COURSE PRICE: $39.00
CONTACT HOURS: 6
Wild Iris Medical Education, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Wild Iris Medical Education, Inc. (CBRN Provider #12300) is approved as a provider of continuing education for RNs and LVNs by the California Board of Registered Nursing.
Course Availability: Expires April 2, 2018. You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. Wild Iris Medical Education, Inc. provides educational activities that are free from bias. The information provided in this course is to be used for educational purposes only. It is not intended as a substitute for professional health care. Medical Disclaimer Legal Disclaimer Disclosures
NEW YORK STATE NURSES: Take the New York version of this course
Copyright © 2015 Wild Iris Medical Education, Inc. All Rights Reserved.
COURSE OBJECTIVE: The purpose of this course is to prepare healthcare workers to prevent and control the spread of infection using current, evidence-based knowledge of the chain of infection, Standard Precautions and transmission-based precautions, and engineering and work practice controls.
Upon completion of this course, you will be able to:
Preventing the spread of infection has been a key component of healthcare since the work of Semmelweis in the 1840s. Dr. Semmelweis dramatically reduced postpartum 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 (IOM, 1999). This brought much-needed attention to the problem of medical errors and healthcare-associated infections. 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 multidrug-resistant organisms (MDROs)—“superbugs” such as methicillin-resistant Staphylococcus aureus (MRSA) and extensively drug-resistant tuberculosis (XDR-TB)—is the subject of attention, as transmission becomes a wider problem both in the healthcare system and in the community. MDROs are increasing in prevalence. Providers working within the healthcare setting can make a difference by being aware of patients at high risk for developing MDROs and by employing measures to prevent the spread of infection.
Education regarding early detection, infection control, and hand hygiene are key elements to consider. Reducing risk for patients is also important; this includes reducing exposure to long-term invasive devices and being aware of patients who are on long-term antibiotic regimens. On a larger scale, programs that promote antibiotic stewardship at all levels in the healthcare system have the potential to reduce the overall incidence of MDROs.
In addition to the emergence of new pathogens, dramatic changes in how and where healthcare is delivered require that infection prevention and control be a high priority outside the hospital. Patients often move from one healthcare setting to others as part of the continuum of care. As increasing numbers of patients receive healthcare in outpatient surgical centers, dialysis centers, outpatient rehab clinics, nursing homes, and at home, the need for infection prevention and control measures in these settings has increased to protect both patients and healthcare workers. The key to elimination of healthcare-associated infections is full adherence to recommendations across the continuum of care.
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 25 hospitalized patients develop a healthcare-associated infection each year. In 2011, over 700,000 HAIs occurred in U.S. hospitals, with 75,000 patients dying from complications of HAIs (CDC, 2014a).
|Type of Infection||Cases|
|Source: CDC, 2014a.|
|Urinary tract infections||93,300|
|Surgical site infection||157,500|
|Other infection sites||118,500|
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 long-term care facilities 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 to 3 million infections occur each year in long-term care facilities—almost as many HAIs as in acute care hospitals (CDC, 2014b). Infections are a primary cause of hospitalization and death in this population. About 380,000 people die of infections acquired in long-term care facilities each year (CDC, 2014b).
In the United States, people are living longer, with the average life expectancy increasing each year. With an increase in the elderly population, the need for long-term care facilities will continue to rise. Today and in the future, long-term care facilities care not only for elderly patients with chronic illness but also provide care for patients who are admitted for short-term rehabilitation following surgical procedures such as joint replacements. These patients may be at increased risk for surgical site infections due to cross contamination of pathogens in the long-term care setting (Korniewicz, 2014).
Standards and guidelines are designed to proactively prevent the spread of infection in healthcare settings. This is evident also from a leadership perspective, with the Centers for Disease Control and Prevention focus not only on “disease control” but also on “prevention.” Changes in regulatory, legal, and financial reimbursement systems reflect the growing consensus that HAIs are preventable (Korniewicz, 2014). In 2008, the Centers for Medicare and Medicaid Services 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 prevention and control practices.
Standard infection prevention and control guidelines for healthcare settings are a collaborative effort between the CDC, the Joint Commission, the World Health Organization (WHO), and the Occupational Safety and Health Administration (OSHA). The CDC primarily focuses on the surveillance, prevention, and control of HAIs in healthcare settings within the United States. The most recent CDC standards were published in 2007 (CDC, 2007).
The Joint Commission issued the first-ever National Patient Safety Goals in 2003 and updates them annually. Each accredited hospital is required to demonstrate programs that address the reduction of HAIs as a goal for improving patient safety. Goals for 2015 specific to preventing infection in the hospital setting include:
The World Health Organization also has specific guidelines for hand hygiene and reporting death or major disability secondary to HAIs.
In 2001, the Occupational Safety and Health Organization, 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. In 2011, OSHA made recommendations for revisions to the standard (OSHA, 2011a). OSHA regularly inspects healthcare agencies for compliance and may fine employers if infractions are identified.
The scientific basis for such infection control guidelines and standards are derived from the work of experts at organizations such as the CDC, the Association for Professionals in Infection Control and Epidemiology, and the Society for Healthcare Epidemiology of America.
Surveillance and outbreak investigations are also key components of hospital epidemiology, including assessing, measuring, and reporting on effective infection prevention and control programs. The National Health Safety Network, based at the CDC, is a voluntary reporting system that monitors the incidence of HAIs. Active surveillance and reporting of HAIs is also a requirement of the Joint Commission’s National Patient Safety Goals; all deaths or major disabilities secondary to HAIs are required to be reported as sentinel events (Sydnor & Perl, 2011).
