This course presents data to assist you in reducing and ...
For the CNA
A Self-instructional Program
Approved for 1 Contact Hour
This study was prepared by Linda S. Greenfield, RN, Ph.D. for
Consultants for the Future
Continuing Education for Healthcare Professionals
Provider No. 50-435
This course teaches what you need to know in order to reduce and control the risk of infections. It is designed to meet the CNA mandatory requirement for continuing education in infection control. It provides continuing education credits only for nursing assistants. There is no more powerful weapon in this war against infectious diseases than knowledge of the enemy.
Please read these IMPORTANT INSTRUCTIONS as they contain answers to many of the questions we are often asked regarding home study.
If you have downloaded this course, you may save it to your hard drive or print all or any part of it. In this way the document is available to you as a resource. As you leaf through this study, you will notice that there are questions placed throughout the reading material. Please notice the last two pages and print these if you have downloaded the course. The first is an answer sheet. As you complete the study, record your answers on this sheet. A passing score of 75% must be achieved to receive credit. In the event that you do not reach 75% on the first submission, you may try a second time without paying again. You must pay again if you need more than two attempts to pass the course. You may refer to the material at any time and you may also study in groups, if you wish. The second sheet is an evaluation form and is to be filled out and submitted along with your answer sheet. If you find any errors, please note them so we may correct them at the next printing. You may submit your answers online and your certificate will be available upon successful completion. Or you may fax your answer sheet to 206-600-6268, or mail it to: Nurse Learning Center 8910 Miramar Pkwy Miramar, FL 33025. Faxed or mailed answer sheets are processed within one week or receipt. You receive credit on the date we process your answer sheet. If you put your fax number on the answer sheet, we will fax back a copy of your certificate before we put the corrected answer sheet and a certificate of completion in the mail to you. Should you decide not to finish the course this year, it can be applied anytime up to two years from the date of purchase.
If you have a certification number (C.N.A. number), put it in the space labeled “License or Certificate number” and it will print on your certificate. If you do not have either number, just leave that space blank.
Initial Printing: December 2006
Current Revision: December 2010
Objective No. 1: Identify specific practices that would slow the spread of organisms between patients as well as staff.
➢ Specifics of hand washing and hand antisepsis.
➢ Specifics of glove use and other personal protective equipment.
The statistics are alarming! Some of the infective organisms are winning. Infections contacted while under medical/nursing care are on the rise, and more organisms are becoming increasingly resistant to our antibiotics. That means the antibiotics won’t work. There are several experts in the field who say we are losing the race against infectious organisms, and the era of confidence in antibiotics is over. It's time we seriously get serious about infection control through other means. In this battle, every person’s efforts are important. Every hand washing becomes significant.
HANDWASHING and ANTISEPSIS
I know you've been lectured to wash your hands thoroughly, too many times to count. I also know that when you're working as hard and fast as possible, even fifteen seconds multiplied many times adds up to a significant time investment. There is not enough time for the many important priorities, and if you effectively wash your hands, which of many other important duties will not then get done? At best, I want to be sure you have adequate information concerning the importance of hand washing so that when you choose priorities, you are choosing wisely. Too many healthcare workers chose to overlook hand washing when there was time, or when the priority was very great. Hand washing seems less necessary if we believe that any infection that may happen can be treated effectively. That's false, as well as expensive (in terms of money and suffering). Many infections do not respond well to our antibiotics and many other infections have no treatment available at all. You might give hand washing a lower priority if you are or will be wearing gloves, when in fact the moist environment gloves create actually increases the bacterial count on your hands, which requires more attention to hand washing.
Most studies indicate that hand washing occurs approximately 1/2 as often as it should, and it is usually of shorter duration than it should be. Most staff, when asked, overestimate the frequency and quality of their hand washing. Common reasons for lack of hand washing are: inadequate staffing, inconvenient placement of sinks, and skin conditions. Common motivators are the awareness of the importance of hand washing -- education. However, most healthcare workers know when hand washing should be done. Education often just makes them aware of what they already know. For that reason, we all need frequent reminders.
Let's categorize the bugs on your skin first. There are two groups -- the insiders and the outsiders. The outsiders are called transient flora (also called noncolonizing flora).”Flora” is just another word for “organisms”. These come and go – transient. They are using your hands as a vehicle to get somewhere else. These can be cultured from skin, but not consistently. They don't want to homestead; there is no commitment on their part. They are just passing through. They are easily picked up and easily removed. These are the bugs we wash away with mechanical friction, and soap and water; or we destroy them with an antiseptic handrubs. When you consider the low-life of organisms that pass on from our hands, you don't want their kind to settle in on your skin! E. coli is one of the lesser bad examples. It survives poorly on the skin, and so it is transient. You can bet, however, that the E. coli would prefer to be transmitted to a more fitting host, than to be stuck with you and risk dying.
