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Infection Control

Guidelines for Healthcare Professionals

Marian McDonald, RN, MSN, CIC

Nancy Evans, BS

Our courses fulfill continuing nursing education requirements in all 50 states. For more accreditation information, click here.

Also available:
New York: Infection Control Guidelines (meets NY requirements)
Puerto Rico Infection Control Guidelines (meets PR requirements)

Infection control is a critical concern for clients, healthcare workers, facility administrators, and government agencies. Infection control measures are designed to combat everything from the spread of colds and flu to hepatitis B and C, SARS, HIV/AIDS, and other potentially life threatening diseases.

Appropriate infection control measures may range from something as simple as following proper hand washing hygiene to coordinated policies involving worker health screening, immunization, and treatment. All these measures should be incorporated into synchronized, organization-wide infection control programs at healthcare facilities of all sizes and types.

Currently, professional organizations specify standards for infection control specialists and many healthcare facilities provide in-house training, as well as mandating specific procedures and behaviors to be followed by all employees. New York state requires infection control training at regular intervals for many kinds of healthcare workers. And, while it is the only state that does, there is a growing interest in the subject on the part of patient organizations, government agencies, and legislative bodies.

A number of states and the federal government are currently developing regulations that will require the reporting of healthcare-associated infections (HAIs, formerly called nosocomial infections), and make this information available to the public. The CDC estimates that 88,000 Americans per year may die of HAIs.

Currently, methicillin- resistant Stapholococcus aureus (MRSA) is the subject of attention as its transmission becomes a wider problem both inside the healthcare system and in the community. (See Wild Iris course on Multidrug-Resistant Organisms, or MDROs.)

We do not know what challenges of infection prevention the future may bring, but the principles of preventing transmission of infection are likely to remain unchanged.

INFECTION CONTROL TRAINING

If you think that infection control is just the concern of certain categories of healthcare workers, consider how many people in patient care areas routinely use shared computer keyboards. Hand hygiene guidelines are known to be extremely effective at preventing the transmission of disease-causing agents. Consider that thirty-four studies have shown that the mean rate of compliance with current hand hygiene guidelines among healthcare workers is only 40%.

Computer keyboards have become reservoirs for pathogens, and the transmission of those pathogens can be prevented by following current hand hygiene guidelines. In addition, proper cleaning and disinfection of keyboards has also been shown to be extremely effective at controlling pathogens (Rutala et al., 2006). Infection control needs to be everyone's concern.

The CDC reminds us that healthcare workers has a broad definition that may include paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air. These individuals may include but are not limited to physicians, nurses, technicians, therapists, pharmacists, nursing assistants, laboratory personnel, autopsy personnel, emergency medical service personnel, dental personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care but potentially exposed to infectious agents (eg, volunteer, dietary, housekeeping, maintenance, and clerical personnel).

In addition, it is important to remember that healthcare is increasingly being provided outside hospitals in facilities such as nursing homes, freestanding surgical and outpatient centers, emergency care clinics, in patients' homes, or during prehospital emergency care. Hospital-based personnel and personnel who provide healthcare outside hospitals may acquire infections from or transmit infections to patients, other personnel, household members, or other community contacts (CDC, 1998).

The goals of infection control training are to:

• Ensure that health professionals understand how bloodborne and other pathogens can be transmitted in the work environment: patient to healthcare worker, healthcare worker to patient, and patient to patient
• Apply current scientifically accepted infection control principles as appropriate for the specific work environment
• Minimize opportunity for transmission of pathogens to patients and healthcare workers

This course explores the six core elements of infection control in depth.

ELEMENT I

Responsibility to adhere to scientifically accepted principles and practices of infection control and to monitor the performance of those for whom the professional is responsible.

Approximately 1.7 million hospital patients each year get an infection while being treated for another illness or injury and almost 99,000 of them die as a direct or indirect cause of their infection. (Klevens, 2007). Healthcare-associated infections not only inflict suffering and death but also cost the United States almost $5 billion each year due to the extra days or weeks of hospitalization needed to treat the infection (McKibben, 2005).

Patients in nursing homes and in home care are also at risk for developing HAIs, particularly if they have invasive medical devices such as urinary catheters or central venous catheters. Nearly 1 million infections occur annually in nursing homes (CDC 2008).

Acute infections account for 27% of transfers of nursing home residents to hospitals (Longo et al., 2002) and complications of infections and their treatment can lead to functional decline among nursing home residents. Infection control programs have helped reduce the human and economic toll associated with infections. According to the CDC, HAIs in hospitals that report their findings to the CDC declined 30% between 1990 and 2000 (CDC, 2000).

Healthcare workers should learn and follow scientifically accepted infection prevention techniques appropriate to their profession for the cleaning and sterilization or disinfection of instruments, devices, materials, and work surfaces, utilization of protective garb, use of covers for contamination-prone equipment, and the handling of sharp instruments. Such techniques include but are not limited to the following:

1. Wearing of appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, nonintact skin, blood-soiled items or bodily fluid–soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures;
2. Discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient and washing hands prior to performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids;
3. Wearing of appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur;
4. Sterilizing equipment and devices that enter the patient's vascular system or other normally sterile areas of the body;
5. Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient's body, or using high-level disinfection for equipment and devices that cannot be sterilized prior to use for a patient;
6. Using appropriate agents, including but not limited to detergents for cleaning all equipment and devices prior to sterilization or disinfection;
7. Cleaning, by use of appropriate agents, including but not limited to detergents, equipment and devices that do not touch the patient or that only touch the intact skin of the patient;
8. Maintaining equipment and devices used for sterilization according to the manufacturer's instructions;
9. Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques;
10. Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized;
11. Maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation;
12. Refraining from all direct patient care and handling of patient care equipment when the healthcare professional has exudative lesions or weeping dermatitis and the condition has not been medically evaluated and determined to be safe, or capable of being safely protected against, in providing direct patient care or in handling patient care equipment;
13. Placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking; and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide.

Failing to use these techniques not only jeopardizes the health and safety of patients and other healthcare colleagues, but may constitute unprofessional conduct and/or be in violation of in-house policies and local, state, or federal regulations.

ELEMENT II

Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control.

The Chain of Infection

The spread of infection is best described as a chain with six links:

1. A pathogen or causative (infectious) agent
2. The reservoir
3. A portal of exit from the reservoir
4. A mode of transmission
5. A portal of entry into a host
6. A susceptible host

If you can break any link of the chain of infection, you can prevent the occurrence of new infection. Infection control measures are designed to break the links and thereby prevent new infection. The chain of infection is the foundation of infection prevention, so we will look at each link and at actions we take to break it.

The chain of infection.

CAUSATIVE AGENTS

Bacteria, viruses, fungi and protozoa ("germs") are very common in the environment, and most of them are beneficial to people. Creating an environment with no organisms is not a realistic goal outside of highly specialized laboratories.

Bacteria are single-celled organisms, some of which can cause disease. We all live with numerous bacteria—referred to as our "normal flora" or "resident bacteria"—which usually do not cause disease unless their balance is disturbed. Most bacteria require an infectious dose to cause disease; that is, it usually takes thousands to cause disease, not just one or two. Bacteria vary in infectivity (how easy they are to catch) and virulence (the level of danger from the infection they cause).

Viruses are intracellular parasites, meaning they can only reproduce inside a living cell. Viruses such as HIV/AIDS and hepatitis B and C have the ability to enter and survive in the body for years before symptoms of disease occur. Other viruses, such as the influenza viruses, quickly announce their presence through characteristic symptoms.

Fungi are prevalent throughout the world but only a few cause disease in humans, and most of them commonly affect the skin, nails, and subcutaneous tissue. Candida is a fungus that causes yeast infections. These infections can be life-threatening in critically ill patients. Fungi such as Pneumocystis carinii can be life-threatening to the person with HIV/AIDS.

Prions are a form of infectious protein believed to be the cause of Creutzfeldt-Jakob disease (CJD).

