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An Infection Control Professional is….

An Infection Control Professional (ICP) is usually required to be a licensed Registered Nurse; in some settings a Vocational Nurse, is assigned the role, depending on state regulations. IPs with experience and expertise in Infection Prevention, are now referred to as Infection Preventionists; 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.

Vaccines: The Most Important Discoveries of the Century

In the United States, vaccines for childhood diseases such as Polio, Diphtheria, Pertussis, Measles, Mumps, Tetanus, Rubella, Meningitis and Chickenpox have been protecting our children, families and communities from serious and even fatal illnesses, for decades. There are many other vaccine-preventable diseases not mentioned here and some, such as Smallpox and Polio are now considered totally eradicated in the United States, all due to vaccines. The History of Vaccines

In terms of pain, suffering and lives saved, the historical development of life saving vaccines has led to the prevention and potential eradication of dozens of once deadly, infectious diseases, revolutionizing modern medicineCDC on Vaccines

 

How Vaccines Work?

The CDC tells us vaccines work by imitating an infection. Once vaccinated, a true infection does not occur, but the presence of the imitating infection causes minor symptoms and most importantly, builds antibodies that keep a memory of the specific disease.  One thing to remember is this; depending on the vaccine, it takes time for the antibodies to fully develop. This means if a person has been exposed to the disease before the antibodies have fully developed, it may be too late to expect full, if any protection; early vaccination provides the most potential for protection.

How do you manage staff vaccinations?  Is your staff compliant?

 

 

 

Standard Precautions

Some diseases such as Hepatitis B and C and HIV/AIDS may go undiagnosed for years, yet they are infectious to others. The H1N1 Influenza virus is infectious and transmissible days before the infected person has any signs and symptoms of disease. Although a history and physical may give us pertinent information regarding the health history of a patient, it may not always tell the whole story. Standard Precautions are practices health care workers use when coming in contact with all patients, at all times, regardless of their documented health status.

The term Standard Precautions speaks for itself. These are basic precautions taken to reduce the possibility of coming in contact with infectious body fluids including blood, secretions, excretions, non-intact skin and mucous membranes. In other words, anything that is warm and wet, except for sweat. Standard Precautions include hand washing, using alcohol hand sanitizers when there are no visible signs of soiling, and barriers such as gloves, gowns, masks and goggles, depending on the situation.

Transmission Based Precautions offer an added level of protection when the route of transmission is suspected or confirmed.  See the CDC 2007 Isolation Guidelines for more information on Droplet, Contact and Airborne Precautions; CDC/HICPAC Isolation Precautions 2007 

(be sure to scroll all the way down to find Isolation Guidelines)

There you will also find Appendix A for type and duration of isolation precautions (pg. 94). These recommendations are the accepted standard for hospitals and long-term care facilities.

 

 

Multi-drug Resistant Organisms

The CDC defines Multidrug-resistant Organisms (MDRO’s) as microorganisms that have developed resistance to multiple antimicrobial drugs; two MDRO’s we are most familiar with in Long-term Care are MRSA (Methicillin-Resistant Staphylococcus Aureus) and VRE (Vancomycin Resistant Enterococcus). Patients, healthcare workers and visitors are potential sources of MDRO’s. They may be colonized, infected, and unknowingly transmitting resistant organisms to one another.

Colonization is defined as the presence of an organism in or on the body but with no clinical signs and symptoms of infection. Infection is defined as tissue invasion by a microorganism accompanied by positive clinical signs and symptoms.

Since health care workers, patients and family alike, could potentially be unaware they are colonized with Multi-Drug Resistant Organisms, it follows they could easily be transmitted from one person to another. Inadequate hand hygiene is the root cause for transmission of pathogens in Long-Term Care and in all other health care settings as well. Health care workers, patients and visitors must do all they can to interrupt the cycle of transmission by consciously and conscientiously washing their hands. 

Multi-drug Resistant organisms are not more virulent than their non-resistant predecessors, but they may be more difficult to treat because they are resistant to many classes of antimicrobials.  Reducing exposure to MDRO’s is accomplished by using the same  approach to preventing transmission of all pathogens found in health care facilities.  

