Infection Control An Introduction to A PowerPoint Presentation by Eddie Newall May 2003.

Infection Control

An Introduction to

A PowerPoint Presentationby Eddie Newall

May 2003

Learning outcomes

Describe the sources of micro-Describe the sources of micro-organisms, routes of transmission and organisms, routes of transmission and key principles of infection controlkey principles of infection control

List the essential elements of universal List the essential elements of universal precautionsprecautions

Understand the importance of risk Understand the importance of risk assessment and management in assessment and management in infection controlinfection control

Epidemics and plagues throughout historyEpidemics and plagues throughout history Physicians fear of contagious diseasePhysicians fear of contagious disease Hippocrates and others suspected an Hippocrates and others suspected an

unseen invisible causeunseen invisible cause Climate and environment blamed - not Climate and environment blamed - not

the ill, dying or deadthe ill, dying or dead

The pre-scientific era

Microbiology - scientific era

Anton van Leeuwenhoek (1632-1722) Dutch linen draperDutch linen draper Amateur scientistAmateur scientist Grinding lenses, magnifying glasses, Grinding lenses, magnifying glasses,

hobbyhobby First to see bacteria “little beasties”First to see bacteria “little beasties” No link between bacteria and diseaseNo link between bacteria and disease

Scientific era continued . . . . .Ignaz Semmelweiss (1818-1865) Obstetrician, practised in ViennaObstetrician, practised in Vienna Studied puerperal (childbed) feverStudied puerperal (childbed) fever Established that high maternal mortality Established that high maternal mortality

was due to failure of doctors to wash was due to failure of doctors to wash hands after post-mortemshands after post-mortems

Reduced maternal mortality by 90%Reduced maternal mortality by 90% Ignored and ridiculed by colleaguesIgnored and ridiculed by colleagues

Scientific era continued . . . . .Louis Pasteur (1822-1895) French professor of chemistryFrench professor of chemistry Studied how yeasts (fungi) ferment wine Studied how yeasts (fungi) ferment wine

and beerand beer Proved that heat destroys bacteria and Proved that heat destroys bacteria and

fungi fungi Proved that bacteria can cause infection Proved that bacteria can cause infection

- the “germ theory” of disease- the “germ theory” of disease

Scientific era continued . . . . .Joseph Lister (1827-1912) Scottish surgeonScottish surgeon Recognised importance of Pasteur’s workRecognised importance of Pasteur’s work Concerned about infection of compound Concerned about infection of compound

fractures and post-operative woundsfractures and post-operative wounds Developed carbolic acid spray to Developed carbolic acid spray to

disinfect instruments, patient’s skin, disinfect instruments, patient’s skin, surgeon’s skinsurgeon’s skin

Largely ignored by medical colleaguesLargely ignored by medical colleagues

Scientific era continued

Robert Kock (1843-1910) German general practitionerGerman general practitioner Grew bacteria in culture mediumGrew bacteria in culture medium Showed which bacteria caused Showed which bacteria caused

particular diseasesparticular diseases Classified most bacteria by 1900Classified most bacteria by 1900

Contemporary issues

Antibiotic resistanceAntibiotic resistance Prevalence of hospital acquired infectionPrevalence of hospital acquired infection Prion diseasesPrion diseases

Antibiotic resistance Not a new problem - Penicillin in 1944Not a new problem - Penicillin in 1944 Hospital “superbugs”Hospital “superbugs” Methycillin Resistant Staphylococcus Methycillin Resistant Staphylococcus

Aureus [MRSA]Aureus [MRSA] Vancomycin Intermediate Vancomycin Intermediate

Staphylococcus Aureus [VISA]Staphylococcus Aureus [VISA] Tuberculosis - antibiotic resistant formTuberculosis - antibiotic resistant form

400 deaths per year in UK400 deaths per year in UK Up to £100,000 per patient to treatUp to £100,000 per patient to treat Annual NHS cost - £5 millionAnnual NHS cost - £5 million

MRSA Discovered in 1981Discovered in 1981 Found on skin and in the nose of 1 in 3 Found on skin and in the nose of 1 in 3

healthy people - symptomless carriershealthy people - symptomless carriers Widespread in hospitals and communityWidespread in hospitals and community Resistant to most antibioticsResistant to most antibiotics When fatal - often due to septicaemiaWhen fatal - often due to septicaemia

