Infection Prevention Toolkit for Nurses - NJSNA

Infection Prevention Toolkit for Nurses - NJSNA

Prepared Nurses Protect Patients: Prevention Strategies for Healthcare-Associated Infections and Emerging Infectious Diseases Objectives List significant healthcare associated infections Understand the epidemiology of significant healthcare associated infections Identify

Utilizing disease transmission evidence based literature develop strategies used to prevent the spread of infection Healthcare-associated Infection (HAI) An infection that patients acquire during the course of receiving treatment for other conditions within a healthcare setting Common type of HAIs include: Catheter-associated Central-line Surgical

urinary tract infections associated bloodstream infections site infections Methicillin Resistant Staphylococcus aureus (MRSA) Clostridium difficile Other infections: Old and New

Tuberculosis Human Immunodeficiency Virus (HIV) Candida ZIKA auris HAIs in the U.S. 1 out of 25 hospitalized patients Increased

morbidity and mortality Increase in length of hospitalization Attributed costs: $26-33 billion annually Impact the patient and family

Germs spread within and across health care facilities National Healthcare Safety Network (NHSN) HAI Progress Reports HAI Progress Reports Value Based Purchasing Type of HAIs and Prevention Strategies

Type of HAIs and Prevention Strategies Catheter associated urinary tract infections (CA UTIs) Central line associated bloodstream infections (CLA-BSI) Surgical Site infections (SSIs) C.difficile MRSA (blood) Catheter associated urinary tract infections (CA UTIs)

Symptomatic UTI (SUTI) Indwelling urinary catheter in place > 2 days on the date of event AND present for any portion of the day on the day of event OR removed the day before the event. Patient has at least one of the following: fever >100.4, suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency, urinary frequency, dysuria Patient has a urine culture with no more than 2 species identified, at least one of which is a bacterium of > 100,000

CFUs Catheter associated urinary tract infections (CA UTIs) Prevention Insert catheter using established indications: Acute urinary retention: e.g., due to medication , anesthesia, paralytics Acute bladder outlet obstruction: e.g., due to severe prostate enlargement Need for accurate measurements of urinary output in the critically ill

To assist in healing of open sacral or perineal wounds in incontinent patients To improve comfort for end of life Patient requires strict prolonged immobilization (e.g., multiple traumatic injuries) Selected peri-operative needs

Catheter associated urinary tract infections (CA UTIs) Prevention Insert under aseptic technique, using staff members Secure catheter to leg Drainage bag is below the level of the bladder to prevent backflow Tubing is not kinked

Label drainage bag with insertion date/time Assess the need for the catheter q shift Perform hand hygiene prior to handling the catheter and after Obtain specimens using sterile technique

Separate emptying container Educate the patient and family on the prevention of CA UTIs Central line associated bloodstream infections (CLA BSIs) Lab-Confirmed Bloodstream Infection Patient has at least one of the following: fever >

100.4F, chills or hypotension AND Organism9S0 identify from blood is not related to an infection at another site Central line associated bloodstream infections (CLA BSIs) Prevention Measures: Insert the catheter under maximal barrier protection using aseptic technique Gown,

gloves, mask, large drape Use alcohol impregnated caps Use endcaps when disconnecting the catheter from tubing Label IV tubing with date/time/ initials Change Assess

IV tubing and dressing per hospital policy the need for the catheter q shift Educate the patient and family on the prevention of CLA BSIs Surgical Site Infections (SSIs) Focus: Colon procedures Total Abdominal Hysterectomies (TAH) Total Knee Replacements (TKR) Coronary Artery Bypass Graphs (CABG) Surgical Site Infections Prevention

(SSIs) Preoperative: Smoking and alcohol cessation, dental care, blood sugar control, no remote sites of infection, discontinuation of certain medications MRSA/MSSA screening CHG baths Correct antibiotic Patient and family education Surgical Site Infections (SSIs) Prevention Intraoperative:

Timing of antibiotics Redosing antibiotics Supplemental oxygen Normothermia

Type of anesthesia Changing gloves at certain times Surgical Site Infections (SSIs) Prevention Postoperative: Stopping antibiotics Change dressing per hospital policy

Ambulate Discontinue indwelling urinary catheter Discharge home Educate the patient and family on infection prevention

