhexidine Gluconate – Primary choiceIodophoresHexachlorophene

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Barrier Precautions 1. Gloves: Disposable gloves must be worn when: a) Direct contact with B/BF is expected. b) Examining a lacerated or non-intact skin e.g wound dressing.

c) Examination of oropharynx, GIT, UIT and dental procedures.

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Barrier Precautions d) Working directly with contaminated instruments or equipment.

e) HCW has skin cuts, lesions and dermatitis

Sterile gloves are used for invasive procedures.

GLOVES MUST BE of good quality, suitable size and material. Never reused.

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Barrier Precautions•Masks & Protective eye wear:

• MUST BE USED WHEN: engaged in procedures likely to generate droplets of B/BF or bone chips

• During surgical operations to protect wound from staff breathings, …

• Masks must be of good quality, properly fixed on mouth and nasal openings.

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Barrier Precautions• 3) Gowns/ Aprons:• Are required when:• Spraying or spattering of blood or body fluids is anticipated

e.g surgical procedures.• Gowns must not permit blood or body fluids to pass through.• Sterile linen or disposable ones are used for sterile

procedures.

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What to do if exposed to blood / body fluids•Puncture wounds should be washed immediately and the wound should be caused to bleed

• If skin contamination should occur, wash the area immediately

•Splashes to the nose or mouth should be flushed with water

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If Exposed•Eye splashes require irrigation with clean water, saline, or a sterile irritant

•Most importantly: Complete a GBMC Employee Incident Report. Report exposure to charge nurse and Agency immediately

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Sharp precautions• Needle stick and sharp injuries carry the risk of blood

born infection e.g AIDS, HCV,HBV and others.• Sharp injuries must be reported and notified•NEVER TO RECAP NEEDLES• Dispose of used needles and small sharps

immediately in puncture resistant boxes (sharp boxes).

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Do not Recap Needles A threat to LIFE

Dr.T.V.Rao MD' TMC Kollam Kerala

Protecting Yourself from Blood-Borne Pathogens

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Aseptic technique• Sepsis - harmful infection by bacteria• Asepsis - prevention of sepsis• Minimise risk of introducing pathogenic micro-organisms into susceptible sites

• Prevent transfer of potential pathogens from contaminated site to other sites, patients or staff

• Follow local policy of your hospital

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Isolation• Single room or group• Source or protective• Source - isolation of infected patient

• mainly to prevent airborne transmission via respiratory droplets

• respiratory MRSA, pulmonary tuberculosis• Protective - isolation of immune-suppressed

patient (May, 2000)• Significant psychological effects (Davies et

al, 1999)

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Linen handling and disposal• Bed making and linen changing techniques

• Gloves and apron - handling contaminated linen

• Appropriate laundry bags• Avoid contamination of clean linen• Hazards of on-site ward-based laundering• NHS Executive guidelines (1995)• Follow local policy of your hospital

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Waste disposal• Clinical waste - HIGH risk

• potentially/actually contaminated waste including body fluids and human tissue

• yellow plastic sack, tied prior to incineration• Household waste - LOW risk

• paper towels, packaging, dead flowers, other waste which is not dangerously contaminated

• black plastic sack, tied prior to incineration• Follow local policy of your Hospitals

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Spillage of body fluids• PPE - disposable gloves, apron• Soak up with paper towels, kitchen roll• Cover area with hypochlorite solution e.g.,

Milton, for several minutes• Clean area with warm water and detergent,

then dry• Treat waste as clinical waste - yellow plastic

sack• Follow local policy (May, 2000)

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Environmental cleaning• Recent concern regarding poor hygiene in

hospital environments (NHSE, 1999)• Some pathogens survive for long periods in

dust, debris and dirt• Poor hygiene standards - hazardous to

patients and staff (May, 2000)• Report poor hygiene to Domestic Services

(UKCC, 1992)• “Hospitals should do the sick no harm”

(Nightingale, 1854)

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Risk assessment• No risk of contact/splashing with blood/body

fluids - PPE not required• Low or moderate risk of contact/splashing -

wear gloves and plastic apron• High risk of contact/splashing - wear gloves,

plastic apron, gown, eye/face protection (Rcn, 1995)

• Cerebrospinal fluid, peritoneal fluid, pleural fluid, synovial fluid, amniotic fluid, semen, vaginal secretions, and

• Any other fluid containing visible blood e.g., urine, faeces (Rcn, 1995)

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In spite many developments in medicine and asepsis hand washing still the best solution

Hand hygiene is the simplest, most effective measure for

preventing hospital-acquired infections.

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Ways to overcome the nosocomial infections

•Besides, hospitals need to have infection control committees to conduct outcome and process surveillance for nosocomial infections. This committee should meet regularly and publish the results of their surveillance. At the same time, healthcare institutions should adopt new and better technology, like closed system IV fluids, in order to reduce the rates of infections.

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Basic hygiene is key to control infections

• Ignaz Semmelweis in 1847 demonstrated that washing hands saves lives

• Old bacteria are causing new problems• New viral and prion diseases are causing new problems

• Reluctance to wash hands still the single most important cause of HAI (ICNA, 1998)

•Growing concern about poor hospital hygiene

Nurses should be familiar with Surveillance Activities

• Operative Procedures• Critical Care Units (MICU,

SICU, NICU)• Targeted Surveillance• Outbreak Investigation

Benchmarking Hospital Acquired Infections

•CDC’s Hospital Infections Program•Submit monthly data on ICU infections•Benchmarking with similar hospitals•Networking opportunities•Annual reports•Start having a Infection Audit

Surveillance DataImproves the Patient Safety • USES

• Improve patient outcomes by• modifying patient care

practices• reducing length of stay

• Identify education needs• Evaluate new products• Identify new opportunities

for improvement

Nurses should Evaluate their Outcome • MEASURE SUCCESS OF

INFECTION CONTROL TECHNIQUES

• COMPARE PATIENT’S RESPONSE TO ACTUAL OUTCOME

• WHAT WILL YOU DO IF GOAL/OUTCOMES NOT ACHIEVED?

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Our Hands are Threat to LIFEJust Washing can Save Many LIVES

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Let us support our hospitals with clean hands

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Soap Water and Common sense are Best Antiseptics- William Osler

WE ARE ALL RESPONSIBLEINFECTION CONTROL

I am thankful to every one at Kinder Hospital Cherthala

Alappuzha Kerala