Inspect Medical/Dental Facilities

1. Inspect Medical/Dental Facilities EO 010.02

2. References • Public health and preventive medicine, 14th edition, Maxy-Roseneau-Last • Hand washing, cleaning, disinfection and sterilization in health care, Canada communicable disease report, Infection control guidelines December 1998 • Occupational safety health (policy and guidance Chapter 2-18)

3. References • Canadian Centre for Occupational Health and Safety (CCOHS), AIDS precautions embalming and morgues June 2000 • Preventive health manoeuvres during exhumation, FHP message unclass dcos FHP 011 section 1 of 2 • CDCP 2007-02 Immunization policy, medical directives 1-97 • Occupation exposure to blood-borne viruses, medical directives 2-97

4. Nosocomial Infections • Or also know as “hospital-acquired”, infections occur at a rate of 5 to 10 per 100 admissions in U.S. hospitals. • Estimated 30,000 patients die each year as a direct result of nosocomial bloodstream infection. • Furthermore, many nosocomial infections are associate with an extended length of stay, substantial morbidity, and prolonged therapy.

5. Descriptive epidemiology • An individuals risk of nosocomial infection is determined by the same three factors responsible for other types of infections: • The host • The agent • The environment

6. Descriptive epidemiology • First, intrinsic host susceptibility to infection is clearly important and is influenced by characteristics such as: (1) age, (2) nutritional status, (3) co morbidities; and (4) severity of underlying disease.

7. Descriptive epidemiology • Second, a variety of organisms are especially important nosocomial pathogens by virtue of intrinsic virulence. • Finally, hospital environment involves a variety of risks. Diagnostic procedures various medical devices, and surgical therapy may breach the normal host defenses and predispose to infections.

8. Descriptive epidemiology • hospital environment may be modified to prevent nosocomial infections by: (1) Proper use of isolation materials, (2) Strategies to increase hand washing, and (3) Other approaches to prevent transmission may be particularly beneficial.

9. Infection Categories • Virtually any infection that occurs in a community may be acquired within the hospital. • Certain sites of infection, however, are particularly common because of unique susceptibility and exposure of hospitalized patient.

10. Infection Categories • Pneumonia (47%) • Lower respiratory tract infection (18%) • Urinary tract infection (18%) • Blood stream infection (12%)

11. Infection categories • Urinary tract infections are the most common infections acquired in hospital, responsible for one-third of nosocomial infections. • Most Common 80% nosocomial UTI’s are related to the use of urinary catheters, with another 5 to 10% due to urinary tract manipulation.

12. Infection categories • Surgical Wound Infectionssecond most common hospital-acquired infections, accounting for 17% of nosocomial infections. • Infection rates vary with the level of contamination of operative site and disease comorbidity. • Comorbidity describes the effect of all other diseases an individual patient might have other than the primary disease of interest.

13. Infection categories • Lower Respiratory Tract Infections:are responsible for approximately 13% of nosocomial infections. • incidence of LRTI is approximately 6 per 1000 discharges in acute care hospitals. • Nosocomial LRTIs are the most common fatal nosocomial infection. • associated with a case fatality rate of 30% ranging from 20% to 50% in different series.

14. Infection categories • Blood stream infections: Perhaps the most frequent hospital-acquired infections. • Responsible for 14% of nosocomial infections. Rates of nosocomial bacteremia have ranged from 1.5 to 4 per 1000 admissions in most series, although higher rates have occasionally been reported.

15. Major Pathogens • Spectrum of microbial organisms causing nosocomial infections continues to evolve. • Gram‑positive organisms now represent top 3 nosocomial bloodstream pathogens: (1) Coagulase‑negative staphylococci, (2) Staphylococcus aureus, and • Enterococci. • Together they now account for approximately one half of nosocomial BSls

16. Major Pathogens • A variety of gram‑negative bacteria remain important causes of nosocomial BSI, UTI, LRTI and SWI. • The most common urinary tract pathogen is Escherichia Coli

17. Major Pathogens • Other bacteria have been recognized as important causes of nosocomial infection.

18. Major Pathogens • Legionella pneumophila is an ubiquitous aquatic organism that thrives in temperatures between 25 and 45 °C. • Some patients also have muscle aches, headache, tiredness, loss of appetite, loss of coordination (ataxia), and occasionally diarrhea and vomiting.

19. Major Pathogens • Fungi have emerged as major nosocomial pathogens, primarily as a result of increasing host susceptibility and therapeutic practices in recent years. • Chemotherapy and immunosuppressant predispose to a variety of microorganisms. • Additionally, widespread antibiotic use appears to reduce host's indigenous flora and predispose to colonization and infection.

