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Healthcare Safety & Standard Precautions Standard Precautions and Transmission-Based Precautions DEDE CARR, BS, LDA KAREN NEU, MSN, CNE, CNP 1 U.S. DEPARTMENT OF LABOR GRANT “This workforce solution was funded by a grant awarded by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use, by and organization and/or personal use by an individual or non-commercial purposes, is permissible. All other uses require the prior authorization of the copyright owner.” 2 COMPETENCY 2 2. Explain the current requirements of standard precautions and the procedures used at a variety of healthcare facilities to support those standards. a. b. c. d. e. f. Explain the purpose of standard precautions and when they are applied. List common pathogens. Identify PPE (personal protective equipment) and usage. List compliance measures for Blood borne Pathogens Standards. Identify types of Isolation Precautions and describe why isolation is used in a healthcare facility. Identify concerns and needs of clients in isolation. 3 Standard Precautions are used in the care of all hospitalized persons regardless of their diagnosis or possible infection status. They apply to blood, all body fluids, secretions and excretions, except sweat (whether or not blood is present or visible), non-intact (broken) skin, and mucous membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from recognized & unrecognized sources. (Berman et al., p. 689) 4 Hand Hygiene Perform proper hygiene after contact with blood, body fluids, secretions, excretions, & contaminated objects whether or not gloves are worn. Perform proper hand hygiene immediately after removing gloves and other wear or equipment. Before eating, drinking, smoking, applying makeup, or changing contact lenses and after using the restroom facilities. Before all other activities that entail hand contact with mucous membranes or a break in the skin. Before and after every patient contact. Use a non-antimicrobial product for routine hand cleaning. Use antimicrobial agent or an antiseptic agent for the control of specific outbreaks. (Berman et al., p. 689) 5 Access the website to watch YouTube video for Correct Procedure for Hand Washing 6 Use of Gloves Wear clean gloves when touching blood, body fluids, secretions, excretions, and contaminated items (i.e., soiled gowns) A. clean gloves can be unsterile, unless their use is intended to prevent entrance of microorganisms into the body (invasive procedures). B. Remove gloves before touching noncontaminated items and surfaces. C. Perform proper hand hygiene immediately after removing the gloves. (Berman et al., p. 689) 7 Mask, Eye Protection, Face Shield-PPE Wear mask, eye protection, or a face shield if splashes or sprays of blood, body fluids, secretions, or excretions can be expected. (Berman et al., p. 689) 8 Gown-PPE Wear a clean, non-sterile gown if client care is likely to result in splashes or sprays of blood, body fluids, secretions, or excretions. The gown is intended to protect clothing. Remove a soiled gown carefully to avoid the transfer of microorganisms to others (i.e., clients or other healthcare workers). Cleanse hands after removing the gown. (Berman et al.. 689) 9 Care Equipment Handle client care equipment that is soiled with blood, body fluids, secretions, and excretions carefully to prevent the transfer of microorganisms to others and to the environment. A. Make sure usable equipment is cleaned and reprocessed correctly. B. Dispose of single-use equipment. (Berman et al., p. 689) 10 Linen Handle, transport, and process linen that is soiled with blood, body fluids, secretions, and excretions in a manner to prevent contamination of clothing and the transfer of microorganisms to others and to the environment. Fold or roll linen so that the dirtiest area is inside before disposing the linen into a bag or hamper. Sharps, Scalpels, Needles, Prevent injuries from scalpels, needles, or other equipment and place in puncture-resistant containers. (Berman et al., p. 689) 11 Dishes Dishes require no special precautions. Soiling of dishes can largely be prevented by encouraging clients to cleanse their hands before eating. Some agencies use paper dishes for convenience, which are disposed of in the proper container. (Berman et al., p. 694) 12 Blood Pressure Equipment Blood pressure equipment needs no special precautions unless it becomes contaminated with infective material. If it does become contaminated, follow your agency’s policy to decontaminate it. In some institutions a disposable cuff is used. The stethoscope should be cleaned between every patient contact. Thermometers Non-disposable thermometers are generally disinfected after use. Check agency policy. (Berman et al., pp. 694-695) 13 Laboratory Specimens Laboratory specimens, if placed in a leak-proof container with a secure lid with a biohazard label, need no special precautions. Use care when collecting specimens to avoid contaminating the outside of the container. Containers that are visibly contaminated on the outside of the container should be placed in a sealable plastic bag before sending them to the laboratory. This prevents personnel from having hand contact with potentially infective material. (Berman et al., p. 694) 14 (http://www.uow.edu.au/content/groups/public/@web/@health/documents/mm/uow025316.jpg, n.d.) 15 Additional requirements for Standard Precautions