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Infection Control in the Hospital Setting
Vickie Brown, RN, MPH, CIC
Associate Director
Hospital Epidemiology
UNC Health Care
Hospital Epidemiology
Director William Rutala, PhD, MPHMedical Director David Weber, MD, MPHPublic Health Epidemiologist Emily Sickbert-Bennett, MS
Infection Preventionists Becky Brooks, RN, CIC Tina Adams, RN Brenda Featherstone, RN Lisa Teal, RN Kirk Huslage, RN, MPH
Location: 1st Floor, West Wing, Memorial HospitalOffice Hours: Monday – Friday 7:30 AM to 4 PMPhone: 966-1638
Infection Control Resources
Infection Control Policies on Hospital Intranet http://intranet.unchealthcare.org/hospitaldepartments/infection
/policies
Infection Control on call pager available 24/7: 216-6652
PURPOSES OF EPIDEMIOLOGY
To plan and evaluate interventions and prevention strategies more effectively by knowing: The distribution of disease Its determinants in person, place, and time
CHAIN OF INFECTION
Infection requires a “chain” of events The role of the hospital epidemiologist/infection control
is to understand this chain and the most efficient means of interrupting transmission
CHAIN OF INFECTION
Causative agent Susceptible host Reservoir Inoculating dose Portal of exit Portal of entry Environmental survival Mode of transmission
SOURCES OF PATHOGENS
People Endogenous: Normal flora or reactivation Exogenous: People (staff, visitors) or environment
Animals Arthropods (insects) Environment
Normal Skin Micro-FloraNormal Skin Micro-Flora
Numbers per square centimeter of skin surface (cfu/cm2).
Numbers of bacteria that colonize different parts of the body
ICU Setting: Multiple Sources of Pathogens
Basic Modes of Transmission
Contact-victim contact with source Direct-physical contact between source (e.g., MRSA on medical
student’s hands) and victim (patient medical student is examining) Indirect-victim contacts contaminated inanimate object (e.g.,
ultrasound probe contaminated with MRSA or VRE) Droplet-infectious droplets deposited on mucous membranes
of the nose or mouth Airborne-airborne phase in disease dissemination Vectorborne-not a significant source in US healthcare facilities
Isolation Precautions to Prevent the Transmission of Infections to Patients and Personnel
STANDARD PRECAUTIONS
Hand hygiene: Before and after each patient contact & after gloves removed
Gloves: When touching contaminated items (blood, body fluids, secretions, excretions). If it is wet and not yours, wear gloves!
Mask, eye protection, face shield: whenever splashes or sprays of body fluids possible
Gown: Whenever splashes or sprays of body fluids possible
Personal Protective Equipment (PPE) Gloves Gown Mask Eyewear
Wear your personal protective equipment correctly!
AIRBORNE PRECAUTIONS
Used for patients with known or suspected diseases transmitted by airborne droplet nuclei (<5 microns)
Private room Negative air pressure in relation to the corridor >6 air exchanges per hour Direct discharge of air to the outside
Personnel: Respiratory protection required N-95 respirator Limit transport of patient to essential purposes
AIRBORNE PRECAUTIONS
Representative pathogens M. tuberculosis Varicella Zoster Measles
HCWs required to wear arespirator to enter room
SPECIAL AIRBORNE PRECAUTIONS
Used for patients with known or suspected diseases transmitted by airborne droplet nuclei and contact
Private room (must meet airborne isolation guidelines) Personnel: Respiratory protection required
N-95 respirator Eye protection: Shield or goggles Gowns and gloves when entering room
Limit transport of patient to essential purposes
SPECIAL AIRBORNE PRECAUTIONS
Representative pathogens Avian influenza Monkey pox SARS Co-V Smallpox Viral hemorrhagic fever (e.g., Ebola,
Lassa)
DROPLET PRECAUTIONS
Used for diseases spreadvia large droplets (>5 microns)
Private roomSpecial air handling not required
PersonnelSurgical mask upon entering room
DROPLET PRECAUTIONS
Representative pathogens Invasive N. meningitidis RSV Bordetella pertussis Rubella Mumps Group A streptococcal pharyngitis Influenza
H1NI Precautions
CONTACT PRECAUTIONS
Used for pathogens thatcan easily be transmitted bycontact with patient and/or itemsin the patient’s environment Private room Gloves and gown when entering room Careful hand hygiene
Representative Pathogens
Methicillin-resistant S. aureus (MRSA) Vancomycin-resistant enterococcus (VRE) C. difficile Norovirus Multiply-drug resistant (MDR) gram negative rods
(e.g., B. cepacia, P. aeruginosa, Acinetobacter)All of the above organisms can survive on environmental surfaces for long periods of time and can be transiently carried on hands.
