Download Physician Infection Control Education Program

*** THIS COMPLETED/PASSING TEST HAS BEEN APPROVED
FOR A MAXIMUM OF 1.5 CATEGORY 1 CREDIT HOURS****
FAIRFIELD MEDICAL CENTER
CONTINUING EDUCATION DEPARTMENT
FROM:
Medical Staff Services
SUBJECT: Infection Control Education Test Packet
Objectives:
After completing this INFECTION CONTROL EDUCATION TEST:



Participants should be able to list 5 opportunities for hand decontamination
Participants should be able to define methods and procedures to prevent
antimicrobial resistance in the healthcare setting.
Participants should be able to describe the procedure for post exposure management
of a blood or body fluid exposure
Comments:
Please find attached the requested INFECTION CONTROL
EDUCATION TEST that is required from Fairfield Medical Center.
Please feel free to call with any questions, 689-4977. Please return the
completed test to the below address:
Fairfield Medical Center
Attn: Pamela Hicks
401 N. Ewing Street
Lancaster, Ohio 43130
Fax ~ 740-689-4477
In order to pass the test you must achieve a minimum score of 80%.
Thank you.
FAIRFIELD MEDICAL CENTER
MEMORANDUM
DATE:
January 1, 2017
TO:
All Medical Staff
FROM:
Andrew Murry, MD, CWS, FACP, IC Medical Director
SUBJECT:
Physician Infection Control Education Program, Credentialing
Based on guidelines published by the Centers for Disease Control and Prevention
(CDC), JCAHO, and the Ohio Department of Health (ODH), completion of the Physician
Infection Control Education Program is required of all physicians on the Medical Staff
for Fairfield Medical Center and can provide 1 CME credit. New medical staff members
must complete the program before privileges will be granted; an active medical staff
member must complete the program every two years as part of the credentialing
process. Upon completion of the program and post-test, Category 1 CME credit will be
awarded. The Physician Infection Control Program includes the following:
1. PPD on initial credentialing for most providers. Those who are
Pulmonary/Critical Care and Thoracic surgeons are required to do this yearly. Fit
testing for N-95 masks can also be arranged on an individual basis by contacting
Respiratory Therapy Department.
2. Read the Physician Infection Control Education Program and take the post-test
this revised test highlights important concepts and changes to policies over the
past two years. Upon completion, the post-test should be submitted to the
medical staff office. Objectives include:
a. Describe the impact of Healthcare Acquired Infections and methods for
prevention.
b. Define methods and procedures to prevent antimicrobial resistance in the
healthcare setting.
c. Describe two methods for hand-hygiene.
d. Delineate modes of transmission of and isolation precautions for the most
common pathogens.
e. Describe the procedure for post exposure management of a blood or body
fluid exposure.
PHYSICIAN INFECTION CONTROL EDUCATION mid 2016 through 2017
Healthcare Associated Infections
Several infections can be classified as healthcare associated. Specifically surgical site infections,
Ventilator associated pneumonias, central catheter infections, Urinary tract infections and Clostridium
difficile colitis.
Surgical Site Infections: For most procedures the time period is 30 days after the surgery but for
implanted devices like hips or knees the period is 90 days. Currently Fairfield Medical Center has an
infection rate for all inpatient and outpatient procedures that is below 0.85%. No good comparisons for
this indicator are currently available that would adjust for types of cases and specific mix of procedures
and patients. We do have information about several common surgeries i.e. hysterectomies, abdominal
surgeries, orthopedic, vascular and cardiovascular procedures that are risk adjusted. This data is
reported to a national database run by the CDC. It is expected this data will eventually be reported in a
hospital compare type website.
Some general methods that might help prevent surgical site infection include:
Pre-operative use of antibacterial soap or chlorhexidiene clothes. We are exploring having all
surgical patients bathe the night before head to toe with chlorhexidiene.
Appropriate antibiotic prophylaxis within 1 hr of skin incision but NOT to continue for great than 24
hours after. The use of prophylactic antibotics post-operatively is not been shown to provide
benefit.
Use of sterile technique for all dressing changes for the first 48 hours after a procedure or if
possible leaving the initial dressing intact for the first 48 hours.
“Tight” Glycemic control.
Maintaining body temperature in patients during and post-op periods.
The use of oxygen post-operatively in patients who have been intubated.
Encouraging patients to stop smoking in the peri-operative period
Colonization with Multi-drug resistant bacteria (MDR) i.e. MRSA or VRE is not necessarily a risk
factor but antibiotic prophylaxis should be adjusted in those cases. The presence of MRSA or
other Multi-drug resistant bacteria (MDR) is NOT a contra-indication to surgery.
