The Preventionist

Posted By Chris on March 7, 2010

The next few posts will highlight some infection control situations that may occur in Long-term Care. These are based on generalities and are for illustration purposes only. Each patient and every plan of care must always be based on a complete patient assessment.   

Situation # 1

An HIV + patient is admitted to your Skilled Nursing Facility for rehab, S/P/ CVA; He is placed in a room with another man who has a history of Hepatitis B and is also S/P CVA. The patients have no indwelling devices or wounds. Two Nursing Assistants are voicing concerns about “catching” HIV or HBV from these patients.

Questions:

Do these patients require a private room?

Should they be on isolation?

Do they need special dishes from dietary?

Should they socialize with other patients?

Can staff “catch HIV or HBV from these patients?

How do you, as the DSD/Infection Control Nurse, respond to their questions?  

First, arrange for a Bloodborne Pathogens in-service for all staff. You have most likely been presenting mandatory, annual in-services on Infection Control and BBP, but a good review will help to put things in perspective. There is plenty of information in your Infection Control Manual, the usual educational videos and from The CDC and OSHA websites.

Reinforce transmission of Blood Borne Pathogens is through direct contact with blood and body fluids. Aids/HIV, HBV and HCV are not transmitted through the air, by touching intact skin, dinnerware or surfaces touched by an infected patient. There is no need for a private room or isolation in this case, because there are no open wounds, IV’s or indwelling devices. The patients are free to socialize, to go to the dining room, physical therapy, library, etc.

To recap: Gather staff for review of review Blood Borne Pathogen Standards and discuss the use of Standard Precautions, Personal Protective Equipment and prevention of potential exposure to blood and body fluids. 

Fear is created by erroneous perceptions and education is the key to correcting misguided assumptions. The Infection Preventionist is the ultimate educator in Long-term Care. Once staff understands the reasoning behind standards, policies and procedures, they will be enabled to participate in their patient’s care with confidence.   

Next: More situations

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Tags: Blood Borne Pathogens, Hepatitis B., transmission of HIV

Posted By Chris on March 6, 2010

The last post briefly explained the roles of both the Centers for Disease Prevention and Control (CDC) and the Occupational Safety and Health Administration (OSHA) and their influence on Universal,  Standard, and Transmission Based Precautions, also known as Isolation Precautions. 

Thinking in terms of interrupting transmission of infectious agents in everyday situations is known as Breaking the Chain of Infection. This term uses a metaphor to create a visual interpretation; each link depends on the last and the next, in order to continue. Break one link and there is no longer a connection. An example might be:

The 1^st link is the pathogen, let’s use MRSA. 

The 2^nd link is the reservoir or house the pathogen lives in. In this case it’s living in the nares (nose) of a nurse but not causing any clinical signs of infection.  

The 3^rd link is the portal of exit (the nurse rubs her nose, now the pathogen is on her hands).

The 4^th link is the mode of transmission, the nurses hands. 

The 5^th link is the new host, her patient.

The 6^th link is the portal of entry. The nurse does not take time to  wash her hands and transmits the MRSA to her patient’s skin while taking her blood pressure. 

The patient is a susceptible host because her immune status is impaired by her chronic medical conditions and diabetes. Her arm itches, she scratches it and places the MRSA she picked up from the nurse, directly into her open skin (portal of entry) and develops an MRSA wound infection.

Looking back we see one of the links could have been broken at any time, to prevent this infection. The only barrier needed was simple, effective hand washing or the use of an alcohol sanitizer, which could have prevented transmission at every link. 

Next: Infection Control Situations in LTC

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Tags: The Chain of Infection, Transmission of Infectious Agents

Posted By Chris on March 2, 2010

What is OSHA?

OSHA is the acronym for the Occupational Safety and Health Administration, an agency of the Federal Government created by Congress in 1970 under The Department of Labor. OSHA mandates  compliance with standards set for employee safety in the workplace. In 1991 OSHA developed the Bloodborne Pathogens Standard to protect workers from the risk associated with sharps injuries, HIV/AIDS, and Hepatitis B & C. Congress developed The Needle stick Safety and Prevention Act in 2000 and OSHA revised the Standard to include the modifications in 2001.

OSHA developed Universal Precautions to protect health care workers from coming in contact with all potentially infected blood and body fluids during patient care. This includes hand washing and the use of bariers such as gloves, gowns and masks when indicated.   

What is the CDC?

CDC is the acronym for the Centers for Disease Prevention and Control, an agency of the Federal Government under the Department of Health and Human Services. The CDC is concerned with Public Health, safety and the prevention and control of disease.

