Infection Prevention &
Control Training Program
Islamabad Pakistan
Standard And Expanded Precautions
Muhammad Yaseen RN, BSN, MSc, CIC, PhD Scholar
Objectives
•
At the end of this session attendees should be able
to:
1.
2.
3.
4.
Describe when to use Standard Precautions
List 5 Moment for Hand Hygiene
List 3 isolation categories
List 2 methods of asepsis
2
DEFINITIONS
Healthcare-Associated Infection
Infection associated with healthcare delivery in any setting
Hospital-associated or Nosocomial Infection
Acquired in hospital after 48 hours of admission (not
incubating nor present on admission)
Community Acquired Infection
Infection that is present or incubating on admission to hospital
that can be traced to a community source
3
The Chain of Infection
Transmission can occur when the six elements
forming the Chain of Infection are present:
1.
2.
3.
4.
5.
6.
An Infectious Agent
Reservoir (or source) of Infectious Agent
Portal of Exit
Means of Transmission
Portal of Entry
Susceptible Host
(Siegel et al. 2017)
Figure M5–1 Breaking any link in the chain of infection will help prevent the
spread of microorganisms (adapted from Siegel et al. 2017)
The Chain of Infection
• An Infectious Agent is an organism that causes disease such as
bacteria, viruses, fungi, protozoa, parasites, and prions.
• A Reservoir is a place where an infectious agent lives and grows
(e.g., the normal flora in gastrointestinal and upper respiratory tract).
There are two sources of infection:
The Chain of Infection
• A Portal of Exit is the way in which an infectious agent exits the source reservoir
to infect a secondary source.
• The Means of Transmission is how the infectious agent travels from the infected
person to another person. The principle means of transmission are: contact
(indirect and direct), droplet, and airborne. The means of transmission varies by
type of infectious agent and some may be transmitted by more than
The Chain of Infection
• The Portal of Entry is any opening on the body that allows the
infectious agent to enter, such as the nose, mouth, eyes, mucous
membranes, a surgical or nonsurgical break in the skin, or medical
devices such as urethral catheters that bypass the body’s natural
defenses.
• A Susceptible Host is a non-infected person who could get
infected. The factors that influence who gets infected and how
severe the infection is, are related to the virulence of the
infectious agent and host factors such as extremes of age,
underlying disease and treatment for complex diseases,
immunosuppression, and recipients of organ and tissue
transplants (APIC 2014; Siegel et al. 2017; GCC 2013).
Modes of Transmission
Mechanism for the transfer of an infectious agent from a
reservoir to a susceptible host:
Contact Transmission
Direct and Indirect
Droplet Transmission
Airborne Transmission
10
Direct Contact Transmission
Organisms are transferred directly from one person to another
e.g.
Blood borne viruses, Hep B&C and HIV transmitted under limited
circumstances via percutaneous or mucous membrane exposure
Herpes Simples Virus (HSV) is transmitted to patient from HCW (mouth
care)
11
Indirect Contact Transmission
Involves transfer of an infectious agent through a contaminated
intermediate object or person
Hands of HCWs most important contributors
Contaminated patient surroundings
Contaminated or improperly handled patient-care sterile
supplies, equipment, and devices (vascular lines, gloves,
catheters, bandages, etc)
Inadequately reprocessed instruments (endoscopes,
bronchoscopes, surgical instruments)
12
Droplet Transmission
 Respiratory droplets are generated by an infected person
coughing, sneezing or talking. Droplets are propelled short
distance
 Transmission occurs when droplets are deposited on
conjunctivae, nasal mucosa or mouth
Can also occur:
During procedures (suctioning, cough induction, chest
physiotherapy, etc)
Microorganisms transmitted by this route are Neisseria
meningitis, influenza virus
13
Airborne Transmission
Airborne droplet nuclei containing very small infectious agents are generated when
an infected person coughs, sneezes or talks.
These tiny droplets are dispersed into the air and stay suspended in the air or move
around on the air currents.
Transmission is inhalation by susceptible person(s)
Can also occur:
During procedures such as suctioning, cough induction, extubation, or
bronchoscopy
Organisms transmitted by this route:
Pulmonary MTB, Rubeola virus (measles), Varicella-zoster virus (chicken pox)
Dangerous and exotic pathogens: SARS, Monkey pox viral hemorrhagic fever
viruses
14
Standard Precautions
Foundation for preventing transmission of infectious agents during
healthcare woker-patients interactions
Work practices required for the basic level of infection control
To reduce the risk of transmission of infectious agents
Apply to all body fluids, non-intact skin and mucous membranes
To be used for all patient care regardless of diagnosis or presumed
infectious status
15
BREAKING THE CHAIN OF INFECTION- REDUCING THE RISK OF
TRANSMISSION
• Standard Precautions
• Hand Hygiene
• PPE
• Expanded Precautions
• Aseptic Technique
• Other recommendations
16
HAND HYGIENE
• Hands can become contaminated with infectious
microorganisms, which could enter the body and cause
infection.