The goals of infection control and prevention training are to:
The process of transmission of an infectious agent can be best explained by the epidemiologic model called the “chain of infection.” An infectious disease results from specific interactions between an agent, host, and environment. Transmission occurs when the infectious agent leaves the reservoir (or host) through a portal of exit, travels by some mode of transmission, and enters through a portal of entry to infect a susceptible host (CDC, 2012a).
Chain of infection. (Source: Wild Iris Medical Education, Inc.)
By breaking any link in the chain of infection, healthcare professionals can prevent the occurrence of new infection. Infection prevention 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 for someone 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. Therefore, a key goal of infection control programs is to reduce the number of infectious microbes in healthcare settings through hygienic practices such as handwashing and environmental cleaning.
Bacteria are single-celled organisms, some of which can cause disease. All people live with numerous bacteria—referred to as “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:
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), hepatitis B virus (HBV), and hepatitis C virus (HCV) 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. Most of these 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, 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.
Causative organisms are eliminated by several methods, including:
Most HAIs are due to lack of proper adherence to established infection control practices. Since most infections occur with direct patient contact, proper hand hygiene (handwashing 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. (See also “Hand Hygiene” later in this course.)
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 gastrointestinal (GI) tract is a reservoir for many different types of organisms, including viruses, bacteria, bacterial spores, and parasites. Pathogens can be spread from both sick people as well as 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 soiled gloves—which provide favorable conditions for the survival and multiplication of infectious agents.
Microbes often require 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.
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 be 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.
Staphylococcus (S. aureus, MRSA)
E. coli and Enterococci
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:
It is usually not known if a person is carrying or incubating an infection. Therefore, 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 (see “Standard Precautions” later in this course).
Possible outcomes of exposure to an infectious agent. (Source: Wild Iris Medical Education, Inc.)
* The term carrier state is used loosely to include the persistence of the microorganism in the body, including latent and clinically unapparent (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.
Inanimate materials, substances, and objects in the environment can serve as environmental reservoirs. 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 (see “Practices and Controls” later in this course).
Environmental reservoirs in healthcare facilities include:
Actions 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 body 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.
Body fluids and matter from various body systems are important sources of infection in healthcare settings. Examples of portals of exit from the human body include:
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 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 people touch so many things with their hands, hand hygiene is still the single most important strategy for preventing the spread of infection.
Transmission can occur by a number of mechanisms.
Sometimes people become infected with microbes from their own natural flora; that is, their 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 urinary tract infections (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 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 and surgical 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 handwashing 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 to protect portals of entry (in healthcare workers and patients) include:
The final link in the chain of infection is the susceptible host. Susceptibility can be reduced in several ways. For some diseases, there are effective vaccines. Other diseases produce lasting immunity after illness. People have better resistance to disease when they 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 that protect from infection include:
A person with normal immune system function is described as being 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 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) are at higher risk of infection too because the immune system becomes less responsive with age. 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.
Robert Turner is an 80-year-old patient admitted to the general medical unit for onset of new delirium and treatment of a pressure ulcer on his sacrum. Because of his declining cognitive condition, he is not able to recognize the urge to urinate. To protect the healing ulcer from his urine, the medical team orders the placement of an indwelling urinary catheter. Mr. Turner is a “susceptible host” at risk of infection because of his advanced age, the fact that he is in the hospital, and because of the indwelling urinary catheter. Complicating this is his delirium, which may mean that he is not able to communicate specific symptoms in a verbal manner.
During the first three days of Mr. Turner’s hospital stay, the medical assessment reveals that a new medication was causing his delirium. The medication is stopped on the third day and on the fifth day his delirium begins to decrease. As his cognitive state improves, the patient is slowly able to participate in activities of daily living (ADLs) with the help of his caregivers. Until his pressure ulcer has sufficiently begun healing, his physicians feel it is in his overall best interest to leave the indwelling urinary catheter in place.
On day seven of his hospital stay, his nurse notices an abrupt change in the patient. He is more confused, agitated, and feels warm to the touch. On assessment, his temperature is 38.1 °C and he is slightly hypotensive. The medical team suspects a UTI may be the cause of a new infection. The urinary catheter is removed, with cultures performed showing positive results for E. coli. Mr. Turner is started on antibiotics and IV fluids and recovers over the next three days.
Actions 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 travels into the “wrong” part of the body and causes 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 also recommended to go from clean to dirty.
Infectious pathogens transmitted in healthcare settings are the primary target of prevention and control because of the potential impact on both patients and providers. The CDC (2007) recommends implementing infection control and prevention guidelines to prevent the transmission of epidemiologically important organisms with the following characteristics:
In addition, ensuring the safety of providers within the healthcare setting is of utmost importance. A multi-faceted approach is needed to reduce the risk of occupational exposure to bloodborne pathogens. The CDC estimates that 5.6 million workers in the healthcare industry and related occupations are at risk of occupational exposure to bloodborne pathogens, including HIV, HBV, HCV, and others (OSHA, 2014).
For example, the CDC estimates that around 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based healthcare personnel on an annual basis (CDC, 2013). Such exposures can occur in other healthcare settings, such as nursing homes, clinics, emergency departments, and homes. Sharps injuries are primarily associated with occupational transmission of HBV, HCV, and HIV, but they may also be involved in the transmission of other pathogens.
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:
Transmission risks within the various healthcare settings are influenced by the characteristics of the population (e.g., immunocompromised patients, exposure to indwelling devices and procedures), intensity of care, exposure to environmental sources, length of stay, and interaction among and between other patients as well as healthcare providers.
