PREVENTION OF PREVENTION OF INFECTION IN THE INFECTION IN THE HOSPITAL SETTINGHOSPITAL SETTING

• Coming together is a beginning, Coming together is a beginning, keeping together is a process, keeping together is a process, working together is a SUCCESS. working together is a SUCCESS. Henry FordHenry Ford

Learning ObjectivesLearning Objectives• To understand the importance and To understand the importance and

implications of Prevention of Infection implications of Prevention of Infection in the Hospital Settingin the Hospital Setting

• To understand how Infection in the To understand how Infection in the Hospital Setting can be prevented Hospital Setting can be prevented

• Consider Infrastructure, Education, Consider Infrastructure, Education, Policies/procedures, Audit, Surveillance, Policies/procedures, Audit, Surveillance, Outbreak Management,Antimicrobial Outbreak Management,Antimicrobial Policy, Occupational Health, Risk Policy, Occupational Health, Risk Management and Outcome Indicators Management and Outcome Indicators in understanding the abovein understanding the above

Contents of LectureContents of Lecture• Infrastructure (environment, Infrastructure (environment,

ventilation, facilities)ventilation, facilities)• EducationEducation• Surveillance/AuditSurveillance/Audit• Infection control policy/procedures Infection control policy/procedures

( e.g transmission precautions, ( e.g transmission precautions, evidence based)evidence based)

• Antimicrobial policyAntimicrobial policy• Occupational Health policyOccupational Health policy• Infection Control indicatorsInfection Control indicators• Possible problem areasPossible problem areas

Infection ControlInfection Control

• SENIC project (Study on the Efficacy of Nosocomial SENIC project (Study on the Efficacy of Nosocomial Infection Control) established the scientific basis of Infection Control) established the scientific basis of efficacy of infection control programmes efficacy of infection control programmes (Haley Am J (Haley Am J Epidemiol 1985; 121: 182-205).Epidemiol 1985; 121: 182-205).

• 32% of blood-stream, respiratory, urinary tract, and 32% of blood-stream, respiratory, urinary tract, and wound infections could be prevented by high intensity wound infections could be prevented by high intensity infection surveillance and control programmesinfection surveillance and control programmes

Consequences of HAIConsequences of HAI

• U.S. U.S. – 2 million infections/year2 million infections/year– 90,000 deaths90,000 deaths– $4.5 billion dollars in excess healthcare costs$4.5 billion dollars in excess healthcare costs

MMWR 1992;41:783-7MMWR 1992;41:783-7

• U.K.U.K.– Estimated to cost £1 billion/year in 1995Estimated to cost £1 billion/year in 1995

PHLS 1999PHLS 1999– 5000 deaths/year5000 deaths/year

MOST IMPORTANTLY HAI IMPACT ON THE MORBIDITY AND MORTALITY FOR THE PATIENT

Extent of the problemExtent of the problem

• About 10% of patients in hospital have a hospital-acquired About 10% of patients in hospital have a hospital-acquired infectioninfection

Emmerson AM, Enstone JE, Griffin M Emmerson AM, Enstone JE, Griffin M et aet al. l. J Hosp Inf J Hosp Inf 1996; 32: 175-1901996; 32: 175-190..

U.S data: 5.7 nosocomial infections per 100 admissions in 1975-6U.S data: 5.7 nosocomial infections per 100 admissions in 1975-6– 42% UTI42% UTI

– 24% surgical wound infections24% surgical wound infections– 10% pneumonia10% pneumonia– 5% bacteraemias5% bacteraemias

Haley et al.Am J Epidemiol. 1985 Feb;121(2):159-67Haley et al.Am J Epidemiol. 1985 Feb;121(2):159-67

Problem AreasProblem Areas

• Increasingly complex patients with increased Increasingly complex patients with increased susceptibility to infectionsusceptibility to infection– Increasing use of invasive devicesIncreasing use of invasive devices

• Increasing problem of antimicrobial resistanceIncreasing problem of antimicrobial resistance• New threats – re-emergence of old threatsNew threats – re-emergence of old threats

– SARS, influenzaSARS, influenza– MDR-TBMDR-TB– Agents of bioterrorism – anthrax, smallpox Agents of bioterrorism – anthrax, smallpox

• OvercrowdingOvercrowding– Frequent patient movementFrequent patient movement– Inability to separate elective and emergency Inability to separate elective and emergency

admissionsadmissions

• UnderstaffingUnderstaffing• Inadequate facilities e.g isolation roomsInadequate facilities e.g isolation rooms

EnvironmentEnvironment

• Consider Patient factors-Consider Patient factors-Increased susceptibilityIncreased susceptibility

• ImmunosuppressedImmunosuppressed

• ImmunodepressedImmunodepressed

• Burns/Large open woundBurns/Large open wound

• Premature neonatesPremature neonates

• ICU and those with invasive devisedICU and those with invasive devised

Intravascular devices• a gateway into the patient’s bloodstream

Destroying physical barriersDestroying physical barriers

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Foreign bodiesForeign bodies

