Infection Prevention and Control Starting with the Basics

Objectives Speak to the relationship between Infection Prevention methods and reduced transmission of multidrug resistant organisms and C. difficile. Explain the importance of hand hygiene including barriers preventing proper hand hygiene Describe environmental cleaning issues and assessment methods for cleaning validation Discuss recommendations for equipment cleaning and disinfection List the personal protective equipment used to prevent the spread of organisms

Multi Drug Resistant Organisms MDRO Definition Multi Drug Resistant Organisms Microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents Some common ones include: MRSA, VRE, CRE ESBL, and Acinetobacter

Colonized or Infected: What is the Difference? People who carry bacteria without evidence of infection (fever, purulent drainage, increased white blood cell count) are colonized If an infection develops, it is usually from bacteria that colonize patients Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers ~ Bacteria can be transmitted even if the patient is not infected ~

Resistant Staphylococcus MRSA-Methicillin-resistant Staphylococcus aureus causes a range of illnesses, from skin and wound infections to pneumonia and bloodstream infections that can cause sepsis and death. Staph bacteria, including MRSA, are one of the most common causes of healthcare-associated infections. Vancomycin is a common antibiotic used for treatment of MRSA infections. Staphylococcus aureus can become resistant to Vancomycin . http://www.cdc.gov/mrsa/

Resistant Enterococcus VRE -Vancomycin resistant enterococcus can live in the human intestines and female genital tract without causing disease. VRE can cause infections of the urinary tract, the bloodstream, or of wounds associated with catheters or surgical procedures. People with colonized VRE  do not need treatment. Most VRE infections can be treated with antibiotics other than Vancomycin. http://www.cdc.gov/HAI/organisms/vre/vre.html

Carbapenem Resistant Organisms CRE - Carbapenem-resistant Enterobacteriaceae bacteria are difficult to treat because they have high levels of resistance to antibiotics. Klebsiella species and Escherichia coli (E. coli) are examples of Enterobacteriaceae, a normal part of the human gut bacteria, that can become carbapenem-resistant. Types of CRE are sometimes known as KPC (Klebsiella pneumoniae carbapenemase) and NDM (New Delhi Metallo-beta-lactamase). KPC and NDM are enzymes that break down carbapenems and make them ineffective. Both of these enzymes, as well as the enzyme VIM (Verona Integron-Mediated Metallo-β-lactamase) have also been reported in Pseudomonas. http://www.cdc.gov/HAI/organisms/cre/

ESBL Resistance ESBL – Some bacteria product Extended Spectrum Beta Lactamase enzymes that mediate resistance to extended-spectrum third generation cephalosporins , but do not affect cephamycins (e.g., cefoxitin and cefotetan) or carbapenems (e.g., meropenem or imipenem). K. pneumoniae, K. oxytoca, E. coli, and some Enterobacteriaceae, such as Salmonella species and Proteus mirabilis, and isolates of Pseudomonas aeruginosa can produce ESBLs. http://www.cdc.gov/HAI/settings/lab/lab_esbl.html

Resistant Acinetobacter Acinetobacter are gram-negative bacteria that cause of pneumonia, bloodstream infections, or wound infections among critically ill patients. Many of these bacteria have become very resistant to antibiotics. May “colonize” a patient especially in tracheostomy sites or open wounds. Can be spread to susceptible persons by person-to-person contact or contact with contaminated surfaces. http://www.cdc.gov/HAI/organisms/acinetobacter.html

Where Does C. difficile fit into this discussion? Clostridium difficile is not a multidrug resistant organism C. difficile is an anaerobic, gram-positive, spore-forming bacillus, first detected in 1935 in lower intestinal microbiota of healthy newborns. C. difficile was thought to be nonpathogenic for nearly four decades In 1978, C.difficile was identified as the primary cause of pseudomembranous colitis in patients treated with antibiotics. http://www.apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325-e8be75d86888/File/2013CDiffFinal.pdf

C. Difficile Facts C. difficile infection (CDI) is the leading cause of antibiotic-associated diarrhea and a highly problematic healthcare-associated infection The major risk factors for CDI are exposure to antibiotics, hospitalization, and advanced age. The incubation period following acquisition is suggested to be short (median of 2–3 days). There are two states of C. difficile: The vegetative stage does not survive long, but the spore state can persist in the environment for many months.