Ventilator Associated pneumonia (VAP): This is defined as evidence for a new pneumonia in a patient
who is currently in-tubated or was. The definition of this changed in 2012 and currently we are using a
complex algorithm that is based on desaturations after a period of stability and intubation. This is an
attempt to automate the collection of this data and standardize it across medical centers. Our VAP rate is
well below our benchmarks.
There are specific methods to reduce these from occurring such as decreasing breaks in the ventilator
circuit, sub-glottic suctioning, chlorhexidiene mouth rinse, oral care by the nurses, and maintaining the
head of the bed at > 30 degree as much as possible. Two other items that are part of formal VAP
bundles include the use of DVT prophylaxis and acid suppression. The mechanism of prevention for
these two items is not entirely clear. Compliance rates of 80-90% for every element of the bundle have
been shown to reduce VAP occurrence essentially to zero.
Central-line Infections (CLI): This is a blood stream infection as a result of a central line including PICC
lines. The rate of CLI at FMC has decreased dramatically over the last five years as we implemented our
line bundle (see below) and line rounds by the Vascular Access Team. The use of antibiotic impregnated
lines in our center did NOT decrease the rate of line infections-it actually increased while they were used
and then decreased to our current low levels once we stopped the trial. Removing the lines as soon as
possible and limiting their use to necessary patients will also help reduce the rate. PICC lines are
counted when they become infected as a central line event. Their rates of infection appear to be similar
to the rate for other central lines especially when TPN and other non-antibiotic infusions are being used.
The risk for upper extremity deep venous thrombosis is higher with these lines. PICC lines should be
avoided in patients who have Stage III or more kidney disease (i.e. estimated GRF is less than 59) due
the increase risk for sub-clavian stenosis.
New policies where adopted in June 2005 to reduce the risk of infection from central lines using evidence
based, standard of care protocols. Key points of this policy relating to physicians include:
1. Maximal barrier precautions must be used (sterile gown, sterile gloves, mask, cap, full body
drape)
2. Pagers or cell phone handed off to an assistant
3. Hands must be washed prior to gloving
4. Chlorhexidiene preps should be used to clean the insertion site
5. Minimize the number of needle sticks
6. Documentation of compliance with these recommendations is collected by the nurse assisting
7. Infection rates will be reported to physicians monthly when an infection has been detected
8. Femoral lines should be avoided unless absolutely needed and the reason for their use clearly
documented due to the substantially higher infection rates.
9. Lines inserted as part of a code should be changed out for new lines within 48 hours
10. The internal jugular site is preferred over sub-clavian for central access.
11. Avoid the insertion of PICC lines when a patient is bacteremic, especially with gram-positive
bacteria. If the line cannot be avoided change the line out after cultures are confirmed negative
for at least 48 hours. Once blood cultures are negative for at least 48 hours a PICC line can be
safely inserted.
Urinary Tract Infections: These infections are generally due to the presence of an indwelling foley
catheter at some point during the hospital stay. We look for changes on the U/A, culture reports, WBC,
temperatures, evidence of treatment and mention in a physician note for patients with catheters and up to
72 hours after removal. A culture and urinanalysis is important to help tell infection from colonization.
Therapy can be initiated empirically but should be adjusted based on the culture results. Removal of the
catheter is generally important to resolve the infection. More attention to removing unneeded catheters
as soon as possible or avoiding their insertion would go along way to prevent hospital acquired infections
of the urinary tract. On day five of foley catheterization, the risk of infection is 50%. Our rate for the last
two years has been steady at around 8 per year. Our goal is none. These are obviously bad for patients
and the hospital through value based purchasing receives decreased re-imbursement based on the
number of these events. When one does occur it is fully investigated to determine anything that could
have been done differently to prevent that occurrence.
We are exploring the following enhancements during 2016:
All orders to insert or maintain a foley will also trigger a nurse driven protocol to remove the foley
if specific parameters are met and there are no contra-indications. These protocols are standard
of care at most hospitial now.
Two person insertions to provide the extra-pair of hands to cleanly insert catheters.
Better evaluation of all patients who present with foleys to determine if they are still needed and
