Infection Control

1. INFECTION CONTROLPrinciples AND Practice Dr.T.V.Rao MD Dr.T.V.Rao MD

2. A Tribute to Ignaz Semmelweiss (1818-1865) Ignaz Semmelweiss (1818-1865) • Obstetrician, practised in Vienna • Studied puerperal (childbed) fever • Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems • Reduced maternal mortality by 90% • Ignored and ridiculed by colleagues Dr.T.V.Rao MD

3. History of infection control and hospital epidemiology in the USA • Pre 1800: Early efforts at wound prophylaxis • 1800-1940: Nightingale, Semmelweis, Lister, Pasteur • 1940-1960: Antibiotic era begins, Staph. aureus nursery outbreaks, hygiene focus • 1960-1970’s: Documenting need for infection control programs, surveillance begins • 1980’s: focus on patient care practices, intensive care units, resistant organisms, HIV • 1990’s: Hospital Epidemiology = Infection control, quality improvement and economics • 2000’s: ??Healthcare system epidemiology modified from McGowan, SHEA/CDC/AHA training course Dr.T.V.Rao MD

4. Why do we need Infection Control?? Hospitals and clinics are complex institutions where patients go to have their health problems diagnosed and treated But, hospitals, clinics, and medical/surgical interventions introduce risks that may harm a patient’s health Dr.T.V.Rao MD

5. What is Nosocomial Infection • Any infection that is not present or incubating at the time the patient is admitted to the hospital Dr.T.V.Rao MD

6. Consequences of Nosocomial Infections • Additional morbidity • Prolonged hospitalization • Long-term physical, developmental and neurological sequelae • Increased cost of hospitalization • Death Dr.T.V.Rao MD

7. Florence Nightingale • It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm" Dr.T.V.Rao MD

8. Links to the Chain of Infection • Portal of Entry • Susceptible Host • Causative Agent • Reservoir • Portal of Exit • Mode of Transmission Dr.T.V.Rao MD

9. Hospital Infections are Emerging challenges in Health Care • Hospital-associated infections represent a serious and growing health problem. The Centers for Disease Control and Prevention (CDC) estimates that 2 million people acquire hospital-associated infections each year and that 90 000 of these patients die as a result of their infections. A variety of hospital-based strategies aimed at preventing such infections have been proposed. Dr.T.V.Rao MD

10. Modern Hospital Infection Control • Modernhospital infection control programs first began in the 1950s in England, where the primary focus of these programs was to prevent and control hospital-acquired staphylococcal outbreaks. In 1968, the American Hospital Association published "Infection Control in the Hospital," the first and only standards available for many years. At the same time, the Communicable Disease Center, later to be renamed the Centers for Disease Control and Prevention (CDC), began the first training courses specifically about infection control and surveillance Dr.T.V.Rao MD

11. CHAIN OF INFECTION Dr.T.V.Rao MD

12. Beginning of Accreditation • In 1969, the Joint Commission for Accreditation of Hospitals--later to become the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)--first required hospitals to have organized infection control committees and isolation facilities. Dr.T.V.Rao MD

13. CDCInitiates Hospital Infection Branch • In 1972, the Hospital Infections Branch at the CDC was formed and the Association for Practitioners in Infection Control was organized. By the close of the decade, the first CDC guidelines were written to answer frequently asked questions and establish consistent practice. Dr.T.V.Rao MD

14. First Data on Infection Control Efficacy • In 1985, the Study of the Efficacy of Nosocomial Infection Control (SENIC) project was published, validating the cost-benefit of infection control programs. Data collected in 1970 and 1976-1977 suggested that one-third of all nosocomial infections could be prevented Dr.T.V.Rao MD

15. Committee Suggested • One infection control professional (ICP) for every 250 beds. An effective infection control physician. A program reporting infection rates back to the surgeon and those clinically involved with the infection. An organized hospital-wide surveillance system. Dr.T.V.Rao MD

16. Infection Control Challenges of Healthcare in 2000 • Decreasing reimbursement • Increasing emerging infections • Increasing resistant organisms • Increasing drug costs • Institute of Medicine Report--healthcare-associated infections • Nursing shortage • OSHA safety legislation • Multiple benchmark systems • FDA legislation on reuse of single-use devices Dr.T.V.Rao MD

17. The nature of infections • Micro-organisms - bacteria, fungi, viruses, protozoa and worms • Most are harmless [non-pathogenic] • Pathogenic organisms can cause infection • Infection exists when pathogenic organisms enter the body, reproduce and cause disease Dr.T.V.Rao MD

18. Modes of spread Two sources of infection: • Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli • Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998) Dr.T.V.Rao MD

19. Spread - entry and exit routes • Natural orifices - mouth, nose, ear, eye, urethra, vagina, rectum • Artificial orifices - such as tracheostomy, ileostomy, colostomy • Mucous membranes - which line most natural and artificial orifices • Skin breaks - either as a result of accidental damage or deliberate inoculation/incision (May, 2000) Dr.T.V.Rao MD

