infection control in neonatology pp.al

Infection Control in Infection Control in Neonatology UnitsNeonatology Units

Dr Anjum Hashmi, MBBS,CCS(USA),MPHInfection Prevention & Control Director,

Director Employee's Health,Advisor Quality Management Department

East Najran Hospital Najran, Saudi Arabia

PIONEERS IN INFECTION CONTROLPIONEERS IN INFECTION CONTROL1815 - 1865

Childbed Fever caused by physicians & medical students washing hands with lime water reduced death rates From 18% to <2%

Finding not accepted By peers

1827 - 1912

Using carbolic acid reduced

Nosocomial infections in the

Glasgow General Hospital

Findings well accepted by peers

Joseph ListerIgnaz Semmelweiss

400 - 800BC• Wrote a Treatise on surgery• Used fumigation techniques• Clip nails and hair Clean and flamed surgical instruments

Sushrutha Considered the Father of Surgery Father of Modern Surgery

TYPES OF INFECTIONSTYPES OF INFECTIONSPatient may acquire infection before admission to

an hospital known as Community acquired infection.

Patient may get infected inside the hospital known as Nosocomial infection/Healthcare Associated Infection (HAIs).

They include:1) Infections not present nor incubating at time of

admission 2) Infections that appear more than 48 hours

after admission 3) Infections acquired in the hospital but appear

after discharge 4) Occupational infections among staff

1 : 20 Gets an infection

Of those infected 1 in 20 will die

Risk of Death is 1:400 from a HAI

X

PREVALENCE OF HAIsPREVALENCE OF HAIsDeveloped countries: Even with sophisticated

treatments and technologies, HAIs continues to account for complications in 5-10% of admissions in acute-care hospitals. HAIs are the 4th leading cause of death in the United States today

Developing countries:The impact of HAIs is far greater, prevalence studies report hospital-wide infection rates usually higher than 15%. In developing countries, over 4000 children die of HAIs every day. (WHO 2013)

PREVALENCE OF HAIs PREVALENCE OF HAIs IN NEONATESIN NEONATES

The rates of bloodstream infections among neonates in developing countries are 3–20 times higher than those reported in developed countries.In developing countries, approximately one-half of patients in neonatal ICUs (NICUs) acquire infections, and more than 52% of affected patients die.

• Zaidi AKM, Huskins WC, Thaver D, Bhutta ZA, Abbas Z, Goldmann DA. Hospital-acquired neonatal infections in developing countries. Lancet 2005; 365:1175–88.

• Editorial Commentary • CID 2009:48

CHAIN OF INFECTIONCHAIN OF INFECTION

AIM OF INFECTION CONTROLAIM OF INFECTION CONTROL

Disease transmission can be prevented by breaking one or more of the links in the chain of transmission.

Basic infection control measures, based on reducing the risk of transmission of pathogens from known, or unknown source.

BASICS OF INFECTION CONTROLBASICS OF INFECTION CONTROLHospital Infection Control policies and procedures are applied to prevent spread of infection in hospital. Prevention of HAIs is the responsibility of all individuals and services providers of the healthcare setting.To practice good asepsis, one should know: what is dirty, what is clean, what is sterile and how to keep them separate.

INFECTION CONTROL PRECAUTIONSINFECTION CONTROL PRECAUTIONS

Standard Precautions– Should be applied for ALL patientsTransmission-based Precautions* – Contact – Droplet – Airborne

*Transmission-based precautions are often used empirically, according to the clinical syndrome and the likely etiological agent

POLICIES FOR INFECTION POLICIES FOR INFECTION

CONTROL IN NEONATOLOGY CONTROL IN NEONATOLOGY All Neonatal Care Units staff shall be familiar with the infection control practices that minimized the infection risk in the staff and patients.Strict Hand Hygiene compliance according to WHO 5 moments of hand hygiene.Invasive procedure shall be used cautiously and with appropriate aseptic technique.Handling of neonates shall be minimized.Equipment and supplies should not be shared between infants.Visitor management.

