PREVENTION OF INFECTION

IN THE HOSPITAL SETTING

• Coming together is a beginning, keeping
together is a process, working together is
a SUCCESS. Henry Ford
Learning Objectives
• To understand the importance and
implications of Prevention of Infection in
the Hospital Setting
• To understand how Infection in the
Hospital Setting can be prevented
• Consider Infrastructure, Education,
Policies/procedures, Audit, Surveillance,
Outbreak Management,Antimicrobial
Policy, Occupational Health, Risk
Management and Outcome Indicators in
understanding the above
Contents of Lecture
• Infrastructure (environment, ventilation,
facilities)
• Education
• Surveillance/Audit
• Infection control policy/procedures ( e.g
transmission precautions, evidence based)
• Antimicrobial policy
• Occupational Health policy
• Infection Control indicators
• Possible problem areas
Infection Control
• SENIC project (Study on the Efficacy of Nosocomial
Infection Control) established the scientific basis of efficacy
of infection control programmes (Haley Am J Epidemiol 1985; 121: 182-
205).

• 32% of blood-stream, respiratory, urinary tract, and wound

infections could be prevented by high intensity infection
surveillance and control programmes
Consequences of HAI
• U.S.
– 2 million infections/year
– 90,000 deaths
– $4.5 billion dollars in excess healthcare costs
MMWR 1992;41:783-7
• U.K.
– Estimated to cost £1 billion/year in 1995
PHLS 1999
– 5000 deaths/year

MOST IMPORTANTLY HAI IMPACT ON THE MORBIDITY AND MORTALITY FOR

THE PATIENT
Extent of the problem
• About 10% of patients in hospital have a hospital-acquired infection
Emmerson AM, Enstone JE, Griffin M et al. J Hosp Inf
1996; 32: 175-190.
U.S data: 5.7 nosocomial infections per 100 admissions in 1975-6
– 42% UTI
– 24% surgical wound infections
– 10% pneumonia
– 5% bacteraemias
Haley et al.Am J Epidemiol. 1985 Feb;121(2):159-67
Problem Areas
• Increasingly complex patients with increased
susceptibility to infection
– Increasing use of invasive devices
• Increasing problem of antimicrobial resistance
• New threats – re-emergence of old threats
– SARS, influenza
– MDR-TB
– Agents of bioterrorism – anthrax, smallpox
• Overcrowding
– Frequent patient movement
– Inability to separate elective and emergency admissions
• Understaffing
• Inadequate facilities e.g isolation rooms
Environment

• Consider Patient factors-Increased

susceptibility
• Immunosuppressed
• Immunodepressed
• Burns/Large open wound
• Premature neonates
• ICU and those with invasive devised
Destroying physical barriers

Deleted pictures

Intravascular devices
• a gateway into the patient’s bloodstream
 Endocarditis on an artificial valve

Foreign bodies

Deleted pictures

Foreign material used in fracture fixation - relative non-pathogens e.g.

Staphylococcus epidermidis are frequent causes of infection in this setting
Destroying physical barriers - 2

Deleted pictures

Skin integrity disrupted in this burn - caused by

a hot-water bottle in a bed-ridden patient
Environmental Items
• Floors/walls/ceilings ( consider dealing with
spills)
• Furniture/fittings
• Beds/pillows/mattresses
• Linen
• Infant incubators-consider manufactors`
instructions
• Baths/Showers/Sinks/ footpedal bins
• Drains/Toilets/toilet seats
• Additional equipment e.g Hydrotherapy pools
Consider Prevention
Environmental items

• Cleaning equipment
- Floor scrubbers, must be amendable to cleaning
- Mops- wet , cleaning on hotwash and dried
throughly, colour code mops for different area
used e.g high risk area as opposed to toliet
- Vaccuum cleaners, must have a filter on the
exhaust , protocol for changing , person in
charge
Environment

• Deleted pictures
Environmental additional items

• Toys
• Telephones- clean on a regular basis, but
hands should be decontaminated before
use
• Flowers/plants- Risk assessment
 Environment
Evidence that a clean environment reduces HAI
– Norovirus
• Indirect transmission occurs
• Cleaning is a key infection control measure
– C. difficile
• Extensive environmental contamination
– MRSA
• Evidence that improved cleaning may assist in termination of outbreaks
– VRE
• Extensive environmental contamination has been described
Ventilation