Within the hospital setting, certain settings and patient populations have conditions that are considered high risk. Intensive care units (ICUs) care for patients who may be immunocompromised or have other life-threatening conditions (e.g., major trauma, transplant, organ failure, myocardial infarction). The ICU setting also puts patients at increased risk because of the use of invasive medical devices (e.g., mechanical ventilation, central venous catheters, and urinary catheters) as well as the frequency of contact with healthcare providers and prolonged length of stay.
Patients on burn units may have open wounds that provide the opportunity for colonization, infection, and transmission of pathogens. Infections involving Staphylococcus aureus, MRSA, enterococci, gram-negative bacteria, and candida are leading pathogens.
Newborn nurseries and pediatric units may have high-risk patients, including low birth weight babies, premature infants, or infants who do not yet have an established immune system. This population may also be exposed to medical devices and procedures that increase their risk. Common infections in this population include respiratory infections, influenza, adenoviruses, rubeola, varicella, and rotavirus.
The operating room setting places both the patient and provider at higher risk for transmission of infectious pathogens. Invasive procedures with instruments (scalpel and other sharps) and tissue and blood exposure are the primary risks at play in this setting.
Patients who reside in long-term care settings may be at increased risk due to close contact with other residents as well as age-related decline in immunity, immobility, chronic disease, and malnutrition. Common infectious disease outbreaks include influenza, norovirus, pneumonia, and pertussis.
For healthcare providers working in a laboratory setting, the increased risk is evident for potential exposure to blood and OPIM, which can put them at risk for infectious diseases from bloodborne pathogens (e.g., HIV, hepatitis).
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:
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. It is not possible to eliminate the reservoirs and susceptible hosts; therefore, it is important to prevent the mode of transmission.
Preventing the spread of infectious organisms includes:
The CDC (2007) describes four types of infection control precautions:
The first of these, Standard Precautions, applies to all patients and all healthcare workers in all settings without any specific infectious process or diagnosis identified. 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 in a patient. Each transmission-based precaution is used in conjunction with Standard Precautions (e.g., Standard Precautions plus Contact Precautions).
Standard Precautions are an infection control strategy to prevent transmission of infectious agents and are recommended for all patient-care delivery settings. They are based on the concept that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents.
All occupational exposures to blood or other potentially infectious materials place healthcare providers at risk for infection with bloodborne pathogens. Standard Precautions are designed to eliminate exposure to blood and OPIM.
OSHA defines blood as:
Other potentially infectious materials (OPIM) include:
Source: OSHA, 2011a.
Standard Precautions include proper hand hygiene and use of gloves, gown, mask, eye protection, face shield, and safe injection practices. Equipment or items used in the patient environment that may be contaminated with infectious body fluids are also handled in a manner to prevent transmission of infection, including cleaning, disinfecting, and sterilizing before use on another patient.
Application of Standard Precautions is determined by the type of care interaction anticipated. For some interactions (e.g., venipuncture), only gloves may be needed. During other interactions (e.g., intubation or tracheostomy care), use of gloves, gown, face shield, or mask and goggles are needed (CDC, 2007).
Long-established Standard Precautions include the following:
Sharon is a nurse working the night shift in respiratory ICU. Her assignment for the night includes three patients, one of whom is currently intubated. As her shift begins, Sharon realizes that she needs to check in on her patient who is intubated and perform tracheotomy care and suctioning. Even though she is behind schedule, she takes the time to consider that the suctioning procedure may expose her to the patient’s secretions. Considering which level of Standard Precautions to apply, she dons personal protective equipment (PPE), including a gown, gloves, mask, and googles, prior to performing the tracheotomy care with the patient. After caring for the patient, she disposes properly of all PPE and washes her hands prior to moving on to care for her next patient.
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:
Healthcare providers should wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space. This infection control practice is two-fold, protecting both the patient and healthcare provider from potential exposure. In 2011, the CDC reported on the results of investigating an outbreak of bacterial meningitis in patients and discovered that the infections occurred in patients who had spinal or lumbar puncture procedures performed by an infected healthcare provider who did not wear a surgical mask. The findings reinforce the risk of droplet-based transmission of oral flora from healthcare providers to patients during spinal or lumbar puncture procedures (CDC, 2011a).
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 2007 CDC Guidelines 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.”
CDC Contact Precautions are summarized below:
Mrs. Alberts is a patient on the hospital surgical unit who is recovering from a complicated hip replacement surgery. She has been on antibiotics during the pre- and post-operative periods. On day four, she develops watery diarrhea, which tests positive for C. difficile.
The charge nurse recognizes that new infection precautions are needed to care for Mrs. Alberts. The nurse initiates Contact Precautions and communicates with Mrs. Albert’s physician to confirm the order. Contact Precautions require all visitors and care providers to wear a gown and gloves when entering the patient’s room. Mrs. Alberts will also need to have dedicated equipment that is used only for her, such as a blood pressure cuff, stethoscope, and other equipment that may be needed for her care. Hand hygiene, including handwashing versus using hand sanitizer, is also a precaution taken by all providers who care for Mrs. Alberts.
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:
It bears repeating that hand hygiene is the single most important procedure for preventing the spread of infection.
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.
Handwashing with soap and water is required when hands are visibly soiled. Handwashing 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 handwashing or the use of surgical scrubs.
Source: CDC, 2012b.
Hands or other exposed skin should be thoroughly washed as soon as possible following a known or possible exposure incident. Hands should also be washed immediately or as soon as feasible after removing gloves or other PPE.
