HAI

2. HOSPITAL ACQUIRED
INFECTION AND
PRESSURE SORE
THANUJA ELEENA MATHEW

4. INTRODUCTION
• A hospital-acquired infection (HAI), also known as a nosocomial
infection, is an infection that is acquired in a hospital or
other health care facility or health care–associated
infection (HAI or HCAI). Such an infection can be acquired in
hospital, nursing home, rehabilitation facility, outpatient clinic,
or other clinical settings.
• Infection is spread to the susceptible patient in the clinical
setting by various means. Health care staff can spread
infection, in addition to contaminated equipment, bed linens, or
air droplets.

5. ORGANISMS
• Staphylococcus aureus
• Methicillin
resistant Staphylococcus aureus
• Candida albicans
• Pseudomonas aeruginosa
• Acinetobacter baumannii
• Stenotrophomonas maltophilia
• Clostridium difficile
• Escherichia coli
• Tuberculosis
• Vancomycin-
resistant Enterococcus
• Legionnaires' disease

6. RISK FACTORS
• hospital roommate
• age, more than 70 years old
• prolonged usage of antibiotics
• having a urinary catheter
• prolonged ICU stays
• in a coma stage
• Shock / any trauma
• compromised immune system

7. CAUSES
• Bacteria, fungus, and viruses can cause HAIs.
• These spread mainly through person-to-person contact.
This includes unclean hands, and medical instruments
such as catheters, respiratory machines, and other
hospital tools. HAI cases also increase when there’s
excessive and improper use of antibiotics.

8. BACTERIA INFECTION TYPE
Staphylococcus aureus
(S. aureus) blood
Escherichia coli (E. coli) UTI
Enterococci blood, UTI, wound
Pseudomonas aeruginosa
(P. aeruginosa)
kidney, UTI, respiratory

9. SOURCES OF INFECTION
• 1.Endogenous or self-infection
• Infection endogenously acquired from one's own body flora. Bacteria are
present on the skin, in the nose, mouth. throat, gastrointestinal tract and in
the female genital tract. Prolonged hospital stays and the use of antibiotics
alters the normal flora
• 2.Exogenous or cross-infection and infection from the environment
• Food, fluids, disinfectants, instruments, equipment, wound dressing, all act
as sources of infection as a result of contamination from human organic
waste, pus, blood and blood products.

10. MAIN ROUTES OF TRANSMISSION
Route Description
Contact
transmission
direct contact.
Droplet
transmission
coughing, sneezing, and talking, and during the performance of certain
procedures, such as bronchoscopy.
Airborne
transmission
Small-particle residue {5 µm or smaller in size} of evaporated droplets
containing microorganisms that remain suspended in the air for long
periods of time or dust particles containing the infectious agent.
Microorganisms : Mycobacterium tuberculosis and rubeola and varicella viruses.

11. Common
vehicle
transmission
contaminated items, such as food, water,
medications, devices, and equipment.
Vector borne
transmission
vectors such as mosquitoes, flies, rats, and other
vermin transmit microorganisms.

12. ROUTES OF CONTACT TRANSMISSION
Route Description
Direct-contact
transmission
It can occur between two patients, with one
serving as the source of the infectious
microorganisms and the other as a susceptible
host.
Indirect-contact
transmission
contaminated intermediate object, usually inanimate, such
as contaminated instruments, needles, or dressings, or
contaminated gloves that are not changed between patients.
In addition, the improper use of saline flush syringes, vials
etc.

13. DURATION OF SPREADING OF INFECTION:
• For a HAI, the infection must occur:
• up to 48 hours after hospital admission
• up to 3 days after discharge
• up to 30 days after an operation

14. TYPES OF HAI’s
• The most common types of HAIs are:
• urinary tract infections (UTIs)
• surgical site infections
• gastroenteritis
• meningitis
• pneumonia

15. SYMPTOMS
• discharge from a wound
• Fever / Cough
• shortness of breathing
• burning with urination or difficulty urinating
• headache
• Nausea/ vomiting
• diarrhoea

16. PREVENTION
• Sterilization.
• Isolation
• Handwashing
• The microbes comprising the resident flora
are: Staphylococcus epidermidis, S. hominis,
and Microccocus, while transient organisms are S. aureus,
and Klebsiella pneumoniae, and Acinetobacter,
Enterobacter and Candida spp.

