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Presentation on theme: "PREVENTION OF INFECTION IN THE HOSPITAL SETTING"— Presentation transcript:


2 Coming together is a beginning, keeping together is a process, working together is a SUCCESS Henry Ford

3 Learning Objectives To understand the importance and implications of Prevention of Infection in the Hospital Setting To understand how Infection in the Hospital Setting can be prevented Consider Infrastructure, Education, Policies/procedures, Audit, Surveillance, Outbreak Management,Antimicrobial Policy, Occupational Health, Risk Management and Outcome Indicators in understanding the above

4 Contents of Lecture Infrastructure (environment, ventilation, facilities) Education Surveillance/Audit Infection control policy/procedures ( e.g transmission precautions, evidence based) Antimicrobial policy Occupational Health policy Infection Control indicators Possible problem areas

5 Infection Control SENIC project (Study on the Efficacy of Nosocomial Infection Control) established the scientific basis of efficacy of infection control programmes (Haley Am J Epidemiol 1985; 121: ). 32% of blood-stream, respiratory, urinary tract, and wound infections could be prevented by high intensity infection surveillance and control programmes

6 Consequences of HAI U.S. U.K. 2 million infections/year 90,000 deaths
$4.5 billion dollars in excess healthcare costs MMWR 1992;41:783-7 U.K. Estimated to cost £1 billion/year in 1995 PHLS 1999 5000 deaths/year MOST IMPORTANTLY HAI IMPACT ON THE MORBIDITY AND MORTALITY FOR THE PATIENT

7 Extent of the problem About 10% of patients in hospital have a hospital-acquired infection Emmerson AM, Enstone JE, Griffin M et al. J Hosp Inf ; 32: U.S data: 5.7 nosocomial infections per 100 admissions in 42% UTI 24% surgical wound infections 10% pneumonia 5% bacteraemias Haley et al.Am J Epidemiol Feb;121(2):159-67

8 Problem Areas Increasingly complex patients with increased susceptibility to infection Increasing use of invasive devices Increasing problem of antimicrobial resistance New threats – re-emergence of old threats SARS, influenza MDR-TB Agents of bioterrorism – anthrax, smallpox

9 Inadequate facilities e.g isolation rooms
Overcrowding Frequent patient movement Inability to separate elective and emergency admissions Understaffing Inadequate facilities e.g isolation rooms

10 Environment Consider Patient factors-Increased susceptibility
Immunosuppressed Immunodepressed Burns/Large open wound Premature neonates ICU and those with invasive devised

11 Destroying physical barriers
Deleted pictures Intravascular devices a gateway into the patient’s bloodstream

12 Foreign bodies Endocarditis on an artificial valve
Deleted pictures Foreign material used in fracture fixation - relative non-pathogens e.g. Staphylococcus epidermidis are frequent causes of infection in this setting

13 Destroying physical barriers - 2
Deleted pictures Skin integrity disrupted in this burn - caused by a hot-water bottle in a bed-ridden patient

14 Environmental Items Floors/walls/ceilings ( consider dealing with spills) Furniture/fittings Beds/pillows/mattresses Linen Infant incubators-consider manufactors` instructions Baths/Showers/Sinks/ footpedal bins Drains/Toilets/toilet seats Additional equipment e.g Hydrotherapy pools

15 Consider Prevention

16 Environmental items Cleaning equipment
Floor scrubbers, must be amendable to cleaning Mops- wet , cleaning on hotwash and dried throughly, colour code mops for different area used e.g high risk area as opposed to toliet Vaccuum cleaners, must have a filter on the exhaust , protocol for changing , person in charge

17 Environment Deleted pictures

18 Environmental additional items
Toys Telephones- clean on a regular basis, but hands should be decontaminated before use Flowers/plants- Risk assessment

19 Environment Evidence that a clean environment reduces HAI Norovirus
Indirect transmission occurs Cleaning is a key infection control measure C. difficile Extensive environmental contamination MRSA Evidence that improved cleaning may assist in termination of outbreaks VRE Extensive environmental contamination has been described

20 Ventilation Prevention of spread of airborne pathogens ( airborne precautions) Positive pressure isolation Negative pressure isolation Special considerations for Operating Theatre

