1. INFECTION PREVENTION and CONTROL

2. Standard Precautions
OR ….How to prevent the spread of disease

3. NORMAL DEFENSES
Normal Defenses: Body Flora Cilia in Lungs Intact Skin pH of Body Fluids acidic gastric secretions/alkanline vaginal secretions

4. Types of Infections HAIs
Heath Care-Associated Infections formerly called nosocomial
HAIs
Iatrogenic:
Exogenous:
Endogenous:
Types of Infections
HAIs: nosocomial: result from delivery of health services in a health care facility
Iatrogenic: a type of HAI from a diagnostic or therapeutic procedure
Exogenous: an infection that is present outside the client, i.e. a post-op infection
Endogenous: an infection that occurs when part of the client’s flora becomes altered or overgrowth results, i.e. C. Diff, vaginal yeast infection

5. CHAIN OF INFECTION

6. Cholera Outbreak in Haiti
Nepalese peacekeeping force
Poop
Latrines near water
River
Drinking contaminated water

7. Historical Perspective
1847 Dr. Ignaz Philip Semmelweiss
Significance of hand washing is demonstrated
Concept of nosocomial infection is born
18% Mortality from puerperal fever caused by Streptococcus organism First simple case control study

8. More History
1950s
Post WWII hospital-based outbreaks of Staphylococcus Aureus occur, mostly in newborn nurseries
Outbreaks demand an organized response for investigation and control: Infection control as an organized and recognized discipline is born.

9. Infectious Disease Process
Infection:
Normal flora:
Colonization:
Infection: presence and multiplication of microorganisms in the tissue of the host which may or may not have signs or symptoms
Normal flora: bacteria that are frequently found in everyone in specific parts of the body
Colonization: presence of bacteria without multiplication and damage to the host tissue

10. Chain of Infection
The interaction in the 6 elements in the chain of infection will determine whether an infection results

11. Causative Agents
Bacteria
Virus
Fungi
Protozoa

12. Characteristics of Causative Agents
Infective dose
Pathogenicity
Invasiveness
Virulence
Host specificity
Viability
Resisitance

13. Reservoirs Humans: Patients and Healthcare Workers Shellfish
Environment
Patient Care Equipment
Environmental Surfaces
Food
Animals
Rodents
Insects

14. NCLEX ?
Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client?
A) Covering the mouth and nose when sneezing B) Wearing disposable gloves C) Isolating client’s articles D) Changing soiled dressings
Correct answer is D

15. Portal of Exit: The path by which the infectious agent leaves the reservoir
Respiratory Tract:
GU Tract
GI Tract:
Skin/Mucous Membranes:
Transplacental
Blood:
Respiratory Tract: coughing, sneezing, talking, suctioning
GU Tract: Foleys, STIs
GI Tract: Feces, Vomitus
Skin/Mucous Membranes: Wounds & Skin Breaks
Transplacental
Blood: Needle Stick, Blood Transfusion

16. Mode of Transmission
The mechanism for transfer of an infectious agent from the reservoir to the susceptible host

17. VIGNETTE
An older adult, hospitalized with a GI disorder is on bedrest and requires assistance for uncontrolled diarrhea stools.
Following one episode of cleaning the patient and changing the bed linens, the nurse went to a second patient to provide tracheostomy care.
The nurse’s hands were not washed before assisting the second patient

18. VIGNETTE ANALYSIS Infectious agent → Escherichia Coli
Reservoir → Large Intestines
Portal of Exit → Feces
Mode of Transmission → Nurses Hands
Portal of Entry → Tracheostomy
Susceptible Host → Older Adult with Trach

19. Modes of Transmission
Contact
Airborne
Vector-Borne

20. Contact Direct: Indirect:
Direct: Immediate transmission, person-to-person, actual personal contact between the patient and the source
Indirect: Patient to contaminated indirect object (contaminated endoscope) or Droplet spread (large particles that rapidly settle out on horizontal surfaces-usually within 3 feet of the source

21. Modes of Transmission Direct Indirect Person to Person (Fecal-Oral)
Hepatitis A
Staph
Indirect
Contact with contaminated object
Hepatitis B and C
HIV
RSV
MRSA

