Infection Prevention and ControlAnnual Education 2010

Authored by:Cathy Clark, RN MPH CIC

Mary Whitaker, RN CICBola Ogundimu, RN MPH

Marie Commiskey, RN CCRN CIC

Modified for affiliated schools’ students & instructors by:Linda Horst, RN, BSN, BC

ObjectivesAfter you complete this Computer-Based Learning (CBL) module, you should be able to:

• Describe where to find Infection Prevention and Control policies and procedures.

• Describe Transmission-Based Precautions (isolation types).

• List the five steps for good hand washing.• Explain why we use Personal Protective

Equipment.• Identify who to call if you have questions about

infectious diseases.

Policy and ProceduresYou can find the following policies and procedures on Gwinnettwork which is the internal web site for the hospital:

• Infection Control Plan• Exposure Control Plan• Tuberculosis Plan• Bloodborne Pathogen Plan• Other policies and procedures related to

infection control and prevention

Hand Hygiene• The most effective way to prevent infections is to wash your

hands.• Practice hand hygiene before, during and after all patient

contacts.• Wash your hands with soap and water when:

• Visibly soiled.• Patient has C. difficile infection.

• Practice hand hygiene every time you remove your gloves.• Keep your hands healthy: Use GMC-approved hand lotion.• Associates involved in any patient care must not wear

artificial fingernails, extensions, wraps or gel overlays.• Infection prevention is in your hands!

Hand Hygiene, Step-by-Step1. Wet hands with comfortably warm running water.2. Apply soap from the dispenser.

• Do not use bar soap.3. Rub hands together for at least 15 seconds,

being sure to cover every part of your hands.4. Rinse hands under running water allowing water

to run off the fingertips.5. Dry hands with a paper towel.

• Use towel to turn off the water and open the door.

‘Foam In, Foam Out’• Clean your hands with waterless alcohol

hand rub between clean-to-clean patient care activities.

• Use foam hand rub when entering and leaving patient rooms.

• Use soap and water after using the toilet.

Cough Etiquette• Cover your cough.

• Cough into the bend of your arm, not your hands.

• Use a tissue.• Clean your hands after you

cough or use a tissue.• Stay home if you are sick.

Food and Medication Safety• Each day, Associates check patient

refrigerators used for food and medication for:• Cleanliness• Expired food and medication• Proper temperature

• Associates document their findings on a temperature log.

• Do not store food or medication or specimens in the same refrigerator.

• No associate or academic affiliate’s food or drinks in clinical areas.

Maintain a Clean Environment• Keep our environments clean, including

clinical areas and patient care equipment.

• Before storing, clean and sterilize patient care equipment and supplies between every patient and when finished using.

• Clean up spills immediately.

Linen Storage• Keep clean linen covered at all times. • Place soiled linen in blue linen bags. • Do not mix soiled linen with sharps or

red bag waste. • Put nothing other than linen down the

linen chute.

Biohazard Waste• Use red biohazard bags for disposable

items saturated with blood (you must be able to squeeze blood from the item).

• Change sharps containers when 3/4 full.• Always use sharp safety devices correctly.• Always place biohazardous waste in a

biohazard bin, located in the soiled utility room in each department.

• Never place sharps, bloody items and red bags in patient linen.

Personal Protective Equipment• Wear Personal Protective Equipment

(PPE) whenever you anticipate contact with blood or body fluids.• For example, wear gloves when drawing

blood.• Put on appropriate PPE before

beginning the task or entering the patient’s room.

• Take off PPE and perform hand hygiene before moving on to the next patient.

Standard Precautions• GMC uses Standard Precautions for

every contact involving a:• Patient• Resident• Volunteer

• Treat all blood and body fluids as if they are potentially infectious.

• If you think you might be exposed to blood or body fluids, put on appropriate PPE before caring for the patient.

• Standard Precautions involves use of hand hygiene andappropriate PPE before caring for any patient if you anticipate any exposure to blood or body fluids.

• Visitor• Associate• Academic Affiliate

Transmission-Based Precautions• Use Transmission-Based Precautions when a patient

requires more than Standard Precautions. • Follow the instructions on the isolation sign on the patient

door. The sign lists specific requirements for each precaution.• Contact:

• All healthcare workers must wear a gown and gloves beforeentering the room.

• Family members and visitors participating in direct patient care activities (such as feeding and bathing the patient) must wear a gown and gloves before participating in those activities.

• Other family members and visitors not participating in direct patient care must only demonstrate good hand hygiene.