Use soft antibacterial soap, if possible. Avoid harsh abrasive soaps, as these may open fragile scabs or other sores. Because handwashing is so important, it is wise to be familiar with the nearest handwashing facilities. Public restrooms, janitor closets, and so forth may be used for handwashing if they are normally supplied with soap and clean paper towels.
When one is working in an area without access to such facilities, an antiseptic cleanser or antiseptic hand wipes (“hand sanitizers”) may be used in conjunction with clean cloth/paper towels. If these alternative methods are used, hands should be washed with soap and running water as soon as feasible (OSHA, 2011a).
The following steps outline techniques for hand hygiene with soap and water. Caregivers are advised to follow the manufacturer’s recommendations about the product they are using.
Duration of the entire procedure: 40–60 seconds
The same technique is used when decontaminating hands with an alcohol-based hand rub (ABHR), however no water is used. Similarly, towels are not used for drying, as hands will quickly dry on their own. When using alcohol-based hand rubs, the CDC recommends healthcare personnel rub their hands until the alcohol evaporates and the hands are dry.
For surgical hand antisepsis:
In addition to the precautions described above, other practices and controls can be employed to prevent and control infection. These include:
Engineering controls isolate (contain) or remove the pathogens hazard from the workplace. Examples include sharps disposal containers, self-sheathing needles, and sharps with engineered sharps injury protection and needleless systems. Likewise, 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 pathogens by changing the way a task is performed, such as appropriate practices for handling and disposing of contaminated sharps. Work practice controls refer to the processes and procedures used to ensure that work is conducted in a safe and healthy manner. Work practice controls are an essential component of a safe work environment.
Work practices to learn and follow include:
Environmental controls help prevent the transmission of infection by reducing the concentration of pathogens in the environment. Such measures include environmental cleaning (housekeeping); cleaning, disinfecting, and sterilizing patient equipment; waste management; and linens (textiles) and laundry management.
Engineering, work practice, and environmental controls have all been developed to prevent and control the spread of infection related to the use of needles and other sharps in the healthcare setting.
In 2000 federal laws were enacted to protect healthcare workers against needlesticks; these laws require that healthcare facilities evaluate and provide safe needles. OSHA’s Bloodborne Pathogens Standard requires 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:
“Sharps” are items with sharp edges or points capable of cutting or puncturing other items (AORN, 2015). A needlestick or a cut from a contaminated sharp can lead to infection from a bloodborne pathogen. Proper handling and disposal of sharps greatly reduces this risk. Sharps containers should be closable, puncture-resistant, and leak-proof on the sides and the bottom. They must be labeled or color-coded.
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.
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 techniques associated with injection therapy, often in outpatient settings.
These lapses have resulted in:
Healthcare providers are required to follow recommended practices for injection and/or IV therapy:
Safe injection practices are also described by OSHA. They include:
Any employer having employee(s) with potential occupational exposure contact with blood or OPIM 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 OPIM 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:
Joanne is a circulating nurse working in the operating room (OR) who has just finished caring for a patient who required a lumbar epidural steroid injection. The anesthesiologist working on the case left the lumbar puncture procedure tray for Joanne to clean up, as he was needed on the next case. Joanne is under pressure to turn over the room quickly because there is a full patient schedule for the day.
As Joanne is cleaning up the tray, she sticks herself with the used lumbar puncture needle, not realizing that the syringe was left in the wrapper of the disposable tray. As per policy, the needle should have been discarded in a sharps container by the anesthesiologist after use.
Joanne immediately flushes the needlestick injury and reports the incident to her immediate supervisor. The report includes the fact that the injury occurred in the procedure room of the OR while cleaning up after a lumbar puncture. Her supervisor starts the process of investigation and exposure management.
The infection control team is also alerted and assists with formal reporting, feedback to the anesthesiologist on duty, and recommended post-exposure protocols. The infection control team works with the entire OR team to review and reinforce safe handling of sharps and needlestick prevention as a result of this incident.
The healthcare environment can become easily contaminated with pathogens. 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.
Proper cleaning is important in healthcare environments and includes surfaces, furnishings, reusable medical equipment, and patient-care devices. Understanding and applying appropriate procedures for cleaning, disinfection, and sterilization are essential to maintaining a safe patient-care environment.
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:
Care must be taken to use the right disinfectant for the purpose, consistent with its U.S. Food and Drug Administration (FDA) or Environmental Protection Agency (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 for Environmental Infection Control in Health-Care Facilities, listed in the “References” at the end of this course, for additional detail.)
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 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.
Healthcare workers carrying out low-level disinfection should follow these practices:
(Refer to CDC Guidelines for Environmental Infection Control in Healthcare Facilities or the AORN Guidelines for Perioperative Practice, listed in the “References” at the end of this course, 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 HBV and HIV. They may be available as a liquid or as disposable wipes.
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:
Blood spills should be cleaned without delay. Wear gloves and other PPE as needed. When cleaning up a blood spill, carefully cover the spill with rags or paper towels. Pour disinfectant solution over the rags or towels and let it sit for 10 minutes, or follow the manufacturer’s recommendations.
Some situations, such as care of the patient on 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 includes items used for patients infected with organisms that are difficult to treat, highly virulent, or easily spread, such as:
Knowing facility policies and/or consulting with infection control staff is 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 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.
