Infection Prevention and Control ; CRITICAL THINKING What Should You Do? a ‘Azryearold child is admitted to the pediatric unitwith a diag- nosis of suspected meningococcal meningitis. What nursing action should the nurse carry out first? ‘Answer located on p. 1079. Health Care-Associated Infections A. Description 1. An infection that is developed during hospital stay and that was not existing or incubating at the time of admission or becomes evident after discharge from the hospital. a Js), excluding infections that have incubation 48-72 hours (Table 75-1) iated pneumonia catheter-elated bloodstream infections |. Ventilator-Associated Pneumonia A. Descri in: SSRN ae SPIE ‘The client develops signs and symptoms of respiratory tract infe ql ventilatio 3. Proper hand hygiene as per WHO recommen- dations. 4, Frequent oral care with antiseptic, unless contra- dicated (Box Itis recommended to avoid histamine receptor ( an ts who are not a oping a stress ulcer or stress gastritis. 7. Itishighly recommended toadoptwaysofreducing thecontamination ofequipmentused to carefordi- ents receiving mechanical ventilation (Box 75 gical Site Infections A Deseipion An SSlis an infection that after the operation in the part of the body ‘where the surgery took place. Surgical site infections can sometimes be superficial infections involving the skin only. Other surgical site infections are mo™ serious and cé organs, or SSls report per year (1796 of all HAls, second *° UTIs). 29-5% of clients undergoing surgery devel? SSI with 3% mortality. B. Risk factors 1. Endogenous lent floraof As; Dn ss Aminimal stitch abscess 1 Alocalized stab wound tr infecton in circumcision site {Surgical bum wound 1s Diry infected cases 1s Apositive culture of « urinary cat tree nan cat ip wth give sl ‘= Purulent phlebitis confirmed with a roe a snd a Oral Care (ral cavity fracture fase sll fracture were thrombocytopenic client ‘cate|Chronic coagulopathy Strategies to Minimize Contamination Bae tia 1 Remove condensate from ventilator circuits by Keping the circuit lose 1 Vihen the ventilator circuit is visibly soiled or malfunction: ing, then only change them Stee and disinfect respiratory equipment proper Stare ina dy place 1 itis must to discard periodiealy any conden inthe tubing of @ mechanical ventilator Set Bes he rc o change ror Pea at ae a ear ewsiure eran! ue ST byadlent, unless visibly soiled/malfunds> 1 Torinse reusable respiratory equipment 1% tse sterile water and then keep it lea" cate that collects visable 8 i. skin and mucous membrancs ii. GI tract and Surgical personnel (SUB? oe team). >. Soiled and i Breaks in aseptic tech? | inadequate hand byBien®, oq _jlation: Physical environment and ver ts brought ¢° Tools, equipment, and materials the operative Fld pia prophv g. iaprepste a 1h, Improper © Clinical features Skin Subcutaneous tissue Deep sot (tascia and rmunscl)| organspace FIGURE 75-1 Skin ayers 2. Infection involves skin or subcutaneous tissue oF the incision. 43, Purulent drainage from the superficial incision. 4. Organisms isolated from the culture of fluid or ym the incision. ‘of superficial incision by surgeon on follow-ups 6. Diagnosis of SSI by the surgeon or attending cian. . Formula to calculate SSIs: Number of SSI cases) 99 Number of surgeries) “ E. Nursing care 1. Educate the management. ‘Proper skin preparation with antiseptic solutions. Hait removal by clipper not by razor. Proper bowel and bladder emptying before operation. ‘sseptic postoperative incision care. Health education about wound care ‘administration of antimicrobial as per policy. Admin hyene a pet WHO recommen- dations. ‘Adhere to prevention strategies (Box 75-3). dlient about postoperative ‘A. Description 1. Catheter-associated urinary tract infection Seen elted tary put of he wsnaryUmts are te st common type of health care Saar ee ‘may pe ‘meatal, rectal, or vaginal colonization) o . , usually via contaminated hands of healthcare personnel during catheter insertion or manipula- tion ofthe collecting system (Table 75-2). = Administer antimicrobial prophylaxis as per evidence- based standards and guidelines. Identify and treat localized infection before elective ‘TABLE 75-2 Causes of CAUTI ator tar ES oak up a Wigan of organism though ee cater soas% ‘surface (catheter-urethra interface) ic Miraon for contaminated alton bag ot —_ayyoX drainage tube : imen with >10 WBC/mm? or fer field of unspun urine). 10, Pyuiria (urine speci >3 WBC/high pow 1. 12. 10° colonies/mL of a single microorganism in a client being treated with an effective antimicro- bial agent for a urinary tract infection. C. Formula to calculate CAUTI cases: Number of CAUTI cases ) eae (rar ‘Number of catheterization days, D. Nursing care 1, Insert catheters only for appropriate indications as discussed in Box 75-4. 2. Leave catheters in place only as long as needed Do not let the catheter in for long time. 3, Ensue that only properly trained persons insert and maintain catheters following the strict asep: tic technique. 4, Ensure proper securement of catheter. 