A Health Professions Module

Dr. Ignaz Semmelweis, a Hungarian physician,

delivered babies in the Vienna General Hospital.
Nearly 20% of the mothers under the doctors care in
that ward died following childbirth.
Dr. Semmelweis instituted a practice which reduced
that mortality rate to 1.3%.
You take this practice for granted now, but the
medical community dismissed his results. What
practice do you think Dr. Semmelweis attempted to
introduce to medicine?

Dr. Semmelweis made his discovery

in 1847. At that time there was no
germ theory to support his findings.
Despite a lifetime of attempting to
promote simple hand washing, his
notion was rejected & ridiculed.

There are no other

illustrations in this
presentation, so enjoy this
one retrieved on 12/01/09
from
http://clendening.kumc.edu/

Not living to see his work

appreciated, Dr. Semmelweis
eventually had a nervous
breakdown & died in an insane
asylum.

Procedures for this module & objectives

This section covers:

Your task to complete this requirement
Student objectives for module

Your task is fairly simple:

Read through this presentation
Take the automated quiz on this same D2L
site.
Present proof of passing the quiz (80% or
better) to your department chair.

Note that throughout the presentation there are Read More notations in
green which allow you to click a link for additional online
information.
You may come upon medical terms that are unfamiliar to you. Please
consult an online or hard copy medical dictionary for clarification.

At the conclusion of this module, you should be able to:

List some of the most high profile healthcare-associated infections

(HAI).
Identify the means by which communicable diseases are transmitted.
Describe the role of the CDC & OSHA in the prevention of HAI
transmission.
State the purpose of universal or standard precautions.
List some worksite procedures relevant to exposure control.
Identify the components of universal/standard precautions including:

TB tests & immunizations for yourself

Hand hygiene
Use of protective barriers
Proper disposal of sharps (any device used to puncture or cut, such as needles &
scapels)

Identify when Transmission-Based Precautions apply

Locate a source of precautions for specific conditions

Putting the term in context

This section covers:

Prevalence of healthcare-associated infections (HAI)
Other terms for HAI
Examples of HAI
Transmission of HAI
Government agencies & their roles in minimizing
transmission of HAI
CDC & recommended practices
OSHA & regulation of practices
Terminology review of this section

The Centers for Disease Control and Prevention

(CDC) provides a vast amount of information
concerning Healthcare-Associated Infections. (
http://www.cdc.gov/ncidod/dhqp/hai.html) The CDC
estimates these account for 1.7 million infections
& 99,000 associated deaths each year in
American hospitals. Of these infections:

32%
22%
15%
14%

are
are
are
are

urinary tract infections

surgical site infections
lung infections (pneumonia)
bloodstream infections

What would a medical term be without a Greek

derivation? Healthcare-Associated Infections
(HAI) are also known as Hospital-Acquired
Infections and as Nosocomial Infections (from
the Greek words for disease & to take care of).
Those in the profession will know what youre
talking about no matter which term you use,
but if you need to sound impressive,
nosocomial wins hands down. Those should be
washed hands.

Bloodborne pathogens (including HIV/AIDS,

Hepatitis B & C)
MRSA (Methicillin-Resistant Staphylococcus
Aureus)
Pneumonia
Influenza
Norovirus
Varicella (chickenpox), mumps, Clostridium
difficile (C. diff), TB, & a host of others.
If you would like to see a more complete list, visit
the CDC at
http://www.cdc.gov/ncidod/dhqp/id.html.

Much of the driving force for the

recommendations & regulations regarding
HAI has stemmed from concern over these
three diseases (though they certainly
arent the only infections with the potential
to circulate in healthcare settings):
HIV/AIDS
Hepatitis B virus (HBV)
Hepatitis C virus (HCV)

Communicable diseases, that is those diseases which are

transmitted to a recipient from a host, make their leap
through one or more of the following pathways:

Direct physical contact including touching & sexual means

Indirect contact via an inanimate object (fomite)
Vector recipient is bitten by an insect or animal (the vector)
Fecal-oral from contaminated food or drink
Droplet expelled through coughing, sneezing, talking
Airborne pathogen hitches a ride on dust or evaporated
droplets
Note that bloodborne pathogens (those in blood or other bodily
fluids) may be transmitted by sexual or direct contact or through
fomites (e.g., surgical instruments or dried blood on an object)

