PREVENTION OF NOSOCOMIAL INFECTION I

Unit of learning code- HE/CU/TT/CR/02/6/A

Introduction to the unit of learning
This unit describes the competencies required to prevent and control
nosocomial infections.
It involves handling Operation Theatre instruments and patients in the
Operation Theatre room. Necessary precautions are taken in the context
of theatre setting to avoid infections.
COURSE OUTLINE
By the end of the unit, students will be able to:
1) Describe infection prevention
2) Personal OT protective gears
3) Describe Sterilization
4) Describe Decontamination
5) Describe Waste management
6) Familiar with Aseptic techniques
7) Know types of surgical instruments
8) Types of surgical packs and sets
9) Differenciate types of surgery
10) Describe sterilization in Operation Theatre

LESSON 1:
Learning Outcomes

By the end of the unit, students will be able to:

 1) Describe infection prevention
2) Personal OT protective gears
3) Describe Sterilization

INFECTION PREVENTION

Infection-State of being infected.

Occurs when microorganisms eg bacteria, fungi, virus etc enters a person’s
body and causes harm
Nosocomial infection-Infections that occur in the process of acquiring health
care that was not present during the time of admission.
Examples- Urinary tract infections, gastro interstinal infections, pneumonia
(ventilator related), central line associated bloodstream infections.
 Infection prevention is a scientific approach and practical solution
designed to prevent harm caused by infection to patients and health
workers
READ ON WAYS TO PREVENT INFECTIONS
-HAND HYGIENE
-PROTECTIVE EQUIPMENTS
Protective gears- Types of equipment that is worn to
increase an individual’s safety while
performing potentially hazardous tasks
Use of perioperative Theatre protective gears
Clothing and Covering for clothing
These serve as part of contact precautions based on
Infection prevention and control
(IPC) principles. Surgical scrubs should be worn as
regular on-duty uniform in the
operation theatre. Fluid-resistant aprons or gowns
should be worn on top to reduce the
likelihood of infected body fluids penetrating and
contaminating the underlying clothes
where splashing of blood or fluids is anticipated.
Footwear
Floors and surfaces may be contaminated with feaces
and body fluids.Foot wear also
provides optimal protection when floors are wet and
rubber boots can protect against
sharps injuries. Foot wear includes boots, closed
shoes that fully cover the dorsum of the
foot without laces, clogs. Shoe covers, preferably
impermeable, should ideally be used
over closed shoes to facilitate decontamination in
procedures with body fluid splashes.
Head cover
It protects the skin and hair of the head and neck
from contamination and the possibility
of subsequent cross-infection. Hair and hair
extensions need to fit inside the head cover.
Single-use head covers are preferred.
Mucous membrane protection
Mucous membranes include the eyes, mouth and
nose. Face shield, goggles and face
masks should be used to completely cover them as
an integral part of standard and
droplet precautions (IPC measures that aim to
prevent infection with pathogens that can
be transmitted by large-particle droplets).
Face shields and goggles should not be used
together, as this does not offer additional
protection and causes more discomfort and fogging
affecting vision.
 Goggles: Good seal with the skin of the face to
protect the eyes from fluid splashes and
infectious droplets.
Face shield: Made of clear plastic and completely
covers the sides and length of the
face. It protects the eyes, nose and mouth’s mucous
membranes.
Surgical mask: It protects the nasal and oral mucosa
from splashes and droplets of
infectious material.
Gloves
They prevent self and cross infection; and reduce
risk from needle-stick injuries. Sterile
Surgical Gloves or High Level Disinfected Surgical
Gloves should be worn during all
procedures in which the main aim is to avoid
introduction of pathogens into the patient.
Single use examination gloves/ clean gloves should
be worn for all procedures in which
one will be in contact with intact mucous membranes
and where the primary purpose of
wearing gloves is to reduce the risk of being exposed
to blood or other body fluids. The
best IPC practice dictates that gloves should be
changed between patients.