20. Major Pathogens • Candida (yeast) species as a group have shown the most rapid growth and are now fourth most common cause of bloodstream infection. • Candida species are responsible for an increasingly large portion of nosocomial BSls and have an attributable mortality of 38%.

21. Major Pathogens • Viruses causing infection in immunocompromised hosts: • cytomegalovirus, (Cytomegalovirus, in humans it is commonly known as HCMV or Human Herpesvirus 5 (HHV-5)) • varicella‑zoster virus, and (3) herpes simplex viruses

22. Major Pathogens • Hepatitis viruses, particularly A and B and C, may be transmitted in hospital between pts and occasionally to health care workers. • Preventive measures, including use of hepatitis B vaccine, have been recently reviewed. Also in practice within Medical Service Staff.

23. Major Pathogens • (AIDS) virus is increasingly prevalent among hospitalized pts, and occasional transmission has occurred. • Routine use of universal precautions has been recommended to attempt to decrease the likelihood of exposure to potentially infectious blood and body fluids. • Measures designed to decrease the likelihood of exposure from contaminated sharp objects should be equally important in prevention of transmission. As discussed within Biomedical Waste Management.

24. PREVENTION AND CONTROL PROGRAMS: • During late 1960s the need for a more vigorous approach to prevention and control of nosocomial infections became apparent. • A model infection control program was adopted by many U.S hospitals in the 1970s and widely published by: • Centers for Disease Control (CDC) • American Hospital Association, and • Joint Commission on Accreditation of Health care Organizations

25. Components of effective programs Surveillance: • Typical surveillance is conducted by an infection control practitioner who actively seeks nosocomial infections by making regular, frequently visits to patients care areas. The practitioner may review patients care plan, microbiology lab results, medical charts. Radiographic reports, and lists of patients receiving antibiotics or isolation precautions. • Other technique such as questionnaire or surveys may be useful in the evaluation of specific problems or clusters of cases.

26. Components of effective programs • An infection program may include surveillance of patients infections, patients care practices, and microbial contamination of the environment. • Evaluation of the patient disease is the most important activity, because the incidence of nosocomial infection is the ultimate measure of program effectiveness. • Surveillance of patients illness should be conducted before patients are discharged.

27. Components of effective programs • Infections rate by: (1) Site (2) Pathogen (3) Speciality service (4) Patient care area Should be calculated at regular interval at least monthly. • Surveillance of patients care practices may also be useful, the infection control committee, is responsible for developing policies and procedures.

28. Components of effective programs Control measures: • Most preventable nosocomial infections are related to specific patient care practices. • The hospital should develop and implement policies for isolation of patients with potentially communicable diseases, use of antimicrobial agents, and control of the hospital environment.

29. Components of effective programs Infection Control Practitioner • The SENIC project, completed by CDC, demonstrated that the presence of at least one full-time infection control nurse (ICN) for every 250 hospitals beds significantly improved the effectiveness of infection control program. • The effectiveness of these programs decrease as the ratio of beds/ ICN increased.

30. Components of effective programs Hospital Epidemiologist • Responsible for the infection control program, • Provides advice about surveillance methods, analysis of surveillance data, method of conducting epidemiologic studies and development of control measures. • Plays a critical role in advising the hospital medical staff about clinical implication of patients care practices, infections problems, and prevention and control measures.

31. Components of effective programs Investigation of problems • The infection control committee is responsible for ensuring that problems are investigated effectively. • Usually these investigations are conducted by the hospitals infection control team, the infection control practitioner, and hospital infection epidemiologist. • Occasionally, outside assistance is required from local or provincial health department.

32. RESOURCES FOR NOSOCOMIAL INFECTION CONTROL • Joint Commission on Accreditation of Health care Organization (JCAHO) requires that accredited hospitals have: • an active infection control program, • an infection control committee, • as well as specific written infection control policies and procedures for each of hospital's departments.

33. RESOURCES FOR NOSOCOMIAL INFECTION CONTROL • JCAHO also requires written definitions of: • (1) nosocomial infections; • (2) a system for reporting of infections; • (3) laboratory support for infection control; • (4) an active employee health program; and • (5) review of antibiotic use. • American Hospital Association's (AHA) Committee on Infections within Hospitals has published guidelines for establishing infection control programs

34. To be continued on Monday

35. Hand washing and gloves General • Disease causing micro-organisms can frequently be isolated on the hands. Hand carriage of bacteria is an important route of transmission of infection between patients or from the health care worker to the patient. • Appropriate hand washing results in a reduced incidence. Guidelines from national and international infection prevention and control organizations have repeatedly acknowledged that hand washing is the single most important procedure for preventing infections of both nosocomial and community infections.

