Nosocomial Infection ----Prevention and control

1. Nosocomial Infection----Prevention and control Wang kefang（王克芳） wangkf@sdu.edu.cn

2. Contents Concepts Principals of Aseptic Technique Aseptic Techniques 教学目标 解释术语：无菌区、非无菌区、无菌物品 掌握无菌技术的原则 熟练掌握无菌技术的基本操作 4 Aseptic Technique

3. Concepts • Aseptic technique • the practices which prevent microorganisms invading human beings, sterile objects and areas from being contaminated during medical procedures and nursing interventions. Aseptic Technique

4. Principals of Aseptic Technique • Environment requirement • Staff preparation • Distinguish different areas • Item management • Aseptic concept during procedures Aseptic Technique

5. Environment requirement • The environment should be clean, spacious, and disinfected routinely. • The Operating table is clean, dry, and flat and the layout is rational • stop cleaning the surroundings 30 minutes before the procedures, and minimize moving to prevent dust from floating. Aseptic Technique

6. Staff • Wearmask and cap, trim fingernails and perform hand hygiene before aseptic procedures. • Wearsterile gown and sterile gloves if necessary. Aseptic Technique

7. Distinguish different areas • Aseptic area • refers to the sterile area which has not been contaminated. • Non-aseptic area • is a non-sterilized area or an area having been sterilized but being contaminated again. • Aseptic supply • is an aseptic item physically or chemically sterilized. Aseptic Technique

8. Item management Aseptic supply is an aseptic item physically or chemically sterilized. • Place aseptic supplies and non-aseptic supplies separately and have distinct label. • Keep aseptic supply in sterile package or container. • Label sterile packages with name, expiration date accurately. Valid time :7 days/14days/1month • A set of aseptic supply is only for a client to use once. Aseptic Technique

9. During Procedures • Keep the body away from the aseptic area during procedures. • Face sterile area during procedures. • Use sterile transfer forceps to fetchsterile items • Keep hands and arms above the waist level. Aseptic Technique

10. During Procedures • Keep the body away from the aseptic area during procedures. • Face sterile area during procedures. • Use sterile transfer forceps to fetchsterile items • Keep hands and arms above the waist level. • Once taken out of the container, aseptic supplies can not be put back even not be used. • Do NOT talk, laugh, cough or sneeze over a sterile field. • When in doubt about the sterility of a package, or consider it contaminated, re-sterilize the items. Aseptic Technique

11. Aseptic Techniques • Apply Sterile Transfer Forceps • Apply Sterile Container • Use Sterile Package • Prepare Sterile Treatment Tray • Pour Sterile Solution • Don and Remove Sterile Gloves Aseptic Technique

12. Do you know how to protect yourself and others from infection? Isolation Do you know what to do if you come in contact with blood?

13. Concepts • Isolation • Using a variety of methods, techniques, and measures to prevent pathogens transmission from patients and carriers. • 采用各种方法、技术，防止病原体从患者及携带者传播给他人的措施。 卫生部医院隔离技术规范 2009 Isolation

14. Concepts • Clean area • the area not contaminated by pathogens • such as treatment room, Nutrition pantry and pharmacy. • Potentially-contaminated area • the area that is potentially contaminated by pathogens • like office, laboratory and disinfection room. • Contaminated area • the area contaminatedby pathogens which is in contact with clients directly and indirectly • such as ward, clients’ restroom and bathroom. Isolation

15. Isolation Principle • 在标准预防(Standard Precautions)的基础上，结合疾病的传播途径制定相应的隔离预防措施(Transmission-based precautions) 。 • 隔离病室应有隔离标志，并限制人员的出入。 Airborne Precautions Droplet Precautions Contact Precautions • 传染病/可疑传染病患者应安置在单人隔离房间。 • 受条件限制的医院，同种病原体感染的患者可安置于一室 • 建筑布局合理，符合有关规定。 卫生部医院隔离技术规范 2009

