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Infection Prevention and Control

101 Overview

March 2017

Overview

• Chain of Infection

• Infection Prevention and Control Basics

• Point of Care Risk Assessment

• Applying Principles

Resource

Infection Prevention and Control Guidelines: Community Health

• Recently Updated: January 2017

Chain of Infection

Infectious Agent

Reservoirs

Portal of Exit

Mode of Transmission

Portal of Entry

Susceptible Host

Chain of Infection

• Infectious/Causative Agent:

– Bacteria

– Fungi

– Viruses

– Parasites

– Prions

Infectious Agent

Chain of Infection

• Reservoirs:

– Humans

– Animals

– Environment

Reservoirs

Chain of Infection

• Portal of Exit:

– respiratory

– gastrointestinal

– Genitourinary

– skin/mucous

– transplacental

– blood

Portal of Exit

Chain of Infection

• Mode of Transmission:

– Contact

– Droplet

– Airborne

– Food

– Water

– Vector

Mode of Transmission

Chain of Infection

• Portal of Entry:

– Mucous Membrane

– Respiratory

– Gastrointestinal system

– Broken Skin

Portal of Entry

Chain of Infection

• Susceptible Host

– Immunosuppression/lack of immunity

– Diabetes

– Burns

– Surgery

– Age

Susceptible Host

Breaking the Chain of Infection

Source: Nunavut Health – Chain of Infection

INFECTION PREVENTION AND CONTROL BASICS

Routine Practices and Additional Precautions

IPC Basics

• Basic elements of Routine Practice include:

– Hand hygiene

– Point of Care Risk Assessment

– Risk Reduction Strategies/Personal Protective Equipment

– Education of Health Care Providers, Clients and Families, Visitors, Volunteers

Infection Prevention and Control Guidelines: Community Health, FNIHB AB Region 2017

HAND HYGIENE

The efficacy of hand disinfection in reducing nosocomial infections was initially recognized by Semmelweiss in 1847.

Source: “Hand Hygiene Practices in Health Care Settings” Public Health Agency of Canada, 2012

Definition

“Hand hygiene is a comprehensive term that refers to hand washing, hand antisepsis and actions taken to maintain healthy hands and fingernails.”

Appendix 1 - Guidelines

Definitions

• Hand washing: process for removal of soil and transient organisms from hands using soap and water

• Hand antisepsis: process for removal or destruction of resident and transient micro-organisms on the hands using an antiseptic agent, either by rubbing hands with alcohol-based hand rub or hand washing with an antiseptic soap

Microbiology Principles

• Microorganisms are present on skin and on inanimate objects

• Hand contamination does not require sustained contact with patients.

• Bacteria and viruses can persist on hands for hours.

• Contaminated hands may transmit microorganisms

• Hand hygiene may be ineffective if an inadequate amount of product is used or if inappropriate product/technique is used.


Resident microorganisms (Normal flora):

• Survive and multiply on skin but do not generally cause illness.

• Implicated in infections linked to invasive procedures or when host is immunocompromised


Transient microorganisms:

• Relatively scarce on clean skin and/or skin unexposed to contaminants.

• Frequently implicated in health-care associated infections

Recommendation

• “the use of an alcohol-based hand rub (ABHR) is the preferred method of hand hygiene in health care settings, unless exceptions apply.”

– Exceptions:

• hands visibly soiled with organic material

• exposure to norovirus; potential spore-forming pathogens (i.e. Clostridium difficile)

Agents Used

• Alcohol based hand rubs: (Ethanol, isopropanol, n-propanol)

– Action is to denature proteins: • excellent bactericidal and fungicidal activity• little to no activity against bacterial spores

– Most rapidly active of all agents: • Product formulation may influence efficacy (i.e. gels, rinses,

foams)

– Should have concentrations of 60 to 90% alcohol– Cautions:

• rub onto dry hands as sensitive to water dilution• Not to be used if visible/potential organic matter on hands• Products are flammable – need to be stored/used carefully

Agents Used

• Other Hand Rub products

– Products with no alcohol or with concentrations less than 60%

× No efficacy data and they should not be used in health care settings.