Norovirus has made the headlines several times for

sickening passengers on cruise ships, kids at
school, and residents of nursing homes. Take a
guess at the means of transmission for this
highly contagious disease. Go onguess:
A. Direct contact
B. Indirect contact
C. Vector
D. Fecal-oral
E. Droplet
F. Airborne

Its almost hard to be wrong. The answers are:

A. Direct contact
B. Indirect contact
C. Vector
D. Fecal-oral
E. Droplet
F. Airborne
The point is that there can be and often are several
routes of transmission which means that you must
be exceptionally aware of your surroundings and
practices.

The answer is ultimately you, but there are a couple of federal

agencies deeply committed to setting standards &
regulating healthcare practice for the safety of your
patients & you.
The Centers for Disease Control & Prevention (CDC, if
your memory is short) has this mission statement
(retrieved 12/1/09 from http://www.cdc.gov/about/):
To collaborate to create the expertise, information,
and tools that people and communities need to protect
their health through health promotion, prevention of
disease, injury and disability, and preparedness for new
health threats.

In the 1983 the CDC authored the Guidelines for Isolation

Precautions in Hospitals. Later in the decade, and
particularly in response to the HIV/AIDS epidemic,
universal precautions were instigated to prevent the
spread of pathogens responsible for diseases such as
HIV/AIDS, HBV & HCV transmitted in blood, other bodily
fluids containing visible blood, semen, & vaginal secretions.
The precautions also apply to tissues, cerebrospinal, synovial,
pleural, peritoneal, pericardial, and amniotic fluids. Saliva is
included if visibly contaminated with blood.
Read more at:
http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.ht
ml
.

The more recent CDC recommendations for hospitals are

called the standard precautions. To quote directly from
page 66 of
2007 Guideline for Isolation Precautions: Preventing
Transmission of Infectious Agents in Healthcare
Settings, (
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf ,
retrieved 12/1/09)

Standard Precautions combine the major features of

Universal Precautions (UP) and Body Substance Isolation
(BSI)* and are based on the principle that all blood, body
fluids, secretions, excretions except sweat, nonintact skin,
and mucous membranes may contain transmissible
infectious agents. Standard Precautions include a group of
infection prevention practices that apply to all patients,
regardless of suspected or confirmed infection status, in
any setting in which healthcare is delivered.
* Defined in the Review of Terms slides at the end of this section.

Its one thing to receive good advice but quite another to be

required to adopt it. Do you think that everyone started
wearing seat belts when they first came out? Hmm? (Quick
quiz: Which state does not have a seat belt law for adults?
Hint: The official state motto is Live free or die. How
interesting.)
The Occupational Safety & Health Administration
(OSHA) is all about regulating (issuing rules & enforcing
them) standards of occupational health including those
related to injuries, fatalities, & illnesses. It is an agency of
the U.S. Department of Labor. If you dont think they mean
business, you ought to take even a brief look at their
website: http://www.osha.gov/index.html. Please do.

Bloodborne Pathogens Standard

29 CFR 1910.1030
Does that not sound like a government decree?
OSHA initially issued 1910.1030 in 1991 and
updated it in 2001. With this, universal
precautions became not just a
recommendation but an enforceable set of
regulations concerning infection control &
bloodborne pathogens in particular.

The following sources would be interesting to those

who want to learn more about how isolation &
precaution practices entered into the realm of
healthcare:

Standard Precautions by Bjerke, N. B. (

http://www.infectioncontroltoday.com/articles/281bpract.ht
ml
) is a thorough & well-written history reaching back from
the 19th century to the present.

This table from the American Dental Association

summarizes the development of isolation precautions:
http://jada.ada.org/cgi/content/full/134/5/569/T2)

This & the following couple of slides have a review of terms to set
the stage for laying out what it actually means to practice universal
precautions. If you would like to delve into the OSHA Standard
1910.1030 for a complete glossary and enumerated subparagraphs
from here to eternity, you will find them at
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_tabl
e=STANDARDS&p_id=10051
. Put your feet up; its a long read.
Agencies
CDC

Centers for Disease Control & Prevention government

agency providing information & recommendations on a
wide array of topics related to health.