Clostridium difficile Risk Factors: Age Previous exposure to health care Previous roommates status Antibiotics Proton Pump Inhibitors (PPIs) Diabetes Dialysis Residence Clostridium difficile

Microbiology Clostridium difficile is an anaerobic gram-positive, sporeforming, toxin-producing bacillus and is the cause for C.difficile associated diarrhea. Epidemiology There has been dramatic change in the epidemiology of Clostridium difficile infection (CDI) since the turn of the 21st century including an increase in incidence and severity, occurring at a disproportionately higher frequency in older

patients. Clostridium difficile Reporting definition specimen collected > 3 days after admission to the facility Colonization data -Prevalence of asymptomatic C. difficile colonization among elderly residents ranged from 0 to 51 %, possibly because CDI is often endemic in units or institutions with elderly patients Clostridium difficile Symptoms Diarrhea Elevated

WBCs Temperature Abdominal pain Clostridium difficile Prevention Isolation Hand Hygiene Antibiotic Stewardship

Clean environment Clean patient care equipment Fecal transplant to prevent recurrence Methicillin Resistant Staphylococcus aureus (MRSA) Microbiology gram

positive cocci resistant to oxacillin Epidemiology The frequency of methicillin-resistant Staphylococcus aureus (MRSA) infections continues to grow in hospitalassociated settings and, more recently, in community settings in the United States and globally. Methicillin Resistant Staphylococcus aureus (MRSA) Methicillin Resistant

Staphylococcus aureus Reporting -Specimen Definition collected > 3 days after admission to the facility Colonization About (MRSA) data one-third of the general population carry staphylococcal microbes. Estimates of healthcare workers carrier status range from

50% to 90%. Methicillin Resistant Staphylococcus aureus (MRSA) Risk Factors Diabetes, Residence prior to admission Participation Symptoms

in group activities/sports Methicillin Resistant Staphylococcus aureus (MRSA) Prevention Isolation Hand hygiene Antibiotic Stewardship Vancomycin time out

Clean environment Clean patient care equipment Decolonization Old and New Infections Tuberculosis Epidemiology

The TB epidemic is larger than previously estimated The number of TB deaths and the TB incidence rate continue to fall globally. In 2015, there were an estimated 10.4 million new (incident) TB cases worldwide, of which 5.9

million (56%) were among men, 3.5 million (34%) among women and 1.0 million (10%) among children. People living with HIV accounted for 1.2 million (11%) of all new TB cases.

Six countries accounted for 60% of the new cases: India, Indonesia, China, Nigeria, Pakistan and South Africa. Tuberculosis Risk Factors Age Foreign born Immunosuppression Exposure Symptoms

Cough Fever Chills Night sweats Hemoptysis Tuberculosis - Prevention Early Identification Early Isolation

Airborne precautions negative pressure room Personnel protective equipment Human Immunodeficiency Virus (HIV) Epidemiology The epidemiology of HIV in the United States has changed significantly from the early 1980s when it began as an epidemic predominantly in young, white, middle-class men who have sex with men (MSM) and who resided

principally in a few of the larger West and East Coast cities . Today, HIV is a disease of a greater demographic diversity, affecting all ages, sexes, races, and income levels; involving multiple transmission risk behaviors; and having a broad geographic distribution in the United States. This epidemiologic diversity is important to understand in order to target the interventions needed to diagnose and treat this disease and to potentially slow the transmission of the virus. Human Immunodeficiency Virus (HIV) Risk

Factors Unprotected sex IVDU Other Symptoms Weight loss Fevers Diarrhea

Rash STIs HIV - Care No isolation if respiratory symptoms are absent Continue Educate antiretroviral therapy patient on transmission of virus toothbrush, razors unprotected sex

PRep Principles of Disease Transmission Infection vs. Colonization Infection Occurs when pathogens and other microorganisms are present in the body and cause tissue damage and signs and symptoms of illness (e.g., fever, redness, pain). Colonization Occurs when pathogens and other microorganisms are present but do not cause signs and symptoms of illness. Incubation Period People

are not immediately infectious after exposure The period between exposure to an infection and the appearance of the first symptoms Can vary by individual, degree of exposure and type of microorganism Chain of Infection Modes of Transmission Three main categories:

Contact Droplet Airborne Modes of Transmission Contact Transmission Direct transmission - microorganisms transferred from one infected person to another person without a contaminated intermediate object or person Indirect transmission - transfer of an infectious agent through a contaminated

intermediate object or person Droplet Transmission-Transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions, e.g., group A strep Airborne Transmission - Transmission of infectious agents that remain infectious over long distances when suspended in the air, e.g., tuberculosis, varicella Prevention Strategies Hand Hygiene

Hand Hygiene: The single most important strategy in the prevention of infections. Use of soap/water or alcohol-based hand sanitizer Before direct patient contact After contact with bodily fluids or excretions, (non-) intact skin Between body sites on the same patient After contact with fomites proximal to patient Before and after removing gloves Hand Hygiene Access to hand hygiene

stations is essential Wash hand for 15 seconds Barriers to effective hand hygiene Standard Precautions Standard Precautions all patients blood and body fluids are potentially infectious

Recommended care of all patients regardless of suspected or confirmed infection Application depends on the nature of healthcare personnel patient interaction and anticipated exposure to blood / body fluids or known infectious agents Standard Precautions Key Elements Hand hygiene

Personal Safe protective equipment injection practices Safe handling of potentially contaminated equipment, environmental surfaces, and linen Respiratory hygiene/cough etiquette

Standard Precautions Personal Protective Equipment Wear PPE appropriate to anticipated patient interaction Gloves, gown, face protection (masks, goggles, face shields), respiratory protection Prevent contamination of clothing and skin during PPE removal Remove and discard PPE before leaving patient room/cubicle Do not reuse disposable PPE Standard Precautions

Respiratory Hygiene and Cough Etiquette Prevention strategies include: Posting signs at entrances Providing tissues and no-touch receptacles for disposal Providing resources for hand hygiene Offering

facemasks to coughing patients and other symptomatic individuals upon entry to the facility Providing space and encouraging persons with symptoms of respiratory infections to sit as far away from others as possible Standard Precautions Injection Safety Unsafe practices that have led to patient harm include: Failure to use aseptic technique when preparing or administering medications

Use of the same syringe (with or without the same needle) to administer medication to >1 patient Reuse of a syringe (with or without the same needle) to access a medication container used for >1 patient Use of medications labeled as single-dose or single-use for >1 patient Standard Precautions Injection Safe Practices

Never administer medications from the same syringe to more than on patient, even if the needle has been change Do not enter a vial with a used syringe or needle Medications packaged as single-use vials never be used for more than one patient Bags or bottles of intravenous solution not be used as a common source of supply for more than one patient Cleanse the access diaphragm of medication vials before inserting a device into the vial Standard Precautions Injection Safe Practices Ensure medication containers labeled as single-dose or single-use

are used for one patient only Dedicate multi-dose vials to a single patient whenever possible If multi-dose vials are used for >1 patient, restrict the vials to a centralized medication area and do not bring them into patient treatment areas (e.g., operating room, patient room/cubicle) Dispose of used sharps at the point of use in a sharps container that is closable, puncture-resistant and leak-proof Standard Precautions

Linen and Laundry Handle used linen with minimum agitation to avoid contamination of air, surfaces, and persons Always laundry use Standard Precautions when handling soiled Standard Precautions Environmental Cleaning Inadequate environmental cleaning and disinfection

practices have led to the transmission of healthcareacquired pathogens related to contamination of nearpatient surfaces and equipment Follow manufacturers recommendations for use of cleaners and EPA-registered disinfectants (know the contact time,) Standard Precautions Instrument Reprocessing Ensure that reusable medical equipment (e.g., point-of-care devices, surgical instruments, endoscopes) is cleaned and reprocessed appropriately prior to use on another patient

If the manufacturer instructions are not provided, the device may not be suitable for multi-patient use Follow manufacturers instructions for proper reprocessing Assign responsibilities for reprocessing of medical equipment to healthcare personnel with appropriate training Transmission-Based Precautions Used in addition to Standard Precautions Contact

Airborne Droplet Contact Isolation For infections spread by direct or indirect contact with patients or patient-care environment (e.g., MRSA, VRE) Private room or room shared with patients with the same infection status Wear disposable gown and gloves when entering the patient room

Remove disposable gown and gloves and discarded inside the patient room Wash hands immediately after leaving the patient room Clean patient room daily using a hospital disinfectant, with attention to frequently touched surfaces Use dedicated equipment if possible (e.g., stethoscopes Droplet Transmission

