IPC FOR PHCU M Approved June 2022
IPC FOR PHCU M Approved June 2022
Table of Contents
ii
6.3. Commonly used disinfectants and their properties .................................................................. 72
6.4. STEPS OF MEDICAL INSTRUMENTS AND OTHER ITEMS REPROCESSING ..................... 75
6.5. Monitoring, Safe Storage of Sterile/ HLD Instrument ............................................................... 85
6.6. Shelf Life ................................................................................................................................ 88
6.7. Summary ............................................................................................................................... 88
CHAPTER 7: LINEN MANAGEMENT................................................................................................... 90
7.1. Standard Laundry Service ...................................................................................................... 91
7.2. Key Steps in Processing Used Linen ...................................................................................... 93
7.3. summary ................................................................................................................................ 97
CHAPTER 8: ENVIRONMENTAL CLEANING ...................................................................................... 98
8.1. Importance of Environmental Cleaning in Healthcare Facilities ............................................... 99
8.2. General Principles of Cleaning and disinfection .................................................................... 100
8.3. Preparation of cleaning and disinfectant solution .................................................................. 101
8.3.1 Preparation of disinfectant and cleaning solution ..................................................................... 102
8.4. CLEANING Methods ............................................................................................................ 103
8.5. Risk Based area categorization and cleaning Schedule ........................................................ 107
8.7 Summary ............................................................................................................................. 110
CHAPTER 9: HEALTH CARE WASTE MANAGEMENT ..................................................................... 111
9.1. Sources and types of healthcare Waste................................................................................ 112
9.2. Risk associated with healthcare waste .................................................................................. 113
9.3. Management of Healthcare Waste........................................................................................ 114
9.4. Summary ............................................................................................................................. 124
CHAPTER 10: FOOD AND WATER SAFETY ...................................................................................... 125
10.1. Principles and Standards of Food Safety at HealthCare Facilities ......................................... 126
10.2. Main Causes of Food Contamination .................................................................................... 128
10.3. Actions for Prevention of Food Poisoning ............................................................................. 130
10.4. Drinking Water Quality and Safety ........................................................................................ 132
10.5. Summary ............................................................................................................................. 134
CHAPTER 11: TRAFFIC FLOW AND FACILITY DESIGN .................................................................... 135
11.1. Significance of Traffic Flow and Activity Pattern .................................................................... 136
11.2. Traffic Flow and Activity Patten Design ................................................................................. 137
11.3. Traffic Flow Requirments in Differnet Areas .......................................................................... 140
11.4. Summary ............................................................................................................................. 145
CHAPTER 12: OCCUPATIONAL HEALTH AND SAFETY IN HEALTH CARE SETTINGS .................... 146
12.1. Introduction of Occupational Health Safety in HealthCare Setting ......................................... 147
12.2. Hazard Identification, Risk Assessment and Risk Control ..................................................... 148
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12.3. Occupational Health Activities for Preventing Infections among Health Care Workers ........... 150
12.4. Occupational Health and Safety for Specific Groups of HealthCare Workers ......................... 151
12.5. Post Exposure Prophylaxis ................................................................................................... 152
12.6. Monitoring Prevention of Occupational Exposures and Injuries ............................................. 160
12.7. Summary ............................................................................................................................. 160
CHAPTER 13: CLIENT EDUCATION ON INFECTION PREVENTION AND CONTROL (IPC) .............. 161
13.1. Significance of Clinet Education on IPC ................................................................................ 162
13.2. Components of Effective Client Education Program .............................................................. 162
13.3. Steps in client’s education on IPC......................................................................................... 163
13.4. Models of Client Education ................................................................................................... 164
13.5. Summary ............................................................................................................................. 166
CHAPTER 14: ANTIMICROBIAL RESISTANCE (AMR) AND RATIONAL USE OF ANTIBIOTICS ........ 167
14.2. Overview of Antimicrobial Resistance and Rational Use of Antibiotics ................................... 169
14.3. Consequences and Magnitude of Antibiotic Resistance ........................................................ 171
14.4. Causes of Antibiotic Resistance ........................................................................................... 173
14.5. Rational Use of Antibiotics .................................................................................................... 176
14.6. Promoting Rational Use of Antibiotics ................................................................................... 177
14.7. Summary ............................................................................................................................. 180
CHAPTER 15: PREVENTING HEALTH CARE ACQUIRED INFECTIONS AT SPECIAL SERVICE AREAS
IN PRIMARY HEALTH-CARE SETTING .............................................................................................. 182
15.1. tHE Epidemiology of HAIS in special health care settings Primary Healthcare Setting ........... 183
15.2. Risk Factors for Mother and New-Born Infection ................................................................... 186
15.3. Prevention of infection during pregnancy, labor and post-natal period ................................... 186
15.4. Safe work practices and IPC practices in laboratory at primary health care setting ................ 192
15.5. Summary ............................................................................................................................. 193
CHAPTER 16: IPC PROGRAM GOVERNANCE AND MANAGEMENT ................................................ 194
16.1. Overview to the National IPC Policy and Strategic Plan Pertaining to Primary Healthcare
Facilities .......................................................................................................................................... 195
16.2. IPC program governance and Management.......................................................................... 196
16.3. The Attributes of Effective Infection Prevention and Control (IPC) Programs ......................... 198
16.4. Major Infection Prevention and Control (IPC) Program Activities ........................................... 199
16.5. Using Quality Improvement models AND MULTIMODAL staregy to Improve IPC Practices... 200
16.6. Summary ............................................................................................................................. 207
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FORWARD
Healthcare associated infections (HAI) are posing a formidable threat to healthcare
providers, patients and community at large. It is affecting millions of patients worldwide
and the problem even more is greater in low- and middle-income countries. In
healthcare settings where the practice of infection prevention and control is inadequate,
healthcare providers and patients would be at an increased risk of acquiring serious
infections like HIV, HBV, HCV, Ebola and other emerging and re-emerging bacterial or
viral infections. It also poses a great risk of spreading multidrug resistant microbial
infections. However, most health care associated infections in healthcare facilities can
be prevented with readily available, relatively inexpensive and simple infection
prevention and control interventions and strategies.
Ministry of health has given particular attention to its national Infection Prevention and
Control program and it is scaling-up health facility infection prevention and control
activities. Infection Prevention and Control (IPC) in healthcare settings is a broad and
cross-cutting component of healthcare which involves every aspect of patient care, food
hygiene, housekeeping, laundry service, healthcare waste management and many
more. For the IPC program to be implemented effectively, preparation of standard
manuals and training of healthcare work force would be of a great importance.
This IPC manual is intended to serve as a training manual for healthcare providers and
managers in primary health care facilities. It is mainly adapted from the national IPC
reference manual and customized to provide guidance in the implementation of
standard Infection Prevention and Control activities in primary health care facilities.
Evidence based international standards and recommendations that known to be
effective in prevention and control of health care associated infection in resource limited
settings are also incorporated.
This training manual embodies particular topics that are pertinent to prevention and
control of health care associated infections in primary healthcare facilities. It is
anticipated that health bureaus, primary health care facilities, CPD training centers and
other stakeholders would use the manual to train health care workers in primary health
care facilities. We also hope that health care workers working at primary health care
setting would improve their IPC practice by regularly consulting the manual. Finally, I
would like to extend my heartfelt gratitude to all individuals and institutions that have
contributed to the realization of this training manual.
v
APPROVAL STATEMENT OF THE MINISTRY
The Federal Ministry of health of Ethiopia has been working towards standardization
and institutionalization of In-Service Trainings (IST) at national level. As part of this
initiative the ministry developed a national in-service training directive and
implementation guide for the health sector. The directive requires all in-service training
materials fulfill the standards set in the implementation Guide to ensure the quality of in-
service training materials. Accordingly, the ministry reviews and approves existing
training materials based on the IST standardization checklist annexed on the IST
implementation guide.
As part of the national IST quality control process, this infection prevention and control
for PHCU training package has been reviewed based on the standardization checklist
and approved by the ministry in June , 2022.
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ACKNOWLEDGEMENT
Ministry of Health-Ethiopia acknowledges the commitment and technical support of the
National Infection Prevention and Control (IPC) Technical Working Group (TWG)
members and key contributors along with their organizations who made the revision of
this training material a reality. The Ministry of Health would like to specially thank, CDC,
RTSL, MSH/MTaPS, EPHI, WHO and ICAP for their technical and financial support in
the preparation of this manual.
The MOH would also like to thank the following individuals and their organization
for the contribution they made on this training material:
Dr Abas Hassen MOH, Clinical Service Directorate
Mr. Biniyam Kemal MOH, Clinical Service Directorate
Mr. Kasu Tola MOH, Clinical Service Directorate
Sr. Gezashign Denekew MOH, Clinical Service Directorate
Dr. Fekadu Assefa MOH, Clinical Service Directorate
Mr. Hailegebriel Abomsa MOH, Clinical Service Directorate
Mr Biruk Kefelegn MOH, Clinical Service Directorate
Mr. Molla Godif MOH/RTSL
Dr. Atkure Defar EPHI
Dr. Birhanu Tekle ICAP- Ethiopia
Mr. Arone Mebrhatu RTSL
Dr. Fahmi Ahmed WHO
Mr. Abebe Shume WHO
Mrs. Selamawit Gebreegziabiher CDC- Ethiopia
Mr.Tewodros Fantahun MSH/MTaPS
Mr Sem Daniel MOH, Clinical Service Directorate
Mr. Abiy Dawit MOH, Clinical Service Directorate
Mr Deneke Ayele MOH, Clinical Service Directorate
Dr Zelalem Tadesse MoH, Health Extension Primary Health Care Directorate
Mr.Kiflemariam Tsegaye MoH, Health Extension Primary Health Care Directorate
Mr. Tegene Arega, MoH, Human Resource Development Directorate
Mr. Leta Tagessu MoH, Human Resource Development Directorate
Mr Salahdin Seid MoH, Human Resource Development Directorate
Mr.Addisalem Bogale St.Paul‘s hospital Millennium Medical college
Danica Gomes,CDC Atlanta
Janelle Kibler,CDC Atlanta
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ACRONYMS
viii
INTRODUCTION TO THE MANUAL
Effective Infection prevention and control (IPC) measures plays critical role in
prevention and control of the spread of infections in healthcare facilities and the
community. For the effective implementation of IPC program and interventions all
healthcare workers require at least a basic understanding of IPC principles and practice.
With this in mind MoH, has tailored this training manual specifically for the purpose
training of health care workers and managers in primary Health care facilities.
The training manual is prepared considering the current training material requirements
that fulfills the minimum in-service training package. This manual incorporates a
participant manual, facilitator guide as well as power point slides for respective
chapters. It will also include tools for facilitation of learning during the training. The
training manual consists of 16 chapters that are thought to be relevant for the functions
of the primary health care facilities. Efforts has been made to make the training more
practical and participatory.
This training manual is prepared as a tool to guide the training of health care providers
and managers in primary health care settings in line with the required in-service training
standards of Ministry of Health. This will enable trainees implement the IPC program
and interventions with clear understanding of the implications
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COURSE SYLLABUS
Course Description: The Four-day course is designed to provide participants with the
basic knowledge,skill and attituide required to provide infection prevention with
recommended IPC principles and practices in primary health care and hospital settings
with limited resources.
Corse Goal: The goal of this course is to enable participants to make healthcare
facilities a safer places.
Learning Objectives: After completing this course, Participants will be able to;
Describe how infections are transmitted in healthcare facilities and the
associated risks to healthcare workers, patients/clients and community at
large.
Demonstrate proper Personal Protective Equipment utilization.
Demonstrate reprocessing instruments and other items (before reuse)
Analyze the proper linen management in our healthcare facility.
Analyze the proper linen management in our healthcare facility.
Demonstrate appropriate segregation, collection, transportation, storage,
treatment, and final disposal of healthcare facility wastes.
Explain principles of food and water safety and measures
Design traffic flow and activity pattern of healthcare workers, patients,
visitors/attendants, and equipment’s.
Discuss assessment and identification of health workers occupational health
risks and their mitigation strategies.
Design effective client education program within their healthcare facility using
recommended delivery techniques.
Explain the basic concept of antimicrobial resistance and rational use of
antibiotics
Discuss how infections are transmitted and prevented in special services
areas
x
Discuss IPC Program Management
Training Methods:
Interactive lecture
Group work and Individual Activities
Demonstration exercises
Training Materials:
Training packages Participant’s Manual and Facilitator’s Guide
Laptop, LCD, Flip chart
Participants Selection Criteria: Health professionals working at the health Centers.
Trainer selection criteria:
Member of Developers of the training manual
Certified TOT Training on Infection Prevention and Control
Continuing Education Unit: 15 CEU’s
Methods of Evaluation
Participants Evaluation
Formative: Individual and Group exercise
Summative: Post test
Course Evaluation:
Daily Evaluation form
Daily Trainers feedback meeting
End of course evaluation
Course venue: The training will be provided at an Accredited CPD Center
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COURSE SCHEDULE
TEA BREAK
Chapter 1: Introduction to Chapter 5: Sharps and
Infection Prevention and Control Injection safety Chapter 15: Preventing heath
(IPC) care acquired infections at
Chapter 11: Traffic flow and special service areas in
Facility design primary health- care settings
LUNCH
Chapter 2: Standard and Chapter 6: Processing of Chapter 12: Occupational Chapter 16: IPC Program
Transmission based Precautions Instruments and Reusable Health and Safety in Health Governance and
items care settings Management
Chapter 7: Linen
Management
TEA BREAK
Chapter 3: Hand Hygiene Chapter 8: Environmental Chapter 13: Client Education Post test
Cleaning on Infection Prevention and Evaluation and Feedback
Control Closing remark
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CHAPTER 1: INTRODUCTION TO INFECTION PREVENTION AND
CONTROL (IPC)
Chapter description: This chapter comprises the definition and goals of infection
prevention and Control (IPC) and an overview of basic microbiology. It also
summarizes the WHO Core components of IPC. The disease transmission cycle and
measures to halt the spread of disease in healthcare delivery settings and the
common healthcare associated infections (HAIs) are also introduced. The ultimate
objective of this chapter is to enable participants to understand IPC practices in
healthcare settings.
Chapter Objective: By the end of this chapter the participants will be able to explain
infection in healthcare facilities.
Enabling Objectives
Chapter Outline:
1.1. The role of IPC in delivery of safe and quality health service
1.2. WHO Core Components of Infection Prevention and Control
1.3. Basic concepts of microbiology
1.4. Infection Transmission Cycle and Measures to Break the Chain of Infection.
1.5. Common Healthcare Associated Infections (HAIs)
1.6. Summary
1
1.1. THE ROLE OF IPC IN DELIVERY OF SAFE AND QUALITY
HEALTHCARE SERVICE
Instruction:
2
diseases, deaths, and higher healthcare costs. The application of evidence-based
IPC practices at all healthcare settings is the key in preventing health care
associated infections.
The goal of IPC is to make healthcare facilities safer for patients, staff, and the
community.
3
Table 1.1: WHO’s Eight Core Components for Infection Prevention and Control
(IPC)
S. N Component Recommendation
1 IPC program An appropriate IPC program with a dedicated, trained
team should be in place in each acute health care
facility for the purpose of preventing HAI and
combating AMR through good IPC practices.
2 IPC guidelines Evidence-based guidelines should be implemented for
the purpose of reducing HAI and AMR.
3 IPC Education and IPC Training should be in place for all health care
training workers by utilizing team and task-based strategies that
are participatory and include bedside and simulation
training to reduce the risk of HAI and AMR.
4 Health care- HAI Surveillance, as per the burden of HAI in the
associated infection facility, can be done to guide IPC interventions and
(HAI) surveillance detect outbreaks, including AMR surveillance, with
timely feedback of results to health care workers and
stakeholders and through national networks.
5 Multimodal strategies IPC activities should be implemented using multimodal
strategies to improve practices and reduce HAI and
AMR.
The WHO multimodal improvement strategy addresses
the areas of system change, training and education,
monitoring and feedback, reminders and
communications, as well as cultural change supporting
IPC in a patient safety perspective.
6 Monitoring and audit Regular monitoring/audit and timely feedback of health
of IPC practices and care practices should be undertaken according to IPC
feedback standards to prevent and control HAIs and AMR at the
health care facility level.
Feed-back should be provided to all audited persons
and relevant staff.
7 Workload, staffing In order to reduce the risk of HAI and the spread of
and bed occupancy AMR, the following should be addressed:
(for facility level) (1) Bed occupancy should not exceed the standard
capacity of the facility.
(2) Health care worker staffing levels should be
adequately assigned according to patient workload.
8 Built environment, Patient care activities should be undertaken in a clean
materials and and/or hygienic environment that facilitates practices
equipment for IPC related to the prevention and control of HAI, as well as
(for facility level) AMR, including all elements around the WASH
infrastructure and services and the availability of
appropriate IPC materials and equipment.
Materials and equipment to perform appropriate hand
hygiene should be readily available at the point of care.
4
1.3. BASIC CONCEPTS OF MICROBIOLOGY
1. Identify
one Common infection, describe its
causative agent, mode of transmission and identify
one key prevention measure
Time Allowed: 10 Minutes
Microorganisms that HCWs and IPC staff may encounter in health care settings
include bacteria, fungi, parasites, and viruses.
BACTERIA
Bacteria are the most common causes of HAIs (WHO 2002) and thus it is helpful for
HCWs as well as the IPC team to know the key characteristics of bacteria commonly
seen in health care facilities.
VIRUSES.
Many viruses can be transmitted in the health care environment and often cause
HAIs and outbreaks. Blood borne viruses, such as HIV and hepatitis B and C, can
spread from patient to patient during transfusions, dialysis, injections, and
endoscopy. Viruses such as SARS CoV-2 influenza and respiratory syncytial virus
(RSV) can spread from patient to patient by respiratory fluid droplets during crowding
or sharing of respiratory equipment, or on contaminated hands. These viruses can
also be spread from healthcare workers to patients and from patients to healthcare
workers if good IPC standards and practices are not adhered to during healthcare
delivery.
The presence or absence of a virus envelope has significance for cleaning and
disinfection. Enveloped viruses (e.g., herpes, HIV, Ebola, COVID-19 etc) are easier
to kill with disinfectants than non-enveloped viruses (e.g., norovirus, rotavirus,
adenovirus, and poliovirus).
FUNGI
While fungi can cause infection in humans (e.g., Candida albicans), most are
opportunistic pathogens that cause infections (which can be severe) in those who are
on extended antibiotic treatment or are immunosuppressed (C. albicans, Aspergillus
5
spp., Cryptococcus neoformans, Cryptosporidium). A species of yeast, Candida
auris, with a propensity to spread in hospitals and resistant to multiple antifungals, is
emerging globally.
PARASITES
Health care-associated parasitic infestations include scabies, lice, and myiasis
(maggots). Water- or foodborne parasite infestations—such as amoebiasis (caused
by Entamoeba histolytica) or cryptosporidiosis (caused by Cryptosporidium
parvum)—mainly occur in community settings but can also spread within hospitals.
Instruction:
All humans are susceptible to infections due to bacteria, viral agents and other
infectious agents. These disease-causing microorganisms are also called
pathogens.
The number (dose) of microorganisms necessary to produce infection in a
susceptible host varies with the body site.
All of us touch surfaces, which contain microorganisms, every day but do not suffer
from an infection because microorganisms coming into contact with intact skin are
6
unlikely to cause a risk of illness. Infections typically occur when microorganisms get
inside the body, which can occur through a puncture, cut, or wound in the skin or
mucosa, through ingestion or even through inhalation.
Infection risk increases greatly when organisms come into contact with normally
sterile body sites. In such cases, the introduction of even just a few microorganisms
may produce disease.
For infectious agents to successfully survive and spread, certain factors or conditions
must be present; these are illustrated as the components or elements of the ‘Chain
of Infection’.
If any of the links or components of the chain are absent or removed, an infection
cannot occur. This interruption of the chain is commonly referred to as breaking the
chain of infection.
The following elements are required in sequential order, for an infection to occur and
spread as shown by the Chain of Infection illustration:
7
bacteria, virus, fungus, parasites etc.
3. Portal of Exit - This is a gateway through which the agent leaves the host
or reservoir. However, the agent must have the right environment for its
survival until it gets an entry to infect another person/animal.
4. Mode of Transmission - An agent which exits and develops in its natural
reservoir can be transmitted in numerous ways to a susceptible host and
get portal of entry. These modes of transmission are classified based their
routes as:
Contact
Droplet
Airborne
8
Breaking the Chain of Infection
Preventing the spread of infectious agents and practicing proper infection prevention
and control requires breaking the chain of infection by removing one or more of the
conditions necessary for transmission of the diseases through practices which:
9
1.5. HEALTH CARE ASSOCIATED INFECTIONS
HAIs may be endogenous (from self) where the infectious agents are from the
patient. And example would be an infection caused by the body’s normal flora which
may cause disease as a result of gaining access into another part of the body where
it is not normally found.
HAIs may also be exogenous (from others or cross-infection). This involves acquiring
infection from an external source, for example a patient or health worker, through
contaminated hands, or contaminated patient care items or the environment.
10
1.6. SUMMARY
The goal of infection prevention and control is to make health care facilities a safe
place for all, including patients, healthcare workers, and visitors.
Understanding each step of the infection chain or cycle is an important step in
preventing and controlling HAI’s.
The basics of Infection prevention and Control are Standard Precautions and
Transmission-Based Precautions.
Generally, effective implementation of the Core components of Infection Prevention
and Control as defined by WHO will help ensure safe healthcare delivery and reduce
the incidence of HAI.
11
CHAPTER 2: STANDARD AND TRANSMISSION BASED
PRECAUTIONS
Chapter Description: In this chapter, the two major precautions that help to prevent
the transmission of micro-organisms are elaborated and discussed. These are
standard and Transmission-based precautions.
Chapter Objective: By the end of this chapter the participants will be able to apply
the basic principles and components of standard precautions and transmission-
based precautions in preventing infection.
Enabling Objectives:
By the end of this chapter, participants will be able to:
Define standard and transmission-based precautions
Apply the principles of standard precaution
Outline components of standard precaution
Identify the three major routes that require transmission-based precaution
Chapter Outline
12
Standard Precautions – are the minimum infection prevention practices that
apply to all patient care, regardless of suspected or confirmed infection status of
the patient, in any setting where health care is delivered. These are a set of
guidelines designed to create physical, chemical, and mechanical protective
barriers between the microorganisms and person to prevent the spread of
infection (please note that these barriers serve to break the diseases
transmission cycle). Can you identify examples of each barrier?
Example of barriers:
Physical-PPE
Use the below list to give examples of organisms transmitted by airborne, droplet, or
contact routes?
13
Important note on Standard Precaution (SP)
Standard Precaution is first and most important level of
precautions.
The aim of SP is to reduce the risk of transmitting
microorganisms from a known or unknown source infection
within health care settings.
Applying SP while providing patient care is based on the
anticipated interaction a HCW will have with blood, body fluid or
any potential pathogen exposure from patients.
Standard Precautions apply to all clients and patients attending
healthcare facilities whereas Transmission-Based Precautions
which apply primarily to hospitalized or isolated patients.
14
The Key Components of Standard Precautions
1. Hand Hygiene –
Hand hygiene involves HCWs cleaning their hands before, after, and at specific
moments during patient care and when performing health care tasks (five moments
for hand-hygiene).
