Infection Control (Safety in the Healthcare Facility) (Nursing) Part 1

Learning Objectives

1. Explain the relationship between Standard Precautions and Transmission-Based Precautions as related to infection control.

2. Explain the purpose, use, and components of Transmission-Based Precautions.

3. Identify how to follow specific airborne, droplet, and contact precautions.

4. Describe how to set up a client’s room for isolation, including appropriate barrier techniques.

5. Demonstrate precautions to take during medication administration, vital sign monitoring, and transport of a client who is potentially infectious.

6. Explain what is meant by protective (neutropenic/ reverse) isolation.

7. Identify the role of the infection control committee.

IMPORTANT TERMINOLOGY
Airborne Precautions	infection	protective isolation
colonization	infectious disease	Special Respiratory Precautions
Contact Precautions	isolation	Transmission-Based
Droplet Precautions	neutropenic isolation	Precautions

Acronyms

BBP

HICPAC

The risks to clients of nosocomial infections have been described in previous topics, as have the risks of infection for healthcare workers. An infection is described as an invasion and multiplication of organisms in body tissues, particularly those causing injury to the host. An infectious disease occurs if the chain of infection is intact. The goal of nursing and of all of healthcare is to break this chain of infection.

Today, a number of organisms are developing resistance to antibiotics, and new organisms are surfacing. Sometimes there is a need for measures in addition to Standard Precautions.This topic discusses special precautions and isolation procedures and their applications.

INFECTION CONTROL

The best method of infection control is prevention, which is successful when the chain of infection is successfully broken.Healthcare facilities use several types of prevention methods, including the aseptic practices discussed.The Joint Commission requires healthcare facilities to have an effective infection control plan in order to qualify for accreditation. The plan must include these elements:

• An infection control committee

• Surveillance and reporting of nosocomial infections

• An employee health program

• Isolation policies

• Infection control, in-service education for employees

• Procedures for environmental sanitation

• An available microbiology laboratory

• Infection control procedures for client care

In 1996, the Centers for Disease Control and Prevention (CDC) and the Hospital Infection Control Practices Advisory Committee (HICPAC) revised their guidelines for isolation precautions in healthcare facilities in an attempt to reduce the risk of transmission of microorganisms from both known and unknown sources of infection. The guidelines include two tiers of precautions. The first and most important are Standard Precautions, designed for the care of all clients, regardless of diagnosis or infection status.The second tier of precautions, Transmission-Based Precautions, is designed for clients with specific infections or diagnoses and is discussed in this topic.

The Infection Control Committee

Each accredited healthcare facility must have an infection control committee that monitors and evaluates any infection occurring in the facility. When the committee identifies the cause, it can take necessary preventive measures. Healthcare workers must report any infection that occurs. The infection control committee will investigate to determine the cause. If a break in nursing technique is identified, the committee will propose different procedures to eliminate the problem. In many cases, the education department will conduct in-service education sessions to teach new techniques. As a nurse, you may be asked to serve on an infection control committee. The goals of the infection control committee are to:

• Provide a central place for reporting infections

• Investigate cases of infection

• Determine the cause of infection

• Maintain total statistics related to the numbers and types of infections that occur in the facility

• Report diseases and infections to local, state, and federal authorities

• Review records of clients to identify organisms that may have become resistant to various drugs

• Study current literature and identify effective national practices for infection prevention

• Design local protocol and policies, following national guidelines, to control infection; the committee enforces Standard and Transmission-Based Precautions for the facility

• Evaluate the effectiveness of protocols after they have been tried

• Conduct research related to infection control practice

• Conduct product evaluations for infection control items

• Offer continuing education for healthcare personnel, to prevent infections

• Serve as consultants in cases of questions or concerns by healthcare personnel

• Assist in employee health and wellness programs

• Work to prevent further recurrences

Standard Precautions

As described Standard Precautions are a combination of Universal Precautions (designed to reduce the risk of blood-borne pathogen transmission) and Body Substance Isolation (designed to reduce the transmission of pathogens from moist body substances). These precautions apply to blood; all body fluids, secretions, and excretions (except sweat); nonintact skin; and mucous membranes. They are designed to reduce the risk of transmission of microorganisms from both known and unknown sources of infection.

