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GUIDELINES ON
INFECTION CONTROL
IN THE INTENSIVE CARE UNIT
CRITICAL CARE MEDICINE SECTION
MALAYSIAN SOCIETY OF ANAESTHESIOLOGISTS
1.
PREAMBLE
Sepsis the most common cause of death in the intensive care unit (ICU). It is also
the leading cause of multiorgan failure in the ICU. Although exogenous infections
do occur, it is widely accepted that many infections acquired in the ICU are
endogenous. Therefore, the transmission of infection between patients deserves to
be recognized as a significant contributing factor.
In order to minimize infection risks, what follows is a guideline based on the
understanding of the risks of such transmission. In certain clinical situations, there
may be a need to adopt more stringent practices. It is essential that this guideline
to be considered together with other documents issued by other authorities and
serve as a framework for the development of more detailed individual policies and
protocols within each centre.
The medical practitioner is encouraged to refer to more detailed
guidelines/policies such as those published by the Center for Disease Control
(CDC). The internet source for the CDC is:
http://www.dcd.gov/ncidod/hip/hip.htm
2.
DEFINITIONS
Hospital acquired infection : An infection found to be active, or under active
treatment at the time of the survey, which as not
present on admission. In general, infections that
manifest after 48 hours of admission are generally
considered to be nosocomial in origin. With patients
recently admitted, it is necessary to judge if any
infection was being incubated on admission, and to
mark such as not hospital acquired, i.e. established
infection which has resulted from an earlier
admission is recorded as suffering from hospital and
not community acquired infection.
Decontamination :
The process of removing infective and unwanted
matter from the surface of an object, i.e., thorough
cleaning.
Disinfection :
A process that eliminates many or all microorganisms except spores.
Asepsis :
The prevention of contact with micro-organisms.
Disposable :
A device intended for single use or single-patient
use.
Reusable :
A device intended for multiple use.
3. GENERAL MEASURES
3.1
Hand Washing
Frequent meticulous handwashing is the single most important infection control
measure. Hands should be washed before and after handling every patient or
equipment to be used on a patient. Hands should also be washed whenever they
become contaminated, before any invasive procedure, after personal use of the
washroom, when coming to and before leaving work.
Caveat : While there are several categories of hand-washing from the simple
hand-wash to the surgical scrub, the actual category of hand-wash to apply would
depend on the needs of the situation, e.g. simple hand-wash for simple contact to
surgical scrub for invasive procedures.
3.2
Physical Barriers
For the ICU personnel protection, gloves are to be worn whenever hand contact
with blood, saliva or any other body fluid is expected and are to be removed after
such a procedure to minimize contamination.
3.3
Consultation
3.3.1
A Medical Microbiologist should be available and consulted concerning
spectrum of micro-organisms, antibiotic sensitivities and any other
matters requiring clarification with local application of this guideline.
Whenever possible, a record of the unit’s spectrum of micro-organism
isolated and its antibiogram should be kept in the unit for quick
reference.
3.3.2
An Infection Control team should be available for consultation of
matters concerning surveillance of infection and assessment of control
measures. Additionally, there should also be measures to establish and to
monitor sterilization and disinfection procedures. A procedure for the
management of needlestick injuries should also be developed.
4.
INVASIVE PRCEDURES
While the use of invasive procedures may be life-saving and useful in the
management of patients, the over and inappropriate use of these procedures leads
to unnecessary infections.
Invasive procedures are to be performed with aseptic techniques. Aseptic
technique is employed in all invasive procedures and dressing changes and
requires the use of sterile gloves. If asepsis has been compromised in an
emergency, items such as catheters or intravenous lines that may be contaminated
must be changed once the patient is stable.
Adequate anchoring of lines should be done to prevent excessive movements. All
lines should be closed systems with limited interruption. Frequent change and
rotation of sites at regular and appropriate intervals is recommended. All invasive
lines, catheters, tubes should be removed when considered no longer necessary.
4.1
Vascular Cannulation
The cannulation site is a potential portal of entry of micro-organisms into the
subcutaneous tissue and circulation. The operator’s hands must be washed and
protective gloves should be worn. Appropriate skin disinfection should be
performed with a suitable preparation before cannulation.
4.2
Central Vascular Cannulation
Cannulation of central veins must be performed under aseptic techniques
including sterile gowning and gloving, thorough skin preparation and the use of a
sterile field bordered by sterile drapes. Sites known to be associated with lower
rates of infection (e.g. subclavian, internal jugular routes) should be chosen over
sites known to have a high rate (e.g. femoral)
4.3
Vascular Administration Sets
Intravascular sets should be changed at regular intervals of not more than 72
hours. Parenteral nutrition sets are changed every 24 hours. Blood administration
sets are changed after use.
5. APPARATUS / EQUIPMENT
Appropriate levels of sterility, disinfection and decontamination are to be applied
to all equipment used. Each patient must have his / her equipment that is
disinfected or discarded on discharge.
5.1
Disposable Items
Disposable items such as airway equipment that are placed in direct contact with
the respiratory tract, e.g. endotracheal tubes and airways, which are labeled by the
manufacturer as disposable or single use, should not be reused or recycled.
