INFECTION PREVENTION and CONTROL Standard Precautions OR ….How to prevent the spread of disease NORMAL DEFENSES Heath Care-Associated Types of Infections Infections formerly called nosocomial HAIs Iatrogenic: Exogenous: Endogenous: CHAIN OF INFECTION Cholera Outbreak in Haiti Cholera Nepalese peacekeeping force Poop Latrines near water River Drinking contaminated water Historical Perspective 1847 Dr. Ignaz Philip Semmelweiss Significance of hand washing is demonstrated Concept of nosocomial infection is born More History Infectious Disease Process Infection: Normal flora: Colonization: Chain of Infection Causative Agents Bacteria Virus Fungi Protozoa Characteristics of Causative Agents Reservoirs 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 Portal of Exit: The path by which the infectious agent leaves the reservoir Respiratory Tract: GU Tract GI Tract: Skin/Mucous Membranes: Transplacental Blood: Mode of Transmission The mechanism for transfer of an infectious agent from the reservoir to the susceptible host 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 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 Modes of Transmission Contact Airborne Vector-Borne Contact Direct: Indirect: Modes of Transmission Direct Person to Person (Fecal-Oral) Indirect Contact with Hepatitis A contaminated object Staph Hepatitis B and C HIV RSV MRSA Airborne Droplets suspended in air after coughing and sneezing or carried on dust particles TB Chicken Pox Measles (Rubeola) Aspergillus Droplet transmission Large particles Can travel up to 3 feet Influenza Rubella (3- day/German Measles) Bacterial Meningitis Vector-Borne Vector External mechanical transfer Mosquito, Louse, Flea, Tick, Fly West Nile Virus Malaria Lyme Disease Hanta Virus 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 Susceptible Host A person or animal lacking effective resistance to a particular pathogenic agent Man-Made Epidemics (NYT July 15, 2012) Diseases have always come out of the woods and wildlife West Nile Virus American Robin Thrives in our backyards and agriculture fields Mosquitoes that spread the disease find robins particularly appealing H1N1 Lyme Disease . Ebola SARS Bird Flu Isolation Precautions Historical perspective 1877 to present 1877 Aseptic technique 1910 “Barrier” Nursing Hospital personnel wear gowns between patients Handwashing between patients with antiseptic solutions after patient contact Disinfection of objects contaminated by patients 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 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) HAIs Surgical Sites Reproductive System Blood Stream Respiratory Urinary System Bone and Joint Cardiovascular Eye/Ear/Throat/Mout h Infection Infection CNS Gastrointestinal Skin and Soft Tissue Immunocompromised Pts Vary in their susceptibility to HAIs Depends on the severity and duration of immunosupression. Use the two-tiered system Neutropenic precautions Critical Thinking Question Clients in the healthcare setting are at risk for acquiring or developing infections because: 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 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 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 hands between patients. wash Prevention To reduce susceptibility provide adequate nutrition and rest, promote body defenses against infection and provide immunization Superbugs MRSA VRE: Vancomycin resistant enterococcus 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) MEDICAL ASEPSIS Clean technique: Aseptic technique 3 components to the technique: Hand washing, Barriers of PPE (gloves, gowns, mask, protective eyewear) Routine environmental cleaning Contaminated area: 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 Aseptic technique Handwashing is the single most important procedure for preventing the transfer of microorganisms and therefore preventing the spread of HAIs CD recommends 10-15 second hand wash. 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. When should hands be washed 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 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 Hand Hygiene 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 N95 Respirator STANDARD PRECAUTIONS Handwashing Gloves (PPE) Masks (PPE) Eye Protection (PPE) Gowns (PPE) Leak-proof linen bags Puncture proof containers for sharps Donning and Removing PPERemoving Donning 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 Gloves Goggles/face shield Gown Mask or respirator Remove at doorway before leaving pt. room Perform hand hygiene immediately after removing all PPE 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 Principles of Surgical Asepsis 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 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 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) 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 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 ? Answer UTI Should the catheter be reinserted? Why or why not? 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 Nursing Response Increase her fluid intake if not clnically contraindicated Check her urinalysis 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? 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? 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. Response Age Potential for poor nutrition Potential for depression 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? Response Airborne precautions Wear an N95 mask Keep the door closed Educate the pt and family on transmission of TB and reason for isolation.