Infection Control Training for New York State Healthcare Professionals

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By Marian McDonald, RN, MSN, CIC

Alice A. Robinson, BS, MPH

LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• Discuss New York State’s requirements for infection control training.
• Spell out professional responsibilities for monitoring infection control practices and interventions for compliance and safety.
• Explain the chain of infection and describe the way infection control concepts are applied.
• Define engineering controls, work practice controls, and environmental controls and give examples.
• Identify barriers and personal protective equipment (PPE) for protection from exposure to potentially infectious material.
• Explain the importance of reprocessing methods (cleaning, disinfection, and sterilization) to ensure the safety and integrity of patient-care equipment.
• Identify occupational health strategies for preventing the transmission of bloodborne and other pathogens to and from healthcare workers.

INTRODUCTION: THE NEED FOR INFECTION CONTROL PRACTICES

Preventing the spread of infection has been a key component of healthcare since the work of Semmelweis in the 1840s. Dr. Semmelweis dramatically reduced post-partum fever—a major cause of maternal mortality at the time—by instructing physicians to disinfect their hands before touching their patients. Fast-forward to the 1980s and the emergence of HIV/AIDS, and infection control gained an importance that continues today and has expanded to include prevention of the transmission of hepatitis B and C viruses, and many other agents within healthcare settings.

In 1999, the patient safety movement began with the publication of To Err Is Human by the Institute of Medicine. This brought much-needed attention to the problem of medical errors and healthcare-associated infections (HAIs). Since September 11, 2001, concern about bioterrorism has heightened awareness of infection control. American soldiers treated in field hospitals during the Iraq war returned with highly resistant infections such as Acinetobacter baumanii, a microbe that is now epidemic in hospitals worldwide (Hospenthal, 2011). In 2003, the epidemic of severe adult respiratory syndrome (SARS) focused global attention on the need for infection control.

Currently, the problem of drug-resistant microbes—“superbugs” such as methicillin-resistant Staphylococcus aureus (MRSA)—is the subject of attention as transmission becomes a wider problem both inside the healthcare system and in the community. Preventing antimicrobial resistance requires special strategies that go beyond traditional infection control, such as implementing policies for the judicious use of antimicrobial medications (“antibiotic stewardship”).

In addition to the emergence of new pathogens, dramatic changes in how and where healthcare is delivered require that infection control be a high priority outside of the hospital. Patients often move from one healthcare setting to others as part of the continuum of care (see figure below). As increasing numbers of patients receive healthcare in outpatient surgical centers, dialysis centers, nursing homes, and at home, the need for infection control measures in these settings has increased. Infection control measures protect both patients and healthcare workers. The key to elimination of HAIs is full adherence to recommendations across the continuum of care (CDC, 2009).

(Source: CDC, 2009.)

Healthcare-associated infections (HAIs) are among the most common adverse events in hospitals, and the morbidity and mortality associated with them are significant. The Centers for Disease Control and Prevention (CDC) estimate that 1 out of every 20 hospitalized patients develop a healthcare-associated infection each year, corresponding to almost 2 million infections and nearly 100,000 deaths in U.S. hospitals alone (Yokoe, 2008; CDC, 2011d).

SELECTED HAIs IN U.S. HOSPITALS

Site of Infection	Total Cases	Percent of Hospital HAIs
Source: Klevens et al., 2007.
Urinary tract	561,667	32
Bloodstream	248,678	14
Pneumonia	250,202	15
Surgical site	290,485	22
Other sites	386,090	17
Total	1,737,125	100

The total burden of HAIs is likely to be even higher, since the CDC estimates indicated above do not include nursing homes, home health care, rehabilitation centers, dialysis centers, outpatient acute care facilities, and so on.

Patients in nursing homes and in home care are at risk for developing HAIs, particularly if they have invasive medical devices such as urinary catheters or central venous catheters in place. In the United States, 1.6 to 3.6 million infections occur each year in long-term care facilities—almost as many HAIs as in acute care hospitals (SHEA/APIC, 2008). About 3% to 15% of nursing home residents acquire infection, and infection accounts for up to 30% of transfers of nursing home residents to hospitals (Mody, 2007).

Healthcare-associated infections not only inflict suffering and death, but the medical costs for treating them range from $35.7 to $45 billion annually (Scott, 2009). Indeed, prevention of HAIs has become a national healthcare priority (IOM, 2003; Yokoe, 2008).

Instituting Standards

Changes in regulatory, legal, and financial reimbursement systems reflect the growing consensus that HAIs are preventable (Yokoe, 2008). In 2008, the Centers for Medicare and Medicaid Services (CMS) implemented a new financial policy that no longer provides payment to hospitals for services related to certain infections not present on admission and deemed preventable (Hoff et al., 2011). Many states now require hospitals to report on specific HAIs as a quality of care indicator.

Prevention of HAIs is the responsibility of all healthcare personnel. Many states and most medical professional organizations have defined standards of professional behavior and responsibility as they pertain to infection control. Healthcare workers—from physicians to dental hygienists—may be sanctioned, including loss of license or practicing privileges, for not following effective infection control practices.

In 2001, the Occupational Safety and Health Organization (OSHA), the federal organization regulating workplace safety, issued the Bloodborne Pathogens Standard aimed at preventing transmission of HIV and Hepatitis B and C viruses in the workplace. The scientific basis for such infection control guidelines and standards are derived from the work of experts at organizations such as the Centers for Disease Control and Prevention (CDC), the Association for the Prevention and Infection Control (APIC), and the Society for Health Care Epidemiology (SHEA).

New York State Requirements

In New York, public health and education laws mandate infection control requirements for healthcare workers. Since 1994 healthcare workers licensed, registered, or certified in New York State (see box) have been required to receive training on infection control and barrier precautions every four years, unless otherwise exempted. Those exempted from training due to nature of practice are required to reapply for their exemption every four years. This requirement was established in 1992 by Chapter 786, later amended in 2008.

The goals of infection control training are to:

• Ensure that health professionals understand how pathogens can be transmitted in the work environment: from patient to healthcare worker, healthcare worker to patient, patient-to-patient, and within the same patient (“endogenous infection”)
• Apply current scientifically accepted infection control principles as appropriate for the specific work environment
• Minimize opportunity for transmission of pathogens to patients and healthcare workers
• Familiarize professionals with the law requiring this training and the professional misconduct charges that may result from failure to comply with the law

This course explores the six core elements of infection control in depth.

INFECTION CONTROL PRINCIPLES AND PRACTICES

Infection control practices can stop the spread of infection in healthcare settings. For this reason, adhering to scientifically accepted principles and practices of infection control is a professional and legal duty.

The New York State Education Department Rules of the Board of Regents, Section 29.2(a) (13), defines unprofessional conduct as failure to use scientifically accepted infection prevention techniques, including:

• Cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces
• Utilization of personal protective equipment (PPE)
• Use of covers for contamination-prone equipment
• Safe handling of sharp instruments (“sharps”)

New York State law mandates that all hospitals:

• Train their staff in infection control techniques
• Provide appropriate protective equipment and safety devices
• Enforce use of universal barrier precautions in situations involving potential exposure to blood or other body fluids

Scientifically Accepted Infection Control Techniques

Specific infection control techniques include, but are not limited to:

1. Wearing of appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, nonintact skin, blood-soiled items or bodily fluid–soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures
2. Discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient and washing hands prior to performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids
3. Wearing of appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur
4. Sterilizing equipment and devices that enter the patient’s vascular system or other normally sterile areas of the body
5. Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient’s body, or using high-level disinfection for equipment and devices that cannot be sterilized prior to use for a patient
6. Using appropriate agents, including but not limited to detergents, for cleaning all equipment and devices prior to sterilization or disinfection
7. Cleaning, by use of appropriate agents, including but not limited to detergents, equipment and devices that do not touch the patient or that only touch the intact skin of the patient
8. Maintaining equipment and devices used for sterilization according to the manufacturer’s instructions
9. Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques
10. Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized
11. Maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation
12. Refraining from all direct patient care and handling of patient-care equipment when the healthcare professional has exudative lesions or weeping dermatitis and the condition has not been medically evaluated and determined to be safe, or capable of being safely protected against, in providing direct patient care or in handling patient-care equipment
13. Placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking; and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide

Failure to Comply

Failing to use these techniques not only jeopardizes the health and safety of patients and other healthcare colleagues but also constitutes unprofessional conduct in the professions of medicine, acupuncture, physical therapy, physician assistant, specialist assistant, chiropractic, dentistry, dental hygiene, pharmacy, podiatry, optometry, ophthalmic dispensing, psychology, social work, massage, occupational therapy, speech pathology, audiology, and nursing (registered professional nurse, licensed practical nurse).

Any licensed healthcare professional who fails to use appropriate infection control techniques to protect patients or fails to ensure that healthcare workers under his or her supervision do so may be subject to charges of professional misconduct. Substantiation of professional misconduct charges can result in disciplinary action, revocation of professional license, and/or professional liability.

Any patient or employee complaint regarding lax infection control practices in a private medical or dental office will prompt an investigation by the Departments of Health and/or Education. Substantiated lapses in infection control in a private practice setting may result in charges of professional misconduct against any licensed professional in the practice who was directly involved, was aware of the violation, or had responsibility for ensuring that the office staff were adequately trained and following patient protection measures.

Health professionals are responsible for monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques (Part 92, Subchapter N of Title 10 of the Official Compilation of Codes, Rules and Regulations of the State of New York).

Similarly, all licensed healthcare facilities are responsible for monitoring and enforcing proper use of infection control practices and Standard Precautions by healthcare personnel functioning under their jurisdiction. Failure to comply with this requirement will result in a DOH citation, potential fines, and other disciplinary action against the institution.

MODES AND MECHANISMS OF PATHOGEN TRANSMISSION: THE CHAIN OF INFECTION

A pathogen may be transmitted in several different ways, but there is usually one predominant mode of transmission. This section discusses the ways in which infections are transmitted and how their spread can be stopped.

The Chain of Infection

The spread of infection is best described as a chain with six links:

1. A pathogen or causative agent
2. A reservoir (human, animal, or environmental source of the pathogen)
3. A portal of exit from the reservoir
4. Mode of transmission
5. A portal of entry into a susceptible host
6. A susceptible host

If you can break any link of the chain of infection, you can prevent the occurrence of new infection. Infection control measures are designed to break the links and thereby prevent new infections. The chain of infection is the foundation of infection prevention.

CAUSATIVE AGENTS

Synonyms:   pathogen, infectious agent, etiologic agent

The pathogens that cause infections are microorganisms. Bacteria, viruses, fungi, and protozoa (“germs”) are very common in the environment, and most of them are harmless or even beneficial to people. Creating an environment with no microorganisms is not a realistic goal outside of highly specialized laboratories.

Most pathogens require an “infectious dose” to cause disease; that is, it usually takes thousands to cause disease, not just one or two. Pathogens also vary in infectivity (how easy they are to catch) and virulence (the level of danger from the infection they cause). Patients in healthcare settings are generally more susceptible to infection due to underlying illness and other factors that weaken their resistance to infection (see below). Therefore, a key goal of infection control programs is to reduce the number of infectious microbes in the healthcare settings through hygienic practices such as hand washing and environmental cleaning (see “Element V” below).

Types of Pathogens

Bacteria are single-celled organisms, some of which can cause disease. We all live with numerous bacteria—referred to as our “normal flora” or “resident bacteria”—which usually do not cause disease unless their balance is disturbed or they are moved to a part of the body where they do not belong or to a new susceptible host. Important bacteria causing human disease include E. coli (urinary tract infection, diarrhea), Streptococci (wound infection, sepsis, death), Clostridium difficile (severe diarrhea, colitis, death), Mycobacterium (tuberculosis), and Staphylococcus (skin boils, pneumonia, endocarditis, sepsis, death).