17. • Gloves
• Surface sanitation
• Modern sanitizing methods such as Non-flammable Alcohol Vapor in Carbon
Dioxide systems have been effective against gastroenteritis, MRSA, and
influenza agents. Use of hydrogen peroxide vapor has been clinically proven
to reduce infection rates and risk of acquisition.
• Antimicrobial surfaces
• Touch surfaces in hospital rooms, such as bed rails, call buttons, chairs, door
handles, light switches, grab rails, intravenous poles, dressing trolleys, and
table tops are known to be contaminated with Staphylococcus, MRSA

18. TREATMENT
• Among the categories of bacteria most known to infect patients are the
category MRSA member of gram-positive
bacteria and Acinetobacter which is gram-negative. While antibiotic drugs
to treat diseases caused by gram-positive MRSA are available, few
effective drugs are available for Acinetobacter.
• Gram-negative can cause severe pneumonia and infections of the urinary
tract, bloodstream
• Antibiotic resistance is spreading to gram-negative bacteria that can infect
people outside the hospital.

19. INFECTION CONTROL COMMITTEE:
↣ Hospital director as chairman
↣ Chief of Infection control team (Microbiology staff)
↣ Chiefs of all the major clinical departments
↣ Chief Nurse.
↣ Chief Pharmacist.
↣ Head of the maintenance and cleaning department.
↣ Director of Central Sterile Supply Department

20. INFECTION CONTROL PROGRAMMES
• HOSPITAL PROGRAMMES
• Infection Control Committee.
• management, physicians, other health care workers, clinical
microbiology, pharmacy, central supply, maintenance,
housekeeping, training services.

21. Role of hospital management
● establishing a multidisciplinary Infection Control Committee
● ensuring education and training of all staff through support of
programmes in disinfection and sterilization techniques
● delegating technical aspects of hospital hygiene to appropriate staff
● reviewing, approving, and implementing policies approved by the
Infection Control Committee
● ensuring the infection control team has authority to facilitate appropriate
programme function
● participating in outbreak investigation

22. Role of the physician
• appropriate practice of hygiene (e.g. handwashing, isolation)
● protecting patients from other infected patients and from hospital staff who may be
infected
● obtaining appropriate microbiological specimens when an infection is present or
suspected
● notifying cases to the team, as well as the admission of infected patients
● complying with the recommendations of the Antimicrobial Use Committee
regarding the use of antibiotics
● advising patients, visitors and staff on techniques to prevent the transmission of
infection

23. Role of the microbiologist
● handling patient and staff specimens to maximize of a microbiological diagnosis
● developing guidelines for appropriate collection, transport, and handling of specimens
● ensuring safe laboratory practice to prevent infections in staff
● performing antimicrobial susceptibility testing following internationally recognized
methods, and providing summary reports of prevalence of resistance
● monitoring sterilization, disinfection and the environment where necessary
● epidemiological typing of hospital microorganisms where necessary

24. Role of the hospital pharmacist
● obtaining, storing and distributing pharmaceutical preparations using practices which
limit potential transmission of infectious agents to patients
● dispensing anti-infectious drugs and maintaining relevant records
● obtaining and storing vaccines, and making them available as appropriate
● participation in development of guidelines for antiseptics, disinfectants, and products
used for washing and disinfecting the hands
● participation in quality control of techniques used to sterilize equipment

25. Role of the nursing staff
● promoting the development and improvement of nursing techniques, and ongoing
review of aseptic nursing policies
● developing training programmes
● supervising the implementation of techniques in specialized areas such as the
operating suite, the intensive care unit, the maternity unit and new-borns
● maintaining hygiene and good nursing practice on the ward
● monitoring aseptic techniques, including handwashing and use of isolation
● initiating patient isolation and ordering culture specimens from any patient showing
signs of a communicable disease

26. ● limiting patient exposure to infections from visitors, hospital staff, other patients, or
equipment used for diagnosis or treatment
● maintaining a safe and adequate supply of ward equipment, drugs and patient care
supplies.
THE NURSE IN CHARGE OF INFECTION CONTROLAND RESPONSIBLE
FOR:
● identifying nosocomial infections and investigation of the type of infection and
infecting organism
● surveillance of hospital infections and participating in outbreak investigation
● development of infection control policy and review and approval of patient care
policies relevant to infection control

27. Role of the central sterilization service
● Reusable equipment
● contaminated equipment including wrapping procedures, according to the type of
sterilization, sterilization methods, according to the type of equipment, sterilization
conditions (e.g. temperature, duration, pressure, humidity)
● communicate, as needed, with the Infection Control Committee, the nursing service,
the operating suite, the hospital transport service, pharmacy service, maintenance, and
other appropriate services.