The insiders are your colonizing flora. These are considered permanent residents -- they have made a commitment to you and have chosen you as their place to make their home and raise their offspring. Mostly nice folks. They are not readily removed by mechanical friction or hand washing.
There are three levels of hand washing you can choose from when hand washing is a priority:
• hand washing with soap and water to remove soil and transient organisms.
• hand antisepsis to remove or destroy transient microorganisms (but not usually soil.)
• surgical hand scrub to remove or destroy transient microorganisms and to reduce colonizing flora. This course will not consider surgical scrubbing.
Most of the time, you should approach work with a mixture of hand washing, and hand antisepsis.
Beginning with the properties of hand washing with soap and water, the best value comes from the friction you use. Soap and water only minimally reduces organism counts, and if the soap is badly contaminated, your bacterial count will rise after using it. Bar soap should only be used if it's kept on a rack that lets water drain. The slime that forms around bar soap grows bacteria. Liquid soap dispensers help, but you need to empty, clean and dry the dispensers before adding any new soap, or use disposable dispensers. Don't add soap to a partially full dispenser, because bacteria are growing within.
Far more important than the amount of soap used, is what you do with it. Rub all surfaces vigorously, especially getting the soap and water under your fingernails, where most of the organisms reside. Also wash carefully under rings. Places usually missed include: the fingertips and nails, the spaces between the fingers, and the back of the thumbs. The friction loosens the bacteria and also the flakes of skin that organisms hide under.
If you're washing after simply straightening sheets or checking equipment, 10 seconds is probably long enough, and in an effort to keep your skin healthy, a mild soap such as Dove is adequate. It won't kill germs, but it will help you rid your hands of them by suspending the organisms in a foamy lather to be rinsed off. If you are about to care for a very sick patient, an infant or burn patient, or become involved in a procedure that invades the body’s defenses, wash longer with an antimicrobial soap. Before a procedure that invades the body’s defenses (one example would be cleaning a bed sore) you must wash for 15 to 30 seconds to rid your hands of transient organisms. Rinse your hands thoroughly to remove all soap residue and reduce skin irritation, and dry them well. This drying business is a bit of a trick. First of all, it's very tempting not to dry well -- it takes too much time. But the friction of drying is half the value, and bacteria love wet surfaces. You will subsequently pick up many more organisms than you rid yourself of, if you go back to work with wet hands. If you have a choice between paper towels and blow dryers, choose paper towel. Blow dryers take longer (7 to 9 seconds by toweling, 25 seconds with an air dryer), and they are usually contaminated, which causes them to spread organisms either through contact or by recirculating bacteria-laden air currents.
Paper towels remove more organisms than linen towels, probably because of increased friction. They rub away transient flora and old dead skin cells, and even rub away some resident (colonizing) flora from the skin brought to the surface by the warmth and moisture of washing, and the friction. The trick is to dry without recontaminating the hands. This means you have to remember to eject the paper towels you want to use (if the dispenser is lever operated) before you start washing your hands, so that you don't use wet hands to deflect the lever, and thus contaminate your hands and the machine for the next person. After you dry, use the paper towel to turn off the water, and hopefully manage to leave the sink area with your hands reasonably clean. You then need to use the paper towel to open the door (the door handle is frequently highly contaminated).
Washing with soap and water by using an effective technique does wonders for infection control. But there are sicker patients these days who require some extra precaution to assure that we don't bring to them highly infectious, drug-resistant organisms, nor that we transfer their organisms to our other sick patients (not to mention ourselves and our families).
There are some definite times you should consider an antiseptic product, or at least a soap mixture that includes an antiseptic product:
1) When beginning your shift. One advantage of the antiseptic products is that they have a lingering effect. To a limited extent, washing with an effective antiseptic (after hand washing to remove soil) is like donning chemical gloves. This won't be enough to let you slack off on hand washing between patients, but just in case you can't do it perfectly, you can have what little assurance the antiseptic washes can provide.
2) When ending your shift. You don't want to take the bugs you meet at work home with you if you love your family.
3) In between if you have been in contact with blood or any body fluids (of course you should make every effort to be wearing gloves also); if you are about to assist with any invasive procedure (IVs, catheters, etc.); if you are with any high risk patient (damage to the skin through burns, wounds, pressure ulcers, extreme age, or known infection) or in any high risk environment such as ICU or burn units, etc.
ANTISEPTICS
There are several good antiseptics on the market. I'll describe the advantages and disadvantages, and when you go to work, read the labels of your soap dispensers and learn which has been chosen for you to use. Most facilities have antiseptic hand washes. Most homes don’t. You might consider taking one with you to home care situations. If you have concerns, talk with those who make the choices.