5.2
Reusable Items
Reusable items must be thoroughly decontaminated and then undergo disinfection
before each use. Where the manufacturer advises that a particular piece of
equipment be sterilized before use, that advice must be followed.
5.3
Ventilator circuits
For each patient, the ventilator/breathing circuit must be regularly sterilized, or
decontaminated and disinfected. Circuits may also be protected by appropriately
positioned filters. More stringent guidelines, e.g. disposable circuits, may be
necessary for patients with infectious diseases.
6. SUPPLIES
6.1
Storage Area
Clean and sterile items should not be stored in the same area. Clean and/or sterile
items must not be stored in the same area where decontamination procedures take
place. Separate rooms or separate locations within a single room are used for
clean and dirty utility areas.
6.2
Sterile Items
All sterilized items must be stored in a clean, dry area. Stock supply must be
rotated so that the oldest is used first. If a sterile package is violated in any way, it
is considered contaminated and not be used. A check at regular intervals for all
items must be performed. All items are also to be checked before use for date and
integrity.
6.3
Linen
Soiled linen is a significant source of microbial contamination. Many of the
pathogens present in the air of the patient unit are liberated into the air from
bedding, dressings and clothes.
Linen is stored in a clean, dry area and kept covered to prevent airborne
contamination. It is recommended that clean linen that has been removed but not
used must not be returned to the storage area.
When changing linen, it must be handled gently with a minimum of agitation and
placed directly into a linen bag, not the floor. Soiled linen is carried away from
the person and placed into a disposal bag.
7. MEDICATION
Medications are prepared using a “no-touch” technique, parenteral drugs are
prepared aseptically using sterile syringe and needle. Sterile intravenous and
irrigation fluids must be labeled with the date and time opened and discarded
within 2 hours.
7.1
Antibiotics
Indiscriminate use of antimicrobial drugs in an ICU can lead to outbreaks of
serious infections with devastating consequences. The availability of an antibiotic
policy in each hospitals, if adhered to, will lead to a more rational and judicious
use of antibiotics.
7.2
Multiple Dose Containers
Due to the potential for cross-infection, the use of contents of multiple dose vials
and ampoules for more than one patient is not recommended. Likewise, it is
recommended that contents of a single dose ampoule are to be used for one
patient only.
8. PATIENT FACTORS
8.1
Bed Assignments
Patients must be admitted into a bed where their condition will not compromise
other patients or vice-versa. Immediate post-operative or immunocompromised
patients should not be placed adjacent to patients who has infected or draining
wounds or an infectious disease.
8.2
Isolation
Any patient deemed to be contagious or at grave risk of contracting an infection
will be placed on an appropriate isolation precaution.
8.3
Hygiene
Patients must be routinely offered or assisted with bathing opportunities. Basic
hygiene measures are important to prevent infection and must be stressed during
patient care.
9.
PERSONNEL
A clean uniform is worn daily. Sweaters/vests, if worn, must be cleaned daily.
Jewellery provides a potential breeding area for colonization of bacteria and
therefore must not be worn.
Any member of the patient management team, with known exposure to a
communicable disease must report this exposure to his/her immediate supervisor.
The Infection Control Co-ordinator is notified to provide additional guidance and
direction to ensure risk to patients and other staff members is limited. He/She
should also ensure necessary precautions have been implemented. Vaccination is
encouraged and should be provided for all direct care providers.
The reader is also referred to WHO recommendations of Universal Precaution.
10.
HOUSEKEEPING
Cleaning of the patient care area is the responsibility of the house-keeping
department. Routine cleaning follows established schedules and cleaning
guidelines established by the unit.
11.
TRAFFIC CONTROL
11.1
Visitors
In specific cases, visitors should be restricted as necessary to provide safe patient
care. If there is a patient on isolation precautions, the visitors must be instructed
with necessary precautions to prevent the spread of infection.
11.2
Limited Access
In special areas designated by the nursing unit, only authorized personnel are
allowed access.
12.
WASTE DISPOSAL
All waste disposal follows guidelines established by the institution.
Needles and other sharps must be disposed in the appropriate needle boxes
provided to avoid danger to other personnel. Needles and syringes are not recapped prior to disposal.
Dressing and other supplies saturated with blood or other potentially infectious
material, e.g. body fluids, are bagged and deposited in a closed “contaminated
waste” receptacle. If there is infectious wastes, items are double-bagged and
placed in a closed receptacle designated for contaminated wastes.
13.
EDUCATION
All personnel should be provided education regarding infection control and safety
on a regular basis. All personnel should be briefed and have an orientation
regarding infection control and universal precautions within the patient care area.
This guideline document has been intentionally prepared to
contain general principles only. It is important that the
practitioner consider the individual characteristics of each
circumstance with regard to the application of this document,
either in whole or in part.
Guideline/policy documents will be reviewed and revised
when the need arises. It is the practitioner’s responsibility to
ensure he has obtained the current version. The document has
been prepared having regard to information available at the
time of its preparation. Therefore, the practitioner should
supplement this document with relevant information that may
become available subsequently. As such, the CCMS/MSA
assumes no responsibility for matters that arise from changed
circumstances or information subsequent to the preparation of
this document.
April 1997