21 Ventilation Negative pressure isolation HEPA filtered air
At least 6 exchanges of air/ hour Air should not be recirculated into system and external exhaust should be away from intake air system Particle Filter Respirator masks for those entering Indicated for Infectious mycobacterium tuberculosis, measles, dissemeinated zoster, varicella ( ideally those immune should deal with the patient with measles etc)

22 Ventilation-Operating Theatre
Operating theatres- purpose to prevent bacteria settling in the wound (HTM 2025) People are constantly sheeding dead skin(squames) around 15 um, rate of shedding increases with movement, some of these may carry bacteria Filtration Differential air pressures, filtered clean air to critical areas to less critical Commissioning of theatres – smoke test, casella air counts, structure , maintaince system, rates Ultraclean theatres required for eye surgery etc, unidirectional flow

23 Operating theatre-Commisioning
Deleted pictures

24 Ward Air Sampling- Which Unit may be of concern?
Deleted pictures

25 Water Systems and Prevention of Legionellosis

26 Hospital Water Sytems Deleted pictures

27 Legionnaire`s Disease
The management of Legionnaire`s Disease in Ireland Scientific Advisory Committee Legionnaire`s Disease sub-committee National Disease Surveillance Centre – Guidelines for Control

28 Legionnaire`s Disease
American Legion convention 221 ill and 34 died Mystery Illness Legionella species 65 serotypes Legionella Pneumophilia serogroup 1 accounts for 71% notified to CDC Deleted pictures

29 Natural History 20-45º C favors growth
Do not multiply below 20 ºC and will not survive above 60 ºC Dormant and multiply when temperature suitable Nutrients to multiply derived from algae, amoebae and other bacteria Sediment, Sludge , Scale, Biofilms

30 Water Systems Drinking water disinfectants , free Cl-, kills free floating coliforms but penetrates poorly into biofilm Legionella is further shieled by the amoebae it parasitises Cl-, does not reach distal sites in water distribution systems Dissipates quickly in heated water or removed in water filtering in Spapools So Require design of water systems, Hyperchlorination and Temperature control of water

31 Legionnaire`s Disease
Cluster/Outbreak 2 or more , Single source < 6 mts Linked 2 or more Single source > 6 mts < 2 yrs Sporadic Single Case

32 POTENTIAL SOURCES Fountains/Sprinklers
Hot/Cold Water Systems Cooling Towers Evaporative condensers Respiratory Equipment Spa pools, Natural pools, Thermal springs Fountains/Sprinklers Humidifiers for food display cabinets Water cooling machine tools Vechicle washes Ultrasonic misting machine In common combination of High Temperature and Potential for Aerosol Formation

33 TRANSMISSION Respiratory: Inhalation of aerosol , microaspiration of water containing legionella species The smaller the aerosol more dangerous ( 1-5um) No person to person Transmission

34 Risk Factors So Risk depends on: Individual susceptibility
> 50 years Male Cig Smokers Chronic underlying Disease With/without Immunodeficiency Incubation Period 2-10 Days Attack rates in Outbreak < 5%, 102 –104 /L and sporadic 104 –106 /L So Risk depends on: Individual susceptibility Degree of Intensity of Exposure ( amt. Of legionella, size of aerosol etc) Length of Exposure

35 Hospital INFECTION-Legionnaire`s Disease
Case Defintion: Definite, Probably, Possible Hospitals at risk those caring for immunocompromised patients Hospital size may be important> 200 beds 31 of 32 outbreaks in US Mostly linked to Legionella colonising hot water system ( also cooling towers near ventilation intake, respiratory equipment cleaned with unsterile water, Ice machines, aspiration of contaminated water etc)

36 Recommendations for Control
Staff Education Surveillance Interrupting Transmission e.g Nebuliser equipment and Water distribution systems Sampling: Sites 1Litre in sterile containers containing sufficient sodium thiosulphate to neutralise any Cl- or oxidising biocide Measure Temperature

37 Guidelines Responsible named person for Legionella control
Kept hot water hot at all times –50-60ºC . Keep cold water cold at all times. Maintained at temperatures below 25ºC Run all taps and showers in rooms for a few minutes daily, even if room is unoccupied

38 Guidelines Keep all showers, showerheads and taps clean and free from scale Clean and Disinfect cooling towers used in air conditioning systems regularly – every 3 months Clean and disinfect heat exchangers( calorifiers) regularly- once a year Disinfect the hot water system with high level ( 50 ppm) chlorine for 2-4 hours after work on heat exchangers

