Lecture by: Dr. Satti M. Saleh Chief of Infectious Diseases Department CBAHI SIT Member Medical Director MGH

1. THE IMPORTANCE OF INFECTION CONTROL
IN PATIENT CARE
Dr. Satti M. Saleh
Chief of Infectious Diseases Department
CBAHI SIT Member
Medical Director MGH

2. PEARLS OF WISDOM
QUALITY OF CARE
IS
AS IMPORTANT AS
QUALITY OF TREATMENT

3. International Patient Safety Goals
IPSG

IPSG.1 Identify Patients Correctly

IPSG.2 Improve Effective Communication

IPSG.3 Improve the Safety of High-Alert
Medications

IPSG.4 Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery

IPSG.5 Reduce the Risk of Health Care–
Associated Infections

IPSG.6 Reduce the Risk of Patient Harm Resulting
from Falls

4. PATIENT SAFETY
An Organisation with a memory
17/02/2014

5. THE PARADIGM OF STRUCTURE , PROCESS & OUTCOME

THE RELATIONSHIP BETWEEN STRUCTURE , PROCESS &
OUTCOME IS A CAUSAL RELATIONSHIP “DONABEDIAN “
ARRANGEMENT OF
PARTS OF CARE
SYSTEM OR
ELEMENT OF CARE
STRUCTURE
CLINICAL
CARE DELIVERY
ADMINISTRATIVE
PROCESS
LEADS TO
LEADS TO
REFERES TO
RESULTS OF CARE
(ADVERSE OR
BENIFICIAL )
OUTCOME
•CLINICAL
•FUNCTIONA
•PECEIVED

6. Infection Control Programme Structure
1) INFECTION CONTROL UNIT : Independent
IPP's all patient care areas
Infection control policy standard
2) CURRENT SCIENTIFIC KNOWLEDGE
3) ICP : FULL TIME
4) QUALIFIED PERSONNEL
5) IC MANUAL
6) CONTINUE EDUCATION.
 Infection
Control Personnel
 Staff Orientation
 Staff Continuous Education
7) IC COMMITTEE

7. GOAL FOR HOSPITAL INFECTION
PREVENTION &CONTROL PROGRAMMS




PROTECT THE PATIENT .
PROTECT HCWS VISITORS &OTHERS IN THE
HEALTHCARE ENVIRONMENT
ACCOMPLISH PREVIOUS GOALS
,WHEREVER POSSIBLE , IN A COST
EFFECTIVE MANNER

8. Definition
Of HCAI

9. 

INFECTION OCCURRING DURING OR
AS A RESULT OF HOSPITALIZATION
WHICH THE PATIENT NEITHER HAVING
NOR INCUBATING AT THE TIME OF
ADMISSION.

10. Importance

11. INCREASE PROBLEMS DUE TO :1-ADVANCE TECHNOLOGY
2-OVERCROWDING
3-POOR RESOURCES
4- USES OF ANTIBIOTICS
5-INCREASE INVASIVE
PROCEDURES
6-IMUNOSUPRESSION
7-SHORTAGE OF TRAINED STAFF

12. MISCONCEPTIONS
?
1-IC IS EXPENSIVE
2-DIFFICULT TO IMPLEMENT
3-NO RISK TO STAFF
4-BLOOD BORN PATHOGENS
5-SCREENING IN EMERGENCY
6-SCREEING IS COSTLY

13. Surveillance Program




CONTINUOUS OR PERIODIC.
DIRECTED TO ALL INFECTIONS OR TARGETED
SITES / DEVICES.
ALL NEED TO BE SUPPLEMENTED BY
MICROBIOLOGY LABORATORY BASED SYSTEMS.
TECHNIQUES:
 REVIEW ANTIBIOTIC RECORDS.
 PATIENT / NURSING CARE RECORDS
 MICROBIOLOGY RESULTS
 AUGMENT BY AFTER ICU FOLLOW UP.
 AUTOPSY REPORTS

14. Surveillance
 INFECTION CONTROL PROGRAM CLOSELY MONITORS THE
FOLLOWING:
PATIENTS AT HIGH RISK OF INFECTION.
PATIENTS WITH ALREADY ACQUIRED INFECTIONS.
PERSONNEL/PATIENTS EXPOSED TO COMMUNICABLE
DISEASES, CONTAMINATED EQUIPMENT, OR
HAZARDOUS REAGENTS.
PATIENTS IN CERTAIN AREAS OF THE HOSPITAL OR IN
CERTAIN ROOMS.
PATIENTS IN AMBULATORY SETTINGS: HOME OR LONG-TERM
CARE FACILITIES.
 SURVEILLANCE IS ALSO INVOLVED IN CLASSIFYING INFECTIONS
ACCORDING TO PREVALENCE RATES AND MONITORING
EMPLOYEE HEALTH INCLUDING SCREENING FOR DISEASES
AND OFFERING IMMUNIZATIONS.
Phlebotomy Handbook: Blood
Collection Essentials, Seventh Edition
Diana Garza • Kathleen Becan-McBride
Pearson Education
Copyright 2005

