Infection control

INFECTION CONTROL

S.V.L PADMAKUMARI M.sc (NURSING)

INFECTION

AN INFECTION IS THE ENTRY AND MULTIPLICATION OF AN INFECTIOUS AGENT IN THE TISSSUES OF A HOST.

CHAIN OF INFECTION

INFECTIOUS AGENT

THESE ARE THE MICRO ORGANISMS WHICH ARE CAPABLE OF PRODUCING AN INFECTIOUS

PROCESS. SUCH AS BACTERIA, VIRUS, PROTOZOA,

RESERVOIR

COMMON RESERVOIR OR SOURCES OF MICROORGANISMS ARE OTHER HUMANS,

CLIENT’S OWN MICROORGANISMS, PLANTS ANIMALS .

PORTAL OF EXIT FROM RESERVOR

BEFORE AN INFECTION CAN ESTABLISH ITSELF IN A HOST, MICROORGANISM MUST LEAVE THE RESEIVOIR. COMMON PORTAL OF EXIT INCLUDE NOSE, MOUTH, URETHRAL MEATUS, VAGINA.

Common escape routes are as follows:

The skin and mucous membrane

Gastrointestinal tractReproductive tractRespiratory tractGenito urinary tract

Blood and serum

Mode of transmission:

After the micro organism leaves its source or reservoir it requires a mean of transmission to reach another person or host.

a)Direct transmission:Direct contactDroplet infectionContract with soil

Inoculation into skin or mucosatransplacental

b) Indirect transmission:Vehicle- borne: water, food, ice, blood, serum,

plasma.eg: cholera,polioVector-borne: arthropod or any living carrier,

eg: malariaAir- borne (droplet nuclei).Fomite borne: inanimate article or substances

other than water or food contaminated by the infections, discharges from a patient,

Unclean hands and fingers:Portal of entry to susceptible host: any person

who is at risk of infection.

Defences against infection

1) Natural defences:

a) skin:

In skin intact multilayered surface is a body’s first line of defence against infections.

b) Mouth:

Intact multilayered mucosa of mouth provides mechanical barriers to micro-organisms. Saliva produces in mouth, washes away particles containing micro-organism.

c) Respiratory tract: cilia lining upper airway, coated by mucus will trap inhaled microbes and sweep them outward in mucus to be expectorated or swallowed.

d) urinary tract: the flushing action of urine flow washes away microorganisms on lining of bladder and urethra.

e) Gastrointestinal tract: Here the acidity of gastric secretions chemically destroys microorganisms incapable of surviving low ph.

f) vagina: At puberty normal for a causing vaginal secretion to achieve low ph, which inhibits growth of many microorganisms.

2) Acquired Defence:

Defences acquired by immunization will prevent the infections.

HOSPITAL ACQUIRED INFECTIONS(NOSOCOMIAL INFECTIONS)

DEFEINITION:

The word nosocomial comes from the Greek Word ‘’nosokomeion’’ meaning hospital.

Nosos =disease

komeo= to take care of

“Nosocomial infections are infections which occurs as a result of treatment in a hospital.” Infections are considered nosocomial if they first appear 48 hrs or more after hispital admission

TYPES OF NOSOCOMIAL INFECTIONS

A) IATROGENIC:

IT is a type of nosocomial infection that results from a diagnostic or therapeutic procedures. Eg UTI may result from catheterization

B) EXOENOUS:

IT arises from microorganisms external to the individual, which do not exit as a normal flora. Eg clostridium tatani

.

C) ENDOGENOUS INFECTION:

It can occur when part of the client’s flora becomes alter and an overgrowth results. Eg infections due to enterococci, yeast.

Causes Of Nosocomial Infections

HOSPITALS WILL HAVE LARGE NUMBER OFF PEOPLE WHO ARE SICK AND WHOSE IMMUNE SYSTEMS ARE OFTEN IN A WEAKEND STATE.

INCREASEED USE OF OP TREATMENT MEANS THAT PEOPLE WHO ARE IN HOSPITAL ARE SICK ON AN AVERAGE.

MEDICAL STAFF MOVIE FROM PATIENT TO PATIENT.

