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Infection Control
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Amber Miller
Issam Dabe
Phyllis Fusco
Sandra Perkins
Sarah Brockett
Infection Control
I.
Overview
Nosocomial Infection is an infection that occurs in a hospital and of hospital-like setting and
those occurring within 48 hours of hospital admission, 3 days of discharge or 30 days of an
operation. Approximately 10% of American hospital patients contract this infection. (Rello,
2007)
In 1976, the Joint Commission on Accreditation of Healthcare Organizations published
accreditation standards for infection control creating the impetus and need for hospitals to
provide administrative and financial support for infection control programs. In 1985, the Centers
for Disease Control and Prevention’s (CDC’s) Study on the Efficacy of Nosocomial Infection
Control reported that hospitals with four key infection control components—an effective hospital
epidemiologist, one infection control practitioner for every 250 beds, active surveillance
mechanisms, and ongoing control efforts—reduced nosocomial infection rates by approximately
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one third (Haley 1985). According to the Centers for Disease Control and Prevention (CDC),
there were an estimated 1.7 million healthcare-associated infections and 99,000 deaths from
those infections in 2002. (Klevens, 2007) A recent CDC report estimated the annual medical
costs of healthcare-associated infections in U.S. hospitals to be between $28 and $45 billion,
adjusted to 2007 dollars.( Scott RD,2009)
There are three factors as to why nosocomial infection exists:. A high prevalence of pathogens, a
high prevalence of compromised hosts and the efficient mechanism of transmission from patient
to patient. These three factors alone lead not just to a higher chance of transmission of pathogens
within hospitals, but potentially to an evolution of enhanced disease which causes potential
among microorganisms present within the hospitals. Nosocomial infections were analyzed by
infection site and pathogen distribution. Urinary tract infections were most frequent (31%),
followed by pneumonia (27%) and primary bloodstream infections (19%). Eighty-seven percent
of primary bloodstream infections were associated with central lines, 86% of nosocomial
pneumonia was associated with mechanical ventilation, and 95% of urinary tract infections were
associated with urinary catheters.(Richard, 1999)
The organisms causing most nosocomial infections usually come from the patient or from
contact directly or indirectly with staff, contaminated instruments and needles. Because hospital
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stays are becoming shorter, patients often are discharged before the infection becomes apparent.
Actually, a large number of nosocomial infections in hospital patients and most of ICU become
apparent only after the patients are discharged. As a result, it is often difficult to determine
whether the source of the infection is exogenous or endogenous. Therefore Infection control is
required to prevent the transmission of communicable diseases in all health care settings.
Infection prevention and control requires a basic understanding of the epidemiology of diseases;
risk factors that increase infections susceptibility; and the main sources of infections such as
practices, procedures and antimicrobial resistance. (Rello, 2007)
II.
Epidemiology of Nosocomial Infections
A nosocomial infection is an infection that a patient acquires when admitted in the
hospital or some other healthcare facility. It is defined as an infection that occurs within 48 hours
of admission, 3 days of discharge, or 30 days of an operation (Inweregbu, 2014). They can affect
the pulmonary system, the urinary tract, the bloodstream, as well as other parts of the body.
Because they are acquired in the hospital, these infections can be difficult to treat with antibiotics
because many of these infections mutate into medicine resistant strains. Every year 100 million
hospital procedures are done, putting just as many people at risk for developing a nosocomial
infection (EHA, 2014). They affect 1 in 10 people and lead to 5000 deaths every year
(Inweregbu, 2014). For this reason, the overturn of inpatient hospital patients is as quick as
possible.
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Nosocomial infections, like most infections, are opportunistic, meaning they attack
people who are more vulnerable. Those most at risk are the very young, the very old, and people
with compromised immune system such as those taking immunosuprressants or those with auto
immune diseases (EHA, 2014). In all these patients, the immune system cannot fight off
infections effectively, making them very susceptible to hospital acquired diseases. These
infections are classified in several ways. First, by site of infection, or part of the body affected.
Because of the use of catheters, urinary tract infections are very common, which can lead to
kidney problems. Respiratory infections occur due to lack of movement or the inability to expel
fluids from the lungs, often leading to pneumonia, which itself can be classified by type. Another
common site for infection is the open wound from surgery, which inadvertently may lead to
bloodstream infections. The second classification is the type of infection, whether it is bacterial
or fungal or if it is resistant to antibiotics.
