An Infection Control Professional (ICP)

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.

Becoming Preventionists

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 and re-emergence of childhood diseases, such as measles and pertussis and the Pandemic H1N1 Influenza outbreaks, not to mention Ebola. Nurses are educated to be 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 within the specialty, are now referred to as Infection Preventionists. After all, preventing healthcare associated infections should be the primary concern. Controlling them implies there is already a problem.

Infection Prevention and Control in Skilled Nursing, Long-term and Long-term Acute 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, please consider becoming a member of our National Professional Association, the Association for Professionals in Infection Control and Epidemiology (APIC). There you will find classes, seminars, videos, podcasts, manuals, books, magazines and information regarding certification in Infection Control. A visit to the website is well worthwhile. APIC.org 

 

 

Standard Precautions First

Standard Precautions First

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. Use Standard Precautions all the time with every patient. Often the term just isn’t understood and is overlooked, instead healthcare workers scramble to determine “What kind of precautions the patient is on.” Barriers are included as part of Standard Precautions, leaving the use of them to be determined by assessing the patient situation. It would make sense to use gloves if there is a possibility of soiling your hands, gowns and goggles if splashing or contact with bodily fluids is anticipated. 

When you think of Standard Precautions, think insurance policy. Why do we use Standard Precautions? Precaution is the key word here. We use precautions in advance of coming upon a situation that might lead to an undesired outcome, one leading to possible transmission of infectious organisms from patient to patient, patient to healthcare worker and what of the visitors? Let us not overlook role of the visitors in the mix.  

We can’t always know who among our patients, employees, physicians, or visitors, may be carrying an infectious or potentially infectious organism. It’s safe to say not only do we not always know, we usually do not know.  So, in order to avoid an unwanted outcome, such as the spread of infectious disease, we use barriers such as gloves, gowns and masks, when indicated. This means we need to rely on our own assessment of a situation when it comes to caring for patients who have not yet been diagnosed with any particular infectious organism. 

Example: A patient has been coughing; do any of us want to inhale droplets sprayed into the air by a coughing or sneezing person? Don’t we usually avoid those situations anyway? So before any tests are completed, before a particular organism is cultured, identified and reported, put a mask on yourself and one on your patient if they are leaving the room.  That’s Standard Precautions.  

Example: A patient has complained of sudden upset stomach and diarrhea. Do any of us want to touch anyone’s feces? Do we want to touch the same places the person with the diarrhea has touched?  So before any tests, cultures and diagnoses are made, put on gloves and even a gown if there is a chance your clothes could become contaminated. That’s Standard Precautions.

Example: A newly admitted patient complains of intense itching, especially bothersome at night. Before you think Scabies, before skin scrapings and identification of mites occurs, put on gloves before touching the patient. That’s Standard Precautions.

Let’s not forget. Patients, just like you and me, touch their bodies, their noses, mouths and their skin. Hopefully we all wash our hands, but we don’t know for sure. We all live in a unique cloud of our own organisms and touch things in the environment over and over again, leaving our own unique brand of micro-organisms behind us. See Microbiome

Fortunately, or unfortunately, we don’t see what is on our hands, our skin or in the environment. When we’re distracted we forget, overlook or postpone doing what we know is the right thing to do; after all, we are very busy. But, if we could actually see the organisms on our hands, our patient’s hands and the environment we might never stop washing, cleaning and sanitizing. At the very least, using Standard Precautions all of the time dilutes the potential number of organisms we transmit to one another. 

To be sure: Every time you enter a patient’s room, sanitize your hands. Every time you care for a patient, and go to another patient, sanitize your hands.  Every time you leave a patient’s room sanitize your hands. That’s Standard Precautions.

 

 

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.

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/

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. 

 

Adult Vaccine Schedule

Every year at this time, we as Infection Preventionist, preach the importance of getting the Influenza Vaccine, but what of the other adult vaccines? Is your staff compliant? Do you keep track of your vaccinations? Are you up to date with your own adult vaccines? What about these:

  • Influenza (Flu) every year
  • Tetanus, diphtheria, pertussis (Td/Tdap)
  • Varicella (Chickenpox)
  • HPV Vaccine for Women
  • HPV Vaccine for Men
  • Zoster (Shingles)
  • Measles, mumps, rubella (MMR)
  • Pneumococcal (pneumonia)
  • Meningococcal
  • Hepatitis A
  • Hepatitis B

Here are some great links to the CDC Adult Vaccine Schedules

CDC Adult Vaccines

Adult Vaccine Schedule

Picture courtesy of CDC:PHIL

 

Healthcare Acquired Infection Prevention (HAI) in Long-term Care

The term Nosocomial Infection has more recently been changed to Health Care Acquired Infection or HAI, but I find Health Care Workers continue to default to using Nosocomial. In any case, a HAI or Nosocomial Infection, is one that develops 48 to 72 hours after admission to a healthcare facility, according to McGeer’s Criteria (McGeer’s, 1991)

Multiple factors contribute to the transmission of infectious organisms in hospitals, long-term care facilities and rehabilitation centers; they include the type of infectious organism, the patient’s proximity to the source of infection, the means by which the organism could potentially be transmitted  and the status of the patient’s immune system.