Bacterial spores (endospores) are thick-walled cells in a resting state (i.e., not multiplying) formed by bacteria. Their thick outer walls make them able to survive in conditions otherwise not conducive to bacterial growth and reproduction. Spores are resistant to disinfectant and drying conditions (specifically the genera Bacillus and Clostridium) (CDC, 2007).

Viruses are intracellular parasites, that is, they can only reproduce inside a living cell. Viruses such as human immunodeficiency virus (HIV) and hepatitis B and C have the ability to enter and survive in the body for years before symptoms of disease occur. Such viruses can be transmitted to others even when the source person appears to be healthy. Other viruses, such as influenza, quickly announce their presence through characteristic symptoms. All of these viruses are of concern in healthcare settings.

Fungi are prevalent throughout the world, but only a few cause disease in healthy people, and most of them commonly affect the skin, nails, and subcutaneous tissue. Candida is a fungus that causes “yeast infections.” These infections can be life threatening in critically ill patients. Fungi such as Aspergillus can be life-threatening to people with HIV/AIDS and other immunological impairment.

Prions are a form of infectious protein believed to be the cause of Creutzfeldt-Jakob disease (CJD), a severe brain disease.

Protozoa are single-celled microorganisms that are larger than bacteria. Examples of disease-causing protozoa include amoebas and giardia, which cause diarrhea, and Pneumocystis carinii, an important cause of pneumonia that is often fatal in people with compromised immune systems, such as those infected with HIV.

Parasites are larger organisms that can infect or infest people. Infestation with arthropods, such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Helminthes include roundworms, tapeworms, and flukes. They infect humans principally through ingestion of eggs or when the larvae penetrate the skin or mucous membranes.

Eliminating Pathogens

We eliminate the causative organism by several methods, including:

• Hand hygiene, which physically removes and/or kills germs on the hands
• Sterilizing surgical instruments and anything that touches sterile spaces of the body
• Using good food safety methods
• Providing safe drinking water
• Vaccinating people so they do not become reservoirs for infectious agents
• Treating people who are ill
• Cleaning surfaces and objects

RESERVOIRS

The next link in the chain of infection is the reservoir, the usual “habitat” in which the infectious agent lives and multiplies. Reservoirs are human, animal, and/or environmental sources of infectious agents.

Humans are the most important reservoirs for HAIs. The nose (nostrils, nares) may harbor bacteria and viruses. The skin is another natural reservoir for yeast and bacteria, and both healthcare workers and patients may carry pathogenic MRSA and Staphylococcus on their skin. The GI tract is a reservoir for many different types of organisms, including viruses, bacteria, bacterial spores, and parasites. As will be discussed below, pathogens can be spread from both sick people as well those who appear to be healthy.

Animal reservoirs include mammals, insects, and many other species that may transmit infections to humans, such as deer ticks (which may carry Lyme disease bacteria), raccoons (which may carry the rabies virus), or fish (which may carry parasites that humans ingest). Because animals and insects are not usually present in healthcare environments, they are not important causes of HAIs.

Environmental reservoirs include inanimate materials, substances, and objects—such as soil, water, air filters, food, soiled linens, and dirty gloves—which provide favorable conditions for the survival and multiplication of infectious agents.

Microbes often prefer moisture to grow and reproduce, so infectious agents often live in moist or wet areas of the reservoirs. In general, if an area is wet, it is probably a reservoir. However, many important human pathogens survive in dry conditions, including those that live on the skin (e.g., yeast, strep, staph, MRSA) and in the environment. Bacterial spores survive in dry environments but often require moisture to multiply (e.g., C. difficile spores survive long periods on dry surfaces in medical environments; tetanus and anthrax spores survive in soil). Hepatitis B virus has been demonstrated to survive in dried blood at room temperature on environmental surfaces for at least 1 week (CDC, 2001). Acinetobacter can live on the skin and may survive in the environment for several days (CDC, 2011b).

Human Reservoir

There are two types of human reservoirs: people who are sick (symptomatic) and people who are well (asymptomatic). Infections can be transmitted from either a symptomatic or asymptomatic person. This is a critically important concept in infection control because many infections are transmitted from people who have no symptoms of disease.

Following exposure to a pathogen, there is a spectrum of possible clinical outcomes:

• Some people never develop symptomatic illness
• Some people develop mild illness
• Some people become severely ill or die

Some individuals are prone to becoming transiently or permanently colonized with organisms they have been exposed to. A person colonized by (or “carrying”) an organism may or may not ever develop symptoms of infection, but they are an important source of transmission to others. Staphylococcus and C. difficile are important examples of HAIs that colonize. Both patients and healthcare workers can become asymptomatically colonized with MRSA and become a source of infection to others.

Host and microbial factors influence whether an infection becomes symptomatic or asymptomatic and whether a person is able to eliminate or clear an infection or becomes a carrier. An important host factor is immunity. An important microbial factor is its ability to evade host defense mechanisms. Certain aspects of transmission are also important–such as the amount of an infectious agent the person is exposed to (infective dose, or inoculum) and the route of exposure.

Not all people who are infected with a pathogen have symptoms or signs of disease at the time they transmit the infection to others. In other words, many infections are transmitted from people who have no symptoms at all; that is, they are asymptomatic. Transmission of an infectious agent from a person who does not have symptoms is referred to as asymptomatic transmission.

Asymptomatic transmission can also occur during the incubation period of an infection. The incubation period is the time between exposure to an infectious agent and the development of symptoms. Different infectious agents have different incubation periods. For example, the incubation period for HIV can be a few months to many years. For the common cold virus, symptoms usually appear 1 to 2 days after exposure.

People who are sick often release microbes into the environment through infected body fluids and substances. For example, sneezing releases influenza virus in secretions from the respiratory tract. Coughing releases tuberculosis bacteria from the lungs. Diarrhea releases C. difficile and many pathogens from the bowel. Exudates from skin lesions release staphylococcus in pus from boils, or herpes virus from fluid in sores around the mouth, hands, or other body areas.

EXAMPLES OF TRANSMISSION FROM HUMAN RESERVOIRS

Infectious Agent	Body Sources	Modes of Transmission	Disease Produced
Staphylococcus (S. aureus, MRSA)	Normal skin, nasal passages; exudates (pus) from boils, drainage from wounds, surgical incisions	Direct skin-to-skin contact; Indirect contact via contaminated surfaces, hands and medical devices	Skin infection, surgical wound infection, sepsis, death
Clostridium difficile	GI tract, feces; colonized skin	Orally via ingestion of bacterium or spores from contaminated hands or environmental fomites; direct contact with skin	Severe diarrhea, colitis, death
E. coli and Enterococci	GI tract, feces	Orally via ingestion of bacteria in fecally contaminated food or water; endogenous spread from one body area to another (via catheters or poor hygiene)	Urinary tract infection, gastrointestinal illness, bloodstream infection, sepsis, death
HIV	Blood, semen, vaginal secretions, breast milk, and other body fluids and tissue	Direct contact with body fluids during sex, breastfeeding; blood splashes to eyes or other mucous membranes; indirect contact thru percutaneous exposure (e.g., needlestick injury, shared needles or equipment)	AIDS-related illnesses, death
Influenza	Respiratory tract secretions, droplets from sneeze and cough	Indirect contact via contaminated fomites, direct contact with nose	Respiratory illness, pneumonia, death (especially in elderly)

The important point to remember is that infectious agents are transmitted every day from people who are sick as well as from those who appear to be healthy. In fact, colonized persons (or “carriers”) and persons who are “incubating” an infection may present more risk for disease transmission than persons who are sick because:

• Their contacts are not aware of their infection
• They are not aware of their infection
• Their activities are not restricted by illness
• They do not have symptoms and therefore do not seek treatment

Since we do not usually know if a person is carrying or incubating an infection, a series of infection control methods called Standard Precautions are required for all patient contact, regardless of their diagnosis or health status. Standard Precautions protect healthcare workers and patients from infection and will be described in detail below.

Possible outcomes of exposure to an infectious agent.
* The term carrier state is used loosely to include the persistence of the microorganism in the body, including latent and clinically inapparent (subclinical) infections. These types of infections may remain asymptomatic or may become apparent at a later time. Carriers and colonized persons may “shed” infectious agent chronically or intermittently and may be a source of infection when that occurs.

Environmental Reservoirs

The environment can serve as the reservoir. For example, water supplies may carry Legionella spp, and inadequate air exchange can allow pathogens such as Mycobacterium tuberculosis and varicella-zoster virus (chicken pox) to contaminate air supplies. Appropriate environmental infection-control measures and engineering controls can remove microbes from the environmental reservoirs.

Reservoirs in healthcare facilities include:

• Ill people
• Well people
• Water from fish tanks or flower vases, which may contain pathogens, especially for compromised patients
• Air filters that have not been properly maintained

Actions we take to eliminate reservoirs include:

• Treating people who are ill
• Vaccinating people
• Handling and disposing of body fluids responsibly
• Storing equipment dry
• Cleaning the healthcare environment using appropriate disinfectants
• Monitoring soil and contaminated water in sensitive areas of the hospital and washing hands carefully after contact with either

PORTAL OF EXIT

The portal of exit is the route (or routes) by which the causative agent gets out of the reservoir.

In human reservoirs, skin is an important portal of exit. Breaks in the skin such as sores, wounds, and cuts may be the portal of exit of infectious microbes, but germs may exit the host from intact skin as well. MRSA and Streptococcus are potent germs that live on skin and thus can easily exit their reservoir. Any bodily fluid or matter may carry microorganisms out of the body. Blood, feces, respiratory secretions, and nasal exudates are examples of body fluids and matter that enable pathogens to exit the body.

Examples of portals of exit from the human body include:

• Respiratory tract
• Gastrointestinal (or alimentary) tract
• Skin
• Genitourinary tract
• Circulatory system (e.g., blood)

Body fluids and matter from various body systems are important sources of infection in healthcare settings. Medical treatments and procedures and illnesses often increase the opportunities for organisms to exit the body, thereby increasing exposure to infectious agents. A common example of this is blood drawing, which allows bloodborne pathogens to exit the circulatory system of the reservoir. Diarrheal disease caused by prolonged treatment with antibiotics is an example of an illness that increases exit of pathogens (such as C. diff) from the GI tract.

Actions we take to reduce risk from portals of exit include:

• Covering coughs and sneezes with a tissue
• Handling bodily fluids with gloves, then practicing hand hygiene
• Keeping draining wounds covered with a dressing
• Not working when one has exudative (wet) lesions or weeping dermatitis

MODES OF TRANSMISSION

In order for an organism to get from one person to another or from one place in the body to another, it must have a way of getting there, or a mode of transmission. For any single agent, there are often many different ways it can be transmitted.

The mode of transmission is the weakest link in the chain of transmission, and it is the only link that healthcare providers can hope to eliminate entirely. Therefore, a great many infection control efforts are aimed at avoiding carrying germs from the reservoir to the susceptible host. Because we touch so many things with our hands, hand hygiene is still the single most important procedure for preventing the spread of infection.

Transmission can occur by a number of mechanisms.

Direct contact is person-to-person transmission of pathogens through touching, biting, kissing, or sexual contact.

Indirect contact is the spread of pathogens by a person or an inanimate go-between, an intermediary between the portal of exit from the reservoir and the portal of entry to the host. Transmission by unwashed hands is a form of indirect contact. Contaminated objects—such as patient-care equipment, cooking or eating utensils, handkerchiefs and tissues, soiled laundry, and doorknobs that can transmit infection—are called fomites. Gloves that touch two or more patients have been shown to carry pathogens. (This practice will result in disciplinary action in most facilities.)