• Hand hygiene is the single most effective means of preventing
transmission of infectious microorganisms.
17
Indications for hand hygiene
• Hand hygiene must be performed exactly where you are delivering
health care to patients (at the point of care)
• During health-care delivery, there are 5 moments when it is essential
that you perform hand hygiene
• You must perform hand hygiene using the appropriate technique and
time duration
18
When to Decontaminate Hands?
Sandwich Test
20
YOUR 5 MOMENTS FOR HAND HYGIENE
Clean your hands immediately
before an aseptic task!
Clean your hands
before touching a
patient-when
approaching him/her!
To protect the patient against
harmful germs, including the
patient’s own, entering
his/her body!
To protect the patient
against harmful germs
carried on your hands!
Clean your hands immediately
after an exposure risk to body
fluids (and after glove
removal)!
To protect yourself and the
health-care environment from
harmful germs!
Clean your hands after
touching a patient and his/her
immediate surroundings,
when leaving the patient’s
side!
To protect yourself and the
health-care environment from
harmful germs!
Clean your hands after touching any
object or furniture in the patient’s
immediate surroundings, when leavingeven if the patient has not been
touched!
To protect yourself and the health-care
environment from harmful germs!
21
Can you identify the main examples of this
indication during your everyday practice of
health care?
Some examples may be:
• shaking hands, stroking an
arm
• helping a patient to move
around, get washed, giving a
massage
• taking pulse, blood pressure,
chest auscultation,
abdominal palpation
Can you identify the main examples of this
indication during your everyday practice of
health care?
Some examples may be:
• oral/dental care, giving eye
drops, secretion aspiration
• skin lesion care, wound
dressing, subcutaneous
injection
• catheter insertion, opening a
vascular access system or a
draining system
• preparation of food,
medication, dressing sets
Can you identify the main examples of this
indication during your everyday practice of
health care?
Some examples may be:
• oral/dental care, giving eye
drops, secretion aspiration
• skin lesion care, wound
dressing, subcutaneous injection
• drawing and manipulating any
fluid sample, opening a draining
system, endotracheal tube
insertion and removal
• clearing up urines, faeces,
vomit, handling waste
(bandages, napkin, incontinence
pads), cleaning of contaminated
and visibly soiled material or
areas (lavatories, medical
instruments)
Can you identify the main examples of this
indication during your everyday practice of
health care?
Some examples may be:
• shaking hands, stroking an
arm
• helping a patient to move
around, get washed, giving a
massage
• taking pulse, blood pressure,
chest auscultation,
abdominal palpation
Can you identify the main examples of this
indication during your everyday practice of
health care?
Some examples may be:
• changing bed linen
• perfusion speed adjustment
• monitoring alarm
• holding a bed rail
• clearing the bedside table
Why perform hand hygiene?
• To remove/reduce the number of microorganisms on the
hands
• To reduce the risk of transmission of infection to
patients and personnel
• To reduce the contamination of the environmental
surfaces
27
Methods of Hand Hygiene
Hand washing
a process for removal of soil and transient microorganisms from the
hands
Using regular or antiseptic soaps
Hand Antisepsis
a process for removal or destruction of transient microorganisms
Using antiseptic, waterless/alcohol base rub
Hand scrub
a process to remove or destroy transient microorganisms and reduce
resident bacterial flora from the hands
Using antiseptic soap/alcohol solution with extended antimicrobial
effect
28
 To effectively reduce
the growth of germs
on hands
 Handwashing
must last 40-60 secs
and should be
performed by
following all steps
illustrated on the left
29
 To be used on
visibly clean hands
 To effectively
reduce the growth of
germs on hands
 Hand rubbing must
be performed by
following all steps
illustrated on the left.
 This takes only
20-30 seconds
30
Hand Hygiene and glove use
Gloves and Hand Hygiene = clean hands
Gloves with no Hand Hygiene = Germ transmission
31
HAND CARE
• If you have any existing skin problems or develop skin
breakdown following repeated hand hygiene, you must
seek medical assistance
• Any concerns with latex allergy must seek medical
assistance
32
Hand Lotions / Moisturisers
• Prevent dehydration and damage to barrier properties of
skin, skin shedding, loss of skin lipids
• Use regularly if washing hands
• Use individual tube or pump dispenser to prevent
contamination
Products used for hand Hygiene
• Soap and water
• Antimicrobial soaps
• Alcohol hand rubs
• Hand Lotions / Moisturisers
Which Product When?