Based on the fact that we cannot know a patient’s status with certainty, The CDC recommends Standard Precautions for the care of all patients no matter their diagnosis.

Standard Precautions include the use of Personal Protective Equipment (PPE) to provide a barrier to blood and body fluids. PPE consists of gloves, gowns, masks.

Hand washing and alcohol hand sanitizers are used appropriately before and after contact with each patient, before and after donning gloves, passing medications, using the restroom, eating, inserting contacts or applying makeup.  

Transmission Based Precautions are recommended to provide additional precautions when it is known or suspected a patient is infected or colonized with a significant pathogen. These precautions are based on the pathogen and their mode of transmission.

They include:

Airborne Precautions for pathogens that travel through small particles in the air such as  Tuberculosis. Airborne Precautions usually require the use of N-95 respirators and negative pressure rooms for patient care, options not normally available in Long-term Care.   

Droplet Precautions are indicated for pathogens traveling on large droplet’s propelled in the air through respiratory secretions while sneezing, coughing or talking. These droplets travel about 3 feet; if it is expected the worker will come within 3 feet of the patient  they wear a mask. If the patient is transported from the room, they wear a mask. Examples of droplet isolation include the influenza viruses, Pneumonias, and Meningitis. (See Appendix A of The CDC Guidelines for Isolation Precautions 2007 for a complete list.

Contact Precautionsare used for infectious pathogens that are transmitted from skin to skin and by contact with a contaminated environment. Examples are C. Difficile, Noro Viruses, MRSA, and VRE. 

Next: InFection Control Situations

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Tags: OSHA, Stanard Precautions, The Bloodborne Pathogens Standard

Posted By Chris on February 26, 2010

In case you’ve never developed a personal relationship with your Infection Control Manual, and if no one has ever mentioned it, you should know you really do have one. You might want to locate it sooner rather than later because this manual should contain written policies and procedures  (P & P’s)  or, the rules to the game of Infection Control in your facility.  Surveyors will ask you to locate it, when it was last updated, if it is compliant and if you are following your own policies and procedures (P & P’s).

A good place to begin looking for the Infection Control Manual you have never been formally introduced to is probably down the hall, in an abandoned office, on the bottom most shelf. With some diligence you might spot it leaning against thirty two other misplaced, dusty manuals of one kind or another. You will soon see they all look alike; they are usually large, white, three ring binders that at first glance, seem to have been deliberately designed to be indistinguishable from every other kind of manual.

There are Long-term Care facilities who are right on top of things and know where their Infection Control manual is at all times. They may have invested in multiple copies, and occasionally one may even be found at, or near the nurses’ station, easily accessible.  Conversely, there are also those facilities that have no idea where to find their manual, or who have multiple editions from extraneous sources such as labs. When vendors change, the manuals are dismissed in favor of the latest provider’s version and so the collection grows until one day, the unfortunate novice Infection Preventionist arrives on the scene, searching for the most recent, updated and compliant manual, only to be faced with an ongoing scavenger hunt.

The Infection Control Manual is more than a resource; its purpose is to contain the Infection Control Policies and Procedures of your facility. They are meant to be based on federal, state and local guidelines, mandates and regulations. These policies and procedures must be reviewed, updated and approved by the Infection Control Committee at least annually and more often as indicated.

In the case of a missing or non-compliant manual, once found, it may be in urgent need of revision. There are companies who produce Infection Control Manuals for Long-term Care and if the facility is a part of a corporation, there is more apt to be help in the form of corporate Infection Control Policies and Procedures.

The Infection Preventionist needs to locate their facility Infection Control Manual, no matter what state it is in, as soon as possible. Once located, set about updating, editing and revising, with the help of any Infection Control Consultants you may have available to you, your nursing, staff and the Infection Control Committee.  

Next: What is OSHA?

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Posted By Chris on February 21, 2010

The acronym ICP (Infection Control Practitioner) is typically used to refer to the Infection Control Nurse in long-term care.

In the past, the term Nosocomial Infection was used to describe facility acquired infections; the newer term, Healthcare-associated Infections (HAI) is in use by Preventionists now.

In our last post we discussed many of the duties assigned to the ICP. One of the most important responsibilities is the surveillance program, which is a means of collecting patient data as it pertains to infection prevention and control.

Pertinent information about newly diagnosed infections, the clinical signs and symptoms supporting the diagnosis, and new orders for antibiotic treatments are reported on surveillance logs and then analyzed.

APIC and McGeer defines a Healthcare-associated infection (HAI) as one that develops more than 48 hours after admission. Conversely, a Community–associated infection is one that was present on admission or developed with-in 48 hours of admission.