OSHA

Occupational Safety & Health Administration government agency that implements & enforces
regulations concerning safety in the workplace.

Practice of Infection Control

Universal
Precautions

Initially a term describing the CDC recommendations

for limiting the spread of bloodborne pathogens &
later adopted by OSHA as a label for their approach
to infection control.

Body
Substance
Isolation
(BSI)

A more inclusive practice of isolation focused on the

isolation of all moist and potentially infectious body
substances (blood, feces, urine, sputum, saliva,
wound drainage, and other body fluids) from all
patients, regardless of their presumed infection
status.
(Retrieved 12/1/09 from
http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp#head00200
6000000000
)

Standard
Precautions

The updated recommendations from the CDC which

combine features of Universal Precautions & Body
Substance Isolation. Read more at:
http://www.cdc.gov/ncidod/dhqp/gl_isolation_standar
d.html

Infectious Materials
Bloodbor Bloodborne pathogens are pathogenic microorganisms
ne
that are present in human blood and can cause disease in
pathoge humans. (http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html,
retrieved 12/1/09)
ns
OPIM

OSHA term = other potentially infectious materials,

including : (http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html,
retrieved 12/1/09)

The following human body fluids: semen, vaginal

secretions, cerebrospinal fluid, synovial fluid, pleural fluid,
pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental
procedures, any body fluid that is visibly contaminated with
blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids;
Any unfixed tissue or organ (other than intact skin) from
a human (living or dead); and

HIV-containing cell or tissue cultures, organ

cultures, and HIV- or HBV-containing culture

Taking precautions to protect your patients AND yourself.

In essence, this means preventing disease

transmission by consistently using infection
control practices with all patients in all
healthcare settings.
This section covers:
Administrative considerations
Confidentiality
TB test & vaccinations
Hand hygiene
Protective Barriers
Additional precautions

Whether your employer calls their program

Standard Precautions in deference to the CDC or
Universal Precautions as promoted by OSHA, you
should become familiar with these worksite
procedures:

Continuing education regarding precautions

The facilitys written exposure control plan
Post-exposure protocols (and be sure to follow
these promptly if exposed!)
Record keeping regarding exposure

It should go without saying (and that is a pun as

well as the truth) that whatever you might learn
about a patients health status is private &
protected information not to be shared beyond
the circle of those involved in the patients care.
The U.S. Department of Health & Human Services
would like to tell you more at their site devoted
to health information privacy, specifically
regarding the Health Insurance Portability &
Accountability Act (HIPAA). It is found at:
http://www.hhs.gov/ocr/privacy/

Tuberculin skin test. (TB is not gone! Almost

13,000 cases were reported in the U.S. in 2008.)
Read more at: http://www.cdc.gov/tb/.

Vaccinations (http://www.immunize.org/catg.d/p2017.pdf)

Influenza
Hepatitis B
Measles, mumps, rubella (MMR)
Varicella (chickenpox)
Tetanus, diphtheria, pertussis (Tdap or variants as indicated)

NOTE: Your school program and/or your eventual employer may

require more vaccinations than those listed above. Certainly you
will require additional vaccinations if you work/study abroad or with
potential exposure to other diseases. (Check out
http://wwwnc.cdc.gov/travel/ if you intend to travel.)