Transmission of MDRO MDRO are often used as surveillance Transmission and persistence of the resistant strain is determined by: Availability of vulnerable patients Selective pressure exerted by antimicrobial use Colonization pressure Utilization of prevention efforts MDRO are often used as surveillance markers to monitor for IC breaches

CDC/HICPAC System for Categorizing Recommendations Category IA Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiologic studies. Category IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale. Category IC Required for implementation, as mandated by federal and/or state regulation or standard. Category II Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. No recommendation Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

CDC Recommendations Two Tiered approach for prevention and control of MDRO in a healthcare setting Tier one are general recommendations for routine prevention and control Tier two are intensified MDRO control efforts to institute when MDRO rates are not decreasing, an outbreak or new MDRO organism is identified http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf

Guideline Area Emphasis Administrative Measures/Adherence Monitoring MDRO Education Judicious Antimicrobial Use Surveillance Infection Control Precautions Environmental Measures Decolonization

Administrative Support Provide administrative support and commit both fiscal and human resources to prevent and control MDRO transmission (IB) Enforce adherence to Standard and Contact Precautions (IB) Feedback to administration and staff on rates (IB) Participation in MDRO coalitions (IB) Effective communication (II)

MDRO Education Staff education should occur as part of orientation and periodically based on facility assessment (IB) Adherence to hand hygiene practices in conjunction with other control measures have been associated temporally with decreases in MDRO transmission in various healthcare settings.

Judicious Antimicrobial Use Hospitals and LTCFs should have a multi-disciplinary process to review susceptibility patterns and antimicrobial agents in the formulary (IB) Implement a system to prompt clinicians to use the appropriate agent and regimen for a given clinical situation (IB) Provide clinicians with antimicrobial susceptibility reports at least annually (IB)

Surveillance Establish a system that the lab promptly notifies IC, Medical Director, or designee if a novel resistance pattern is detected (IB) Hospitals and LTCF labs: Lab protocols for storing isolates for elected molecular typing when needed to confirm epi-link (IB) System to detect and communicate evidence of MDRO’s in clinical isolates (IB) Prepare facility and special care unit specific antimicrobial susceptibility reports and monitor for resistance changes (IA/IB/IC) Monitor trends in incidence of target MDRO’s over time (IA)

Environmental Measures Follow recommended cleaning, disinfection, and sterilization guidelines Dedicate non-critical medical items Prioritize room cleaning Focus on cleaning and disinfecting frequently touched surfaces and equipment in immediate vicinity of patient.

Decolonization Generally not routinely recommended Do not use topical Mupirocin to routinely decolonized MRSA patients as a component for MRSA control in any healthcare setting (IB) Limit decolonization to health care providers found to be colonized with MRSA who have an epi-link to ongoing transmission of MRSA to patients (IB) Consult with experts on a case-by-case basis regarding decolonization.

Tier 1 - IC Precautions to Prevent Transmission Acute Care Settings Follow Standard Precautions in all healthcare settings (IB) Contact precautions in acute care settings Implement for all patients known to be colonized or infected with target MDRO (IB) Patient placement in single room or cohort (IB)

Tier 2 - Intensified MDRO Control Acute Care Settings Contact precautions should be used routinely for all infected and known colonized patients (IA) Don gowns and gloves upon entry to patient’s room or cubicle (IB) Maintain contact precautions if active surveillance cultures are obtained until results are negative (IB) Patient placement-single room or cohort Implement admission and placement policies as needed (IB) Stop new admissions to the unit or facility if transmission continues despite intensified control measures (IB)