Hand hygiene is the most important intervention for preventing transmission of
infections (help to prevent 50-60% of HAI)
It must be performed consistently at the recommended moments during patient care
using soap and water or alcohol-based hand rub (ABHR) and with a precise
technique and steps that effectively remove microorganisms from hands.
4. Environmental Cleaning –
15
5. Instrument Processing –
Re-processing instruments and other items following the correct steps must be done
before reuse for any clinical procedures.
Removes pathogens from the textiles and protects cleaned textiles from
reintroduction of pathogens.
Reduces risk for transfer of pathogens to HCWs, other patients, and the
environment. [For detailed information see CHAPTER 7: LINEN MANAGEMENT].
Is a key issue to control and reduce HAIs in healthcare facilities (HCF) and to ensure
that the environment is well protected? Healthcare Waste Management (HCWM)
should be part of the overall management system of a HCF and reflect the quality of
the services provided by the facilities.
Key Components of SP
Hand Hygiene
Use of PPE
Respiratory hygiene and cough etiquette
Safe injection practice and Sharps Safety
Environmental cleaning and disinfection
Medical instrument reprocessing
Processing of linen
Health-care waste management
16
2.3. TRANMISSION-BASED PRECAUTION: COMPONENTS AND
PRECAUTION REQUIRED FOR EACH COMPONENT
Form three groups and discuss the following questions in your group
and report the work in the plenary (share group response with the
larger groups using flipchart)
Discussion Question:
19
Use of PPE Wear eye protection
Wear a particulate Use gown and gloves for
and a face mask or
respirator such as a all interactions that
face shield, to cover
fit-tested N95, may involve contact
eyes, nose, and
In case of chickenpox with patient or patient
mouth completely,
or measles, no mask environment
is needed for
immune persons,
Gown, gloves, and eye
protection are
needed for
microorganism
transmitted by
multiple routes (e.g.,
varicella virus,
SARS-Cov).
Patient 3. Limit transport of patient to critical service 1. Limit transport of
Transport /procedures that cannot be performed in the patient to critical
patient’s room. service/20rocedur
4. If the patient needs to leave the room for a e that cannot be
test or procedure: performed in the
patient’s room.
Alert the department or facility to which the
2. When
patient is being transported so they can prepare
transporting
to receive a patient on Transmission-Based
patient: cover
Precautions.
patient with clean
HCWs who transport the patient need to Use
linen, never use a
PPE appropriately.
linen that was
Ensure that patients on Droplet or Airborne
used on patients’
Precautions wear a surgical mask while outside
bed.
of the patient room.
Cover wounds with appropriate dressings
Clean and disinfect the wheelchair or coach
after transportation.
Remove PPE and perform hand hygiene once
the patient has been transported.
Cleaning
20
Precautions.
Empiric/ Syndromic Use of Transmission Based Precaution
Every effort should be made to diagnose the microorganism responsible for infection;
however, laboratory diagnosis is not immediately available and not always available.
In these circumstances, precautions must be based on empiric/syndromic findings. If
there is any question about whether a patient without a known diagnosis has specific
infection, implement Transmission-Based Precautions based on the patient’s signs
and symptoms until a definitive diagnosis (i.e., laboratory test results) can be made.
2.4. SUMMARY
Please Note that: to protect HCWs, patients, and visitors from acquiring infections
during health care facility visits, ensure compliance with:
Standard Precautions, including hand hygiene, are the cornerstone of IPC. They
provide the first line of defense in the prevention of transmission of pathogens in
health care facilities.
21
CHAPTER 3: HAND HYGIENE
Chapter Objective
By the end of this chapter the participants will be able to practice proper hand
hygiene techniques and improve hand hygiene compliance.
Enabling Objectives
Chapter outline
22
3.1. IMPORTANCE OF HAND HYGIENE
23
Other opportunities for hand hygiene
Immediately on arrival and before departure from work (the health facility).
Immediately after touching contaminated instruments or articles.
Before putting on gloves and after removing them
Whenever the hands become visibly soiled
After nasal blowing or following a covered sneeze
Before touching the face (eyes, nose or mouth)
Before and after cleaning the environment
Before and after preparing food
Before eating and drinking or serving food
After visiting the toilet.
Instruction:
The cleansing activity of hand washing is achieved by both friction and the detergent
properties of the soap. Plain soap has minimal antimicrobial properties, but assists
with the mechanical removal of debris and loosely adherent microbes, while the
mechanical action removes some bacteria from hands. Time is also an important
24
factor—hand washing for 30 seconds has been shown to remove 10 times the
number of bacteria as hand washing for 15 seconds. The entire hand washing
procedure, if completed properly, as described step by step in Figure 1-2, should
take 40–60 seconds. (CDC 2002; WHO 2009a)
Figure 3.1: The Steps for Routine Hand washing (How to Properly Wash Your
Hands)
Hand washing with soap and water is recommended (rather than using ABHR) in the
following situations:
1. If hands are visibly soiled or contaminated with blood or body fluids
2. After using the toilet
3. Before eating
4. To remove the buildup of emollients (e.g., glycerol) on hands after repeated
use of ABHR
5. In outbreaks of C. difficile, but not in health care settings with only a few
cases of C. difficile.
2. Alcohol-Based Hand Rub (ABHR)
The antimicrobial activity of alcohol results from its ability to denature proteins (i.e.,
the ability to dissolve some microbe components) and kill microbes. Alcohol
solutions containing 60–80% alcohol are most effective, with higher concentrations
25
being less effective. This paradox results from the fact that proteins are not
denatured easily in the absence of water; as a result, microorganisms are not killed
as easily with higher alcohol-based solutions (> 80% alcohol).
The use of an ABHR is more effective in killing transient and resident flora than hand
washing with antimicrobial agents or plain soap and water. It also has persistent
(long-lasting) activity. ABHR is quick and convenient to use and can easily be made
available at the point of care. ABHR usually contains a small amount of an emollient
(e.g., glycerol, propylene glycol, or sorbitol) that protects and softens skin. ABHR
should be used at any of the 5 Moments described earlier in this chapter, unless
hands are visibly soiled.
26
Figure 3.2: WHO Recommendation on How to Perform Hand Hygiene with
ABHR
Please check the link below that shows the correct procedure
for hand hygiene with ABHR. (Source: WHO)
https://player.vimeo.com/video/406383268
3. Antiseptic Soaps
Antiseptic soaps may be used in place of plain soap during the ―My 5 Moments for
Hand Hygiene described above but are not recommended for most settings. Hand
washing with antiseptic soap is more irritating to the skin and more expensive than
using ABHR. Therefore, if available, ABHR should be used under normal
circumstances. Use of antiseptic soaps is recommended for surgical hand scrub and
before entry into special areas of health care facilities (e.g., neonatal intensive care
units).
27
3.5. SUMMARY
The goal of hand hygiene is to remove soil, dirt, and debris and reduce both transient
and resident flora.
Five moments of hand hygiene are: before making contact with a patient, before
performing a clean/aseptic task, after performing a task involving the risk of exposure
to a body fluid, after patient contact, and after touching/contact with patient
environment.
ABHR is more effective in killing transient and resident flora than hand washing with
antimicrobial agents or plain soap and water.
28
CHAPTER 4: PERSONAL PROTECTIVE EQUIPMENT
Chapter Objective:
By the end of this chapter participants will be able to properly utilize the appropriate
PPE.
Enabling Objectives:
Chapter outline
29
4.1. BENEFIT OF PPE
Healthcare workers are confronted each day with the difficult question of how to work
safely within the potentially hazardous environment of health care facilities. Today,
the most common occupational risk that healthcare personnel face is due to contact
with blood and bodily fluids during routine work like cleaning, instrument processing
and patient care. This exposure to pathogens increases the risk of getting
Healthcare Associated Infections and possible death. Use of risk appropriate
personal protective equipment (PPE) is one of the components of Standard
Precautions, which refers to wearing of protective barriers or clothing. Hospital
administrators, supervisors and healthcare workers need to be aware not only of the
benefits and limitations of specific PPE, but also of the actual role PPE plays in
preventing infection so that they can use them effectively and efficiently.
30
Table 4.1: How Personal Protective Equipment Blocks the Spread of Microorganisms
WHERE MICROORGANISMS HOW MICROORGANISMS BARRIERS TO STOP THE MUST BE WHO THE BARRERS
ARE FOUND (RISK ARE SPREAD SPREAD OF USED FOR PROTECT
ASSESMENT) MICROORGANISMS (Examples of indications)
Healthcare Staff
Hair and scalp Shedding skin or hair Cap Invasive procedures where tissue beneath the Service Provider
Nose and mouth Coughing, talking, Mask (water resistant), skin is exposed and Patients
sneezing Situation where splashing or exposure
Face (eyes nose or mouth) Splashing, coughing and Masks, face shields, of blood, body fluids, secretions or excretions is
taking goggles likely
Body, Arm and skin Shedding skin or hair Scrub suit, cover gowns
Nose and mouth Coughing, talking Masks Situation which calls for droplet transmission
Special Masks (N95%) When airborne transmission is anticipated.
Hands Touching Gloves with hand washing When there is a reasonable chance of hand Patient
or alcohol hand rubbing coming in contact with blood and other body
fluids
Closed boots or closed-
Splashes, Spills and Situation where splashing or blood, body
Feet and lower legs toe shoes (open sandals Service provider
Sharp Material fluids, secretions or excretions is likely
are not acceptable)
Patient
Mucous membrane and non- Situation where there is direct contact with Service provider
Touching Gloves
intact skin mucous membrane and non-intact skin and Patient
Gloves, eyewear, mask,
Splashing or spraying
drapes, and apron
Touching (contact) Instrument processing Invasive procedures where tissue beneath the
Protective footwear, skin is exposed Service provider
Blood and body fluids
Accidental exposure with decontamination and Situation where splashing or exposure of blood, and Patient
contaminated needles disposal; use of a Safe or body fluids, secretions or excretions is likely
and scalpel blades Neutral Zone during
surgery
Utility gloves, plastic bags
Contaminated Items or waste Infectious waste Collection, transportation, and disposal of waste Staff
and proper disposal
Skin preparation, drapes, Invasive procedures where tissue beneath the
Unprepared skin Touching Patient
gloves skin is exposed
Clinic or hospital Gloves, hand washing, Staff and their
Touching Environmental cleaning and disinfection
environment Appropriate dressing families
31
As a rule, PPE selection should be based on risk assessment. If there is risk of exposure of
patients or health workers, then the PPE or combination of PPEs appropriate for the
identified risk should be used. Effectiveness in protection is also dependent on the practice of
correct procedures and adherence to rules for wearing (donning) and removing (doffing) of
PPE.
32
Shoe cover Shoes
Head Covering/Caps
Head covers are most commonly used as part of surgical attire in surgical and
procedure areas. When used, head covers or caps should be large enough to cover
the entire scalp and hair (see Figure 4-1A–C: Surgical Head Coverings A, B, and C).
Facial hair is also required to be covered for surgical procedures in sterile areas (e.g.,
in the operating theater) using a facial hair covering. They can be disposable or made
of reusable cloth that can be laundered. In the surgical and procedure areas, a new
clean head covering should be worn each day and changed sooner when soiled with
blood or bodily fluids. The same standard and regularity of cleaning expected for
surgical scrubs should be applied when cleaning head/facial coverings (e.g.,
laundered at the health center and changed at least daily).
C. Surgical Hood
33
Eye Wear
There are four different types of eye protection that are effective in preventing infection
in health care facilities (see Figure 4-2: Different types of Eye Protection Equipment’s):
Goggles
Safety Glass
Masks attached shield
Face shield
Eye protection should be comfortable, allow for sufficient peripheral vision (i.e., the
area that is visible outside the central area of focus), and must be adjustable to
ensure secure fit. Compared to older styles of goggles, newer styles may provide
better indirect airflow properties to reduce fogging, provide better peripheral vision,
and offer more size options for fitting goggles to different HCWs.
Eye wear protects the staff during accidental splash of blood or other bodily fluids
by covering the eyes. Masks and eyewear should be worn when performing any
task where an accidental splash into the face could occur (e.g., performing
cesarean section, vaginal delivery, or cleaning instruments) when giving care to
patients with droplet precautions. If face shields are not available, goggles or
glasses and mask can be used together. If reusable eye/face protection is used, it
should be decontaminated in accordance with the manufacturer’s guidelines.
Hands should always be decontaminated after removing the equipment.
Note: Personal eyeglasses and contact lenses are NOT considered adequate
eye protection.
34
Cover the entire face area (e.g., face shield) if protection of the mouth and nose
area is also required
Be changed if visibly soiled
Be removed using the earpieces / headband to avoid touching potentially
contaminated surfaces
Be disposed of after use if single-use or placed into a receptacle for reprocessing
Fit over personal glasses and anti-fog properties should be considered
Figure 4.2: Different types of Eye Protection Equipment and how to wear the
protective eyewear
Put on eye protection after putting on the isolation gown and mask (if used) but
before putting on gloves (see Figure 4.3: Putting on Eye Protection).
Removal of face shield, goggles, and mask can be performed safely after gloves
have been removed (see Figure 4.4: Taking off Eye Protection). The ties, ear pieces,
35
and/or head band used to secure the equipment to the head are considered clean
and safe to touch with bare hands. If the ties, ear pieces, and/or head band are
found to be contaminated, they should be removed using gloved hands and the
skin/face should be rinsed using ample running water and soap. The front of a
mask, goggles, and face shield is considered contaminated.
Masks
There are many different types of masks used to cover the mouth and nose. Masks
made from cotton or paper are comfortable but are not fluid-resistant (do not
protect from splashes) and are not an effective filter to prevent inhalation of
microorganisms transmitted via droplet nuclei (≤ 5 µm). Masks made from
synthetic materials provide protection from large droplets (> 5 µm) spread by
coughs or sneezes. They may be more difficult to breathe through than cotton or
paper masks. The use of masks during patient care is part of Standard Precautions
when there is a potential for splashes or droplet transmission and is part of Droplet
Precautions. (Siegel et al. 2007).
Surgical masks: Regulating bodies (such as The United States Food and Drug
Administration [FDA], the European Union, and WHO) require surgical masks to
have fluid-resistant properties.
Procedure/isolation masks: These are not regulated, and they do not have any
specifications for their manufacture.
36
1. Surgical Masks
Masks should be large enough to cover the nose, the lower part of the face, the
jaw and all of the facial hair. They are worn in an attempt to retain/confine moist
droplets expelled as health Workers or surgical staff speaks, cough or sneeze.
Equally important, is its protective function against accidental splashes of blood or
other contaminated body fluids on the health workers’ nose or mouth. This
preventive function, however, would not be effective unless the masks are made of
fluid-resistant materials.
When removing, one should handle the masks by the strings, do it with great care
as the center of the mask is the most contaminated site of all other parts
(Rothrock, McEwen & Smith, 2003).
2. Respirators
This are special types of masks called particulate respirators worn by healthcare
personnel for protection against inhalation exposure to airborne infectious agents
that are < 5μm. These include infectious droplet nuclei from patients with
Mycobacterium tuberculosis, Variola virus (smallpox), SARS-CoV, and dust
particles containing infectious particles such as spores of environmental fungi (e.g.,
Aspergillus sp.). Respirators should be worn when filtering inhaled air is deemed
important. These articles contain multiple layers of filter material and fit into the
face tightly allowing no air leaks around the mask when breathing. The N95
disposable
particulate and air purifying respirator are the type used most commonly by
healthcare personnel. Other respirators used include N-99 and N-100 particulate
respirators; powered air-purifying respirators with high efficiency filters; and non-
powered full-face piece electrometric negative pressure respirators (Siegel JD. et
37
al.; HICPAC, 2007).
Gowns
Types of gowns and their purposes Gowns should fully cover the torso of the
HCW, fit comfortably over the body, and have long sleeves that fit snuggly at the
wrists.
There are three types of protective gowns used in health care facilities:
Isolation gowns,
Surgical gowns, and
Coverall suits (Siegel et al., 2007)
Note: Isolation gowns should be worn in combination with gloves and other
PPE, as recommended.
Surgical gowns are sterile and preferably fluid-resistant, with sleeves that either
taper gently toward the wrists or end with elastic or ties around the wrists. Large,
droopy sleeves are not recommended because they can cause accidental
contamination. Surgical gowns are used during surgery or procedures to protect
patients and the sterile field from microorganisms from blood and other body fluids
(e.g., amniotic fluid) present on the HCW’s clothing, the front of the HCW’s body,
and the HCW’s arms.
When the surgical gowns are put on, the cuffs of sterile surgical gloves should
completely cover the end of the sleeves of the gowns.
Lightweight cloth or paper gowns are not recommended because they offer little
protection against moisture, which can easily pass through, allowing the passage
38
of microorganisms. If a cloth or paper gown is used, always wear a plastic apron
under/over it.
If a protective covering fails (e.g., during a large spill) and skin/clothing becomes
contaminated with blood or body fluids, clothing should be removed and laundered
immediately. The HCW should bathe as soon as possible after completing the
operation or procedure. Coveralls are full-body suits made from materials that are
lightweight, breathable, and impermeable to liquids (see Figure 2-1). These are to
be worn by all HCWs who work in isolation areas for treating highly infectious
diseases (e.g., VHF). They are designed to go over a scrub suit and create a
barrier to eliminate or reduce contact exposure to blood, body fluids, and highly
infectious microorganisms (CDC 2015). Coveralls without attached hood and with
thumbholes are recommended.
The type of gown to use is based on the type of patient interaction, including the
anticipated degree of contact with infectious material and the potential for blood
and body fluid penetration of the barrier and the type of task to be carried out by
the HCW:
39
During surgical procedures, deliveries, or other aseptic procedures, a sterile
surgical gown is worn to protect the sterile field and the clothes of the scrub
team or those performing the procedure.
Full coverage of the arms and body front, from the neck to the mid-thigh or below,
will ensure that clothing and exposed areas of the upper body are protected.
Isolation gowns are usually the first piece of PPE to be put on (see Figure 4-7 A
and B: Putting on and removing an Isolation Gown). HCWs should remove
isolation gowns before leaving the patient care area to prevent possible
contamination of the environment outside of the patient care area (see Figure 4-7
A and B: Putting on and Removing an Isolation Gown). (Siegel et al. 2007)
40
Plastic Apron
Aprons keep contaminated fluids off the healthcare worker’s clothing’s and skin.
For example, during invasive procedures, wearing a water-resistant apron
(disposable or reusable) will not only help to guard the healthcare providers
against exposure to blood or body fluids (e.g., amniotic fluid), but also prevents the
healthcare workers’ abdominal skin from being a source of contamination to the
patient.
Gloves
Types of Gloves
41
when cleaning contaminated surfaces. Double gloving of either new examination
gloves or reprocessed surgical gloves provide some protection in case utility
gloves are not available.
Note:
Clear understanding of the parameters to opt for sterile or high- level disinfected
gloves is important. Judicious use of these options can reduce costs and at times
maintain safety both for the patients and the staff.
The use of high-level disinfected surgical gloves when performing surgical or
invasive procedures is the only acceptable alternative on the condition that sterile
surgical gloves are not available.
Non-sterile Gloves can be made form:
1. Latex
2. Vinyl
3. Nitrile
42
Not recommended for HCWs
Nitrile Allergy-free
with known allergies to nitrile
Preferred choice for HCWs with latex allergies
compounds
Made from synthetic materials and are very elastic
Can be used with petroleum-based substances,
including hand moisturizers
3–5 times more puncture-resistant than latex
gloves
Fit well on hands like latex gloves
More elastic than vinyl gloves
Available in various thicknesses and colors
Note:
When using latex rubber gloves, avoid use of hand cream or lotions that contain
mineral oil, petroleum jelly (Vaseline) or lanolin to protect your hands, because
they may cause the gloves to break down within minutes.
There is a chance of hands coming in contact with blood or other body fluids,
mucous membranes or non-intact skin.
They perform invasive medical procedures (e.g., inserting vascular devices
such as peripheral venous lines); or
They handle contaminated waste items or touch contaminated surfaces.
The Glove Pyramid – to aid decision making on when to wear (and not wear)
gloves
Gloves must be worn according to standard and contact precautions. The pyramid
details some clinical examples in which gloves are not indicated, and others in
which clean or sterile gloves are indicated. Hand hygiene should be performed
when appropriate regardless of indications for glove use (see Figure 4.8: The
Decision Pyramid – when to and not to wear gloves)
43
Note:
The acceptable ―leak rate for new surgical and examination gloves
designated by regulatory agencies is up to 4% (Davis 2001).
Although double gloving is of little benefit in preventing exposure to blood in case
of needle sticks or other similar injuries, it may decrease the risk of blood-hand
contact. A recent study, for instance, showed that surgeons wearing single gloves
had a blood-hand contact rate of 14% while those wearing double gloves had only
a rate of 5% (Tokars et al., 1995; Tokars et al., 1992).
Figure 4.8: The Decision Pyramid – when to and not to wear gloves
Image from WHO (2009); Hand Hygiene Why, How and When
The procedure involves coming in contact with large amounts of blood or other
body fluids (e.g., vaginal deliveries and cesarean sections).
Performing orthopedic procedures in which sharp bone fragments, wire sutures
and other sharp-edged materials are likely to be encountered.
44
Performing surgical procedures lasting more than 30 minutes. (Most surgeons,
these days use double glove routinely).
When double gloving, the first glove should be a half size larger than normally
worn gloves. The second pair, however, should be the correct size as this will help
prevent the hand from cramping. In general, for short time surgical procedures (30
minutes or less) and those involving minimal exposure to blood or mucous
secretions (e.g., laparoscopy or mini-laparotomy), double gloving is probably not
necessary.
Elbow length gloves should be used during vaginal deliveries and caesarean
sections where the chance of coming in contact with blood is 25% and 35%
respectively. Elbow length gloves are also recommended to be used during
performing procedures like manual removal of placenta and any other procedure
where contact with a large volume of blood or body fluids is likely. This kind of
glove is generally meant to give protection to the hands including the forearms.
When readymade elbow length gloves are not available, an effective alternative
material (as described below) can easily be made from new or previously used
surgical latex gloves that have been re-processed (decontaminated, cleaned and
dried, through the two methods of either sterilization or high-level disinfection).
Cut one or more fingers depending on the size of your hands completely off each
glove just below where all the fingers join to allow all of the fingers slip into the
gloves. (Figure 4.9).
How to Use
45
Figure 4.9: Technique how to make elbow length gloves
Note:
Practice of hand hygiene, coupled with the use of protective gloves, is a key
component in minimizing the spread of disease.
46
Figure 4.10: How to don and remove examination gloves
47
Figure 4.11: How to wear (don) sterile gloves
The purpose of donning and removing sterile gloves as indicated in Figure 4.11:
How to wear (don) sterile gloves is to ensure maximum asepsis for patients and
protect the healthcare workers from the patient’s body fluid. In the correct usage of
gloves-an instrument to achieve this double goal, the skin of the healthcare worker
remains exclusively in contact with the inner surface of the glove and has no contact
with the outer surface. Any error in the performance of this technique leads to a lack
of asepsis requiring a change of glove.
48
paper and keep it open.
4. Using the thumb and index finger of one hand, carefully grasp the folded cuff
edge of the glove.
5. Slip the other hand into the glove in a single movement, keeping the folded
cuff at the wrist level.
6. Pick up the second glove by sliding the fingers of the gloved hand underneath
the cuff of the glove (Includes Step7).
7. In a single movement, slip the second glove on to the ungloved hand while
avoiding any contact/resting of the gloved hand on surface other than the glove
to be donned (contact/resting constitutes a lack of asepsis and requires a change
of glove) (also includes step 9 and 10).
