ASEPSIS and INFECTION CONTROL

ASEPSIS and INFECTION CONTROL

DEFINITION OF TERMS:

• INFECTION – invasion of the body tissue by microorganisms

• ASEPSIS – absence of disease-producing microorganisms / the state of being free from microorganisms

• SEPSIS – severe toxic febrile state resulting from infection with pyrogenic microorganism (substance or agent that cause body temp to rise).

• STERILE - the method by which contamination with microorganism is prevented, free of microorganism, including spores.

• MEDICAL ASEPSIS – clean technique– Practices designed to reduce the

number and transfer of pathogens

• SURGICAL ASEPSIS – sterile technique– Practices that render and keep

objects and areas free from microorganisms

• STERILIZATION - the process by which all pathogenic microorganisms, including spores are killed; used constantly to operative techniques.

• TERMINAL STERILIZATION– in the OR, it is the destruction of the pathogens at the end of the operative procedure after removal of the patient.

• DISINFECTION – the process of destroying all pathogenic organism except spore-bearing ones.

• DISINFECTANTS – are used to eliminate exogenous bacteria on inanimate objects but not on tissues

• ANTISEPTICS– substances which combat sepsis; they are used on skin and tissue and arrest the growth of endogenous bacteria.

• BACTERICIDES - agents which kills bacteria.

• SURGICAL CONSCIENCE– awareness which develop from a knowledge based on the importance of strict adherence to principles of aseptic and sterile techniques.

• NOSOCOMIAL INFECTION – Hospital-acquired infection– It develops during the patient’s

hospital stay or shortly after discharge

CHAIN OF INFECTION

ETIOLOGIC/INFECTIOUS AGENT

– The microorganism responsible for the infection

– Bacteria - Parasite - Yeast– Fungi - Viruses

– Potential for microorganism to produce disease depends on the following:

– Number of microorganisms– Virulence of the microorganisms– Competence of the person’s immune system– Length and intimacy of the contact between

an individual and the microorganisms

THE RESERVOIR

• Natural habitat for the growth and multiplication of microorganisms

• Sources of microorganisms• Humans (visitors, patient, healthcare

personnel)• Patient’s own microorganisms• Plants• Animals• General environment (soil, food, water,

air)

•  

PORTAL OF EXIT • The way microorganisms leave the

reservoir– Respiratory tract: droplets, sputum– Gastrointestinal tract: vomitus, feces,

saliva, drainage tubes– Urinary tract: urine, urethral

catheters– Reproductive tract: semen, vaginal

discharge– Blood: open wound, needle puncture

site

MODE OF TRANSMISSION• The way microorganisms reach another persons or host

1. Contact transmissiona. Direct contact involves immediate

and direct transfer from person to person; direct transfer between two clients, with one acting as the source and the other as a host

b. Indirect contact occurs when a susceptible host is exposed to a contaminated object such as dressing, needle or surgical instruments

c. Droplet transmission• Occurs when mucous membrane

of the nose, mouth, or conjunctiva are exposed to secretions of an infected person who is coughing, sneezing, laughing or talking usually within a distance of 3 feet.

2. Vehicle transmission – transfer of microorganisms by way of contaminated items that transmit pathogens (food, water, eating utensils, pillows, mattress)

3. Airborne transmission – occurs when fine particles are suspended in the air for a long time or when dust particles contain pathogens

4. Vectorborne transmission – Biologic vectors are animals, rats,

snail, mosquitos– Mechanical vectors are inanimate

objects that are infected with body fluids

PORTAL OF ENTRY

– The way microorganisms enter the body

– Usually the same way they exit from the reservoir

SUSCEPTIBLE HOST• A person at risk for infection from

microorganisms• Age

– Newborns and infants have immature immune systems• Protected for the first two to three

months by immunoglobulins passed on the mother

• Start synthesizing their own immunoglobulins between one to three months of age

– Elderly have weakened immune systems

• Inadequate Primary Defenses– Broken skin or mucous membranes– Traumatized tissue– Decrease in ciliary action– Change in pH of secretions

