Hosptial Acquired Infection

Propose how would you minimise the occurrence of hospital acquired infection and monitor degree of success of these measures. INTRODUCTION The occurrence and undesirable complications from hospital acquired infections (HAIs) have been well recognized for the last several decades. The occurrence of HAIs continues to escalate at an alarming rate. HAIs originally referred to those infections associated with admission in an acute-care hospital (formerly called a nosocomial infection).

These unanticipated infections develop during the course of health care treatment and result in significant patient illnesses and deaths (morbidity and mortality); prolong the duration of hospital stays; and necessitate additional diagnostic and therapeutic interventions, which generate added costs to those already incurred by the patient’s underlying disease (Bauman, 2011). HAIs are considered an undesirable outcome, and as some are preventable, they are considered an indicator of the quality of patient care, an adverse event, and a patient safety issue.

Patient safety studies published in 1991 reveal the most frequent types of adverse events affecting hospitalized patients are adverse drug events, nosocomial infections, and surgical complications (Aboelela, 2006). Over years there is an alarming increase in HAI, which is influenced by factors such as increasing inpatient acuity of illness, inadequate nurse-patient staffing ratios, unavailability of system resources, and other demands that have challenged health care providers to consistently apply evidence-based recommendations to maximize prevention efforts.

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Read Chapter 8 Microbial Genetics

Despite these demands on health care workers and resources, reducing preventable HAIs remains an imperative mission and is a continuous opportunity to improve and maximize patient safety. Another factor emerging to motivate health care facilities to maximize HAI prevention efforts is the growing public pressure on State legislators to enact laws requiring hospitals to disclose hospital-specific morbidity and mortality rates.

Institute of Medicine report identified HAIs as a patient safety concern and recommends immediate and strong mandatory reporting of other adverse health events, suggesting that public monitoring may hold health care facilities more accountable to improve the quality of medical care and to reduce the incidence of infections. Monitoring both process and outcome measures and assessing their correlation is a model approach to establish that good processes lead to good health care outcomes.

Process measures should reflect common practices, apply to a variety of health care settings, and have appropriate inclusion and exclusion criteria. Examples include insertion practices for central intravenous catheters, appropriate timing of antibiotic prophylaxis in surgical patients, and rates of influenza vaccination for health care workers and patients. Outcome measures should be chosen based on the frequency, severity, and preventability of the outcome events. Examples include intravascular catheter-related blood stream infection rates and surgical-site infections in selected operations.

Although these occur at relatively low frequency, the severity is high—these infections are associated with substantial morbidity, mortality, and excess health care costs—and there are evidence-based prevention strategies available (Filetoth, 2003). PATIENTS RISK FACTORS FOR HEALTH CARE-ASSOCIATED INFECTIONS Transmission of infection within a hospittal requires three elements: a source of infecting microorganisms, a susceptible host, and a means of transmission for the microorganism to the host.

During the delivery of health care, patients can be exposed to a variety of exogenous microorganisms (bacteria, viruses, fungi, and protozoa) from other patients, health care personnel, or visitors. Other reservoirs include the patient’s endogenous flora (e. g. , residual bacteria residing on the patient’s skin, mucous membranes, gastrointestinal tract, or respiratory tract) which may be difficult to suppress and inanimate environmental surfaces or objects that have become contaminated (e. g. , patient room touch surfaces, equipment, medications).

The most common sources of infectious agents causing HAI, described are the individual patient, medical equipment or devices, the hospital environment, the health care personnel, contaminated drugs, contaminated food, and contaminated patient care equipment. Patients have varying susceptibility to develop an infection after exposure to a pathogenic organism. Some people have innate protective mechanisms and will never develop symptomatic disease and others exposed to the same microorganism may establish a commensal relationship and retain the organisms as an asymptomatic carrier (colonization) or develop an active isease process. Intrinsic risk factors predispose patients to HAIs. The higher likelihood of infection is reflected in vulnerable patients who are immunocompromised, underlying diseases, severity of illness, immunosuppressive medications, or medical/surgical treatments (Bauman, 2011). Extrinsic risk factors include surgical or other invasive procedures, diagnostic or therapeutic interventions (e. g. , invasive devices, implanted foreign bodies, organ transplantations, immunosuppressive medications), and personnel exposures.

In addition to providing a portal of entry for microbial colonization or infection, they also facilitate transfer of pathogens from one part of the patient’s body to another, from health care worker to patient, or from patient to health care worker to patient. Infection risk associated with these extrinsic factors can be decreased with the knowledge and application of evidence-based infection control practices. Among patients and health care personnel, microorganisms are spread to others through four common routes of transmission: contact (direct and indirect), respiratory droplets, airborne spread, and common vehicle.