28. Role of the food service
● defining the criteria for the purchase of foodstuffs, equipment uses, and cleaning
procedures to maintain a high level of food safety
●ensuring that the methods used for storing, preparing and distributing food will
avoid contamination by microorganisms
● issuing written instructions for the cleaning of dishes after use, hand washing
including special considerations for infected or isolated patients where appropriate
● ensuring appropriate handling and disposal of wastes

29. Role of the laundry service
● distribution of working clothes and, if necessary, managing changing rooms
● developing policies for the collection and transport of dirty linen
● defining, where necessary, the method for disinfecting infected linen, either
before it is taken to the laundry or in the laundry itself
● developing policies for the protection of clean linen from contamination during
transport from the laundry to the area of use

30. Role of the housekeeping service
● developing policies for appropriate cleaning techniques
• disposal of different types of waste (e.g. containers, frequency)
● pest control (insects, rodents)
● providing appropriate training for all new staff members and, periodically, for other
employees, and specific training when a new technique is introduced
● establishing methods for the cleaning and disinfection of bedding (e.g. mattresses,
pillows)
● determining the frequency for the washing of curtains, screening curtains between
beds, etc.

31. Role of maintenance
● collaborating with housekeeping, nursing staff or other appropriate groups in selecting
equipment and ensuring early identification and prompt correction of any defect
● inspections and regular maintenance of the plumbing, heating, and refrigeration
equipment, and electrical fittings and air conditioning
● developing procedures for emergency repairs in essential departments
● ensuring environmental safety outside the hospital, e.g. waste disposal, water sources.

32. Role of the infection control team
● organizing an epidemiological surveillance programme for nosocomial infections
● participating with pharmacy in developing a programme for supervising the use of
anti-infective drugs
● checking the efficacy of the methods of disinfection and sterilization and the efficacy
of systems developed to improve hospital cleanliness
● participating in development and provision of teaching programmes for the medical,
nursing, and allied health personnel, as well as all other categories of staff
● providing expert advice, analysis, and leadership in outbreak investigation and control

33. PREVENTING INFECTIONS OF STAFF
• Exposure to human immunodeficiency virus (HIV) The probability of HIV infection
following needlestick injury from an HIV-positive patient is 0.2% to 0.4% per injury
● adherence to standard precautions with additional barrier protection as appropriate
● use of safety devices and a needle disposal system to limit sharps exposure
● continuing training for health care workers in safe sharps practice.

34. • Exposure to hepatitis B Virus Estimates of the probability of HBV infection by
needlestick injury range from 1.9% to 40% per injury. With a sharps injury, the
source person must be tested at the time of exposure to determine whether he or
she is infected.
• Mycobacterium tuberculosis
• Transmission to hospital staff occurs through airborne droplet nuclei, usually
from patients with pulmonary tuberculosis. The association of tuberculosis with
HIV infection and multidrug-resistant tuberculosis are a current major concern.

35. PRESSURE SORE

36. PRESSURE SORE
• INTRODUCTION
• Pressure ulcers, also known as pressure sores, pressure injuries, bedsores, and decubitus
ulcers, are localized damage to the skin and/or underlying tissue that usually occur over
a bony prominence as a result of pressure, or pressure in combination with shear and/or
friction.
• The most common sites are the skin overlying the sacrum, coccyx, heels or the hips, but
other sites such as the elbows, knees, ankles, back of shoulders, or the back of
the cranium can be affected.

42. • Unstageable: Full thickness tissue loss in which actual
depth of the ulcer is completely obscured by slough (yellow,
tan, grey, green or brown) and/or eschar (tan, brown or
black) in the wound bed. Until enough slough and/or eschar
is removed to expose the base of the wound, the true depth,
and therefore stage, cannot be determined.

43. Suspected Deep Tissue Injury:
• A purple or maroon localized area of discoloured intact skin or blood-
filled blister due to damage of underlying soft tissue from pressure and/or
shear. A deep tissue injury may be difficult to detect in individuals with
dark skin tones. Evolution may include a thin blister over a dark wound
bed. The wound may further evolve and become covered by thin eschar.