MANY MEDICAL PROCEDURES BYPASS THE BODY’S NATURAL PROTECTIVE BARRIERS.

ROUTINE USE OF ANTIMICROMIAL AGENTS IN HOSPITALS CREATES SELECTIVE PRESSURE FOR THE EMERGENCE OF RESISTANT STRAINS.

TRANSMISSION OF NOSOCOMIAL INFECTINS

There are five main routes of transmission:

1)Contact transmission

a) Direct

b) Indirect

2) Droplet transmission

3) Air-borne transmission

4) Vehicle born

5) Vector- borne transmission

CONTROL OF HOSPITAL INFECTIONS

Concept of asepsis:

Definition: absence of pathological germs or microorganisms or free from infections.

Types of asepsis:

1)Medical asepsis

2)Surgical asepsis

1) Medical Asepsis:

It refers to all practices used to protect the patient and his environment from the transmission of disease- producing organisms. In medical asepsis objects are referred to as clean, which means the absence of almost all microorganisms, or dirty.

Principles of medical asepsis: wash hands frequently before handling food,

eating food, and after using toilets.

Keep soiled items and equipments from touching the clothing.

Avoid having client cough, sneeze or breath directly on others.

Instruct them as indicated to cover theie mouth.

Move equipments awaay from you when dusting or scrubbing.

Avoid raising dust.

clean the less soiled area first and then mores soiled ones.

Dispose soiled or used items directly into the appropriate container.

Pour liquids to avoid spillage in the sink and on to you.

Use practices of personal grooming that helps prevent microorganisms.

Follow guidelines consciously for isolation in barrier techniques.

Surgical asepsis

it refers to all procedures used keep objects or areas sterile or completely free from all microorganisms.

Principles of surgical asepsis

1)Always face the sterile field.

2)Keep sterile equipment above your waist level or above table level.

3)Do not speak, cough or sneeze over a sterile field.

4)Never reach across a sterile field.

5) Prevent excessive air currents around the sterile areas. Air currents can be caused by moving fast, flapping the cloths and drapes and by closing the doors.

6) Keep the unsterile object away from the sterile field.

7) Handle liquids cautiously near the sterile field.

8) Keep the sterile field dry.

9) Each sterile supply should be clearly labeled as to its contents, final date of sterilization.

10) Always check the sterility expiration date.

11) Avid sweeping and dusting when the sterile objects are opened.

12) Wash hands put on gowns and masks before handling the sterile supplies.

13) Open the sterile package in such a way that the edges of the wrappers is directed away from the worker.

14) While transferring the forceps hold the pointing down-wards.

15) When removing the forceps from the container, lift it without touching the sides and the rim of the container.

16) Keep the tip of forceps within the vision.

17) Gently tap the prongs together directly over the container to remove the excess solution

18) Remove the cover from the container when necessary and only for a short period of time.

19) Lift the cover of the container in such a way that inside of the lid is pointing down.

20) Invert the cover only when it is necessary to place it down objects.

21)Consider the rim the cover and the container to be contaminated,

22)Do not return the unused sterile object to the container.

Isolation precautions (barrier nursing)Barrier nursing or isolation techniques is

intended to confine the microorganisms within a given and recognized area

Isolation precaution:

Types of isolation

1)Contact isolation:

This is designed to prevent transmission of highly transmission of highly transmissible or epidemiologically important infections that do not warrant strict isolation.

Precautions:- Private room is indicated although patients

infected with the same organisms may share room.

- Masks are indicated for those who come close to the patient.

- Gowns and gloves are indicated for touching infective material.

- Hands must be washed after touching the patient or potentially contaminated articles and before taking care of another patient.

- Contaminated articles should be discarded.

2) Respiratory isolation:

This is designed to prevent transmission of infectious diseases over short distances through the air.

Precautions:- Private room is indicated.- Mask and gown are also worn.- Hands must be washed after touching the

patient.- restrict the number of visitors.- Nurse must be taken while collecting the sputum

specimen.

3) Enteric isolation:

Enteric precautions are designed to prevent infections that are transmitted by direct or indirect contact with faeces.

Precautions:- A private room is indicated if patient hygiene is

poor and thus at risk of contaminating others.- Gowns and gloves should be used.- Hands must be washed.- Contaminated articles must be discarded.- The soiled articles must be disinfected.