22. Airborne
Droplets suspended in air after coughing and sneezing or carried on dust particles TB
Chicken Pox
Measles (Rubeola)
Aspergillus
Organisms contained within droplet nuclei or dust particles (ie. droplet nuclei of tuberculosis)
Suspended in air for extended periods, may be spread through ventillation systems
Airborne
Droplets suspended in air after coughing and sneezing or carried on dust particles TB
Chicken Pox
Measles (Rubeola)
Aspergillus

23. Droplet transmission Large particles Can travel up to 3 feet Influenza
Rubella (3- day/German Measles)
Bacterial Meningitis

24. Vector-Borne Vector External mechanical transfer
Mosquito, Louse, Flea, Tick, Fly
West Nile Virus
Malaria
Lyme Disease
Hanta Virus
External vector-borne transmission; mechanical transfer of microbes on external appendages (feet of flies)
Harbored by vector, but no biological interaction between vector and agent (ie.Yellow fever)
Vector
External mechanical transfer
Mosquito, Louse, Flea, Tick, Fly
West Nile Virus
Malaria
Lyme Disease
Hanta Virus

25. Portal of Entry: path by which an infectious agent enters the susceptible host
Respiratory tract
GU tract
GI tract
Transplacental (fetus from mother)
Parenteral: percutaneous, via blood
Skin/Mucous Membranes

26. Susceptible Host
A person or animal lacking effective resistance to a particular pathogenic agent
Client Susceptibility
Status of defense mechanisms (smoker?)
Age – very young and very old
Nutritional status – decreased protein intake reduces the body’s defenses against infection and impairs wound healing
Stress – lowers immunity
Disease process – HIV, Leukemia, Lymphoma

27. Man-Made Epidemics (NYT July 15, 2012)
Most epidemics of infectious disease just don’t happen. They are a result of things people do to nature.
Disease is largely an environmental issue.
60% of emerging infectious diseases that effect humans are zoonotic-they originate in animals.
Deforestation of the Amazon by 4% increased malaria by 50% (mosquitoes thrived in the right mix of sunlight and water)

28. Diseases have always come out of the woods and wildlife
and found their way into humans
Malaria and the plague
Emerging diseases have quadrupled in the past 50 years due to increased human encroachment into habitat in “hot spots”, modern air travel and robust trafficking in wildlife
Developing the forest in the wrong way can be like opening Pandora’s box.

29. West Nile Virus
A mosquito-borne illness that causes sx in about a fifth of those exposed. One in 150 becomes severely ill with encephalitis.
Animal reservoir: various birds, especially robins in the U.S.
First human case: West Nile district of Uganda, 1937; first U.S. case was in Queens in 1999.
Why it emerged: International travel
Susceptible hosts: humans, birds, especially crows and horses.

30. American Robin Thrives in our backyards and agriculture fields
Mosquitoes that spread the disease find robins particularly appealing

31. H1N1 “Swine flu”, killed thousands and infected millions in 2009
Humans in turn spread the disease to pigs, triggering a pandemic in livestock.
Animal reservoir: waterfowl and pigs
First Human Case: Veracruz, Mexico, 2009; first U.S. case was in San Diego in 2009.
Why: Livestock production (pigs and poultry); contact with wild waterfowl.
Susceptible: Humans, pigs

32. Lyme Disease . East Coast scourge
Very much a product of human changes to the environment
Reduction of large forests & development chased off predators-foxes, wolves and hawks
Resulted in 5 fold increase in white-footed mice, which are a great reservoir for the bacteria probably because they have weak immune systems and they are terrible groomers
When possums or grey squirrels groom they remove 90% of the larval ticks that spread disease, while mice kill just half.
Mice produce huge numbers of infected nymphs.

