Introduction to Infection Control

1. Introduction to Infection Control Marian McDonald, RN, MSN, CIC Infection Control at YOUR Service Consulting

2. Welcome! • This talk is an introductory overview. • It is OK to be a beginner. • You do NOT need to know everything to start. • You do need to know enough to keep your patients and yourselves safe. • That is not too difficult and is our focus today. • These are skills you will use every single day you work as a nurse, no matter where you work. • At the end we will review the parts that you really need to get today. You will have more chances to learn some of the details. • We will leave time for questions.

3. Objectives • Who does Infection Control protect? • What is the weakest link in the chain of infection? • What is the most important procedure to prevent spread of infection? • Which kind of hand hygiene is better for routine use? • What kind of patients need Standard Precautions?

4. The purpose of Infection Control is to protect EVERYONE in the hospital from catching a new infection they did not already have. • The patients always come first, because they are already compromised by being sick. • We take many actions to protect staff from infection (that means you and your co-workers!) • We even work to protect visitors and the flower delivery folks! We don’t want ANYONE to catch a new infection!

5. Healthcare-associated infections (HAIs) • New infections not present or incubating at the time of admission are called healthcare-associated infections or HAIs. • They used to be called “nosocomial” infections.

6. We will be talking a lot about GERMS! • “Germs” is a non-scientific term which is very useful. • “Germs” include bacteria, viruses, fungi, and protozoans. • These types of organisms are different in many ways, but they are transmitted in similar ways. • To prevent new infections, we must prevent transmission of all kinds of germs!

7. The Chain of Infection

8. Infectious agent • These are the germs. • Can we get rid of them? Some yes, but not all. • Actions we take to eliminate germs include • Sterilizing surgical instruments • Cleaning reusable equipment such as commodes. • Safe food handling practices • Telling sick people to stay home

9. Reservoir • Reservoirs are where the germs live and grow. • Reservoirs are generally WET. As a rule, anything that stays wet is germy! • The most important reservoirs in the hospital are PEOPLE. • Sick people with infections • Well people with their normal flora (mouth, etc.) We can’t get rid of the most important reservoirs!

10. Portal of exit • This is the way the germs get out of the reservoir. • This is usually a break in the skin, a natural orifice, or a body fluid. We can’t do much about most portals of exit, but we can • Cover a draining wound with a bandage. • Do hand hygiene after contact with any body fluid.

11. Means of transmission • Very few germs can fly. • Almost all have to be CARRIED from one place to another. • The main means of transmission are • The HANDS if the caregivers • THINGS that move from patient to patient. The means of transmission is the only link in the chain of transmission that you can actually eliminate!

12. Portal of entry • No kind of germ in the world can make you sick until they get INSIDE your body. • They cannot go through intact skin, so they have to find a HOLE (the portal of entry!) • Keep anything germy away from any hole in your patient. • Keep anything germy away from any hole in yourself! • Take good care of your skin to prevent holes!

13. Susceptible host • Can we eliminate susceptible hosts? Yes, partially, by vaccination or natural disease that causes immunity. • We can also reduce susceptibility by keeping our resistance up. • However, no one is immune to all disease, so everyone, patients and staff, is a susceptible host.

14. One of the MAIN POINTS of this talk: • The weakest link in the chain of transmission is the means of transmission. • Most of the efforts of Infection Control are aimed at NOT CARRYING GERMS from the reservoir to the susceptible host! • The reservoir and the susceptible host may be the same person!

15. This is why hand hygiene is still the single most important procedure for preventing the spread of infection!

16. How to save lives: Read the name band! Wash your hands!

17. What is hand hygiene? Hand hygiene includes • washing with soap and water • De-germing hands with alcohol-based hand sanitizers. So which one is better?

18. Hand Hygiene If you canSEE dirt on your hands, whether blood, body fluid, or dirt from the ground, WASH HANDS WITH SOAP AND WATER! • Wet hands before applying soap. • UseFRICTIONon all surfaces • For 15 seconds. (row, row, row your boat TWICE!) • Water temperature should be comfortable. Washing with soap and water physically removes the dirt from your hands. (It does NOT kill germs!)

19. Hand Hygiene If your hands LOOK clean and just need to be de-germed, an ALCOHOL-based HAND HYGIENE PRODUCT is PREFERRED! They are better 3 ways: • They DO kill most germs (including viruses). • They leave skin condition better. • They are quicker and easier to use!

20. Hand Hygiene A couple of notes on how to use the alcohol products right: • Use the alcohol products on DRY skin only. • Do use a hand hygiene product and not plain alcohol. Plain alcohol evaporates too fast and there is not enough contact time to kill the germs. • Use one squirt of alcohol gel or foam, and rub until hands are completely dry! Do not wipe off with a paper towel!

21. Hand Hygiene • There is no need for an antimicrobial soap, since the alcohol product is your antimicrobial. • If you get into something really terrible, first wash with soap and water, dry your hands, then use the alcohol gel. That is the best hand hygiene possible, since you are getting the germs by two different methods!