Droplet transmission can spread diseases such as influenza, pertussis (whooping cough), and some forms of bacterial meningitis. Droplets are produced when the infected person coughs, sneezes, or speaks, and they travel about three to six feet before drying out or falling to the ground or another surface.

Airborne transmission can occur when respiratory droplets evaporate, leaving behind droplet nuclei that are so small they remain suspended in the air. Very few diseases are transmitted by the true airborne route, since most organisms cannot survive drying. Diseases transmitted by this route include tuberculosis, chickenpox, measles, possibly SARS, and smallpox.

Sometimes people become infected with microbes from their own natural flora; that is, our own germs get in the wrong place. This is referred to as an endogenous infection, meaning that the organism came from the same person. Endogenous infections are an important cause of HAIs and occur when invasive procedures create opportunities for microbes to get into new places. For example, if sterile techniques are not used, surgical wounds may become infected with bacteria transferred from another area of the person’s body, such as Staphylococcus, which is commonly present on the skin. The urinary tract may be infected with microbes from the gastrointestinal tract, such as Enterococcus and E. coli. Indwelling urinary catheters are an important risk factor for UTIs caused by endogenous microbes from the GI tract.

Transmission of infection by vectors (such as mosquitoes and ticks) is not an important mode of transmission in most healthcare settings. Common-source vehicles such as contaminated food or water are also not common modes of transmission in healthcare settings. However, shared medical equipment that has not been properly cleaned between patient uses has been implicated in many common-source outbreaks in healthcare settings.

Actions we take to eliminate the mode of transmission include:

• Hand hygiene
• Wearing gloves to minimize contamination of hands and discarding them after each patient
• Maintaining Contact, Droplet and Airborne Precautions as indicated.
• Cleaning, disinfection, or sterilization of equipment used by more than one patient
• Cleaning of the environment, especially high-touch surfaces

PORTALS OF ENTRY

The term portal of entry refers to the anatomical route (or routes) by which an infectious organism gains entry to a susceptible host. The portal of entry is often the same as the portal of exit from the reservoir but may include other portals of entry as well.

For example, the flu virus exits the respiratory tract when a person sneezes and enters the respiratory tract of a new host who inhales the infectious virus released into the air. Flu viruses can also exit the body when a person blows his or her nose in a tissue. If another person touches the contaminated tissue and then touches his nose, the portal of exit from the reservoir and the portal of entrance is the same.

However, sometimes the exit and entry portals are different. For example, staph bacteria may escape one person’s respiratory tract or nose to infect another person’s skin. Or a wound infected with MRSA may infect another person’s nasal passage. E. coli, hepatitis A, and many other microbes exit the bowel in feces and infect a new host via the oral route.

Medical procedures often introduce new portals or facilitate the entry of infectious agents. Examples include IV catheters, surgical wounds, intubation, and percutaneous injuries. Healthcare workers may develop dermatitis from frequent hand washing or allergy to latex gloves, thereby creating new portals of entry for infection. They may receive needlestick injuries that allow microbes access to their bloodstream. Any invasive procedure may facilitate entry of microbes into the host.

Examples of portals of entry include:

• Mouth, nose, and eyes
• Other anatomical openings
• Skin “breaks” (cuts, rashes, or less-visible microabrasions)
• Surgical wounds
• Intravenous sites
• Anatomical openings with tubes in place (more susceptible than those without)
• Needle puncture injuries

Actions we take to protect portals of entry (our own and our patients) include:

• Dressings on surgical wounds
• IV site dressings and care
• Elimination of tubes as soon as possible
• Masks, goggles, and face shields
• Keeping unwashed hands and objects away from the mouth (e.g., not licking one’s fingers to turn pages)
• Actions and devices to prevent needlesticks
• Food and water safety

SUSCEPTIBLE HOST

The final link in the chain of infection is the susceptible host. Susceptibility can be reduced in several ways. For some diseases we have effective vaccines. Other diseases produce lasting immunity after illness. We have better resistance to disease when we are well rested, well fed, and relatively stress free. People who have healthy immune systems are often able to resist infection even when microorganisms do invade.

Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system, and the presence or absence of an invasive device.

Natural Barriers

Natural barriers to infection include:

• Intact skin and mucous membranes
• Cilia (small, hairlike projections that line the respiratory system, filtering inhaled air and trapping microorganisms)
• Lung macrophages (large white blood cells that ingest microorganisms, other cells, and foreign particles in a process called phagocytosis)
• Antibodies (humoral immunity) resulting from immunization or previous disease
• Acidic environment in the stomach, urine, and vaginal secretions
• Normal flora that provide competition to pathogens; an upset to the balance of normal flora can allow pathogens to cause infection, such as when a yeast infection follows a course of antibiotics
• The immune system, a complex network of cells, tissues, and organs that interact to defend the body against infections; defense mechanisms can be nonspecific or specific and include humoral immunity (antibodies that circulate in the blood), cell-mediated immunity (white blood cells), and the inflammatory response, which brings an increase in these infection-fighting defenses to the site of infection

Immune System

A person with normal immune system function is described as immunocompetent. Someone whose immune system is impaired by illness or age-related factors is said to be immunocompromised. For example, a person with HIV/AIDS is immunocompromised.

The very young and the very old are also at risk for compromised immune function. Infections are a major cause of death among newborns. Although babies receive certain temporary immunities from their mothers through the placenta and in breast milk, their immune systems are still developing, making them vulnerable to infection. Older people (>65 years old) are at higher risk of infection too because the immune system becomes less responsive with age. In addition, very old people are more likely to have other health problems or normal declines related to aging that render them more susceptible to infection.

Nutritional status is a key factor in immune function. A person who is poorly nourished may not be able to fight off an infection.

People with chronic disease may also be immunocompromised. People with diabetes mellitus or peripheral vascular disease are at high risk for infection because of impaired circulation.

Certain medications can impair immunity. For example, cancer drugs and anti-inflammatory medications such as corticosteroids can interfere with normal immune function.

Invasive Devices

Any surgical procedure carries the risk of infection because it penetrates the skin. Special precautions are required for wound care to prevent surgical site infections (SSIs). Diagnostic or therapeutic procedures that involve an invasive device such as a urinary catheter or an intravascular (IV) catheter also increase the risk of infection. Caring for patients with these devices demands strict attention to infection control standards and continuous monitoring for any sign of infection. To reduce risk of infections associated with these devices, the device should be discontinued as soon as the patient no longer needs it.

Any foreign body, even a joint prosthesis, can act as a focus for infection and increases the risk of infection.

Minimizing Risk

Actions we take to minimize risk to susceptible hosts include:

• Vaccinating people against infections before they are exposed
• Preventing new exposure to infection in people who are already ill, are receiving immunocompromising treatment, or are infected with HIV
• Maintaining good nutrition
• Maintaining good skin condition
• Covering skin breaks
• Encouraging rest and balance in our lives

As mentioned above, the reservoir and the susceptible host may be the same person, such as when an individual’s normal flora get into the “wrong” part of the body and cause disease. Examples of this situation include:

• Oral flora in the lungs, causing aspiration pneumonia
• Skin flora in an IV site, causing a site infection or even a bloodstream infection
• Fecal flora in the urinary tract, causing a urinary tract infection (UTI)

Thus, to avoid spreading germs between different body sites of the same patient, it is important to change gloves and wash hands when moving from a contaminated area to a different body site. It is recommended to go from clean to dirty.

Preventing the Spread of Infectious Organisms

The nature of healthcare settings makes them likely environments for the spread of infections because they bring together many ill people who are both reservoirs and susceptible hosts. Staff are also both reservoirs and susceptible hosts. We cannot eliminate the reservoirs and susceptible hosts, so we must eliminate the mode of transmission.

Preventing the spread of infectious organisms includes:

• Practicing hand hygiene before and after every patient contact, including dry skin contact
• Using Standard Precautions with every patient
• Promptly isolating the patient when indicated, using the appropriate type of precautions
• Quickly identifying an infectious organism and initiating appropriate treatment

HAND HYGIENE

It bears repeating that hand hygiene is the single most important procedure for preventing the spread of infection. This is because we are constantly touching things with our hands, picking up many microorganisms each time.

Hand hygiene includes both using alcohol-based hand hygiene products and washing with soap and water. Alcohol-based hand hygiene products are often preferred over soap and water because they are faster and easier to use, so people use them more. Also, most studies have found them to be more effective in killing microorganism, except C. difficile spores and noroviruses.

Hand washing with soap and water is required when hands are visibly soiled. Hand washing with soap and water may also be recommended when in contact with patients suspected or known to be infected with C. difficile and norovirus, because of their resistance to alcohol-based hand rubs. Washing with soap and water physically removes microbes from the hands. Check with your facility for its policy.

The CDC Hand Hygiene Guideline specifies: Do not wear artificial fingernails or extenders when having direct contact with patients at high risk. Check with your facility for their policy. Nails should be unpolished and less than 1/4-inch long. Chipped nail polish, long nails, artificial fingernails, or nail extenders may tear gloves and can harbor pathogens, even after careful hand washing or the use of surgical scrubs.

Despite the importance of hand hygiene in preventing infection, compliance with recommended guidelines is low—about 40% on average. The CDC Guideline for Hand Hygiene in Health-Care Settings (CDC, 2002) recommends that facilities should make hand hygiene adherence an organizational priority by implementing a multidisciplinary program to improve adherence. Failure to use proper hand hygiene can result in disciplinary action against the healthcare worker, and many facilities are now carefully monitoring staff for compliance.

STANDARD PRECAUTIONS

The CDC (2007) describes four types of precautions:

1. Standard Precautions
2. Contact Precautions
3. Droplet Precautions
4. Airborne Precautions

The first of these, Standard Precautions, applies to all patients and all healthcare workers in all settings. Contact, Droplet, and Airborne Precautions are transmission-based precautions that should be applied when a specific infectious agent is known or suspected to be present. Each transmission-based precaution is used in conjunction with Standard Precautions, e.g., Standard Precautions plus Contact Precautions.

Standard Precautions are used with all patients, regardless of diagnosis. Standard Precautions, formerly known as Universal Precautions, were initially designed to minimize risk to staff from unknown carriers of bloodborne pathogens, such as hepatitis B, hepatitis C, or HIV. In addition to protecting staff, Standard Precautions also protect patients from organisms shed in the body fluids and other potentially infectious material from other patients and from healthcare workers. Standard Precautions are required by good science and by federal law under the OSHA Bloodborne Pathogens Standard.

Long-established Standard Precautions include the following:

• Hand hygiene. Wash hands with plain soap and water when visibly soiled or alcohol-based product after touching blood, body fluids, and contaminated items, whether or not gloves are worn. Wash hands or use an alcohol-based product immediately after gloves are removed, between patient contacts, and when otherwise indicated. Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Avoid unnecessary touching of surfaces near the patient to prevent contaminating clean hands and to prevent transmission of pathogens from contaminated hands to surfaces. Do not wear artificial fingernails or extenders. (See also “Summary of Hand Hygiene” above.)
• Gloves. Wear clean gloves when touching blood, body fluids, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use and do hand hygiene immediately before touching non-contaminated items and environmental surfaces, and before going to another patient. (See also “Summary of Hand Hygiene” above.)
• Mask, eye protection, face shield. Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during activities that are likely to generate splashes or sprays of blood or body fluids (such as suctioning, irrigation, or delivery of a newborn).
• Gown. Wear a gown to protect skin and to prevent soiling of clothing during activities that are likely to generate splashes or sprays of blood or body fluids. Select a gown that is appropriate for the amount of fluid likely to be encountered. Remove the soiled gown as promptly as possible and do hand hygiene. (See additional details below on personal protective equipment.)
• Patient-care equipment. Handle used patient-care equipment soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Clean or reprocess reusable equipment before using it for the care of another patient. Ensure that single-use items are discarded properly.
• Environmental control. Follow hospital procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces.
• Linen. Handle, transport, and process used linen soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments.
• Occupational health and bloodborne pathogens. Take care to prevent injuries when using or disposing of needles, scalpels, and other sharp instruments or devices. Never recap used needles using both hands or use any other technique that involves directing the point of a needle toward any part of the body. Do not manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers that are located as close as practical to the area in which the items were used. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.
• Patient placement. Place a patient who contaminates the environment or who does not assist in maintaining appropriate hygiene (children, patients with altered mental status) in a single-patient room. If a single-patient room is not available, consult with infection control professionals regarding patient placement or other alternatives. If it is necessary for an infected patient to share a room with a noninfected patient, it is important that roommates are selected carefully and that patients, personnel, and visitors take precautions to prevent the spread of infection.
• Equipment needed for Standard Precautions. Routinely, hand hygiene products, gloves, safety sharps, sharps disposal boxes, and disinfectant wipes or equivalent. Occasionally, gowns, facemasks, eye protection, or face shields.