Hospital acquired infection Incidence of 10%Incidence of 10% 5,000 deaths per year - direct result of HAI5,000 deaths per year - direct result of HAI 15,000 deaths per year linked to HAI15,000 deaths per year linked to HAI Delayed discharge from hospitalDelayed discharge from hospital Expensive to treat [£3,500 extra]Expensive to treat [£3,500 extra] Cost to NHS - £1 billion per yearCost to NHS - £1 billion per year Effective hand washing is the most Effective hand washing is the most

effective preventative measureeffective preventative measure Dirty wards and re-use of disposable Dirty wards and re-use of disposable

equipment also blamedequipment also blamed

Prion diseases Prions [“pree-ons”] - proteinaceous Prions [“pree-ons”] - proteinaceous

infectious particlesinfectious particles Corrupted form of a normally harmless Corrupted form of a normally harmless

protein found in mammals and birdsprotein found in mammals and birds Causes fatal neurodegenerative diseases of Causes fatal neurodegenerative diseases of

animals and humansanimals and humans Animals: scrapie - sheep, bovine spongiform Animals: scrapie - sheep, bovine spongiform

encephalopathy [BSE or Mad Cow Disease]encephalopathy [BSE or Mad Cow Disease] Humans: Creutzfeldt-Jakob disease [CJD]Humans: Creutzfeldt-Jakob disease [CJD] Prions found in blood, tonsil and appendix Prions found in blood, tonsil and appendix

tissuetissue

Prions and surgery Prions cannot be Prions cannot be

destroyed by destroyed by sterilisationsterilisation

Theoretical risk of Theoretical risk of cross infection cross infection from from contaminated contaminated instruments and instruments and blood transfusionblood transfusion

Comparisons of mortality

02,0004,0006,0008,00010,00012,00014,00016,00018,00020,000

RTA SUICIDE HAI

Deaths per year in the UK

The nature of infection

Micro-organisms - bacteria, fungi, viruses, Micro-organisms - bacteria, fungi, viruses, protozoa and wormsprotozoa and worms

Most are harmless [non-pathogenic]Most are harmless [non-pathogenic] Pathogenic organisms can cause infectionPathogenic organisms can cause infection Infection exists when pathogenic Infection exists when pathogenic

organisms enter the body, reproduce and organisms enter the body, reproduce and cause diseasecause disease

Hospital acquired infection

Infection which was neither present nor Infection which was neither present nor incubating at the time of admissionincubating at the time of admission

Includes infection which only becomes Includes infection which only becomes apparent after discharge from hospital apparent after discharge from hospital but which was acquired during but which was acquired during hospitalisation (Rcn, 1995)hospitalisation (Rcn, 1995)

Also called nosocomial infectionAlso called nosocomial infection

Modes of spread

Two sources of infection:Two sources of infection: Endogenous or self-infection - Endogenous or self-infection -

organisms which are harmless in one organisms which are harmless in one site can be pathogenic when transferred site can be pathogenic when transferred to another site e.g., E. colito another site e.g., E. coli

Exogenous or cross-infection - Exogenous or cross-infection - organisms transmitted from another organisms transmitted from another source e.g., nurse, doctor, other patient, source e.g., nurse, doctor, other patient, environment (Peto, 1998)environment (Peto, 1998)

Spread - entry and exit routes Natural orifices - mouth, nose, ear, eye, Natural orifices - mouth, nose, ear, eye,

urethra, vagina, rectumurethra, vagina, rectum Artificial orifices - such as tracheostomy, Artificial orifices - such as tracheostomy,

ileostomy, colostomyileostomy, colostomy Mucous membranes - which line most Mucous membranes - which line most

natural and artificial orificesnatural and artificial orifices Skin breaks - either as a result of Skin breaks - either as a result of

accidental damage or deliberate accidental damage or deliberate inoculation/incision (May, 2000)inoculation/incision (May, 2000)

Chain of infection Source/reservoir of micro-organismsSource/reservoir of micro-organisms

infected person [host] or other sourceinfected person [host] or other source Method of transmissionMethod of transmission

hands, instruments, clothing, hands, instruments, clothing, coughing, sneezing, dust etc.coughing, sneezing, dust etc.