• Inadequate Secondary Defenses– Decreased haemoglobin– Leukopenia

• Inadequate Active Immunity– Lack of childhood immunization, lack of

exposure to childhood infections, lack of hepatitis B vaccinations

• Tissue Destruction– Scalds, gangrene, sunburn

• Increased Environmental Exposure– Crowded living conditions, poor air

circulation in airplanes, hospital rooms

• Chronic Diseases

• Trauma

• Malnutrition

• Insufficient knowledge to avoid exposure to microorganisms

BREAKING THE CHAIN OF INFECTION• ASEPTIC PRACTICES

– Hand washing– Cleaning, Disinfection, Sterilization– Use of Barriers– Personal protective equipment– Isolation System– Medical and Surgical Asepsis

STANDARD PRECAUTION

• Standard precautions are to be instituted on ALL patients receiving care in a hospital regardless of their diagnosis or possible infection status.

• Standard precautions are utilized for the ff:– Blood– All body fluids with or without blood– Secretions and excretions (except sweat)– Non-intact skin– Contaminated items– Mucous membranes

Steps in standard precautions:

Wash hands before and after patient care, regardless of whether gloves are worn

Wash hands immediately after gloves are removed and between patient contacts

Wear gloves when touching blood, body fluids, secretions, excretions, and contaminated items

Put on clean gloves just before touching mucous membranes and non-intact skin

Wear mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and patient care and activities that are likely to generate splashes or sprays of blood and body fluids

Wear a gown to protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood and body fluids

Be careful to prevent injuries when using needles, scalpels and other sharp instruments or devices; when handling sharp instruments after procedures; when cleaning used instruments and when disposing of used needles.

Use mouthpieces, resuscitation bags or other ventilation devices as an alternative to mouth-to-mouth resuscitation

ASEPSISTYPES:

Medical asepsis

Surgical asepsis

MEDICAL ASEPSIS

Practices intended to confine a specific microorganism to a specific area

CLEAN TECHNIQUE

• Basic principles of medical asepsis1. Wash hands frequently, but especially

before handling foods, before eating, after using a handkerchief, after going to the toilet, before and after each patient contact, and after removing gloves.

2. Keep soiled items and equipment from touching the clothing.

3. Do not place soils bed linen or nay other items onto the floor.

4. Avoid having patient’s cough, sneeze, or breath directly on others.

5. Move equipment away from you when brushing, dusting, or scrubbing articles

6. Avoid raising dust.7. Clean the least soiled areas first then

more soiled ones.8. Dispose of soiled or used items directly

into appropriate containers.

9. Pour liquids that are to be discarded directly into the drain so as to avoid splattering in the sink and onto you.

10.Use practices of personal grooming that help prevent spreading microorganisms.

11.Follow guidelines conscientiously for isolation techniques as prescribed by the healthcare agency.

SURGICAL ASEPSIS• Principles of Aseptic Technique:1. Only sterile items are used within the

sterile field.  Proper packaging, sterilizing and handling

should provide such assurance. If you are in doubt about the sterility of

anything, consider it not sterile. If unsterile package is found in a nonsterile

workroom consider it unsterile. If unsterile person comes into close contact

with a sterile table and vice versa consider unsterile.

If sterile package falls to the floor, it must then be discarded.

2. Gowns are considered sterile only from the waist to shoulder level in front and the sleeves Keep hands in sight and at or above

waist level Hands are kept away from the face. Elbows are kept close to sides. Hands are never folded under arms

because of perspiration in the axillary region.

Items dropped below waist level are considered unsterile and must be discarded

3. Tables are sterile only at table level Only the top of a table with sterile

drape is considered sterile. Edges and sides of drape extending below table level are considered unsterile

Anything falling or extending over table edge, such as a piece of suture, is unsterile. Do not touch the part hanging below table level.

In unfolding sterile drape, the part that drops below table surface is not brought back up to table level.

4. Persons who are sterile touch only sterile items or areas; Persons who are not sterile touch only unsterile items or areas Sterile team members maintain

contact with sterile field by means of gowns and gloves

Nonsterile circulating nurse does not directly come into contact with the sterile field

Supplies for sterile team members reach them by means of the circulating nurse who opens wrapper on sterile packages

5. Unsterile persons avoid reaching over a sterile field; Sterile persons avoid leaning over an unsterile area. Unsterile circulating nurse never reach

over sterile field to transfer sterile items.

