CPNE

®

Infection Control Study Module Effective November 2013

Contents Infection Control Practices/Asepsis Practices. . . . . 3 Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Medical Asepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Infection Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Standard Precautions (Tier 1). . . . . . . . . . . . . . . . . . . . . . . 4 Infection Control Methods . . . . . . . . . . . . . . . . . . . . . . . . . 5 Hand Hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Techniques for Hand Hygiene Utilizing Alcohol-Based Products.. . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Personal Protective Equipment (PPE) . . . . . . . . . . . . . . . . . 6 Transmission Based Precautions (Tier 2) . . . . . . . . . . . . . . . . 8 Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

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Excelsior College does not discriminate on the basis of age, color, religion, creed, disability, marital status, veteran status, national origin, race, gender, or sexual orientation in the educational programs and activities which it operates. Portions of this publication can be made available in a variety of formats upon request. The CPNE® is held at a location that is accessible to individuals with disabilities. If you will need auxiliary aids or services, please contact CPNE® Nurse Faculty at 518-464-8500 or toll free at 888-647-2388 (TDD: 518-464-8501). At the automated greeting, press 1-3-1-2 for information or assistance.

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Infection Control Practices/Asepsis Practices Purpose The purpose of this module is to educate the learner in the application of the basic principles of infection control and asepsis. The guidelines in this module were developed in accordance with recommendations published by the Centers for Disease Control and Prevention (CDC) and Healthcare Infection Control Practices Advisory Committee (HICPAC) which are followed nationwide to control and prevent the transmission of infection.

Introduction Administrators in health care facilities are required to ensure that health care providers know and consistently apply the principles of Standard Precautions for all patient care activities. This mandate includes Excelsior College nursing students who are providing care while taking the Clinical Performance in Nursing Examination (CPNE®). After reviewing and studying this content, you should be ready to apply the practices listed below. Please contact the Excelsior College Nursing Faculty if you have any questions at 888-647-2388. This module provides information about the following practices: Standard Precautions. Transmission-based precautions (Droplet, Airborne, and Contact) Hand hygiene practices Use of Personal Protective Equipment (PPE) When you feel confident in your ability to perform the expected Infection Control and Asepsis practices, you should electronically acknowledge this in the Clinical Performance in Nursing Examination application. Your acknowledgement signifies that you will apply the needed Infection Control practices during the CPNE®.

Overview The Centers for Disease Control and Prevention estimates that there are approximately 1.7 million new cases of infections acquired by patients during their stay in hospitals every year. “Approximately 99,000 of these cases result in death (although there may be other factors besides infection), making health care-associated infections (HAIs) one of the top ten causes of death in the United States. From a business perspective, this translates into a cost of approximately $4.5–$6.5 billion a year for hospitals to combat these infections” (The Joint Commission, 2013). Healthcare-associated infections (HAI) are defined by the World Health Organization as those that develop after 48 hours of hospitalization at a health care facility that were not present or incubating at the time of admission (Kelley & Monson, 2012). There are two tiers of precautions: standard and transmission based. Standard Precautions are used to reduce the risk of transmission of blood, body fluids, secretions, and excretions (except sweat) to non-intact skin and mucous membranes. The second type, transmission based, is used in addition to Standard Precautions when there is the possibility of infections being

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Infection Control Practices/Asepsis Practices spread by droplet, airborne, or contact transmission. It is further recommended that PPE (personal protective equipment) be used for this type of precaution (Taylor, LeMone, Lillis, & Lynn, 2011). It is the responsibility of the Registered Nurse to provide a biologically safe environment for patients and care providers. To do so, the RN must maintain the principles of asepsis to guide all nursing actions. Asepsis includes all activities to prevent infections or to break the chain of infection. There are two categories of asepsis: medical asepsis and surgical asepsis. “Medical asepsis, often called clean technique, includes procedures and practices that decrease the number and transfer of pathogens. Surgical asepsis or sterile technique involves practices used to render and keep objects and areas free from microorganisms” (Taylor et al., 2011, p. 661). For the purposes of this module, we will focus on medical asepsis.

