14. hospital infections and isolation nursing part ii

8/7/2019 14. hospital infections and isolation nursing Part II

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Important NosocomialImportant Nosocomial

InfectionsInfectionsManagement of InfectiousManagement of Infectious

PatientsPatients

Chapters 13 and 14 ofChapters 13 and 14 of

your textbookyour textbook


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Aseptic TechniqueAseptic Technique

Prevent introduction of microorganismsPrevent introduction of microorganismsinto sites during treatment orinto sites during treatment or

manipulationmanipulationUse for wound dressing, IV lines,Use for wound dressing, IV lines,

catheters, suturing, vaginal examination,catheters, suturing, vaginal examination,invasive proceduresinvasive procedures

Wear gloves, use sterile packWear gloves, use sterile pack


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Wound InfectionWound Infection

Look for signs of infection regularlyLook for signs of infection regularly

Risks:Risks:

Site of woundSite of woundPatient susceptibilityPatient susceptibility

Presence of foreign materialPresence of foreign material

PrePre--operative stayoperative stay

Duration of operationDuration of operationSurgical skillSurgical skill


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Check records of surgicalCheck records of surgicalinfectioninfection -- note thenote the

surgeon. Is anyonesurgeon. Is anyonegetting more infectedgetting more infectedpatients than average?patients than average?

Inform the surgeonsInform the surgeonswith poor records ofwith poor records oftheir statustheir status -- oftenoftenresults in improvement!results in improvement!


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Prevention of Wound InfectionPrevention of Wound Infection

Preparation of patientPreparation of patientHealthy if possibleHealthy if possible

Preoperation showerPreoperation showerClean skin with disinfectant before surgeryClean skin with disinfectant before surgery

Shave immediately before surgeryShave immediately before surgery


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Hand washingHand washingSurgical scrubSurgical scrub removes resident andremoves resident and

transient organismstransient organismsChlorhexidine or povidoneChlorhexidine or povidone--iodineiodine

TheatreTheatreClean airClean air

Protective clothingProtective clothing


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PostPost--operative careoperative careFirst 24 hours most importantFirst 24 hours most important

Inspect regularly for signs of infectionInspect regularly for signs of infectionAntiseptics may not be usefulAntiseptics may not be useful


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Chronic woundsChronic wounds

Clean gloves and apronsClean gloves and aprons

Prevent crossPrevent cross--infectioninfection

Creams etc for one patient onlyCreams etc for one patient onlyBurns especially at risk of infectionBurns especially at risk of infection


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Bloodstream InfectionBloodstream Infection

6% of HAI6% of HAI mostly in ICUmostly in ICU

SepticaemiaSepticaemia symptomssymptoms

BacteraemiaBacteraemia no symptomsno symptomsFrom IV devicesFrom IV devices oror infectionsinfections

elsewhere in the bodyelsewhere in the body


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IV device infectionIV device infection

RisksRisks MultiMulti--lumen lineslumen lines

SiteSite (femoral vein for central venous(femoral vein for central venous

catheters?? x) Subclavian catheters?? x) Subclavian DurationDuration

Pressure monitoringPressure monitoring

Cannula materialCannula material impregnated materialsimpregnated materials Implantable devicesImplantable devices--lower rate infectionlower rate infection

Smooth surface-TeflonAntiseptic/antibiotics

Staphylococcus epidermidis!!Can (a) adhere to catheters and (b) produce

slime


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IV device infectionIV device infection

Prevention Catheter Insertion asepsis, protective clothing, skin

preparation, firm anchoring of the catheter

Maintenance of site polyurethane dressings to cover

insertion site Management of fluid administration equipment

reduce manipulation, change sets every 72 hours or ifused for blood or lipid emulsion, parenteral feeding

should have designated tube Catheter Replacement remove and resite peripheral

lines every 72 hours, do not move central lines


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Urinary Tract InfectionUrinary Tract Infection

Most common form of HAI (20% of allMost common form of HAI (20% of allHAI)HAI)

