Hospital Patient Safety Initiatives: Infection Control

1. Hospital Patient Safety Initiatives:Infection Control Bernard C. McDonnell, DO

2. Urinary Catheter Tracer • Use of urinary catheters in a manner to minimize infection • Hospital maintains guidelines for appropriate use of urinary catheters • Hand hygiene • Before and after insertion • Placement of catheter using aseptic technique • Catheter properly secured after insertion

3. Urinary Catheter Tracer • Catheter insertion and indication are documented • Hand hygiene before and after manipulation of catheter • Avoid irrigation • Collection bag emptied using aseptic technique • Aseptic collection of urine samples • Small amounts through needleless port

4. Urinary Catheter Tracer • Keep urine collection bag below level of bladder at all times • Catheter tubing unobstructed with no kinking • Need for catheter reviewed daily • Prompt removal when deemed unnecessary • No “convenience”

5. Central Venous Catheter Tracer • Central venous catheters are inserted, assessed and maintained in a manner to minimize infection • Hand Hygiene performed before and after insertion • Maximal barrier precautions used for insertion • Surgical protection including full patient body drape • Use of >0.5% chlorhexidine with alcohol used for skin antisepsis prior to insertion • Can use tincture of iodine, iodophor or 70% alcohol alternatively

6. Central Venous Catheter Tracer • Dressing to cover catheter insertion site • Sterile gauze • Transparent, semi-permeable dressing • Well healed and tunneled catheters may not need to be covered • Central line insertion and indication documented • Hand hygiene performed before and after manipulating catheter • Gloves • Soiled dressings are changed promptly • All dressings changed using aseptic technique • Gloves

7. Central Venous Catheter Tracer • Access port is scrubbed with an appropriate antiseptic prior to accessing • Chlorhexidine • Povidone iodine • An iodophor • 70% alcohol • Catheter accessed with sterile devices • Need to central venous catheters reviewed daily with prompt removal when not necessary

8. Ventilator/Respiratory Therapy Tracer • Respiratory procedures are performed in a manner consistent with hospital infection control policies to maximize the prevention of infection and communicable disease • Hand hygiene • Gloves • Sterile water for nebulization • Single dose vials for aerosolized medications • Using manufacturer’s instructions for handling, storing and dispensing of medications

9. Ventilator/Respiratory Therapy Tracer • If multi-dose vials for aerosolized medications are used for more than one patient— • Restricted to a centralized medication location • They do not enter the immediate patient treatment area

10. Ventilator/Respiratory Therapy Tracer • Ventilators are used in a manner consistent with hospital infection control policies to maximize the prevention of infection and communicable disease • Ventilator circuit is changed if visibly soiled or mechanically malfunctioning • Sterile water is used to fill bubbling humidifiers • Condensate in tubing is periodically drained and discarded • Condensate should not drain toward the patient

11. Ventilator/Respiratory Therapy Tracer • Use of sterile single-use suction catheter • Multi-use closed system catheter • Only sterile fluid is used to remove secretions • Sedation is lightened daily in eligible patients • Spontaneous breathing trials are performed daily in eligible patients • “Weaning”

12. Spinal Injection Procedures • Spinal injection procedures are performed in a manner to minimize infection and the spread of communicable disease • Hand hygiene • Spinal injection • Aseptic technique • Surgical masks are used when placing a catheter or injecting materials into the epidural or subdural space

13. Point of Care Devices • Blood Glucose Meter • INR Monitor

14. Point of Care Devices • Hand hygiene • Gloves • Used for “finger-stick” procedures • Removed after the procedure • Followed by hand hygiene • Finger stick devices are used for 1 patient • Lancet • Lancet holding device

15. Point of Care Devices • Point of Care device is cleaned and disinfected after every use according to manufacturer’s instructions • Single use only if no manufacturer’s instructions for cleaning and disinfection

16. Isolation/Contact Precautions • Patients requiring contact isolation are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease

17. Isolation/Contact Precautions • Gloves are available and located near point of use • Signs indicating that the patient is in contact isolation • Patients in contact isolation are in single rooms • Can be cohorted based on clinical risk assessment

18. Isolation/Contact Precautions • Soap and water must be used when bare hands are visibly soiled (e.g., blood, body fluids) or after caring for a patient with known or suspected C. difficile or norovirus during an outbreak. In all other situations, ABHR is preferred.

19. Isolation/Contact Precautions • Gloves and gowns • Before entering patient care environment • Removed and discarded; hand hygiene is performed before leaving the patient care environment

20. Isolation/Contact Precautions • Dedicated or disposable noncritical patient- care equipment (e.g., blood pressure cuffs) is used or if not available, then equipment is cleaned and disinfected prior to use on another patient according to manufacturer's instructions.