• Prevention of spread of airborne

pathogens ( airborne precautions)
• Positive pressure isolation
• Negative pressure isolation
• Special considerations for Operating
Theatre
Ventilation
• Negative pressure isolation
• HEPA filtered air
• At least 6 exchanges of air/ hour
• Air should not be recirculated into system and
external exhaust should be away from intake air
system
• Particle Filter Respirator masks for those
entering
• Indicated for Infectious mycobacterium
tuberculosis, measles, dissemeinated zoster,
varicella ( ideally those immune should deal with
the patient with measles etc)
Ventilation-Operating Theatre
• Operating theatres- purpose to prevent bacteria
settling in the wound (HTM 2025)
• People are constantly sheeding dead
skin(squames) around 15 um, rate of shedding
increases with movement, some of these may
carry bacteria
• Filtration
• Differential air pressures, filtered clean air to
critical areas to less critical
• Commissioning of theatres – smoke test, casella
air counts, structure , maintaince system, rates
• Ultraclean theatres required for eye surgery etc,
unidirectional flow
Operating theatre-Commisioning

• Deleted pictures
Ward Air Sampling- Which Unit may
be of concern?
• Deleted pictures
Water Systems and Prevention
of Legionellosis
Hospital Water Sytems

Deleted pictures
Legionnaire`s Disease

• The management of Legionnaire`s

Disease in Ireland
• Scientific Advisory Committee
Legionnaire`s Disease sub-
committee National Disease
Surveillance Centre – Guidelines for
Control
http://www.HPSC.ie
Legionnaire`s Disease
• American Legion
convention
• 221 ill and 34 died
• Mystery Illness
Deleted pictures
• Legionella species 65
serotypes
• Legionella
Pneumophilia
serogroup 1 accounts
for 71% notified to
CDC
Natural History

• 20-45º C favors growth

• Do not multiply below 20 ºC and will
not survive above 60 ºC
• Dormant and multiply when
temperature suitable
• Nutrients to multiply derived from
algae, amoebae and other bacteria
• Sediment, Sludge , Scale, Biofilms
Water Systems
• Drinking water disinfectants , free Cl-, kills free
floating coliforms but penetrates poorly into
biofilm
• Legionella is further shieled by the amoebae it
parasitises
• Cl-, does not reach distal sites in water
distribution systems
• Dissipates quickly in heated water or removed in
water filtering in Spapools
• So Require design of water systems,
Hyperchlorination and Temperature control of
water
Legionnaire`s Disease

Cluster/Outbreak Linked
2 or more , 2 or more
Sporadic Single source Single source
Single Case < 6 mts > 6 mts < 2 yrs
POTENTIAL SOURCES
• Hot/Cold Water Systems • Fountains/Sprinklers
• Cooling Towers • Humidifiers for food
• Evaporative condensers display cabinets
• Respiratory Equipment
• Water cooling
• Spa pools, Natural pools,
machine tools
Thermal springs
• Vechicle washes
• Ultrasonic misting
machine
In common combination of High Temperature and Potential for
Aerosol Formation
TRANSMISSION

• Respiratory: Inhalation of aerosol ,

microaspiration of water containing
legionella species
• The smaller the aerosol more
dangerous ( 1-5um)
• No person to person Transmission
Risk Factors
• > 50 years • So Risk depends
• Male on:
• Cig Smokers
• Chronic underlying • Individual
Disease susceptibility
• With/without
Immunodeficiency
• Degree of Intensity
of Exposure ( amt.
• Incubation Period 2-10 Of legionella, size
Days
Attack rates in Outbreak <
of aerosol etc)
5%, 102 –104 /L and sporadic • Length of Exposure
104 –106 /L
Hospital INFECTION-
Legionnaire`s Disease
• Case Defintion: Definite, Probably, Possible
• Hospitals at risk those caring for
immunocompromised patients
• Hospital size may be important> 200 beds
31 of 32 outbreaks in US
• Mostly linked to Legionella colonising hot
water system ( also cooling towers near
ventilation intake, respiratory equipment
cleaned with unsterile water, Ice machines,
aspiration of contaminated water etc)
Recommendations for
Control
• Staff Education • Sampling:
• Surveillance • Sites
• 1Litre in sterile
• Interrupting containers containing
Transmission e.g sufficient sodium
Nebuliser thiosulphate to
equipment and neutralise any Cl- or
Water distribution oxidising biocide
systems • Measure Temperature
Guidelines