8. If necessary, after donning both gloves, adjust the fingers and inter-digital
spaces until the gloves fit comfortably.
9. Unfold the cuff of the first gloved hand by gently slipping the fingers of the
other hand inside the fold, making sure that any contact with the outer surface of
the glove is avoided (lack of asepsis requiring a change of gloves) (Includes
Step13).
10. The hands are gloved and must touch exclusively sterile devices or the
previously- disinfected patient’s body area.
11. Remove the first glove by peeling it back with the fingers of the opposite
hand. Remove the glove by rolling it inside out to the second finger joint (do not
remove completely) (Includes step 16 and 17).
12. Remove the other glove by turning its outer edge on the fingers of the partially
un-gloved hand.
13. Remove the glove by turning it inside out entirely (ball forming) to ensure that
the skin of the health-care worker is always and exclusively in contact with the
inner surface of the glove.
14. Discard gloves.
15. Perform hand hygiene after glove removal according to the recommended
indication.
Donning surgical sterile gloves at the time of a surgical intervention follows the
same sequences except that:
It is preceded by a surgical hand preparation.
Donning of the gloves is performed after putting on the sterile surgical
49
gown.
The opening of the first packaging (non-sterile) is done by an assistant.
The second packaging (sterile) is placed on a sterile surface and then
used for the intervention.
Gloves should cover the wrists of the sterile gown.
Do wear the correct size gloves, A poorly fitting glove can limit your ability to
perform the task and may get damaged easily
Do change surgical gloves periodically (every 45 minutes) during long cases
as the protective effect of latex gloves decreases with time and in apparent
tears may occur.
Do keep fingernails trimmed moderately short (less than 3mm beyond the
finger tip) to reduce the risk of tears.
Do pull gloves up over cuffs of gown (if worn) to protect the wrists.
Do use water-soluble hand lotions and moisturizers often to prevent hands
from drying, and cracking due to frequent hand washing and gloving.
50
Re-process utility gloves by immersing them in a 0.5% Chlorine solution
briefly, remove gloves by inverting them and then soak them in the 0.5%
Chlorine solution for 10 minutes before washing and drying them for reuse.
Don’t use oil-based hand lotions or creams, because they will damage latex
surgical and examination gloves.
Don’t use latex gloves if you or the patients have an allergy to latex.
Don’t store gloves in areas where there are extremes of temperature (e.g.,
direct sunlight, near the heater, air conditioner, ultraviolet light, and X-ray
machine). These conditions may damage the gloves (cause breakdown of
the material they are made of), thus reducing their effectiveness as a
barrier.
Don’t reprocess gloves that are cracked or have detectable holes/tears.
Don’t reprocess examination gloves for reuse.
Note:
A separate pair of gloves must be used for each client to avoid cross-contamination
or when moving from one site to another site on the same patient (i.e., from
respiratory care to a dressing change). It is preferable to use new and single use
(disposable) gloves only.
Footwear
Footwear is worn to protect the feet from injury by sharp or heavy items or fluids that
may accidentally spill over, drip, or even pour out upon them. All footwear should
have closed toes, low heels, and non-skid soles. Clean, sturdy shoes are
recommended for all clinical areas. Rubber boots or leather shoes provide the best
protection. They must be kept clean. For this reason, sandals and other open-toe
shoes or shoes made of soft materials are not acceptable. Rubber boots or leather
shoes are acceptable, but they must be kept clean and free of contamination from
blood or other body fluid spills. Shoe covers are unnecessary, if clean and sturdy
shoes are available for dedicated use only in the surgical area. However, Shoe
covers may be needed to minimize contamination from and of shoes. Shoe covers
are not meant to prevent transmission of bacteria from the floor but rather prevent
contamination of shoes with blood and body fluids. (AORN 2015; Bearman et
al.,2014).
51
Activity 4.3: Case study
Instruction:
Form a group of 4-5 participants
Discuss on the following case study in your group and report
the summary of discussion in the plenary (share group
response with the larger groups using flipchart)
Case studies
Sr.Hana reports to work one day. The year is 2023, and she
is feeling good because the COVID-19 pandemic is over and
there are no known cases of COVID-19 in her area.
However, she also knows that the region is experiencing a
spike in seasonal influenza (flu). As she enters the clinic,
she notices that some patients in the waiting area are
coughing.
These patients are sitting on benches in a tight crowd,
waiting to be seen by staff. Sr.Hana knows that respiratory
secretions could spread infections in the waiting area. What
are some things that Sr.Hana and her colleagues at her
health center could do to reduce the spread of respiratory
infections in this setting?
Discussion Questions
1. If this were your institution, what kind of possible
interventions would you put in place?
2.If you are in the position of Sr.Hana what would you do?
Time Allowed: 15 min. (5 min for discussion and 10 min
for presentation)
Donning and doffing of PPE in the proper order and manner is just as important as
wearing PPE. Failure to properly put on or remove PPE could lead to exposure to or
lack of protection against infectious agents. The order of putting on and removing
PPE depends upon the purpose for which the PPE is being used. PPE is used for
Standard Precautions, operating theatres, isolation rooms during Transmission-
52
Based Precautions, and during disease outbreaks (e.g., novel respiratory disease,
VHF).
PPE should be removed at the doorway before leaving the patient room or in the
outer room:
1. Remove gloves.
2. Remove goggles/ face shield by the head band or ear pieces.
3. Remove the gown.
4. Remove the mask or respirator.
5. Dispose of single-use and reusable PPE in designated containers.
6. Remove shoe covers or boots (if used) before leaving the area.
7. Perform hand hygiene.
Sequence for donning on PPE for Sterile Surgical Procedures in the Operating
Theater
1. Change from street clothes to a clean scrub suit (one that has been
processed in the health care facility laundry). Remove all jewelry.
2. Put on non-skid, low-heel shoes with closed toes and backs, rubber boots, or
shoe covers when there is a risk of gross contamination with blood or body
fluids.
3. Perform hand hygiene.
4. Put on a plastic apron if the sterile surgical gown is not fluid-resistant.
5. Put on a surgical head cover (and facial hair cover, if needed) to ensure that
53
hair on the head (and beard) are fully covered.
6. Put on a surgical mask, one that fits well and fully covers the mouth and the
nose.
7. Put on appropriately sized, well-fitting goggles or a chin-length face shield.
8. Perform a surgical hand scrub using soap and water and ABHR (see: HAND
HYGIENE chapter).
9. Put on a sterile surgical gown without contamination (see Figure 5-7 A and
B: Putting on and removing an Isolation Gown).
10. Lastly, put on sterile surgical gloves without contamination (see Figure 5-11:
How to wear (don) sterile gloves).
Note: There may be instances where PPE to protect the HCW from infectious
diseases may be required in addition to surgical attire, such as a respirator for
surgery on a patient with known or suspected TB or additional skin coverage for
surgery on a patient with known or suspected viral hemorrhagic fever.
1. Remove the gloves following the recommended steps and dispose of in a waste
container; do not reprocess or reuse the gloves.
2. Remove the gown, avoid touching the outer side of the gown, and dispose of in a
waste container (if a single-use gown) or place the used gown in a container for
processing later.
3. Remove the plastic apron, if one was used, and dispose of in a waste container
(if a single-use apron) or place the used apron in a container for processing later.
4. Remove eye protection.
5. Remove the surgical mask.
6. Perform hand hygiene.
7. These steps will be performed at the end of day unless any item becomes soiled.
8. Remove the head cover (and facial cover).
9. Remove shoe covers (if worn).
10. Remove shoes.
11. Remove scrub suit.
12. Lastly, perform hand hygiene.
54
Adapted from: AORN 2015.
PPE recommended by the World Health Organization (WHO) for HCWs who provide
care and treatment to VHF (E.g., Ebola, COVID-19) patients includes:
55
4.5. SUMMARY
The use of PPE is recommended to protect HCWs, patients and visitors from
hazards encountered during their regular, daily duties.
An adequate supply of PPE should be available for use at the point of care.
Management staff should be aware when and how to replenish PPE supplies.
Health center staff should be educated and trained on the indications for PPE
56
CHAPTER 5: SHARPS AND INJECTION SAFETY
Chapter Description: This chapter discusses the risks and impact of unsafe
injections and help them recognize the role of healthcare workers in preventing
health risks associated with unsafe injections by avoiding unnecessary injections.
Chapter Objective
By the end of this chapter, the participants will be able to demonstrate how to safely
handle and dispose of sharps.
Enabling Objectives
Explain the common reasons for providing unnecessary and unsafe injection
Identify the risk and impact associated with unsafe injection
Demonstrate how to handle sharps safely
Chapter outline
57
5.1. RISKS AND IMPACT OF UNSAFE INJECTION AND CONDITIONS
CAUSING THE RISKS
Safe injection can be defined as: an injection that does not harm the recipient,
does not expose the HCW to any avoidable risks, provided by skilled person, using
appropriate injection equipment and does not result in waste that is dangerous for
the community.
58
5.1.2. Risk and Impacts of Unsafe Injection
Table 5.1: Conditions Causing Risks to Community, Patients/Clients and Providers
Community Patient/client Providers
Unsafe waste Use of injections when there are Shortage or absence of
disposal system other suitable alternatives appropriate injection and
of healthcare Applying pressure to bleeding sites safety devices
facilities with dirty material or finger Carrying used needles
Receiving Drug administered at incorrect before disposal
injections from anatomical site Placing needle on a
informal injectors Use of unsterile syringes and surface prior to disposal
Leaving sharps in needles (or use of ―new but Recapping needles
accessible place damaged compromised package) (either one or two hand)
to the public, Re-use of syringe and needles Manually detaching
especially Use of opened multi-use vials needles from syringes
children stored beyond recommended time Manipulating used
Sharing needles (contaminated drug use) sharps (cleaning,
and syringe Using wrong diluents or wrong bending, breaking or
Reusing needles amount cutting hypodermic
and syringes Use of expired drugs needle)
Syringes are loaded with different Passing on sharps from
medications one health worker to
Loading syringe with multiple doses another
Drugs and vaccines are stored in Sharps are found in
the same refrigerator unexpected places like
Accidental switching of drugs linen
Health workers not following aseptic Overfilling of sharps’
techniques containers
Patient/client moves during Using a syringe on an
administration of injection agitated patient without
Sharps are found in unexpected assistant or patient/client
places like linen moves during
Self-medication administration of injection
i. Risk to patients
Unsafe injections can result in: -
Transmission of blood born infections – example: - HBV, HCV,
HIV/AIDS…etc.
Injection abscesses
Paralysis
Drug/allergic reactions shock
ii. Risk to Health Care Workers
Globally, in the course of their duties, HCWs are at an increased risk from blood
borne pathogens. It was estimated that 39% of HCV, 37% of HBV, and 4.4% of HIV
infection among HCWs worldwide are attributable to occupational exposure to
sharps injuries. (Prüss-Üstün et al., 2005).
In addition – the indirect medical costs of due to HBV, HCV & HIV/AIDS is huge and
the psycho-social impact is also immense.
59
5.2. THE ROLE OF PRESCRIBERS AND PROVIDERS IN INJECTION
SAFETY
Encourage patients to accept oral medications; and explain the risks associated with
injections, when possible, to limit the use only when necessary.
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Table 5.2: Right Ways to Give Safe Injection
Standards
Rights Method of Verification
Always check and verify all ‘rights’
What is the name on the prescription? Is Ask patient/guardian, etc. to
1. Right Patient this the right patient? repeat name
Is the name of the drug on the prescription Verify name of drug on
the same as the injection you are about to prescription with injection to be
2. Right Drug administer? administered
If you are unsure verify with
physician or pharmacist
3. Right Could the medication be given orally Discuss with patient available
Formulation instead of as an injection? choices
Use only sterile, non-reusable syringes, Check to ensure that
4. Right Injection dental cartridge, etc syringe/needle package is
Equipment unbroken
Check dosage against patient’s age, weight Read the pharmaceutical
and the pharmacokinetics of the drug recommendations of the drug If
5. Right Dosage unsure, verify with the
physician/prescriber
Follow the specific dose interval Be mindful of the action of the
drug and why the time interval
6. Right Time should be followed. Explain the
importance of this to the patient
Be sure to use the correct route of Observe the direction of the
administration (intra-muscular, intravenous, prescriber
7. Right Route intra-dermal or subcutaneous) Check prescription or other
related records
Right temperature, Vaccine Vial Monitor Check cold chain issues including
8. Right Storage (VVM) shake test VVM
Do not recap needle. Check the safety box for correct
Dispose of used syringe and needle method of disposal
9. Right Method immediately after use in appropriate safety
of Disposal box
Or
Use the needle cutter and safety box
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Use Sterile Injection Equipment
Single use syringe and needle for each injection is recommended and Auto-disable
syringes are mandatory for all immunization injections.
Injuries may occur during procedures (health professionals), cleaning and washing
(house- keepers & laundry workers) and handling waste materials.
62
Anticipate and take measures to prevent sudden patient movement during and after
injection.
Do not recap, bend or break needles prior to disposal of single use needles and
syringes after giving injections. However, if there is a need to recap a needle due to
various reasons, needles must be recapped using the ―one-handed‖ recap method
as follows:
1. Place the cap on a flat surface, and then remove your hand
from the cap. With one hand, hold the syringe and use the
needle to scoop up the cap.
2. When the cap covers the needle completely, use your other
hand to secure the cap on the needle hub. Handle the cap at
the bottom, near the hub.
All patients undergoing an injection should be counseled before injection is given e.g., on
the type of drug, side effects, possible adverse effects/events following the administration of
the injection and total number of doses to be given by injection.
Self-injecting patients such as diabetic patients should be properly informed about their
medications and how to ensure safety or injection. In case a patient needs to take the
injection equipment home, he/she should be counseled on the storage, disposal and sterility
of their drugs and equipment.
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Standards for Administering Injections
Ensure that the patient is adequately prepared for and informed about the
procedure.
Keep the injection preparation area free of clutter; so, all surfaces can be
easily cleaned or if contaminated with blood & body fluids clean and disinfect
with 0.5% sodium hypochlorite solution or 70% alcohol solution,
Assemble all equipment needed for the injection: sterile, single-use needles
and syringes; reconstitution solution (sterile water or a specific diluent);
alcohol swab or cotton wool; and a sharps container
Prepare a well-laid up tray including emergency drugs for management or
possible drug reaction.
Wash hands with soap and water; dry
Check for expiry date, breach, leaks, particles or any contamination.
Use a sterile syringe and needle to withdraw the medication from the ampoule
or vial.
Open the package in front of the patient to reassure the person that the
syringe and needle have not been used previously,
Wipe the top of the vial with 70% alcohol (isopropyl alcohol or ethanol) using a
swab or cotton-wool ball. Allow it to dry.
Make sure that the right drug, dose, formulation and route are used for the
right patient or client at a right time,
Follow the manufacturer’s instruction and use the correct diluent, if needed
Draw the right dose as prescribed, including expelling the air using right
injection equipment,
Ensure aseptic technique while giving the injection,
Administer the drug at the correct site,
Dispose the used syringes and needles immediately into the sharp’s
container,
A patient should be kept in the room for at least 5 minutes after the injection
has been given and be observed for any possible adverse effect or events.
Thank the patient or the client.
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5.4. PRACTICAL GUIDANCE ON HANDLING PARENTERAL
MEDICATION
When using a sterile, single-use device (i.e., a syringe and hypodermic needle that
are not separated or manipulated unless necessary):
Use a new device for every patient, including for withdrawing medication. This
practice is considered a very basic IPC precaution and is promoted by WHO
(Safe Injection Global Network [SIGN]) and the US Centers for Disease Control
and Prevention (CDC), among others.
Inspect the packaging of the device to ensure that the protective barrier has not
been breached.
Discard the device if the package has been punctured, torn, or damaged by
exposure to moisture, or if the expiry date has passed. (WHO 2010)
ALWAYS follow the one needle, one syringe, and one injection rule.
DO NOT use the same mixing syringe and needle to reconstitute several vials.
DO NOT combine leftover medications for later use.
DO NOT use single-use vials for multiple patients, if possible.
When using single-use vials:
Vials labeled by the manufacturer – single dose, should be used only for a
single patient.
There may be circumstances when the contents of single-use vials must be
used for multiple patients. In this situation, contents from an unopened single-
use vial can be repackaged one time into multiple single-use syringes for
65
multiple patients. However, this should be performed only by a trained HCW
in an area away from patient care and in accordance with strict IPC
standards. Label as described below. Store for only 24 hours.
Check that you have the right medication vial for the patient’s prescription.
Double-check the expiration date and if the vial has previously been opened,
the current date is within 24 hours of opening (unless a shorter or longer time
frame is otherwise specified by the manufacturer).
Follow the principle of ― ONE SYRINGE, ONE NEEDLE, ONLY ONE TIME.
Discard the single-use vial after use.
If a dose has been withdrawn into a syringe and cannot be administered
immediately for any reason, cover the needle with the cap using a one-
handed scoop technique. Do not keep the medication longer than 24 hours
unless a shorter or longer time frame is otherwise specified by the
manufacturer. Inject the medication as soon as possible after withdrawing
from the vial.
When using multi-dose vials:
If a multi-dose vial is assigned to a single patient (e.g., insulin pen), check that
you have the right vial for the patient.
Double-check the expiration date and if previously opened, check that the vial
is labeled by the manufacturer as a multi-dose vial and the current date is
within 28 days of opening, unless a shorter or longer time frame is otherwise
specified by the manufacturer.
Follow the principle of ― ONE SYRINGE, ONE NEEDLE, ONLY ONE TIME.
When withdrawing medication from a multi-dose vial, avoid double dipping,
this may contaminate the contents of the vial and transmit infection to
subsequent patients.
DO NOT store multi-dose vials in patient care areas, where they could be
inadvertently contaminated.
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Procedure for vials with a rubber septum
Wipe the access rubber septum with 70% alcohol (isopropyl alcohol or
ethanol) with a swab or cotton-wool ball and allow it to dry before piercing the
vial or inserting a device into the bottle.
Use a new, single-use, disposable, sterile syringe and needle for each
insertion into a vial.
Never leave a needle in a multi-dose vial. This practice provides a direct route
for microorganisms including HIV to enter the bottle and contaminate the fluid
between each use.
Once the loaded syringe and needle have been withdrawn from a multi-dose
vial, administer the injection as soon as possible.
Labeling
67
Sharps Safety or Boxes:
68
Don’t place containers in high traffic areas where people could bump into
them or be stuck by someone carrying sharps to be disposed of.
Always put on a heavy-duty glove when handling sharps containers.
Dispose of the sharps and sharp containers by burning, burying or
encapsulation.
5.6. SUMMARY
Injections present risks to patients, HCWs, and the community and should be limited
where alternative administration routes are available. Safe injection practices are
one of the components of Standard Precautions. It is the responsibility of each HCW
to ensure safe injection practice.
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CHAPTER 6: Reprocessing of Instruments and Reusable Items
Chapter Description:
This chapter explains instrument and reusable items reprocessing by explaining and
demonstrating the importance and steps of instrument processing (cleaning, HLD
and sterilization) as well as safe storage and transport.
Chapter Objective
By the end of this chapter the participants will be able to apply reprocessing of
instruments and other items before reuse.
Enabling Objectives
By the end of this module, participants will be able to:
Define medical instrument reprocessing practice
Distinguish level of medical instruments disinfection or sterilization required
List commonly used disinfectants
Distinguish the Processes of medical instruments cleaning process,
sterilization and HLD
Identify monitoring mechanism, safe storage and transport of
reprocessed/decontaminated reusable medical devices
Session outline
6.1. Overview of Medical instrument reprocessing
6.2. Level of disinfection or sterilization required
6.3. Commonly used disinfectants and their properties
6.4. Steps of medical instruments and other items reprocessing
6.5. Monitoring, Storage and transport of sterilized and high-level disinfected
instrument and other item
6.6. Summary
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6.1. OVERVIEW OF INSTRUMENT REPROCESSING
71
Spaulding classified instruments and patient care devices into three categories, based
upon how the device is used. Items are classified as:
Non-critical — come in contact with intact skin but not mucous membranes
Semi-critical — come in contact with mucous membranes or non-intact skin
Critical — come in contact with sterile areas of the body including the vascular
system
Instruction:
Reflect on the following questions
Discussion Question:
1. What is the difference between antiseptic and disinfectant
2. What are the commonly used chemical disinfectants in
your healthcare settings?
Time Allowed: 5 Minutes
Commonly Used Chemical Disinfectants and their properties
A. Alcohols
Ethyl and isopropyl (2-propyl) alcohol (60 to 90%) are disinfectants which are
relatively cheaper and commonly available.
They are primarily used as antiseptic and as a low or intermediate-level
disinfectant (wiping oral and rectal thermometers and disinfecting external
surfaces of equipment- stethoscopes, cryoprobe tips, ultrasound probes, Ambu
bags or anatomic models).
Should be stored in a cool and well-ventilated place for they are flammable.
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B. Chlorine and chlorine releasing compounds
They are fast acting, very effective against HBV, HCV and HIV/AIDS, relatively
cheaper and readily available intermediate level disinfectants (CDC, 1987; WHO,
1989).
A major disadvantage is that concentrated Chlorine solutions (>0.5%) can corrode
metals. commonly used are Sodium hypochlorite (Chlorine bleach), Calcium
hypochlorite or chlorinated lime, Sodium dichloroisocyanurate.
NOTE: CHLORINE SOLUTIONS SHOULD NOT BE USED AS for HLD
Can be used in both liquid and gaseous forms for a chemical sterilization, as well
as a high-level disinfectant (Taylor, Barbeito & Gremillion 1969; Tulis, 1973).
Note: Formaldehyde is being used as a high-level disinfectant as well as a sterilant in
Ethiopia, but globally it’s slowly being phased out because of its toxicity. It produces a
dangerous gas (bis-chloroethyl-ether) when mixed with chlorine. Switching to less toxic
compounds such as Glutaraldehyde’s or other newer high-level disinfectants is strongly
recommended.
D. Glutaraldehyde
Glutaraldehyde’s are widely used for chemical sterilization and HLD of medical
instruments. The most commonly used antiseptic is an alkaline-stabilized 2%
Glutaraldehyde available commercially as Cidex® or Cidex 7®. These chemicals
which are derivatives of Formaldehyde are also irritating and their fumes are very
unpleasant. Therefore, they should be used only in well-ventilated rooms.
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E. Orthophthalaldehyde (OPA)
Have a number of features that make it a good choice for high-level disinfecting
instruments and medical devices.
Do not dilute this chemical unless specified in the manufacturer’s instructions
It is often available locally and is relatively cheaper than any other chemical
disinfectants and can be used to achieve HLD and sterilization. It has activity
against a wide range of microorganisms including vegetative bacteria, fungi, and
viruses.
A 3% solution can achieve HLD using a contact time of 30 minutes at 20°C
(68°F). To achieve sterilization, a higher concentration (7.5% solution) and a
longer contact time are required (6 hours at 20°C [68°F]).
H. Other Chemical Sterilant:
Storage of Disinfectants
Each item, be it soiled metal instruments requires special handling and processing in
order to
Minimize the risk of accidental injury or exposure to blood or body fluid to the
cleaning and housekeeping staff; and
Provide a high-quality end product (i.e., sterile (if not available high-level
disinfected
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EFFECTIVENESS
METHOD (Kill or remove END POINT
microorganisms)
Cleaning (soap and
Up to 80% Until visibly clean
rinsing with water)
High-Level Disinfection 95% (does not Boiling or chemical for 20
inactivate endospores) minutes
Sterilization High-pressure steam, dry heat
100% or chemical for the
recommended time
Cleaning
Cleaning is a process of physically removing infectious agents and other organic
matters on which they live and thrive but does not necessarily destroy infectious agents.