Transmission-Based Precautions, cont.• Follow the instructions on the isolation sign on the patient

door.• The sign lists specific requirements for each precaution:

• Droplet• Everyone must wear a surgical mask before entering the room.

• Airborne• Place patient in a negative pressure Airborne Isolation room.• Everyone must wear an N-95 respirator mask every time before

entering the room.

Transmission-Based Precautions - Contact Precautions

Contact Precautions• This applies when microorganisms can be transmitted to a

patient by contact between:• The patient and a healthcare worker, or • The patient and a contaminated object (such as toys, clothing,

inadequately disinfected endoscopes or other medical equipment).

• Use when caring for patients with multidrug-resistant bacteria, and various enteric, parasitic, and viral pathogens.• Examples of multidrug-resistant organisms include:

• MRSA (Methicillin-resistant Staphylococcus aureus)• VRE (Vancomycin resistant Enterococcus faecalis or faecium)• ESBL (Extended Spectrum beta-lactamase producer)

• All healthcare workers involved in the care of patients on Contact Precautions must wear gowns and gloves before entering the patients’ rooms.

Transmission-Based Precautions - Contact Precautions

Contact PrecautionsStandard Precautions, plus…

• Gowns and gloves before entering the room.

• Use dedicated equipment or clean equipment thoroughly between patients.

• Environmental Services must change curtains after a patient on Contact Isolation has occupied the room.

Transmission-Based Precautions - Contact Precautions

Applying Contact PrecautionsStart empiric (practical) application of Contact Precautions in the following situations:

• Patients with suspected or confirmed infectious diarrhea, such as Clostridium difficile or Norovirus

• Patients with severe cellulitis, such as weeping skin or necrotizing fasciitis

• Patients with draining or open wounds, with suspected MDROs like MRSA, VRE, ESBL, and others

• Patients colonized with MDROs like MRSA and VRE• Scabies• Impetigo

Transmission-Based Precautions - Contact Precautions

Transporting Patients• Before leaving a Contact Isolation room:

• Ensure the patient’s wounds or lesions are covered.• Contain any drainage.• Dress the patient in a clean hospital gown.• The transporter and patient both must perform hand hygiene

immediately prior to leaving the room.

• Any patient on Contact Precautions for MRSA pneumonia (in the sputum or other respiratory secretion) must wear a surgical mask during transport.

• Patients with any MDRO (MRSA, VRE, ESBL) colonization or infections at other sites do not need to wear a surgical mask during transport.

Transmission-Based Precautions - Contact Precautions

Transporting Patients, cont.• The transporter does not wear a gown,

gloves or mask in the hallway when transporting patients on Contact Isolation Precautions.

• The transporting unit and the transporter must notify the receiving department of:• The impending arrival of the patient.• Precautions necessary to reduce the risk of

transmission of infectious microorganisms.

NOTE! Academic Affiliates

• Students are not to be assigned to patients on droplet or respiratory precautions.

Transmission-Based Precautions – Droplet Precautions

Droplet Precautions• Droplets are particles of respiratory secretions larger than 5

micrometers.• They do not remain suspended in the air for extended periods.• They can be transmitted within 3-6 feet from the source patient.

• Some organisms (such as some respiratory viruses) can be transmitted by both droplet and contact.• Implement both droplet and contact precautions.

• You do not have to use special air handling systems and higher level respirator masks to care for patients with diseases capable of droplet transmission.

• The doors of droplet precaution rooms may remain open, unlike with airborne precautions.

• Everyone entering these rooms must wear a surgical mask.

Transmission-Based Precautions – Droplet Precautions

Droplet PrecautionsStandard Precautions, plus…

• Surgical mask• Use dedicated equipment or clean

equipment thoroughly between patients

Transmission-Based Precautions – Droplet Precautions

Droplet PrecautionsStart empiric (practical) application of Droplet Precautions in the following situations:

• Influenza• Mumps• Mycoplasma pneumoniae• Pertussis (whooping cough)• Rubella (German measles)• Suspected bacterial meningitis

Transmission-Based Precautions – Droplet Precautions

Transporting Patients• The patient must wear a surgical mask during transport.• If needed, escort the patient while he or she is

transported to procedure areas to ensure that the patient does not remove his or her mask during transport.

• The transporter does not wear a gown, gloves or mask in the hallway when transporting these patients.

• The transporting unit and the transporter must notify the receiving department of the:• Impending arrival of the patient.• Precautions necessary to reduce the risk of transmission of

infectious microorganisms.