• Responsible named person for Legionella

control
• Kept hot water hot at all times –50-60ºC .
• Keep cold water cold at all times.
Maintained at temperatures below 25ºC
• Run all taps and showers in rooms for a
few minutes daily, even if room is
unoccupied
Guidelines
• Keep all showers, showerheads and taps clean
and free from scale
• Clean and Disinfect cooling towers used in air
conditioning systems regularly – every 3
months
• Clean and disinfect heat
exchangers( calorifiers) regularly- once a year
• Disinfect the hot water system with high level (
50 ppm) chlorine for 2-4 hours after work on
heat exchangers
Guidelines

• Clean and disinfect all water filters

regularly- every one to three months
• Inspect storage tanks, cooling towers and
visible pipe work monthly. Ensure all
coverings are intact and firmly in place
• Ensure that system modifications or new
installations do not create pipework with
intermittent or no water flow
Emergency Control
Measures
• Precautionary Shock • Cleaning of tanks,
Heating ( min 5 mins shower heads, water
each water outlet heaters and
65º C)-Disinfection, circulation of 5 ppm
disabling free Cl- through water
• Hyperchlorination system for min. 3
( > 10 PPM) of cooling hours
tower on 3 occasions • Storage tanks and
including mechanical pipework temp below
cleaning 20ºC
Waste Segretation/Disposal

• Black Bags-non-clinical waste e.g paper

• Yellow bags-Clinical waste not containing
sharps
• Yellow rigid sharps bin/box for sharps
disposal
• Contaminated linen alginate bags
• Each hospital may have separate colour
scheme
SJH
Deleted pictures
Food

• Cook –Chill System

• HACCP(critical control point) analysis
• Microbiolgical Testing of Food
Cook-Chill system

• Deleted pictures
Facilities

• Ideally lass than 100% occupancy allows

for cleaning and maintaince
• In the U.K 50% of New Hospitals will be
isolation rooms
• Lower rates of MRSA acquistion in
countries that have hospitals with <90%
bed occupancy
Examples

• Policies/Procedures in Infection Control

Manual
• SJH 016-Safe Disposal of Sharps etc
covered in Hand Hygiene Practical
Dealing with blood spillage
Policy for dealing with blood
and body fluid spillages
• Put on plastic apron and non-sterile disposable
gloves
• Use masks and visors if splashing in the nose, eye
and mouth are likely to occur
• Cover the spill with disposable paper towels to
absorb liquid . Discard into clean yellow
infectious waste bag
• Avoiding contamination of the outside of the new
bag.
• Wipe up excess spillages with disposable paper
towel and place into yellow infectious waste bag
 Policy for dealing with blood
and body fluid spillages
• Apply a chlorine based solution, strength
10,000 ppm(part per million) and soak for 10
minutes (Klorsept 87 , 1 tablet / 500mls water)
• Ensure a “wet floor “ sign is in place.
• Mop up any excess solution. If applied to
chrome or metal surfaces wash area with
detergent and water.
• Remove aprons and gloves and discard into
yellow waste bag. Tie securely.
• Wash hands
Policy for dealing with blood
and body fluid spillages

• Klorsept 87 is Sodium
dichloroisocyanurate freshly
prepared daily
1 tablet Klorsept 87 / 500mls water
Effective Infection Control Team

• Deleted pictures
3. Education

• Organised educational training programme

• HCW acquisition of SARS was significantly
associated with
– Amount of PPE perceived to be inadequate
– Having <2 h infection control training
– Not understanding infection control procedures
Lau et al. Emer Infect Dis 2004;10.
Prevention of Infections

Hepatitis B , 1995 800 healthcare

workers infected in the US, IN 1983
17,000 , 95% decline due to
universal precautions and
vaccination
GUIDELINES ON STANDARD
PRECAUTIONS
• Standard Precautions describe the guidelines
which are designed to protect patients and
healthcare workers from contact with
infectious body fluids. Bloodborne viruses of
concern are Hepatits C, Hepatitis B/D and
HIV.
• The most serious risk is associated with
infected blood, while tears, saliva and urine
are considered less hazardous due to lower
level of infectious agent present in these
fluids
GUIDELINES ON STANDARD
PRECAUTIONS
• It is not possible to identify every
potentially infectious person,
therefore it is prudent to adopt
“Universal precautions” (Standard
Precautions)
Principles of Standard
Precautions
• Avoid contact with body fluids at all times
• Avoid cuts, abrasions and puncture
wounds
• Cover existing cuts and abrasions with a
water proof dressing
• Avoid contamination of personal clothing
with body fluids
• Protect mucus membranes, eyes and
mouth from splashes with body fluids
Principles of Standard
Precautions
• Regular handwashing and good hygiene
practices are vital
• Dispose of waste and linen contaminated with
blood or body fluids correctly
• Decontaminate all items soiled with blood and or
body fluids correctly
• Remember Hands, mucous membranes, eyes,
clothes and Protection: Gloves, masks,
Goggles/visors, Aprons
• Avoid recapping of needles and always dispose
of sharps safely
 Personal Protective Clothing
and its use covered previously
 Deleted pictures