Infection Control and prevention Extended/Long-term Care Different patient population Mobile population Cognitive issues may be a factor Incontinence issues may be a factor Frequent hospitalizations Increased antibiotic use Colonization pressure Double-room/roommates Group living for extended time period Group activities This is their home!! http://www.apic.org/Resource_/TinyMceFileManager/Practice_Guidance/id_APIC-SHEA_GuidelineforICinLTCFs.pdf

IC Precautions to Prevent Transmission LTCFs Tier 1 and Tier 2 Follow Standard Precautions in all healthcare settings (IB) Consider the individual patient’s clinical situation and facility resources in deciding whether to implement Contact Precautions (II) Patient placement in single room or cohort (IB) Tier 2: Use contact precautions routinely for patients colonized or infected (IA) Modify Contact Precautions for patients whose site of colonization or infection can be contained and who can observe good hand hygiene to enter common areas and group activities Maintain Contact Precautions until active surveillance cultures are negative (IB) Implement policies for patient admission and placement (IB) Stop admissions if transmission continues (IB)

Patient Placement When single-patient rooms are available, assign priority for these rooms to patients with known or suspected MDRO colonization or infection. When single-patient rooms are not available, cohort patients with the same MDRO in the same room or patient-care area. When cohorting patients with the same MDRO is not possible, place MDRO patients in rooms with patients who are at low risk for acquisition of MDROs and associated adverse outcomes from infection and are likely to have short lengths of stay. Give highest priority to those patients who have conditions that may facilitate transmission, e.g., uncontained secretions or excretions.

Impact of Contact precautions on patient well-being Studies found that HCP, including attending physicians, were half as likely to enter the rooms of or examine patient on contact precautions Patients placed on Contract Precautions for MRSA had significantly more preventable adverse events, expressed greater dissatisfaction with their treatment and had less documented care than non-isolated patients

Infection Prevention Commonality Proper hand hygiene, proper use of PPE, Proper environmental cleaning, and proper cleaning, disinfection and/or sterilization of equipment, and avoiding reuse of single-use items. Infection Prevention encompasses many factors Breaks or missteps with any of these factors can result in risk of infection Patients Staff Visitors

Improper Disinfection And Sterilization Reuse of single-use items Multidose vials Contaminated Hands Patient Staff Visitors Radiation Diabetes Surgical incision Invasive devices/ Lines Immune Status Medication Medical Procedures Environmental Surfaces Environmental Cleaning Equipment Disinfection Sterilization Personal Protective Patient & Staff Education Hand Hygiene Reusable Equipment Sick Visitors Improper PPE Use Prolonged Use of lines Contaminated meds Improper Disinfection And Sterilization Reuse of single-use items Ill Employees

Hand Hygiene

Hand Hygiene Hand hygiene should be a cornerstone of prevention efforts Prevents transmission of pathogens via hands of healthcare personnel As part of a hand hygiene intervention, consider: Ensuring easy access to soap and water/alcohol-based hand sanitizer Education for healthcare personnel and patients Observation of practices - particularly around high-risk procedures (before and after contact with colonized or infected patients) Feedback – “Just in time” feedback if failure to perform hand hygiene observed Positive and Negative feedback http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

Alcohol Hand Sanitizer Know the Regulations Fire Code and/or Life Safety The maximum individual dispenser fluid 1.2 Liters (1200mL; 0.3 gallons) for dispensers in patient rooms, corridors and areas open to corridors Corridors must be at least 6 feet wide 2.0 Liters (2000mL; 0.5 gallons) for dispensers in suites of rooms. Dispensers must be installed at least 4 feet apart Dispenser must measure at least 6 inches from the center line to the ignition source. Dispensers installed directly over carpeted floors shall be permitted only in sprinkler smoke compartments More storage and use regulations can be found at: https://www.ndhealth.gov/LifeSafety/PDF_Files/ALCOHOL_BASED_HAND_RUB_SOLUTIONS.pdf