Foreign material used in fracture fixation - relative non-pathogens e.g. Staphylococcus epidermidis are frequent causes of infection in this setting

Endocarditis on an artificial valve

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Skin integrity disrupted in this burn - caused by a hot-water bottle in a bed-ridden patient

Destroying physical barriers - 2Destroying physical barriers - 2

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Environmental ItemsEnvironmental Items

• Floors/walls/ceilings ( consider dealing with Floors/walls/ceilings ( consider dealing with spills)spills)

• Furniture/fittingsFurniture/fittings• Beds/pillows/mattressesBeds/pillows/mattresses• LinenLinen• Infant incubators-consider manufactors` Infant incubators-consider manufactors`

instructionsinstructions• Baths/Showers/Sinks/ footpedal binsBaths/Showers/Sinks/ footpedal bins• Drains/Toilets/toilet seatsDrains/Toilets/toilet seats• Additional equipment e.g Hydrotherapy poolsAdditional equipment e.g Hydrotherapy pools

Consider PreventionConsider Prevention

Environmental itemsEnvironmental items

• Cleaning equipmentCleaning equipment

- Floor scrubbers, must be amendable to Floor scrubbers, must be amendable to cleaningcleaning

- Mops- wet , cleaning on hotwash and dried Mops- wet , cleaning on hotwash and dried throughly, colour code mops for different area throughly, colour code mops for different area used e.g high risk area as opposed to tolietused e.g high risk area as opposed to toliet

- Vaccuum cleaners, must have a filter on the Vaccuum cleaners, must have a filter on the exhaust , protocol for changing , person in exhaust , protocol for changing , person in chargecharge

EnvironmentEnvironment

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Environmental additional Environmental additional itemsitems

• ToysToys

• Telephones- clean on a regular basis, Telephones- clean on a regular basis, but hands should be decontaminated but hands should be decontaminated before usebefore use

• Flowers/plants- Risk assessmentFlowers/plants- Risk assessment

Evidence that a clean environment reduces HAIEvidence that a clean environment reduces HAI– NorovirusNorovirus

• Indirect transmission occursIndirect transmission occurs• Cleaning is a key infection control measureCleaning is a key infection control measure

– C. difficileC. difficile• Extensive environmental contaminationExtensive environmental contamination

– MRSAMRSA• Evidence that improved cleaning may assist in termination of Evidence that improved cleaning may assist in termination of

outbreaksoutbreaks

– VREVRE• Extensive environmental contamination has been describedExtensive environmental contamination has been described

Environment

VentilationVentilation

• Prevention of spread of airborne Prevention of spread of airborne pathogens ( airborne precautions)pathogens ( airborne precautions)

• Positive pressure isolationPositive pressure isolation

• Negative pressure isolationNegative pressure isolation

• Special considerations for Operating Special considerations for Operating TheatreTheatre

VentilationVentilation• Negative pressure isolationNegative pressure isolation• HEPA filtered airHEPA filtered air• At least 6 exchanges of air/ hourAt least 6 exchanges of air/ hour• Air should not be recirculated into system Air should not be recirculated into system

and external exhaust should be away from and external exhaust should be away from intake air systemintake air system

• Particle Filter Respirator masks for those Particle Filter Respirator masks for those entering entering

• Indicated for Infectious mycobacterium Indicated for Infectious mycobacterium tuberculosis, measles, dissemeinated tuberculosis, measles, dissemeinated zoster, varicella ( ideally those immune zoster, varicella ( ideally those immune should deal with the patient with measles should deal with the patient with measles etc)etc)

Ventilation-Operating Ventilation-Operating TheatreTheatre• Operating theatres- purpose to prevent Operating theatres- purpose to prevent

bacteria settling in the wound (HTM 2025)bacteria settling in the wound (HTM 2025)• People are constantly sheeding dead People are constantly sheeding dead

skin(squames) around 15 um, rate of skin(squames) around 15 um, rate of shedding increases with movement, some shedding increases with movement, some of these may carry bacteriaof these may carry bacteria

• FiltrationFiltration• Differential air pressures, filtered clean air Differential air pressures, filtered clean air

to critical areas to less criticalto critical areas to less critical• Commissioning of theatres – smoke test, Commissioning of theatres – smoke test,

casella air counts, structure , maintaince casella air counts, structure , maintaince system, ratessystem, rates

• Ultraclean theatres required for eye surgery Ultraclean theatres required for eye surgery etc, unidirectional flowetc, unidirectional flow

Operating theatre-Operating theatre-CommisioningCommisioning

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Ward Air Sampling- Which Unit Ward Air Sampling- Which Unit may be of concern?may be of concern?

