8/28/2014. Topics of Concern: Infection Control in LTC Settings in North Dakota. Bonnie M. Barnard, MPH, CIC

Transcription

1 Topics of Concern: Infection Control in LTC Settings in North Dakota Bonnie M. Barnard, MPH, CIC 1

2 Objectives List three mechanisms of transmission for bloodborne pathogens in long term care settings (Assisted) blood glucose / INR monitoring Injections Nail / foot care Contracted services Describe the appropriate cleaning and disinfection process for different types of equipment used in the care of residents of long term care settings Understand the importance of hand hygiene and proper glove usage in preventing transmission of infections in long term care settings Bloodborne Pathogens Germs that are carried in the blood and can be transmitted by contact with infected blood or body fluids are called bloodborne pathogens. The most common types include the following viruses: Hepatitis B Hepatitis C HIV 2

3 Bloodborne Pathogens Hepatitis B virus (HBV) Risk of transmission from needlestick: 6-31% Viable 7 days on surfaces Hepatitis C virus (HCV) Risk of transmission from needlestick: 1.8% Viable >16 hours 4 days on surfaces Human immunodeficiency virus (HIV) Risk of transmission from needlestick: 0.3% Very short viability Hepatitis C 70-80% of people do not have any symptoms When symptoms do occur, they are similar to those of hepatitis B virus Transmission can occur regardless of symptoms 60-70% of cases develop chronic liver disease No vaccine for prevention 3

4 Healthcare-Associated Hepatitis B and C Outbreaks Reported to the Centers for Disease Control and Prevention (CDC) in outbreaks 36 in non-hospital settings 15 in long term care facilities 18 hepatitis C 87 cases >68,500 notifications for screening Hepatitis C -North Dakota Setting Year State Persons Notified for Outbreak- Associated Infections Known or suspected mode of transmission Screening Skilled nursing 2013 ND > Preliminary epidemiologic analysis suggested podiatry care, phlebotomy, and nail care performed at the skilled nursing facility were associated with HCV infection 4

5 Activities of Concern in Long Term Care Settings Safe Injection Practices 5

6 What Can Happen When You Do Not Follow Safe Injection Practices? Transmission of disease to patients Patients at risk for bacterial, fungal, viral, and parasitic infections Notification of thousands of patients who have been exposed; recommendations to test Referral of providers to licensing boards for disciplinary action Malpractice suits filed by patients/residents COSTLY TO PATIENTS, PROVIDERS, and HEALTH DEPARTMENTS Safe Injection Practices Preparation - Location Draw up medications in a designated clean medication area Injections should be prepared in a clean areafree from contamination or contact with blood, body fluids, or contaminated equipment Separation of clean and dirty areas is a basic infection prevention and control principle 6

7 Safe Injection Practices Preparation - Technique Use aseptic technique to avoid contamination of sterile injection equipment/supplies Aseptic technique includes: Hand hygiene Use of gloves and other personal protective equipment Creation of a sterile/clean field Opening and introducing packages and fluids in a way that avoids contamination Safe Injection Practices Before the Procedure Carefully read the label of the medication vial Visually inspect the vial to ensure there is no visible contamination Is it single-dose? (SDV) If it has already been accessed (e.g., punctured by a needle), throw it away. Is it multi-dose? (MDV) Double-check the expiration date and the beyond-use date if it was previously opened discard if passed When in doubt, throw it out. 7

8 Safe Injection Practices During the Procedure Use aseptic technique. Use a NEW needle and syringe for every injection. Use a new needle and syringe even when obtaining additional doses for the same person Do not leave the needle in the medication vial septum if using the vial for multiple uses Clean your hands immediately before handling any medication Disinfect the medication vial by wiping the rubber septum with alcohol Safe Injection Practices After the Procedure Appropriately discard all used needles, syringes, and SDVs after the procedure is over Store used MDVs appropriately Discard MDVs when: The beyond-use date has been reached Doses are drawn in a patient treatment area Any time vial sterility is in question 8

