hospital aquired infections and infection control in a healthcare setup
TRANSCRIPT
HOSPITAL AQUIRED INFECTIONS &
INFECTION CONTROL IN A HEALTH CARE SETUP
Dr. SUMI NANDWANI
Goals of Infection Control Training
• Ensure that health professionals understand how pathogens can be transmitted in the work environment (patient to healthcare worker, healthcare worker to patient and patient to patient )
• Apply current scientifically accepted infection control principles
• Minimize opportunity for transmission of pathogens to patients and healthcare workers
Points to be discussed …………
History of HygieneOverview : Hospital Aquired infections (HAI)Other definitionsPublic Health Importance, ConsequencesSources, Routes of Transmission & Factors influencing HAISites and Criteria for HAIControl of HAITake Home Message
History of Hygiene
Greek Era : Aristotle recommended Boiling water to armies. Advised the Alexander
Semmelweis: Practiced & emphasizes the importance of washing hands with chlorinated water in Obstetrics to reduce maternal mortality
Historical Aspects Changed the History
1867 –Dr. Joseph Lister first identifies airborne bacteria and uses Carbolic acid spray in surgical areas
1880 – Johnson and Johnson introduce antiseptic surgical dressings.
Reduction of Hospital associated infections
Mortality reduced Morbidity reduced
What are Hospital Acquired Infections ? (Nosocomial Infections,
Health Care Associated Infections) Any infection that is not
present or incubating at the time the patient is admitted to the hospital
This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility
Other definitions Community Acquired Infection An infection Present or Incubating at the time of admission to a health care facility without any association to previous hospitalization at the same facility
Colonization The presence of microorganism in or on a host, with growth and multiplication but without tissue invasion or damage ContaminationThe presence of microorganism on inanimate objects (Clothing, surgical instruments, water, food, milk ) or in substances
Public Health Importance
Major public health problem Incidence- 2% to 12% in the developed countries The overall incidence in various hospitals in India
varies between 10-20% (inadequately reported/ under reported)
The incidence depends on type of hospital, type of patients and the type of surgeries performed.
Consequences of Hospital Infections Prolongs hospital stay. An estimated 1 to 4 extra days for a urinary
tract infection, 7 – 8 days for a surgical site infection, 7 – 21 days for a blood stream infection, and 7 – 30 days for pneumonia.
Extra expenses US$5 billion are added to US health costs every year as a result of NI
The patient suffers bodily mentally and economically. Increase in mortality rate Law suits Technical competence of experienced doctors turned into disaster Quality of care suffers and it leads to bad public image Infected patients are twice as likely to die, twice as likely to spend time
in ICU and five times more likely to be readmitted after discharge
Source of HAI Endogenous : normal flora of the patient- About 50% of
N.I.
Exogenous :
1. Other patients and environment
2. Hospital personnel (surgical team/staff)
3. Inanimate objects-Tools, instruments, and materials used
4. Seeding from distant focus of infection (prosthetic device,
implants)
Good infrastructures do not mean a safe environment
Routes of TransmissionTransmission Contact Transmission
Direct Indirect
Droplet Transmission Airborne Transmission Common Vehicle Transmission(uncommon) Vector-borne Transmission (uncommon)
Factors Influencing H.A.I.
The microbial agent
Patient susceptibility
Environmental factors
ª Urinary tract infection: most common type of N I (30-40% of reported cases), associated with an indwelling urinary catheter or instrumentation.
ª Lower respiratory and surgical wound infections are the next ( each about 15%).
ª Less frequent include bacteraemia (5%), intravenous site infection, gastrointestinal tract and
skin infections.
Nosocomial Infection Sites
Criteria of Nosocomial InfectionsSurgical site infection Any purulent discharge, abscess or
spreading cellulitis at the surgicalsite during the month after operation
Urinary infection Positive urine culture (1 or 2species) with at least 100000bacteria/ml, with or without clinicalsymptoms
Respiratory infection Respiratory symptoms with at least2 signs: cough; purulent sputum;new infiltrate on chest, appearingduring hospitalization
Vascular catheterinfection
Inflammation, lymphangitis orpurulent discharge at the insertionsite
Septicaemia Fever or rigours and at least onepositive blood culture
The chain of infection.
