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An Introduction to

Infection Control
A PowerPoint Presentation by Eddie Newall May 2003

Learning outcomes

Describe the sources of micro-organisms, routes of transmission and key principles of infection control List the essential elements of universal precautions Understand the importance of risk assessment and management in infection control

The pre-scientific era

Epidemics and plagues throughout history Physicians fear of contagious disease Hippocrates and others suspected an unseen invisible cause Climate and environment blamed - not the ill, dying or dead

Microbiology - scientific era


Anton van Leeuwenhoek (1632-1722) Dutch linen draper Amateur scientist Grinding lenses, magnifying glasses, hobby First to see bacteria little beasties No link between bacteria and disease

Scientific era continued . . . . .


Ignaz Semmelweiss (1818-1865) Obstetrician, practised in Vienna Studied puerperal (childbed) fever Established that high maternal mortality was due to failure of doctors to wash hands after post-mortems Reduced maternal mortality by 90% Ignored and ridiculed by colleagues

Scientific era continued . . . . .


Louis Pasteur (1822-1895) French professor of chemistry Studied how yeasts (fungi) ferment wine and beer Proved that heat destroys bacteria and fungi Proved that bacteria can cause infection the germ theory of disease

Scientific era continued . . . . .


Joseph Lister (1827-1912) Scottish surgeon Recognised importance of Pasteurs work Concerned about infection of compound fractures and post-operative wounds Developed carbolic acid spray to disinfect instruments, patients skin, surgeons skin Largely ignored by medical colleagues

Scientific era continued


Robert Kock (1843-1910) German general practitioner Grew bacteria in culture medium Showed which bacteria caused particular diseases Classified most bacteria by 1900

Contemporary issues

Antibiotic resistance Prevalence of hospital acquired infection Prion diseases

Antibiotic resistance

Not a new problem - Penicillin in 1944 Hospital superbugs Methycillin Resistant Staphylococcus Aureus [MRSA] Vancomycin Intermediate Staphylococcus Aureus [VISA] Tuberculosis - antibiotic resistant form 400 deaths per year in UK Up to 100,000 per patient to treat Annual NHS cost - 5 million

MRSA

Discovered in 1981 Found on skin and in the nose of 1 in 3 healthy people - symptomless carriers Widespread in hospitals and community Resistant to most antibiotics When fatal - often due to septicaemia

Hospital acquired infection


Incidence of 10% 5,000 deaths per year - direct result of HAI 15,000 deaths per year linked to HAI Delayed discharge from hospital Expensive to treat [3,500 extra] Cost to NHS - 1 billion per year Effective hand washing is the most effective preventative measure Dirty wards and re-use of disposable equipment also blamed

Prion diseases

Prions [pree-ons] - proteinaceous infectious particles Corrupted form of a normally harmless protein found in mammals and birds Causes fatal neurodegenerative diseases of animals and humans Animals: scrapie - sheep, bovine spongiform encephalopathy [BSE or Mad Cow Disease] Humans: Creutzfeldt-Jakob disease [CJD] Prions found in blood, tonsil and appendix tissue

Prions and surgery

Prions cannot be destroyed by sterilisation Theoretical risk of cross infection from contaminated instruments and blood transfusion

Comparisons of mortality
Deaths per year in the UK
20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 RTA SUICIDE HAI

The nature of infection


Micro-organisms - bacteria, fungi, viruses, protozoa and worms Most are harmless [non-pathogenic] Pathogenic organisms can cause infection Infection exists when pathogenic organisms enter the body, reproduce and cause disease

Hospital acquired infection


Infection which was neither present nor incubating at the time of admission Includes infection which only becomes apparent after discharge from hospital but which was acquired during hospitalisation (Rcn, 1995) Also called nosocomial infection

Modes of spread
Two sources of infection: Endogenous or self-infection - organisms which are harmless in one site can be pathogenic when transferred to another site e.g., E. coli Exogenous or cross-infection - organisms transmitted from another source e.g., nurse, doctor, other patient, environment (Peto, 1998)

Spread - entry and exit routes


Natural orifices - mouth, nose, ear, eye, urethra, vagina, rectum Artificial orifices - such as tracheostomy, ileostomy, colostomy Mucous membranes - which line most natural and artificial orifices Skin breaks - either as a result of accidental damage or deliberate inoculation/incision (May, 2000)

Chain of infection

Source/reservoir of micro-organisms infected person [host] or other source Method of transmission hands, instruments, clothing, coughing, sneezing, dust etc. Point of entry orifices, mucous membranes, skin Susceptible host low resistance to infection (May, 2000)

HAI - common bacteria


Staphylococci - wound, respiratory and gastro-intestinal infections Eshericia coli - wound and urinary tract infections Salmonella - food poisoning Streptococci - wound, throat and urinary tract infections Proteus - wound and urinary tract infections (Peto, 1998)

HAI - common viruses


Hepatitis A - infectious hepatitis Hepatitis B - serum hepatitis Human immunodeficiency virus [HIV] acquired immunodeficiency syndrome [AIDS] (Peto, 1998)

Common types of HAI


Other 27% UTI 23%

Blood 6% Skin 10% Lower Wound 11% respiratory 23%

(May, 2000)

Universal infection control precautions

Devised in US in the 1980s in response to growing threat from HIV and hepatitis B Not confined to HIV and hepatitis B Treat ALL patients as a potential biohazard Adopt universal routine safe infection control practices to protect patients, self and colleagues from infection

Universal precautions

Hand washing Personal protective equipment [PPE] Preventing/managing sharps injuries Aseptic technique Isolation Staff health Linen handling and disposal Waste disposal Spillages of body fluids Environmental cleaning Risk management/assessment

Hand washing

Single most effective action to prevent HAI resident/transient bacteria Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken No recommended frequency - should be determined by intended/completed actions Research indicates: poor techniques - not all surfaces cleaned frequency diminishes with workload/distance poor compliance with guidelines/training

Hand washing areas missed


Taylor (1978) identified that 89% of the hand surface was missed and that the areas of the hands most often missed were the fingertips, finger-webs, the palms and the thumbs.