HAND HYGIENE

The Carriers of Top Ten Infectious Diseases Germs

In US 20,000 cases of HAIs are directly related to poor hand hygiene annually.

Ignaz Semmelweis 1815 - 1865

Hand Hygiene – Not a New ConceptHand Hygiene – Not a New ConceptHungarian obstetrician, Ignaz Semmelweis is considered the

father of infection control.He noted that in his ward up to

18% of women died due to puerperal infections K/A “Childbed Fever” after delivery but death rate was less in home delivery cases.

He also noted that doctors & medical students did not wash their hands between patients & after autopsies'.

Hand Hygiene – Not a New Hand Hygiene – Not a New ConceptConcept

Maternal Mortality due to Postpartum Infection

General Hospital, Vienna, Austria, 1841-1850

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MD's Midwives

Semmelweis’ Hand

Hygiene Intervention

He enforced hand washing with lime water before & after patients contact, and the mortality

rate in his ward dropped to 1-2%.

Hand hygiene is the single most effective measure to reduce health care-associated infections

There are five steps in Hand transmission

1. Presence of Germs2. Transmission to Hands3. Survival Germs on Hands4. Defective Hand Hygiene5. Cross Transmission of Germs

Hand TransmissionHand Transmission

Hand Transmission:Hand Transmission:Step 1Step 1

Nearly 1 million skin squames cells containing viable germs sheds daily from normal skin. Patient immediate surroundings (bed linen, furniture, objects) become contaminated (especially by staphylococci and enterococci). Germs present on patients skin

and environmental surfaces

The Lancet Infectious Diseases 2006


Nurses can contaminate hands with 100-1,000 CFU of Klebsiella spp. during “clean” activities (lifting patients, taking the patient's pulse, blood pressure, or oral temperature).

15% of nurses working in an isolation unit carried a median of 10,000 CFU of S. aureus on their hands. Germ transfer on health-care workers’

hands


Hand Transmission: Hand Transmission: Step 3Step 3

Following contact with patients and/or contaminated environment, germs can survive on hands for differing lengths of time (2-60 minutes) In the absence of hand hygiene, the longer the duration of care, the higher the degree of hand contamination

Germs survival on hands



Insufficient amount of soap and/or insufficient duration of hand hygiene leads to poor hand decontamination.Use of alcohol hand rub has been proven more effective for visibly clean hands.


Defective hand cleansing

TYPES OF HAND HYGIENETYPES OF HAND HYGIENE Routine hand hygiene: Washing hands with ordinary soap and warm water for at least 40-60 seconds, then drying with a disposable paper towel. (CDC 2005)

Alcohol-based hand rub 20-30 Sec Can be used instead of hand washing, if hands

are not visibly soiled. (CDC, 2005)

TYPES OF HAND HYGIENETYPES OF HAND HYGIENEAntiseptic hand wash:

An adequate volume of antiseptic soap should be applied to wet skin for at least 60 seconds, and then rinsed and dry hands with a disposable paper towel. (CDC, 2005)

TYPES OF HAND HYGIENETYPES OF HAND HYGIENESurgical hand antisepsis should be performed prior to all surgical procedures, with the aim of removing all transient flora and substantially reducing resident flora.Duration of pre-operative surgical scrub varies between 3 and 5 minutes, as per manufacturers recommended guidelines. (CDC, 2005)

The antiseptic agent used must provide broad-spectrum microbiocidal activity, act rapidly, and persist on the skin over several hours, and ideally also provide a cumulative effect after repeated use.

TYPES OF HAND HYGIENETYPES OF HAND HYGIENESurgical hand antisepsis should be performed prior

to all surgical procedures, with the aim of removing all transient flora and substantially reducing resident flora.Duration of pre-operative surgical scrub varies

between 3 and 5 minutes, as per manufacturers recommended guidelines. (CDC, 2005)

The antiseptic agent used must provide broad-spectrum microbiocidal activity, act rapidly, and persist on the skin over several hours, and ideally also provide a cumulative effect after repeated use.