Conti….- All personnel caring for the sick and also the

public should have immunization.- In the case of enteric infections the patient

should have a commode for their use only left in the room.

4) Blood or body fluid isolation:

Precautions: - A private room is indicated if patient hygiene is

poor because of higher risk to others.- Masks are not indicated but glove and gown are

only indicated.- Hands must be washed after touching the

patient.- Care should be taken to avoid needle stick injury.- Used needles should not be recapped.- Blood spills should be cleaned up promptly with

hypochlorite.

5) Wound and shin isolation:- Safe disposal of dressing and discharges from

the wounds and the disinfection of articles.- Gowns and glove are only indicated.- hands must be washed.- Strict isolation techniques should be followed

while caring of client with abscesses, boils, infected burns, gas gangrene.

- Great care should be taken by the nurses to prevent cuts or abrasions on the hands.

General precautions: maintain a high degree of cleanliness.Health teaching: the client and his relatives are

to be taught. Minimize the number of visitors.Emphasize on hand washing.Keep toilet articles separate for each person.All persons caring for the sick and public should

have immunization.As war as possible the client should be nursed

in separate room.

HAND WASHINGThe most important techniques for interrupting the

infectious process is hand washing.

1)Medical hand washing:

The most important techniques in preventing and controlling transmission of pathogens is hand washing. Hand washing is a vigorous brief rubbing together of all surfaces of hands lathered in soap, followed by rinsing under a stream of water. its main purpose is to remove soiled microorganisms from the hands and to reduce total microbial count over time.

Indications: - Before contact with patient who are susceptible to

infection( eg: newborn infants or immuno suppressed patients)

- After caring of an infected patient.- After touching organic material.- Before performing invasive procedures such as

administration of injection, catheterization.- Before and after handling wound dressing or

touching open wounds.- After handling contaminated equipments.- Between contacts with different patients in high –

risk units.

purposes

- Prevent nosocomial infections- Maintain safe, clean environment for patient.- Provide safety for health care workers.- Prevent cross- contamination of patient or the

spread of micro-organisms.

Equipment

- Easy to reach sink with warm running water.- Antimicrobial soap/regular soap.- Nail brush to clean nail.- Paper towel.

Steps for surgical hand wash

1) Remove all jewelry on hands and wrists.

2) Adjust water to a warm temperature and thoroughly hands and forearms to 5 cm above the elbows in order to remove dirt and transient flora.

3) Clean under each fingernail and around the nail bed with a nail cleaner prior to performing the first surgical scrub of the day. Keep nails short and do not wear artificial nails or fingernail polish. 4) Holding hands up above the level of the elbow, apply antimicrobial agent to hands and forearms up to the elbows. Using a circular motion, begin at the fingertips of one hand and lather and wash between the fingers, continuing from fingertip to 5 cm above the elbow. Repeat this process for the other hand and arm. Continue rubbing for 3-5 minutes.

5) Rinse each arm separately, fingertips first, holding hands above the level of the elbow. 6) Using a sterile towel, dry the fingertips to 5 cm above the elbow. Use one side of the towel to dry the first hand and the other side of the towel to dry the second hand. 7) Keep hands above the level of the waist and do not touch anything before putting on sterile gown and surgical gloves. 29

Hand Washing Technique - WHO Approved.flv

Surgical anti-sepsis(scrub)Surgical hand washing is a procedure by

which dirt and microorganisms are destroyed and removed from hands and fingers by chemical action and mechanical friction.

Purposes:- To remove dirt and transient

microorganisms from hands.- To reduce the risk of transmission of

micro organisms to patient.- To reduce the risk of cross infection

among patients.

To reduce the risk of transmission of infectious agents to oneself.

To prevent iatrogenic infections.

Preparation for scrubbing:- All staff should be in suitable surgical attire, with

sleeves above the elbow and tops tucked into trousers.

- All hair should be contained with in a surgical hat.

- Finger nail should be short and free from polish or artificial nails.

- Nails may be cleaned if necessary by using a disposable pick under running water.

- All jeweler should be removed.

Equipment

- soap/ antiseptic detergent.