Cleaning is the first step in reprocessing a device after use and a critical step in
instrument processing because:
It reduces damage to instruments. Long contact with blood is corrosive and can
damage surgical instruments.
It makes instruments easier to process. Once blood dries on an instrument, it is
difficult to clean, especially if the blood has entered the hinges and sockets.
Steps of cleaning:
Facilities with minimal resources can adequately clean and prepare devices for
sterilization with an effective manual cleaning process. However, it is vital that all
devices be disassembled so that all surfaces may be cleaned and disinfected,
irrespective of the cleaning method chose.
Ensure that the device to be cleaned is compatible with the chemical solution
used in the facility
Completely submerge immersible items during the cleaning process to minimize
aerosolization and to assist in cleaning
Remove gross soil using tools, such as brushes and cloths
Clean devices that have lumens with an appropriate brush, then manually or
mechanically
flush with a detergent solution and rinse with potable water
Check devices with lumens for obstructions and leakage
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1. Put on Personal Protective Equipment (PPE) including a water-resistant gown, gloves,
face mask and head cover. If gloves are torn or damaged, they should be discarded;
otherwise, they should be cleaned and left to dry for re-use in the following day. Even
when wearing heavy-duty utility gloves, care should be taken to prevent needle sticks or
cuts when washing sharps.
2. Fill sink or appropriate basin with sufficient warm water for complete immersion of the
devices being cleaned
3. Add the appropriate quantity of detergent following the manufacturer ‘s instructions for
dosage
4. Clean the device under the surface of the water so that aerosols are not produced
5. Use appropriate brushes to properly clean box locks, lumens and other hard-to-clean
areas
A. Use soft (nylon) bristle brushes so that the surface of the instrument is not
damaged
B. Brushes used to clean lumens must be the same diameter as the instrument to
ensure that all internal surfaces can be reached
C. Brushes must also be long enough to exit the distal end of the instrument
6. In another sink or basin, completely immerse the device in clean purified water and
rinse the device thorough
7. Air-dry or hand-dry using a disposable clean, non-linting cloth
N.B: One can clean without sterilizing, but one cannot sterilize without cleaning!
77
Wrapping items to be sterilized permit sterile items to be handled and stored without
being contaminated (Figure 6.2: Typical instrument Wrapping Techniques). Materials
used for wrappers should:
Allow air removal and steam penetration
Act as a barrier to microorganisms and fluids
Capable of withstanding high temperatures
Resist tears and punctures and be free of holes
Be nontoxic and low lint
Not be costly
78
Tips for wrapping
At least two layers of wrapping should always be used to reduce the possibility of
contaminating the contents during unwrapping.
Do not wrap packages too tightly.
If they are wrapped too tightly, air can become trapped at the center of the
packages preventing the temperature from getting high enough to kill all the
microorganisms.
Also, wrapping with strings or rubber bands or tying linen too tightly can prevent
steam from reaching all surfaces.
The outer wrapper of the pack can be loosely secured using linen ties.
Packs can be secured with linen ties made from the same cloth.
Hemmed strips of about ½ inch wide and of varied lengths.
One or two of such strips can be used for each package. Because they can fit to
almost any size of package, they eliminate the need for an expensive and hard-to-
remove indicator tape.
Do not wrap items in any waterproof material such as plastic or canvas for steam
sterilization as the steam cannot penetrate the material and leave the item
unsterilized.
Wrappers should not be reused if they are torn, stained with oils or have hard or
gummy deposits.
High-Level Disinfection
High-Level Disinfection can be achieved by:
79
Boiling has been a common practice for HLD of instruments and equipment used
for semi-critical and sometimes critical procedures as it was the only available
option in some low-income countries.
Tips on Boiling
Always boil for the required time period in a container with a lid.
Start timing when the water begins to boil.
Metal instruments should be completely covered with water during boiling.
Do not add anything to the pot after timing begins.
80
Figure 6.3: Steamer Used for HLD
High-Level Disinfection Using Chemicals
Thoroughly clean instruments and other items that may have been
contaminated with blood and body fluids and thoroughly clean and dry them
before placing them in the disinfectant solution.
Completely immerse all items in the high-level disinfectant.
Soak them for 20 minutes.
Remove items using high-level disinfected or sterile forceps or gloves.
Rinse well with boiled and filtered (if necessary) water three times and air dry.
Use promptly or store in a dry, high-level disinfected and covered container.
Sterilization
Note: Rinsing an item with Alcohol and then igniting it with a match (flaming) is not an
effective method of disinfection or sterilization.
Methods of Sterilization
Steam is an effective sterilant in that it can soften any resistant and protective
outer layer of the micro-organisms allowing coagulation of the inner sensitive
portion of the micro- organisms.
82
As an alternative, it could be set at a higher temperature of 1320C (2700F) with
the pressure of 30lbs/in2; and the duration being 15 minutes for wrapped items.
Whatever the case may be, one should allow all items to dry before removing them from
the sterilizer.
These include:
Routine maintenance,
Preparing items to be sterilized,
Packaging and wrapping,
Loading,
Operating, and
Unloading the sterilizer.
Instructions of Operating a Steam Sterilizer
STEP 1 Thoroughly clean and dry all instruments and other items to be sterilized.
STEP 2 All jointed instruments should be in an open or unlock position, while
instruments composed of more than one part or sliding parts should be
disassembled.
STEP 3 Instruments should not be held tightly together by rubber bands or any other
means that will prevent steam contact with all surfaces.
STEP 4 Arrange packs in the chamber to allow free circulation and penetration of
steam to all surfaces.
STEP 5 when using a steam sterilizer, it is best to wrap clean instruments or other
clean items in a double thickness of muslin or newsprint. (Unwrapped instruments
must be used immediately after removal from the sterilizer, unless they are kept in
a covered, sterile container.)
STEP 6 Sterilize at 1210C (2500F) for 30 minutes for wrapped items and 20 minutes
for unwrapped items; set time of the clock.
STEP 7 Wait 20 to 30 minutes (or until the pressure gauge reads zero) to permit the
sterilizer to cool sufficiently. Then open the lid or door to allow steam to escape.
83
Allow instrument packs to dry completely before removal which may take up to 30
minutes (Wet packs act like a wick drawing in bacteria, viruses and fungi from the
environment). Wrapped instrument packs are considered unacceptable if there are
water droplets or visible moisture on the package exterior when they are removed
from the steam sterilizer Chamber. If using rigid containers (e.g., drums), close the
gaskets.
STEP 8 To prevent condensation when removing the packs from the chamber, place
sterile trays and packs on a surface padded with paper or fabric.
STEP 9 after sterilizing, items wrapped in cloth or papers are considered sterile as
long as the pack remains clean, dry (including no water stains) and intact.
Unwrapped items must be used immediately or stored in covered sterile containers.
Maintain a steam sterilizer log including heat begun, correct temperature and
pressure achieved, heat turned down, and heat turned off.
Each load should be monitored with mechanical (time, temperature and pressure)
and chemical (internal and external chemical test strips) indicators.
Autoclave should be tested daily with an air-removal test to ensure proper
removal of air.
If steam escapes from the safety valve or under the lid, the autoclave is not
working
correctly. Rather, it is merely steaming items at low-pressure (which may be
equivalent to
HLD, not sterilization). Then, what is to be done?
If steam escapes from the safety valve instead of the pressure valve, the pressure
valve
must be cleaned and inspected.
If steam escapes from under the lid, the gasket (rubber ring) must be cleaned and
dried or
replaced
2.Dry Heat Sterilization Method
Dry heat sterilization is caused by hot air that destroys micro-organism through
oxidation that causes slow destruction of the micro-organism’s protein.
84
When available, dry heat is a practical means by which needles and other sharp
instruments are sterilized.
Dry-heat sterilization can be achieved with a simple oven as long as a
thermometer is used to verify the temperature inside the oven.
3 Chemical Sterilization
Biological Indicators
Chemical Indicators
Chemical indicators include indicator tape or labels which monitor time, temperature
and pressure for steam sterilization and for dry-heat sterilization. These indicators
should be used on the inside and outside of each package or container.
External Indicators - are used to verify whether the items have been exposed to
the correct conditions of the sterilization process and the specific pack has been
sterilized.
Internal Indicators - are placed inside a pack or container in the area most
difficult for the sterilization agent to reach (i.e., the middle of a linen pack). This is
the indicator that tells if the item has been sterilized.
Chemical indicators like heat sensitive tape or glass vials containing pellets that melt at
certain temperatures and duration do not imply achieved/successful sterilization. They
do, however, indicate whether mechanical or procedural problems have occurred in the
sterilization process.
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Mechanical Indicators
Provide a visible record of the time, temperature and pressure of the sterilization
cycle for sterilizers. This is usually a printout or graph from the sterilizer, or it can
be a log of time, temperature and pressure kept by the person responsible for the
sterilization process that day.
Safe Storage of Sterile/ HLD Instrument
All sterile items should be stored appropriately to protect them from dust, dirt, moisture,
animals, and insects.
The storage area should be located next to the place of sterilization or connected to it in
a separately enclosed area with limited access that is used just to store sterile and clean
patient care supplies.
Handling and Transporting Instruments and Other Items
Keep clean and highlevel disinfected or sterile instruments and other items separ
ate from soiled equipment and waste items. Do not transport or store these items
together.
Transport high-level disinfected and sterile instruments and other items to the
procedure or operating room in a closed cart or container with a cover to prevent
contamination.
Transport soiled supplies and instruments to the receiving/cleanup area in leak
proof and covered waste containers.
Note:
If supplies are being delivered to the surgical area; one person standing outside should
pass them through the door to a person inside the operating room.
Instructions for Storing Sterile Items
1. Keep the storage area clean, dry, dust-free and lint-free.
2. Control temperature and humidity (approximate temperature 24oC and relative
humidity <70%) when possible.
2. Packs and containers with sterile (or high-level disinfected) items should be
stored 20 to 25cm off the floor, 45 to 50cm from the ceiling and 15 to 20cm
from an outside wall.
3. Do not use cardboard boxes for storage because cardboard boxes shed dust
and debris and may harbor insects.
87
4. Date and rotate the supplies (first in/first out). This process serves as a
reminder, but does not guarantee sterility of the packs.
5. Distribute sterile and high-level disinfected items from this area
6.6. SHELF LIFE
The shelf life of an item (how long items can be considered sterile) after
sterilization is event related.
To make sure items remain sterile you need to prevent events that can
contaminate sterile packs and protect them by placing them in plastic covers (thick
polyethylene bags).
An event can be a tear or worn-out area in the wrapping, the package becoming
wet or anything else that will enable microorganism to enter the package becoming
wet or anything else that will enable microorganism to enter the package or
container.
The Shelf Life of Sterilization Depends on the Following Factors:
Quality of the wrapper or container.
Number of times a package is handled before use.
Number of people who have handled the package.
Whether the package is stored on open or closed shelves.
Condition of storage area (e.g., humidity and cleanliness).
Frequent or improper handling or storage.
Use of plastic dust cover and method of sealing
Note: Maximum shelf life is 1 month period even under safe environmental
conditions
6.7. SUMMARY
Applying Spaulding’s classification of non-critical, semi-critical, or critical items
determines the method that should be used to process instruments.
Cleaning is the most important step in instrument processing because it makes
instruments safer for additional processing prevents bioburden
HLD should be carried out for instruments and devices that come in contact with
mucous membranes and non-intact skin by chemical, steaming or boiling.
Sterilization is a process in which the destruction of all micro-organisms including
bacterial endospores takes place.
88
All sterile items should be stored appropriately to protect them from dust, dirt,
moisture, animals, and insects.
An item remains sterile until something causes the package or container to
become contaminated
89
CHAPTER 7: LINEN MANAGEMENT
Duration: 45 Min
Chapter Description:
This chapter overview plan on standard laundry services, use proper personal
protective equipment in laundry services, demonstrate how used textiles collected,
transported sorted, washed, dried, stored, and distributed hygienically.
Chapter Objective
By the end of this chapter the participants will be able to analyze the proper linen
management in healthcare facility.
Enabling Objectives
Chapter outline
90
7.1. STANDARD LAUNDRY SERVICE
Table 7.1: Recommended PPE for Processing Textiles for different activities
92
7.2. KEY STEPS IN PROCESSING USED LINEN
Processing linen consists of all the steps required to collect, transport and sort soiled
linen as well as to launder (wash, dry and fold or pack), store and distribute it. Safely
processing textile from multiple sources is a complex process. To reduce the risk of
contamination, procedures should be in place to safely handle, process, and store
linens.
Collecting
93
According to my assumption, the above diagram leads us what should be done
at each key step. Ensure mechanism to protect hospital acquired infection at
each segment of process of laundry service.
Collecting
Linen, surgical drapes, window curtains, rags, mops, uniforms, gowns, lab coats and
others could be laundered. Sorting in the laundry area is essential. Sorting should be
done separate from clean areas with limited traffic. Work surfaces are at or above the
waist height. The sorting area needs to be equipped with sink, disposable gloves, soap
and towels. The area should be provided by sharps containers.
Sorting of laundry should be done either before or after washing. Large health facilities
usually sort laundry before washing due to existence of high volumes of laundry.
94
Sort same textile, same fiber or sort by products needed or by those who
are packed together (gowns, curtains, etc.).
95
reduction this allows exposure to ultraviolet sunrays, which produces natural
disinfection.
Dryer heat is also effective in ensuring total bacterial kill. Ironing has the same
effect but linen need not be sterilized.
Store clean linen and supplies in a separate place away from the soiled linens.
Three clean sets of linen per bed should be available.
Mattresses and pillows
96
Include the laundry activity in weekly, monthly, quarterly and yearly plan and
report accordingly.
7.3. SUMMARY
Health care outbreaks and HAI occur because of contaminated linens and HCWs
can experience injuries and exposures if recommendations are not followed.
Proper storing, transporting, and distributing hygienically clean linens is important
to avoid any microbial contamination
Periodic monitoring the laundry service functionality is very important
97
CHAPTER 8: ENVIRONMENTAL CLEANING
Chapter Description:
Chapter Objective
By the end of this chapter, participants will be able to illustrate proper environmental
cleaning in primary health care setting.
Enabling Objectives
Chapter outline
98
8.1. IMPORTANCE OF ENVIRONMENTAL CLEANING IN HEALTHCARE
FACILITIES
99
Environmental cleaning is a very simple activity which based on the above simple
practical principles but its impact in preventing a range of healthcare associated
infections is very tremendous.
Scrubbing (frictional cleaning) is the best way to physically remove dirt, debris
and microorganisms.
Cleaning is required prior to any disinfection process because dirt, debris and
other materials can decrease the effectiveness of many chemical disinfectants.
Cleaning products should be selected on the basis of their use, efficacy, safety
and cost.
Cleaning should always progress from the least soiled areas to the most soiled
areas and from high to low areas so that the dirtiest areas and debris falling on
the floor will be cleaned up last.
Dry sweeping, mopping and dusting should be avoided to prevent dust, debris
and microorganisms from getting into the air and landing on clean surfaces, as
airborne fungal spores can cause fatal infections in immune- suppressed
patients.
Instructions for mixing (dilution) should strictly be followed when using
disinfectants. (Too much or too little water may reduce the effectiveness of
disinfectants).
Cleaning methods and written cleaning schedules should be based on the type of
the surface, the amount and the extent of the soil present and the purpose of the
area.
Routine cleaning is necessary to maintain the standard of cleanliness. Also,
schedules and procedures should be consistent and posted.
During cleaning, workers should always wear gloves (preferably heavy utility gloves)
and shoes that cover the toes. If there is a potential for splashing or for splattering (e.g.,
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during the cleaning of toilets), they may need additional protection such as an
impermeable apron, mask, and protective eyewear.
Disinfectants are only for disinfecting after cleaning and are not substitutes for cleaning.
Before disinfecting, use a cleaning product to remove all organic material and soil.
Provide training and simple instructions (e.g., standard operating procedures (SOPs))
for preparing solutions according to manufacturer’s instructions.
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How to Prepare Chlorine Solution
Equation 1-1
Mix 1part concentrated bleach with the total parts water required
Example: Make a dilute solution (0.5%) from 5% concentrated solution
• Surface cleaning supplies: portable containers (e.g., bottles, small buckets) for
storing environmental cleaning products (or solutions) and surface cleaning
cloths.
• Floor cleaning supplies: mops or cleaning squeegee with floor cloths, buckets,
and wet floor/caution signs.
Cleaning should start with the least soiled area and extend to the most soiled area and
from high to low surfaces. Common methods of cleaning are briefly described below:
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Cleaning and Disinfecting of High Touch Surfaces and Items
The identification of high-touch surfaces and items in each patient care area is a
necessary prerequisite to the development of cleaning procedures, as these will often
differ by room, ward and facility.
Common high touch surfaces includes door handle (doorknobs), sink handles, switches,
examination tables, bedrails, IV poles, bedside tables, tables where medications and
supplies are prepared, Edges of privacy curtains, screens…..
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Wet Mopping Method for Floor Cleaning
Single-Bucket (Basin) Technique
Only one bucket of cleaning solution is used here.
The solution, however, needs to be changed when dirty.
The killing power of the cleaning product decreases with the increased
load of soil and organic material present
Double-Bucket Technique: -
Two different buckets are used here
One containing a cleaning solution and the other containing water for
rinsing.
The mop is always rinsed and wrung out before it is dipped into the
cleaning solution.
The double-bucket technique extends the life of the cleaning solution
(fewer changes are required) saving both labor and material costs.
Triple-Bucket Technique: -
The third bucket is used for wringing out the mop before rinsing
This extends the life of the rinse water.
Flooding Followed by Wet Vacuuming Method
It is preferable for surgical suits.
It eliminates mopping and minimizes the spread of micro-organisms.
It increases the contact time of the disinfectant and the area to be
cleaned.
Preferably, it should be done at night when the traffic flow of the facility is
low.
Wet Dusting
Should be used for cleaning walls, ceilings, doors, windows, furniture, and
other environmental surfaces.
Clean clothes or mops are made wet with cleaning solution contained in a
basin or bucket. The double-bucket system minimizes the contamination
of the cleaning solution.
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Dry dusting should be avoided, and dust cloths should not be shaken
either for fear of spreading of micro-organisms.
Should be performed in a systematic way using a starting point as a
reference to ensure that all surfaces have been reached.
Check for a stain that may indicate possible leaks when doing high
dusting, (ceiling tiles and walls). Leaking holes or cracks should be
repaired as soon as possible because moist structure provides a reservoir
for fungal growth.
Dry Vacuuming
This is recommended only for cleaning carpets
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8.5. RISK BASED AREA CATEGORIZATION AND CLEANING
SCHEDULE
These areas are usually not contaminated with blood or body fluids or with
associated infectious microorganisms, so the risk of infection is minimal. Routine
cleaning- the kind of cleaning you would do in your home – is usually good enough
for these areas. In general, clean these areas with a cloth or mop dampened with
detergent and water at least once daily
These are areas used for the care of patients who are not obviously infectious and
not highly susceptible. These areas are usually cleaned by procedures that control
dust, such as damp mopping with detergent cleaners. Dry sweeping or vacuum
cleaners are not recommended. The use of detergent solution improves the quality
of cleaning. Spills of blood and body fluids are cleaned up with a disinfectant
solution. Patient rooms should be cleaned daily and right after patient is discharged
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These are special care areas (e.g., isolation wards, intensive therapy units, operating
room, and dialysis unit). In these areas there is a greater potential pathogen
contamination with infectious materials and more of a concern about potential
infection transmission to both patient and clinic staff. These areas must be cleaned
with care using a cleaning solution and separate cleaning equipment; disinfectant-
detergent solutions are used as needed. Total cleaning is not necessary between
each case for surgical procedures. Total cleaning or terminal cleaning (mopping
floors and scrubbing all surfaces from top to bottom) of the operating room should be
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Table 8.1: Cleaning different areas with different risk level in health facilities
When spills of blood, body fluids and other potentially infectious fluids occur:
1. Restrict the activity around the spill until the area has been cleaned and disinfected
and is completely dry.
2. Wear appropriate PPE.
3. Confine the spill and wipe it up immediately with absorbent (paper) towels, cloths, or
absorbent granules (if available) that are spread over the spill to solidify the blood or
body fluid (all should then be disposed as infectious waste).
4. Clean thoroughly, using neutral detergent and warm water solution.
5. Disinfect by using a facility-approved intermediate-level disinfectant, typically 0.5%
chlorine-based disinfectant and allow the disinfectant to remain wet on the surface for
10 minutes and then rinse the area with clean water to remove the disinfectant
residue (if required).
6. Immediately send all reusable supplies and equipment (e.g., cleaning cloths, mops)
for reprocessing (i.e., cleaning and disinfection) after the spill is cleaned up.
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Place in a small, closed container for disposal (possibly encapsulation and
burial of the waste away from water resource area) or reuse,
Wash or clean the area with a chlorine solution,
Remove used gloves carefully and wash hands properly.
STEP 1, Decontaminate cleaning equipment that has been contaminated with blood or body
fluids by soaking it for 10 minutes in a 0.5% Chlorine solution or other locally
approved and available disinfectants.
STEP 2, Wash cleaning buckets, cloths, brushes, mops and the like with detergent and
water daily or right away if visibly dirty.
STEP 4, Dry them completely before reuse. (Wet clothes and mop heads are heavily
contaminated with microorganisms).
8.7 SUMMARY
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CHAPTER 9: HEALTH CARE WASTE MANAGEMENT
Chapter Description
This chapter describes the overall health care waste management, which includes
generation, collection, transport, storage, and disposal through which they must be
handled properly because they may carry microorganisms that have the potential to
infect individuals who come in contact with them that effective waste management is
critical to infection prevention and control in the health Centers.
Chapter Objective
By the end of this chapter the participants will be able to apply appropriate waste
management.
Enabling Objectives
By the end of this module, participants will be able to:
Define healthcare waste
Distinguish different types of health care waste
Discover risks related to healthcare waste
Demonstrate how health care waste are segregated and disposed in a heath
care facility
Chapter outline
9.1. Source and Types of healthcare waste
9.2. Risk associated with healthcare waste
9.3. Management of Healthcare waste
9.4. Summary
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9.1. SOURCES AND TYPES OF HEALTHCARE WASTE
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Pharmaceutical Pharmaceuticals wastes that are expired or no longer needed and items contaminated
waste by or waste containing pharmaceuticals.
Cytotoxic waste Cytotoxic waste contains by-products of drugs that kill dividing cells, which are waste
used for treatment of certain cancers. It also includes waste materials that can damage
human genes (e.g., DNA) and may cause cancers or congenital deformities among
babies. This waste can include sharps, PPE, and body fluid exposed to the drugs
Chemical waste Waste containing chemical substances (e.g., laboratory reagents, film developer);
disinfectants that are expired or no longer needed; solvents; and waste with a high
content of heavy metals (e.g., batteries, broken thermometers, and blood pressure
gauges).
Radioactive waste Waste containing radioactive substances (e.g., unused liquids from radiotherapy or
laboratory research; contaminated glassware, packages, or absorbent paper; urine and
excreta from patients treated or tested with unsealed radionuclides; and sealed
sources—containers in which radioactive substances are stored and sealed).
