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5/23/2017 INFECTION CONTROL Annual Review Topics: OSHA Standards Isolation Review Multiply Resistant Organisms Emerging Pathogens JCAHO Patient Safety Goal #7 Bioterrorism 5/23/2017 OSHA STANDARDS Bloodborne Pathogens Tuberculosis 5/23/2017 Bloodborne Pathogens Hepatitis B Hepatitis C HIV 5/23/2017 Sharps Safety Devices Required by OSHA Designed to prevent needlestick and sharps exposures May include retractable needles, resheathing devices, or cover shields Selection of devices is partly based on input from the user. 5/23/2017 Sharps Safety Always wear gloves when handling sharps. Never bend, break or recap a needle. Activate the safety feature before disposal. Dispose of sharps into an approved container immediately, as close to the point of use as possible. Never force items into the container. EMS should replace the liner when 3/4 of the way full. 5/23/2017 Types of Exposures Blood-to-blood contact through a sharps or needlestick injury Splash exposure to mucous membrane or non-intact skin 5/23/2017 Exposure Protocol Immediately wash affected area with soap and water. Notify your supervisor and report to Employee Health ASAP. Off tours and weekends: Urgent Care (WP) Nursing Supervisor (BV). If known source, patient will be tested for HBV, HCV and HIV (informed consent required). 5/23/2017 Post-Exposure Prophylaxis Employee Health will evaluate the level of risk and determine the need for postexposure prophylactic medication (PEP). If employee is not immune to HBV, a dose of vaccine or hepatitis B immune globulin may be appropriate. No PEP is indicated for Hepatitis C exposure. Must follow-up with Employee Health. 5/23/2017 Tuberculosis 5/23/2017 High-risk Groups HIV+ History of IV drug use Close contacts of a person with active TB Homeless people Residents of long-term care facilities, shelters, mental institutions, prisons Chest x-ray consistent with TB Immigrants or people born in highprevalence areas 5/23/2017 Medical Factors Increasing the Risk of Active TB Diabetes Mellitus Silicosis >10% below ideal body weight Chronic renal failure Immunosuppressive therapy Hematologic disorders Other malignancies 5/23/2017 Symptoms of TB Fever and chills Night sweats Loss of appetite Unexplained weight loss Productive cough Bloody sputum Elevated WBC count 5/23/2017 How is TB Transmitted? Usually a pulmonary disease, transmitted through the air by tiny particles called droplet nuclei. Can be spread when a person with active disease coughs, sings, sneezes, laughs, etc. Healthcare workers are at higher risk due to possible exposure to sick patients. Appropriate isolation precautions must be followed. 5/23/2017 Airborne Isolation -TB Known or suspected cases should be placed in a negative pressure room. HCW must verify negative pressure Some outpatient areas have portable HEPA filter fans to be used prior to transfer. Respiratory Hygiene and Cough Etiquette: Instruct patient to cover his/her cough, or wear surgical mask. Employee must wear N-95 Particulate Respirator (fit-testing required by OHSU) 5/23/2017 TB Screening PPD skin test is the preferred method of screening. Required annually of all Medical Center employees. Required upon admission and annually for all long-term care patients. RNs must be trained to administer and interpret PPDs within the VA. 5/23/2017 Latent TB vs. Active TB A positive PPD skin test indicates that there was an exposure to TB at one time. Most cases of latent (inactive) TB never progress to active disease, but the skin test usually remains positive for life. Prophylactic treatment may prevent active TB from ever developing. 5/23/2017 Influenza Flu season is October through March. Vaccination is strongly recommended. No risk of getting the flu from the flu shot. Available for patients 10/15/03 Available for employees 11/1/03 Refer to Flu Plan in public drive. 5/23/2017 Isolation Precautions Standard Precautions - Use for all patients. All body fluids/substances considered potentially infectious. Use appropriate personal protective equipment (PPE). 5/23/2017 Personal Protective Equipment Gloves Gowns Masks Goggles Face Shield 5/23/2017 PPE - Gloves Wear gloves when contact with blood/body fluids, mucous membranes, or non-intact skin could occur. Change gloves when moving from a contaminated body site to a clean body site. Remove gloves after caring for a patient. Decontaminate your hands after gloves are removed! 