Infection Control in the Hospital Setting

Vickie Brown, RN, MPH, CIC

Associate Director

Hospital Epidemiology

UNC Health Care

Hospital Epidemiology

Director William Rutala, PhD, MPHMedical Director David Weber, MD, MPHPublic Health Epidemiologist Emily Sickbert-Bennett, MS

Infection Preventionists Becky Brooks, RN, CIC Tina Adams, RN Brenda Featherstone, RN Lisa Teal, RN Kirk Huslage, RN, MPH

Location: 1st Floor, West Wing, Memorial HospitalOffice Hours: Monday – Friday 7:30 AM to 4 PMPhone: 966-1638

Infection Control Resources

Infection Control Policies on Hospital Intranet http://intranet.unchealthcare.org/hospitaldepartments/infection

/policies

Infection Control on call pager available 24/7: 216-6652

PURPOSES OF EPIDEMIOLOGY

To plan and evaluate interventions and prevention strategies more effectively by knowing: The distribution of disease Its determinants in person, place, and time

CHAIN OF INFECTION

Infection requires a “chain” of events The role of the hospital epidemiologist/infection control

is to understand this chain and the most efficient means of interrupting transmission

CHAIN OF INFECTION

Causative agent Susceptible host Reservoir Inoculating dose Portal of exit Portal of entry Environmental survival Mode of transmission

SOURCES OF PATHOGENS

People Endogenous: Normal flora or reactivation Exogenous: People (staff, visitors) or environment

Animals Arthropods (insects) Environment

Normal Skin Micro-FloraNormal Skin Micro-Flora

Numbers per square centimeter of skin surface (cfu/cm2).

Numbers of bacteria that colonize different parts of the body

ICU Setting: Multiple Sources of Pathogens

Basic Modes of Transmission

Contact-victim contact with source Direct-physical contact between source (e.g., MRSA on medical

student’s hands) and victim (patient medical student is examining) Indirect-victim contacts contaminated inanimate object (e.g.,

ultrasound probe contaminated with MRSA or VRE) Droplet-infectious droplets deposited on mucous membranes

of the nose or mouth Airborne-airborne phase in disease dissemination Vectorborne-not a significant source in US healthcare facilities

Isolation Precautions to Prevent the Transmission of Infections to Patients and Personnel

STANDARD PRECAUTIONS

Hand hygiene: Before and after each patient contact & after gloves removed

Gloves: When touching contaminated items (blood, body fluids, secretions, excretions). If it is wet and not yours, wear gloves!

Mask, eye protection, face shield: whenever splashes or sprays of body fluids possible

Gown: Whenever splashes or sprays of body fluids possible

Personal Protective Equipment (PPE) Gloves Gown Mask Eyewear

Wear your personal protective equipment correctly!

AIRBORNE PRECAUTIONS

Used for patients with known or suspected diseases transmitted by airborne droplet nuclei (<5 microns)

Private room Negative air pressure in relation to the corridor >6 air exchanges per hour Direct discharge of air to the outside

Personnel: Respiratory protection required N-95 respirator Limit transport of patient to essential purposes

AIRBORNE PRECAUTIONS

Representative pathogens M. tuberculosis Varicella Zoster Measles

HCWs required to wear arespirator to enter room

SPECIAL AIRBORNE PRECAUTIONS

Used for patients with known or suspected diseases transmitted by airborne droplet nuclei and contact

Private room (must meet airborne isolation guidelines) Personnel: Respiratory protection required

N-95 respirator Eye protection: Shield or goggles Gowns and gloves when entering room

Limit transport of patient to essential purposes

SPECIAL AIRBORNE PRECAUTIONS

Representative pathogens Avian influenza Monkey pox SARS Co-V Smallpox Viral hemorrhagic fever (e.g., Ebola,

Lassa)

DROPLET PRECAUTIONS

Used for diseases spreadvia large droplets (>5 microns)

Private roomSpecial air handling not required

PersonnelSurgical mask upon entering room

DROPLET PRECAUTIONS

Representative pathogens Invasive N. meningitidis RSV Bordetella pertussis Rubella Mumps Group A streptococcal pharyngitis Influenza

H1NI Precautions

CONTACT PRECAUTIONS

Used for pathogens thatcan easily be transmitted bycontact with patient and/or itemsin the patient’s environment Private room Gloves and gown when entering room Careful hand hygiene

Representative Pathogens

Methicillin-resistant S. aureus (MRSA) Vancomycin-resistant enterococcus (VRE) C. difficile Norovirus Multiply-drug resistant (MDR) gram negative rods

(e.g., B. cepacia, P. aeruginosa, Acinetobacter)All of the above organisms can survive on environmental surfaces for long periods of time and can be transiently carried on hands.

