Infection control: Wikis

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Infection control is the discipline concerned with preventing nosocomial infection. As such, it is a practical (rather than an academic) sub-discipline of epidemiology. It is an essential (though often under-recognized and under-supported) part of the infrastructure of health care. Infection control and hospital epidemiology are akin to public health practice, practiced within the confines of a particular health-care delivery system rather than directed at society as a whole.

Infection control addresses factors related to the spread of infections within the health-care setting (whether patient-to-patient, from patients to staff and from staff to patients, or among-staff), including prevention (via hand hygiene/hand washing, cleaning/disinfection/sterilization, vaccination, surveillance), monitoring/investigation of demonstrated or suspected spread of infection within a particular health-care setting (surveillance and outbreak investigation), and management (interruption of outbreaks). It is on this basis that the common title being adopted within health care is "Infection Prevention & Control."

Contents

Infection control in healthcare facilities

Aseptic technique is a key component of all invasive medical procedures. Similarly, infection control measures are most effective when applied universally because undiagnosed infection is common.

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Hand hygiene

Independent studies by Ignaz Semmelweis in 1847 in Vienna and Oliver Wendell Holmes in 1843 in Boston established a link between the hands of health care workers and the spread of hospital-acquired disease.[1] The Centers for Disease Control and Prevention (CDC) has stated that “It is well-documented that the most important measure for preventing the spread of pathogens is effective handwashing.” [2] In the United States, hand washing is mandatory in most health care settings and required by many different state and local regulations.[3]

In the United States, Occupational Safety and Health Administration (OSHA) standards[4] require that employers must provide readily accessible hand washing facilities, and must ensure that employees wash hands and any other skin with soap and water or flush mucous membranes with water as soon as feasible after contact with blood or other potentially infectious materials (OPIM).

Mean percentage changes in bacterial numbers
Method used Change in
bacteria present
Paper towels (2-ply 100% recycled). - 48.4%
Paper towels (2-ply through-air dried, 50% recycled) - 76.8%
Warm air dryer + 254.5%
Jet air dryer + 14.9%

Drying is an essential part of the hand hygiene process. In November 2008, a non-peer-reviewed[5] study was presented to the European Tissue Symposium by the University of Westminster, London, comparing the bacteria levels present after the use of paper towels, warm air hand dryers, and modern jet-air hand dryers.[6] Of those three methods, only paper towels reduced the total number of bacteria on hands, with "through-air dried" towels the most effective.

The presenters also carried out tests to establish whether there was the potential for cross-contamination of other washroom users and the washroom environment as a result of each type of drying method. They found that:

  • the jet air dryer, which blows air out of the unit at claimed speeds of 400 mph, was capable of blowing micro-organisms from the hands and the unit and potentially contaminating other washroom users and the washroom environment up to 2 metres away
  • use of a warm air hand dryer spread micro-organisms up to 0.25 metres from the dryer
  • paper towels showed no significant spread of micro-organisms.

In 2005, in a study conducted by TUV Produkt und Umwelt, different hand drying methods were evaluated [7] . The following changes in the bacterial count after drying the hands were observed:

Drying method Effect on bacterial count
Paper towels and roll Decrease of 24%
Hot-air drier Increase of 117%

Cleaning, disinfection and sterilization


Sterilization is a process intended to kill all microorganisms and is the highest level of microbial kill that is possible. Sterilizers may be heat only, steam, or liquid chemical.[8] Effectivness of the sterilizer (e.g., a steam autoclave") is determined in three ways.[8] First by the mechanical indicators and gauges on the machine itself, second the heat sensitive indicators or tape on the sterilizing bag turn color, and thirdly and most importantly is the biological test. With the biological test, a highly heat and chemical resistant microorganism (often the bacterial endospore) is selected as the standard challenge. If the process kills this microorganism, the sterilizer is considered to be effective. It should be noted that in order to be effective, instruments must be cleaned, otherwise the debris may form a protective barrier, shielding the microbes from the lethal process. Similarly care must be taken after sterilization to ensure sterile instruments do not become contaminated prior to use.[8]