5. Maintain a closed drainage system following the aseptic insertion of catheter. 6. Maintain unobstructed urine flow by keeping the bag below bladder level. Regular catheter care with perineal care. Sateen A. Description; Catheter-related bloodstream infection can be described as the presence of bacteremia origi ating from a catheter after 48 hours of insertion, It Extraluminal * Early, at insertion * Lato, by capiary action I ‘intraluminal ‘Break in closed drainage ‘Contamination o collection bag urine FIGURE 75:2 Catheterassociated urinary tact infection development.js one of the most frequent, lethal, and costly plications of central venous catheterization Itis also : the most common cause of health care associated bacteremia. 2, Pathogenes 1. CDCestimates that 15 million CVC days occur (Table 75:3). the United States ICUs each yea alas 5 eas tcaneparent and semipermeable cre infection rate of 5.3 per 1000 catheter days in at cover the ethers al pice es ICU yields approximately 80,000 CRBS! in IC Semanal alone with morality rate 35%. Main causes are as follows: a. Invasion of the percutaneous tract (during insertion or in the subsequent days). b. Contamination of the catheter hub during guidewire insertion or during manipulation. . Seeding from a remote source of localized infection. ¢. Clinical features 1. CVC in situ with signs of catheter insertion site infection. Standard Precautions 2. Clinical symptoms and signs of Description: Standard precautions are the minimum i mms of bacter- infection prevention practices that apply to all client care, regatdless of suspected or confirmed infection sta- tus ofthe client, in any setting where health care is deliv ered. They are meantto reduce the risk of transmission of blood borne and other pathogens from both recognized and unrecognized sources. Number of CRBSI cases ) foo "Standard precautions in sails Total Number of catheter days, ‘ E, Nursing care ves, gowns, Xproectve rumen(PP ob ; and aseptic technique. * |. Hand hygiene ey petal sterile barier precautions : 3. Prepare clean skin with an at) a ‘A. Hand hygiene before CVC insertion. 1, Hand hygiene, including use or gst ‘Ha (AE an hand washing with soap and water or antimicrobial agent, is critical to reduce the risk of spreading infections. The use of ABH is the primary mode of hand hygiene in health care settings. 2. Benefits of ABHR: D. Formula to calculate ‘Appropriate Indications for Catheterization fe Acute urinary retention ot sction in fete bladder outlet obstu a. Activity against abroad spectrum of pathogen ca vce who need accra mensuremers of Se aeeane Gi ing eg client has open sacral or per . Less hand irritation = Bak wot et a 4d. Can be facilitated at the client bedside sa Taimprove comfort for end of ie, oe i ToimPrqutes srt prolonged immobilization feg die ents feature of oh multiple injures ef) TABLE 75.3 Hierarchy of Catheter Insertion Site a leted perioperative needs ac Sipe nein Oe ince re atracures of the genitournay tack Cetin « Asatedplorged uation fey oP Sh Rate (%) © areearge volume infusions or duets ae atch opm saeaey pated during surgery ies a 4s «When there isa need for intraoperative monitoring of ess optimal Internal jugular os Ferra 38 urinary output Anat3. For these reasons, ABHR is the preferred method. for hand hygiene except when hands are visibly soiled (eg. dirt, blood, body fluids), or after car- ing for clients with known or suspected infectious diarthea (eg. Clostridium difficile, norovirus), in Which case soap and water should be used. Aisiesh hands afer emoral of gloves and any means of Pts. 4. Key elements at a glance a. Perform hand hygiene by means of hand rub- bing or hand washing (refer specific indica- tions in Fig. 75-3). 'b, Must perform hand washing with soap and water if hands are visibly soiled, or exposure to spore-forming organisms is proven or strongly suspected, or after using the restroom, © Otherwise, if resources permit, perform hand rubbing with an alcohol-based preparation. 4. Ensure availability of hand-washing facilities ‘with clean running water. e, Ensure availability of hand hygiene products (clean water, soap, single-use clean towels, ABHR). ABHRs should ideally be available at the point of care. £ Summ: i ands and ‘apply soap; rub all sui hands and dry thoroughly with a single-use tows faucet. it, ply enough as of the hands; rub hands until dry. iii, Technique of hand hygiene; refer to Fig. 75-4 M B® FIGURE 75-4 Steps of hand hygiene. B. Personal protective equipment i Personal protective equipment (PPE) refers to ‘wearable equipment that is used to protect health care worker from exposure to or contact with infectious agents (Table 75-4). Selection or choice ‘of PPE depends on different variables (Box75-5). Indications of PPEs (Table 75-5) Key recommendations for use of PPE a. ‘The hospitals should ensure sufficient avail ability of PPE. It should be readily accessible to health care worker. All the health care workers must be educated on appropriate selection and usage of PPE. Educate all health care workers on proper selection and use of PPE. . Ensure to remove and discard PPE before leaving the client's room.