With the ghost of Dr. Semmelweis hovering above you at this

moment, the weight of years of CDC proclamations on your
shoulders, & the watchful eye of OSHA over your shoulder,
acknowledge that timely & proper hand washing is probably the
single most effective way to prevent the spread of infection.
Hand cleansing should be done prior to and after each patient interaction,
prior to and after each procedure. (You would also faithfully cleanse
your hands prior to preparing food & eating, after blowing your nose in
a tissue, going to the bathroom, etc., wouldnt you? Of course you
would.)
A note on professionalism: Most healthcare facilities have soap & sinks
and/or hand sanitizer lotion in every room & at every station. This is
obvious. So, too, should your practice of hand cleansing be obvious.
Let the patient see you enter his/her domain vigorously cleansing your
hands. Theres a story here

The second year medical student conducted a preliminary evaluation of her patient
who was in for a routine annual physical. She (the medical student) was clearly
well-versed in the examination process and took delight in carefully explaining
each of the tests she performed. She chatted amicably throughout, thereby
developing a fine patient rapport.
At length the attending physician entered the room (rolling a dab of hand sanitizer
around his fingers) introduced himself to the patient and took his turn at
reviewing the records and confirming the results of the students evaluation. Now
there is perhaps no way to conduct the final step of the examination to
everyones complete satisfaction, but the physician introduced the digital rectal
exam as kindly as any human could, explaining that this was still an important
method of detecting prostate irregularities. (If you cannot now guess the gender
of the patient, perhaps you should review anatomy.)
As he and the medical student prepared for this last step, the medical student
brightly chirped:
I guess I should have washed my hands prior to entering the room.
This is a regrettable show stopper. The patient, himself a healthcare provider and the
author of this module, did not retrieve his eyebrows from the oh my! position
for quite some time.

The Guideline for Hand Hygiene in Health-Care Settings CDC document at

http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf will answer virtually any
question you might have on the topic. Hand hygiene includes the following
practices:

Hand washing with plain soap & water

Hand washing with antimicrobial soap (soap with antiseptic agent) &
water

The choice for visibly dirty hands

Little to no antimicrobial activity

See table of antiseptic agents on next slide

Using an antiseptic hand rub

Waterless, typically alcohol-based solutions

See table of antiseptic agents on next slide

Not all of these are interchangeable, meaning that there are some
situations in which one method is preferred over the other. An individual
must also consider any history of allergic reaction to various products &
the potential for contact dermatitis resulting from chronic use of a
product.

Table excerpted from the CDCs Guidelines for Hand Hygiene in Health-Care Settings , p. 45 retrieved 12/1/09 at
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.

Clostridium difficile, a bacterium transmitted by contact with feces (as in:

diarrhea) is a major problem in healthcare institutions particularly affecting
older adults & especially those who have been on a course of antibiotics.
(Read more at the Mayo Clinic site devoted to the topic:
http://www.mayoclinic.com/health/c-difficile/DS00736).
Heres a sobering note from the Guidelines for Hand Hygiene in Health-Care
Settings regarding C. difficile (p. 17 at
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf ) :
None of the agents (including alcohols, chorhexidine, hexachlorophene,
iodophors, PCMX, and triclosan) used in antiseptic handwash or antiseptic
hand-rub preparations are reliably sporicidal against Clostridium
As a presumably healthy individual you may not get ill, but you may be a
carrier. The CDC encourages you to:
Wear gloves (this presumes you suspect C. difficile!)
After removing the gloves, wash your hands with a non-antimicrobial or an
antimicrobial soap & water or disinfect with an alcohol-based hand-rub.

Wash Your Hands: The Right Way

When washing hands with soap and water:

Wet your hands with clean running water and apply soap.
Use warm water if it is available.
Rub hands together to make a lather and scrub all surfaces.
Continue rubbing hands for 15-20 seconds. Need a timer?
Imagine singing "Happy Birthday" twice through to a friend.
Rinse hands well under running water.
Dry your hands using a paper towel or air dryer. If possible,
use your paper towel to turn off the faucet.
Always use soap and water if your hands are visibly dirty.

The above is directly from the CDC at http://www.cdc.gov/Features/HandWashing/

(retrieved 12/1/09). If you would like to see pictures of hand washing or review their
video, please visit that site. Noteworthy in the script for the video is the statement
that up to 80% of all infections are transmitted by hand.

Also from the CDC is this regarding the use of hand sanitizers:
When using an alcohol-based hand sanitizer:
Apply product to the palm of one hand.
Rub hands together.
Rub the product over all surfaces of hands and fingers until
hands are dry.
Alcohol-based hand sanitizers are NOT effective when hands
are visibly dirty or contaminated with blood or fecal matter
as examples. (In these instances, washing with an
antimicrobial soap & water might be indicated.)

