PREVENTION OF INFECTION IN THE HOSPITAL SETTING

1. PREVENTION OF INFECTION IN THE HOSPITAL SETTING

2. Coming together is a beginning, keeping together is a process, working together is a SUCCESS. Henry Ford

3. Learning Objectives • To understand the importance and implications of Prevention of Infection in the Hospital Setting • To understand how Infection in the Hospital Setting can be prevented • Consider Infrastructure, Education, Policies/procedures, Audit, Surveillance, Outbreak Management,Antimicrobial Policy, Occupational Health, Risk Management and Outcome Indicators in understanding the above

4. Contents of Lecture • Infrastructure (environment, ventilation, facilities) • Education • Surveillance/Audit • Infection control policy/procedures ( e.g transmission precautions, evidence based) • Antimicrobial policy • Occupational Health policy • Infection Control indicators • Possible problem areas

5. Infection Control • SENIC project (Study on the Efficacy of Nosocomial Infection Control) established the scientific basis of efficacy of infection control programmes (Haley Am J Epidemiol 1985; 121: 182-205). • 32% of blood-stream, respiratory, urinary tract, and wound infections could be prevented by high intensity infection surveillance and control programmes

6. Consequences of HAI • U.S. • 2 million infections/year • 90,000 deaths • $4.5 billion dollars in excess healthcare costs MMWR 1992;41:783-7 • U.K. • Estimated to cost £1 billion/year in 1995 PHLS 1999 • 5000 deaths/year MOST IMPORTANTLY HAI IMPACT ON THE MORBIDITY AND MORTALITY FOR THE PATIENT

7. Extent of the problem • About 10% of patients in hospital have a hospital-acquired infection Emmerson AM, Enstone JE, Griffin M et al. J Hosp Inf 1996; 32: 175-190. U.S data: 5.7 nosocomial infections per 100 admissions in 1975-6 • 42% UTI • 24% surgical wound infections • 10% pneumonia • 5% bacteraemias Haley et al.Am J Epidemiol. 1985 Feb;121(2):159-67

8. Problem Areas • Increasingly complex patients with increased susceptibility to infection • Increasing use of invasive devices • Increasing problem of antimicrobial resistance • New threats – re-emergence of old threats • SARS, influenza • MDR-TB • Agents of bioterrorism – anthrax, smallpox

9. Overcrowding • Frequent patient movement • Inability to separate elective and emergency admissions • Understaffing • Inadequate facilities e.g isolation rooms

10. Environment • Consider Patient factors-Increased susceptibility • Immunosuppressed • Immunodepressed • Burns/Large open wound • Premature neonates • ICU and those with invasive devised

11. Destroying physical barriers Deleted pictures • Intravascular devices • a gateway into the patient’s bloodstream

12. Endocarditis on an artificial valve Foreign bodies Deleted pictures Foreign material used in fracture fixation - relative non-pathogens e.g. Staphylococcus epidermidis are frequent causes of infection in this setting

13. Destroying physical barriers - 2 Deleted pictures Skin integrity disrupted in this burn - caused by a hot-water bottle in a bed-ridden patient

14. Environmental Items • Floors/walls/ceilings ( consider dealing with spills) • Furniture/fittings • Beds/pillows/mattresses • Linen • Infant incubators-consider manufactors` instructions • Baths/Showers/Sinks/ footpedal bins • Drains/Toilets/toilet seats • Additional equipment e.g Hydrotherapy pools

15. Consider Prevention

16. Environmental items • Cleaning equipment • Floor scrubbers, must be amendable to cleaning • Mops- wet , cleaning on hotwash and dried throughly, colour code mops for different area used e.g high risk area as opposed to toliet • Vaccuum cleaners, must have a filter on the exhaust , protocol for changing , person in charge

17. Environment • Deleted pictures

18. Environmental additional items • Toys • Telephones- clean on a regular basis, but hands should be decontaminated before use • Flowers/plants- Risk assessment

19. Environment Evidence that a clean environment reduces HAI • Norovirus • Indirect transmission occurs • Cleaning is a key infection control measure • C. difficile • Extensive environmental contamination • MRSA • Evidence that improved cleaning may assist in termination of outbreaks • VRE • Extensive environmental contamination has been described

20. Ventilation • Prevention of spread of airborne pathogens ( airborne precautions) • Positive pressure isolation • Negative pressure isolation • Special considerations for Operating Theatre

21. Ventilation • Negative pressure isolation • HEPA filtered air • At least 6 exchanges of air/ hour • Air should not be recirculated into system and external exhaust should be away from intake air system • Particle Filter Respirator masks for those entering • Indicated for Infectious mycobacterium tuberculosis, measles, dissemeinated zoster, varicella ( ideally those immune should deal with the patient with measles etc)

22. Ventilation-Operating Theatre • Operating theatres- purpose to prevent bacteria settling in the wound (HTM 2025) • People are constantly sheeding dead skin(squames) around 15 um, rate of shedding increases with movement, some of these may carry bacteria • Filtration • Differential air pressures, filtered clean air to critical areas to less critical • Commissioning of theatres – smoke test, casella air counts, structure , maintaince system, rates • Ultraclean theatres required for eye surgery etc, unidirectional flow

23. Operating theatre-Commisioning • Deleted pictures

24. Ward Air Sampling- Which Unit may be of concern? • Deleted pictures

25. Water Systems and Prevention of Legionellosis

26. Hospital Water Sytems Deleted pictures

27. Legionnaire`s Disease • The management of Legionnaire`s Disease in Ireland • Scientific Advisory Committee Legionnaire`s Disease sub-committee National Disease Surveillance Centre – Guidelines for Control http://www.HPSC.ie