Source of infection
Method of spreading
Person at risk Point of entry
Breaking this chain by removing any part of it will control or stop the spread of infection
Control of Hospital Infections
Infection control is an essential component of care and one which has too often been undervalued
Prevention of HAI require a multifaceted approach
Three main principles : Remove source of infection Block route of transfer Increase in resistance of host
To prevent infection, one must break the chain of
infection.
Thus the Control may be through:
General measures Special Control measures Infection Control Organisation in Hospitals Surveillance and control programmes Prevention of infections like HIV, Hepatitis B,C in
Health Care setting and Health care workers Proper management of waste in hospital
General Measures
Personal hygiene Standard Precautions Environmental sanitation Efficient house keeping services Provision of ancillary facilities (Good and efficient CSSD,
Mechanised laundry, waste disposal , Minimum handling of food , Isolation and reverse isolation facilities, Procedure manuals, Regular health check-up of the workers, Check on visitors)
Personal hygiene
The most important person in this organisation is
YOU.
You get it right and both you and the organisation will meet all the legal requirements.
You get it wrong and someone could become ill: That someone could be YOU.
Isolation Precautions (CDC Recommendations)
Four types of precautions, evidence-based recommendations based on the mode of transmission of the organism known or suspected to be present. 1.Standard PrecautionsTransmission Based Precautions: 2.Contact Precautions3. Airborne Precautions4. Droplet Precautions
Standard - Apply for Blood, All body fluids, Non-intact skin, Mucous membranes
Transmission-Based Precautions-Contact Precautions- Apply for Gastrointestinal, respiratory,
skin, or wound infections, Skin infections that are highly contagious
Airborne Precautions- Apply to Tuberculosis ,Measles, Varicella (including disseminated zoster) ,
Droplet Precautions- Apply to Haemophilus influenzae type b, Neisseria meningitidis, Diphtheria (pharyngeal), Mycoplasma pneumonia, Pertussis, Pneumonic plague, Streptococcal,, pharyngitis, pneumonia, or scarlet fever, Serious viral infections eg. Adenovirus , Influenza, Mumps, Parvovirus B19, Rubella
These guidelines were developed for hospitalized inpatients, and the principles can be applied in outpatient settings
Standard PrecautionsStandard Precautions are to be used with all patients, regardless of diagnosis. formerly known as Universal Precautions#1: Handwashing#2: Gloves#3: Mask, Eye Protection, Face Shield#4: Gown# 5: Patient-care Equipment#6: Environmental Control#7: Linen#8: Sharps#9: Ventilation Devices#10: Patient PlacementAll our patients should be treated as though they have potential blood born infections
#1: Handwashing
Hand hygiene is still the single most important procedure for preventing the spread of infection!
(Wash hands with plain soap or waterless antiseptic agent, alcohol-based product)
Words of Wisdom on HandWashing
Soap, water and Common sense are still
the Best Antiseptics
William Osler
2,3,4- Personnel safety devicesThe use of protective gears should be made mandatory
for all the personnel if chances of contact with Blood or Body fluid is anticipated/inevitable
# 5: Patient-care EquipmentClean or reprocess reusable equipment
before using it for the care of another patient.
Ensure that single- use items are discarded properly.
# 6: Environmental ControlRoutine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces. #7: LinenHandle, transport, and process used linen soiled with blood or body fluids
#8: Sharps All used needles and sharps should be
deposited in puncture resistant containers. Bending, Reshaping, should be prohibited. Do not recap the needles . All used Disposable syringes and needles
should be discarded into Bleach solution at the work station before final disposal.
DISPOSAL OF USED NEEDLES AND SYRINGESOF SHARPSDestroy
needle
Cut syringe tip
Decontaminate in twin bucket having 1% bleach
SHARPS including catheter guide wires
Dealing with Needle stickInjuries Consider all Needle stick injuries as a serious health
hazard in the era of AIDS
All events of Needle stick injuries to be reported to the supervisory staff.