16. Infectious Agent Contact Droplet Airborne Direct Indirect Droplet Nuclei Hands Injection Equipment/ Environment Insect/ Animal

17. Isolation measures ----标准预防（Standard  Precautions） ----基于传播途径的隔离 （ Transmission-based precautions）

18. A quick recap how isolation precautions evolved over time

19. HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS

20. HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS contd--

21. WHAT ARE STANDARD PRECAUTIONS? Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered ---- America CDC in 1996 and updated in 2007 (Siegal JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007)

22. All healthcare workers MUST..... • Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting. • Apply a set of work practices to • Blood • all body fluids (except sweat) • mucous membranes • non intact skin.

23. Key Components of Standard Precautions Hand hygiene Patient placement PPE Standard Precautions C&D Respiratory hygiene Waste Management Safe injection Linen & laundry

24. Cover the nose/mouth when coughing or sneezing Perform hand hygiene if contact respiratory secretions and contaminated objects Put on a surgical mask Recommendation for all individuals with respiratory symptoms Respiratory hygiene and cough etiquette • Use tissue paper to contain respiratory secretions and dispose in the waste receptacle

25. Key Components of Standard Precautions Hand hygiene PPE Patient placement Standard Precautions C&D Respiratory hygiene Waste Management Safe injection Linen & laundry

26. Personal Protective Equipment(PPE) specialized clothing or equipment worn by an employee for protection against infectious materials PPE Use in Healthcare Settings

27. Types of PPE Used in Healthcare Settings • Gloves – protect hands • Gowns/aprons – protect skin and/or clothing • Masks and respirators– protect mouth/nose • Goggles – protect eyes • Face shields – protect face, mouth, nose, and eyes

28. PPE for Standard Precautions: Based on Risk Assessment • IF direct contact with blood & body fluids, secretions, excretions, mucous membranes, non-intact skin • Gloves • Gown • IF there is the risk of spills onto the body and/or face • Gloves • Gown • Face protection (mask plus eye protection goggle; face shield)

29. What Type of PPE Would You Wear? ? • Drawing blood from a vein? • Gloves • Responding to an emergency where blood is spurting? • Gloves, fluid-resistant gown, mask/goggles or a face shield • Cleaning an incontinent patient with diarrhea? • Gloves / gown • Irrigating a wound? • Gloves, gown, mask/goggles or a face shield • Giving a bed bath? • Generally none • Suctioning oral secretions? • Gloves and mask/goggles or a face shield – sometimes gown • Transporting a patient in a wheel chair? • Generally none • Taking vital signs? • Generally none

30. Isolation measures ----Standard  Precautions Should be applied for ALL patients ----Transmission-based precautions • Contact • Droplet • Airborne *Transmission-based precautions are often used empirically, according to the clinical syndrome and the likely etiological agent

31. All healthcare workers MUST..... • Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting. • Apply a set of work practices to • Blood • all body fluids (except sweat) • mucous membranes • non intact skin.

32. Contact Precautions 耐甲氧西林金黄色葡萄球菌-MRSA 耐万古霉素肠球菌-VRE 产超广谱β-内酰胺酶-ESBLs细菌 多重耐药铜绿假单胞菌-MDR-PA • 经接触传播疾病如肠道感染、多重耐药菌感染、皮肤感染等的患者 • 在标准预防的基础上，还应采用接触隔离措施

33. Contact Precautions ----患者的隔离 • Limit patient contact with non-infected persons • Place patient in a single room or cohort with similar patients • Limit transportation 患者接触过的物品 • 可重复使用的（被单、衣物） 灭菌-清洁-消毒-灭菌 • 无保留价值的：焚烧处理

34. Contact Precautions ----医务人员的防护(2-1) • Use disposable, gown or apron 进入隔离病室，戴口罩、帽子，从事可能污染工作服的操作时，应穿隔离衣；离开病室前，脱下隔离衣，按要求悬挂，每天更换清洗与消毒;或使用一次性隔离衣。 接触甲类传染病穿脱防护服。 鼠疫 霍乱 H1NI SARS

