Infection Control

in Hospital

Very Warm Welcome to

All

ContentsIntroductionSpread of infection in HospitalInfection control PracticesEnvironmental Management of Infection

ControlDecontamination, Sterilization and

DisinfectionApplication of Nursing Process in

Infection Control

IntroductionInfection may be transferred

◦ patient-to-patient,

◦ patients to staff

◦ staff to patients,

◦ or among-staff.

Infection control includes

◦ prevention (via hand hygiene/hand washing,

cleaning/disinfection/sterilization, vaccination, surveillance),

◦ monitoring/investigation of demonstrated or suspected

spread of infection within a particular health-care setting

(surveillance and outbreak investigation),

◦ and management (interruption of outbreaks).

History of Hospital Infection Control

Florence Nightingale was the first person to work for infection control in hospital.

In 1847 Dr. Ignaz Philip Semmelweis identified that 18% Mortality due to Puerperal Fever.

Case control study significance of hand washing was

demonstrated. Concept of “nosocomial infection was born.

Background Infection rate in developing countries was 15.5 per 100

patients, compared to “.1 [per 100 patients] in Europe and in the U.S., 4.5- BBC

ICU infection - developing countries: 47.9 per 1,000 patient, compared to 13.6 in the U.S.

In countries like India and Nepal, hospital infection data not reliably estimated.

Surgical infection at BPKIHS -1339 (7.3%) among 18325 total surgeries.

Estimates vary from 10 to 30%, the least being about 3% in the best of hospitals

Wound sepsis alone affects 20% of post-operative cases

Hospital infection adversely affects the image of hospital.

Nosocomial infections : ◦direct death 1%◦Indirectly mortality in 3%

50% of nosocomial infections are preventable.

The main health care related infections are

1. Urinary tract infections

(catheter-associated)

2. Surgical site Infections

3. Bloodstream infections

(central line-associated)

4. Pneumonia (ventilator-

associated)

Healthcare-Associated Infections – Numbers and Costs in USA

Total HAIs 1.7 million

Deaths 99,000

Average additional direct cost to hospital

$13.6 billion

Overall net hospital cost $8.5 billion

Not counted are •Costs to patient/QALY, payer, provider, society, caregiver time/resource•Intangibles such as pain and suffering•Indirect: lost productivity, lost retirement savings and benefits•Decreasing HAIs by 25% would save $148,667 per hospital

Infectious Agent

Sources

Portal of Exit

Mode of Transmission

Portal of Entry

Susceptible Host

Spread of INFECTION

Bacteria, Fungi, Virus, Parasites

Human BeingsAnimalInanimate Object

Sputum, Emesis, Stool, Blood

Contact, Vehicle, Air borne, Vector borne

Mucus Membrane, Non intact Skin, GI tract, GU tract, Respiratory Tract

Immuno -Suppressed, Elderly, Chronically ill, trauma, newborn, surgery

3. Infection control practices

Standard Precautions

Additional (Transmissio

n-Based) Precautions

3.1. Standard Precaution

Hand washing

Use of personal protective equipment

Appropriate handling of patient care equipment and soiled linenPrevention of needlestick/sharp

injuriesEnvironmental cleaning and spills-

management

Appropriate handling of waste

Additional (Transmission-Based) Precautions

Airborne precautions

Droplet precautions

Contact precautions

4. Environmental Management for Infection Prevention

Air, Ventilation

WaterCleani

ng The Hospit

al Environment

Vector

Control

Waste Management

Radioactive Waste

TYPES OF PATHOGENIC WASTE IN HOSPITAL

4.5.2. Color Coding of Container for Bio- Medical Wastes Disposal

Red Colour:Blood and its product, pad contaminated

with body fluid, dressing items, used infusion sets, used catheter set, contaminated cotton roll etc.

Human anatomical waste(eg. tissues, organs, body parts etc).

BlueFree from blood contaminated

items such as; saline bottle, gauze, pad, I/v set, drugs cover and literature.

GreenFruits cover,kitchen waste, non ca.

medicine ampoule, and dry items only.Non con blood taminated items should be kept in green color's container.

Plastic container or cartoon boxSharps items or skin pricking

materials Such as: needles, syringes, scalpels, blades, glass etc. that may cause puncture and cuts. This includes both used and unused sharps.

Extra bucket or black plastic bag:From the site of operation theatre

items such as; body parts, tissues).

Orange: Laboratory related items eg.

vial,chemical reagents etc.

4.5.3.Laundry

Handle all linen with minimum agitation.

