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INFECTION PREVENTION PART I MARIANNE LAFF, APN STUDENT HEALTH Infection Prevention Welcome to the Infection Prevention Course. This course has been developed to help prevent the Healthcare associated spread of contact, droplet, and airborne transmitted diseases by providing you with information on: Part I- included in this presentation: •Standard Precautions •Personal protective equipment •Contact, droplet, and airborne precautions •Proper procedure for Donning •Proper procedure for Doffing Part II Interprofessional Education- scheduled at a later time: •View patient care video on Hand washing, Hospital acquired infection, & Donning/Doffing •Review proper procedure for Donning and Doffing •Return demonstration that will take place in the simulation lab. You will be scheduled at a later time for Part II. In the simulation lab you will work with another student or “buddy” and demonstrate correct Hand Hygiene with alcohol based gel and soap and water; and donning and doffing of gloves, masks, and gowns. •There are 52 slides followed by a 20 question post-test INFECTION PREVENTION OBJECTIVES PART I 1. Define Standard precautions and the utilization of the appropriate Personal Protective Equipment (PPE) for the presenting patient scenario. 2. Differentiate between Contact, Droplet, & Airborne precautions. 3. Recall how pathogens are transmitted through contact, droplet, & airborne infections. 4. Know the correct order to Don & Dof PPE. INFECTION PREVENTION OBJECTIVES PART II Group discussion stating how the visitor, new nurse, Nurse Dena at nurses station, Infection Prevention Nurse, medical student, and the Director of Post-op could have prevented the transmission of MRSA. Return demonstrate the correct process to Don PPE using the “buddy system” and checklist. Return demonstrate the correct process to Dof PPE using the “buddy system” and checklist. Return demonstrate the correct hand washing technique. Standard Precautions Standard Precautions (SP) previously called Universal Precautions are Infection Prevention practices that apply to all patients regardless of suspected or confirmed infectious status. This means that all blood and body fluids are treated as if they are infectious. This includes: •blood, all body fluids, secretions and excretions(except sweat) whether or not they contain visible blood. SPs are used to prevent contact with blood & body fluids with your non-intact skin (healthy intact skin is the best natural defense against blood borne pathogens) with your mucous membranes on Equipment or surfaces that have blood, or body fluids, or microorganisms on them that you may not see Standard Precautions Main foundations of Standard Precautions are: Hand hygiene- Before and after every patient contact Use of PPE based on risk assessment Clean/safe environment/safe disposal or cleaning of instruments and linen Safe injection practices Respiratory hygiene/cough etiquette- Patients and visitors should cover their nose or mouth when coughing, promptly dispose used tissues and practice hand hygiene after contact with respiratory secretions PPE for Standard Precautions (1) • Gloves – Use when touching blood, body fluids, secretions, excretions, or contaminated items and for touching mucus membranes and nonintact skin. • also reduces the transmission of microorganisms on the hands of hospital staff to patients; • reduces the chance of skin colonization of healthcare workers from a patient who is infected. • Gowns – Should be used during procedures and patient care activities when contact of clothing &/or exposed skin with blood, body fluids, secretions, or excretions is anticipated. PPE Use in Healthcare Settings PPE for Standard Precautions (2) • Mask and goggles or a face shield – Protects healthcare workers from infectious material from patients and should be used during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. • They also protect patients undergoing sterile procedures from respiratory aerosols from the healthcare worker. • They also limit spread of infectious respiratory secretions from patients who are coughing. PPE Use in Healthcare Settings Standard Precautions Be Proactive Handle all blood and body fluids with gloves. Perform hand hygiene before and after contact with the patient or their environment. Perform hand hygiene after removing gloves (as gloves may have small defects or tears that are not apparent, and hands routinely become contaminated during removal of gloves). Remove gloves and perform hand hygiene upon ending patient care or contact with their environment and before proceeding to the next patient care/environment. Wear a mask and eye shield when splashes to the face may occur. Wear a gown if soiling of clothes may occur. No eating or drinking in patient care areas. Misty green scrubs must be covered with a buttoned lab coat when leaving unit where they are worn. Perform hand hygiene: The most effective method of preventing the spread of infection is practicing hand hygiene. Before donning gloves and wearing PPE on entry to the isolation room/area. Before any clean/aseptic procedures being performed on a patient. After any exposure risk or actual exposure with the patient’s blood and body fluids. After touching (even potentially) contaminated surfaces/items/equipment