1. PREVENTION OF INFECTION IN THE HOSPITAL SETTING

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

57. GUIDELINES ON STANDARD PRECAUTIONS
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

58. GUIDELINES ON STANDARD PRECAUTIONS
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

65. HAND HYGIENE GUIDELINES FOR HAND HYGIENE IN IRISH
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