21. Isolation/Contact Precautions • Traffic control • Into patient’s room • Patient moving out of the room to other parts of the hospital • Contact precautions outside the patient’s room • Cleaning of objects and patient care areas that are touched in patient’s isolation room • When visibly soiled • At least once a day • Terminal cleaning • All surfaces thoroughly cleaned and disinfected and all textiles are replaced with clean textiles • Cleaners and disinfectants are labeled and used in accordance with hospital policy and procedure and manufacturer’s instructions

22. Isolation: Droplet Precautions • Patients requiring Droplet Precautions are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following:

23. Isolation: Droplet Precautions • Masks • On entering • Discarded when leaving • Signs • Patient on droplet precautions are housed in a single room or cohorted based on clinical risk assessment • Hand hygiene • Limited patient movement for droplet isolation patients • Medically necessary procedures • Patient wears surgical mask when transported • Communication of patient’s status

24. Isolation: Droplet Precautions • Cleaning • Once a day per policy and manufacturer’s instruction while patient is admitted • Terminal cleaning after discharge including wiping and disinfection of all hard surfaces • Changing all textiles in the isolation room • All cleaners are used in accordance with hospital policy and procedure and manufacturer’s instructions

25. Isolation: Airborne precautions • Patients requiring Airborne Precautions are identified and managed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following:

26. Isolation: Airborne precautions • Use of N-95 or higher particulate respirators • Available and near point of use • Signs indicating patient is on airborne precautions • Clear and visible • Patients on airborne isolation are housed in airborne isolation rooms • Hand hygiene before entering • And leaving • N-95 or higher particulate respirator to be worn when entering patient room for confirmed or suspected TB

27. Isolation: Airborne precautions • Facility limits movement of patients on airborne isolation to medically necessary purposes • Patient wears surgical mask per hospital policy • Hospital has means to communicate patient’s status

28. Surgical procedure tracer • Surgical procedures are performed in a manner consistent with hospital infection control policies and procedures to maximize the prevention of infection and communicable disease including the following:

29. Surgical procedure tracer • Surgical scrub before donning of sterile gloves for a surgical procedure in the OR • Use of either • Antimicrobial surgical scrub • FDA-approved alcohol-based antiseptic surgical hand rub • Visibly soiled hands should be washed with soap and water prior to the above procedures • After surgical scrub hands and arms are dried with a sterile towel and sterile surgical gown and gloves are donned in the OR

30. Surgical procedure tracer • Surgical attire • Scrubs • Surgical caps/hoods covering all head and facial hair • Worn by all personnel in semi restricted and restricted areas • Restricted areas include • OR • Procedure rooms • Clean core • Semi restricted areas include • Peripheral support areas of the surgical suite

31. Surgical procedure tracer • Masks • Properly tied and fully covering mouth and nose are worn by all personnel in restricted areas where open sterile supplies or scrubbed persons are located • Sterile drapes are used to establish the sterile field • Sterile field • Items in sterile field are sterile • Items introduced to the sterile field are opened, dispensed and transferred in a manner to maintain sterility • Established in a location where it will be used and as close as possible to the time of use • Movement around the sterile field is done in a manner to maintain sterility

32. Surgical procedure tracer • Traffic in and out of the OR is kept to a minimum and is limited to essential staff • Traffic Control Policies and Procedures • Surgical masks are removed when leaving the sterile areas and are not reused when returning

33. Surgical procedure tracer • Cleaners and disinfectants • Used according to hospital policy and procedure and manufacturer’s instructions

34. Surgical procedure tracer • Cleaning—start of the day • Horizontal surfaces • Damp dusted with a lint-free cloth and EPA-registered hospital detergent/disinfectant • High touch surfaces cleaned and disinfected between patients • Anesthesia equipment is cleaned and disinfected between patients • Reusable noncritical items (BP cuffs, etc.) are cleaned and disinfected between patients

35. Surgical procedure tracer • Terminal cleaning of Operating Rooms • After the last procedure of the day • Including weekends! • Includes • Wet-vacuuming or moping the floor with an EPA-registered disinfectant • All surfaces • Internal components of anesthesia machine breathing circuit are cleaned according to manufacturer’s instructions

36. Surgical procedure tracer • Ventilation requirements • Positive pressure, 15 air exchanges per hour—at least 3 of which are fresh air • 90% filtration • HEPA optional • Air filters are checked regularly and replaced according to hospital policies and procedures • Temperature and relative humidity are maintained at required levels • Doors are self-closing • Air vents and grill work are clean and dry

37. A Protective Environment (e.g. Bone Marrow patients) • Positive pressure—air flow out to the corridor from the room • 12 air exchanges per hour • Supply air is HEPA filtered • Well sealed rooms so that there are no penetration spaces in the walls, ceilings or windows • Self closing door that fully closes on all room exits • Failures are addressed and documented • Ventilation requirements are monitored using visual methods • “Kleenex test”; flutter strips, etc.

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