Azharuddin

Department of Surgery, Zainoel Abidin Hospital/Faculty of Medicine Syiah Kuala University, Banda Aceh

2011

Objectives Define Infection Control and Aseptic Technique Discuss the 3 elements of transmission of infections List the 5 means of transmission of infectious microorganisms Describe the five modes of transmission of infectious

microorganisms Define isolation and discuss isolation precautions List and describe the five crucial areas, according to the C.D.C.,

for maintaining isolation precautions and their implementations Describe Standard precautions, including who is responsible for

implementation, when to implement, and methods of implementation

Demonstrate proper procedure for donning a sterile gown Demonstrate proper procedure for removal of contaminated

gloves Recognize when the guidelines for a sterile field are violated and

how to act appropriately Describe the purposes, types, materials, and methods of wound

dressings

Definitions Infection Control

Program of disease surveillance, designed to investigate, prevent, and control the spread of infections and their causative microorganisms

Aseptic Techniques Are the methods and procedures used to

create and maintain a sterile field

Infection Control

Prevention of disease in hospitals is a major concern

Transmission of infection requires three elements A source of infecting microorganisms A susceptible host A means of transmission for the

microorganism

Sources of Infection Humans Sources

Include patients personnel Visitors

Can be Carrying an acute disease In the incubation period of a disease Colonized by an infectious agent Chronic carriers of an infectious agent

Other Sources

Pt’s own Endogenous Flora (internal microbes useful to the body)

Contaminated Objects Equipment Medications

Susceptible Host Resistance among persons to pathogenic microorganisms

varies greatly Person may,

Be immune Resistant to colonization Become asymptomatic carriers May develop clinical disease

Host factors may include, but not be limited to: Age Underlying diseases Certain treatments with immunodepressive agents

Antimicrobials Corticosteroids

Irradiation Breaks in the first line of defense mechanisms caused by

Surgical operations Anesthesia Indwelling catheters

Means of transmission

Microorganisms are transmitted in hospitals by several routes

The same microorganism may be transmitted by more than one route

The five main routes of transmission are Contact Droplet Airborne Common vehicle Vectorborne

Contact Transmission

The most important and frequent mode of infection transmission

Divided into two subgroups Direct contact transmission

Direct body to surface contact Physical transfer of microorganisms between a susceptible

host and an infected or colonized person

Indirect contact transmission Contact of a susceptible host with a contaminated

intermediate object, usually inanimate

Droplet Transmission Droplets are generated from a source person by:

Coughing Sneezing Talking Performance of certain procedures

Suctioning Wound care

Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance through the air and deposited on a host’s conjunctivae, nasal mucosa or mouth

Droplets do not stay suspended in air

Airborne Transmission

Occurs by two modes of dissemination Airborne droplet nuclei

Are evaporated droplets containing the infectious agent

Remain suspended in air for long periods of time

Dust particles containing the infectious agent Dispersed widely by air currents Inhaled by a susceptible host

Common Vehicle Transmission

Applies to microorganisms transmitted by contaminated items such as: Food Water Medications Devices Equipments

Vectorborne Transmission

Occurs when vectors transmit microorganisms

Vectors are vermin such as: Mosquitos Flies Rats

This method is of less significance in hospitals

Isolation One means of infection control is isolation Isolation is the separation and placement of

patients in environments that reduce the potential for transmission of infectious microorganisms

When a patient is placed in isolation: Signage is posted outside the patient’s room

indicating specifically required isolation practices A request is posted for visitors to see the

patient’s nurse prior to entering the patient’s room

Isolation Precautions There are two levels of isolation precautions

Standard precautions Designed for the care of all patients in hospitals

regardless of diagnosis or suspected infection status Is the primary strategy for successful nosocomial

infection control

Transmission precautions Based on the concept of avoiding infection by limiting the

potential for transmission of microorganisms Are designed only for the care of specified patients who

are known or suspected to be infected by epidemiologically important pathogens

Standard Precautions

Apply to All patients receiving care in hospitals regardless of

diagnosis or presumed infection status Blood All body fluids, secretions, and excretions except

sweat Non-intact skin Mucous membranes

Are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals

Transmission Based Precautions Designed for patients documented or suspected

to be infected with highly transmissible pathogens for which additional precautions, beyond standard precautions, are needed

There are three types of transmission based precautions Airborne Droplet Contact

Are used in addition to standard precautions

can be used in any combination

C.D.C.

