Contact Hours: 4
This online independent study activity is credited for 4 contact hours at completion.
Overview
The role of infection control is to reduce and prevent the risk for hospital-acquired infections. To practice effective infection control practices, the healthcare professional must be knowledgeable of methods to prevent infection transmission. This training encompasses the seven core elements on infection control and barrier precautions and covers the most current and scientifically accepted practices in infection control as recommended by the Center for Disease Control (CDC).
Objectives
Upon completion of the independent study, the learner will be able to:
- Understand the seven elements in relation to infection control
Policy Statement
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Disclosures
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Barriers: Equipment such as gloves, gowns, aprons, masks, or protective eyewear, which when worn, can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials.
Cleaning: The process of removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object.
Common Vehicle: Contaminated material, product, or substance that serves as a means of infection transmission.
Communicable Disease: An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent from an infected person, animal, or inanimate source to a susceptible host.
Contamination: The presence of microorganisms on an item or surface.
Critical Device: An item that enters sterile tissue or the vascular system (e.g., intravenous catheters, needles for injections). These must be sterile prior to contact with tissue.
Decontamination: The use of physical or chemical means to remove, inactivate, or destroy bloodborne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles.
Disinfection: The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on objects.
The disinfectant does not harm the recipient, does not expose the provider to any avoidable risks and does not result in waste that is dangerous for the community.
Engineering Controls: Controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace.
Healthcare-Associated Infections (HAIs): Infections associated with healthcare delivery in any setting (e.g., hospitals, long-term care facilities, ambulatory settings, home care).
High Level Disinfection: Disinfection that kills all organisms, except high levels of bacterial spores, and is affected with a chemical germicide cleared for marketing as a sterilant by the Center for Disease Control.
Infectious Disease: A clinically manifest disease of humans or animals resulting from an infection.
Injection Safety (or safe injection practices): A set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others.
Intermediate Level Disinfection: Disinfection that kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a “tuberculocide” by the U.S. Environmental Protection Agency (EPA).
Low Level Disinfection: Disinfection that kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.
Multi-dose Medication Vial: bottle of liquid medication that contains more than one dose of medication and is often used by diabetic patients or for vaccinations.
Non-Critical Device: An item that contacts intact skin but not mucous membranes (e.g., blood pressure cuffs, oximeters). It requires low level disinfection.
Occupational Health Strategies: As applied to infection control, a set of activities intended to assess, prevent, and control infections and communicable diseases in healthcare workers.
Pathogen or Infectious Agent: A biological, physical, or chemical agent capable of causing disease. Biological agents may be bacteria, viruses, fungi, protozoa, helminths, or prions.
Personal Protective Equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard.
Portal of Entry: The means by which an infectious agent enters the susceptible host.
Portal of Exit: The path by which an infectious agent leaves the reservoir.
Reservoir: Place in which an infectious agent can survive but may or may not multiply or cause disease. Healthcare workers may be a reservoir for several nosocomial organisms spread in healthcare settings.
Semi Critical Device: An item that encounters mucous membranes or non-intact skin and minimally requires high level disinfection (e.g., oral thermometers, vaginal specula).
Single-use Medication Vial: A bottle of liquid medication that is given to a patient through a needle and syringe. Single-use vials contain only one dose of medication and should only be used once for one patient, using a new sterile needle and new sterile syringe.
Standard Precautions: A group of infection prevention and control measures that combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents.
Sterilization: The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores.
Susceptible Host: A person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting infection or disease when exposed to the agent.
transmission of an infectious agent from a reservoir to one or more susceptible hosts through a suitable portal of entry.
Transmission: Any mechanism by which a pathogen is spread by a source or reservoir to a person.
Work Practice Controls: Controls that reduce the likelihood of exposure to bloodborne pathogens by altering the way a task is performed (e.g., prohibiting recapping of needles by a two-handed technique).
The Centers for Disease Control (CDC) and the Occupational Safety and Health Administration (OSHA) are the regulating bodies of infection control, prevention, and awareness. Infection control refers to the policies and procedures that are practiced to reduce and prevent the spread of infections. Specific precautions, such as standard precautions, contact precautions, droplet precautions, airborne precautions, and bloodborne precautions, are utilized by healthcare providers to prevent the spread of infectious organisms.
Decades ago, a small number of hospitals began to recognize healthcare associated infections (HAIs) and developed infection control concepts. The main purpose of infection control programs in hospital settings during that time was to conduct surveillance for HAIs and incorporate epidemiology to explain risk factors. ⁶ However, most of the infection control programs were organized and managed by large academic centers rather than public health agencies which lead to sporadic efficiency and suboptimal outcomes. It was not until the 1990s that a new era in infection control began because of three pivotal events. These events included the Institute of Medicine’s 1999 report on errors in health care⁵, the 2002 Chicago Tribune representation on healthcare associated infections⁵, and the 2004 publications of the significant reductions in bloodstream infection rates through the standardization of central venous catheter placement.⁵ The new information and practices that resulted from healthcare epidemiology also caused consumer demands for more transparency and accountability, increased regulation, and expectations for rapid reductions in HAIs rates. ⁶ The role of infection control is to reduce and prevent the risk for hospital-acquired infections. This can be achieved by implementing infection control programs in the forms of surveillance, isolation, outbreak management, environmental hygiene, employee health, education, and infection prevention policies and management. This course provides healthcare professionals within New York State with education on infection control and barrier precautions, and rules and regulations that apply to the state.
In August 1992, Chapter 786 of the Laws of 1992 established a requirement that certain healthcare professionals licensed in New York State receive training on infection control and barrier precautions by July 1994, and every four years thereafter unless otherwise exempted. ¹⁰ The goal of the infection control training requirement is to:
- Assure that licensed, registered, or certified health professionals understand how bloodborne pathogens may be transmitted in the work environment: patient to healthcare worker, healthcare worker to patient, and patient to patient.
- Apply current scientifically accepted infection prevention and control principles as appropriate for the specific work environment.
- Minimize opportunity for transmission of pathogens to patients and healthcare workers.
- Familiarize professionals with the law requiring this training and the professional misconduct charges that may be applicable for not complying with the law.
Chapter 786, and the infection control and barrier precautions training requirement for healthcare professionals licensed in New York State applies to the following professionals¹⁰:
- Dental hygienists
- Dentists
- Licensed practical nurses
- Optometrists
- Physicians
- Physician assistants
- Podiatrists
- Registered professional nurses
- Specialist assistants
- *Medical students
- *Medical residents
- *Physician assistant students
(* These categories were added pursuant to legislation enacted in November 2008.)
The New York State law requires training to control transmission of disease from healthcare worker to patient, patient to healthcare worker, and patient-to-patient. This training encompasses the seven core elements on infection control and barrier precautions and covers the most current and scientifically accepted practices in infection control as recommended by the Center for Disease Control (CDC). The seven core elements are as follows¹⁰:
Element I
Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible
Learning objectives:
- Recognize the benefit to patients and healthcare workers of adhering to scientifically accepted principles and practices of infection prevention and control.
- Recognize the professional’s responsibility to adhere to scientifically accepted infection prevention and control practices in all healthcare settings and the consequences of failing to comply.
- Recognize the professional’s responsibility to monitor infection prevention and control practices of those medical and ancillary personnel for whom he or she is responsible and intervene as necessary to assure compliance and safety.
