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COURSE OBJECTIVE: The purpose of this course is to provide healthcare professionals with information on infection control practices and procedures, including the chain of infection; CDC guidelines; Standard Precautions, Contact Precautions, Droplet Precautions, and Airborne Precautions; and engineering controls, work practice controls, and environmental controls.
Upon completion of this course, you will be able to:
Healthcare-associated infection (HAI): Infection associated with healthcare delivery in any setting (e.g., hospitals, long-term care facilities, outpatient clinics, ambulatory settings, and home care). Patients may acquire HAIs while receiving treatment for other conditions, i.e., HAIs are not present or incubating at the time of entry into the healthcare process. Because patients often receive medical care in more than one setting, infection control is increasingly important outside acute care hospitals (e.g., long-term care facilities).
Healthcare-associated disease transmission is transmission of infectious agents that results in the development of HAIs.
Healthcare workers (HCWs): Any person who has contact with patients, body fluids, or supplies used for patient care as part of their job. HCWs include interns, volunteers, and paid workers/employees who are involved in any aspect of healthcare in any setting. This includes physicians, nurses, occupational therapists, physical therapists, as well as administrative, environmental hygiene, and laboratory staff in medical facilities. All healthcare workers should be trained in basic infection control regardless of whether they deliver direct care to patients.
Nosocomial infection: An infection that develops during or as a result of an admission to a hospital and was not incubating at the time of admission (Siegel et al., 2007).
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).
|Site of Infection||Total Cases||Percent of Hospital HAIs|
|Source: Klevens et al., 2007.|
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).
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).
The goals of infection control training are to:
Asymptomatic infection: Absence of symptoms or signs of illness in the infected person. Synonyms: subclinical infection, inapparent infection.
Colonization: Proliferation of microorganisms on or within body sites without detectable host immune response, cellular damage, or clinical expression (i.e., without symptoms or signs of disease). The presence of a microorganism within a host may occur with varying duration, but may become a source of potential transmission. Synonyms: carriage, carrier state.
Common vehicle: Contaminated material, product, or substance that serves as a mode of transmission by which an infectious agent is transported to multiple susceptible hosts. Outbreaks of disease are linked to common vehicles, such as bacteremia resulting from use of intravenous fluids contaminated with a gram-negative organism, or gastroenteritis resulting from food contaminated with E. coli.
Fomite: An inanimate object that conveys infection because it has been contaminated by pathogenic organisms. Examples include tissues, doorknobs, telephones, bed linens, toilet seats, and clothing. Any healthcare equipment, supplies, or surfaces that have become contaminated with pathogens can become a fomite.
Mode of transmission: The ways in which a pathogen is spread from an infected person to another person. Common modes of transmission include carrying pathogens on unwashed hands, contact with surfaces or medical instruments that are not cleaned between patients, droplets released into the environment when an infected person coughs, or for a few diseases, airborne transmission. Most agents have multiple modes of transmission.
Pathogen or causative agent: A biologic agent (organism) capable of causing disease. These include bacteria, viruses, fungi, and protozoa. Sometimes collectively referred to as “germs.”
Portal of entry: The path by which the causative agent gets into a susceptible host. Common portals of entry include the mouth, nose, eye, skin abrasions, rashes, cuts, needlestick injuries, surgical wounds, and IV sites. A pathogen may have multiple paths for entering the body.
Portal of exit: The path by which the causative agent gets out of the reservoir. In a person, this is often by a body fluid; some bacteria, such as MRSA, can live and grow on the skin. An organism may have multiple paths of exit from the body.
Reservoir: A person, animal, arthropod, plant, soil, or substance (or combination of these) in which an causative agent lives and multiplies, on which it depends primarily for survival, and where it reproduces itself in such numbers that it can be transmitted to a susceptible host. Reservoirs can be thought of as the source of the infectious agent.
Susceptible host: A person or animal lacking effective resistance to a particular infectious agent.
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 spread of infection is best described as a chain with six links:
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.
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.
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.
We eliminate the causative organism by several methods, including:
Most HAIs that occur are due to lack of proper adherence to established infection control practices. Since most infections occur with direct patient contact, proper hand hygiene (hand washing or using alcohol-based rubs) remains the single most effective way to prevent infection to and from patients. Unfortunately, although HAIs continue to increase, 100% compliance with basic hand hygiene requirements is still lacking.
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).
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 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.
|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:
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.
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:
Actions we take to eliminate reservoirs include:
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:
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:
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:
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:
Actions we take to protect portals of entry (our own and our patients) include:
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 to infection include:
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.
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.
Actions we take to minimize risk to susceptible hosts include:
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:
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.
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:
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 microorganisms, 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.