Contact transmission is the most important and frequent mode of transmission in the health care setting. Organisms are transferred through direct contact between an infected or colonized patient and a susceptible health care worker or another person. Microorganisms that can be spread by contact include those associated with impetigo, abscess, diarrheal diseases, scabies, and antibiotic-resistant organisms (e. g. , methicillin-resistantStaphylococcus aureus [MRSA] and vancomycin-resistant enterococci [VRE]).

Droplet-size body fluids containing microorganisms can be generated during coughing, sneezing, talking, suctioning, and bronchoscopy. They are propelled a short distance before settling quickly onto a surface. They can cause infection by being deposited directly onto a susceptible person’s mucosal surface (e. g. , conjunctivae, mouth, or nose) or onto nearby environmental surfaces, which can then be touched by a susceptible person who autoinoculates their own mucosal surface.

Examples of diseases where microorganisms can be spread by droplet transmission are pharyngitis, meningitis, and pneumonia. When small-particle-size microorganisms (e. g. , tubercle bacilli, varicella, and rubeola virus) remain suspended in the air for long periods of time, they can spread to other people. The CDC has described an approach to reduce transmission of microorganisms through airborne spread in its Guideline for Isolation Precautions in Hospitals. Proper use of personal protective equipment (e. g. gloves, masks, and gowns), aseptic technique, hand hygiene, and environmental infection control measures are primary methods to protect the patient from transmission of microorganisms from another patient and from the health care worker (Filetoth, 2003). Personal protective equipment also protects the health care worker from exposure to microorganisms in the health care setting. Common vehicle (common source) transmission applies when multiple people are exposed to and become ill from a common inanimate vehicle of contaminated food, water, medications, solutions, devices, or equipment.

Bacteria can multiply in a common vehicle but viral replication cannot occur. Examples include improperly processed food items that become contaminated with bacteria, waterborne shigellosis, bacteremia resulting from use of intravenous fluids contaminated with a gram-negative organism, contaminated multi-dose medication vials, or contaminated bronchoscopes. Common vehicle transmission is likely associated with a unique outbreak setting and will not be discussed further in this document. STEPS TO MINIMISE THE RISK

Essential components of effective infection control programs included conducting organized surveillance and control activities, a trained infection control physician, an infection control nurse for every 250 beds, and a process for feedback of infection rates to clinical care staff. These programmatic components have remained consistent over time and are adopted in the infection control standards of the Joint Commission. The evolving responsibility for operating and maintaining a facility-wide effective infection control program lies within many domains.

Both hospital administrators and health care workers are tasked to demonstrate effectiveness of infection control programs, assure adequate staff training in infection control, assure that surveillance results are linked to performance measurement improvements, evaluate changing priorities based on ongoing risk assessments, ensure adequate numbers of competent infection control practitioners, and perform program evaluations using quality improvement tools as indicated. a)Infection Control Personnel

It has been demonstrated that infection control personnel play an important role in preventing patient and health care worker infections and preventing medical errors. An infection control practitioner (ICP) is typically assigned to perform ongoing surveillance of infections for specific wards, calculate infection rates and report these data to essential personnel, perform staff education and training, respond to and implement outbreak control measures, and consult on employee health issues.

This specialty practitioner gains expertise through education involving infection surveillance, infection control, and epidemiology from current scientific publications and basic training courses offered by professional organizations or health care institutions. The Certification Board of Infection Control offers certification that an ICP has the standard core set of knowledge in infection control. Expert review panel recommends 1 full-time ICP for every 100 occupied beds (Filetoth, 2003).

To maximize successful strategies for the prevention of infection and other adverse events associated with the delivery of health care in the entire spectrum of health care settings, infection control personnel and departments must be expanded. b)Nursing Responsibilities Clinical care staff and other health care workers are the frontline defense for applying daily infection control practices to prevent infections and transmission of organisms to other patients.

Although training in preventing bloodborne pathogen exposures is required annually by the Occupational Safety and Health Administration, clinical nurses (registered nurses, licensed practical nurses, and certified nursing assistants) and other health care staff should receive additional infection control training and periodic evaluations of aseptic care as a planned patient safety activity. Nurses have the unique opportunity to directly reduce health care–associated infections through recognizing and applying evidence-based procedures to prevent HAIs among patients and protecting the health of the staff.