In 2007 three new elements were added to Standard Precautions:

• Respiratory hygiene
• Safe injection practices
• Lumbar puncture procedures

Respiratory Hygiene

Respiratory hygiene is a relatively new concept introduced after the SARS outbreak in 2003, comprising vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting (reception and triage areas, outpatient clinics, and physician offices). It is directed to patients and family members with signs of respiratory illness such as cough, congestion, or increased respiratory secretion. Components include:

• Educate healthcare workers on the importance of source-control methods to contain respiratory secretions, especially during outbreaks of respiratory illness such as influenza.
• Post signs at entrances in languages appropriate to the population served asking patients and family members to cover the mouth and nose when coughing or sneezing or to wear a mask and to do hand hygiene after contact with respiratory secretions.
• Provide tissues, masks, hand hygiene products, and waste receptacles convenient to patients entering the facility and assign responsibility for maintaining the supplies.
• Maintain separation, ideally by at least 3 feet, between ill persons and others. Move ill patients to rooms promptly to remove them from common waiting areas.
• Healthcare personnel should use Droplet Precautions (wear a simple mask) and do hand hygiene when caring for any patient with symptoms of respiratory infection unless those symptoms are known due to a noninfectious cause.
• Healthcare workers with respiratory infection should avoid patient contact if possible and should wear a mask if contact cannot be avoided.

Safe Injection Practices

Infection control problems identified in the course of outbreak investigations sometimes indicate the need for reinforcement of existing infection control recommendations to protect patients. Failure to adhere to recommendations for safe injection practices has resulted in several outbreaks of hepatitis B and C. Lack of oversight of personnel and failure to follow up on reported breaches of practice have contributed to these outbreaks.

The CDC recommends that these practices be incorporated into institutional policies that are monitored for adherence:

• Use aseptic technique to avoid contamination of sterile injection equipment.
• Do not administer medications from a syringe to multiple patients.
• Needles, cannulae, and syringes are single-patient-use items.
• Use IV bags, tubing, and connectors for one patient only.
• Do not use bags of IV solution as common source of supply for multiple patients.
• Consider a syringe or needle/cannula contaminated after it has entered an IV bag or set.
• Use single-dose vials whenever possible.
• Do not use one single-dose vial for several patients or combine contents of several vials.
• If multidose vials must be used, both the needle/cannula and syringe used to access them must be sterile.
• Do not keep multidose vials (such as insulin) in the immediate patient-care areas. Store as recommended by the manufacturer and discard if sterility is compromised.

Lumbar Puncture Procedures

Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.

TRANSMISSION-BASED PRECAUTIONS: CONTACT, DROPLET, AIRBORNE

In addition to Standard Precautions, which are used with all patients, some patients require additional precautions known as transmission-based precautions. There are three types of transmission-based precautions: Contact, Droplet, and Airborne

Contact Precautions

Contact Precautions are designed to minimize transmission of organisms that are easily spread by contact with hands or objects. The CDC Guidelines of 2007 made changes to recommended practices for Contact Precautions. Among these changes is the direction to “wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient’s environment. Don gown upon entry into the room or cubicle.”

CDC Contact Precautions are summarized below:

• Patient Placement. In acute care hospitals, place the patient in a single-patient room when available. When a single-patient room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection (cohorting). Consultation with infection control professionals is advised before cohorting.
• Gloves and hand washing. Wear gloves to enter the room. Change gloves after contact with infective material that may contain high concentrations of microorganisms, such as fecal material or wound drainage. Do not soil the environment with used gloves. Remove gloves before leaving the patient’s room and wash hands immediately. After glove removal and hand washing, ensure that hands do not touch potentially contaminated environmental surfaces or items in the patient’s room.
• Gown. Wear a gown to enter the room. Remove the gown before leaving the patient’s environment. After gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces. Do not reuse gowns, even for repeated contacts with the same patient.
• Environmental measures. Ensure that rooms of patients on Contact Precautions are prioritized for frequent cleaning and disinfection (at least daily) with a focus on frequently touched surfaces (e.g., bed rails, over-bed table, bedside commode, lavatory, doorknobs) and equipment in the immediate vicinity of the patient.
• Patient transport. Limit the movement and transport of the patient from the room to medically necessary purposes. When transport is necessary, ensure that infected or colonized areas of the patient’s body are contained and covered. Remove and dispose of contaminated PPE and perform hand hygiene prior to transporting patients on Contact Precautions. Notify the receiving department of precautions prior to transport. Check hospital policy regarding ambulatory patients in Contact Precautions. At a minimum, the patient must perform hand hygiene before leaving the isolation room.
• Patient-care equipment. When possible, dedicate the use of noncritical patient-care equipment (stethoscope, BP cuff, thermometer, etc.) to a single patient or cohort of patients to avoid sharing among patients. Clean and disinfect any equipment that must be brought out of the room before use with others.
• Equipment needed for Contact Precautions. Gloves, gowns, dedicated patient equipment, disinfectant wipes or equivalent.

Droplet Precautions

Droplet precautions are designed to prevent transmission of diseases easily spread by large-particle droplets produced when the patient coughs, sneezes, or talks, or during the performance of procedures.

Droplet Precautions are summarized below:

• Patient placement. In acute care hospitals, place the patient in a single-patient room when available.
  • When a single-patient room is not available, place the patient in a room with a patient(s) who has active infection with the same microorganism but with no other infection (cohorting)
  • Refer to the 2007 CDC Guidelines for recommendations for cohorting and for patient placement recommendations in long-term care settings.
  • In ambulatory settings, place patients who require Droplet Precautions in an examination room or cubicle as soon as possible and instruct them to use Respiratory Hygiene.
  • When a single-patient room is not available and cohorting is not achievable, maintain spatial separation of greater than 3 feet and keep cubicle curtains drawn between patient beds.
  • A negative-pressure room is not necessary, and the door may remain open.
• Mask. Wear a mask (a simple surgical or procedure mask, not an N-95 respirator) upon entry into the patient room or cubicle.
• Patient transport. Limit the movement and transport of the patient from the room to medically necessary purposes. Ask the patient to wear a mask and follow Respiratory Hygiene. No mask is required for persons transporting patients on Droplet Precautions. Notify the receiving department of precautions prior to transport.
• Equipment needed for Droplet Precautions. Isolation masks (i.e., simple masks, not N-95 respirators).

Airborne Precautions

Airborne Precautions are designed to prevent transmission of diseases spread by the true airborne route. These organisms are released from the patient in respiratory droplets, which evaporate shortly after release. Most organisms die when they dry out, but the organisms of these few diseases—tuberculosis, chickenpox, measles, SARS, and smallpox—can survive drying out. The droplet nuclei (small-particle residue of evaporated droplets) remain suspended in the air and can be dispersed widely by air currents within a room or even over a long distance.

Airborne Precautions are the only type that requires a negative-pressure airborne infection isolation room (AIIR) with door kept closed and use of an N-95 respirator.

Airborne Precautions are summarized below:

• Patient placement. Place the patient in a designated AIIR. See the 2007 CDC Guidelines for specifications of these rooms. Keep the room door closed and the patient in the room, as feasible. While the room is in use for Airborne Precautions, air pressure must be monitored daily with a visual indicator regardless of the presence of differential pressure sensing devices.
• When an AIIR is not available, transfer the patient to a facility that has an available AIIR. In the event of an outbreak involving large numbers of patients who require Airborne Precautions, consult with infection control professionals or the Department of Health.
• In ambulatory settings, develop systems (signage, etc.) to identify patients on Airborne Precautions. Place the patient in an AIIR if available. If none is available, place a surgical mask on the patient and put him/her in an examination room. After the patient leaves, that room should remain vacant with the door closed to allow for a full exchange of air, generally for one hour.
• Respiratory protection. Wear a fit-tested NIOSH-approved N-95 or higher-level respirator when entering the room of a patient with known or suspected infectious pulmonary tuberculosis. Refer to the 2007 CDC Guidelines for Isolation for recommendations regarding respiratory protection against smallpox. (See additional information about N-95 respirators below.)
• Alternative respiratory protection. Many facilities provide powered air-purifying respirators (PAPRs) in addition to or instead of N-95 respirators. PAPRs have the advantage that they do not require fit testing and they can be used by people with facial hair that precludes wearing of an N-95. PAPRs do require training and maintenance. Check your facility’s policy if you may need to use them.
• Susceptible persons should not enter the room of patients known or suspected to have measles or chickenpox if immune caregivers are available. The 2007 CDC Guidelines do not make recommendations for respiratory protection of people believed to be immune to measles or chickenpox or for those believed to be susceptible to those diseases. Refer to your facility’s policies.
• Patient transport. Limit the movement and transport of the patient from the room to medically necessary purposes. If transport or movement is necessary, place a surgical mask on the patient, if possible. Notify the receiving department of precautions prior to transport. In general, do not place an N-95 respirator on a patient as it is not likely to be tolerated and is not indicated. NEVER place a PAPR on a patient on Airborne Precautions as that device disperses the air from the wearer.
• Additional precautions for preventing transmission of tuberculosis. Consult CDC’s Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings (2005b) for additional prevention strategies.
• Equipment needed for Airborne Precautions. N-95 respirators and/or PAPRs.

PROTECTING AGAINST ACCIDENTAL EXPOSURES

The infection control practices described in this section are intended to protect healthcare workers and patients from accidental infection. Failing to follow these guidelines can result in a charge of professional misconduct.

High-Risk Practices and Settings

Every area of the healthcare facility and every type of patient care holds the potential for exposure to pathogens, but some settings and practices hold greater risk than others. High-risk settings include:

• Intensive-care units (surgical, medical, coronary, pediatric)
• Operating rooms
• Delivery rooms
• Newborn nurseries
• Isolation units
• Clinical laboratories

High-risk practices and procedures that increase the opportunity for healthcare worker and patient exposure to potentially infectious materials include percutaneous, mucous membrane/non-intact skin, and parenteral exposures from:

• Injuries with contaminated sharps, which can result from sharps being left undiscarded when a procedure has been completed, failure to activate safety sharps after use, recapping used needles using both hands, and removing scalpel blades from their handles by hand.
• Poor visualization during certain procedures also poses a hazard to both patient and healthcare worker. These procedures include blind suturing, a nondominant hand opposing or next to a sharp, and removal of bone or metal fragments. Situations involving use of sharps with poor visualization should be minimized or eliminated when possible.
• Procedures which may expose the mucous membranes of eyes, nose, mouth, or other mucous membranes to spray or splatter of blood or other potentially infectious materials (such as irrigation or suctioning), contact with contaminated hands or gloves, or contact with open skin lesions or dermatitis.
• Accidental injection of infectious material via shared devices (e.g., blood glucose monitoring devices, such as glucometers or lancets), shared injectable medication vials, or infusion of contaminated fluids.