Hand Hygiene – ABHR

• Preferred product for HCW use

– Make sure no organic matter on hands

– Hands should be dry

– Apply “dose”

– Rub over entire hand until absorbed

Hand Hygiene - Handwashing

• Handwashingcomponents

– Soap

– Friction

– Rinsing

– Drying

– (moisturizing)

Routine Practices and Additional Precautions for Health Care Workers. PHAC, 1998

Hand Hygiene - Handwashing

• Performed: – to remove visible soil or organic matter

– when build up of ABHR product feels uncomfortable

• Efficacy depends on the time taken and technique used:– Greatest reduction of transient bacteria was

within first 30 seconds

Agents Used

• Plain Soaps

– Limited antimicrobial activity – removes loose transient flora

– Cautions:

• Potential for contamination

Agents Used

• Antimicrobial Soaps

– Routine use is not necessary

– Recommended use:

• procedures requiring aseptic technique

• surgical procedures

Agents Used

• Hand Wipes

– May be used to remove soil or organic material and should be followed by use of ABHR

– NOT a substitute for ABHR or hand antisepsis

– May be a substitute for hand washing ifsoap/water not available

Hand Hygiene - Drying

• Dry hands are important as wet hands facilitate transmission of microorganisms

– Single use towels

– Avoid recontamination of hands

• Automatic hand dryers are not appropriate in clinic setting:

– Noisy, potential for aerosolization?

Hand Hygiene – Hand Care

Hand and fingernail care is very important

• Damaged skin sheds microorganisms

• Cracked hands and cuticles reduces hand-hygiene adherence

• Cautions:– Water too hot

– Applying soap before wetting hands

– Not using hand lotions

– Poor quality paper towels

Hand Hygiene – Nails, Jewelry

• Chipped nail polish increases bacterial load

• Bracelets, wrist watches and rings may prevent effective hand hygiene.

POINT OF CARE RISK ASSESSMENT

Point of Care Risk Assessment & Personal Protective Equipment in Health Care Workers

No Yes

Assess patient, environment, and interaction

Contact with patient

or environment

expected?

No PPE required

Hand hygiene

Splash or spray of

blood/body fluids

anticipated?

Facial protection

Contact with mucous

membranes, non-intact skin,

body fluids, secretions, or

soiled surfaces anticipated?

Hand hygiene before

leaving patient

environment

Put on gloves;

Put on a gown if soiling

of clothes is likely

Airborne Exposure*

potential?

Yes

No

No

Yes

Routine Practices

Yes

No

N95 Mask

*Airborne Exposure can include:

Infectious TB

Measles

some foot care practices

Methotrexate

spill.

On OneHealth

Personal Protective Equipment (PPE) used for Additional Precautions

Contact Precautions

For microorganisms of very low infective dose (i.e. Shigella) or situation of heavy environmental contamination

Gloves

Gown*

*if contamination of clothes can be expected from the patient or environment

Droplet Precautions

For microorganisms transmitted via small droplets such as most respiratory pathogens (i.e. Pertussis)

Facial mask for respiratory and ocular protection

Gloves*

Gown*

*if contamination of clothing expected from the patient or environment

Airborne Precautions

For microorganisms transmitted through air over extended period of time/space by small particles (i.e. TB)

N95 respirator

Gloves*

Gown*

Eye protection**

*if contamination of clothing expected from the patient or environment

**if splashing of blood/body fluids is possible

Respiratory

Contact and droplet: influenza

Airborne: infectious/suspected TB

Contact and airborne: health care worker (HCW) susceptible to measles and varicella

Droplet: pertussis and HCW susceptible to mumps

Gastrointestinal

Contact precautions for most organisms as well as patients who may soil environment

Neurological Syndromes

Droplet: bacterial and unknown organisms

Routine practices: viral organisms

Droplet and contact: bacterial and unknown organisms in children

Contact: viral organisms in children

Rash

Varies by the cause:

Airborne: HCW susceptible to measles

Contact and airborne: HCWs susceptible to zoster and varicella

Contact and droplet: streptococcal rashes (i.e. invasive group A strep)

Droplet: HCW susceptible to rubella

Contact: herpes simplex (neonatal only), scabies, and enteroviruses (in children)

Wounds

Contact: if drainage cannot be contained by dressing

Contact and droplet: necrotizing fasciitis or any other invasive group A streptococcal infection with or without drainage

Intramuscular/Subcutaneous Cytotoxic drugs (methotrexate)

Contact precautions

Facial/eye protection if splashing of blood/bodily fluids is anticipated

AROs (MRSA, VRE, ESBL)

Routine practices in home care setting

Contact precautions recommended for acute care

FNIHB AB Region April 2014 – Additional Precautions Chart

PERSONAL PROTECTIVE EQUIPMENT

Gloves

• Protects HCWs hands from contact with body substances

• Not a substitute for hand hygiene

• Change between clients


Section 3.4 and Appendix 3A - Guidelines

Masks• Protects HCW from

organisms spread by droplet/aerosols

• Respiratory EtiquetteProcedure Mask

N95 Respirator

Surgical Mask


Respiratory Etiquette

Visitors to health centres should have access to:• Signage: coughing/sneezing,

handwashing• Hand washing facilities:

soap, single-use hand towels, or ABHR

• Facial tissue and garbage receptacles

• Surgical or procedure masks for those coughing, especially during respiratory season or outbreaks.