could be removed on admission.
The indication of “strict monitoring of inputs and outputs” should not be used for extended periods
once a patient is stabilized. Monitoring of this type can occur without a urinary catheter in most
patients.
Clostridium difficile colitis: This infection is generally attributed to hospital or extended care facility
exposure and use of antibiotics. The rates at FMC are stable over the last 10 years.
The risk of this infection is one of the primary risks and reasons not to use antibiotics without good
justification. The standard therapy has been metronidazole by mouth but it can be used intravenously as
well. Oral vancomycin is good for relapses, and may now be best for first line therapy. These patients
have one or more of these factors: age over 60 years, WBC over 18,000, changes on abdominal films of
megacolon or dilated bowel. Use of combination antibiotics, yogurt, kefir, and surgical removal of the
colon may all be required. The use of cholystyramine with oral vancomycin, which is 100% intraluminal
agent, does not seem prudent as the cholystyramine binds this agent and greatly reduces its effective
levels in the intestinal track. Isolation of these patients is required and the use of handwashing is the
acceptable method of hand hygiene since the C. dif spores are not killed by alcohol based hand
preparations (i.e. Purell). Repeat testing at the end of treatment often does not show clearance and the
significance of these results is not reliable so should not be done. Patients are generally left in isolation
for the remainder of the hospital stay or treatment which ever is longer. Fecal transplantation is a method
for treating refractory C dif infections involving the donation of stool from a non-infected person to the
patient with the infection via post pyloric gastic tube or colonic edemas and may be available at FMC by
mid-2016.
HAND HYGIENE
In October 2002, the CDC released the new recommendations for hand hygiene (Boyce JM, Didier P, et
al. Guideline for Hand Hygiene in Health-Care Settings. MMWR 2002;51:1-45). The guideline provides
health-care workers (HCWs) with a review of data regarding hand washing and hand antisepsis in
healthcare settings. In addition, it provides specific recommendations to promote improved hand hygiene
practices and reduce transmission of pathogenic microorganisms to patients and personnel. Key
recommendations are:
Indications for hand washing and hand antisepsis:
A. Decontaminate hands before having direct contact with patients including before donning
gloves and entering a patient’s room,
B. Decontaminate hands before donning sterile gloves when inserting a CVC.
C. Decontaminated hands before inserting indwelling urinary catheters, peripheral vascular
catheters, or other invasive devices that do not require a surgical procedure.
D. Decontaminate hands after contact with a patient’s intact skin.
E. Decontaminate hands after contact with body fluids, or excretions, mucous membranes,
nonintact skin, and wound dressings.
F. Decontaminate if moving from a contaminated-body site to a clean-body site during
patient care.
G. Decontaminate hands after contact with inanimate objects (including medical equipment)
in the immediate vicinity of the patient.
H. Decontaminate hands after removing gloves.
Alcohol-based hand rubs are the most efficacious agents for reducing the number of bacteria on the
hands of HCWs. Alcohol based hand rubs are recommended for routine decontamination of hands for all
clinical indications (except when hands are visibly soiled). Alcohol based hand rubs have been shown to
improve hand hygiene compliance because it is readily available, takes less time, and is less drying than
soap and water.
Purell alcohol-based gel dispensers are located at all patient bedsides, at other convenient locations
throughout the Center and in 2 oz. Pocket-sized dispensers. The manufacturer recommends applying a
thumbnail amount of product to the palm of the one hand and rub hands vigorously together, covering all
surfaces of hands and fingers, until dry.
Soap and water are recommended when the hands are visibly soiled, before eating, after using a
restroom and with patients who have C. dif colitis. When washing hands with soap and water, wet hands
first with water, apply a small amount of product to hands and rub hands together vigorously for at least
15 seconds, be sure to cover all surfaces of the hands and fingers. Rinse hands with water and dry
thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because
repeated exposure to hot water may increase the risk of dermatitis.
Artificial nails or extenders should not be worn by anyone when having direct contact with patients.
Artificial nails have been shown to harbor high concentrations of bacteria, most frequently coagulasenegative staphylococci, gram-negative rods (including Pseudomonas spp.), Cornynebacteria, and yeasts.
ISOLATION PROCEDURES
The use of Standard (previously called Universal) Precautions does not eliminate the need for other