22. WHEN should you do Hand Hygiene? (Part 1) When youfirst come on duty. Before and after every patient contact, including touching intact skin. (You can count one hand hygiene for both if you do not touch anything else!) Before anyclean or invasiveprocedure. Before putting onsterile gloves. After youremove gloves, every time! Aftercontact with any body fluids, INCLUDING YOUR OWN!(Coughing, sneezing, blowing your nose) When leaving an isolation room.

23. When should you do Hand Hygiene? (Part 2) Going from adirtier to a cleanerpart of the patient. (Don’t carry germs…) Any timehands feel or look dirty. After contact withcontaminated things or environments, such as charts. After handlingused equipment or linen. Afterusing the bathroom. Before contact with any portal of entry, your patient’s or your own. Before and aftereating. Whengoing off duty.

24. Let’s review the basics! Means of transmission Reservoirs There are lots of germy places in the hospital, mostly patients and staff. Susceptible hosts Everyone can catch something, patients and staff That is WHY hand hygiene is the single most important procedure for preventing the spread of infection!

25. What is infection? • Germs are present. • They are invading tissue and causing tissue damage. • Tissue damage causes symptoms. • The infection is a reservoir for spread of infection. • Infections produce greater NUMBERS of germs than colonization.

26. What is colonization? • Germs are present. • They are NOT invading tissue and causing tissue damage. • There areNO symptoms. • The germs are still a reservoir for spread of infection. • Numbers of germs shed are fewer than with infection.

27. What is an unknown carrier? • An unknown carrier has an infection which has not been diagnosed. • There may or may not be symptoms. • This is why we stay out of the body fluids of ALL patients, because we never know who might be an unknown carrier of what! • That sounds pretty scary, but you will see that it is easier that you think. • Most nurses you know do seem to be pretty healthy, don’t they?

28. Where do the germs come from? • Endogenous flora – the patient’s own germs they come in with. Includes their normal flora (their good germs) and any pathogens (bad germs) they may be carrying. • Exogenous flora – germs the patient did NOT bring in with them, that came to them from outside themselves. Either kind can cause healthcare-associated infections (HAIs).

29. Standard Precautions • Use Standard Precautions in the care of ALL patients! • Standard Precautions used to be called Universal Precautions or Body Substance Precautions. • Standard Precautions protect both staff and patients from infection. • Standard Precautions are required by both good science and by LAW!

30. Standard Precautions • Standard Precautions are used to care for ALL patients so that we use the right precautions with both known cases and unknown carriers of diseases carried in blood and body fluids. • They are all you need to care for a patient known to havehepatitis B, hepatitis C, or HIV. • We must do Standard Precautions right with EVERY patient so we are protected from the unknown carriers of those diseases.

31. Universal Precautions and Standard Precautions • Universal Precautions started first and were designed to protect employees. • They are required by OSHA – federal law! • They focus on bloodborne viruses, HBV, HCV, HIV. • Stay out of blood and OPIM, which includes semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids. • Standard Precautions is the current term from the CDC, designed to protect patients and workers. • If it is wet and not yours, stay out of it! Any body fluid probably carries germs!

32. How to do Standard PrecautionsPart 1 – all about GLOVES • Use goodhand hygiene, of course! • Use glovesfor contact withbody fluids, non-intact skin(this includesrashes),mucous membranes, used equipment, linen, and trash. • Change glovesif they become heavily soiled, orif you must go from a dirtier area to a cleaner one.(Don’t carry germs!) • NEVER touch the second patient with the same pair of gloves! • Do not wear gloves in the hall unless you can say why you are wearing them. • Don’t soil the environment with dirty gloves!

33. How to do Standard PrecautionsPart 2 – OTHER STUFF , NOT gloves • Use a gown any time your clothing may be soiled. • Use a mask AND eye protection if you may be splashed. (Your glasses do NOT meet OSHA!) • Know where to find the personal protective equipment (PPE) you will need. • Don’t recap sharps unless you absolutely must, and use a one-handed technique if you must. • Discard used sharps into a sharps box immediately. • Be sure to activate safety sharps before discard. • Be sure you learn how to use each type of safety sharp before you use it!

34. OSHA Bloodborne Pathogens Standard • Federal and state LAW require many of the basics of Infection Control. • Bloodborne pathogens are organisms in blood which can cause disease. The main ones are hepatitis B, hepatitis C, and HIV. • They can be transmitted by needlesticks, body fluid contact with mucous membranes, such as eyes or mouth, or body fluid contact with broken skin. • Most patients with these infections have NO symptoms! • The Biohazard Symbol identifies some contaminated items, but many items are contaminated which don’t show the symbol. • It also REQUIRES the use of red bags, hepatitis vaccine, and follow-up after exposures.

35. BIOHAZARD

36. Exposure to body fluids • Exposures include needlestick, face splash, and blood on broken skin. • Avoid exposure! Be very careful! Use PPE! • If you have an exposure, first wash, then tell your instructor. • The source patient will be tested for HBV, HCV, and HIV.