in the patient’s surroundings. After removal of PPE, upon leaving the patient care area. Hand hygiene How to perform hand hygiene: Clean your hands by rubbing them with an alcohol based formulation, as the preferred means for routine hygienic hand antisepsis if hands are not visibly soiled (EXCEPT in the setting of Clostridium difficile) It is faster, more effective, and better tolerated by your hands than washing with soap and water. Wash your hands with soap and water when hands are visibly dirty or visibly soiled with blood or other body fluids including infectious diarrhea i.e. c.diff (in order to remove the spores), norovirus How to handrub Handrubbing must be performed by following all of the illustrated steps. Remember to include under fingernails and rings! This takes only 20–30 seconds! WHO (2014) Key Measures for Prevention and Control of Ebola Virus Disease How to handwash Handwashing must last 20 seconds and should be performed by following all of the illustrated steps. WHO (2014) Key Measures for Prevention and Control of Ebola Virus Disease Hand Hygiene- Most important strategy in preventing infection in yourself & others • Before and after contact with patient or environment • Before and after wearing gloves • After contact with body fluids, mucous membranes, non-intact skin or wound dressings • When moving from a contaminated to a clean body site WHO (2014) Key Measures for Prevention and Control of Ebola Virus Disease Personal Protective Equipment (PPE) The goal of PPE in the Healthcare setting is to improve personnel safety and prevent employee exposures to hazardous body fluids, waste, materials and disinfectants. PPE definition by OSHA are “specialized equipment worn to minimize exposure to materials”. OSHA requires employers to protect their employees from workplace hazards. CDC recommends when, what, and how to use the PPE. Personal Protective Equipment (PPE) Key Points Know what type of PPE is necessary for the duties you perform and use it correctly Factors influencing the PPE selection depends on the: •Type of exposure anticipated: • Touch • Splash/spray •Category of isolation • Contact • Droplet • Airborne Standard Precautions: Use of PPE based on risk assessment 17 | Key Measures for Prevention and Control of Ebola Virus Disease PPE for Standard Precautions • Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin. Change gloves if they are torn or heavily soiled and after use on each patient. • Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated. PPE Use in Healthcare Settings Face Protection A combination or PPE types is available to protect all or parts of the face. The selection is determined by the type of isolation precaution for the patient and nature of the contact ie. procedure that may cause a splash or aerosol. •Masks – protect nose and mouth – Should fully cover nose and mouth and prevent fluid penetration •Goggles – protect eyes – Should fit snuggly over and around eyes – Personal glasses not a substitute for goggles – Antifog feature improves clarity PPE Use in Healthcare Settings Face Protection • Face shields – protect face, nose, mouth, and eyes – Should cover forehead, extend below chin and wrap around side of face PPE Use in Healthcare Settings Key Points About PPE • Don (put on) 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 PPE Use in Healthcare Settings 3 Expanded (Isolation) Precautions In addition to consistent use of Standard Precautions, there are 3 isolation categories that reflect the major modes or microorganism transmission in nosocomial settings. They are: Contact Droplet & Airborne Isolation The rooms of these patients should be clearly marked with a sign on the door with the type of isolation and instructions regarding the type of precautions that must be observed. An isolation cart will be outside of the patient room with ample supplies that are readily available. Contact Infection Transmission Direct CONTACT Transmission- The infected person makes direct body surface to body surface contact with a host. Indirect CONTACT Transmission occurs when: Body surface to body surface contact via an inanimate object when: 1.The infected person contaminates an object ie. bedding, needle, dressing, equipment then 2.The host makes contact with the contaminated object or 3.There is a physical transfer of the infections organism from the object to the host. Expanded (Isolation) Precautions Contact Isolation- prevents contact transmission. Contact Isolation: Applies to patient with any of the following conditions and/or diseases: Stool incontinence/Enteric infections (may include norovirus, rotavirus or Clostridium difficile C.Diff, E. coli) Viral infections (RSV, HSV, enterovirus, parainfluenza) Draining wounds, uncontrolled secretions, pressure ulcers, ostomy tubes and/or bags draining body fluids (Especially Staphylococcus aureus and group A streptococcus) Presence of generalized rash or exanthems; scabbies, impetigo Colonization of any bodily site with multidrug-resistant bacteria (MRSA, VRE) You must use soap and water to remove C. diff spores(alcohol based gel will not remove the C. diff spores) In addition to Standard Precautions: PPE: Gloves upon entering room & gown (if clothing may come contact with the patient or environmental surfaces, or if the patient has diarrhea) Private room