Disinfection refers to the use of liquid chemicals on surfaces and at room temperature to kill disease causing microorganisms. Disinfection is a less effective process than sterilization because it does not kill bacterial endospores.[8]

Personal protective equipment

Disposable PPE

Personal protective equipment (PPE) is specialized clothing or equipment worn by a worker for protection against a hazard. The hazard in a health care setting is exposure to blood, saliva, or other bodily fluids or aerosols that may carry infectious materials such as Hepatitis C, HIV, or other blood borne or bodily fluid pathogen. PPE prevents contact with a potentially infectious material by creating a physical barrier between the potential infectious material and the healthcare worker.

In the United States, the Occupational Safety and Health Administration (OSHA) requires the use of Personal protective equipment (PPE) by workers to guard against blood borne pathogens if there is a reasonably anticipated exposure to blood or other potentially infectious materials.[9]

Components of Personal protective equipment (PPE) include gloves, gowns, bonnets, shoe covers, face shields, CPR masks, goggles, surgical masks, and respirators. How many components are used and how the components are used is often determined by regulations or the infection control protocol of the facility in question. Many or most of these items are disposable to avoid carrying infectious materials from one patient to another patient and to avoid difficult or costly disinfection. In the United States, OSHA requires the immediate removal and disinfection or disposal of worker's PPE prior to leaving the work area where exposure to infectious material took place.[10]

Vaccination of health care workers

Health care workers may be exposed to certain infections in the course of their work. Vaccines are available to provide some protection to workers in a healthcare setting. Depending on regulation, recommendation, the specific work function, or personal preference, healthcare workers or first responders may receive vaccinations for hepatitis B; influenza; measles, mumps and rubella; Tetanus, diphtheria, pertussis; N. meningitidis; and varicella. In general, vaccines do not guarantee complete protection from disease, and there is potential for adverse effects from receiving the vaccine.[11]

Post exposure prophylaxis

In some cases where vaccines do not exist Post Exposure prophylaxis is another method of protecting the health care worker exposed to a life threatening infectious disease. For example, the viral particles for HIV-AIDS can be precipitated out of the blood through the use of an antibody injection if given within 4 hours of a significant exposure.

Surveillance for emerging infections

Surveillance is the act of infection investigation using the CDC definitions. Determining an infection requires an Infection Control Practitioner (ICP) to review a patient's chart and see if the patient had the signs and symptom of an infection. Surveillance definition cover infections of the bloodstream, urinary tract, pneumonia, and sugical sites.

Surveillance traditionally involved significant manual data assessment and entry in order to assess preventative actions such as isolation of patients with an infectious disease. Increasingly, integrated computerised software solutions are becoming available that assess incoming risk messages from microbiology and other online sources. By reducing the need for data entry, this software significantly reduces the data workload of ICPs, freeing them to concentrate on clinical surveillance.

As approximately one third of healthcare acquired infections are preventable, surveillance and preventative activities are increasingly a priority for hospital staff. In the United States, a study on the Efficacy of Nosocomial Infection Control Project (SENIC) by the CDC found that hospitals reduced their nosocomial infection rates by approximately 32 per cent by focusing on surveillance activities and prevention efforts.

Isolation

In the health care context, isolation refers to various physical measures taken to interrupt nosocomial spread of contagious diseases. Various forms of isolation exist, and are applied depending on the type of infection and agent involved, to address the likelihood of spread via airborn particles or droplets, by direct skin contact, or via contact with body fluids.

Outbreak investigation

When an unusual cluster of illness is noted, infection control teams undertake an investigation to determine whether there is a true outbreak, a pseudo-outbreak (a result of contamination within the diagnostic testing process), or just random fluctuation in the frequency of illness. If a true outbreak is discovered, infection control practitioners try to determine what permitted the outbreak to occur, and to rearrange the conditions to prevent ongoing propagation of the infection. Often, breaches in good practice are responsible, although sometimes other factors (such as construction) may be the source of the problem.