In 1992, the Occupational Safety and Health Administration (OSHA) implemented “Occupational Exposure to blood-borne pathogens (BBP)” (Standard 29 CFR 1910.1030). This standard requires and enforces the implementation of policies, procedures, and control measures that will prevent employee exposure to the blood and body fluids of clients (Standard Precautions). Violations of Standard Precautions carry a severe fine to the healthcare facility. OSHA regulations require that healthcare employers:

• Develop an infection control policy that conforms to OSHA guidelines. This policy must identify when personal protective equipment (PPE) is required, how to clean up spills of blood or body fluids, how to take or send specimens to the laboratory, and how to dispose of infectious waste.

• Educate staff about the policies.

• Provide free hepatitis B immunizations to staff who might be exposed to blood or body fluids.

• Provide follow-up care to staff members who are accidentally exposed to splashes of blood or body fluids or needlesticks.

• Supply rapidly accessible PPE.

• Provide proper sharps disposal containers and replace them regularly.

Standard Precautions stress the use of handwashing and PPE to protect against contracting diseases.

Nursing Alert You must report unusual exposure to potential infection (e.g., a needlestick or body fluid splash into your eyes) immediately OSHA requires initial screening and follow-up care.

Key Concept In most cities, blood and body fluids can be flushed down the client’s toilet or the central hopper Most municipal sewage treatment systems are able to decontaminate this sewage. Protective gear against splashing must be worn when emptying these materials. If the amount of fluid or tissue is too large or bulky to be flushed, it must be bagged in a biohazard bag and placed in the special biohazard container (see Fig. 41-2).

Cleaning up spills of biohazardous materials requires the use of special supplies and equipment (see Fig. 39-3 and the protocols of your facility).

Handling of materials and equipment, such as suction containers, chest tubes, blood infusion fluids, or dialysis fluids, requires special in-service education.

Cytotoxic wastes (e.g., materials used in cancer chemotherapy or body fluids of these clients) also require special handling and disposal. Usually staff working with these materials require special in-service education as well

Transmission-Based Precautions

Standard Precautions are used when caring for all clients. Transmission-Based Precautions are implemented when caring for clients with a suspected or known infectious disease, based on the disease’s route of transmission. Transmission-Based Precautions are designed to interrupt the transmission of epidemiologically important pathogens in healthcare facilities. These precautions are designed to break the “chain of infection” described previously, by providing a barrier for either the client or the healthcare worker. They are grouped into three types: airborne precautions, droplet precautions, and contact precautions. When treating clients who require any of these precautions, you will use them in addition to Standard Precautions. Table 42-1 presents an overview of Transmission-Based Precautions and the types of diseases for which they are used.

TABLE 42-1. Transmission-Based Precautions

CLIENT PLACEMENT	PROTECTION	EXAMPLES OF DISEASES
Airborne
• Private room; keep door closed	• Follow Standard Precautions.	• Tuberculosis
• Negative air flow pressure*	• Wear a mask for airborne pathogens, or particulate air	• Measles
• Discharge of room air to environment or	filter respirator in the case of tuberculosis (TB).	• Chickenpox
filtered before circulation	• Place a mask on the client if transport is required.
• Keep door closed
• Confine client to room
Droplet
• Private room or in a room with a similarly infected client(s) or one in which there is at least 3 feet between other client(s) and visitors	• Follow Standard Precautions.	• Influenza
	• Wear a mask when entering the room, but especially	• Rubella
	when within 3 feet of infected client. • Place mask on the client if transport is required. • Door may be open or closed.	• Meningococcal meningitis
Contact
• Private room or in room with similarly infected	• Follow Standard Precautions.	• Gastrointestinal, respiratory, skin, or wound infections that are drug-resistant
client(s), or	• Don gloves before entering room.
• Consult with an infection control professional if the above options are unavailable.	• Remove gloves before leaving room.
	• Change gloves after contact with infective material.	• Acute diarrhea
	• Perform handwashing with an antimicrobial agent	• Draining abscess
	immediately after removing gloves.	• Impetigo
	• Wear gown when entering room if possibility exists that your clothing will touch client or items in the room, or if client is incontinent, has diarrhea, an ileostomy, colostomy, or wound drainage not contained by a dressing.	• MRSA
	• Avoid transporting client; if required, use precautions that minimize disease transmission.
	• Clean bedside equipment and client care items daily.
	• Use items such as stethoscope, blood pressure apparatus, and other assessment tools exclusively for infected client and terminally disinfect when precautions are no longer necessary.
	• Door may be open or closed.

^Negative air pressure pulls air from the hall into the room when the door is opened, as opposed to positive air pressure, which pulls room air into the hall. (Garner & HICPAC, 2001.)

