PREVENTION IS BETTER THAN CURE

Isabelita T. Arao RN, PhD October 13, 2011

Outline
Review of the common hazards in healthcare setting How to prevent from acquiring such infections How to prevent Healthcare Associated Infections (HAI)

Definition..
PREVENTION - actions we take to prevent us for illness and promote better health

CURE to make healthy again through treatment

Common Hazards in Healthcare Setting

1. Blood-borne and biological hazards 2. Potential chemical and drug exposure 3. Waste anesthetic gas exposure 4. Respiratory hazards 5. Ergonomic hazards from lifting and repetitive tasks

Percutaneous Injury as a means of Transmission of Bloodborne Pathogen

Needle stick injury Cut with a sharp object Contact with mucous or non intact skin or body fluids

Needle stick injury (NSI)

1 in 8 HCW receives a NSI 800,000-1 Million HCW annually (US) >100,00 United Kingdom Hospitals/year 86% of all occupationally related infections 385,000 sharps injuries annually (CDC) Nurses have the highest rate

Single NSI Probability of Infection

HIV ----------3-5 chances in 1000

Hepatitis B --------300 chances in 1000 Hepatitis C --------- 20-50 chances in 1000

Risk of Infection Depends on:

Pathogen involved
Immune status of the HCW The severity of the NSI

Main Causes of NSI

24%--Injuries which occur during a clinical exposure (IV insertions, restless patient) 48% -- injuries which occur after Clinical procedure but before disposal (collision with HCW, disposal, clean up, recapping) 28% - injuries which occur after disposal (concelled sharps)

Risk of HIV Transmission in Hospital Setting

1 in 1000 mucous membrane exposure 3-5 chances in 1000 NSI Syringes containing HIV infected blood can still transmit even after being rinsed for up to 4 weeks HIV can survive up to 2 hours outside the body

Risk of Hepatitis B Transmission

Over 300 million carriers globally 100-200 HCW died annually in the US Highly infectious if transmitted by blood or via contact with other body fluids 10 % leads to chronic infection 30% risk from NSI or mucosal exposure

Prevention of Occupational Exposure to HIV/HBV

1, Using Standard Precautions (Universal Precaution) 2. Wearing heavy duty gloves when disposing sharps 4. Adapting safe technique and procedures (no recapping, single-handed method)

Prevention of Occupational Exposure to HIV/HBV

5. Making appropriate disinfectants and cleaning materials available 6. Sterilizing equipment properly 7. Eliminating unnecessary injections, lab tests, covering breaks in skin especially the hands

General Measures to reduce the Risk of Occupational Exposure to BBV in Healthcare Setting
1. Wash hands before and after contact with each patient, before donning & after removing gloves. 2. Change gloves between patients 3. Cover existing wounds, skin lesions and all breaks in exposed skin with waterproof dressing

General Measures to reduce the Risk of Occupational Exposure to BBV in Healthcare Setting
4. Wear gloves when contact with blood can be anticipated 5. Avoid sharp usage where possible 6. Avoid wearing open footwear in situations where blood maybe spilt, or where instruments or needles are handled 7. Clean up spillage promptly and disinfect surfaces

General Measures to reduce the Risk of Occupational Exposure to BBV in Healthcare Setting
8. Wear gloves when cleaning equipment prior to sterilization or disinfection, when handling chemical disinfectant and when cleaning up spillage. 9. Follow safe procedures for disposal of contaminated waste

Safe Handling and Disposal of Sharps

Place disposable sharps in sharp container immediately after use. Provide sharp containers in adequate numbers and never overfill. Avoid recapping Discard disposable syringes and needles into sharp container, never re-use

Safe Handling and Disposal of Sharps

Remove needles from syringe when essential (transferring blood to a container, aspirating anesthesia)

Reducing Risk of Blood-Skin Contact

Change glove if puncture is suspected. Change glove regularly if performing prolonged surgical procedures Protect body, eyes and face Waterproof gown or wear a surgical gown with waterproof cuff and sleeves