Although there are dozens of infections that are possible to contract while in a healthcare facility,
certain ones are more prevalent and lead to more problems than others. More often than not, the
infection that occurs is a type of pneumonia. It accounts for 15-20% of all hospital acquired
infections, making it the second most commonly contracted illness while admitted in a hospital
(Mandell, 2004). Patients are confined to hospital beds and have very little movement, if any.
This leads to a buildup of fluid in the lungs, which is necessary to expel. However, if the person
is an inpatient, coughing may be difficult or even impossible in the case of ICU patients, leaving
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the fluid and leading to an infection of the respiratory system. The other very common infection
is MRSA. This is an antibiotic resistant form of the staphylococcus pathogen. This infection does
not become symptomatic unless it comes in contact with an open wound, so doctors may be
carriers and not even know it. Once in an open wound, this can spread through the blood stream
and lead to severe illnesses or even death. While there are many more infections, both
pneumonia and MRSA are prevalent across the healthcare world, leading to increased infections
and illnesses in patients.
While hospital acquired pneumonia is very serious, it is a hard infection to prevent due to its
most common causes. MRSA or other staphylococcus infections are a very different story. Even
though 1 in every 10 patients will get a nosocomial infection, 1/3 of these are preventable
(Inweregbu, 2014). Doctors, nurses, and everyone in between see dozens of patients a day, one
after the other. Though these people wear gloves, which are changed for every single patient, the
bacteria may be present on the skin. Hand washing is so crucial to sanitary and healthy
conditions for this reason. If proper hand washing is not executed before and after each and
every patient, the acting provider may transfer staphylococcus from one patient to another
(Inweregbu, 2014). This may not be an issue, but if it comes in contact with an open lesion, it
becomes a serious infection. Not only are patients susceptible to this bacteria, but family
members of carrying patients. The health of patients and all surrounding people depends on
proper hand care.
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III.
Infection Transmission
Nosocomial infections are transmitted directly or indirectly or via droplet spread.
The first way in which these infections can be transmitted via direct contact would be from direct
physical contact of touching, most commonly through the hands, which come into contact with
an infected area.
The second method of transmission is indirect contact. The physical presence of
the infected host doesn’t have to present for an infection to spread. The bedding, clothing, toys,
handkerchiefs, and surgical instruments all can serve as vehicles in the spread of infection.
Anything inanimate that can harbor an infection and come into contact with the patient is a
viable source of infection transmission.
Another method of transmission is through droplet spread. An infected patient sneezing,
coughing, singing, and sometimes even talking can spread the infection. Although, droplets
usually do not travel more than a few feet away from the source, they are still a method of
infection transmission. Airborne infections can remain suspended in the air for long periods of
time, although not that common. Inhalation of these infected particles can lead to a transmission.
The last method of transmission is through vehicles, such as water, food, or biological products.
Ingestion, inoculation, or by deposit on skin or of the mucous membrane is yet another path for
infection transmission. (WHO).
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How to prevent transmission/Hygiene/Hand Washing Compliance:
It is the responsibility of all health professionals to be aware of the risks of infection transmission
and be educated in proper prevention measures to minimize the risk. Compliance programs
should have in place policies and procedures focused on infection control. The areas that it
should include are the following:
A) Hand washing-Proper hand washing techniques have demonstrated to minimize
transmission, however it is less than successful due a variety of reasons such as lack of access,
high pt.- staff ratios, time constraints, and solution allergies. When done consistently and
properly infection can be minimized. It is important to have a lsrge wash basin with running
water, anti splash guards along with hands free controls. In addition a drying method without
contamination, such as disposable paper towels.. When using routine and the antiseptic hand
hygiene it is important to have 1 complete minute of contact and in surgical scrub routine a full
3-5 minutes contact.
B) Hygiene/Uniform – It is important that all staff maintain good personal hygiene.
Keeping hair pinned back, and facial hair neatly trimmed. Fingernails should be clean and
trimmed. Uniforms typically are some sort of scrubs, but any other uniform or clothing
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worn should be clean, easy to decontaminate and changed when exposed to blood or
become wet from excessive fluids.