First is 70% solution of alcohol. Although it dries the skin, alcohol is effective very quickly. Alcohols provide the most rapid and the greatest reduction in bacterial counts on skin. Fifteen seconds is effective, but one minute vigorous rubbing with enough to thoroughly wet the hands is the most effective. This has been shown to be as effective as a 4 - 7 minute scrub with other antiseptics in reducing bacteria. Rubbing with alcohol for 3 minutes is as effective as a 20 minute scrub with other products. Caution: it is necessary to use a sufficient quantity of alcohol; enough to thoroughly wet all hand surfaces. When used as a brief wipe with alcohol impregnated pads, the effects are less than washing with liquid soap that contains antiseptics. Alcohol has less of a residual effect than other antiseptics. It doesn’t last as long.
Three alcohols can be used: ethanol, n-propyl, and isopropyl. The concentration is much more important than the type. In order to work, they must be diluted with water. Concentrations between 60 - 90% are most effective. Most products won't go above 70% because the higher concentrations cause more skin drying and skin irritation and infection. Sometimes products add emollients (lotions) to minimize the drying. This reduces the drying tendency without sacrificing the bacterial-killing effects. Plus, it may enhance antibacterial activity by increasing the contact time of the alcohol with the skin. Alcohol should be allowed to evaporate from the skin to be fully effective and reduce irritation. Several studies suggest that alcohol-based hand rinses and gels containing lotions may cause less dermatitis than hand washing with soap and water. (Boyce 154)
Another popular antiseptic is chlorhexidine gluconate. (CHG) It is nontoxic and skin absorption is minimal. It has a relatively low skin irritation potential. It is toxic however if it is instilled in ears, eyes, etc. As true with most of these antiseptics, it is strictly designed for external use. Its action is not quite as fast as alcohol, but it is fast, so that a 15 second hand wash provides a good reduction of organisms. The longer you can scrub, the better your results will be. The best advantage of CHG is its persistent action. It is strongly attracted to the skin, and will remain chemically active for 6 hours. It probably has the best persistent effect of any agent we have. Thus, if you use CHG frequently, your bacterial counts will reach the low levels that alcohol will provide with less drying of the skin. CHG is available in a variety of formulations. Most common is a 4% formulation, but 2% aqueous formulas available are also effective. It is combined with alcohol as a hand rinse, which combines the benefits of both products.
Iodine and Iodophors. Tincture of iodine is old stuff. It is relatively safe and fast acting, but not commonly used for hand washing. It must be removed from the skin after drying because of the risk of skin irritation. Any iodine-based products used in handwashing are iodophors, which are complexes of iodine and a carrier, such as providone. One common example is Betadine. This increases the ability of the iodine to go into a solution and provides a reservoir for it. It is the amount of free iodine that kills the organisms, and this changes with concentration. Recommended levels of free iodine for antiseptics are 1 - 2 mg/L. However, iodophors are rapidly neutralized and not effective when there is organic matter such as blood or sputum. Iodine based products have a tendency to cause skin irritation and damage, as well as allergic and toxic effects in sensitive persons. Absorption of iodine occurs to some extent and can cause hypothyroidism (a poor thyroid functioning) in newborn infants.
Another is Para-chloro-meta-zylenol (PCMX or chloroxylenol) With the addition of another chemical (EDTA), it is effective specifically for Pseudomonas, which is a rather persistent and trouble-causing bacteria. Its speed of activity is intermediate, and it is persistent over a few hours. It, like CHG, is inactivated by many formulations, skin situations, etc.
Lastly is Triclosan, which can be absorbed through intact skin, but it appears to be nonallergic and non-cancer causing. The speed of activity is intermediate, it has excellent residual activity. Its activity is only minimally affected by organic matter, so it is not formula dependent. It is commonly used in commercial soaps in concentrations up to 1% to reduce body odor by inhibiting growth of skin bacteria over time. Read the labels of some “antibacterial soaps” in the grocery store. You’ll find Triclosan often.
Of course many products are combinations, either of soap and an antimicrobial agent, or of multiple agents. There are usually advantages to combining agents. Become aware of the product you are using, or the range of products that might be available for you to use.
You can use antimicrobial hand lotions to protect your skin from irritation or to act as an antimicrobial barrier if you have irritated skin. Just try not to apply it right after you have washed with antimicrobial soap, because it interferes with the residual effect and reduces the shedding of the organisms. Apply it in those in-between times when you're not directly giving patient care. Be sure to use small containers of hand lotions. The larger ones allow organisms to grow around the cap, and if you have an outbreak of an organism, consider the lotion as a possible place it is growing. Newer products are creams that bond with your skin to extend protection from drying and irritation. Some examples are "Glove in a Bottle" and "Allergy Guard Plus." Their protecting activity can last up to four hours, and even reduce the allergic activity of latex proteins. The products wear away as the skin sheds.
