Medical Directors Leadership Program Infection Control Module

Transcription

1 Medical Directors Leadership Program Infection Control Module Patricia Daly MD, FRCPC Medical Health Officer and Director of Communicable Disease Control Vancouver Coastal Health

2 Outline 1. Background and definitions 2. Principles of infection control Standard Precautions Transmission-based Precautions 3. Common infections in long term care 4. Implementing infection control programs

3 Part 1 - Background Recent infection control concerns: Clostridium difficile in Montreal hospitals Emergence of antibiotic-resistant organisms Influenza and norovirus outbreaks in long term care

4 History of Isolation & Precaution Techniques Isolation Precautions: Fever hospitals for the care of patients with TB, smallpox Over time, modifications to isolation precautions: Most dramatic: 1980 s with HIV/AIDS epidemic and need to protect HCWs from bloodborne pathogens ( Universal precautions )

5 Recent Developments Mid 1990 s terminology change: Universal Precautions became Standard Precautions Standard Precautions (U.S.) also called Routine Practices (Canada) Routine Practices developed for different care settings (acute, residential, ambulatory)

6 Standard Precautions Those practices recommended for routine care of all patients Assumes any patient may be infectious Applies to all body fluids, mucous membranes and non-intact skin

7 Definitions Infection: Entry and multiplication of an organism in the tissues of a host. Inapparent infection: No symptoms Apparent infection: Symptoms (i.e. disease) Colonization: Organism living in or on a host with multiplication but does not cause disease. Communicable disease: Infection that can be transmitted from person-to-person

8 Definitions Community-acquired infection: Acquired outside a healthcare setting (present or incubating on admission). Nosocomial infection: Acquired while in a healthcare setting. Iatrogenic infection: Caused by the actions or treatments of health care workers

9 Agent-Host-Environment Triad Environment e.g. Crowding, housekeeping X X Host e.g. Open wounds, invasive devices X Agent e.g. Infective dose, survival in environment

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11 Infectious Agents Viruses Tiny, genetic material Replicate inside host cells Hard to treat Bacteria Larger, single-celled Cell wall Treatable with antibiotics Parasites Lives commensally within host Can be single-celled or complex Prions Protein particles, no genetic material Yet to be isolated

12 Incubation period The time from INFECTION to onset of symptoms (DISEASE) Characteristic of the agent Diagnosis Time Infection Screening Test Onset symptoms

13 Transmission The mechanism by which an infectious agent is spread from one person (or animal) to another person An agent may be transmitted in more than one way

14 Modes of Transmission 1. Airborne 2. Droplet 3. Contact direct or indirect 4. Common vehicle 5. Vector-borne

15 1. Airborne Organisms that can be aerosolized to droplet nuclei (particles < 5 um) and remain suspended in the air Limited to these diseases only: Tuberculosis Measles Varicella (chickenpox) (Smallpox, VHF with pneumonia)

16 2. Droplet Transmission Generated from respiratory tract by coughing, sneezing Travel < 1 metre > 5 um diameter May survive on environmental surfaces

17 3. Contact Direct: Skin-to-skin Mucous membrane to mucous membrane Sexually transmitted Bloodborne Fecal-oral Indirect Contaminated hands Sharing drinks, cigarettes Medical instruments Sharing needles for injection drug use Environment

18 4. Common Vehicle Single source transmits infection to multiple hosts Food Water Contaminated medication or equipment

19 5. Vector-borne Transmitted by insects Mosquitoes Ticks

20 Communicability How likely an agent is to be transmitted i.e. infectiousness, contagiousness Period of communicability : Period of time a case can transmit the agent to others Chickenpox: Period of communicability is from 1-2 days before symptoms until 5 days after onset of rash

21 Reservoir The natural habitat of an infectious agent i.e. person, animal, insect, plant, soil or other substance where an agent normally lives and reproduces

22 Portal of Entry/Exit Non-intact skin Mucous membranes Respiratory tract Gastrointestinal tract Genitourinary tract

23 Susceptibility How likely a person is to be infected with an agent. Increased by: Underlying illness or immunosuppression Extremes of age Invasive procedures or devices Non-intact skin Contrast: Resistance. Increased by: Pre-existing immunity (disease or vaccination)

24 Part 2- Components of Infection Control in Long Term Care Standard or Routine Precautions Transmission-based precautions Airborne Transmission Precautions Droplet Transmission Precautions Contact Transmission Precautions

25 Precautions in Long Term Care Balancing the risk of spread of infection and the consequences of the preventive measures This is the residents home

26 Balance of Risks Disease Transmission Hospitalization Cost of individual therapy, outbreaks Rights of other residents Legal issues Prevention Cost of equipment, singles rooms Increased resources Reduced quality of life Stigmatization Ethical restriction of rights