Wash the injured areas with soap and water.
Encourage bleeding if any.
Prophylaxis for prevention of HIV/HBV is top priority.
Risk of Transmission – Blood borne viruses
Human immunodeficiency virus (HIV) Percutaneous exposure 0.33%Mucocutaneous 0.09%
Hepatitis B virus (HBV)Percutaneous exposure
sAg 1 – 6%eAg 22 – 31%
Hepatitis C virus (HCV)Percutaneous exposure 1.9%
#9: Ventilation DevicesUse mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods.
#10: Patient PlacementPlace a patient who contaminates the environment in a private room.
Special Measures Proper planning of OTs and monitoring of its
functioning Monitoring Functioning of Nurseries and ICUs Isolation facilities, daily washing, asepsis Infection Oriented training to hospital staff to
assess the standards of asepsis, personal hygiene and cleanliness
ORGANIZATION
Hospital administrator/head
should establish
ICC (provides resources for ICP)
ICT
IC OfficerIC Nurse Microbiologist
Hospital Surveillance and Control Programme
Weekly Report
OPD Reports
Bacteriological Reports
Discharge Reports
Personal Clinics
Ward Visits Autopsies
Training Programm
e
Regular Reports
Infection Committee
Investigations
CONTROL
Handling , Operating on HIV/High risk groups
It is a concern - all should be cared equally. Law may not change for equality but motivated
health workers should bring in change of attitude. Adherence of Universal Health precautions
bring in safety to all HCW. Follow the precautions even in Non HIV patients as
some of our patients are in window period and more dangerous than truly positive with Sero testing.
We handle so many patients in emergency situation with out any details.
Post Exposure Management
Managing the siteCounselingVaccine and prophylaxis
Post Exposure Management HBV
In susceptible HCWs who have never been immunized, the HBV vaccine series and one dose of HBIG at 0.06 ml/kg should be immediately administered.
Exposures to nonresponders and hyporesponders to the HBV vaccine require HBIG at the time of exposure
Routine follow up should include anti-HBs, anti HBc, HBsAg, and liver functions tests with repeat at 1 and 6 months.
The HCW should be instructed to be aware of the signs and symptoms of acute hepatitis
Importance of Vaccination in Hepatitis B Infection.
We have > 400 Million carriers with Hepatitis B infections. Every HCW is at risk of infection. Vaccination is safe - great hope for prevention All HCW’s must take at least three doses of Vaccine, At 0
– 1 – 6 months High risk HCW’s should undergo estimation of anti HB s
( antibodies ) to know whether they were well protected.
Never forget to take Hepatitis B Vaccine if You are a HCW
Post Exposure Management of HIVHIV PEP Evaluation
Exposure Status of Source
HIV+ andAsymptomatic
HIV+ andClinically symptomatic
HIV status unknown
Mild Consider 2-drug PEP Start 2- drug PEP Usually no PEP or consider 2-drug PEP
Moderate Start 2-drug PEP Start 3- drug PEP Usually no PEP or consider 2-drug PEP
Severe Start 3-drug PEP Start 3- drug PEP Usually no PEP or consider 2-drug PEP
Handling of Spills & Surface Disinfection
• Notify people in the area• Don appropriate PPE• Place absorbent material on spill• Apply appropriate disinfectant 1% hypochlorite– min contact time (30 min)
• Pick up material; dispose • Reapply disinfectant and wipe• For large/high hazard spills use 5 % hypochlorite
CATEGORIES OF BIO-MEDICAL WASTECategory
Waste type
Colour coding
Treatment & Disposal
1. Human anatomical
Yellow Incineration / deep burial
2. Animal waste Yellow Incineration / deep burial
3 Microbiology & Biotechnology Waste
Yellow/ Red Autoclaving/microwaving/ Incineration
4 Waste Sharps White / blue / Translucent puncture proof containers
Disinfection by chemical treatment/autoclaving/ Microwaving & mutilation/shredding
5 Discarded medicines and Cytotoxic drugs
Black Destruction/ neutralization & disposal in secured landfills