Poor Adherence to Hand Hygiene Self Reported • Hand washing agents cause irritation and dryness • Sinks are inconveniently located/shortage of sinks • Lack of soap and paper towels • Often too busy/insufficient time • Understaffing/overcrowding • Patient needs take priority • Hand hygiene interferes with health-care worker relationships with patients • Low risk of acquiring infection from patients • Wearing of gloves/beliefs that glove use obviates the need for hand hygiene • Lack of knowledge of guidelines/protocols • Not thinking about it/forgetfulness • No role model from colleagues or superiors • Skepticism regarding the value of hand hygiene • Disagreement with the recommendations • Lack of scientific information of definitive impact of improved hand hygiene on health-care–associated infection rates

Personnel with heavy workloads have little time to wash their hands A recent study showed that the busier healthcare workers are, the less likely they are to wash their hands when recommended. Hand washing Compliance Increasing Workload

Sinks are often poorly located Sinks used for hand washing are often installed in inconvenient locations. Can you find the sink in this picture?

Location, location, location ... The sink is located behind the patient’s bed and behind several IV pumps. (see arrow) Personnel are unlikely to use hand washing sinks if they are not readily accessible. Be involved with all remodel and construction projects from the design phase to completion of the project

Another reason why personnel don’t wash their hands often Frequent hand washing with soap and water often causes skin irritation and dryness. Staff should be involved with hand hygiene product selection Facilities should provide lotion that is compatible with soaps, sanitizers, and gloves

Many personnel don’t realize when they have germs on their hands Healthcare workers can get 100s or 1000s of bacteria on their hands by doing simple tasks, like: pulling patients up in bed taking a blood pressure or pulse touching a patient’s hand rolling patients over in bed touching the patient’s gown or bed sheets touching equipment like bedside rails, over-bed tables, IV pumps Culture plate showing growth of bacteria 24 hours after a nurse placed her hand on the plate

Using alcohol-based hand sanitizer to improve hand hygiene More than 20 published studies have shown that alcohol-based hand sanitizers are more effective than either plain soap or antibacterial soaps in reducing the number of live bacteria on the hands. Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Alcohol-based Hand Sanitizer Advantages When compared to traditional soap and water hand washing, alcohol hand sanitizers have the following advantages: take less time to use can be made more accessible than sinks cause less skin irritation and dryness are more effective in reducing the number of bacteria on hands makes alcohol-based hand sanitizers readily available to personnel has led to improved hand hygiene practices Infection Preventionists need to assess that hand sanitizer is available in convenient locations

Soap and Water has it’s Place Hand Sanitizer has it’s Place also For hands that are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids Before eating After using the restroom After exposure to C. difficile or Bacillus anthracis is suspected or proven. Hand Sanitizer has it’s Place also Hand sanitizer dispensers should be placed in safe locations Pediatric units, chemical dependency units, cognitive and behavioral settings

Measuring Hand Hygiene Methods of Measure Consider two methods of measurement: Observation Time consuming/bias Patient or visitor/family surveys Patient knowledge/cognition/recall Product Measurement Proxy measure/inaccuracies Electronic Monitoring Cost

Measuring Hand Hygiene Compliance Observation most common type used Issues include: Hawthorne Effect Time Consuming Bias by observers Inability of anonymously observe behind closed doors Objective Measurable Unbiased Consistent Repeatable Accurate Comparable Staff education and feedback are very important components to a hand hygiene program

How Healthcare workers contaminate their hands Frequency of Environmental Contamination of Surfaces in the Rooms of Patients with Methicillin-Resistant S. aureus (MRSA) Resistant bacteria on the skin or in the gastrointestinal tract of patients can often be found on common items Healthcare workers can contaminate their hands by touching environmental surfaces near affected patients. Percent of Surfaces Contaminated

Environmental Cleaning

VRE on Hands and Environmental Surfaces Studies have been conducted to monitor the transmission of VRE Up to 41% of healthcare worker’s hands sampled (after patient care and before hand hygiene) were positive for VRE1 VRE were recovered from a number of environmental surfaces in patient rooms VRE survived on a countertop for up to 7 days2 1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065. 2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581.