36. Microbiology of the skin • The finger nail area is associated with a major portion of the hand flora. The subungual areas (located under the fingernail) often harbour high numbers of microorganisms, which may serve as a source of continued shedding, especially under gloves. • The microbial flora of the skin consist of resident (colonizing) and transient (contaminating) microorganisms

37. Microbiology of the skin • The microbial flora of the skin consist of: • Resident (colonizing) microorganisms survive and multiply on the skin. Resident flora include the staphylococci. Resident skin microorganisms are not usually implicated in nosocomial infections, other than minor skin infections; however, some can cause infections after invasive procedures; and

38. Microbiology of the skin • The microbial flora of the skin consist of (cont): • The transient (contaminating)microbial flora represent recent contaminants of the hands acquired from colonized or infected patients/clients or contaminated environment or equipment. The most common transient flora include gram negative coliforms and Staphylococcus aureus. Hand washing with plain soap (detergents) is effective.

39. Soaps & antiseptic agents for hand washing • The purpose of hand washing is to remove soil, organic material and transient microorganisms from the skin. • Few clinical studies have defined the absolute indications for hand washing with plain soaps (detergents) versus hand antisepsis with antimicrobial products.

40. Soaps & antiseptic agents for hand washing • If an antiseptic product is used, it should be selected for its chemical composition, its type and spectrum of activity, its onset and duration of activity, the application for which it will be used, its cost, allergenic potential and acceptability to the users. • Antiseptic hand cleansers are designed to rapidly wash off the majority of the transient flora by their mechanical detergent effect and to exert an additional sustained antimicrobial activity on the resident hand flora

41. Soaps & antiseptic agents for hand washing

42. Recommendation on hand washing Hands must be washed: (1) between direct contact with individualpatients/residents/clients; (2) before performing invasive procedures; (3) before caring for patients in intensive care unitsand immunocompromised patients; (4) before preparing, handling, serving or eatingfood, and beforefeeding a patient;

43. Recommendation on hand washing Recommendations on Hand Washing (cont) (5) when hands are visibly soiled; (6) after situations or procedures in whichmicrobial or blood contamination of hands islikely; (7) after removing gloves ; and (8) after personal body functions, such as using thetoilet or blowing one’s nose;

44. Recommendation on hand washing • Hand washing should be encouraged whenever ahealth care provider is in doubt about the necessityfor doing so. • Between patient/resident/client contacts,hand washing may be indicated more than once inthe care of one person, for example after touchingexcretions or secretions and before going on toanother care activity for the same person. • Superficial contact with an object not suspected ofbeing contaminated, such as when touching orcollecting food trays, generally does not require handwashing.

45. Recommendation on hand washing • Hand washing facilities should be convenientlylocated throughout the health care setting. Theyshould be available in or adjacent to rooms wherehealth care procedures are performed. • Faucets with foot,wrist, or knee operated handles should be installedwherever possible; faucets with an electric eye arealso desirable. If automated faucets are not available,single-use towels should be supplied for user to turnoff faucets.

46. Recommendation on hand washing • Hands should be dried thoroughly with either asingle-use towel or electric air dryer. • Hand lotion may be used to prevent skin damagefrom frequent hand washing. • Compatibility between lotion and antiseptic productsand lotion’s potential effect on glove integrity shouldbe checked.

47. Recommendation on hand washing • Liquid hand wash products should be stored in closedcontainers and dispensed from either disposablecontainers or containers that are washed and driedthoroughly before refilling. • Hand washing with plain soap is indicated in routinehealth care and for washing hands soiled with dirt,blood or other organic material.

48. Recommendation on hand washing • Hand washing with an antiseptic agent is indicatedfor the following situations: • when there is heavy microbial soiling; • prior to performing invasive procedures; • before contact with patients who have immunedefects, damage to the integumentary ( skin) system; and • before and after direct contact with patientswho have antimicrobial-resistantorganisms.

49. Recommendation on hand washing • Hand washing with waterless/alcohol-based agents isequivalent to soap and water, and these agents shouldbe made available where access to water islimited. • If there is heavy microbial soiling,hands must first be washed with soap and water toremove visible soiling.

50. Recommendation on hand washing • Patients/clients/residents in settings where patienthygiene is poor should have their hands washed.Patients/residents should be helped to wash theirhands before meals, after going to the bathroom,before and after dialysis, and before leaving theirroom.