A chronic infection is one present at the same site from 1-3 months. These are monitored by the ICP and nursing staff as are all other infections, but for the purposes of statistical reporting they are referred to as chronic rather than Healthcare-associated infections.

For statistical reporting McGeer’s Definitions of Infection for Surveillance in Long-term Care Facilities are generally recommended as a resource for analyzing and quantifying patient’s signs and symptoms. This information, in combination with reviewing of cultures and sensitivities, drug resistant organisms and anti-biotic usage, is recommended for monitoring and reporting infection rates.

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Tags: Chronic Infections, Community Acquired Infections, HAI's

Posted By Chris on February 14, 2010

An Infection Control professional, more recently referred to as an Infection Preventionist (ICP) is usually required to be a licensed Registered or Vocational Nurse, depending on state regulations. Some of the duties of the Infection Preventionist may include:

Surveillance: In infection control, surveillance is the term used to describe the function of observing, gathering, investigating and reviewing information about the patient as it pertains to infection prevention and control.

 Patient Assessment: Accurately reporting signs, symptoms, and changes in condition and initiating isolation precautions as  indicated.   

Tracking and Trending: Tracking and trending information from  surveillance; Practicing outbreak prevention and investigation,  monitoringates of infection and communicating findings in the form of verbal and written reports.  

Orientation and Staff Education: Educating staff, patients and families to Infection Prevention. Monitoring staff compliance with basic infection control principles such as; hand washing, isolation, transmission based precautions, and use of personal protective equipment (PPE).

 Monitor Antibiotic Usage:  Reviewing and reporting antibiotic usage and trends of antibiotic resistance reported in antibiograms.   

Revise Policies and Procedures: Participates in updating policies and procedures needed to maintain compliance with current recommendations from agencies of the federal and local government such as; OSHA, the CDC, state and local departments of health. 

Environmental Rounds: Monitoring department compliance with Infection Control guidelines; conducting environmental rounds and consultation as needed.

Monitor Employee Health: This may or may not be the direct responsibility of the Infection Preventionist. Responsibilities  include annual physicals and tuberculosis screening for new hires and employees, offering influenza and Hepatitis B. vaccines, keeping accurate employee records, initiating workplace restrictions if indicated, becoming familiar with OSHA regulations and educating staff to Infection Control and Blood Borne Pathogens standards.

Each facility will have their own policies and procedures regarding the expectations of the Infection Control Designee. Responsibilities may be shared and hopefully, the nurse will be given the support they need to do their job efficiently and with satisfaction.

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Tags: Orientation, Patient Assessment, Regulations, Surveillance, Tracking & Trending

Posted By Chris on February 14, 2010

You are an Infection Preventionist: I am a what?

Infection Prevention and Control is not a new specialty but it is one that has gained attention locally, nationally and globally, in light of the emergence of the H1N1 Influenza Pandemic. Nurses are familiar with basic Infection Control principles whether they work in acute care settings, long-term care, home health, clinics or physician’s offices. The term Infection Control has recently been changed to Infection Prevention and Control with an emphasis on prevention. It follows that nurses and other medical professionals who work closely in the specialty, are now referred to as Infection Preventionists. After all, preventing health care associated infections should be the primary concern. Controlling them implies there is already a problem.

Infection Prevention and Control in Long-term Care begins with developing a strong Infection Prevention and Control program designed to prevent transmission of infection from resident to staff, staff to patient and patient to patient. In Long-term Care the job typically, but not always, falls to the Staff Developer. Often times there is a sudden vacancy, for whatever reason, and an urgent assignment is made to a nurse who may have no measurable experience in the specialty. Before the appointee begins to feel overwhelmed, it is very important that the Infection Preventionist have the support of physicians, nursing, administration and ancillary services.

To those nurses who find themselves feeling unprepared for the new role suddenly thrust upon them, there are professional organizations such as the Association for Professionals in Infection Control and Epidemiology. This organization provides classes, seminars, videos, podcasts, manuals, books, magazines and even certification in Infection Control. A visit to the website is well worthwhile. www.http://apic.org

The Preventionist is dedicated to facilitating information and links to resources for Nurses who have an interest in developing their skills in Infection Prevention and Control in Long-term Care.  

 Next: Typical Duties of the Infection Preventionist in Long-term Care

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Tags: Infection Prevention, Infection Preventionist, Long-term Care

Posted By Chris on February 14, 2010

The Preventionist has moved to join WordPress.Org. If you are a returning visitor you may notice a slightly different look but the information and resources will remain the same as  former posts are added to the new site. Thank you for your patience during this transition, I am hopeful that you will find the new format more easily navigated and that added features will contribute to your experience while searching for information, links and resources. I look forward to hearing from you.

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