-RESPIRATORY HYGIENE
-SHARPS SAFETY

PERSONAL OT PROTECTIVE GEARS

 These are physical barriers used to prevent transmission of infection
to the patient or from the patient to the persons attending them.
 They include Gloves, Gowns/Aprons, Surgical masks, Protective
eyewear, Headgear and Boots.
a) Gowns and Aprons
-These should be made of waterproof material and worn full
size to give maximum protection.
-They should be used when splashing of blood or other body
fluids or when any other potentially infectious materials are
anticipated.
b) Gloves
-Provide a barrier against potentially infectious microorganisms in
blood, other body fluids, and medical waste, thus lowering the risk
of transmitting infections to both health care workers and patients.
-Sterile surgical gloves should be worn during all procedures in
which the main aim is to avoid introduction of pathogens into the
patient, for example during surgical procedures.
-Single use examination gloves should be worn for all procedures
in which the healthcare worker will be in contact with intact
mucous membranes.
c) Masks and Eye Shields
-These provide some protection against airborne pathogens and
shield against splashes.
d) Headgear
-Caps are worn full length to cover the head.
e) Boots and shoe covers
-should be waterproof

Sterilization
-Sterilization-Processes by which all pathogenic and non-
pathogenic microorganisms, including endospores, are killed.
-This term refers only to a validated process capable of
destroying all forms of microbial life, including endospores.
-Bacterial endospores (e.g., clostridia and bacillus) are the most
resistant of all living organisms because of their capacity to
withstand external destructive agents.
-Although the physical or chemical process by which all
pathogenic and non-pathogenic microorganisms (including
endospores) are destroyed is not absolute, supplies and
equipment are considered sterile when all parameters have been
met during a sterilization process.
-The sterilizer is a piece of equipment used to attain either
physical or chemical sterilization.
-The agent used must be capable of killing all forms of
microorganisms.
Methods of Sterilization
-Reliable sterilization depends on the contact of the sterilizing
agent with all surfaces of the item to be sterilized.
-Selection of the agent used to achieve sterility depends
primarily on the nature of the item to be sterilized.
-The time required to kill endospores in the available equipment
then becomes critical.
-Sterilization processes are either physical or chemical, and
each method has its advantages and disadvantages.
The following are available sterilizing agents (sterilants):
1. Thermal (physical)
-Steam under pressure/moist heat
-Hot air/dry heat
2. Chemical
-Ethylene oxide gas
-Formaldehyde gas and solution
-Hydrogen peroxide plasma/vapor
-Ozone gas e. Acetic acid solution
-Glutaraldehyde solution
- Peracetic acid 0.2% solution
- Hypochlorous acid (electrochemical conversion
process)
3. Radiation (physical)
-Microwave (nonionizing)
-X-ray (ionizing)
Sterilization Cycle
The time required to achieve sterilization is
referred to as the process cycle, which includes the
following:
• Heat up and/or penetration of the agent
• Kill time (i.e., exposure to the agent)
• Safety factor for bioburden
• Evacuation or dissipation of the agent

READING ASSIGNMENT:

Chemical Sterilizing agents

-Ethylene Oxide Ethylene oxide (EO)
-Formaldehyde
-Glutaraldehyde
- Steam Under Pressure (Moist Heat
Sterilization)
LESSON 2:
Decontamination
-Cleaning reusable items with an approved sporicidal
disinfectant to render the item safe for handling.
-Decontamination of instrumentation is performed in a
designated area by specially trained personnel immediately
after completion of the surgical procedure.
-The scrub person can facilitate the instrument decontamination
process by wiping instruments as they are used on the sterile
field and then opening the instruments completely before
placing in a tray for return to the processing area.
-This is referred to as point of use cleaning.
-An enzymatic cleaner such as a foam or solution can applied to
the instruments to prevent debris from drying during transport
to the central service area.
-All instruments on the table during a surgical procedure
require decontamination before processing to the required level
of safety for patient use.
-Decontamination combines mechanical or manual cleaning
and a physical or chemical microbicidal process.
-Prerinsing, washing, rinsing, and disinfecting/sterilizing is
done in the processing department to render the instrumentation
safe for handling.
-This part of the process is referred to as thorough cleaning or
return-to-use cleaning.