Personal protective equipment


PPE when contamination or splashing with blood or body fluids is anticipated Disposable gloves Plastic aprons Face masks Safety glasses, goggles, visors Head protection Foot protection Fluid repellent gowns (May, 2000)

Sharps injuries

Prevention correct disposal in appropriate container avoid re-sheathing needle avoid removing needle discard syringes as single unit avoid over-filling sharps container Management follow local policy for sharps injury (May, 2000)

Aseptic technique

Sepsis - harmful infection by bacteria Asepsis - prevention of sepsis Minimise risk of introducing pathogenic micro-organisms into susceptible sites Prevent transfer of potential pathogens from contaminated site to other sites, patients or staff Follow local policy (May, 2000)

Isolation

Single room or group Source or protective Source - isolation of infected patient mainly to prevent airborne transmission via respiratory droplets respiratory MRSA, pulmonary tuberculosis Protective - isolation of immunosuppressed patient (May, 2000) Significant psychological effects (Davies et al, 1999)

Staff health

Risk of acquiring and transmitting infection Acquiring infection immunisation cover lesions with waterproof dressings restrict non-immune/pregnant staff Transmitting infection advice when suffering infection Report accidents/untoward incidents Follow local policy (May, 2000)

Linen handling and disposal


Bedmaking and linen changing techniques Gloves and apron - handling contaminated linen Appropriate laundry bags Avoid contamination of clean linen Hazards of on-site ward-based laundering NHS Executive guidelines (1995) Follow local policy (May, 2000)

Waste disposal

Clinical waste - HIGH risk potentially/actually contaminated waste including body fluids and human tissue yellow plastic sack, tied prior to incineration Household waste - LOW risk paper towels, packaging, dead flowers, other waste which is not dangerously contaminated black plastic sack, tied prior to incineration Follow local policy (May, 2000)

Spillage of body fluids


PPE - disposable gloves, apron Soak up with paper towels, kitchen roll Cover area with hypochlorite solution e.g., Milton, for several minutes Clean area with warm water and detergent, then dry Treat waste as clinical waste - yellow plastic sack Follow local policy (May, 2000)

Environmental cleaning

Recent concern regarding poor hygiene in hospital environments (NHSE, 1999) Some pathogens survive for long periods in dust, debris and dirt Poor hygiene standards - hazardous to patients and staff (May, 2000) Report poor hygiene to Domestic Services (UKCC, 1992) Hospitals should do the sick no harm (Nightingale, 1854)

Risk assessment

No risk of contact/splashing with blood/body fluids - PPE not required Low or moderate risk of contact/splashing - wear gloves and plastic apron High risk of contact/splashing - wear gloves, plastic apron, gown, eye/face protection (Rcn, 1995)

Body fluids

Cerebrospinal fluid, peritoneal fluid, pleural fluid, synovial fluid, amniotic fluid, semen, vaginal secretions, and Any other fluid containing visible blood e.g., urine, faeces (Rcn, 1995)

Cost of HAI

Direct cost to NHS for: extended hospital stay, extra resources, extra treatment, extra equipment, and extra community care costs if discharged needing follow-up Direct cost to patient/family for: pain and scarring, extended stay away from family, working days lost, family income loss, financial strain - increased visiting etc, increased morbidity, increased mortality (ICNA, 1998)

Summary

Ignaz Semmelweis in 1847 demonstrated that washing hands saves lives Research indicates that 10% of patients develop HAI costing the NHS 1 billion and 20,000 deaths per year Old bacteria are causing new problems New viral and prion diseases are causing new problems Reluctance to wash hands still the single most important cause of HAI (ICNA, 1998) Growing concern about poor hospital hygiene

Core references

Davies, H. and Rees, J. (2000) Psychological effects of isolation nursing (1): mood disturbance. Nursing Standard. 14, 28, 35-38. May, D. (2000) Infection control. Nursing Standard. 14, 28. 51-57. ICNA (1998) Guidelines for hand hygiene. Belper: ICNA. NHS Executive (1995) Hospital laundry arrangements for used and infected linen - HSG (95) 18. London: DoH. Nightingale, F. (1854) Notes on nursing. Edinburgh: Churchill Livingstone Peto, R. (1998) Infection control, In: Mallik, M., Hall, C. and Howard, D. (eds) Nursing knowledge and practice - a decision making approach. London: Bailliere Tindall. Rcn (1995) Infection control in hospitals. London: Rcn.

Internet sites

http://www.icna.co.uk/ http://www.nursing-standard.co.uk/ http://www.medscape.com/ http://www.anes.uab.edu/medhist.htm http://www.shef.ac.uk/~nhcon/ http://medweb.bham.ac.uk/nursing/ http://www.healthcentre.org.uk/hc/library /default.htm

The end

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