Category
Waste type
Colour coding Treatment & Disposal
6 Soiled waste
Yellow/red Incineration / autoclaving/ microwaving
7 Solid ( plastic)
Blue/ White/ Red Disinfection by chemical
treatment/autoclaving/ Microwaving & mutilation/shredding
8 Liquid waste
------- Disinfection by chemical treatment and discharge into drains
9 Incineration Ash
Black Disposal in municipal landfill
10 Chemical Black Chemical treatment and discharge into drains for liquids and secured landfill for solids
Prevention of Urinary tract InfectionCDC: Guideline for prevention of catheter-associated urinary tract infections 2009
Avoid catheterization Use intermittent catheterization Decrease duration of catheterization Insert catheters aseptically Maintain a close sterile drainage system Use condom catheter in cooperative patients Maintain gravity drainage Apply topical meatal antimicrobials in women Separate infected and non-infected patients
Prevention of Surgical site infections Pre-operative
Intra-operative
Post-operative
Preoperative preventive measures
Preparation of the patient
Hand/ forearm antisepsis for surgical team
Antimicrobial prophylaxis
Intra-operative preventive measures
Ventilation Cleaning & disinfection of surfaces Sterilization of surgical instruments Surgical attire & drapes Asepsis & surgical technique Normothermia and glucose control
Post-operative incision care
Protect with a sterile dressing for 24-48 hrs
Wash hands before & after dressing changes & any
contact with the surgical site
Use aseptic technique when an incision dressing
must be changed
Prevention of ventilator associated pneumonia
• Standard Precautions (Hand hygiene, Gloving)• Aseptic technique for performing or changing tracheostomy
tube• Sterile fluid to remove secretion• Sterile single use catheter if open system suction• Elevation of the head end of bed 30°-45°
• Care of oral cavity• Sedation vacation• Spontaneous breathing trial• Oral access to trachea and stomach• EVAC tube for drainage of subglottic secretion
Prevention of Blood Stream InfectionsCDC: Guidelines for the Prevention of Intravascular Catheter-
Related Infections, 2011
Hand hygiene Maximal barrier precautions Chlorhexidine skin antisepsis Optimal catheter site selection, with Subclavian
vein as the preferred site for non-tunneled catheters in adults
Daily review of line necessity with prompt removal of unnecessary lines
Line secure and dressing clean and intact
Staff health promotion and education:
1. HCW are at risk of acquiring infection, they can also transmit infection to patients and other employee.
2. Employee health history must be reviewed, immunizations recommendations to be considered.
3. Release from work if sick, occupation injury must be notified.4. Continuous education to improve practice, better
performance of new techniques.
Infection Controlis
Responsibility Of
Everyone
Take Home Message
ALL Hospitals should implement Infection
Control Program
References Principles, And Practices of Disinfection, Preservation and Sterilization by A.D.Russel, W.B.Hugo & G.A.J Ayliffe. www.cdc.gov/cdc.htm www.cdc.gov/ncidod/dhqp/gl_isolation.html. www.his.org.uk www.ific.narod.ru WHO : Prevention of Hospital aquired infections. A practical guide. 2nd ed. 2002. Computational Fluid Dynamics Applications in Hospital Ventilation Design. The Australian Hospital Engineer 2003; 26(1):35-40. Nosocomial Infections, Burke JP. N Engl J Med. 2003;348:651-656. The direct medical costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention, 2009, R.
Douglas Scott II, CDC. CDC: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 CDC: Guideline for prevention of catheter-associated urinary tract infections 2009 CDC: Guideline for prevention of Surgical Site Infections, 1999
Dr. SUMI NANDWANI Associate Professor, Microbiology, E.S.I.C-P.G.I.M.S.R and Hospital,
Basaidarapur, New Delhi E Mail [email protected]