Petroleum jelly used under gloves does not change the organism ratio, but there are concerns that petroleum-based lotions weaken latex gloves and cause a loss of protection. There are specific lotions formulated to protect against latex sensitivity without risking the effectiveness of your gloves. One study found no interference with the effectiveness of the scrub or wash, nor any increase in leakage in gloves worn 2 hours after the application of the specially formulated lotion. However, if your facility uses an antiseptic that contains CHG, remember that this product is neutralized with many moisturizing products and lotions. Many think that the antiseptic products are harsher to the skin than soap and water. This is often not true. Detergent-based soaps can be very harsh.
As glove use has increased, there are more reports of reactions to latex. Irriation (dermatitis) is a problem for both staff and patients. The number of organisms do not decrease with hand washing if the skin is irritated. Plus, workers with irritated skin have a higher risk of exposure to blood born pathogens because the skin is inflamed. Multiple solutions are offered:
1) use lotions and emollients to treat inflamed skin;
2) use nonlatex, powder, or chemical free gloves;
3) use vinyl gloves under latex gloves.
Because fingernails are where bacteria like to hide, this is an area of concern. Although studies are not conclusive, it appears that artificial or long nails increase the risk of a higher organism load on your hands, particularly of gram-negative (really bad-guys) organisms and fungi. If the artificial nails were broken or had separated from the natural nails, the counts of organisms were consistently high, even after a 30 second hand wash with providone-iodine. If your own body is reacting to the nail lacquers or hardeners used, you can have a secondary infection with Pseudomonas and Candida organisms, both of which you or your patients do not need. Nail polish on natural nails does not seem to increase bacterial counts, unless the polish is chipped.
If you decide to use polish, have long natural nails, or artificial nails, you have an additional requirement to pay special attention to hand washing and to wash longer. You are also increasing your risk of tearing gloves if your nails are longer. I am concerned when people insist to keep longer nails. I find it difficult to believe they will take extra precautions, because most who wear long, pretty nails do not wish to risk marring them. I am also concerned about people who decide to wear multiple rings. It is difficult to assure that the area under each ring is adequately cleaned, and rings also increase the risk of glove tears. If you respect the danger of infectious spread, you simply will choose not to decorate your hands when you are working. I even remove my engagement ring and wear only the wedding band for these reasons. I cook my family's food. I do not want to bring home organisms in the crevices of my engagement ring that can transfer to my family.
GLOVE USE
Wearing gloves is an important aspect to infection control, and one that needs to also be emphasized. Wearing gloves does not eliminate the need to wash your hands between patients and before procedures, etc. Keep reminding yourself that when you have worn gloves, your moisture level of your hands has increased, and your organisms count increased. Bacteria can penetrate through microscopic tears in the gloves.
There is concern about the quality of gloves used. There are two types of materials commonly available. The most frequently used are the latex gloves, which are made from natural rubber latex. These mold easier to your hand, allowing more fine motor movements. Plus, latex reseals easily if tiny punctures occur. Also available are synthetically manufactured materials, including vinyl. Wear vinyl gloves if you or your patient is allergic to latex, or perhaps put a vinyl glove under a latex glove if you wish the extra protection latex offers.
There are extreme variabilities in different glove manufacturers. Leakage has been reported in 4% to 63% of vinyl gloves, and in 3% to 52% of latex gloves. Generally speaking, vinyl gloves are considered to be less protective, and many advocate double gloving if you are using vinyl gloves. Whether or not double gloving helps with any type of glove is still being argued, although if I were involved in a high-risk procedure, I'd double glove while the experts are fighting this one out.
Don't store latex gloves longer than six months, and keep them away from ultraviolet and fluorescent lights. These weaken the integrity of the gloves. Check the expiration dates on glove packages and keep them current.
Gloves are single use items. Use them and toss them. Do not wash the gloves and continue to the next patient. This weakens the glove and organisms aren't easily removed from gloves, despite friction, the cleansing agent or drying.
OSHA mandates gloves when there is "a reasonable likelihood of hand contact" with blood or other potentially infectious material, mucus membranes, or nonintact skin, and when performing invasive procedures and handling contaminated items or surfaces. Each person and facility interprets "reasonable likelihood". There are times when you can decide to provide better than minimum protection. For example, gloves are a definite if you are working around blood or equipment associated with blood (such as needles, knives, etc.) The risk of contacting blood is not real high, but studies show that the risk of needle stick injury is less (up to 50% less blood on needles that pass through latex gloves.) Sometimes you didn’t use the needle, but the one who did missed picking up one needle, which is hiding in the bedding. You might be the one picking up the bedding after the procedure. Wear gloves.