33. Ebola
Hemorrhagic fever is among the most virulent known diseases. There is no specific treatment or vaccine available; patients must be strictly isolated.
Animal reservoir: Various bats
First human case: Yambuku region, Zaire (now Democratic Republic of Congo, 1976)
Why: Contact with or eating infected wildlife, especially gorillas.
Susceptible: Humans, chimpanzees, gorillas duilers (small African antelope)

34. SARS
A severe viral respiratory infection that quickly spread from China to more than two dozen countries. The outbreak was contained, and since 2004 no new cases have been reported.
Animal Reservoir: Horseshoe bats
First human case: Guangdong Province, China, 2003
Why: Wildlife markets and trade; global travel
Susceptible: Humans, civats

35. Bird Flu
A deadly strain of the avian virus called H5N1 has spread to humans via contact with live or dead poultry
Animal Reservoir:
Wild waterfowl
First human case: Hong Kong, It re-emerged widely in 2003 and 2004.
Why: global expansion of intensive poultry farming; contact with infected birds
Susceptible: Humans, poultry, cats

36. Isolation Precautions
Historical perspective 1877 to present
1877
Aseptic technique
1910
1877: first published recommendations for isolation precautions, birth of infectious disease hospitals where pts with infectious disease processes were placed in separate hospitals
Aseptic technique used to combat transmission of disease
1910: isolation practices are altered by the introduction of the “cubical” system, replaced isolation hospitals, multiple bed wards

37. “Barrier” Nursing Hospital personnel wear gowns between patients
Handwashing between patients with antiseptic solutions after patient contact
Disinfection of objects contaminated by patients
Hospital personnel wear gowns between patients
Handwashing between patients with antiseptic solutions after patient contact
Disinfection of objects contaminated by patients

38. More Hx
1950s: Infectious Disease hospitals begin to shut down except for TB sanitariums
1960s: TB hospitals begin to shut down
1970: CDC publishes first manual on Isolation Techniques for Use in Hospitals. Diseases were lumped into categories
1980s: Hospitals began to experience new endemic and epidemic nosocomial infection problems caused by multi-drug-resistant organisms

39. HX 1980: CDC publishes new Isolation guidelines
1985: Universal precautions come into being (HIV, HBV, blood borne pathogens)
1990s HICPAC: 2 tier system
Standard Precautions
Transmission-Based Precautions (Contact, Droplet, Airborne)

40. HAIs Surgical Sites Blood Stream Urinary System Cardiovascular
Eye/Ear/Throat/Mout h Infection
Reproductive System
Respiratory
Bone and Joint Infection
CNS
Gastrointestinal
Skin and Soft Tissue

41. Immunocompromised Pts
Vary in their susceptibility to HAIs
Depends on the severity and duration of immunosupression.
Use the two-tiered system
Neutropenic precautions

42. Critical Thinking Question
Clients in the healthcare setting are at risk for acquiring or developing infections because:

43. Prevention
Most HAIs are transmitted by the HCWs and clients as the result of direct contact
We as nurses must pay attention to handwashing after contact with clients and equipment

44. Prevention Microorganisms move through space on air currents
Microorganisms are transferred from one surface to another whenever objects touch, a clean item touching a less clean item becomes “dirty”
Microorganisms are transferred by gravity when one item is held above another
Microorganisms move through space on air currents: avoid shaking or tossing linen
Microorganisms are transferred from one surface to another whenever objects touch, a clean item touching a less clean item becomes “dirty”- keep hands away from face, keep linens away from uniforms an item dropped on the floor is considered dirty.
Microorganisms are transferred by gravity when one item is held above another, avoid passing dirty items over clean items eg clean items on upper shelves dirty items on lower shelves (bedpan

45. Prevention
Microorganisms are released into the air on droplet nuclei whenever a person breaths or speaks-
Microroganisms move slowly on dry surfaces, but very quickly through moisture –
Proper handwashing removes many of the microorganaisms that would be transferred by the hands from one item to another- always wash hands between patients.
Microorganisms are released into the air on droplet nuclei whenever a person breaths or speaks- avoid breathing directly in someone’s face; when someone coughs/sneezes, cover mouth with kleenex, dicard and wash hands
Microroganisms move slowly on dry surfaces, but very quickly through moisture – use paper towels to turn off faucets, dry bath basin before returning to bedside table.
Proper handwashing removes many of the microorganaisms that would be transferred by the hands from one item to another- always wash hands between patients.