ASEPTIC TECHNIQUES
-The methods by which microbial contamination is contained in
the environment
-Aseptic technique is a set of specific practices and procedures
performed under carefully controlled conditions with the goal
of minimizing contamination by pathogens.
-Aseptic technique can be applied in any clinical setting.
Pathogens may introduce infection to the patient through
contact with the environment, personnel, or equipment.

Purpose
 Aseptic technique is employed to maximize and maintain
asepsis, the absence of pathogenic organisms, in the
clinical setting.
 The goals of aseptic technique are to protect the patient
from infection and to prevent the spread of pathogens.
-Often, practices that clean (remove dirt and other impurities),
sanitize (reduce the number of microorganisms to safe levels),
or disinfect (remove most microorganisms but not highly
resistant ones) are not sufficient to prevent infection.
 Aseptic technique is vital in reducing the morbidity and
mortality associated with surgical infections.

KEY ELEMENTS OF ASEPSIS

 Items have been cleaned and decontaminated so they are
safe to handle with clean, bare hands.
 Items in use in patient care are handled with examination
gloves for the protection of both the caregiver and the
patient.
 Items have been cleaned, decontaminated, disinfected, or
terminally sterilized without a wrapper, and stored in a
clean, dry place.
 Items may start out sterile but not are maintained or used
under sterile conditions.
 Skin preps may be packaged sterile, but skin cannot be
sterilized. The process is aseptic.
 Items are set up on clean towels or drapes and used with
examination gloves.
 Items are not sterile or maintained sterile during use.
Extraneous contamination is avoided.
  Disposable items are not cleaned and reused for another
patient.

ASEPSIS IN THE OPERATING ROOM

-All patients are potentially vulnerable to infection, although
certain situations further increase vulnerability, such as
extensive burns or immune disorders that disturb the body’s
natural defenses.
-Typical situations that call for aseptic measures include surgery
and the insertion of intravenous lines, urinary catheters, and
drains.
-The most common source of pathogens that cause surgical site
infections is the patient.
-While microorganisms normally colonize parts in or on the
human body without causing disease, infection may result when
this endogenous flora is introduced to tissues exposed during
surgical procedures.

PREOPERATIVE PRACTICES AND PROCEDURES

 The patient is prepared or prepped by shaving hair from
the surgical site; cleansing with a disinfectant containing
such chemicals as iodine, alcohol, or chlorhexidine
gluconate; and applying sterile drapes around the surgical
site.
 Handwashing is an important step in asepsis.
Indications for handwashing
 when visibly soiled
 before and after contact with the patient
 after contact with other potential sources of
microorganisms
 before invasive procedures
 after removal of gloves.
  A surgical scrub is performed by members of the surgical
team who will come into contact with the sterile field or
sterile instruments and equipment.
-This procedure requires use of a long-acting, powerful,
antimicrobial soap on the hands and forearms for a longer
period of time than used for typical handwashing.
 Sterile surgical clothing or protective devices such as
gloves, face masks, goggles, and transparent eye/face
shields serve as barriers against microorganisms and are
donned to maintain asepsis in the operating room.
This practice includes
 covering facial hair,
 tucking hair out of sight, and
 removing jewelry or other dangling objects that may
harbor unwanted organisms.
 Personnel assist the surgeon to don gloves and garb and
arrange equipment to minimize the risk of contamination.
 Donning sterile gloves requires specific technique so that
the outer glove is not touched by the hand.
 Creating sterile surgical fields with drapes.
 Sterilization of medical Equipment and supplies also
need careful attention.
-checking sterility indicators such as dates or colored
tape that changes color when sterile