15. CHAIN OF INFECTION
Organism
Source
Mode of
Transmission
Host

16. NEW ISOLATION PRECAUTIONS, 1996
‘’ STANDARD’’
AND
‘’ TRANSMISSION – BASED PRECAUTIONS’’

17. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE
.
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE
DISPOSAL.

18. HAND HYGIENE
. HAND HYGIENE IS THE SINGLE MOST
IMPORTANT PRACTICE TO REDUCE THE
TRANSMISSION OR INFECTIOUS AGENTS IN
HEALTHCARE SETTINGS .
. THE TERM “HAND HYGIENE” INCLUDES :

HAND WASHING WITH EITHER PLAIN OR ANTISEPTIC
CONTAINING SOAP AND WATER .

USE OF ALCOHOL-BASED PRODUCTS ( GELS,
RINSES, FOAMS) CONTAINING AN EMOLLIENT
THAT DO NOT REQUIRE THE USE OF WATER.

19. RATIONALE
TRANSIENT FLORA (Contaminating or non –
colonizing)


Attached to the superficial layer of skin.
Microbes isolated from skin not consistently
present in majority of persons associated with
HCAI .
RESIDENT FLORA
 Attached to deeper layer of the skin persistently
isolated from skin of most persons (cons,
diphtheriods )

21. TYPE OF HAND HYGIENE
1)
2)
3)
4)
Intensity of contact .
Degree of contamination .
Susceptibility of patient to infection .
Prove dure to be performed .

23. HAND HYGIENE

In the absence of visible soiling of
hands, approved alcohol-based
products for hand disinfection are
preferred over hand washing with
water and antimicrobial or plain soap
because of their superior microbiocidal
activity, reduced drying of the skin,
and convenience.

24. HAND HYGIENE
In observational studies of opportunities
for hand washing in health care workers
in U.S.A
 The overall compliance was 40% (range 5
– 81%) .
 Compliance was highest among nurses
and lowest among physicians, in intensive
care units, and when required intensity of
care was greater .


25. HAND WASHING STUDY IN RIYADH
MEDICAL COMPLEX-GENERAL
HOSPITAL
Overall frequency of hand washing .
 23.7% after patient contact .
 6.7% before patient contact .


26. HAND WASHING


-
Health care infection control practices
advisory committee (HICPAC) former
recommendations
Plain soap and water was recommended for
routine hand washing.
Antimicrobial soaps (e.g. : chlorhexidine) was
recommended for :
Patients under contact precautions .
During instances of epidemic or
hyperendemic spread of infections.

27. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2-Personal Protective
Equipment (PPE)
.
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE DISPOSAL.

28. What are Personal Protective
Equipment (PPE)?

Items specified for
protection of many parts
of body (to reduce risks to
the health and safety of
HCWs, and to minimize
risks of cross infection
between patients, staff,
visitors) e.g. gloves,
masks, respirators,
goggles, specialized
clothing (aprons & gowns)

29. Common PPEs
Gloves
 Aprons and gowns
 Face, mouth, nose, eye Protection
 Foot protection
 Head coverings


30. Evidence shows hand washing
prevents infections, but does PPE?

If health workers currently use PPE that
doesn’t mean it is effective.

One role of Infection Control Staff is to
assess the changing risks and practices.
◦ Stop practices that are ineffective, expensive.
◦ Help institute cost-effectiveness practices of
proven efficacy.

31. Last reminder




Don’t assume current PPE use is effective
Assess where and how employees are getting
exposed to body fluids and harmful exposures.
Assess how patients are getting disease from
staff
Select PPE that rationally protects patients
and staff.
Measure costs.

32. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE
3- ASEPTIC TECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE
DISPOSAL.

33. ASEPSIS (ASEPTIC TECHNIQUE)
REFERS TO PRCEDURES PERFORMED
UNDER STERILE CONDITION
 DEFINED AS A SET OF SPECIFIC
PRACTICES & PROCEDURES
PERFORMED UNDER CAREFULLY
CONTROLLED CONDITIONS WITH THE
GOALOF MINIMIZING CONTAMINATION
BY PATHOGENS


e.g.