39 Guidelines Clean and disinfect all water filters regularly- every one to three months Inspect storage tanks, cooling towers and visible pipe work monthly. Ensure all coverings are intact and firmly in place Ensure that system modifications or new installations do not create pipework with intermittent or no water flow

40 Emergency Control Measures
Precautionary Shock Heating ( min 5 mins each water outlet º C)-Disinfection, disabling Hyperchlorination ( > 10 PPM) of cooling tower on 3 occasions including mechanical cleaning Cleaning of tanks, shower heads, water heaters and circulation of 5 ppm free Cl- through water system for min. 3 hours Storage tanks and pipework temp below 20ºC

41 Waste Segretation/Disposal
Black Bags-non-clinical waste e.g paper Yellow bags-Clinical waste not containing sharps Yellow rigid sharps bin/box for sharps disposal Contaminated linen alginate bags Each hospital may have separate colour scheme SJH

42 Deleted pictures

43 Food Cook –Chill System HACCP(critical control point) analysis
Microbiolgical Testing of Food

44 Cook-Chill system Deleted pictures

45 Facilities Ideally lass than 100% occupancy allows for cleaning and maintaince In the U.K 50% of New Hospitals will be isolation rooms Lower rates of MRSA acquistion in countries that have hospitals with <90% bed occupancy

46 1. Policies and Procedures
Based on scientific evidence-Evidence-based Practical Easily audited Regularly reviewed

47 Examples Policies/Procedures in Infection Control Manual
SJH 016-Safe Disposal of Sharps etc covered in Hand Hygiene Practical

48 Dealing with blood spillage


50 Policy for dealing with blood and body fluid spillages
Put on plastic apron and non-sterile disposable gloves Use masks and visors if splashing in the nose, eye and mouth are likely to occur Cover the spill with disposable paper towels to absorb liquid . Discard into clean yellow infectious waste bag Avoiding contamination of the outside of the new bag. Wipe up excess spillages with disposable paper towel and place into yellow infectious waste bag

51 Policy for dealing with blood and body fluid spillages
Apply a chlorine based solution, strength 10,000 ppm(part per million) and soak for 10 minutes (Klorsept 87 , 1 tablet / 500mls water) Ensure a “wet floor “ sign is in place. Mop up any excess solution. If applied to chrome or metal surfaces wash area with detergent and water. Remove aprons and gloves and discard into yellow waste bag. Tie securely. Wash hands

52 Policy for dealing with blood and body fluid spillages
Klorsept 87 is Sodium dichloroisocyanurate freshly prepared daily 1 tablet Klorsept 87 / 500mls water

53 Effective Infection Control Team
Deleted pictures

54 2. Audit Key component of infection control
Defined as systematic review of care/policies/procedures against explicit criteria and the implementation of change

55 3. Education Organised educational training programme
HCW acquisition of SARS was significantly associated with Amount of PPE perceived to be inadequate Having <2 h infection control training Not understanding infection control procedures Lau et al. Emer Infect Dis 2004;10.

56 Prevention of Infections
Hepatitis B , healthcare workers infected in the US, IN ,000 , 95% decline due to universal precautions and vaccination

Standard Precautions describe the guidelines which are designed to protect patients and healthcare workers from contact with infectious body fluids. Bloodborne viruses of concern are Hepatits C, Hepatitis B/D and HIV. The most serious risk is associated with infected blood, while tears, saliva and urine are considered less hazardous due to lower level of infectious agent present in these fluids

It is not possible to identify every potentially infectious person, therefore it is prudent to adopt “Universal precautions” (Standard Precautions)

59 Principles of Standard Precautions
Avoid contact with body fluids at all times Avoid cuts, abrasions and puncture wounds Cover existing cuts and abrasions with a water proof dressing Avoid contamination of personal clothing with body fluids Protect mucus membranes, eyes and mouth from splashes with body fluids

60 Principles of Standard Precautions
Regular handwashing and good hygiene practices are vital Dispose of waste and linen contaminated with blood or body fluids correctly Decontaminate all items soiled with blood and or body fluids correctly Remember Hands, mucous membranes, eyes, clothes and Protection: Gloves, masks, Goggles/visors, Aprons Avoid recapping of needles and always dispose of sharps safely