Aside from hand washing and gloves, there are other decisions your facility or you will make in regard to protection and infection control. When do you want to wear a gown or a mask or eye protective equipment? Gloves, masks and gowns and goggles are all grouped under the term "personal protective equipment". In making choices beyond those mandated by facility policy, you need to think in terms of possible risk. For example, if you are helping a nurse change the dressing on a wound or a pressure sore, probably gloves with hand washing will be enough protection. But, if the nurse is going to irrigate that wound on a non-cooperative patient, there might be backsplash. If you are close to the scene, you might need a moisture proof apron or gown, glasses and/or goggles, or a face protector or a mask, as well as gloves. It really doesn't matter if you know there is an infection or not. We treat all patients alike -- as if they are HIV and Hepatitis positive.
Linen gowns provide a coverage for your clothes, but if fluid is involved, the linen gown will just pass the organisms right through to your uniform. This can easily happen if you place a linen pad under your patient to collect the fluid, and then lean against the bed. Your uniform would contact the drainage from the pad. You also want a mask to provide fluid protection, and if you expect a non-cooperative patient situation, and if the nature of the wound irrigation is such that fluid could literally go anywhere, glasses won't provide much comfort, because there are no side-shields. If you don’t work in surgery, Emergency or ICU, the numbers of times that you will need this level of protection are few.
Let me give you a specific example. One man had repeated bouts of resistant S. Aureas pneumonia (MRSA), and so we were careful to contain his organisms to his room with isolation. This particular organism did not respond well to antibiotics and he was contagious. He was a totally "frozen" Parkinson's patient who had great difficulty swallowing, but was not yet tube fed. He did not talk and seldom made any eye contact and he had been this way for years beyond count. He had to be fed. I learned early, that he would often spit out his food, usually with a coughing force that spread MRSA everywhere. My head was close to him as I worked to encourage a safe and cooperative swallow. When he coughed unexpectantly, I was covered with drops of food all contaminated with MRSA. Not only did I learn quickly to keep my head out of the line of fire, I also needed to consider personal protective equipment. I needed to protect my face and my uniform with something waterproof. Gloves were an automatic response.
This kind of situation will not be printed in any OSHA material. There will not be a rule that says, "whenever you feed your patients with pneumonia, gown up." But common sense tells you that if you receive the sputum / food mix coming back at you with a coughing force, you have been covered with copious staph organisms that will use you as a vehicle to get to other patients. This is an example of thinking about the degree of risk and providing the necessary protection.
Question No. 1: True or false? Artificial nails and multiple rings tend to increase the risks of
transmitting organisms and increasing infections.
a. True. b. False.
Question No. 2: True or false? Many infections do not respond well to antibiotics, and many other
infections have no treatment available, so prevention of infection through hand washing is very important.
a. True. b. False.
Question No. 3: Which is NOT true about latex gloves?
a. Latex reseals if a tiny puncture occurs.
b. They are considered more protective than vinyl gloves.
c. They shouldn’t be stored longer than 6 months or exposed to ultraviolet light (sunlight) or fluorescent lights.
d. When wearing gloves, the bacterial count on your hands inside is decreasing.
Question No. 4: Lotions:
a. Are safer if small bottles are used, and then either thrown away or cleaned thoroughly before re-filling.
b. Should be applied between hand washings, rather than immediately after washing.
c. When specially prepared, they can bond to the skin to provide longer protection to your skin.
d. All of these are true about lotions.
Question No. 5: Which of these is NOT true about your colonizing hand flora (organisms)?
a. They are easily removed by mechanical friction and hand washing.
b. They live on your skin more or less permanently.
c. They tend to be less dangerous than transient organisms.
d. All of these are true.
Question No. 6: All but one of these are true about cleaning with soap and water. Which is NOT ?
a. Bar soap has the lowest probability of being contaminated with organisms.
b. Don’t add liquid soap to a partially full dispenser.
c. Liquid soap dispensers are the least contaminated type of soap, when the dispenser is disposable, and not re-filled.
d. Use lots of friction by rubbing all surfaces vigorously.
Question No. 7: Which is NOT valid about hand drying?
a. Blow dryers are usually less contaminated than paper towels.
b. It’s best to dry your hands thoroughly, as bacteria stick well to wet surfaces.
c. The friction of drying with paper towels helps.
d. Think about what you have to touch (e.g. paper towel dispenser levels) with wet hands, and use a paper towel, or do that action before washing.
