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CHALLENGES IN HEALTHCARE AND
INFECTION CONTROL
DR LEE OI WAHPEG PERUBATAN UD 54
Challenges
Prevention of infection
Early and accurate diagnosis
Effective treatment
Outbreak prevention and management
Greatest challenge in infection control is ……….. Outbreak prevention and
management
Healthcare Associated Infections (HAIs)
Multidrug Resistant Organisms (MDROs)
MRSA E.coli VRE
Our usual response has been…….
Surveillance
Control measures
BUT problem continues…….
HISTORICALLY
SARS VRE H5N1
New Challenges (continue)
Changing healthcare system- Rising healthcare costs- Length of stay- Moving healthcare from inpatient
to other settings - outpatient care, long term care facilities
We need to be prepared!!HOW?
Hayati S, ID HSB 2010
CDC UNIVERSAL PRECAUTIONS (1987) Recommendations for Prevention of HIV Transmission in
Health Care Setting. Universal Blood and Body Fluid Precautions.
Universal Infection Control Precautions.
The entire focus: protection of HCW from parenteral, mucous membrane and non intact skin exposure to bloodborne pathogens (blood & blood stained body fluids)
BASIC ELEMENTS OF STANDARD PRECAUTION Hand hygiene Correct usage of gloves Correct usage of PPE ~ goggle/shield ~ gown/apron ~ mask Cleaning/disinfection/sterilization Handling of clinical waste/linen/speciment Waste segregation Safe handling of sharps Handling of spillage
Hayati S, ID HSB 2010
Hayati S, ID HSB 2010
CDCStandard Precautions & Additional precautions (1996)
Revised recommendations Focus - Protection of HCWs and to reduce transmission of infectious agents among HCWs (clinical & non-clinical), patients, relatives and environment.New addition : Respiratory hygiene
Protective environment
Hand hygiene
Hayati S, ID HSB 2010
Hayati S, ID HSB 2010
RESPIRATORY HYGIENE
RESPIRATORY HYGIENE
Cover your mouth and nose with tissue when you cough or sneeze
Throw your used tissue into the plastic bag
Throw the plastic bag into the clinical waste bin
Hand hygiene with soap and water or alcohol hand rubs
Wear the surgical mask to protect other
New category in Expanded PrecautionsProtective Environment (PE): for allogenic haemopoetic stem cell transplantation (HSCT)
patients Environmental controls
HEPA filtration of incoming air directed room air flow positive room air pressure relative to corridor well-sealed rooms (sealed walls, floors, ceilings, windows,
electrical outlets) 12 ACH (Air Exchanges per Hour) no carpets and upholstery, routine cleaning of sprinkler heads no dried / fresh flowers and potted plants
Other measures N95 mask for patients upon leaving room
NEW
Routes of disease transmissionInfected humanInfected human
AirAirFood Direct Indirect Vectors WoundsFood Direct Indirect Vectors WoundsWater contact contactWater contact contact
Susceptible HumanSusceptible Human
Ref: Microbiology, Fundamentals and applicationsRef: Microbiology, Fundamentals and applications
TRANSMISSION BASED PRECAUTIONS
Hayati S, ID HSB 2010
Definition of Healthcare Associated Infection Outbreak (Either One )
1. Two or more associated cases occurs at the same time within same locality/department
2. Greater than expected rate of infection compared with the usual background case for the place and time
3. In certain newly emerging disease e.g. Legionnaires infection or anthrax, will only require 1 single case.
Why Infection Control? The rise in the rate of HAI over the past 20 The rise in the rate of HAI over the past 20
years (36%)!years (36%)! Various Impacts of HAIVarious Impacts of HAI To minimize risks to patients, staff and To minimize risks to patients, staff and
visitors from HAIvisitors from HAI To reduce hospital costs of treating HAI and To reduce hospital costs of treating HAI and
tying up hospital beds.tying up hospital beds. SENIC study: SENIC study:
18% increase in infections – no IC 18% increase in infections – no IC programmeprogramme
32% reduction in infections – with IC 32% reduction in infections – with IC programme.programme.
Predisposing factors for HAI Extended length of stay esp in
intensive care or HDU Length of antibiotic treatment Prior administration of broad spectrum
antibiotic esp. 3rd generation cephalosporins.
Proximity to another patient with multiple resistant organism (MRO).
Exposure to healthcare worker for a patient that carried MRO.
Ventilator-assisted pt.
RISK FACTORS FOR HAI Iatrogenic ~ hands of HCW
~ invasive procedures eg IV,
CBD , CVP etc Organizational ~ overcrowding
~ air-conditioning system
~ physical lay-out & staffing
pattern Patient related ~ chronic illness
~ immunosuppression
~ prolong stay in the ward
Common sites associated with etiological agents Urinary tract (UTI) Surgical wounds (SSI) Respiratory tract Skin (especially burns) (MRSA) Blood (bacteraemia) Gastrointestinal tract Central nervous system
Doctorrao’s ‘e’ learning series
The Principles of Infection Control
Hands Hygiene FoodFoodPracticePractice
ClothingClothing LinenLinen
EnvironmentEnvironmentEquipmentEquipment
DisposalDisposal
Infection control Every health worker plays a vital part
in helping to minimise the risk of cross infection
For example by making certain that hands are properly washed, the clinical environment is as clean as possible, ensuring knowledge and skills are continually updated and by educating patients and visitors.