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Water Systems and Water Systems and Prevention of LegionellosisPrevention of Legionellosis

Hospital Water SytemsHospital Water Sytems

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Legionnaire`s DiseaseLegionnaire`s Disease

• The management of The management of Legionnaire`s Disease in IrelandLegionnaire`s Disease in Ireland

• Scientific Advisory Committee Scientific Advisory Committee Legionnaire`s Disease sub-Legionnaire`s Disease sub-committee National Disease committee National Disease Surveillance Centre – Guidelines Surveillance Centre – Guidelines for Controlfor Control

http://www.HPSC.iehttp://www.HPSC.ie

Legionnaire`s DiseaseLegionnaire`s Disease

• American Legion American Legion conventionconvention

• 221 ill and 34 died221 ill and 34 died• Mystery IllnessMystery Illness• Legionella species Legionella species

65 serotypes 65 serotypes • Legionella Legionella

Pneumophilia Pneumophilia serogroup 1 serogroup 1 accounts for 71% accounts for 71% notified to CDCnotified to CDC

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Natural HistoryNatural History

• 20-4520-45ºº C favors growth C favors growth• Do not multiply below 20 Do not multiply below 20 ººC and C and

will not survive above 60 will not survive above 60 ººCC• Dormant and multiply when Dormant and multiply when

temperature suitabletemperature suitable• Nutrients to multiply derived from Nutrients to multiply derived from

algae, amoebae and other bacteriaalgae, amoebae and other bacteria• Sediment, Sludge , Scale, BiofilmsSediment, Sludge , Scale, Biofilms

Water SystemsWater Systems• Drinking water disinfectants , free Cl-, kills Drinking water disinfectants , free Cl-, kills

free floating coliforms but penetrates free floating coliforms but penetrates poorly into biofilmpoorly into biofilm

• Legionella is further shieled by the Legionella is further shieled by the amoebae it parasitisesamoebae it parasitises

• ClCl--, does not reach distal sites in water , does not reach distal sites in water distribution systemsdistribution systems

• Dissipates quickly in heated water or Dissipates quickly in heated water or removed in water filtering in Spapoolsremoved in water filtering in Spapools

• So Require design of water systems, So Require design of water systems, Hyperchlorination and Temperature Hyperchlorination and Temperature control of watercontrol of water

Legionnaire`s DiseaseLegionnaire`s Disease

SporadicSingle Case

Cluster/Outbreak2 or more ,

Single source < 6 mts

Linked2 or more

Single source> 6 mts < 2 yrs

POTENTIAL SOURCESPOTENTIAL SOURCES

• Hot/Cold Water Hot/Cold Water SystemsSystems

• Cooling TowersCooling Towers

• Evaporative Evaporative condenserscondensers

• Respiratory Respiratory EquipmentEquipment

• Spa pools, Natural Spa pools, Natural pools, Thermal springspools, Thermal springs

• Fountains/SprinklersFountains/Sprinklers

• Humidifiers for food Humidifiers for food display cabinetsdisplay cabinets

• Water cooling Water cooling machine toolsmachine tools

• Vechicle washesVechicle washes

• Ultrasonic misting Ultrasonic misting machinemachine

In common combination of High Temperature and Potential for Aerosol Formation

TRANSMISSIONTRANSMISSION

• Respiratory: Inhalation of Respiratory: Inhalation of aerosol , microaspiration of aerosol , microaspiration of water containing legionella water containing legionella speciesspecies

• The smaller the aerosol more The smaller the aerosol more dangerous ( 1-5um)dangerous ( 1-5um)

• No person to person No person to person TransmissionTransmission

Risk FactorsRisk Factors

• > 50 years> 50 years• MaleMale• Cig SmokersCig Smokers• Chronic underlying Chronic underlying

DiseaseDisease• With/without With/without

ImmunodeficiencyImmunodeficiency• Incubation Period 2-10Incubation Period 2-10 DaysDaysAttack rates in Outbreak Attack rates in Outbreak

< 5%, 10 < 5%, 1022 –10 –1044 /L and /L and sporadic 10sporadic 1044 –10 –1066 /L /L

• So Risk depends So Risk depends on:on:

• Individual Individual susceptibilitysusceptibility

• Degree of Degree of Intensity of Intensity of Exposure ( amt. Of Exposure ( amt. Of legionella, size of legionella, size of aerosol etc)aerosol etc)

• Length of Length of ExposureExposure

Hospital INFECTION-Hospital INFECTION-Legionnaire`s DiseaseLegionnaire`s Disease• Case Defintion: Definite, Probably, PossibleCase Defintion: Definite, Probably, Possible• Hospitals at risk those caring for Hospitals at risk those caring for

immunocompromised patients immunocompromised patients • Hospital size may be important> 200 beds Hospital size may be important> 200 beds