Element II
Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control
Learning objectives:
- Describe how pathogenic organisms are spread in healthcare settings.
- Identify the factors which influence the outcome of an exposure to pathogenic organisms in healthcare settings.
- List strategies for preventing transmission of pathogenic organisms.
- Describe how infection control concepts are applied in professional practice.
Element III
Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings
Learning objectives:
- Define healthcare-associated disease transmission, engineering controls, safe injection practices, and work practice controls.
- Describe specific high-risk practices and procedures that increase the opportunity for healthcare worker and patient exposure to potentially infectious material.
- Describe specific measures to prevent transmission of bloodborne pathogens from patient to patient, healthcare worker to patient, and patient to healthcare worker via contaminated injection equipment.
- Identify work practice controls designed to eliminate the transmission of bloodborne pathogens during use of sharp instruments (e.g., scalpel blades and their holders (if not disposable), lancets, lancet platforms/pens, puncture devices, needles, syringes, injections).
- Identify where engineering or work practice controls can be utilized to prevent patient exposure to bloodborne pathogens.
Element IV
Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with potentially infectious material
Learning objectives:
- Describe the circumstances that require the use of barriers and personal protective equipment to prevent patient or healthcare worker contact with potentially infectious material.
- Identify specific barriers or personal protective equipment for patient and healthcare worker protection from exposure to potentially infectious material.
Element V
Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfection, and sterilization
Learning objectives:
- Define cleaning, disinfection, and sterilization.
- Differentiate between noncritical, semi critical, and critical medical devices.
- Describe the three levels of disinfection (i.e., low, intermediate, and high).
- Recognize the importance of the correct application of reprocessing methods for assuring the safety and integrity of patient care equipment in preventing transmission of bloodborne pathogens.
- Recognize the professional’s responsibility for maintaining a safe patient care environment in all healthcare settings.
- Recognize strategies for, and importance of, effective and appropriate pre-cleaning, chemical disinfection, and sterilization of instruments and medical devices aimed at preventing transmission of bloodborne pathogens.
Element VI
Prevention and control of infectious and communicable diseases in healthcare workers
Learning objectives
- Recognize the role of occupational health strategies in protecting healthcare workers and patients.
- Recognize non-specific disease findings that should prompt evaluation of healthcare workers.
- Identify occupational health strategies for preventing transmission of bloodborne pathogens and other communicable diseases in healthcare workers.
- Identify resources for evaluation of healthcare workers infected with HIV, HBV, and/or HCV.
Element VII
Sepsis awareness and education
Learning objectives
- Describe the scope of the sepsis problem and the NYS Sepsis Improvement Initiative.
- Describe persons at increased risk of developing sepsis.
- Identify common sources of infection that may lead to sepsis.
- Describe early signs and symptoms that may be associated with sepsis in adults and children and infants.
- Understand the need for immediate medical evaluation and management if sepsis is suspected.
- Educate patients and families on methods for preventing infections and illnesses that can lead to sepsis and on identifying the signs and symptoms of severe infections and when to seek medical care.
The following provides an overview of Part 92 of Title 10⁷:
Training Requirement: Minimum Core Elements
Coursework must be tailored to meet the specific needs of the professional audience and will be relevant to the most current and scientifically accepted practices in infection control.
Comparison to Required Training as Part of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard
The New York State law requires training to control transmission of disease from healthcare worker to patient, patient to healthcare worker, and patient-to-patient. OSHA requirements do not meet the New York State law for mandatory training since their focus is limited to preventing occupational exposure.
Time Requirements
The initial course program may be designed to last between 2-4 hours and can be done in a single session or in divided time slots.
Course Provider Approval
Organizations interested in seeking provider approval for infection control course work or training must seek application from the appropriate department.
- For all Article 28 health care facilities seeking providership, the recommendationfor the qualifications of the Course Provider are:
- Current experience in infection control, and/or
- Certification as an infection control practitioner (e.g., certification by the Certification Board of Infection Control and Epidemiology, Inc. [CIC®]).
- For any non-Article 28 applicants seeking providership with the DOH, the following requirement
- must be met:
- Current certification as an infection control practitioner (e.g., CIC®), or
- Active in infection control practice within an institution for a minimum of 2 years, or
- Active infectious disease physician.
Documentation Requirements for Providers
NYS-approved Course Providers must document completion of training as prescribed. This shall include:
- Name of the participant
- Date of course completion
- NYS-approved Course Provider name and identification number
- Signature of the NYS-approved Course Provider
Maintenance of Records
Course Providers must maintain a record of persons who completed the course for a minimum of six years. This record may be stored on computer or hard copy, at the discretion of the provider. All participants should be instructed to retain their certification of completion.
The following provides an overview of Part 92 of Title 10⁷:
Training Requirement: Minimum Core Elements
Coursework must be tailored to meet the specific needs of the professional audience and will be relevant to the most current and scientifically accepted practices in infection control.
Comparison to Required Training as Part of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard
The New York State law requires training to control transmission of disease from healthcare worker to patient, patient to healthcare worker, and patient-to-patient. OSHA requirements do not meet the New York State law for mandatory training since their focus is limited to preventing occupational exposure.
Time Requirements
The initial course program may be designed to last between 2-4 hours and can be done in a single session or in divided time slots.
Course Provider Approval
Organizations interested in seeking provider approval for infection control course work or training must seek application from the appropriate department.
- For all Article 28 health care facilities seeking providership, the recommendationfor the qualifications of the Course Provider are:
- Current experience in infection control, and/or
- Certification as an infection control practitioner (e.g., certification by the Certification Board of Infection Control and Epidemiology, Inc. [CIC®]).
- For any non-Article 28 applicants seeking providership with the DOH, the following requirement must be met:
- Current certification as an infection control practitioner (e.g., CIC®), or
- Active in infection control practice within an institution for a minimum of 2 years, or
- Active infectious disease physician.
Documentation Requirements for Providers
NYS-approved Course Providers must document completion of training as prescribed. This shall include:
- Name of the participant
- Date of course completion
- NYS-approved Course Provider name and identification number
- Signature of the NYS-approved Course Provider
Maintenance of Records
Course Providers must maintain a record of persons who completed the course for a minimum of six years. This record may be stored on computer or hard copy, at the discretion of the provider. All participants should be instructed to retain their certification of completion.
American Nurse Association:
Infection control and prevention, and its main tenants are often forgotten. The healthcare provider must do the following to improve infection control⁴:
- Wash hands thoroughly and often
- Stay home when ill
- Cover your mouth and nose when sneezing and coughing with a tissue and perform hand hygiene afterwards
- Ensure immunizations are up to date
- Use the appropriate personal protective equipment (PPE) when interacting with patients
Center for Disease Control:
Infection control prevents or stops the spread of infections in healthcare settings through Standard Precautions and Transmission-Based Precautions. ¹
In the state of New York, Healthcare professionals must take an approved course in infection control and barrier precautions every 4 years. ⁸ The course is taken to improve infection control practices of healthcare providers, because although the principles of infection control may be known, they are not always practiced. Healthcare professionals have a duty to provide high-quality care that reduces or prevents infection transmission, and that adheres to scientifically accepted or evidence-based practices of infection control.