Mostly linked to catheter useMostly linked to catheter use1010 --30% develop infection30% develop infection

One third of infected patients haveOne third of infected patients have

symptoms including fever and painsymptoms including fever and painUncomplicated infections can be easilyUncomplicated infections can be easily

treatedtreated


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Long term catheterisationLong term catheterisation

Repeated infection, spread to kidney,Repeated infection, spread to kidney,

urinary stones.urinary stones.Risk of bacteraemia and septicaemiaRisk of bacteraemia and septicaemia

can be fatalcan be fatal Gram negativeGram negative

septicaemiasepticaemia


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Symptoms and DiagnosisSymptoms and DiagnosisEcoli, Pseudomonas, ProteusEcoli, Pseudomonas, Proteus

Often no symptoms in catheterisedOften no symptoms in catheterisedpatientspatients

Suspect UTI if patient is pyrexicSuspect UTI if patient is pyrexic


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Role of the CatheterRole of the Catheter

Enables bacteria from perineum to reachEnables bacteria from perineum to reachbladderbladder

Organisms enter system when bag isOrganisms enter system when bag isemptiedemptied

Risk of infection increases with timeRisk of infection increases with time byby30 days almost all infected30 days almost all infected


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Preventing UTI infectionPreventing UTI infection

InsertionInsertionUseUse anaestheticanaesthetic gel togel to meatusmeatus

Carefully position patientCarefully position patientAvoid touchingAvoid touching periurethralperiurethral

areaarea

Aseptic technique!Hand hygiene!


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Choose 10 ml balloon, narrow lumenChoose 10 ml balloon, narrow lumenunless urine has a lot of debrisunless urine has a lot of debris

SiliconeSilicone resistant to biofilm build upresistant to biofilm build up good for long term catheterisationgood for long term catheterisation


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RemovalRemovalRemove as soon as possibleRemove as soon as possible

Only change if encrustedOnly change if encrustedUse of disinfectants around meatus do notUse of disinfectants around meatus do not

appear to reduce infectionappear to reduce infection


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Avoid disconnection of catheter and bagAvoid disconnection of catheter and bag

Prevent kink in the tubePrevent kink in the tube refluxreflux

Encourage high fluid intakeEncourage high fluid intake-- lemon andlemon andcranberry drinkscranberry drinks

Aseptic handling of catheterAseptic handling of catheter

Always use gloves to handle catheter andAlways use gloves to handle catheter andwash hands afterwash hands after


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UTIUTI -- Use ofCathetersUse ofCatheters

Treatment of UTI in Catheterised patientsTreatment of UTI in Catheterised patients

Only treat asymptomatic patients with catheterOnly treat asymptomatic patients with catheteron removalon removal -- just exchange sensitive forjust exchange sensitive forresistant strainsresistant strains

Treat symptomatic infectionsTreat symptomatic infections

Encouragesantibioticresistance


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LowerRespiratory InfectionLowerRespiratory Infection

Serious LifeSerious Life--threateningthreatening

Important type of HAIImportant type of HAI

Gram negative organismsGram negative organisms KlebsiellaKlebsiellapneumoniaepneumoniae

High mortality rateHigh mortality rate


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Risk FactorsRisk Factors Inhalation of airborne particlesInhalation of airborne particles

Aspiration of material from oropharynxAspiration of material from oropharynx

Increased risk if oropharynx colonised by GramIncreased risk if oropharynx colonised by Gramnegative organismsnegative organisms

Age, illness, immunosuppressionAge, illness, immunosuppression

Antibiotics, surgery, nasogastric tubes,Antibiotics, surgery, nasogastric tubes,

endotracheal tubeendotracheal tube Supine position, unconsciousness,Supine position, unconsciousness,

AerosolsAerosols nebulisers, ventilatorsnebulisers, ventilators

Narcotics for pain reliefNarcotics for pain relief


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Supine


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Colonisation of oropharynx and stomachColonisation of oropharynx and stomach