Adapted from: World Health Organization (WHO). 2013. Safe Management of Wastes from HealthCare Activities, 2nd ed. page
4. WHO: Geneva, Switzerland. http://apps.who.int/iris/bitstream/10665/85349/1/9789241548564_eng.pdf?ua=1.
The preferred strategies for reducing health care waste are to minimize waste
generation by preventing waste production, reducing waste production, reusing, and
recycling waste, and recovering useful substances from waste. The least preferable
strategy is treating and disposing of health care waste.
The ability of the health care facility to safely dispose of the product after it is finished
should be one of the considerations during product selection.
While general waste is the least expensive and easiest to dispose of, infectious and
hazardous waste, which makes up 15% of waste, is more expensive and riskier to
handle. When general waste is mixed with infectious or hazardous waste, the cross‐
contamination is introduced, and all the resulting waste must be treated as infectious
and hazardous.
Mixed waste occurs when wastes are not properly separated at the point of
generation or are mixed during any part of the waste management process.
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Segregation at the point of waste generation will reduce the amount of waste
that the facility must treat as infectious or hazardous and is a key strategy for
improving waste management at health care facilities.
Note: Approximately 75–90% of the general waste produced by health care facilities
is non-contaminated and poses no risk of infection for those who handle it. Similar in
nature to municipal waste, all or most general waste can be discarded in dumps or
landfills or burned in incinerators. (WHO 2014).
Use the following guidelines when disposing of infectious and general waste at the
point of generation in all types of health care facilities
The HCW who generates the waste should segregate it where it is generated
(e.g., before leaving a patient’s room, examination room, operating theater or
laboratory).
The waste should be separated into the local or WHO categories (based on
its potential hazard and final disposal method) [see Table 9.2 in this chapter].
Separating wastes by hand after generation puts HCWs at risk and should not
be allowed.
Deposit infectious waste in a labeled or color-coded, leak-proof, puncture-
resistant container.
Use leak-proof (plastic or galvanized metal) containers with tight-fitting covers
for contaminated and hazardous wastes to protect patients and HCWs.
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Where available and feasible, use sturdy plastic bags/bin liners inside of the
waste collection containers to assist with waste collection and transport.
o DO NOT re-use plastic bags or bin liners.
Use puncture-resistant sharps containers for all disposable sharps (e.g.,
sharps that will not be reused).
Note: The waste containers and sharp containers should be placed at the point of use
so that HCWs do not have to carry waste items.
o There must be separate bins for at least three different kinds of waste:
general, infectious, and sharps.
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Note: It is important to train all HCWs, including clinicians and cleaning staff, and
patients to keep infectious and non-infectious waste separate.
To manage waste in healthcare facilities and ensure timely and safe disposal, waste
collection and transportation systems should be developed using the following
criteria:
Waste collection time table and routes should be carefully planned and drawn
out taking into consideration the principle of collecting from least to most
infectious waste (e.g., the laboratory would be last on a collection route).
Collect waste on a regular basis such as daily or sooner if needed according
to the rate it is generated and the size of the waste containers.
o For example, operating theaters (if available), labor and delivery areas,
laboratories, and outpatient clinics may generate more waste at
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different times than other areas and require more frequent collection
schedules.
Note:
Never use hands to compress waste into containers.
Hold plastic bags at the top.
Keep bags from touching or brushing against the body while lifting or during
transport.
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Note: Waste bags and sharps containers should NOT be filled more than three-
quarters full.
Storage of Waste in Health Care Facilities
Waste storage areas in the health care facility should be kept clean, organized,
protected from pests and the public (children or scavengers), and well-shaded to
reduce heat buildup). The area must have separate store for difference waste
categories and should have good water supply with sink for hand hygiene and
should be regularly cleaned.
Disposal of Health Care Waste
Recommended Waste Disposal Methods
Choosing the best currently available waste disposal method and working towards
safer waste disposal to protect the community and the environment is essential.
Infectious and hazardous waste should be treated prior to final disposal.
Sharps (e.g., hypodermic needles, suture needles, razors, and scalpel blades
require special handling because they are the items most likely to injure the
HCWs who use them as well as people in the community if these items go to
the municipal landfill without proper treatment methods.
o By autoclave, followed by shredding (mechanical), and then disposal in
a landfill or sharps pit
o By incineration (sharp objects may not be completely destroyed by
incineration, but it does make them less likely to be reused or
repurposed and less risky to handle) and disposal in an ash pit
o By shredding (mechanical) and disposal in a sharps pit (there is a risk
of exposure to staff handling non-decontaminated sharps).
If other treatment options are not available, small quantities of sharps waste
can be encapsulated and disposed of in a landfill.
Liquid infectious waste includes liquid culture media, blood, body fluids, and
human excreta. Products that can be added to liquid waste to solidify it for
safer handling may be available.
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Other Hazardous Wastes
Chemical waste
Chemical waste includes residues of chemicals in their packaging, outdated
or decomposed chemicals, or chemicals that are no longer required.
Chemical wastes are generally collected in containers with infectious waste
and can be incinerated at a high temperature, encapsulated, or buried. Return
the chemical waste to the original supplier, if possible.
Note: Different types of chemical waste should never be mixed. Chemical
waste should not be disposed of in a sewer system.
Chemical containers
For plastic containers that held toxic substances such as glutaraldehyde (e.g.,
Cidex) or formaldehyde, rinse three times (dispose of rinse water as chemical
waste) with water and dispose of by burning, encapsulating, or burying. Do
not reuse these containers for other purposes.
Wear proper PPE to protect eyes and skin from splashes and rinse glass
containers thoroughly with water. Glass containers may be washed with soap,
rinsed, and reuse.
Pharmaceutical waste
Small quantities of non-hazardous pharmaceutical (drugs or medicines) waste
are usually incinerated, encapsulated, or safely buried. Examples of non-
hazardous pharmaceutical waste include vitamins, salts and amino acids
(ampoules and fluids), solid or semi-solid tablets, granules, powders, creams,
gels, lotions and suppositories, and aerosols (e.g., sprays and inhalers).
o All controlled substances, cytotoxic/genotoxic drugs, anti-
infective/antibiotic drugs, and disinfectants and antiseptics are
considered hazardous waste (WHO 2014). It should be noted that
temperatures reached in a single-chamber drum or brick incinerator
may be insufficient to totally destroy pharmaceuticals and therefore
they can remain hazardous.
o Water-soluble, relatively mild pharmaceutical mixtures (e.g., vitamin
solutions, cough syrups, intravenous solutions, eye drops) may be
diluted in large amounts of water and then discharged into sanitation
systems.
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Antibiotics or cytotoxic drugs should not be discharged into municipal sewers
or watercourses.
o Return of expired pharmaceuticals to the donor or manufacturer
Waste with a high content of heavy metals
Examples of wastes with heavy metal content include batteries that contain
cadmium, thermometers, and blood pressure machines containing mercury.
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Open burning, because:
It is dangerous.
Temperatures reached are not adequate to treat health care waste.
It is unsightly
The smoke is a pollutant.
Incineration is one method of waste disposal and involves controlled burning of
solid, liquid, or gaseous combustible wastes that result in inorganic, non-combustible
residue.
Types of Wastes That Should Not Be Incinerated
Plastics at low temperatures
Large amounts of reactive chemical waste
Pressurized gas containers (e.g., aerosol cans)
Silver salts and photographic or radiographic wastes
Plastics containing polyvinyl chloride (e.g., blood bags, IV tubing, or
disposable syringes)
Waste with high mercury or cadmium content (e.g., broken thermometers,
used batteries, and lead-lined wooden panels)
Radioactive materials
Pharmaceuticals thermally stable in conditions below 1,200°C (2,192°F) (e.g.,
5 fluorouracil) Source: WHO 2014
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9.4. SUMMARY
Health care waste is a waste from different sources of the health facility service
areas. A health care waste is potentially hazardous and can by generally classified
as either non-hazardous or hazardous waste. The hazardous/infectious waste further
can be classified by its type (table 9.1). Contact to health care waste can cause a
risk of injury and different infections resulting in morbidity and mortality.
Waste minimization to limit the volume of hazardous waste produced and waste
segregation to minimize the proportion of the total waste are key waste management
measures in all settings.
Choosing the best available waste disposal method and working towards safer waste
disposal to protect the community and the environment is essential.
Effective waste management will save resources, reduce costs, and prevent injuries
and exposure to infectious disease.
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CHAPTER 10: FOOD AND WATER SAFETY
Duration: 45 Min
Chapter Description
This chapter describes good hygiene and food safety practices as well as measures
to be taken to prevent food contamination while transportation, preparation, storage
and serving food in the primary health care settings.
Chapter Objective
By the end of this chapter participant will be able to explain principles of food and
water safety and measures.
Enabling Objectives
Chapter outline
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10.1. PRINCIPLES AND STANDARDS OF FOOD SAFETY AT HEALTHCARE
FACILITIES
Activity 10.1: Individual reflection
Instruction:
Share your ideas with your facilitator and trainees on the
following discussion points
Discussion Question
1. Why the safety of food is more critical in health care
facilities?
Time Allowed: 5 minutes
All activities in the food service department should be monitored regularly to be sure
that safety principles and standards are being followed. These include:
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Know how to clean and operate equipment they use such as knives and
dishwashers
Kitchen staff should have access to PPE (face masks, hair covers, and
plastic aprons at a minimum). Other personal protective equipment should be
supplied as necessary
Able to plan and conduct management of wastes.
Holding temperatures:
Cooking of food
Purchase raw food from known vendors that meet local inspection standards
/specification of the HC.
Purchased raw food has to be transported to the health care facilities with
transportation free from biological and chemical contaminants.
Storage of raw and cooked food should be separate and with recommended
temperature
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Based on the type of food to be stored (for example easily perishable and
cereals) and it has to be monitored on daily basis
Educate about hand washing during critical times (before preparing food,
before eating, after toilet, after contact with contaminated surface, after
wiping/blowing the nose, after handling soiled tissues, before & after giving
care for their patients)
Prohibit health care workers consuming or storing food in areas where blood
or other potentially infectious or toxic materials are located or stored, including
refrigerators, cabinets, shelves, and counters.
Instruction:
Discussion Question
1. What are the common types of food contamination in
healthcare facilities and how can we prevent it?
Time Allowed: 5 Minutes
Please note that: Food that is contaminated with any of these hazards is
unsafe and unsuitable to eat.
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To survive and multiply, bacteria need; water, food, correct temperatures,
time, most but not all, need oxygen.
Under these conditions, bacteria will multiply by dividing in two every 10-20
minutes. After 6 hours, 1 bacterium can multiply into 262,144 bacteria, more
than enough to cause food poisoning.
How do bacteria enter a food premises?
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Unclean food premises
Dirty kitchens increase the risk of cross-contamination from pests and
particles of food, grease and dirt.
Poor pest control
Common pests found in food premises includes: flies, Cockroaches, Rats
and mice. These pests can carry food poisoning bacteria and may also cause
physical contamination of food with their droppings, eggs, fur and dead
bodies.
Temperature control
o Minimise the time that potentially hazardous foods spend in the danger
zone; always remember to keep cold food cold at 5°C or colder and hot
food hot at 60°C or hotter.
o All food Health facilities are required to obtain and use a probe
thermometer, accurate to +/-1°C to monitor the temperature of
potentially hazardous foods.
Avoid cross-contamination – to avoid cross-contamination do the following:
o Keep food covered until use,
o Separate raw and cooked, and old and new food at all times,
o Use separate equipment and utensils when preparing raw meats,
o Clean and sanitise all equipment, utensils, and food contact surfaces
and
o Store chemicals separate from food.
o Practice corrects personal hygiene – the following should be
considered:
Clean hands and clothing,
Minimise jewellery on hands and wrists,
Tie-back or cover hair,
Clean and short fingernails,
Avoid unnecessary contact with food,
Cover all cuts and sores with a brightly coloured waterproof
dressing,
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Do not eat over food or on food surfaces,
Do not prepare food when you are ill,
Avoid touching your face and hair,
Do not cough or sneeze over food,
Do not taste food with your fingers or “double dip” with a spoon
and
If wearing gloves, change frequently.
Proper Hand Washing: When should you wash your hands?
o Before commencing or resuming work,
o After using the toilet,
o After handling rubbish,
o After using a handkerchief or tissue,
o After touching your hair or face,
o Before and after handling raw food,
o Before handling cooked food and
o After any cleaning task.
Avail Hand washing facilities
o Must be accessible to all food handlers, to be used only for the
washing of hands, provide soap and warm potable water, provide
disposable towels for drying hands, provide a bin for the disposable
towels.
Cleaning
o Must be continuous and ongoing; thoroughly clean and sanitise all food
surfaces, equipment and utensils with hot water and detergent and
chemicals (sanitisers). Remember that most detergents do not kill
bacteria, but hot water and sanitisers do! Implement a cleaning
schedule to ensure that cleaning is conducted on a regular basis
(including hard reaching places).
Cleaning and sanitising with/without a dishwasher
o Wear rubber gloves to protect your hands from the hot water and
chemicals.
o Remove food particles by scraping or soaking.
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o Wash using hot water and detergent – change the water if it becomes
cool or greasy.
o Rinse in hot water with chemical sanitiser or in very hot water (above
80°C - only if sink has heating element and rinsing baskets) and leave
to soak for 30 seconds.
o Either drip-dry or use a clean tea towel to reduce the risk of cross-
contamination.
Pest Control
o Keep them out – seal the food premises.
o Starve them out – keep food premises clean.
o Throw them out – conduct regular pest inspections or services.
o Don’t give them a home - remove all unnecessary equipment and
items.
o Report all pest sightings or evidence of pest activity to your supervisor.
o Waste management
o Place waste in plastic lined bins.
o Remove all waste from the premises as required.
o Empty and clean waste bins regularly.
o Ensure all external bins are covered.
o Protect external waste bin area from pests and birds.
Contamination and chemical introduction can occur across the water supply
chain, including:
o At the catchment areas and water sources (by human and animal
feces),
o Contamination in the distribution system (through “leaking” pipes,
obsolete infrastructure, and inadequate treatment and storage) and
o Unhygienic handling of stored household water.
o Climate change can also affect the quality of drinking water.
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Method how to make water safe if it is from unsafe source
A. Water boiled for 1 to 5 minutes is considered safe to drink, while water boiled
for 20 minutes is high-level disinfected.
B. Alternatively, water can be disinfected and made safe for drinking by using
sodium hypochlorite.
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10.5. SUMMARY
Healthcare facilities are responsible to keep the principles and standards of food
and water safety measures during transportation, preparation, storage, and service
of food at all times to break the chance of contamination and food poisoning.
They need to ensure cleanliness of the kitchen has to be done on daily basis and
utensils for preparation and serving food and cups for drinking must be properly
cleaned.
It is essential to carry out regular medical checkup of food handlers and education
of hospitalized patients and care takers on need of hand washing during critical
times.
The quality of water supply in the health care facility must also be also monitored
regularly in order to early detection of contaminants to ensure water quality.
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CHAPTER 11: TRAFFIC FLOW AND FACILITY DESIGN
Chapter Description:
This chapter describes the relationship between Infection prevention and Control
(IPC) and the design and flow of activities in primary healthcare settings to minimize
the level of microbial contamination in areas where patient care and instrument
processing take place.
Chapter Objective
By the end of this chapter the participants will be able to design traffic flow and
activity pattern in triage, procedure areas, surgical units, and work areas within a
facility.
Enabling Objectives
Examine the significance of regulating traffic flow and defining activity patterns
in primary health facilities
Design traffic flow and activity patterns in triage, procedure rooms, surgical
areas, and other service areas
Identify the traffic flow requirements for different service areas
Session outline
11.1. Significance of regulating traffic flow and activity patterns
11.2. Traffic flow and activity pattern design
11.3. Traffic flow requirements of different areas.
11.4. Summary
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11.1. SIGNIFICANCE OF TRAFFIC FLOW AND ACTIVITY PATTERN
Activity 11.1: Reflection on Traffic Flow and Activity Pattern
Instruction:
Think about the below questions by yourself and dot down
your thought in your not book and share the work in the
plenary.
Reflection Question
1. What do you understand/what meaning does it give to you,
when you hear traffic flow and activity pattern within the
healthcare setting?
2. What do you think the importance of regulating traffic flow
and activity pattern in each area or space?
3. Imagine that you are working in health center as Medical
Director and asked to design the traffic flow and activity
pattern of the health center what do you recommend?
Time Allowed: 6 minutes to thinking and jot down
Regulating the flow of visitors, patients and the staff plays a central role in preventing
disease transmission in healthcare facilities. This is so for the number of
microorganisms in a designated area tends to be related to that of the number of
people present and their activity. Microbial contamination is found to be high in
areas such as waiting rooms and places where soiled surgical instruments and
other equipment are initially processed. Microbial contamination is minimized by
reducing the number of people coming to the area and defining the activities
taking place at each place.
These include dirty and clean areas where soiled instruments, equipment’s and
other items are first cleaned and then processed and stored. It is important to direct
activity patterns and traffic flow in the above-mentioned areas to keep contaminated
areas separate from areas where procedures take place. The major areas are:
Triage - are settings where patient information is collected, and patients are
systematically prioritized for care. It’s the sorting out and classification of
patients to determine priority of need and proper place of treatment.
Procedure areas - are settings where patients are examined and
procedures (e.g., pelvic examinations, wound care management, blood
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drawing, immunizations, IUD insertions and removals, and normal childbirth)
are carried out.
Surgical units - are settings where major and minor operations are
performed. The surgical unit also includes preoperative and recovery rooms
as well as several other areas
Work areas - are settings where instruments are being processed. These
include dirty and clean areas where soiled instruments, equipment and other
items are first cleaned and either high-level disinfected or sterilized and then
stored.
It is important to direct activity patterns and traffic flow in these areas to keep
contaminated areas separate from areas where procedures take place.
11.2. TRAFFIC FLOW AND ACTIVITY PATTEN DESIGN
Activity 11.2 Group Discussion on traffic flow and activity pattern design
Instruction:
Be in a group of four participants and
Discuss the below question in your group and report the
work in the plenary (share group response to the larger
groups using flipchart)
Discussion Question:
1. What is the key facility design and space requirement
considerations that we need to consider during
designing …?
Group 1: Triage
Group 2: Procedure areas
Group 3: Surgical Units
Group 4: Work areas
Time Allowed: 10 minutes for group discussion and 12 minutes
for presentation (3 minutes per group)
Microbial contamination can be substantial in highly trafficked areas and places
where soiled surgical instruments and other equipment are initially processed. The
amount of traffic and the number of individuals present in a designated area and
their activities contribute to the number of microorganisms present in that area.
137
Basic principles of facility design, traffic flow, and work practices that can be applied
to reduce microbial contamination include:
Designating appropriate traffic flow for patients, health care workers (HCWs),
and equipment to ensure safe separation between contaminated items and
clean/sterile items.
Developing policies and procedures that establish clear authority,
responsibility, and accountability to ensure that these safe practices are
adopted and practiced.
Regulating the flow of visitors, patients, and staff using signs (e.g., authorized
personnel only), reminders (e.g., red line on the floor), and physical barriers
(e.g., closed doors).
Using work practices that prevent contaminated items from contacting clean
items, such as working from dirty to clean. This is especially important if
separate spaces for dirty and clean items are not available.
Ensuring that all staff understands the policies and procedures, for example,
through new staff orientation and ongoing training, to guarantee safe handling
of clean and soiled items.
Ensuring appropriate ventilation of Operation Theaters (OTs), procedure
areas, Central Sterile Supply Departments (CSSDs), and instrument
processing areas.
Using fans in facilities without mechanical ventilation to optimize existing
ventilation. The air should be drawn into the area and should be exhausted
outside using one-way exhaust fans. Where mechanical ventilation or fans are
not available, the only option is to use natural ventilation with open windows
and doors fitted with mosquito nets.
In primary healthcare facilities triages should be designed to foster a system for
assessing all patients at entrance and encourage source control, allowing for early
recognition of infection. Ideally the following should be in place at triage area:
A functional Hand hygiene stations
A well-equipped station at the entrance to the facility, supported by trained
staff
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Traffic flow and work practices within the triage should allow for physical
separation between patients as well as healthcare workers with a
unidirectional flow
In primary healthcare setting where only minor procedures are performed, a
procedure room with a hand washing sink is required for examining clients and
performing procedures.
Regardless of the size of the facility or the complexity of the procedure, it is critical to
ensure that there is no cross-contamination during the handling, transporting,
processing, and storage of instruments. Ideally, the following should be in place:
Sterile supplies and instruments should not be stored in procedure areas.
Instrument processing should be done in an area away from the procedure
rooms or operating suites, ideally in a central location such as a CSSD.
Traffic flow and work practices within the procedure area should allow for
physical separation between clean and dirty processes to prevent cross-
contamination.
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ot found.a), soiled equipment should be received and cleaned in an area of the
room distant enough from areas where equipment’s are high-level disinfected or
sterilized and then stored.
As a guide, the space requirements for the types of surgery typically performed at
primary healthcare facilities are roughly the same as that of a busy surgical center or
polyclinic. These include:
Changing room and scrub area for the clinic staff.
Preoperative area where clients are examined and evaluated prior to surgery.
Staff toilets
Area for surgical hand scrub and putting on PPE
Operating room
Recovery area for observation of patients after surgery.
Processing area for cleaning and sterilizing or high-level disinfecting
instruments and other items.
Space for storing sterile packs and/or high-level disinfected containers of
instruments and other items.
11.3. TRAFFIC FLOW REQUIRMENTS IN DIFFERNET AREAS
Activity 11.3: Group work on traffic flow requirements in different areas
Instruction:
Divide participants in to three groups
Read the topics below and discuss in your group and
report the work in the plenary (share group response to the
larger groups using flipchart) using Session 11.3.
Discussion Question:
1. What are the recommend infection prevention and
control practices in…?
Group 1: Isolation Room and Procedure area
Group 2: Surgical Unit
Group 3: Work area
Time Allowed: 10 minutes for group discussion and 12 minutes
for presentation (4 minutes per group)
The recommended infection prevention and control practices for minimizing microbial
contamination of specific areas in healthcare facilities are briefly described below.
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Isolation room
Limit traffic to always authorized staff and patients.
Permit only the patient and staff (performing and assisting)
If mandated only one family member (attendant) should be allowed at a time
in one room for limited period of time in a day wearing clean attire, head-cover
and other PPE as indicated.
Patients can wear their own clean clothing.
Staff should wear attire and personal protective equipment (PPE) according to
procedures performed.
Family member who reported to have acute Upper Respiratory Tract Infection
(URTI) should not be allowed to enter.
Procedure area
Limit traffic to authorized staff and patients at all times.
Permit only the patient and staff (performing and assisting) in the procedure
room (family members should be limited with obstetrical procedures).
Staff should wear attire and personal protective equipment (PPE) according to
procedures performed.
Place a clean container filled with clean water mixed with detergent (when
available use enzymatic detergents) for immediately immersing of instruments
and other items once they are no longer needed.
Have a leak proof and covered waste container for disposal of contaminated
waste items (cotton, gauze, dressings) right after use.
Have a puncture-resistant container for safe disposal of sharps (e.g., used
suture needles, hypodermic needles and syringes, and disposable scalpel
blades) right after use.
Have storage space in procedure rooms for clean, high-level disinfected and
sterile supplies (Storage shelves should be enclosed to minimize dust and
debris collecting on stored items).