The ability of an infectious organism to be transmitted within a healthcare setting is dependent on three elements: a source of infection, a susceptible host with a portal of entry for the infectious organism to enter, and a mode of transmission for the source of infection. ³ For instance, a patient is diagnosed with a healthcare acquired infection caused by Staphylococcus aureus after a surgical site becomes infected. In this setting, the Staphylococcus aureus is the source of infection, the patient’s surgical site represents the portal of entry for the Staphylococcus aureus, and the transmission of the healthcare acquired infection likely occurred during the dressing change of the surgical site.
Infectious organisms that are transmitted during healthcare usually occur from human contact but can also occur because of contact with inanimate objects in the environment. ¹˒³ Human reservoirs (carriers of an infectious organism) that are capable of transmitting infections include healthcare providers, visitors, and the patients themselves. Human reservoirs can unknowingly transmit infectious organisms because they may be asymptomatic or may be transiently or chronically colonized with microorganisms. These also are sources for healthcare acquired infections. Contact is the most common mode of infection transmission. It is divided into two subgroups: direct contact and indirect contact.
Direct Contact
Direct contact of an infection occurs when infectious organisms are transferred directly from one infected person to another. ¹˒³ Examples of direct contact include:
- Patient’s blood or body fluids entering the body of a healthcare provider through contact with mucous membranes.
- Mites from scabies transmitted to the ungloved skin of a healthcare provider.
Indirect Contact
Indirect contact involves the transfer of an infectious organism because of encountering a contaminated object or person. ¹˒³ Examples of indirect contact include:
- A healthcare provider not performing hand hygiene after touching a contaminated inanimate object and transmitting an infectious organism to a patient.
- Using a glucose monitoring device between patients without thoroughly cleaning and disinfecting it, resulting in the transmission of infected blood.
- A caregiver sharing toys with groups of children without effectively cleaning and disinfecting them.
Modes of Transmission
There are several classes of pathogens that can cause infection, including bacteria, fungi, parasites, prions, and viruses. ¹˒¹² The modes of transmission of the pathogens varies depending on the type of organism. Some infectious organisms may be transmitted by more than one route. For instance, Herpes simplex virus, respiratory syncytial virus, and Staphylococcus aureus are transmitted through direct and indirect contact, influenza virus and B. pertussis are transmitted by droplets, and tuberculosisis transmitted via airborne routes. Bloodborne viruses such as hepatitis B and C, and HIV are rarely transmitted in healthcare settings.
Standard precautions are used for all patient care. ¹² Standard precautions include hand hygiene, personal protective equipment, appropriate patient placement, cleaning and disinfecting patient care equipment, safe injection practices, and proper disposal of needles and other sharp objects.
- Hand Hygiene
Hand Hygiene describes cleaning hands through handwashing with soap and water or using alcohol-based hand sanitizers. ¹˒¹¹- When washing hands, the healthcare provider must first wet their hands with water, apply soap, and rub hands together vigorously, covering all surfaces of the hands and fingers for at least 20 seconds. Because germs can live under artificial nails, their use is not recommended in healthcare settings. Nails should be natural and less than ¼ inch long. Hands should always be washed when they are visibly soiled, after caring for someone with suspected or known infectious diarrhea, and after known or suspected exposure to spores.
- When considering using hand sanitizer, it should be put directly on hands and the hands should be rubbed together, covering all surfaces of the hands and fingers until they feel dry, this should take approximately 20 seconds. Hand sanitizer should be used immediately before touching a patient, before performing an aseptic task such as catheter insertion, after touching contaminated surfaces, after touching objects in that patient’s environment, and immediately after removing gloves.
- Glove considerations: Glove use should never be substituted for hand hygiene. Gloves should be worn according to standard precautions, including when the healthcare provider anticipates having contact with infectious materials, non-intact or contaminated skin or equipment, mucous membranes, or blood.
- If a task requires gloves, the healthcare provider should perform hand hygiene prior to donning gloves, and before touching the patient or the patient’s environment.
- The healthcare provider should perform hand hygiene immediately after removing their gloves.
- During patient care, the healthcare provider should change their gloves and perform hand hygiene if the gloves become damaged, they become visibly soiled after completing a task, or when moving from a dirty site to a clean body site on the same patient.
- The healthcare provider must never wear the same pair of to provide care for more than one patient.
- Personal Protective Equipment
Personal Protective Equipment (PPE) are specialized clothing and equipment that are used to protect the healthcare provider from infection or injury. ¹˒¹² Occupational Safety and Health Administration (OSHA) issues regulations for workplace health and safety. ¹³ These regulations require use of PPE in healthcare settings to protect healthcare providers from exposure to airborne and bloodborne pathogens. However, under OSHA’s General Duty Clause PPE is required for any potential infectious disease exposure. Employers must provide their employees with appropriate PPE and ensure that PPE is disposed, and if reusable, that it is thoroughly cleaned or laundered, repaired, and stored after use.- Three things must be considered when using PPE:
- First is the type of anticipated exposure, such as touch, splashes or sprays, or large volumes of blood or body fluids that might penetrate the clothing. PPE selection, in particular the combination of PPE, also is determined by the category of isolation precautions a patient is on.
- Second, is the durability and appropriateness of the PPE for the task. This will affect whether a gown or apron is selected for PPE, or, if a gown is selected, whether it needs to be fluid resistant or fluid proof.
- Third is fit. The selected PPE must fit the healthcare provider, and it is up to the employer to ensure that all PPE are available in sizes appropriate for the healthcare providers.
- Steps for donning PPE as recommended by the CDC ¹²:
- Identify and gather the proper PPE to don. Ensure isolation gown selected is the correct size.
- Perform hand hygiene using hand sanitizer.
- Put on the isolation gown and tie all the ties on the gown.
- Depending on the organism and type of isolation, selecta facemask, or NIOSH-approved N95 filtering facepiece respirator or higher. When using a facemask, tie all the ties together. When using an N95 filtering facepiece (or higher), if the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one handed., as this may cause it to not be flush with the skin. Respirators and facemasks should be extended under chin, and the mouth and nose should be covered. They should never be worn under the chin or stored in scrubs pocket between patients.
- Facemask: Mask ties should be secured on the crown of the head (top tie) and base of neck (bottom tie). If the mask has loops, hook them appropriately around ears.
- Respirator: Respirator straps should be placed on the crown of the head (top strap) and base of neck (bottom strap). A user seal check should be performed each time a respirator is put on.
- Put on face shield or goggles. Face shields should provide full face coverage and must not interfere with the use of a respirator. Goggles may also be used, as they provide excellent protection for eyes, but fogging is of goggles may occur
- Put on gloves. Gloves should cover the cuff (wrist) of gown.
- Steps for doffing PPE as recommended by the CDC ¹²:
Before exiting the room:- Remove gloves. Ensure removing gloves does not cause additional contamination of hands.
- Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Break the gown in a gentle manner, avoiding a forceful movement. When breaking a gown, reach up to the shoulders and carefully pull gown down and away from the body. Rolling the gown down is an acceptable approach. When the gown is removed, dispose of it in the appropriate trash receptacle.
- Healthcare providers may now exit patient room. After exiting the room
- Perform hand hygiene.
- Remove the face shield or goggles. Carefully remove the face shield or goggles by grabbing the strap and pulling upwards and away from the head. Do not touch the front of the face shield or goggles.