 Risk assess:




What are you about to do?
What have you just done?
Are your hands visibly soiled?
Is this a high risk procedure or a vulnerable
patient?
Soap and Water
• Mechanical removal of soil and contaminants
• Minimal microbial kill
• No sustained activity
• Suitable for most clinical activities
• Removes 99% of transient organisms
Antimicrobial Soaps
• Reduce resident and transient organisms
• May have sustained activity
• Use only when higher level of kill required
• i.e. when skin contaminated or sterile gloves to be
worn
• Surgical scrubbing
• Kills and removes 99.9% of transient organisms
Alcohol Handrubs
• Very rapid kill
• No residual effect
• Contain emollients
• Use on visibly clean hands only
• Emollients residue can build up over time
• Wash hands when sticky
• Useful where facilities not available or time short
• Kills 99.99% of transient organisms
Alcohol Handrubs
There are some special considerations while using Alcohol
Handrubs that include:
• Alcohol handrub dispensers should be away from electric sockets
• The bottles should be stored in metal cupboards
• The use of alcohol handrub should be discouraged while looking
after patients with infections with spore forming bacteria
especially Clostridium difficille related diarrhea.
UK Department of Health (2005)
Are Alcohol-Based Hand Rubs Really Effective?
• Numerous published studies have shown that alcohol-based
hand rubs remove bacteria from hands more effectively than
washing hands with plain soap and water
• In most studies, alcohol-based hand rubs removed bacteria from
the hands to a greater degree than did washing hands with an
antimicrobial soap and water
• It can be used at the point of care
Boyce JM, Pittet D et al. MMWR 2002;51 (RR-16):1-45
Definition of Point of Care
Point of care - refers to the place where three elements
occur together: the patient, the health-care worker, and
care or treatment involving patient contact.
Application time of hand hygiene (handwashing and
handrubbing) and reduction of bacterial
contamination
Hand hygiene
with:
Handwashing
Handrubbing
Pittet and Boyce, Lancet Infectious Diseases 2001
More Tips on How to Use an AlcoholBased Hand Rub
• If you feel a “build-up” of emollients on your
hands after cleaning your hands 5 to 10 times
with an alcohol-based hand rub, wash your
hands with soap and water
• If you clean your hands with an alcohol-based
hand rub before putting on gloves, make sure
the alcohol has dried completely before
putting on gloves
Won’t Frequent Use of Alcohol Dry Out
My Skin?
• Several studies have proven that nurses who routinely cleaned their
hands between patients by using an alcohol-based hand rub had
less skin irritation and dryness than nurses who washed their hands
with soap and water
• Alcohol-based hand rubs contain skin conditioners (emollients) that
help prevent the drying effects of alcohol
Boyce JM et al. Infect Control Hosp Epidemiol 2000;21:442
Winnefeld M et al. Br J Dermatol 2000;143:546
BREAKING THE CHAIN OF INFECTION REDUCING THE RISK OF
TRANSMISSION
• Standard Precautions
• Hand Hygiene
• PPE
• Expanded Precautions
• Aseptic Technique
• Other recommendations
47
PRESONAL PROTECTIVE EQUIPMENT
• PPEs should be worn when exposure to body fluids is likely.
• PPE is used to create a barrier between HCW and patient,
substance, or surface.
• The use of one or more of these is based on the degree and
risk of exposure anticipated.
• These include the use of gloves, gowns, plastic aprons, eye
protection and resuscitation devices.
48
GLOVES
• Gloves are used as a barrier
• Gloves are for single patient use only
• Perform hand hygiene before wearing gloves
• Wear gloves when handling:
• Blood and other body fluids
• Mucous membranes
• Non-intact skin
• Contaminated surfaces and items
• Select gloves for the particular task to be undertaken, i.e.
sterile/unsterile procedures
49
GLOVES
• Change gloves when they become contaminated:
• Between patients
• Between procedures
• Between different procedures on the same patient
• Gloves are to be worn at the bedside
• Do not leave patient room with gloves on
• Remove and discard gloves promptly:
• After use before leaving the area of activity
• Before touching environmental surfaces
• Wash hands immediately
50
GOWN/PLASTIC APRON
• Gown/plastic apron (clean/non-sterile)
• Wear during procedures and patient-care activities that are
likely to generate splashes or sprays of body fluids
• Worn to protect bare skin
• To prevent soiling of clothing
51
GOWN/PLASTIC APRON
• Select a gown/plastic apron that is appropriate for the
activity and the amount of fluid likely to be
encountered.