INTRAOPERATIVE PRACTICES AND

PROCEDURES
-In the operating room, staff have assignments so that
those who have undergone surgical scrub and donning of
sterile garb are positioned closer to the patient.
 Only scrubbed personnel are allowed into the sterile
field.
 Arms of scrubbed staff are to remain within the field at
all times
 No reaching below the level of the patient or turning
away from the sterile field because that is considered
breach in asepsis.
 Unscrubbed personnel may relay equipment to scrubbed
personnel only in a way that preserves the sterile field.
-For example, an unscrubbed nurse may open a package
of forceps in a sterile fashion so that he or she never
touches the sterilized inside portion, the scrubbed staff,
or the sterile
field.
-The uncontaminated item may either be picked up by a
scrubbed staff member or carefully placed on to the
sterile field.
 Restricting traffic in the operating room
 Maintaining positive-pressure airflow (to prevent air
from contaminated areas
from entering the operating room)
 Using low-particle generating garb help to minimize
environmental hazards.
-The environment contains potential hazards that may
spread pathogens through movement, touch, or
proximity.
 All items in a sterile field must be sterile.
 Sterile packages or fields are opened or created as close
as possible to time of actual use.
 Moist areas are not considered sterile.
 Contaminated items must be removed immediately from
the sterile field
 Only areas that can be seen by the clinician are
considered sterile (i.e., the back of the clinician is not
sterile).
 Gowns are considered sterile only in the front, from chest
to waist and from the hands to slightly above the elbow.
 Tables are considered sterile only at or above the level of
the table.
 Nonsterile items should not cross above a sterile field.
  There should be no talking, laughing, coughing, or
sneezing across a sterile field.
 Personnel with colds should avoid working while ill or
apply a double mask.
 Edges of sterile areas or fields (generally the outer inch)
are not considered sterile.
 When in doubt about sterility, discard the potentially
contaminated item and begin again.
 A safe space or margin of safety is maintained between
sterile and nonsterile objects and areas.
 When pouring fluids, only the lip and inner cap of the
pouring container is considered sterile; the pouring
container should not touch the receiving container, and
splashing should be avoided.
 Tears in barriers and expired sterilization dates are
considered breaks in sterility.

GENERAL HABITS THAT HELP TO PRESERVE A CLEAN MEDICAL

ENVIRONMENT include:
 safe removal of hazardous waste, i.e., prompt disposal of contaminated
needles or blood-soaked bandages to containers reserved for such purposes
prompt removal of wet or soiled dressings
 prevention of accumulation of bodily fluid drainage, i.e., regular checks and
emptying of receptacles such as surgical drains or nasogastric suction
containers avoidance of backward drainage flow toward patient, i.e., keeping
drainage tubing below patient level at all times immediate clean-up of soiled
or moist areas
 labeling of all fluid containers with date, time, and timely disposal per
institutional policy maintaining seals on all fluids when not in use
 The isolation unit is another clinical setting that requires a high level of
attention to aseptic technique.
- Isolation is the use of physical separation and strict aseptic technique for a patient
who either has a contagious disease or is immunocompromised.
For the patient with a contagious disease, the goal of isolation is to prevent the
spread of infection to others.
-In the case of respiratory infections (i.e., tuberculosis), the isolation room is
especially designed with a negative pressure system that prevents airborne flow of
pathogens outside the room.
The severely immunocompromised patient is placed in reverse isolation, where
the goal is to avoid introducing any microorganisms to the patient.
-In these cases, attention to aseptic technique is especially important to avoid
spread of infection in the hospital or injury to the patient unprotected by sufficient
immune defenses.
LESSON 3

WASTE MANAGEMENT
Medical waste is defined as: potentially infectious
materials generated at health care facilities, such as
hospitals, clinics, physician's offices, dental practices,
blood banks, and veterinary hospitals/clinics, as well as
medical research facilities and laboratories.
Waste management -the various schemes to manage
and dispose of wastes. It can be by discarding,
destroying, processing, recycling, reusing, or
controlling wastes
The major sources of health-care waste are:
1. hospitals and other health facilities eg used gloves
2. laboratories and research centers eg specimens
3. mortuary and autopsy centers
4. animal research and testing laboratories
5. blood banks and collection services
6. nursing homes for the elderly/disabled