for the patient is preferred; cohorting allowed if necessary. Contact Precautions Wash hands with soap and water before entering and after leaving the patient’s room Gloves required upon entering the room. Change gloves after contact with contaminated secretions. Perform hand hygiene- (Wash hands with soap and water if patient has C. diff) Remove gloves before leaving the room then immediately perform hand hygiene. After hand hygiene make certain not to touch the patients environment. Gown required if clothing may come into contact with the patient or environmental surfaces, or if the patient has diarrhea or condition/disease mentioned. Remove before leaving the patient’s room. Place patient in a gown during transport to minimize environmental contamination. Droplet Infection Transmission Droplet transmission occurs when relatively large (larger than 5 micron) respiratory droplets containing an infectious organism are propelled a short distance (usually only up to 3 feet) and land on the mucous membranes (eyes, nose, or mouth) of a host. Respiratory droplets are generated during: •Coughing, sneezing, talking •During procedures ie. Suctioning & bronchoscopy Note: A few organisms (eg. Some respiratory viruses) can be transmitted by droplets and via direct patient contact. In this setting, both droplet & contact isolation is needed. Expanded (Isolation) Precautions Droplet isolation- prevents droplet transmission. In addition to Standard precautions: PPE: Regular yellow earloop surgical mask (due to relatively large droplet size), gloves, gown, face shield- if anticipate spraying of respiratory secretions. Private room for the patient Regular mask on patient when transported Prevents transmission via droplets of Influenza, Meningitis, Pertussis, Resp. Syncytial Virus (RSV), group A strep, Invasive Haemophillus influenzae type B, diphtheria, Mycoplasma pneumoniae, pneumonic plague Healthcare workers within 6-10 feet of patients on droplet precautions should wear a mask. Airborne Infection Transmission Airborne transmission occurs when tiny respiratory droplet nuclei (smaller than 5 micron) containing an infectious organism are propelled in the air. These droplet nuclei can travel for long periods of time, traveling long distances on air currents. Transmission occurs when droplet nuclei are inhaled. The nuclei droplets are generated during: talking, laughing, coughing, or sneezing procedures involving the respiratory tract such as suctioning, intubation, or bronchoscopy. Expanded (Isolation) Precautions Airborne isolations- prevents airborne transmission.In addition to Standard Precautions: PPE: N-95 respirators (due to small nuclei size) for staff; gloves, gown, goggles or face shield if anticipate spraying of respiratory fluids Private room with negative pressure AIIR(airborne infection isolation room) Regular mask on patient being transported (exception Ebola) Prevents transmission of: TB, Chickenpox (until lesions are crusted over), Severe Acute Resp. Syndrome (SARS), and Varicella Zoster(localized in immunocompromised patient) or disseminated (until lesions are crusted over), Measles, and Aspergillus. Because of Ebola’s high mortality rate, high viral load to low infectious dose, airborne isolation is used (PAPR full body suit; no exposed skin) ( .,.. . . " ) : , . . . ........... . '·The paUent in the next bed is highry infectious. Thank God ror these curtains;ti ,_,......,,,,,,,,,.,....,.,. _..,,,.,.,.w_,.,....,,.._ . . _ _.,....,.,.w..,..........,.,._ . • .• . When using PPE Don PPE before contact with the patient & before entering the room Avoid touching or adjusting PPE Remove gloves if they become torn or damaged Change gloves between patients Perform hand hygiene before donning new gloves and after doffing PPE Avoid touching your eyes, mouth, or face with gloved or ungloved hands Remove & discard PPE carefully then immediately perform hand hygiene PPE soiled with blood or body fluids must be removed before leaving the work area. Discard bloody scrubs into the soiled linen container. Donning PPE The next 8 slides will review the sequence and correct technique to Don (Put on) PPE Sequence for putting on (DONNING) Personal Protective Equipment (PPE) Hand Hygiene Gown- fully cover torso from neck to knees, arms to end of wrists, wrap around the back, fasten in back of neck and waist Mask or Respirator Goggles or Face Shield (if indicated) - place over face and eyes and adjust to fit Gloves- to cover wrist of isolation gown Keep hands away from face Limit surfaces touched Change gloves when torn or heavily contaminated then perform hand hygiene How to Don a Gown • 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 PPE Use in Healthcare Settings Correct Mask technique For the Yellow surgical mask: Take out a face mask from the box and inspect it for rips or holes. If you notice the mask is ripped or torn, throw it out and select another one. Hold the mask by the ear loops and place the loops over your ears. Verify which sides are the top and front of the mask. The part of the mask with a stiff bendable edge or metal strip is the top. The brighter yellow side of the mask faces outward, while the lighter yellow side is against your face. Pinch the metal strip, or stiff edge, of the mask so it molds to the shape of your nose. Pull down the mask's bottom