SUMMARY OF HAND HYGIENE
When hands are visibly dirty or are visibly soiled with blood or other body fluids, use soap and water:
When hands are not visibly soiled, use an alcohol-based hand rub:
Note: Some bacterial spores and some viruses are not killed effectively by alcohol rubs, such as Bacillus anthracis (anthrax), Clostridium difficile, and norovirus. If a patient has infectious diarrhea, consider using soap and water for hand hygiene. Check with your facility for its policy.
Hand hygiene is required:
For surgical hand antisepsis:
Source: CDC, 2002.
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.
The following section is based on the CDC’s most recent Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (CDC, 2007). This guideline provides recommendations for patients in ambulatory, long-term care, and residential settings, in addition to those in acute-care hospitals. Refer to your facility’s policies for specific procedures.
The CDC (2007) describes four types of 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.
BLOOD AND OTHER POTENTIALLY INFECTIOUS MATERIAL (OPIM)
Many organisms that are present in blood are also present in other body fluid or matter. For example, HIV may be present in blood, breast milk, vaginal secretions, menstrual fluid, and semen.
Standard Precautions are designed to eliminate exposure to blood and all “other potentially infectious material” (OPIM) from the human body, including:
Long-established Standard Precautions include the following:
In 2007 three new elements were added to Standard Precautions:
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:
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:
Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.
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 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:
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:
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:
OSHA Bloodborne Pathogens Standard (OSHA, 2001) requires the use of engineering controls, work practice controls, and personal protective equipment (PPE) to protect employees from transmission of bloodborne pathogens (HIV, hepatitis B, and hepatitis C viruses) in the workplace. These precautions are built into the 2007 Standard Precautions guidelines of the CDC.
Engineering controls isolate (contain) or remove the bloodborne pathogens hazard from the workplace. Examples include sharps disposal containers, self-sheathing needles, and sharps with engineered sharps injury protection and needleless systems. Splatter shields on medical equipment associated with risk-prone procedures or locking centrifuge lids isolate or contain the hazard. Hand hygiene is also an engineering control, since it removes microorganisms from the workplace.
Work practice controls reduce the likelihood of exposure to bloodborne pathogens by altering the manner in which a task is performed, such as prohibiting recapping of needles using a two-handed method. These workplace procedures tell providers how to do the job safely. (Be sure you know where to find the procedure manuals for your workplace and be sure those procedures are current and complete if that falls within your scope of practice.)
Personal protective equipment (PPE) provides barriers to the transmission of infectious organisms, thereby protecting both the healthcare professional and the patient.
Safe injection practices are a set of measures taken to provide injections in a manner that is optimally safe for patients, healthcare personnel, and others. Injection safety includes practices intended to prevent transmission of bloodborne pathogens between one patient and another or between a healthcare worker and a patient, and also to reduce risk of needlestick injury to others.
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.
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:
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:
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:
RISK OF INFECTION FOLLOWING PERCUTANEOUS INJURY
Giving injections, disposing of syringes with needles, or reprocessing needles and other sharps all hold potential risk for exposure to pathogens. An estimated 385,000 sharps-related injuries occur annually in U.S. hospitals. These figures represent only part of the picture because they do not include nonhospital settings, which employ more than half of all healthcare workers. In addition, it is estimated that one half of such injuries go unreported. Most reported sharps injuries involve nursing staff, but laboratory staff, physicians, housekeepers, and other health care workers are also injured (CDC, 2011a).
Hepatitis B is definitely the greatest risk for transmission, and we are fortunate that there is a safe and effective vaccine against it. Employers whose employees may have exposure to hepatitis B on the job are required to offer hepatitis B vaccine free to employees who may be exposed. There is also postexposure prophylaxis (PEP) that can be used following exposure to hepatitis B to reduce risk of infection.
There is no vaccine against HIV at this time, but medication may reduce risk of transmission following accidental exposure. There is neither vaccine nor preventive medication against Hepatitis C. Prevention is the only means of reducing risk of transmission (CDC, 2001).
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:
Work practice controls to prevent percutaneous exposure from sharps include:
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:
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:
The above EPA-registered disinfectant lists are updated periodically to reflect changes, cancellations, and transfers of product 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 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:
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.
The following practices are required of all providers of injection and/or intravenous (IV) therapy:
Safe injection practices designed to prevent disease transmission from patient to healthcare worker are described by OSHA. They include:
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:
(Postexposure management is described below under “Postexposure Prophylaxis”.)
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 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:
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:
Other considerations to minimize risk of sharps injuries include:
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).
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 control measures also help prevent the transmission of infection. These measures include:
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:
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:
These items require special handling, transport, and storage procedures. The CDC (2003) recommends the following guidelines:
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:
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.
Other Potentially Infectious Material (OPIM). In addition to blood, other body substances and tissues should be considered potentially infectious in healthcare settings. These are defined in OSHA’s Bloodborne Pathogen Standard (see box below). The older term blood and other body fluids is gradually being replaced by this term, which is sometimes abbreviated as “OPIM.”