‘Washing gloves for reuse is strictly prohibited. Such practices are discouraged. Perform hand hygiene immediately after removing gloves. ‘e. Change gloves while moving from one client to another. Do not wear the same gown for the care of more than one client. f. Always wear mouth, nose, and eye protection during procedures that are likely to cause splashes or spsays of blood or otherbody fluids. g. Always wed a surgical mask when placing a oF injecting material into the spinal ‘anal or subdural space. «Injection safety 1, Injection safety includes practices that will pre- vent transmission of infectious diseases from one source to another. Health care workers are responsible for passing infection. 2, Nonaseptic method of medication administra- tion can cause bacteremia, which can lead TABLE 75-4 Infectious and Noninfectious Agents 1 Blood 1 Saliva Sere f= Sweat 1 Vaginal secretions = Urine 1 Cerebrospinal uds 1 emesis 1 Synovial fd f Fecal maters 1 Pleural fie Note: Not considered as Peritoneal fd potently infectious unless they Peieatdal uid and arwiotic contin blood uid ‘= Human breast mil, all ral Secretion: in dentistry id any body ud, which contains sible blood —_EEETE oa Type of exposure anticipated ® Splash/spray versus touch 1 Category of isolation precautions: ‘© Durability and appropriateness forthe task ——_ TABLE 75.5 Indications of PPES Usage Contact withbloed or body Mud, mucous rombranes, nonintat skin or potentially Infectious materi ‘To protect cothing while doing activities which ean antcpate splash exprators Protect expiratory ac from aibome Infectious agents /Gorsies To protect face and eve to bloodstream infection and other infective complications. i 3. Cross-contamination of administrative devices can increase the risk of health care associated infections. 4. Key recommendations for safe injection practices a. Always follow aseptic technique when pre, paring and administering medications an‘ injections. b. Use 70% alcohol for cleaning the access dia- phragms of medication vials before inserting the needle into the vial. Needles/syringes ‘must never be shared between clients. € Do not reuse a syringe to enter a medication vial or solution. 4. Ensure multidose vials to one client only. fe. Do not administer medications from ampoules, bags, bottles, and single-dose or single-use vials of intravenous solution to ‘more than one client. £ Do not use fluid infusion or administration sets (eg, intravenous tubing) for more than one client. sg Usage of multidose vials should be limited to centralized medication area only ifitis to be used for more than one client. Scrub the hub of cannula before administering medications. There should be a separate facility for prepar- ing the medications. D. Cleaning and disinfections (Box 75-6) 1. Cleaning refers to the removal of visible soil and ‘organic contamination from a device or environ ‘mental surface using the physical action of scrub- bing with a surfactant or detergent and water, oF ‘an energy-based process (e.g, ultrasonic cleaners) ‘with appropriate chemical agents. This process removes large numbers of microorganisms from. surfaces and must always precede disinfection, Disinfection is generally a less lethal process of microbial inactivation (compared to steriliza- tion) that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g, bacterial spores), Sterilization is the total destruction or removal of all living organisms includin; ‘Any microorganism, that come in contact 8 bacterial spores. including bacterial spores i with normally sterile ts can cause intone that come i ‘act with normally sterile tissues s robe ecard ies should be steri- Management of health care wastea 8 sibility in Cleaning and 1% The policies and procedures for routine leaning and dis- Infection of environment surfaces shouldbe in place. = There should be proper allocation of responsibly for cleaning of various environment surfaces. Adequate train- ing tobe provided before delegating the task Cleaning pro cedures should be periodically monitored or assessed to check the efficacy ofthe product being used. = Potency of disinfectants or detergents should be monitored, 1 Follow the manufacturer's instruction for amount, dite tion, contact time, safe use, and disposal. 