Question No. 8: Which statement is NOT valid?
a. Alcohol kills many organisms quickly, but doesn’t have a good residual effect.
b. Betadine is not as effective if there is blood or sputum, and it causes many allergic reactions.
c. CHG can be active on your skin for up to 6 hours, and the more frequently it is used, the lower the bacterial count.
d. Triclosan is seldom used as it tends to be allergenic and it doesn’t last long enough to help.
Question No. 9: True or false? Using only an antiseptic to clean your hands will usually remove soil
as well as some transient organisms, therefore antiseptics clean your hands.
a. True. b. False.
Objective No. 2: Recognize the labels of various types of infection-control precautions and know the appropriate protective equipment for each type.
First, there is a difference between "Standard Precautions" and infection control procedures. Standard Precautions is not a synonym for infection control. Standard Precautions means taking routines to protect staff and patients from infection by blood and bodily fluids, such as Hepatitis B, HIV, and multiple other blood-borne diseases. You use standard precautions with everyone. There are many infectious risks, however, in which the blood is not the mechanism of transmission, so other infection controls procedures (airborne precautions, droplet precautions, contact precautions) maybe necessary.
Use of standard precautions is a mandatory requirement for all patients regardless of any infection status. Violators can be punished with stiff fines.
CDC recommendations for health care workers precautions:
-Avoid accidental wounds from sharp instruments such as scalpels and needles, which might be contaminated with material from any patients.
-Avoid contact of open skin lesions with material from any patient.
-Wear gloves when handling blood specimens, blood-soiled items, body fluids, excretions and secretions, non-intact skin, or when handling any objects that have been exposed.
-Wear gowns and other personal protective equipment when clothing or skin may be soiled by any body fluids.
-Wash hands before performing invasive procedures, and after touching blood, body fluids, secretions, excretions and contaminated items or removing gown and gloves.
-Label specimens with "Standard Precautions" and transport them in impervious containers.
-Clean blood spills with a bleach solution or hospital-grade disinfectant solutions.
-Place articles soiled with blood in an impervious container labeled "Standard Precautions" before sending for reprocessing or disposal.
-Place needles in a puncture resistant container after use without bending the needle. Needles should not be replaced in their sheaths after use, as this is a common cause of needle injury. The old practice of replacing the cap is too risky. Actually, this procedure accounted for 30% of all needle sticks according to one study. If you must recap a needle after use, never use two hands or any technique that points the needle toward any part of the body. A needle-recapping device is probably safest, or a needle “scoop” using one hand can be used. Don’t remove used needles from syringes by hand.
-Use disposable needles whenever possible. There is ongoing research and development of safer devices for needle disposal.
-Place patients in private rooms if they are too ill to practice good hygiene with regard to body secretions.
Masks are necessary only when the patient has a lung infection with an organism that is airborne and is actively coughing. The correct term is “Airborne Precaution” if the organism (TB, chickenpox, measles) can remain suspended in the air for long periods and are transmitted when the person inhales small airborne particles. This person should be in a negative-pressure room (one that does not allow the room air to circulate into the building) with the door closed. Respiratory protection with a high-efficiency particulate air filter (HEPA) or equivalent, is used when entering the room of a patient with TB, or if you are susceptible to rubeola or varicella virus. The patient should wear a surgical mask when leaving the room. A surgical mask filters EXPIRED air. A HEPA filter filters INSPIRED air.
If the organism is transmitted by large droplet (rubella, diphtheria, mumps, pertussis, influenze, and many cold viruses), the precaution title is “Droplet Precautions”. These organisms are propelled into the air with sneezing, coughing, talking, singing, etc. and they can infect conjunctivas (white area of the eyes), nasal mucosa or the mouth. This patient should be in a private room, or with another patient who has the same disease. Caregivers should wear a surgical mask, and the patient should wear a surgical mask if he must leave the room. Large particle droplets only travel about three feet before they fall from the air, so the patient’s door can be left open. If you have a cold, wear a mask to protect the patient.
“Contact Precautions” are used when the patient has an organism that spreads through direct contact or touch with a contaminated article. Again, the room should be private, or shared with another patient who has the same infection. Gloves are worn when entering the room, and gowns are worn if you anticipate contact with the patient or items in his room. Much of the equipment will be dedicated to his room. Some infections are spread with two methods: direct contact and droplet, for example.
There are multiple other concerns in infection control. Consider unit equipment that is shared by multiple patients. Even your own personal stethoscopes (or blood pressure cuffs) may be carriers of multiple, potentially infective organisms. One facility cultured their stethoscopes to learn what was on them. Ninety percent had staph bacteria. Simply wiping the stethoscopes with alcohol swabs dropped the bacterial count by 87 - 100%. Swab you stethoscopes between patients!