Clinical care nurses directly prevent infections by performing, monitoring, and assuring compliance with aseptic work practices; providing knowledgeable collaborative oversight on environmental decontamination to prevent transmission of microorganisms from patient to patient; and serve as the primary resource to identify and refer ill visitors or staff. PREVENTION STRATERGIES Multiple factors influence the development of HAIs, including patient variables (e. g. , acuity of illness and overall health status), patient care variables (e. g. antibiotic use, invasive medical device use), administrative variables (e. g. , ratio of nurses to patients, level of nurse education, permanent or temporary/float nurse), and variable use of aseptic techniques by health care staff. Although HAIs are commonly attributed to patient variables and provider care, researchers have also demonstrated that other institutional influences may contribute to adverse outcomes. To encompass overall prevention efforts, a list of strategies are reviewed that apply to the clinical practice of an individual health care worker as well as institutional supportive measures.

Adherence to these principles will demonstrate that you H. E. L. P. C. A. R. E. This acronym is used to introduce the following key concepts to reduce the incidence of health care–associated infections. It emphasizes the compassion and dedication of nurses where their efforts contribute to reduce morbidity and mortality from health care–associated infections. Hand Hygiene For the last 160 years, we have had the scientific knowledge of how to reduce hand contamination and thereby decrease patient infection.

Epidemiologic studies continue to demonstrate the favorable cost-benefit ratio and positive effects of simple hand washing for preventing transmission of pathogens in health care facilities. The use of antiseptic hand soaps (i. e. , ones containing chlorhexidine) and alcohol-based hand rubs also effectively reduce bacterial counts on hands when used properly. Although standards for hand hygiene practices have been published with an evidence-based guideline and professional collaborations have produced the How-to-Guide: Improving Hand Hygiene, there is no standardized method or tool for measuring adherence to institutional policy.

Key points •The practice of appropriate hand hygiene and glove usage is a major contributor to patient safety and reduction in HAIs. It is more cost effective than the treatment costs involved in a health care–associated infection. •Joint Commission infection control standards include hand washing and HAI sentinel event review, which are applicable to ambulatory care, behavioral health care, home care, hospitals, laboratories, and long-term care organizations accredited by the Joint Commission. Hand hygiene is the responsibility of the individual practitioner and the institution. Developing a patient safety culture backed by administrative support to provide resources and incentives for hand washing is crucial to a successful outcome. •Hand hygiene promotion should be an institutional priority. •Select methods to promote and monitor improved hand hygiene. Monitor outcomes of adherence to hand hygiene in association with reduced incidence of HAI. •Establish an evaluation model to recognize missed opportunities for appropriate hand hygiene.

Environmental cleanliness The health care environment surrounding a patient contains a diverse population of pathogenic microorganisms that arise from a patient’s normal, intact skin or from infected wounds. Approximately 106 flat, keratinized, dead squamous epithelium cells containing microorganisms are shed daily from normal skin, and patient gowns, bed linens, and bedside furniture can easily become contaminated with patient flora. Surfaces in the patient care setting can also be contaminated with pathogenic organisms (e. g. from a patient colonized or infected with MRSA, VRE, or Clostridium difficile) and can harbor viable organisms for several days. Contaminated surfaces, such as blood pressure cuffs, nursing uniforms, faucets, and computer keyboards, can serve as reservoirs of health care pathogens and vectors for cross-contamination to patients. It is necessary to consistently perform hand hygiene after routine patient care or contact with environmental surfaces in the immediate vicinity of the patient. Infection control procedures are recommended to reduce cross-contamination under the following situations. . Use EPA-registered chemical germicides for standard cleaning and disinfection of medical equipment that comes into contact with more than one patient. 2. If Clostridium difficile infection has been documented, use hypochlorite-based products for surface disinfection as no EPA-registered products are specific for inactivating the spore form of the organism. 3. Ensure compliance by housekeeping staff with cleaning and disinfection procedures, particularly high-touch surfaces in patient care areas (e. . , bed rails, carts, charts, bedside commodes, doorknobs, or faucet handles). 4. When contact precautions are indicated for patient care (e. g. , MRSA, VRE, C. difficile, abscess, diarrheal disease), use disposable patient care items (e. g. , blood pressure cuffs) wherever possible to minimize cross-contamination with multiple drug-resistant microorganisms. 5. Advise families, visitors, and patients regarding the importance of hand hygiene to minimize the spread of body substance contamination (e. g. respiratory secretions or fecal matter) to surfaces. A patient safety goal could be to adopt a personal or an institutional pledge, similar to the following: I (or name of health care facility) am committed to ensuring that proper infection control and environmental disinfection procedures are performed to reduce cross-contamination and transmission so that a person admitted or visiting to this facility shall not become newly colonized or infected with a bacterium derived from another patient or health care worker’s microbial flora.