9 Safe Injection Practices Multiple-Dose Vials Use single dose vials whenever possible Single dose vials should never be used for more than one person, regardless of vial size If multiple-dose (multi-dose) vials must be used: Designate to a single person Both the needle and syringe used to access the vial must be sterile Do not keep multi-dose vials in the immediate patient/resident treatment area (e.g., patient s room) Store them in accordance with the manufacturer s recommendations Discard vial if sterility is compromised or questionable Safe Injection Practices Neveradminister medications from the same syringe to more than one person, even if the needle is changed After a syringe or needle has been used to enter or connect to a person s IV, it is contaminatedand should notbe used on another person or to enter a medication vial 9

10 Safe Injection Practices Safe Blood Glucose Monitoring and Insulin Administration Person-to-Person Transmission of Bloodborne Pathogens During Blood Glucose Monitoring Infected with Agent (ex. HepC) Susceptible Person Contaminated Equipment/Supplies 10

11 Blood Glucose Monitoring (BGM) Inserting a test strip into a blood glucose monitor Drawing blood with a fingerstickdevice Applying blood to a test strip and placing it in the blood glucose monitor Obtaining a reading (glucose level) from the blood glucose monitor Administering insulin as needed Fingerstick Devices: Single-Use Disposable Go into sharps container Prevent reuse through autoretracting feature Appropriate for situations and settings where assisted monitoring of blood glucose is performed Assisted monitoring means that a patient or resident needs help performing BGM and cannot do it by themselves Select single-use devices that permanently retract upon puncture 11

12 Fingerstick Devices: Reusable Often resemble a pen ( penlet ) In general, use not recommended: Failure to change disposable pieces New lancet is required every time the device is used Failure to clean and disinfect properly Linked to multiple HBV outbreaks (including in Virginia) Risk for occupational needlesticks Only appropriate for people who are able to perform BGM independently and do not require assistance Recommended Practices for Reusable Fingerstick Devices Restrict use to individual persons who do notrequire assistance with monitoring their blood glucose o Never share reusable devices between persons Clearly label any fingerstickdevice designed for reuse on a single person o o Label with individual patient/resident s name Store in a secure area Dispose of used lancets at the point of use in an approved sharps container 12

13 Blood Glucose Monitors When possible, assign blood glucose monitors to an individual person; do not share Clean and disinfect meter, even if not shared Label device with patient/resident s name and store in a secure place such as a locked cabinet or keep in resident s room Sharing Blood Glucose Monitors Effectively If sharing is necessary, clean and disinfect the monitor after every use, per manufacturer s instructions If the manufacturer does not specify how the monitor should be cleaned and disinfected, then it should not be shared. Manufacturer s cleaning instructions are included in the glucometer s packaging. How to effectively share two glucometers Alternate use of monitors between patients/residents so that sufficient contact and dry time for disinfectant 13

14 Insulin Administration Multi-Dose Vials Dedicate to a single person Do NOT borrow insulin from another person s vial Always puncture the vial with a newneedle and new syringe for each dose Neverreuse needles or syringes Do not recap needles Do not carry insulin or other supplies in your pocket Make sure an approved sharps container is available Place used sharps in sharps container immediately Insulin Administration Insulin Pens Pen-shaped injector devices for insulin o o Contains an insulin reservoir or cartridge; an individual usually self-injects several doses of insulin before the reservoir is empty The needle is changed in the insulin pen before each injection Assign to individuals and label appropriately Never share insulin pens between people Should be used only by individuals who are able to administer insulin and change the pen needle independently. Use of insulin pens for more than one person, like other forms of syringe reuse, imposes unacceptable risks and should be considered a never event. 14

15 Contracted Services Podiatry Cosmetology Phlebotomy / Laboratory Dentistry Home Care Wound Care Podiatry Services Due to increased risk of blood exposure, strict attention to technique is necessary Location with sink hand hygiene! Sterilized instruments (packs), separate for each resident Dirty vs clean area Glove use Towel use 15