Point of entryPoint of entry orifices, mucous membranes, skinorifices, mucous membranes, skin

Susceptible hostSusceptible host low resistance to infection (May, 2000)low resistance to infection (May, 2000)

HAI - common bacteria Staphylococci - wound, respiratory and Staphylococci - wound, respiratory and

gastro-intestinal infectionsgastro-intestinal infections Eshericia coli - wound and urinary tract Eshericia coli - wound and urinary tract

infectionsinfections Salmonella - food poisoningSalmonella - food poisoning Streptococci - wound, throat and urinary Streptococci - wound, throat and urinary

tract infectionstract infections Proteus - wound and urinary tract Proteus - wound and urinary tract

infections (Peto, 1998)infections (Peto, 1998)

HAI - common viruses Hepatitis A - infectious hepatitisHepatitis A - infectious hepatitis Hepatitis B - serum hepatitisHepatitis B - serum hepatitis Human immunodeficiency virus [HIV] - Human immunodeficiency virus [HIV] -

acquired immunodeficiency syndrome acquired immunodeficiency syndrome [AIDS] (Peto, 1998)[AIDS] (Peto, 1998)

Common types of HAIOther

27%

UTI

23%

Lower

respiratory

23%

Wound

11%

Skin

10%

Blood

6%

(May, 2000)

Universal infection control precautions Devised in US in the 1980’s in response Devised in US in the 1980’s in response

to growing threat from HIV and hepatitis to growing threat from HIV and hepatitis BB

Not confined to HIV and hepatitis BNot confined to HIV and hepatitis B Treat ALL patients as a potential bio-Treat ALL patients as a potential bio-

hazardhazard Adopt universal routine safe infection Adopt universal routine safe infection

control practices to protect patients, self control practices to protect patients, self and colleagues from infectionand colleagues from infection

Universal precautions Hand washingHand washing Personal protective equipment [PPE]Personal protective equipment [PPE] Preventing/managing sharps injuriesPreventing/managing sharps injuries Aseptic techniqueAseptic technique IsolationIsolation Staff healthStaff health Linen handling and disposalLinen handling and disposal Waste disposalWaste disposal Spillages of body fluidsSpillages of body fluids Environmental cleaningEnvironmental cleaning Risk management/assessmentRisk management/assessment

Hand washing Single most effective action to prevent HAI - Single most effective action to prevent HAI -

resident/transient bacteriaresident/transient bacteria Correct method - ensuring all surfaces are Correct method - ensuring all surfaces are

cleaned - more important than agent used or cleaned - more important than agent used or length of time takenlength of time taken

No recommended frequency - should be No recommended frequency - should be determined by intended/completed actionsdetermined by intended/completed actions

Research indicates:Research indicates: poor techniques - not all surfaces cleanedpoor techniques - not all surfaces cleaned frequency diminishes with frequency diminishes with

workload/distanceworkload/distance poor compliance with guidelines/trainingpoor compliance with guidelines/training

Hand washing – areas missed

Taylor (1978) Taylor (1978) identified that 89% of identified that 89% of the hand surface was the hand surface was missed and that the missed and that the areas of the hands areas of the hands most often missed most often missed were the finger-tips, were the finger-tips, finger-webs, the palms finger-webs, the palms and the thumbs.and the thumbs.

Personal protective equipment PPE when contamination or splashing PPE when contamination or splashing

with blood or body fluids is anticipatedwith blood or body fluids is anticipated Disposable glovesDisposable gloves Plastic apronsPlastic aprons Face masksFace masks Safety glasses, goggles, visorsSafety glasses, goggles, visors Head protectionHead protection Foot protectionFoot protection Fluid repellent gowns (May, 2000) Fluid repellent gowns (May, 2000)

Sharps injuries PreventionPrevention

correct disposal in appropriate correct disposal in appropriate containercontainer

avoid re-sheathing needleavoid re-sheathing needle avoid removing needleavoid removing needle discard syringes as single unitdiscard syringes as single unit avoid over-filling sharps containeravoid over-filling sharps container

ManagementManagement follow local policy for sharps injury follow local policy for sharps injury

(May, 2000)(May, 2000)