31 of 32 outbreaks in US31 of 32 outbreaks in US• Mostly linked to Legionella colonising hot Mostly linked to Legionella colonising hot

water system ( also cooling towers near water system ( also cooling towers near ventilation intake, respiratory equipment ventilation intake, respiratory equipment cleaned with unsterile water, Ice machines, cleaned with unsterile water, Ice machines, aspiration of contaminated water etc)aspiration of contaminated water etc)

Recommendations for Recommendations for ControlControl• Staff EducationStaff Education

• SurveillanceSurveillance

• Interrupting Interrupting Transmission e.g Transmission e.g Nebuliser Nebuliser equipment and equipment and Water Water distribution distribution systemssystems

• Sampling:Sampling:

• SitesSites

• 1Litre in sterile 1Litre in sterile containers containers containing sufficient containing sufficient sodium thiosulphate sodium thiosulphate to neutralise any Cl- to neutralise any Cl- or oxidising biocideor oxidising biocide

• Measure Measure TemperatureTemperature

Guidelines Guidelines

• Responsible named person for Responsible named person for Legionella controlLegionella control

• Kept hot water hot at all times –50-Kept hot water hot at all times –50-6060ºC .ºC .

• Keep cold water cold at all times. Keep cold water cold at all times. Maintained at temperatures below 25ºCMaintained at temperatures below 25ºC

• Run all taps and showers in rooms for Run all taps and showers in rooms for a few minutes daily, even if room is a few minutes daily, even if room is unoccupiedunoccupied

Guidelines Guidelines

• Keep all showers, showerheads and taps Keep all showers, showerheads and taps clean and free from scaleclean and free from scale

• Clean and Disinfect cooling towers used Clean and Disinfect cooling towers used in air conditioning systems regularly – in air conditioning systems regularly – every 3 monthsevery 3 months

• Clean and disinfect heat Clean and disinfect heat exchangers( calorifiers) regularly- once a exchangers( calorifiers) regularly- once a yearyear

• Disinfect the hot water system with high Disinfect the hot water system with high level ( 50 ppm) chlorine for 2-4 hours level ( 50 ppm) chlorine for 2-4 hours after work on heat exchangers after work on heat exchangers

Guidelines Guidelines

• Clean and disinfect all water filters Clean and disinfect all water filters regularly- every one to three monthsregularly- every one to three months

• Inspect storage tanks, cooling towers Inspect storage tanks, cooling towers and visible pipe work monthly. Ensure all and visible pipe work monthly. Ensure all coverings are intact and firmly in placecoverings are intact and firmly in place

• Ensure that system modifications or new Ensure that system modifications or new installations do not create pipework with installations do not create pipework with intermittent or no water flowintermittent or no water flow

Emergency Control Emergency Control MeasuresMeasures• Precautionary Precautionary

Shock Heating ( min Shock Heating ( min 5 mins each water 5 mins each water outlet 65outlet 65ºº C)- C)-Disinfection, Disinfection, disablingdisabling

• Hyperchlorination Hyperchlorination ( > 10 PPM) of ( > 10 PPM) of cooling tower on 3 cooling tower on 3 occasions including occasions including mechanical cleaningmechanical cleaning

• Cleaning of tanks, Cleaning of tanks, shower heads, shower heads, water heaters and water heaters and circulation of 5 ppm circulation of 5 ppm free Clfree Cl-- through through water system for water system for min. 3 hoursmin. 3 hours

• Storage tanks and Storage tanks and pipework temp pipework temp below 20below 20ººCC

Waste Segretation/DisposalWaste Segretation/Disposal

• Black Bags-non-clinical waste e.g Black Bags-non-clinical waste e.g paper paper

• Yellow bags-Clinical waste not Yellow bags-Clinical waste not containing sharpscontaining sharps

• Yellow rigid sharps bin/box for sharps Yellow rigid sharps bin/box for sharps disposaldisposal

• Contaminated linen alginate bagsContaminated linen alginate bags• Each hospital may have separate Each hospital may have separate

colour schemecolour schemeSJH

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Food Food

• Cook –Chill SystemCook –Chill System

• HACCP(critical control point) analysisHACCP(critical control point) analysis

• Microbiolgical Testing of FoodMicrobiolgical Testing of Food

Cook-Chill systemCook-Chill system

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FacilitiesFacilities

• Ideally lass than 100% occupancy Ideally lass than 100% occupancy allows for cleaning and maintainceallows for cleaning and maintaince

• In the U.K 50% of New Hospitals will In the U.K 50% of New Hospitals will be isolation roomsbe isolation rooms

• Lower rates of MRSA acquistion in Lower rates of MRSA acquistion in countries that have hospitals with countries that have hospitals with <90% bed occupancy <90% bed occupancy

ExamplesExamples

• Policies/Procedures in Infection Policies/Procedures in Infection Control ManualControl Manual

