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Hospital Acquired Infections

Role for Everyone


Principles Practice and Prevention

Dr.T.V.Rao MD

Dr.T.V.Rao MD

The very first


requirement in
a hospital is
that it should do
the sick no
harm
Dr.T.V.Rao MD

Scientific era continues . . . . .


Ignaz Semmelweiss (18181865)
Obstetrician, practised in Vienna
Studied puerperal (childbed)
fever
Established that high maternal
mortality was due to failure of
doctors to wash hands after
post-mortems
Reduced maternal mortality by
90%
Dr.T.V.Rao MD

INFECTION
Definition: Injurious
contamination of body or
parts of the body by
bacteria, viruses, fungi,
protozoa and rickettsia or by
the toxin that they may
produce.
Dr.T.V.Rao MD

our HOSPITALS ARE A


BALANCE OF TWO FORCES

Main Sources of Infection


Person to person via hands of health-care providers, patients,
and visitors
Personal clothing and equipment (e.g. Stethoscopes,
flashlights etc.)
Environmental contamination
Airborne transmission
Hospital staff who are carriers
Rare common-source outbreaks

Campaigns to Decrease Infection Rates


WHO Clean hands are safer hands campaign
Centres for Disease Control and Prevention
(CDC) prevent antimicrobial resistance
campaign in health-care settings
Institute for Healthcare Improvement (IHI)
5 million lives campaign
Developing country focus

Hospital Infection
Hospital
infection is also
called
Nosocomial
infection.
It is the single
largest factor
that adversely
affects both the

Dr.T.V.Rao MD' TMC Kollam Kerala

Organization of an infection
control programme
As with all other functions of a health care facility,
the ultimate responsibility for prevention and control
of infection rests with the health administrator. The
hospital administrator/head of hospital should:

Establish an infection
control committee which will in turn appoint an
infection control team; and
provide adequate resources for effective
functioning of the infection control programme.

Infection control committee


An infection control committee
provides a forum for multidisciplinary
input and cooperation, and information
sharing. This committee should include
wide representation from relevant
departments:
e.g. management, physicians,
other health care workers, clinical
microbiology, pharmacy, sterilizing

Reporting the Matters to


whom
The committee must?
have a reporting
relationship directly
to either
administration or
the medical staff to
promote programme
visibility and
effectiveness.

The infection control team should:


A hospital-associated infection
prevention manual containing
instructions and practices for patient
care is an important tool. The manual
should be developed and updated by
the infection control team and
reviewed and approved by the
committee. It must be made readily
available for health care workers, and

Sings of Infection
Once the infectious agent enters the
host it begins to proliferate and reacts
with the defence mechanisms of the
body producing infection symptoms and
signs: pain, swelling, redness, functional
disorders, rise in temperature and pulse
rate and leucocytosis.
Dr.T.V.Rao MD

13

The risk of infection is always


present.
Patient may acquire infection before admission to the
hospital = Community acquired infection.

Patient may get infected inside the


hospital = Nosocomial infection.
It includes infections not present nor incubating at
admission, infections that appear more than 48 hours
after admission, those acquired in the hospital but
appear after discharge also occupational infections
among staff.
Dr.T.V.Rao MD

14

Cannot autoclave patients

Life is a experience start learning


The TIME IS TICKING

HEALTH CARE ASSOCIATED INFECTION


(NOSOCOMIAL)
Infections that are a
result of health care
delivery, not present at
admission
EXOGENOUS
ENDOGENOUS
IATROGENIC
Refer to Potter & Perry Table 34-2 Pg. 648 (Sites
for Causes of HAIs)

Common Health-Care Associated


Infections
Urinary Tract
Infection
Surgical/Traumatic
Wound Infection

Respiratory Tract
Bloodstream

Urinary
Catheterization

Dr.T.V.Rao MD

19

Defining a Nosocomial infection


A nosocomial infection (nos-oh-koh-mial), also known as a hospital-acquired
infection or HAI, is an infection whose
development is favored by a hospital
environment, such as one acquired by a
patient during a hospital visit or one
developing among hospital staff. Such
infections include fungal and bacterial
infections and are aggravated by the
Dr.T.V.Rao MD

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Leading causes of death


53.9 million from all causes, worldwide

21

Major Sites of Nosocomial Infections

Urinary tract infection

Bloodstream infection
Pneumonia (ventilatorassociated)
Surgical site infection

Sources of SSIs
Endogenous: patients skin or mucosal flora

Increased risk with devitalized tissue, fluid collection, edema,


larger inocula

Exogenous

Includes OR environment/instruments, OR air, personnel

Hematogenous/lymphatic: seeding of surgical site


from a distant focus of infection
May occur days to weeks following the procedure