Bloodborne Pathogens
Blood Exposure Trends, 1999-2008
0
50
100
150
200
250
300
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Years
Num
ber o
f Exp
osur
es
Percutaneous/Lacerations Mucous Membrane/Non-Intact Skin Bite/Scratch
UNC Hospital Employees
BLOODBORNE PATHOGENSTRANSMITTED BY NEEDLESTICKS
Big 3 Hepatitis B Hepatitis C HIVOthers Argentinean VHF (Junín virus) Blastomycosis Brucellosis Corynebacterium diphtheria Cryptococcus Dengue Diphtheria
Ebola virus infection Herpes simplex I Leptospirosis Malaria Marburg VHF Mycobacterium marinum Mycoplasma caviae infection Rocky Mountain spotted fever Syphilis Toxoplasmosis Tuberculosis Varicella zoster West Nile
Tarantola A, et al. AJIC 2006;34:367-75
Campus Health
Blood/body fluid exposure reporting: 966-6561
After hours, weekends call Health Link: 966-2281
Additional Information: Exposure Control Plan for Bloodborne Pathogens; attachment 12: 55-58.
http://intranet.unchealthcare.org/hospitaldepartments/infection/policies/Ecpbbp.pdf
Other Communicable Diseases with Risk of Occupational Exposure
Tuberculosis Varicella zoster Pertussis Influenza Meningococcal Meningitis Parvo Virus-B19
UNC OHS EVALUATIONS, 2007-08
Disease 2007 Index Cases
2007Staff
Screened
2007 Infected
2008IndexCases
2008Staff
Screened
2008Infected
Tuberculosis 9 38 1 4 14 0Pertussis 4 11 0 5 19 0Varicella 1 0 0 0 0 0Zoster 3 0 0 0 0 0Syphilis 5 9 0 6 9 0N. meningitidis 1 49 0 3 16 0Hepatitis B 2 2 0 2 2 0Hepatitis C 27 27 0 39 39 1HIV 12 0 0 10 10 0All blood 269 269 0 314 314 1
Health Care Associated Infections
(HAIs)
Impact of HAIs
2002 data from CDC National Nosocomial Infections Surveillance Systems
Estimated number of HAIs: 1.7 million Estimated number of deaths associated with the HAI:98,987
Pneumonia: 35,967 Bloodstream: 30,665 Urinary tract: 13,088 Surgical site: 8,205 Other sites: 11,062
Klevens RM. Public Health Rep. 2007, 122(2):160-6
Economic Costs of HAIs
Overall annual direct medical costs range from $28.4 to $33.8 billion (adjusted to 2007 dollars).
Scott DR, CDC, March 2009
http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf
COST ESTIMATES FOR SPECIFIC HEALTHCARE-ASSOCIATED INFECTIONS
HAI type Weight-Adjusted Cost per HAIMean + SE
Range of Published Estimates of Cost per HAI
VAP 25,072 + 4,132 8,682-31,316BSI 23,242 + 5,184 6,908-37,260SSI 10,443 + 3,249 2,527-29,367CA-UTI 758 + 41 728-810
Anderson DJ, et al. ICHE 2007;28:767-773
(2005 dollars)
UNC HOSPITALSSELECTED HAIs AND ESTIMATED COST
HAI type UNC Cases, 2008 Estimated Cost
VAP 82 2,055,904
BSI 231 5,368,902
SSI 335 3,498,405
CA-UTI 339 256,962
Total 987 11,180,173
Total cost estimated by multiplying number of cases at UNC Hospitals bymean cost derived from Duke meta-analysis
What is the most effective and simplest method to protect your health and to help prevent HAIs?
UNC Hospitals Intensive Care Units: Hand Hygiene Compliance (%), 2003-2008
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1004
Q0
3
1Q
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% C
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Hand Hygiene: Methods
Soap and water Hand washing with antimicrobial soap (e.g.CHG) and water for 15
seconds Alcohol-based handrubs (e.g. Alcare) when…
Hands are not visibly soiled, or Hand washing facilities are not available in patient rooms
Use soap and water when… Patient known or suspected to have C. difficile disease or norovirus
infection (alcohol not effective against spores or nonenveloped viruses)
Indications for Handwashing and Hand Antisepsis
Before having direct contact with patients. Before donning sterile gloves for sterile/aseptic
procedures (e.g., central venous catheter placement) After glove removal After patient contact After contact with a contaminated instrument or
surface- Artificial nails and nail extenders are prohibited for direct patient care providers.
In Review
Infections can be transmitted in the hospital setting via contact, droplet, or airborne spread
Adherence to Isolation Precautions prevents transmission of disease to you and to other persons
Appropriate use of PPE and safe handling of sharp devices can reduce your risk of exposure to bloodborne pathogens
Hand hygiene reduces the risk of transmission of pathogenic organisms Questions related to infection prevention and control: contact Hospital
Epidemiology @ 6-1638 and after hours on pager 216-6652
Thank You!
“I don't see the glass as half-empty or half-full.I see it as a glass somebody else has already puttheir lousy germs on.”
Maxine
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