The safety of sharing equipment is a common question. As long as there is no infections, blood or open lesions, patients can share:
-blood pressure cuffs
-food trays and dishes
-reusable respiratory or ventilatory equipment that has been appropriately disinfected. Disposable equipment, however, is single use.
-stethoscopes (swabbed, of course)
-room equipment such as telephones or toilets.
Items which should not be shared include:
-glass oral and rectal thermometers
-disposable protective sheathes for automated thermometers
-electric and safety razors. These can exchange blood between patients. Used safety razors should be disposed of in the needle disposal boxes. The patient can bring his own electric razor, but throw it away if he dies. “Facility” electric shavers are to be used only if the head of the razor can be disassembled and completely immersed in a disinfectant.
-toothbrushes
-tweezers without soaking in a disinfectant between patients.
-nail clippers without soaking in a disinfectant between patients.
Linen is obviously a source of organisms. Handle it as little as possible. Do not hold it against your uniform, and try not to put it on the floor or furniture. Put it in the hamper, which is hopefully, right outside the door. If the linen is soiled with body fluids, wear gloves to handle it, and place it in a leakproof bag.
Question No. 10: “Contact Precautions” means:
a. The organism is carried by large droplets propelled about 3 feet with a sneeze, cough, etc.
b. The organism is spread by touching it, and carrying it on your skin or stethoscope, for example, to another patient.
c. The organism is spread through inhaling small air-born particles that can circulate through the building.
d. You should use a HEPA filter with this patient.
Question No. 11: Which is NOT valid?
a. A single patient might need both standard precautions (e.g. use gloves if cleaning an open, but healing wound), and infection control procedures (e.g. the patient is confined to his room and you need gowns and gloves to enter.)
b. Standard precautions are mandatory for every patient, while infection control procedures are used with those patients who have a known infection.
c. Standard precautions concern blood and bodily fluids as the route of transmission.
d. “Standard Precautions” is just another way to say “Infection Control.”
Question No. 12: Which of these can be safely shared as long as there are no infections, blood, or
open lesions?
a. Blood pressure cuffs.
b. Electric razors with an attached head.
c. Stethoscopes that haven’t been swabbed between patients.
d. Toothbrushes.
Objective No. 3: Recognize the means of transmission of the more common organisms.
There are many circumstances in which you will not receive directions or instructions for the minute at hand, in which you will use your own knowledge level to decide safe practice. As you learn more about the organisms, methods of transmission, etc. you will be able to make wise choices. To begin, I'll define "infection". Obviously we coexist with millions of organisms around us. Actually, only very few organisms are able to cause disease. Infection occurs only if there is an imbalance between the environment, the host (our patients), and the organism. The organism has been able to reach a vulnerable site in sufficient quantities to continue multiplying, and create a disease. If there are no symptoms, the situation is referred to as "colonization", not infection.
There are three elements in the chain of infection: the source, the means of transmission, and a susceptible host (who then becomes the source).
THE SOURCE
The origin or source can be from inside the patient or outside. “Inside” means that organisms that exist harmlessly in one part of the body have been transferred to another body site and are now causing symptoms. Consider a usually friendly skin organism, Staphylococcus epidermidis. On the skin, he causes very few problems. But, he loves plastic, such as IV cannulas or orthopedic prostheses, and when allowed to contact these surfaces, he can cause serious infections.
In cancer patients receiving chemotherapy or radiation, there is often a loss of white-blood cells that are the army that protects us from infections. Roughly 50% of the infections in these patients are from re-location of bacteria from the GI tract to somewhere else in the body where the organism causes an infection. There are over 500 species in the normal GI tract. In patients receiving chemotherapy, there are often changes in the barrier systems that no longer keep these organisms contained in the GI tract. They are allowed to enter the body, where they cause infections.
Infections caused by “outside” sources are cross infections, in which the organism has come from some other source. The possible contaminating sources seem endless, and include your hands.
Disease does not necessarily follow an invasion by a microorganism. The bug has to be able to survive after leaving the source, and has to sufficiently multiply. The more toxic the organism, the less quantity there needs to be to create disease.
THE MEANS OF TRANSMISSION
The means of transmission is the second link in the chain of infection. How does this bug get from the source to another site? An organism can have a single mode of transmission, or multiple modes. For example, S. aureus may be transmitted by direct contact, or it may be airborne. Salmonella may be transmitted by direct contact, by indirect contact, or it may be vector-borne.
a. Direct contact spread: As an example, when we contact infected body fluids, our hands then carry the transient organism. When we then contact another patient, maybe just by holding hands, we transmit the organism from our hands to his. When that patient uses his hands to rub his nose, or any number of possibilities, the organism can gain entrance. Dirty hands are the most significant method of cross-infection.
b. Indirect spread: This implies an intermediate object in the process, such as food, blood products, fluids, equipment, etc. In the above example, we picked up the organism by contacting infected body fluids, perhaps when we emptied a urinary drainage bag. Picking it up from equipment in the environment is indirect spread.
c. Air-borne spread: means the organism is floating in the air, through respiratory droplets, from environmental sources such as bacteria spores in dust, showers or cooling equipment, and via patient equipment such as nebulizers and humidifiers.