Appropriate practices for carrying out high-level disinfection include:
|Type of Device||Disinfection Level|
|Critical: instrument enters sterile spaces or bloodstream
|Sterilization (physical or chemical)|
|Semi-critical: instrument comes in contact with mucous membranes or non-intact skin
|High-level disinfection, only if sterilization not possible|
|Non-critical: instrument contacts intact skin
|Note: The degree of contamination overrides the usual level of disinfection. For example, a reusable pneumatic tourniquet cuff (normally subjected to intermediate-level disinfection) that has been contaminated with blood would require high-level disinfection before it is handled by ungloved healthcare workers or used again for patient care.|
“Reprocessing” is the term used to describe all operations to render a contaminated reusable, reposable (has limited use or a combination of reusable and disposable components), or single-use device patient ready (AORN, 2015).
Reprocessing includes 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 may include both high-level disinfection and sterilization, preceded by decontamination and careful, thorough cleaning.
Prior to the decision to purchase an item available in either single-use, reposable, or reusable versions, a facility should consider several factors:
Any consideration of reuse of single-use devices should be reviewed by the facility’s risk manager to assure that the requirements of the FDA for such reuse are met. (See also “Resources” at the end of the course.)
Any reusable device that appears on the FDA list as known to have been reprocessed should never be used more than once. The only possible situation in which a non-FDA-listed device should be considered for reprocessing is one in which all of the following criteria have been met:
For facilities electing to routinely reprocess single-use items as a cost-savings measure, there can be severe financial penalties if an untoward patient event occurs that can be traced to this practice.
During a cardiac ablation procedure, the surgeon requests that an additional single-use ablation probe be opened. Because the scrub is involved in holding a retractor and cannot accept the device, the circulator opens it on a separate small table and rolls the table near, but not in contact with, the sterile field. Before either the surgeon or scrub retrieve the item, the patient’s condition deteriorates and the procedure is aborted.
After the patient is stabilized and transported to the intensive care unit, the nursing team begins preparing the room for another procedure. The scrub and circulator verify with each other that the table holding the probe has not been touched by any member of the sterile team nor come into contact with any items that were themselves contaminated.
Given the cost of the ablation probe, it meets the facility’s financial criteria for possible reprocessing. The probe, its container, all wrappings, and all included paperwork are placed in a sealable plastic container. The scrub and circulator document the circumstances surrounding the opening and handling of the probe. The probe container and nursing documentation are given to the surgical suite nurse manager, who reviews the documentation and forwards it to the appropriate risk manager for final review and a decision on reprocessing.
The probe meets all criteria for reprocessing and is sent to a third-party reprocessor with which the facility has a contract.
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). 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 piece of equipment to be reprocessed.
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, 2009). The major sterilizing agents used in hospitals are:
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 includes different recordkeeping for different methods:
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), which is the human form of bovine spongiform encephalopathy (“mad cow disease”). Special procedures are required for handling instruments in contact with brain, spinal, or nerve tissue from patients known or suspected to have CJD.
For all practical purposes, the reprocessing performed on devices known or suspected to be contaminated with prions is intended to create waste that is as clean and safe as possible. Once a device has been subjected to the processes that destroy prions, it has been destroyed or rendered unfit for further use.
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 the 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.
Jennifer is a nurse and manager of an outpatient procedure center that performs colonoscopies and endoscopies on a regular basis. In the past three months, the center has had reports of six patients with a diagnosis of a strain of Carbapenem-resistant Enterobacteriaceae (CRE) Escherichia coli (E. coli) that occurred within a few weeks of their GI procedures. An investigation was initiated by the CDC to identify the source and prevent further transmission to other patients.
The investigators work with Jennifer and the center to review the histories of all patients and discover that each patient had undergone a similar invasive procedure using an endoscope. On reviewing the center’s procedures, CDC officials find that the center has been cleaning and reprocessing the endoscopes according to manufacturer-recommended procedures for disinfecting. However, one endoscope is cultured and found to contain the resistant strain of E. coli. Investigators recommend to Jennifer and the center that they switch to a liquid chemical, high-level disinfection system that is appropriate to their endoscope inventory and monitor the effectiveness by following the recommendations of the manufacturers of both the disinfection system and the endoscopes.
Jennifer and her instrument processing personnel meet with their counterparts and an infection preventionist at the hospital with whom their physicians have privileges. Using the expertise and experience of their colleagues, they are able to make recommendations to the management team of their clinic regarding equipment acquisitions and policy/procedure changes.
After the center changes its disinfection procedures, no additional cases of E. coli occur and patient safety is maintained. The center invests a significant amount of its capital improvement and inventory budgets to purchase and install the disinfection system and acquire additional endoscopes and accessory instruments because of this outbreak.
Appropriate housekeeping and sanitation practices are essential to reduce the spread of infection, particularly in high-risk areas such as nurseries, operating rooms, and ICUs. The CDC guidelines (2007) include the following recommendations:
There are two categories of hospital waste: regulated medical waste and unregulated waste. About 20% of hospital waste requires special handling. The other 80% is similar to domestic waste (WHO, 2011).
Regulated medical waste requires special precautions in handling and disposal. Regulated medical waste includes:
These items require special handling, transport, and storage procedures. The CDC recommends the following guidelines:
The risk of actual disease transmission from soiled laundry is negligible. However, the hands of healthcare workers may be contaminated by contact with patient bed linens. Thus, common sense hygienic practices for handling, processing, and storage of textiles are recommended. These practices include:
OSHA’s Bloodborne Pathogens Standard requires employers to ensure that employees who have contact with contaminated laundry wear protective gloves and other appropriate PPE.
Employers are responsible for laundering reusable PPE. Work clothes such as uniforms are not considered to be PPE. Provided gowns or other PPE should be used to prevent soiling of uniforms.
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.