isolation procedures when a patient is known to have certain communicable diseases. Standard
Precautions are utilized to reduce the risk of transmission of any pathogenic microorganisms from
unrecognized sources within the hospital. Standard Precautions (previously called Universal Precautions)
apply to blood and all body fluids, secretions and excretions, including feces, vomitus, urine, tears and
saliva, whether or not visible blood is present. FMC utilizes Standard Precautions for the management of
all patients.
Standard Precautions include:
Thorough hand hygiene before and after patient contact. Providers are encouraged to let the family and
patient see them do this as much as possible.
Gloves if in contact with blood, body fluids or non-intact skin
Gown if contamination of skin and/or clothing with blood or body fluids is anticipated.
Mask and goggles, or face shield, if splashing or spraying of blood or body fluids is anticipated
Sharps must be handled with extreme caution and discarded in sharps containers
A. The diseases which require a patient to be placed into isolation are those infectious conditions
which may be spread by contact with the patient or the patient’s environment, or those spread by
airborne or droplet transmission.
1. Isolation categories (see Table 2)
a) Contact Precautions (includes all patients being treated with confirmed Clostridium difficile)
b) Contact plus Mask (when MRSA, VRE, Stenotrophomonas, or RSV are in sputum)
c) Droplet Precautions
d) Airborne Precautions
e) Airborne plus (for H1N1 Pandemic Flu, MERS-CoV)
f) Presumptive Contact precautions
B. Isolation categories are derived by grouping diseases for which similar isolation precautions are
indicated. These groupings are based upon scientific data concerning pathogenesis and
transmission of these infectious diseases.
C. In addition to specified isolation procedures, all aspects of Standard/Universal Precautions are to be
incorporated into the care of patients who are isolated.
D. Other pathogens that are not listed may require isolation in a potential outbreak situation.
Direction will come from the Infection Control Department.
Table Precaution Types
Precaution
Common clinical
Room
type
syndromes
Assignment
Mask
Gown
Gloves
Patient Transport /
Discontinuing Isolation
Contact
________
Contact plus
Mask
__________
Presumptive
MRSA, VISA,
Private room or
VRE,
cohort with
Aminoglycoside
patient with
Yes, if
resistant Gram
same infection.
pathogen is
attempted if on antibiotics (that
negatives, lice,
Dedicated
in sputum.
treat that infection).
scabies, impetigo
equipment in
See specifics below for D/C of
______________
the room.
isolation.*
Possible MRSA
No
Yes– any
Yes
Minimize transport as feasible.
entry into the
Clearing the patient from MRSA
room
or VRE isolation should NOT be
No
Boils, “spider
bites”
unconfirmed
MRSA history
_________________________
__________
________
Wash hands with soap and
C. dif colitis
C. difficile
water not alcohol based
No
cleaners
Droplet
Mumps, rubella,
Private room; or
Yes, when
Neisseria
cohort with
meningitidis
Influenza
No
When
Minimize transport of patient.
working
handling
Mask patient when transport is
patient with
within three
respiratory
necessary.**
same infection.
feet of
secretions
does not require
patient
negative air flow
Airborne
Measles,
Private room
Yes –N95
When
Minimize transport of patient.
pulmonary
with negative
Respirator
No
handling
Mask patient when transport is
tuberculosis
airflow. Keep
Mask
respiratory
necessary.***
door closed.
Airborne PLUS
Contact
secretions
Chicken pox, and
Private room
Yes – N95
Yes
Yes
Minimize transport of patient.
disseminated
with negative
Respirator
Mask patient when transport is
herpes zoster in
airflow. Keep
Mask
necessary. Continue for
immunocomprom
door closed.
duration of illness.
ised hosts,
MERS CoV,
smallpox, SARS,
Avian influenza,
H1N1 influenza
*MRSA-two negative anterior nares screens plus original site (if present), obtained 24 hours apart off active antibiotics for
at least 48 hours.
We are now recommending not to do these screening tests but will clear
patients if they have not had any other cultures positive for MRSA for 3 years.
VRE- 3 negative peri-rectal screens plus one from original site (if present or inguinal or axilla or umbilical areas), screens should
be obtained at least 7 days apart off active antibiotics at least 48 hours
C. difficile patient can generally stay in isolation for the duration of treatment or the duration of the hospital stay whichever is
longer. Negative stool studies are NOT required. Hand hygiene should be with soap and water not alcohol based preps.
**Isolation for N.meningitidis may be discontinued after 24 hours of appropriate antibiotic therapy. Isolation for influenza
can be discontinued when therapy with appropriate antiviral is completed.
*** Isolation must be continued for Mtb until there are 3 negative AFB smears.
Other multi-drug resistant bacteria St Mal generally can be cleared if a repeat culture is negative off active therapy.