Place soiled/contaminated linen in impervious bags

for transportation.

Disinfect by using hot water and/or bleach (use

heavy-duty gloves, eye protection and masks to

protect against splashes).

Wash linen in hot water (70°C to 80°C) and detergent,

rinse and dry preferably in a dryer or in the sun.

Wash woollen blankets in warm water and dry in the sun.

Bed Cover: Change weekly or whenever soiled and on discharge.

Bed sheet: Change on alternate day or whenever soiled and on discharge.

Mattresses and pillows: Cover with inpervious plastic. They can be cleaned by wiping with a housekeeping disinfectant- detergent.

Blood stained linen: Soak in 1% sodium hypochloride for 30 min. and send to laundry.

Decontamination, Sterilization, Disinfection

5.1. DecontaminationDecontamination of medical equipment

involves the destruction or removal of any organisms present in order to prevent them infecting other patients or hospital staff.

14 gm≈ 3 tea spoon Bleaching

Powder/lt

1 part Sodium Hypochloride to 4 parts of water

SterilizationSterilization is the destruction of all

micro-organisms.1. Autoclave (Steam Under Pressure)2. Flamming3. Chemical Sterilization

i. Glutaraldehydeii. Alcoholiii. Formalin

4. Gas Sterlizationi. Ethylene Oxide

5. Iradiation

5.2.2. Sterilization Method Available In BPKIHS

Autoclaving: 4 machine in CSSD, 1 not functioning

2% Glutaraldehyde solution : as necessity in each ward

Gas sterilization by formalin tablet in OT for suction pipe, cautry wire, tip etc.

5.2.2. Storage of Sterile Equipment

Keep the storage area clean, dry, dust-free and lint-free.

Control temperature and humidity (approximate

temperature 240C and relative humidity <70%) when

possible.

Packs and containers with sterile (or high-level disinfected)

items should be stored 20–25 cm (8–10 inches) off the

floor, 45–50 cm (18–20 inches) from the ceiling and 15–20

cm (6–8 inches) from an outside wall.

Do not use cardboard boxes for storage.

Date and rotate the supplies (first in/first out).

Change the cydex solution in each 28th day

Disinfection

Disinfection removes micro-organisms without complete sterilization.

5.3.1. List Of Disinfectants Available In BPKIHS

1. Methylated spirit (70%)

2. Isopropyl alcohol (70%)

3. Povidone Iodine solution (7.5%)

4. Povidone Iodine (7.5) and Detergent (Surgical Scrub/ Betadine Scrub/ wokadine Scrub etc.)

5. Sodium hypo chloride (1% solution)

6. Bleaching powder (14gms/Litre)

7. Formalin (40%Liquid)

8. Glutaraldehyde (2% activated)

9. Carbolic Acid (2%)

10. Detergent powder

5.3.2. Selection of disinfectantThere is no single ideal disinfectant.

Glutaraldehyde is the generally the most appropriate chemical disinfectant that will provide high level disinfection.

5.3.3.Common Disinfectants Used For Environmental Cleaning In Hospitals

Disinfectants

Recommended Use

Precautions

Sodium Hypochloride

Decontamination of material contaminated with blood and body fluids

- Should be used in well ventilated areas.-Protective clothing required while handling and using undiluted.- Do not mix with strong acids to avoid release of chlorine gas.- Corrosive to metals

Bleaching Powder Toilet/ bathrooms Same as Sodium Hypochloride

Alcohol (70%): Ethyl Alcohol, Methylated spirit

Smooth Metal Surfaces tabletops and other surfaces where bleach can not be used

- Flammable, toxic, to be used in well ventilated area, avoid inhalation.- Keep away from heat source, electrical equipment, flames, hot surfaces.- allow it to dry completely, particularly when using diathermy as it can cause diathermy burn.

Carbolic Acid (Phenol)

Floor mopping, cleaning OT room, Contaminated bed, furniture etc

- toxic

Phenyle, Lysol Black Phenyle is used in cleaning toilet and bathroom.White phenyl is used in routine mopping of the floor.

- Poisonous

5.3.4. Common Antiseptic

Antiseptics

Recommended Use

Precaution

Chlorhexidine combined with alcohol or detergent

Antiseptic for skin and mucous membranes, preoperative skin preparation, disinfection of the hands

- Inactivated by soap and organic matter.- Relatively non toxic.- Do not allow contact with brain meninges, eye or middle ear.