  • Use Standard Precautions at all times and Transmission Based Precautions for known or suspected infections. Standard Precautions
  • Always practice responsible Hand Hygiene
  • Use optimum Room Placement of patients with known infections;  co-hort those with like infectious organisms.  
  • PPE (Personal Protective Equipment) use gloves, gowns and masks appropriately. Give frequent demonstrations on the correct procedures for donning, removing and disposing of PPE,  followed by staff return demonstrations. Donning and Removing PPE

Assess patients for group activities. In general, if a patient’s wounds are covered and contained, if they are not exhibiting signs and symptoms of infection, and if they are able to demonstrate responsible hygiene practices, it is usually acceptable for them to leave their room. Check the Policies & Procedures for your facility. Conversely, if wounds cannot be covered and drainage contained, if the patient is confused or unable to engage in good hygiene practices, if they demonstrate clinical signs of infection such as fever, active vomiting/diarrhea or if they are coughing productively, they should remain in their rooms until their signs and symptoms have subsided. Again, review and educate your staff to your facility Policy & Procedures, which should be updated as needed for federal, state and local Standards of Care and Best Practice Guidelines.

What’s That on Your Hands?

Bacteria are everywhere; they co-exist with us, occupying their own intrinsic colonies on our skin, nasal passages, mouths, well you get the picture. Many bacteria are vital to our good health, while other would-be intruders are capable of declaring war with our immune systems, depending on their virulence (relative strength) and our own current state of health. If we could see the bacteria that have colonized our bodies with the naked eye, it is safe to say we’d be washing our hands more often. 

Try to remember everything your hands touch every day. Then allow yourself the visual image of everyone else touching the same surfaces, people, places and things. If we don’t wash our hands, we transfer all of that to others, to ourselves and to our families as well. Not washing our hands, besides being inconsiderate, is potentially dangerous in a healthcare delivery setting. 

We use barriers such as gloves, gowns and masks and we place patients in isolation, but first, we should make a habit of diluting organisms on a consistent basis. The more we dilute potential pathogens, the less chance there is of transmitting bacteria viruses, fungi and fomites to ourselves and others. When we consistently wash our hands, we dilute the organisms. When we vaccinate ourselves, co-workers, residents, families and the community, we dilute the virulence of disease by preventing it all together. Regularly cleaning the immediate environment creates further dilution. 

Healthcare workers need to wash their hand or use hand sanitizers before:

  • Each patient contact
  • After each patient contact
  • Donning gloves
  • Passing medication
  • Performing treatments
  • Serving food
  • Assisting with drinking or eating
  • After using the rest room.

Well, we all know the drill. But are we compliant? Hand washing is the most important step we can take in reducing and diluting the number of pathogens our patients, families and co-workers are exposed to on a daily basis. Their lives are in our hands. It’s just that simple.

C. Difficile

C. Difficile Infection (CDI); what it is, how it is transmitted and what can be done to prevent its spread.

Clostridium Difficile is an Antibiotic- Associated Diarrhea Disease (AAD) found in hospitals, skilled nursing facilities and long-term care settings subsequent to antibiotic treatment.  It is a tough little anaerobic, gram-positive, spore forming bacillus that produces two exotoxins which attack  the mucosal lining of the colon, usually subsequent to antibiotic usage; the action  neutralizes the normal flora of the bowel, allowing for C. Dif proliferation.

The clinical signs and symptoms of C. Difficile are abdominal pain, watery diarrhea, nausea and fever. The bacillus is shed in the feces and transmission is by oral ingestion. How does this occur? Contamination of the environment by an infected patient allows for transmission from feces to hands, to surfaces, and then to others, when adequate precautions are not followed.

C. Difficile spores are capable of living in the environment for days, weeks and even months.  Severe cases of C. Difficile carry the potential for colon perforation, mega-colon, sepsis and even death.

Treatment of C. Difficile may consist of physician ordered Vancomycin and/or Flagyl but about 23 percent of patients recover within a few days if the offending antibiotics have been discontinued. Of special note: The CDC does not recommend re-culturing of patients who have completed treatment or have resolved on their own and remain asymptomatic because they may be colonized.   

  • Always use Standard precautions for all patients in Long-term Care and use Transmission Based Precautions for known or suspected infections. With symptomatic C. Difficile   patients with watery diarrhea may be placed on contact precautions until asymptomatic, which means no further diarrhea.
  • The CDC recommendations for hand hygiene when caring for patients with C. Difficile consist of hand washing; alcohol sanitizers are not effective against C. Difficile spores. Hand washing does not kill the spores but the friction with soap and running water allows for them to be washed down the drain.
  • Environmental cleaning consists of Hypochlorite/bleach solutions with careful attention to protocols for contact time. Information can be found in the CDC’S Frequently Asked Questions about C. Difficile for professionals: CDC/C.Dif / Hand Hygiene and C. Dif

Reference picture: CDC PHIL. http://phil.cdc.gov/

Shingles

Situation: A 72 year old female patient develops a painful rash with fluid filled blisters on the right side of her face, but nowhere else. What should you, the Infection Preventionist do?