5/23/2017 PPE - cont. Don PPE prior to patient contact Remove PPE at point of use, before leaving the area Observe proper technique to prevent contamination DECONTAMINATE hands after PPE removal 5/23/2017 Isolation Precautions Transmission - Based Precautions Airborne - TB, Chickenpox Droplet - MRSA pneumonia Contact - VRE, C. Difficile 5/23/2017 Contact Precautions Private room or cohort when possible. Private or designated bathroom. Wear gloves when entering room; other PPE as needed. Clean and disinfect all equipment before use with another patient. Hang stop sign outside door. 5/23/2017 Multiply Resistant Organisms MRSA VRE C. Difficile Other resistant organisms 5/23/2017 MRO-cont. Contact isolation - private room or cohort if necessary. Be aware of environmental contamination Target antibiotic therapy 5/23/2017 At your hospital, what percentage of Staph aureus isolates are resistant to methicillin? 1. <5% 2. 15% 3. 20% 4. 30% 5. >50% 5/23/2017 Colonized or Infected: What is the Difference? People who carry bacteria without evidence of infection (fever, increased white blood cell count) are colonized If an infection develops, it is usually from bacteria that colonize patients Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers ~ Bacteria can be transmitted even if 5/23/2017 the patient is not infected ~ The Iceberg Effect Infected Colonized 5/23/2017 Vancomycin-Resistant Enterococcus (VRE) Most often associated with antibiotic use. Colonization is asymptomatic. Diagnosis can only be made with a VRE culture. Requires contact isolation and weekly specimens until there are three consecutive negative cultures. History of VRE-isolate on admission . No treatment for colonization. 5/23/2017 Recovery of VRE from Hands and Environmental Surfaces Up to 41% of healthcare worker’s hands sampled (after patient care and before hand hygiene) were positive for VRE1 VRE were recovered from a number of environmental surfaces in patient rooms VRE survived on a countertop for up to 7 days2 1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065. 5/23/2017 2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581. The Inanimate Environment Can Facilitate Transmission X represents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. 5/23/2017 Clostridium Difficile (C. Diff.) Also associated with recent exposure to antibiotics. Symptoms usually include diarrhea and abdominal cramping. Recommended treatment is oral metronidazole (Flagyl) x10 days. Requires contact isolation until symptoms resolve (usually within a few days of treatment). 5/23/2017 Emerging Pathogens SARS West Nile Smallpox Monkeypox To be announced….. WWW.CDC.GOV 5/23/2017 JCAHO Patient Safety Goal #7 Reduce the Risk of Health Care-Acquired Infections CDC Hand Hygiene Guidelines Sentinel Events Related to Infections 5/23/2017 CDC Guideline for Hand Hygiene in Health-Care Settings Published in October 2002 Provides recommendations for hand hygiene among healthcare workers Addresses alcohol-based hand rubs (gel, foam, etc.) 5/23/2017 “Hand washing is generally considered to be the most important measure in preventing the spread of infection.” “Hands should be washed before significant contact with any patient and after activities likely to cause contamination.” 5/23/2017 So Why All the Fuss About Hand Hygiene? Most common mode of transmission of pathogens is via hands! Infections acquired in healthcare Spread of antimicrobial resistance 5/23/2017 Definitions Hand hygiene • Performing handwashing, antiseptic handwash, alcoholbased handrub, surgical hand hygiene/antisepsis Handwashing • Washing hands with plain soap and water Antiseptic handwash • Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub • Rubbing hands with an alcohol-containing preparation Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; 5/23/2017 vol. 51, no. RR-16. Definitions Hand decontamination • Performing handwashing using antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis Surgical hand hygiene/antisepsis • Use antiseptic handwash or an alcohol-based handrub with persistance before operations by surgical personnel Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; 5/23/2017 vol. 51, no. RR-16. Indications for Hand Hygiene When hands are visibly dirty, contaminated, or soiled, wash with nonantimicrobial soap and follow with decontamination using alcohol-based handrub if situation dictates; or use antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol.5/23/2017 51, no. RR-16. Specific Indications for Hand Decontamination Before: • Patient contact • Donning gloves when inserting a CVC • Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery Guideline 5/23/2017for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. Specific Indications for Hand Decontamination After: • Contact with a patient’s skin • Contact with body fluids or excretions, nonintact skin, wound dressings • Contact with the environment/equipment in patient room/area • Removing gloves Guideline 5/23/2017for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Plain Soap Antimicrobial soap 5/23/2017 Best Alcohol-based handrub Alcohol-Based Hand Rubs Require less time Can be strategically placed Readily accessible Multiple sites All patient care areas 5/23/2017 Alcohol-Based Hand Foam Dispense a golf ball-sized amount of foam, covering all surfaces of both hands, and rub in until dry. Preferred method of hand hygiene when hands are not visibly soiled. 