Protozoa are single- or multi-celled microorganisms that are larger than bacteria. Examples of disease-causing protozoa include amoebas and giardia, which cause diarrhea, and plasmodium species, the cause of malaria. They may be transmitted via direct or indirect contact or an arthropod vector (an infected carrier) such as a mosquito.

Parasites are larger organisms that can infect or infest people. Infestation with arthropods, such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Helminths include roundworms, tapeworms, and flukes. They infect humans principally through ingestion of fertilized eggs or when the larvae penetrate the skin or mucous membranes.

We eliminate the causative organism by several methods, including:

• Sterilizing surgical instruments and anything that touches sterile spaces of the body
• Using good food safety methods
• Providing safe drinking water
• Vaccinating people so they do not become reservoirs of illness
• Treating people who are ill

RESERVOIRS

Like other organisms, germs require water to grow and reproduce, so reservoirs are commonly wet. In general, if an area is wet it is probably a reservoir unless something specific has been done to prevent bacterial growth. The bacteria may not be pathogens. Sometimes the reservoir contains our own normal flora; that is, we get our own germs in the wrong place.

In some cases the environment can serve as the reservoir. For example, water supplies may carry Legionella spp. Inadequate air exchange can allow pathogens such as Mycobacterium tuberculosis and varicella-zoster virus to contaminate air supplies. Appropriate environmental infection-control measures and engineering controls can prevent these environmental reservoirs.

Common reservoirs in healthcare facilities include:

• Ill people.
• Well people. Our normal flora (the germs we live with) include bacteria that can be pathogens if they get into the wrong part of the body. For example, our mouths contain many different kinds of bacteria.
• Soil has rich microbial life, which may include pathogens.
• Raw meat may harbor pathogens.
• Water from fish tanks or flower vases may contain pathogens, especially for compromised patients.

Actions we take to eliminate reservoirs include:

• Treating people who are ill
• Vaccinating people
• Handling and disposing of body fluids responsibly
• Storing equipment dry
• Handling food safely
• Monitoring soil and contaminated water in sensitive areas of the hospital and washing hands carefully after contact with either

HUMAN RESERVOIRS AND TRANSMISSION OF INFECTIOUS AGENTS

Reservoir	Transmission vehicle	Infectious agent
Blood	Blood, needle stick, other contaminated equipment	Hepatitis B and C; HIV/AIDS, S. aureus, S. epidermidis
Tissue	Drainage from a wound or incision	S. aureus,, E. coli, Proteus spp
Respiratory tract	Droplets from sneezing or coughing	Influenza viruses, Strep spp., S. aureus
Gastrointestinal tract	Vomitus, feces, bile, saliva	Hepatitis A, Shigella spp, Salmonella spp
Urinary tract	Urine	E. coli, enterococci
Reproductive tract and genitalia	Urine and semen	N. gonorrhoeae, T. pallidum, Herpes simplex virus type 2, Hepatitis B

PORTAL OF EXIT

The portal of exit is the way the causative agent gets out of the reservoir, and it is the link of the chain that we can do the least about. Any break in the skin, including natural anatomical openings and draining lesions, may be the portal of exit from a person. Any bodily fluid may carry microorganisms out of the body. Some potent germs such as MRSA live on the patient's skin, and thus can easily exit their reservoir.

Actions we take to reduce risk from portals of exit include:

• Covering coughs and sneezes with a tissue
• Handling body fluids with gloves, then doing hand hygiene
• Keeping draining wounds covered with a dressing
• Not working when you have exudative (wet) lesions or weeping dermatitis

MODES OF TRANSMISSION

The mode of transmission is the weakest link in the chain of transmission, and it is the only link we can hope to eliminate entirely. Therefore, a great many of the efforts of Infection Control are aimed at avoiding carrying germs from the reservoir to the susceptible host. Because it addresses the weakest link in the chain of transmission, hand hygiene is still the single most important procedure for preventing the spread of infection!

Transmission can occur by a number of mechanisms.

Direct contact is person-to-person transmission of pathogens through touching, biting, kissing, or sexual intercourse.

Indirect contact is the spread of pathogens by a person or an inanimate go-between, an intermediary between the portal of exit from the reservoir and the portal of entry to the host. Transmission by unwashed hands is a form of indirect contact. Inanimate objects such as patient-care equipment, cooking or eating utensils, handkerchiefs and tissues, soiled laundry, and door knobs that can transmit infection are sometimes called fomites. Gloves that touch two or more patients have been shown to carry pathogens. (This practice will result in disciplinary action in most facilities!)

Droplet transmission can spread diseases such as influenza, pertussis (whooping cough), and some forms of bacterial meningitis. Droplets are produced when the infected person coughs, sneezes, or speaks, and they travel only about three to six feet before drying out or falling to the ground.

Airborne transmission can occur when respiratory droplets evaporate, leaving behind droplet nuclei that are so small they remain suspended in the air. Very few diseases are transmitted by the true airborne route since most organisms cannot survive drying. Diseases transmitted by the airborne route include tuberculosis, chickenpox, measles, possibly SARS, and smallpox.

Modes of transmission that are not common in hospitals include:

• Common-source vehicles such as blood, serum, plasma, water, food, and milk. For example, food can be contaminated by E. coli if food handlers do not practice appropriate hand washing techniques after using the bathroom. If the food is eaten by a susceptible host, such as a young child or a person with HIV/AIDS, the resulting infection can be life-threatening.
• Vector-borne transmission is by an animate intermediary—an animal, insect or parasite that transports the pathogen from reservoir to host. Transmission takes place when the vector injects salivary fluid by biting the host, or deposits feces or eggs in a break in the skin. Mosquitoes are vectors for malaria and West Nile virus. Rodents can be vectors for hantavirus.

Actions we take to eliminate the mode of transmission include:

• Hand hygiene
• Wearing gloves to minimize contamination of hands and discarding them after each patient
• Maintaining Contact, Droplet and Airborne Precautions as indicated.
• Cleaning, disinfection, or sterilization of equipment used by more than one patient
• Cleaning of the environment, especially high-touch surfaces

PORTAL OF ENTRY

The portal of entry can be thought of as the break in the skin that allows the germ to get into the body and cause disease. Pathogens cannot cause disease if they cannot get into the body.

Examples of portals of entry include:

• Mouth, nose, and eyes
• Other anatomical openings
• Skin breaks (cuts, rashes)
• Surgical wounds
• Intravenous sites
• Anatomical openings with tubes in place (more susceptible than those without)
• Needle puncture injuries

Actions we take to protect portals of entry (our own and our patients) include:

• Dressings on surgical wounds
• IV site dressings and care
• Elimination of tubes as soon as possible
• Masks, goggles and face shields
• Keeping unwashed hands and objects away from the mouth (Don't lick your fingers to turn pages!)
• Actions and devices to prevent needlesticks
• Food and water safety

SUSCEPTIBLE HOST

Susceptibility can be reduced in several ways. For some diseases we have effective vaccines. Some diseases produce lasting immunity after illness. We have better resistance to disease when we are well-rested, well-fed, and relatively stress-free. People who have healthy immune systems are often able to resist infection even when bacteria do invade.

Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system, and the presence or absence of an invasive device.

Natural barriers to infection include:

• Intact skin and mucous membranes
• Cilia (small, hairlike projections that line the respiratory system) that filter inhaled air and trap microorganisms
• Lung macrophages—large white blood cells that ingest microorganisms, other cells and foreign particles—in a process called phagocytosis
• Antibodies (humoral immunity) resulting from immunization or previous disease
• Acidic environment in the stomach, urine, and vaginal secretions
• Normal flora provide competition to pathogens. An upset to the balance of normal flora can allow pathogens to cause infection, such as when a yeast infection follows a course of antibiotics.
• The immune system is a complex network of cells, tissues, and organs that interact to defend the body against infections. Defense mechanisms can be nonspecific or specific and include humoral immunity (antibodies that circulate in the blood), cell-mediated immunity (white blood cells), and the inflammatory response, which brings an increase in these infection-fighting defenses to the site of infection.

A person with normal immune system function is described as immunocompetent. Someone whose immune system is impaired by illness or age-related factors is said to be immunocompromised. For example, a person with HIV/AIDS is immunocompromised.