20. HAI - common bacteria • Staphylococci - wound, respiratory and gastro-intestinal infections • Escherichia coli - wound and urinary tract infections • Salmonella - food poisoning • Streptococci - wound, throat and urinary tract infections • Proteus - wound and urinary tract infections (Peto, 1998) Dr.T.V.Rao MD

21. HAI - common viruses • Hepatitis A - infectious hepatitis • Hepatitis B - serum hepatitis • Human immunodeficiency virus [HIV] - acquired immunodeficiency syndrome [AIDS] (Peto, 1998) Dr.T.V.Rao MD

22. Components of Infection Control Programme • The important components of the infection control programme are: • ·Basic measures for infection control, i.e. standard and additional precautions; · education and training of health care workers; · protection of health care workers, e.g. immunization; identification of hazards and minimizing risks; · routine practices essential to infection control such as aseptic techniques, use of single use devices, reprocessing of instruments and equipment, antibiotic usage, management of blood/body fluid exposure, handling and use of blood and blood products, sound management of medical waste; Dr.T.V.Rao MD

23. Need For Control programme? • Effective work practices and procedures, such as environmentalmanagement practices including management of hospital/clinical waste, support services (e.g., food, linen), use of therapeutic devices; surveillance; · incident monitoring; outbreak investigation; infection control in specific situations; and research. Dr.T.V.Rao MD

24. Developing Infection Control Programme • Every infection control program should develop a well-defined written plan outlining the organizational philosophy regarding infection prevention and control. The plan should take into account the goals, mission statement, and an assessment of the infection control program. It should include a statement of authority, and should review patient demographics including geographic locations of patients served by the healthcare system Dr.T.V.Rao MD

25. Administrative control measures Assignment of responsibilities Responsibility on implementing, monitoring, enforcing, evaluating, and revising infection control programs on a routine basisincluding linkage to TB diagnostics and other communicable Infections Dr.T.V.Rao MD

26. Infection control committee • An infection control committee provides a forum for multidisciplinary input and cooperation, and information sharing. This committee should include wide representation from relevant departments: e.g. management, physicians, other health care workers, clinical microbiology, pharmacy, sterilizing service, maintenance, housekeeping and training services. The committee must have a reporting relationship directly to either administration or the medical staff to promote programme visibility and effectiveness. Dr.T.V.Rao MD

27. Prevention of Hospital Infection-Planning • Implemented, monitored and enforced IC plan • Educated and trained HCW to ensure good work practices • Counselling and screening HCW periodically • Evaluated and revised plan 4 times LIFECYCLE OF IC PLAN Develop Evaluate Revise Implement Dr.T.V.Rao MD

28. The Infection Control Team • Consist of at least an infection control practitioner who should be trained for the purpose; carry out the surveillance programme; develop and disseminate infection control policies; monitor and manage critical incidents; coordinate and conduct training activities. Dr.T.V.Rao MD

29. Infection Control Committee Purpose • Advisory • Review ideas from infection control team • Review surveillance data • Expert resource • Help understand hospital systems and policies • Decision making • Review and approve policies and surveillance plans • Policies binding throughout hospital • Education • Help disseminate information and influence others Dr.T.V.Rao MD

30. Infection Control Committee - Represented Committee Representatives • Hospital Epidemiologist • Infection Control Practitioners • Administrator • Ward, ICU and Operating room Nurses • Medicine/Surgery/Obstetrics/Pediatrics • Central Sterilization • Hospital Engineer • Microbiologist • Pharmacist Dr.T.V.Rao MD

31. Skin shaved the night before surgery Inappropriate peri-op antibiotic prophylaxis Instruments used for dressing changes submerged disinfectant Large containers of antiseptics, no routine for cleaning and refilling Eliminate shaving of skin the night before surgery Single dose peri-op antibiotic prophylaxis guidelines Use individual sterile packs of wound care instruments Use small containers of antiseptics; clean and dry containers before refilling Identify problems with polices and procedures Example: Pre- and Post-Operative Carecreate your protocols Problem Area Recommendation Dr.T.V.Rao MD

32. Aims of Infection Control • To review and approve a yearly programme of activity for surveillanceand prevention; to review epidemiological surveillance data and identify areas for intervention; to assess and promote improved practice at all levels of the health facility; to ensure appropriate staff training in infection control and safety management, provision of safety materials such as personal protective equipment and products; and training of health workers. Dr.T.V.Rao MD

33. Education is the Real Strength of Infection Control programme • Education programs for employees and volunteers are one method to ensure competent infection control practices. It is a unique challenge since employees represent a wide range of expertise and educational background. The ICP must become knowledgeable in adult education principles and use educational tools and techniques that will motivate and sustain behavioral change. Much has been written about the education of healthcare workers (HCWs). Dr.T.V.Rao MD