61 Personal Protective Clothing and its use covered previously


63 Deleted pictures Foot pedal bin

64 Deleted pictures

HEALTHCARE SETTING 2004 See handout Copies in the Library

66 Why wash your hands? Handwashing is one of the most important procedures in preventing the spread of disease



69 Hands should be washed - Before commencement of duty
- Before handling food - Before attending patients - Before entering protective isolation rooms - Before performing non-touch or aseptic techniques

70 - After visiting the toilet
- After removing gloves - After any microbial contamination - After handling contaminated linen and infectious waste -After patient contact

71 Resident Micro-organisms (normal flora)
Resident micro-organisms are normally found on the hands e.g. CNS. They are deep-seated within the epidermis and are not easily removed. Transient Organisms Transient micro-organisms e.g. MRSA and E. Coli are located on the surface of the skin. Direct contact with people or equipment all result in the transfer of these micro-organisms to and from the hands with ease. They are easily removed with handwashing and the risk of cross infection is then immediately reduced.

72 Contact spread of resistant pathogens via HCW hands
MRSA VRE Pan-resistant Acinetobacter spp. Others

73 U.S. Army Camp Hospital No. 45, Aix-Les-Bains,
Deleted pictures U.S. Army Camp Hospital No. 45, Aix-Les-Bains, France, Influenza Ward No. 1, 1918

74 Hand washing –Evidence -base
Major reduction in postpartum mortality when routine hand washing introduced. (Semmelweis 1861) Important risk factors for non compliance were high work load and being a physician. (Pittet et. al. 2000) Alcohol based hand rub use associated with a steady reduction in nosocomial infection rate over a 4 year period Another key feature was active involvement of hospital management in promoting hand hygeine. (Pittet et. al. 2000) Key to prevention of nosocomial infection Frequency of hand washing in health care workers remains low - less than 50% Continued performance feedback has positive influence on hand washing behaviour

75 Pittet et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet : Interventions : A multidisciplinary project team Priority from senior hospital management Posters emphasising the importance of hand washing, particularly disinfecting. Distribution of individual bottles of alcohol-based chlorhexidine solution Funding A series of educational sessions in individual medical departments. Feedback from results of surveys and hospital infection through hospital newsletters.

76 Overall nosocomial infection rates decreased from a prevalence of 16
Overall nosocomial infection rates decreased from a prevalence of 16.9% to 9.9% (p<0.04)

77 Impact of hand hygiene on infection rates
Year Author Setting Impact on Infection Rates 1977 Casewell adult ICU Klebsiella decreased 1982 Maki adult ICU decreased HAI rates 1984 Massanari adult ICU decreased HAI rates 1990 Simmons adult ICU no effect 1992 Doebbeling adult ICU decreased with one versus another hand hygiene product 1994 Webster NICU MRSA eliminated 1995 Zafar nursery MRSA eliminated 1999 Pittet hospital MRSA decreased

78 5. Surveillance ‘the on-going, systematic collection, analysis, interpretation and dissemination of data regarding a health-related event for action to reduce morbidity and mortality and to improve health’ Single most important factor in prevention of nosocomial infections Hospitals with active surveillance programmes have significantly less nosocomial infection rates

79 Identify patient groups/types of infection
Ensure completeness of data collection Post-discharge surveillance Must Use standardised, objective definitions Validate the data Adjust for risk Produce reports/feedback

80 Catheter Associated Blood stream infection (CABSI)
Less strict definition Expressed as a rate using Catheter days as denominator Rates usually higher than CRBSI as definition is less specific

81 CRBSI / CABSI Surveillance Project in SJH.
Aims of Project To determine the catheter-related and catheter-associated bloodstream infection rate within the hospital. To audit all aspects of central and peripheral line care including insertion, maintenance, drug administration, dressing changes, TPN administration, line removal and documentation. To conduct educational sessions to inform staff involved in line care of the line infection rates and audit findings and to educate and update staff where needs are identified. To reduce patient morbidity, mortality, hospital stay and hospital costs.