In pouring solution into sterile basin, circulating nurse holds only lip of bottle over basin to avoid reaching over a sterile area

Scrub nurse drapes a nonsterile table toward self first to protect gown

6. Edges of anything that encloses sterile contents are considered unsterile In opening sterile packages, a margin of

safety is always maintained. Ends of flaps are secured in hand so they do not dangle loosely. The last flap is pulled toward the person opening the package thereby exposing package contents away from nonsterile hand.

After a sterile bottle is opened, contents must be used or discarded. Cap cannot be replaced without contamination pouring edges.

7. Sterile field is created as close as possible to time of use Degree of contamination is proportionate

to length of time sterile items are uncovered and exposed to the environment.

Sterile tables should be set up just prior to the operation

It is difficult to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended

8. Sterile areas are continuously kept in view Sterile persons face sterile areas.

When sterile packs are opened or a sterile field is set up, someone must remain in the room to maintain vigilance

9. Sterile persons keep well within the sterile area.

Sterile persons stand back at a safe distance from the operating table when draping the patient.

Sterile persons pass each other face to face and back to back.

Sterile person turns back to nonsterile person or area when passing.

Sterile persons stay within and around a sterile field. They do not walk around or go outside room

10. Sterile persons keep contact with sterile areas to a minimum Sterile persons do not lean on sterile

tables and on the draped patient.

Sitting or leaning against a nonsterile surface is abreak in technique. If the sterile team sits to operate, they do so without proximity to nonsterile areas.

11.Unsterile person avoid sterile areas

Unsterile person maintain at least one foot (30 cm) distance from any area of the sterile field.

Unsterile persons never walk between two sterile areas (between sterile instrument tables).

12.Destruction of integrity of microbial barriers results in contamination To ensure sterility sterile package are

laid on dry surfaces.

If sterile package becomes damp or wet, it is re-sterilized or discarded. A package is considered nonsterile if any part of it comes in contact with moisture.

Sterile package are handled with clean dry hands

13. Microorganisms must be kept to an irreducible minimum. Skin cannot be sterilized and is a

potential source of contamination.

Mechanical washing and chemical antisepsis are used to remove or inactivate transient and resident flora from the skin around the surgical site and from the hands and arms of sterile team.

Gowning and gloving must be accomplished without contaminating the sterile exterior of gowns and gloves.

If a glove is torn or punctured by a needle or instrument, it must be changed immediately. The puncturing needle or instrument is also removed from the sterile field.

Use a sponge only once, then discard it. Minimize talking in the OR. Moisture

droplets are expelled with force into the mask when talking is done.

OR attire must be worn properly: the mask must cover the nose and mouth; hair must be completely covered by a sterile cap; and body covers must be close-fitting.

SURGICAL SCRUBDefinition:

– Is the removal of as many bacteria as possible from the hands and arms by mechanical washing and chemical disinfection before participating in an operation.

– Done just prior to gowning and gloving for each operation.

Purposes:– To help prevent the possibility of contamination of

the operative wound by bacteria on the hands and arms.

– To remove soil, debris, natural skin oils, hand lotions and transient microorganisms from the hands and forearms of sterile team members.

– To decrease the number of resident microorganisms on skin to a minimum

– To keep the population of microorganisms minimal during the operative procedure by suppression of its growth

– To reduce the hazard of microbial contamination of the operative wound by skin flora

SINK– Should be adjacent to the O.R. for

safety and convenience– Must have automatic controls or foot-

or knee-operated faucets to eliminate the hazard of contaminating hands after cleaning

• Should be used only for scrubbing or handwashing

EQUIPMENT• scrub brushes or disposable

sponges• scrubbing solution

PROCESSES USED IN FREEING THE SKIN OF

MICROORGANISMS

• mechanical – removes oil, and transient microorganisms with friction

• chemical- reduces resident flora and inactivates microorganisms with a microbial or antiseptic agent.

Preparation Prior to Surgical Scrub:

– Skin and nails should be kept clean and in good condition and cuticles uncut.

– Fingernails should not reach beyond the fingertip to avoid glove puncture.

– Fingernail polish should not be worn.– Inspect hands for cut and abrasions. Skin of hands and

forearms should be intact, without open lesion or cracked skin.