Other Measures to Prevent BBV Transmission

Hepatitis B immunization Decontamination and waste disposal Decontamination of equipment Disposal of clinical waste (sharps) Double bag contaminated linen (for safe transportation and laundry) Label specimen (danger of infection or color coding))

CHEMICAL HAZARDS
CARCINOGENIC any substance or agent capable of promoting or causing the development of cancer.
CHEMOTHERAPEUTIC AGENTS

> 42% of nurses who worked for long periods of time developed cancer > 16% incidence of cancer of those who worked frequently to radiation

TERATOGENIC substances capable of causing congenital malformation de to action on the embryo. ANESTHETIC AGENT > 36% of nurses who worked with anesthetic agents during pregnancy have birth defects (CNS, cardiovascular, genitourinary and musculoskeletal disorders)

 USE OF LATEX GLOVES, DISINFECTANTS AND OTHER CHEMICALS may actually be accountable for the higher asthma rate among nurses and HCW

 REPRODUCTIVE TOXICITY substance affecting fertility (miscarriage, infertility and fetal death) ANTIRETROVIRAL MEDICINES > 19% higher rate in difficulty conceiving was reported among nurses with frequent and long term exposure to these drugs

 LONG TERM EXPOSURE TO MERCURY > neurotoxin

Exposure Routes
Inhalation Skin contact Skin absorption Ingestion injection

Activities which may Lead to Exposure

Reconstituting powdered drug (Fransman et al. 2004) Expelling air from syringes filled with hazardous drugs Administering by IM, SQ, or IV routes Counting out individual, uncoated oral doses and tablet from multi-dose bottles

 Crushing tablets to make oral liquid doses Contracting measurable concentrations of drugs present or drug vial exteriors, work surfaces, and floors Generating aerosols during the administration of drugs Priming the IV set with a drug containing solution at bedside

 Handling body fluids or body fluid contaminated clothing, dressing, linens and other materials. Decontaminating and cleaning drug preparation or clinical areas. Transporting infectious, chemical or hazardous waste containers Removing and disposing PPE

Preparing Hazardous Drugs

Use a ventilated cabinet designed to reduce workers exposure while preparing hazardous drugs Practice proper technique and use of equipment Wear PPE (double gloves and protective gowns while reconstituting and administering drugs.

Administering Hazardous Drugs

Use protective medical devices (needless) and techniques (under the luminar hood) Wear PPE for all activities associated with drug administration (opening to disposing) Place disposable items directly in a chemotherapy waste container and close the lid

Administering Hazardous Drugs

Double bag the chemotherapy waste before removing the inner gloves Consider double bagging all contaminated equipment Wash hands with soap and water before leaving the administration site

Keeping Safe at Work

Dealing with Aggression How to Respond to this Behavior? 1. Remain calm be polite and do not raise your voice. 2. Call for assistance (supervisor or another staff to assist)

Keeping Safe at Work

3. Keep out of reach 4. Do not antagonize let the aggressor leave and do not attempt to detain the person 5. and finally, report the incident to your supervisor or SHO.

Keeping Safe at Work

INFECTION CONTROL 1. ensure that you follow Standard practices. 2. wear PPE appropriate to the task (gloves, aprons, mask, goggles, N95 mask, boots) 3. Ensure appropriate handling and disposal of sharps and other clinical waste (avoid recapping, reuse,needless)

4. wash your hands frequently

5. ensure contaminated waste is disposed of in line with the clients waste disposal procedure (city ordinance of color coded waste disposal, MRSA).

MANAGING FATIGUE

nurses often work long hours through shift work and rotation. Can affect individuals health and well being as well as their ability to perform their duties safely. Can also compromise clinical care

Tips to help Prevent Fatigue

1.

2.

3.