Most infections occur due to organisms implanted


during the procedure

When you say


Hospital acquired infection
Infection which was neither present nor
incubating at the time of admission
Includes infection which only becomes
apparent after discharge from hospital
but which was acquired during
hospitalisation (Rcn, 1995)

Also called nosocomial infection


Dr.T.V.Rao MD

24

Sources of

Hospital acquired infections

1.Patients own flora - Endogenous


(50%)
Autoinfection ( Greatest source of
potential danger)
2.Environment - Exogenous(15%)
(Air-5%; Instruments-10%)
3.Another Patient/Staff - Cross
Infection (35%)
Dr.T.V.Rao MD

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Types of Infections

Burke J Infection control-a problem for patient safety New Eng Journal
of Medicine (February 13, 2003)

ARE OUR HANDS CLEAN

JUST NO

The hands of staff


are the commonest
vehicles by which
microorganisms are
transmitted
between patients.
Hand washing is
accepted as the
single most

Steps in Hand Washing

What to Use for Hand Washing


Alcoholic hand
disinfection is
generally used in
Europe, while hand
washing with
medicated soap is
more commonly
practised in the
United States.

What is the Best Soap


to wash Hands

Alcohol-based hand rubs are more effective


against most bacteria and many viruses than
either medicated or non-medicated soaps

CAN I USE THE ALCHOOL HAND


WASH
Require less time to use
Result in a significantly
greater reduction in bacterial
numbers than soap and water
in many clinical situations
Cause less irritation to the
skin
Can be made readily
accessible to HCWs
Are more cost effective

Three Levels of
Infection Control
Sanitization
cleaning and
scrubbing
Disinfection second level used on
instruments and equipments that come in
instruments and
contact with intact mucous membrane
equipment to
remove
contaminated
materials
and
Sterilization complete destruction of all
microorganisms
microorganisms-pathogenic, beneficial, and
harmless- surface of instrument and
equipment
33
Dr.T.V.Rao MD

Sanitization
Methods

Collecting instruments place in


container with water and neutral pH
detergent until you can get to them.
Use utility gloves always and mask,
eye protection and protective
clothing if blood, body fluids or
tissue are present
Dr.T.V.Rao MD

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Standard Precautions

Apply standard precautions


to all patients regardless of
their diagnosis, and to all
contaminated equipments
and materials.
Use judgment in determining
Dr.T.V.Rao MD

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Scope of Infection Control


Aiming at preventing spread of infection:
Standard precautions: these measures must be applied during
every patient care, during exposure to any potentially infected
material or body fluids as blood and others.

Components:
A. Hand washing.
B. Barrier precautions.
C. Sharp disposal.
D. Handling of contaminated material
Dr.T.V.Rao MD

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1st principale of infection


prevention
at least 35-50% of all healthcare-associated
infections are asociated with only 5 patient care
practices:

Use and care of urinary catheters


Use and care of vascular access lines
Therapy and support of pulmonary
functions

Surveillance of surgical procedures


Hand hygiene and standard
precautions
Dr.T.V.Rao MD

37

Healthcare-Associated Urinary
Tract Infection
Urinary tract infection (UTI)
causes ~ 40% of hospitalacquired infections
Most infections due to urinary
catheters
25% of inpatients are catheterized
Leads to increased morbidity and
Dr.T.V.Rao MD

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Nurses should be Familiar


INTERVENTIONS

ISOLATION PRECAUTIONS
HYPERTHERMIA INTERVENTION
ELIMINATE UNDERLYING CAUSE
FEVER MANAGEMENT

HEALTH TEACHING
ANTIBIOTIC THERAPY
PSYCHOSOCIAL SUPPORT
HEALTH CARE RESOURCES

Read Manuals on Isolation


Precautions
CDC and OSHA Guidelines on
1. Contact
2. Droplet
3. Airborne

Why Hand Washing

Dr.T.V.Rao MD

41

Impression of my Hand Showing


the Growth of Bacteria

HAND WASHING
Proper hand washing is the

single most important way


to prevent and reduce
infections
Wash and rinse hands for
15 seconds, using a dry
paper towel to turn off
faucet

Alcohol based hand


wash is also available
in all patient care areas
Dr.T.V.Rao MD

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Hands should be washed:


Before and after patient contact
Before putting on gloves and after
taking them off
After touching blood and body
substances (or contaminated
patient-care equipment), broken
skin, or mucous membranes (even
Dr.T.V.Rao MD

44

HAND WASHING
Hand washing is the single most effective
precaution for prevention of infection
transmission between patients and staff.
Hand washing with plain soap is mechanical
removal of soil and transient bacteria (for 10- 15
sec.)
Hand antisepsis is removal & destroy of transient
flora using anti-microbial soap or alcohol based
hand rub (for 60 sec.)
Dr.T.V.Rao MD

45

Methods in Hand Washing


Surgical hand scrub: removal or destruction of transient flora and
reduction of resident flora using anti-microbial soap or alcohol
based detergent with effective rubbing (for least 2-3 min)

Our hands and fingers are our best friends but still
could be our enemies if they carry infective organisms
and transmit them to our bodies and to those whom

we care for.
Sinks & soap must be found in every
patient care room. Doctors, nurses must
comply to hand washing policy.
Dr.T.V.Rao MD

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Children too are at Risk from


Hospital Infections.

Dr.T.V.Rao MD

47

Hand Hygiene Techniques


Many Ways

1.

Alcohol hand rub

2.

Routine hand wash 10-15 seconds

3.

Aseptic procedures 1 minute

4.

Surgical wash 3-5 minutes

Dr.T.V.Rao MD' TMC Kollam Kerala

48

Risk Reduction:

Antimicrobial
Pre-Operative Shower

Chlorhexidine
Gluconate Primary
choice
Iodophores
Hexachlorophene
Dr.T.V.Rao MD

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Barrier Precautions
Gloves:
Disposable gloves must be worn when:
a) Direct contact with B/BF is expected.
b) Examining a lacerated or non-intact skin
e.g wound dressing.
c) Examination of oropharynx, GIT, UIT
and dental procedures.

1.

Dr.T.V.Rao MD

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Barrier Precautions
Working directly with
contaminated instruments or
equipment.
e) HCW has skin cuts, lesions
and dermatitis

Sterile gloves are used for


invasive procedures.
d)

GLOVES MUST BE of good


quality, suitable size and
material. Never reused.
Dr.T.V.Rao MD

51

Barrier Precautions
Masks & Protective eye wear:
MUST BE USED WHEN: engaged in
procedures likely to generate droplets
of B/BF or bone chips
During surgical operations to protect
wound from staff breathings,
Masks must be of good quality,
properly fixed on mouth and nasal
openings.

Dr.T.V.Rao MD

52

Barrier Precautions
3) Gowns/ Aprons:

Are required when:


Spraying or spattering of blood or body fluids is
anticipated e.g surgical procedures.
Gowns must not permit blood or body fluids to
pass through.
Sterile linen or disposable ones are used for
sterile procedures.
Dr.T.V.Rao MD

53

What to do if exposed to blood /


body fluids
Puncture wounds should be washed
immediately and the wound should be
caused to bleed
If skin contamination should occur,
wash the area immediately
Splashes to the nose or mouth should
be flushed with water
Dr.T.V.Rao MD

54

If Exposed
Eye splashes require irrigation
with clean water, saline, or a
sterile irritant
Most importantly: Complete a
GBMC Employee Incident
Report. Report exposure to
charge nurse and Agency
Dr.T.V.Rao MD

55

Sharp precautions
Needle stick and sharp injuries carry the
risk of blood born infection e.g AIDS,
HCV,HBV and others.
Sharp injuries must be reported and notified

NEVER TO RECAP NEEDLES


Dispose of used needles and small sharps
immediately in puncture resistant boxes
(sharp boxes).
Dr.T.V.Rao MD

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Do not Recap Needles


A threat to LIFE

Dr.T.V.Rao MD

57

Protecting Yourself from BloodBorne Pathogens

Dr.T.V.Rao MD' TMC Kollam Kerala

Aseptic technique
Sepsis - harmful infection by bacteria
Asepsis - prevention of sepsis
Minimise risk of introducing pathogenic
micro-organisms into susceptible sites
Prevent transfer of potential pathogens
from contaminated site to other sites,
patients or staff
Follow local policy of your hospital
Dr.T.V.Rao MD

59

Isolation
Single room or group
Source or protective
Source - isolation of infected patient
mainly to prevent airborne transmission via
respiratory droplets
respiratory MRSA, pulmonary tuberculosis