• Secure the strings to keep the gown or apron in place
• Remove soiled gown/plastic apron promptly and
wash hands to prevent transfer of microorganisms to
other patients and environmental surfaces.
• Untie strings and fold away from you in an inside out
manner to prevent transfer of microorganisms to
yourself
52
MASKS
• Wear a surgical mask to prevent exposure of the mucous membranes of
your mouth and nose during procedures that are likely to generate
aerosol droplets or splashes of blood or other body fluids.
• Wear an N95 Respirator mask to enter the room of any patient room in
Airborne Isolation (unless it is known that you have immunity to that
disease, e.g. Chickenpox).
53
MASKS
• Wear the mask to fully cover the nose and mouth
so that you are breathing through it.
• Discard surgical mask before leaving the area of
activity.
• N95 respirator mask must be removed outside of
the patients’ room.
54
PROTECTIVE EYEWEAR
• Wear protective eyewear such as glasses,
goggles or shields to protect your eyes, and in
conjunction with a mask to protect your face,
during procedures where splashes of blood or
body fluid are likely to occur.
• Ensure that protective eyewear is readily
available anywhere there is a risk of splashes
of body fluid e.g. ER, Endoscopy, O.R, ICU, L&D,
cardiac arrest carts.
55
PPE use in non-patient care areas
• The concepts of who, when, and how to wear PPEs
are the same in non-patient care areas
• Applies to areas where patients receive diagnostic
testing and specimen are processed
• Medical imaging
• Laboratory
• Physiotherapy, etc
56
Putting PPEs on safely
Put on in this order:
1. Hand hygiene
2. Mask, goggles or face shield
3. Gown
4. Gloves
57
Removing PPEs safely
Remove in this order:
1. Gloves
2. Wash or cleanse hands
3. Mask, face shield or goggles (not N95 respirator)
4. Gown
5. Cleanse hands
 N95 respirator is remove when outside of the Airborne
Isolation room
58
BREAKING THE CHAIN OF INFECTION REDUCING THE RISK OF
TRANSMISSION
• Standard Precautions
• Hand Hygiene
• PPE
• Expanded Precautions
• Aseptic Technique
• Other recommendations
59
EXPANDED PRECAUTIONS
Transmission Based Precautions
Isolation Precautions
EXPANDED PRECAUTIONS
• Used when infectious status of patient is known or suspected with
epidemiologically significant organism (e.g. highly transmissible, difficult to
treat)
• Determined by the modes of transmission of the infecting agent
• 3 Categories of precautions (Isolation)
1.Contact
2.Airborne
3.Droplet
61
Contact Isolation
• Contact isolation is designed to interrupt transmission of
infection transmitted by contact route.
• Must be used in conjunction with Standard Precautions.
• Requires a single room
• Used for patients known or suspected to be infected or
colonized with resistant, epidemiologically important or
highly transmissible pathogens (MRSA, VRE, RSV, etc.)
62
Droplet Isolation
• To prevent transmission of infectious agents, spread by droplet
contact route to mucous membranes, conjunctiva, nose and mouth
• Must be used in conjunction with Standard Precautions
• Droplets generated by coughing, sneezing and suctioning
• Requires close contact (patient surroundings) for transmission
Pertussis
Mumps
Influenza
Rubella Invasive
Neisseria meningitidis
63
Airborne Isolation
• To prevent transmission of organisms spread by airborne
route that remain suspended in the air
• Must be used in conjunction with Standard Precautions
• Requires a single room with negative pressure ventilation
• Used for patients known or suspected to be infected with
Measles Varicella Pulmonary Tuberculosis
64
When to isolate?
•
Type and duration of precautions (Contact, droplet, or
airborne isolation) needed for selected microorganisms
and diseases
1. For the duration of hospital stay
2. For the duration of illness
3. For time specified in hours or days of antimicrobial
therapy
4. Until lesions are crusted
5. Until there are negative culture or cultures
1.
2.
Guidelines from Association for Professionals in Infection Control and Epidemiology 2009 (APIC) 3 rd Edition
(HICPAC 2007)
65
When to isolate and how long?
•
Patients that are:
A. RSV (+)?
B. Chickenpox?
C. Query Neisseria meningitis?
D. Query or rule out pulmonary tuberculosis?
66
When to discontinue isolation?
A. Isolate patient for duration of illness:
1. RSV: Contact Isolation and Standard Precautions
• For the duration of illness (2-5days)
2. Chickenpox: Airborne and Contact Isolation and Standard
Precautions
• Until lesions are crusted/dried (usually 5 days)
• Infection Control Practitioner should review patient status before
removing patient from isolation.