C)
Equipment safety-Most hospitals have a central supply department, which is
responsible for the sterilization, decontamination , preparation for use and aseptically
storing all hospital equipment , which will include: reusable equipment and contaminated
equipment. There must be detailed instructions, policies and procedures in place for the
sterilization, and wrapping of such equipment according to sterilization requirements. A
qualified individual must be responsible for overseeing this department's daily operations,
communicate with staff and the infection control dept, maintain accurate records on
equipment sterilization with scheduled reviews and reporting for prevention.
D)
Point of use care- proper procedures for infection control regarding all point of
use care including suction devices , proper disposal of syringes and other hazmat materials,
ventilator equipment, blood testing devices. Each patient room should be equipped with the
appropriate sealed disposal containers to eliminate transmission of infection
D)
Cleaning & decontamination- A thorough cleaning program with instructions ,
policies and procedures to include proper washing and decontamination of walls, floors,
beds, linen and all other room areas with adequate disinfection solutions. In addition,
special precautionary measures and procedures for proper handling of blood and body fluid
incidents to minimize exposure and infection transmission.
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G)
Isolation- To assist hospitals in maintaining up-to-date isolation practices, the
Centers for Disease Control and Prevention (CDC) and the Hospital Infection Control
Practices Advisory Committee (1) (HICPAC) have revised the "CDC Guideline for
Isolation Precautions in Hospitals." HICPAC was established in 1991 to provide advice
and guidance to the Secretary, Department of Health and Human Services (DHHS); the
Assistant Secretary for Health, DHHS; the Director, CDC; and the Director, National
Center for Infectious Diseases, regarding the practice of hospital infection control and
strategies for surveillance, prevention, and control of nosocomial infections in US
hospitals. HICPAC also advises the CDC on periodic updating of guidelines and other
policy statements regarding prevention of nosocomial infections (CDC). The following
should be incorporated as part of the isolation protocol for effective infection prevention
when a patient or patients are identified as high risk for nosocomial infection transmission:
Standard Precautions, or the equivalent, for the care of all patients.
1) Handwashing Wash hands after touching blood, body fluids, secretions, excretions, and contaminated
items, whether or not gloves are worn. Wash hands immediately after gloves are removed,
between patient contacts, and when otherwise indicated to avoid transfer of microorganisms to
other patients or environments. It may be necessary to wash hands between tasks and procedures
on the same patient to prevent cross-contamination of different body sites. Category IB (2) Use a
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plain (non antimicrobial) soap for routine hand washing. (3) Use an antimicrobial agent or a
waterless antiseptic agent for specific circumstances (eg, control of outbreaks or hyperendemic
infections), as defined by the infection control program. Category IB (See Contact Precautions
for additional recommendations on using antimicrobial and antiseptic agents.)
2) Gloves Wear gloves (clean, nonsterile gloves are adequate) when touching blood, body fluids,
secretions, excretions, and contaminated items. Put on clean gloves just before touching mucous
membranes and nonintact skin. Change gloves between tasks and procedures on the same patient
after contact with material that may contain a high concentration of microorganisms. Remove
gloves promptly after use, before touching non contaminated items and environmental surfaces,
and before going to another patient, and wash hands immediately to avoid transfer of
microorganisms to other patients or environments.
3) Mask, Eye Protection, Face Shield -Wear a mask and eye protection or a face shield to protect
mucous membranes of the eyes, nose, and mouth during procedures and patient-care activities
that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.
4) Gown
Wear a gown (a clean, non sterile gown is adequate) to protect skin and to prevent soiling
of clothing during procedures and patient-care activities that are likely to generate splashes or
sprays of blood, body fluids, secretions, or excretions. Select a gown that is appropriate for the
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activity and amount of fluid likely to be encountered. Remove a soiled gown as promptly as
possible, and wash hands to avoid transfer of microorganisms to other patients or environments.
5) Patient-Care Equipment Handle used patient-care equipment soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures, contamination of
clothing, and transfer of microorganisms to other patients and environments. Ensure that reusable
equipment is not used for the care of another patient until it has been cleaned and reprocessed
appropriately. Ensure that single-use items are discarded properly.