Medical Asepsis Nursing actions include: Practice good hand hygiene techniques. Prevent all soiled items, including equipment and other used articles, from touching clothing. Items should be carried away from the body. Avoid placing soiled bed linens or any other items on the floor. Avoid having patients cough, sneeze, or breathe directly on others. Be sure to provide patients with disposable tissues, and instruct them to cover their nose and mouth to prevent spread of airborne droplets.

Infection Control Standard Precautions (Tier 1) Standard Precautions include a group of prevention practices that apply to all patients in any health care setting regardless of diagnosis or possible infection status. The intent of these precautions is to reduce the risk of transmission of both recognized and unrecognized sources of infection (Siegel, Rhinehart, Jackson, & Chiarello, 2007). Compliance with Standard Precautions is mandated and closely regulated by Occupational Safety and Health Administration (OSHA). These practices include: Performing hand hygiene Use of personal protective equipment (gowns, mask, gloves, and eye protection/ face shield) Avoidance of recapping needles Proper handling of used patient-care equipment Maintaining a clean environment Reviewing patient’s room assignments to prevent infecting other patients November 2013



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Using puncture proof containers for sharps Providing immunizations (Taylor et al., 2011)

Infection Control Methods Several infection control methods are used to decrease the risk of transmission of microorganisms in hospitals. These include:

Hand Hygiene Hand hygiene is the most effective way to help prevent the spread of infectious agents (Taylor et al., 2011). According to the CDC, hand hygiene refers to hand washing with plain soap and water, use of antiseptic hand rubs including alcohol-based products, or surgical antisepsis (CDC, 2011). Wearing gloves is not enough to prevent the transmission of pathogens in health care settings (CDC, 2012). Recommendations for hand washing with soap and water include: When hands are visibly soiled Before eating After using restrooms Prior to and after contact with each patient Before putting on sterile gloves Before performing any invasive procedures such as placement of a peripheral vascular catheter After accidental contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressing When moving from a contaminated body site to a clean body site during patient care After contact with inanimate object within the immediate vicinity of the patient (including medical equipment) After removing gloves If hands are not visibly soiled, the use of an alcohol based antiseptic agent may be utilized for routine hand decontamination in all other clinical situations. Gloves should always be worn when there is contact with blood, infectious material, mucous membranes, and non-intact skin. Additionally, natural nails should be kept to less than ¼ inch long and artificial fingernails or extenders must not be worn when having direct patient contact (Siegel et al., 2007). Handwashing Technique. To properly wash hands: Stand in front of sink and do not allow clothing to come in contact with sink Remove jewelry

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Infection Control Practices/Asepsis Practices Turn on water and adjust temperature and force Wet hands and wrists, keeping hands lower than elbows so water flows toward the fingertips Apply soap; lather covering all areas of hands with soap Firmly rub hands in circular motion, wash the palms and back of hands, each finger and the area between fingers, the wrist, and the forearm Wash at least 1 inch above the area of contamination or at least one inch above the wrist if hands are not visibly soiled Continue this friction motion for at least 15 seconds If necessary, use fingernails of opposite hand or orange stick to clean under fingernails. Rinse thoroughly with water flowing toward fingertips Pat hands dry with paper towel, beginning with the fingers and moving upward to toward the forearms. Use another clean paper towel to turn off faucet (Taylor et al., 2011).

Techniques for Hand Hygiene Utilizing Alcohol-Based Products To properly cleanse hands utilizing an alcohol based product, follow these steps (Taylor et al., 2011). Apply approximately 1–3 ml. of the product to the palm of one hand Rub hands together covering all surfaces, including between fingers and under nails Continue rubbing together until hands are completely dry Many hospitals have adopted the practice of only using soap and water hand washing in the presence of C. difficile. The CDC has not formally issued a recommendation on this practice. (Taylor et al., 2011).