Mouth pieces, resuscitation bags, or other ventilation devices should be available for use in areas in which the need for resuscitation is predictable. Pregnant health care workers are not known to be at any greater risk of contracting HIV infection than those who are not pregnant. Because the infection can be transmitted perinatal route, pregnant health care workers should be especially familiar with and strictly adhere to precautions to minimize the risk of acquiring HIV or Hepatitis B. Immunization of employees is required for infectious agents (measles, mumps, rubella) transmitted by air. 16 17 Transmission-based precautions are used in addition to standard precautions for clients with known or suspected infections that are spread in one of three ways by: Airborne transmission Droplet transmission Contact transmission The three types of transmission-based precautions can be used alone or in combination, but always in addition to standard precautions. (Berman et al., p. 689) 18 19 Airborne precaution are used for clients known to have or suspected of having serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns. Examples of such illnesses include measles (rubeola), varicella (chicken pox), disseminated zoster (shingles), and tuberculosis. (Berman et al., p. 670) 20 Airborne Precautions-use Standard Precautions as well as: Place the client in a private room that has a negative air pressure (6-12 air exchanges per hour and either discharge of air to the outside or a filtration system for the room air). If a private room is unavailable, place client with another who is infected with the same microorganism. Wear a respiratory device (N59 respirator) when entering the room of a client who is known or suspected of having primary tuberculosis. Susceptible people should not enter the room of a client who has rubeola (measles) or varicella (chicken pox). If they enter the room, they should wear a respirator. Limit movement of the client outside the room to essential purposes only. Place a surgical mask on the client during transport. (Berman et al., p. 689) 21 22 Droplet precautions are used for clients known or suspected to have serious illnesses transmitted by particle droplets larger than 5 microns. Examples of such illnesses are diphtheria (pharyngeal); mycoplasma pneumonia, pertussis, mumps, rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants and small children; and pneumonic plague. (Berman et al., p. 670) 23 Droplet Precautions Use Standard Precautions as well as: Place client in a private room. If a private room is unavailable, place client with another who is infected with the same microorganism. Wear a mask if working within 3 feet of the client. Limit movement of the client outside the room to essential purposes. Place a surgical mask on the client during transport. (Berman et al., p. 689) 24 25 Contact precautions are used for client known or suspected to have serious illnesses easily transmitted by direct client contact or by contact with items in the client’s environment. According to the CDC, such illnesses include gastrointestinal, respiratory, skin, or wound infections or colonization of multi-drugresistant bacteria; specific infections, such as C. difficile, and enterohemorrhagic Escherichia coli 0157:H7, Shigella, and hepatitis A, for diapered or incontinent clients; respiratory syncytial virus (RSV), parainfluenza virus, or enteroviral infections in infants and young children; and highly contagious skin infections, such as herpes simplex virus, impetigo, pediculosis, and scabies. In addition to the preceding conditions, special contact precautions are used for Vancomycin-resistant enterococci (VRE) infections. CDC recommends using an antimicrobial soap for hand washing and no sharing of equipment among clients with or without VRE & continued isolation until 3 cultures taken one week apart are negative. (Berman et al., p. 690) 26 Contact Precautions: Use Standard Precautions as well as: Place client in a private room. If a private room is unavailable, place client with another who is infected with the same microorganism. Wear gloves as described in standard precautions A. Change gloves after contact with infectious materials. B. Remove gloves before leaving client’s room. C. Cleanse hands immediately after removing gloves. Use an antimicrobial agent. Note: If the client is infected with C. difficile, DO NOT use an alcohol-based hand rub as it may not be effective on these spores. Use soap and water. D. After hand cleansing, do not touch possibly contaminated surfaces or items in the room. (Berman et al., p. 689) 27 Contact Precautions Wear a gown (see standard precautions) when entering the room if there is possibility of contact with infected surfaces or items, or if the client is incontinent, or has diarrhea, a colostomy, or wound drainage not contained by a dressing. A. Remove the gown in the client’s room. B. Make sure your uniform does not contact possible contaminated surfaces. Limit movement of client outside the room. Dedicate the use of non-critical client care equipment to a single client or to clients with the same infecting microorganisms. 