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Infection Control. by Simran S Ghatore. The pre-scientific era. Epidemics and plagues throughout history (black plague..) Physicians fear of contagious disease Hippocrates and others suspected an unseen invisible cause Climate and environment blamed - not the ill, dying or dead.

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Infection control

Infection Control

by Simran S Ghatore


The pre scientific era
The pre-scientific era

  • Epidemics and plagues throughout history (black plague..)

  • Physicians fear of contagious disease

  • Hippocrates and others suspected an unseen invisible cause

  • Climate and environment blamed - not the ill, dying or dead


Microbiology scientific era
Microbiology - scientific era

Anton van Leeuwenhoek (1632-1722)

  • Dutch linen draper

  • Amateur scientist

  • Grinding lenses, magnifying glasses, hobby

  • First to see bacteria “little beasties”

  • No link between bacteria and disease


Scientific era continued
Scientific era continued . . . . .

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


Scientific era continued1
Scientific era continued . . . . .

Louis Pasteur (1822-1895)

  • French professor of chemistry

  • Studied how yeasts (fungi) ferment wine and beer

  • Proved that heat destroys bacteria and fungi

  • Proved that bacteria can cause infection - the “germ theory” of disease


Scientific era continued2
Scientific era continued . . . . .

Joseph Lister (1827-1912)

  • Scottish surgeon

  • Recognised importance of Pasteur’s work

  • Concerned about infection of compound fractures and post-operative wounds

  • Developed carbolic acid spray to disinfect instruments, patient’s skin, surgeon’s skin

  • Largely ignored by medical colleagues


Scientific era continued3
Scientific era continued

Robert Kock (1843-1910)

  • German general practitioner

  • Grew bacteria in culture medium

  • Showed which bacteria caused particular diseases

  • Classified most bacteria by 1900


Contemporary issues
Contemporary issues

  • Antibiotic resistance

  • Prevalence of hospital acquired infection

  • Prion diseases - BSE ‘mad cow disease’ - new variant Creutzfeldt-Jakob disease (nvCJD) (thought to be the humanequivalent) - Gerstmann-Straussler-Scheinker disease – kuru and fatal insomnia.

    -Prions are mutated proteins

    -majority of prion related diseases involve neurological damage.

    -not all scientists accept they are the cause of disease.

    (see later)

    (more info)


Antibiotic resistance
Antibiotic resistance

  • Not a new problem - Penicillin in 1944 (A.Flemming) – 1st antibiotic – most resistance?

  • Hospital “superbugs”

  • Methycillin Resistant Staphylococcus Aureus [MRSA]

  • Vancomycin Intermediate Staphylococcus Aureus [VISA]

  • Tuberculosis - antibiotic resistant form

    • 400 deaths per year in UK

    • Up to £100,000 per patient to treat

    • Annual NHS cost - £5 million!!


MRSA

  • Discovered in 1981

  • Found on skin and in the nose of 1 in 3 healthy people - symptomless carriers

  • Widespread in hospitals and community

  • Resistant to most antibiotics

  • When fatal - often due to septicaemia


Hospital acquired infection
Hospital acquired infection

  • Incidence of 10%

  • 5,000 deaths per year - direct result of HAI

  • 15,000 deaths per year linked to HAI

  • Delayed discharge from hospital

  • Expensive to treat [£3,500 extra]

  • Cost to NHS - £1 billion per year

  • Effective hand washing is the most effective preventative measure

  • Dirty wards and re-use of disposable equipment also blamed


Prion diseases
Prion diseases

  • Prions [“pree-ons”] - proteinaceous infectious particles

  • Corrupted form of a normally harmless protein found in mammals and birds

  • Causes fatal neurodegenerative diseases of animals and humans

  • Animals: scrapie - sheep, bovine spongiform encephalopathy [BSE or Mad Cow Disease]

  • Humans: Creutzfeldt-Jakob disease [CJD]

  • Prions found in blood, tonsil and appendix tissue


Prions and surgery
Prions and surgery

  • Prions cannot be destroyed by sterilisation

  • Theoretical risk of cross infection from contaminated instruments and blood transfusion


Comparisons of mortality
Comparisons of mortality

Deaths per year in the UK


The nature of infection
The nature of infection

  • Micro-organisms - bacteria, fungi, viruses, protozoa and worms

  • Most are harmless [non-pathogenic]

  • Pathogenic organisms can cause infection

  • Infection exists when pathogenic organisms enter the body, reproduce and cause disease


Hospital acquired infection1
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


Modes of spread
Modes of spread

Two sources of infection:

  • Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli

  • Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998)


Spread entry and exit routes
Spread - entry and exit routes

  • Natural orifices - mouth, nose, ear, eye, urethra, vagina, rectum

  • Artificial orifices - such as tracheostomy, ileostomy, colostomy

  • Mucous membranes - which line most natural and artificial orifices

  • Skin breaks - either as a result of accidental damage or deliberate inoculation/incision (May, 2000)


Chain of infection
Chain of infection

  • Source/reservoir of micro-organisms

    • infected person [host] or other source

  • Method of transmission

    • hands, instruments, clothing, coughing, sneezing, dust etc.