Gowns

• Long sleeved gowns protect forearms and clothing of HCW from splashing and soiling with body substances

• Single use only



Eye Protection

• Protects mucous membranes of eyes

– splashes or sprays of blood, body fluid, secretions or excretions

• Eye protection includes

– Safety glasses

– Safety goggles

– Face shields

– Visors (with mask)

Health Care Equipment

Standard: single use if available, if not:

• Follow guidelines* for:

– Cleaning

– Disinfection/sterilization

– Autoclave maintenance and procedures

*Reprocessing Reusable Medical and Dental Equipment: Policy and Protocols April 2015


Health Care Equipment

Cleaning, Disinfection and Sterilization

• Level of reprocessing is determined by the classification of the instrument and invasiveness into tissues.

• Follow guidelines* for cleaning, disinfection and sterilization for all reusable medical and dental equipment

*Reprocessing Reusable Medical and Dental Equipment: Policy and Protocols and instructional manual April 2015


Environmental Control

• Ensure appropriate procedures are in place for routine cleaning of:

– Surfaces

– Toys

– High touch areas

– Public Areas• Kitchens

• bathrooms

Surface/Object Procedure FrequencyDisinfectant

Type

Surfaces:

- Examining

tables

- Baby weigh

scales

- Baby change

tables

- Beds, Bedrails

- Cribs

- Mattresses

- Call bells

- If soiled, first remove debris with a detergent solution and

rinse with warm clean water.

- Then, disinfect with a low level disinfectant as per

manufacturer’s instructions.

- Allow to air dry.

Between

patients

and when

visibly

soiled.Low level

Surfaces:

- Door

knobs/handles

- Handrails

- Countertops

- Tables, Chairs

- Phones, water

coolers

- Other common

items

- If soiled, first remove debris with a detergent solution and

rinse with warm clean water.

-Then, disinfect with a low level disinfectant as per


- Allow to air dry.

Daily

and/or

when

visibly

soiled. Low level

Toilets

Sinks and Taps

Water fountains

Clean and disinfect with a low level disinfectant.

Daily

and/or

when

visibly

soiled.

Low level

Walls

Windows

Blinds/Curtains

Clean with detergent, or launder.

Monthly or

when

soiled.

No disinfection

required

Floors Clean with detergent. Daily

and/or

when

visibly

soiled.

No disinfection

required

Carpets

Upholstery (sofas,

armchairs, etc)

Vacuum and shampoo as necessary

* Use vacuums equipped with HEPA filtration in patient-

care rooms

Daily

and/or

when

visibly

soiled.

No disinfection

required

Toys

* Toys should be

non-porous and not

plush

** Toys to be

removed during

outbreaks

- Wash with detergent and rinse.

- Disinfect with a low level disinfectant as per


- Allow to air dry.

Daily

and/or

when

visibly

soiled.

Low level

*phenols not to

be used on toys

Laundry Sorting, washing and disinfecting as per procedures

outlined in Health ’s Infection Control Guidelines- Hand

washing, Cleaning, Disinfection and Sterilization in Health

Care

After each

use.____

When blood / body fluids spills occur on any of the above surfaces or objects, refer to your Nursing Procedures for

specific cleaning and disinfection instructions.

Please consult with your Nurse in Charge or Environmental Health Officer.

During an outbreak, thorough environmental cleaning and disinfection with a disinfectant that has demonstrated

effectiveness against the specific organism is required. Increasing the disinfectant level may also be required.

Please consult with your Nurse in Charge or Environmental Health Officer.

Routine Practices and Additional Precautions for Health Care Workers. PHAC, 1998Environmental Services Training Guide - 2016


Environmental cleaning in Health Care Facilities – one of most important steps in breaking chain of infection.