Ensure that you have had adequate sleep (7-9 hours is recommended for adults) Manage your shifts and workload (rest, naps) Take at least a 30 minutes break after 6 hours work

4. It is recommended that working hours does not exceed 48 hours/week 5. Maintain health and fitness at a good level. Take care when driving home after a night shift (consider alternate transport methods)

Precautions to Prevent other Transmissions

STANDARD PRECAUTIONS a group of infection precaution that apply to all patients regardless of suspected or confirmed infection status in any setting 1. hand hygiene (5 moments) 2. Personal Protective Equipment 3. Respiratory hygiene and cough etiquette (cover mouth and nose, throw right away, use medical mask)

4. Prevention of injuries from needles and other sharps instruments 5. Cleaning and disinfection of respiratory equipment (between use) 6. Cleaning the patient care environment (avoid aerosolisation) 7. Linen and waste management (bags)

DROPLET PRECAUTIONS - they should be applied whenever providing care to a patient suspected or confirmed of having disease spread by droplets - organism floats in the air up to 3 feet away - e.g. pneumonia, meningococcemia,

DROPLET PRECAUTION GUIDELINES: Private room if possible but can open the door Maintain spatial separation of at least 3 feet between infected patient and other patients. Medical mask by staff Limit the patient movement if needed, let the patient wear mask

Use clean gloves and gown when performing direct care Perform hand hygiene after removing PPE Dedicate specific equipment for use with a single patient and ALWAYS clean and disinfect shared equipment between patient use avoid touching face, eyes or mouth

AIRBORNE PRECAUTIONS - Tuberculosis (PTB or EPTB) - Measles - Chickenpox - nurses who have had chickenpox before should be the one to be assigned with such case.

Isolation, always close the door Organism can float in the air 3 meters away Can open the windows Wear N95 mask

Contact Precaution

Wounds, diarrheal patients, MRSA Wear gloves, gowns when touching the patient Isolation but can practice co-horting MRSA cases should have dedicated equipment for the patient

What is a BUNDLE?

A group of things fastened together for convenient handling ( Webster ) A group of interventions related to a disease that when instituted together give better outcomes than when done individually.

A BUNDLE IS :

Small and straightforward Group of best practices Scientifically grounded Protocol based Executed collectively and reliably All or Nothing indicator

Preventing Catheter Related Bloodstream Infections

FIVE COMPONENTS OF CARE 1. HAND HYGIENE when caring for central lines, strictly comply to the following : Before and after palpating catheter insertion sites Before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter

Preventing Catheter Related Bloodstream Infections

When hands are obviously soiled or if contamination is suspected. Before and after invasive procedures Between patients Before donning and after removing gloves After using the bathroom

Steps of Effective Hand Hygiene

1.

2.
3. 4.

5.

6.
7.

Palm to palm Right palm over dorsum and vice versa Palm to palm with fingers interlaced Back of fingers to opposing palms fingers interlocked and vice versa Rotational rubbing of thumb Tip of fingers rub to palm Wrist

Preventing Catheter Related Bloodstream Infections

2. MAXIMAL BARRIER PRECAUTIONS Strict compliance with: Hand hygiene Cap Mask Sterile gown Sterile gloves The patient should be covered with a sterile drape from head to toe with small opening for the site of insertion.

Preventing Catheter Related Bloodstream Infections

3. CHLORHEXIDINE SKIN ANTISEPSIS

proven to provide better skin antisepsis than other antiseptic agents such as povidone-iodine solutions Allow antiseptic solution time to dry completely before puncturing the site.

Preventing Catheter Related Bloodstream Infections

4. Optimal catheter site selection, with subclavian vein as the preferred for adults. 5. Daily review of central line necessity with prompt removal of unnecessary lines. The risk of infection increases over time as the line remains in place.

PREVENTING VENTILATOR ASSOCIATED PNEUMONIA

FOUR COMPONENTS OF CARE
1.

Elevation of the head of the bed 30-45 degrees Decreases the risk of aspiration of gastrointestinal contents oropharyngeal or nasopharyngeal secretions. To improve patients ventilation. Aid in ventilatory efforts and minimize atelectasis.

PREVENTING VENTILATOR ASSOCIATED PNEUMONIA

2. Daily sedation vacation and daily assessment of readiness to extubate Lightening sedation decreases the amount of time spent on mechanical ventilation Weaning patients from ventilator becomes easier when patients are able to assist themselves at extubation with coughing and control of secretions.