5/23/2017 Time Spent Cleansing Hands: one nurse per 8 hour shift Hand washing with soap and water: 56 minutes – Based on seven (60 second) handwashing episodes per hour Alcohol-based handrub: 18 minutes – Based on seven (20 second) handrub episodes per hour ~ Alcohol-based handrubs reduce time needed for hand disinfection ~ 5/23/2017 Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208. Summary Alcohol-Based Handrubs: What benefits do they provide? Require less time More effective for standard handwashing than soap More accessible than sinks Reduce bacterial counts on hands Improve skin condition 5/23/2017 Hand Washing (15 seconds of friction) Non-antimicrobial lotion soap: Use only to wash if hands are soiled or visbly dirty. FOLLOW WITH ALCOHOL-BASED HANDRUB IF HANDS NEED TO BE DECONTAMINATED! Antimicrobial soap: Use to decontaminate hands, clean hands when visibly soiled, and when caring for a patient with Clostridium difficile 5/23/2017 Routine Hand Wash 5/23/2017 Repeat procedures until hands are clean Can a Fashion Statement Harm the Patient? % Recovery of gram negative bacteria 40 Natural (n=31) Artificial (n=27) Polished (n=31) 35 30 ARTIFICIAL 20 10 10 0 5 POLISHED NATURAL p<0.05 Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for high risk patients (ICU, OR) 5/23/2017 Edel et. al, Nursing Research 1998: 47;54-59 Artificial Nails Associated with outbreaks in healthcare due to bacterial and fungal contamination. Artificial nails are prohibited in high-risk areas; strongly discouraged for anyone providing patient care. No chipped nail polish. Natural nails should be kept less than 1/4 inch long. 5/23/2017 What is the Story on Moisturizers and Lotions? ONLY USE facility-approved and supplied lotions Because: Some lotions may make medicated soaps less effective Some lotions cause breakdown of latex gloves Lotions can become contaminated with bacteria if dispensers are refilled ~ Do not refill lotion bottles ~ 5/23/2017 Surveillance Activities Line-related bacteremias Ventilator-associated pneumonia Surgical wound infections Resistant organisms- C. difficile UTIs in nursing home 5/23/2017 Surveillance- cont. Notify Infection Control of any increased incidence of infections. If you are sick, report to Employee Health before coming to work. Report to Infection Control any adverse patient outcomes related to infection. 5/23/2017 Sentinel Event All cases of unanticipated death or permanent loss of function associated with a health care-acquired infection. Notify Infection Control if you are aware of any cases. 5/23/2017 Bioterrorism 5/23/2017 All employees should be aware of the Hospital Bioterrorism Plan. 5/23/2017 Significant agents of bioterrorism Anthrax Smallpox Plague Tularemia Viral Hemorrhagic Fevers Botulism 5/23/2017 Anthrax Caused by bacillus anthracis bacteria May cause inhalational, cutaneous or gastrointestinal disease. Transmitted by inhaling or handling spores, but not transmitted person-to-person. Antibiotic treatment is necessary. 5/23/2017 Smallpox Caused by variola virus Last case identified in 1977; declared eradicated in 1980. Person-to-person transmission through contact or airborne route is likely. Smallpox vaccine is available, but only to be used if there is an identified risk. Treatment is supportive care. 5/23/2017 Smallpox Vaccine Made with vaccinia virus, another orthopox virus similar to variola. Causes the body to produce antibodies which protect against all orthopox viruses. This is a live virus vaccine, so the vaccination site must be cared for to prevent the virus from spreading. Many contraindications. 5/23/2017 Plague Bacterial infection that causes bubonic or pneumonic disease. Most commonly transmitted through infected fleas or infected animal tissues. Antibiotic treatment effective when administered early. 5/23/2017 Fortunately, most illnesses caused by potential bioterrorist agents are treatable when promptly diagnosed. Early recognition is the key! 5/23/2017 When you suspect bioterrorist activity, immediately call the VA Police by dialing 2222! 5/23/2017 For more information on bioterrorism, see the Bioterrorism Module located on the public drive in the Infection Control Education folder. http://www.cdc.gov 5/23/2017 Questions? Contact Infection Control Wade Park: ext 4791/4792 Brecksville: ext 6571 5/23/2017