Warning labels are to be affixed to containers of regulated waste; refrigerators and freezers containing blood or OPIM; and other containers used to store, transport, or ship blood or OPIM. These labels are fluorescent orange, red, or orange-red. Bags used to dispose of regulated waste must be red or orange-red, and they too must have the biohazard symbol in a contrasting color readily visible upon them.
Biohazard warning label. (Source: OSHA.)
David is a charge nurse in the emergency department (ED) in a rural hospital and is working with a team who is caring for a trauma case. The patient is a farmer who was transported after an accident involving harvesting equipment. The patient is bleeding out from a partially severed arm on arrival, and the ED team stabilizes the patient prior to transfer to the OR.
Once the patient is transferred to the OR, David returns to the ED to work with housekeeping to ensure proper cleanup of the room. The housekeeping team on duty have had their required infection control training, however they have had little experience with this type of trauma cleanup. As the charge nurse on duty, David is responsible for supervising the team and ensuring that proper procedure is followed.
David confirms that the housekeeping team has appropriate PPE donned prior to starting cleanup. All surfaces that are contaminated with blood are first cleaned with recommended disinfectant. All soiled items are contained, placed in biohazard bags, and secured for disposal. David also takes a second look to make sure that any sharps are placed in sharps containers and secured for disposal. Laundry that is contaminated with blood is also secured according to hospital procedures.
After cleanup, PPE is removed and discarded by the team in biohazard bags as well. Each team member monitors their uniform for any soiled items and performs hand hygiene as a final step prior to moving on to their next work assignment.
Personal protective equipment (PPE) is specialized clothing and/or equipment worn by a healthcare worker for protection against a hazard. PPE provides barriers to the transmission of infectious organisms, thereby protecting both the healthcare professional and the patient.
Wearing gloves, gowns, masks, eye, and face/neck protection can significantly reduce health risks for employees exposed to blood and OPIM. Employers are required to provide, clean, and maintain appropriate PPE and clothing free of charge to employees. Latex-free PPE must be made available on request (OSHA, 2011b).
PPE must be readily accessible to employees and available in appropriate sizes. It is important to know which type of PPE is available at work and where it is stored. To protect themselves, healthcare workers must have a barrier between them and any potentially infectious material.
Use of PPE is built in to 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.
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.
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:
|Gloves||Nonsterile, disposable; worn when soiling of the hands with blood or body fluids is likely|
|Utility gloves||To prevent injuries during extrication or when working in other hazardous environments where broken glass or sharps may be present|
|Gowns||Outerwear to protect from blood and body fluids; worn when soiling of exposed skin or clothing is likely|
|Tyvek suit||One-piece, impervious outerwear with zipper; may have hood and booties attached; worn when gross contamination with blood and body fluids is anticipated|
|Face shield||One-piece face protection; worn while performing invasive techniques, including IV therapy, suctioning, and intubations, or any time there is an opportunity for blood or body fluids to be splashed, sprayed, or splattered; not to be used for TB protection|
|Goggles||Eye protection that includes shielding front, sides, and top; goggles/safety glasses with side and top shields as well as full-face shielding are all acceptable; prescription glasses are acceptable if side shields are added|
|Mask (surgical)||Disposable; to be placed over the mouth and nose; worn when splashing of blood or body fluids is likely; worn with eye protection|
|Head coverings||Cap that covers hair; worn when splashing of blood or body fluids is possible|
|Booties||Outerwear used to cover shoes/boots when exposed to blood and body fluids|
|Turnout gear||Fire-resistant coat and pants; may provide protection during extrication|
|Steel-toed shoes/boots||Protective footwear|
|Hard hats||Protective head covering; worn during extrication|
|Body armor||Bulletproof vest; worn for protection in potentially hostile situations|
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). Individuals with an allergy to latex 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).
Nitrile or other appropriately protective gloves are always used when handling chemotherapy or other chemicals. Both examination (nonsterile, clean) gloves and surgical (sterile) gloves must be available for specific healthcare tasks. Use of petrolatum-based lotions or creams is to be avoided 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 handwashing 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.
Theresa is a nurse in the GI procedure room and is preparing for an emergency endoscopy for a patient who has an active esophageal bleed. The patient is being stabilized in the ED and is expected to arrive for the procedure soon. Theresa reviews the needed PPE in this case and anticipates that the patient may be bleeding out on arrival.
Theresa dons an impervious gown, booties, head covering, mask, full face shield, and gloves as she prepares to receive this patient. She also checks to see that all other team members in the room are prepared with the proper PPE in order to minimize any exposure during the procedure.
As part of the protocol, she also has additional PPE available for other team members as well as sharps containers and biohazard bags for cleanup and disposal of sharps, contaminated materials, and equipment.
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 periOperative Registered Nurses (AORN, 2015) 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.
The key principle for healthcare workers to remember when removing personal protective equipment is to avoid contact with blood, body fluids, secretions, excretions, and other contaminants. When hands become contaminated, they should be washed or decontaminated as soon as possible.
In response to concerns raised by nurses during the 2014 Ebola outbreak, the American Nurses Association (ANA, 2014) made several suggestions to the CDC regarding additional precautions to be used by healthcare workers caring for Ebola patients in the United States. Among their requests were clear, specific PPE standards for both points of entry and after admission of patients suspected to have Ebola; training on effective, evidence-based use of PPE; and more rapid dissemination of any changes to procedures, guidelines, and recommended care.
The CDC subsequently developed new recommendations entitled “Guidance on Personal Protective Equipment to Be Used by Healthcare Workers During Management of Patients with Ebola Virus Disease in U.S. Hospitals, Including Procedures for Putting On (Donning) and Removing (Doffing)” (see “Resources” at the end of this course). This guidance emphasizes the importance of training, practice, competence, and observation of healthcare workers.