Personal Protective Equipment (PPE) PPE is used to prevent the transmission of infection during patient care for all patients regardless of known or unknown infectious status. Several types of PPE are: Gloves Gloves provide a protective barrier when contact with a potentially infected substance is possible. Change gloves as needed when providing care or performing different procedures for the same patient. Wear gloves for any care that may involve contact with patient’s blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes. Wear gloves for all vascular access procedures such as finger sticks, changing IV dressings, removing IV lines, and administering IV push medication. Wearing gloves does not replace the need for hand-washing. Gloves may have small defects or may become torn during use. Hands can become contaminated during removal of gloves. Remove gloves promptly after use and wash hands immediately (Siegel et al., 2007). November 2013



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Masks, Eye Protection and/or a Face Shield These are used to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions (Taylor et al., 2011). Gowns Gowns should be worn to protect the skin and to prevent soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. The following nursing actions should be taken: Select a gown that is appropriate for the activity and amount of fluid likely to be encountered Remove a soiled gown as promptly as possible Wash hands to avoid transfer of microorganisms to other patients or environments (Taylor et al., 2011) Mouthpieces or other Ventilation Devices Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouthmouth resuscitation methods (Taylor et al., 2011). Contaminated Needles and Sharps Contaminated needles and other contaminated sharps must not be bent, recapped, or removed. Place used syringes and needles, scalpel blades, or other sharps in designated puncture–resistant sharps containers (Taylor et al., 2011). If a designated puncture-resistant sharps container is not readily available, recapping of the needle may be performed using the one-handed scoop method. The syringe and needle must be disposed of in a designated puncture-resistant sharps container as soon as is feasibly possible. Specimen Handling and Transport Standard Precautions must be used to obtain, transport and handle all specimens and in accordance with hospital policy (Taylor et al., 2011). Contaminated Equipment Use Personal Protective Equipment (PPE) to handle used equipment that is soiled with blood, body fluids, secretions, and excretions to prevent: Exposures to skin and mucous membrane Contamination of clothing Transfer of microorganisms to other patients and environments Nursing actions will ensure that: Reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed. Single-use items are properly discarded (Taylor et al., 2011).

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Infection Control Practices/Asepsis Practices Contaminated Laundry Contaminated laundry is placed in a bag and handled in a way that avoids transfer of microorganisms to other patients, staff, and the environment. Linen that is wet with blood or body secretions must be placed in a leak proof bag (Taylor et al., 2011). Blood/Body Fluid Spills Always use gloves when cleaning up a blood/body fluid spill. Follow the hospital’s policy on cleaning up a blood or body fluid spill (Taylor et al., 2011). Treatment of Exposure Incidents Incidents that result in injury or contamination of a care provider must be reported and treated immediately. Follow the hospital’s protocols for treating and reporting these incidents. Every facility is required to have a plan for documenting, tracking and treating these occurrences (Siegel et al., 2007).

Transmission Based Precautions (Tier 2) Transmission based precautions are used in addition to Standard Precautions for hospitalized patients who are suspected to have an infection that can be transmitted by airborne, droplet, or contact routes. These precautions can be utilized alone or in combination with the others. Airborne Precautions Airborne precautions are used for patients who have infections that are spread through the air, such as tuberculosis, varicella (chicken pox), and measles. Principles include: The patient will be in a private room that has monitored negative pressure. Anyone entering the room must always follow standard precautions and must wear a fitted N95 respirator (Siegel et al., 2007). Wear a N95 or higher respirator for potential exposure to infectious agents transmitted via the airborne route. N95 respirators/masks should not be shared, because they may become contaminated with germs that can be spread between people (FDA, 2013). All health care personnel that use N95 or higher respirators/masks are required to be fit tested annually according to OSHA requirements (CDC, 2011). N95 respirators/masks are devices that may help prevent the spread of viruses and bacteria from one person to another. They are one part of an infection-control strategy that should also include frequent hand washing and social distancing.

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All persons with signs and symptoms of a respiratory infection are instructed to: Cover the mouth and nose with a tissue when coughing or sneezing Dispose of the used tissue in the nearest waste receptacle Perform hand hygiene after contact with respiratory secretions and contaminated objects/materials (CDC, 2011) Droplet Precautions Droplet precautions are used for patients with an infection spread by large droplets such as rubella, mumps, diphtheria, and adenovirus in infants and children. This involves contact of the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with large particle droplets containing microorganisms. Droplets are usually generated through coughing, sneezing, or talking. The patient should be in a private room. All staff must wear a mask when working within three feet of the patient. Masks are not necessary for health care workers transporting such patients as long as the patient is wearing a mask (Taylor et al., 2011). Health care personnel observe droplet precautions in addition to Standard Precautions, when examining and caring for patients with signs and symptoms of a respiratory infection spread by airborne route. These precautions are maintained until it is determined that the cause of the symptoms is not an infectious agent that requires droplet or airborne precautions. Health care personnel with a respiratory infection should avoid direct patient contact; if this is not possible, a face mask should be worn while providing patient care. Frequent hand hygiene should be reinforced. (CDC, 2011). Contact Precautions Contact precautions are used for patients who are infected with a microorganism that spreads by direct or indirect contact such as Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant Staphylococcus aureus (VRE) and Vancomycin-intermediate Staphylococcus aureus (VISA) (Taylor et al., 2011). A new organism Carbapenem-resistant Enterobacteriaceae (CRE) has been identified by the CDC as a growing problem in health care facilities (CDC, 2012). Direct contact involves skin to skin contact. Indirect contact involves the host contaminating an inanimate object in the patient’s environment. The patient may be in a private room and gloves as well as a gown should be worn while providing care (Taylor et al., 2011).