The very young and the very old are also at risk for compromised immune function. Infections are a major cause of death among newborns. Although babies receive certain temporary immunities from their mothers through the placenta and in breast milk, their immune systems are still developing, making them vulnerable to infection. Nutritional status is a key factor in immune function.

People with chronic disease may also be immunocompromised. People with diabetes mellitus or peripheral vascular disease are at high risk for infection because of impaired circulation.

Certain medications can impair immunity. For example, cancer drugs and anti-inflammatory medications such as corticosteroids can interfere with normal immune function.

Any surgical procedure carries the risk of infection because it penetrates the skin. Diagnostic or therapeutic procedures that involve an invasive device such as a urinary catheter or an intravascular (IV) catheter also increase the risk of infection. Caring for patients with these devices demands strict attention to infection control standards and continuous monitoring for any sign of infection. To reduce risk of infections associated with these devices, the device should be discontinued as soon as the patient no longer needs it.

Any foreign body, even a joint prosthesis, can act as a focus for infection and increase the risk of infection. Examples of susceptible hosts include:

• People who are already ill
• People with invasive devices or tubes in place
• Malnourished people
• The very old and very young
• People who are tired or under high stress
• People with skin breaks such as surgical wounds or IV sites
• People undergoing steroid therapy or treatment for cancer
• People with HIV infection
• People who are well and healthy. None of us are immune to all disease!

Actions we take to minimize risk to susceptible hosts include:

• Vaccinating people against illnesses to which they may be exposed
• Preventing new exposure to infection in people who are already ill, are receiving immunocompromising treatment, or are infected with HIV
• Maintaining good nutrition
• Maintaining good skin condition
• Covering skin breaks
• Encouraging rest and balance in our lives

The nature of healthcare settings makes them vulnerable to the spread of infections because they bring together many ill people who are both reservoirs and susceptible hosts. Staff are also both reservoirs and susceptible hosts, so we cannot eliminate those two major links of the chain of infection. That is why we make such efforts to eliminate the mode of transmission, and that is why hand hygiene is still the single most important procedure to prevent the spread of infection.

The reservoir and the susceptible host may reside in the same person, if the individual's normal flora get into the "wrong" part of the body and cause disease. Examples of this situation include:

• Oral flora in the lungs, causing aspiration pneumonia
• Skin flora in an IV site, causing a site infection or even a bloodstream infection
• Fecal flora in the urinary tract, causing a urinary tract infection (UTI)

So we take care to avoid providing the mode of transmission between different body sites of the same patient, changing gloves and washing hands when we must go from a contaminated area to a cleaner one.

Preventing the spread of infectious organisms includes:

• Hand hygiene before and after every patient contact, including dry skin contact.
• Using Standard Precautions with every patient so that precautions are used with unknown carriers of most diseases.
• Prompt isolation of the patient when indicated, using the appropriate type of precautions.
• Early identification of the infectious organism and initiation of appropriate treatment

Hand Hygiene

It bears repeating that hand hygiene is still the single most important procedure for preventing the spread of infection! This is because healthcare facilities bring many reservoirs (the patients and staff) into close contact with many susceptible hosts (the patients and staff). We cannot eliminate the reservoirs and susceptible hosts, so we must eliminate the mode of transmission. We must not carry germs from reservoir to susceptible host!

Hand hygiene includes both using alcohol-based hand hygiene products and washing with soap and water (Box 8). Alcohol-based hand hygiene products are preferred over soap and water when hands are not visibly soiled. Alcohol-based products are better in three ways:

• They kill the germs better.
• They leave skin in better condition.
• They are quicker and easier to use, so people use them more. (CDC 2002)

Use alcohol-based hand hygiene products only on dry hands. Use enough of the product so that hands are dry again in 15 seconds, and rub hands together until they are completely dry.

If hands are visibly soiled, wash with soap and water, using friction, for at least 15 seconds. (Sing "Happy Birthday" twice.)

The CDC Hand Hygiene Guideline specifies: Do not wear artificial fingernails or extenders when having direct contact with patients at high risk. Check with your facility for their policy. Nails should be unpolished and less than one-quarter inch long. Chipped nail polish, long nails, artificial fingernails, or nail extenders may tear gloves and can harbor pathogens, even after careful hand washing or the use of surgical scrubs.

CDC-Recommended Precautions

The following section on types of precautions is based on the CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007. CDC Guidelines are not regulations, but they are evidence-based recommendations. The 2007 Guidelines provide recommendations for patients in ambulatory settings, long-term care, and residential settings, in addition to those in acute care hospitals. Refer to your facility's policies for specific procedures.

The Centers for Disease Control (CDC) describe four types of precautions, based on the mode of transmission of the organism known or suspected to be present. In addition to Standard Precautions, they identify three precautions that are transmission-based: Contact, Droplet, and Airborne Precautions.

STANDARD PRECAUTIONS

Standard Precautions are to be used with all patients, regardless of diagnosis. Standard Precautions, formerly known as Universal Precautions, were initially designed to minimize risk to staff from unknown carriers of bloodborne pathogens, such as hepatitis B, hepatitis C, or HIV. In addition to protecting staff, Standard Precautions also protect patients from organisms shed in the body fluids of other patients. Standard Precautions are required by good science and by federal law under the OSHA Bloodborne Pathogens Standard.

Long-established Standard Precautions include the following:

• Hand hygiene. Wash hands with plain soap or alcohol-based product after touching blood, body fluids, and contaminated items, whether or not gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when otherwise indicated. It may be necessary to wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. Avoid unnecessary touching of surfaces near the patient to prevent contaminating clean hands and to prevent transmission of pathogens from contaminated hands to surfaces. See additional detail on hand hygiene, above.
• Gloves. Wear clean gloves when touching blood, body fluids, and contaminated items. Put on clean gloves just before touching mucous membranes and nonintact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another patient, and do hand hygiene immediately.
• Mask, eye protection, face shield. Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during activities that are likely to generate splashes or sprays of blood or body fluids (such as suctioning, irrigation, or delivery of the newborn).
• Gown. Wear a gown to protect skin and to prevent soiling of clothing during activities that are likely to generate splashes or sprays of blood or body fluids. Select a gown that is appropriate for the amount of fluid likely to be encountered. Remove the soiled gown as promptly as possible and do hand hygiene. (See additional details on personal protective equipment under Element IV.)
• Patient-care equipment. Handle used patient-care equipment soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients and environments. Clean or reprocess reusable equipment before using it for the care of another patient. Ensure that single-use items are discarded properly.
• Environmental control. Follow hospital procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces.
• Linen. Handle, transport, and process used linen soiled with blood or body fluids in a manner that prevents skin and mucous membrane exposures and contamination of clothing and that avoids transfer of microorganisms to other patients and environments.
• Occupational health and bloodborne pathogens. Take care to prevent injuries when using or disposing of needles, scalpels, and other sharp instruments or devices. Never recap used needles using both hands or use any other technique that involves directing the point of a needle toward any part of the body. Do not manipulate used needles by hand. Place used disposable syringes and needles, scalpel blades, and other sharp items in appropriate puncture-resistant containers that are located as close as practical to the area in which the items were used. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in areas where the need for resuscitation is predictable.
• Patient placement. Place a patient who contaminates the environment or who does not assist in maintaining appropriate hygiene (children, patients with altered mental status) in a single-patient room. If a single-patient room is not available, consult with infection control professionals regarding patient placement or other alternatives. If it is necessary for an infected patient to share a room with a noninfected patient, it is important that roommates are selected carefully and that patients, personnel, and visitors take precautions to prevent the spread of infection.
• Equipment needed for Standard Precautions: Routinely, hand hygiene products, gloves, safety sharps, sharps disposal boxes, and disinfectant wipes or equivalent. Occasionally, gowns, face masks, eye protection or face shields.

In 2007 three new elements were added to Standard Precautions: respiratory hygiene, safe injection practices, and lumbar puncture procedures.