27 Components of Standard Precautions 1. Hand washing 2. Gloves 3. Masks and eye protection 4. Gowns 5. Accommodation 6. Patient care equipment 7. Environment

28 1. Hand washing Most effective way of preventing infection

29 When to Wash Hands Upon arrival and when leaving work Before and after client contact After handling contaminated items Between procedures on a resident if soiled, to avoid cross-contamination Before handling, serving or eating food After toileting or wiping nose

30 Hand Washing: What s Needed Adequate amount of soap, friction, running water Wash hands thoroughly with soap & water for at least seconds Antimicrobial soap not needed Paper towels to dry Alcohol-based hand sanitizers (at least 60% ethyl alcohol): Acceptable substitute Not effective when hands are visibly soiled

31 Implications for Hand Washing Sufficient number and accessibility of sinks Provision of alcohol hand sanitizers to staff if sinks not available in all resident rooms

32 Hand Washing for Others Encourage residents to wash hands before eating, after toileting Encourage visitors to wash hands before and after providing care or feeding residents

33 2. Gloves Not a substitute for hand washing Not required for routine patient care Contact with intact skin Feeding residents

34 When to Wear Gloves Contact with blood, body fluids, secretions, mucous membranes, draining wounds or non-intact skin Handling items soiled with blood/body fluids Health care worker has open skin lesions

35 Procedure for Glove Use Non-sterile, non-latex (vinyl) gloves Put on immediately prior to procedure, remove immediately afterwards Wash hands after gloves removed Single use one patient only

36 Implications for Facilities Ensuring sufficient quantity of gloves Be cognizant of latex allergies Avoid over-use and mis-use

37 3. Masks and Eye Protection For procedures likely to generate splashes of blood or body fluids Surgical masks sufficient single use (N95 masks only required for TB) Eye protection personal eyeglasses not sufficient

38 4. Gowns Not for routine use in long term care For protection of exposed skin and to prevent soiling of clothing during procedures likely to generate splashes

39 5. Accommodation Single rooms rarely required TB During some outbreaks, cohorting may be recommended Grouping residents with the same illness Residents can share washrooms but should not share personal care items e.g. razors

40 6. Patient Care Equipment Clean and disinfection of reusable items Clean with soap, water, detergent Most items require only low level disinfection Disposal of sharps Disposal of waste

41 Cleaning and Disinfection Clean equipment before disinfecting or sterilizing Follow manufacturers guidelines, Health Canada, CSA Standards Do not re-use single-use items Consider routine equipment: stethoscopes, otoscopes, ophthalmoscopes, BP cuffs

42 Sharps Disposal Don t recap needles Sharps containers must be puncture-proof Locate close to point of use Empty regularly

43 7. Environment Clean resident rooms, common areas regularly Dispose of biomedical waster appropriately Disinfection when required (e.g. blood spill) with detergent and 1:10 bleach solution

44 Airborne Precautions in Long Term Care Tuberculosis (active cases) Transfer to acute care (negative pressure room) Single room with door closed until transfer N95 masks for those entering the room, surgical mask on patient if s/he leaves the room Continue until sputum is negative on treatment

45 Airborne Precautions in Long Term Care Varicella (chickenpox, disseminated zoster) No precautions if all staff/residents immune (vaccination free for healthcare workers) Otherwise like TB + cover lesions Measles No precautions if all staff/residents immune (vaccinated or born before 1957) Otherwise like TB

46 Droplet Precautions in Long Term Care Viral respiratory tract infections (influenza) Maintain 1 metre distance from other residents Reduce group activities until symptoms resolved Masks not needed, even in influenza outbreaks

47 Contact Transmission Precautions in Long Term Care Diarrhea, scabies, draining wounds, disseminated zoster Maintain 1 metre distance from other residents Reduce group activities until symptoms resolved Gowns and gloves for direct patient contact Dedicated equipment for the resident Minimize environmental soiling

48 Part 3 - Common Infections in Long Term Care 1. Gastrointestinal infections Norovirus 2. Influenza 3. Antibiotic resistant organisms (AROs) MRSA and VRE 4. Tuberculosis 5. Skin infections (scabies) 6. Other: UTI, C. difficile

49 1. Gastroenteritis Norovirus most common cause of outbreaks Calcivirus small RNA virus Incubation period hours Sudden onset vomiting +/- diarrhea Duration of symptoms hours Communicable up to 72 hours after symptoms resolve