Protective - isolation of immune-suppressed


patient (May, 2000)
Significant psychological effects (Davies et
al, 1999)
Dr.T.V.Rao MD

60

Linen handling and disposal


Bed making and linen changing techniques
Gloves and apron - handling contaminated
linen
Appropriate laundry bags
Avoid contamination of clean linen
Hazards of on-site ward-based laundering
NHS Executive guidelines (1995)
Follow local policy of your hospital
Dr.T.V.Rao MD

61

Waste disposal
Clinical waste - HIGH risk

potentially/actually contaminated waste including


body fluids and human tissue
yellow plastic sack, tied prior to incineration

Household waste - LOW risk

paper towels, packaging, dead flowers, other


waste which is not dangerously contaminated
black plastic sack, tied prior to incineration

Follow local policy of your Hospitals


Dr.T.V.Rao MD

62

Spillage of body fluids


PPE - disposable gloves, apron
Soak up with paper towels, kitchen roll
Cover area with hypochlorite solution e.g., Milton,
for several minutes
Clean area with warm water and detergent, then
dry
Treat waste as clinical waste - yellow plastic sack
Follow local policy (May, 2000)

Dr.T.V.Rao MD

63

Environmental cleaning
Recent concern regarding poor hygiene in hospital
environments (NHSE, 1999)
Some pathogens survive for long periods in dust,
debris and dirt
Poor hygiene standards - hazardous to patients
and staff (May, 2000)
Report poor hygiene to Domestic Services (UKCC,
1992)
Hospitals should do the sick no harm
(Nightingale, 1854)
Dr.T.V.Rao MD

64

Risk assessment
No risk of contact/splashing with blood/body
fluids - PPE not required
Low or moderate risk of contact/splashing - wear
gloves and plastic apron
High risk of contact/splashing - wear gloves,
plastic apron, gown, eye/face protection (Rcn,
1995)
Cerebrospinal fluid, peritoneal fluid, pleural fluid,
synovial fluid, amniotic fluid, semen, vaginal
secretions, and
Any other fluid containing
blood e.g., urine,
Dr.T.V.Raovisible
MD

65

In spite many developments in medicine and


asepsis hand washing still the best solution

Hand hygiene is the


simplest, most
effective measure for
preventing hospitalacquired infections.
Dr.T.V.Rao MD

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Dr.T.V.Rao MD

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Ways to overcome the


nosocomial infections
Besides, hospitals need to have
infection control committees to
conduct outcome and process
surveillance for nosocomial infections.
This committee should meet regularly
and publish the results of their
surveillance. At the same time,
healthcare institutions should adopt
new and better technology, like closed
Dr.T.V.Rao MD

68

Basic hygiene is key to control


infections
Ignaz Semmelweis in 1847 demonstrated
that washing hands saves lives
Old bacteria are causing new problems
New viral and prion diseases are causing
new problems
Reluctance to wash hands still the single
most important cause of HAI (ICNA, 1998)

Growing concern about poor


hospital hygiene
Dr.T.V.Rao MD

69

Nurses should be familiar with


Surveillance Activities
Operative Procedures
Critical Care Units
(MICU, SICU, NICU)
Targeted Surveillance
Outbreak Investigation

Benchmarking Hospital
Acquired Infections
CDCs Hospital Infections Program
Submit monthly data on ICU infections
Benchmarking with similar hospitals
Networking opportunities
Annual reports
Start having a Infection Audit

Surveillance Data
Improves the Patient Safety
USES
Improve patient
outcomes by
modifying patient care
practices
reducing length of stay

Identify education
needs
Evaluate new products
Identify new
opportunities for

Nurses should Evaluate their


Outcome
MEASURE SUCCESS OF
INFECTION CONTROL
TECHNIQUES
COMPARE PATIENTS
RESPONSE TO ACTUAL
OUTCOME
WHAT WILL YOU DO IF
GOAL/OUTCOMES NOT
ACHIEVED?

Our Hands are Threat to LIFE


Just Washing can Save Many LIVES

Dr.T.V.Rao MD

74

Let us support our hospitals with


clean hands

Dr.T.V.Rao MD

75

Soap Water and Common sense are Best


Antiseptics- William Osler

Dr.T.V.Rao MD' TMC Kollam Kerala

76

WE ARE ALL RESPONSIBLE


INFECTION CONTROL

I am thankful to every one at


Kinder Hospital Cherthala
Alappuzha Kerala