All sharps devices can cause injury and disease transmission if not used and disposed of properly. Some characteristics of sharps make them potentially more dangerous, such as:

• Devices with a hollow bore, such as needles for injection, can contain blood and carry higher risk to transmit infection.
• Some devices, such as “butterfly” needles, devices with recoil action, and lancets may be more likely to cause injury.

Work Practice Controls

Work practice controls eliminate or reduce the likelihood of exposure to potentially infectious material. Work practice controls include modifying procedures and use of equipment.

General work practice controls include:

• Hand hygiene, to protect both patients and workers (described above)
• Following Standard Precautions (described above)

SAFE SHARPS PRACTICES

Work practice controls to prevent percutaneous exposure from sharps include:

• Avoid unnecessary use of needles and other sharps.
• Use care in handling and disposing of needles and other sharps.
  • Do not recap unless absolutely medically necessary and use a mechanical device or one-handed technique when recapping is necessary.
  • Do not pass sharp instruments from hand to hand. A designated “safe zone” should be used.
  • Disassemble sharp instruments using forceps or other devices.
  • Close are replace sharps containers when they are full; do not overfill them.
  • Use forceps, suture holders, or other instruments for suturing.
  • Avoid holding tissue with fingers when suturing or cutting.
  • Avoid leaving exposed sharps of any kind on procedure work surfaces. (In many facilities, the person who uses the sharp is responsible to dispose of it safely. If this is not done, the person who leaves the sharp should report its presence to the person who will discard it.)
• Use safety devices as designed.
  • Always activate safety features that require activation.
  • Never circumvent (defeat or destroy) safety features.

ENVIRONMENTAL HYGIENE

Whenever possible, work surfaces should be protected from contamination using appropriate barriers. For example, in dental work areas, work surfaces may be protected from splashes and sprays of body fluids by using appropriate barriers. (Refer to the CDC Guideline for Disinfection and Sterilization, 2008, for specific details.)

Additional work practices to contain environmental contamination include:

• Prompt cleanup of blood and body fluid spills with appropriate disinfectant
• Proper disposal/handling of blood and body fluid, including contaminated patient-care items (facility procedures should comply with local regulations)
• Safe handling of used linen and waste

When blood or other potentially infections materials are spilled or splashed, proper procedures for cleaning begins with wearing appropriate personal protective equipment, then initial removal of bulk material using disposable absorbent material (such as paper towels), followed by disinfection with a product effective against organisms transmitted by blood or other body fluids.

Specific products, approved by the EPA, can be found in:

• EPA List D, which contains registered antimicrobial products effective against human HIV-1 and hepatitis B virus
• EPA List E, which contains registered antimicrobial products effective against Mycobacterium tuberculosis, human HIV-1 and hepatitis B virus

The above EPA-registered disinfectant lists are updated periodically to reflect changes, cancellations, and transfers of producct registrations. If a question arises about the appropriateness of a product, consult the EPA website (see “Resources” at the end of this course).

In addition, freshly diluted 1:100 sodium hypochlorite, i.e., 1/4 cup bleach to 1 gallon of water, may be used (CDC, 2008a).

Proper selection, donning (putting on), doffing (taking off), and disposal of personal protective equipment are required (see below under “Personal Protective Equipment”). Gloves generally should be put on last, covering gown cuffs, and removed first. (Refer to the CDC Guideline for Isolation Precautions, 2007, for specific details.)

(See also “Environmental Controls” below for additional information on waste management and laundry management.)

Safe Injection Practices

Safe injection practices were added to the CDC’s Standard Precautions in 2007. Many of these practices are not new but were added to Standard Precautions after several outbreaks of disease due to bloodborne pathogens were traced back to compromised aseptic technique associated with injection therapy, often in outpatient settings.

These lapses have resulted in:

• Transmission of bloodborne viruses, including hepatitis B and C to patients
• Notification of thousands of patients to possible exposure to these pathogens and recommendation that they be tested for hepatitis B, hepatitis C, and HIV
• Referral of providers to licensing boards for disciplinary action, and
• Malpractice suits filed by patients

Pathogens for Hepatitis B, hepatitis C, HIV and other diseases can be present in sufficient quantity to cause disease in the absence of visible blood, clouding of fluid, or other visible evidence of contamination. Used syringes, IV tubing, multidose medication vials, and blood glucose monitoring devices may have no visible blood or sign of contamination but still carry potentially infectious agents. All used injection supplies and materials are potentially contaminated and must be discarded.

PRACTICES TO PREVENT PATIENT-TO-PATIENT AND HEALTHCARE WORKER-TO-PATIENT TRANSMISSION

The following practices are required of all providers of injection and/or intravenous (IV) therapy:

• Ensure proper hand hygiene before handling medications.
• Maintain aseptic technique throughout all aspects of injection preparation and administration.
  • Medications should be prepared (“drawn up”) in a designated clean medication area that is not adjacent to areas where potentially contaminated items are placed. For example, a cart with both blood glucose testing devices (contaminated) and syringes and insulin (supplies for injection) would not meet this requirement.
  • Use a new sterile syringe and needle to draw up medications, preventing contact between the injection materials and the non-sterile environment.
  • If a medication vial has already been opened, the rubber septum should be disinfected with alcohol prior to piercing it.
  • Never leave a needle or other device (e.g., “spikes”) inserted into a medication vial septum or IV bag/bottle for multiple uses, since this provides a direct route for contamination.
  • Medication vials should be discarded on or before the manufacturer’s expiration date, the date set by facility expiration policy, or any time there are concerns regarding the sterility of the medication.
• Never administer medications from the same syringe to more than one patient, even if the needle is changed.
• Never use the same syringe or needle to administer IV medications to more than one patient, even if the medication is administered into IV tubing, regardless of the distance from the IV insertion site.
  • All of the infusion components from the infusate (IV fluid) to the patient’s catheter are a single interconnected unit.
  • All of the components are directly or indirectly exposed to the patient’s blood and cannot be used for another patient.
  • Syringes and needles that enter any port in the IV system are contaminated and cannot be used for another patient or used to re-enter a non-patient-specific multi-dose vial.
  • Separation from the patient’s IV by distance, gravity, and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items.
• Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient.
• Dedicate vials of medication to a single patient.
  • Medications packaged as single-use must never be used for more than one patient.
  • Never combine leftover contents for later use.
  • Medications packaged as multi-use (such as insulin) should be assigned to a single patient whenever possible.
  • Never use bags or bottles of intravenous solution as a common source of supply for more than one patient.
• Never use peripheral capillary blood monitoring devices (such as lancets or platforms) packaged as single-patient use on more than one patient.
  • Restrict use of peripheral capillary blood sampling devices to individual patients.
  • Never reuse lancets. Consider selecting single-use lancets that permanently retract upon puncture.

PRACTICES TO PREVENT PATIENT-TO-HEALTHCARE WORKER TRANSMISSION

Safe injection practices designed to prevent disease transmission from patient to healthcare worker are described by OSHA. They include:

• Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed except as noted below. Shearing or breaking of contaminated needles is prohibited.
• If an employer can demonstrate that no alternative is feasible or that such an action is required by a specific medical or dental procedure, bending, recapping or needle removal must be accomplished through the use of a mechanical device or one-handed technique.
• Immediately or as soon as possible after use, contaminated reusable sharps shall be placed in appropriate containers until properly reprocessed. Reusable sharps that are contaminated with blood or other potentially infectious materials shall not be stored or processed in a manner that requires employees to reach by hand into the container.

Any employer having employee(s) with potential occupational exposure contact with blood or other potentially infectious materials must have a written Exposure Control Plan to eliminate or minimize risk. “Potential occupational exposure” is defined as “reasonably anticipated skin, eye, mucous membrane, or parenteral (piercing) contact with blood or other potentially infectious materials that may result from the performance of the employee’s duties.”Among the requirements for this Exposure Control Plan is identification of which employee groups may be at risk for exposure. In general, any worker who has contact with patients or with body fluids is at risk for exposure.

When accidental exposure occurs in any work setting, employers should document and track:

• Which devices are associated with blood exposures
• Where the exposures occur (area, setting)
• The circumstances in which exposures occur
• Postexposure management taken to prevent infection

(Postexposure management is described below under “Postexposure Prophylaxis”.)

Engineering Controls

Many of the practices described in the section on safe injection practices include engineering controls that protect patients from exposure to bloodborne pathogens. When safe injection practices are used, bloodborne pathogens are contained to the patient who carries them and their equipment, isolated from other patients. The hazard is then removed from the facility when the carrier patient departs.

Safety sharps devices and containers are types of engineering control, since they isolate or contain the hazard—used sharps. The Occupational Safety and Health Administration (OSHA, 2001) requires the use of safety sharps when feasible. Healthcare workers may be exposed percutaneously (through the skin) by sharps or needle sticks to HIV, hepatitis B and C, and other bloodborne pathogens. One out of five HCW sustain injuries from sharps and are at risk of exposure to HIV, HBV, and/or HCV. Even though recapping of sharps is not recommended, it still accounts for about 5% of all needlestick injuries (Premier, 2007).

In 2000 both New York State and federal laws were enacted to protect healthcare workers against needlesticks; these laws require that healthcare facilities evaluate and provide safe needles. OSHA has revised their Bloodborne Pathogen Standard to require that employers:

• Use engineering controls or work practices that “eliminate or minimize exposures” (OSHA 2001, CPL2-2.44D)
• Involve employees in the selection process
• Provide effective safe needles and sharps
• Provide training covering personal protective equipment, how to use safe-needle devices, and limitations of such devices

Employers must provide and workers must use safer devices whenever possible to prevent sharps injuries. Those devices must be evaluated and chosen to give preference to:

• Passive protection that does not depend on the worker to activate it
• Mechanisms that provide protection without delay
• Safety mechanisms that are integrated into (built into) the device, not an add-on

Other considerations to minimize risk of sharps injuries include:

• Educating all staff who will use a specific device on its proper use
• Eliminating non-safety alternatives wherever possible
• Using additional specific safety devices, as needed, for specialty areas or settings

Puncture-resistant containers must be used for the disposal and transport of needles and other sharp objects.

• Information on selection, evaluation, and placement of containers for sharps disposal is available from NIOSH (1998).
• Guidelines for safe disposal of household sharps in New York are available from the New York Department of Environmental Conservation (2011).

In addition to sharps safety, other kinds of engineering controls contain or remove other kinds of hazards. For example, some kinds of medical equipment that may have risk of splatter, such as lab centrifuges, should be equipped with splatter shields.

Environmental Controls

Environmental control measures also help prevent the transmission of infection. These measures include:

• Environmental cleaning (housekeeping)
• Waste management
• Linens (textiles) and laundry management

HOUSEKEEPING

Appropriate housekeeping and sanitation practices are essential to reduce the spread of infection, particularly in high-risk areas such as nurseries, operating rooms, and intensive-care units. The CDC guidelines (2008a; 2007) include the following recommendations:

• Keep housekeeping surfaces (e.g., floors, walls, tabletops) visibly clean on a regular basis and clean up spills promptly.
• Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas.
• Follow proper procedures for effective uses of mops, cloths, and cleaning solutions.

WASTE MANAGEMENT

There are two categories of hospital waste: regulated medical waste and unregulated waste. About 20% of the hospital waste requires special handling. The other 80% is similar to domestic waste (WHO, 2011).