- Remove and discard facemask or respirator. Do not touch the front of the respirator or facemask.
- Facemask: Carefully untie (or unhook from the ears) and pull away from face without touching the front.
- Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator.
- Perform hand hygiene again.
- Three things must be considered when using PPE:
- Patient Placement
Patient placement within the healthcare setting and the prioritization of single room isolation is not solely dependent on the mode of transmission and infectivity of a pathogen, but also on the contagiousness of the infection to other people. ¹²˒¹³ Single rooms should be considered for all patients who require isolation due to infectious conditions and negative pressure rooms are always indicated for patients requiring airborne precautions. Designated bathroom facilities should also be available, and the door must be kept closed with appropriate signage displayed outside the room. In addition, a risk assessment should be considered whenever a patient is placed in a healthcare setting. There are several factors in a risk assessment, including:- The healthcare provider should consider how the known or suspected infectious organism is transmitted.
- Whether or not a patient exhibits signs and symptoms that coincide with infection.
- Whether or not a patient has a suspected or known Infection or is known to be colonized with a highly transmissible pathogen, such as a multidrug-resistant organism.
- Cleaning and Disinfecting Patient Care Equipment
The Occupational Safety and Health Administration (OSHA) standards are designed to limit bloodborne pathogen occupational exposure. All equipment and working surfaces must be cleaned and decontaminated with an appropriate disinfectant after contact with infectious materials or blood. ³ Using disinfectants is part of a multibarrier strategy to prevent healthcare associated infections. In general, for smaller spills, OSHA requires the use of EPA-registered tuberculocidal disinfectants or hypochlorite solution (diluted 1:10 or 1:100 with water), and for larger spills, a 1:10 final dilution of EPA-registered hypochlorite solution should be used to inactivate bloodborne viruses. Noncritical items, such as surfaces, only encounter intact skin. As a result, noncritical items pose little risk of causing an infection. Thus, the routine use of germicidal chemicals to disinfect hospital floors, surfaces and other noncritical items is effective. Medical equipment surfaces such as blood pressure cuffs, stethoscopes, hemodialysis machines, and X-ray machines, have the potential to become contaminated with infectious organisms and contribute to the spread of healthcare associated infections. For this reason, noncritical medical equipment surfaces should be disinfected with an EPA-registered low- or intermediate-level disinfectant. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. Use of a disinfectant will provide antimicrobial activity that is likely to be achieved with minimal additional cost or work.- Cleaning Frequency, Procedures, Principles, and Reprocessing
- Avoid exposing immunocompromised and infants to cleaning and aerosolization of potential contaminants.
- Avoid cleaning methods that aerosolize contaminants in patient-care areas.
- Change the mop head daily and more frequently if used on a large spill.
- Clean and disinfect high touch surfaces frequently
- Clean floors, tabletops, walls, and tabletops frequently.
- Clean noncritical medical equipment surfaces with a detergent or disinfectant.
- Consult an infection control expert for cleaning and disinfecting if known or suspected prion disease.
- Do not use alcohol to disinfect large environmental surfaces.
- Do not disinfectant with fogging in patient-care areas.
- Do not use mats with tacky surfaces in or near operating rooms of ICU.
- Do not use phenolics or chemical germicide to disinfect bassinets or incubators while the infant is present. When using phenolic disinfectants, prepare solutions in accordance with manufacturers’ instructions.
- Devices, equipment, and instruments should be managed and reprocessed according to recommended methods.
- Follow proper procedures for effective uses of cloths and mops.
- Instructions should be readily available for cleaning and disinfection of devices, equipment, and instruments.
- Prepare cleaning solutions daily.
- Use vacuums with HEPA filters.
- Use barrier protective coverings noncritical surfaces that are commonly contaminated, challenging to clean, or touched frequently.
- Use an EPA-registered hospital detergent or disinfectant designed for one-step housekeeping purposes.
- When using a disinfectant wipe, make sure the surface remains visibly wet.
- Reprocessing
Considerations for reprocessing equipment include:- Frequent cleaning solution changes
- Pre-cleaning internal and external surfaces removing debris and soilage.
- Clean with brushes, scrubbing, and automated washers.
- For disinfection, sufficient contact time with the chemical solution is necessary.
- For sterilization, sufficient exposure time to chemicals, heat, or gases is necessary.
- The reprocessing sequence should be based on the manufacturer’s instructions for use.
- Prior cleaning and removal of organic matter and biofilms.
- Selection and use of disinfectants and sterilization techniques.
- Monitoring activity and stability of disinfectant contact time, and usage.
- Post-disinfection/sterilization handling, packaging, and storage.
- Potential Sources of Cross-contamination
- Surfaces which require cleaning between procedures.
- Practices that contribute to hand contamination
- Reuse of devices, equipment, and instruments
- Cleaning Frequency, Procedures, Principles, and Reprocessing
Health professionals should be aware of the OSHA Guidelines and the CDC Guidelines that use the Spaulding classification, depending on the need for disinfection or sterilization and the categories of critical, semi-critical, or non-critical items.
- Safe Injection Practices and Proper Needle Disposal
Safe injection practices are intended to prevent transmission of infectious diseases between patients or between a patient and healthcare provider. According to the CDC, safe injection practices include³:- Prepare injections using aseptic technique.
- Disinfect the rubber septum on a medication vial with alcohol before piercing.
- Do not use needles or syringes for more than one patient.
- Use a new needle and new syringe on medication containers even when withdrawing additional doses of medication for the same patient.
- Use single-dose vials for intravenous medications.
- Do not use single-dose medication vials, ampules, bags, or bottles of intravenous solution for more than one patient.
- Do not combine the leftover contents of single-use vials for later use.
- Do not use fluid infusion or administration sets for more than one patient.
- If a needle has a sharps injury protection feature, such as needles that retract or are covered by a sheath use it immediately after need use and as directed per facility policy prior to disposing the needle and syringe in the appropriate labeled container.
- Never place needles or syringes in the trash, even when the sharps injury protection feature is in place.
Contact precautions are used for patients with known or suspected infections that can be transmitted directly or indirectly through patient contact, or their environment, including their room or objects within the room.¹˒³ For instance, patients with acute infectious diarrhea such as Clostridium difficile (an organism that can be transmitted fecal-orally), vesicular rashes, respiratory tract infection with a multidrug-resistant organism such as methicillin-resistant Staphylococcus aureus (MRSA), or an abscess or draining wound that cannot be covered should be placed on contact precautions. In addition to contact precautions, standard precautions must also be used. Patients should also be placed in a single patient room, transport and patient movement should be limited, disposable patient care equipment should be used, and thorough cleaning and disinfecting should be completed regularly.
- In an acute care hospital setting, the healthcare provider should ensure that a patient with contact precautions is placed in a single patient room. In long-term and other residential settings, the healthcare provider should make patient placement decisions with considerations to risks posed to other patients. In ambulatory settings, patients requiring contact precautions should be placed in an exam room or cubicle as soon as possible.
- The healthcare provider should wear a gown and gloves for all interactions that may involve patient contact or contact with the patient’s environment. Personal protective equipment should be donned just before to entering the room and properly discarded before exiting the room to reduce the transmission of infectious organisms.