Depletion of fibronectin allows colonisationDepletion of fibronectin allows colonisation occurs in severe illnessoccurs in severe illness

Occurs in postOccurs in post--surgical patientssurgical patients

Tubes enhance colonisation and aspirationTubes enhance colonisation and aspiration

Stomach colonised if antacids given to preventStomach colonised if antacids given to prevent

stress bleeding, also old age, gastro disease andstress bleeding, also old age, gastro disease andenteral feedsenteral feeds -- refluxreflux


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VentilationVentilation Risk increase daily by 1%Risk increase daily by 1%

Biofilm on tubeBiofilm on tube

ContaminatedContaminatedaerosolsaerosols

NebulisersNebulisers for drugsfor drugs increase colonisationincrease colonisation


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Prevention ofLRTIPrevention ofLRTI

Handwashing / alcohol rub if touching ventilatorHandwashing / alcohol rub if touching ventilatortubingtubing

Clean gloves for contact with mucousClean gloves for contact with mucous

membranesmembranes

Drain humidifier reservoirs and wash withDrain humidifier reservoirs and wash withdetergent, dry and refill every 48 hoursdetergent, dry and refill every 48 hours

Use filters with resuscitation bagsUse filters with resuscitation bags Decontaminate if possible between patientsDecontaminate if possible between patients


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Tracheal and endotrachealTracheal and endotrachealtubes can introduce organismstubes can introduce organismsand accumulate bacteria inand accumulate bacteria in

biofilmsbiofilms Regular suctioning ofRegular suctioning of

secretionssecretions

Decontaminate suctionDecontaminate suctionequipmentequipment

Use suction catheter once onlyUse suction catheter once only


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NebulisersNebulisers wash and dry after eachwash and dry after eachuseuse

Only use sterile solutionsOnly use sterile solutions

Oxygen delivery equipmentOxygen delivery equipment change tubing, prongs and masks afterchange tubing, prongs and masks afterevery patientevery patient

Enteral feedingEnteral feeding position patient toposition patient toprevent aspiration; prepare freshlyprevent aspiration; prepare freshly


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Enteral feed


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PostPost--operative measures to preventoperative measures to preventpneumoniapneumonia

Breathing exercisesBreathing exercises

Pain controlPain control

Support of abdominal wounds to enable patientSupport of abdominal wounds to enable patientto cough up secretionsto cough up secretions

Prophylactic antibiotic does not reduce incidenceProphylactic antibiotic does not reduce incidenceof infectionof infection


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Other Hospital AcquiredOther Hospital Acquired

PneumoniaPneumonia

Respiratory VirusesRespiratory Viruses RSVRSV mainly children, prevent spread ofmainly children, prevent spread of

infection by isolation, gloves aprons,infection by isolation, gloves aprons,

handwashinghandwashing InfluenzaInfluenza young, elderly immunocompromised,young, elderly immunocompromised,

isolate, vaccineisolate, vaccine

SARSSARS patients with underlying illness havepatients with underlying illness have

highest mortality, isolation, strict droplethighest mortality, isolation, strict dropletprecautionsprecautions


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PneumoniaPneumoniaegionnaires DiseaseLegionnaires Disease

Legionella pneumophilaLegionella pneumophila

Infection from aerosolsInfection from aerosols

Cooling water from air conditioners, hot waterCooling water from air conditioners, hot watersystems, humidifiers, nebuliserssystems, humidifiers, nebulisers regular cleaningregular cleaningand disinfection, hot water above 50Cand disinfection, hot water above 50C

Elderly and imunocompromisedElderly and imunocompromised


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PneumoniaPneumonia

AspergillosisAspergillosisFungus in soil water andFungus in soil water and

decaying vegetablesdecaying vegetablesSpores in airSpores in air

Immunocompromised, cystic fibrosis, boneImmunocompromised, cystic fibrosis, bone

marrow transplantsmarrow transplantsFilter airFilter air


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AspergillisAspergillis

Spores


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Isolation NursingIsolation Nursing