CRE and ESBL clearance is generally not possible best to contact Infection Control for a case-by-case evaluaton.
II.
Purpose
A. Isolation techniques provide a simple, workable framework of policies and procedures for:
1. The care of patients with communicable diseases
2. The care of patients with antibiotic resistant microorganisms.
B. Utilization of established procedures will maintain the patient’s dignity by isolating the pathogen
and not the patient.
III.
Physician’s Order
Physicians should include orders for isolation to highlight the need and indicate the type of
isolation and pathogen. A nurse may initiate the appropriate isolation precautions. An order
should be entered into CPOE. This information often helps to track the number of isolated
patients, is added to hand-off reports and notifies infection control of the isolated patient.
A new i-form to assist with clearance was created. Any doctor can start the clearance process
but for MRSA it can be easier and best to use the new “3 year rule” to clear patients. The isolation
status of the patient at discharge can also be documented on the Discharge Instruction/COC iform and where in the clearance process the patient is. Infection Control can also be consulted to
assist and to follow up after discharge to keep the process on track.
IV.
ISOLATION SIGNS
Place the appropriate isolation sign for the isolation category on the patient's door. Do not write
the patient's diagnosis or reason for isolation on the isolation sign or on the patient's door.
V.
Contact Precautions
Contact Precautions are designed to prevent the spread of certain highly transmissible
epidemiologically important organisms. See Table for the list of Infectious Disease Precautions.
These organisms are spread primarily by close or direct contact with body sites that are positive for
the organisms, environmental surfaces, or inanimate objects that have become contaminated.
Patients with growth of antimicrobial resistant organisms in the urine require isolation, despite the
presence of an indwelling catheter. Regardless of the site, patients with growth of antimicrobial
resistant organisms are colonized over their entire body with that organism.
A. Specifications for CONTACT, CONTACT plus MASK and CONTACT-PRESUMPTIVE
PRECAUTIONS:
1. Private room is required. If necessary, patients with same organism may share a room (cohort).
2. Gloves are to be worn when entering the room.
3. Gowns are required when entering the room.
4. The door to the room can remain open.
5. Hands must be washed thoroughly before leaving room if the organism is C. difficile soap and
water should be used.
6. Patient care items should remain in the room. If any item must be removed, it must be
disinfected or bagged.
7. If the patients organism is in the sputum or respiratory secretions a mask must be worn to enter
the room (Contact plus Mask Precautions-purple sign)
8. Presumptive precautions should only be used for a patient with an abscess that developed
quickly and for whom Community Acquired MRSA (CA-MRSA) is being considered. A culture
must be done to qualify for this type of isolation if there is nothing to culture i.e. cellulitis only then
the patient should not be isolated unless there is a known history indicating a need for isolation.
For presumptive precautions Infection Control will be alerted so that evaluation can occur quickly
and it can be determined if isolation should continue or be stopped. Note: microbiology will
often report preliminary data that an organism is MRSA. This will end up being MRSA 99% of the
time. These patients should be placed in CONTACT or CONTACT plus MASK precautions not
Presumptive.
B. Discontinuation of Precautions for MRSA
Isolation may be discontinued with approval from the FMC Infection Control Department when
patient is off antibiotics for at least 48 hours that are effective against Staphylococcus aureus AND
after obtaining:
1. One negative cultures from each previously positive site, AND
2. Two negative anterior nares screens for MRSA, obtained 24 hours apart (send for MRSA
screen).
A culture and screen may be obtained on the same day. Referral to MRSA clinic for clearance
after discharge is available by calling 740-687-8805 ext 2.
If the original site is difficult to culture (e.g., central nervous system or biopsy specimen) and the
patient is no longer symptomatic from an infection at that site, 2 negative anterior nares screens
should be sufficient. If the patient was bacteremic with MRSA, a repeat negative blood culture and
2 negative anterior nares screens are necessary. If the original site is no longer present (e.g.
amputation, healed wound), 2 negative anterior nares screens should be obtained.
There is an additional way that patients can be cleared for MRSA. If the patient has not had any
other cultures positive for MRSA for 3 years infection control can use the “3 year rule” to clear the
person. Screening swabs are not required in this case.
C. Contact Precautions Considerations for VRE
1. The microbiologist will promptly notify appropriate center staff when VRE is detected. This