• SJH 016-Safe Disposal of Sharps etc SJH 016-Safe Disposal of Sharps etc covered in Hand Hygiene Practicalcovered in Hand Hygiene Practical

Dealing with blood spillageDealing with blood spillage

Policy for dealing with Policy for dealing with blood and body fluid blood and body fluid spillagesspillages• Put on plastic apron and non-sterile Put on plastic apron and non-sterile

disposable glovesdisposable gloves• Use masks and visors if splashing in the Use masks and visors if splashing in the

nose, eye and mouth are likely to occurnose, eye and mouth are likely to occur• Cover the spill with disposable paper towels Cover the spill with disposable paper towels

to absorb liquid . Discard into clean yellow to absorb liquid . Discard into clean yellow infectious waste baginfectious waste bag

• Avoiding contamination of the outside of the Avoiding contamination of the outside of the new bag. new bag.

• Wipe up excess spillages with disposable Wipe up excess spillages with disposable paper towel and place into yellow infectious paper towel and place into yellow infectious waste bagwaste bag

Policy for dealing with Policy for dealing with blood and body fluid blood and body fluid spillagesspillages• Apply a chlorine based solution, strength Apply a chlorine based solution, strength 10,000 ppm(part per million) and soak for 10,000 ppm(part per million) and soak for 10 minutes (Klorsept 87 , 1 tablet / 10 minutes (Klorsept 87 , 1 tablet / 500mls water)500mls water)

• Ensure a “wet floor “ sign is in place.Ensure a “wet floor “ sign is in place.• Mop up any excess solution. If applied to Mop up any excess solution. If applied to

chrome or metal surfaces wash area with chrome or metal surfaces wash area with detergent and water.detergent and water.

• Remove aprons and gloves and discard Remove aprons and gloves and discard into yellow waste bag. Tie securely.into yellow waste bag. Tie securely.

• Wash handsWash hands

Policy for dealing with Policy for dealing with blood and body fluid blood and body fluid spillagesspillages

• Klorsept 87 is Sodium Klorsept 87 is Sodium dichloroisocyanurate freshly dichloroisocyanurate freshly prepared dailyprepared daily

1 tablet Klorsept 87 / 500mls 1 tablet Klorsept 87 / 500mls waterwater

Effective Infection Control Effective Infection Control TeamTeam

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3.3. EducationEducation

• Organised educational training programmeOrganised educational training programme• HCW acquisition of SARS was significantly HCW acquisition of SARS was significantly

associated withassociated with– Amount of PPE perceived to be inadequateAmount of PPE perceived to be inadequate– Having <2 h infection control trainingHaving <2 h infection control training– Not understanding infection control proceduresNot understanding infection control procedures

Lau et al. Lau et al. Emer Infect DisEmer Infect Dis 2004;10. 2004;10.

Prevention of InfectionsPrevention of Infections

Hepatitis B , 1995 800 healthcare Hepatitis B , 1995 800 healthcare workers infected in the US, IN workers infected in the US, IN 1983 17,000 , 95% decline due 1983 17,000 , 95% decline due to to universal precautionsuniversal precautions and and vaccinationvaccination

GUIDELINES ON GUIDELINES ON STANDARD STANDARD PRECAUTIONSPRECAUTIONS• Standard Precautions describe the Standard Precautions describe the

guidelines which are designed to protect guidelines which are designed to protect patients and healthcare workers from patients and healthcare workers from contact with infectious body fluids. contact with infectious body fluids. Bloodborne viruses of concern are Bloodborne viruses of concern are Hepatits C, Hepatitis B/D and HIV.Hepatits C, Hepatitis B/D and HIV.

• The most serious risk is associated with The most serious risk is associated with infected blood, while tears, saliva and infected blood, while tears, saliva and urine are considered less hazardous due urine are considered less hazardous due to lower level of infectious agent to lower level of infectious agent present in these fluidspresent in these fluids

GUIDELINES ON STANDARD GUIDELINES ON STANDARD PRECAUTIONSPRECAUTIONS

• It is not possible to identify It is not possible to identify every potentially infectious every potentially infectious person, therefore it is prudent to person, therefore it is prudent to adopt “Universal precautions” adopt “Universal precautions” (Standard Precautions)(Standard Precautions)