- When a patient with contact precautions must be transported or moved, the healthcare provider should cover or contain the infected or colonized areas of the patient’s body. Prior to transporting or moving the patient, the healthcare provider should remove and appropriately dispose of all contaminated personal protective equipment and perform hand hygiene. Upon arrival to the transport or movement location, the healthcare provider should don the appropriate clean personal protective equipment prior to touching the patient with contact precautions.
- Disposable or dedicated patient-care equipment, such as blood pressure cuffs should be used for a patient with contact precautions. If equipment must be used for multiple patients, it must be cleaned and disinfected between use for each patient.
- Routinely cleaning and disinfecting the rooms of patients on contact precautions must be performed with attention to frequently touched surfaces and equipment in the immediate vicinity of the patient.
Droplet precautions are used for patients with known or suspected infections that can be transmitted by air droplets from respiratory secretions by coughing, sneezing, talking, and by close contact with an infected patient’s breathing. ¹˒³ Droplets are about 30 to 50 micrometers in size. Because these infectious organisms do not remain infectious over long distances, special air handling and ventilation are not required to prevent droplet transmission. Patients who have droplet precautions should, however, be placed in a single patient room. When a single-patient room is not available, risks associated with exposure to other patients within a multibed room must be considered. Spatial separation of more than three feet and drawing the curtain between patient beds is especially important for patients in multibed rooms with infections transmitted by the droplet route.
Patients who have droplet precautions should also have limited transportation and movement within a healthcare setting, as much as possible. During instances when transportation or movement is necessary, the patient who has droplet precautions should wear a mask if tolerated and follow respiratory hygiene/cough etiquette. In addition to standard precautions, healthcare providers should also wear protective surgical masks and gloves before interacting with the patient or their environment. ¹²
Airborne precautions are used for patients with known or suspected infections that can be transmitted by the airborne route. ¹˒³ These infections are 5 micrometers or smaller in size, can be transmitted over long distances, and can remain suspended in the air for long periods of time. Because airborne infections are transmissible at long distances and can remain suspended in the air, patients with airborne precautions should be placed in an airborne infection isolation room (AIIR). An AIIR is a single-patient room that is equipped with special air handling, filtering, and ventilation, allowing 6 to 12 air exchanges per hour, such as negative pressure rooms, and air that is exhausted directly to the outside environment or recirculated through high efficiency particulate air (HEPA) filtration before return. In addition to airborne precautions, standard precautions must be utilized. In addition, any healthcare setting that treats patients with airborne precautions must also have a respiratory protection program that includes education about use of respirators, fit testing, and user seal checks. In settings where airborne precautions cannot be implemented, such as physician offices, the patient should be masked and placed in a private room with the door closed. The healthcare provider should wear a N95 masks or higher-level respirators whenever engaging with the patient with airborne precautions. Wearing masks will reduce the likelihood of airborne transmission until the patient is either transferred to a facility with an airborne infection isolation room or returned to the home environment, whichever is medically appropriate.
- The most important pathogens that need airborne precautions are tuberculosis, measles, chickenpox, and disseminated herpes zoster, and SARS-CoV.
- Patients with suspected vesicular rash, cough/fever with pulmonary infiltrate, maculopapular rash with cough/coryza/fever should have airborne precaution.
Bloodborne precautions are usually due to the blood-borne transmission of infectious organisms through percutaneous injuries, which can be prevented using changes in technique, experience, and safety devices. ¹˒¹³ These precautions apply to any blood-containing fluids, including cerebrospinal fluid, pericardial fluid, pleural fluid, and peritoneal fluid. The absence of visible blood or signs of contamination in a used syringe, IV tubing, multi- or single-dose medication vial, or blood glucose monitoring device does not mean the item is free from potentially infectious agents.
According to the OSHA database, HIV, hepatitis B and C, tuberculosis, malaria, measles, herpes, chickenpox, and various other bacterial infections are known for being transmitted through blood-containing fluids and products.
- Blood-borne precautions include wearing gloves, facemasks, protective eyewear or goggles, and proper handling of sharp objects with appropriate disposal. ¹˒³
- Sharps should be disposed in an approved puncture-proof “sharp-only” locked and secured bin.
- All sharps should not be re-capped.
- All sharps should not be bent or broken.
- Safety devices should be implemented to prevent contact with needles and other sharps.
Sputum, vomitous, sweat, feces, and nasal secretions do not require blood-borne precautions unless there is visible blood noted. If contact with blood containing fluids or products occurs, it is important to immediately wash the affected area with soap and water and follow institutional guidelines for exposure. ¹
Below is a table of precaution requirements for common infections. This topic will focus on Hepatitis, HIV, and Tuberculosis.
| Standard Precautions | Contact Precautions | Droplet Precautions | Airborne Precautions | Bloodborne Precautions |
| CMV HIV Hepatitis B and C Aspergillosis | MRSA VRE Adenovirus C. Difficile E. Coli Salmonella Shigella Hepatitis A Herpes Zoster Herpes Simplex Lice Scabies | Pertussis Influenza A or B MRSA Bacterial Meningitis RSV Mumps Rubella | Chicken Pox Shingles Measles Tuberculosis Covid-19 SARS Avian influenza | Anytime there is risk of exposure to blood or body fluids |
Hepatitis
Hepatitis refers to an inflammatory condition of the liver and is usually caused by a viral infection, medications, drugs, toxins, and alcohol use, or because of an autoimmune response. ¹⁵ People at increased risk for hepatitis infection include:
- Hemodialysis patients
- Household contacts or sexual partners of known people with chronic hepatitis
- infection
- International travelers
- Men who have sex with men
- People who are homeless
- People who use drugs
- People with occupational risk for exposure
There are 5 types of hepatitis: A, B, C, D, and E. ¹⁵
- Hepatitis A
Hepatitis A is a liver infection caused by the hepatitis A virus (HAV). It is highly contagious and is found in the stool and blood of people who are infected. Hepatitis A is spread when someone unknowingly ingests the virus through close personal contact with an infected person, sexual contact, or through eating contaminated food or drink. Symptoms of hepatitis A usually occur abruptly and can last up to 2 months. They include:
| Abdominal pain | Clay-colored stool | Dark urine |
| Diarrhea | Fatigue | Fever |
| Jaundice | Joint pain | Loss of appetite |
| Nausea | Vomiting |
Vaccination with the full, two-dose series of hepatitis A vaccine is the best way to prevent infection, however if someone is infected with HAV, immunoglobulin G antibodies which appear early in the course of infection will provide lifelong protection against becoming infected with the disease again.
- Hepatitis B
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). Hepatitis B is spread when blood, semen, or other body fluids from a person infected with the virus enters the body of someone who is not infected through sexual contact, sharing needles, syringes, or from mother to baby at birth. Not all people newly infected with HBV have symptoms, but for those that do, symptoms can include:
| Abdominal pain | Clay-colored stool | Dark urine |
| Fatigue | Fever | Jaundice |
| Joint pain | Loss of appetite | Nausea |
| Vomiting |
Many people with HBV may be asymptomatic or experience a short-term illness. For others, it can become a long-term, chronic infection that can lead to serious, even life-threatening health issues, such as cirrhosis or liver cancer. If symptoms do occur, they usually begin within 90 days and can last 6 months or more. Hepatitis B virus can become chronic, and the risk of chronic infection varies with age. For instance, approximately 90% of infants and up to 50% of children aged 1-5 will remain chronically infected, as opposed to 5% of adults. For those that do experience chronic infection, antiviral medications are available. People with previous HBV may also experience reactivation; where the virus abruptly reappears, often because of a flare in disease activity. Hepatitis B virus reactivation has the potential to be sever, even resulting in death. The best way to prevent HBV is to get vaccinated through three inoculations: the initial dose, and two more at 1 month and 6 months, respectively.