46. Prevention
To reduce susceptibility provide adequate nutrition and rest, promote body defenses against infection and provide immunization

47. Superbugs
MRSA
VRE: Vancomycin resistant enterococcus

48. Break The Chain!
Implement ASEPSIS: absence of disease-producing microorganisms; refers to practices/procedures that assist in reducing the risk of infection
2 Types
Medical (clean technique)
Surgical (sterile technique)

49. MEDICAL ASEPSIS Clean technique: 3 components to the technique:
Aseptic technique
3 components to the technique:
Hand washing,
Barriers of PPE (gloves, gowns, mask, protective eyewear)
Routine environmental cleaning
Contaminated area:
A clean technique that limits the number of pathogens that could cause infections
Aseptic technique: practices/procedures that assist in reducing the risk for infection
3 components to the technique:
Hand washing,
Barriers of PPE (gloves, gowns, mask, protective eyewear)
Routine environmental cleaning
Contaminated area: one suspected of containing pathogens eg. used bedpan, wet gauze, soiled linen, laboratory specimens, etc 49

50. Disinfection/Sterilization
Disinfection = the process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects
Sterilization = complete elimination or destruction of all microorganism, including spores
Disinfection = the process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects
Disinfection of surfaces
High-level disinfection
Alcohols, chlorines, glutaraldehydes, hydrogen peroxide
Sterilization = complete elimination or destruction of all microorganism, including spores
Steam under pressure, ethylene oxide gas (ETO)

51. Aseptic technique
Handwashing is the single most important procedure for preventing the transfer of microorganisms and therefore preventing the spread of HAIs
CD recommends second hand wash.
Handwashing is the single most important procedure for preventing the transfer of microorganisms and therefore preventing the spread of HAIs
CD recommends second hand wash. This will remove most transient organisms form the skin resident: normally reside on the skin in stable #s
Transient: attach loosely to the skin by contact with another-easily removed by handwashing.

52. Personal Hygiene
Restrain Hair: hair falling forward may drop organisms
Keep nails short: no acrylic nails or chipped nail polish
Minimum jewelry (see agency policy)
Cover open wounds with an occlusive dressing.

53. When should hands be washed
When visibly soiled
Before and after client contact
After contract with a source of microorganism: blood, body fluids, mucous membrane, non-intact skin or inanimate objects that might be contaminated
Prior to an invasive procedure: IV catheter, indwelling cath
Before and after removing gloves: wearing gloves does not remove the need to wash hands
At the beginning and end of every shift.

54. CDC GUIDELINES Standard Precautions apply to: Blood
All body fluids and secretions (feces, urine, mucus, wound drainage) except sweat
Non-intact skin
Mucous membranes
Respiratory secretions 54

55. STANDARD PRECAUTIONS TIER 1
Hand Hygiene: see next slide
Gloves: for touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated areas
Masks, Eye Protection or Face Shields: if in contact w/ sprays or splashes of body fluids
Gowns: to protect your clothing
Contaminated Linen: place in leak-proof bag so no contact with skin or mucous membranes
Respiratory Hygiene/Cough Etiquette: provide client with tissues and containers for disposal; stand ~3 feet away from coughing; use masks prn 55

56. Hand Hygiene Number one defense against infection
Soap and water if hands are visibly soiled
Friction for 15 seconds
After 3-5 uses of hand gel
Alcohol-based hand products are accepted if hands not visibly soiled
Before and after providing client care
Before eating
After contact with body fluids or excreta
After contact with inanimate objects in immediate area of the client
Before procedures
After removing gloves
Is NOT effective against C-Diff

58. ISOLATION PRECAUTIONS TIER 2
Contact = private room or cohort clients, gloves and gowns
MDRO, C-Diff, RSV
Droplet = private room or cohort clients, mask is required
Strept, pertusis, mumps, flu
Airborne = private room, negative airflow, hepa filtration; N95 respirator mask required
TB, chickenpox, measles
Protective Environment = private room, positive- pressure room; hepa filtration; gloves, gowns, mask (controversial); NO flowers or potted plants
Stem cell transplant

60. N95 Respirator

61. STANDARD PRECAUTIONS Handwashing Gloves (PPE) Masks (PPE)
Eye Protection (PPE)
Gowns (PPE)
Leak-proof linen bags
Puncture proof containers for sharps

62. Donning and Removing PPE
Gown
Mask or respirator
Goggles/face shield
Gloves
Keep hands away from face
Work from clean to dirty
Lime surfaces touched
Change when torn or heavily soiled
Removing
Gloves
Goggles/face shield
Gown
Mask or respirator
Remove at doorway before leaving pt. room
Perform hand hygiene immediately after removing all PPE