Leadership Health care workers dedicate enormous effort to providing care for complex medical needs of patients, to heal, to continuously follow science to improve the quality of care—all the while consciously performing to the best of their ability to Primum non nocere (First, do no harm). Though medical errors and adverse events do occur, many can be attributed to system problems that have impacted processes used by the health care worker, leading to an undesired outcome.

Responsibility for risk reduction involves the institution administrators, directors, and individual practitioners. It is clear that leaders drive values, values drive behaviors, and behaviors drive performance of an organization. The collective behaviors of an organization define its culture. The engagement of nursing leaders to collaborate with coworkers and hospital administrators in safety, teamwork, and communication strategies are critical requirements to improve safe and reliable care.

Each institution must communicate the evidence-based practices to health care staff, have access to expertise about infection control practices, employ the necessary resources and incentives to implement change, and receive real-time feedback of national and comparative hospital-specific data. Health care institutions simply must expect more reliable performance of essential infection-control practices, such as hand hygiene and proper use of gloves. It is no longer acceptable for hospitals with substandard adherence to these basic interventions to excuse their performance as being no worse than the dismal results in published reports.

Institution improvements should focus on process improvements that sustain best practices, using multifactorial approaches, and a commitment from the top administration through all levels of staff and employees to implement best practices. Use of personal protective equipment Infection control practices to reduce HAI include the use of protective barriers (e. g. , gloves, gowns, face mask, protective eyewear, face shield) to reduce occupational transmission of organisms from the patient to the health care worker and from the health care worker to the patient.

Personal protective equipment (PPE) is used by health care workers to protect their skin and mucous membranes of the eyes, nose, and mouth from exposure to blood or other potentially infectious body fluids or materials and to avoid parenteral contact. The Occupational Safety and Health Administration’s Bloodborne Pathogens Standard states that health care workers should receive education on the use of protective barriers to prevent occupational exposures, be able to identify work-related infection risks, and have access to PPE and vaccinations.

Proper usage, wear, and removal of PPE are important to provide maximum protection to the health care worker. Various types of masks, goggles, and face shields are worn alone or in combination to provide barrier protection. A surgical mask protects a patient against microorganisms from the wearer and protects the health care worker from large-particle droplet spatter that may be created from a splash-generating procedure. When a mask becomes wet from exhaled moist air, the resistance to airflow through the mask increases.

This causes more airflow to pass around edges of the mask. The mask should be changed between patients, and if at anytime the mask becomes wet, it should be changed as soon as possible. Gowns are worn to prevent contamination of clothing and to protect the skin of health care personnel from blood and body fluid exposures. Gowns specially treated to make them impermeable to liquids, leg coverings, boots, or shoe covers provide greater protection to the skin when splashes or large quantities of potentially infective material are present or anticipated.

Gowns are also worn during the care of patients infected with epidemiologically important microorganisms to reduce the opportunity for transmission of pathogens from patients or items in their environment to other patients or environments. When gowns are worn, they must be removed before leaving the patient care area and hand hygiene must be performed. Wise use of antimicrobials Over the last several decades, a shift in the etiology of more easily treated pathogens has increased toward more antimicrobial-resistant pathogens with fewer options for therapy.

Infections from antimicrobial-resistant bacteria increase the cost of health care, cause higher morbidity and mortality, and lengthen hospital stays compared to infections from organisms susceptible to common, inexpensive antimicrobials (Aboelela, 2006). Antimicrobial resistance has continued to emerge as a significant hospital problem affecting patient outcomes by enhancing microbial virulence, causing a delay in the administration of effective antibiotic therapy, and limiting options for available therapeutic agents.

Authors of evidence-based guidelines on the increasing occurrence of multidrug-resistant organisms propose these interventions: stewardship of antimicrobial use, an active system of surveillance for patients with antimicrobial-resistant organisms, and an efficient infection control program to minimize secondary spread of resistance. Antimicrobial stewardship includes not only limiting the use of inappropriate agents, but also selecting the appropriate antibiotic, dosage, and duration of therapy to achieve optimal efficacy in managing infections (Aboelela, 2006).

Hospital campaigns to prevent antimicrobial resistance include steps to (1) employ programs to prevent infections, (2) use strategies to diagnose and treat infections effectively, (3) operate and evaluate antimicrobial use guidelines (stop orders, restrictions, and criteria-based clinical practice guidelines), and (4) ensure infection control practices to reduce the likelihood of transmission. Nurse practitioners have a role as part of the health care team diagnosing and treating infections appropriately and should be familiar with strategies to improve antimicrobial use.