44. RISK FACTORS
• immobility
• diabetes mellitus
• malnutrition
• cerebral vascular accident
• hypotension.
• age of 70 years and older
• current smoking history,
• dry skin,
• low body mass index,
• physical restraints
• malignancy
• history of pressure ulcers.
• after surgery
• paralysis
• obesity
• urinary incontinence & bowel
incontinence
• a poor diet
• kidney failure
• heart failure
• Parkinson's disease

45. CAUSES
• External (interface) pressure applied over an area of the body, especially
over the bony prominences can result in obstruction of the blood
capillaries, which deprives tissues of oxygen and nutrients, causing
ischemia hypoxia, oedema, inflammation, and, finally, necrosis and ulcer
formation.
• Friction is damaging to the superficial blood vessels directly under the
skin. It occurs when two surfaces rub against each other. The skin over the
elbows, back can be injured due to friction.

46. • Shearing is a separation of the skin from underlying tissues.
When a patient is partially sitting up in bed, their skin may stick
to the sheet, making them susceptible to shearing in case
underlying tissues move downward with the body toward the foot
of the bed.
• Moisture is also a common pressure ulcer culprit. Sweat, urine,
faeces, or excessive wound drainage can further exacerbate the
damage done by pressure, friction, and shear. It can contribute to
maceration of surrounding skin thus potentially expanding the
deleterious effects of pressure ulcers.

47. SYMPTOMS OF PRESSURE ULCERS
• Early symptoms
• part of the skin becoming discoloured – people with pale skin tend to
get red patches, while people with dark skin tend to get purple or blue
patches
• discoloured patches not turning white when pressed
• a patch of skin that feels warm, spongy or hard
• pain or itchiness in the affected area

48. • Later symptoms
• The skin may not be broken at first, but if the pressure ulcer gets worse, it
can form:
• an open wound or blister – a category two pressure ulcer
• a deep wound that reaches the deeper layers of the skin – a category three
pressure ulcer
• a very deep wound that may reach the muscle and bone – a category four
pressure ulcer

49. PATHOPHYSIOLOGY
Force [from pressure friction]
Rise in pressure above capillary filling pressure
microcirculatory occlusion
Ischemia [insufficient blood flow]
Inflammation
Tissue anoxia[ decrease in the level of oxygen]
Cell death
Ulceration

50. RISK ASSESSMENT FOR PRESSURE SORE
• Reduced mobility or immobility
• The longer pressure is exerted over a bony prominence, the higher that pressure will
become. This results in increased period of reduced or occluded blood flow to the
tissues, which results in tissue hypoxia leading to tissue death.
• Lack of sensation
• If pain signals are absent because of a lack of sensation, patients will not be aware that
damage is occurring
• This increases the risk of pressure ulcer development in those with, for example,
cerebrovascular accident, multiple sclerosis, spinal cord injury and neuropathy.

51. • Skin marking
• The change of colour in the skin associated with pressure damage is an early warning
sign of risk.
• In pale skin a visible circular pink/red blanching mark, known as blanching
erythema, over a bony prominence is an indication that pressure damage is starting.
If this is not noticed and continued pressure is sustained, the discolouration will
become darker until it is purple/black
• Nutritional status
• It is widely accepted that undernourished people are at increased risk of pressure
ulcer development.

52. • Compromised vascular supply
• An already compromised vascular supply will be further hampered by pressure,
resulting in a more rapid deterioration of skin. Patients with peripheral arterial disease
may be at increased risk of damage to their heels. Patient who experience events such as
cardiac arrest or hypovolaemic shock may be at increased risk of skin damage
• Shear
• This force is additional to pressure, and further hampers blood flow to the skin by
stretching and contorting blood vessels. Shear is commonly seen over the sacrum and
heels, where patients may slide down a surface and use their heels to resist this
movement. Considering their seated position in the chair and bed will help to reduce
this risk.

53. • Surface
• The surface on which patients sit, lie or lean can influence their risk of
pressure ulcers. Bony prominences resting against a hard surface result
in high pressures at the bone/tissue interface and pressure damage may
occur relatively quickly.
• Changing the mattress or cushion on which patients lie or sit can
reduce the risk of pressure ulcer development.

54. MANAGEMENT FOR PRESSURE SORE.
• Reducing pressure
• Repositioning.
• Using support surfaces. Use a mattress, bed and special cushions that help sit
or lie in a way that protects vulnerable skin.
• Cleaning and dressing wounds
• Putting on a bandage. A bandage speeds healing by keeping the wound
moist. This creates a barrier against infection and keeps the surrounding skin
dry. Bandage choices include films, gauzes, gels, foams and treated coverings.