The C.D.C. stands for Center for Disease Control

It is the hospital responsible for developing and issuing guidelines for aseptic techniques and isolation systems.

C.D.C. The C.D.C.

Recommends isolation procedures based on 7 categories Strict isolation Respiratory isolation Protective isolation Enteric precautions Wound and skin precautions Discharge precautions Blood precautions

Requires that guidelines Have a basis that is epidemiologically sound Emphasize the importance of all body fluids, secretions and excretions

of nosocomial pathogens Contain precautions for infections transmitted by airborne, droplet, and

contact routes of transmission Be simple to understand and use Use terms to avoid confusion with existing systems

CDC Cont’d The C.D.C. deemed five

areas crucial to maintaining isolation precautions in hospitals Administrative controls Standard precautions Airborne precautions Droplet precautions Contact precautions

Administrative Controls

Include Education

Developing systems to ensure that patients, personnel and visitors are educated about the use of precautions and their responsibility to adhere to them

Adherence to precaution Periodic evaluation of adherence to precautions Use of findings to direct improvements

Standard Precautions Include:

Handwashing Gloves Mask and eye protection Gown Patient care equipment Environmental control Linen Occupational health and

bloodborne pathogens

Handwashing

Hands should be washed: Immediately after touching,

Blood Body fluids Secretions Excretions Contaminated items

Immediately after gloves are removed Between tasks and procedures on the same patient

Plain soap should be used Procedures

Should last a minimum of 15 seconds Involves vigorous rubbing together of all surfaces of lathered

hands Followed by rinsing under a stream of water

In the case of specific circumstances such as control of outbreak or hyperendemic infections, an antimicrobial agent may be used

Gloves

Clean gloves should be worn when: Touching

Blood Body fluids Secretion Excretions Contaminated items Mucous membranes Non-intact skin

Gloves should be changed in between tasks and procedures on the same patient

Gloves should be removed promptly after use

Gloving Procedures Glove pack is opened Sterile wrapping containing gloves should be opened on a sterile

surface with cuffs toward person gloving Sterile portion of a glove pack is opened by grasping the folds of the

paper enclosing the gloves Grasp the left glove with your right hand by its cuff on the non-

sterile portion and work your left hand into it. Once left is in place, place the first two or three fingers of the left

hand inside the sterile side of the cuff of the other glove He lift the right glove using the fingers inside the cuff only Then work the right hand into the glove pulling the sleeve over the

gown Now place the right fingers on the inside of the left glove cuff and

pull that over the gown Once gloved both hands must remain above waist level

Removal of Gloves

One hand grasps the cuff of the other glove The glove that is grasped is turned inside out as it is

removed The glove that is removed is compacted into the other

glove The thumb of the ungloved hand is hooked inside the

remaining glove The remaining glove is pulled towards the fingers while

being turned inside out Both gloves are removed with contaminated sides

inward Do not snap the gloves Dispose the gloves in the appropriate container

Mask and Eye Protection

Are worn to protect mucous membranes of the eyes, nose & mouth of health care providers

Should be worn when performing procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions

Gown

A clean sterile gown can protect the skin and prevent soiling of clothing of health care workers

Should be worn when performing procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions

Should be removed promptly after procedure

Gowning Procedures

Open sterile pack Grasp gown with hands above waist at

all times Shake open gown so it unfolds Locate the neck and armholes of the

gown Without touching the outside, work

both arms into the sleeves Have a nurse or other personnel tie the

gown at the back and neck

Patient Care & Equipment

Used patient care equipment that is soiled in blood, body fluids, secretions or excretions should be handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms

Ensure that equipment is not used for another patient until it is cleaned appropriately

Ensure that single use items are discarded properly

Environmental Control & Linen Ensure that hospital protocols are in place

regarding routine care, cleaning, disinfection of environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces

Handle, transport, and process linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing

Occupational Health & Bloodborne Pathogens Disposable syringes and needles, scalpel blades and

other sharp items should be Handled with care Disposed of in proper puncture proof containers.