- Nail brush in antiseptic lotion.

- Running warm water.- Towels.- Mask and cap

Steps of Procedure 1) Before entering in OT apply cap ,face mask

and eye wear.

2) Hands and arms should be washed with plain microbial solution and running water immediately before beginning the surgical scrub.

3) Hands and arms should be wet before applying scrub solution.

4) Use circular movement to wash palms, back of hands, wrist, forearms and interdigital spaces for 20-25 sec`

5) The first wash should encompass the hands and arms to the elbow, utilizing a systematic method to cover all areas.

6) Hands must be rinsed thoroughly from fingertip to elbow, allowing excess water to drain from the elbows into the sink.

7) Holding the brush perpendicularly scrub palm each side of thumb and fingers and posterior side of hand with 10 strokes each.

8) Scrub from wrist to 5 cm above each elbow that is lower arm, upper forearm and antecubital fossa to marginal area above elbows.

9) Entire scrub should last for 5 to 10 min.

10) Discard brush and rinse hands from fingertips to elbows.

11) Take care not to touch the tap or sides of the sink during the procedures.

12) Use a sterile towel to dry one hand moving from fingers to elbow. Dry from cleanest to least clean area.

13) Repeat drying of the other hand using a different towel. Use one side to dry one hand reverse side for other hand, if only one towel is available.

14) Discard towel.

15) Proceed with sterile gowning.

16) Avoid splashing attire-if this becomes excessively wet it can compromise the protection afforded by the gown. It may be necessary to change attire and begin the scrub procedure again.

Scrubbing.flv

Personal protective equipments

• Personal protective equipment is special equipment wearing to create a barrier between host and germs.

• PPE help to prevent the spread of germs in the hospital.

• All hospital staff, patients, visitors should use PPE.

Types of PPE a) Wearing gloves:

protects the hands from germs and helps to reduce the spread of germs.

b) Masks: Masks cover the mouth and nose.

- A surgical mask will helps to stop germs from your nose and mouth from spreading.

- a special respiratory mask forms a tight seal around your nose and mouth.

c) Eye protection: Includes face shields and goggles. These protects the mucous membrane in your eyes.

d) Clothing: Includes gown , apron , head covering and shoe covers.

- these often used during surgery to protect you and the patient.

- also used to protect you when you work with body fluids.

- visitors wear gowns if they are visiting a patient who is in isolation.

- you may need special PPE when handling some cancer drugs.

e) Gowning: clean or disposable gowns or plastic aprons are worn during procedure.

Purpose:- To prevent soiling of cloths during contact

with the patient.

- To prevent health care personnel from coming in contact with infected materials.

General instructions:- Gown is worn only in the client’s unit and

never outside.

- The gown is worn by a nurse when caring for a client whose infection is known to be spread by direct contact.

- Gowns are worn by the nurses when caring for the person whose resistance to infection is diminished. Eg: premature babies.

- The outside of the gown is considered to be highly contaminated.

- If the gown is to be reused , hang the gown inside the client’s unit with the contaminated side folded out.

Gowning procedure1) Perform hand washing thoroughly .

2) Pick up the sterile gown.

3) Allow it in fold keeping inside of the gown towards the body without allowing the outside of the gown to touch any area .

4) With hands at shoulder level, slip both arms into arm holes simultaneously.

5) Ask the circulatory nurse to bring the gown over the shoulder touching the inner aspect of gown.

6) Ask the circulatory nurse to fasten and lie the neck.

7) Overlap the gown at the back as much as possible and fasten the waist ties or belt.

8) Prevent the gown from becoming wet.

9) Removing of gown:

to remove a gown untie the waist band; wash hands; untie the neck ties; side the gown down the arms and over the hands by holding the inside of the sleeves.

10) Hold the gown with both hands; inside the shoulder at the shoulder seams, gown is turned inside out: hands are brought together: gown is rolled and discarded: wash hands thoroughly.

Gloving (closed technique) :

donning of a pair of sterile gloves to protect one’s own hands from pathological microorganisms and to avoid contamination of sterile area by hand.

Purposes:

1)To protect the nurse from pathogenic microorganisms.

2)To handle sterile articles without contaminating.