34. Minimal Needs to Start Infection Control Unit • 1 Organized surveillance and control activities 2. One infection control practitioner for every major Health Facility. 3. A Trained Hospital Epidemiologist 4. A system for reporting surgical wound infection rates and other infection back to the practicing surgeons and physicians. Dr.T.V.Rao MD

35. GUIDELINES for Effective Control of Infections • Hand washing and Hospital Environmental Control * Immunization * Infectious Diseases Control * Intravascular Device-Related Infections and its control * Isolation Precautions * Long-Term Care Facilities Dr.T.V.Rao MD

36. GUIDELINES for Effective Control of Infections • * Guidelines for Infection Control in Health Care Personnel * Surgical Site Infections Control * Urinary Tract and Respiratory Tract Infections Control * Ordering and Preparing Guidelines appropriately • * Home care • * Hospital Construction • * Sterilization / Disinfection Dr.T.V.Rao MD

37. Your Unwashed Hand a Great Concern to Your Patient Dr.T.V.Rao MD

38. Hand Washing is the Foundation of Infection Control • Hand washing is the single most important procedure for preventing nosocomial infections. Hand washing is defined as a vigorous, brief rubbing together of all surfaces of lathered hands, followed by rinsing under a stream of water. Although various products are available, hand washing can be classified simply by the nature of the products used: • plain soap • detergents • Antimicrobial containing products Dr.T.V.Rao MD

39. Hand Washing is the Foundation of Infection Control • Hand washing with plain soaps or detergents (in bar, granule, leaflet or liquid form) suspends microorganisms and allows them to be rinsed off; this process is often referred to as mechanical removal of microorganisms. In addition, hand washing with antimicrobial containing products kills or inhibits the growth of microorganisms; this process is often referred to as chemical removal of microorganisms. Dr.T.V.Rao MD

40. Hand washing Technique • For routine hand washing, a vigorous rubbing together of all surfaces of lathered hands for at least 10 seconds, followed by thorough rinsing under a stream of water, is recommended. Dr.T.V.Rao MD

41. Hand washing • Single most effective action to prevent HAI - resident/transient bacteria • Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken • No recommended frequency - should be determined by intended/completed actions • Research indicates: • poor techniques - not all surfaces cleaned • frequency diminishes with workload/distance • poor compliance with guidelines/training Dr.T.V.Rao MD

42. Taylor (1978) identified that 89% of the hand surface was missed and that the areas of the hands most often missed were the finger-tips, finger-webs, the palms and the thumbs. Hand washing – Areas Missed Dr.T.V.Rao MD

43. Successful Promotionin Hand Washing  • Education • Routine observation & feedback • Engineering controls • Location of hand basins • Possible, easy & convenient • Alcohol-based hand rubs available • Patient education (Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381) Dr.T.V.Rao MD

44. Successful Promotioncan Improve Hand Washing  • Reminders in the workplace • Administrative sanctions ?? • Change in hygiene agent (not in Winter) • Promote and facilitate skin care • Avoid understaffing and excessive workload Dr.T.V.Rao MD

45. Hand Hygiene TechniquesMany Ways • Alcohol hand rub • Routine hand wash 10-15 seconds • Aseptic procedures 1 minute • Surgical wash 3-5 minutes Dr.T.V.Rao MD

46. Advantages of Alcoholic Hand Wash • Require less time • Can be strategically placed • Readily accessible • Multiple sites • All patient care areas • Acts faster • Excellent bactericidal activity • Less irritating (??) • Sustained improvement Dr.T.V.Rao MD

47. Antibiotic resistanceNot a new problem - Penicillin in 1944 • Hospital “superbugs” • Methicillin Resistant Staphylococcus Aureus [MRSA] • Vancomycin Intermediate Staphylococcus Aureus [VISA] • Tuberculosis - antibiotic resistant an Emerging Global Concern Dr.T.V.Rao MD

48. MRSA • Discovered in 1981 • Found on skin and in the nose of 1 in 3 healthy people - symptomless carriers • Widespread in hospitals and community • Resistant to most antibiotics • When fatal - often due to septicaemia Dr.T.V.Rao MD

49. Hospital Acquired Infections and Consequences • Incidence of 10% • 5,000 deaths per year - direct result of HAI • 15,000 deaths per year linked to HAI • Delayed discharge from hospital • Expensive to treat [£3,500 extra] • Cost to NHS - £1 billion per year • Effective hand washing is the most effective preventative measure • Dirty wards and re-use of disposable equipment also blamed Dr.T.V.Rao MD

50. The nature of infection • Micro-organisms - bacteria, fungi, viruses, protozoa and worms • Most are harmless [non-pathogenic] • Pathogenic organisms can cause infection • Infection exists when pathogenic organisms enter the body, reproduce and cause disease Dr.T.V.Rao MD