Infection control 1—Achieving optimum hand hygiene. 2 – Using personal protective equipment. 3 – Safe handling and disposal of clinical
waste and bodily fluids. 4 – Achieving and maintaining a clean
clinical environment. 5 – Good communication, with other health
care workers, patients and visitors 6 – Training and education.
The chain of infection.
Source of infection
Method of spreading
Person at risk Point of entry
Breaking this chain by removing any part of it will control or stop the spread of infection
Contaminated surfaces increase cross-transmission
Hayati S, ID HSB 2010
Breaking the chain…..
Hayati S, ID HSB 2010
Surveillance and Outbreak investigation
~ An important role of ICN~ 30-60% of work time~Purpose of surveillance : 1. To establish the endemic baseline rates of NI. 2. To identify impending outbreak. 3. Convince clinical personnel - For implementation of infection control policies and protocol. 4. For evaluation of infection control measures.
5. Supportive evidence of quality.6. To defend malpractice.7. Satisfy regulators (accrediting bodies)8. Inter hospital comparison.
Purpose of surveillance
Establish background rateVerify diagnosisFormulate a case definitionIdentify cases
Outbreak control measures according to known mode of transmission and appropriate source control
Methods of surveillance
Passive/active Retrospective/prospective Observation/Questionnaires Reviews
Surveillance Studies Involves data collection 2 primary methods:
i) hospital-wide ii) targeted“Focused epidemiological studies” MRSA Multi-resistant gram negatives (Klebsiella,
Acinetobacter, E. Coli) Outbreak investigation
CASE FINDING
ActiveLab reportPatient chart reviewRegular review with ward staff.Nursing kardex /care planObservation chart (temp)Survey discharge patients
PassiveReport by ward staffDischarge record review.
Suspicion of an impending OB
Two or more patients are found to have an infection attributed to a same species of organism.
Multiple infection of a similar nature are reported by ward staff,
Emergence of organism not previously noted in the specific unit.
ROLE OF ICN IN OUTBREAK
Ward visit
~ Check for any breach in infection control
procedures.
~ Any deviation in the ward routine
environment eg ventilation, new staff,
influx of trainee
~ Studying each case /line list sequence of
event
~ Sampling when applicable
Collection of Data in Cross Infections Always collect information and document
information on 1 Patient details 2 Site and extent of infection 3 Date of admission – operative procedure first recognition of infection 4 Specimen and laboratory isolates and typing results
5 Ward and staff details. Doctorrao’s ‘e’ learning series
ROLE OF ICN IN OUTBREAK
Liaise with clinical staff ~ Advise, recommendations, at hoc awareness program. ~ To stop further cross infection. ~ Discuss the possible control measure to be initiated. ~ Pt progress report.
ROLE OF ICN IN OUTBREAK
Inform the administrator ~ Report incidence of OB to the management for decisions ~ Closing of ward. ~ Alternative ward to cohort the infected patients
ROLE OF STAFFS IN INFECTION CONTROL
Staff education ~ Familiarization with hospital infection control policies and procedures ~ On-going education, campaigns and
specialized education to increase awareness of illnesses, infection risks and preventive measures ~ Staff education is of UTMOST importance in infection control
Containment of Infection Good patient care practices
HANDWASHING Care of hospital equipment Infection control policies Prophylaxis of health care workers
Efficacy of Infection control
The Following measures will certainly control the infections
1 Sterilization 2 Hand washing 3 Closed drainage systems for urinary catheters.� 4 Intravenous catheter care
5 Peri operative antibiotic prophylaxis for contaminated wounds, and care of equipment used in respiratory therapy.
飈
EMPLOYEE HEALTH PROGRAM
Objectives:1. To improve the safety of the hospital
environment2. To maintain the well-being of healthcare
workers3. To contain or reduce costs resulting from
absenteeism
Immunization Program Ensuring that staff are immuned to
vaccine preventable diseasesi) Immunization of new and currently
employed staffii) Continual review of immunization status
Sharp injuries and Post-exposure Management Prompt diagnosis and management is
important A hospital policy on reporting and
management should be made known to all staff
Record keeping
KEY ELEMENT FOR THE SUCCESS OF INFECTION CONTROL PROGRAM
Learn the expertise and skills required for the practice of infection control in hospitals
Collect data on hospitals-acquired infections in the country
Press the health authorities to provide resources and deploy full-time ICNs
Initiate training for IC personnel Initiate IC programmes at the local hospital
level Provide vehicles for collaboration and
continuing education.
“Above all, a hospital must do the patient no harm”
(Florence Nightingale)
Hayati S, ID HSB 2010
The End. Thank you!!
There are 3 types of people in the world
Those who MAKE things happen
Those who LET things happen
Those who WONDERED what happened!