Transmission-Based Precautions – Airborne Precautions

Airborne Precautions• Airborne nuclei particles, in contrast to larger droplets, are

particles of respiratory secretions smaller than 5 micrometers.• They can remain suspended in the air for an extended time

and thus can be a source of human inhalational exposure for individuals who are susceptible.

• Put patients on airborne isolation precautions in an airborne infection isolation room (AIIR) or negative air pressure room.• The AIIR must be a private room with negative air pressure

and a minimum of 6-12 air changes per hour. • The door to AIIR isolation rooms must remain closed, except

for entering and exiting the rooms.• Everyone entering these rooms must wear an N95 respirator

mask.

Transmission-Based Precautions – Airborne Precautions

Airborne PrecautionsStandard Precautions, plus…

• N-95 or particulate respirator mask• Put the patient in a private negative air

pressure room or AIIR immediately.

Transmission-Based Precautions – Airborne Precautions

Airborne PrecautionsStart empiric (practical) application of Airborne Precautions in the following situations:

• Lung cavity or other reason to suspect tuberculosis (TB). Common TB symptoms include, but are not limited to:

• Unintentional weight loss• Cough• Chest pain• History of travel outside the U.S.

• Measles• Chickenpox or disseminated zoster, per MD’s diagnosis

(plus Contact Precautions)• Smallpox (plus Contact Precautions)

Transmission-Based Precautions – Airborne Precautions

Transporting Patients• The patient must wear a surgical mask during transport.• If needed, escort the patient while he or she is being

transported to procedure areas to ensure that the patient does not remove his or her mask during transport.

• The transporter does not wear a gown, gloves or mask in the hallway when transporting patients on Airborne Isolation Precautions.

• The transporting unit and the transporter must notify the receiving department of the:• Impending arrival of the patient.• Precautions necessary to reduce the risk of transmission of

infectious microorganisms.

Transmission-Based Precautions

Isolation SignsTo view the isolation signs go to Gwinnettwork (on –site), cut and paste this link into the web address:http://sharepoint/InfectionControl/Shared%20Documents/Forms/AllItems.aspx

Tuberculosis, DefinedTuberculosis (pulmonary TB) is a contagious bacterial infection caused by mycobacterium tuberculosis (MTB).

Mycobacterium Tuberculosis (TB)Mycobacterium tuberculosis (TB):

• Is transferred through the air when a person coughs, sneezes, sings, talks or breathes.• The particles are so small that normal air

currents keep them airborne and can spread them throughout a room or building unless isolation measures are used.

• May cause infection when you inhale the organism exhaled by a person with TB disease.

Mycobacterium Tuberculosis, cont.Mycobacterium tuberculosis (TB):

• Primarily involves the lungs, but the infection can spread to other organs.• Infection outside the pulmonary tract is not

contagious.• Is curable if diagnosed and treated early.• Anyone who shares air with a person who

has TB in the lungs or larynx is at risk for TB.

TB Illness v. Latent TB InfectionWith TB illness, the patient:

• Has signs and symptoms of infection.• Is contagious if in the lungs or larynx.• Needs to take medications until told they

are no longer needed.• Needs follow-up by the Health Department.• Needs to wear a surgical mask until told by

the Health Department it is OK not towear it.

Illness vs. Latent TB Infection, cont. With latent TB infection (LTBI), the patient:

• Has a positive tuberculin skin test (TST, formerly called PPD).

• Has no signs or symptoms.• Is not contagious at this time.

• Patient could become sick and contagious if not treated appropriately.

• Needs to be treated for nine to 12 months.• Does not need to wear any mask.• Needs follow-up by the Health Department.

Tuberculosis in Georgia• Tuberculosis cases (illness) in Georgia

decreased by 46 percent from 1992 through 2006.

• The number of TB cases (illness) in Gwinnett County increased by 200 percent since 2001.

TB in Gwinnett by Race, EthicityIn 2007, regardless of country of origin, TB case rates in Gwinnett were:

• 29.7 Asians• 10.6 Hispanics• 6.9 non-Hispanic blacks• 1.5 non-Hispanic whites

(Case Rate = Number of TB cases per 100,000 people)

Risk Assessment• Infection Prevention and Control performs a TB risk

assessment annually, comparing GMC’s rates of TB per 100,000 population to:• Gwinnett County• Georgia• The United States

• The GMC rate is significantly higher than the U.S. and state rates.

• Since TB patients often are admitted to the hospital, rates at GMC (Lawrenceville and Duluth campuses) are higher than the community rate.

• Associates are at medium risk for contracting TB.