Surgical unit
The surgical unit is often divided into four designated areas defined by the activities
performed in each area, these are unrestricted area, transition zone, semi
restricted and restricted area. Environmental controls and use of surgical attire
increase as one move from unrestricted to restricted areas. Moreover, staff with
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respiratory or skin infections and/uncovered open sores should not be allowed in the
surgical unit.
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Restricted Area
This designated area consists of the operating room(s) and scrub sink areas.
Never store instruments and other items in the operating room
Limit traffic to authorized staff and patients at all times.
Keep the door closed at all times, except during movement of the staff,
patients, supplies and equipment.
Scrubbed staff must wear full surgical attire and cover head and facial hair
with a cap and mask.
Staff should wear clean and closed shoes that will protect their feet from fluids
and dropped items.
Masks are required when sterile supplies are open and when the scrubbed
staffs are operating.
Patients entering the surgical unit should wear clean gowns or be covered
with clean linen and have their hair covered.
Patients do not need to wear masks during transport (unless they seek
airborne precautions).
Operating Room(s)
The operating room should be enclosed to minimize dust and eliminate flies;
however, central air conditioning is necessary (If windows are the only
ventilation, provide tight- fitting screens).
The operating room should be located away from areas of the hospital or
healthcare facility that are heavily staffed with frequent movements of the staff
and patients.
Work Area (Instrument processing area)
According to the size and type of the healthcare facility, the work area for
processing instruments (e.g., the Central Sterile Supply Department or CSSD)
may be part of the surgical unit; or just connected to it; or an independent
area somewhere away from it.
This is the area where instruments, surgical gloves and equipment are
processed and where the staff should be specially trained in handling,
processing, and storing instruments, equipment and other clean, sterile or
high-level disinfected items. The CSSD is considered a semi-restricted area;
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hence all the recommendations for traffic patterns and proper attire described
above should be followed.
Permit only authorized personnel to enter this area.
Note: Develop flow patterns to help ensure that contaminated items never
come in contact with clean, disinfected or sterile items.
The function and equipment requirements for the four areas of a typical CSSD are
summarized below.
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Sterile or High-Level Disinfected Storage Area
Store sterilized packs and covered sterile or high-level disinfected containers in this
area. This area should be separated from the central sterile supply area:
Limit access to the storage area and/or store items in closed cabinets or
shelves. (Shelves or cabinets had better be closed as they protect packs and
containers from dust and debris. Open shelves are acceptable only if the area
has limited access and if housekeeping and ventilation practices are
controlled).
Keep the storage area clean, dry, dust-free and lint-free by following a regular
housekeeping schedule.
Packs and containers with sterile or high-level disinfected items should be
stored 20 to 25 cm (8 to 10 inches) off the floor, 45 to 50cm (18 to 20 inches)
from the ceiling and 15 to 20cm (6 to 8 inches) from an outside wall.
Do not use cardboard boxes for storage. (Cardboard boxes shed dust and
debris and may harbor insects).
Date and rotate the supplies (first in, first out). This process serves as a
reminder that the package is susceptible to contamination and conserves
storage space, but it does not guarantee sterility.
Packs will remain sterile as long as the integrity of the package is maintained.
Sterile or high-level disinfected containers remain so up until they are opened.
Dispense sterile and high-level disinfected articles from this area.
11.4. SUMMARY
Irrespective of the existing layout of the facility, design traffic flow and work practices
in such a way that keeps soiled/contaminated instruments, equipment, and textiles
separate from the clean and sterile instruments, equipment, and textiles, whether in
the OT or in the CSSD. Appropriate traffic flow and work practices prevent accidental
contamination of clean items and reduce the risk of infections to patients, HCWs,
and visitors.
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CHAPTER 12: OCCUPATIONAL HEALTH AND SAFETY IN
HEALTH CARE SETTINGS
Chapter Description
The chapter describes common occupational safeties and occupational health issues
in health centers that need to be identified, prevented, and treated.
Chapter objective
By the end of this chapter participants will be able to discuss assessment and
identification of health workers occupational risks and their mitigation strategies.
Enabling objectives
By the end of this module, participants will be able to:
List down steps of occupational health risk assessment and prevention.
Describe the prevention and management of common occupational health
care worker infections.
List Occupational Health safeties for Specific Groups of Health Care Workers.
Describe steps of Post Exposure Prophylaxis for HIV and HBV exposures.
Outline assignment considerations for HCWs with infectious health problems.
Explain Monitoring of occupational health activities in a health center.
Chapter outline
12.1. Introduction of occupational health safety in health care setting
12.2. Hazard Identification, Risk Assessment and Risk Control
12.3. Occupational health activities for the prevention and management of
infections in HCWs
12.4. Occupational Health Activities for Specific Groups of Health Care Workers
12.5. Post Exposure Prophylaxis for HIV and HBV
12.6. Monitoring of occupational health activities
12.7. Summary
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12.1. INTRODUCTION OF OCCUPATIONAL HEALTH SAFETY IN
HEALTHCARE SETTING
Activity 12.1: Reading and reflection
What do you think is the burden of occupational health
problems among health workers in Ethiopia?
Time: 5 min discussion.
Over 59 million health workers who are routinely exposed to a variety of health and
safety risks (WHO 2016a). These risks include exposure to infectious agents such as
blood borne pathogens, tuberculosis (TB), viral respiratory infections, vaccine-
preventable diseases, bacterial infections, and gastrointestinal infections, among
others.
Occupational exposures to sharps injuries are an example of the substantial impact
of occupational infections among HCWs. It is estimated that 39% of hepatitis C virus
(HCV), 37% of hepatitis B virus (HBV), and 4.4% of HIV infections among HCWs
worldwide are attributable to occupational exposure due to sharps injuries. This
amounts to an estimate of 16,000 HCV, 66,000 HBV, and 1,000 HIV occupational
infections annually (Prüss-Üstün et al. 2005). It is thought that more than 90% of
these are in limited-resource countries. (IFIC 2003). The practice of infection
prevention among health facilities was found to be poor in Ethiopia. One hospital has
identified that 48% of health care workers did not have gloves during a critical
procedure1.
Actual risk of infectious exposure for HCWs depends somewhat upon the job
description and the setting. Attention to IPC helps protect staff and patients in all
settings. Recent communicable disease outbreaks e.g., severe acute respiratory
syndrome (SARS), COVID19 and Ebola Virus Disease (EVD) have demonstrated
that strategies to protect HCWs from exposure to infectious risks in the workplace
are critically important and that facilities must have the infrastructure in place to be
1
Hailu et al Occupational Health Safety of Health Professionals and Associated Factors During COVID-19
Pandemics at North Showa Zone, Oromia Regional State, Ethiopia. Risk Management and Healthcare Policy
2021:14
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able to adapt to changes in emerging infectious threats. Staffs in healthcare facilities
need to be knowledgeable in IPC to conduct and support sound occupational health
activities to minimize the risk of occupational infection in HCWs and provide a safe
environment for patients and staff.
12.2. HAZARD IDENTIFICATION, RISK ASSESSMENT AND RISK CONTROL
Workplace hazard identification, assessment and control is an on-going process. It
should be undertaken at various times, including:
If it has not been done before.
When a hazard has been identified
When a change to the workplace may introduce or change a hazard. Such as
when changes occur to the work equipment, practices, procedures, or
environment.
As part of responding to a workplace incident, even where an injury has not
occurred.
Where new information about a risk becomes available or concerns about a
risk are raised by workers
At regularly scheduled times appropriate to the workplace.
Risk Assessment: Is defined as the process of assessing the risks associated with
each of the hazards identified so the nature of the risk can be understood. This
includes the nature of the harm that may result from the hazard, the severity of that
harm and the likelihood of this occurring.
Risk Control: Taking actions to eliminate health and safety risks so far as is
reasonably practicable. Where risks cannot be eliminated, then implementation of
control measures is required, to minimize risks so far as is reasonably practicable. A
hierarchy of controls has been developed and is described below to assist in
selection of the most appropriate risk control measure/s.
It is recommended to follow the following five steps in assessing occupational health
risk at health care settings2:
Step 1: Identifying hazards and those at risk
Step 2: Evaluate and prioritize risks
Step 3: Decide on Preventive Action
2
European Commission; Occupational health and safety risks in the health care sector: guide to prevention
and good practice.
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Step 4: Taking action
Step 5: Documentation, Monitoring and Review
Hazard Identification and Identifying those at risk:
This is the process of examining each work area and work task for the purpose of
identifying all the hazards which are “inherent in the job”. Additionally identifying
employees at increased risk (special risk) is critical. Checklists, screening
instruments or other tools and recommendations need to be used for the process.
Evaluating and prioritizing risks
Not all of the identified risks and hazards will have the same importance, nor can
they all be addressed at the same time. It is recommended to prioritize within the
risks and hazards and to agree which ones should be tackled first. Improving the
working conditions should be seen as a continuous improvement process of your
facility, which starts with more urgent risks and hazards and continuously moves on
to other related topics to establish a safe, healthy, and productive work environment.
Deciding on Preventive action
After identifying and prioritizing the risks in your facility, the next step is the
identification of the appropriate measures to eliminate or control the risks. The
following hierarchy should be considered regarding preventive measures: first
technical solutions should be considered, followed by organizational and finally
personal/individual measures.
Taking action
Implement the preventive and protective measures according to the prioritization
plan. Employees have to be informed about the results of the risk assessment and
the planned improvements. The long-term implementation of measures within the
daily work depends greatly on the participation of the workers and their acceptance
of the measures. Specialists in occupational health (focal person and committee)
and safety and quality management should compare and coordinate their activities
and establish an integrated quality, as well as health and safety, management
system.
Documentation, Monitoring and Review:
The risk assessment has to be documented. The documentation should include the
results of the risk analysis, the improvements implemented and the results of the
evaluation of the improvements. What risks were identified for the workers? How
high is the risk of being exposed to those risks? Is the risk negligible, acceptable for
a short time or not acceptable? Which measures have been taken and which ones
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planned for the future? Who is responsible for the implementation of the measures?
By when should the measures have been taken and how will their effectiveness be
evaluated?
This also involves ongoing monitoring of the hazards identified, risks assessed and
risk control processes and reviewing them to make sure they are working effectively.
Hazard identification, risk assessment and control are an on-going process.
Therefore, regularly review the effectiveness of your hazard assessment and control
measures. Make sure that you undertake a hazard and risk assessment when there
is a change to the workplace including when work systems, tools, machinery, or
equipment change. Provide additional supervision when new employees with
reduced skill levels or knowledge are introduced to the workplace. The effectiveness
of control measures can be checked through regular reviews as well as consultation
with workers.
12.3. OCCUPATIONAL HEALTH ACTIVITIES FOR PREVENTING INFECTIONS
AMONG HEALTH CARE WORKERS
The goal of occupational health activities is to protect HCWs—and thereby their
patients—from acquiring an infection or any other hazard while working in a health
care facility. This goal is achieved by implementing proper hazard identification, risk
assessment and control interventions.
Major occupational health activities
2. For newly employed Health Workers
A. Pre-employment evaluation
I. Baseline medical evaluation
II. Assessment of immunization status
III. Training/education of IPC
a) Tailored to job functions
IV. Counselling for occupational exposure infections
a) If needed on issues of prevention, preventions including PEP and risk
to family etc.
3. For all Health care workers
I. Monitoring employee health status
II. Periodic IPC trainings
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III. Vaccinations- WHO recommended vaccines
4. Facility wide activities
I. Exposure reporting
II. Occupational health program monitoring and review
12.4. OCCUPATIONAL HEALTH AND SAFETY FOR SPECIFIC GROUPS OF
HEALTHCARE WORKERS
Activity 12.2: Group work and discussion
Make a group of 5-6 participants and discuss the question below:
document your discussions and reflect group discussions.
- Are there groups of HCWs at increased risk for
occupational health hazards?
Time: 10 min discussion 5 min for presentation
Certain groups of workers at a health care facility may require special attention
related to occupational health activities. They include pregnant staff, laboratory staff,
emergency response staff, and HCWs infected with HIV, HBV, or HCV.
Pregnant Health Care Workers
Non-immune pregnant HCWs should not care for patients with measles, rubella,
parvovirus 16, and varicella (APIC 2014b). Table 2-7 provides information on
occupational exposure to infection among pregnant HCWs, risks to their babies, and
prevention strategies. The information provided in the table will guide the
occupational health team members in making appropriate decisions. Table 2-7
describes additional pertinent facts to assist with management of relevant
occupational exposures in pregnant HCWs.
Laboratory Staff
HCWs in laboratories may be at increased risk of occupational exposure to the
pathogens with which they work. Laboratory staff should receive specific training on
the risks and how to avoid them (such as working under a bio-containment hood,
using a closed centrifuge, avoiding mouth pipetting) and have access to PPE, as
required, according to the procedures they perform and the pathogens with which
they have contact. In addition to the vaccines routinely recommended for all HCWs,
further vaccinations may be appropriate for HCWs working in a clinical or research
laboratory. National recommendations should be consulted and followed if available.
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Emergency Response Staff
HCWs who respond to emergencies and transport patients should not be overlooked
during occupational health activities. These HCWs are at a high risk of exposure to
blood borne pathogens and should have access to HBV vaccination, have adequate
PPE and thorough instruction on proper PPE use, and be taught to always apply
Standard Precautions for all patients. Furthermore, they may transport patients
before the infection status of the patient is known (e.g., meningococcal meningitis,
influenza, novel respiratory viruses, viral hemorrhagic fever) and thus should be
aware of how to apply Isolation Precautions based on disease syndromes, be
informed about patients who later develop infections of occupational health concern
and be included in exposure follow-up and relevant PEP and work restrictions.
Health Care Workers exposed TO HIV and/or Hepatitis B or C
HIV, HBV and HCV are the primary infectious agents that can be transmitted via
exposure to bodily fluids. In addition to percutaneous injury, contact of mucous
membranes or non-intact skin with blood, fluids containing blood, tissue or other
potentially infectious bodily fluids pose an infectious risk. Potentially infectious body
fluids include semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural
fluid, peritoneal fluid, pericardial fluid, amniotic fluid, pus, etc. In this case, body fluids
like feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomits are not
considered infectious unless they contain blood.
12.5. POST EXPOSURE PROPHYLAXIS
Occupational exposure to HIV
Each day, thousands of people around the world experience accidental exposure to
blood and other body fluids or tissues while performing their work duties. Hence, it
could be said that healthcare workers are especially vulnerable for infections.
The risk of acquiring HIV after a mucous membrane exposure to blood is
approximately 0.09 % while the acquisition through a percutaneous exposure
is approximately 0.3% (Cardo DM et al., 1997).
The risk of acquiring HIV percutaneous is associated with deeper injuries,
visibly bloody devices, and more advanced disease (likely due to a higher
viral load) in the source patient. Hollow bore needle exposures have higher
risk of transmission than that of solid bore needle exposures.
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The use of post exposure prophylaxis against HIV infection dates back to
the early 1990s for both direct and indirect evidence suggested that the
treatment with ARVs soon after exposure to HIV decreases the risk of
transmission. Animal studies have demonstrated mixed results on the efficacy
of PEP (Black RJ, 1997).
A retrospective case-control study demonstrated that PEP with AZT for 4
weeks was associated with an 81% reduction in transmission of HIV in
humans. In that study, approximately 70% of patients received AZT within 4
hours of the exposure (Cardo DM, 1997). It is not known how long after an
exposure PEP would turn to be ineffective. However, the data from animal
studies mentioned above, suggest that PEP is effective when initiated within
72 hours of exposure. Taking the evidence mentioned above in to
consideration, most international guidelines recommend PEP drugs to be
started for exposed persons (based on the indication) as early as possible
preferably within 2 hours of exposure but giving PEP drugs after 72 hours of
exposure is not generally advisable. Measures that should be taken on initial
management of exposure exposed persons are put on Annex 16. 1. Full
description and guidance on the management of HIV post exposure
prophylaxis is well document in the national comprehensive HIV care
and treatment guideline-trainees are advised to collaborate with ART
clinics in their facility.
Occupational exposure to Hepatitis B Virus
HBV infection is a well-recognized occupational risk for HCP (Mast EE et al.,
1993). The risk of HBV infection is primarily related to the degree of contact
with blood in the workplace and also to hepatitis B e antigen (HBeAg) status
of the source person.
In studies of Health Care Professionals who sustained injuries from needles
contaminated with blood containing HBV, the risk of developing clinical
hepatitis, if the blood was both hepatitis B surface antigen (HBsAg) and
HBeAg-positive was22% to 31%; the risk of developing serologic evidence of
HBV infection was 37% to 62%.
By comparison, the risk of developing clinical hepatitis from a needle
contaminated with HBsAg-positive, HBeAg-negative blood was 1% to 6%,
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while the risk of developing serologic evidence of HBV infection was 23% to
37% (Werner BG et al., 1982).
Table 12.1: Recommended Post-Exposure Prophylaxis for Hepatitis B Virus
Exposure
Vaccination and antibody Treatment
response status of
exposed workers*
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Offer HIV post-test counseling per the national counseling and testing
guidelines.
Refer to HIV care and treatment for those who test positive.
STEP 4: Time frame—as soon as possible, preferably within 24 hours,
simultaneously with Step 3 above. Person responsible: In-Charge of PEP
management, patient’s treating physician.
Evaluate the exposure source:
Obtain detailed information on clinical status of the source person.
Determine vaccination and immune status of the source person:
Test known source person for HBsAg.3
Test known source person for anti-HCV antibodies.
Check known source person for HIV status and history of previous HIV
testing.
Conduct clinical assessment of known source person for HIV/AIDS.
Provide HIV pretest counseling.
Conduct HIV testing if the source person provides informed consent.
Offer HIV post-test counseling per the national counseling and testing
guidelines.
Refer to HIV care and treatment for those who test positive.
STEP 5: Time frame—as soon as test results return (if any), must be within 72 hours
from exposure. Person responsible: Physician, In-Charge of PEP management,
HCW.
Establish eligibility for PEP:
Refer to Table 12.1 to determine the PEP required for HBV exposure.
Parenteral or mucous membrane exposure (e.g., sexual exposure, splashes
to the eye, nose, or oral cavity)
Exposure to blood, blood-stained saliva, breast milk, genital secretions, or
cerebrospinal, amniotic, peritoneal, synovial, pericardial, or pleural fluids
PEP is not indicated if: The exposed HCW is known to be HIV-positive, the
source person is HIV-negative.
Exposure is limited to intact skin.
3 Hepatitis B surface antigen (HBsAg)—indicates that the person is infectious (CDC. Hepatitis).
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Testing the source person and the exposed HCW is helpful but it is not
mandatory to have either test results to initiate HIV PEP. The decision is
sometimes based on an individual’s level of concern as well as background
HIV prevalence.
STEP 6: Prescribe PEP: Time frame—initiate PEP as early as possible but within 72
hours
Continue ARVs for HIV for 28 days.
Continue HBV vaccine schedule over 6 months
Provide adherence counseling and address any drug interactions.
Follow national guidelines or WHO recommendations for PEP
STEP 7: Time frame—72 hours―6 months after exposure. Person responsible:
Physician, In Charge of PEP Management, HCW.
Follow-up:
Provide follow-up for adherence and any side effects of ARVs and address
questions that the individual may have.
Arrange for an HIV test at 3 months after the exposure.
Arrange for HBV vaccine at 1 and 6 months, if indicated.
Link HIV care and treatment, including prevention measure for protecting
others, in case the HIV test results are positive.
Provide additional counseling and other preventive interventions, as needed,
and if test results are negative.
Document all PEP provided, following facility and national guidelines.
Monitor PEP provision in the facility.
Health Care Workers Infected with HIV and/or Hepatitis B or C
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HCWs infected with HIV and/or HBV or HCV should inform the facility
manager of their status. The facility IPC team should strive to prevent
transmission of infections to patients and at the same time maintain the
livelihood and privacy of the infected staff members.
These HCWs should not be prohibited from providing patient care if they are
not performing invasive procedures, the infection is well-controlled, they fully
comply with recommended IPC practices, and there are no other factors that
would prevent them from safely carrying out the patient care activities.
HCWs with these conditions should be closely followed up by a team of
clinicians for periodical clinical monitoring, to assess treatment response and
viral suppression, when appropriate, and to revise recommendations about
duty restrictions accordingly.
They should avoid performing procedures that may result in increased risk of
contact with large amounts of blood and body fluids. There are no restrictions
for those staff with viral loads less than designated levels. (Henderson et al.
2010)
The Society of Healthcare Epidemiology of America (SHEA) has classified
patient care and clinical procedures into three different categories based on
the risk of transmission of bloodborne pathogens:
Category I: Procedures with minimum risk of bloodborne virus transmission.
Clinical procedures and patient care activities that either do not involve
touching patients (e.g., history taking, counseling) or are limited to touching
patients’ intact skin (e.g., performing physical examinations) and mucous
membranes (e.g., performing vaginal examinations, performing some dental
procedures, phlebotomy).
It also includes minor surgical procedures with very minimal exposure to
patients’ blood and body fluids (e.g., surface stitches, gastrointestinal
endoscopy procedures).
Category II: Procedures for which bloodborne virus transmission is
theoretically possible but unlikely.
Several surgical procedures are examples of such procedures, including
ophthalmic surgery, dental surgery that requires local anesthesia, minor oral
surgical procedures, endoscopic and arthroscopic procedures, provision of
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contraceptive methods, minor gynecological procedures, starting of central
lines, and medical male circumcisions.
Category III: Procedures for which there is definite risk of blood borne
transmission of viruses or that have previously been classified as “exposure-
prone.”
All major surgical procedures that involve a high volume of blood and body
fluids are Category III procedures with definite risk of exposure.
Examples of Category III procedures are: general surgery; oral surgery with
difficult access for suturing; emergency surgical procedures involving bleeding
and exposure to a high volume of blood; obstetric procedures, including
cesarean section; and orthopedic surgeries.
Any major surgical procedure that goes beyond 3 hours and requires
changing gloves should not include staff members infected with blood borne
pathogens.
Managing HCWs infected with HIV and/or hepatitis B or C
HCWs infected with blood borne pathogens whose viral load is below the minimum
designated level should follow a six-point plan described below to safely provide
patient care and be productive.
The HCWs should:
Not have transmitted infection to any patient.
Obtain advice from a team of clinicians about continuing to care for patients.
Undergo testing twice a year to demonstrate the maintenance of a viral
burden below designated levels.
Receive follow-up by a clinician with expertise in managing blood borne
pathogen infections and
Consent to share their results with the IPC/occupational health team at the
facility.
Consult closely with experts on the use of optimal IPC procedures:
This may include guidance on double gloving, changing gloves during
procedures, avoiding digital palpation of needle tips, and performing all
procedures under direct view. It also includes promptly withdrawing from a
procedure if they have any injury that bleeds and informing the IPC/occupational
health team about any injuries.
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Adhere strictly to recommended procedures, including the routine use of double
gloving for Category II (such as minor surgery) and Category III (such as major
surgery) procedures and frequent glove changes during procedures, particularly
if performing technical tasks that have a potential to compromise glove integrity.
Agree in writing to comply with recommendations and guidance of the expert
clinicians as well as the facility IPC/occupational health and management team.
Adapted from: Henderson et al. 2010.
12.6. MONITORING PREVENTION OF OCCUPATIONAL EXPOSURES AND
INJURIES
Health care facilities should evaluate the effectiveness of occupational health
interventions and practices on a routine basis. They should conduct
surveillance to collect, analyze, and disseminate data on risks to HCWs.