Quaternary Ammonium Compound: eg. Dettol

Antiseptic for cleaning dirty wounds

- Relatively non toxic.- Dilution are likely to get contaminated and grow gram negative bacteria, hence:- Use in correct dilution and only pour enough solution for single patient use.- Discard any solution that is left over single use.

Povidine Iodine (Betadine) 5%, 7.5% and 10%

In BPKIHS, 7.5% + detergent combination is recommended to use in pre-operative hand wash and part preparation. 7.5% solution is recommended for wound dressing .

5.3.5. Method of Diluting Chlorine Solution

Product Chlorine Available

How to dilute to 0.5%

How to dilute to 1%

How to dilute to 2%

Sodium Hypochlorite- liquid bleach

3.5% 1 part bleach to 6 parts of water

1 part bleach to 2.5 parts water

1part of bleach to 0.7 parts of water

Sodium Hypochlorite- liquid

5% 1 part bleach to 9 parts of water

1 part bleach to 4 parts of water

1 part bleach to 1.5 parts of water

Beaching Powder

34% 14gm powder in 1liter water

Chloramine Powder (Virex)

25% 20gm to 1Litre of water

40gm to 1 litre of water

80gm to 1 lt of water

5.3.6. Disinfection of Linen and Equipments

Equipments Standard Procedure According to WHO

In BPKIHS Protocal

Furniture, bed, IV stand, wheel chair, fan and light etc

Clean with detergent and water and wipe dry. If contaminated or use by infected patient wipe by 1% sodium hypochloride or 70% alcohol.

Cleaning by detergent and water.In OT wiped by 2% carbolic acid.

Mattress and Pillows(always cover with plastic bag)

Clean with detergent and water in between patients and as required.If contaminated with blood and body fluid wipe with 70% alcohol or 1% sodium hypochloride.

If contaminated with blood and body fluid wipe with or 1% sodium hypochloride.

Telephone Disinfect with 70% alcohol daily.

Dressing trolley Clean with detergent and water and wipe dry. Disinfect with 70% alcohol daily.

Ventilator, Suction Equipment and Mask

Clean machine with detergent and water, dry and disinfect with 70% alcohol.Mask and suction tube should be used for single use.AMBU bag after use send for Sterilization to CSSD.

Soiled patient care equipment, stethoscope, blood pressure apparatus

Clean with detergent and water. If not washable wipe with 1% sodium hypochlorite or 70% alcohol.

Thermometer Clean with 70 % alcohol, store dry

5.3.7. Cleaning of Environmental SurfaceArea Recommended by WHO In BPKIHS Protocal

Floor Damp mopping with detergent and water and some disinfectant twice in each shift.

Dry sweeping followed by wet mopping by 2% carbolic acid.

20ml of Carbolic Acid in

1 litre of Water

Spilling of blood and body fluid

- Cover with the absorbent like cotton, wool, gauze, paper, towel etc.- Pour liberally 1% sodium hypochloride/ bleaching powder solution (14gm/lt)- Allow to stand for 30 min.Clean with carbolic acid.

Walls and Curtains If visibly soiled clean with detergent and water.

Toilet and commode Clean with detergent and water and wipe with 2% carbolic acid.

In BPKIHS Protocol

•Floor is cleaned with detergent and water

•Mopping by 2% Carbolic acid

•Seal the room with adhesive tape

•For each 1000 cu feet of space place 500 ml of formalin and 1000 ml of water in an electric boiler with a safety cut out and a time switch. Switch on the boiler. •Open the room after 24 hr, let some time to evaporate the vapour. •Ammonia gas is used to help the easy evaporation

Mooping of OT table and surrounding after every case is with 2% carbolic acid.

Bacillocid special: Recommended use at all Jigh Risk areas. Spray 2% solution over all exposed surfaces with a sprayer allowing 60 min. after sealing all doors and windows.

Preparation of 2% Carbolic Acid solution

Carbolic Acid (Phenol)

Available concentration = 100%

To make 2% solution add 20 ml of carbolic acid in 980 ml of water (aprrox.1 litre)

Application of Nursing Process in Infection Control and Prevention:

I. Nursing Assessment1. Client’s susceptibility to infection◦Age, nutritional status, stress level, associated

disease like diabetes mellitus.

2. Cleanliness of ward environment◦Linen◦Ventilation◦Water supply◦Floor◦Health of staff◦Patient’s clothing and personal Hygiene etc.

Decontamination, Disinfection and Sterilization

Procedure

Dressing

Hand washing

IV insertion

Catheterization etc.

Isolation of Infected case

Standard Precaution

Availability of Personnel Protective Equipment eg. Gloves, mask, gown etc.