82 CRBSI / CABSI Surveillance Project in SJH.
Project started : 09/05/2005 Duration to date: weeks Weeks 1 –2 : Surveillance forms developed Database to collect and analyse data tested

83 Future of the Project Continuous CRBSI surveillance to monitor changes in rate over time. IV Steering Group to oversee the implementation and maintenance of a quality assured service related to all aspects of IV practice. This will include: Education programme. To address findings of audit . Re audit to evaluate education provided.

84 PROCESSES All processes need to be quality control, quality assurance, accreditation New product evaluation Step by step procedure defined Quality indictators of process Manufactors guidelines e.g single use adhered to Risk Management and Sterivigilance

85 Process Control- Example Decontamination of Endoscope

86 Process Example- Decontamination
Decontaminaton is the process which removes or destroys contamination and thereby prevent microorganisms or other contaminants reaching a susceptible site in sufficient numbers to initiate infection or some other harmful response. It included cleaning, disinfection and sterilization.

87 Categories of Infection Risk to patient treatment of equipment
High Risk- Items in close contact with break in the skin or mucous membranes or introduced into a sterile body cavity Sterilization required Intermediate risk- Items in contact with intact mucous membranes Disinfection or Sterilization required

88 Process From Purchasing to decomissioning Clearly outline
Quality control Quality assurance Accreditation All involves documentation and monitoring

89 Process Example- Decontamination of Endoscopes
Good Cleaning is essential -removes potentially infectious microorganisms -removes organic material -soil that may protect microorganisms -soil that may inactivate disinfectants

90 Selection of Endoscope washer disinfectors
This should throughly clean all instrument surfaces and lumens This should disinfect instruments with an effective non-damaging disinfectant at use concentration and temperature This should remove irritant disinfectant residues with sterile or bacteria free water It should have a self disinfecting facility Contain of remove all toxic vapour emissions Produce a print out for cycle validation and instrument traceability Monitor Rinse water microbiologically

91 Antimicrobial Policy see previous lecture

92 Transmission of antibiotic resistance
Mutation - random genetic change Incidence of mutations: 1 bacterium in 10 million One bacterium can produce 1 billion progeny in 10 hours Antibiotics: select mutant strains from patients flora modify flora to resistant strains or species Transfer between bacteria of resistant genes via plasmids or transposons, bacteriophages or naked DNA Spread of resistant strains between patients - via contaminated hands or equipment Also importance of prudent use of antibiotics following Hospital Antimicrobial Policy advised

93 What preventative strategies can be put in place?
Deleted pictures TABLE Examples of Risk Factors for Nosocomial Pneumonia What preventative strategies can be put in place?

94 Resistance to Antibiotics
No antibiotic – no selection for resistant organisms Hydrolyses B-lactam ring sensitive resistant

95 Resistance to Antibiotics
antibiotic – selects for resistant organisms Hydrolyses B-lactam ring sensitive sensitive resistant

96 MRSA CONTROL Reduce antimicrobial use, reduce selection
Reduce MRSA Reservoir and potential for spread by -Ward closures/cohort, Decolonisation, early discharge Infection Control Measures to prevent spread -PROMOTE HAND HYGIENE -Effective isolation measures -Screening

97 Occupational Health Policy
Vaccination Education Risk Assessment ,PEP and follow-up Standard Precautions

98 Infection Control Indicators
Control Assurance Standards for Infection Control- capable of showing improvement in infection control and/or providing early warning of risk are used at all levels of organisation including review of the efficacy and usefulness of indicator

99 Indicators may be Structure Indicators -or compliance indicators with national/local guidelines Process Indicators- how people in an organisation follow internal rules and guidelines e.g audit of hand hygiene compliance Outcome Indicators- link a risk indicator to the progress of patients Surrogate indicator- relates action to effects

100 Examples of Indicators
Structure- Process- Outcome- Healthcare associated Infections, Surgical site infection following clean surgery, Alert organisms -MRSA colonisation -C.difficile diarrhoea -Gentamicin resistant GNB`s -Penicillin resistant pneumococcus -Actinebacter in ITU`s Surrogate – -Length of Hospital stay, Use of oral vancomycin etc

101 See link

102 Contents of Lecture Infrastructure (environment, ventilation, facilities) Education Surveillance/Audit Infection control policy/procedures ( e.g transmission precautions, evidence based) Antimicrobial policy Occupational Health policy Infection Control indicators Possible problem areas

103 Nothing but Healing Hands


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