28 Compromised clients (those highly susceptible to infection) are often infected with their own microorganisms, by microorganisms on the inadequately cleansed hands of healthcare workers, and by non-sterile items, (food, water, air, and client-care equipment). Clients who are severely compromised include those who have: Diseases, such as leukemia, that depress the client’s resistance to infectious microorganisms Extensive skin impairments, such as severe burns, which cannot be effectively covered with dressings. Sometimes these patients are placed in “reverse isolation” & standard precautions with gowns, gloves, & masks are used to protect the client from exposure to microorganisms rather than to prevent transmission of microorganisms from the client to others. (Berman et al., p. 690) 29 Review of Standard Precautions Previously called Universal Precautions, standard precautions assumes blood and body fluids of ANY patient could be infectious and recommends the use of personal protective equipment (PPE) and other infection control practices to prevent the transmission of microorganisms in any healthcare setting. • Decisions about what PPE to use is determined by the type of clinical interaction with patient. 30 http://www.uow.edu.au/content/groups/public/@web/@health/documents/mm/uow025317.jpg 31 32 All health care workers must apply clean or sterile gloves, gowns, masks, and protective eyewear according to the risk of exposure to potentially infective materials. (CDC) 33 Gloves are worn for three reasons: First, they protect the hands when the nurse is likely to handle any body substances, for example, blood, urine, feces, sputum, and non-intact skin. Second, gloves reduce the likelihood of healthcare workers transmitting their own endogenous microorganisms to individuals receiving care. Healthcare workers with open sores or cuts on their hands must wear gloves for protection. Third, gloves reduce the chance that the healthcare worker’s hands will transmit microorganisms from one client or fomite to another client. In all situations, gloves are changed between client contacts. (Berman et al., p. 690) 34 Gloves: The hands are cleansed each time gloves are removed for two primary reasons: A. The gloves may have imperfections or be damaged during wearing, so that they could allow microorganisms entry and B. The hands may become contaminated during glove removal. Access YouTube video (1.26 minutes) @ Proper Removal of Contaminated Gloves 35 Gloves Work from “clean to dirty” Limit opportunities for “touch contamination” protect yourself, others, and the environment Don’t touch your face or adjust PPE with contaminated gloves Don’t touch environmental surfaces except as necessary during patient care Discard in appropriate receptacle Never wash or reuse disposable gloves (CDC) 36 Gowns – Clean or disposable impervious (water-resistant) gowns or plastic aprons are worn during procedures when the healthcare worker’s uniform is likely to become soiled. Sterile gowns may be worn by the nurse when changing dressings on a client with extensive wounds (i.e., burns). Single-use gown technique (using a gown only once before it is discarded or laundered) is the usual practice. After the gown is worn, the nurse discards it (if it is paper) or places it into a laundry hamper. Before leaving the client’s room, the healthcare worker cleanses his/her hands. Use a gown during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated. (Berman et al., p. 693) 37 Masks– Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Masks – protect nose and mouth – Should fully cover nose and mouth and prevent fluid penetration Surgical masks and respirators are not the same. Masks are used for large particles & to protect the healthcare worker from splashes or exposure to mouth. Respirators are used in airborne precautions to prevent inhalation of small microorganisms, such as tuberculosis and SARS. (CDC) See the YouTube video (5.37 min.) describing the: Difference between Respirators & Surgical Masks 38 Respirators Purpose – protect from inhalation of infectious aerosols (e.g., Mycobacterium tuberculosis) PPE types for respiratory protection Particulate respirators Half- or full-face elastomeric respirators Powered air purifying respirators (PAPR) (CDC) 39 Goggles -Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Goggles – protect eyes * Should fit snuggly over and around eyes * Personal glasses are not a substitute for goggles because they do not extend around the sides of the glasses, which the goggles do. * Anti-fog feature improves clarity (CDC) 40 Face Shields-Protect the face, nose, mouth and eyes. Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Should cover the forehead, extend below the chin and wrap around the side of the face. (CDC) 41 42 Key Points About PPE • Don before contact with the patient, generally before entering the room • Use carefully – don’t spread contamination • Remove and discard carefully, either at the doorway or immediately outside patient room; remove respirator outside room • Immediately perform hand hygiene (CDC) 43 Watch the following YouTube video to learn how and in what order to apply and remove personal protective equipment: Proper Application and Removal of PPE Grey Bruce Health Unit Personal Protective Equipment YouTube Video (4.42 minutes) 44 45 Sequence* for Donning PPE Gown first Mask or respirator Goggles and/or face shield Gloves *Combination of PPE will affect sequence – be practical (CDC) 46 Select appropriate type and size Opening is in the back Secure at neck and waist If gown is too small, use two gowns Gown #1 ties in front Gown #2 ties in back (CDC) 47 Place over nose, mouth, and