Foot pedal bin

• Deleted pictures
HAND HYGIENE

GUIDELINES FOR HAND HYGIENE IN IRISH

HEALTHCARE SETTING 2004

http://www.ndsc.ie/Publications/HandHygieneGuidelines/

See handout

Copies in the Library

Why wash your hands?

Handwashing is one of the most

important procedures in preventing
the spread of disease
Hands should be washed

- Before commencement of duty

- Before handling food
- Before attending patients
- Before entering protective isolation rooms
- Before performing non-touch or aseptic
techniques
- After visiting the toilet
- After removing gloves
- After any microbial contamination
- After handling contaminated linen and
infectious waste
-After patient contact
Resident Micro-organisms (normal
flora)
Resident micro-organisms are normally found on
the hands e.g. CNS. They are deep-seated within
the epidermis and are not easily removed.

Transient Organisms
Transient micro-organisms e.g. MRSA and E. Coli
are located on the surface of the skin. Direct
contact with people or equipment all result in the
transfer of these micro-organisms to and from the
hands with ease. They are easily removed with
handwashing and the risk of cross infection is then
immediately reduced.
Contact spread of resistant pathogens
via HCW hands

• MRSA
• VRE
• Pan-resistant Acinetobacter spp.
• Others
 Deleted pictures

U.S. Army Camp Hospital No. 45, Aix-Les-Bains,

France, Influenza Ward No. 1, 1918
Hand washing –Evidence -base

• Major reduction in postpartum mortality when

routine hand washing introduced. (Semmelweis
1861)

• Important risk factors for non compliance were

high work load and being a physician. (Pittet et.
al. 2000)

• Alcohol based hand rub use associated with a

steady reduction in nosocomial infection rate
over a 4 year period
• Another key feature was active involvement of
hospital management in promoting hand
hygeine. (Pittet et. al. 2000)
Pittet et al. Effectiveness of a hospital-wide programme to improve
compliance with hand hygiene. Lancet 2000 356: 1307-1312

Interventions :
• A multidisciplinary project team
• Priority from senior hospital management
• Posters emphasising the importance of hand washing, particularly disinfecting.
• Distribution of individual bottles of alcohol-based chlorhexidine solution
• Funding
• A series of educational sessions in individual medical departments.
• Feedback from results of surveys and hospital infection through hospital
newsletters.
• Overall nosocomial infection rates decreased from
a prevalence of 16.9% to 9.9% (p<0.04)
5. Surveillance
• ‘the on-going, systematic collection, analysis, interpretation
and dissemination of data regarding a health-related event
for action to reduce morbidity and mortality and to improve
health’
• Single most important factor in prevention of nosocomial
infections
– Hospitals with active surveillance programmes have significantly
less nosocomial infection rates
• Identify patient groups/types of infection
– Ensure completeness of data collection
• Post-discharge surveillance
• Must
– Use standardised, objective definitions
– Validate the data
– Adjust for risk
• Produce reports/feedback
 Catheter Associated Blood stream
infection (CABSI)

• Less strict definition

• Expressed as a rate using Catheter days as denominator
• Rates usually higher than CRBSI as definition is less specific
 CRBSI / CABSI Surveillance Project in
SJH.
Aims of Project

• To determine the catheter-related and catheter-associated bloodstream

infection rate within the hospital.
• To audit all aspects of central and peripheral line care including
insertion, maintenance, drug administration, dressing changes, TPN
administration, line removal and documentation.
• To conduct educational sessions to inform staff involved in line care of
the line infection rates and audit findings and to educate and update staff
where needs are identified.
• To reduce patient morbidity, mortality, hospital stay and hospital costs.
 CRBSI / CABSI Surveillance
Project in SJH.