• Signs and symptoms (subsided respiratory illness or no new
lesion eruption)
• In these cases (re)screening is not necessary
67
B. Isolate patient for time specified in hours or days of
antimicrobial therapy
1. Neisseria meningitidis: Droplet Isolation and SP
• Only discontinue droplet isolation after completion of 24
hours of effective antibacterial therapy
• Infection Control Practitioner should review patient
status before removing patient from isolation.
68
When to discontinue isolation?
C. Isolate patient until there are negative culture(s)
1. Query (R/O) pulmonary Tuberculosis: Airborne Isolation and SP
• Discontinue isolation:
 If another diagnosis is made that explains the clinical syndrome
or review of patient shows TB infection is negligible
 OR
 3 negative AFB stain are required
• obtained on 8-24 hours
• one must be morning specimen
69
2. Patient in Airborne Isolation for (+)AFB sputum smear
(pulmonary Tuberculosis)
• Discontinue isolation:
• After patient receive ≥14 days of effective anti-TB therapy
• AND 3 negative AFB stain
• obtained on 8-24 hours
• one must be morning specimen
• Infection Control Practitioner should review patient
status/results before removing patient from isolation.
OTHER RECOMMENDATIONS
OTHER RECOMMENDED PRACTICES TO FURTHER REDUCE THE RISK OF
TRANSMISSION OF INFECTION IN HEALTHCARE SETTING
New Standard Precautions
• Respiratory Hygiene/Cough Etiquette was added in 2004 for the
purpose of source containment of respiratory tract pathogens
(e.g., severe acute respiratory syndrome (SARS) variant Co-V,
avian influenza H5N1, human influenza.
• Procedure:
• Use tissues cover the nose and mouth when coughing or
sneezing to contain respiratory secretions
• Dispose them in the nearest waste disposal then perform
hand hygiene.
72
RESUSCITATION DEVICES
• Avoid the need for emergency mouth-to-mouth resuscitation by
using mouthpieces, resuscitation bags or other ventilation
devices.
• Ensure that this is available in your work area and any area
where the need for resuscitation is predictable.
• Know where and how to use the equipment.
73
HANDLING CONTAMINATED ITEMS
• Proper and safe handling of the following items in the patient care
areas is crucial to reduce the risk of exposure to and transmission of
infectious microorganisms
• Needles and Sharps
• Linen
• Medical waste
• Patient care equipment
• Laboratory specimen
74
AVOIDING INJURIES
•
•
•
•
YOU USE IT YOU DISPOSE OF IT
DO NOT discard needles/sharps in the garbage or linen bag
DO NOT leave used needles/sharps unattended on open surfaces
DO NOT overfill sharps containers
• Containers must be replaces when it is at the full-line
• DO NOT recap used needle
75
LINEN
• Handle soiled linen in a manner that prevents skin and mucous
membrane exposures, contamination of clothing, and transfer
of microorganisms to other patients and the environment.
• Wrap soaked linen so that the heavily soiled area is in the
middle and immediately after removing from the patient’s
bed.
76
CONT’D
• Do not overfill laundry bags - remove from the laundry
hamper when bag 2/3 full and securely tie the mouth.
• Do not put soiled linen on the floor. Avoid repeated handling,
to minimize agitation that will cause contamination of the air.
• Wash hand after handling soiled linen.
77
WASTE MANAGEMENT
Medical waste is those items soaked with blood stained
fluid, which are judged to have a relative risk of disease
transmission and therefore special handling is indicated
for their disposal.
78
Medical waste include
• Sharps/Needles and syringes
• Fluid filled disposable suction devices/canisters that cannot be emptied
• Blood soaked items from any area
• Dialyzersdialysis bags and lines
• Large volume urine/stool collections
• Laboratory specimens and their disposable containers
• Body part (human and animals)
• Disposable patient care items (heavily soiled with blood)
79
Cont’d
• Dispose of infectious waste in the appropriate containers.
• Ensure that garbage containers are lined with color-coded
bags to effect proper disposal.
• Wear the appropriate protective apparel when handling
medical waste.
• Wash hands after handling medical waste and containers.
80
SUMMARY
• Standard Precautions must be used for all patient care
regardless of their known or suspected infectious status.
• Standard Precautions is designed to reduce the risk of
exposure to potentially infectious microorganisms in body
fluids.
• Applied universally, it will improve the standard of care for
all patients rather than focusing special attention on the
few patients with identified infections/infectious diseases.
81
THANK YOU