There should be a system to report any occupational exposure and injury,
which should be supported by prompt management and PEP.
The rates of injuries or exposures among HCWs should be routinely reviewed
and reported back to the staff and strategies and action plans to prevent
future injuries should be developed and updated.
Surveillance activities can be conducted by the staff organizing occupational
health activities at the facility and/or with the assistance of IPC staff.
12.7. SUMMARY
In the course of their duties, millions of HCWs around the world are routinely
exposed to a variety of health and safety hazards, including infectious agents.
Hazard identification and risk assessment is critical for programming IPC in a
health center
There is a need for risk reduction to patients while being care for by
HIV/HBV/HCV infection.
HCWs should be provided with occupational health safety during employment
and regularly then after.
HCW exposed for infectious hazards need to get appropriate intervention
timely as per national standards
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CHAPTER 13: CLIENT EDUCATION ON INFECTION PREVENTION
AND CONTROL (IPC)
Chapter Description:
Chapter Objective
By the end of this chapter the participants will be able to design effective client
education program within their healthcare facility using recommended delivery
techniques.
Enabling Objectives
Session outline
161
13.1. SIGNIFICANCE OF CLINET EDUCATION ON IPC
Educating and empowering patients and clients to actively participate in their care
help reduce a patient's risk of hospital acquired infections. Creating an open
dialogue, however, can be a challenge in today's healthcare system.
Client education can be defined as the transmission to the patient, family, care giver
and community of the knowledge, skills and attitude which empowers them to
actively participate in the promotion and maintenance of a safe health care facility
environment, particularly for infection prevention.
Four components have been reported as being fundamental to the process of
patient/client empowerment:
1. Patient understands of his/her own role;
2. Patient’s acquisition o f sufficient knowledge on their ability to collaborate
or involve with their healthcare provider;
3. Patient’s knowledge and skills; and
4. The presence of facilitating environment
163
a long way in preventing infections.
Help the patient become an active participant
Talk to the patient about what he or she can do to optimize care, instead of focusing
solely on what the healthcare provider is going to do for the patient. Patients want to
be involved in their care. They want to be an active participant. And family members
want to be involved in any way they can.
Let patients know what their care should look like as well
Educate the patient on what dressings or catheters need to be changed on a daily
basis and what the process looks like. Showing the patient what to expect and what
techniques help prevent infections empowers him or her to look out for potential risks
when shifts change and someone else begins changing his or her dressings.
Don't forget about high-risk patients
For patients at a higher risk of infection, such as those who are diabetic, taking
immune suppressive drugs, overweight or smokers, healthcare providers need to
discuss how these issues heighten their risk for infection. Patients in the intensive
care unit are also considered high risk. Healthcare providers should encourage ICU
patients to get up and out of bed.
Understand the patient's rights of education
According to EFDA standards, the patient possesses the right to receive information
in a manner that the patient understands. In certain cases, the hospital may need to
provide interpreting or translation services to accommodate the patient's
communication needs. These needs should be determined during the initial learning
needs assessment.
13.4. MODELS OF CLIENT EDUCATION
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13.5. SUMMARY
Educating and empowering patients and clients to actively participate in their care
help reduce a patient's risk of hospital acquired infections. Actionable strategies are
being developed with a strong emphasis on working in partnership with healthcare
authorities, partners, and professionals.
They are the basis of infection control precautions which are to be used as a minimal
expectation in the care of all patients. Supplementary to the practices carried out by
health workers when providing care, all individuals (including patients and visitors)
should comply with infection control practices in health care settings.
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CHAPTER 14: ANTIMICROBIAL RESISTANCE (AMR) AND
RATIONAL USE OF ANTIBIOTICS
Chapter Description
This chapter discusses about what AMR is and how resistant infections occur, which
pathogens cause the biggest problems globally and in the health care setting, the
Activity 13.3: Case Study on client education program
Instructions:
Read the below case study carefully and be in a group of four and
Discuss the below questions in your group and report the work in the
plenary
Case study
You are assigned as an IPC foal person and was assigned to follow up on
the health education program on your facility.
Sr. Sara is a newly trained Nurse at XX Health Center in 2021, she has
been assigned to provide a health education to patients, attendants, and
clients on Tuberculosis focusing on pulmonary TB on a busy Monday
morning at outpatient department. She asks one of the guards to gather the
patients, attendants, and clients in the waiting area, which is very small and
confined, so that she could conduct her health education program.
After the patients, attendants, and clients gathered in the waiting area, one
of the patients seems to be coughing heavily and the audiences near the
patient seem to feel very uncomfortable.
Sr. Sara thanked the audiences and after introducing herself, she started
providing her health education on Tuberculosis by, first introducing what
Tuberculosis is? and the causes of Tuberculosis, then listed the types of
Tuberculosis diseases. She followed it up by addressing the sign and
symptoms of pulmonary TB, then she quickly winded the health education
program by address the medications required to treat the different types of
pulmonary TB cases.
Discussion Question:
Group 1: What did Sr. Sara do correctly and incorrectly in the case
study?
Group 2: What contents should she have added/considered to the
health education while educating patients about pulmonary TB?
Group 3: What feedback or recommendations would you provide Sr.
Sara to improve her health education provision techniques?
Group 4: What tailored IPC precautions should she have used?
Time Allowed: 5 minutes to read the case study, 5 minutes to discuss in
pairs groups and 20 minutes for reflection (5 minutes per group).
167
determinants and causes of AMR, rational use of antibiotics and, most importantly,
the role of IPC in reducing AMR through promotion of the rational use of antibiotics.
Chapter Objective
By the end of this chapter participants will be able to explain the basic concept of
antimicrobial resistance and the rational use of antibiotics to reduce the emergence
and spread of resistant microbes in healthcare facilities
Enabling Objectives
By the end of this chapter the participants will be able to
Outline the Consequences and magnitude of antibiotic resistance
Classify the Causes of antibiotic resistance
Describe Rational use of antibiotics
Apply Strategies for promotion of rational use of antibiotic
Session outline
14.1. Overview of Antimicrobial Resistance the rational use of antibiotics
14.2. Consequences and magnitude of antibiotic resistance
14.3. Causes of antibiotic resistance
14.4. Rational use of antibiotics
14.5. Promotion of rational use of antibiotics
14.6. Summary
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14.2. OVERVIEW OF ANTIMICROBIAL RESISTANCE AND RATIONAL USE
OF ANTIBIOTICS
Activity 14.1: Antimicrobial resistance and rational use of antibiotics
Instruction:
Think about the following questions by yourself and dot down
your thought in your notebook and share the work in the
plenary.
Reflection Question
1. How do you describe “Antimicrobial Resistance”?
2. How does this differ from antibiotic resistance?
Time Allowed: 5 minutes to thinking and doting down and 5 minutes
to reflect
169
when microorganisms adapt and grow in the presence of the substance used against
them (that is, it resists the effects). AMR is a broad term that applies to:
Fungi becoming resistant to antifungals;
Parasites becoming resistant to antiparasitic drugs;
Bacteria becoming resistant to antibiotics; and
Viruses becoming resistant to antivirals.
Antibiotic resistance is a specific term that refers to a subset of AMR; it refers to
bacteria becoming resistant to antibiotics. In this chapter, we will focus on antibiotic
resistance. However, many of the recommended activities to reduce antibiotic
resistance can also be used to combat resistance in other microorganisms that
cause fungal, viral and parasitic diseases.
Critical aspects of the broader global response to antimicrobial resistance are efforts
to minimize the emergence and transmission of resistance to drugs used to treat
tuberculosis (TB), HIV, and malaria. The use and misuse of antimicrobials have led
to persistent expansion of antimicrobial resistance, thereby lowering the
effectiveness of some of these drugs (e.g., chloroquine and penicillin). Resistance to
the most commonly available antimicrobials requires the use of more expensive
alternative regimens. Unfortunately, while resistance has created a demand for new
treatment options, there has been a significant drop in the development of new
antimicrobial agents in recent decades. This has compromised the ability of HCWs to
treat infectious diseases and has increased health care costs. It is critical that
necessary measures to respond to the resistance crisis be taken at all levels (by
institutions as well as local and national governments). Measures should include
rational use of antimicrobials through the incorporation of careful antimicrobial
stewardship activities and programs. Ultimately, improving antimicrobial use involves
actions at the national level to guide treatment decisions made by informed HCWs
as well as the awareness and cooperation from patients. While this chapter focuses
on antibiotics, its recommendations can be applied to all antimicrobials. (WHO 2015;
WHO 2016).
170
14.3. CONSEQUENCES AND MAGNITUDE OF ANTIBIOTIC RESISTANCE
Activity 14.2: Consequences and magnitude of antibiotic resistance
Instruction:
Think about the following questions by yourself and dot down
your thought in your notebook and share the work in the
plenary.
Reflection Question
1. What are the most common health care-associated
pathogens in your facility? In your country?
2. What are the consequences of Antibiotic Resistance?
Time Allowed: 5 minutes to thinking and doting down and 5 minutes
to reflect
Antibiotic resistance has a significant impact not only on patients, but also on the
health care facility and system. When bacteria fail to respond to first- or second-line
antibiotics, patient morbidity and mortality increase often are resulting in longer
hospital stays, thereby placing a greater burden on facilities and the health care
system. A study on carbapenems-producing Enterobacteriaceae found that patients
have, on average, 1.79 times higher risk of dying in the ICU than non-colonized
patients (Dautzenberg et al).
Antibiotic resistance also increases health care costs: last line/combination
antibiotics are more expensive, patients require more diagnostic tests, and infections
result in longer hospital stays and more complications to treat. Ultimately, patients
with antibiotic-resistant infections can not only divert resources from regular delivery
of care (i.e., because they require additional supplies, isolation, etc.), but also limit
the number of available beds for other patients due to increased length of stay.
Resistance also means that there is a limited choice of older, “tried and tested”
antibiotics whose efficacy and side effects are well known. Newer antibiotics
have restricted licensing conditions due to limited availability of clinical data on their
efficacy and significant side effects.
171
Antibiotic resistance makes it harder to treat infections were effectively treated a few
decades ago leads to increased medical costs, extended hospital stays, increased
toxicity, adverse effects, and mortality. Antibiotic resistance is present in all parts of
the world and threatens the effective prevention and treatment of a long list of
infections, including multidrug-resistant Mycobacterium tuberculosis, methicillin-
resistant Staphylococcus aureus (MRSA), vancomycin resistant Enterococci (VRE),
and multidrug-resistant Neisseria gonorrhoeae. Mortality among patients infected
with resistant microbes can be about twice that of patients with infections caused by
the same species of bacteria that is sensitive to antibiotics. (NIAID 2011) The
increased use and misuse of antibiotics accelerate the emergence of drug-resistant
strains of microorganisms, which threatens our ability to treat common infectious
diseases (WHO 2016). Infections such as pneumonia, tuberculosis, bloodstream
infections (sepsis), and sexually transmitted infections are becoming more difficult,
and at times impossible, to treat due to antibiotic resistance. Magnitude of Antibiotic
Resistance WHO has classified priority pathogens into three categories for which
new antibiotics should be developed (Table 14.1).
Table 14.1: WHO Priority Pathogens List for Research and Development of New
Antibiotics
Priority 1: Critical Priority 2: High Priority 3: Medium
Acinetobacter Enterococcus faecium, Streptococcus
baumannii, vancomycin resistant pneumoniae, penicillin-
carbapenem-resistant Staphylococcus aureus, no susceptible
Pseudomonas methicillin resistant, Haemophiles
aeruginosa, vancomycin- influenzae, ampicillin
carbapenem resistant intermediate, and resistant
Enterobacteriaceae, resistant Shigella spp.,
carbapenem-resistant, Helicobacter pylori, fluoroquinolone
Extended Spectrum clarithromycin resistant resistant
Beta Lactamase- Campylobacter spp.,
producing fluoroquinolone resistant
Salmonellae,
fluoroquinolone-resistant
172
Neisseria gonorrhoeae,
cephalosporin resistant,
fluoroquinolone-resistant
Adapted from: WHO 2017c.
173
Societal Contributions
Some antibiotic use practices by HCWs and communities create pressure that allows
resistant organisms to survive and grow. These ―societal pressures‖ can accelerate
the development of microbial resistance. Societal pressures include:
Inappropriate selection, dosage, and duration of antibiotics prescribed by
clinicians, including issuing prescriptions for viral diseases such as diarrhea
and seasonal influenza.
Prescribers not complying with prescribing the right drug (only when
indicated), in the right dose, for the right duration, and with the right route of
administration.
Prescription of broad-spectrum antibiotics rather than a specific antibiotic in
situations where laboratory support is not available to identify specific
causative organisms and their susceptibility to antibiotics.
Admission to hospitals of critically ill patients who are more susceptible to
infections and therefore are more likely to be on antibiotics. The heavier use
of antibiotics in these patients can worsen the problem by promoting the
selection of antibiotic-resistant microorganisms. The extensive use of
antibiotics and close contacts among sick patients promote the spread of
antibiotic-resistant microorganisms.
Poor compliance with recommended infection prevention and control (IPC)
practices, such as Standard Precautions and Transmission-Based
Precautions, including respiratory infection prevention and control, contributes
to transmission of resistant microorganisms from one patient to another.
Antibiotic use in agriculture and the poultry industry exposes animals and
humans to unnecessary and inadequate doses of antibiotics that may lead to
antibiotic resistance in humans.
In some countries, policies and regulatory frameworks to control misuse of
antibiotics are not available. This results in antibiotics being available without
a prescription from a clinician authorized to prescribe, which increases
inappropriate use of antibiotics. (NIAID 2011; WHO 2015; WHO 2016).
174
Commonly Available Antibiotics Table 14.2 Provides examples of the classes and the
individual antibiotics within each class that is commonly available. When bacteria
develop resistance to an antibiotic, resistance to other members within the same
class is possible.
Table 14.2: Commonly Available Classes of Antibiotics
Class Antibiotics
Glycopeptides Vancomycin, teicoplanin, dalbavancin, telavancin, oritavancin
Aminoglycosides Gentamicin, tobramycin, amikacin, streptomycin, neomycin, kanamycin,
paromomycin
Chloramphenicol Chloramphenicol
Ansamycins Rifampicin, geldanamycin
Sulphonamides Sulfadiazine, sulfamethoxazole, sulfasalazine, sulfamethizole
Tetracyclines Tetracycline, oxytetracycline, doxycycline, minocycline
Macrolides Erythromycin, azithromycin, clarithromycin
Oxazolidinones Linezolid, tedizolid
Quinolones Norfloxacin, ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin
Lipopeptides Daptomycin
Lincosamides Clindamycin
β-lactams Penicillins: penicillin G*
Penicillin V, propicillin
Aminopenicillins: amoxicillin, amoxicillin-clavulanate, amipicillin,
ampicillin-sulbactam
Anti-staphylococcal penicillins: methicillin, oxacillin, dicloxacillin,
flucloxacillin
Extended-spectrum penicillins: ticarcillin, ticarcillin-calvulanate,
piperacillin, piperacillin-tazobactam
Cephalosporins:
First generation: cefazolin, cefadroxil, cephalexin, cephalothin
Second generation: cefoxitin, cefotetan, cefuroxime
Third and fourth generation: cefdinir, cefpodoxime, cefotaxime,
ceftazidime, ceftriaxone, cefepime
Fifth generation: ceftaroline
Carbapenem: imipenem-cilastatin, ertapenem, doripenem,
meropenem
Monobactams: aztreonam
Azole Miconazole, ketoconazole, fluconazole, voriconazole, posaconazole,
derivatives isavuconazonium sulfate
Nitroimidazole Metronidazole
Polymixins Colistin, polymixin B
* Antibiotics in bold are on the WHO list of essential medicines.
175
Source: Frank and Tacconelli 2012.
Instruction:
Divide in to three groups
Discuss the following concepts in your group and report the
work in the plenary (share group response to the larger
groups using flipchart)
Discussion Points:
Group 1: Rational uses of antibiotics
Group 2: Irrational uses of antibiotics
Group 3: Promotion of rational uses of antibiotics
Time Allowed: 5 minutes for group discussion and 9 minutes for
presentation (3 minutes per group)
Medications are used rationally when they are:
Clinically appropriate for the patient
Prescribed in doses that meet the patient ‘s requirements
Taken for the recommended time period
Taken at the recommended frequency
The lowest cost option for the patient and the community
Medications are not used rationally in the following circumstances:
Excessive use of multiple medicines for the same purpose in the same
patient, also known as polypharmacy
Use of injections when oral formulations would be an equally appropriate or
more preferred route of administration
Inappropriate use of antibiotics, such as failure to narrow the therapy when
culture results are known, or use of antibiotics to treat viral infections
Antibiotic selection that differs from what is recommended in standard
treatment guidelines
Self-medication with antibiotics, such as buying them without a prescription
written by a health care provider
176
Determinants of Irrational Use of Antibiotics
There are several determinants of irrational use of antibiotics:
Lack of provider knowledge, particularly with regard to prescribers who are
insufficiently qualified, supervised, or supported.
Prescriber habits (prescribing without following the guidelines).
Non-availability of standard treatment guidelines for prescribing antibiotics
Non-availability of a specific drug to treat a clinical condition, resulting in
prescribing a less effective or inappropriate alternative.
Lack of unbiased, independent, government-funded continuing medical
education and supervision that include prescribing.
Excessive promotion and incentives for prescribing offered by the
pharmaceutical industry.
Short consultations that do not provide time to explain to the patients that there
is no need for antibiotics and that the condition will improve in a few days
without antibiotics
Following practices of senior practitioners.
Perceived patient demand.
Lack of diagnostic and laboratory support.
Inappropriate procurement of antibiotics by hospitals and the public sector
supply chain
(Radyowijati and Haak 2003; Rowe et al. 2005; Sketris et al. 2009; WHO
2002).
14.6. PROMOTING RATIONAL USE OF ANTIBIOTICS
Promoting rational use of antibiotics and other medicines requires concerted
efforts at all levels, starting from the Ministry of Health at the national level
and extending out to the community. WHO recommends the following core
interventions to promote rational use of medicines, including antibiotics, at the
national level:
A mandated multidisciplinary national body to coordinate the development of
medicine use policies
Up-to-date standard treatment guidelines for prescribing antibiotics
177
An essential medicines list based on treatments of choice, consistent with
standard treatment guidelines
Drugs and therapeutics committees to oversee antibiotic use in districts and health
care facilities
Strengthening of pre-service curricula to include problem-based
pharmacotherapy
Continuing in-service medical education as a regulatory requirement
Supervision, audits, and feedback on antibiotic use
Independent information on medicines
Avoidance of any financial incentives in order to prevent over-prescribing
Public education about rational use of medicines
Appropriate and enforced regulation
Sufficient government expenditure to ensure availability of medicines and
trained staff
(WHO 2002).
Facility-level recommendations and strategies
Ideally, facility-level activities to promote rational use of antibiotics in large hospitals
are organized by a stewardship technical working group in collaboration with the IPC
technical working group. While IPC staff can contribute significantly to reducing
antimicrobial resistance, other interventions to ensure rational use of antibiotics
should have support of the management team of the health care facility as well as
the quality improvement technical working group or other clinical staff members
interested in promoting rational use of antibiotics. Small successes can be built upon
over time to reach the goal of having an antibiotic stewardship program. (For details,
see the Antibiotic Stewardship Programs section of this chapter. The
recommendations and strategies mentioned in this section should be appropriately
adjusted for smaller health care facilities.)
Provide continuing education: Education is a fundamental element of any
program designed to improve prescribing behavior. Education can also provide
a foundation of knowledge that will enhance and increase the acceptance of
stewardship strategies. However, education alone, without the inclusion of
178
active interventions, is not very effective in changing antibiotic prescribing
practices and will not produce a prolonged impact. (Barlam et al. 2016)
Improve use of standard treatment guidelines: Clinical practice guidelines
are being produced with increasing frequency to improve the quality of care
(Box 2-1-1-0-1) Antibiotic stewardship programs should improve clinicians
access to and use of national, evidence-based practice guidelines that integrate
local microbiology and resistance patterns. Guideline’s implementation can be
facilitated through provider education and feedback on antibiotic use and
patient outcomes (Barlam et al. 2016; Ministry of Health, Republic of Ghana
2010).
Streamline or de-escalate therapy: Antibiotic streamlining, or de-escalation
should be based on culture results and elimination of redundant combination
therapies to effectively target the causative microorganisms. This will ultimately
help to decrease antibiotic exposure and result in cost savings (Barlam et al.
2016; Masterton 2011).
Changing from parenteral (i.e., IV) to oral antibiotic therapy: A pharmacist
can change antibiotic therapy from parenteral to oral in consultation with the
clinician, based on a patient ‘s ability to take an appropriate oral alternative.
This change should improve patient safety and may decrease the length of
hospital stay.
Practice good IPC: Good IPC will reduce health care-associated infections and
the resulting use of antibiotics.
Reputable, Evidence-Based Clinical Practice Guidelines on Antimicrobial Use
The Infectious Diseases Society of America:
http://www.idsociety.org/IDSA_Practice_Guidelines/
The European Society of Clinical Microbiology and Infectious Diseases:
https://www.escmid.org/escmid_publications/medical_guidelines/
Johns Hopkins Medicine ‘s Antibiotic Guidelines 2Box 0-3017–2018:
http://www.hopkinsmedicine.org/amp/guidelines/Antibiotic_guidelines.pdf
All guidelines are updated on a yearly basis. Always ensure that you are referring to the
most up-to-date version
Minister of Health, Ethiopia. 2021.Health Sector Transformation Plan (HSTP-II) of Ethiopia.
Ethiopia, Ministry of health. 2021. Antimicrobial Resistance Prevention and Containment
Strategic Plan.
179
General public/community-level recommendations and strategies
Steps should be taken at all levels of society to reduce antibiotic resistance. Patients
and the community can be educated in the following actions to increase rational
antibiotic use:
Prevent the spread of infections through regular hand washing, good food
preparation practices, and respiratory etiquette, avoiding close contact
with sick people, and keeping individual vaccinations up to date.
Use antibiotics only when prescribed by a licensed health care
professional.
Take all antibiotics according to the clinician ‘s advice—right dose, right
duration (e.g., number of days), and at the right time of day.
Do not use antibiotics left over from previous illnesses or from other
people.
Refrain from sharing antibiotics with others.
Refrain from pressuring the doctor to prescribe antibiotics when it is
determined that antibiotics are not indicated for the condition (such as for
viral upper-respiratory illness).
There are a variety of ways to inform patients and the community within the facility
(such as patient education and information material, posters in the clinics, direct
reinforcement from HCWs) and through community outreach (TV/radio messages,
involvement of informal leaders).
14.7. SUMMARY
Antibiotics have been able to save many lives however, the use and
misuse of antibiotics have led to significant antibiotic resistance, thereby
limiting their effectiveness.
AMR along with irrational antibiotic use, is a major threat to health care.
Antibiotic resistance affects not only patients, but also the health care
facility and health system in various ways.
Natural causes and societal contributions are the two most important
causes of antibiotic resistance.
180
Rational antibiotic use must be addressed at all levels: nations, facilities,
individual clinicians, and the general public.
Promoting rational use of antibiotics and applying good IPC practices is
key.
