Hospital infection Control(Induction ppt.) Dr Jayant balani Consultant Microbiologist(MBBS,MD)) Dharamshila hospital &research centre, New Delhi

Definition

• Health Care-associated Infection (HCAI)– Also referred to as “nosocomial” or “hospital”

infection • “An infection occurring in a patient during the process of

care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge, and also occupational infections among health-care workers of the facility”

Sources of infection

• Self( immunity)• Staff (contact)• Environment (air, water)• Instrumentation• Food• Iatrogenic or Procedural• Surgical site infection

The impact of HCAI• HCAI can cause:

– more serious illness– prolongation of stay in

a health-care facility– long-term disability– excess deaths – high additional

financial burden– high personal costs on

patients and their families

Importance of hospital associated infection

• Term based payment system for hospitals• Quality indicator: Accreditation• Hub of M.D.R.O organisims-empiric antibiotic

guidelines/Cancer patients

Estimated rates of HCAI worldwide– At any time, hundreds of millions of people worldwide are

suffering from infections acquired in health-care facilities– In modern health-care facilities in the developed world:

5–10% of patients acquire one or more infections– In developing countries the risk of HCAI is 2–20 times higher

than in developed countries and the proportion of patients affected by HCAI can exceed 25%

– In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%

UNIVERSAL PRECAUTIONS

• Under Universal precautions , blood and certain bodily fluids of all patients are considered as potentially infectious for HIV, HBV and other bloodborne diseases (12). These precautions include the use of personal protective equipment (PPE), such as gloves, mask, gown and eyewear appropriate for the anticipated risk, and hand hygiene, as well as precautions to avoid needle stick injuries to both patients and health care workers.

STANDARD AND TRANSMISSIONPRECAUTIONS

• Standard precautions: They are based on the principle that all blood and other bodily fluids, secretions and excretions, excluding perspirations, may contain transmissible infectious agent. These precautions include; hand hygiene; the use of gloves, a gown, a mask, eye protection or a face shield, depending on the anticipated exposure; and safe injection practices. Equipment or items in the patient environment likely to have been contaminated with infectious bodily fluids must be handled appropriately to prevent transmission of infectious. Respiratory hygiene/cough etiquette.

• Transmission-based precautions should be used suspected to be infected or colonized with infectious agents.

Most frequent sites of infection and their risk factors

LOWER RESPIRATORY TRACT INFECTIONSMechanical ventilationAspirationNasogastric tubeCentral nervous system depressantsAntibiotics and anti-acidsProlonged health-care facilities stayMalnutritionAdvanced ageSurgeryImmunodeficiency

13%

BLOOD INFECTIONSVascular catheterNeonatal ageCritical care Severe underlying diseaseNeutropeniaImmunodeficiencyNew invasive technologiesLack of training and supervision

14%

SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxisIncorrect surgical skin preparation

Inappropriate wound care Surgical intervention duration

Type of woundPoor surgical asepsis

DiabetesNutritional state

ImmunodeficiencyLack of training and supervision 17%

URINARY TRACT INFECTIONSUrinary catheter

Urinary invasive proceduresAdvanced age

Severe underlying diseaseUrolitiasisPregnancy

Diabetes

34%

Most common sites of health care-associated infection and the risk factors

underlying the occurrence of

infections

LACK OF HAND

HYGIENE

Prevention of HCAI

– Validated and standardized prevention strategies have been shown to reduce HCAI

– At least 50% of HCAI could be prevented – Most solutions are simple and not resource-

demanding and can be implemented in developed, as well as in transitional and developing countries

SENIC study: Study on the Efficacy of Nosocomial Infection Control

– >30% of HCAI are preventable

With infection control

-31% -35%-35%-27%

-32%

Without infection control

14%9%

19%26%

18%

LRTI SSI UTI BSI Total

Relative change in NI in a 5 year period (1970–1975)