• Janitor training: see Environmental Training Guide for Cleaning Basics



• Routine cleaning – removes visible debris and foreign material– Water, detergents and mechanical action

• Additional cleaning and disinfection– Especially for high touch surfaces– Effective pre-cleaning– Correct use of disinfectants:

• Concentration• Contact time• Correct amount


Appendix 6: Infection Prevention and Control Guidelines, 2016; Environmental Services Training Guide


• Nursing Best Practices:– Management of medications, biologicals, lab

specimens, sharps• TDG

• Sharps management

• Vaccine management

– Waste management

– Food Safety

– Pest control


• Best Practices away from Health Centre

– Nursing bags

– Supplies

– Aseptic field creation

• Barriers

• Hand hygiene

– Records management

Best Practices – “Sharps”

• Single Use

• Never recap needles

• Approved sharps containers

• TDG guidelines during transport

• Designated space for biohazardous waste bag/box

Best Practices: Laboratory Specimens

• PCRA: appropriate PPE for collection of specimens

• Ensure proper labelling and completion of requisition

• Transport patient specimens as per TDG guidelineshttp://www.provlab.ab.ca/guide-to-services.pdf

http://www.provlab.ab.ca/guide-to-services.pdf

Best Practices: Waste Disposal

Most waste can go in “regular” garbage• General office waste• Used PPE; dialysis waste• Non-sharp medical

supplies

Extra precautions:• Bag BBF contaminated

bandages/dressings first→ “regular” garbage

• All sharps: (e.g. lancets, needles, scalpel blades)

→ Sharps containers

• Blood, blood products, expired biologicals→ Sharps container → Biohazardous disposal→ DDC (some vaccines)

Best Practices: Personal Care Supplies

• Single use preferred

• Do not share

• Minimize handling

• Only take what is required into home

• Ensure proper cleaning


Best Practices: Pest Exposure

• If providing care in home with suspect/known infestation: (i.e. bed bugs, head lice, mice, etc.)

– Use PPE based on PCRA

– End of day visit

– Limit supplies in home

– Create “clean or aseptic” field

– Appropriate teaching

APPLYING THESE PRINCIPLES

Point of Care Risk Assessment & Personal Protective Equipment in Health Care Workers

No Yes

Assess patient, environment, and interaction

Contact with patient

or environment

expected?

No PPE required

Hand hygiene

Splash or spray of

blood/body fluids

anticipated?

Facial protection

Contact with mucous

membranes, non-intact skin,

body fluids, secretions, or

soiled surfaces anticipated?

Hand hygiene before

leaving patient

environment

Put on gloves;

Put on a gown if soiling

of clothes is likely

Airborne Exposure*

potential?

Yes

No

No

Yes

Routine Practices

Yes

No

N95 Mask

*Airborne Exposure can include:

Infectious TB

Measles

some foot care practices

Methotrexate

spill.

WOUND MANAGEMENT

Using Chain of Infection

• Agent: see lab work to confirm organism

– MRSA, C. diphtheriae, Streptococcal organism (Group A or B), etc.

• Reservoir: blood, wound, other

• Exit/Entry: direct contact, respiratory, indirect contact

• Host: self care, household factors, susceptibility

Agent

• MRSA: clinical or screening specimen– Check drug sensitivity on lab results – right Rx?

– Mitigate risk for transmission: • Client and family education

• HCW PCRA: appropriate PPE, follow wound protocols

– Prevention measures: • appropriate use of antibiotics

• hand hygiene

• appropriate cleansing and dressing techniques

– Decolonization? • seldom of benefit in a home setting.

Infectious Agent

Agent

• Corynebacterium Diphtheriae – may be 2nd or third organism on lab results– Site of specimen collection, Characteristics of site.

• Superficial? Mucky? Membranous? Other?

– Will need confirmation re toxigenic or not.• Follow wound management protocols

• PCRA: Routine practices, especially hand washing.

– Prevention: • immunization – diphtheria part of primary

immunizations and part of adult booster (Td, dTap).

Infectious Agent

Agent

• Streptococcal Organisms:– Group A: streptococcus pyogenes.

• only of public health concern if deemed invasive (Specimen from normally sterile site or body fluid.)

– Strept. sore throat, impetigo, erysipelas, scarlet fever, puerperal fever, rheumatic fever, septicemia, cellulitis, mastoiditis, otitis media, pneumonia, wound infections, necrotizing fasciitis, toxic shock-like syndrome.

• Frequently in wound specimens along with MRSA

– Management: • PCRA - focus on hand washing, appropriate PPE• wound management protocols, appropriate treatment based

on manifestation• Client and family education

Infectious Agent

Agent

• Streptococcal Organisms:

– Group B: streptococcus agalactiae

• Public health concern if mother is carrier because of risk to babe.– Sepsis, pneumonia, meningitis, osteomyelitis, septic arthritis

• All women are screened during pregnancy:– antibiotics offered based on lab results during intrapartum

period.