55. • Removing damaged tissue
• To heal properly, wounds need to be free of damaged, dead or infected tissue.
Removing this tissue (debridement) is accomplished with a number of
methods, such as gently flushing the wound with water or cutting out damaged
tissue.
• Drugs to control pain. Nonsteroidal anti-inflammatory drugs such as
ibuprofen (Advil, Motrin IB, others) and naproxen sodium (Aleve) might
reduce pain. These can be very helpful before or after repositioning and wound
care. Topical pain medications also can be helpful during wound care.

56. • Drugs to fight infection. Infected pressure sores that aren't responding to other
interventions can be treated with topical or oral antibiotics.
• A healthy diet.
• Negative pressure therapy. This method, which is also called vacuum-assisted
closure (VAC), uses a device to clean a wound with suction.
• Surgery
• A large pressure sore that fails to heal might require surgery. One method of surgical
repair is to use a pad of muscle, skin or other tissue to cover the wound and cushion
the affected bone (flap reconstruction).

57. PREVENTION
• Changing position
• Moving and regularly changing position helps to relieve the pressure on ulcers that have
already developed. It also helps prevent pressure ulcers developing.
• correct sitting and lying positions
• sitting and lying positions
• support feet to relieve pressure on heels
• Mattresses and cushions
• Creams and ointments
• Antibiotics
• Diet and nutrition

58. • Dressings
• alginate dressings – these are made from seaweed and contain sodium and calcium, which
are known to speed up the healing process
• hydrocolloid dressings – contain a special gel that encourages the growth of new skin cells
in the ulcer, while keeping the surrounding healthy skin dry
• other dressing types – such as foams, films, hydro fibres/gelling fibres, gels and
antimicrobial (antibiotic) dressings may also be used
• Removing damaged tissue (debridement)
• applying special dressings that speed up the healing process and may help to relieve
pressure
• moving and regularly changing position
• Surgery

59. • Risks after surgery include:
• implanted skin tissue dying
• blood poisoning
• infection of the bone (osteomyelitis)
• abscesses
• deep vein thrombosis

60. COMPLICATIONS
Cellulitis.
Bone and joint infections.
Cancer.
Sepsis.

61. BIBLIOGRAPHY
• SHABEER. P. BASHEER “A CONCISE TEXT BOOK OF ADVANCED NURSING
PRACTICE, 2013 EMMESS MEDICAL PUBLICATION PAGE NO: 324-332.
• BRUNNER AND SUDDARTH, “TEXT BOOK OF MEDICAL AND SURGICAL
NURSING”, 12TH EDITION, WOLTER KLUWER INDIA PRIVATE LIMITED,
PAGE NUMBER:183-191.
• LEWIS, HEITKEMPER DIRKSEN, “MEDICAL SURGICAL NURSING” 6TH
EDITION, MOSBY PUBLICATIONS, PAGE NO: 191-200.
• NAVDEEP KAUR BRAR, “TEXTBOOK OF ADVANCED NURSING PRACTICE”,
2015, JAYPEE BROTHERS MEDICAL PUBLISHERS PRIVATE LIMITED, PAGE
NO: 507-530.

62. • JEAN FORT GIDDENS, “CONCEPTS FOR NURSING PRACTICE,”, 2013,
ELSEVIER PUBLICATIONS, PAGE NO: 227-237.
• PERLE SLAVIK COWEN, SUE MOORHEAD, “CURRENT ISSUES IN
NURSING” EIGHT EDITIONS, MOSBY ELSEVIER PUBLICATIONS, PAGE NO:
753-754.
• BEVERLY WITTER DU GAS, “INTRODUCTION TO PATIENT CARE” FOURTH
EDITION, ELSEVIER PUBLICATIONS, PAGE NO: 551-572.
• CHRIS BOOKER, MAGGIE NICOL “ALEXANDER’S NURSING PRACTICE, 4
TH EDITION, ELSEVIER PUBLICATIONS, PAGE NO: 499-518.

63. • NET REFERENCE
• http://www.thehindu.com/sci-tech/health
• http://www.indiamedicaltimes.com
• https://www.healthissuesindia.com
• http://www.e-jmii.com
• http://indianexpress.com/article/opinion/colum
ns
• https://pdfs.semanticscholar.org
• JOURNAL REFERENCE
• http://www.ncbi.nlm.gov/pmc/articles
• http://academic.oup.com/cid/articles
• https://www.cdc.gov/hai/surveillance
• https://timesofindia.indiatimes.com/in
dia
• http://www.bmj.com
• https://innovareacademics.in