- Hepatitis C
Hepatitis Cis a liver infection caused by the hepatitis C virus (HCV). Hepatitis C is spread through contact with blood from an infected person, usually by sharing needles or other equipment used to prepare and inject drugs. Hepatitis C virus may also be transmitted through:- Needlestick injuries in health-care settings
- Other health-care procedures that involve invasive procedures
- Receipt of donated blood, blood products, and organs
- Sex with an HCV-infected person
- Sharing personal items contaminated with infectious blood, such as razors
- Unregulated tattooing
Hepatitis C virus may be a short-term illness for some people, but unfortunately, over half will develop a chronic infection. Cirrhosis and liver cancer can both result from chronic HCV, and they both can be life-threatening. People who develop chronic HCV may be asymptomatic, however when symptoms do arise, they are usually a sign of advanced disease. Symptoms include:
| Abdominal pain | Clay-colored stool | Dark urine |
| Fatigue | Fever | Jaundice |
| Joint pain | Loss of appetite | Nausea |
| Vomiting |
There is no vaccine for hepatitis C. The best way to prevent hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs. Getting tested for hepatitis C is important, because treatments can cure most people with hepatitis C in 8 to 12 weeks.
- Hepatitis D
Hepatitis D, also known as “delta hepatitis,” is a liver infection caused by the hepatitis D virus (HDV). It is also known as a satellite virus because it can only infect people who are also infected with HBV. Hepatitis D is spread through blood and body fluids, most often through used needles and mucosal contact. Both HDV and HBV can occur at the same time, also known as coinfection, or HDV can occur after being infected with HBV first, also known as superinfection. Hepatitis D can be an acute, short-term infection or become a long-term, chronic infection. Hepatitis D can cause severe symptoms and serious illness that can lead to life-long liver damage and even death. There is no vaccine to prevent hepatitis D. However, prevention of hepatitis B through hepatitis B vaccine use will also protects against future hepatitis D infection. - Hepatitis E
Hepatitis E is a liver infection caused by the hepatitis E virus (HEV) that is found in the stool of an infected person. It is spread through ingestion of the virus, and the virus is transmittable even if microscopic amounts of it is consumed. Hepatitis E virus is mostly present in underdeveloped countries. People most often get hepatitis E from drinking water contaminated by feces from people who are infected with the virus. In the United States and other developed countries where hepatitis E is not common, people have gotten sick with hepatitis E after eating raw or undercooked pork, venison, wild boar meat, or shellfish. In the past, most cases in developed countries involved people who have recently traveled to countries where hepatitis E is common. Symptoms of hepatitis E can include fatigue, poor appetite, stomach pain, nausea, and jaundice. However, many people with hepatitis E, especially young children, have no symptoms. Except for the rare occurrence of chronic hepatitis E in people with compromised immune systems, most people recover fully from the disease without any complications. No vaccine for hepatitis E is currently available in the United States.
Human Immunodeficiency Virus
Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system. ² If HIV is not treated, it can lead to Acquired Immunodeficiency Syndrome (AIDS). ² HIV is spread through blood and body fluids through anal or vaginal sex, sharing needles, syringes, or other drug injection equipment, and mother-to baby during pregnancy, delivery, or breastfeeding. In the first two to four weeks of infection (namely acute HIV infection), some people may experience flu-like symptoms, including²:
- Chills
- Fatigue
- Fever
- Mouth ulcers
- Muscle aches
- Night sweats
- Rash
- Sore throat
- Swollen lymph nodes
These symptoms may last several weeks. There currently is no cure for HIV or AIDS, however there are effective mediations that when taken appropriately, can make HIV nondetectable in blood samples. This does not however, mean that one infected with HIV is cured.
Human Immunodeficiency Virus (HIV) is a virus that attacks the body’s immune system. ² If HIV is not treated, it can lead to Acquired Immunodeficiency Syndrome (AIDS). ² HIV is spread through blood and body fluids through anal or vaginal sex, sharing needles, syringes, or other drug injection equipment, and mother-to baby during pregnancy, delivery, or breastfeeding. In the first two to four weeks of infection (namely acute HIV infection), some people may experience flu-like symptoms, including²:
- Chills
- Fatigue
- Fever
- Mouth ulcers
- Muscle aches
- Night sweats
- Rash
- Sore throat
- Swollen lymph nodes
These symptoms may last several weeks. There currently is no cure for HIV or AIDS, however there are effective mediations that when taken appropriately, can make HIV nondetectable in blood samples. This does not however, mean that one infected with HIV is cured.
Turberculosis
Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. ¹⁴ The bacteria usually attack the lungs, but TB bacteria can attack any part of the body, including the kidneys, spine, and the brain. Tuberculosis is spread through the air from one person to another through coughing, speaking, or singing. ¹⁴ There are two TB-related conditions that exist: latent TB infection (LTBI) and TB disease. ¹⁴
A person can be asymptomatic with tuberculosis This is called latent TB infection. Often, when someone becomes infected with TB bacteria, the body can fight it and prevent it from spreading. Because the body can fight the infection, someone with latent TB will be asymptomatic and will not be able to spread TB to others. They will, however, have a reactive TB test, and they may develop TB disease if the latent TB is not treated. Still, many people with latent TB infection may never develop TB disease, and the bacteria will remain inactive for their lifetime without causing disease.
Tuberculosis can become active if the immune system is incapable from stopping its spread. When Tuberculosis can multiple and spread, it is called TB disease. ¹⁴ People who have TB disease are symptomatic, and they can spread the infection to others. The symptoms of TB disease are dependent parts of the body that are infected. For instance, if Tuberculosis grows in the lungs, if may cause hemoptysis and pain in the chest. Tuberculosis may also cause fatigue, fevers, loss of appetite, night sweats, and weight loss, depending on the area of the body that it affects.