Stock of sterile items

Waste disposal

Adherence of health personnel to IP guideline

Familiarity of staff about IP guidelines

II. Nursing Diagnosis1. Risk for infection related to

Improper technique while inserting cannula Using same syringes, cannula, IV set for prolonged time Failure to recognize early sign of infection and infiltration Indwelling catheter Unsterile technique while inserting catheter Touching the connection tubing with contaminated hands Back flow of urine from the tubing and uro bag. Failure to follow aseptic technique during change of dressing Contamination of opened wound with soiled linen, cloths and

hands Cross infection with other patient or health personnel. Transmission of disease from patient to patient, patient to staff

and staff to staff.

Knowledge deficit among nursing and cleaning staff about the procedure of making disinfect solution of different concentration

Risk for impair skin integrity

Social Isolation

III. Nursing Goal

Prevention of exposure to infectious organism.

Controlling and reducing the extent of infection

Maintaining resistance to infection

Educating the clients and family about infection control technique.

Expected Outcome The overall goal of IP program is the reduction of nosocomial infection in

the ward

Client will remain free of infection as evidenced by

Client will remain afebrile

Client will develop no signs and symptoms of local infection (eg. Remain free of cough, purulent drainage from wound or normal body opening)

Client will become knowledgeable of infection risk.

Client will identify routine to follow in the hospital as well as in hospital that reduce transmission of micro organism.

Client will identify signs and symptoms to report health care provider indicating infection.

IV. Nursing Intervention

Monitor client’s body temperature routinely, inspect oral

cavity for lesions, inspect urethral and vaginal orifice for

drainage or discharge, assess IV assess site for sign of

infection and observe the client for evidence of cough.

Practice hand hygiene routinely before caring for client,

between clients, and before any invasive procedure.

Supervision and education of cleaning staff in preparation of

solution for floor mopping, carbolization, decontamination etc.

Use aseptic technique perfoming all surgical procedure like

dressing, catheterization, ET tube suctioning etc.

Use aseptic technique while inserting IV cannula, change cannula, IV set in 72 hrs, Change labeled syringe for IV injection in every 24 hours.

Teach the patients’ relative about the way of emptying urobag.

Provide catheter care to the patient.

Change foley’s catheter in every 7 days.

Follow standard precautions.

Provide education to the patient and relatives about importance and process of deep breathing and coughing.

Proper disposal of waste in color coded bucket, monitor and supervise the use by all staff, patients and patient’s relatives.

Controlling of visitors.

Change dressing that become wet and soiled.

Adequate supplies of clean and sterile gloves, gown, mask, detergent, disinfectants should be there in the ward.

Monitoring of use of antibiotics. Change Gltutareldehyde solution in every 28th days

Monitoring of the shelf life of sterile equipment, if not used

within 7 days send to CSSD for resterilization without

reopening the pack. Supervise the cleaning of equipment like AMBU bag, mask,

O2 mask, tubing, Nebulizer set etc. Wipe the thermometer with 70%alcohol after using each

patient. Send periodic culture of different sites like dressing,

treatment trolley, cydex container, tap water etc. Appropriate use of isolation procedure for infected case. Maintain the ventilation of the ward. Stay healthy, take nutritious food. Use available protective device and also encourage others to

use.

Take Home Message

Person to Contact if any confusion about Infection Control

Thank You for Your Participation

References

1. Deb M. hospital-acquired Infections: Guidelines for Control, BP Koirala Institute of Health Sciences, Dharan, Nepal.

2. Wenzel, Brewer, Butzler. A Guide to Infection Control in the Hospital. International Society of Infection Control. Hamilton. Ontario. BC Decker Inc; 2nd Edition; 2002.

3. Sakarkar BM. Principles of Hospital Administration and Planning.New Delhi. Jaypee Brothers Medical Publishers P. Ltd; first Edition; 1998.

4. WHO. Practical Guidelines for Infection Control in Health care Facilities. WHO; 2003.

5. WHO. A manual on Infection Control in Health Facilities. WHO Regional Office for South East Asia. New Delhi; 1990.

6. Hospital Infection Society. Department of Health, England. Third Prevalence Survey in HCAI in England. Wilington House. Waterloo Road. London 2006.

7. Poudyal P.Simkhada P. Bruce J. Infection control knowledge, attitude and practice among Nepalese health care workers. American Journal of Infection Control; October 2008; 36(8) : 595-597.

8. Potter PA, Perry AG. Fundamental of Nursing. St. Louis. Missouri. Mosby; 6th Edition; 2005