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11/12/2009 ASHA 2009 Infection control: Brief overview of infectious diseases Review of literature Practical implications for implementing and monitoring infection control Standard precautions Standard precautions (“universal precautions”) Cleaning and sterilizing procedures Two general areas: Barrier techniques: Reduction or elimination of infectious agents Approaching each client as having the potential to be infected with pathogens that could be transmitted to others Center for Disease Control (CDC), 2007 1. Barrier techniques Gloves, gowns, shoe covers, caps and masks (CDC, 2002;WHO,2006) CDC, 2007 1 11/12/2009 Barrier techniques, continued 2. Reduction or elimination of infectious agents In the typical university setting, the main barrier technique practiced by both student clinicians and clinical supervisors is the use of disposable gloves Besides promoting proper hand washing techniques, facilities should also have procedures in place to clean, disinfect, or sterilize objects as needed (CDC, 2007). (Smith, Brandell, Poyner & Tatchell, 1993) Cleaning: removing foreign agents through washing. This should precede the other two. Disinfection: destroying most organisms. Sterilization: completely destroying microorganisms and spores through a physical or chemical process. (CDC, 2007; Rutala & Weber, 2008) Use of products and procedures Products vary in amount of time they must remain on surfaces to be effective. (Rutala & Weber, 2008) Be aware of what the products are capable of doing, Clean: for observable foreign materials; precedes the other types for multiple use items. Disinfect: Items used for multiple clients that do not carry body fluids: Toys, tabletops, chairs Sanitize: Items reused on clients that have potential to carry body fluids: impedance probe tips; otoscopic mirrors; laryngeal mirrors. (CDC, 2007; Lubinski, 2007) It is important to have PROTOCOLS in place FOLLOW THROUGH with protocols Do they match your needs? 2 11/12/2009 Types of infectious diseases prevalent in clinical settings-Virus • • • • • • • HIV/AIDS Chicken pox Common cold Cytomegalovirus (CMV) Hepatitis A Hepatitis B Influenza • Infectious mononucleosis • Infectious meningitis • Measles (German) & measles (rubeola) • Mumps • Herpes simplex • Herpes zoster Types of infectious diseases prevalent in clinical settings-Bacteria ) • • • • Coag neg staphylococcus Otitis externa Pseudomonas aeruginosa Methicillin-resistant staphylococcus aureus (MRSA) • Staphylococcus aureus (Bankaitis & Kemp, 2005; Clark,Kemp,& Bankautis,2003; CDC, 2006) • Streptococcal infection • Tuberculosis • Vancomycin-resistant enterococci (VRE) • Infectious meningitis • Legionellosis • Pneumonia • Tuberculosis (Bankaitis & Kemp, 2005; Clark,Kemp,& Bankautis,2003; CDC, 2006) Types of infectious diseases prevalent in clinical setting ) • Fungus – Aspergillus – Candida – Otitis externa • Prion – SARS • Parasite – Toxoplasmosis – Scabies • Bacteria and fungus In both studies, the majority of hearing aids were contaminated with at least one bacterium Fungus on 4 out of the 17 hearing aids(Sturgulewski, et al. 2006) and on 4 out of the 10 hearing aids (Bankaitis, 2002) (Bankaitis & Kemp, 2005) http://www.doctorshearingcare.net Rare form of yeast Unidentified yeast Gram positive cocci Aspergillus Flavus Candida parapsilosis Unspecified mold Staphyloccous (coag neg) Kebsiella pneumoniae Pseudomonas aeruginosa Gram positive rods Staphylococcus aureus Diphtheroids Gram positive cocci Lactobacilli Enterobacter cloacae Enterococci Bacillus species 3 11/12/2009 Most common bacterium Commonly found on skin including ear canal So why is it dangerous? ◦ Many different species ◦ Immunosuppressed individuals ◦ Accounts for the highest rates of hospital-acquired infection ◦ Ear canal is a perfect petrie dish In the second study, 5 of the 6 hearing aid pairs showed bacterial and fungal growth that differed between the two instruments Cross-contamination even when only working with one person Treat cerumen as an infectious substance (Cohen & McCollough, 1996) Handle hearing aids as if contaminated with cerumen Use gloves Wash hands before and after Front-desk staff or assistants should also handle hearing aids as if contaminated Principle of Ethics I Individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally or participants in research and scholarly activities and shall treat animals involved in research in a humane manner. Ensure the safety of the patient/client and clinician Adhere to universal health