Principles of Standard Principles of Standard PrecautionsPrecautions• Avoid contact with body fluids at all Avoid contact with body fluids at all

timestimes• Avoid cuts, abrasions and puncture Avoid cuts, abrasions and puncture

woundswounds• Cover existing cuts and abrasions Cover existing cuts and abrasions

with a water proof dressingwith a water proof dressing• Avoid contamination of personal Avoid contamination of personal

clothing with body fluidsclothing with body fluids• Protect mucus membranes, eyes and Protect mucus membranes, eyes and

mouth from splashes with body fluidsmouth from splashes with body fluids

Principles of Standard Principles of Standard PrecautionsPrecautions• Regular handwashing and good hygiene Regular handwashing and good hygiene

practices are vitalpractices are vital• Dispose of waste and linen contaminated Dispose of waste and linen contaminated

with blood or body fluids correctlywith blood or body fluids correctly• Decontaminate all items soiled with blood Decontaminate all items soiled with blood

and or body fluids correctlyand or body fluids correctly• Remember Hands, mucous membranes, Remember Hands, mucous membranes,

eyes, clothes and Protection: Gloves, eyes, clothes and Protection: Gloves, masks, Goggles/visors, Apronsmasks, Goggles/visors, Aprons

• Avoid recapping of needles and always Avoid recapping of needles and always dispose of sharps safelydispose of sharps safely

Personal Protective Personal Protective Clothing and its use Clothing and its use covered previouslycovered previously

Foot pedal bin

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HAND HYGIENEHAND HYGIENE

GUIDELINES FOR HAND HYGIENE IN IRISH HEALTHCARE SETTING 2004

http://www.ndsc.ie/Publications/HandHygieneGuidelines/

See handout

Copies in the Library

Why wash your hands?Why wash your hands?

Handwashing is one of the most important procedures in preventing

the spread of disease

Hands should be washedHands should be washed

- Before commencement of duty- Before handling food- Before attending patients- Before entering protective isolation rooms- Before performing non-touch or aseptic techniques

- After visiting the toilet - After removing gloves- After any microbial contamination- After handling contaminated linen and infectious waste-After patient contact

Resident Micro-organisms (normal flora)Resident micro-organisms are normally found on the hands e.g. CNS. They are deep-seated within the epidermis and are not easily removed.

Transient OrganismsTransient micro-organisms e.g. MRSA and E. Coli are located on the surface of the skin. Direct contact with people or equipment all result in the transfer of these micro-organisms to and from the hands with ease. They are easily removed with handwashing and the risk of cross infection is then immediately reduced.

Contact spread of resistant Contact spread of resistant pathogens via HCW hands pathogens via HCW hands

• MRSAMRSA• VREVRE• Pan-resistant Pan-resistant AcinetobacterAcinetobacter spp. spp.• OthersOthers

U.S. Army Camp Hospital No. 45, Aix-Les-Bains, France, Influenza Ward No. 1, 1918

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Hand washing –Evidence -baseHand washing –Evidence -base

• Major reduction in postpartum mortality Major reduction in postpartum mortality when routine hand washing introduced.when routine hand washing introduced. (Semmelweis 1861)(Semmelweis 1861)

• Important risk factors for non compliance Important risk factors for non compliance were high work load and being a were high work load and being a physician. physician. (Pittet et. al. 2000)(Pittet et. al. 2000)

• Alcohol based hand rub use associated Alcohol based hand rub use associated with a steady reduction in nosocomial with a steady reduction in nosocomial infection rate over a 4 year period infection rate over a 4 year period

• Another key feature was active Another key feature was active involvement of hospital management in involvement of hospital management in promoting hand hygeine. promoting hand hygeine. (Pittet et. al. 2000)(Pittet et. al. 2000)

Pittet et al. Effectiveness of a hospital-wide programme to Pittet et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000 improve compliance with hand hygiene. Lancet 2000 356: 1307-1312356: 1307-1312

Interventions : Interventions : • A multidisciplinary project team A multidisciplinary project team • Priority from senior hospital management Priority from senior hospital management • Posters emphasising the importance of hand washing, particularly Posters emphasising the importance of hand washing, particularly

disinfecting. disinfecting. • Distribution of individual bottles of alcohol-based chlorhexidine solution Distribution of individual bottles of alcohol-based chlorhexidine solution • Funding Funding • A series of educational sessions in individual medical departments. A series of educational sessions in individual medical departments. • Feedback from results of surveys and hospital infection through Feedback from results of surveys and hospital infection through

hospital newsletters. hospital newsletters.

• Overall nosocomial infection rates decreased Overall nosocomial infection rates decreased from a prevalence of 16.9% to 9.9% (p<0.04)from a prevalence of 16.9% to 9.9% (p<0.04)

5.5. SurveillanceSurveillance

• ‘‘the on-going, systematic collection, analysis, the on-going, systematic collection, analysis, interpretation and dissemination of data regarding a interpretation and dissemination of data regarding a health-related event for action to reduce morbidity and health-related event for action to reduce morbidity and mortality and to improve health’mortality and to improve health’

• Single most important factor in prevention of Single most important factor in prevention of nosocomial infectionsnosocomial infections– Hospitals with active surveillance programmes have Hospitals with active surveillance programmes have

significantly less nosocomial infection ratessignificantly less nosocomial infection rates

• Identify patient groups/types of infectionIdentify patient groups/types of infection– Ensure completeness of data collectionEnsure completeness of data collection

• Post-discharge surveillancePost-discharge surveillance

• Must Must – Use standardised, objective definitionsUse standardised, objective definitions– Validate the dataValidate the data– Adjust for riskAdjust for risk

• Produce reports/feedbackProduce reports/feedback

Catheter Associated Blood stream Catheter Associated Blood stream infection (CABSI)infection (CABSI)

• Less strict definition

• Expressed as a rate using Catheter days as denominator

• Rates usually higher than CRBSI as definition is less specific

CRBSI / CABSI Surveillance Project CRBSI / CABSI Surveillance Project in SJH.in SJH.