Regulated medical waste (“red bag” waste) requires special precautions in handling and disposal. Regulated medical waste includes:

• Microbiology laboratory waste
• Pathology and anatomy waste
• Bulk blood or blood products
• Sharps items such as used needles or scalpel blades (CDC, 2003)

These items require special handling, transport, and storage procedures. The CDC (2003) recommends the following guidelines:

• Personnel responsible for waste management must receive appropriate training in handling and disposal methods in accordance with hospital policy.
• Waste generated in isolation areas should be handled using the same methods used for waste from other patient care areas.
• Disposable syringes with needles, including sterile sharps that are being discarded, scalpel blades, and other sharp items, should be disposed of in puncture-resistant containers located as close as practical to the point of use.
• Do not bend, recap, or break used syringe needles before discarding them into a container.
• Sanitary sewers may be used for safe disposal of blood, suctioned fluids, ground tissues, excretions, and secretions provided that local sewage discharge requirements are met and that the state has declared this to be an acceptable method of disposal.
• Store regulated medical wastes awaiting treatment in a properly ventilated area inaccessible to vertebrate pests. Use waste containers that prevent development of noxious odors.
• If treatment options are not available at the site where the waste is generated, transport regulated medical waste in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate.
• Regulated medical waste must be treated by a method (steam sterilization, incineration, interment, or an alternate treatment technology) approved by the appropriate authority (e.g., the state, Veterans Administration, Indian Health Service) before disposal in a sanitary landfill.

LINENS AND LAUNDRY

According to CDC (2003), except for soiled textiles from patients in isolation, the risk of actual disease transmission from soiled laundry is negligible. However, the hands of healthcare workers can be contaminated by contact with patient bed linens (Hand Hygiene Resource Center, 2011). Thus, commonsense hygienic practices for handling, processing, and storage of textiles are recommended. These practices include:

• Do not shake items or handling them in any way that may aerosolize the infectious agents.
• Avoid contact of one’s own body and personal clothing with the soiled items being handled.
• Wear gloves and other protective equipment, as appropriate, when handling contaminated laundry.
• Contain soiled items in a laundry bag or designated bin at the location where it was used, minimizing leakage.
• Do not sort or rinse textiles in the location of use.
• Label or color-code bags or containers for contaminated waste.
• If laundry chutes are used:
  • Ensure that laundry bags are securely closed before they are placed in the chute.
  • Do not place loose items in the laundry chute.
• For textiles heavily contaminated with blood or other body fluids, bag and transport in a manner that will prevent leakage.
• Do not use dry cleaning for routine laundering in healthcare facilities.
• For clean textiles, handle, transport, and store by methods that will ensure their cleanliness.

OSHA’s Bloodborne Pathogen Standard requires employers to ensure that employees who have contact with contaminated laundry wear protective gloves and other appropriate personal protective equipment (PPE).

Employers are responsible for laundering reusable personal protective equipment. Work clothes such as uniforms are not considered to be PPE. Provided gowns or other PPE should be used to prevent soiling of uniforms (CDC, 2007; OSHA, 2001).

Training healthcare workers who are responsible for housekeeping and management of linen and waste in appropriate infection control for their particular duties is essential for safe patient care.

BARRIERS AND PERSONAL PROTECTIVE EQUIPMENT (PPE)

Use of PPE is built into the descriptions of all four isolation precautions (Standard, Contact, Droplet, and Airborne) described by the CDC. Healthcare workers should use appropriate barriers and/or PPE whenever they may have contact with the blood or body fluids of any patient and to prevent exposure to the droplets from patients with respiratory symptoms.

A barrier is a material object that separates a person from a hazard. The type of PPE selected should be based on the procedure and reasonably anticipate events such as:

• Blood or body fluid splash
• Contact with minimal bleeding/drainage/body substances
• Contact with large volume bleeding/drainage/body substances that are likely to soak through the contact area
• Respiratory droplet pathogens
• Airborne pathogens

Some barriers are used to protect the patient, including:

• Sterile barriers for invasive procedures
• Masks for the prevention of droplet contamination

Personal protective equipment includes:

• Gloves
• Cover garb (gowns, aprons, fluid-resistant laboratory coats)
• Face shields
• Masks
• Eye protection
• Caps and hoods

Gloves

Gloves should be worn when contact with blood or OPIM, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated patient care equipment is anticipated.

• Wear gloves with fit and durability appropriate to the task, such as disposable exam gloves for patient care and disposable or reusable gloves for cleaning.
• Remove gloves in a manner than minimizes risk of hand contamination.
• Do not wear the same pair of gloves for the care of more than one patient.
• Do not wash disposable gloves.
• Change gloves during the care of one patient if moving from a contaminated body site to a cleaner one. Recommendation is to go from clean to dirty. (CDC, 2007)

Gloves are available in several materials, including latex, nitrile, or rubber (utility/housekeeping). Some healthcare workers have developed an allergy to latex and should use gloves made of nitrile or another latex-free alternative. Latex or nitrile gloves are preferable over vinyl gloves for clinical procedures, since several studies have shown that vinyl gloves have higher failure rates in use (CDC, 2007).

Always use nitrile or other appropriately protective gloves when handling chemotherapy or other chemicals. Both examination (nonsterile, clean) gloves and surgical (sterile) gloves must be available for specific healthcare tasks. Avoid use of petrolatum-based lotions or creams when using latex gloves since these products may affect the integrity of the gloves.

Gloves are the first line of PPE and can prevent heavy contamination of hands during patient care and transmission of pathogens. However, wearing gloves does not provide complete protection. Wearing gloves does not replace the need for hand washing because gloves may have small, unnoticeable defects or may tear during use, and hands can become contaminated during glove removal.

Hands should be washed with soap and water immediately after glove removal if hands are visibly soiled or if the glove has torn. In the absence of visible hand contamination, hand hygiene with alcohol hand rubs is appropriate after glove removal (CDC, 2007). Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks, even with the same patient.

The 2007 CDC guidelines do not recommend the use of double gloving. However, some studies have found that, for some procedures, wearing two pairs of gloves helps reduce the risk of contamination with blood and body fluids. One clinical study found that wearing a single pair of surgical gloves resulted in a failure rate (loss of glove integrity) of 51%. Double gloving reduced the failure rate to 7% (Quebbeman et al., 1992).

Another study recommended double gloving for surgical procedures in which the patient is known or suspected to be infected with a transmissible virus and for all procedures expected to last more than two hours. If double gloving is not done, healthcare workers should frequently check for blood penetration and should change gloves every 1 to 3 hours (Raahve, 1996). There was an 87% reduction in risk with double gloving during intraoperative procedures (Berguer & Heller, 2004). The recommendation from the Association of Surgical Technicians (2006) is that all surgical sterile team members should double glove.

Gowns

Gowns are available in both sterile (surgical) and nonsterile (clean) versions and in fabrics of varying permeability (impervious, fluid-resistant, permeable). Gowns protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to involve contact with or generate splashes or sprays of blood or body fluids. Choose the type of gown that will provide adequate protection for the task planned.

When using Standard Precautions, an isolation gown is worn only as needed to protect the wearer from contact with blood or body fluids. Wear a gown for direct patient contact if the patient has uncontained body substances.

When Contact Precautions are in use, both gown and gloves should be worn on entry into the room to reduce unintentional contact with contaminated surfaces. Do not reuse gowns, even for repeated contacts with the same patient (CDC, 2007).

Respiratory Protection

Masks, respirators, and powered air-purifying respirators (PAPRs) protect the healthcare worker, the patient, or both from transmission of pathogens. Different types of respiratory protection are available for different tasks and purposes, including:

• Single-use disposable masks are used for Droplet Precautions. They are also used on patients with respiratory symptoms as part of respiratory hygiene or on patients known or suspected to have TB. Simple masks contain the droplets coming out of the person wearing the mask (covering their portal of exit).
• Single-use disposable masks with eye shield should be used when splash and/or splatter is anticipated, such as in the OR. These must be changed if wet or soiled. These protect the patient and sterile field from the exhaled droplets of the surgical staff as well as protecting the eyes of surgical staff.
• N-95 respirators are required for staff for Airborne Precautions (e.g., caring for patients known or suspected to have pulmonary tuberculosis). They must make a tight seal against the face and must be fit tested. This type of respirator protects the person wearing it from possible pathogens in the air of the room, protecting their portal of entry. Some N-95 respirators have an exhalation valve; these do not prevent contamination of a sterile field and should not be worn alone in the OR.
• PAPRs are used in many facilities in addition to or instead of N-95 respirators as an Airborne Precaution. They do not require fit testing, and they can be used by people with facial hair that precludes wearing of an N-95. PAPRs do require training and maintenance. Check your facility’s policy if you may need to use them.

All respiratory protection should cover both the mouth and the nose. If the mask or respirator has a metal strip, it should be fitted securely over the bridge of the nose to prevent inhalation or exhalation of pathogens and to prevent fogging of eyeglasses. If glasses are worn, the upper edge of the mask should fit under the glasses to prevent fogging.

When wearing a mask with strings, tie both strings securely to prevent strings from coming loose during the procedure. Tie the upper strings at the back of the head and the lower strings at the neck.

N-95 respirators must be worn as specified on the product package or protection may not be provided. Specifically, if the respirator has two straps, they must be placed as directed, not left dangling or placed together.

Face protection with mask plus eye shield, face shield, or goggles is essential to protect the mucous membranes of the eyes, nose, and mouth during procedures that are likely to generate splashes or sprays of blood or body fluids. Although percutaneous injuries (needle sticks) are the most common route for transmission of bloodborne viruses, splashes or sprays to the mucous membranes are the second most common route. When eye protection is worn, a mask must also be worn (CDC, 2007).

Some barriers and PPE are worn to protect the patients from the germs of healthcare professionals, especially in the OR. Sterile drapes are used to create a sterile field in which the operative procedure can take place. Surgical masks reduce risk of droplet contamination of the operative field. Caps and hoods are worn to reduce shedding and promote environmental control. The Association of Operating Room Nurses recommends that a cap or hood be worn that fully covers all hair on the head and face when in restricted and semi-restricted areas of the surgical suite.

Selection of PPE should consider the possibility of coming into contact with infectious material from splashes, respiratory droplets, and airborne pathogens, as well as the anticipated volume of exposure. This depends in part on the type of procedures or activity being performed. In addition, consideration should be given to whether protection from exposure is needed for patient safety, healthcare worker safety, or both. When infection control precautions are instituted (e.g. Contact, Droplet, and Airborne Precautions), recommendations for specific PPE should be followed.

Barriers and PPE are most effective when appropriately selected, properly fitted, worn according to manufacturer’s instructions, inspected frequently to verify integrity of the barrier, and changed between patients. The cost of barriers and PPE are far less than the cost of treating preventable infections of patients and personnel.

A SAFE ENVIRONMENT: CLEANING, DISINFECTION, AND STERILIZATION

This section deals with proper cleaning in healthcare environments, including surfaces, furnishings, and reusable medical equipment and patient-care devices. Cleaning of reusable patient-care tools and equipment is referred to as reprocessing.

Understanding and applying appropriate procedures for cleaning, disinfection, and sterilization are essential to maintaining a safe patient-care environment.

Contamination

The potential for contamination exists in every area of the hospital or other healthcare facility. Contaminated patient-care equipment (wet or soiled dressings), invasive devices that were used in diagnosis and treatment (surgical instruments or endoscopes), and environmental surfaces (doorknobs, floors, toilets) can act as vehicles for the transmission of infection to healthcare workers and/or patients.

Potential for contamination is dependent upon:

• Type of instrument, medical device, equipment, or environmental surface (material, configuration, or presence of hinges, crevices, or lumens)
• Frequency of hand contact with the device or surface
• Potential for contamination with body substances or environmental organisms
• Level of contamination, i.e. the types and numbers of microorganisms and potential for cross-contamination

Cross-contamination refers to transfer of microorganisms from one person or place to another. Every healthcare professional should recognize potential sources of cross-contamination in the healthcare environment and apply infection-control procedures to avoid cross-contamination. These sources include:

• Surfaces or equipment that require cleaning between patients
• Practices that contribute to hand contamination
• Re-use of single-use/disposable instruments, medical devices, or equipment.