Aseptic technique

Sepsis - harmful infection by bacteriaSepsis - harmful infection by bacteria Asepsis - prevention of sepsisAsepsis - prevention of sepsis Minimise risk of introducing pathogenic Minimise risk of introducing pathogenic

micro-organisms into susceptible sitesmicro-organisms into susceptible sites Prevent transfer of potential pathogens Prevent transfer of potential pathogens

from contaminated site to other sites, from contaminated site to other sites, patients or staffpatients or staff

Follow local policy (May, 2000)Follow local policy (May, 2000)

Isolation Single room or groupSingle room or group Source or protectiveSource or protective Source - isolation of infected patientSource - isolation of infected patient

mainly to prevent airborne mainly to prevent airborne transmission via respiratory dropletstransmission via respiratory droplets

respiratory MRSA, pulmonary respiratory MRSA, pulmonary tuberculosistuberculosis

ProtectiveProtective - - isolationisolation of immuno of immuno--suppressed patient (May, 2000)suppressed patient (May, 2000)

Significant psychological effects (Davies Significant psychological effects (Davies et al, 1999)et al, 1999)

Staff health Risk of acquiring and transmitting Risk of acquiring and transmitting

infectioninfection Acquiring infectionAcquiring infection

immunisationimmunisation cover lesions with waterproof dressingscover lesions with waterproof dressings restrict non-immune/pregnant staffrestrict non-immune/pregnant staff

Transmitting infectionTransmitting infection advice when suffering infectionadvice when suffering infection

Report accidents/untoward incidentsReport accidents/untoward incidents Follow local policy (May, 2000)Follow local policy (May, 2000)

Linen handling and disposal Bedmaking and linen changing Bedmaking and linen changing

techniquestechniques Gloves and apron - handling Gloves and apron - handling

contaminated linencontaminated linen Appropriate laundry bagsAppropriate laundry bags Avoid contamination of clean linenAvoid contamination of clean linen Hazards of on-site ward-based launderingHazards of on-site ward-based laundering NHS Executive guidelines (1995)NHS Executive guidelines (1995) Follow local policy (May, 2000)Follow local policy (May, 2000)

Waste disposal Clinical waste - Clinical waste - HIGHHIGH risk risk

potentially/actually contaminated waste potentially/actually contaminated waste including body fluids and human tissueincluding body fluids and human tissue

yellowyellow plastic sack, tied prior to incineration plastic sack, tied prior to incineration Household waste - Household waste - LOWLOW risk risk

paper towels, packaging, dead flowers, paper towels, packaging, dead flowers, other waste which is not dangerously other waste which is not dangerously contaminatedcontaminated

black plastic sack, tied prior to incineration plastic sack, tied prior to incineration Follow local policy (May, 2000)Follow local policy (May, 2000)

Spillage of body fluids PPE - disposable gloves, apronPPE - disposable gloves, apron Soak up with paper towels, kitchen rollSoak up with paper towels, kitchen roll Cover area with hypochlorite solution Cover area with hypochlorite solution

e.g., Milton, for several minutese.g., Milton, for several minutes Clean area with warm water and Clean area with warm water and

detergent, then drydetergent, then dry Treat waste as clinical waste -Treat waste as clinical waste - yellow yellow

plastic sackplastic sack Follow local policy (May, 2000)Follow local policy (May, 2000)

Environmental cleaning Recent concern regarding poor hygiene Recent concern regarding poor hygiene

in hospital environments (NHSE, 1999)in hospital environments (NHSE, 1999) Some pathogens survive for long Some pathogens survive for long

periods in dust, debris and dirtperiods in dust, debris and dirt Poor hygiene standards - hazardous to Poor hygiene standards - hazardous to

patients and staff (May, 2000)patients and staff (May, 2000) Report poor hygiene to Domestic Report poor hygiene to Domestic

Services (UKCC, 1992)Services (UKCC, 1992) ““Hospitals should do the sick no harm” Hospitals should do the sick no harm”

(Nightingale, 1854) (Nightingale, 1854)

Risk assessment No risk of contact/splashing with No risk of contact/splashing with

blood/body fluids - PPE not requiredblood/body fluids - PPE not required Low or moderate risk of contact/splashing Low or moderate risk of contact/splashing