There are actually two types of air-borne spread, that create differences in the isolation procedures. Tuberculosis is spread by small droplets that can stay suspended in the air for a very long time, and be carried by air currents to other locations. It is very important that the air around a TB patient be controlled in its flow pattern so that these germs are not spread throughout a care facility. Influenza (the flu) can also be airborne, but this organism is spread by large droplets that fall out of solution in about three feet. Unless we are very close to a person who sneezes without covering his mouth, we'll most likely contact influenza by touching a surface that the droplets have contaminated.
d. Vector spread: The organisms are carried in or on the body of a vector. For example, flies can carry shigella, and malaria is transmitted by the mosquito. In the case of malaria, the organism undergoes biological changes within the vector (mosquito) before it is passed to the host.
THE HOST
The Host: This is the third link. Once invaded, the host can a) become a carrier (but not diseased) b) effectively fight off the organism using the body's defenses or therapy; or c) become diseased. Understanding factors that increase a patient's risk for disease helps us to know which patients are most vulnerable. Anything that reduces the patient’s immunity (e.g. aging, some drugs, some diseases) obviously creates a significant risk. Anytime the body's defenses are not intact, there is a greater risk, e.g.: wounds or any break in skin integrity; reduced GI acidity; changes in urinary pH or catheters which violate several body defenses; a loss of normal flora; etc.
Question No. 13: A patient with the flu coughed into his hands. Then he picked up a glass of juice
and drank it. The aide picked up the glass with her bare hands to remove it from the room, and then went to tend a 90-year-old who was very sick. No one washed their hands. Now the 90-year-old has the flu. Which of these is NOT true?
a. The most obvious source of the 90-year-old’s flu was probably from her own GI tract.
b. This flu virus must have been spread by at least contact.
c. This is an example of indirect spread.
d. This may have been prevented if the first patient, or the aide or both had washed their hands.
Question No. 14: If the aide in question No. 13 never came down with the flu herself:
a. It would be easy for her/him to argue that s/he was not involved in passing this infection.
b. S/he would be classified as a “carrier.”
c. You could say that in her case the organism couldn’t reach a vulnerable site in sufficient quantities to continue multiplying.
d. All of these are valid.
Question No. 15: A nurse indicates that an elderly patient is “colonized” in her urinary tract with
rather toxic organisms. This means:
a. Colonizing flora are usually transient and it’s easy to get rid of them.
b. That the patient’s urine will contain these organisms, while the patient will not have any symptoms of an infection.
c. That the patient has an infection.
d. All of these are valid.
The World Health organization has established a special bureau dedicated to fighting new and re emerging microbial threats. The Federation of American Scientists has devised a global monitoring network. The US Centers for Disease Control and Prevention has created a strategy for surveillance. The world is beginning to pay attention to a growing threat among us. I doubt very seriously that any of these nationally based organizations can impact the problem, if those of us at the ground level fail to take it seriously. You are key to the safety of your patients.
BIBLIOGRAPHY
Belkin, Nathan, “The New ‘Standard’ For Aseptic Barrier Materials,” Healthcare Purchasing
News, June 2005.
Boyce, John, "Its Time for Action," Annuals Internal Medicine, January 19, 1999, pg. 153-155.
Foley, Mary, “Needlestick Safety and Prevention,” Nevada RNformation, February 2005.
“Handwashing Antisepsis: The Product Selection Challenge,” Nursing Homes, December 2004.
Helder, Darey, “The Importance of Education,” Healthcare Purchasing News, March 2005.
Hill, Emma, “Alcohol Rub, Soap and Water Equally Effective for Hand Disinfectant for Surgical
Site Care,” Medscape Medical News, March 2010, viewarticle/718934.
Patterson, Renee, “The Basics of Improving Infection Control,” Nursing Homes, June 2005.
Perry, Adam, Trafeli, John, “Hand Dermatitis,” Journal of the American Board of Family
Medicine, December 2009, pg. 325-330.
Rinehart, Emily and McGoldrick, Mary, Infection Control in Home Care and Hospice, 2nd Edition,
Jones & Bartlett, 2006.
Rosenblatt-Farrell, Noah, “The Landscape of Antibiotic Resistance,” Environmental Health
Perspectives, June 2009,, pg. A244-A250.
“Sharps Injury Prevention in the Perioperative Setting,” AORN Journal, March 2005.
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