6) Environmental Control Ensure that the hospital has adequate procedures for the routine care, cleaning, and disinfection
of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched
surfaces and ensure that these procedures are being followed.
7) LinenHandle, transport, and process used linen soiled with blood, body fluids, secretions, and
excretions in a manner that prevents skin and mucous membrane exposures and contamination of
clothing, and that avoids transfer of microorganisms to other patients and environments.
8) Occupational Health and Bloodborne Pathogens Take care to prevent injuries when using needles, scalpels, and other sharp instruments or
devices; when handling sharp instruments after procedures; when cleaning used instruments; and
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when disposing of used needles. Never recap used needles, or otherwise manipulate them using
both hands, or use any other technique that involves directing the point of a needle toward any
part of the body; rather, use either a one-handed "scoop" technique or a mechanical device
designed for holding the needle sheath. Do not remove used needles from disposable syringes by
hand, and do not bend, break, or otherwise manipulate used needles by hand. Place used
disposable syringes and needles, scalpel blades, and other sharp items in appropriate punctureresistant containers, which are located as close as practical to the area in which the items were
used, and place reusable syringes and needles in a puncture-resistant container for transport to
the reprocessing area. Use mouthpieces, resuscitation bags, or other ventilation devices as an
alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is
predictable.
9) Patient Placement Place a patient who contaminates the environment or who does not (or cannot be expected to)
assist in maintaining appropriate hygiene or environmental control in a private room. If a private
room is not available, consult with infection control professionals regarding patient placement or
other alternatives. (CDC, 01/01/96)
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IV.
Financial Impact of Nosocomial Infections
It’s clear that a compliance program plays an important role in preventing nosocomial
infections and it’s also clear that nosocomial infections have a significant financial impact on
hospitals and the entire healthcare system. It is estimated that the top five infections that patients
get after being admitted to the hospital cost the U.S. healthcare system $10 billion a year, and
estimates for all types of infections range from $20 - $40 billion a year (Goodman, 2013).
Below is a table showing the types of infection as well as an estimated cost to treat the infection
per case.
Type of Infection
Cost to Treat/Case
Central-line associated bloodstream
$45,000
Pneumonia
$40,000
Surgical Site
$21,000
C. Difficile
$11,000
Urinary Tract
$900
It’s estimated that approximately 5% of patients admitted to the hospital will pick up an
infection while there, this is approximately 2 million patients per year (Goodman, 2013). A
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recent study of surgical site infections at four hospitals in the Johns Hopkins Health System
showed that if hospitals could eliminate these surgical site infections, they could increase their
revenue by $2 million per year (Goodman, 2013). Hospital leaders need to understand that an
effective compliance program resulting in infection prevention will help their financial bottom
line, and hospital scorecards include infection data as well as financial data.
In the past, hospital executives had assumed that infections meant longer hospital stays
and greater reimbursement. They also assumed that compliance programs cost more money to
implement and manage than they would save. This changed with the Deficit Reduction Act of
2005 (DRA). It is in a hospitals’ best interest to create and maintain a compliance program that
contains measures to prevent and/or limit nosocomial infections not only to improve the quality
of care to its patients but to receive the maximum reimbursement possible. The quality of care
resulting from the adherence (or lack thereof) to the compliance program are reflected in the
reimbursement received from Medicare. Medicare will no longer reimburse hospitals for
treating certain secondary diagnoses if they are not present on admission (POA) for discharges
occurring on or after October 1, 2008. The following factors are used by Medicare to identify
HACs, including some infections, for non-payment (Infectious Disease Society of America,
2013):
● High Cost and/or High Volume
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● Result in the allocation of a case to a Diagnosis-Related Group (DRG) that has a greater
payment when submitted as a secondary diagnosis
● Could reasonably have been prevented through the use of evidence-based guidelines.
Beginning in FY2015, CMS will implement the Hospital Acquired Condition
Reduction Program where hospitals in the lowest quartile for medical errors or hospital-acquired
infections will receive a 1 percent penalty on reimbursement (Rodak, 2013). The HAC reduction
program was created under the Patient Protection and Affordable Care Act and it is supposed to
give hospitals incentives to reduce the occurrence of hospital acquired infections. The first
measures for FY2015 focus on central-line bloodstream infections and catheter-associated
urinary tract infections. CMS proposed adding surgical site infections for fiscal year 2016 and
Methicillin-resistant Staphylococcus aureus Bacteremia and Clostridium difficile infection for
FY 2017 (Rodak, 2013).