so it covers your mouth and chin. h e l p ful w h e n a s k I o r p o s it i o ,n . f hair or jewelry mask headband Le mask seal is Jr air leaks. a comf ortable s with the mask , a fit-test by the style and is best f or you. r- Small ah leaks ue present even when the su:rglal/ pn>eedare mask ispn>pe:rly -worn.. 41 N 95 Respirator Mask For the N95 mask (filtering capacity of 95% of airborne particles): Select the size that you were fitted for. Take out the mask and inspect it for rips or holes. Separate the edges to fully open it. Slightly bend the nose wire to form a gentle curve. Hold the mask upside down to expose the 2 headbands. Separate and pull the headbands up over your head. Release the lower headband and position it at the base of our neck. Position the remaining headband on the crown of your head (See photo next slide). Conform the nosepiece across the bridge of your nose by firmly pressing down with your fingers. Continue to adjust the respirator and secure the edges until you feel you have achieved a good facial fit. Take a few deeps breaths in and out to check for a leak, adjust if necessary. If a mirror is not available, ask another healthcare professional to confirm correct mask placement. If you do not put your N95 on correctly, it won’t be as protective for you as it should be. If you have a large mustache, goatee, or beard, you cannot use the N95 mask for airborne exposure protection. You will need to use a PAPR (powered air purifying respirator) hood to protect you. r o p e r ly w e a r a n N -95 m a s k Step 8:Next release the upper e headband over the top back of yo The top headband ho .ds the Illasl in proper position. Step 9: Us fingers to co nose wire to of the rniddl face by prest mask down your nose w fingers. Adj --- - -l - - - -- • 1 -- How to Don Eye and Face Protection • Position goggles over eyes and secure to the head using the ear pieces or headband. Googles should feel snug but not tight. • Position face shield over face and secure on brow with headband • Adjust to fit comfortably PPE Use in Healthcare Settings How to Don Gloves The last of PPE to be donned is a pair of gloves. •Don gloves last •Select correct type and size that best fits you. •Insert hands into gloves.Adjust as needed •Extend gloves over isolation gown cuffs PPE Use in Healthcare Settings Doffing PPE The next 6 slides will review the sequence and correct technique to Dof (remove) PPE Sequence for Removing (Doffing) PPE Gloves- hand hygiene between steps if hands become contaminated Goggles or face shield (if used) - outside of goggles or face shield is contaminated! Gown- front of gown and sleeves are contaminated! Mask or respirator- front is contaminated! Hand hygiene- immediately after removing all PPE and between steps if hands become contaminated. “Contaminated” and “Clean” Areas of PPE To remove PPE Safely, you must first be able to identify what sites are “contaminated” or “clean” •Contaminated –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. •In general, the outside front and sleeves of the isolation gown and outside front of the goggles, mask respirator, face shields & gloves are considered contaminated. •Clean – Areas of PPE that are not likely to have been in contact with the infectious organism. • Inside of gloves; inside and back of the gown including ties; ties, elastic or ear pieces of the mask, goggles and face shield. PPE Use in Healthcare Settings Where to Remove PPE • 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 PPE Use in Healthcare Settings Sequence for Removing (Doffing) PPE Gloves- hand hygiene between steps if hands become contaminated Goggles or face shield (if used) - outside of goggles or face shield is contaminated! Gown- front of gown and sleeves are contaminated! Mask or respirator- front is contaminated Hand hygiene- immediately after removing all PPE How to Remove Gloves (1) • Grasp outside edge near wrist • Peel away from hand, turning glove inside-out • Hold in opposite gloved hand PPE Use in Healthcare Settings How to Remove Gloves (2) • Slide ungloved finger under the wrist of the remaining glove • Peel off from inside, creating a bag for both gloves • Discard PPE Use in Healthcare Settings Remove Goggles or Face Shield • Grasp ear or head pieces with ungloved hands • Lift away from face PPE Use in Healthcare Settings • Place in designated receptacle for reprocessing or disposal Removing Isolation Gown • Unfasten ties • Peel gown away from neck and shoulder • Turn contaminated outside toward the inside PPE Use in Healthcare Settings • Fold or roll into a bundle Hand Hygiene • 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 PPE Use in Healthcare Settings Conclusion I hope this course has been both informative and helpful. Please exit the course and take the mandatory postassessment test in myLUMEN > myExams/Quizzes, InfectionPrevention_InterPro_PCM1_2017. You will be notified when you will be required to participate in Part II- Interprofessional Education. References • • • CDC.gov CDC.gov. PPE use in Health Care settings CDC.gov > Ebola update > For Healthcare Workers > Medscape: PPE Donning & Doffing Demonstration N95/Gown • OSHA.gov/publications/OHSA3151.html • WHO (2014) Key Measures for Prevention and Control of Ebola Virus Disease • 2014 Up to date:General principles of infection control