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1 INFECTION CONTROL DEFINITIONS Antibacterial ~ containing chemical agents that reduce or inhibit microbes Blood ~ blood or blood products including serum, packed cells, and plasma Body Substances ~ any body fluid, secretion, or excretion, including, but not limited to, urine, feces, amniotic fluid, joint fluid, cerebrospinal fluid, wound drainage, saliva, and breast milk Communicable Disease ~ disease that can be transmitted directly or indirectly from one person to another Community-Acquired Infection ~ infection acquired by a resident prior to admission to a medical facility; infection that develops as a result of day-to-day interaction in the community Conjunctivitis ~ highly contagious infection of the membrane which lines the eyelid; usually bacterial or viral Contamination ~ introduction of disease germs or infectious material onto a clean or sterile surface Disinfection ~ process of using chemical agents to kill most infectious organisms, with the exception of bacterial spores and some viruses Environmental Surface ~ items in the physical environment with which residents and staff may routinely come in contact Ethylene Oxide ~ chemical used to sterilize heat-sensitive or delicate equipment that cannot be steam-autoclaved Iatrogenic ~ induced by a physician or more loosely caused by medical care Immunization ~ process of protecting an individual from a known disease using a vaccine to stimulate antibody production Implantable Device ~ sterile medical device introduced into a resident using an invasive procedure and remaining in the resident for a period of time Intravascular Device ~ sterile device that enters the bloodstream or through which blood flows Invasive Procedure ~ procedure requiring entry into the body or sterile tissue of a resident Nosocomial Infection ~ infection developed after treatment by or admission to a medical facility; healthcare-associated infection that develops as a result of or is directly related to a facility stay Pathogen ~ microorganism or substance that can cause disease PPE ~ Personal Protective Equipment worn by healthcare workers to protect them from exposure to blood or other infectious body substances, including gloves, goggles, mask, gown, apron, face shield Spore ~ thick-walled reproductive form of an infectious agent capable of withstanding unfavorable environmental conditions like drying and extremes of temperature Sterilization ~ process of killing all vegetative microorganisms as well as spores by exposure to heat, steam, or chemical agents Suppressed Immune System ~ decreased response or capability of white blood cells to fight infection Vaccine-Preventable Disease ~ disease for which there are known vaccines that may be administered to prevent infection LESSON 1 ~ INTRODUCTION LEARNING OBJECTIVES This course is designed to introduce you to the basic principles of infection transmission in healthcare settings, including methods commonly used to reduce transmission risk for residents, personnel, and visitors. Recognize the importance of infection prevention and control. Discuss how infections are spread and prevented. Understand your role and responsibilities in infection control and prevention. INFECTION CONTROL 2011 Page 1 of 8

2 Function of Infection Control Program ~ Prevention and control of infection in residents, staff, and visitors are the key functions of an infection control program. Nosocomial infections (infections caught during a facility stay) are common. Although such infections do not necessarily occur due to identifiable errors by medical personnel, many nosocomial infections could be prevented if facility staff placed greater emphasis on preventive measures such as hand-washing and sterilization. Development of Infection Control Program ~ An infection control practitioner or medical director with specific experience and training in infection prevention and control principles and practices is responsible for the infection control program. Processes, policies and procedures are developed by an administrator or committee in order to protect residents, staff and visitors from exposure to infectious agents in the healthcare environment. Infection Control Practices ~ Many people who work in healthcare participate in infection prevention and control every day. Nurses, physicians, pharmacists, facility service providers and even security officers must be familiar with infection control practices to prevent transmission of disease. Nosocomial Infections ~ An infection present or developing at the time of facility admission is referred to as a Community-Acquired Infection. Most residents, however, do not have infections when they come to healthcare facilities. If an infection develops more than 48 hours after treatment or admission, it is referred to as a Nosocomial Infection. Another term for Nosocomial is Iatrogenic. The rate of Iatrogenic Infections has increased 36% in the past 20 years, partly because people entering facilities today tend to be sicker and more vulnerable then they were 20 years ago, and partly because excessive use of antibiotics has created antibiotic-resistant microbes. LESSON 2 ~ THE CHAIN OF INFECTION LEARNING OBJECTIVES This lesson describes how infections are transmitted in the healthcare environment. After completing the lesson, you should be able to: Describe the chain of infection. List the most common methods of infection transmission. Identify host factors that increase the risk of infection. How are infections spread from person to person? The best way to begin this discussion is to review the Chain of Infection: Pathogen, Source, Exit, Transmission, Entry and Host. CHAIN OF INFECTION The elements needed to transmit an infection include: Infectious Agent (Pathogen) ~ any disease-cause germ, such as a virus, fungus, bacteria or parasite Reservoir (Source/Home) ~ home of the pathogen before it infects a host, for example food, water, animal or dirt Portal of Exit (Exit) ~ opportunity for the organism to leave its reservoir or home, such as through a sneeze or a cough Method of Transmission (Route) ~ how the pathogen gets from its source/home to its host, for example, through sexual contact, animal bite, or blood or body fluid exposure Portal of Entry (Entry) ~ where the pathogen enters the body, for example, through the mouth, the eyes, or broken skin Susceptible Host (Host) ~ host whose climate is hospitable to the pathogen; host most susceptible to a particular disease, due to circumstances such as demographics, compromised immune system, chemotherapy, or lack of vaccination INFECTIOUS AGENT Bacteria and viruses are the most common cause of nosocomial infection. Nosocomial fungal infections also may occur, but are not as common. Examples of bacterial infection include staphylococcus, E. coli, and tuberculosis. Viral infections include influenza, hepatitis B, and herpes zoster. INFECTION CONTROL 2011 Page 2 of 8