Lapses in infection control practices resulting in cross-contamination of instruments, medical devices, or equipment have led to reported cases of disease transmission. Identified factors that have led to this cross contamination include:

• Failure to discard single-use (disposable) items
• Failure to reprocess items between patients
• Inadequate cleaning
• Inadequate disinfection or sterilization
• Contamination of disinfectant or rinse solutions
• Improper packaging, storage and handling
• Inadequate or inaccurate record keeping of reprocessing requirements.

Devices labeled “for single patient use only” should be discarded properly following use. Any consideration of re-use of single-use devices should be reviewed by the facility’s risk manager to assure that the requirements of the FDA for such re-use are met. (See “Resources” below.)

Cleaning and Disinfection

The healthcare environment can become easily contaminated with pathogens. Concern about the increasing rates of multi-drug resistant pathogens and Clostridium difficile (C. diff) have focused attention on the importance of effective environmental cleaning. Care must be taken to use the right disinfectant for the purpose, consistent with its FDA or EPA registration. Some organisms are easily killed while others are highly resistant to disinfection.

 Environmental surfaces such as floors and tabletops should be cleaned or disinfected on a regular basis, when spills occur, and when they are visibly soiled. The disinfectant manufacturer’s instructions for dilution, use, and contact time should be followed. (Refer to CDC guidelines (2008a) for further detail.)

Keep in mind that all disinfectants and sterilizing chemicals have a degree of toxicity necessary to kill the microorganisms. In general, the lowest level of product that will do the job should be used to minimize exposure of healthcare workers to toxic chemicals.

LOW-LEVEL DISINFECTION

Low-level disinfection kills some viruses and bacteria using a chemical germicide registered as a hospital disinfectant by the U.S. Environmental Protection Agency (EPA). It is used to clean the environment and items that touch only intact skin. It does not kill bacterial spores and is less active against some gram-negative rods, such as pseudomonas and mycobacteria.

Low-level disinfection includes the following:

• Use EPA-registered disinfectants in accordance with manufacturer’s directions. In general, this is the disinfectant found on the housekeepers’ carts.
• Keep environmental surfaces visibly clean on a regular basis and clean up spills promptly.
• Clean high-touch surfaces (monitor controls, doorknobs, bed rails, light switches) often.
• Avoid cleaning methods that produce aerosols or disperse dust.
• Use barrier protective coverings as appropriate for high-touch surfaces such as computer keyboards.
• Do not use high-level disinfectants for environmental cleaning due to toxicity.

(Refer to CDC Guidelines for Environmental Infection Control in Healthcare Facilities, 2003, for additional detail.)

INTERMEDIATE-LEVEL DISINFECTION

Intermediate-level disinfection kills most viruses, bacteria, and mycobacteria using a chemical germicide registered as a tuberculocide by the EPA. It does not kill bacterial spores. It is often used to clean blood spills and other environmental cleaning and is not licensed for disinfection of patient care equipment that touches mucous membranes. These disinfectants are typically labeled as tuberculocidal to give evidence that they kill the bacterium that causes tuberculosis, as well as the viruses that cause hepatitis B and HIV. They may be available as a liquid or as disposable wipes.

Blood spills should be cleaned without delay:

• Wear gloves and other personal protective equipment as needed.

Proper procedures for cleaning of blood and body fluid spills begins with initial removal of bulk material using disposable absorbent material (such as paper towels) as needed, followed by disinfection with a product effective against organisms transmitted by blood or other body fluids. These include:

• Products from EPA List D, which contains registered antimicrobial products effective against human HIV-1 and hepatitis B virus
• Products from EPA List E, which contains registered antimicrobial products effective against Mycobacterium tuberculosis, human HIV-1 and hepatitis B virus
• • Freshly diluted 1:100 sodium hypochlorite, i.e., 1/4 cup bleach to 1 gallon of water

Some situations, such as care of the patient in Contact Precautions, may require specified patient-care items to be either dedicated to one patient or patient cohort or subjected to special disinfection procedures between patient uses. This would include items used for patients infected with organisms that are difficult to treat, highly virulent, or easily spread, such as:

• Patients infected with MRSA, vancomycin-resistant enterococci (VRE), C. diff, and other microorganisms of special concern
• Patients infected with highly virulent microorganisms, e.g., viruses causing hemorrhagic fever (e.g., Ebola or Lassa)

Knowing your facility policies and/or consulting with infection control staff are important in these situations.

HIGH-LEVEL DISINFECTION

High-level disinfection kills all organisms except high levels of bacterial spores using a chemical germicide cleared for marketing as a sterilant by the U.S. Food and Drug Administration (FDA). It is used for patient-care equipment that touches intact mucous membranes, called semi-critical devices, such as laryngoscopes or endoscopes. It is used when sterilization is not feasible.

Endoscopes can transmit pathogens to patients by contaminated internal channels even if the exterior has been disinfected, the internal channels have not been adequately cleaned, or contact of the disinfecting solution with the internal channel is incomplete or does not last long enough.

Requirements for high-level disinfection:

• When handling and cleaning contaminated items, wear appropriate personal protective equipment, i.e., gloves, eye protection, and/or gown as needed.
• Always clean items thoroughly before reprocessing. First rinse with cold water to remove blood or body fluids, then wash with hot soapy water and rinse again to remove the soap before disinfecting or sterilizing. Cleaning methods may be manual or mechanical and may require a rinse or presoak depending on the nature and amount of blood or body fluids. Once cleaned, avoid cross-contamination by other articles or surfaces.
• For devices with internal lumens, such as endoscopes, methods for verifying contact with all internal channels and components must be monitored.
• Always follow the recommendation of the device/equipment manufacturers of both the device to be disinfected and the disinfectant recommendations for reprocessing to ensure that the method chosen is compatible with the components and materials in terms of heat and pressure tolerance and time required for reprocessing.

Sterilization

Sterilization is required for reusable patient-care instruments that touch sterile spaces in the body. Steam sterilization is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture (CDC, 2008a). The major sterilizing agents used in hospitals are:

• Moist heat by steam autoclaving (the gold standard, also minimally toxic)
• Ethylene oxide gas (highly toxic; use is decreasing)
• Peracetic acid (used in proprietary machines, often for endoscopes)
• Plasma (new method with little toxicity)
• Dry heat

Reprocessing

Reprocessing refers to special infection control procedures for killing microbes on instruments and patient-care equipment that are reused with the same patient or shared between patients. Reprocessing of reusable patient-care equipment includes both high-level disinfection and sterilization (see above). Both these processes must also be preceded by decontamination and careful, thorough cleaning.

The choice of level of reprocessing (sterilization or high-level disinfection) depends on the intended use of the item (whether it will touch sterile spaces or intact mucous membranes). Remember that intermediate and low-level disinfection are used only for environmental cleaning and items that will touch intact skin.

The choice of reprocessing methods must also consider the manufacturer’s recommendations for compatibility among equipment components and materials and the chemicals to be used, the heat and pressure tolerance of the equipment, and the time and temperature requirements of the reprocessing methods. For example, steam sterilization would not be appropriate for equipment that cannot tolerate heat and moisture.

Industry guidelines and manufacturer recommendations (of both chemicals and equipment) should be used to develop and update reprocessing policies and procedures. Written instructions should be available for each instrument, medical device, and equipment reprocessed.

REPROCESSING STEPS

• Pre-cleaning should be done as soon as possible after use, usually at the use location. This removes soil, debris, and lubricants from internal and external surfaces.
• Cleaning may be manual (scrubbing with brushes) or mechanical, using an automated washer. Cleaning equipment must be used appropriately (for example, do not reuse disposable cleaning equipment). Cleaning solutions must be changed as directed by the manufacturer.
• Cleaning is followed by either disinfection or sterilization.
• Disinfection requires sufficient contact time of all internal and external surfaces with the solution.
• Sterilization requires sufficient exposure time to heat, chemicals, or gases.

INSURING EFFECTIVENESS

Effectiveness of reprocessing depends on a number of variables.

• Thorough cleaning is essential before either disinfection or sterilization.
• The right disinfectant product must be chosen. High-level disinfectants require immersion, while surface disinfectants are for environmental use.
• Presence of organic matter (inadequate cleaning) inactivates many disinfectants.
• Biofilms are constructed by some bacteria, providing protection for the bacteria from hostile environments such as disinfectants. In general, biofilms are not readily removed by chemicals alone but require mechanical scrubbing. An example of a biofilm is the film on our teeth in the morning, not removed by mouthwash, requiring brushing.

Monitoring of disinfection is essential to document the effectiveness of reprocessing. Factors to be documented include:

• Activity (concentration) of the disinfectant
• Contact time with internal and external components
• Record keeping and tracking of equipment usage and reprocessing
• Handling and storage after disinfection to prevent contamination

Monitoring of sterilization requires different documentation for different methods.

• Steam sterilization is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture (CDC, 2008a)
• Most sterilization methods require documentation of:
  • Biologic monitors: test organisms that are exposed to the sterilization process then incubated to verify that the process killed them
  • Process monitors, such as indicator tapes or strips, which change visibly to distinguish between packs that have or have not yet been processed
  • Physical monitors (time, temperature, pressure), which document that the physical parameters for sterilization have been met
  • Record keeping and a recall system for each item sterilized
• Packaging, handling, and storage after sterilization, including definition of when reprocessing is needed (either by event or by time)

HANDLING AND STORAGE OF REPROCESSED ITEMS

Once devices/equipment have been disinfected, proper handling and storage are required to maintain these items in ready-to-use condition. See your facility’s policies for specific details.

Proper handling and storage after sterilization—including package integrity and shelf life or event-related sterility criteria—are required to maintain these items in a sterile state.

Event-related sterility means that sterilized items do not outdate by an arbitrary date but are judged to be sterile unless an “event” has compromised sterility. Compromising events include circumstances that break the integrity of the sterile packaging by creating holes or wetting the package, which could carry bacteria into it. This means that the once-sterile package that has come loose, has holes, or shows evidence of wetting, presently or in the past, cannot be used because sterility may have been compromised. The end user of the package is responsible for inspecting its integrity, verifying that no event has compromised sterility.

New York State Professional Expectations

The New York State Department of Health has stated its expectations with respect to differing levels of disinfection and sterilization methods and agents based on the area of professional practice, setting, and scope of responsibilities.

WHEN DISINFECTION/STERILIZATION IS PERFORMED ELSEWHERE

The area of professional practice dictates the level of responsibility for recognizing various levels of disinfection/sterilization methods and agents. Those health professionals who practice in settings where handling, cleaning, and reprocessing equipment, instruments, or medical devices are performed elsewhere (such as a dedicated Sterile Processing Department) should:

1. Understand core concepts and principles including:
   • Standard/Universal Precautions, such as the wearing of personal protective equipment
   • The steps of reprocessing and choice of reprocessing methods as described previously
   • Safe practices for handling instruments, medical devices, and equipment in the area of professional practice
   • Physical separation of patient-care areas from cleaning and reprocessing areas as recommended by the New York State Department of Health (NYSDOH)
2. Verify with those responsible for reprocessing what steps are necessary before return for reprocessing, such as pre-cleaning and/or soaking. The methods for accomplishing these steps should be described in written procedures.

