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Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Objectives
Infection Control in Doctors’ Offices
z Discuss
z Look
Jim Gauthier, MLT, CIC
Kingston, ON
Routine Practices
Need for additional precautions
z Post SARS lessons
z
office
at the issues of the physician’s
Regular cleaning, sanitizing
Disinfection
z Sterilization
z Risks
z
z
Hosted by Paul Webber
Sponsored by
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www.webbertraining.com
JohnsonDiversey
www.johnsondiversey.com
Jim’s Basics
Jim’s Basics
z We
are buggy people
z Our patients are buggy people
z Some have fancy names
z
Stenotrophomonas maltophilia
z Others
z
get the label “Superbug”
z Also
known as Standard Precautions
Adapted from Universal Precautions, and
Body Substance Precautions
z Premise:
assume all patients are
infectious
z
forget we need a mode of
transmission!
Hands
Equipment
z Coughing/Sneezing/Snorting
z
z
MRSA, VRE, C. difficile
Routine Practices
z
z Never
Blood and body fluids, excretions,
secretions or any object soiled with these
substances
Routine Practices - Hands
z Hand
z
Hygiene
Soap and water
Requires a minimum of 10 – 15 seconds to
adequately remove transient flora and soil
z Very technique dependent
z Red finger paint check!!
z
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
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Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Routine Practices - Hands
z Antibacterial
Soap
Routine Practices - Hands
z Hand
Triclosan, chlorhexidine, PCMX
z Used before invasive procedures
z Leaves residue on hands, can be irritating
z Routine in a General Practice?
z
z
z
Not sure!
z Alcohol
z
and C. difficile
Hands should be wet for 15 – 20 seconds
z
Gel vs. liquid formulations
z
For Physician and
staff
z
If hands soiled – WASH, don’t use alcohol
If no contact with feces is this still applicable?
z If contact with feces with gloves on, is this still
applicable?
z
z
z
The debate will continue!
z Is C. difficile there or not?
z
z
z
If TB, measles or
chickenpox is
suspected, an N95
or equivalent mask is
required.
If immune to
measles and chicken
pox, not required
I like to use two pumps of product
Routine Practices - Masks
Many authors and facilities are
recommending not to use alcohol if C.
difficile is suspected.
Routine Practices – Masks
If soiled, must wash!
z
z
Routine Practices - Hands
Sanitizers
Alcohol based products
z Easier on hands that soap and water
z Use on visibly clean hands
z
At minimum a
procedure mask or
surgical mask with
febrile, coughing
patients
Eye protection is
also necessary
Routine Practices – Masks
z
Ask patient to wear a
mask
z
z
Limits soiling of
environment
If not able, provide
tissues to cover
coughs and
sneezes
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
Page 2
Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Routine Practices – Gloves
z
z
Used for contact
with, or anticipated
contact with blood or
body fluids
Must be used
appropriately to
protect environment
Routine Practices – Gowns
z Used
if chance of soiling clothes
Plastic aprons
z Cover gowns
z
z Need
to be “single patient use”
Routine Practices – Gloves
z Keep
task specific
z Really not required if touching intact skin
z Wash or sanitize hands after removal
z Latex allergies on increase
z
z
Vinyl and Nitrile now more widely used
Neoprene also coming into it’s own
Additional or Transmission Based
Precautions
z Acute
Care has Contact, Droplet and
Airborne precautions
z Ongoing discussion to Non-acute
settings
Long term care
Complex continuing care
z Physician’s office
z
z
Contact Precautions - Organisms
z Methicillin
Resistant Staphylococcus
aureus (MRSA)
z Vancomycin Resistant Enterococci
(VRE)
z Clostridium difficile (CD)
z Antibiotic Resistant Organisms (ARO)
Contact Precautions – Acute Care
z Gown
and gloves for all contact with
patient
z
If patient is not soiling the environment, is
this necessary?
z
Any patient soiling the environment
z
z
z
Research indicates it does limit spread
Use gown, gloves, face protection
Clean in a standard manner (more later)
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
Page 3
Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Doctor’s Office
z Any
patient soiling the environment –
protect yourself
z
Waiting Room
z Screening
Fever and cough
z
Rash
Contact, droplet
suspicion of TB – mask them or
yourself – N95 or equivalent
z Hand hygiene before and after contact
with patient
z
z Any
z
z Immunocompromised
patients need
some space also
z Masking for them, as a routine, is
controversial
Many illnesses are from their own flora
z But, being coughed on does not help!
z
Office Equipment
z
z
z
z
Cleaning is very important for reusable
equipment
Single use equipment MUST be single
use
Need for disinfection or sterilization based
on equipment use
Disposable is best, if available
Mask Please!
Mask Please!
z Need
z
z
Waiting Room
still applicable
z
some space between patients
Move to an empty exam room
End of day visit
Patient with MRSA, VRE, etc.
z Some
recommendations to practice
Contact Precautions in Doctor’s offices
z
zI
Flag charts
am not so sure about the necessity
z
If not soiling the environment…
z Community
Acquired MRSA
Spaulding’s Classification
CLASS
USE
REPROCESSING
Minimum requirement
Critical
Sterile body site
or vascular
system
Semi-Critical Intact mucous
membranes or
non-intact skin
Cleaning followed by
sterilization
Non-Critical
Low or intermediate
disinfection
Intact skin
High Level
disinfection
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
Page 4
Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Cleaning
Sterilization
z Removes
dirt, body substances
z Dishwasher can be used for non-lumen
instruments
z Soap and water
z Enzymatic cleaners
z Done as soon after use as possible
Sterilization
z Chemicals
z Table
z
Daily? Weekly?