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Infection Control Practices/Asepsis Practices Immunizations Health care workers have the potential for exposure to patients and/or to infectious materials including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces, or contaminated air (CDC, 2011). Due to patient contact of infective material from patients, many health care personnel are at risk for exposure to (and possible transmission of) vaccine-preventable diseases. Health care personnel must be up-to-date with all recommended vaccinations, including an annual influenza vaccine (CDC, 2011). The Immunization Action Coalition (2012) recommends that all health care workers be immunized for: Hepatitis B Influenza Measles/Mumps/Rubella (MMR) Varicella Tetanus Diphtheria Pertussis Meningococcal Meningitis Required immunizations for CPNE® are based on the CDC “Recommended Vaccines for Healthcare Workers” which can be viewed on the CDC website at www.cdc.gov/vaccines /adults/rec-vac/hcw.html

Summary The best assurance for prevention of illness caused by blood borne pathogens is education related to the mode of transmission, careful practice, the use of Standard Precautions and adherence to the recommendations of the CDC regarding vaccination.

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References Centers for Disease Control and Prevention (2012). CRE Toolkit—Guidance for control of Carbapenem-resistant Enterobacteriaceae (CRE). Retrieved March 11, 2013 from: http:// www.cdc.gov/hai/organisms/cre/cre-toolkit/ Centers for Disease Control and Prevention (2011). Hand hygiene in healthcare settings. Retrieved Feb. 27, 2013 from: http://www.cdc.gov/handhygiene/ Centers for Disease Control and Prevention (2011). Morbidity and mortality weekly report, Immunization of health care personnel, from: Recommendations of the Advisory Committee on Immunization practices. Retrieved Feb.27, 2013 from: http://www.cdc.gov/ mmwr/pdf/rr/rr6007.pdf Centers for Disease Control and Prevention (2011). National Healthcare Safety Network (NHSN Reports) Retrieved March 4, 2013 from: http://www.cdc.gov/nhsn/dataStat.html Food and Drug Administration (2013). In medical devices, masks and N95 respirators. Retrieved March 4, 2013 from: http://www.fda.gov/MedicalDevices/ ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/ PersonalProtectiveEquipment/ucm055977.htm#1 Immunization Action Coalition (2012). Healthcare personnel vaccination recommendations. Retrieved Feb. 27, 2013 from: http://www.immunize.org/catg.d/p2017.pdf Kelly, K & Monson, J. (2012). Hospital acquired infections. Surgery Oxford,30.12.,640–644. Retrieved March 1, 2013 from: http://dx.doi.org.vlib.excelsior.edu/10.1016/j. mpsur.2012.10.005 Siegel, J., Rhinehart, E., Jackson., Chiarello, L. (2007). Guidelines for isolation precautions: Preventingtransmission of infectious agents in healthcare settings. Retrieved March 4, 2013 from: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf Taylor, C., Lillis, C., Lemone, P., & Lynn, P. (2011). Fundamentals of nursing, The art and science of nursing Care 7th edition pp. 652–682. Philadelphia, PA: Lippincott, Williams & Wilkins. The Joint Commission (2013). New tool in the fight against health care–associated infections: Compendium of strategies to prevent healthcare–associated infections in acute care hospitals. Retrieved Feb. 28, 2013 from: http://www.jcrinc.com/New-Tool-in-the-FightAgainst-Health-Care-Associated-Infections/

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