To organize and implement a well-structured infection control program, hospitals should employ epidemiologists and infection preventionists, and create an infection control committee. ⁶ The role of the hospital epidemiologist (a physician with a subspecialty in infectious disease) is to oversee the infection control program and the quality improvement program. The epidemiologist is also required to communicate with the various hospital departments and administrators and discuss responsibilities, expectations, and available resources. ⁶ A registered nurse (with experience in clinical work, epidemiology, and microbiology) typically functions as an infection preventionist. The number of infection preventionists that a hospital employs is dependent on the number of hospital beds the healthcare facility has, the type of services it offers, and current recommendations of the Center for Disease Control and Prevention (CDC).¹² The last aspect of a functioning infection control program is the infection control committee, which consists of an interprofessional group of clinicians, nurses, administrators, epidemiologist, infection preventionists and other representatives from the laboratory, pharmacy, operating rooms, and central services. The responsibilities of this committee are to generate, implement, and maintain policies related to infection control. ¹² To achieve a successful an infection control program, an infection control committee can consider implementing the following measures⁶:
- Surveillance:
The primary goal of surveillance programs is to assess the rate of infections and likelihood of occurrences. The assessment usually begins as surveillance for hospital acquired infections in areas where the highest rate of infection exists, usually surgery units, intensive care units, and hematology/oncology units, expanding throughout the healthcare facility. To improve surveillance, many hospitals have developed sophisticated algorithms in their electronic health systems that can streamline surveillance and identify patients with the highest risk for hospital acquired infections (HAIs). As a result, a hospital-wide surveillance that targets a specific infection can be implemented relatively easily. - Isolation:
The main purpose of isolation is to prevent the transmission of infectious organisms from infected patients to others. Hospitals that have single-patient rooms can efficiently implement isolation precautions however, there are a significant number of healthcare facilities that do not have single-patient rooms and must adjust per facility policy to appropriately and adequately isolate patients to reduce the spread for infection. The CDC and the Healthcare Infection Control Practice Advisory Committee have also issued guidance on approaches to enhance isolation and infection transmission reduction. These guidelines are based on standard and transmission-based precautions. For instance, standard precaution refers to the assumption that all patients are possibly colonized or infected with microorganism and therefore, precautions must be applied to all patients, always, and within all departments. The main elements for standard precautions are hand hygiene (before and after patient contact), personal protective equipment (for contact with body fluid, mucous membrane, or nonintact skin), and safe needle practices (using one needle only one time for a single dose of medication, and properly disposing of it in a safe container). - Outbreak Investigation and Management:
Outbreaks of infectious organisms can be identified through the surveillance system. Once a particular infection rate crosses the 95% confidence interval threshold, an investigation is warranted for a possible outbreak. Also, clusters of infections can be reported by the healthcare providers of laboratory staff, which may investigate to assess whether the cluster of infections is an outbreak. Usually, clusters of infections involve a common organism which can be identified by using the pulsed-field gel electrophoresis or the whole-genome sequencing which provides a more detailed tracking of the organism. Most outbreaks are a result of direct or indirect contact involving multidrug-resistant organisms. Infected patients should be separated and isolated with the appropriate precautions as necessary, depending on what the suspected cause of infection is. - Education:
Healthcare providers should be educated through seminars and workshops to remain up-to-date and improve understanding on the steps for prevention of communicable disease transmission. - Employee Health:
It is essential for the infection control program to work closely with employee health services. Both teams should address important topics related to the well-being of healthcare providers and infection prevention, including management of exposure to bloodborne pathogens and other communicable infections. For the most part, a healthcare provider who is newly hired to a facility will likely undergo a screening by the employee health service to ensure that they are up to date with their vaccinations and have adequate immunity against some of the common communicable infections such as hepatitis B, measles, mumps, rubella, tetanus, pertussis, and varicella. Employ health services should develop proactive campaigns and policies to engage healthcare providers in their wellbeing and prevent infections, such as improving annual flu vaccine efforts, or routine testing for tuberculosis. - Antimicrobial Stewardship:
Antimicrobials are widely used in healthcare settings. Many hospitals are adapting antimicrobial stewardship programs to control antimicrobial resistance, improve outcomes, and reduce healthcare costs. Antimicrobial stewardship should be programmed to monitor antimicrobial susceptibility profiles to anticipate and assess any new antimicrobial resistance patterns. These trends need to be correlated with the antimicrobial agents used to evaluate susceptibility. Antimicrobial stewardship programs can be designed to be active or passive and can target pre-prescription or post-prescription periods. In the pre-prescription period, an active program includes prescription restrictions and preauthorization, while passive initiative includes education, guidelines, and antimicrobial susceptibility reports. On the other hand, an active post-prescription program would focus on a real-time feedback provision to healthcare providers regarding antibiotic use, dosage, bioavailability, and susceptibility with automatic conversion of intravenous to oral formulations, while passive post-prescription involves the integration of the electronic medical records to generate alerts for prolonged prescriptions and antibiotic-microorganism mismatch. - Policy and Interventions:
The main purpose of the infection control program is to develop, implement, and evaluate policies and interventions to minimize the risk for hospital acquired infections. Policies are usually developed by the hospital’s infections control committee to enforce procedures that are generalizable to the various hospital departments. These policies are developed based on the hospital’s needs and evidence-based practice. Interventions that impact infection control can be categorized into two categories: vertical and horizontal interventions. Vertical interventions involve the reduction of infection risk from a single pathogen, such as Methicillin Resistant Staphylococcus Aureus (MRSA). Horizontal interventions target multiple different pathogens that are transmitted. An example of a horizontal intervention is hand hygiene; a healthcare provider performs hand hygiene between patients to prevent the spread of multiple pathogens that may be on their hands. Vertical and horizontal interventions can be implemented simultaneously and are not mutually exclusive.
Sepsis occurs because of asevere infection that has spread to a person’s blood stream, causing widespread inflammation and damage to tissues. ¹ Almost any type of infection can lead to sepsis, but usually the infections are most likely to start in the lung, urinary tract, skin, or gastrointestinal tract. For instance, Healthcare-associated infections are often resistant to antibiotics and can cause a deterioration in health. The resistance to antibiotics is also a major factor that results in clinical unresponsiveness to treatment and rapid evolution of an infection that spread to the blood stream, causing sepsis. If not recognized early and managed promptly, sepsis can lead to septic shock, which can lead to organ failure and death, on average, has a 50% mortality rate. Due to its significant morbidity and mortality and increased incidence in institutional settings, all health professionals should know the signs, symptoms, and treatment of sepsis.
For example, New York State has successfully implemented the New York State Sepsis Care Improvement Initiative and “Rory’s Regulations”, a directive to doctors and hospitals on how to treat sepsis, including rapid diagnosis, administration of antibiotics, and careful management of fluids. The purpose of Rory’s Regulations includes¹⁰:
- Increase early recognition of suspected sepsis by all healthcare professionals by requiring such individuals to complete course work or training on sepsis
- Stress the importance of timely initiation of evidence-based protocols to improve sepsis outcomes.
New York State regulations at 10 NYCRR §§ 405.2 and 405.4 require hospitals to, among other things⁷:
- Adopt evidence-based protocols to ensure early diagnosis and treatment of sepsis; and
- Ensure hospital staff are trained to implement such sepsis protocols.
Despite increased awareness of sepsis (especially through the Center for Disease Control and World Health Organization), mortality from sepsis remains the most common cause of death in hospitalized patients. In the hopes of allowing earlier therapeutic intervention, an international consensus meeting in 1991 created and defined terms, such as systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock (known now as Sepsis-1). SIRS describes the inflammatory process that is evidenced by a combination of vital signs and blood work.
Systemic Inflammatory Response Syndrome (SIRS) includes two or more of the following ¹:
- Temperature greater than 38 C or less than 36 C
- Heart rate greater than 90 beats per minute
- Tachypnea greater than 20 breaths per minute or PaCO2 less than 32 mm Hg
- White blood cell (WBC) count greater than 12,000 per cubic millimeter or fewer than 4000 per cubic millimeter, or greater than 10% immature (band) forms
Sepsis includes:
- SIRS as the result of an infection
Severe Sepsis includes
- Sepsis associated with organ dysfunction (one or more), hypo-perfusion abnormality, or sepsis-induced hypotension
- Hypo-perfusion abnormalities may include but are not limited to lactic acidosis, oliguria, or acute change in mental status.