THE 5 STEPS OF HAND TRANSMISSION

Pittet D et al, Lancet Infect Dis, Oct 2006

5 MOMENTS FOR HAND HYGIENE5 MOMENTS FOR HAND HYGIENE

Clean hands before touching a patient!

To protect the patient against harmful germs carried on HCW hands!

Clean hands immediately after an exposure risk to body fluids and after glove removal)!

To protect HCW and the health-care environment from harmful germs!

Clean hands immediately before an aseptic task!

To protect the patient against harmful germs, including the patient’s own one! Clean hands after touching a

patient and immediate surroundings, when leaving the patient’s side!


Clean hands after touching any object or furniture in the patient’s immediate surroundings, when leaving-even if the patient has not been touched!


The Main Examples of this Indication During The Main Examples of this Indication During Everyday Practice of Health Care?Everyday Practice of Health Care?

Some examples may be:Shaking hands,Helping a patient to move around, Cleaning & washing of patients,Taking pulse, blood pressure, chest auscultation,

abdominal palpation

Some examples may be: Suction of secretion Skin lesion care, Wound dressing, Catheter insertion, Opening a vascular

access system or a draining system

Preparation of medication/dressing sets.


Some examples may be: oral/dental care, giving eye

drops, secretion aspiration Skin lesion care, wound

dressing, subcutaneous injection Drawing and manipulating any

fluid sample, opening a draining system, Endotracheal tube insertion

and removal Cleaning urines, faeces, vomit,

handling waste (bandages, napkin, incontinence pads), Cleaning of contaminated and

visibly soiled material or areas (lavatories, medical or surgical instruments)


Some examples may be: Shaking hands, Helping a patient to

move around, Cleaning & washing of

patients, Taking pulse, blood

pressure, chest auscultation,

abdominal palpation


Some examples may be:

Changing bed linenMonitoring alarm Holding a bed rail Clearing the bedside

table


To effectively reduce germs on

hands, HANDWASHING

must last 40-60 secs

and should be performed by

following all steps illustrated in figure.

Gloves are not substitute hand

washing, it must be done before putting

on gloves

and after their

removal.

FEW FACTSFEW FACTSA surface as small as a pinhead may contain up to 10 million bacteria.Bacteria can double their number in 20 minutes.We can eliminate 90% of germs through proper hand washing.Wet hands spread 60,400 bacteria, while dry hand can only spread 200.Residual moisture left on improperly dried hands is the key factor for

Bacterial Contamination & Transmission. Thus drying of hands is a key factor in reducing the risk of infection and key part of hand hygiene.

To effectively reduce germs on hands,

ALCOHAL HANDRUBBING

must last for 20-30 secs & should be

performed by following all steps

illustrated in figure.Take 2cc of gel, as less

amount dries within 15 secs which is non compliance

REMEMBERREMEMBER

I hope you washed your HANDS

PROCEDURES PROCEDURES USED USED

NEONATOLOGY NEONATOLOGY UNITSUNITS

Techniques Used for Infection Techniques Used for Infection Control Control

Clean TechniqueAseptic TechniqueSterile Technique

All these techniques includes:1. HCW2. Patient3. Environment4. Instrument / Equipment

CLEAN TECHNIQUECLEAN TECHNIQUE Clean technique is used for routine patient care

procedures; e.g., patient exam, taking pulse temperature, BP, feeding, social touch.

1. HCW should use routine hand wash / Alcohol hand rub before & after patient contact.

No need of developing barrier between HCW & patient (CDC & WHO).

2. No skin preparation as patient skin is intact.3. Environment should be clean.4. Instrument / Equipment should cleaned or

disinfected by low level disinfectant.

ASEPTIC TECHNIQUEASEPTIC TECHNIQUE Medical Asepsis is a set of specific practices and

procedures done under carefully controlled conditions mostly out side operation theater, e.g., IM/IV injections.