Respiratory Hygiene

Respiratory hygiene is a relatively new concept introduced after the SARS outbreak in 2003, comprising vigilance and prompt implementation of infection control measures at the first point of encounter within a healthcare setting (reception and triage areas, outpatient clinics, and physician offices). It is directed to patients and family members with signs of respiratory illness such as cough, congestion, or increased respiratory secretion. Components include:

• Educate healthcare workers on the importance of source-control methods to contain respiratory secretions, especially during outbreaks of respiratory illness such as influenza.
• Post signs at entrances in languages appropriate to the population served asking patients and family members to cover the mouth and nose when coughing or sneezing or to wear a mask, and to do hand hygiene after contact with respiratory secretions.
• Provide tissues, masks, hand hygiene products, and waste receptacles convenient to patients entering the facility, and assign responsibility for maintaining the supplies.
• Maintain separation, ideally by at least 3 feet, between ill persons and others. Move ill patients to rooms promptly to remove them from common waiting areas.
• Healthcare personnel should use Droplet Precautions (wear a simple mask) and do hand hygiene when caring for any patient with symptoms of respiratory infection unless those symptoms are known due to a noninfectious cause.
• Healthcare workers with respiratory infection should avoid patient contact if possible, and should wear a mask of contact cannot be avoided.

Safe Injection Practices

Infection control problems identified in the course of outbreak investigations sometimes indicate the need for reinforcement of existing infection control recommendations to protect patients. Failure to adhere to recommendations for safe injection practices has resulted in several outbreaks of hepatitis B and C. Lack of oversight of personnel and failure to follow up on reported breaches of practice have contributed to these outbreaks.

The CDC recommends that these practices be incorporated into institutional policies that are monitored for adherence:

• Use aseptic technique to avoid contamination of sterile injection equipment.
• Do not administer medications from a syringe to multiple patients, even if the needle or cannula is changed. Needles, cannulae, and syringes are single-patient-use items.
• Use IV bags, tubings, and connectors for one patient only.
• Do not use bags of IV solution as common source of supply for multiple patients.
• Consider a syringe or needle/cannula contaminated after it has entered an IV bag or set.
• Use single-dose vials whenever possible.
• Do not use one single-dose vial for several patients or combine contents of several vials.
• If multidose vials must be used, both the needle/cannula and syringe used to access them must be sterile.
• Do not keep multidose vials (such as insulin) in the immediate patient care area. Store as recommended by the manufacturer, and discard if sterility is compromised.

Lumbar Puncture Procedures

Wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space.

CONTACT PRECAUTIONS

In addition to Standard Precautions, which are used with all patients, some patients require additional precautions, known as Transmission-Based Precautions. There are three types of transmission-based precautions: Contact, Droplet, and Airborne. (Isolation precautions have disadvantages to the hospital, patients, personnel, and visitors, including the cost of specialized equipment and environmental controls, inconvenience to healthcare workers, and forced solitude for patients. However, these disadvantages must be weighed against the hospital's mission to prevent the spread of serious infection in the hospital.)

Contact Precautions are designed to minimize transmission of organisms that are easily spread by contact with hands or object. The CDC Isolation Guidelines of 2007 made changes to recommended practices for Contact Precautions (see box). Among these changes is the direction to "Wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Don gown upon entry into the room or cubicle."

DROPLET PRECAUTIONS

Droplet Precautions are designed to prevent transmission of diseases easily spread by large-particle droplets produced when the patient coughs, sneezes, or talks, or during the performance of procedures (see box).

AIRBORNE PRECAUTIONS

Airborne Precautions are designed to prevent transmission of diseases spread by the true airborne route (see box). These organisms are released from the patient in respiratory droplets, which evaporate shortly after release. Most organisms die when they dry out, but the organisms of these few diseases—tuberculosis, chickenpox, measles, SARS, and smallpox—can survive drying out. The droplet nuclei (small-particle residue of evaporated droplets) remain suspended in the air and can be dispersed widely by air currents within a room or even over a long distance.

ELEMENT III

Use engineering and work practice controls to reduce the opportunity for patient and healthcare worker contact with potentially infectious material for bloodborne pathogens.

The OSHA Bloodborne Pathogens Standard requires the use, in this order, of:

1. Engineering controls
2. Work practice controls
3. Personal protective equipment

These precautions are built into the isolation precautions guidelines of the CDC.

Engineering controls include equipment, devices or instruments that remove or isolate (contain) a hazard. For example, the puncture-resistant containers required by Standard Precautions for the disposal and transport of needles and other sharps are an engineering control. Splatter shields on medical equipment associated with risk-prone procedures such as locking centrifuge lids isolate or contain the hazard. Hand hygiene is also an engineering control, since it removes the microorganisms from the workplace.

Work practice controls are modifications in technique that reduce or eliminate the likelihood of exposure by altering the manner in which a task is performed. These are the workplace procedures that tell you how to do the job safely. Be sure you know where to find the procedure manuals for your workplace.

Personal protective equipment is mutually beneficial for the healthcare professional and the patient, since they provide a barrier to the transmission of infectious organisms.

Following guidelines carefully is not only effective but also an expression of good professional practice, whereas neglecting to follow guidelines could lead to a charge of professional misconduct.

Engineering Controls

Every area of the healthcare facility and every type of patient care holds the potential for exposure to pathogens but some settings and practices hold greater risk than others. High-risk settings include:

• Intensive-care units (surgical, medical, coronary, pediatric)
• Operating rooms
• Delivery rooms
• Newborn nurseries
• Isolation units
• Clinical laboratories

Engineering controls used to prevent transmission of airborne infections include:

• Isolation rooms with appropriate air exchanges (negative pressure and/or direct exhaust)
• HEPA filtration
• Ultraviolet irradiation

Safety sharps devices and containers are another type of engineering control, since they isolate or contain the hazard—used sharps. The Occupational Safety and Health Administration (OSHA) requires the use of safety sharps when feasible. Healthcare workers may be exposed percutaneously (through the skin) by sharps or needle sticks to HIV, hepatitis B and C, and other bloodborne pathogens.

When using a safety sharp device, be sure to activate the safety feature before discarding. The stick you prevent may be your own!

Giving injections, disposing syringes with needles, or reprocessing needles and other sharps all hold potential risk for exposure to pathogens. An estimated 600,000 to 800,000 percutaneous injuries occur annually in U.S. hospitals. These figures represent only part of the picture because they do not include nonhospital settings, which employ more than half of all healthcare workers (NIOSH, 1999).

The average risk of transmission from a single needlestick contaminated with HIV has been estimated to be approximately 0.3%. (MMWR, 2005)

The risk of transmission from a single needlestick contaminated with hepatitis B ranges from 1% to 30%, depending on the infectivity of the source. (MMWR, 2001)

The risk of transmission from a single needlestick contaminated with hepatitis C is 1.8 %. (MMWR, 2001)

Hepatitis B is definitely the greatest risk for transmission, and we are fortunate that there is a safe and effective vaccine against it. Employers whose employees may have exposure to hepatitis B on the job are required to offer hepatitis B vaccine free to employees who may be exposed. There is also postexposure prophylaxis (PEP) that can be used following exposure to hepatitis B to reduce risk of infection.

There is no vaccine against HIV at this time, but medication may reduce risk of transmission. There is neither vaccine nor preventive medication against Hepatitis C. Prevention is the only means of reducing risk of transmission (MMWR, 2001).

Poor visualization during certain procedures also poses a hazard to both patient and healthcare worker. These procedures include blind suturing, a nondominant hand opposing or next to a sharp, and removal of bone or metal fragments. Situations involving use of sharps with poor visualization should be minimized or eliminated when possible.

In 2000 federal laws were enacted to protect healthcare workers against needle sticks; these laws require that healthcare facilities evaluate and provide safe needles. OSHA has revised their guidelines on bloodborne pathogens to require that employers:

• Use engineering controls or work practices that "eliminate or minimize exposures" (OSHA 2001, CPL2-2.44D)
• Involve employees in the selection process
• Provide effective safe needles and sharps
• Provide training covering personal protective equipment, how to use safe-needle devices, and limitations of such devices

Always use safety sharps and other devices when available. Always activate the safety feature. Never try to work around or disable it.

