Download Infection Control

11/12/2009
ASHA 2009
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Infection control:
Brief overview of infectious diseases
Review of literature
Practical implications for implementing and
monitoring infection control
Standard precautions
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Standard precautions (“universal precautions”)
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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
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Barrier techniques
Gloves, gowns, shoe covers, caps and masks
(CDC, 2002;WHO,2006)
CDC, 2007
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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,
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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
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PROTOCOLS in place
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FOLLOW THROUGH with protocols
Do they match your needs?
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Types of infectious diseases prevalent in
clinical settings-Virus
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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
)
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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
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Rare form of yeast
Unidentified yeast
Gram positive cocci
Aspergillus Flavus
Candida parapsilosis
Unspecified mold
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Staphyloccous (coag neg)
Kebsiella pneumoniae
Pseudomonas aeruginosa
Gram positive rods
Staphylococcus aureus
Diphtheroids
Gram positive cocci
Lactobacilli
Enterobacter cloacae
Enterococci
Bacillus species
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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
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 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)
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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.
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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
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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)
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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
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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
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One clinic meeting lecture
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Infection control supplies
present in rooms
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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
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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?
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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?
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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
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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%
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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)
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Education on infection control
(Amlani, 1999) (Burco, 2008)
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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
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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
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Need to be sterilized (Wavicide or Sporox)
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Ear tips
Speculums
Earmolds
Curettes
Some toys
http://www.nowihear.com/
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Need to be cleaned and disinfected (hospitalgrade)
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HA stethoscopes
Toys
Work surfaces
Headphones
Bone oscillators
Response buttons
Tables/chairs/door handles, etc
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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
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If hands are visibly soiled, washing is needed
(not just a hand sanitizer).
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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
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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
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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.
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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
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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
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Research on how infection control practices
are communicated to student clinicians.
How well are the practices enforced?
Guthmiller, 2006
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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.
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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
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Infection control practices are part of clinical
practice
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Compliance is a problem
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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
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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.
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on prevention and control of hospital associated infections. Retrieved July 14, 2006 at
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