Source: CDC, 2014d.
Prevention of infectious diseases in healthcare workers means protecting them from infections they do not already have. Management of infectious diseases in HCWs means protecting others (including patients) from any infectious or communicable diseases that the HCW may have.
Protecting HCWs from disease is accomplished in many ways, including:
If a healthcare worker has been exposed on the job to a communicable disease, the supervisor and infection control practitioner should be notified without delay. This will allow evaluation of the circumstances and prevent exposure of others, management of the exposure, and appropriate medical follow-up as needed. For some diseases, post-exposure prophylaxis (preventive medication) is available (see below).
Protection of patients and others from the risk of infections from health professionals includes:
Preventing transmission of infection is the responsibility of the facility and the individual healthcare worker.
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 when they have 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 many 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:
The following standards are based on recommendations in the Society for Healthcare Epidemiology of America Guidelines (2011).
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.
Influenza vaccination is offered annually, and staff should be encouraged to accept it as a method for protecting themselves and patients. Since 1981 the CDC has recommended healthcare workers receive influenza vaccination, and the coverage among healthcare workers during the 2013–14 flu season was 75.2%. Coverage was highest (97.8%) among healthcare personnel working in settings in which flu vaccination was a requirement for employment (CDC, 2014e).
The Affordable Care Act includes mandates for flu vaccinations of healthcare workers. Beginning in 2015, failure to meet certain percentages of a healthcare facility’s employees vaccinated for influenza will jeopardize federal reimbursement of Medicare and Medicaid funds. The goal is to have 90% compliance for healthcare workers by 2020 (U.S. DHHS, 2011).
While it is obvious that recommending and increasing influenza vaccination in healthcare workers is important, it is less obvious how best to achieve this goal. During 2013 there was an increase in the number of healthcare facilities mandating nurses and other healthcare workers to receive flu vaccinations as a condition of employment.
There is great controversy, however, over the issue of mandatory vaccination, with strong arguments for differing points of view regarding individual rights versus the right of patients to be protected from disease transmitted by a healthcare worker.
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 three 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|
|Sources: CDC, 2011c, 2010.|
|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 1) receipt of two doses of live vaccine on or after their first birthday, 2) physician-diagnosed measles, or 3) 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 two 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., asplenic) 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.
Although HBV and HIV are specifically identified in the OSHA Bloodborne Pathogens 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 HCV, 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 Ebola (also known as Ebola hemorrhagic fever).
To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends:
Employers are required to develop and share an exposure control plan (ECP). The plan is in place to protect employees from health hazards associated with bloodborne pathogens and provide appropriate treatment and counseling if an exposure incident occurs. Employees should know where their facility’s exposure control plan is located and what it includes.
The exposure control plan includes detailed information about the ways an employer provides a safe and healthy work environment, including:
Employers are required to implement these preventive measures to reduce or eliminate the risk of 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.
Source: CDC, 2011d.
In the event of an exposure incident to pathogens, healthcare workers should be assessed for possible post-exposure prophylaxis (PEP).
|Source: CDC, 2010.|
|HIV/AIDS||Those with percutaneous or mucous-membrane exposure to blood or OPIM (immediate treatment if source known to be HIV +)|
|Diphtheria||Those exposed to diphtheria or identified as carriers|
|Hepatitis A||Those exposed to feces of infected persons during outbreaks|
|Hepatitis B||Those who are HBV-susceptible and with percutaneous or mucous-membrane exposure to blood known to be HBsAg seropositive|
|Meningococcal disease||Those 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||Those with direct contact with respiratory secretions or large aerosol droplets from respiratory tract of infected persons|
|Rabies||Those bitten by a human being or animal with rabies or with scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infective material (e.g., brain tissue)|
|Tuberculosis||Those with unprotected close contact to a patient with active TB|
|Varicella zoster virus||Those 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 adherence.
Employers must provide a written report explaining how a bloodborne pathogen might have entered the healthcare worker’s body and a description of risk during the exposure. The employer must identify the source individual (the patient involved in the exposure) unless the source individual is unknown or state or local law prohibits disclosure. If the source person is known, many states require that the person be tested for HBV and HIV and notified of the results. The healthcare worker’s blood must also be collected and tested after they have agreed to the test.
Medical care as the result of an exposure is provided by the employer at no charge to the healthcare worker. All test records are confidential. The exposed worker must be given a copy of the healthcare professional’s written opinion with 15 days after the medical evaluation is finished. Post-exposure prophylaxis may be administered if medically necessary, as recommended by the U.S. Public Health Service. The healthcare worker should also be offered counseling that includes recommendations for transmission and prevention of HIV.
Robert is a nurse who works in the emergency department. He is in the trauma bay when a patient arrives who has been in a car accident. The patient is actively bleeding out from the abdomen. Robert dons a gown, gloves, mask, and goggles as he cares for the patient. During the process of care, Robert applies pressure to the traumatic wound prior to stabilizing the patient. His gown and gloves become covered in blood as he works with the patient.
Later, as he is taking off the gloves, Robert notices that there is a hole in his left-hand glove and that his hands have been exposed to the patient’s blood. He also remembers that the day prior, he cut his left hand at home while he was chopping vegetables in his kitchen and forgot to cover the cut prior to starting his shift. The ED is so busy that he goes on with his shift and does not report the exposure.