50 Gastroenteritis - Norovirus Transmission fecal/oral, hands, food (e.g. raw oysters, contaminated food), fomites, airborne Very few viral particles needed for infection Outbreaks explosive, >50% attack rates Circulating strains may be increasing, more virulent

51 Gastroenteritis Other Etiologies Rotavirus More common in children, longer duration and more serious than norovirus Salmonella Fever, abdominal pain, diarrhea; incubation 6-72 hours; often foodborne Campylobacter Associated with raw poultry E. coli 0157:H7 Bloody stools, hemolytic uremic syndrome

52 2. Influenza Acute viral illness of the respiratory tract Influenza A and B viruses Emergence of new subtypes each year Occasional pandemics

53 Influenza Acute onset of fever (>38ºC), cough and one or more of: sore throat, joint pain, muscle aches, headache, malaise. Fever may not be present in the elderly Other symptoms in the elderly may include change in behavior, chest congestion, decrease in appetite

54 Epidemiology Mode of transmission Direct, indirect, droplet (and aerosolization) Incubation 1-3 days Period of Communicability 24 hours before onset 3-5 days after onset

55 Influenza Morbidity and Mortality Each year: 5 million Canadians (1 in 6) are infected 50,000 will be hospitalized 4,500 will die 1.5 million work-days will be lost In BC 1,400 die from the influenza and pneumonia

56 Goals of BC Influenza Prevention Program Reduce illness and death associated with influenza in the frail elderly Immunize 80% of healthcare workers in long term care Immunize 90% of residents Reduce pressure on the health care system during the influenza season

57 Vaccination Response Poor vaccine response (30-40%) in frail elderly Facility outbreaks can occur with 100% residents vaccinated Immunity in the frail elderly wanes in 4-6 months

58 Vaccination of Staff Vaccination 70-90% effective in health adults Healthcare workers who are ill with influenza frequently come to work, exposing others British Study: 59% of healthcare workers with serologic evidence of influenza did not recall symptoms Influenza transmissible before symptoms start

59 Vaccination of Health Care Workers in Long-Term Care 1995/96 UK study 1,059 patients in 12 facilities Effect of patient and staff vaccination Mortality reduced 40% when staff vaccinated No reduction with patient vaccination Potter et al. J Inf Dis1997;175:1-6

60 Healthcare Worker Vaccination Policy Influenza vaccination is strongly recommended for all healthcare workers, in order to protect patients/clients Vaccination is not mandatory in BC There are consequences if healthcare workers choose not to be vaccinated

61 High staff immunization rates CAN Tips be achieved Management lead the way Champions on each unit Communicate, educate and promote Convenient to get; flexible times Sign up sheet visible to all Follow-up those not yet received Contests, competitions, prizes, stickers

62 Identifying an Outbreak in a facility Be on the alert Two or more cases influenza-like illness (ILI) in staff or residents in a one-week period = outbreak Influenza outbreaks are not: Vomiting and diarrhea Runny nose and sneezing: think cold unless there are chest symptoms

63 Outbreak Measures Notify the MHO Facility closed to admissions and transfers until 6 days after onset of last case Obtain specimens Nasopharyngeal washings are best (VIRAP program at BC Children s Hospital) Standard Precautions

64 Outbreak Measures Offer vaccine to unvaccinated staff, residents Use of antiviral agents: Amantadine (100 mg daily for adults, adjust for reduced renal function) or oseltamivir (75 mg bid) Recommended for all residents and unvaccinated staff 5 days for treatment, until outbreak declared over for prophylaxis Standing orders for residents, including annual creatinine, facilitates implementation

65 Healthcare Worker Exclusion Unvaccinated staff who refuse antivirals are excluded until the outbreak is declared over Done by the Medical Health Officer under the authority of the Health Act Usually without pay (Employer decision) Asymptomatic, excluded staff must wait 3 days after their last day of work at an outbreak facility before working elsewhere

66 Other Outbreak Control Measures Standard Precautions Handwashing Enhance housekeeping Keep ill residents in their rooms or cohort them Cancel group activities Restrict visitors, post signage

67 3. Antibiotic Resistant Organisms Methicillin-resistant Staphyloccus aureus (MRSA) Vancomycin-resistant enterococcus (VRE) These are NOT superbugs

68 Emergence of Antibiotic-resistant Organisms in Hospitals Prolonged use of broad-spectrum antibiotics High levels of medical care Vulnerable patient populations Increase in invasive devices

69 Why Are They a Concern? Limited antibiotics to treat infections Infection control costs Unwarranted fears, sigmatization Fully resistant S. aureus