63. Surgical Asepsis
Sterile technique that prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains sterile field for surgery
Includes procedures used to eliminate all microorganisms, including pathogens and spores from an object or area
Used in the following situations:
Procedures requiring perforation of the skin
When the skin’s integrity is broken as a result of trauma, surgery or burns
During procedures that involve insertion of catheters or surgical instruments into sterile body cavities

64. Principles of Surgical Asepsis
A sterile object remains sterile only when touched by another sterile object
Only sterile objects may be placed on a sterile field
A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated
A sterile object or field becomes contaminated by prolonged exposure to air
When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action
Fluid flows in the direction of gravity so a sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the object’s surface
The edges of a sterile field or container are considered to be contaminated – a 1 inch border around the drape is considered contaminated

65. For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile technique?
A) Aseptic technique for urinary catheterization in the hospital and sterile technique for cleaning surgical wound
B) Aseptic technique for changing the patient’s linen and sterile technique for assisting in surgery
C) Aseptic technique for food preparation and sterile technique for starting an IV line
D) Aseptic technique for a spinal tap and sterile technique for placing a central line
Correct answer is B

66. LAB Practice: Isolation Precautions
Demonstrate donning Isolation Gown, Mask, Gloves, Eyewear
Demonstrate removing Isolation Gown, Mask, Gloves, Eyewear
Demonstrate proper disposal of PPE before leaving Isolation Room
When performing care/treatments use hospital provided stethoscope and leave in the room 66

67. Lab Practice Cont’d.
Practice pretending you are entering patient room (use curtains) and give Complete Bed Bath and do Bed Linen Change wearing PPE (gown, mask, gloves)
Remember to dispose of PPE INSIDE the patient’s room before you leave
Practice bringing in all the supplies you need so you can stay in the room & not have to leave (de-gown etc) and come back in (re-gown etc)

68. LAB Practice: Sterile Procedures
Opening sterile packages – Flap fartherest away from nurse first, then sides, then flap closest to nurse
Preparing a sterile field
Pouring sterile solutions – label to palm, “lip” it
Donning sterile gown and gloves

69. Critical Thinking Exercise
Mrs. Jaycock had an indwelling urethral catheter for 1 week. The catheter has now been out for 24 hours. She complains of frequency and pain on urination. Mrs. Jaycock suggests reinsertion of the catheter because of the need to get up frequently. What can frequency or pain on urination be an indication of?

70. Answer
UTI
Should the catheter be reinserted?
Why or why not?

71. Answer
No reinserting the catheter may aggravate the infection and promote the spread of the infection to the bloodstream.
Describe at least one appropriate assessment measure and one independent nursing action or intervention for Mrs. Jaycock

72. Nursing Response
Increase her fluid intake if not clnically contraindicated
Check her urinalysis

73. Situation
You are caring for Mr. Huang, who has a large open, and draining abdominal wound. You notice another health care worker changing Mr. Huang’s dressing without wearing gloves or using sterile technique. When you question the health care worker regarding his or her practice, this person says, “Don’t worry, the wound is already infected, and the antibiotics and drainng will take care of any contaminants.” How would you respond to this comment?

74. Response
It is important to not only protect Mr. Huang from additional infection, but also to protect ourselves from becoming contaminated.
What would your next steps be in following up on this incident?

75. Situation
Mrs. Niles is 83 years of age and lives alone. She has difficulty walking and relies on a church volunteer group to deliver lunches during the week. Her fixed income limits her ability to buy food. Last week, Mrs. Niles’ 79-year-old sister died. The two sisters had been very close. As a home care nurse, explain the factors that might increase Mrs. Niles’ risk for infection.

76. Response
Age
Potential for poor nutrition
Potential for depression

77. Situation
Mr. Vargas is admitted to the facility with a history of recent weight loss, a cough that has persisted for 2 months, and hemoptysis. His chest x-ray film shows a cavity lesion in one lung, and his physician suspects tuberculosis. What type of isolation precautions would you use for Mr. Vargas? What protection would you use to provide care? What education would you provide to the family?

78. Response Airborne precautions Wear an N95 mask Keep the door closed
Educate the pt and family on transmission of TB and reason for isolation.