Work Practice Controls

Work practice controls to eliminate or reduce the likelihood of exposure to potentially infectious material include general practices such as the following:

• Prompt cleanup of blood and body fluid spills with appropriate disinfectant
• Proper disposal/handling of blood and body fluid, including contaminated patient-care items
• Safe handling of used linen and waste

Work practice controls also include specific practices to avoid exposure and injury by modifying procedures and use of equipment. Percutaneous exposures can be prevented by:

• Avoiding unnecessary use of needles and other sharps
• Using care in the handling and disposal of needles and other sharps
• Not recapping unless absolutely medically necessary and then using one-hand technique or safety device to recap
• Passing sharp instruments by use of designated "safe zones"
• Disassembling sharp equipment by using forceps or other devices
• Closing and replacing sharps containers when they are full (rather than overfilling) according to the manufacturer's instructions
• Using forceps, suture holders, or other instruments for suturing
• Not holding patient tissue with fingers when suturing or cutting
• Having the patient wear a surgical mask
• Instructing the patient to cover the mouth with tissue when coughing or sneezing
• Early identification and isolation of suspect cases
• Transportation of potentially infectious patients

Work practices used when patients potentially or actually infected with virulent or epidemiologically important microorganisms are transported include:

• Appropriate barriers (eg, masks, impervious dressings) should be worn or used by the patient to reduce transmission of infection to other patients, personnel, and visitors, and to avoid contamination of the environment.
• Personnel in the area to which the patient is to be taken should be notified of the impending arrival of the patient and precautions to be used to reduce the risk of transmission.
• Patients are informed of ways in which they can assist in preventing the transmission of their infection to others.

Environmental Controls

Environmental control measures also help prevent the transmission of infection. These measures include:

• Environmental cleaning (housekeeping)
• Waste management
• Linens (textiles) and laundry management

HOUSEKEEPING

Appropriate housekeeping and sanitation practices are essential to reduce the spread of infection, particularly in high-risk areas such as nurseries, operating rooms, and intensive-care units. The CDC guidelines include the following recommendations:

• Keep housekeeping surfaces (eg, floors, walls, tabletops) visibly clean on a regular basis and clean up spills promptly.
• Avoid large-surface cleaning methods that produce mists or aerosols or disperse dust in patient-care areas.
• Follow proper procedures for effective uses of mops, cloths and solutions.

WASTE MANAGEMENT

There are two categories of hospital waste: regulated medical waste and unregulated waste. According to the CDC (2000), most hospital waste is no more infective than ordinary residential waste, nor is there evidence that current hospital waste management practices have caused disease in the community.

Regulated medical waste ("red bag" waste) requires special precautions in handling and disposal. Regulated medical waste includes:

• Microbiology laboratory waste
• Pathology and anatomy waste
• Bulk blood or blood products
• Sharps items such as used needles or scalpel blades (CDC, 2003)

These items require special handling, transport, and storage procedures. The CDC (2003) recommends the following guidelines:

• Personnel responsible for waste management must receive appropriate training in handling and disposal methods in accordance with hospital policy.
• Waste generated in isolation areas should be handled using the same methods used for waste from other patient care areas.
• Disposable syringes with needles, including sterile sharps that are being discarded, scalpel blades, and other sharp items, should be disposed of in puncture-resistant containers located as close as practical to the point of use.
• Do not bend, recap, or break used syringe needles before discarding them into a container.
• Sanitary sewers may be used for safe disposal of blood, suctioned fluids, ground tissues, excretions, and secretions, provided that local sewage discharge requirements are met and that the state has declared this to be an acceptable method of disposal.
• Store regulated medical wastes awaiting treatment in a properly ventilated area inaccessible to vertebrate pests. Use waste containers that prevent development of noxious odors.
• If treatment options are not available at the site where the waste is generated, transport regulated medical waste in closed, impervious containers to the on-site treatment location or to another facility for treatment as appropriate.
• Regulated medical waste must be treated by a method (steam sterilization, incineration, interment, or an alternate treatment technology) approved by the appropriate authority (eg, the state, Veterans Administration, Indian Health Service) before disposal in a sanitary land fill. (CDC, 2003)

LINENS AND LAUNDRY

According to CDC (2003), except for soiled textiles from patients in isolation, the risk of actual disease transmission from soiled laundry is negligible. Thus commonsense hygienic practices for handling, processing and storage of textiles are recommended. These practices include:

• Not shaking the items or handling them in any way that may aerosolize the infectious agents.
• Avoid contact of one's own body and personal clothing with the soiled items being handled.
• Containing soiled items in a laundry bag or designated bin at the location where it was used, minimizing leakage.
• No sorting or rinsing of textiles in the location of use.
• Labeling or color-coding bags or containers for contaminated waste.
• If laundry chutes are used:
• Ensure that laundry bags are securely closed before they are placed in the chute.
• Do not place loose items in the laundry chute.
• Textiles heavily contaminated with blood or other body fluids should be bagged and transported in a manner that will prevent leakage.
• Do not use dry cleaning for routine laundering in healthcare facilities.
• Clean textiles should be handled, transported, and stored by methods that will ensure their cleanliness.

Note: Employers are responsible for laundering reusable personal protective equipment (PPE). Work clothes such as uniforms are not considered to be PPE. Provided gowns or other PPE should be used to prevent soiling of uniforms. (OSHA, 2001).

Training healthcare workers who are responsible for housekeeping and management of linen and waste in appropriate infection control for their particular duties is essential for safe patient care.

ELEMENT IV

Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with potentially infectious material.

Personal protective equipment (PPE) is specialized clothing or equipment worn by a healthcare worker for protection against a hazard. OSHA guidelines state that PPE will be considered "appropriate" only "if it does not permit blood or other potentially infectious materials to pass through or reach the employee's work clothes, street clothes, undergarments, skin, eyes, mouth, or other mucous membranes under normal conditions of use and for the duration of time which the protective equipment will be used." (OSHA, 2001).

Use of PPE is built into the descriptions of all four kinds of isolation precautions (Standard, Contact, Droplet, and Airborne) described by the CDC. Use appropriate barriers and/or PPE whenever you may have contact with the blood or body fluids of any patient and to prevent exposure to the droplets of patients with respiratory symptoms.

A barrier is a material object that separates a person from a hazard. The type of PPE selected should be based on the procedure and reasonably anticipated events such as:

• Blood or body fluid splash
• Contact with minimal bleeding/drainage/body substance
• Contact with large volume bleeding/drainage/body substance that is likely to soak through the contact area
• Respiratory droplet pathogens
• Airborne pathogens

Some barriers are used to protect the patient, including:

• Sterile barriers for invasive procedures
• Masks for the prevention of droplet contamination

Personal protective equipment includes:

• Gloves
• Cover garb (gowns, aprons, fluid-resistant laboratory coats)
• Face shields
• Masks
• Eye protection
• Caps and hoods

Gloves should be worn when contact with blood or body fluids, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated patient care equipment is anticipated.

• Wear gloves with fit and durability appropriate to the task, such as disposable exam gloves for patient care and disposable or reusable gloves for cleaning.
• Remove gloves in a manner than minimizes risk of hand contamination.
• Do not wear the same pair of gloves for the care of more than one patient.
• Do not wash disposable gloves.
• Change gloves during the care of one patient if moving from a contaminated body site to a cleaner one. (CDC 2007)

Gloves are available in several materials including latex, nitrile, or rubber (utility/housekeeping). Some healthcare workers have developed an allergy to latex and should use gloves made of nitrile or other latex-free alternative.

The 2007 CDC Guidelines for Isolation Precautions do not recommend the use of double-gloving. However, some studies have found that, for some procedures, wearing two pair of gloves helps reduce the risk of contamination with blood and body fluids. One clinical study found that wearing a single pair of surgical gloves resulted in a failure rate (loss of glove integrity) of 51%. Double-gloving reduced the failure rate to 7% (Quebbeman et al., 1992).