Categorization of health care waste

1. Infectious waste (e.g., tissues, materials, or equipment that
have been in contact with blood or other body fluids).
2. Pathological waste (e.g., tissues, organs, body parts, blood,
infected animals from laboratories, and body fluids).
3. Sharps (e.g., needles, hypodermic needles, scalpels, and other
blades, knives, infusion sets, saws, and broken glass)
4. Pharmaceutical waste (e.g., expired, spilt, and contaminated
pharmaceutical products, discarded bottles or boxes with
residues, and drug vials).
5. Radioactive waste includes solid, liquid, and gaseous
materials contaminated with radionuclide.
6. Genotoxic/cytotoxic waste may include certain cytotoxic
drugs often used in cancer therapy, vomit, urine or feces from
patients treated with cytotoxic drugs, chemicals, and radioactive
material.
7. Chemical waste consists of discarded solid, liquid, and
gaseous chemicals (e.g., from diagnostic and experimental
work and from cleaning, housekeeping, and disinfecting
procedures).
8. Waste with heavy metal content includes waste containing
mercury, cadmium, lead, and drugs containing arsenic, among
others.
9. Non-infectious/general waste includes waste generated from
offices, kitchens, packaging material, and from stores. It is
similar to domestic waste.
10. Other wastes generated from health care settings include:
 Electronic waste.
 Construction waste.
 Obsolete equipment/furniture.
Purpose of proper waste management
 Protect people who handle waste items from
accidental injury
 Prevent the spread of infection to patients, clients, and
HCWs
 Prevent the spread of infection to the local community
 Safely dispose of hazardous materials

Health Care Risks of Hospital Wastes

1. Potentially harmful microorganisms that can infect
hospital patients, health workers and the general public
2. Drug-resistant microorganisms can spread from
health facilities into the environment.
3. Sharps-inflicted injuries;
4. Toxic exposure to pharmaceutical products, in
particular, antibiotics and cytotoxic drugs released into
the surrounding environment, and to substances such as
mercury or dioxins, during the handling or incineration
of health care wastes;
5. Chemical burns arising in the context of disinfection,
sterilization or waste treatment activities;
6. Air pollution arising as a result of the release of
particulate matter during medical waste incineration;
7. Thermal injuries occurring in conjunction with open
burning and the operation of medical waste
incinerators;
8. Radiation burns.

Principles of Waste Management

Key steps in the management of health care waste are as
follows:
Principles of Waste Management
Key steps in the management of health care waste are
as follows:
1. Waste minimization
- Techniques which focus on reducing creation of
wastes
-E.g waste recycling, waste treatment, use of re-
usable substances/ wastes, waste decomposition
2. Segregation (separation)
Segregation means separating different wastes into
different color-coded bins with liners or sharps
containers at locations where they are generated, and it
is always the first and the most
 important activity in the hospital set up.
Color Coded Waste Bins
1. Red bin—you put highly infectious wastes like
blood, blood products, tissues, specimens, blood
giving sets, tooth, amputated body parts etc.
2. Yellow bin—you put infectious wastes like fluid
giving sets, used gloves, empty syringes, vials,
ampules, tubing, wipes, and empty IVs etc.
3. White bin—you put the food remains e.g. banana
peels, fruit remains etc.
4. Black Bin—you put waste papers like drugs cartons
and packages
3. Collection
It is the transfer of solid waste from the point of use and disposal to the
point of treatment or landfill. Waste collection also includes
the collection of recyclable materials that technically are not waste, as
part of a municipal landfill diversion program
4. Transportation
is the movement of waste over a specific area by trains, tankers, trucks,
barges, or other vehicles.
5. Storage
-Temporary holding of waste pending treatment or disposal. Storage
methods include containers, tanks, waste piles, and surface
impoundments.
6. Treatment
-the process of managing, treating, and disposing of waste in a safe and
environmentally responsible manner. The goal of waste treatment is to
reduce the harm caused by waste to human health and the environment.
- Hazardous waste can be treated by chemical, thermal, biological, and
physical methods. Chemical methods include ion exchange,
precipitation, oxidation and reduction, and neutralization.
7. Disposa
-the collection, processing, and recycling or deposition of the waste
materials of human society. Waste is classified by source and
composition.