• To determine the catheter-related and catheter-associated bloodstream infection rate within the hospital.

• To audit all aspects of central and peripheral line care including insertion, maintenance, drug administration, dressing changes, TPN administration, line removal and documentation.

• To conduct educational sessions to inform staff involved in line care of the line infection rates and audit findings and to educate and update staff where needs are identified.

• To reduce patient morbidity, mortality, hospital stay and hospital costs.

Aims of Project

CRBSI / CABSI Surveillance CRBSI / CABSI Surveillance Project in SJH.Project in SJH.

Project started : 09/05/2005

Duration to date: 38 weeks

Weeks 1 –2 : Surveillance forms developed

Database to collect and analyse data tested

Future of the ProjectFuture of the Project

• Continuous CRBSI surveillance to monitor changes Continuous CRBSI surveillance to monitor changes in rate over time.in rate over time.

• IV Steering Group to oversee the implementation IV Steering Group to oversee the implementation and maintenance of a quality assured service and maintenance of a quality assured service related to all aspects of IV practice. related to all aspects of IV practice.

• This will include:This will include:– Education programme.Education programme.– To address findings of audit .To address findings of audit .– Re audit to evaluate education provided.Re audit to evaluate education provided.

PROCESSESPROCESSES

• All processes need to be quality control, All processes need to be quality control, quality assurance, accreditationquality assurance, accreditation

• New product evaluationNew product evaluation• Step by step procedure definedStep by step procedure defined• Quality indictators of processQuality indictators of process• Manufactors guidelines e.g single use Manufactors guidelines e.g single use

adhered to adhered to • Risk Management and SterivigilanceRisk Management and Sterivigilance

Process Control- Example Process Control- Example Decontamination of Decontamination of

EndoscopeEndoscope

Process Example- Process Example- Decontamination Decontamination

• Decontaminaton is the process which Decontaminaton is the process which removes or destroys contamination removes or destroys contamination and thereby prevent microorganisms and thereby prevent microorganisms or other contaminants reaching a or other contaminants reaching a susceptible site in sufficient numbers susceptible site in sufficient numbers to initiate infection or some other to initiate infection or some other harmful response. It included cleaning, harmful response. It included cleaning, disinfection and sterilization.disinfection and sterilization.

Categories of Infection Risk to Categories of Infection Risk to patient treatment of patient treatment of equipmentequipment• High Risk-High Risk- Items in close contact with Items in close contact with

break in the skin or mucous break in the skin or mucous membranes or introduced into a sterile membranes or introduced into a sterile body cavity body cavity Sterilization requiredSterilization required

• Intermediate risk-Intermediate risk- Items in contact Items in contact with intact mucous membranes with intact mucous membranes Disinfection or Sterilization Disinfection or Sterilization requiredrequired

Process Process

• From Purchasing to decomissioningFrom Purchasing to decomissioning

• Clearly outlineClearly outline

• Quality controlQuality control

• Quality assuranceQuality assurance

• AccreditationAccreditation

• All involves documentation and All involves documentation and monitoringmonitoring

Process Example- Process Example- Decontamination of Decontamination of EndoscopesEndoscopes• Good Cleaning is essentialGood Cleaning is essential

-removes potentially infectious -removes potentially infectious microorganismsmicroorganisms

-removes organic material-removes organic material

-soil that may protect microorganisms-soil that may protect microorganisms

-soil that may inactivate disinfectants-soil that may inactivate disinfectants

Selection of Endoscope washer Selection of Endoscope washer disinfectorsdisinfectors• This should throughly clean all instrument This should throughly clean all instrument

surfaces and lumenssurfaces and lumens• This should disinfect instruments with an effective This should disinfect instruments with an effective

non-damaging disinfectant at use concentration non-damaging disinfectant at use concentration and temperatureand temperature

• This should remove irritant disinfectant residues This should remove irritant disinfectant residues with sterile or bacteria free waterwith sterile or bacteria free water

• It should have a self disinfecting facilityIt should have a self disinfecting facility• Contain of remove all toxic vapour emissionsContain of remove all toxic vapour emissions• Produce a print out for cycle validation and Produce a print out for cycle validation and

instrument traceabilityinstrument traceability• Monitor Rinse water microbiologicallyMonitor Rinse water microbiologically