Training in infection control and health care epidemiology

Practitioners can come from several different educational streams. Many begin as nurses, some as medical technologists (particularly in clinical microbiology), and some as physicians (typically infectious disease specialists). Specialized training in infection control and health care epidemiology are offered by the professional organizations described below. Physicians who desire to become infection control practitioners often are trained in the context of an infectious disease fellowship.

In the United States, Certification Board of Infection Control and Epidemiology is a private company that certifies infection control practitioners based on their educational background and professional experience, in conjunction with testing their knowledge base with standardized exams. The credential awarded is CIC, Certification in Infection Control and Epidemiology. One must have 2 years of Infection Control experience in order to sit for the boards. Certification must be renewed every five years.

A course in hospital epidemiology (infection control in the hospital setting) is offered jointly each year by the Centers for Disease Control and Prevention (CDC) and the Society for Healthcare Epidemiology of America.

http://www.apic.org/ offers a training course for practitioners called EPI 101 and .

Standardization

Australia

In 2002, Royal Australian College of General Practitioners has published a revised standard for office-based infection control which covers the sections of managing immunisation, sterilisation and disease surveillance [12], [13]. However, the document on the personal hygiene of health workers is only limited to hand hygiene, waste and linen management, which may not be sufficient since some of the pathogens are air-born and could be spread through air flow [14], [15]

United States

Currently, the standard that is related to this topic is 29 CFR Part 1910.1030 Bloodborne pathogens

See also

Footnotes

  1. ^ CDC Guideline for Hand Hygiene in Health-Care Settings
  2. ^ CDC General information on Hand Hygiene
  3. ^ http://www.safechemdirect.co.uk
  4. ^ OSHA Bloodborne Pathogens Regulations 1910.1030
  5. ^ According to p. 35 of the Redway/Fawdar presentation, "Note: this study has not been peer reviewed but it is intended that the test methods described in this document are provided in sufficient detail to allow replication by those who wish to confirm the results."
  6. ^ Keith Redway and Shameem Fawdar (School of Biosciences, University of Westminster London) (November 2008). "A comparative study of three different hand drying methods: paper towel, warm air dryer, jet air dryer’". Table 4. European Tissue Symposium. p. 13. http://www.europeantissue.com/pdfs/090402-2008%20WUS%20Westminster%20University%20hygiene%20study,%20nov2008.pdf. Retrieved 2009-10-31. 
  7. ^ TÜV Produkt und Umwelt GmbH Report No. 425-452006 A report concerning a study conducted with regard to the different methods used for drying hands; September 2005
  8. ^ a b c d (Miller, Chris H.. Infection Control and Management of Hazardous Materials for the Dental Team, 4th Edition. Mosby Elsevier Health Science, 2010. chpt 11).
  9. ^ OSHA Bloodborne Pathogens Regulations 1910.1030(d)(2)(i)
  10. ^ OSHA 1910.1030(d)(3)(vii)
  11. ^ CDC Vaccine Site
  12. ^ The Royal Australian College of General Practitioners. "RACGP Infection Control Standards for Office-based Practices (4th Edition)". http://www.racgp.org.au/infectioncontrol. Retrieved 8 November 2008. 
  13. ^ The Royal Australian College of General Practitioners. "Slides - RACGP Infection Control Standards for Office-based Practices (4th Edition)" (PDF). http://www.racgp.org.au/Content/NavigationMenu/PracticeSupport/StandardsforGeneralPractices/200708RACGP_Infection_Control_Standards.pdf. Retrieved 8 November 2008. 
  14. ^ Dix, Kathy. "Airborne Pathogens in Healthcare Facilities". http://www.infectioncontroltoday.com/articles/581clinical.html. Retrieved 11 December 2008. 
  15. ^ Nicas, Mark et al. (2005). "Toward Understanding the Risk of Secondary Airborne Infection: Emission of Respirable Pathogens". Journal of Occupational and Environmental Hygiene 2 (3): 143–154. doi:10.1080/15459620590918466. 

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