3 SOURCE RESERVOIR The Source reservoir is an environment that provides optimal conditions for an organism to survive. Each organism has specific environmental conditions that promote its survival; these conditions include specific ranges of temperature and humidity. Understanding the conditions that promote an unwanted organism's survival can help us interrupt disease transmission. Common source reservoirs of infectious organisms include medications, environmental surfaces, hands of personnel, and even food. PORTAL OF EXIT The portal of exit refers to the mechanism through which an infectious agent is released from its reservoir. Portals of exit include coughing, sneezing, and indirect transfer of blood or body substances from contaminated surfaces or objects. METHOD OF TRANSMISSION Infectious agents or materials may be transmitted by: Direct skin-to-skin contact Direct or indirect contact with respiratory droplets Tiny airborne particles Contaminated instruments, devices, or environmental surfaces Insect vectors, such as mosquitoes or ticks PORTAL OF ENTRY The infectious organism must enter the host to cause an infection. Broken skin, catheter use, and surgical or other invasive procedures all can allow organisms to enter the body and potentially cause infection. SUSCEPTIBLE HOST Residents undergoing certain surgical procedures, as well as residents with other known risk factors (such as obesity, smoking, alcohol/drug use, or suppressed immunity), are at the greatest risk of infection. In the healthcare setting, resident susceptibility to infection is a factor over which we have no direct control. Therefore, providing an environment to minimize the risk of resident exposure to infection is the responsibility of all healthcare personnel. THE WEAKEST LINK IN THE CHAIN Most infection prevention strategies interrupt the chain of infection at its weakest link, the method of transmission. Hand hygiene, aseptic technique, standard precautions, isolation practices, disinfection, and sterilization are performed routinely to reduce or eliminate the risk of transmission to residents and personnel. We will discuss each of these practices further throughout the course. SUMMARY Remember, it is important to understand how infections are transmitted, so that the proper steps to prevent infection may be followed routinely. In the next lesson, we discuss in greater detail how infection risks may be reduced or eliminated in the healthcare environment. LESSON 3 ~ INFECTION PREVENTION LEARNING OBJECTIVES In this lesson, we will discuss ways in which the chain of infection may be interrupted by eliminating or reducing opportunities for exposure to infectious materials or agents. At the end of the lesson, you should be able to: Describe practices that ensure good hand hygiene. Discuss the major elements of standard precautions. List the types of isolation used to prevent disease transmission. Define disinfection and sterilization. INFECTION CONTROL 2011 Page 3 of 8

4 HAND HYGIENE Hand hygiene is a relatively new term used to describe methods for healthcare personnel to degerm their hands before AND after patient care practices. Excessive jewelry or artificial nails/tips can interfere with good hand hygiene and should not be worn by patient care providers. Hands always should be washed: With warm water and soap Using friction for a minimum of 15 seconds At the beginning and end of the work shift Before eating, drinking, or applying cosmetics Following contact with contaminated items or surfaces After gloves are removed After using the bathroom or blowing the nose Before handling food, medications, or cleaning supplies Before or after patient contact Prior to an invasive or surgical procedure, scrubbing with an antibacterial soap is recommended to reduce the bacterial count on hands even further. ALCOHOL HAND RINSE As stated in the CDC Hand Hygiene Guidelines, the use of alcohol-based foams and gels is recommended following routine contact with residents or contaminated surfaces. These products have been shown to be highly effective at eliminating organisms from the hands of healthcare personnel. Alcohol-based products also can be used safely in surgical settings. For more information please visit the CDC website at Remember: A routine soap-and water hand wash is recommended at the beginning of the shift, periodically throughout the day and at any time hands are visible soiled. ASEPTIC TECHNIQUE Many procedures performed by healthcare personnel on a routine basis require the use of aseptic technique. Aseptic means without microorganisms. Aseptic technique refers to the practices performed immediately before and during a clinical procedure to reduce infection-causing microorganisms and risk of infection. These include: Handwashing Surgical scrub Using barriers (surgical attire) Client prep (preparing a client for clinical procedures) Maintaining a sterile field Using safe operative technique (making small incisions, avoiding trauma to tissue and surrounding structures, controlling bleeding) Maintaining a safe environment in the surgical/procedure area Key Thoughts: Prior to any invasive procedure, proper preparation is critical to infection control, regardless of the size or extent of the procedure. Most infections after a procedure develop as a result of contamination during the procedure not because clients fail to keep the wound clean. STANDARD PRECAUTIONS Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in the facility. Standard precautions apply to all residents, regardless of their diagnosis. Standard precautions expand the coverage of universal precautions by recognizing that any body fluid may contain contagious microorganisms. Each and every time you perform a job task in the healthcare setting, you must determine if the potential to encounter blood or body substances, via direct or indirect contact, splash, or splatter, exists. If the answer is 'yes' or even 'maybe,' then standard precautions must be followed. Standard precautions include the use of personal protective equipment (PPE), work practice controls, and engineering controls to provide a safe work environment. INFECTION CONTROL 2011 Page 4 of 8