Therefore, the adoption of rational antibiotic use must be a global priority
to be addressed at all levels: nations, facilities, individual clinicians, and
the public. Measures at the facility level include activities to promote the
rational use of antibiotics using broad interventions, pharmacy-driven
interventions, and interventions targeted at effective treatment of specific
infections or syndromes. Clinicians can increase the rational use of
antibiotics in their practices by streamlining or de-escalating therapy,
changing from parenteral to oral therapy, following standard treatment
guidelines, and using good IPC practices.
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CHAPTER 15: PREVENTING HEALTH CARE ACQUIRED
INFECTIONS AT SPECIAL SERVICE AREAS IN PRIMARY HEALTH-
CARE SETTING
Chapter Description
This chapter discusses safely collect respiratory samples, capture epidemiological
data, conduct surveillance, control and manage the occurrence of the HCAIs in
primary health care settings.
Chapter Objective
At the end of this chapter the participants will be able to illustrate the
techniques to control HAIs.
Enabling Objectives
At the end of this chapter, the participants will be able to:
Identify the magnitude of HCAIs at the special health care settings
Explain the risk factors for maternal and new-born HCAIs in primary health
care settings
Discuss the transmission cycle of HCAIs in primary health care settings
Identify the techniques to prevent maternal and newborn HCAIs in special
health care setting
Discuss the recommended safe work practices to prevent HAIs in special
health care settings
Chapter outlines
Definitions
Health Care Acquired Infection (HCAI): is a preventable infection that a patient
can encounter in a healthcare facility while receiving medical care. It occurs after
48h of hospital admission, up to 3 days after discharge, or up to 30 days after the
operation when someone was admitted for reasons other than infection (Sartelli,
Mckimm, Bakar, 2018:2321).
Special health care setting: is a designated area for clinical service delivery which
includes laboratory, maternal, fetal and new born care service points.
Gram-negative bacilli and staphylococcus aureus are among the most common
pathogenic organisms for hospital acquired infections. In addition to these
pathogenic organisms’ streptococcus pneumonia, pseudomonas aeruginosa,
acinetobacter species, methicillin-resistant Staphylococcus Aureus (MRSA) and
pseudomonas aeruginosa are also causes for HCAIs.
183
B. primary (e.g., bacterial) or secondary (e.g., yeast);
C. chronic (e.g., syphilis) or recurrent (e.g., herpes simplex virus [HSV]);
D. Intrinsic or extrinsic sources (e.g., methicillin-resistant Staphylococcus-
aureus [MRSA]); or
E. Acquired before or during pregnancy or after the birth.
184
meningitides are the most common causes. Infections due to the blood borne
pathogens (hepatitis B virus, hepatitis C virus, and human immunodeficiency virus)
remain the most common reported viral infections, whereas the dimorphic fungi are
responsible for the greatest number of fungal infections that could occur in
laboratories.
Table 15.1: Infection Risk Factors for Mothers and Newborns
185
15.3. RISK FACTORS FOR MOTHER AND NEW-BORN INFECTION
Activity 15.2: Group Discussion on risk factors for mothers and newborn
HCAIs
Instructions:
Be in a group of four and then
Discuss the on the following two questions in your group
and report the work in flip chart paper to the plenary (share
group response to the larger groups using flipchart).
Discussion Question:
What are the risk factors for infection during pregnancy,
labor, and post-natal period?
o Group 1: Risk related to mother,
o Group 2: Risk related to labor,
o Group 3: Risk related to new-born and
o Group 4: Risk related to peri-natal care
Are these risks preventable? How?
Time Allowed: 25 minutes
10 minutes for group discussion and 15 minutes for
presentation (5 minutes per group)
Clean hands—vigilant hand hygiene and new gloves for vaginal exams
Apply the Six or when handling the baby.
Cleans:
Clean perineum—feces should be wiped away and the perineum
washed prior to the birth (mother can shower or bathe).
(It is a memory
Nothing unclean introduced into vagina—hands, herbs, or other
aid for birth
substances.
attendants)
Clean childbirth surface—a plastic cover is appropriate for home
births; at facilities, the childbirth surface should be cleaned of blood and
body fluids and then wiped with disinfectant cleaning solution after
each use (e.g., hypochlorite solution).
187
Sterile cord cutting instrument - at home, use a new razor blade.
Note: if sterile instruments are not available, high-level disinfected
items are acceptable (WHO 2016).
Source: Partnership for Maternal, Newborn & Child Health 2006; WHO 2013b.
188
NOTE-1
Intra-partum practices that reduce of infection of the mother and newborn
In the presence of meconium-stained amniotic fluid:
Do not perform tracheal suctioning and avoid suctioning of the mouth and nose
before initiating positive pressure ventilation for infants who do not start breathing
on their own.
For newborns that do not start breathing on their own by 1 minute after birth, start
positive pressure ventilation with room air with a self-inflating bag and mask.
(WHO, UNICEF, UNFPA 2013)
Within the first hour of life:
Initiate breastfeeding within 1 hour of birth. Encourage exclusive
breastfeeding.
Apply antiseptic eye drops or ointment (e.g., Tetracycline ointment) to both
eyes only once, according to national guidelines. DO NOT wash away the eye
ointment.
Administer vitamin K and recommended immunizations (birth dose of oral
polio vaccine and HBV vaccine), using safe injection practices and sharps
safety.
Apply relevant IPC precautions (Transmission-Based Precautions and
prophylaxis) to those who are exposed or infected during or before birth (e.g.,
congenital syphilis, rubella, HIV, HBV, and other infectious diseases).
NOTE-2
189
2. Interventions after Delivery: Postpartum Care of the mother
A. Preventing infection in the mother during the postpartum period
Minimizing the risk of HAIs in mothers during the postpartum period includes the
following:
1. Infection prevention education:
2. Limit use of antibiotics after birth to recommended indications:
3. Preventing infection during the postpartum period for mothers who have given
birth vaginally includes the following:
4. In the immediate postpartum period, check to be sure the patient is voiding
within 6 hours and without difficulty.
5. Wear new, sterile gloves when performing perineal care or touching the
episiotomy.
6. Wear new, non-sterile gloves when handling perineal pads, touching lochia
(vaginal discharge), assisting with breastfeeding, etc.
B. Preventing infection during the postpartum period for mothers who have had
a C-section includes the following:
Surgical wound care
Post-operative pneumonia prevention
Care of urinary catheter Remove the catheter as soon as possible (within 24–
48 hours).
Maintain a closed drainage system and perform regular perineal care.
i. Care of intravascular device
Preventing infection in newborns
ii. Remove at birth
the intravascular device as soon as possible.
190
15.3. Preventing infection in newborns includes the following general
practices relevant to all newborns.
Always comply with Standard Precautions and use Transmission-Based
Precautions when indicated.
Keep the mother separated from the baby for IPC purposes only when the
mother has multidrug-resistant TB.
Consult to IPC staff regarding precautions for other infections in the mother.
There are few reasons to keep the mother from the baby.
Follow patient spacing guidelines in the newborn nursery. See section on
Management if the NICU in this chapter.
Encourage exclusive breastfeeding. Manage expressing and storage of breast
milk carefully to prevent infection.
Manage the preparation of formula
Screen visitors and exclude for signs of infection such as fever, respiratory
infection, diarrhea, and draining skin infection (case by case exceptions can be
made for parents with guidance from IPC staff).
Perform recommended cord care using Standard Precautions.
Immunization and post-exposure prophylaxis
Provide non-live vaccines to medically stable infants (including premature
infants) according to the national immunization schedule for age. Infants may
be hospitalized for long periods.
Do not provide live vaccines such as polio and rotavirus during admission due
to the risk of transmission of vaccine virus to immune-compromised patients.
Follow adjusted guidelines for HBV vaccine in premature infants.
Provide post-exposure vaccination prophylaxis and/or immunoglobulin, if
available, for infants exposed from the mother or from other infants (e.g., HBV,
hepatitis A, varicella, and measles).
Provide post-exposure antibiotic or antiviral prophylaxis, if available, for infants
exposed to pertussis, H. influenzae type b, meningococcal infection,
gonorrhea, syphilis, and infectious TB, and for certain high-risk newborns with
intra-partum exposure to GBS, HSV, or HIV. (WHO 2017a)
191
15.5. SAFE WORK PRACTICES AND IPC PRACTICES IN LABORATORY
AT PRIMARY HEALTH CARE SETTING
192
Untidy and noisy working environment.
15.6. SUMMARY
193
CHAPTER 16: IPC PROGRAM GOVERNANCE AND
MANAGEMENT
Chapter Description:
This chapter describes the recommendations of the IPC program governance and
management including the national IPC policy strategic plan in terms of establishing
facility level IPC functions, structures and the roles and responsibilities of those who
will be providing managerial and technical services within the limits and scope of
health center services.
Chapter Objective
By the end of this chapter the participant will be able to design the management
structure for specific IPC function in line with national IPC policies and strategies.
Enabling Objectives
By the end of this chapter the participants will be able to
Outline national IPC policy and strategic plan pertaining to health centers
Create an organizational structure for IPC program management
Highlight the attributes of effective infection prevention and control (IPC)
programs
Identify the major infection prevention and control program activities
Design IPC continuous quality improvement model using multimodal
strategies
Chapter outline
16.1. Overview to the national IPC policy and strategic plan
16.2. IPC program governance and Management
16.3. The attributes of effective infection prevention and control (IPC) programs
16.4. Major infection prevention and control program activities
16.5. Using Quality improvement model and multimodal strategies to improve IPC
practices
16.6. Summary
194
16.1. OVERVIEW TO THE NATIONAL IPC POLICY AND STRATEGIC PLAN
PERTAINING TO PRIMARY HEALTHCARE FACILITIES
Activity 16.1: Think in pair and share on National IPC Policy and Strategy
Instruction:
Think about the below questions in pairs and dot down your
thought in your notebook and share the work in the plenary.
Reflection Question:
1. How many of you know the Ethiopia has National IPC policy
and strategy?
2. How is the IPC program structure/organized in your facility?
3. How would you describe the implementation in your facility or
beyond?
Time Allowed: 5 minutes to discuss and 5 Minutes to reflection
The threats posed by epidemics, pandemics and antimicrobial resistance (AMR) have
become increasingly evident as ongoing universal challenges and they are now
recognized as a top priority for action on the global health agenda. Effective IPC
Program at all levels is the cornerstone of such action.
The organization of IPC programs must have clearly defined objectives based on the
facility context according to risk assessment and functions that align with and
contribute to the prevention of HAI and the spread of AMR in health care.
Developing an IPC policy and strategy provides a framework to develop and
implement IPC guidelines and standard operating procedures (SOPs) in order to
improve the quality of service in healthcare facilities. Ethiopia has launched National
Infection Prevention and Control policy, strategy, and strategy roadmap in September
2021 which is designed based on WHO eight core components.
The rational for developing the national IPC document was to establish the foundations
for IPC programs at the national, regional, and healthcare facility levels and across
both public and private health sectors.
The policy focus areas have been identified and adopted from the WHO IPC core
components that are known to be evidence based and are recommended for use, this
includes:
195
1. IPC Program Management and Institutional Coordination Structure
2. National Infection Prevention and Control Standards and Guidelines
3. IPC education, training, and quality improvement
4. HAIs’ surveillance
5. Multimodal strategies and policy implementation
6. Workload, staffing & bed occupancy
7. Built environment, materials & equipment
8. Research and development
9. Monitoring, Evaluation, Audit and Feedback
10. Advocacy, Social Mobilization and Partnership
11. Resource allocation and mobilization
16.2. IPC PROGRAM GOVERNANCE AND MANAGEMENT
Activity 16.2: Individual Reflection on IPC governance and management
Instruction:
Think about the below questions by yourself and dot down your
thought in your notebook and share the work in the plenary.
Discussion Question:
12. How IPC program in healthcare facilities should be
structure/organized? Put an organogram of good IPC
Program in Primary healthcare Facilities
13. What are the successes and challenges of IPC program in
your facility?
Time Allowed: 5 minute to think and 5 Minutes to reflect
The national IPC strategy in terms of PHCU level IPC program governance and
arrangement recommend the establishment of following functions and positions. In
addition to the designated program leader, key staff and groups involved in Infection
Prevention and Control Programs and who play a major role in the oversight of a
successful program include:
Administrative leadership:
The reporting structure for the IPC program varies among health care facilities and can be
adapted to fit to the local context of the facility. One or more health care administrators will
196
supervise the leader of the IPC program and will take an active role in helping to shape and
support the program’s priorities and plans.
IPC committee:
The purpose of the committee is to guide and support the use of recommended
Practices and to review and resolve related problems that may arise. Additionally, the
committee advocates for resources required for effective implementation of the IPC
program. This committee should include representatives from different wards and
units, including procurement, laboratory, sterilization, environmental cleaning…etc. In
small facilities (e.g., health post & clinics) where these functions often overlap, the
group may consist of only two or three individuals. The IPC committee should meet on
a regular basis, at least monthly, to review the available IPC data and any problems or
issues that are identified but the IPC team (usually composed of key persons involved
in the day-today activity such as the IPC focal, the Lab personnel and the pharmacist)
may meet more frequently on need basis.
Task forces/working groups:
These may be permanent or temporary groups and may be created as needed to
provide input and oversight for a particular issue. Examples include groups focused on
disinfection and sterilization, waste management, or emergency preparedness. Task
forces/working groups should consist of individuals with multidisciplinary expertise and
should be granted authority to make decisions and advise and oversee the IPC
leadership and team in addressing the issue. IPC leadership or team members should
also be included. (WHO 2016) Organizational oversight from top facility leadership:
The person or group with organizational authority should periodically review the status
of HAIs at the facility and the effectiveness of measures designed to contain them
(WHO 2002). This process can highlight important areas of risk and opportunities for
improvement. (See the Program Evaluation section later in this chapter.)
197
National or regional public health authorities:
Public health authorities work closely with and support the facility-level IPC program,
providing expertise, partnership, assistance, guidance documents, support for
outbreak investigations, and authority to enforce IPC measures. The Facility-level IPC
team provides important front-line information to the public health authorities.
Roles and responsibilities of facility level staffs
The organization and structure of a facility’s IPC program, should have a clear concept
of the composition, roles, and responsibilities of important program staff, including the
IPC committee, program leader, IPC task forces, and facility staff. Facility leadership
should adapt the program structure based on the scope of the IPC program and the
needs of the facility small health care facilities in rural areas may have one staff nurse
or a medical officer and a few nurses, midwives, and other HCWs and limited scope of
IPC.
A successful IPC program must be able to effectively guide, support, and assess IPC
at the facility. Some of these attributes will be managed by senior facility leadership
and some by those designated as responsible and accountable for the facility’s IPC
program. In both cases, the following are necessary for an IPC program to succeed.
To achieve this, the program must acquire and retain the following attributes:
198
Designated staff member/Team who is responsible and accountable for IPC at
the facility
Competent IPC Program leaders with appropriate training and education
Formal authority granted to the IPC program
Tangible support from facility leadership
Adequate resources for IPC activities
Partnerships with key stakeholders and front-line HCWs
Effective communication about IPC
16.4. MAJOR INFECTION PREVENTION AND CONTROL (IPC) PROGRAM
ACTIVITIES
Activity 16.4: Individual Refection on major activities on IPC
Instruction:
Think about the below questions by yourself and dot down
your thought in your notebook and share the work in the
plenary
Question:
What are the some of the major activities that you would consider
as if assigned as an IPC program leader at your Primary facility?
199
16.5. USING QUALITY IMPROVEMENT MODELS AND MULTIMODAL
STAREGY TO IMPROVE IPC PRACTICES
Activity 16.5: Individual Refection on Quality Improvement
Instruction:
Think about the below questions by yourself and dot down
your thought in your notebook and share the work in the
plenary
Question:
What is quality in healthcare service?
What is quality improvement?
What is the quality improvement model?
Time Allowed: 5 Minutes to think and 5 minutes to reflect
Quality is defined by the US Institute of Medicine as “the degree to which health
services for individuals and populations increase the likelihood of desired health
outcomes and are consistent with current professional knowledge”. There seven
dimensions of quality of care. These are.
1. Safe: avoiding injuries to patients from the care that is intended to help them.
2. Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care.
3. Efficient: avoiding waste, including waste of equipment, supplies, ideas, and
energy.
4. Effective: providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit.
5. Equitable: providing care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and
socioeconomic status.
6. Patient-centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values, and ensuring that patient
values guide all clinical decisions.
7. Integrated: providing care that makes available the full range of health services
throughout the life course.
A major function of an IPC program is to make healthcare facilities safer to work-in and
be cared for by identifying areas in which improvements in quality of care are needed.
200
IPC program activities (such as surveillance and observations of clinical practice)
should identify these areas.
Quality improvement (QI) consists of systematic and continuous actions that lead to
measurable improvement in health care services and the health status of targeted
patient groups.
Once areas for improvement are identified, IPC committee and facility staff need to
work together to apply evidence-based IPC strategies to change priorities, beliefs,
habits, and loyalties of staff to make healthcare facilities safer.
Quality improvement models offer a systematic approach for assessing and improving
care services. Quality improvement models are framework or roadmap that is used to
organize the work of an improvement initiative. Using QI models help an improvement
team to focus on changes that have already proven to be effective. They also provide
guidance on different ways to approach change.
Model for improvement focuses on three questions: to set the aim or organizational
goal, to establish measures/define measurements and select changes/find promising
ideas for change. It also incorporates plan-do-study-act (PDSA) cycles to test changes
on a small scale.
Central principles of improvement
Fundamental to the success of any improvement effort, is the understanding that every
improvement requires change. But not all changes result in an improvement. There are
five fundamental principles of improvement we need to take into consideration while
attempting to improve quality.
1. Know why you need to improve (aim or purpose of improvement effort)
2. Have a way to get feedback to let you know if improvement is happening
(observation, use of indicator data, feedback from service users etc.)
3. Develop a change that you think will result in improvement
4. Test a change before any attempt to improve
5. Implement a change
201
•Establish a mulit-displanary committed team that has expet
konwlge on IPC and Qualitiy Improvemt Initiative (if availble)
Form a team •Select a team who are data driven that have good
understaning of system thinking
•Use diffent models to identify the mojor IPC gap in your healthcare facility
•Including Data form various sources, barinstorming, Risk Assessement,
Identification of
Problem/ Gap Observation or Walk through, Process map
202
Do—the health care facility staff implement the intervention
Study—the health care facility staff analyze results of the interventions that
were gathered through the timely collection of monitoring data
Act—the health care facility staff institutionalize or reject the intervention based
on the results and plan another intervention.
203
4. Reminders in the workplace/communications and
5. Culture change with the establishment or strengthening of a safety climate
A bundle is an implementation tool aiming to improve the care process and patient
outcomes in a structured manner. It comprises a small, straightforward set of
evidence-based practices (generally 3 to 5) that have been proven to improve patient
outcomes when performed collectively and reliably.
In order to address both technical challenges for which there are knowledge to
implement a solution as well as adaptive challenges in which the priorities, beliefs,
habits, and loyalties of staff a knowledge of quality improvement methods is important
for those overseeing and implementing IPC programs (Pronovost 2011).
Example of applying in PDSA cycle and multimodal strategies
Abebe have been assigned as an IPC leader in XX heath care facility. He asked his
multidisciplinary IPC committee and department head nurses to conduct risk
assessment on infection prevention and control to identify the major gaps/problems
within their departments using a standardized checklist. Using a pareto chart the team
prioritize the problems to focus on the most important ones and found that the major
problem in healthcare facility was hand hygiene (HH) compliance.
After prioritization, the team developed a problem statement on the top issue/gap
identified as “Over the past 2 months, 60% of the healthcare workers are not adhering
to the 5 moments of Hand Hygiene as per the WHO recommendation.” Using fishbone
analysis, they sought to identify the root causes of the problem to identify interventions
that can be implemented to alleviate the problem.
After identing the root causes of the problem, Abebe and his team used both subject
matter knowledge and literature reviews/desk review on how to improve hand hygiene
compliance in their healthcare facility. They identified 6 specific intervention activities
that needs to be tested to improve hand hygiene compliance which includes:
A. Provision of alcohol-based hand rubs,
B. Increasing access to continuous water supply and towels,
C. Training and education on HH,
D. Continuous monitoring and feedback
204
E. Posting reminders in workplace
F. Role modeling
After identifying the intervention, they agreed that they need to test each specific
intervention activities to prove that they are effective. They laid out a detail test method
using PDSA cycle as follows:
Intervention Plan Do Study Act
Provision of Plan: We will ask XX The assigned The team We are
alcohol- department in the team will analyzes the ready to
based hand healthcare facility to place monitor and data and finds introduce the
rubs alcohol-based dispensers at record the hand that there Provision of
point of care and to provide hygiene have been alcohol-
their full staff alcohol-based compliance improvements based hand
hand rub and monitor. every day in XX in hand rubs to the
Goal: We want to improve department hygiene entire
the hand hygiene from X-Y time compliance in departments.
compliance of healthcare for one month. the 5
workers during their 5 moments of
moments of hand hygiene hand hygiene
Steps:
The facility will provide
improvised types of hand
hygiene despisers with
alcohol and install them to
XX department,
The facility will also provide
Y amount small bottles of
sanitizers (alcohol based)
equal to the number of
healthcare workers in XX
department.
205
Activity 16.6: Group work on PDSA quality improvement model
Instruction:
Group the participants in to three groups
Ask participant in the group to do a PDSA for each of the
following interventions by assigning one intervention to
one group
Discuss the below questions in your group and report the
work in flip chart to the plenary
Discussion Question:
A. Increasing access to continuous water supply and towels,
B. Training and education on HH,
C. Posting reminders in workplace
Time Allowed: 10 Minutes for group Discussion and 15 minutes
(5 minutes for each group)
After Abebe and the team had designed their PDSA cycle they had to get small
funding to test each intervention strategies. So, they advocated to the senior
management team on the importance of hand hygiene and how each strategy that
would improve hand hygiene compliance and how they want to pilot in a test
department.
(If you want to learn more about how to advocate for a cause please visit
https://healthlearn.org/courses/advocacy-for-health-care-workers-introduction/).
Once they got the small fund from the senior management team to test these
interventions, they went ahead and tested each intervention in a different department.
The results were very good, each intervention has shown an improvement to hand
hygiene compliance as compared to the baseline, seeing the result, the again went to
the senior management and presented their results and asked the senior management
to invest more money so that they can implement the interventions in a multimodal
strategy. Once the had the green light to implement the strategy they designed their
multimodal strategies as follows.
1A. System change: Bottles of alcohol-based hand rub positioned at the point
alcohol-based hand rub of care in each ward, or given to staff
1B. System change: One sink to at least every 10 beds
Access to safe continuous Soap and fresh towels available at every sink
water supply and towels
2. Training and education All staff involved in the test phase receive training
A program to update training over the short-, medium-
and long-term is established
206
3. Observation and Setup two periods of observational monitoring to be
feedback undertaken (for training and education and reminders in
the workplace)
4. Reminders in the “How to” and “5 Moments” posters are displayed in all
workplace test wards (e.g., patients’ rooms; staff areas; out-
patient/ambulatory departments)
5. Institutional safety The chief executive, chief medical officer/medical
climate superintendent and chief nurse all make a visible
commitment to support hand hygiene improvement
during observation and feedback serving as a role model
(e.g., announcements and/or formal letters to staff)
207
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208
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CHAPTER 15: PREVENTING HEALTH CARE ACQUIRED INFECTIONS AT SPECIAL
SERVICE AREAS IN PRIMARY HEALTH-CARE SETTING
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