The Inanimate Environment Can Facilitate Transmission X represents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~

Disinfectant Use In patient-care areas, visibly soiled areas should first be cleaned and then chemically disinfected. For disinfection, the precleaned areas should be moistened with the appropriate disinfectant for the stated contact time and allowed to air dry. Gloves should be worn during cleaning and decontaminating procedures.

Types of Disinfectants Spaulding Categorization There are three levels of disinfection: High Level kills all organisms, except high levels of bacterial spores Intermediate Level kills mycobacteria, most viruses, and bacteria as chemical germicide registered as a "tuberculocide" by the EPA Low Level kills some viruses and bacteria as a chemical germicide registered as a hospital disinfectant by the EPA. http://www.cdc.gov/hicpac/Disinfection_Sterilization/2_approach.html

Low or Intermediate Level Disinfection Contact Time Short contact time may be difficult to obtain Room turn around time can be a factor Orientation and ongoing staff education Quiz staff and provide real-time education Manufacturer recommendations Review to make sure disinfectants can be used CDC guidelines Some non critical equipment may not have M. recommendations available. CDC guidelines should be considered based on equipment construction and usage.

Types of Devices Spaulding Categorization Critical Devices Reusable instruments or devices that enter sterile tissue, including the vascular system of any patient, and devices through which blood flows should be sterilized before reuse. Semi Critical Devices Reusable devices or items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients. Noncritical Devices Except on rare and special instances, items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients.

Environmental Cleaning for C. difficile Bleach can kill spores, whereas other standard disinfectants cannot Limited data suggest cleaning with bleach reduces C. difficile transmission 1:10 dilution prepared fresh daily 1:10 Prepackaged with stabilizers Two before-after intervention studies demonstrated benefit of bleach cleaning in units with high endemic CDI rates Therefore, bleach may be most effective in reducing burden where CDI is highly endemic Mayfield et al. Clin Infect Dis 2000;31:995-1000. Wilcox et al. J Hosp Infect 2003;54:109-14.

Environmental Cleaning Strategies Assess adequacy of cleaning before changing to new cleaning products Ensure that environmental cleaning is adequate and high-touch surfaces are not being overlooked One study used a fluorescent environmental marker to assess cleaning: only 47% of high-touch surfaces in 3 hospitals were cleaned sustained improvement in cleaning of all objects, especially in previously poorly cleaned objects, following educational interventions with the environmental services staff Carling et al. Clin Infect Dis 2006;42:385-8.

CDC Recommendations Environmental Cleaning Evaluations Level One (basic program) Level Two (advanced program http://www.cdc.gov/HAI/pdfs/toolkits/Environ-Cleaning-Eval-Toolkit12-2-2010.pdf

http://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist-10-6-2010.pdf

Observation Feedback Covert environmental marking Real time feedback for Environmental Services staff Let them see the areas that were missed Test at least 3 times a year using different time frames to capture different cleaning variances Provide overall rates and findings to Environmental Services, Infection Control Committee and Administration

Cleaning of Patient Care Equipment http://www.cdc.gov/HAI/prevent/sd_medicalEquip.html

Manufacturer’s Recommendations Is IP staff involved and providing input into new equipment and devices BEFORE they’re ordered? Can new equipment be cleaned properly with the disinfectants available? Are manufacturer recommendations accessible to the people responsible for cleaning and disinfecting the equipment? Can staff pull the recommendations on demand and are they following them correctly?

Processing of Medical Devices Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce material/bio burden before being exposed to the germicide. Germicide and/or device manufacturers' instructions should be closely followed.

Disinfection of Medical Devices Disinfection means the use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects.

Types of Disinfectants There are three levels of disinfection: High Level kills all organisms, except high levels of bacterial spores, and is effected with a chemical germicide cleared for marketing as a sterilant by the FDA Intermediate Level kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a "tuberculocide" by the EPA Low Level kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.