Another study recommended double-gloving for surgical procedures in which the patient is known or suspected to be infected with a transmissible virus and for all procedures expected to last more than two hours. If double-gloving is not done, healthcare workers should frequently check for blood penetration and should change gloves every 1 to 3 hours (Raahve, 1996).

Latex or nitrile gloves are preferable over vinyl gloves for clinical procedures, since several studies have shown that vinyl gloves have higher failure rates in use (CDC, 2007).

Always use nitrile or other appropriately protective gloves when handling chemotherapy or other chemicals. Both examination (nonsterile, clean) gloves and surgical (sterile) gloves must be available for specific healthcare tasks. Avoid use of petrolatum-based lotions or creams when using latex gloves since these products may affect the integrity of the gloves.

Gloves are the first line of PPE, and can prevent heavy contamination of hands during patient care and transmission of pathogens. However, wearing gloves does not provide complete protection against acquiring viral infections, particularly hepatitis B and herpes simplex viruses.

Wearing gloves does not replace the need for hand washing because gloves may have small, unnoticeable defects or may tear during use, and hands can become contaminated during glove removal. Hands should be washed with soap and water after glove removal if hands are visibly soiled or if the glove has torn. In the absence of visible hand contamination, hand hygiene with alcohol hand rubs is appropriate after glove removal (CDC, 2007). Gloves should also be changed any time the healthcare worker switches from contaminated to clean tasks, even with the same patient.

Gowns are available in both sterile (surgical) and nonsterile (clean) versions and in fabrics of varying permeability (impervious, fluid-resistant, permeable). Gowns protect skin and prevent soiling of clothing during procedures and patient-care activities that are likely to involve contact with or generate splashes or sprays of blood or body fluids. Choose the type of gown that will provide adequate protection for the task planned.

When using Standard Precautions, an isolation gown is worn only as needed to protect the wearer from contact with blood or body fluid. Wear a gown for direct patient contact if the patient has uncontained body fluids.

When Contact Precautions are in use, both gown and gloves should be worn on entry into the room to reduce unintentional contact with contaminated surfaces. Do not reuse gowns, even for repeated contacts with the same patient. (CDC, 2007).

Masks, respirators, and powered air-purifying respirators (PAPRs) protect the healthcare worker, the patient or both from transmission of pathogens. Different types of respiratory protection are available for different tasks and purposes, including:

• Single-use disposable masks are used for Droplet Precautions. They are also used ON patients with respiratory symptoms as part of respiratory hygiene or ON patients known or suspected to have TB. Simple masks contain the droplets coming out of the person wearing the mask (covering their portal of exit).
• Single-use disposable mask with eye shield should be used when splash splatter is anticipated, such as in the OR. These must be changed if wet or soiled. These protect the patient and sterile field from the exhaled droplets of the surgical staff as well as protecting the eyes of surgical staff.
• N-95 respirators are required for staff sharing air space with the patient known or suspected to have tuberculosis. They must make a tight seal against the face, and must be fit tested. This type of respirator protects the person wearing it from possible pathogens in the air of the room, protecting their portal of entry. Some N-95 respirators have an exhalation valve, and these do not prevent contamination of a sterile field and so should not be worn alone in the OR.
• Powered air-purifying respirators (PAPRs) are used in many facilities in addition to or instead of N-95 respirators. They do not require fit testing and they can be used by people with facial hair that precludes wearing of an N-95. PAPRs do require training and maintenance. Check your facility's policy if you may need to use them.

All types of respiratory protection should cover both the mouth and the nose. If the mask or respirator has a metal strip, it should be fitted securely over the bridge of the nose to prevent inhalation or exhalation of pathogens and to prevent fogging of eyeglasses. If glasses are worn, the upper edge of the mask should fit under the glasses to prevent fogging.

When wearing a mask with strings, tie both strings securely to prevent strings from coming loose during the procedure. Tie the upper strings at the back of the head and the lower strings at the neck.

Masks with eye shields or face shields and other eye protection (goggles, safety glasses) are essential to protect the mucous membranes of the eyes, nose, and mouth during procedures that are likely to generate splashes or sprays of blood or body fluids. Although percutaneous injuries (needle sticks) are the most common route for transmission of bloodborne viruses, splashes or sprays to the mucous membranes are the second most common route.

Eye protection includes masks with eye shields, goggles, and face shields. Eyes should be protected whenever splash or splatter of blood or body fluids may be anticipated. When eye protection is worn, a mask must also be worn (OSHA, 2001).

N-95 respirators must be worn as specified on the product package or protection may not be provided. Specifically, if the respirator has two straps, they must be placed as directed, not left dangling or placed together.

Some barriers and PPE are worn to protect the patients from the germs of healthcare professionals, especially in the OR. Sterile drapes are used to create a sterile field in which the operative procedure can take place. Surgical masks reduce risk of droplet contamination of the operative field. Caps and hoods are worn to reduce shedding and promote environmental control. The Association of Operating Room Nurses recommends that a cap or hood be worn that fully covers all hair on the head and face when in restricted and semi-restricted areas of the surgical suite.

Barriers and PPE are most effective when appropriately selected, properly fitted, worn according to manufacturer's instructions, inspected frequently to verify integrity of the barrier, and changed between patients. The cost of barriers and PPE are far less than the cost of treating preventable infections of patients and personnel.

ELEMENT V

Creation and maintenance of a safe environment for patient care through application of infection control principles and practices for cleaning, disinfection, and sterilization.

The potential for contamination exists in every area of the hospital or other healthcare facility. Contaminated patient-care equipment (wet or soiled dressings), invasive devices that were used in diagnosis and treatment (surgical instruments or endoscopes), and environmental surfaces (doorknobs, floors, toilets) can act as vehicles for the transmission of infection to healthcare workers and/or patients.

Understanding and applying appropriate procedures for cleaning, disinfection, and sterilization are essential to maintaining a safe patient-care environment.

Cleaning

Except in rare and special instances (as mentioned below), items that do not ordinarily touch the patient are not involved in disease transmission and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, and a variety of other medical accessories. Consequently, depending on the particular piece of equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed.

Keep in mind that all disinfectants and sterilizing chemicals have a degree of toxicity necessary to kill the microorganisms. In general, the lowest level of product that will do the job should be used, to minimize exposure to toxic chemicals.

Care must be taken to use the right disinfectant for the purpose, consistent with its legal registration.

Disinfection

Low-level disinfection includes the following:

• Use EPA-registered disinfectants in accordance with manufacturer's directions. In general, this is the disinfectant found on the housekeepers' carts.
• Keep environmental surfaces visibly clean on a regular basis and clean up spills promptly.
• Clean high-touch surfaces (monitor controls, doorknobs, bed rails, light switches) often.
• Avoid cleaning methods that produce aerosols or disperse dust.
• Use barrier protective coverings as appropriate for high-touch surfaces such as computer keyboards.
• Do not use high-level disinfectants for environmental cleaning due to toxicity.
• Refer to the CDC Guidelines for Environmental Infection Control in Healthcare Facilities, 2003, for additional detail.

Intermediate-level disinfection is used primarily for cleaning of blood spills and other significant environmental cleaning. These disinfectants are typically labeled as "tuberculocidal" to give evidence that they exceed requirements to kill hepatitis B and HIV. They may be available as a liquid or as disposable wipes.

Blood spills should be cleaned without delay.

• Wear gloves and other personal protective equipment as needed.
• If large amount of liquid is involved, remove visible matter with disposable absorbent material such as paper towels and discard according to hospital policy and local regulation.
• Clean the area with an EPA-registered hospital disinfectant labeled as tuberculocidal or with label claims against HIV or hepatitis B, allowing contact time as specified by manufacturer's directions. (OSHA, 2001)
• Alternatively, a 1 to 100 dilution of household bleach (1/8 cup bleach to 1 gallon of water) may be used. (CDC, 2003)

Some situations, such as care of the patient in Contact Precautions, may require noncritical items to be either dedicated to one patient or patient cohort, or subjected to low-level disinfection between patient uses.