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IsolationIsolation

Segregation of patients with infectiousSegregation of patients with infectiousdisease goes back thousands of yearsdisease goes back thousands of years

Isolation aims to prevent spread ofIsolation aims to prevent spread ofinfectious disease and nosocomialinfectious disease and nosocomialpathogenspathogens

Required when routine control cannotRequired when routine control cannotprevent spreadprevent spread


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HistoryHistory

Barrier nursingBarrier nursing

1920s sterile conditions1920s sterile conditions

1970s different isolation procedures for1970s different isolation procedures fordifferent infectionsdifferent infections too complicated!too complicated!

1990s simplified1990s simplified one basic set of rulesone basic set of rules

with some extras for specific infectionswith some extras for specific infections


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PrinciplesPrinciples

Prevent microorganisms being transmittedPrevent microorganisms being transmittedfrom infected or colonised patients to othersfrom infected or colonised patients to others

Interrupt spread of infectionInterrupt spread of infection break chainbreak chainof transmissionof transmission

Disturbing for patientDisturbing for patient use reasonableuse reasonable

precautions and as short a period asprecautions and as short a period aspossiblepossible

Consult Infection Control TeamConsult Infection Control Team


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Points to considerPoints to consider

OrganismOrganism Body site of infectionBody site of infection Transmission routeTransmission route

Are other patients / staff vulnerable?Are other patients / staff vulnerable? How can the infection be controlled?How can the infection be controlled? Consider state of the patientConsider state of the patientOften too lateOften too late use for unknown rashes oruse for unknown rashes or

pyrexiapyrexia Use for reUse for re--admissions with MRSAadmissions with MRSA


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Transmission of InfectionTransmission of Infection

In the hospital, three routes important:In the hospital, three routes important:

ContactContact

directdirect indirectindirect

DropletDroplet

AirborneAirborne


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Contact TransmissionContact Transmission

Most frequent routeMost frequent route

DirectDirect -- organisms transferred by bodilyorganisms transferred by bodily

contact between infected and uninfectedcontact between infected and uninfectedperson e.g. during bathing or turning aperson e.g. during bathing or turning apatientpatient

IndirectIndirect -- contaminated instruments orcontaminated instruments orhandshands

Prevent byPrevent by: handwashing, gloves: handwashing, gloves


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Droplet TransmissionDroplet Transmission

Respiratory secretions of patient expelledRespiratory secretions of patient expelledinto air by sneezing, coughing etc.into air by sneezing, coughing etc.

Droplets propelled up to 1 metreDroplets propelled up to 1 metre

May land on upper respiratory tractMay land on upper respiratory tractmucosa or conjunctiva of susceptible hostmucosa or conjunctiva of susceptible host----> infection> infection

Prevent byPrevent by: use of masks: use of masks


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Airborne TransmissionAirborne Transmission

Spread of small dried particles of dust orSpread of small dried particles of dust ordroplet nuclei containing infectiousdroplet nuclei containing infectiousmicroorganismsmicroorganisms

Can stay in the air for a long time and beCan stay in the air for a long time and bewidely dispersed on air currentswidely dispersed on air currents

Can be inhaled and reach the lungsCan be inhaled and reach the lungs

Prevent byPrevent by: good ventilation systems,: good ventilation systems,single room, protective clothingsingle room, protective clothing


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TransmissionTransmission--basedbased

precautio

nsprecautio

ns

Additional to standard precautionsAdditional to standard precautions

Used when patients have highlyUsed when patients have highlytransmissible or epidemiologicallytransmissible or epidemiologicallyimportant pathogensimportant pathogens


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IsolationIsolation -- STRICTSTRICT

Separate room, gowns, gloves, masks,Separate room, gowns, gloves, masks,glovesgloves

Strict hand washingStrict hand washingOwn instrumentsOwn instruments

Dressings incinerated, linen doubleDressings incinerated, linen double--baggedbagged

May need to change gloves etc if severalMay need to change gloves etc if severalprocedures carried out on same patientprocedures carried out on same patient