28. Legionnaire`s Disease • American Legion convention • 221 ill and 34 died • Mystery Illness • Legionella species 65 serotypes • Legionella Pneumophilia serogroup 1 accounts for 71% notified to CDC Deleted pictures

29. Natural History • 20-45º C favors growth • Do not multiply below 20 ºC and will not survive above 60 ºC • Dormant and multiply when temperature suitable • Nutrients to multiply derived from algae, amoebae and other bacteria • Sediment, Sludge , Scale, Biofilms

30. Water Systems • Drinking water disinfectants , free Cl-, kills free floating coliforms but penetrates poorly into biofilm • Legionella is further shieled by the amoebae it parasitises • Cl-, does not reach distal sites in water distribution systems • Dissipates quickly in heated water or removed in water filtering in Spapools • So Require design of water systems, Hyperchlorination and Temperature control of water

31. Legionnaire`s Disease Cluster/Outbreak 2 or more , Single source < 6 mts Linked 2 or more Single source > 6 mts < 2 yrs Sporadic Single Case

32. Hot/Cold Water Systems Cooling Towers Evaporative condensers Respiratory Equipment Spa pools, Natural pools, Thermal springs Fountains/Sprinklers Humidifiers for food display cabinets Water cooling machine tools Vechicle washes Ultrasonic misting machine POTENTIAL SOURCES In common combination of High Temperature and Potential for Aerosol Formation

33. TRANSMISSION • Respiratory: Inhalation of aerosol , microaspiration of water containing legionella species • The smaller the aerosol more dangerous ( 1-5um) • No person to person Transmission

34. > 50 years Male Cig Smokers Chronic underlying Disease With/without Immunodeficiency Incubation Period 2-10 Days Attack rates in Outbreak < 5%, 102 –104 /L and sporadic 104 –106 /L So Risk depends on: Individual susceptibility Degree of Intensity of Exposure ( amt. Of legionella, size of aerosol etc) Length of Exposure Risk Factors

35. Hospital INFECTION-Legionnaire`s Disease • Case Defintion: Definite, Probably, Possible • Hospitals at risk those caring for immunocompromised patients • Hospital size may be important> 200 beds 31 of 32 outbreaks in US • Mostly linked to Legionella colonising hot water system ( also cooling towers near ventilation intake, respiratory equipment cleaned with unsterile water, Ice machines, aspiration of contaminated water etc)

36. Staff Education Surveillance Interrupting Transmission e.g Nebuliser equipment and Water distribution systems Sampling: Sites 1Litre in sterile containers containing sufficient sodium thiosulphate to neutralise any Cl- or oxidising biocide Measure Temperature Recommendations for Control

37. Guidelines • Responsible named person for Legionella control • Kept hot water hot at all times –50-60ºC . • Keep cold water cold at all times. Maintained at temperatures below 25ºC • Run all taps and showers in rooms for a few minutes daily, even if room is unoccupied

38. Guidelines • Keep all showers, showerheads and taps clean and free from scale • Clean and Disinfect cooling towers used in air conditioning systems regularly – every 3 months • Clean and disinfect heat exchangers( calorifiers) regularly- once a year • Disinfect the hot water system with high level ( 50 ppm) chlorine for 2-4 hours after work on heat exchangers

39. Guidelines • Clean and disinfect all water filters regularly- every one to three months • Inspect storage tanks, cooling towers and visible pipe work monthly. Ensure all coverings are intact and firmly in place • Ensure that system modifications or new installations do not create pipework with intermittent or no water flow

40. Precautionary Shock Heating ( min 5 mins each water outlet 65º C)-Disinfection, disabling Hyperchlorination ( > 10 PPM) of cooling tower on 3 occasions including mechanical cleaning Cleaning of tanks, shower heads, water heaters and circulation of 5 ppm free Cl- through water system for min. 3 hours Storage tanks and pipework temp below 20ºC Emergency Control Measures

41. Waste Segretation/Disposal • Black Bags-non-clinical waste e.g paper • Yellow bags-Clinical waste not containing sharps • Yellow rigid sharps bin/box for sharps disposal • Contaminated linen alginate bags • Each hospital may have separate colour scheme SJH

42. Deleted pictures

43. Food • Cook –Chill System • HACCP(critical control point) analysis • Microbiolgical Testing of Food

44. Cook-Chill system • Deleted pictures

45. Facilities • Ideally lass than 100% occupancy allows for cleaning and maintaince • In the U.K 50% of New Hospitals will be isolation rooms • Lower rates of MRSA acquistion in countries that have hospitals with <90% bed occupancy

46. Examples • Policies/Procedures in Infection Control Manual • SJH 016-Safe Disposal of Sharps etc covered in Hand Hygiene Practical

47. Dealing with blood spillage

49. Policy for dealing with blood and body fluid spillages • Put on plastic apron and non-sterile disposable gloves • Use masks and visors if splashing in the nose, eye and mouth are likely to occur • Cover the spill with disposable paper towels to absorb liquid . Discard into clean yellow infectious waste bag • Avoiding contamination of the outside of the new bag. • Wipe up excess spillages with disposable paper towel and place into yellow infectious waste bag

50. Policy for dealing with blood and body fluid spillages • Apply a chlorine based solution, strength 10,000 ppm(part per million) and soak for 10 minutes (Klorsept 87 , 1 tablet / 500mls water) • Ensure a “wet floor “ sign is in place. • Mop up any excess solution. If applied to chrome or metal surfaces wash area with detergent and water. • Remove aprons and gloves and discard into yellow waste bag. Tie securely. • Wash hands