It’s clear based on the dollar amounts provided above, that preventing Nosocomial
Infections through an effective compliance program is necessary for a hospital’s financial health.
The cost of the infections and complications that go along with it far outweigh the cost of
implementing and managing a compliance program. Now that reimbursement can be adjusted
based on when these infections are acquired, hospital executives must realize they are losing out
on revenue when not preventing these nosocomial infections. The CDC and JCAHO (Joint
Commission on Accreditation of Healthcare) provide guidelines for infection control that can be
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incorporated into a hospital’s compliance program. Toolkits can also be purchased to assist in
infection prevention. With all these tools at their fingertips and evidence that nosocomial
infections are far more costly, every hospital executive should require an infection prevention
policy and procedure in their compliance program.
V. Importance of Compliance Program
Environmental work practice controls are key components to a comprehensive infection control
compliance program. They maximize protection against infectious diseases for both workers and
patients. Work practice controls include hand washing and utilizing appropriate personal
protective equipment and barrier techniques such as safety googles, masks, gloves, and
protective gowns. Additional controls include cleaning contaminated areas and properly
disposing of contaminated equipment. Utilizing work practice controls minimizes the chance of
coming in contact with blood and body fluid thus reduces the potential for contacting or
spreading an infectious disease. Additional work practice controls (i.e. precautions and / or
isolation) may be required for certain diagnosis. The following policies and procedures apply to
the standard universal precautions that must be followed regardless of diagnosis.
Policy
Standard environmental work practice controls must be followed by all healthcare personnel for
all patients regardless of their diagnosis.
Purpose
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The following table lists individual components of universal environmental work practice
controls and describes the appropriate procedures to be followed for each one. It provides a quick
reference for all healthcare workers responsible for the placement and management of patients.
Table 1
Environmental Work Practice Controls
Component
Work Practice Control / Procedure
Hand Hygiene
Wash hands after touching blood or body
fluids or contaminated items, immediately
following glove removal, and between patients
Gloves
For touching blood, body fluids contaminated
items, mucus membranes and skin that is
perforated, must be changed between patients
Gown
During patient care procedures that are likely
to generate sprays or splashes of blood or body
fluids
Googles / Mask
During patient care procedures that are likely
to generate sprays or splashes of blood or body
fluids
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Standard Environmental Control
Needles and Sharps
Clean and decontaminate any items with spills
of blood or other potentially infectious
materials, change the paper covering on the
exam table between patient use, place any
used linens (e.g., exam gowns, sheets) in a
designated container after each patient use
Do not recap or break used needles. Place used
sharps in puncture resistant receptacle.
Patient Resuscitation
Use mouthpiece or ventilation device to avoid
contact with oral secretions
Patient Placement
Place in single room if patient is likely to
contaminate the environment or is at risk of
acquiring infection
Soiled Equipment
Wear gloves and perform hand hygiene, handle
in a way that prevents transfer of micro
organisms
VI. Conclusion
Infections and infections complications are a very important clinical area in the hospital setting.
Community-acquired infections and nosocomial infections both contribute to the high level of
disease acquisition common among critically ill patients. The correct diagnosis of nosocomial
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infections and the delivery of appropriate treatment, including pharmacological drugs effective
against the identified agents of infection, have been shown to be important determinants of
patient outcome. Nosocomial infections are associated with a high rate of morbidity, mortality
and increased financial burden. Infection control measures are important for the effective control,
prevention and treatment of infection. The major advances in overall control of infectious
diseases have resulted from immunization and improved hygiene, particularly hand washing.
Hand washing is the single most important measure to preventing nosocomial infections. Gloves
must not be used as a substitute for hand washing; hands must be washed upon removal of
gloves. In addition to hand hygiene, an effective compliance program and its related infection
control policies and procedures will help control nosocomial infections thus saving the lives of
many patients.
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Goodman, Brenda. September 3, 2013. Hospital-Acquired Infections Cost $10 Billion a Year:
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