chin Fit flexible nose piece over nose bridge Secure on head with ties or elastic Adjust to fit (CDC) 48 Select a fit-tested respirator Place over nose, mouth, and chin Fit flexible nose piece over nose bridge Secure on health with elastic Adjust to fit Perform a fit check – Inhale – respirator should collapse Exhale – check for leakage around face (CDC 49 Position goggles over eyes and secure to the head using the ear pieces or headband Position face shield over face and secure on brow with headband Adjust to fit comfortably (CDC) 50 Don gloves last Select correct type and size Insert hands into gloves Extend gloves over isolation gown cuffs (CDC) 51 Keep gloved hands away from face Avoid touching or adjusting other PPE Remove gloves if they become torn; perform hand hygiene before donning new gloves Limit surfaces and items touched (CDC) 52 53 “Contaminated”-Outside front of PPE Areas of PPE that have or are likely to have been in contact with body sites, materials, or environmental surfaces where the infectious organism may reside “Clean” – inside, outside back, ties on head and back of PPE Areas of PPE that are not likely to have been in contact with the infectious organism (CDC) 54 Gloves Face Shield Goggles Gown Mask or Respirator (CDC) 55 At doorway, before leaving patient room or in anteroom* Remove respirator outside room, after door has been closed* *Ensure that hand hygiene facilities are available at the point needed, (e.g., sink or alcohol-based hand rub) (CDC) 56 Grasp the outside edge near the wrist Peel away from hand, turning glove inside out Hold in opposite gloved hand (CDC) 57 Slide ungloved finger under the wrist of the remaining glove. Peel off from the inside, creating a bag for both gloves. Discard. (CDC) 58 Grasp the ear or head pieces of the goggles or face shield with ungloved hands. Lift away from the face. Place mask or face shield into designated receptacle for reprocessing or disposal. (CDC) 59 Unfasten ties Peel gown away from neck and shoulders Turn contaminated outside toward the inside Fold or roll into a bundle Discard (CDC) 60 Untie the bottom, then top tie Remove from face Discard (CDC) 61 Lift the bottom elastic over your head first Then lift off the top elastic Discard (CDC) 62 Perform hand hygiene immediately after removing PPE. If hands become visibly contaminated during PPE removal, wash hands before continuing to remove PPE Wash hands with soap and water or use an alcohol-based hand rub *Ensure that hand hygiene facilities are available at the point needed, e.g., sink or alcohol-based hand rub (CDC) 63 Transporting clients with infections outside their own rooms (isolation) is avoided unless absolutely necessary. If the client must be moved, the healthcare worker implements the appropriate precautions and measures to prevent soiling of the environment. For example, the healthcare worker ensures that any draining wound is covered securely and places a surgical mask on a patient with an airborne infection. In addition, the personnel at the receiving area are notified of any infection risk so they can maintain necessary precautions. (Berman et al., p. 695) 64 Clients requiring isolation precautions can develop several problems as a result of the separation from others and of the special precautions taken in providing their care. Two of the most common problems are: Sensory deprivation Decreased self-esteem related to feelings of inferiority (Berman et al., p. 695) 65 Sensory deprivation-occurs when the environment lacks normal stimuli for the client, for example, communication with others. Healthcare workers should be alert for common clinical signs, such as boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought disorganization, anxiety, hallucinations, and panic. (Berman et al., p. 695) 66 Take measures to improve the client’s sensory stimulation during isolation. Open the drapes or shades; make sure the environment is clean and pleasant; remove excess supplies and equipment; listen to the client’s concerns or interests. Do not appear rushed when providing care. Mealtime is a great time for conversation. Provide comfort measures, such as repositioning, a back massage, or a warm sponge bath to increase physical stimulation. If client’s condition warrants, encourage the client to walk around in the room or sit up in a chair. Discuss situation with family to encourage them to show support and to avoid negative expressions. (Potter & Perry, pp. 663664) 67 Decreased Self-Esteem A client’s feeling of inferiority can be due to the perception of the infection itself or to the required precautions. In North America, many people place a high value on cleanliness and the ideal of being “soiled,” “contaminated,” or “dirty” can give clients the feeling that they are at fault and substandard. The infected persons may feel unclean, rejected, lonely, or guilty. Although this is obviously not true, the infected persons may feel “not so good” --others may blame them for the illness or they may blame themselves. (Berman et al., p. 695) 68 Healthcare workers can prevent these two psychosocial problems or deal with them positively: Assess individual’s needs for stimulation Initiate measures to help meet the need, including regular communication with the client and diversionary activities: toys for a child, books, TV, or radio, music; provide a variety of foods to stimulate the sense of taste; stimulate the visual