Personal protective equipment (PPE) is specialized clothing and/or equipment worn by a healthcare worker for protection against a hazard. OSHA guidelines state that PPE will be considered “appropriate” only “if it does not permit blood or other potentially infectious materials to pass through or reach the employee’s work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used” (CDC, 2004; OSHA, 2001).
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:
Some barriers are used to protect the patient, including:
Personal protective equipment includes:
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.
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 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).
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:
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.
Contamination: The presence of microorganisms on an item or surface.
Cleaning: The process of removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object.
Decontamination: The use of physical or chemical means to remove, inactivate, or destroy disease-producing microorganisms on a surface or item to the point where they are no longer capable of transmitting infectious particles.
Disinfection: The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms, such as bacterial endospores, on inanimate objects.
Sterilization: The highest level of disinfection. The use of a physical or chemical process to destroy all microbial life including highly resistant bacterial spores. Sterilization is required for patient-care equipment that touches sterile spaces of the body.
Non-critical device: An item that contacts intact skin but not mucous membranes. It requires low-level disinfection. Examples include blood pressure cuffs and crutches.
Semi-critical device: An item that comes in contact with mucous membranes or non-intact skin and requires high-level disinfection. Examples include laryngoscopes, endoscopes, and vaginal ultrasound probes. They should be sterile if possible or receive high-level disinfection if sterilization is not feasible.
Critical device: An item that enters sterile spaces such as the intravascular system or joint spaces. Examples include surgical tools. Critical items must be sterile.
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.
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:
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:
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:
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” at the end of the course.)
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 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:
(Refer to CDC Guidelines for Environmental Infection Control in Healthcare Facilities, 2003, for additional detail.)
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:
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:
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:
Knowing your facility policies and/or consulting with infection control staff are important in these situations.
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:
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:
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.
Effectiveness of reprocessing depends on a number of variables.
Monitoring of disinfection is essential to document the effectiveness of reprocessing. Factors to be documented include:
Monitoring of sterilization requires different documentation for different methods.
REPROCESSING AND PRION DISEASE
Instruments, medical devices and equipment should be managed and reprocessed according to recommended and appropriate methods regardless of a patient’s diagnosis except for cases of suspected prion disease, such as Creutzfeldt-Jakob disease (CJD). Special procedures are required for handling instruments in contact with brain, spinal, or nerve tissue from patients known or suspected to have CJD. Consult with infection control experts before performing procedures on such patients.
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.
Infectious disease: A clinically manifest disease of man or animal resulting from an infection.
Communicable disease: An illness due to a specific infectious agent, which arises through transmissionof that agent from an infected person, animal, or inanimate reservoir to a susceptible host.
Occupational health strategies: As applied to infection control, a set of activities intended to assess, prevent, and control infections and communicable diseases in 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:
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:
Preventing transmission of infection is the responsibility of the facility and the individual HCW.
Laws vary from state to state pertaining to occupational hazards for infectious diseases and for healthcare workers with communicable diseases. The following is general information; healthcare providers should check for any regulations in their own state.
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 typically include:
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 states, persons who have mandatory reportable communicable disease must have their illness reported to the local health unit for follow-up.
Other occupational health strategies for preventing transmission of bloodborne pathogens and other communicable diseases to and from healthcare workers include:
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. Federal OSHA law requires that that all employees whose jobs involve participation in tasks or activities with potential exposure to blood/OPIM be offered hepatitis B vaccination. The vaccination is free, safe, and highly protective. This vaccine is given in 3 doses. Serologic testing after vaccination (to verify that the vaccination was effective) is recommended.
Vaccinations recommended by the CDC for healthcare workers who do not have evidence of immunity are shown below.
|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.
OSHA also requires employers to provide bloodborne pathogens training for all workers who may come into contact with blood and OPIM in their jobs. This training includes:
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.
To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends:
In the event of an exposure incident to pathogens, healthcare workers should be assessed for possible postexposure prophylaxis (PEP).
|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|
CDC GUIDELINES FOLLOWING EXPOSURE TO BLOODBORNE PATHOGENS
Any healthcare worker who receives a needle or other significant exposure to potential HIV, HBV, or HCV infection should follow the guidelines issued by CDC.
Sources: CDC, 2001; CDC, 2005a; Mountain Plains AIDS Education and Training Center, 2006.
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.
The following standards are based on recommendations by the SHEA Guidelines (2010).
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:
Healthcare facilities are encouraged 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. Most states prohibit HIV testing of any citizen without written informed consent.
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 file a complaint, and HIV-infected healthcare workers are entitled to protection under the HIV confidentiality laws, as are other citizens. Such workers are generally not required to disclose their status to patients or employers.
Association for Professionals in Infection Control and Epidemiology
Centers for Disease Control and Prevention: Healthcare-associated infections
Environmental Protection Agency (EPA): Selected EPA-registered disinfectants
FDA: Reprocessing single-use devices
Society for Healthcare Epidemiology of America
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