0

10

20

30

-40

-30

-20

-10

%

Haley RW et al. Am J Epidemiol 1985

Hand transmission

– Hands are the most common vehicle to transmit health care-associated pathogens

– Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps

5 stages of hand transmission

Germs present on patient skin and immediate environment surfaces

Germ transfer onto health-care worker’s hands

Germs survive on hands for several minutes

Suboptimal or omitted hand cleansing results in hands remaining contaminated

Contaminated hands transmit germs via direct contact with patient or patient’s immediate environment

one two three four five

Why should you clean your hands?– Any health-care worker, caregiver or person involved in

patient care needs to be concerned about hand hygiene– Therefore hand hygiene concerns you!– You must perform hand hygiene to:

– protect the patient against harmful germs carried on your hands or present on his/her own skin

– protect yourself and the health-care environment from harmful germs

The “My 5 Moments for Hand Hygiene” approach

How to clean your hands

– Handrubbing with alcohol-based handrub is the preferred routine method of hand hygiene if handsare not visibly soiled

– Handwashing with soap and water – essential when when hands are visibly dirty or visibly soiled (following visible exposure to body fluids)1

1 If exposure to spore forming organisms e.g. Clostridium difficile is strongly suspected or proven, including during outbreaks – clean hands using soap and water

To effectively reduce the growth of germs on hands, handrubbing must be performed by following all of the illustrated steps.This takes only 20–30 seconds!

How to handrub

How to handwash

To effectively reduce the growth of germs on hands, handwashing must last 40–60 seconds and should be performed by following all of the illustrated steps.

Hand hygiene and glove use

– The use of gloves does not replace the need to clean your hands!

– You should remove gloves to perform hand hygiene, when an indication occurs while wearing gloves

– You should wear gloves only when indicated (see the Pyramid in the Hand Hygiene Why, How and When Brochure and in the Glove Use Information Leaflet) – otherwise they become a major risk for germ transmission

BARRIERS TO HAND HYIEGINE

Time constraint = Major factor

• Adequate handwashing with water and soap requires 40–60 seconds

• Average time usually adopted by health-care workers: <10 seconds

• Alcohol-based • handrubbing: 20–30 seconds

HAND HYIEGINE COMPLIANCE

DOCTORS

NURSING ST

AFF

PHYSIOTHERAPIST

HOUSEKEEPIN

G STAFF

0

18

35

53

70

88

HAND WASH HAND RUB

HAND HYIEGIENE COMPLIANCE

I.C.U/H.D.U 3 FLOOR 2 A& B 3 FLOOR 4 FLOOR0

0

0

1

1

Series 1

Series 1

PPE

Sterile gloves indicated Any surgical procedure; vaginal delivery; invasive radiological procedures; vascular access and procedures (central lines); preparation of total preparation of total parenteral nutrition and chemotherapeutic agents.

Clean gloves indicated Potential for touching blood, bodily fluids, secretions, excretions and items visibly soiled by bodily fluids, secretions, excretions and items visibly soiled by bodily fluids. Direct patient exposure : contact with blood; contact with mucous membrane and non-intact skin; potential presence of highly infectious and dangerous organism; epidemic or emergency situations; IV insertion and removal; drawing blood; discontinuation of a venous line; pelvic and vaginal examinations; suctioning non-closed systems of endotracheal tubes. Indirect patient exposure: emptying emesis basins; handling/cleaning instruments; handling waste; cleaning up spills of body fluids.