Gwinnett Medical Center’s Rate• The number of people in Gwinnett County with TB is

rising. • The number of patients in the county tested for TB

also is growing.At GMC the number of documented and confirmed TB cases (illness) identified by Infection Prevention and Control include:

Period # of TB CasesJuly 1, 2006 - June 30, 2007 34

July 1, 2007 - June 30, 2008 26

July 1, 2008 - June 30, 2009 25

July 1, 2009 - Dec. 1, 2009 9

Assessing for TB Infection• Upon admission, assess all patients for these

five signs and symptoms of tuberculosis:1. New cough that has lasted more than three

weeks.2. Unexplained weight loss.3. Night sweats.4. Fever.5. Coughing up blood.

• Take action if they have two or more symptoms.

Take Action

Prevent Transmission: Isolate EarlyIf the patient has two or more symptoms:

• Place a surgical mask on the patient.• If unable to mask the patient, put him into an airborne

isolation room until cleared.• Notify Infection Prevention and Control through the Extend

paging system.• Notify the doctor.

• Ask for an order for a chest x-ray.• If the chest x-ray is positive, ask for a TST (PPD) and

maintain patient in airborne isolation until cleared by Infection Prevention and Control.

• Ask for an order for three AFB sputum cultures.• Give the patient the Patient Information Sheet for TB.

Take Action

TB Precautions• TB patients must wear surgical masks when they leave

their rooms for medically necessary tests.• This protects others from exposure to the TB germ.

• Place the patient on Airborne Precautions.1. Keep the door to their room closed at all times. 2. Put an Airborne Precautions and a STOP sign on their door,

instructing all persons to report to the nurses’ station before entering the room.

3. Call Engineering every day to check the room for negative pressure while the patient is in isolation.

• Wear an N-95 respirator mask every time you enter the room.

• Get fit tested and a TST annually.

Take Action

AFB CulturesObtain three sputum cultures.

• Taken at least eight hours apart.• One must be an early morning sputum.

• Have Respiratory obtain by induction if necessary.

Transporting a TB Isolation Patient• Always notify the receiving department that the patient is

in isolation for TB.• Mask the patient with a surgical mask during the screening

process and for any transportation to other departments• Once patient is masked, you may remove your own mask.• If for any reason you are unable to mask the patient, for

example: on respirator or in respiratory distress:• Everyone involved in transport must wear an N-95

respirator mask.• Ask Public Safety (Security) for assistance to clear hallways

for patient transportation.• Don’t let anyone else on the elevator while transporting the

patient.

Protect Yourself and Others• If you think you may have been exposed

to TB, contact Occupational Health.• If your exposure is confirmed,

get your follow-up TST.• Don’t forget to get it read!

• Remember to use cough etiquette.• Use a tissue to cover your cough or cough

into your elbow.

Discontinuing Isolation, TB Ruled Out• Prior to removing a patient who is ruled out as having

TB from isolation, the patient must meet the following criteria:• Three consecutive negative sputum cultures • Negative chest x-ray• Negative TST• Have another definitive diagnosis

• Infection Prevention and Control must be contacted for clearance to discontinue isolation!

• Remove the isolation sign and notify Environmental Services (EVS) that the patient was ruled out for TB.

Discontinuing Isolation, Confirmed TB• Prior to removing a patient with TB from isolation, the patient

must meet the following criteria:• Three consecutive negative sputum cultures• Be on medication for at least 14 days and take all doses• Be clinically improved.

• You must contact Infection Prevention and Control for clearance to discontinue isolation!

• Do not admit a patient to the airborne isolation room for at least 69 minutes after the patient with TB leaves.• The door must remain closed during the 69-minute interval.• You must leave the isolation sign on the door of the airborne isolation

room for EVS. • EVS can clean the room during the 69-minute interval, but

associates must wear an N-95 respirator mask while in the room.

Conclusions• TB has increased 200 percent in Gwinnett County in

the past five years.• The risk of TB in the Gwinnett population is significantly

higher that in the U.S. and the rest of Georgia.

• Mask or isolate patients with two or more symptoms of TB until they are screened with a chest x-ray.

• Isolate patients with possible or confirmed TB until they meet the criteria for discontinuing isolation.

• Protect yourself by wearing an N-95 respirator mask.• Occupational Health requires a medical evaluation for

any associate exposed to a patient with active TB before isolation precautions were implemented.

Congratulations!• You have completed this Computer-

Based Learning (CBL) module.• Continue on to take the test by referring

back to the Student Orientation Website. Questions? • Contact the on-call Infection

Control Practitioner using the XTEND paging system, or by calling the hospital operator.