1 ‘Shelf ofthe chemical should be maintained as pr hos- pital policy The date of opening end expiry must be men- tioned wherever applicable. TABLE 75-6 Spaulding Classification Device iMding Process Product Gieieaton —lasfetion Gaal Ciel eter sre Stizton= ——__Strlam/dinfctane tissue of vascular” spool chemin! system) Prolonged contact Semicitsl (ouches Hightevel mucous) membranes disinfection (evcept dena) ‘Sterlant/ disinfectant Spoil chemi short contact [Nonestial (touches Intact stn) Lower dsinfection Hospital disinfectant swith label lai for Tubereulodal activity Not all the hospital waste is hazardous. Some are nonhazardous like kitchen waste or recyclable items. Infectious waste causes health hazard to those who manage or handle it, and nearly most of the reported cases of disease transmission from ‘thehospital arerelated toimpropersharps disposal 2. Segregation is the most important and vital step in waste management system. With proper segre- gation at source, a hospital can reduce the following: a. Total treatment cost b. The impact of the waste on the surrounding, environment ‘The chance of infecting waste handlers ‘The hospital personnel should be well trained in hospital waste management sys tem. There are few variations in the color of the bins as per the state regulations. 3. According to the recommendation of Centers for Disease Control and Prevention, medical waste that needs special treatments are as follows ‘a. Contaminated sharps . Microbiological waste from laboratory Based Infect Precautions Airborne infection (Tuber ‘oss, varicella, Herpes zoster, measles) Aime precautions 1 Standard precastion © Isolation oom wth negate pressure and specs eye and Ee management Droplet infection (Pertussis, ciptheria, mumps, mening) Droplet precautions Standard precaution isoaton/Snglereom/cubice ‘her with Sane miroorgeism hreefet distance betwecs best Contact infection (RSA, MR, veal hemor thagieconjunetitis, skin Infections) Conte: precautions {Standard precaution 2 Single roomjeubicie 1» Cohor with ame microorganism 2 Three fet dstane betwen beds ES _—_—__—_ aa ¢. Pathological tissues and organs 4. Blood and blood products . Items contaminated with blood or body fluids Transmission-Based Precautions 1. Precautions for (Table 75-7) 2. Additional considerations Isolation practices and other transmission-based precautions are needed for selected cases like air bone, droplet, or contact mode infections. Source isolation can be divided into three categories: 4, Strict Forhighly transmissible or dangerousdliseases b. Standard: For most other communicable diseases For diseases where the main pathway ion is airborne, including pulmonary tuberculosis ‘ransmission-based infections Sharps injuries ‘A. Sharps injuries are well-known and documented for the risk associated with them, Sharps contaminated with an infected client's blood can transmit more than 20 diseases, including hepatitis B, Cand human immunodeficiency virus (HIV) B, A sharps injury isan incident, which causes a needle: blade (such as scalpel), or other medical instruments to penetrate the skin. oe €. One sharps injury can cause a number of direct an indirect costs for the health care facility, includingyr of ob/away from work Aas UXcof weatment oO replacing staff 4 Oo of compensation to staff 2 Cos on the affected worker ‘Waiting peviod stress Mpls of hits situations epg et cae: Petnseting oF withdrawing a needle, espec hile giving injections bp inserting needles into TV Tines, lea tdient bedside or table eis lee ¢. Handling or passing sharps especially i 4. immediately after sharps use neuer Oh a. Recapping a used needle b. Transferring or processing specimens ¢. Needle left in tray after procedure 44 During and afier sharps disposal: a. Disposing of sharps into proper cont 'b. Cleaning up after a procedure oe ce Sharps (needles, lancet, etc) lefton floors and tables, or found in linen, beds, or waste containers 2 E. Key points to follow after shanps injuries 1 ercourage the wound to gently bleed, ideally hholding,it under running water downward ‘2. Wash the wound using running water and plenty of soap a eat erubjsquecze oF milk the wound while 4, Dontt suck the wound S. Dry the wound and cover i planer or dressing 6 Bose np co ER ion See pt use tc. #8 PET YOU a tan jy youremplavenfeion o> twol team i with a waterproof acre worker in the ete nee ote sharp devices, ‘Torani sharps 30) cei TABLE 75-8 HIV Prophylaxis Type Duration F. Pre-exposure prophylaxis for Hep B infection G. Vaccination series L 2. Mandatory for all staff in contact with clients and lient-conta f H. Post exposure prophylaxis for nonvaccinated victim from positive source: 1. Hep B: 2. HIV prophylaxis (Table 75-8) Key recommendations for prevention of sharps injuries 11 The safety devices on needles and other sharps should be activated immediately after use. 2. Used needles should be discarded immediately afer use. 43. Never recap, bent, cut, removed from the syringe ot tube holder, of otherwise manipulated 44 Any used needles lancets,or other contaminated ‘Sharps should be placed ina leak-proof, puncture- fesistant sharps container that is either prominent in color or labeled with a bioh: 6. Used sharps containers may be taken to a collec: tion facility, and do the treatment as per local policy. CRITICAL THINKING What Should You Do’ Wi ‘Answer The frst therapeutic intervention includes adoption ‘of isolation precautions. Remember to protect yourself too. 927. The clinical educator is taking a class for nurs Studs on vanomision of anthrax The nase tell those attending that anthrax can be trans- ‘mitted by which route(s)? Select all that apply.