Project started : 09/05/2005

Duration to date: 38 weeks
Weeks 1 –2 : Surveillance forms developed
Database to collect and analyse
data tested
 Future of the Project

• Continuous CRBSI surveillance to monitor changes in

rate over time.
• IV Steering Group to oversee the implementation and
maintenance of a quality assured service related to all
aspects of IV practice.
• This will include:
– Education programme.
– To address findings of audit .
– Re audit to evaluate education provided.
PROCESSES

• All processes need to be quality control,

quality assurance, accreditation
• New product evaluation
• Step by step procedure defined
• Quality indictators of process
• Manufactors guidelines e.g single use
adhered to
• Risk Management and Sterivigilance
 Process Control- Example
Decontamination of Endoscope
Process Example- Decontamination

• Decontaminaton is the process which

removes or destroys contamination and
thereby prevent microorganisms or other
contaminants reaching a susceptible site
in sufficient numbers to initiate infection
or some other harmful response. It
included cleaning, disinfection and
sterilization.
Categories of Infection Risk to
patient treatment of equipment
• High Risk- Items in close contact with
break in the skin or mucous membranes
or introduced into a sterile body cavity
Sterilization required
• Intermediate risk- Items in contact with
intact mucous membranes Disinfection
or Sterilization required
Process

• From Purchasing to decomissioning

• Clearly outline
• Quality control
• Quality assurance
• Accreditation
• All involves documentation and monitoring
Process Example- Decontamination
of Endoscopes
• Good Cleaning is essential
-removes potentially infectious
microorganisms
-removes organic material
-soil that may protect microorganisms
-soil that may inactivate disinfectants
Selection of Endoscope washer
disinfectors
• This should throughly clean all instrument surfaces and
lumens
• This should disinfect instruments with an effective non-
damaging disinfectant at use concentration and
temperature
• This should remove irritant disinfectant residues with
sterile or bacteria free water
• It should have a self disinfecting facility
• Contain of remove all toxic vapour emissions
• Produce a print out for cycle validation and instrument
traceability
• Monitor Rinse water microbiologically
Antimicrobial Policy see previous
lecture
Transmission of antibiotic resistance

• Mutation - random genetic change

• Incidence of mutations: 1 bacterium in 10 million
• One bacterium can produce 1 billion progeny in 10 hours

• Antibiotics: select mutant strains from patients flora

modify flora to resistant strains or species
• Transfer between bacteria of resistant genes via plasmids or
transposons, bacteriophages or naked DNA
• Spread of resistant strains between patients - via
contaminated hands or equipment
• Also importance of prudent use of antibiotics
following Hospital Antimicrobial Policy advised
 Deleted pictures

What preventative strategies can be put in place?

Resistance to Antibiotics
No antibiotic – no selection for resistant organisms

sensitive resistant
Resistance to Antibiotics
antibiotic – selects for resistant organisms

sensitive resistant
MRSA CONTROL
• Reduce antimicrobial use, reduce selection
• Reduce MRSA Reservoir and potential for spread
by
• -Ward closures/cohort, Decolonisation, early
discharge
• Infection Control Measures to prevent spread
• -PROMOTE HAND HYGIENE
• -Effective isolation measures
• -Screening
Occupational Health Policy

• Vaccination
• Education
• Risk Assessment ,PEP and follow-up
• Standard Precautions
Infection Control Indicators

• Control Assurance Standards for Infection

Control- capable of showing improvement
in infection control and/or providing early
warning of risk are used at all levels of
organisation including review of the
efficacy and usefulness of indicator
Indicators may be

• Structure Indicators -or compliance indicators

with national/local guidelines
• Process Indicators- how people in an
organisation follow internal rules and guidelines
e.g audit of hand hygiene compliance
• Outcome Indicators- link a risk indicator to the
progress of patients
• Surrogate indicator- relates action to effects
Examples of Indicators
• Structure-
• Process-
• Outcome- Healthcare associated Infections, Surgical site
infection following clean surgery,
Alert organisms
-MRSA colonisation
-C.difficile diarrhoea
-Gentamicin resistant GNB`s
-Penicillin resistant pneumococcus
-Actinebacter in ITU`s
• Surrogate –
-Length of Hospital stay, Use of oral vancomycin etc
• See link
• http://www.bms.jhmi.edu/CFI/inside/studi
es/CFI_IH_CaseStudy_CatheterRelatedBlo
odstreamInfections
Contents of Lecture
• Infrastructure (environment, ventilation,
facilities)
• Education
• Surveillance/Audit
• Infection control policy/procedures ( e.g
transmission precautions, evidence based)
• Antimicrobial policy
• Occupational Health policy
• Infection Control indicators
• Possible problem areas
Nothing but Healing Hands