DRAIN REMOVAL & CARE
RESPIRATORY SUCTION

34. A-ESSENTIAL STANDARD PRECAUTIONS
1-
HAND HYGIENE.
2- PPE
3-
ASEPTICTECHNIQUES
4- REPROCESSING OFINSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE DISPOSAL.

35. REPROCESSING OF REUSABLE INSTRUMENTS
CLEANED & MAINTAINED ACCORDING
TO MANIFACTURER INSTRUCTIONS
 SINGLE USE DEVICES DISCARDED
AFTER ONE PATIENT
 DEVICES FLOW FROM HIGH
CONTAMINATION TO STERILE AREA
 DEVICES STORED IN A MANNER TO
PROTECT FROM DAMAGE


36. A-ESSENTIAL STANDARD PRECAUTIONS
1- HAND HYGIENE.
2- PPE
.
3- ASEPTICTECHNIQUES
4- REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE
DISPOSAL.

37. 5- ENVIROMENTAL CLEANING
SURFACE CLEANED & DISINFECTED
 CLEANERS & DISINFECTANTS ARE
USED IN ACCORDANCE WITH
MANIFACTIORER INSTRUCTIONS.


38. A-ESSENTIAL STANDARD PRECAUTIONS
1234-
HAND HYGIENE.
PPE
.
ASEPTIC TECHNIQUES
REPROCESSING OF INSTRUMENT
/STERILE SERVICES
5- ENVIROMENTAL CLEANING.
6- PROPER SHARPS &WASTE DISPOSAL.

39. Factors which increase risk of
infection







Deep injury.
Visible blood on the device.
High viral titer.
Artery or vein device.
Combined factors.
Un-immunized against hepatitis B.
No post exposure prophylaxis with
Zidovidine (prophylaxis decrease risk by
80%).
2/17/2014
39

40. Risk of Transmission of
Blood born Infection
Occupational
Exposure
Hepatitis B Virus
Risk of
Transmission
2-40%
Hepatitis C Virus
2.7-10%
HIV
0.3% (1 in 300
chance of infection)
2/17/2014
40

41. Hazards of Needle stick injuries
Hepatitis B and C.
 HIV.
 Brucellosis.
 Malaria.
 S. aureus and S. pyogenes.
 Toxoplasmosis.
 Tuberculosis.

2/17/2014
41

42. How can needle stick injuries be
prevented
Employee training.
 Recommended guidelines.
 Safe recapping procedures.
 Effective disposal systems.
 Surveillance programs.
 Improved equipment design.

2/17/2014
42

43. B-Transmission-Based
Precautions

Three categories of Transmissionbased Precautions :
 Contact Precautions .
 Droplet Precautions .
 Airborne Precautions .

44. Contact transmission





Examples of organisms spread by contact:
Multi-drug-resistant organisms in the
gastrointestinal tract, sputum, or wounds
(MRSA, MDR Gram –ve, VRE).
Clostridium difficile.
Herpes simplex virus (mucocutaneous).
Scabies.

45. Contact precautions
. Wash hands with antimicrobial soap before leaving
the patient's room .
. Minimize risk or environmental contamination
during patient transport (e.g. patient can be
placed in a gown ).
. Patient’s care devices ( e.g. thermometer , BP
cuffs , stethoscopes ) should be dedicated to use
for a single patient if possible , otherwise, they
should be rigorously cleansed and disinfected
before use for other patients .

46. Contact precautions
. Private room preferred; cohorting allowed if necessary .
. The door of the room may remain open .
. Gloves :
- upon entering room .
- change gloves after contact with contaminated secretions .
- should be removed before leaving the room .
. Gown:
- if clothing may come into contact with the patient or environmental
surfaces .
- should be removed before leaving the room .

47. DROPLET TRANSMISSION

Respiratory droplets are large particles (>5 micron) expelled
during :- Coughing .
- Sneezing .
- Talking.
- During procedures such as suctioning and bronchoscope .


Droplets travel < 1,5 meter from the source patient .
Example :
• Neisseria meningitides .
• Haemophilus influenza type b ( invasive ) .
• Streptococcus pyogenes (group A Streptococcus) .
• Mycoplasma pneumonia .

48. DROPLET PRECAUTIONS
Private room preferred; cohorting allowed
if necessary.
 Special air handling and ventilation are
unnecessary .
 The door of the room may remain open .
 Wear a mask when within 1 meter of the
patient .
 Mask the patient during transport .