37. So what DOES go into a red bag? • Blood or liquids which cannot be emptied must go into a red bag for special handling. • Different facilities have different policies. • Different states have different policies. • Find out where the red bag container is. • Do not throw things into red bag trash unless they need to go it, since it costs up to 80 times as much as regular trash!

38. Aerosol-Transmissible Diseases (ATD) Standard • NEWCalifornia law went into effect 2009. • Specifies actions to protect workers from any disease requiring Airborne or Droplet Precautions. • Use precautions with any patient with symptoms of a respiratory infection, such as cough, sore throat, or runny nose. • You will get workplace-specific information from your employers.

39. Respiratory Hygieneis part of the new ATD Standard • Wear a mask (surgical or isolation mask) when caring for any patient with symptoms of a respiratory infection, until it is clear that the cause of the symptoms does not require those precautions. • Use eye protection with the mask if you may be splashed. • Do not wear eye protection without a mask! • In ambulatory care sites, assist patients with respiratory symptoms to cover coughs with tissues or wear a mask themselvesand to do hand hygiene before being seen.

40. Could this patient have TB??? Only ACTIVE TB is contagious(not latent). Active TB has SYMPTOMS • Cough that lasts more than 3 weeks • Unexplained weight loss or loss of appetite • Night sweats • Bloody sputum

41. Could this patient have TB??? Groups at higher risk to have TB include • Foreign born persons from areas with high incidence of TB, such as Africa, Asia, Eastern Europe, Latin America and Russia • Residents and employees of congregate care facilities at higher risk, including prisons • Medically underserved populations. The patient most likely to transmit TB is the patient who has NOT BEEN DIAGNOSED AND ISOLATED!

42. Identifying people with active TB • Screening for TB infection, which may be latent, is often done by a TB skin test, but false negatives can occur if the person is immune compromised. • People with active TB are likely to have an abnormal chest X-ray. • Diagnosis is by microscope examination of sputum. DO NOT WAIT FOR A FIRM DIAGNOSIS! Get an order to isolate as soon as TB is suspected!

43. CDC has 4 kinds of isolation,but only 3 isolation signs! • Standard Precautions are used with ALL patients, and no sign is placed on the door. These 3 will have a sign on the door and they will need a private room. • Airborne Precautions • Droplet Precautions • Contact Precautions

44. Airborne PrecautionsPart 1 • Use Airborne Precautions for patients who may have TB, chickenpox, disseminated zoster, measles, SARS, or smallpox. • Patients with chickenpox are not usually admitted to the hospital, but they may be admitted for ANOTHER REASON! • Most patients in Airborne Precautions are having TB “ruled out,” and most of them DO “rule out.” There is not much TB around here, but there is some. • TB is NOT super-contagious!

45. Airborne PrecautionsPart 2 • This is the ONLY kind of isolation which requires use of a negative pressure room. • “The room sucks!” • This is the ONLY kind of isolation which requires use of an N-95 respirator.Do not refer to it as a “TB mask.” • Keep the door to the room CLOSEDto maintain negative pressure. IMPORTANT POINT! • For patients with chickenpox, disseminated zoster, or measles, only IMMUNE STAFF should enter the room, if possible. • If the patient must come out of the room, put a regular mask on him/her. Do not put an N-95 on the patient!

46. Droplet Precautions • DROPLET PRECAUTIONS are used for patients with respiratory infections which have not yet been diagnosed, also with seasonal INFLUENZA, pertussis (whooping cough) some kinds of meningitis, and others. • Wear a surgical or isolation mask (NOT an N-95 respirator) to enter the room.

47. PANDEMIC INFLUENZA • Last year’s H1N1 pandemic has been declared over. • It is now considered part of seasonal influenza, and a droplet mask is enough. • In any future pandemic, expect guidance to change, sometimes often, as the science evolves. • Do diagnose and ISOLATE patients with either pandemic or seasonal influenza.

48. Contact Precautions • Contact Precautions are used for infections which are easily spread by hands or things. • Think of these germs as being sticky. Hand hygiene is the critical keyto preventing spread of these germs!

49. Contact Precautions Contact Precautions are used in some (but not all) facilities for patients with • MRSA – Methicillin-Resistant Staph aureus, a skin germ • VRE – Vancomycin-resistant Enterococcus, a poop germ • C diff – Clostridium difficile, another poop germ • Norovirus – another poop germ! • And a number of less common infections.

50. To do Contact Precautions • Wear gown and gloves for ALL interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. (This is a 2007 change from earlier recommendations which did not require a gown every time.) • Patient care equipment (stethoscopes, thermometers, etc.) should NOT BE SHARED! You should find that equipment already in the room for that patient only. • Equipment which must be brought out of the room must be WIPED DOWN with disinfectant. Most places have disinfectant wipes which are handy for that. • Masks are not needed except as required by Standard Precautions.