sense by providing a view or an activity to watch. (Berman et al., p. 695) 69 Explain the infection and associated procedures to help clients and their support people understand and accept the situation. Demonstrate warm, accepting behavior. Avoid conveying to the client any sense of annoyance about the precautions or any feelings of revulsion about the infection. Be very aware of your attitude and body language as you are providing care. Do not use stricter precautions than are indicated by the diagnosis or the client’s condition. (Berman et al., p. 695) 70 It is important that healthcare workers know & understand the following regarding isolation of clients & how to make it more effective. Before instituting isolation measures, nurses should help clients & their family understand: The nature of the disease or condition, Purposes of isolation Steps for carrying out specific precautions. If they are able to participate in maintaining infection prevention and control practices, the chances of reducing the spread of infection increases. Nurses teach the client & family to perform hand hygiene & use of barrier protection if appropriate. Important to teach how infectious organisms are transmitted so client/family can understand differences between clean and contaminated objects. (Potter & Perry, pp. 662-663) 71 72 The following slides will present information regarding to the Bloodborne Pathogens Standards. OSHA 73 What are bloodborne pathogens? Bloodborne pathogens are infectious microorganisms present in blood that can cause disease in humans. These pathogens include, but are not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the virus that causes AIDS. Workers exposed to bloodborne pathogens are at risk for serious or life-threatening illnesses. (OSHA, 2011) 74 Bloodborne Pathogens Standards state what employers must do to protect workers who are occupationally exposed to blood or other potentially infectious materials (OPIM), as defined in the standard. That is, the standard protects workers who can reasonably be anticipated to come into contact with blood or OPIM as a result of doing their job duties. (OSHA, 2011) 75 Bloodborne Pathogens Standards require employers to: Establish an exposure control plan. Employers must update the plan annually to reflect changes in tasks, procedures, and positions that affect occupational exposure, and also technological changes that eliminate or reduce occupational exposure. Implement the use of universal precautions. Identify & use engineering controls. Identify & ensure the use of work practice controls. Provide personal protective equipment (PPE), such as gloves, gowns, eye protection, & masks. (OSHA, 2011) 76 Exposure Plan This is a written plan to eliminate or minimize occupational exposures. The employer must prepare an exposure determination that contains a list of job classifications in which all workers have occupational exposure and a list of job classifications in which some workers have occupational exposure, along with a list of the tasks and procedures performed by those workers that result in their exposure. (OSHA, 2011) 77 Bloodborne Pathogens Standards requirements of employers: Make available hepatitis B vaccinations to all workers with occupational exposure. Make available post-exposure evaluation & follow-up to any occupationally exposed worker who experiences an exposure incident. Use labels & signs to communicate hazards. Provide information & training to workers. Maintain worker medical and training records. (OSHA, 2011) 78 Engineering Controls These are devices that isolate or remove the bloodborne pathogens hazard from the workplace. They include sharps disposal containers, selfsheathing needles, and safer medical devices, such as sharps with engineered sharps-injury protection and needleless systems. (OSHA, 2011) 79 Work Practice Controls These are practices that reduce the possibility of exposure by changing the way a task is performed, such as appropriate practices for handling and disposing of contaminated sharps, handling specimens, handling laundry, and cleaning contaminated surfaces and items. (OSHA) 80 Access the YouTube Video (10 minutes) to learn about 81 Berman, A., Snyder, S.J., Kozier, B., & Erb, G. (2008).Asepsis. In A. Berman, S.J. Snyder, B. Kozier, & G. Erb (Eds.). Kozier & Erb’s Fundamentals of nursing: Concepts, process, and practice (8th ed.) (pp. 668-709). Upper Saddle River, NJ: Prentice Hall Centers for Disease Control & Prevention. (2007). Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings. [Power Point] Retrieved from http://www.cdc.gov/ Juliar, K. (2003). Minnesota health care core curriculum, 2e. Clifton Park, NY: Delmar Publishing, Thompson Custom Publishing Kockrow, E.O.(2006). Medical/Surgical asepsis and infection control. In B.L. Christensen & E. O. Kockrow (Eds.). Foundations and adult health nursing (5th ed.) (pp. 270-314). St. Louis, MO: Elsevier, Mosby Occupational Safety & Health Administration. (2011, January). OSHA Fact Sheet: Bloodborne Pathogens Standard. Retrieved from www.osha.gov Potter, P.A. & Perry, A.G. (2009). Infection prevention and control. In P.A. Potter & A.G. Perry (Eds.). Fundamentals of nursing (7th ed.) (pp. 641-685). St. Louis, MO: Elsevier, Mosby Ramon, P.R. & Niedringhaus, D. M. (2008). Infection control and asepsis. Fundamental nursing care (2nd ed.) (pp. 149-176). Upper Saddle River, NJ: Person Prentice Hall 82