Ultimately, it is the responsibility of the facility to develop policies and procedures designed to interrupt the transmission of infectious organisms from the source to the patient and to maintain a strong Infection Control Surveillance program. That is where you, the DSD, Infection Preventionist, or DON, and your Infection Control Committee, come in. Preventing HAI in Healthcare Facilities CDC

References:

McGeer A, Campbell B, Emori TG, Hierholzer WJ, Jackson MM, Nicolle LE, Peppler C, Rivera A, Schollenberger DG, Simor AE, Smith PW, Wang E. Definitions of Infection for Surveillance in Long Term Care Facilities. American Journal of Infection Control 1991; 19(1):1-7.

PHIL ID # 10068
Photo Credit: Janice Haney Carr, Centers for Disease Control and Prevention

PHIL ID # 10045
Photo Credit: Janice Carr, Centers for Disease Control and Prevention

CDC Newsroom Image Library

 

 

ESBLS

ESBL
is the acronym for Extended Spectrum Beta Lactamase. If it sounds somewhat complicated it is; basically, ESBLs are bacteria that produce an enzyme capable of neutralizing the effectiveness of certain classes of Beta-lactam antibiotics such as, carbapenems, cephalosporins and certain penicillin derivatives. The end result is yet another type of Multi-drug resistant Organism (MDRO).

The bacteria are spread in the same way all organisms are transmitted depending on their site.  Those at highest risk are usually hospitalized patients who have been on extensive antimicrobial therapy and have already compromised immune systems.

What should be done about ESBLs in long-term care?

  • If you are new to infection prevention, be sure to locate your facility policy for MDROS in your Infection Control Manual.  Hopefully, the policy will be up to date and based on the evidence based guidelines and recommendations available to long-term care facilities in your state.
  • The CDC, your state Department of Public Health and APIC (Association for Professionals in Infection Control and Epidemiology) are the Big 3 support systems for Infection Preventionists. Visit their websites frequently.
  • If you aren’t sure or have questions, seek out the support of your DON, and the Infection Control Committee.
  • Together, you can review, update and sign off on a current policy.  As soon as appropriate, announce the presence of an updated policy for MDROs (including ESBLS) to the staff and educate them to its definition, treatment and potential precautions.
  • Standard Precautions are THE place to start; utilize Transmission Based Precautions for infections that cannot be contained. Think about that.

Is an ESBL in the urine contained in a Foley bag, a diaper or as a continent patient?

If the source of the organism is contained, the patient’s hands are clean, they are wearing clean clothes and want to socialize, could they be managed with Standard Precautions?  

What is the policy for your facility? Is your staff educated frequently to the principles of Standard Precautions?

CDC on ESBLS

 

The Infection Control Manual in Long-term Care/ Where is it Written?

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 your manual sooner, rather than later, because this great white book 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 exactly 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 they contracted with years ago and have long since lost communication with.

When vendors change, the manuals are usually 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 large 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.

Picture reference: Old Computers.com; manuals close up; (March 26, 2012)

APIC: Your Professional Association

 

This is the logo associated with the Infection Prevention and Control Professional Association known as The Association for Professionals in Infection Control and Epidemiology (APIC)

What is APIC?

APIC is the Infection Preventionists (IPs) Professional Association. I encourage any person who is in any way associated with Infection Prevention and Control to visit the APIC website and to also consider joining the organization.

What does APIC do? Visit the APIC website and take a look. 

Here you will find evidence-based and scientifically proven resources you will feel confident in using to support your Infection Prevention and Control program. There are many, many more resources available to you as well

APIC and the CDC work in concert with one another to provide the most consistent and up to date resources, guidelines and recommendations in the Infection Prevention and Control environment.  

Why become a member?

APIC members are comprised of nurses, public health professionals, physicians, epidemiologists and others who among other things, are involved with collecting, analyzing and interpreting surveillance data collected in their respective work environments. It makes sense to seek out others with mutual educational and professional interests in order to strengthen and support your role as an Infection Preventionist.

And one more thing…

Long-term Care Nurses share a common need to become actively involved in establishing scientifically based infection prevention practices. We need to collaborate with not only Long-term Care Nurses, but all member of the healthcare team to insure prevention of healthcare-associated infections (HAIs). Education is the answer. Do it for yourself; yes, it requires an additional personal investment of your time and a determination to become better prepared to practice in your profession. 

Reference: APIC website http://www.APIC.org