70 Evolution of Antimicrobial Resistance Penicillin Methicillin Penicillin-resistant Methicillin-resistant S. aureus [1950s] S. aureus [1980s] S. aureus (MRSA) [1997] Vancomycin [1990s] Vancomycin- Resistant S. aureus [ 2002 ] Vancomycin (glycopeptide) - intermediate Vancomycin-resistant enterococcus (VRE) resistant S. aureus

71 Staphylococcus aureus 30% nose or skin carriage (colonization) Can cause infection: impetigo, skin infections, abscesses, wound infections, invasive infections Resistant to penicillin

72 MRSA Infections Is MRSA more likely to cause infections than other S. aureus? No Does MRSA cause more serious infections than other S. aureus? No

73 How Common Are MRSA? 1995: 1.1% of S. aureus isolates (Canada) 1998: 4.85% of isolates 2004: Stabilized or decreasing in Vancouver hospitals

74 VRE Enterococci: Common GI bacteria in 95% of people Usually non-pathogenic; disease only in severely immunosuppressed Vancomycin: Antibiotic for treating multidrug resistant enterococci First identified in Canada in 1993 Small clusters in Canada

75 MRSA Colonization Most cases colonized, not infected Sites of colonization: Nose, axillae, wounds or ulcers, perineum

76 VRE Colonization Most cases colonized, not infected Sites of colonization: Bowel, female genital tract

77 MRSA/VRE Transmission Hands of healthcare worker - transiently colonized Contaminated environmental surfaces Contaminated medical devices

78 Why Screen and Isolate in Acute Care? Highly vulnerable patients (ICU, burn units) High level of antibiotic use, potential for development of further resistance

79 Long Term Care Facility is the patient s home Residents with MRSA/VRE do not endanger the health of staff or other residents Isolation (private rooms) not necessary Can participate in all social activities

80 Recommendations for Long Term Care Screening not recommended Admission should not be denied on the basis of MRSA/VRE Can share rooms Private rooms preferred for those colonized with VRE who have diarrhea No signage Can participate in all activities Standard precautions: Handwashing

81 Recommendations for Long Term Care MRSA: Decolonization is not recommended VRE: Frequently fails Can lead to mupirocin resistance No effective decolonization Dedicated commode if needed

82 4. Tuberculosis Reactivation of latent infection increases with age Assess all admissions for high risk factors: Born in a high-risk area (Asia, Africa, Eastern Europe) Aboriginal History of TB Immunocompromised Symptoms

83 Screening of High-Risk Tuberculin skin test Chest X-ray Sputum if abnormal Residents After initial screen, follow-up only as recommended by TB control or after exposure

84 Screening of Staff TB skin test on commencing employment Not provided free of charge CXR if history of positive skin test If negative, repeat only after exposure If positive, follow-up by TB Control

85 5. Scabies Infestation of mite Sarcoptes scabiei Beware of bed bug bites! Highly communicable Skin-to-skin contact Fomites (survives 2 days off of a host) Communicable before symptoms

86 Scabies Assess skin of all new admissions Characteristic: Burrows under the skin, linear tracts visible Found in skin folds, back, buttocks, perineum Diagnosis: Scrapings (microscope)

87 Scabies Treatment Single case: Treat case and contacts at the same time Scabicide: 5% permethrin cream Wear gown and gloves Bathe resident to remove crusts Trim nails Apply cream in thin layer from neck to soles of the feet (from head down if atypical) Apply clean clothes, change linen Wash off after 8-12 hours Apply clean clothes, change linen Second application may be needed

88 Scabies Treatment Environment: Clothes, linen, slings used in the 1 week prior to treatment and during treatment are laundered Non-washables sealed in a plastic bag for 7 days

89 Scabies Outbreak Multiple cases in a facility Treatment of all residents, staff and visitors at the same time

90 Others Asymptomatic bacteriuria is common and benign in the elderly and does not require treatment Clostridium difficile: Overgrowth if patient on antibiotics Transmission by environmental contamination Problem of elderly in acute care

91 Part 4 Implementing an Infection Control Program 1. Identify a responsible staff person Director of Care 2. Contact your local public health unit and regional infection control committee 3. Identify key resources 4. Adopt a manual Generic manual available in BC OR Contact other facilities

92 Components of an Infection 1. Education of staff Control Program 2. Surveillance for infections 3. Policies and procedures 4. Reporting and management of cases of communicable disease and outbreaks Public health will assist you 5. Employee Health

93 Employee Health TB screening upon hire Vaccination: Hepatitis B 3 dose series, no booster needed Td every 10 years MMR Varicella if susceptible Annual influenza vaccination Monitor staff absenteeism; staff should not work if ill with a communicable disease

94 Acknowledgement Louise Holmes RN, BSN, CIC Educator, Infection Prevention and Control Vancouver Coastal Health