Tape only shows temperature was achieved
z Wrapping important if not being used right
away
z Trays for procedures available
z
Disinfection
(Cold Sterilization)
z High
Issue with toxicity and ventilation
z Storage of equipment after
z Time (usually hours)
z Rinse water should be sterile
z New products being introduced all the time
z http://www.fda.gov/cdrh/ode/germlab.html
z
z
Least Susceptible
SPORES
B. subtilis, C. tetani, C. difficile
High
top autoclaves
Must maintain
z Must challenge with biological indicator
z
MYCOBACTERIA
NON ENVELOPED VIRUS
M. tuberculosis
Poliovirus, Rotavirus,
Norovirus
FUNGI
Candida sp., Cryptococcus sp., Aspergillus sp.
VEGETATIVE BACTERIA
Level
Kills all microorganisms, with the exception
of high numbers of bacterial spores
Disinfection
z High
z
Kills all microorganisms, with the exception
of high numbers of bacterial spores
z Intermediate
z
Level
Kills M. tuberculosis, vegetative bacteria,
most viruses and fungi, but not spores
Staph. aureus, MRSA, VRE, Salmonella typhi,
coliforms, Pseudomonas aeruginosa
Most Susceptible
ENVELOPED VIRUSES
Herpes simplex, VZV, Hep. B&C, HIV, MMR
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
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Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
SPORES
Least Susceptible
B. subtilis, C. tetani, C. difficile
MYCOBACTERIA
NON ENVELOPED VIRUS
M. tuberculosis
Poliovirus, Rotavirus,
Norovirus
Intermediate
FUNGI
Candida sp., Cryptococcus sp., Aspergillis sp.
Disinfection
z High
z
z Intermediate
z
VEGETATIVE BACTERIA
Staph. aureus, MRSA, VRE, Salmonella typhi,
coliforms, Pseudomonas aeruginosa
Most Susceptible
Kills all microorganisms, with the exception
of high numbers of bacterial spores
Kills M. tuberculosis, vegetative bacteria,
most viruses and fungi, but not spores
z Low
z
Level
Kills vegetative bacteria, enveloped viruses
ENVELOPED VIRUSES
Herpes simplex, VZV, Hep. B&C, HIV, MMR
Least Susceptible
SPORES
B. subtilis, C. tetani, C. difficile
MYCOBACTERIA
NON ENVELOPED VIRUS
M. tuberculosis
Poliovirus, Rotavirus,
Norovirus
FUNGI
Methodology
z Sterilization
is preferred over High
Level Disinfection if tolerated or
available
z
Candida sp., Cryptococcus sp., Aspergillis sp.
Low
Most Susceptible
Margin of safety
VEGETATIVE BACTERIA
Staph. aureus, MRSA, VRE, Salmonella typhi,
coliforms, Pseudomonas aeruginosa
ENVELOPED VIRUSES
Herpes simplex, VZV, Hep. B&C, HIV, MMR
Disinfection
z Usually
Bleach
done with liquid chemicals
Bleach, hydrogen peroxide, alcohol most
common, glutaraldehyde has ventilation
issues
z Quats are mainly for cleaning, or low level
disinfection
z
z Low
z
to intermediate disinfection
Some evidence it will kill spores with high
concentrations and long contact time
z Corrosive
z Inactivated
by organic matter
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
Page 6
Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Alcohol
z Low
z
Hydrogen Peroxide
to intermediate disinfection
Thermometers, stethoscope
z 3%
- low level
z 6% or Accelerated Hydrogen Peroxide
z Flammable
z
z Not
z
effective against some nonenveloped viruses
z 7%
z
Quaternary Ammonium Compounds
z Low
level
z Floors, surfaces
Intermediate to high level
Depends on contact time and concentration
range
Sterilant in 2 – 6 hours
Fixed Equipment
z Exam
z
z
z
z Waiting
Room
Clean at end of every day
z Surfaces must be able to be wiped
z Magazines should be disposed of if appear
soiled
z
Routine
Between patients?
If soiled, written procedure in place
z
Fixed Equipment
tables
Change covering between patients
z Need for “wiping”
z
Clean, then disinfect
Toys
z Hmmm,
z Clean
z
what to do??
after use?
Sanitize with freshly prepared bleach
solution or spray with disinfectant that
leaves no residue (hydrogen peroxide
agents – check label)
z No
cloth or plush toys!
stations should be wiped down daily
z Play
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
Page 7
Infection Control in Doctors’ Offices
Jim Gauthier, MLT, CIC
Sponsored by JohnsonDiversey (www.johnsondiversey.com)
Staff
Staff
z Immunizations
up to date
MMR
z Tetanus
z Varicella
z Hepatitis B (if possibility of blood exposure)
z Annual influenza vaccination
z Pneumovax for at risk
z
z Need
to have written exposure protocol
z Check with Infectious Disease expert
z Check with Medical Officer of Health
z
http://www.cpso.on.ca/Publications/publications.htm
November 2005 Teleclasses
Wrap Up
For more information, refer to
www.webbertraining.com/schedule.cfm
z Assume
every patient has left you a
present
z Assume every patient can make you or
your next patient sick
z We cannot perform too much hand
hygiene!!
November 15 – UK Teleclass – ESBL Management
Presented by Dr. Graham Harvey
Sponsored by JohnsonDiversey (www.johnsondiversey.co.uk
December 1 – Preventing Ventilator Assisted Pneumonia
Presented by Dr. Robert Garcia
Sponsored by Sage Products (www.sageproducts.com)
December 8 – Bloodborne Pathogen Control in the Community
Presented by Dr. Jun Wu
December 15 – C. difficile: Environmental Survival
Presented by Dr. Michelle Alfa
Sponsored by Virox Technologies (www.virox.com)
Questions?
Contact Paul Webber [email protected]
A Webber Training Teleclass
Hosted by Paul Webber [email protected]
www.webbertraining.com
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