Personal protective equipment (PPE) or personal protective

attire (PPA) are selected and worn based upon the
nature of the patient interaction* and the likely mode of
pathogen transmission.** PPE include:

Gloves
Masks
Gowns & other apparel
Eye, face, mouth, & inhalation protection

*Naturally the CDC has recommendations on when to use PPE. The Yale-New

Haven Hospital
(http://www.med.yale.edu/ynhh/infection/precautions/intro.html) offers

more on the use of PPE along with instruction on how to don (put on) the
equipment & remove the equipment. This is presented in the following slides.
**A presentation of Transmission-Based Precautions follows the PPE information.

CDC: 2007 Guidelines for Isolation Precautions, p. 134,

retrieved 12/1/09 from
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.
pdf.

Gloves are worn to prevent the health care worker's hands from
becoming contaminated with blood or body substances. Gloves
should be worn for:

Procedures involving direct contact with the blood and body substances of any patient.

Procedures where contact with blood and body substances might be expected to occur.

Procedures involving direct or potential contact with the mucous membranes of any
patient.

Procedures involving direct or potential contact with the non-intact skin of any patient.
Non-intact skin is skin that is cut, chapped, abraded, cracked, afflicted with weeping or
exudative lesions, or is otherwise broken. Touching or handling any instruments,
equipment, or surfaces that have been, or may have been, in contact with blood or
body substances.

In addition, gloves should be worn in providing care to a patient or in managing

equipment when the health care worker has cuts, scratches, or other breaks in the skin
on his/her hands.

Sterile gloves should be used for all sterile

procedures and for activities that involve contact
with areas of the body that are normally sterile.
There should be an adequate supply of clean
disposable gloves on the standard precautions
stations or in other locations that are convenient
to each patient's room.
Gloves used in patient's care should be worn only for
contact with the patient. Once used, gloves must
be discarded before leaving the patient's room.

Procedure for donning sterile gloves:

1. Remove all jewelry, including rings.
2. Wash hands using an antimicrobial cleansing agent.
3. Dry hands thoroughly with a paper towel. Use the towel to turn off the
faucet.
4. Remove the packet of gloves from the outer wrapper. Place this packet on a
clean, dry, flat surface.
5. Unfold the packet as if opening a book. Position the packet so that the
cuffed ends of the gloves are nearest to you.
6. Grasp the center flaps and open. Both gloves must have folded cuffs.
Position the packaging so that it lies flat.
7. Use one hand to glove the other. Grasp the edge of the right glove cuff with
the fingers of the left hand, and slip the right hand into this glove. Pull it on
by holding onto the cuff, but do not touch the outside of the glove.
8. Adjust both gloves so they fit properly. Make sure there are no gaps
between the fingertips and the ends of the gloves.
9. Inspect the gloves for nicks and tears before and during the procedure.
Obtain a new pair of sterile gloves if there is a break in aseptic technique or
if a nick or tear occurs.

The three categories of Transmission-Based Precautions come into effect

when Standard Precautions are insufficient to interrupt the route(s) of
transmission. (This means that Standard Precautions AND the indicated
Transmission-Based Precautions should be in effect.) The categories are:

Contact precautions

Droplet precautions

Apply when excessive wound drainage, fecal incontinence, or other discharges

Ideally entails single room or spatial arrangements to protect others in shared room
Caregiver wears gown & gloves
Apply with respiratory illnesses spread through relatively close approximation to others
Ideally entails single room or spatial arrangements & curtain to protect others in shared
room
Caregiver wears mask

Airborne precautions

Apply when infectious agents may be suspended in the air over long distances
Preferred placement for patient in airborne infection isolation room
Caregiver wears mask or respirator as indicated by disease-specific recommendations

CDC: 2007 Guidelines for Isolation Precautions, p. 121, retrieved 12/1/09 from
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf.

The CDCs 2007 Guidelines for Isolation Precautions contains a 23 page Appendix listing
precautions for selected infections & conditions. A sample of this (retrieved 12/1/09 from
page 94 of that document at
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf) is displayed below.