Types of Devices Noncritical Devices Except on rare and special instances, items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission, and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, blood pressure cuffs, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed. If noncritical items are grossly soiled with blood or other body fluids, follow instructions outlined in the section on HIV-related sterilization and disinfection of this information system. http://www.cdc.gov/HAI/prevent/sd_medicalDevices.html

Exceptions to Standard Disinfection Exceptional circumstances that require noncritical items to be either dedicated to one patient or patient cohort, or subjected to low-level disinfection between patient uses are those involving: Patients infected or colonized with drug-resistant microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance MRSA, VRE, CRE, C. difficile Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic fever (such as Ebola or Lassa). Prions

Types of Devices Semi Critical Devices Reusable devices or items that touch mucous membranes should, at a minimum, receive high-level disinfection between patients. These devices include reusable flexible endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment, dental instruments that do NOT penetrate soft tissue and bone. The other ones: Vaginal probes and speculums, anoscopes, rectal thermometers Are yours single-use disposable or reprocessed?

Types of Devices Critical Devices Reusable instruments or devices that enter sterile tissue, including the vascular system of any patient, and devices through which blood flows should be sterilized before reuse. Dental equipment that penetrates soft tissue and bone. http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

Sterilization of Medical Devices Sterilization means the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. The major sterilizing agents used in hospitals are: moist heat by steam autoclaving, chemical, ethylene oxide gas, and dry heat. http://www.cdc.gov/HAI/prevent/sd_medicalDevices.html

Single-Use vs. Multi-Use Items Single-use is just that-it is used one time for one patient and disposed of properly. Multi-use items can be used more than once but manufacturer’s recommendations must be followed regarding amount of use, cleaning and disinfection between use, labeling, and storage. Reuse of single-use devices -FDA jurisdiction with strong mandates to insure the device is safe for use Hospital or third-party processor is considered the manufacturer and held to the same standards and liability Provide education to staff so they understand what is meant by single-use vs. reusable equipment, supplies, or devices Have a policy defining your facility’s processes http://www.oneandonlycampaign.org/content/cdc-guidelines http://www.cdc.gov/hicpac/Disinfection_Sterilization/14_00ReuseMedicalDevices.html

Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) “Specialized clothing or equipment worn by an employee for protection against infectious materials” (OSHA) Improve personnel safety in the healthcare environment through appropriate use of PPE. Personal protective equipment, or PPE, as defined by the Occupational Safety and Health Administration, or OSHA, is “specialized clothing or equipment, worn by an employee for protection against infectious materials.”

Regulations and Recommendations for PPE OSHA issues workplace health and safety regulations. Regarding PPE, employers must: Provide appropriate PPE for employees Ensure that PPE is disposed or reusable PPE is cleaned, laundered, repaired and proper storage OSHA also specifies circumstances for which PPE is indicated CDC recommends when, what and how to use PPE https://www.osha.gov/pls/oshaweb/owadisp.show_document?p_id=10051&p_table=STANDARDS http://www.cdc.gov/hicpac/pdf/isolation/isolation2007.pdf OSHA issues regulations for workplace health and safety. These regulations require use of PPE in healthcare settings to protect healthcare personnel from exposure to bloodborne pathogens and Mycobacterium tuberculosis. However, under OSHA’s General Duty Clause PPE is required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure that PPE is disposed or, if reusable, that it is properly cleaned or laundered, repaired and stored after use. The Centers for Disease Control and Prevention (CDC) issues recommendations for when and what PPE should be used to prevent exposure to infectious diseases. This presentation will cover those recommendations, beginning with the hierarchy of safety and health controls.