Gloves not indicated (except for contact precautions)

Direct patient exposure; taking blood pressure, temperature and pulse; performing subcutaneous and intramuscular injections; bathing and dressing a patient, transporting a patient, caring for eyes and ears any vascular line manipulation absence of blood leakage.Indirect patient exposure: using the telephone, writing in the patent chart, giving oral medications, distributing or collecting patient dietary trays, removing and replacing linen for a patient’s bed; placing non-invasive ventilation equipment and oxygen cannula; moving patient furniture. No potential for exposure to blood or bodily fluids, or contaminated environment. Gloves must be worn according to standard and contact precautions. Hand hygiene should be performed when appropriate, regardless of indications for glove use

GOWNS AND FACE MASKS

• Wear full-body, fluid-repellent gowns when there is a risk of extensive splashing of blood, bodily fluids, secretions or excretions, with the exception of perspiration (e.g. trauma, operating theatres, obstetrics). In situations in which the splashing of blood or fluid is likely or expected (e.g. in a labour room during delivery), shoe covers should also be worn;

• Face masks and eye protection should be worn when there is a risk of blood, bodily fluids, secretions and /or excretions splashing into the face and eyes.

RESPIRATORY HYGIENE/COUGH ETIQUETTE

• Steps in respiratory hygiene/cough etiquette • Anyone with signs and symptoms of a respiratory infection,

regardless of the cause, should follow or be instructed to follow respiratory hygiene/cough etiquette as follows;

 • Cover the nose/mouth when coughing or sneezing;• Use tissues to contain respiratory secretions;• Dispose of tissues in the nearest waste receptacle after use;• If no tissues are available, cough or sneeze into the inner elbow

rather than the hand;• Practice hand hygiene after contact with respiratory secretions and

contaminated objects/materials

PPE includes• Gloves (Double gloves where used? )• Aprons, masks, goggles. In certain situations• In theatre, it may also include caps and

footwear • Gloves should be worn whenever there might

be contact with blood and body fluids, mucous membranes or non intact skin.

• Semi recumbent positioning.• Aseptic intubation and suctioning.• Good oral care• Maintain gastric ph/Stress ulcer prophylaxis• Daily weaning assessment/D.V.T Prophylaxis.• Humidifier sterilized daily/use only distilled water.• Suction apparatus to be cleaned daily.• Envoirmental care during renovation.legionella,aspergillus

• Aseptic precautions to be used at time of insertion

• Line to be changed every 72 hours.• Date of insertion to be mentioned at time of

insertion.• Upper extremity site better as compared to

lower extremity site.

• Use appropriate site-subclavian preferred over jugular/femoral site.

• Clean the site with alcohol/iodine before and after inserting/use gloves ,drape and put date of insertion.

• Use a single lumen/as per requirement/minimal hubs.• Use stop cock on hubs when not in use/clean with alcohol

solution prior to using hub./Closed systems.• Change guaze dressing every 2 days/transparent dresssing

every 7 days.No frequent changes.• Central line change if signs of infec tion. No fixed time.• Antibiotic coated catheter for short term catheterisation.

• Use an appropriate size catheter./smallest diameter catheter.

• Use a no touch technique while inserting catheter. Perineal cleaning/appropriate lubricant helps.

• Limit duration/maintain closed drainage.• Bag should be at a lower position but should not touch the

floor.• Urine for sampling should be taken by clamping , cleaning

with 70% alcohols solution and removing sample with a syringe.

• Remove when signs of uti/no fixed change time

• Perineal hygiene for patients.• Good hydration for patients.NOT INDICATED• Antimicrobial coated catheter..• Neurogenic bladder• Avoid an indwelling catheter.• Intermittent urinary catherisation.

Prevention of hosp infection

• Use PPE• Hand washing(6 pt)• Sterile precaution• Environment cleaning• Vaccination• Universal precaution• Surveillance• Linen management• Safe blood product• Sharp management

Universal precaution

• Universal precautions should be applied to all body fluids when it is difficult to identify the specific body fluid or when body fluids are visibly contaminated with blood.

• Irrespective of HIV status of patient

Summary of infection control precautions of various categories.