precautions Decontamination (e.g., cleaning, disinfection, or sterilization) of multiple-use equipment before reuse 4 11/12/2009 Ensure the safety of the patient and clinician Adhere to standard health precautions (used to be “universal precautions”) Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse The CDC (2002) summarized a number of hospital studies which demonstrated reduced infection rates after implementation of improved hand hygiene practices. Carry through of recommended hand washing techniques can be problematic. A review of 34 studies of adherence to hand hygiene guidelines by health care workers in a variety of settings in the U.S. yielded an overall average of only 40%. (CDC, 2002). Survey of the university setting indicated that only 55% of the 497 respondents (students, supervisors and faculty) felt that the infection control practices utilized at their university during SLP and/or audiology services were “adequate” or “more than adequate”. Smith, Brandell, Poyner, & Tatchell (1993) 57% had received training in infection control 54% indicated they “always” wash hands before an oral exam (11% “never”) 25% “always” washed hands before/after client groups (18% never) 19% “always” disinfect work surfaces (17% never) Grube & Nunley, 1995 5 11/12/2009 Guthmiller, 2006 Comparison of percentage of universities requiring specific infection control procedures and Clinicians’ self-report of compliance Student clinicians and clinic directors from university clinics in the upper Midwest surveyed. (Guthmiller, 2006). All 8 universities participated for total of 8 clinical supervisors and 98 student clinicians. Procedure % Universities requiring compliance(n=8) Students reporting procedure (n=98) 100% 99-75% 74-50% 49-25% 24%-1% Never Sanitize hands prior to session 87.8 Sanitize hands after session 87.8 10.2 21.4 NR 35.7 19.4 10.2 13.3 9.2 2 28.6 21.4 13.3 9.2 4.1 2 Guthmiller, 2006, continued Procedure % Universities requiring compliance Students reporting procedure 100% 99-75% 74-50% 49-25% 24%-1% Never Sanitize tables after session 100 25.5 12.2 10.2 7.1 Sanitize light switches after session 13 7.1 5.1 6.1 1.2 Sanitize door handles after session 37.5 7.1 5.1 7.1 2 NR 10.2 30.7 4.1 10.2 46.9 23.4 9.2 65.4 4.1 Two years later, a similar study was carried out using observations of clinical sessions. 10 clinicians were rated after two clinical sessions each regarding compliance with the clinic’s rules for sanitizing: -table -light switch -door handle During direct observation of 8 student clinicians’ infection control practices after SLP sessions (all required by the clinic) Table 37% Light switch 0% Door handle 12.5% Guthmiller, 2006 Simonson, 2008 Clinic Handbook “ One clinic meeting lecture “ “ Infection control supplies present in rooms “ “ “ Compliance checks about once per semester; results shared with clinicians Signage re: hand washing throughout clinic Signage re: disinfecting tables; door handles & light switches Hand sanitizer dispensers added in hallways 6 11/12/2009 Difference in percentages between studies: Disinfected: Undergraduate Table 8/10 Light switch 6/10 Door handle 7/10 Graduate ( TOTAL) 10/10 (90%) 9/10 (80%) 10/10 (85%) Guthmiller, 2006: combined undergrad/grad Simonson (undergrad;grad) combined 37% 0% 12.5% (80;100) 90% (60;90) 80% (70;100) 85% Table Light switch Door handles Improvement across the 2 years What might explain the differences? How to close the gap between undergrad/grads? Do audiologists practice infection control? What personal protective measures are being employed? Are audiologists able to make distinctions among nomenclature relevant to infection control? Do audiologists believe more education is needed in the area of infection control? Four general areas ◦ Extent of Universal Precautions in the clinical setting ◦ Clinicians/students application of personal protective barriers ◦ General infection control nomenclature ◦ Future education directives 7 11/12/2009 Do audiologists practice infection control? (Amlani, 1999) (Burco, 2008) Are you aware of OSHA mandates? Are infection control standards in place? 