will include patient’s primary physician, nursing unit and Infection Control Coordinator.
2. Gloves and gown are required whenever entering the room of a VRE infected or colonized
patient.
3. The door to the patient’s room may be kept open.
4. Information sheets are available for the patient and/or family and the patient and/or family.
Isolation may be discontinued with approval from the FMC Infection Control Department when
patient is off antibiotics that are effective against Enterococcus sp. for at least 48 hours AND after
obtaining:
1. One negative culture from each previously positive site AND
2. Three negative peri-rectal screens in a row for VRE, obtained 7 days apart (send VRE
Screen).
3. One culture and one screen can be obtained on the same day, i.e., a total of 3 samples (screens
and cultures) on three separate weeks.
The patient is more likely to have negative culture results after approximately 30 days post
antibiotics. It may be more cost effective to obtain the cultures in the outpatient setting. Proof of
clearance must be furnished to Infection Control before isolation can be discontinued. The
facesheet is flagged with a Y. All patients with a Y on their facesheet must be admitted to
appropriate isolation until cleared by Infection Control. There is an isolation screen in the AS400
computer a floor clerk can print this for a physician it outlines the reason the patient’s chart is
flagged, what cultures were positive and when, what attempts have been made to clear the
patient.
If the original site is difficult to culture (e.g., central nervous system or biopsy specimen) or the
original site is no longer present (e.g. amputation, healed wound), another body site (axilla, umbilical,
or inguinal area) may be cultured in lieu of the original site. Peri-rectal screens are to be paired with
these other body sites.
If the original site is blood, a single repeat blood culture is sufficient to document clearance of the
blood stream infection.
II.
Droplet Precautions
Droplet Precautions are designed to prevent transmission of infectious diseases spread over short
distances through the air (droplet transmission). See Table for the list of Infectious Disease
Precautions. Direct and indirect contact transmission occurs with some infections in this isolation
category but is rare.
Specifications for DROPLET PRECAUTIONS
1. Private room is required, patients may be cohorted
2. Masks are required for everyone working within three feet of the patient. Mask is to be worn by
patient when leaving room.
3. Hands must be washed before entering and leaving room.
III.
AIRBORNE PRECAUTIONS
Airborne Precautions are designed for all inpatients with known or suspected pulmonary or laryngeal
tuberculosis. Airborne Precautions are also used in conjunction with Contact Precautions for
patients with primary chicken pox or disseminated herpes zoster in immunocompromised hosts,
smallpox or SARS. Airborne Precautions prevent contact of others with aerosolized particles
containing Mycobacterium tuberculosis, measles virus, or chicken pox virus. See Table for a more
complete list of Infectious Disease Precautions.
Specifications for AIRBORNE PRECAUTIONS:
1. Private room with negative airflow is required. These rooms are located on 3rd Floor (rooms 322
and 324), ED (rooms 1, 2 and 3), Intensive Care (room 6), and PCU (room 345). The door must
remain closed.
2. An N95 (dust-mist) respirator must be worn when entering the room. The respirator must be
checked for proper fit and tight facial seal. Respiratory Therapy should be consulted to fit test.
3. Remove respirator when leaving the room.
4. Patient must wear a surgical mask when leaving the room.
5. Hands must be washed on entering and leaving room.
IV.
Protective Precautions is NOT generally used except for bone marrow transplant units. We do
not recommend using these precautions and are working to discontinue their inclusion on the
iforms.
V.
Visitors
Nursing staff should instruct visitors on the appropriate use of gown, mask, gloves, hand washing
or other special precautions. Visitors must comply with all isolation precautions in order to be
able to visit patient. Those that do not will be asked to leave.
VI.
TRANSPORTING ISOLATED PATIENTS
Patients on isolation precautions should leave their room only for essential purposes. Nursing
personnel should insure that the patient uses appropriate barriers (mask, impervious dressing, etc.)
to prevent transmission of the microorganism. The front of the patient's chart should be labeled
"isolation".
Personnel in the area to which the patient is to be transported should be notified by nursing
service of the impending arrival of the patient and of the precautions to be used to prevent
transmission of infection. Patients should be knowledgeable regarding the potential spread of
their disease and informed as to how they can assist in preventing transmission of their infection
to others. Areas where isolation patients are sent should be cleaned appropriately after the