5 PERSONAL PROTECTIVE EQUIPMENT Personal protective equipment, or PPE, is designed to protect employees from serious workplace injuries or illnesses resulting from contact with chemical, radiological, physical, electrical, mechanical, or other workplace hazards. In addition to face shields, safety glasses, hard hats, and safety shoes, PPE includes a variety of devices and garments such as goggles, coveralls, gloves, vests, earplugs, and respirators. To help ensure your own safety, you must know how to use PPE properly, what kind of PPE to wear, and when PPE is necessary. For example: Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect patients and health care personnel from infection. Handrubs should be used before and after each patient just as gloves should be changed before and after each patient. For the entire fact sheet, please visit Masks and protective eyewear are required if splashing of blood or body fluids is anticipated. A gown, cap, and/or shoe covers are required if heavy soiling is expected, especially during invasive procedures. WORK PRACTICE CONTROLS Work practice controls refer to the job tasks and steps used to eliminate or reduce exposure to blood and body fluids, whether by splashing, spraying, splattering, or generation of droplets. Examples of work practice controls include: Careful handling and bagging of soiled linen Safe handling and disposal of medical waste Proper labeling of patient specimens and the refrigerator used to store them Use of bulb pipettes ENGINEERING CONTROLS Equipment and devices have been developed to eliminate or minimize risk of exposure to blood and body fluids by incorporating safety measures in their design. You are familiar with a number of these items used daily in healthcare settings: Sharps disposal containers Splash shields Self-sheathing needles Hands-free sinks Foot-operated soap dispensers Foot-operated waste baskets Special bio-hazard containers for dressings, pads, and other materials soiled with body fluids ISOLATION PRECAUTIONS Isolation measures are used on residents known to be, or suspected of being, infected with a highly transmissible pathogen. In addition to standard precautions, these additional measures may be needed to minimize or eliminate risk of exposure during routine care or procedures, usually in the inpatient setting. Isolation measures may include: Wearing a mask or N95 respirator Wearing protective clothing in addition to gloves Thorough cleaning and disinfection of potentially contaminated environmental surfaces between residents CATEGORIES OF ISOLATION PRECAUTIONS Isolation categories are designed to protect personnel, visitors, and other residents from infectious diseases by placing barriers between the infected resident and the route of exit of the infectious agent. In other words, isolation categories are transmission-based. Airborne Isolation ~ Measures implemented to prevent transmission of infectious diseases transmitted by the airborne route. Examples: TB (pulmonary), chickenpox, measles, herpes zoster (presenting as shingles in immune-compromised residents) INFECTION CONTROL 2011 Page 5 of 8