Equipments:- soap/ antiseptic detergent- Nail brush in antiseptic lotion.- A pair of sterile surgical gloves.- Running warm water.- Towels mask and cap.

Steps of the procedure1) perform thorough surgical hand wash and dry

hands using sterile towel.

2) if glove are not pre- powered take packet of powder and apply lightly to hand over sink or waste basket.

3) Identify right and left glove. Each glove has a cuff of approximately 5cm wide. Glove dominant hand first.

4) With thumb and first two fingers of non- dominant hand. Grasp edge of cuff of glove of dominant hand. Touch only the inside surface of gloves.

5) Carefully pull glove over dominant hand making sure the thumb and fingers fit into the proper spaces of the glove.

6) Slip in the fingers of the gloved dominant hand under the cuff of the other glove. Keep thumb of gloved dominant hand abducted back to avoid touching of exposed non- gloved hand.

7) Care fully slip the glove into your non dominant hand making sure that the fingers slip into the proper spaces.

8) With gloved hands interlock fingers to fit yhe glove into each fingers.

Removal of gloves

1) Remove the first glove by grasping it on its palmar surface taking care to avoid touching wrist.

2) Pull the first glove completely off by inverting or rolling the glove inside out.

3) Take fingers of bare hand and tuck inside remaining glove cuff. Pull glove off, inside out.

4) Wash hands.

Masking

Definition:

Masking covers both the nose and the mouth to maintain asepsis during procedures and patient care activities.

Purposes:

To prevent dispersal of droplets from wearer to environment and patient.

Procedure

1) After performing surgical hand washing take the sterile mask handed to you by the circulating nurse. Hold it by top two strings, keeping top edge above bridge of nose.

2) Tie both top strings at back of head above ears.

3) Tie the two lower strings snugly around neck well under the chin.

4) Gently pinch upper portion of mask around bridge of nose.

Removal of mask:

1)Wash hands. Untie lower strings first, then the top strings and pull mask away from face.

2)Hold mask by strings and discard into appropriate receptacle.

Open gloving technique.flv

Closed gloving technique.flv

Gowning and gloving.flv

Decontamination of equipments and unit

Decontamination of medical equipment involves the destruction or removal of any organisms present in order to prevent them from infecting other patients or hospital staff.

Definitions:

1) cleaning: it is the process that removes contaminants including dust, soil, large numbers of micro-organisms and organic matter(eg. Blood , vomit)

2) Disinfection: It is a process used to reduce the number of micro-organisms but not usually bacterial spores. The process does not necessary kill or remove all micro organisms, but reduces their number to a level which is not harmful to health.

3) sterilization: It removes or destroys all forms of microbial life including bacterial spores.

Techniques of disinfection and sterilization

Before equipment is to be disinfected or sterilized, it should be thoroughly cleaned to remove any visible dirt or secretions. This involves washing with water and detergent.

1)Disinfection:

Disinfectants are substance that are applied to non-living objects to destroy microorganisms that are living on the objects.

Chemical disinfectant solutions: a) clear soluble phenolics (eg: stericol and hycolin) are good for killing most bacteria including TB.

b) Hypochlorites (eg: presept and milton) have a wide range of activity against bacteri, fungi, viruses and bacterial spores. They may be used for decontaminating any area with blood spillage.

c) Alcohol ( methanol, ethanol and isopropanol) have good activity against bacteria and viruses. They should only be used after all the visible surface dirt has been removed.

d) Aldehydes( eg. Glutaraldehyde and formaldehyde) are active against bacteria, viruses and fungi. They have a slow action against tubercle bacilli.

e) Cidex: complete disinfection of instruments that cannot be autoclaved(eg. Endoscopes, sharp instruments, rubber goods) .

Sterilization1) autoclaving: it uses stream under pressure. A

temperature of 134c for 3min or 121c for 15 min.

Formaldehyde is irritant to the eyes, respiratory tract and skin.

2) Sterilization of ethylene oxide: it is a colourless gas which is toxic to inhale. The operating cycle ranges from 2-24hrs.

3) Sterilization by irradiation: it is an industrial process and particularly suited to the sterilization of large batches of products. It is not suitable for resterilization as it causes deterioration of material