Waste management: Reasons for Failure

1. Lack of awareness about the health hazards related to health-care
waste
2. Inadequate training in proper waste management
3. Absence of waste management and disposal systems
4. Insufficient financial and human resources and the low priority given
to the topic are the most
common problems connected with health-care waste.
5. Many countries either do not have appropriate regulations, or do not
enforce them.
Ways of improving health-care waste management are:
1. Promoting practices that reduce the volume of wastes generated and
ensure proposer waste
segregation;
2. Developing strategies and systems along with strong oversight and
regulation to incrementally
improve waste segregation, destruction and disposal practices with the
ultimate aim of meeting
national and international standards;
3. Where feasible, favoring the safe and environmentally sound
treatment of hazardous health care
wastes (e,g, by autoclaving, microwaving, steam treatment integrated
with internal mixing, and
chemical treatment) over medical waste incineration;
4. Building a comprehensive system, addressing responsibilities,
resource allocation, handling and
disposal. This is a long-term process, sustained by gradual
improvements;
5. Raising awareness of the risks related to health-care waste, and of safe
practices; and
6. Selecting safe and environmentally-friendly management options, to
protect people from hazards
when collecting, handling, storing, transporting, treating or disposing of
waste.
METHODS OF WASTE MANAGEMENT
Landfills
-This process of waste disposal focuses attention on burying the waste in
the underground.
-There is a process used that eliminates the odors and dangers of waste
before it is placed
into the ground.
-Landfills give rise to air and water pollution which severely affects the
environment and
can prove fatal to the lives of humans and animals.
Incineration/Combustion
-Incineration or combustion is a type disposal method in which
municipal solid wastes are burned at high temperatures. The process
eventually converts them into residues and gaseous products.
-The biggest advantage of this type of method is that it can reduce the
volume of solid waste to 20 to 30 percent of the original volume.
-Additionally, it also decreases the space they take up while also
reducing the stress on landfills. Incinerators are primarily used in
thermal treatment where solid waste materials are converted to heat, gas,
steam, and ash.
Recovery and Recycling
Resource recovery is the process of taking useful discarded items for a
specific next use.
These discarded items are then processed to extract or recover materials
and resources or convert them to energy in the form of useable heat,
electricity or fuel.
-Recycling is the process of converting waste products into new
products to prevent energy usage and consumption of fresh raw
materials.
The advantages of recycling are to reduce energy usage, reduce the
volume of landfills, reduce air and water pollution, reduce greenhouse
gas emissions, and preserve natural resources for future use.
Plasma gasification
- Plasma is primarily an electrically charged or highly ionized gas.
Lighting is one type of plasma that produces temperatures that exceed
12,600 °F.
-With this method of waste disposal, a vessel uses characteristic plasma
torches operating at +10,000 °F which is creating a gasification zone till
3,000 °F for the conversion of solid or liquid wastes into a syngas.
-During the treatment of solid waste by plasma gasification, the waste’s
molecular bonds are broken down as a result of the intense heat in the
vessels and the elemental components.
Composting
-Composting is an easy and natural bio-degradation process that takes
organic wastes i.e. remains of plants and garden and kitchen waste and
turns into nutrient-rich food for your plants.
-Composting, normally used for organic farming, occurs by allowing
organic materials to sit in one place for months until microbes
decompose it.
Waste to Energy (Recovery Energy)
-Waste to energy (WtE) process involves the conversion of non-
recyclable waste items into useable heat, electricity, or fuel through a
variety of processes.
-This type of so energy is a renewable energy source as non-recyclable
waste can be used over and over again to create it.
-WtE can also help reduce carbon emissions by offsetting the need for
energy from fossil sources.
-Over time, this reduces global warming and makes our environment
better.
Special Waste Disposal
-There are certain waste types that are considered hazardous and cannot
be disposed of without special handling which will prevent
contamination from occurring.
-Biomedical waste is one example of such a waste disposal method.
-It is primarily practiced in health care facilities and similar institutions.
-The special waste disposal system effectively disposes of hazardous
biomedical waste.
Avoidance/Waste Minimization
-The easier method of waste management is to reduce the creation of
waste materials
thereby reducing the amount of waste going to landfills.
-Waste reduction can be done through recycling old materials like jar,
bags, repairing broken items instead of buying a new one, avoiding the
use of disposable products like plastic bags, reusing second-hand items,
and buying items that use less designing.
 LESSON 4
SURGERY
Surgery-