1. Activity Standard Precautio

n

Additional precaution Airborne

transmissionDroplet

Transmission Contact Transmission

Tuberculosis, Varicella (chickenpox) Rubella (Measles ) Droplet size ≤ 5yM

Streptococcal pharyrigitis , Influenza, Mumps Droplet size ≥ 5yM

M.R.S.A, V.R.E, Scabies, E.Coli Diarrogenic strain

Single Room Noa Yes – door Closed Yes Yes – if possible (cohort with patient with the same infection)

Negative pressure Ventilation

No Yesb No No

Hand washing Yes Yes Yes Yes

Gloves For body substances

For body substances

For body substances

Yes

Gown If soiling likely

If soiling likely If soiling likely If HCW’s clothing will have substantial contact with the patient, environmental surface of items in the patient’s room

Mask Protect face if splash likely

Particulate mask for tuberculosis only . All others, regular mask

NoC Protect face if splash likely

Goggles/ Face-shields

Protect face if splash likely

Protect face if splash likely

Protect face if splash likely

Protect face if splash likely

Miscellaneous Avoid contaminating environmental surfaces with gloves

Teach patient to cover nose and mouth when coughing or sneezing

Provide 1 m of separation between patients in cohort

Remove gloves and gown, wash hands before leaving patient’s room

Gown If soiling likely If soiling likely

If soiling likely If HCW’s clothing will have substantial contact with the patient, environmental surface of items in the patient’s room

Vaccination

• Hepatitis B vaccination• Staff screening (kitchen staff)• PEP (In HIV )

Environment cleaning

• Surface should be cleaned with phenyl 2-3 times a day

• The floor and walls should be carbolised once a day

• ICU and OT tables, fans, lights should be carbolised once a day or after every infected case

S.NO PURPOSE ITEM NAME GENERIC NAME BRAND PACK SIZE NET RATE/PCS

CONSUMPTION Apr 11 to Jan 12 (10 months)

TOTAL PURCHASE IN Rs.

1 CARBOLISATION/ FLOOR AND SURFACE DISINFACTANT

PHENOL IP CARBOLIC ACID AGGRAWAL 400 GM 147.60 95 14022.00

2 FUMIGATION MICROGEN D-125 MICROGEN 1 LTR 285.60 23 6568.80

3 INSTRUMENT CLEANING

NEODISHER-LM2 ELDER 1 LTR 1239.75 39 48350.25

4 SURGICAL HAND WASH / SCRUB

CHLOREHEXIDINE CHLORHEXIDINE GLUCONATE SOLUTION IP

RAMAN AND WEIL

500 ML 170.57 246 41960.22

STERIMAX BIOSHIELD 500 ML 182.50 200 bottle 36500.00

5 DISINFECTANT IN INFECTED CASE

SODIUM HYPOCHLORITE 2%

SODIUM HYPOCHLORITE

MERCK 5 LTR 396.90 165 65488.50

PHENOL IP CARBOLIC ACID AGGRAWAL 400 GM 0 0 0.00

6 PREPERATION OF PRE-OPERATIVE SITE

AND SKIN CLEANING.

BETADINE SOLUTION

POVIDONE IODINE IP 5%

WIN MEDICARE 1 LTR 236.25 355 83868.75

DENATURE SPIRIT 20 LTR 101.25 per ltr.

400 ltr 40500.00

7 ANTISEPTIC ACEPTIK CHLORHEXIDINE GLUCONATE SOLUTION IP, ISOPROPYL ALCOHOL IP

RAMAN AND WEIL

1 LTR 168.00 30 5040.00

8 RUST REMOVER NEODISHER-IR PHOSPHORIC ACID ELDER 1 LTR 1721.25 10 17212.50

9 CHITTLE FORCEPS TRIDEX 28LL TORRELL 5 LTR 549.00 36 19764.00

10 DISINFECTANT FOR EQUIPMENTS TUBINGS AND SCOPES

KORSOLEX GLUTARALDEHYDE RAMAN AND WEIL

500 ML 448.9 184 82597.60

11 INSTRUMENT LUBRICANT

NEODISHER IP SPRAY

ELDER 500 ML 1300 1 1300.00

Total 463172.62

Spill Management• Pour freshly made 1% sodium hypochlorite solution on and

around the spill area and cover with gauge/paper/absorbent material for at least 15-20 minutes.