Factors Influencing PPE Selection Type of exposure anticipated Splash/spray versus touch Category of isolation precautions Durability and appropriateness for the task Fit When you are selecting PPE, consider three key things. First is the type of anticipated exposure. This is determined by the type of anticipated exposure, such as touch, splashes or sprays, or large volumes of blood or body fluids that might penetrate the clothing. PPE selection, in particular the combination of PPE, also is determined by the category of isolation precautions a patient is on. Second, and very much linked to the first, is the durability and appropriateness of the PPE for the task. This will affect, for example, whether a gown or apron is selected for PPE, or, if a gown is selected, whether it needs to be fluid resistant, fluid proof, or neither. Third is fit. (optional question) How many of you have seen someone trying to work in PPE that is too small or large? PPE must fit the individual user, and it is up to the employer to ensure that all PPE are available in sizes appropriate for the workforce that must be protected. (Segue to next slide) With this as background, let’s now discuss how to select and use specific PPE. After that we’ll talk about which PPE is recommended for Standard Precautions and the various Isolation Precaution categories.

PPE for Standard Precautions Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated Under Standard Precautions, gloves should be used when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucous membranes and nonintact skin. A gown should be used during procedures and patient care activities when contact of clothing and/or exposed skin with blood, body fluids, secretions, or excretions is anticipated. Aprons are sometimes used as PPE over scrubs, such as in hemodialysis centers when inserting a needle into a fistula.

PPE for Standard Precautions Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions Mask and goggles or a face shield should be used during patient care activities that are likely to generate splashes and sprays of blood, body fluids, secretions, or excretions.

PPE for Enhanced Precautions Expanded Precautions include Contact Precautions Droplet Precautions Airborne Infection Isolation In some instances, healthcare personnel are required to wear PPE in addition to that recommended for Standard Precautions. The three Expanded Precaution categories (formerly called Transmission-Based Precautions) where this applies are Contact and Droplet Precautions and Airborne Infection Isolation.

Use of PPE for Enhanced Precautions Contact Precautions – Gown and gloves for contact with patient or environment of care (e.g., medical equipment, environmental surfaces) these will likely be required upon entering the patient’s environment Droplet Precautions – Surgical masks within 3-6 feet of patient Airborne Infection Isolation – Particulate respirator* Contact Precautions requires gloves and gown for contact with the patient and/or the environment of care; in some instances, use of this PPE is recommended for even entering the patient’s environment. Droplet Precautions requires the use of a surgical mask, and Airborne Infection Isolation requires that only a respirator be worn. *Negative pressure isolation room also required

Respiratory Protection Purpose – protect from inhalation of infectious aerosols (e.g., Mycobacterium tuberculosis -TB) PPE types for respiratory protection Particulate respirators Half or full-face elastomeric respirators Powered air purifying respirators (PAPR) What is your facilities TB plan? Accept the patient Transfer the patient PPE also is used to protect healthcare workers’ from hazardous or infectious aerosols, such as Mycobacterium tuberculosis. Respirators that filter the air before it is inhaled should be used for respiratory protection. The most commonly used respirators in healthcare settings are the N95, N99, or N100 particulate respirators. The device has a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. Respirators are approved by the CDC’s National Institute for Occupational Safety and Health. Like other PPE, the selection of a respirator type must consider the nature of the exposure and risk involved. For example, N95 particulate respirators might be worn by personnel entering the room of a patient with infectious tuberculosis. However, if a bronchoscopy is performed on the patient, the healthcare provider might wear a higher level of respiratory protection, such as a powered air-purifying respirator or PAPR.

Elements of a Respiratory Protection Program Medical evaluation Annual Fit testing Training Fit checking before use http://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf Prior to your using a respirator, your employer is required to have you medically evaluated to determine that it is safe for you to wear a respirator, to fit test you for the appropriate respirator size and type, and to train you on how and when to use a respirator. YOU are responsible for fit checking your respirator before use to make sure it has a proper seal.

For additional information on respirators…. http://www.cdc.gov/niosh/npptl/respirators/ respsars.html http://www.cdc.gov/niosh/99-143.html http://www.cdc.gov/niosh/topics/respirators These websites can provide you with the most up-to-date information on respirators.