isolation patient has left that area.
MULTIDRUG RESISTANT BACTERIA:
MRSA: The most common source of MRSA infections are now in the community. The hospital
nosocomial infection rate for 2012 was 0.02% or 7 transmissions per 32853 patient days. Over 70% of
Staphylococcus aureus isolates are now methicillin resistant. The community-acquired types often have
several oral antibiotics that show susceptibility. In general, the quinolones (ciprofloxacin, moxifloxacin and
levofloxacin) should not be used to treat MRSA even when the report indicates activity as the isolates can
develop resistance during treatment. Information on Vancomycin MICs shows increasing trends and
recommendations in 2009 for Vancomycin IV dosing were changed to reflect this by increasing the target
trough levels to 15-20. Most otherwise healthy younger patients will need more than the standard 1 gram
very 12 hours to have levels in the target zone. It is not recommended to do peak levels. Oral
vancomycin is never appropriate for treatment of anything but C.dif colitis due to its lack of systemic
absorption. Other agents are also available including Daptomycin (Cubicin). This drug is dosed
intravenously, daily based on patient weight and generally indicated for skin and complicated soft tissue
infections. It is not indicated for pneumonias due to that fact that pulmonary surfactants inactivate the
drug. Linezolid (Zyvox) has been show to be at least as effective as Vancomycin for the treatment of
Staphylococcal pneumonia. It is attractive due to the excellent bioavailability of the oral formulation for
treating out patients. Their biggest problem is the extraordinary cost (one tablet is approximately $60).
VRE: We have rare nosocomial transmission of VRE. Stenotrophomonas continues to be seen only
sporadically.
OTHERS: The presence of bacteria with Extended spectrum beta-lactamase (ESBL) is relatively
increasing at our facility but the microbiology department can detect them and will note their presence on
the susceptibility report. We do isolate persons with these organisms. So called Klebsiella Pneumoniae
Carbapenemases (KCP) resistance has not been seen at our facility, but is widespread and renders the
organisms basically untreatable. Organisms that are resistant to carbapenums (imipenum, ertapenum)
have been increasingly seen. These are designated as carbapenum resistant or CRE. It is possible that
patients infected with these bacteria would have no antibiotic therapy available. Their presence in a
medical facility is a very serious event and we have a specific plan in place in the event that one is
isolated in a clinical specimen at Fairfield Medical Center. In general isolation is a step up with private
room, limitations on visitors, designated staff to care for patient and increase surveillance for additional
cases. These are referred to as ENHANCED precautions.
BLOODBORNE PATHOGENS (BBP) and the OSHA BBP STANDARD
The Bloodborne Pathogen Standard is a federal regulation of OSHA intended to limit occupational
exposure to blood and other potentially infectious materials since any exposure could result in
transmission of BBP, which could lead to disease or death. Exposure to a BBP is considered a medical
emergency. Treatment must be started within 2 hours for HIV prophylaxis.
Employees or physicians experiencing a BBP exposure should notify Employee Health or the Nursing
Supervisor immediately. The employee/physician should follow the Post Exposure Management Plan.
Definitions and Occupational Exposure Criteria
A. Defined as a contact by a Fairfield Medical Center employee, physician, contractor, volunteer
or student during the performance of duties that may place the individual at risk of a BBP
infection. This includes exposure to source blood, tissues or other body fluids to which
standard precautions apply (e.g. semen, vaginal secretions, cerebrospinal fluid, synovial fluid,
pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, and laboratory specimens that
contain BBP).
B. Occupational exposure may be the result of:
1. Percutaneous injury (e.g. needle stick or cut with sharp object).
2. Contact of mucous membranes.
3. Contact of non-intact skin (e.g. when skin is chapped, abraded or afflicted with
dermatitis).
4. Contact with intact skin when the duration of contact is prolonged (i.e. several minutes or
more) or involves an extensive area, with blood, tissue and other body fluids.
a. Body fluids: Semen, vaginal secretions or other body fluids contaminated with visible
blood that have been implicated in the transmission of HIV infection, HBV and
possibly HCV.
b. Cerebrospinal, synovial, pleural, peritoneal, pericardial and amniotic fluids are also
potentially infectious.
c. Any direct contact (i.e. without barrier protection) to concentrate HIV in a research
lab.
d. In the absence of visible blood in saliva, exposure to saliva from a person infected
with HIV is not considered a risk to HIV.
e. Exposure to tears, sweat or non-bloody urine or feces does not require post exposure
follow-up.
Human Immunodeficiency Virus (HIV)