For infections spread by splashes generated by coughs, sneezes, etc. (e.g., meningitis, pertussis, seasonal influenza) Patients should be placed in single-patient room PPE: Eye protection and a mask (facemask, N-95, etc.), or face shield are worn to prevent droplets reaching the mucous membranes of the eyes, nose and mouth upon room entry or within 6 feet of the patient Patient should wear a surgical mask when outside of the patient

room Airborne Precautions For infections spread by particles that remain viable and suspended in the air (TB, measles, chickenpox, and smallpox) Patient should be placed in negative pressure (airborne isolation) room PPE: N-95 or higher respirator for personnel inside isolation room

Patient should wear a surgical mask when outside of the patient room Practice Exercise 1: Disease Transmission A 35 year old patient on hospice develops a cough, fever, and pancytopenia three weeks after admission. Cultures reveal Aspergillus. Who is the host? What is the agent?

What are possible environments sources/reservoirs? Exercise 1: Disease Transmission 35 year old patient on hospice develops a cough, fever, and pancytopenia three weeks after admission. Cultures reveal Aspergillus. Host: Immunocompromised patient Agent: Aspergillus Potential environmental sources: Construction, ventilation system Exercise 2: Reservoirs Your patient is a 84 year old woman admitted to your telemetry unit for a wound infection caused by group A streptococcus (GAS). She lives in a nursing home and receives only enteral feedings. She has chronic hepatitis B, C. difficile, diabetes, is incontinent and has dementia.

What potential environmental sources/reservoirs of infection exist in this situation? Exercise 2: Reservoirs Your patient is a 84 year old woman admitted to your telemetry unit for a wound infection caused by group A streptococcus (GAS). She lives in a nursing home and receives only enteral feedings. She has chronic hepatitis B, C. difficile, diabetes, is incontinent and has dementia. Potential Reservoirs Hepatitis B-patients blood and other body fluids, used lancet, insulin syringe and vial, dried blood on glucometer, contaminated gloves Group C.

A Streptococcus- Intact skin, sheets, bed rails, HCW hands diff- surfaces; spores on counter tops and not killed, HCW hands, diapers, telemetry equipment Exercise 3: PPE You are the primary nurse for a 45 year male that suffered a spinal cord injury. He is quadriplegic and now has multiple decubiti. Upon your assessment, you note that he has a large, unstageable sacral decubitus that has foul-smelling, copious drainage. As you prepare for his wound care (at a minimum) what PPE should you anticipate using? A. Gown B.

Gloves C. Gloves only D. A&B E. No PPE required Exercise 3: PPE You are the primary nurse for a 45 year male that suffered a

spinal cord injury. He is quadriplegic and now has multiple decubiti. Upon your assessment, you note that he has a large, unstageable sacral decubitus that has foul-smelling, copious drainage. As you prepare for his wound care (at a minimum) what PPE should you anticipate using? A. Gown B. Gloves C. Gloves only

D. A&B E. No PPE required Emerging Diseases Candida auris Fungus resistant to common antifungals Causes

severe infections and invasive disease 33 cases in four states identified since 2013; all but one case was identified between 2015-2017 60% mortality rate Infections identified in blood, wound, ear; isolated in respiratory tract and urine

Candida auris Risk factors include recent surgery, diabetes, antifungals, broad-spectrum antibiotic and central venous catheters Difficult to identify with standard laboratory methods Likely spread by contact with contaminated surfaces, equipment and person to person Treatable

with a class of antifungal drugs called echinocandins Standard and Contact Precautions are recommended Enhanced environmental cleaning using an EPA-registered disinfectant with fungal claim Zika Zika is spread mostly by the bite of an

infected Aedes species. These mosquitoes bite during the day and night. Zika can be passed from a pregnant woman to her fetus. Infection during pregnancy can cause certain birth defects. There is no vaccine or medicine for Zika. Local mosquito-borne Zika virus transmission has been reported in the continental United States.

Zika Many people infected with Zika virus wont have symptoms or will only have mild symptoms. The most common symptoms of Zika are Fever Rash

Headache Joint pain Conjunctivitis (red eyes) Muscle pain Summary Preventing

the transmission of infection is everyones responsibility and nurses have an impactful role in promoting and modeling best infection control practices. Disease transmission can be prevented by consistently using infection control strategies. New disease threats require increased vigilance by everyone involved in caring for patients.

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