35. Contact Precautions ----医务人员的防护(2-2) • Use disposable gloves 接触隔离患者的血液、体液、分泌物、排泄物等物质时，应戴手套；离开隔离病室前，接触污染物品后应摘除手套，洗手/手消毒。手上有伤口时应戴双层手套。

36. Airborne Precautions • 病原微生物经悬浮在空气中的微粒-气溶胶来传播的疾病如肺结核、水痘等 • 在标准预防的基础上，还应采用空气隔离措施。

37. Airborne Precautions ----患者的隔离 • Use surgical mask • Place patient in a single room or cohort with similar patients • Limit patient movement • Room ventilation or disinfect

38. Airborne Precautions ----医务人员的防护 • Use a particulate respirator(医用防护口罩)when entering the patient isolation room； 进行可能产生喷溅的诊疗操作时，应戴防护目镜或防护面罩，穿防护服 当接触患者及其血液、体液、分泌物、排泄物等物质时应戴手套。

39. Droplet Precautions • 接触经飞沫传播的疾病，如百日咳、白喉、流行性感冒、病毒性腮腺炎、流行性脑脊髓膜炎等 • 在标准预防的基础上，还应采用飞沫隔离措施。

40. Droplet Precautions ----患者的隔离 • Use surgical mask； • Limit patient movement。 • Maintain a distance ≥ 1 meter between infectious patient and others • Place patient in a single room or cohort with similar patients • Room ventilation or disinfect

41. Droplet Precautions ----医务人员的防护 • Use a mask when < 1 m of patient 进行可能产生喷溅的诊疗操作时，应戴护目镜或防护面罩，穿防护服； 当接触患者及其血液、体液、分泌物、排泄物等物质时应戴手套。

42. 保护性隔离----反向隔离（protective isolation） • 适用范围 • 抵抗力低下或极易感染的患者，如严重烧伤、早产儿、白血病、脏器移植及免疫缺陷患者等。

43. 保护性隔离措施 患者 工作人员 家属访客 环境管理 单间隔离，有条件可放在正压病房 注意口腔卫生，采用洗必泰漱口，每天至少4次 尽量不与其他无关人员接触 严格执行手卫生规范 正确穿戴口罩、帽子、隔离衣（接触患者面为清洁面） 患感染性疾病期间，不得进入隔离室 无关人员不得进入隔离室 治疗、护理应有计划的集中进行，减少出入室的次数 不进入隔离室内探视。必要时应做好手卫生并戴口罩 疑患感染时，不得探视 不得携带鲜花、宠物入室 保证隔离室内压力高于走廊 定期对室内环境进行消毒。

44. Terminal Disinfection • Terminal disinfection of theclient • Terminal disinfection of the ward Isolation

45. Terminal disinfection of the client • Transferred to other wards or discharged • bathe the clients and wear clean clothes • take their personal items with them after disinfection. • For the dead client • clean the body with disinfectant and plug the mouth, nose, ears, anus with sterile cotton, change wound dressing, envelop the body with disposable linen. Isolation

46. Terminal disinfection of the ward • Close the doors and windows, open bedside table, spread the quilt and place the mattress vertically on the bed, fumigate them with disinfectant or disinfect by ultraviolet light. • Then open the door and windows • furniture and floor: rubbing • Thermometer: immersion • Blood-pressure meter and stethoscope: fumigation • Mattress, quilt and pillows: ultraviolet light. Isolation

47. Isolation techniques • Hand hygiene • Cap and mask • Goggles/Face shields • Gloves • Gowns/aprons

48. Cap

49. masks 滤过率取决于纱布厚度 滤过率90% 滤过率95%---99% Pm： Particulate matter

50. wash hands: Before Wear a mask after taking off the mask