Key Concept

• Standard Precautions—Treat blood and all body fluids (except sweat) from all clients as infectious.

• Transmission-Based Precautions—Use barrier precautions for clients with suspected or diagnosed infections.

• The combination of Standard Precautions and Transmission-Based Precautions minimizes the risk of exposure from known infectious agents, as well as undiagnosed infectious agents.

• Special situations—Use PPE as needed (e.g., for a violent client who spits or bites). Goggles are often recommended (Fig. 42-1).

• In some cases, reverse (protective) isolation is needed to protect the client.

Airborne Precautions

Airborne transmission occurs when tiny microorganisms from evaporated droplets remain suspended in the air or are carried on dust particles. Air currents disperse the microorganisms, which a susceptible host can easily inhale. Special air handling and ventilation are required to prevent this type of disease transmission. Tuberculosis (TB), measles, and chickenpox are examples of airborne-transmitted infections.

FIGURE 42-1 · Protective eyewear is worn to protect the mucous membranes of the nurse’s eyes from accidental splashing of clients’ body fluids.

Clients requiring Airborne Precautions are placed in a private room that has monitored negative airflow pressure. Six to 12 air changes occur per hour, with the air being discharged to the outdoors or specially filtered before circulating to other areas of the healthcare facility. Many facilities have special portable air-filtering machines to use when maintaining airborne precautions. Doors to rooms with clients who require airborne precautions are kept closed.

When caring for clients requiring airborne precautions, respiratory protection is necessary.

Special Respiratory Precautions

Because of the recent resurgence of TB cases, healthcare facilities require the use of Special Respiratory Precautions as protection for nurses and other direct care staff when caring for those with active TB (in a communicable state). A special high-filtration particulate respirator (N95 or HEPA-filtered) (see Fig. 41-3) or the positive air purified respirator (PAPR) must be used, as per CDC recommendations. The air-purifying respirator is fitted to the individual nurse. It fits the face more tightly than does the typical surgical mask and can filter out 95% of particulates in the air. These devices provide the greatest respiratory protection available. Most facilities also require all direct client care staff to have either a negative purified protein derivative (PPD) or negative chest x-ray yearly. The client with Special Respiratory Precautions must be assigned to a room with the same engineering controls as those in Airborne Precautions.

Droplet Precautions

Droplet transmission occurs when droplets containing microorganisms are propelled through the air from an infected person and deposited on the host’s eyes, nose, or mouth. Transmission can occur through sneezing, coughing, talking, or during certain procedures such as suctioning. Examples of illnesses spread by droplets include meningococcal meningitis, streptococcal pharyngitis (in infants and young children), pertussis, influenza, mumps, and rubella.

A client requiring Droplet Precautions is placed in a private room. However, if a private room is unavailable, he or she can share a room with another client with the same infectious disease. The room’s door may remain open. Wear a mask when working within 3 feet of the client. Have the client wear a mask if you must transport him or her to an area outside the room.

Contact Precautions

Contact transmission is the most frequent mode of disease transmission in healthcare facilities. Transmission can occur as a result of direct contact between a susceptible host’s body surface and an infected or colonized person. (Colonization occurs when a microorganism is present in a client, but he or she shows no clinical signs or symptoms of infection.) Indirect contact occurs when a susceptible host comes into contact with an intermediate contaminated object (e.g., dirty instrument, needle, or hands). Examples of illnesses spread by contact transmission include gastroenteritis and respiratory, skin, and wound infections. Hepatitis A, herpes simplex virus, impetigo, scabies, and pediculosis are other examples. Precautions are particularly important in cases caused by drug-resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) or VRE (vancomycin-resistant Enterococcus).

FIGURE 42-2 · When using personal protective equipment (PPE), the nurse removes and disposes of the most contaminated items first. Gloves are removed before the gown.

A client who requires Contact Precautions can be placed in a room with other clients who are infected with the same microorganism if a private room is unavailable. The door may remain open. Wear gloves when entering the room and remove them before leaving. Change your gloves after contact with a client’s infective material (e.g., fecal matter or wound drainage). Wash your hands with an antimicrobial agent. Wear a gown, gloves, and mask into the room if you anticipate contact with this client; remove protective gear before leaving the room (Fig. 42-2). When possible, try to restrict the use of noncritical equipment to one client only. If equipment must be used for multiple clients, carefully and thoroughly clean and disinfect it before using it for other clients.