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Infection Control Chapter 27 Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 1 Learning Objectives Define, spell, and pronounce the terms listed in the vocabulary. Describe the characteristics of pathogenic microorganisms and the diseases they cause. Apply the chain-of-infection process to healthcare practice. Compare viral and bacterial cell invasion. Differentiate between humoral and cell-mediated immunity. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 2 Learning Objectives Summarize the impact of the inflammatory response on the body’s ability to defend itself against infection. Analyze the differences among acute, chronic, latent, and opportunistic infections. Specify potentially infectious bodily fluids. Integrate OSHA’s requirement for a sitebased Exposure Control Plan into office management procedures. Explain the major areas included in the OSHA Compliance Guidelines. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 3 Learning Objectives Remove contaminated gloves while following Standard Precautions principles. Perform an eyewash procedure for the removal of contaminated material. Summarize the management of postexposure evaluation and follow-up. Apply the concepts of medical and surgical asepsis to the healthcare setting. Demonstrate the proper hand-washing technique for medical asepsis. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 4 Learning Objectives Differentiate among sanitization, disinfection, and sterilization procedures. Demonstrate the correct procedure for sanitization of contaminated instruments. Apply patient education concepts to infection control. Discuss legal and ethical concerns regarding medical asepsis and infection control. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 5 Disease An alteration in the normal structure or function of an organism or a cell. Causes specific clinical signs, symptoms, and laboratory findings that set it apart. A disease could be either inherited, drug-induced, autoimmune, degenerative, or infectious. Any disease caused by the growth of pathogenic microorganisms in the body is considered an infectious disease. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 6 Conditions Required for Microbial Growth To maintain a healthcare environment that is as free as possible of pathogenic organisms, the medical assistant (MA) must prevent or eliminate as many growth requirements as possible. Nutrients Moisture Temperature Oxygen—aerobes or anaerobes Neutral pH Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 7 Chain of Infection Infectious diseases can spread only if certain factors occur. These factors, or links, make up the chain of infection. Break the chain, and you break the infectious process. Wearing appropriate protective equipment and effective hand washing can break the chain of infection. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 8 Chain of Infection Infectious agent Reservoir host – an infected patient Means or portal of exit – coughing, sneezing, blood product, specimen, etc. Method of transmission – contaminated hands, equipment or supplies; air borne; contaminated food or water; etc. Portal of entry into a new host – exposure to contaminated equipment, inhalation, broken skin, etc. Susceptible host – unvaccinated, weak, debilitated individual Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 9 Chain of Infection Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 10 Reservoir Hosts May be people, insects, animals, water, food, examination rooms, contaminated instruments, and so on Supply nutrition for the organism, allowing it to multiply Either cause infection in the host and/or exit from the host to cause disease in another host Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 11 Portal of Exit How the pathogen escapes the reservoir host Includes mouth, nose, eyes, intestines, urine, reproductive tract, and so on Standard precautions prevent spread Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 12 Transmission Direct—contact with infected person or with discharges (feces, urine, sputum, etc.) Indirect—from droplets expelled with coughing, sneezing, or speaking; vectors; contaminated food; contaminated objects called fomites. Controlled with sanitization, disinfection, sterilization, and so on Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 13 Portal of Entry How the pathogen gains entry to a new host Similar to means of exit (e.g., mouth, eyes, nose) Intact integumentary system is first line of defense Inflammatory response and immune system are second lines of defense Humoral immunity—produces antibodies specific to antigen exposure Cell-mediated immunity—destroys pathogens at the site; e.g., phagocytosis Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 14 Susceptible Host Must be capable of supporting the pathogen Susceptibility depends on: Location of entry Dose of pathogen Health state of new host Immunization status Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 15 Critical Thinking Application Tommy Anderson, a 5-year-old patient, is seen in the office because of an outbreak of impetigo. Rosa must apply the concepts of the chain of infection and infection control methods to teach Tommy and his mother how to prevent the spread of the infection to other members of the family. What procedures should she follow after Tommy’s visit to prevent the spread of the infection to other patients, other staff members, and herself? Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 16 Infectious Agents Pathogenic microorganisms include: Viruses—smallest; obligate intracellular parasites; palliative treatment; EX: hepatitis B Bacteria—classified by their morphology; some produce spores; normal flora vs. pathogenic microbes; EX: tuberculosis Protozoa—unicellular parasites; frequently transmitted by vectors; EX: giardiasis Fungi—molds and yeasts; mycotic infections and tineas; EX: candidiasis Rickettsiae—similar to both viruses and bacteria; carried by vectors; EX: Rocky Mountain spotted fever Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 17 Antibiotic Resistance Antibiotic resistance is one of the world’s most significant public health problems. Infectious microorganisms whose presence were once easily treated with antibiotics are growing increasingly resistant to the drugs. Resistance occurs when an antibiotic is used inappropriately to treat an infection. The pathologic organism mutates, decreasing the effectiveness of the drug. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 18 CDC Recommendations Prescribe antibiotic therapy only when it will benefit the patient. Bacterial infections can be treated with antibiotics, but viral infections, because they involve viral takeover of cellular DNA or RNA material, cannot. Treat the patient with an antibiotic that is specific to the bacterial infection. Prescribe the label-recommended dose and time interval for the medication. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 19 Body’s Natural Protection Intact skin. Mucous membranes protect underlying tissues and trap foreign substances. Cilia trap invading microbes. Sneezing and coughing expel organisms. Body secretions, such as tears and sweat, expel foreign substances from the body. pH of many of the body’s organs discourages microbial growth. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 20 The Inflammatory Response The inflammatory response is the body’s protective reaction to a foreign substance or antigen. To defend itself, the body initiates specific responses that destroy and remove pathogenic organisms. The release of inflammation mediators, through three separate actions, results in an increase in white blood cells (WBCs) at the site. WBCs attack the pathogen and attempt to contain the infection at its original site. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 21 Inflammatory Response Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 22 Site of Injury Blood vessels dilate, causing an increase in the local blood flow, resulting in redness and heat. Blood vessel walls become more permeable, which helps in releasing WBCs to the site. Blood plasma filters out of the more permeable vessel walls, resulting in edema, causing pressure on nerves and pain. Finally, chemotaxis, the release of chemical agents, attracts WBCs. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 23 WBC Protection WBCs form a fibrous capsule around the injury, protecting surrounding cells from damage or the source of infection. Destroyed pathogens, cells, and WBCs collect and form a thick, white substance called pus. WBCs engage in phagocytosis, or the engulfing and destruction of microorganisms and damaged cells. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 24 Four Classic Signs and Symptoms of Inflammation Redness or erythema Swelling or edema Pain Heat Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 25 Inflammatory and Infection Terms Lymphadenopathy Septicemia Pyemia Prodromal period Chronic vs acute infection Latent infection—relapse and remission (e.g., oral herpes simplex) Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 26 Critical Thinking Application Rosa’s next patient appears to have a localized inflammatory response to a splinter. What signs and symptoms should she expect the patient to exhibit? Rosa answers a telephone call from a patient who had surgery 3 days ago. The patient is concerned that the incision site is red, swollen, and hot. Is this a normal post-surgical response? How could Rosa know if the response is abnormal? Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 27 Infectious Bodily Secretions OSHA has designated the following bodily fluids as potentially infectious with blood-borne pathogens: Cerebrospinal fluid (CSF); synovial, pleural, pericardial, peritoneal, mucous, and amniotic fluids Blood, vaginal and seminal secretions, saliva, and human tissue Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 28 OSHA Standards for Healthcare Workers Healthcare workers face significant health risks from occupational exposure to blood or other potentially infectious materials that may contain hepatitis B virus (HBV), hepatitis C virus (HCV), or the human immunodeficiency virus (HIV). The MA should use precautions for all patients, regardless of knowledge of their individual health histories. Implementation of the Bloodborne Pathogen Standard also protects patients from any blood-borne infection the healthcare worker may be carrying. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 29 Exposure Control Plan Plan must detail employee protection procedures. Must identify job classifications and/or specific work-related tasks that might lead to exposure. Must contain specifics on controls including PPE, training, hepatitis B immunization, record keeping, postexposure follow-up, and labeling and disposal of biohazard waste. Must be reviewed and updated at least annually to incorporate the use of safer medical devices. Must be available to employees for review and training. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 30 Bloodborne Pathogen Standard Employers must keep a confidential sharps injury log that describes the device involved and the details of how and where the incident occurred. Must have available sharps management devices, such as self-sheathing or retracting needles, and needleless intravenous (IV) systems. Should wash exposed area immediately or as soon as possible after exposure. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 31 Hand Hygiene Guidelines Visibly soiled hands should be washed for a minimum of 15 seconds with antimicrobial soap and warm running water. Alcohol-based handrubs, if used correctly, significantly decrease the number of microorganisms, take less time to use, and cause less irritation than traditional hand washing. Hand washing or alcohol handrubs should be used before and after each patient is seen as well as after gloves are removed. Apply label-recommended amount of handrub to palm of one hand and rub hands together, covering all surfaces until hands are dry. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 32 Handrubs and Antimicrobial Soap From Bonewit-West K: Clinical procedures for medical assistants, ed 7, St Louis, 2008, Saunders. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 33 Hand Hygiene Studies show that even after careful hand hygiene, healthcare workers with artificial nails have more pathogenic microbes than workers with natural nails. Natural nail tips should be no longer than ¼ inch. Contact dermatitis from alcohol handrubs is uncommon. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 34 Compliance Guidelines Safety and infection control fundamentals go beyond hand washing and knowledge of the disease cycle. Five basic parts to compliance: Barrier protection Environmental protection Housekeeping controls Hepatitis B vaccination Postexposure follow-up Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 35 Barrier Protection Protective equipment must be used if you will be involved in any of these activities: Touching a patient's blood and body fluids, mucous membranes, or broken skin Handling items and surfaces contaminated with blood and body fluids Performing venipuncture, finger punctures, injections, and other vascular-access procedures Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 36 Barrier Protection Assisting with any surgical procedure. If a glove is torn or an injury occurs, the glove is removed and replaced with a new glove. The instrument is removed from the sterile field. Handling, processing, and disposing of all specimens of blood and body fluids. Cleaning and decontaminating spills of blood or other body fluids. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 37 Personal Protective Equipment (PPE) Specialized clothing or equipment that prevents blood or other potentially infectious material from passing through to reach the healthcare worker Includes latex gloves, face masks, face shields, protective glasses, laboratory coats, barrier gowns, shoe covers, mouthpieces, and resuscitation bags that protect the healthcare worker from potentially infectious substances Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 38 Personal Protective Equipment (PPE) Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 39 PPE Guidelines Protective equipment contaminated with body fluids of any kind must be removed and placed in a designated area or biohazard container. Protective eyewear and/or face shields must be worn whenever splashes, sprays, or droplets may occur. Utility gloves may be reused if they are intact without cracks, tears, or punctures and are disinfected after each use. All PPE must be removed before the worker leaves the medical facility. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 40 Environment Protection Observe warning labels on biohazard containers and equipment. Minimize splashing, spraying, and spattering of drops. Bandage any breaks on hands before gloving. Do not recap, bend, break, or resheath contaminated sharps. Immediately after use dispose of sharp items in a labeled, leakproof, puncture-resistant biohazard container. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 41 Environment Protection All specimens must be placed in a container that prevents leakage. Contaminated equipment should be sanitized before being repaired in the office or transported to the manufacturer. Smoking, eating, drinking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is reasonable likelihood of contamination from blood-borne pathogens. Food and drink cannot be kept in the same areas as potentially infectious materials. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 42 Housekeeping Controls Post the schedule for cleaning and specific information about each work area in which exposure could occur. Immediately decontaminate areas after accidental spills and at the end of each procedure. Disinfect reusable containers on a routine basis. Sharps containers must be upright and as close as possible to the work usage area; not overfilled; replaced on a routine basis with the lid closed securely. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 43 Housekeeping Controls: Cleaning Spills Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 44 Housekeeping Controls Use appropriate equipment to pick up spilled material or broken glassware. Place in impervious biohazard bag or container. Use an absorbent professional biohazard spill preparation as directed to decontaminate the site. Wear gloves to handle soiled linen; should be double-bagged and transported in labeled, leakproof biohazard bags. Biohazard waste must be collected in impermeable red biohazard-labeled bags or containers and sealed. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 45 Housekeeping Controls Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 46 Hepatitis B Vaccination Must be available free of charge within 10 days of starting employment to all employees who are at risk. Intramuscular injection in three doses; second injection 4 weeks after first, and third injection 6 months after first. U.S. Public Health Service does not currently recommend routine boosters. Should have blood titer drawn after completion to determine if antibodies are present. Employees have the right to decline immunization but must sign a declination form. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 47 Hepatitis B Vaccination Occupational Safety and Health Administration: Available at: www.osha.gov Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 48 Postexposure Follow-up Postexposure follow-up involves immediate cleansing of the site, completion of an exposure incident form, confidential medical evaluation, examination of the source individual and worker’s blood, health counseling, and confidential treatment of all medical records. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 49 Critical Thinking Application Rosa’s office has been especially busy today. While administering an injection to a frightened 6-year-old child, a co-worker has an accidental needlestick. She tells Rosa about the incident but does not know what to do. What steps should be taken to manage the situation? Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 50 Aseptic Techniques: Prevention of Disease Transmission Medical asepsis. Surgical asepsis. Medical aseptic techniques: Create an environment as free of pathogens as possible to prevent reinfection or cross-infection. Surgical aseptic or sterile technique: Used when the patient’s skin or mucous membranes are disrupted. Prevents patient exposure to all microbes (e.g., for minor surgery, urinary catheterizations, injections). Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 51 Hand Washing Reduce skin bacteria with mechanical friction, antimicrobial soap, and warm running water. Goal is to remove or decrease the numbers of transient bacteria on the surface of the skin, thus preventing transient bacteria from becoming resident bacteria. Proper hand washing depends on two factors: warm running water and friction. All jewelry except a plain wedding band should be removed. Lotion may be used to prevent cracked or chapped skin. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 52 Hand Washing Wash hands under running water with fingertips pointing down. Apply antimicrobial soap and use friction to hands and wrists. Run water from the wrists down toward the fingertips. Alcohol handrubs may substitute for hand washing unless hands are visibly contaminated. Handrubs can be more effective in reducing nosocomial infections than hand washing. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 53 Hand Washing Continued Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 54 Sanitization Cleaning of contaminated articles or surfaces to reduce the number of microorganisms to a safe level as dictated in public health guidelines. Removes debris such as blood and other body fluids from instruments or equipment. Must wear utility gloves to prevent possible personal contamination. Completed immediately after use in a separate workroom or area to avoid cross-contamination. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 55 Sanitization Separate sharp instruments from others to prevent injury and protect instruments. Open hinges and scrub serrations and ratchets. Rinse instruments in hot water and check proper working order. Items should be hand dried. Ultrasonic sanitizers are helpful because they do not damage instruments and workers are protected from accidental sharps injuries. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 56 Sanitization Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 57 Disinfection Process of killing pathogenic organisms or making them inactive. Not always effective against spores and viruses. 1:10 bleach solution is an effective disinfectant for surfaces contaminated with viruses, including HIV. Important to follow the manufacturer’s guidelines on how to properly prepare and use each disinfectant. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 58 Disinfection Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 59 Disinfection Errors Instruments not thoroughly sanitized and organic matter inhibit or prevent action. Moisture on instruments dilutes disinfectant solution beyond effective concentration. Solution left in an open container. Solutions not changed as recommended and expire. Not prepared properly. Recommended manufacturer’s temperature for use and storage is not maintained. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 60 Sterilization Destruction of all microorganisms. Requires space for a sink as well as receiving basins, proper cleaning agents, brushes, autoclave wrapping paper, sterilizer envelopes and tape, sterilizer indicators, disposable gloves, and designated biohazard waste containers. Another area needed for storage of sterile items. Details discussed in Chapter 56. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 61 Role of the Medical Assistant It is important that aseptic techniques and infection control be done on such a routine basis that they become an unbreakable habit. MA should teach patients about infection control and the potential danger of blood and body fluids, including demonstrating aseptic techniques, the management of infectious materials at home, and the importance of frequent and consistent hand washing. Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved. 62