• Cover spills of infected or potentially infected material on the floor with paper towel/blotting paper/newspaper.

• After 20 minutes, remove absorbent material with gloved hands and discard in yellow bag.

• Clean the area with soap and water.

MONTHLY SURVEILLANCE PRLOTOCOL

MONTHLY SURVEILLANCE PROTOCOL

MONTHLY SURVEILLANCE PROTOCOL

Linen management

• Change the bed sheets daily• Soiled sheets should be put in

separate bag for pretreatment in the laundry

• Disinfect with sodium hypochlorite 1% for 20-30min

Sharp management

• Needles should be destroyed by needle destroyer• Put in puncture proof container• Syringe should be put in hypochlorite solution• Syringes after pretreatment should be put in red

bag

Things not to do • You should ensure that:• Sharps are not passed directly from hand to hand• Handling is kept to a minimum• Needles are not broken or bent • Needles are never re-capped• Staff take personal responsibility for any sharps they use

and dispose of them in a designated container at the point of use

Handling of Accident

• Complete an accident form.• Seek help to initiate an investigation into the cause of the

incident and risk assessment.• If blood and body fluids splash into your mouth, do not

swallow. • Rinse out several times with cold water.• If blood and body fluids splash into eyes, irrigate with cold

water.

Handling sharps

To pick Broken glass pieces use broom and card board

NEEDLE STICK INJURY DATA

NEEDLE STICK INJURY GRAPHICAL PRESENTATIONHANDLING B,M,W

SURGICAL PROCEDURES

WITHDRAWING BLOOD

04 02 02 012345

Series 1

Series 1

HICC

• Members• Job profile• Issues to discuss• Surveillance

HICC Manual contents• Cleaning and decontamination of surfaces• Procedures for patient isolation• Management of spills• Hand washing• Protective clothing• Handling of Linen• House keeping job• Waste management• Sharps disposal• Sharp injuries post exposure prophylaxis

Hospital strains

• MRSA• VRE• ESBL• M.D.R

Klebsiella,Acinetobacter,Pseudomonas

ORGANISINTYPE

NO.OF CASES LOCATION

TOTAL DAYS

RATE=NO.CASES/ TOTAL PATIENT DAYS X100

MDR PSEUDOMONAS

ICU 1 598 0.16WARD 4 9839 0.04

MDR KLEBSIELLA

ICU 6 598 1.0WARDS 10 9839 0.10

MDR AINETOBACTER

ICU 3 598 0.5WARDS 0 9839 0

MDR TOTAL ICU 16 598 2.6WARDS 17 9839 0.17

ORGANISINTYPE

NO.OF CASES

TOTAL DAYS

RATE=NO.CASES/ TOTAL PATIENT DAYS X100

M,R,S,A ICU 1 598 0.16%

WARDS 4 9839 0.04%

E,S,B.L ICU 1 598 0.16%\

WARDS 3 9839 0.03%

M.D.R.O PRECAUTIONS

• Shift to isolation room if available• Strict hand washing for patient• Separate equipment like thermometer ,b.p

apparatus ,nebuliser.

Care of patient

• Isolation

• Reverse isolation

BMW rule

• Bio-Medical Waste (Management and Handling) Rule – 1998

• Under Forest Ministry• The Private company makes the

arrangement to collect the bio-medical waste from Hospital

Steps taken

• Segregation• Collection• Transportation• Treatment

Hospital color coding

• Yellow bag- Infectitious material• Red bag- Plastic, disposable catheter,

syringes, gloves• White (puncture proof)- Sharps• Green- General waste• Black- Medicines

Pre treatment• Red bag material are pretreated• Hypochlorite solution is added • 1% freshly prepared solution is used• Double Basket dust bin is used• After treatment plastic, syringes etc. are put in

red bag• Gloves are cut before putting in bag

Transportation

• Waste is weighed according to color coded bags and recorded

• Private company transport waste in closed vehicle• Taken to treatment plant (area)• Dumping and treating site is Okhla, New Delhi.• Treated according to color coded bags