The next day, the ED supervisor reports that the patient was found to be positive for HIV and asks the team to report any concerns. Robert is now faced with the possibility that he was exposed to HIV-positive blood. He immediately reports the blood exposure incident from the previous day. His supervisor takes all of the information and together they work closely with the infection control nurse to implement testing, post-exposure prophylaxis, and surveillance. As Robert starts his medical care, he also receives counseling to understand his risk for developing HIV as a result of the exposure.
The supervisor reinforces to Robert that it was important for him to report the exposure as soon as it happened. The supervisor also debriefs the remainder of the team to do the same any time an exposure occurs. The supervisor stresses the importance of protecting employee health and well-being as well as reviews the reporting requirements of the OSHA Bloodborne Pathogens Standard.
During the past four decades, healthcare-associated infections have emerged as a significant risk to patient and healthcare provider safety. In order to ensure both patient and healthcare provider safety, infection control and prevention strategies are needed in all healthcare settings. Outcomes of infection control programs should be continually assessed and reported for their effectiveness.
Healthcare workers need to understand the chain of infection as it applies to basic infection prevention and control concepts. Effective infection control programs include an emphasis on Standard Precautions and transmission-based precautions, along with updates on the most current recommendations for PPE, work practices, and engineering controls. As seen in recent infectious disease outbreaks, such as the 2014 Ebola virus outbreak, there is a need to recognize unique situations requiring enhanced infection control precautions.
AORN Association of periOperative Registered Nurses)
APIC (Association for Professionals in Infection Control and Epidemiology)
Ebola PPE procedures (CDC)
PEPline Poster (PDF) (CDC)
Selected EPA-registered disinfectants (Environmental Protection Agency)
SHEA (Society for Healthcare Epidemiology of America)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
American Nurses Association (ANA). (2014). ANA calls on the CDC for clear, concrete guidelines to ensure patient, health care professional safety in light of Ebola transmissions. Retrieved from http://nursingworld.org
Association of periOperative Registered Nurses (AORN). (2015). Guidelines for perioperative practice. Denver: AORN, Inc.
Centers for Disease Control and Prevention (CDC). (2014a). Healthcare-associated infections. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2014b). Nursing home and assisted living (long-term care facilities). Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2014c). Hepatitis B FAQs for health professionals. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2014d). Guidance on personal protective equipment to be used by healthcare workers during management of patients with Ebola virus disease in U.S. hospitals, including procedures for putting on (donning) and removing (doffing). Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2014e). What you should know for the 2014–2015 influenza season. Retrieved from http://cdc.gov
Centers for Disease Control and Prevention (CDC). (2013). National Institute for Occupational Safety and Health (NIOSH)—stop sticks campaign. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2012a). Principles of epidemiology in public health practice (3rd ed.): an introduction to applied epidemiology and biostatistics: lesson 1: introduction to epidemiology. Atlanta: U.S. Department of Health and Human Services. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2012b). Hand hygiene basics. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2012c). TB infection control and prevention. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2011a). CDC clinical reminder: spinal injection procedures performed without a facemask pose risk for bacterial meningitis. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2011b). Sterilization or disinfection of medical devices. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2011c). Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC) (2011d). Bloodborne infectious diseases: HIV/AIDS, hepatitis B, hepatitis C. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2010). Healthcare-associated infections (HAI): guidelines and recommendations. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2009). Guideline for disinfection and sterilization in healthcare facilities, 2008. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2007). 2007 Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Retrieved from http://www.cdc.gov
Hoff T, Soerensen C, Wroe P, Dutta-Linn M, Lee G. (2011). Making the CMS payment policy for healthcare-associated infections work: organizational factors that matter. J Healthcare Management, 56(5), 319–35.
Hospenthal DR, Crouch HK, English JF, Leach F, Pool J, Conger NG, Whitman TJ, et al. (2011). Multidrug-resistant bacterial colonization of combat-injured personnel at admission to medical centers after evacuation from Afghanistan and Iraq. J Trauma, 71(1 Suppl), S52–7.
Institute of Medicine (IOM). (1999). To err is human: building a safer health system. Washington DC: National Academy Press.
Joint Commission (2015). 2015 hospital national patient safety goals. Retrieved from http://www.jointcommission.org
Korniewicz DM. (2014). Infection control for advanced practice professionals. Lancaster: DEStech Publications, Inc.
Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. (2014). Bloodborne pathogens and needlestick prevention. Retrieved from https://www.osha.gov
Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. (2011a). OSHA fact sheet: OSHA’s bloodborne pathogens standard. Retrieved from https://www.osha.gov
Occupational Safety and Health Administration (OSHA), U.S. Department of Labor. (2011b). Personal protective equipment (PPE) reduces exposure to bloodborne pathogens. Retrieved from https://www.osha.gov
Society for Healthcare Epidemiology of America (SHEA). (2011). Guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus and/or human immunodeficiency virus. Retrieved from http://www.shea-online.org
Sydnor ERM & Perl TM. (2011). Hospital epidemiology and infection control in acute-care settings. Clinical Microbiology Reviews, 24(1), 141–73.
U.S. Department of Health and Human Services (U.S. DHHS), Centers for Medicare & Medicaid Services. (2011). Acute care hospitals and long-term care hospital prospective payment system and FY 2012 rates; hospital FTE resident caps for graduate medical education payment; final rule. Retrieved from http://www.gpo.gov
U.S. Food and Drug Administration (FDA). (2005). Medical devices; reprocessed single-use devices; termination of exemptions from premarket notification; requirement for submission of validation data. Federal Register, 70(188), 56911–25. Retrieved from http://www.fda.gov
World Health Organization (WHO). (2011). Waste from health-care activities. Retrieved from http://www.who.int
World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in healthcare. Retrieved from http://whqlibdoc.who.int