All health care workers play a critical role in reducing the risk of transmission. Respiratory hygiene Respiratory viruses are easily disseminated in a closed setting such as a health care facility and can cause outbreaks that contribute to the morbidity of patients and health care staff. Personnel and patients with a respiratory illness commonly transmit viruses through droplet spread. Droplets are spread into the air during sneezing, talking, and coughing and can settle on surfaces.

Transmission occurs by direct contact with mucous membranes or by touching a contaminated surface and self-inoculating mucous membranes. Respiratory viruses can sometimes have aerosol dissemination. Precautions to prevent the transmission of all respiratory illnesses, including influenza, have been developed. The following infection control measures should be implemented at the first point of contact with a symptomatic or potentially infected person. Occupational health policies should be in place to guide management of symptomatic health care workers. 1.

Post visual alerts (in appropriate languages) at the entrance to outpatient facilities instructing patients and escorts (e. g. , family, friends) to notify health care personnel of symptoms of a respiratory infection when they first register for care. 2. Patients and health care staff should consistently practice the following: a. Cover the nose/mouth when coughing or sneezing. b. Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use. c. Perform hand hygiene after having contact with respiratory secretions and contaminated objects or materials. . During periods of increased respiratory infection activity in the community or year-round, offer masks to persons who are coughing. Either procedure masks (i. e. , with ear loops) or surgical masks (i. e. , with ties) may be used to contain respiratory secretions. Encourage coughing persons to sit at least 3 feet away from others in common waiting areas. 4. Health care personnel should wear a surgical or procedure mask for close contact (and gloves as needed) when examining a patient with symptoms of a respiratory infection.

Maintain precautions unless it is determined that the cause of symptoms is not an infectious agent (e. g. , allergies). CONCLUSION It is the responsibility of all health care providers to enact principles of care to prevent hospital acquired infections, though not all infections can be prevented. Certain patient risk factors such as advanced age, underlying disease and severity of illness, and sometimes the immune status are not modifiable and directly contribute to a patient’s risk of infection.

Depending on the patient’s susceptibility, a patient can develop an infection due to the emergence of their own endogenous organisms or by cross-contamination in the health care setting. Nurses can reduce the risk for infection and colonization using evidence-based aseptic work practices that diminish the entry of endogenous or exogenous organisms via invasive medical devices. Proper use of personal protective barriers and proper hand hygiene is paramount to reducing the risk of exogenous transmission to a susceptible patient.

Health care workers should be aware that they can pick up environmental contamination of microorganisms on hands or gloves, even without performing direct patient care. Proper use and removal of PPE followed by hand hygiene will reduce the transient microbial load that can be transmitted to self or to others. ? REFERENCE •Aboelela S W, Saiman L, Stone P, et al. (2006) Effectiveness of barrier precautions and surveillance cultures to control transmission of multidrug-resistant organisms: a systematic review of the literature. J Infect Control, vol: 34(8):484–94. Bauman W R (2011), Microbiology with disease taxonomy, Pearson International Edition, 4th Edition, Pg no: 430 – 434. •Carlos F (2007), Antimicrobial resistance in Bacteria, Horizon Bioscience Publications, Pg no: 7 – 14. •Filetoth Z (2003), Hospital Acquired Infection, Whurr publishers, Pg no: 97 – 102, 180 – 196, 220 – 232. •I W Fong, Drlica K(2008), Antimicrobial resistance and implication for the 21st century, Springer publications, Pg no: 231- 235. •Madigan M, Martinko J, Stahl D (2009), Brock Biology of Microorganisms, Pearsons Publications, 13th Edition, Pg no: 954- 957. Muto C A, Jernigan J A, Ostrowsky BE, et al. (2003) SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus. Infect Cont Hosp Epidem, Vol: 24(5):362–86. •Ryan J, Ray C G et al. (2010), Sherris Medical Microbiology, International Edition, 5th Edition, Pg no: 89 – 98. •Wyllie D, Connor L, Walker S, Davies J et al (2013), Annual Report of Chief Medical Officier, Chapter 4: Health care associated infections, Pg no: 63-72. Centers for Disease Control and Prevention. Respiratory hygiene/cough etiquette in healthcare settings. 2010. [Accessed march 2013]. Available at: http://www. cdc. gov/flu/professionals/infectioncontrol/resphygiene. htm. •Institute for Healthcare Improvement. How-to guide: improving hand hygiene. a guide for improving practices among health care workers. [Accessed March 2013]. Author. Available at: http://www. ihi. org/IHI/Topics/CriticalCare/IntensiveCare/Tools/HowtoGuideImprovingHandHygiene. htm.

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