• Patients infected with methicillin-resistant Stapholococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or other drug-resistant microorganisms judged by the infection control program, based on current state, regional, or national recommendations, to be of special or clinical or epidemiologic significance
• Patients infected with highly virulent microorganisms, eg, viruses causing hemorrhagic fever (eg, Ebola or Lassa)

Reprocessing of reusable patient-care equipment includes both high-level disinfection and sterilization. Both these processes must be preceded by decontamination and careful, thorough cleaning.

High-level disinfection is used for reprocessing of reusable patient equipment that touches mucous membranes, such as laryngoscopes or endoscopes when sterilization is not feasible.

Endoscopes can transmit pathogens to patients by contaminated internal channels even if the exterior has been disinfected, if the internal channels have not been adequately cleaned or if contact of the disinfecting solution with the internal channel is incomplete or does not last long enough.

• When handling and cleaning contaminated items, wear appropriate personal protective equipment, gloves and eye protection and/or gown as needed.
• Always clean items thoroughly before reprocessing. First rinse with cold water to remove blood or body fluids, then wash with hot soapy water and rinse again to remove the soap before disinfecting or sterilizing. Cleaning methods may be manual or mechanical and may require a rinse or presoak, depending on the nature and amount of blood or body fluids. Once cleaned, avoid cross-contamination by other articles or surfaces.
• For devices with internal lumens such as endoscopes, methods for verifying contact with all internal channels and components must be monitored.
• Always follow the device/equipment manufacturer's recommendations for reprocessing to ensure that the method chosen is compatible with the components and materials in terms of heat and pressure tolerance and time required for reprocessing.

When inadequately reprocessed patient care equipment has been used, this has usually been due to:

• Failure to reprocess or dispose of equipment between patients
• Inadequate cleaning before reprocessing
• Contamination of disinfectant or rinse solutions
• Inadequate disinfection or sterilization processes (failure to monitor the quality of the process)
• Improper storage or handling following reprocessing

Devices labeled "for single patient use only" should be discarded properly following use. Reuse of such devices is prohibited unless specific FDA regulations are followed and documented. Check with your facility's risk management department if reuse of devices so labeled is considered.

Sterilization

The CDC (2002) recommends the following principles concerning sterilization or disinfection of patient-care equipment:

1. Medical devices that require sterilization or disinfection must be thoroughly cleaned to reduce organic material or bioburden before being exposed to germicide. The instructions from the manufacturers of the germicide and the device should be closely followed. Items that have been wet for several hours may have developed biofilm, complex colonies of bacteria protected by "slime" which protects the bacteria from contact with disinfecting chemicals. (An example of biofilm is the coating on our teeth when we awaken.) Biofilm must be removed by mechanical action (scrubbing) before disinfection or sterilization.
2. In general, reusable medical devices or patient-care equipment that enter normally sterile tissue or the vascular system or through which blood flows should be sterilized before each use. Sterilization means the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. The major sterilizing agents used in hospitals are:
• Moist heat by steam autoclaving (the gold standard, also minimally toxic)
• Ethylene oxide gas (highly toxic; use is decreasing)
• Peracetic acid (used in proprietary machines, often for endoscopes)
• Plasma (new method with little toxicity)
• Dry heat
3. Heat-stable reusable medical devices that enter the bloodstream or enter normally sterile tissue should always be reprocessed using heat-based methods of sterilization (eg, steam autoclave, dry-heat oven) (CDC, 2002).
4. Effectiveness of the sterilization process depends on:
• Selection and use of appropriate sterilization methods
• Monitoring the sterilization process using biologic and process monitors, such as time, pressure, and temperature gauges.

Handling and Storage of Reprocessed Items

Once devices/equipment have been disinfected, proper handling and storage are required to maintain these items in ready-to-use condition. See your facility's policies for specific details.

Proper handling and storage after sterilization, including package integrity and shelf-life or event-related sterility criteria, are required to maintain these items in a sterile state.

Event-related sterility means that sterilized items do not outdate by an arbitrary date, but are judged to be sterile unless an "event" has compromised sterility. Compromising events include circumstances that break the integrity of the sterile packaging by creating holes or wetting the package, which could carry bacteria into it. This means that the once-sterile package that has come loose, has holes, or shows evidence of wetting, presently or in the past, cannot be used because sterility may have been compromised. The end user of the package is responsible for inspecting its integrity, verifying that no event has compromised sterility.

Compromising events include circumstances that break the integrity of the sterile packaging by creating holes or wetting the package, which could carry bacteria into it. The end user of the package is responsible for inspecting its integrity, verifying that no event has compromised sterility. In use, this means that the sterile package that has come loose, has holes, or shows evidence of wetting, presently or in the past, cannot be used because sterility may have been compromised.

Every healthcare professional should recognize potential sources of cross-contamination in the healthcare environment and apply infection-control procedures to avoid cross-contamination. These sources include:

• Surfaces or equipment that require cleaning between patients
• Practices that contribute to hand contamination and potential for cross-contamination
• Implications of reuse of disposable equipment or devices

The area of professional practice dictates the level of responsibility for recognizing various levels of disinfection/sterilization methods and agents. Those health professionals who practice in settings where handling, cleaning, and reprocessing equipment and devices are performed elsewhere, such as a central sterile processing facility, should be cognizant of the basic concepts and principles of cleaning, disinfection, and sterilization described above. In addition, these professionals are responsible for application of safe practices for handling devices and equipment in the area of their professional practice.

Those individuals who have primary or supervisory responsibilities for equipment or device reprocessing should also understand the core concepts and principles of cleaning, disinfection, and sterilization as described above. They also are responsible for appropriate application of safe practices for handling devices and equipment. In addition, these individuals require more detailed knowledge of the various considerations for selecting of appropriate methods, which include:

• Antimicrobial efficacy
• Time constraints and requirements for various methods
• Compatibility with equipment/materials
• Toxicity
• Residual effect
• Ease of use
• Stability
• Odor
• Cost
• Ability to monitor process
• FDA regulations for reuse of single devices

ELEMENT VI

Prevention and management of infectious or communicable diseases in healthcare workers (HCWs).

Prevention of infectious diseases in healthcare workers (HCWs) means protecting them from infections they do not already have. Management of infectious diseases in HCWs means protecting others from the diseases the HCW already does have. This protection must work in both directions!

Protecting HCWs from disease is accomplished in many ways, including:

• Use of Standard Precautions with all patients
• Use of additional isolation precautions to protect HCWs as well as patients
• Influenza vaccine is offered annually and staff are encouraged to accept it as a method for protecting patients. Vaccinating staff against influenza is associated with lower patient death rates from influenza (Carman et al., 2000)

If you suspect that you have been exposed on the job to a communicable disease, let your supervisor and your infection control practitioner know without delay. This will allow evaluation of the circumstances to prevent exposure of others, management of the exposure, and appropriate follow-up of your health as needed. For some diseases, post exposure prophylaxis (preventive medication) is available.

Protecting others from infections of health professionals is a responsibility of the facility and the individual HCW. Employees should report to their supervisor or occupational health service any signs or symptoms of a communicable disease. Symptoms that should be reported and evaluated include:

• Fever
• Unusual rash
• Unexplained blisters
• Purulent skin lesions, such as boils
• Exudative (weeping) dermatitis
• Sore throat with fever
• Gastrointestinal symptoms (vomiting, diarrhea)
• Recent onset of unexplained cough or congestion suggesting an acute respiratory infection
• Jaundice
• Symptoms suggesting active tuberculosis (chronic productive cough with unexplained weight loss, fever, night sweats or hemoptysis [bloody sputum])

Institutional Infection Control Programs

According to the CDC, infection control objectives for healthcare workers should be an integral part of a healthcare organization's overall program for infection control. These objectives, which cannot be met without the support of the healthcare organization's administration, medical staff, and other healthcare personnel, usually include the following:

• Educating personnel about the principles of infection control and stressing individual responsibility for infection control
• Collaborating with the infection control department in monitoring and investigating potentially harmful infectious exposures and outbreaks among personnel
• Providing care to personnel for work-related illnesses or exposures
• Identifying work-related infection risks and instituting appropriate preventive measures
• Containing costs by preventing infectious diseases that result in absenteeism and disability (CDC, 1998).