Never Recap used needles Manipulate them using both hands Direct the point of a used needle toward any part of

the body Remove needles from disposable syringes by hand Bend, break, or manipulate used needles by hand

Mouthpieces, resuscitation bags & other devices should be used as an alternative to mouth to mouth rescusitation

Airborne Precautions

Respiratory Protection Such as an, N95 respirator, should be

worn when entering room

Patient Transport Movement should be limited to essential

purposes Surgical Mask should be worn by the

patient

Droplet Precautions

Mask Should be worn when working within

three feet of the patient or upon entering room

Patient Transport Should be limited to essential purposes

only Patient must wear a surgical mask

Contact Precautions

Gloves Should be used as outlined under standard

precautions Must be changed constantly during the course of

patient care Must be removed before leaving patient’s room

Handwashing Must use an antimicrobial agent

Gown Must be removed before leaving room

Patient transport Should be limited to essential purposes only

Patient Care Equipment Use of this equipment should be limited to a single

patient only

Sterile Field Another aseptic technique is to provide

and maintain a sterile field.

A sterile field is most commonly required in an operating room

There are 8 requirements for providing and maintaining a sterile field.

Requirement 1

All items used within the boundary of a sterile field must be sterile

Single use items are preferred

Packages are considered sterile only when Initial packaging was performed properly Package was stored in a proper manner Package was not mishandled during distribution Shelf life data has not been exceeded

Requirement 2

Once a package is opened, the edges are not considered sterile

Care in opening sterile packages is required to avoid having edges touch the contents of the package, or having the edges touch the gloved hands or sterile gown

Requirement 3

Once donned properly, sterile gowns are considered sterile in the front from the shoulder level to table top level, including the sleeves

Hands should be held above table top level, in front of body during and after scrubbing, gowning & gloving

Requirement 4

Only the top surface of a table is considered sterile

Any surface above the level of the instrument table, or above waist level, whichever is higher, is a sterile surface as long as it is draped properly

Undraped or improperly draped surfaces, or surfaces below the top level of the instrument table or waist, are considered unsterile

Requirement 5

Only sterile items and personnel in sterile attire may enter the field or touch items in a sterile area.

Forceps can be used to transfer items into a sterile area, but are considered contaminated after one use.

Requirement 6

Activity in a sterile area cannot be allowed to render the area unsterile.

Movement within the sterile area must be measured and careful to avoid contact between sterile and unsterile surfaces.

Any contamination of a sterile area must be pointed out immediately by any personnel present for the protection of the patient

Requirement 7

Penetration of a sterile barrier is considered to cause contamination of a sterile field.

Penetration can be via Liquid (most likely) Airflow

Requirement 8

Sterile areas and fields should be prepared as close to the time of use as feasible

They should not be left unattended Where there is doubt about the

sterile quality of an area, a field, or an item, it should be considered unsterile.

Wound Dressings Two factors may dictate the type of

dressing applied or the method of application of a wound dressing The location of the wound The underlying pathologic conditions

No dressing should ever be applied that impedes circulation

When non institutional care is appropriate, a patient or patient’s family must be instructed carefully in proper wound care

Purpose of Wound Dressings The purposes of wound dressings are

to Protect physically the site of injury Prevent contamination of a wound Prevent transmission of infection from a

wound Promote healing

Evaluation of the Wound

Documentation of wound characteristics is necessary for: Appropriate selection of dressing materials and protective

agents Monitoring progress in wound healing

Evaluation of the wound is necessary to determine: Cause Location Area Depth Whether the wound is wet or dry Whether wound is infected

Source of infection Mechanism of infection Microorganism of infections

Wounds can be measured with a ruler Wounds can be documented by photograph.