– Remove all finger jewelry.– Be sure all hair is covered by headgear. – Adjust disposable mask snugly and comfortably over nose

and mouth.– Adjust eyeglasses comfortably in relation to mask.– Adjust water to comfortable temperature.

Length of Scrubbing• Surgical Scrub Method:• time method

– fingers, hands and arms are scrubbed by allotting a prescribed amount of time to each anatomical area or each step of the procedure.

– Complete scrub takes 5-7 minutes, this is done:• In the morning before the 1st gowning and gloving.• Following a clean case, if gloves have been removed

inadvertently, before the gown.• Following a clean case if hands have been

contaminated in any other way.• Before an emergency case at anytime.

– Short scrub takes 3 minutes, done following a clean case, if the hands and arms have not been contaminated. It is done to remove bacteria that have emerged from the pores and multiplied while the gloves were on.

brush stroke method– a prescribed number of brush

strokes, applied lengthwise of the brush or sponge is used for each surface of the fingers, hands and arms.• Scrub the nails of 1 hand 30 strokes, all

sides of each finger 20 strokes, the back of the hand 20 strokes, the palm of the hand 20 strokes, the arms 20 strokes for each 3rd of the arm to 3 inches above the elbow.

Proper Scrub Technique for the 1st 5

Minutes of a 10 Minutes Scrub:

• Turn on water and get antiseptic solution.• Wash hands prior to scrub.• Clean fingernails under running water.• Scrub left hand, arm, and elbow area.• Rinse brush and transfer to other hands.• Scrub right hand, arm and right elbow

area.• Rinse.• Complete scrub as indicated with

anatomical timed or stroke count scrub method.

Drying Hands After Surgical Scrub:

– When drying stand away from objects and people. To eliminate unnecessary movement of the towel, move the hand that is being dried rather than the towel. The drying procedure is done as follows:

• When picking up the towel, do it with a swift, efficient motion.• Take the towel in the middle, being careful not to contaminate

the sterile gown under it.• Bend at the waist to help prevent the sterile towel from

touching the unsterile gown while drying your hands and arms.

• Dry hand to mid-lower arm; then transfer dry end of towel to other hand.

• Do not dry hand then arm and return to same hand.• After the 2nd hand and mid-lower have been dried, fold towel

in thirds and dry elbows.• Be sure hand is well covered. When transfer of towel is made

from hand to hand, do not allow hand to touch where elbow has been touched.

• Discard towel in linen hamper.

GOWNING• Purposes:

– To exclude skin as a possible contaminant and to create a barrier between sterile and unsterile areas.

– To permit the wearer to come within the sterile field.

– To carry out sterile techniques during an operative procedure.

General Considerations:

– The scrub nurse gowns and gloves self, then gowns and gloves the surgeon and assistants.

– Gown package preferably are opened on a separate table from other packages to avoid any chance of contamination from dripping water.

– After scrubbing, hands and arms must be thoroughly dried before the sterile gloves is donned to prevent contamination of the gown by strike-through of organisms from skin and scrub attire.

– The gown package for the scrub nurse contains 1 sterile gown, folded before sterilization, with the inside out, so that the bare scrubbed hands will not contaminate tile outside of the gown.

– A towel for drying hands is placed on top of the gown during packaging. Scrub nurse holds the towel away from the body , dries only well-scrubbed areas, hands first and avoids contaminating hands on the areas proximal to the elbows.

– Dry both hands, then one arm on one end of the towel, use the opposite end of the towel for the other arm.

– To put on sterile gown, the scrub nurse needs the assistance of the circulating nurse.

Gowning Techniques:• gowning for open/close glove technique

• reach down the sterile package and lift the folded gown directly upward or scrub nurse receives sterile gown from the circulating nurse.

• Step back away from the table, into a clear area, to provide a wide margin of safety while gowning.

• Holding the folded gown, carefully locate the neckband and centerfold.

• While holding the neckband with both hands or holding the centerfold with one hand, gently shake the folds from the gown.

• Slip both hands into the sleeves, holding the hands upward on level with the shoulder without touching the outside part of the gown with bare hands.

• Circulating nurse reaches inside the gown to the sleeve seams and pulls the sleeves over the hands to the wrists.