Septic Shock
- Sepsis-induced hypotension despite adequate fluid resuscitation
Sepsis High Risk Groups
Anyone affected by an infection, severe injury, or serious non-communicable disease can progress to sepsis, but vulnerable populations are at higher risk including¹:
- Hospitalized patients
- Neonates
- Older persons
- Patients in intensive care units
- People with autoimmune diseases
- People with cancer
- People with HIV/AIDS
- People with kidney disease
- People with liver cirrhosis
- People with no spleen
- Pregnant or recently pregnant women
Sepsis Signs and Symptoms
Sepsis is a medical emergency and can present with various signs and symptoms at different times. Warning signs and symptoms include¹:
- Altered mental status
- And extreme body pain or discomfort
- Cold extremities
- Cyanotic or mottled skin
- Difficulty breathing/rapid breathing
- Fever or low temperature and shivering
- Increased heart rate
- Low urine output
- Weak pulse/low blood pressure
Suspecting sepsis is a first major step towards early recognition and diagnosis.
Sepsis Diagnosis and Treatment
Identifying and not underestimating the signs and symptoms of sepsis, along with the detection of some biomarkers (such as C reactive protein and procalcitonin), are crucial elements for early diagnosis of sepsis and establishing timely clinical management. ³ After early recognition, diagnostics to help identify a cause of infection leading to sepsis are important to guide targeted antimicrobial treatment. Once the source of infection is determined, source control, such as drainage of an abscess, is critical. Early, aggressive treatment increases the likelihood of recovery. People who have sepsis require close monitoring and treatment. Lifesaving measures may be needed to stabilize breathing and heart function, such as intubation and intravenous medications. Therapies are directed at the basic elements of sepsis as a syndrome of infection, the host response, and organ dysfunction. The initial management of infection requires forming a probable diagnosis, obtaining cultures, and initiating appropriate and timely empirical anti-microbial therapy and source control.
Medications
Several medications are used in treating sepsis and septic shock. They include¹:
- Antibiotics. Treatment with antibiotics begins as soon as possible. Broad-spectrum antibiotics, which are effective against a variety of bacteria, are usually used first. After learning the results of blood tests, a healthcare professional may change to a different antibiotic that is able to better target and fight the bacteria causing the infection.
- Intravenous fluids. The use of intravenous fluids begins as soon as possible.
- Vasopressors. If a patient’s blood pressure remains low even after receiving intravenous fluids resuscitation, they may be given a vasopressor medication. These medications constrict blood vessels and help increase the blood pressure.
Other medications that may be administered include low doses of corticosteroids, insulin to help maintain stable blood sugar levels, drugs that modify the immune system responses, and sedatives or medications for pain.
Infection control clinically translates to identifying and containing infections to minimize transmission. Healthcare providers play a significant role in infection control by identifying a patient’s signs and symptoms that may be suspicious for transmissible diseases. When infectious disease is suspected, precautions should be implemented, even before a diagnosis is confirmed to avoid the possible transmission of the infectious organism. Clinically, an efficient infection control program results into fewer infection rates and lower risks for the development of multidrug-resistant pathogens.
Maintaining infection control has many challenges, especially with the increasing number of hospitalized patients, a greater prevalence of invasive technologies, and a higher prevalence of immunocompromised patients. Hospital-acquired infections are one of the most common healthcare complications. Poor infection control programs lead to increased rates of infections, increase the likelihood of multidrug-resistant bacteria, and increases the risk of outbreaks in departments that can spread to other areas within a healthcare facility. All healthcare professionals have a duty to prevent infection and maintain an aseptic environment when possible. Also, healthcare facilities must have the necessary personal protective equipment to implement the standard precautions for all patients. The most significant precaution that is effective in preventing infection transmission is hand hygiene. In addition to hand hygiene, the CDC recommends the appropriate use of PPE to prevent the transmission of infectious organisms. In addition to the use of PPE, infection control must also be maintained through proper cleaning and disposal of patient care equipment and housekeeping tools. Infection control equipment also includes the housekeeping tools where adequate and routine disinfection of surfaces and floors are implemented. Understanding and practicing infection control is a shared responsibility of all healthcare professionals, and as evidenced by Rory’s Regulations, can be an effective tool in reducing complications associated with infections.
Public Health Law
§ 230-a. Infection control standards
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “230-a”
§ 230-d. Office-based surgery
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “230-d”
§ 239. Course work or training in infection control practices
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “239”
§ 239-a. Infection control guidelines
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “239-a”
§ 2760. Advisory panel established
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “2760”
§ 2761. Function, powers, and duties
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “2761”
Education Law
§ 6505-b. Course work or training in infection control practices
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “6505-b”
§ 6509. Definitions of professional misconduct
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “6509”
§ 6530. Definitions of professional misconduct
Visit: http://public.leginfo.state.ny.us/lawssrch.cgi?NVLWO: and search term “6509”
Health Regulations (10 NYCRR)
Part 92 Infection Control Requirements
Visit: https://www.health.ny.gov/regulations/nycrr/title_10/ and search Title 10 term “92”
Education Regulations (8 NYCRR)
Part 58 Approval of Course Work or Training in Infection Control Practices and Barrier Precautions
- Control and prevent the spread of germs. (2020, May 6). Retrieved from https://www.cdc.gov/infectioncontrol/index.html
- HIV. (2020, June 10). Retrieved from https://www.cdc.gov/hiv/default.html
- How infections spread. (2019, March 25). Retrieved from https://www.cdc.gov/infectioncontrol/spread/index.html
- Infection prevention & control. (n.d.). Retrieved from https://www.nursingworld.org/practice-policy/work-environment/health-safety/infection-prevention/
- The Institute of Medicine report on medical errors. (2000). New England Journal of Medicine, 343(9), 663-665. doi:10.1056/nejm200008313430917
- Jefferson, J., & Mermel, L. A. (2017). Coordination of infection control activities at the healthcare system level: Survey results. Infection Control & Hospital Epidemiology, 39(1), 121-122. doi:10.1017/ice.2017.257
- New York codes, rules and regulations, title 10. (n.d.). Retrieved from https://www.health.ny.gov/regulations/nycrr/title_10/
- New York codes, rules, and regulations. (n.d.). Retrieved from https://govt.westlaw.com/nycrr/Browse/Index?bhcp=1&transitionType=Default&contextData=%28sc.Default%29
- NYS rules of the board of Regents:Part 29. (2018, December 12). Retrieved from https://www.op.nysed.gov/title8/part29.htm
- OP:Training:Mandated training related to infection control. (2018, August 9). Retrieved from https://www.op.nysed.gov/training/icmemo.htm
- Pittet, D., Boyce, J. M., & Allegranzi, B. (2017). Hand hygiene: A handbook for medical professionals. John Wiley & Sons.
- Precautions | Isolation precautions | Guideline’s library | Infection control | CDC. (2019, July 22). Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html
- Raznahan, R. (2020). Barriers factors of infection control and prevention in intensive care units. International Journal of Psychosocial Rehabilitation, 24(5), 1136-1144. doi:10.37200/ijpr/v24i5/pr201788
- Tuberculosis (TB). (2020, June 16). Retrieved from https://www.cdc.gov/tb/default.htm
- Viral hepatitis. (2020, September 18). Retrieved from https://www.cdc.gov/hepatitis/index.htm
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