Consider this a potential case of Shingles; This is the same virus that causes Chicken Pox, a disease that used to be prevalent in childhood until an FDA approved vaccine was developed in 1995 (CDC.gov/vaccines/2009).

After Chicken Pox runs its course, the Varicella Zoster Virus remains dormant in the body for life, and in some cases, the virus re-surfaces years later as Shingles.

The typical signs and symptoms of Shingles include a painful rash with fluid filled blisters that are limited to one side of the face or body. Headache, malaise and fever may also be present. Anyone who has had Chicken Pox, including children, may develop Shingles, but it is more common in older people, those with impaired immune systems or people on immunosuppressive drugs, such as steroids.

  • Report your findings in detail to the DON and the patient’s physician. Treatment for a confirmed case of Shingles may include prescriptions for anti-virals such as Zovirax, Acyclovir, or Valtrex. Pain medications may also be prescribed.
  • Educate patients, staff and family members; explain that Shingles itself cannot be transmitted to anyone else, in other words, you cannot “catch” Shingles, it is a re-activation of the Chicken Pox Virus. Draining blisters are potentially contagious to those who have never had Chicken Pox. If they come in contact with the draining blisters, they could be at risk for developing Chicken Pox. This is important information, especially to women who may be pregnant, because Chicken Pox can cause birth defects.
  • Standard precautions should be used for all patients in Long-term Care. The CDC’s 2007 Isolation Guidelines recommend Standard Precautions for Shingles. Contact Precautions may be used while the Shingles blisters are draining but once they are dried and crusted over, the patient is no longer considered contagious.

Patients and health care workers who have not had Chicken Pox should not be placed in contact with a patient diagnosed with Shingles while the blisters are draining. See CDC: Shingles

 

 

 

Infection Control Resources in Long-term Care

I live and work in Southern California; for these reasons, the resources I use for my contributions to The Preventionist come mainly from:

  • The California Department of Public Health Infection Control Guidelines
  • The Los Angeles County Department of Public Health
  • The Centers for Disease Control (CDC)
  • The National Institutes of Health (NIH)
  • And the Association for Professionals in Infection Control and Epidemiology (APIC), our national, professional Infection Control Association.

These resources base their guidelines and recommendations on scientifically gathered, evidence based and peer reviewed information.

Infection Control Nurses living in other states rely on their individual State and County Infection Control Guidelines to be compliant. Here are some Infection Control links you may find useful in California and nationally as well:

 

 

 

Breaking the Chain of Infection…in Plain English

Thinking in terms of interrupting the transmission of infectious agents 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 1st   link in the chain is the causative agent or pathogen, let’s use MRSA
  • The 2nd link is the reservoir or the house the pathogen lives in. In this case it’s living in the nares (nose) of a nurse but not causing her any
    clinical signs of infection. She is not even aware she has MRSA organisms in her nasal passages. 
  • The 3rd link is the portal of exit (the nurse rubs her nose, now the pathogen is on her hands). 
  • The 4th link is the mode of transmission or the route the organisms use to travel to their newest destination; in this case, the nurse’s unwashed hands. 
  • The 5th link is the portal of entry or the skin of the potential host, her patient. 
  • The 6th link is the susceptible host, the patient; susceptible is the keyword. If the patient has an altered immune system, and chronically ill people do, the organism stands a very good chance of gaining entrance and setting up shop at
    the first opportunity. 

So let’s see what happens. The nurse did not take the time to wash her hands before visiting her patient and so she 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. The patient’s arm itches, she scratches it and causes a small break in the integrity of her skin; the MRSA she picked up from the nurse gains entrance (portal of entry) and the patient develops an MRSA wound infection. 

Looking back we can see any one of the links in the chain of infection could easily have been broken, beginning with the nurse always washing her hands or using an alcohol sanitizer before and after visiting each patient.

The concept of breaking the chain of infection is not limited to long-term care; it can and should be used to prevent transmission of micro-organisms in all healthcare facilities and in the community as well. If we could see the multitude of organisms that are living on our hands and in our immediate environment, we would probably never stop washing our hands.

 

What are OSHA and The CDC?

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 Precautions are 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.