- wear gloves and plastic apron- wear gloves and plastic apron High risk of contact/splashing - wear High risk of contact/splashing - wear

gloves, plastic apron, gown, eye/face gloves, plastic apron, gown, eye/face protection (Rcn, 1995)protection (Rcn, 1995)

Body fluids

Cerebrospinal fluid, peritoneal fluid, Cerebrospinal fluid, peritoneal fluid, pleural fluid, synovial fluid, amniotic pleural fluid, synovial fluid, amniotic fluid, semen, vaginal secretions, andfluid, semen, vaginal secretions, and

Any other fluid containing visible blood Any other fluid containing visible blood e.g., urine, faeces (Rcn, 1995)e.g., urine, faeces (Rcn, 1995)

Cost of HAI Direct cost to NHS for:Direct cost to NHS for:

extended hospital stay, extra resources, extended hospital stay, extra resources, extra treatment, extra equipment, and extra extra treatment, extra equipment, and extra community care costs if discharged needing community care costs if discharged needing follow-upfollow-up

Direct cost to patient/family for:Direct cost to patient/family for: pain and scarring, extended stay away from pain and scarring, extended stay away from

family, working days lost, family income family, working days lost, family income loss, financial strain - increased visiting etc, loss, financial strain - increased visiting etc, increased morbidity, increased mortality increased morbidity, increased mortality (ICNA, 1998)(ICNA, 1998)

Summary Ignaz Semmelweis in 1847 demonstrated Ignaz Semmelweis in 1847 demonstrated

that washing hands saves livesthat washing hands saves lives Research indicates that 10% of patients Research indicates that 10% of patients

develop HAI costing the NHS £1 billion and develop HAI costing the NHS £1 billion and 20,000 deaths per year20,000 deaths per year

Old bacteria are causing new problemsOld bacteria are causing new problems New viral and prion diseases are causing New viral and prion diseases are causing

new problemsnew problems Reluctance to wash hands still the single Reluctance to wash hands still the single

most important cause of HAI (ICNA, 1998)most important cause of HAI (ICNA, 1998) Growing concern about poor hospital Growing concern about poor hospital

hygienehygiene

Core references Davies, H. and Rees, J. (2000) Psychological effects of Davies, H. and Rees, J. (2000) Psychological effects of

isolation nursing (1): mood disturbance. isolation nursing (1): mood disturbance. Nursing Nursing StandardStandard. 14, 28, 35-38.. 14, 28, 35-38.

May, D. (2000) Infection control. May, D. (2000) Infection control. Nursing StandardNursing Standard. 14, . 14, 28. 51-57.28. 51-57.

ICNA (1998) ICNA (1998) Guidelines for hand hygieneGuidelines for hand hygiene. Belper: ICNA.. Belper: ICNA. NHS Executive (1995) NHS Executive (1995) Hospital laundry arrangements Hospital laundry arrangements

for used and infected linen - HSG (95) 18for used and infected linen - HSG (95) 18. London: DoH.. London: DoH. Nightingale, F. (1854) Nightingale, F. (1854) Notes on nursingNotes on nursing. Edinburgh: . Edinburgh:

Churchill Livingstone Churchill Livingstone Peto, R. (1998) “Infection control”, In: Mallik, M., Hall, C. Peto, R. (1998) “Infection control”, In: Mallik, M., Hall, C.

and Howard, D. (eds) and Howard, D. (eds) Nursing knowledge and practice - Nursing knowledge and practice - a decision making approacha decision making approach. London: Bailliere Tindall.. London: Bailliere Tindall.

Rcn (1995) Rcn (1995) Infection control in hospitalsInfection control in hospitals. London: Rcn.. London: Rcn.

Internet sites http://www.icna.co.uk/http://www.icna.co.uk/ http://www.nursing-standard.co.uk/http://www.nursing-standard.co.uk/ http://www.medscape.com/http://www.medscape.com/ http://www.anes.uab.edu/medhist.htmhttp://www.anes.uab.edu/medhist.htm http://www.shef.ac.uk/~nhcon/http://www.shef.ac.uk/~nhcon/ http://medweb.bham.ac.uk/nursing/http://medweb.bham.ac.uk/nursing/ http://www.healthcentre.org.uk/hc/http://www.healthcentre.org.uk/hc/

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