Infectious Agent

Lab Reports

• Key factors:

– Organism(s) identified

– Site of specimen

– Date collected

– Sensitivity results

– Lab notes

Infectious Agent

RN Roles and Responsibility

• PCRA for all interactions– Gloves? Gown? Mask?

• Wound Management:– Monitor clinical status: update MD/NP of wound

status if not healing appropriately• Ordering HCP also receives copies of labs – and will be aware

of Sensitivity results

• Follow best practices: cleansing , dressing techniques

– Collect specimen if warranted

• Appropriate client and family education

Sample Lab Report

“ROUTINE” CONTACTS

Routine Contacts

Examples include:

• Monitoring for therapeutic interventions– BP, VS, blood glucose

• Post-natal home visits

• Well child clinics

• Dental clinics

Additional Factors:

• Extended family present

Routine Contacts

• Using PCRA:

– Will there be contact with BBF?

• No: hand hygiene

• Yes: gloves may be warranted; masks may be warranted

• Using Chain of Infection:

– Host factors (symptoms, immune status)

• E.g. Respiratory symptoms – offer mask to individual; limit contact with others

PERSONAL CARE

Personal Care

Examples include:

• Baths

• Pericare

• Oral hygiene

Personal Care

• Using PCRA:

– Will there be contact with BBF?


• Yes: gloves

– Is there be potential for spraying/splashing?


• Yes: gloves, possibly gowns, possibly eye protection

SPECIMEN COLLECTION

Specimen Collection

• Using PCRA/Chain of Infection:

– Suspected /known organism?

• i.e. Measles, TB, MRSA– May need mask

– Type of specimen required

• i.e. Sputum, Blood, Swab (NP, wound, throat)– May need mask, gloves

Specimen Collection

• Do not need a physician’s order to collect specimens:

– Wounds

– CDC related

• Work with local lab re appropriate specimens and lab requisitions.

– Guide to Services

http://www.albertahealthservices.ca/assets/wf/plab/wf-provlab-guide-to-services.pdf

INJECTIONS OR TESTING

Injections or Testing

Examples include:

• Intramuscular or subcutaneous injections

– Vaccines

– Treatments: B12, methotrexate

• Intradermal tests

• Glucose tests

Injections or Testing

• Using PCRA:

– Exposure to BBF?

• No: hand hygiene – Other measures: clean site before injection, sharps

management

– Other risks?

• PPE based on assessment

Education of Clients/Families

• Base specific teaching on:

– applying what is relevant from the Chain of Infection

– Incorporating Infection Prevention and Control basics.

Our Responsibility

• Routine practices are the foundation for prevention and control

• You are the important link in all prevention activities.

The Chain of Infection can be Broken

Source: Nunavut Health – Chain of Infection

References

• Public Health Agency of Canada – Routine Practices and Additional Precautions for Health Care Workers– Hand washing, Cleaning and Disinfection– http://www.phac-aspc.gc.ca/nois-sinp/guide/pubs-eng.php

• Alberta Health– Hand Hygiene– Infection Prevention and Control Standards– http://www.health.alberta.ca/newsroom/pub-infection-

prevention.html

• Alberta Health Services– Many resources– http://www.albertahealthservices.ca/6410.asp

http://www.phac-aspc.gc.ca/nois-sinp/guide/pubs-eng.php

http://www.health.alberta.ca/newsroom/pub-infection-prevention.html

http://www.albertahealthservices.ca/6410.asp

Resources

• FNIHB AB Region – :

– OneHealth “CDC Resources”

• Infection Control Guidelines: Community Health

• Reprocessing Reusable Medical and Dental Equipment: Policy and Procedures

– FNIHB Regional Dental Infection Prevention and Control Standards Manual

Resources

• Alberta Health, Public Health Notifiable Disease Management Guidelines

• Alberta Health Services, Infection Control in Community Setting

http://www.health.alberta.ca/health-professionals.html

http://www.albertahealthservices.ca/info/Page6410.aspx

FNIHB Regional Contacts

• Key Regional contact:

– Ruth Richardson: 780-495-5439 [email protected]

• Other contacts:

– Nursing Practice Standards and Guidance:

• Home Care Advisor

• Wound Management Consultant

• Regional Nursing Team

– Environmental Health Officers

mailto:[email protected]

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