• Circulating nurse fastens back part, ties waist band, touching outside of the gown at the line of ties or fastens in the back only.

gowning another person

• – a team member in sterile gown and gloves may assist another team member in gowning by taking the following steps:

• give the rowel to the surgeon being careful not to touch the hand.

• Unfold the gown, holding it at the neckband.• Keep the hands on the outside part of the gown

under the protective cuff and shoulder area, offer the inside part of the gown to the surgeon. The surgeon slips into the sleeves.

• Release the gown. The surgeon holds arms outstretched while the circulating nurse pulls the gown onto the shoulders and adjusts the sleeves and cuffs.

changing gown during the operation

• circulating nurse unfastens neck and waist. By grasping it at shoulders, the gown is pulled off inside out. The gown is always removed 1st before the gloves. If only the sleeves are contaminated, a sterile sleeve may be put on over the contaminated one.

• Preferably a sterile team member may gown another. If this is not possible, step aside and put on sterile gown.

removing gown• the gown is always removed before the

gloves. It is pulled downward from the shoulders, turning the sleeves inside out as it is pulled off the arms.

• Sequence of scrub nurse removing soiled gown at the end of operation. Clean arms and scrub dress are protected from contaminated outside part of gown:

– With gloves on, loosen cuffs of gown and shake them down over wrists. Then grasps right shoulder of gown (unbottonned or untied) with left hand.

– Pulling the gown off arms, turn arm of gown away from body with flexed elbow.

– Then grasp the other shoulder with the other hand and remove gown entirely, pulling it off inside out; thus arms are kept clean.

GLOVING• Gloves

– Sterile gloves complete the attire of scrubbed team members.

– The sterile gloves are put on immediately after gowning.

• Purposes:– To exclude skin as a possible contaminant.– To create a barrier between sterile and unsterile

areas.– To permit the wearer to handle sterile supplies or

tissues of the operative wound.

Gloving Techniques:closed glove technique

– preferred except when changing a glove during an operation or when donning gloves for procedures not requiring gowns

– if properly executed it affords assurance against contamination.

• using the left hand, and keeping it within the cuff of the left sleeve, pick up the glove, from the inner wrap of the glove package, by grasping the folded cuff.

• Extend the right forearm with palm upward. Place the palm of the glove against the palm of the right hand, grasping in the right hand the edge of the cuff, above the palm. In correct position, glove fingers are pointing toward you and thumb of the glove is to the right. The thumb side of the glove is down.

• Grasp the back of the cuff in the left hand and turn it over the end of the right sleeve and hand. The cuff of the glove is now the stockinet cuff of the gown, with hand still inside the sleeve.

• Grasp the top right glove and underlying gown sleeve with covered left hand. Pull glove on over extended right fingers until completely covers the stockinet cuff.

• Glove the left hand in the same manner, reversing hands. Use gloved right hand to pull on the left glove.

open glove technique– uses skin-to-skin, glove-to-glove technique.

• With left hand, grasp the cuff of the right glove on the fold. Pick up the glove and step back from the table. Look behind you before moving.

• Insert right hand into the glove and pull it on, leaving the cuff turned well down over hand.

• Slip finger of the gloved right hand under the everted cuff of the left glove. Pick up the glove and step back.

• Insert hand into left glove and pull it and leaving the cuff turned down over the hand.

• With fingers of the right hand, pull cuff of the left glove over cuff of the left sleeve.

• Repeat step 5 for the right cuff, using the left hand, and thereby completely gloving the right hand.

gloving another person• pick up the right glove, grasp it firmly,

with fingers under the everted cuff.• Stretch the cuff sufficiently for the

surgeon to stretch the hand. Avoid touching the hands by holding your thumbs out.

• Exert upward pressure as the surgeon plunges the hand into the glove. Unfold the everted glove cuff over the cuff of the sleeve.

• Repeat for the left hand.

changing glove during operation

• turn away from sterile field.• Extend the contaminated hand to the

circulating nurse who grasps the outside of the glove cuff about 2 inches below the top of the glove and pulls the glove off, inside out.

• Preferably a sterile team member gloves another. If this is not possible step aside and glove the hand using the open glove technique.

removing gloves– glove is removed after the gown.

• Gloves are turned inside out, using glove-to-glove then skin-to-skin technique