FOR THOSE WITH PRIMARY OR SUPERVISORY RESPONSIBILITIES

Professionals who have primary or supervisory responsibilities for equipment, instruments or medical device reprocessing (such as Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site) should:

1. Understand core concepts and principles identified in #1 above
2. Determine appropriate reprocessing practices and selection of appropriate methods. Critical factors to consider are:
   • Antimicrobial efficacy
   • Time constraints and requirements for various methods
   • Compatibility among equipment/materials, including corrosiveness, penetrability, leaching, disintegration, heat tolerance, and moisture sensitivity
   • Toxicity issues, including potential for patient toxicity/allergy, risks to staff, environmental hazards and potential abatement methods, and monitoring of exposures
   • Residual effects of methods considered, including potential for patient toxicity/allergy and antibacterial residual
   • Ease of use, including the need for specialized equipment and/or special training requirements
   • Stability of the materials to be used, including concentration, potency, efficacy of use, and the effect on the process of organic material
   • Odor
   • Cost
   • Monitoring frequency and impact of FDA regulations

INFECTIOUS DISEASES AND HEALTHCARE WORKERS

Prevention of infectious diseases in healthcare workers (HCWs) means protecting them from infections they do not already have. Management of infectious diseases in HCWs means protecting others from the diseases the HCW already does have.

Protecting HCWs from disease is accomplished in many ways, including:

• Use of Standard Precautions with all patients, especially hand hygiene
• Use of additional transmission precautions (e.g., Contact, Airborne, Droplet)
• Vaccination (e.g., influenza, hepatitis B)
• Postexposure prophylaxis
• Environmental hygiene to reduce exposure to pathogens in healthcare settings

If you suspect that you have been exposed on the job to a communicable disease, let your supervisor and your infection control practitioner know without delay. This will allow evaluation of the circumstances to prevent exposure of others, management of the exposure, and appropriate follow-up of your health as needed. For some diseases, postexposure prophylaxis (preventive medication) is available (see below).

Protecting others from infections from health professionals includes:

• Vaccination
• Evaluation of acute symptoms
• Evaluation of safety to work and reassignment or furlough when unsafe
• Strict adherence to infection control guidelines

Preventing transmission of infection is the responsibility of the facility and the individual HCW.

Requirements Pertaining to Reporting and Informing Healthcare Workers

Healthcare workers are responsible for reporting to their supervisor or occupational health service any signs or symptoms of a communicable disease. Symptoms that should be reported and evaluated include:

• Fever
• Unusual rash
• Skin infections, such as boils, impetigo, and herpetic whitlow
• Exudative (weeping) dermatitis
• Sore throat with fever
• Gastrointestinal symptoms (vomiting, diarrhea)
• Recent onset of unexplained cough
• Recent onset of congestion suggesting an acute respiratory infection
• Jaundice
• Symptoms suggesting active tuberculosis (chronic productive cough with unexplained weight loss, fever, night sweats, or hemoptysis [bloody sputum])

Employees who report symptoms of illness should be removed from duty and medically evaluated to determine their ability to work and the duration of work restrictions. In New York and other states, persons who have mandatory reportable communicable disease must have their illness reported to the local health unit for follow-up (NYSDOH, 2011).

New York State law also requires that:

• All healthcare workers whose job responsibilities involve contact with blood or sharp objects likely to be contaminated with blood should be offered and encouraged to receive the hepatitis B vaccine.
• All healthcare personnel should receive information about the risks associated with HIV, HBV, and HCV infection and the advantages of knowing their status if they have been exposed, so that they may benefit from medical management.
• All healthcare workers should be informed that if they have an impaired immune system due to HIV infection or other medical condition or treatment, they are at risk of acquiring potentially life-threatening infections, including TB, from patients.
• Information on the availability of voluntary, confidential, anonymous counseling and testing for HIV, HBV, and HCV must be made available to all healthcare workers.
• Employees must be offered the HBV vaccine, and the NYS Department of Health strongly recommends that at-risk healthcare workers receive this vaccine.

The New York State Department of Health (DOH) (1994) recommends that every health facility and home health agency incorporate the evaluation of personnel for a communicable disease into a broader occupational health program. Policies and procedures should be developed for reporting signs and symptoms of illness and diagnosis of or exposure to a communicable disease. All employees must receive initial and ongoing education regarding these policies and procedures.

Other occupational health strategies for preventing transmission of bloodborne pathogens and other communicable diseases to and from healthcare workers include:

• Pre-employment evaluation to screen for:
  • Tuberculosis
  • Rubella (German measles) immunity
  • Measles immunity
• Annual assessment of staff (including surveillance for TB)
• Influenza immunization
• Removal from work or modification or limitation of work practices

Immunizations Recommended for Healthcare Workers

Influenza vaccine is offered annually, and staff should be encouraged to accept it as a method for protecting themselves and patients. Many healthcare workers get influenza from patients, and transmission from healthcare workers to patients has also been documented. Vaccinating staff against influenza is associated with lower patient death rates from influenza (CDC, 2006; CDC, 2011e). The concern is so great that some hospitals now require healthcare personnel who refuse influenza vaccine to wear a mask daily during flu season. This has resulted in higher rates of immunization among health care workers.

Hepatitis B vaccine. New York and other states require that all employees whose jobs involve participation in tasks or activities with exposure to blood/OPIM be offered the first of the hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccination is free, safe, and highly recommended. This vaccine is given in 3 doses. Serologic testing after vaccination (to verify that the vaccination was effective) is recommended for all persons with potential occupational exposures.

Vaccinations recommended by the CDC for healthcare workers who do not have evidence of immunity are shown below.

HEALTHCARE PERSONNEL VACCINATION RECOMMENDATIONS

Vaccine	Recommendations in Brief
Source: CDC, 2011.
Hepatitis B	All healthcare personnel at risk of exposure to blood and body fluids if they do not have evidence of immunity
Influenza	All healthcare personnel, including volunteers and students
MMR (measles, mumps, and rubella)	All healthcare personnel who do not have documented evidence of immunity; healthcare personnel born in or after 1957 without documentation of (a) receipt of two doses of live vaccine on or after their first birthday, (b) physician-diagnosed measles, or (c) laboratory evidence of immunity; should be considered for all personnel, including those born before 1957, who have no proof of immunity
Varicella (chickenpox)	All healthcare personnel who do not have documented evidence of immunity: 1) documentation of 2 doses of varicella vaccine given at least 28 days apart; 2) history of chickenpox or shingles based on physician diagnosis; 3) laboratory evidence of immunity, or 4) laboratory confirmation of disease
Tetanus, diphtheria, and pertussis (Td/Tdap)	All healthcare personnel who have not or are unsure if they have received a dose of Tdap; boosters needed every 10 years

In special circumstances, additional immune protection may be advisable, such as for HCWs with increased susceptibility (e.g., aspleenic) or increased exposure (e.g., diagnostic laboratory workers) to specific infections.

Bloodborne Pathogens Training

Bloodborne pathogens training must include:

• Information on hazards associated with blood or other potentially infective material
• Protective measures to minimize risk of occupational exposure
• Information on appropriate actions to take if exposure occurs

New York State law requires retraining employees every four years or when changes in procedures or tasks affecting occupational exposure occur.

Although HBV and HIV are specifically identified in the standard, bloodborne pathogens include any pathogen present in human blood or OPIM that can infect and cause disease in people exposed to the pathogen. There are approximately 20 additional pathogens that can be transmitted by blood, including Hepatitis C virus, malaria, West Nile virus, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I–associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

The risk of developing HIV infection from a needle stick with infected blood is about 1 in 300. Through December 2001, there have been 57 documented cases of HIV transmission to healthcare workers and an additional 139 “possible” cases (CDC, 2011a). Most were exposed to blood through percutaneous injuries, and eight of the workers were infected despite receiving postexposure prophylaxis (PEP) (Do et al., 2003). Twenty-six later developed AIDS. There have been no new confirmed cases of occupational transmission of HIV to healthcare workers in the United States since 1999 (CDC, 2011a).

To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends:

• Strict adherence to sharps safety guidelines and Standard Precautions
• Hepatitis B vaccination of healthcare workers
• Postexposure prophylaxis and counseling in the event of exposure incident

Postexposure Prophylaxis

In the event of an exposure incident to pathogens, healthcare workers should be assessed for possible postexposure prophylaxis (PEP).

POSTEXPOSURE PROPHYLAXIS FOR SELECTED INFECTIOUS DISEASES

Disease	Indication
Sources: CDC, 1998; CDC, 2005b; ACOEM, 2008.
HIV/AIDS	For healthcare personnel with percutaneous or mucous-membrane exposure to blood or OPIM (immediate treatment if source known to be HIV +)
Diphtheria	For healthcare personnel exposed to diphtheria or identified as carriers
Hepatitis A	May be indicated for healthcare personnel exposed to feces of infected persons during outbreaks
Hepatitis B	HBV-susceptible healthcare personnel with percutaneous or mucous-membrane exposure to blood known to be HBsAg seropositive
Meningococcal disease	Personnel with direct contact with respiratory secretions from infected persons without the use of proper precautions (e.g., mouth-to-mouth resuscitation, endotracheal intubation, endotracheal tube management, or close examination of oropharynx)
Pertussis	Personnel with direct contact with respiratory secretions or large aerosol droplets from respiratory tract of infected persons
Rabies	Personnel who have been bitten by a human being or animal with rabies or have had scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infective material (e.g., brain tissue)
Tuberculosis	Personnel with unprotected close contact to a patient with active TB
Varicella zoster virus	Personnel known or likely to be susceptible to varicella and who have had close and prolonged exposure to an infectious healthcare worker or patient, particularly those at high risk for complications, such as pregnant or immunocompromised persons

The CDC recommends that healthcare facilities monitor the effects of PEP and track safety and acceptability of different PEP regimens that include new antiretroviral agents. Communication prior to treatment about possible side effects and follow-up during treatment with PEP increase compliance.

Healthcare Workers with Hepatitis B, Hepatitis C, or HIV Infection

The following standards are based on recommendations by the SHEA Guidelines (2010) and New York State law.

Healthcare workers who have or may have HBV, HCV, or HIV should be evaluated for the ability to work safely. This evaluation should be based on the premise that HBV, HCV, or HIV alone is not sufficient justification to limit the worker’s professional duties. Case-by-case evaluation should be done to determine whether an individual healthcare worker poses a risk to patients that warrants job modification, limitation, or restriction. If a patient is exposed to the blood of a healthcare worker, that patient must be informed of the exposure and appropriate follow-up offered.

Periodic re-evaluation of a healthcare worker infected with HBV, HCV, or HIV may be appropriate if the disease progression alters physical or mental functioning. Other factors that may affect the ability of healthcare workers to provide quality healthcare include:

• Lack of compliance with established infection control guidelines
• Appropriateness of techniques as related to performance of procedures
• Any health condition that would pose a significant risk to others

Healthcare facilities are required to establish a mechanism for evaluating healthcare workers with HBV, HCV, or HIV infection. However, this does not include involuntary screening of employees for HBV, HCV, or HIV. New York State law prohibits HIV testing of any citizen without written informed consent.

Institutional evaluation of individual workers known to be infected with HBV, HCV, or HIV shall be based on New York State DOH criteria and shall involve consultation with experts who can provide a balanced perspective. Such experts can include:

• An infectious disease physician and/or hospital epidemiologist with an understanding of HBV, HCV, or HIV
• A representative from the infected healthcare worker’s practice area
• The personal physician of the infected worker

All matters related to evaluation must be handled confidentially.

Any modification of work practice must seek to impose the least-restrictive alternative in accordance with federal disability laws. Workers who believe that their employment has been unfairly restricted or terminated may ask for a second opinion from a DOH review panel and/or file a complaint with the NYS Human Rights Commission.

All HIV-infected healthcare workers are entitled to protection under the NYS HIV Confidentiality Law, as are other citizens. Such workers are not required to disclose their status to patients or employers.