Antimicrobial Policy see Antimicrobial Policy see previouspreviouslecturelecture

Transmission of antibiotic resistance Transmission of antibiotic resistance

• Mutation - random genetic change Mutation - random genetic change • Incidence of mutations: 1 bacterium in 10 million Incidence of mutations: 1 bacterium in 10 million • One bacterium can produce 1 billion progeny in 10 One bacterium can produce 1 billion progeny in 10

hours hours • Antibiotics: select mutant strains from patients floraAntibiotics: select mutant strains from patients flora modify flora to resistant strains or speciesmodify flora to resistant strains or species• Transfer between bacteria of resistant genes via Transfer between bacteria of resistant genes via

plasmids or transposons, bacteriophages or naked plasmids or transposons, bacteriophages or naked DNADNA

• Spread of resistant strains between patients - Spread of resistant strains between patients - via contaminated hands or equipmentvia contaminated hands or equipment

• Also importance of prudent use of antibiotics Also importance of prudent use of antibiotics following Hospital Antimicrobial Policy advisedfollowing Hospital Antimicrobial Policy advised

What preventative strategies can be put in place?

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Resistance to Resistance to AntibioticsAntibiotics

No antibiotic – no selection for resistant organisms

sensitive resistant

Resistance to Resistance to AntibioticsAntibiotics

antibiotic – selects for resistant organisms

sensitive resistantsensitive

MRSA CONTROLMRSA CONTROL

• Reduce antimicrobial use, reduce selectionReduce antimicrobial use, reduce selection• Reduce MRSA Reservoir and potential for Reduce MRSA Reservoir and potential for

spread byspread by• -Ward closures/cohort, Decolonisation, early -Ward closures/cohort, Decolonisation, early

dischargedischarge• Infection Control Measures to prevent spreadInfection Control Measures to prevent spread• -PROMOTE HAND HYGIENE-PROMOTE HAND HYGIENE• -Effective isolation measures-Effective isolation measures• -Screening-Screening

Occupational Health PolicyOccupational Health Policy

• VaccinationVaccination

• EducationEducation

• Risk Assessment ,PEP and follow-upRisk Assessment ,PEP and follow-up

• Standard PrecautionsStandard Precautions

Infection Control IndicatorsInfection Control Indicators

• Control Assurance Standards for Control Assurance Standards for Infection Control- capable of showing Infection Control- capable of showing improvement in infection control improvement in infection control and/or providing early warning of risk and/or providing early warning of risk are used at all levels of organisation are used at all levels of organisation including review of the efficacy and including review of the efficacy and usefulness of indicatorusefulness of indicator

Indicators may be Indicators may be

• Structure Indicators -or compliance Structure Indicators -or compliance indicators with national/local guidelinesindicators with national/local guidelines

• Process Indicators- how people in an Process Indicators- how people in an organisation follow internal rules and organisation follow internal rules and guidelines e.g audit of hand hygiene guidelines e.g audit of hand hygiene compliancecompliance

• Outcome Indicators- link a risk indicator to Outcome Indicators- link a risk indicator to the progress of patientsthe progress of patients

• Surrogate indicator- relates action to effectsSurrogate indicator- relates action to effects

Examples of IndicatorsExamples of Indicators• Structure- Structure- • Process-Process-• Outcome- Healthcare associated Infections, Outcome- Healthcare associated Infections,

Surgical site infection following clean surgery, Surgical site infection following clean surgery, Alert organismsAlert organisms-MRSA colonisation-MRSA colonisation-C.difficile diarrhoea-C.difficile diarrhoea-Gentamicin resistant GNB`s-Gentamicin resistant GNB`s-Penicillin resistant pneumococcus-Penicillin resistant pneumococcus-Actinebacter in ITU`s-Actinebacter in ITU`s• Surrogate –Surrogate –-Length of Hospital stay, Use of oral vancomycin etc-Length of Hospital stay, Use of oral vancomycin etc

• See link See link

• http://www.bms.jhmi.edu/CFI/inside/http://www.bms.jhmi.edu/CFI/inside/studies/studies/CFI_IH_CaseStudy_CatheterRelatedBlCFI_IH_CaseStudy_CatheterRelatedBloodstreamInfectionsoodstreamInfections

Contents of LectureContents of Lecture• Infrastructure (environment, Infrastructure (environment,

ventilation, facilities)ventilation, facilities)• EducationEducation• Surveillance/AuditSurveillance/Audit• Infection control policy/procedures Infection control policy/procedures

( e.g transmission precautions, ( e.g transmission precautions, evidence based)evidence based)

• Antimicrobial policyAntimicrobial policy• Occupational Health policyOccupational Health policy• Infection Control indicatorsInfection Control indicators• Possible problem areasPossible problem areas

Nothing but Healing Nothing but Healing HandsHands