2/3 believed their clinics were NOT at risk 51% were aware of mandates 44% reported that NO universal precautions standards were in place ½ believed their clinics were at risk 82% were aware of mandates 2/3 reported audiology-specific plans in their clinic Are your clinics at high risk? Washing hands (Amlani, 1999) (Burco, 2008) After each patient After lavatory After cerumen management After earmold impressions 25% 50% 46% 63% 82% 87% 45% 73% Only Burco (2008) asked about washing hands after handling hearing aid with a bare hand~ 73% Gloves (Amlani, 1999) (Burco, 2008) During cerumen management • 8% • 18% During AEPs • 6% • 0% During EMIs • 0% • 6% Cleaning equipment used during testing (Amlani, 1999) (Burco, 2008) Otoscope specula Probe tips Headphones 12% 87% 97% 72% 63% 42% before and after use* During vestibular testing • 0% • 1.41% (1 person) 15% cleaned and disinfected touch and splash surfaces after each patient Less than 1/3 disinfected motivational toys used during testing after each patient 58% reported waiting room toy disinfection was not applicable Can audiologists correctly identify these infection control terms? “Sterilize, disinfect and clean” • 74% reported they could accurately identify infection control terms • Correct responses ranged from 55-93% • More difficulty distinguishing between disinfect and clean (Amlani, 1999) • ¾ correctly identified the term “cleaning” • 76% correctly identified the term “disinfection” • 85% correctly identified “sterilization” • All with definitions provided (Burco, 2008) 8 11/12/2009 Education on infection control (Amlani, 1999) (Burco, 2008) Education on IC? 2/3 have never attended a workshop or shortcourse on IC Should IC education be mandatory? 76% have attended at least one Awareness of infection control has increased ◦ May be due to more clinicians receiving training than before 61% thought it should be required for licensure and/or certification Infection control is being implemented but still not at the level that it should be ◦ More training on audiology-specific procedures? ◦ Reluctance for infection control education to be mandatory? 44% thought it should be mandatory Need to be sterilized (Wavicide or Sporox) ◦ ◦ ◦ ◦ ◦ Ear tips Speculums Earmolds Curettes Some toys http://www.nowihear.com/ Need to be cleaned and disinfected (hospitalgrade) ◦ ◦ ◦ ◦ ◦ ◦ ◦ HA stethoscopes Toys Work surfaces Headphones Bone oscillators Response buttons Tables/chairs/door handles, etc When arriving to work Before and after working with a patient/client When contaminated with bodily fluids or blood After using the lavatory After removing gloves Before leaving work 9 11/12/2009 If hands are visibly soiled, washing is needed (not just a hand sanitizer). Sanitizers should have at least 60% alcohol. Technique is important: cover all surfaces of hands. CDC (2007) A combination of ways to monitor hand washing compliance may be most effective: -direct observations: on frequency and technique. -Self reports -note usage rates of soap/hand sanitizers,etc. Boyce, 2008 Sinks should be added in therapy rooms to promote timely hand washing Designate individuals to monitor and restock infection control items in each therapy room Provide feedback to clinicians on a periodic basis regarding percentage of compliance Involve supervisors in providing feedback to student clinicians Simonson, 2008 “Monitoring hand hygiene compliance and providing healthcare workers with feedback regarding their performance are considered integral parts of a successful hand hygiene promotion program.” Boyce, 2008, p. 2. As noted in the literature review, the therapy setting also needs to be disinfected: Tables Chairs Therapy materials Carefully dispose of: used gloves, tongue depressors, etc. Lubinski, 2007 **Keep cleaning materials out of reach of children **Be aware that some individuals have allergies to cleaning products. Lubinski, 2007 10 11/12/2009 Grube & Nunley, 1995 We should incorporate training on infection control into SLP and Aud university coursework. Feedback could also be provided when rating on clinical competencies. Barriers to follow through with infection prevention programs in SLP and Aud professions: Not taking the risks seriously (trivializing) Ignorance of correct practices Insufficient supplies, equipment and/or space to store them. Lubinski, 2007 Guest speakers were especially helpful Clear and available policies, as in a clinic handbook ◦ Clear policies on staying home when ill Cumulative education was most effective Efforts to develop uniform and efficient ways of monitoring hand hygiene should be explored. ◦ i.e. Electronic methods for monitoring compliance of hand hygiene should be explored. Boyce, 2008 Research on how infection control practices are communicated to student clinicians. How well are the practices enforced? Guthmiller, 2006 11 11/12/2009 Study a program of educating and promoting infection control practices and determine if improved compliance is noted both shortterm