1. HCW should use antiseptic soap for hand wash / Alcohol hand rub before & after patient contact.

Barrier between HCW hand & patient should be created by using gloves (Non-sterile (CDC)/ sterile).

2. Patient skin needs disinfection by short acting disinfectant like alcohol.

3. Environment should be clean and disinfected.4. Instrument / Equipment should disinfected by high level

disinfectant or sterile.

STERILE TECHNIQUESTERILE TECHNIQUE Surgical Asepsis is used in procedures designed to prevent

bloodstream infection & surgical site infection, e.g., insertion of umbilical line, PICC, Central line, surgeries.

1. HCW should use surgical scrub with antiseptic hand wash solution / Avaguard ( Chlorohexadine 1% w/w in 61% w/w alcohol) hand rub lotion.

Barrier b/w HCW & pt created by using sterile PPE.2. Patient skin needs disinfection by long acting

disinfectant like Chlorohexadine, Pyodine etc.3. Environment: Sterile field should be created.4. Instruments / Equipments should sterile.

ASEPTIC NEONATAL CARE ASEPTIC NEONATAL CARE PRACTICESPRACTICES

Peripheral Venous Catheter ( PVC) Insertion:IV Therapy:Preparation of IV fluids: IV Therapy - Umbilical Catheters:Administration of IV medications/drugs

PERIPHERAL VENOUS CATHETER PERIPHERAL VENOUS CATHETER (PVC) INSERTION (PVC) INSERTION

1) Do aseptic hand wash. 2) Wear sterile gloves

1) Disinfect the skin : Clean 5 cm of the skin at the site, working from inside to outwards, with 2% chlorhexidine / 70% alcohol swab with friction for at least 60 seconds.

2) Leave the site to dry for 30 sec. i ) Do not re-palpate the vein once the skin has

been cleaned. ii) Use no-touch technique.

Use aseptic technique.Establish a specific area for preparation of medications and IV fluids.

1.This area should not be used to store / place any biologic material (e.g., blood, milk formula etc.).

2.All prepared fluids store in fridge at 2-8 C ( Portion of fluid which is not used should to be disposed after 24 hours max.).

IV THERAPY & PREPARATION OF IV THERAPY & PREPARATION OF

IV FLUIDSIV FLUIDS

ADMINISTRATION OF IV MEDICATIONSADMINISTRATION OF IV MEDICATIONS

–Every step must follow strict aseptic techniques–Maintain a closed system at all times.–Do not mix medications together.– If medications are not compatible with IV fluid, do the

following procedure :»Stop the IV fluid first»Flush the cannula with saline solution» Infuse the medication»Flush again» If needed infuse the second medication and flush

again. »Restart the routine IV fluid.

IV THERAPY - UMBILICAL CATHETERSIV THERAPY - UMBILICAL CATHETERS– Insertion of umbilical catheter: Umbilical catheters should be

inserted using sterile techniques.– Replacement of catheters:

» Replace umbilical venous catheters only if the catheter site is infected.

» Remove and do not replace umbilical artery catheters if any signs of CRBSI, vascular insufficiency, or thrombosis are present.

– Catheter-site care:» Clean the site with an antiseptic before catheter insertion. » Do not use topical antibiotic ointment or creams on

umbilical catheter insertion sites. » Umbilical venous catheter can be used up to 14 days if

managed aseptically.

Expression of breast milk may be necessary when a sick infant is unable to suck.Breast milk shall be collected and stored aseptically.Hands shall be washed with an antiseptic and the milk shall be expressed into sterile containers.All breast pump components in contact with milk should be washed with hot soapy water after each use and disinfected daily.Milk must be stored in a refrigerator for no more than 48 hours.