PREVENTING VENTILATOR ASSOCIATED PNEUMONIA

3.

Peptic Ulcer Disease Prophylaxis > This is an appropriate intervention in all patients who are sedentary > Decreasing the pH of gastric contents may protect against a greater pulmonary inflammatory response to aspiration of GIT contents. > H2 receptor inhibitors are more efficacious than sucralfate and are the preferred agents.

PREVENTING VENTILATOR ASSOCIATED PNEUMONIA

4. Deep Venous Thrombosis ( DVT )

Prophylaxis > While it is unclear if there is any associated between DVT prophylaxis and decreasing rates of VAP, studies have shown that DVT prophylaxis is applied as part of a package of interventions for ventilator care, the rate of pneumonia decreases precipitously.

WHAP VAP
This program targets interventions known to decrease complications W Wean patient from the ventilator as soon as possible H Meticulous Hand hygiene A Aspiration precautions P Prevent contamination of respiratory therapy equipment

PREVENTING SURGICAL SITE INFECTION

FOUR COMPONENTS OF CARE 1. Appropriate use of prophylactic antibiotics > Antibiotics within one hour before surgical incision > Discontinuation of prophylactic antibiotics within 24 hours after surgery. > Reassign dosing responsibilities to holding area nurse to improve timeliness.

PREVENTING SURGICAL SITE INFECTION

2. Appropriate Hair Removal > For many years, it has been known that the use of razors prior to surgery increases the incidence of wound infection when compared to clipping, depilatory use, or no hair removal at all.

PREVENTING SURGICAL SITE INFECTION

3. Maintenance of Postoperative Glucose Control

> Review of medical literature shows that the degree of hyperglycemia in the postoperative period was correlated with the rate of SSI in patients undergoing major cardiac surgery. Other articles have demonstrated that stringent glucose control in surgical intensive care unit patients reduces mortality.

PREVENTING SURGICAL SITE INFECTION

Glucose Control is defined as serum glucose level below 2oomg/dl, collected once on each of the first two postoperative days. 4. Establishment of Postoperative Normothermia Literature indicates that patients undergoing surgery have a decreased risk of surgical site infection if they are not allowed to became hypothermic during the postoperative period.

PREVENTING SURGICAL SITE INFECTION

Anesthesia, anxiety, wet skin preparations, and skin exposure in cold operating rooms can cause patients to became clinically hypothermic during surgery.

PREVENTING SURGICAL SITE INFECTION

Use warmed forced air blankets preoperatively, during surgery and in Post Anesthesia Care Unit ( PACU ) Use warm fluids Increase the ambient temperature in the operating room Use hats and booties on patients postoperatively

CATS Decrease Surgical Site Infection

C Clippers Hair removal: If hair must be removed from the surgical site, clippers are the best option. Never use a razor A Antibiotics Prophylactic Antibiotics: Antibiotics consistent with national guidelines should be administered within 1 hour of incision time and discontinued within 24 hours, in most cases.

CATS Decrease Surgical Site Infection

T TEMPERATURE Normothermia: > Colorectal surgery patients should be normothermia ( 96.8 100.4 F ) within the first hour surgery. S SUGAR- Glucose Control: Cardiac surgery patients should have controlled 6 am serum glucose ( <200mg/dl ) on postoperative Day 1 and 2.

PREVENTING URINARY TRACT INFECTION

SIX COMPONENTS OF CARE 1. Foley Trapped to Leg > All urinary catheter must be secured to decrease movement of catheter. 2. Foley Bag Below Bed > Drainage bag must be kept lower than patients bladder at all times.

PREVENTING URINARY TRACT INFECTION

3. Daily Review for Necessity > Can urinary catheter be removed? 4. Clarity of Urine > Change out catheter if patient having symptoms, insert silver coated catheter. 5. Strict Hand Hygiene 6. Pericare daily and after each Bowel Movement