and long-term. Wider quantitative survey Qualitative study to determine underlying reasons infection control is/is not carried through. Outcome measures. Does spread of infectious diseases actually decrease through implementation of certain infection control practices? If infection control procedures are added to clinical competencies and rated consistently, would compliance improve? How much of an impact does modeling these procedures (supervisor to clinician have?) American Speech-Language-Hearing Association. (2002). Code of Ethics. Rockville, MD: Author Infection control practices are part of clinical practice Compliance is a problem Practical implications were discussed. American Speech-Language-Hearing Association. (1997). Preferred practice pattern for the profession of Audiology. Rockville, MD: Author. American Speech-Language-Hearing Association. (2004). Preferred practice patterns for the profession of Speech-Language Pathology. Available at http://www.asha.org/ members/deskref-journals/deskref/default Amlani, A. M. (1999). Current trends and future needs for practices in audiologic infection control. Journal of the American Academy of Audiology, 10, 151-159. Ballachanda, B.B., Roeser, R.J., & Kemp, R. J. (1996). Control and prevention of disease transmission in audiology practice. American Journal of Audiology, 5, 74-82. Bankaitis, A.U. (2002). What’s growing on your patients’ hearing aids? A study gives you an idea. The Hearing Journal, 55 (6), pp 48-53. Bankaitis, A.U. & Kemp, R.J. (2005). Infection Control in the Audiology Clinic. Boulder, CO: Auban. Boyce, J.M. (2008). Hand hygiene compliance and monitoring: current perspectives from the USA. Journal of Hospital Infection, 70. p. 2-7. Available from www.elsevierhealth.com/ journals/jhin Burco, A. (2008). Current Infection Control Trends in Audiology. (Unpublished capstone Project). Washington University School of Medicine/Program in Audiology and Communication Sciences. Centers for Disease Control (CDC). (n.d.). Community-Associated MRSA Information for the Public Retrieved November 3, 2009, from http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html#2 Centers for Disease Control and Prevention (2002). Guideline for Hand Hygiene in Health-Care Settings. Morbidity and Mortality Weekly Report , 51, 156. CDC (2007). Guidelines for isolation precautions: Preventing transmission of infectious agents in healthcare settings 2007. Retrieved 11/09/09 from CDC (2006). Infectious diseases in healthcare settings. Retrieved 11/6/09 at http://www.cdc.gov/ncidod/dhqp/id.html Centers for Disease Control (CDC). (n.d.). Vancomycin-resistant Enterococci (VRE)Retrieved November 3, 2009, from http://www.cdc.gov/ncidod/dhqp/ar_vre.html Clark, J.G., Kemp, R. J., & Bankaitis, A.U. (2003). American Academy of Audiology guideline. Audiology Today, 15 (5), 12-19. Cohen, M. & McCollough, T. (1996). Infection Control Protocols for Audiologists. American Journal of Audiology, 5, 20-22. Grube, M, & Nunley, R. (1995). Current Infection control practices in Speech-Language Pathology. American Journal of Speech-Language Pathology, 4, 14-23. Guthmiller, M. (2006). Implementation of infection control procedures by certified Speech-language pathologists and student clinicians. (Unpublished Master’s research project). Minnesota State University Moorhead, Moorhead, MN. http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html 12 11/12/2009 Lubinski, L. (2007). Infection prevention. In R. Lubinski, L.C. Golper, & C. Farrali (Eds.), Professional issues in Speech-Language Pathology and Audiology (pp. 444460). Rutala, W.A. & Weber, D.J. (2008). Guideline for disinfection and sterilization in Healthcare facilities,2008. Retrieved on 10-15-09 from www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf Simonson, A. (2008). Infection control compliance among student clinicians at a university Speech-Language-Hearing clinic. (Unpublished Master’s research project). Minnesota State University Moorhead, Moorhead, MN. Smith, K., Brandell, M.E., Poyner, R.E., & Tatchell, R.H. (1993). Infection control procedures in universities. Asha, 35(6), 59-62. Sturgulewski, S. K., Bankaitis, A.U., Klodd, D.A., & Haberkamp, T. (2006). What’s still growing on your patients’ hearing aids? The Hearing Journal, 59, 9, pp. 45-53. World Health Organization (2006). Blood Safety and Clinical Technology: Guidelines on prevention and control of hospital associated infections. Retrieved July 14, 2006 at http://www.searo.who.int/en/section10/section17/section53/section362_1115.htm 13