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IsolationIsolation -- STRICTSTRICT

Private RoomPrivate Room

For patients who contaminate theFor patients who contaminate the

environment or cannot maintain hygieneenvironment or cannot maintain hygieneOnly relevant if patient is only source ofOnly relevant if patient is only source of

organism in areaorganism in area

Profuse diarrhoea and vomiting, MRSAProfuse diarrhoea and vomiting, MRSA

Infected burns, congenital rubella, neonatalInfected burns, congenital rubella, neonatalHerpes, major skin infection, Varicella,Herpes, major skin infection, Varicella,Staphylococcal pneumoniaStaphylococcal pneumonia


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Airborne PrecautionsAirborne Precautions

Prevents transmission of organisms byPrevents transmission of organisms bydroplet nuclei or dustdroplet nuclei or dust

Private room or cohortingPrivate room or cohortingSpecial ventilationSpecial ventilation negative pressurenegative pressure

Mask, limited visitorsMask, limited visitors

Use mask for patient if movedUse mask for patient if movedMeasles, T.B., chickenpox, SARSMeasles, T.B., chickenpox, SARS


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Droplet PrecautionsDroplet Precautions

Prevents transmission of organisms byPrevents transmission of organisms bydroplets that are coughed into thedroplets that are coughed into theenvironmentenvironment

Private room or cohortingPrivate room or cohorting

Mask within 1 metreMask within 1 metre

Limit movement of patientLimit movement of patient

Patient wears mask if moved out of roomPatient wears mask if moved out of room

Pneumonia, pertussis, meningococcus,Pneumonia, pertussis, meningococcus,mumps, rubella, influenzamumps, rubella, influenza


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Contact PrecautionsContact Precautions

For patients with infections spreadFor patients with infections spreadby direct or indirect skin contactby direct or indirect skin contact

P

rivate room or cohortingP

rivate room or cohortingGloves, gownGloves, gown

Limiting movement of patientLimiting movement of patient

Avoid sharing of equipmentAvoid sharing of equipmentRubella, varicella, diarrhoea, Herpes,Rubella, varicella, diarrhoea, Herpes,skin or wound infectionskin or wound infection


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TransportTransport

Reduce movement of isolated patients toReduce movement of isolated patients toother areas of the hospitalother areas of the hospital

If necessary to transport cover infectedIf necessary to transport cover infected

lesionslesionsWear mask for airborne infectionWear mask for airborne infection

Inform mortuary if a patient has died ofInform mortuary if a patient has died of

tuberculosis, bloodborne virus ortuberculosis, bloodborne virus orCreutzfeldtCreutzfeldt--Jacob diseaseJacob disease


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VisitorsVisitors

Wash hands before leaving roomWash hands before leaving room

Restrict visitors for airborne infectionsRestrict visitors for airborne infections

Remember isolation is stressful for theRemember isolation is stressful for thepatientpatient may have behavioural problemsmay have behavioural problems

Inform/explain to patient and family soInform/explain to patient and family so

that they can be preparedthat they can be preparedDo not prolong for longer than necessaryDo not prolong for longer than necessary


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IsolationIsolation -- PROTECTIVEPROTECTIVE

Uninfected burns, severe immuneUninfected burns, severe immunedeficiency other than AIDS, radiation ordeficiency other than AIDS, radiation or

chemotherapy, leukaemia, severechemotherapy, leukaemia, severedermatitisdermatitis

However most infections from own floraHowever most infections from own flora

Private room, filtered airPrivate room, filtered airMask, gowns, gloves, strict handwashingMask, gowns, gloves, strict handwashing

Staff/visitors with RTI should stay awayStaff/visitors with RTI should stay away


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IsolationIsolation -- PROTECTIVEPROTECTIVE

Low bacteria diet, thoroughly cook meat,Low bacteria diet, thoroughly cook meat,wash fruit/veg & peeledwash fruit/veg & peeled

14. hospital infections and isolation nursing part ii

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