Bloodborne Pathogens

Blood Exposure Trends, 1999-2008

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UNC Hospital Employees

BLOODBORNE PATHOGENSTRANSMITTED BY NEEDLESTICKS

Big 3 Hepatitis B Hepatitis C HIVOthers Argentinean VHF (Junín virus) Blastomycosis Brucellosis Corynebacterium diphtheria Cryptococcus Dengue Diphtheria

Ebola virus infection Herpes simplex I Leptospirosis Malaria Marburg VHF Mycobacterium marinum Mycoplasma caviae infection Rocky Mountain spotted fever Syphilis Toxoplasmosis Tuberculosis Varicella zoster West Nile

Tarantola A, et al. AJIC 2006;34:367-75

Campus Health

Blood/body fluid exposure reporting: 966-6561

After hours, weekends call Health Link: 966-2281

Additional Information: Exposure Control Plan for Bloodborne Pathogens; attachment 12: 55-58.

http://intranet.unchealthcare.org/hospitaldepartments/infection/policies/Ecpbbp.pdf

Other Communicable Diseases with Risk of Occupational Exposure

Tuberculosis Varicella zoster Pertussis Influenza Meningococcal Meningitis Parvo Virus-B19

UNC OHS EVALUATIONS, 2007-08

Disease 2007 Index Cases

2007Staff

Screened

2007 Infected

2008IndexCases

2008Staff

Screened

2008Infected

Tuberculosis 9 38 1 4 14 0Pertussis 4 11 0 5 19 0Varicella 1 0 0 0 0 0Zoster 3 0 0 0 0 0Syphilis 5 9 0 6 9 0N. meningitidis 1 49 0 3 16 0Hepatitis B 2 2 0 2 2 0Hepatitis C 27 27 0 39 39 1HIV 12 0 0 10 10 0All blood 269 269 0 314 314 1

Health Care Associated Infections

(HAIs)

Impact of HAIs

2002 data from CDC National Nosocomial Infections Surveillance Systems

Estimated number of HAIs: 1.7 million Estimated number of deaths associated with the HAI:98,987

Pneumonia: 35,967 Bloodstream: 30,665 Urinary tract: 13,088 Surgical site: 8,205 Other sites: 11,062

Klevens RM. Public Health Rep. 2007, 122(2):160-6

Economic Costs of HAIs

Overall annual direct medical costs range from $28.4 to $33.8 billion (adjusted to 2007 dollars).

Scott DR, CDC, March 2009

http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf

COST ESTIMATES FOR SPECIFIC HEALTHCARE-ASSOCIATED INFECTIONS

HAI type Weight-Adjusted Cost per HAIMean + SE

Range of Published Estimates of Cost per HAI

VAP 25,072 + 4,132 8,682-31,316BSI 23,242 + 5,184 6,908-37,260SSI 10,443 + 3,249 2,527-29,367CA-UTI 758 + 41 728-810

Anderson DJ, et al. ICHE 2007;28:767-773

(2005 dollars)

UNC HOSPITALSSELECTED HAIs AND ESTIMATED COST

HAI type UNC Cases, 2008 Estimated Cost

VAP 82 2,055,904

BSI 231 5,368,902

SSI 335 3,498,405

CA-UTI 339 256,962

Total 987 11,180,173

Total cost estimated by multiplying number of cases at UNC Hospitals bymean cost derived from Duke meta-analysis

What is the most effective and simplest method to protect your health and to help prevent HAIs?

UNC Hospitals Intensive Care Units: Hand Hygiene Compliance (%), 2003-2008

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Hand Hygiene: Methods

Soap and water Hand washing with antimicrobial soap (e.g.CHG) and water for 15

seconds Alcohol-based handrubs (e.g. Alcare) when…

Hands are not visibly soiled, or Hand washing facilities are not available in patient rooms

Use soap and water when… Patient known or suspected to have C. difficile disease or norovirus

infection (alcohol not effective against spores or nonenveloped viruses)

Indications for Handwashing and Hand Antisepsis

Before having direct contact with patients. Before donning sterile gloves for sterile/aseptic

procedures (e.g., central venous catheter placement) After glove removal After patient contact After contact with a contaminated instrument or

surface- Artificial nails and nail extenders are prohibited for direct patient care providers.

In Review

Infections can be transmitted in the hospital setting via contact, droplet, or airborne spread

Adherence to Isolation Precautions prevents transmission of disease to you and to other persons

Appropriate use of PPE and safe handling of sharp devices can reduce your risk of exposure to bloodborne pathogens

Hand hygiene reduces the risk of transmission of pathogenic organisms Questions related to infection prevention and control: contact Hospital

Epidemiology @ 6-1638 and after hours on pager 216-6652

Thank You!

“I don't see the glass as half-empty or half-full.I see it as a glass somebody else has already puttheir lousy germs on.”

Maxine