Certain elements are necessary to attain infection control goals related to healthcare workers:

• Coordination with other departments
• Medical evaluations
• Health and safety education
• Immunization programs
• Management of job-related illnesses and exposures to infectious diseases, including policies for work restrictions for infected or exposed personnel
• Counseling services for personnel on infection risks related to employment or special conditions
• Maintenance and confidentiality of personnel health records (CDC, 1998)

The CDC provides detailed recommendations and documentation for all of the above elements on their website. Of particular interest to healthcare workers are the immunization recommendations presented in the following tables.

IMMUNIZING AGENTS RECOMMENDED FOR HCWs

Generic name	Indications
Hepatitis B recombinant vaccine	Healthcare personnel at risk of exposure to blood and body fluids
Influenza vaccine (inactivated whole or split virus)	Healthcare personnel with contact with high-risk patients or working in chronic care facilities; personnel with high-risk medical conditions and/or ≥65 yr
Measles live virus vaccine	Healthcare personnel born in or after 1957 without documentation of (a) receipt of two doses of live vaccine on or after their 1st birthday, (b) physician-diagnosed measles, or (c) laboratory evidence of immunity; vaccine should be considered for all personnel, including those born before 1957, who have no proof of immunity
Mumps live virus vaccine	Healthcare personnel believed to be susceptible can be vaccinated; adults born before 1957 can be considered immune
Rubella live virus vaccine	Healthcare personnel, both male and female, who lack documentation of receipt of live vaccine on or after their 1st birthday, or of laboratory evidence of immunity; adults born before 1957 can be considered immune, except women of childbearing age
Varicella zoster live virus vaccine	Healthcare personnel without reliable history of varicella or laboratory evidence of varicella immunity
Source: CDC, 1998.

IMMUNIZING AGENTS FOR SPECIAL CIRCUMSTANCES

Generic name	Indications
BCG vaccine (for tuberculosis)	Healthcare personnel in communities where (a) MDR-TB is prevalent, (b) strong likelihood of infection exists, and (c) full implementation of TB infection control precautions has been inadequate in controlling the spread of infection (Note: BCG should be used after consultation with local and/or state health department)
Hepatitis A vaccine	Not routinely indicated for U.S. healthcare personnel; persons who work with HAV-infected primates or with HAV in a laboratory setting should be vaccinated
Meningococcal polysaccharide (quadrivalent A, C, W135, and Y) vaccine	Not routinely indicated for healthcare workers in the United States
Polio vaccine	Healthcare personnel in close contact with persons who may be excreting wild virus and laboratory personnel handling specimens that may contain wild poliovirus
Rabies vaccine	Personnel who work with rabies virus or infected animals in diagnostic or research activities
Tetanus and diphtheria (Td)	All adults; tetanus prophylaxis in wound management
Typhoid vaccines: IM, SC, and oral	Personnel in laboratories who frequently work with Salmonella typhi
Vaccinia vaccine (smallpox)	Personnel who directly handle cultures of or animals contaminated with recombinant vaccinia viruses or orthopox viruses (monkeypox, cowpox, vaccinia, etc.) that infect human beings
Source: CDC, 1998.

Bloodborne Pathogens Training

Bloodborne pathogens training should include:

• Information on hazards associated with blood or other potentially infective material (OPIM)
• OPIM includes semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, any body fluid that is visibly contaminated with blood, and all body fluids in situations where it is difficult or impossible to differentiate between body fluids
• Protective measures to minimize risk of occupational exposure
• Information on appropriate actions to take if exposure occurs

All employees whose jobs involve participation in tasks or activities with exposure to blood/OPIM should be offered the first of the hepatitis B vaccination series within 10 working days of employment and/or new assignment. The vaccination is safe and highly recommended; in many areas it is also free.

Serologic testing after vaccination (to verify that the vaccination was effective) is recommended for all persons with potential occupational exposures. The brief summary that follows is not meant to replace or supplant bloodborne pathogens training required by your facility or state.

Although HBV and HIV are specifically identified in the standard, bloodborne pathogens include any pathogen present in human blood/OPIM that can infect and cause disease in people exposed to the pathogen. Bloodborne pathogens may also include HCV, malaria, West Nile virus, syphilis, babesiosis, brucellosis, leptospirosis, arboviral infections, relapsing fever, Creutzfeldt-Jakob disease, adult T-cell leukemia/lymphoma (caused by HTLV-I), HTLV-I–associated myelopathy, diseases associated with HTLV-II, and viral hemorrhagic fever.

The risk of developing HIV infection from a needle stick with infected blood is about 1:300 without prompt antiretroviral treatment. As of December 2002 (latest statistics available), the CDC reported 57 documented and 139 possible cases of HIV seroconversion among healthcare personnel in the United States. Most were exposed to blood through percutaneous injuries, and eight of the workers were infected despite receiving postexposure prophylaxis (PEP) (Do et al., 2003). Twenty-six later developed AIDS.

To prevent transmission of bloodborne pathogens to healthcare workers, the CDC recommends that postexposure prophylaxis (PEP) begin within 1 to 2 hours after the exposure (MMWR, 2001). Specific guidelines are summarized in the box below.

The CDC recommends that healthcare facilities monitor the effects of PEP and track safety and acceptability of various PEP regimens that include new antiretroviral agents. Communication prior to treatment about possible side effects and follow-up during treatment with PEP increase compliance (see table below).

POSTEXPOSURE PROPHYLAXIS FOR HCWs

Disease	Indication
Diphtheria	For healthcare personnel exposed to diphtheria or identified as carriers
Hepatitis A	May be indicated for healthcare personnel exposed to feces of infected persons during outbreaks
Hepatitis B	HBV-susceptible healthcare personnel with percutaneous or mucous-membrane exposure to blood known to be HBsAg seropositive
Meningococcal disease	Personnel with direct contact with respiratory secretions from infected persons without the use of proper precautions (eg, mouth-to-mouth resuscitation, endotracheal intubation, endotracheal tube management, or close examination of oropharynx)
Pertussis	Personnel with direct contact with respiratory secretions or large aerosol droplets from respiratory tract of infected persons.
Rabies	Personnel who have been bitten by human being or animal with rabies or have had scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infective material (eg, brain tissue)
Varicella zoster virus	Personnel known or likely to be susceptible to varicella and who have close and prolonged exposure to an infectious healthcare worker or patient, particularly those at high risk for complications, such as pregnant or immunocompromised persons
Source: CDC, 1998.

The following standards are based on recommendations by the CDC (1998).

Healthcare workers who have or may have HBV or HIV should be evaluated for the ability to work safely. This evaluation should be based on the premise that HIV or HBV alone is not sufficient justification to limit the worker's professional duties. Case-by-case evaluation should be done to determine whether an individual healthcare worker poses a risk to patients that warrants job modification, limitation, or restriction. If a patient is exposed to the blood of a healthcare worker, that patient must be informed of the exposure and appropriate follow-up offered.

Periodic re-evaluation of a healthcare worker infected with HIV may be appropriate if the disease progression alters physical or mental functioning. Other factors that may affect the ability of healthcare workers to provide quality healthcare include:

• Lack of compliance with established infection control guidelines
• Appropriateness of techniques as related to performance of procedures
• Any health condition that would pose a significant risk to others

Healthcare facilities are required to establish a mechanism for evaluating healthcare workers with HIV or HBV infection. However, this does not include involuntary screening of employees for HIV or HBV.

Institutional evaluation of individual workers known to be infected with HIV or HBV should involve consultation with experts who can provide a balanced perspective. Such experts can include:

• An infectious disease physician and/or hospital epidemiologist with an understanding of HIV/HBV
• A representative from the infected healthcare worker's practice area
• The personal physician of the infected worker

All matters related to evaluation must be handled confidentially.

Any modification of work practice should seek to impose the least-restrictive alternative in accordance with federal disability laws.

Posted September 29, 2008

Expires September 1, 2010

Copyright © 2008 Wild Iris Medical Education. All rights reserved.