Types of Dressings

Five methods of dressing applications for wound management are Dry to dry

Application of a dry absorbent or non absorbent dressing to cover the wound

Damp to damp Application of a gauze pad moistened with saline

solution Damp to dry

Application of a moistened dressing that is allowed to dry before removal

Occlusive dressing Applied to provide a semipermeable barrier to air and

moisture penetration Rigid dressing

Provides physical protection to a wound and the adjacent area

Materials/Application Choice of materials for, and method of

application of dressing depends on: Cause of the wound Whether wound is clean or infected If infected, what microorganism caused the

infection The type of dressing The type, if any, of microbial agent to be

applied The site, area & depth of wound Whether a trained professional, the patient, or

the patient's family will be responsible for monitoring and changing the dressing

Types of Materials

The most basic dressing is a Band Aid Telfa pads are best for small wounds Gauze is the most common material used or

dressings Topical antimicrobial agents may be applied

under the gauze portion of the dressing Compression wraps are applied to control edema

in a limb segment or to provide support to a join Edges of lacerations can be approximated using

Steri Strips Tape used to secure an adhesive can be cloth

adhesive or paper tape

Preparation of a Dressing

Supplies must be easily accessible during procedure Sterile fields, when required, must be prepared

appropriately Use appropriate application of aseptic techniques Tape needs to be prepared before starting the application of

a dressing If tape is applied circumferentially on a limb segment, the

ends should not overlap The size of the dressing should cover the wound site In no case should adhesive portion of a dressing come in

contact with a wound

Packing a Wound

Wound may be packed with gauze depending on the depth

Ensure that deeper layers of a wound heal before surface layers

Once packed, cover the wound and packing with additional dressing that is secured with a tape

Applying a Gauze Wrap

Lay portion of gauze roll against limb segment with the still rolled gauze away from the limb

Wrap gauze in a spiral wrap which means in a continuous spiral manner around the limb segment

Angle the roll of the gauze slightly to accommodate for sloping contour and to avoid creating a tourniquet

Unroll the gauze around the limb segment with each successive wrap overlapping the previous wrap by half

Secure the wrap with tape When removing carefully use bandage scissors to cut gauze

Applying a Compression Wrap Involves applying pressure when

wrapping The pressure should be more distal

than proximal Compression wraps may be applied as:

Spiral wraps Figure eight wraps

Same as spiral wrap except the direction of the wrap changes each time the wrap completes one loop of a figure eight

Summary Infection Control and Aseptic

techniques are programs and procedures put in place to limit or prevent the spread of infectious microorganisms

Transmission of infection requires three elements, a source of infecting

microorganisms, a susceptible host and a means of transmission for the microorganism

The five modes of transmission of infections are contact, droplet, airborne, common vehicle and vectorborne

Summary....

Isolation is the separation and placement of patients in environments that reduce the potential for transmission of infectious microorganisms

There are two tiers of isolation precautions: standard precautions and transmission based precautions

The five crucial areas for maintaining isolation precautions are administrative controls, standard precautions, airborne precautions, droplet precautions and contact precautions

Summary....

Standard precautions include proper handwashing, gloving, face & eye protection, gowning, managing of patient care equipment, environmental control, linen care, observance of procedures regarding occupational health & bloodborne pathogens

Maintenance of a sterile field is usually applied for surgical procedures

Summary..... There are 8 requirements of maintaining

a sterile field they are proper handling of opened packages, proper gowning, table sterility, only sterile items can enter field, activity cannot be allowed to render area unsterile, penetration of sterile barriers are considered contamination and sterile fields should be prepared as close to procedure time as possible

Wound care is designed to protect and prevent infection of wound and involves proper evaluation, type of, preparation and application of dressing

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