49. AIRBORNE TRANSMISSION


-
-
Airborne spreads upon aerosolization of small
particles (=< 5 micron) of the infectious agent that
can then travel over long distances through the air
.
Most common nosocomial pathogens transmitted
by this route :
Mycobacterium tuberculosis .
Varicella-zoster virus (chickenpox) .
Measles .
Smallpox.
? SARS .

50. AIRBORNE PRECAUTIONS
Place the patient in a negative pressure
room with at least 6 – 12 air exchanges
per hour .
 Room exhaust must be appropriately
discharged outdoors or passed through a
HEPA ( high – efficiency particulate
aerator ) filter before recirculation within
the hospital .
 The door of the room should be kept
closed .


51. Precautions Needed for Cases




Condition
Pulmonary TB
Negative
Chicken Pox
M-meningitis
HIV
Type
S+A
S+A
S+D
S
Duration
Till sputum
Till rash crusted
24 Hrs
Duration of stay
Clinical Syndromes:
Empiric precautions as per clinical presentation

57. COMMUNICABLE
DISEASE

58.  Staff
awareness
 Measures toward patient's
diagnosis, isolation
disinfection etc.
 Notification
◦ Class I, Class II

59. EMPLOYEE HEALTH

60. 




Staff health clinic
Physical examination
Screening
Vaccination
Post exposure management
◦ *Blood, body fluids
◦ *Needle stick injury
◦ *Vaccine
 -Staff accommodation

Vaccine preventable disease

61. SUPPORT SERVICES

62. a) CSSD
b) House Keeping
c) Mortuary & Postmortem
Written policy
disinfection & cleaning
morgue temperature (2-8) logged daily
d) Kitchen
Environment & function Food container Food protection PPE
Staff health & screening Written policy
e)Laundry
Linen management
Laundry structure & function
f)Haemodialysis Staff knowledge
-PPE Standard precaution Structure Patient Medical Records (Screen Vaccination) Staff Medical
Record
-Haemodialysis water dialysate Water treatment -Written policy
g) Operating Room
Structure Traffic Control Pressure gradient & air cycle Cleaning Written policy

63. STERILIZATION

64. STERILIZATION OF REUSABLE INSTRUMENTS
&DEVICES
STERILIZATION
PROCESS OF ELIMENATING
(REMOVING)OR KILING MICROBIAL
ORGANISMS PRESENTING ON THE
SURFACE OR IN FLUID OR MEDIA
 METHODS:
◦
◦
◦
◦
◦
HEAT
IRRADIATION
CHEMICAL
HIGH PRESSURE
RADIATION

65. DISINFECTION
THE PROCESS OR ACT OF
DISTROYING PATHOGENIC MICROORGANISMS OR MAKING THEM
INERT (SOME CERTAIN BACTERIA
SPORES MAY SURVIVE)
 COULD BE CHEMICAL OR BY HEAT


66. HIGH LEVEL
DISINFECTION OF
REUSABLE DEVICES

67. CLEANING
REMOVAL OF VISIBLE SOIL FROM
OBJECT & SURFACES
 IT’S A FORM OF
DECONTAMINATION


68. OUTBREAK INVESTIGATION

OUTBREAKS ARE RECOGNIZED
BY:◦
◦
◦
◦
PRACTITIONER
PATIENT &PATIENT FAMILY
PUBLIC HEALTH SURVEILLANCE
LOCAL DATD-MEDIA

69. OUTBREAK INVESTIGATION

REASONS TO INVESTIGATE :◦
◦
◦
◦
PREVENT ADDITIONAL CASES
PREVENT FUTURE CASES OUTBREAK
LEARN ABOUT NEW DISEASES
LEARN SOMETHING NEW ABOUT OLD
DISEASES
◦ REASSURE THE PUBLIC
◦ ECONOMIC &SOCIAL REASONS

70. OUTBREAK INVESTIGATION

CONDUCTING AN OUTBREAK
INVESTIGATION:-
◦ CASE INVESTIGATION
◦ CAUSE INVESTIGATION
◦ CONTROL MEASURES SHOULD BE DONE
EARLY
◦ CONDUCT ANALYTIC STUDY IF
NECESSARY
◦ CONCLUSIONS
◦ CONTINUE SURVEILLANCE
◦ COMMUNICATE FINDINGS eg.
EPIDEMIOLOGICAL,CLINICAL,FORENSIC
INVESTIGATION