  • Point of entry

    • orifices, mucous membranes, skin

  • Susceptible host

    • low resistance to infection (May, 2000)


Hai common bacteria
HAI - common bacteria

  • Staphylococci - wound, respiratory and gastro-intestinal infections

  • Eshericia coli - wound and urinary tract infections

  • Salmonella - food poisoning

  • Streptococci - wound, throat and urinary tract infections

  • Proteus - wound and urinary tract infections (Peto, 1998)


Hai common viruses
HAI - common viruses

  • Hepatitis A - infectious hepatitis

  • Hepatitis B - serum hepatitis

  • Human immunodeficiency virus [HIV] - acquired immunodeficiency syndrome via infected blood transfusion! [AIDS] (Peto, 1998)


Common types of hai
Common types of HAI

(May, 2000)


Universal infection control precautions
Universal infection control precautions

  • Devised in US in the 1980’s in response to growing threat from HIV and hepatitis B

  • Not confined to HIV and hepatitis B

  • Treat ALL patients as a potential bio-hazard

  • Adopt universal routine safe infection control practices to protect patients, self and colleagues from infection


Universal precautions
Universal precautions

  • Hand washing

  • Personal protective equipment [PPE]

  • Preventing/managing sharps injuries

  • Aseptic technique

  • Isolation

  • Staff health

  • Linen handling and disposal

  • Waste disposal

  • Spillages of body fluids

  • Environmental cleaning

  • Risk management/assessment


Hand washing
Hand washing

  • Single most effective action to prevent HAI - resident/transient bacteria

  • Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken

  • No recommended frequency - should be determined by intended/completed actions

  • Research indicates:

    • poor techniques - not all surfaces cleaned

    • frequency diminishes with workload/distance

    • poor compliance with guidelines/training


Hand washing areas missed

Taylor (1978) identified that 89% of the hand surface was missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

Hand washing – areas missed


Personal protective equipment
Personal protective equipment missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • PPE when contamination or splashing with blood or body fluids is anticipated

  • Disposable gloves

  • Plastic aprons

  • Face masks

  • Safety glasses, goggles, visors

  • Head protection

  • Foot protection

  • Fluid repellent gowns (May, 2000)


Sharps injuries
Sharps injuries missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • Prevention

    • correct disposal in appropriate container

    • avoid re-sheathing needle

    • avoid removing needle

    • discard syringes as single unit

    • avoid over-filling sharps container

  • Management

    • follow local policy for sharps injury (May, 2000)


Aseptic technique
Aseptic technique missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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 (May, 2000)


Isolation
Isolation missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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 immuno-suppressed patient (May, 2000)

  • Significant psychological effects (Davies et al, 1999)


Staff health
Staff health missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • Risk of acquiring and transmitting infection

  • Acquiring infection

    • immunisation

    • cover lesions with waterproof dressings

    • restrict non-immune/pregnant staff

  • Transmitting infection

    • advice when suffering infection

  • Report accidents/untoward incidents

  • Follow local policy (May, 2000)


Linen handling and disposal
Linen handling and disposal missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • Bedmaking 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 (May, 2000)


Waste disposal
Waste disposal missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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 (May, 2000)


Spillage of body fluids
Spillage of body fluids missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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)


Environmental cleaning
Environmental cleaning missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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)


Risk assessment
Risk assessment missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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)


Body fluids
Body fluids missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • 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)


Cost of hai
Cost of HAI missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • Direct cost to NHS for:

    • extended hospital stay, extra resources, extra treatment, extra equipment, and extra community care costs if discharged needing follow-up

  • Direct cost to patient/family for:

    • pain and scarring, extended stay away from family, working days lost, family income loss, financial strain - increased visiting etc, increased morbidity, increased mortality (ICNA, 1998)


Summary
Summary missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • Ignaz Semmelweis in 1847 demonstrated that washing hands saves lives

  • Research indicates that 10% of patients develop HAI costing the NHS £1 billion and 20,000 deaths per year

  • 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


Internet sites
Internet sites missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs.

  • http://www.icna.co.uk/

  • http://www.nursing-standard.co.uk/

  • http://www.medscape.com/

  • http://www.anes.uab.edu/medhist.htm

  • http://www.shef.ac.uk/~nhcon/

  • http://medweb.bham.ac.uk/nursing/

  • http://www.healthcentre.org.uk/hc/library/default.htm

  • http://www.parliament.uk/documents/upload/POSTpn247.pdf (excellent article)