HIV, the agent of AIDS, is transmitted through contact with blood and other potentially infectious
materials.

Standard precautions are to be applied.

The average risk of HIV infection following all types of percutaneous exposure to HIV-infected
blood is about 0.3%. Risk increases significantly if: the needle-stick injury is deep; there is visible
blood on the device; the device was previously in a vessel; the source patient dies within 2
months of the HCW exposure (usually due to late stage disease and a high viral load).

The CDC has documented <100 cases of HIV seroconversion in HCW due to job-related
exposures. Acute infection may occur 3-6 weeks after exposure and is characterized by flu-like
symptoms.

Post exposure prophylaxis (PEP) decreases the risk of seroconversion in the HCW. It should be
initiated within 2 hours of exposure.
To facilitate this the first dose of triple drug therapy
will be offered immediately to persons with significant exposures while the source
patient status for HIV is being determined. Treatment is in Employee Health during
regular weekday hours and in the Emergency Department after hours.
Viral Hepatitis

Signs and symptoms of hepatitis include fatigue, joint and muscle pain, fever, loss of appetite,
nausea and vomiting, diarrhea or constipation and the liver may become enlarged or tender.

Hepatitis B and C are bloodborne, transmitted by percutaneous and mucosal exposures.
Hepatitis B virus (HBV)

Hepatitis B vaccination is the most effective way to prevent Hepatitis B. The vaccine is provided
at no charge to employees and medical staff through Employee Health Services.

Employees who have not been successfully vaccinated against HBV and who are exposed to the
HBV must be evaluated and treated with Hep B immune globulin and or Hep B vaccine.
Treatment must be given within seven days of exposure.
Hepatitis C virus (HCV)

An estimated 4 million Americans are currently infected with HCV. Between 8-10 thousand
deaths occur annually due to HCV-related chronic liver disease.

HCW are at an increased risk for HCV due to potential occupational exposure.

Percutaneous transmission rate is 3-10%.

The CDC does not currently recommend post-exposure prophylaxis for HCV exposure.
Administration of immune globulin after HCV exposure is unlikely to prevent infection, as no
neutralizing antibody to HCV is found.

New evidence suggests that treatment of acute occupational HCV conversion as demonstrated
by a positive PCR test (the Antibody test can be negative still at this point) is very successful in
clearing the virus and preventing chronic infection from being established.
2016-17 Physician Infection Control Education Post-Test
Name (print) _________________________________
Signature __________________________________
Date __________________
Please return a copy of this test to me ___yes ___no
Successful completion of this test is 80% (16 or more correct answers) and qualifies for 1 Category 1 CME.
Circle correct answer.
1.
T
F
The number of cases of catheter acquired urinary tract infections is dramatically higher at
FMC over the last 2 years.
2.
T
F
Elevation of the head of the bed greater than or equal to 30 degrees can help reduce the
rates of ventilator-associated pneumonia.
3.
T
F
Infection rates for PICC lines are significantly lower than for other types of central lines.
4.
T
F
Increasing duration of urinary tract catheterization does not correlate with increasing risk of
infection.
5.
T
F
Hands should be washed or sanitized only when exiting a patient room.
6.
T
F
Even if gloves are worn hands should always be washed or sanitized when exiting a patient
room.
7.
T
F A patient is admitted to the hospital through the emergency room with cellulitis. There is
nothing to culture. Presumptive pre-cautions are appropriate.
8.
T
F
Hand washing or hand gel do not need to be used to enter a contact isolation room because
gloves will be used
9.
T
F
Persons entering a room with CONTACT PRECAUTIONS who are not going to touch the
patient or items in the room do have to wear gown or gloves.
10.
T
F
Any nurse or doctor can isolate a patient and any doctors can also clear a patient.
11.
T
F
VRE urinary tract infection does not require isolation if the patient has an indwelling urinary
catheter in place.
12.
T
F
PICC lines can be inserted without any concerns in patients with any amount of renal
function.
13.
T
F
Daptomycin should be avoided for treatment of Staphylococcal pneumonia.
14.
T
F
The N-95 respirator is used in AIRBORNE PRECAUTIONS and the door must remain closed.
15.
T
F
Maximal barrier precautions are the standard of care for the insertion of all central lines.
16.
T
F
Best practice for percutaneous exposure to blood or body fluid for HIV prophylaxis is to
administer meds within 24 hours.
17.
T
F
A patient has a history of a wound with MRSA in 2012. There are no other cultures that grew
MRSA since then but no nasal swabs have been done. The patient can be cleared by Infection
Control under the “3 year rule.”
18.
T
F
First dose of HIV chemoprophylaxis for significant exposure should be given before results
from source patient are known.
19.
T
F
Treatment for acute occupational infection with HCV has not been shown to be effective.
20.
T
F Central lines placed in a code situation should be changed out for a new line within 48 hours.