Sequence* for Donning PPE Staff education: Gown first Mask or respirator Goggles or face shield Gloves The gown should be donned first. The mask or respirator should be put on next and properly adjusted to fit; remember to fit check the respirator. The goggles or face shield should be donned next and the gloves are donned last. Keep in mind, the combination of PPE used, and therefore the sequence for donning, will be determined by the precautions that need to be taken. *The combination of PPE will affect sequence – be practical

“Contaminated” and “Clean” Areas of PPE Contaminated – outside front Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside Clean – inside, outside back, ties on head and back Areas of PPE that are not likely to have been in contact with the infectious organism To remove PEP safely, you must first be able to identify what sites are considered “clean” and what are “contaminated.” In general, the outside front and sleeves of the isolation gown and outside front of the goggles, mask, respirator and face shield are considered “contaminated,” regardless of whether there is visible soil. Also, the outside of the gloves are contaminated. The areas that are considered “clean” are the parts that will be touched when removing PPE. These include inside the gloves; inside and back of the gown, including the ties; and the ties, elastic, or ear pieces of the mask, goggles and face shield.

Hand Hygiene Perform hand hygiene immediately after removing PPE If hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE Wash hands with soap and water or use an alcohol-based hand rub Hand hygiene is the cornerstone of preventing infection transmission. You should perform hand hygiene immediately after removing PPE. If your hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE. Wash your hands thoroughly with soap and warm water or, if hands are not visibly contaminated, use an alcohol-based hand rub. * Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand sanitizer

Key Points About PPE Don before contact with the patient, generally before entering the room Use carefully – don’t spread contamination Remove and discard carefully, either at the doorway or immediately outside patient room; remove mask/respirator outside room Immediately perform hand hygiene There are four key points to remember about PPE use. First, don it before you have any contact with the patient, generally before entering the room. Once you have PPE on, use it carefully to prevent spreading contamination. When you have completed your tasks, remove the PPE carefully and discard it in the receptacles provided. Then immediately perform hand hygiene before going on to the next patient.

PPE Use in Healthcare Settings: Final Thoughts PPE is available to protect staff from exposure to infectious agents in the healthcare workplace Periodically assess staff compliance to PPE usage and communicate the findings to staff These are a few final thoughts before ending today’s presentation. Remember, PPE is available to protect you from exposure to infectious agents during healthcare. It is important that you know what type of PPE is necessary for the procedures you perform AND that you use it correctly. Thank you for your attention and participation. Are there any questions?

Improper Disinfection And Sterilization Reuse of single-use items Multidose vials Contaminated Hands Patient Staff Visitors Radiation Diabetes Surgical incision Invasive devices/ Lines Immune Status Medication Medical Procedures Environmental Surfaces Environmental Cleaning Equipment Disinfection Sterilization Personal Protective Patient & Staff Education Hand Hygiene Reusable Equipment Sick Visitors Improper PPE Use Prolonged Use of lines Contaminated meds Improper Disinfection And Sterilization Reuse of single-use items Ill Employees

Putting it all Together An Infection Preventionist is an investigator and an advocate for patients and staff Ask questions Be observant Find solutions Work as a team-you are the leader of many Stay current on national guidelines Network-Where do you go for answers?

References/Resources Speak to the relationship between Infection Prevention methods and reduced transmission of multidrug resistant organisms and C. difficile. http://www.cdc.gov/hicpac/pdf/MDRO/MDROGuideline2006.pdf http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf Explain the importance of hand hygiene including barriers preventing proper hand hygiene http://www.cdc.gov/handhygiene/guidelines.html http://www.cdc.gov/handhygiene/download/hand_hygiene_core.pdf   Describe environmental cleaning issues and assessment methods for cleaning validation http://www.cdc.gov/hai/toolkits/evaluating-environmental-cleaning.html http://www.cdc.gov/HAI/toolkits/Environmental-Cleaning-Checklist10-28-2010.doc Discuss recommendations for equipment cleaning and disinfection http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf List the personal protective equipment used to prevent the spread of organisms http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-gl-standared-precautions.html https://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html

Thank You Julie Jacobson, RN BSN CIC Dacotah Plains APIC Chapter julie.jacobson@sanfordhealth.org http://www.apic.org/