INFECTION CONTROL PROGRAMME

• GOAL• TO REDUCE THE INCIDENCE OF

HOSPITAL ACQUIRED INFECTIONS,CATER TO PATIENT AND HEALTHCARE WORKER SAFETY

Surveillance

• LABORATORY BASED WARD ALLIASON

POLICYFOR H.I.C

• COMPLIANCE WITH I.P.C PROCEDURES PART OF PERFORMANCE EVALUATION FOR STAFF.

• ESTABLISHING ROLE MODELS FOR EMPLOYEES BY ENCOURAGEMENT OF STAFF FOLLOWING GOOD INFECTION CONTROL PRACTICES.

• COMMUNICATION WITH HEALTH DEPARTMENT,DELHI GOVT. PROVIDING FEEDBACK ABOUT COMMUNICABLE INFECTIONS.

. BENCHMARKING OF HOSPITAL DATA WITH N.H.S.N

POLICY FOR H.I.C

• ADRESSING ISSUES RELATED TO HEALTHCARE WORKER SAFETY-NEEDLE STICK INJURY,VACCINATION OF STAFF,BIOMEDICAL WASTE MANAGEMENT.

• MONITORING USE OF ANTIBIOTICS IN HOSPITAL AND ENCOURAGING GOOD ANTIBIOTIC PRACTICES.

• REGALAR AUDITS IIN FOLLOWING AREAS AS MEASURE OF PROCESS OUTCOME

POLICYFOR H.I.C

• Antibiotic prescribing audit• Surgical site audit• Laundry and housekeeping audit• Kitchen audit• Isolation room audit• C.S.S.D audit.• Endoscope reprocessing audit

POLICY FOR H.I.C

1. BUDGETARY ALLOCATION AND AMOUNT OF 14,87,463 SPENT ON INFECTION CONTROL PROGRAMME.

SPENDING

DISINFECTANTS P.P.ESURVEILLANCE

TYPE SPENDING

DISINFECTANTS 4,63172

PPERSONAL PROTECTIVE EQUIPMENT

7,79,291

SURVEILLANCE CULTURES

2,45,000

TYPE OF ISOLATES

H.A.I INDICATORS

TYPE JAN FEB MAR

APR MAY JUN JULY AUG SEP. OCT. NOV.

DEC.

C.R.B.S.I (I.C.U)

1.1 2.9 0.6 1.17 0.8 0.44 0.6 0 0.5 0 0 0

C.U.A.T.I (I.C.U)

5.3 6.8 5.3 3.3 4 3.5 3.3 0 1.9 0 6.8 3.9

C.A.U.T.IWARDS

4,.9 5.1 4.3 2.1 2.1 2.2 2.3 0 .8 1.1 2.3 2.1

S.S.I 6.4 5 5.7 6.6 13.5 11.1 8.1 7 9.5 10 14.5 8.5

VAP(I.C.U)

0 0 90.9*1 case

0 0 0 0 0 0 0 0 0

CATEGORY

DHARAMSHILA HOSPITAL

I.N.I.C.C2004-2009MEAN(95%c.i)

U.S N.H.S.N2006-2008Mean95%c.i

CRBSI 0.67 6.8 1.5

C.A.U.T.I 3.675 7.1 3.1

V.A.P 7.5 18.4 1.9

S.S.I 8.32 15*Jjournal of hospital infection,2000:45:173-184

CATHETER ASSOSCIATED U.T.I(C.U.A.T.I)

SURGICAL SITE INFECTION(S.S.I)

CENTRAL LINE BLOOD STREAM INFECTION I.C.U

Important point (carry home message)

• Hand washing is must• Self protection by following

universal precaution• Follow sterile precaution

Sterility leads to infection free atmosphere, we are responsible for it.

Thank you