INFANT FEEDING MATERNAL INFANT FEEDING MATERNAL BREAST MILKBREAST MILK

INFECTION CONTROL INFECTION CONTROL PRECAUTIONS PRECAUTIONS

IN NEONATOLOGYIN NEONATOLOGYUNITS UNITS

BARRIER PRECAUTIONS BARRIER PRECAUTIONS Gloves : Single-use gloves are recommended during all patient

contacts (especially with septic neonates) Indication for wearing gloves:

Infants with infectious diarrhea, draining skin lesions, purulent conjunctivitis, infection with rotavirus, hepatitis A, or enterovirus.Care of infants with respiratory viral infections in order to reduce the risk of accidental self-inoculation.Wear sterile gloves before performing invasive procedures and IV fluid preparation. Single use gloves are recommended before any patient’s contact.Change gloves between patients or if gloves are visibly soiled or contaminated even when handling the same patient.

BARRIER PRECAUTIONS BARRIER PRECAUTIONS Gowns: A gown protects the infant from contact

with the wearer’s clothing and prevents contamination of the healthcare worker’s exposed skin with the infant’s flora.A gown shall be worn if a newborn is to be handled outside the incubator where direct contact is expected and invasive procedures are done. A single gown shall be used for one baby.

Gowns are recommended for contacts with infants with certain infections like MRSA.

Newborn delivered in same hospital is admitted in MAIN-NURSERY/ MAIN NICU.

Newborn delivered in same hospital is admitted to ISO-NURSERY or ISO- NICU. If Newborn with clinical or laboratory evidence of infection. Newborn delivered outside is admitted to ISO-NURSERY or ISO- NICU in following situations:

1. Newborn admitted from ER, OPD. 2. Newborn referred from other hospital. In this

case the newborn must be screened for MRSA.

PREVENTION OF TRANSMISSION OF PREVENTION OF TRANSMISSION OF INFECTIONS BETWEEN NEWBORNS INFECTIONS BETWEEN NEWBORNS

SINGLE ROOM ISOLATIONSINGLE ROOM ISOLATIONTo prevent the spread of communicable diseases. Newborn

with documented or suspected infection with communicable or epidemiologically important pathogen.

1- Infants of mothers with parental varicella or varicella, measles, tuberculosis ( Airborne Precaution).

2- Infants with infections with droplet transmission, such as, mumps, meningitis ( Droplet Precautions).

3- Infant with MRSA, MDRO (Contact Precaution).

No visiting time.Visitors should be treated on a individual basis. View babies through the viewing box. If mandatory to enter in the unit allow only parents after rounds with hand hygiene protocol and use protective clothing.

VISITORS MANAGEMENT VISITORS MANAGEMENT

STAFFING NORMSSTAFFING NORMSAdequate staff is mandatory to allow for

hand washing between patients’ contact.

Normal nursery - staffing ratio is: one professional nurse to every 6-8 infants. Intermediate care nursery - staffing ratio is: one professional nurse for ever 2-3 patients. NICU - one professional nurse for every 1-2 patients.

LINEN HANDLINGLINEN HANDLING Ensure that linen handling policy is adhered

to, to prevent cross-infection. Enough clean linen must be made available Clean linen should be transported in covered carts or laundry bags. Soiled linen should be discarded into leak proof yellow bags, taken to the laundry twice daily. Nappy changes should be done wearing disposable rubber gloves to prevent heavy contamination and transient colonization of the hands.

WASTE DISPOSALWASTE DISPOSALHandling and processing infectious waste

Waste must be placed in color coded, leakage proof bags, collected with barrier precautions like gloves.Soiled diapers and medical waste should be collected 3-6 hourly.Proper disposal of sharps to be practiced to prevent needle stick injuries.

NEONATOLOGY UNIT NEONATOLOGY UNIT EMPLOYEE HEALTHEMPLOYEE HEALTH

Personnel allocated to work in neonatology should be immune to rubella, measles, polio and chicken pox. HBV and yearly influenza vaccination should be offered. Proper PPE should be readily available for use, when blood splashes and body fluids spillages are anticipated.Infection safety & sharp disposal to be practiced to prevent needle stick injuries.

THANK THANK YOUYOU

Email: [email protected]

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infection control in neonatology pp.al

Health & Medicine

infection controlpioneers

director employees health

physicians medical students

lime water

childbed fever

saudi arabia

death rates