16 Cosmetology Services Clearly delineated clean vs dirty areas for towels and equipment Proper cleaning and disinfection of all reusable equipment (e.g, nippers, clippers) between uses Disposal of supplies/equipment that cannot be cleaned/disinfected (e.g., emery boards) Clean towel for each client Phlebotomy Services Change gloves and use alcohol gel between blood draws on each resident Do not reuse vacutainer sleeves Do not reuse needles even on the same resident (i.e., re-stick) Do not palpate the venipuncture site after antiseptic applied 16

17 Hand Hygiene Hand hygiene is the cornerstone of prevention efforts Prevents transmission of pathogens via hands of healthcare personnel Hand hygiene programs include: Ensuring easy access to soap and water/alcohol-based hand sanitizer Education for personnel AND residents Observation of care practices Just in time feedback Reinforce positive behavior 17

18 Poor Adherence to Hand Hygiene Hand hygiene agents cause irritation and dryness Sinks/gel dispensers are inconveniently located Understaffing/Too busy/insufficient time Inappropriate use of gloves / glove use is a substitute for hand hygiene Not thinking about it/forgetfulness No role model from colleagues or superiors Hand Wash vs Hand Gel Soap and Water For hands that ARE visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids Before eating After using the restroom Alcohol Hand Gel For hands that are NOT visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids 18

19 Glove Use, Hand Hygiene & Disease Transmission Hands / gloves can become contaminated with blood while performing procedures Blood glucose monitoring Pricking patient/resident s finger, Handling test strip Nail care / podiatric care Accidental nips to skin Phlebotomy During stick and filling tubes Blood can be transferred back to equipment / other residents if gloves not changed and hand hygiene performed Hand Hygiene and Gloves Wear gloves Blood glucose monitoring Any procedures where contact with blood or body fluids might occur Change gloves Between patient/resident contacts Aftertouching fingerstickwounds or potentially contaminated objects/equipment Before touching clean surfaces Discard gloves in appropriate receptacles do not keep in pocket! 19

20 Cleaning and Disinfection Clean AND Disinfect Cleaning Washing with soap and water, detergent or antiseptic agent to remove dirt and residue from an item You cannot disinfect a porous item and cannot disinfect unless the item is clean first! Disinfection Use of chemicals to reduce or eliminate microorganisms from an item Examples include EPA registered bactericidal, fungicidal, virucidalagent; EPA registered tuberculocidal agent 20

21 Three Levels of Disinfectants High Level kills all organisms, except high levels of bacterial spores with a chemical germicide cleared for marketing as a sterilant by the FDA Intermediate Level kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a tuberculocide by the EPA Low Level kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA Disinfectants Mix, use, store and dispose of per manufacturer recommendations Mix daily and replace if contaminated or diluted Do not use contrary to labeling Contact time is critical cannot always be guaranteed with spraying Label containers properly Some products can be corrosive to instruments/equipment read labels! Cannot disinfect unless cleaning done first! 21

22 Low Level Disinfection EPA registered hospital grade disinfectants with bactericidal, fungicidal and virucidal claim 1:10 dilution bleach solution (1 part bleach: 9 parts water) 70-90% isopropyl or ethyl alcohol Due to hepatitis C outbreak -> Tuberculocidalnow recommended by NDDOH for non-porous foot and nail care equipment such as nail clippers Examples of TuberculocidalDisinfectants 1 Quaternary ammonium chloride e.g., Barbicide Ethyl or isopropyl alcohol (70-90%) Sodium hypochlorite (5.25% diluted 1:500 provides >100 ppm) 1 For non-porous nail and foot care equipment used by cosmetologists in ND 22

23 UNSAFE Practices Using fingerstick devices for more than one person Using a blood glucose/inr meter for more than one person without cleaning and disinfecting it between uses per manufacturer s instructions Using insulin pens or multi-dose insulin vials for more than one person Failing to change gloves and perform hand hygiene between procedures BGM, foot care, phlebotomy Sharing any supplies/equipment that may be contaminated with blood without cleaning anddisinfecting appropriately nail clippers, non-porous foot care implements Goal Oriented Infection Prevention and Control Program Policies and procedures specific to resident population and activities AND reflective of current evidence-based guidelines On-boarding and ongoing training and education Observation and feedback 23

24 Questions? 24