6 Contact Precautions ~ Measures implemented to prevent transmission of infectious agents by direct or indirect contact with drainage or secretions. Examples: scabies/lice, multi-drug resistant organisms, major wound infections, herpes simplex. Droplet Precautions ~ Measures to reduce the risk of droplet transmission by direct or indirect contact with infectious agents released through coughing, sneezing, or suctioning. Examples: rubella, diphtheria, influenza, meningococcal meningitis. DO NOT display specific precautions on a resident's door. This is considered to be a violation of PRIVACY and is subject to HIPAA regulations. DISINFECTION AND STERILIZATION Environmental surfaces, resident equipment, and devices become contaminated with blood and other potentially infectious materials during routine resident care. The methods used to render surfaces and equipment clean and safe to be handled or used on other residents depends on how the item is used and what kind of resident contact is anticipated. To help you select the proper sanitation method, items are classified into one of the following three risk categories: Low Risk ~ Items have contact with intact skin only. Low-level disinfection is adequate. Example: environmental surfaces Moderate Risk ~ Items come in contact with mucous membranes or non-intact skin. High-level disinfection is required. Examples: speculum, some endoscopes High Risk ~ Items come in contact with sterile tissue or are placed in the bloodstream. Sterilization is required. Examples: surgical instruments, implantable devices, intravascular (IV) devices DEFINITIONS Let's define some of the terms we have used to describe important infection control practices. Cleaning ~ The first and most important step in the cleaning process is the removal of blood and other body substances from the surface to be disinfected. Some items must be soaked in a detergent solution to facilitate removal of proteinaceous substances. After soaking, items are scrubbed, using friction, rinsed with water, and dried to remove excess water. Disinfection ~ Low-level disinfection refers to the destruction of most microorganisms, with the exception of highly resistant spores and some viruses. High-level disinfection refers to the destruction of all microorganisms. EPA-approved disinfectant chemicals are selected based on the kind of equipment or devices to be processed. The surface to be disinfected must be in contact with the chemical germicide for ten minutes or more for the disinfectant to be effective. Some instruments, such as endoscopes, may be processed in machines specifically designed to disinfect equipment automatically. Remember: A routine soap-and water hand wash is recommended at the beginning of the shift, periodically throughout the day and at any time hands are visible soiled. Instruments and devices must be cleaned before disinfection. Always follow the manufacturer s instructions carefully for proper dilution and contact time. Use appropriate PPE to prevent exposure to chemicals and body fluids. Follow departmental policies for proper cleaning and disinfection procedures. Sterilization ~ Sterilization refers to the destruction of all microorganisms, including viruses and all spores. Sterilization methods commonly used in healthcare settings include steam autoclave and gas sterilization with ethylene oxide (EtO). Specific training is required to develop the competencies necessary for instrument sterilization. SUMMARY Remember, good hand hygiene, standard precautions, aseptic technique, and sterilization practices all contribute to the reduction of nosocomial infections in residents and personnel. Be certain to familiarize yourself with organizational infection control policies specifically addressing all of these practices. INFECTION CONTROL 2011 Page 6 of 8

7 LESSON 4 ~ EMPLOYEE HEALTH AND INDIVIDUAL RESPONSIBILITY LEARNING OBJECTIVES In this lesson, we will discuss the importance of understanding the employee health issues related to infection control, and your personal responsibilities in the infection control program. After completing this lesson, you should be able to: List essential immunizations for healthcare workers. Describe exposure follow-up practices. Discuss your role in reducing your personal risk of occupational exposure to infection. IMMUNIZATIONS Healthcare workers must maintain immunity to vaccine-preventable diseases such as: Hepatitis B Measles Varicella (chickenpox) Rubella Mumps Your employer's occupational health program can provide you with information regarding the immunization program available to you. As an employee, you may be tested to determine your immune status and need for immunization. REPORTING EXPOSURES When you experience a needle-stick, cut, or puncture from a contaminated needle or sharp, you must report the incident immediately to your supervisor. Your supervisor will help you complete the necessary incident report form, and will direct you to occupational health services for assessment and treatment as necessary. Your employer's exposure control plan provides for additional procedures to ensure prompt testing of employees and residents for bloodborne pathogens, as well as follow-up testing as appropriate to the exposure. It is your responsibility to familiarize yourself with these procedures in advance of an incident, so you can act promptly in the event of an exposure. COMMUNICABLE DISEASES Occasionally, residents are admitted to healthcare facilities prior to diagnosis. In some cases, their illness may be due to a communicable disease, such as TB or chickenpox. If you treat such a resident, you may need to report to occupational health for assessment, testing, or other follow-up procedures. In some instances, you will have immunity to the disease under investigation, and no further action will be necessary. Other times, you may be required to remain away from work for a few days so that you do not transmit infection to other residents or coworkers. Your supervisor and occupational health professionals will provide information and follow-up as appropriate to the exposure and the disease involved. If you have an infection or communicable disease, report to your supervisor before beginning work duties. In most cases, you will need to remain away from work until proper treatment is completed or until you have completely recovered from your illness. Do NOT come to work if you have: Fever Conjunctivitis Vomiting or diarrhea Coughing or sneezing Unexplained rash INFECTION CONTROL 2011 Page 7 of 8

8 SUMMARY Immunization, reporting occupational exposures, and adhering to all infection control policies and practices will help reduce your risk of developing a communicable disease on the job. Infection prevention and control is a shared responsibility. Good hand hygiene is the single most important means of preventing the spread of infection. All healthcare workers play an essential and valued role in reducing the risk of transmission of infection to residents, staff, and visitors. Always practice good aseptic technique. Be familiar with and adhere to departmental infection control practices and policies. INFECTION CONTROL 2011 Page 8 of 8