CRITICAL CARE NURSING

UNIT V
INFECTION CONTROL

BY :
Dr S.PUNITHA JOSEPHINE
Vice principal ,
KVCN
DEFINITION:
Infection is the process of bacteria or viruses
invading the body or making someone ill or
diseased.
When you catch a cold, this is an
example of aninfection.
A virus is an example of an infection.
 Infection may be local or generalized and
spread throughout the body.

Once the infectious agent enters the host it

begins to proliferate and reacts with the defense
mechanisms of the body producing infection
symptoms and signs: pain, swelling, redness,
functional disorders, rise in temperature and
pulse rate and leukocytosis.
 Types of infection:
Primary infection
Secondary infection
Local infection
Systemic infection
Chronic infection
Acute infection
Iatrogenic infection
Nosocomial infection (HAI)
Chain of infection:
Causative
Agent

Susceptible Reservoir
Host

Portal of Portal of
Entry Exit

Mode of
Transmis
sion
Causative Agent - the microorganism
(for example bacteria, virus or fungi).
Reservoir (source) - a host which allows
the microorganism to live, and possibly
grow, and multiply. Humans, animals
and the environment can all be
reservoirs for microorganisms.
Portal of Exit - a path for
the microorganism to
escape from the host.
The blood, respiratory
tract, skin and mucous
membranes,
genitourinary tract,
gastrointestinal tract, and
transplacental route from
mother to her unborn
infant are some
examples.
Mode of Transmission - since
microorganisms cannot travel on their own;
they require a vehicle to carry them to other
people and places.
Infectious diseases and even
certain contagious diseases spread through
the following agencies. Their ways of
spreading is also given along with these
agencies.
 Air-borne transmission
 Contact transmission-direct and indirect
 Vehicle transmission (Water, milk, food
etc.)
 Vector-transmission
 Tran placental transmission
Portal of Entry - a path for the
microorganism to get into a newhost,
similar to the portal ofexit.

Susceptible Host - a person susceptible to

the microorganism
 Who is at risk of infection?
Staff: service provide are at significant risk for
infection because they are exposed to potentially
infectious blood and otherbody fluids on daily
basis.
Clients: they are at risk of post procedural infection
when, e.g. service providers do not wash hands
between client and procedure.
Community: it is also at risk of infection,
particularly from inappropriate disposalof medical
waste.
Breaking chain of infection:
As health professional, we cannot provide health care
services without some exposure to potentially
infectious materials, but we can prevent transmission in
many cases. The only way to prevent infection is to
break the chain of infection. The nurse must follow
certain principle and procedures to prevent infection and
control its spread.
 Breaking the chain 1 of
infection:
1. Rapid and accurate identification of
organism:
Routinely send blood cultures, urine
culture, skin swabs, throat swabs,
tracheal aspirate culture.
Send endotracheal tube tip, urinary
catheter tip and central line tip for culture
after removal.
 2. Control or elimination of infectious
agents including:
Proper cleaning by the water and
mechanical action with orwithout
detergents.
 Disinfection.
Sterilization of contaminatedobjects.
 High level of disinfectants:
Activated glutaraldehyde (cidex2%)
Sodium hypochloride 1%
Carbolic solution 5%
Bleaching powder 1%
 Low level of disinfectant:
Methylated spirit 70%
Betadine solution 10%
Savlone 1%
 Breaking the chain 2 of
infection:
Measures to control or eliminate of reservoir
of infection.
Employee health:
Immunization of health personnel’s e.g.
hepatitis Bvaccine
Regular checkup for early detection of any
communicable disease
Restriction from work of patient contact
when infected with communicabledisease.
 Environmental disease:
Cleaning with hospital approved clear
disinfectant, e.g. phenol
Through cleaning of bed and bedside
equipments before admitting newpatient.
Separate mops should be used for cleaning
of unit. (Twice aday).
Damp dusting should be done.
Drains should be patent.
 Handling of linen:
Keep bed sheets dry and clean.
Change sheets every day.
Do not shake blankets and linen.
Do not throw them onfloor.
Soiled linen counting should be done in
separate place.
 Pest control:
Measures to be taken to avoid their entry
into unit. E.g. proper cleaning, sealing and
draining.
Patient’s diet should be kept in covered
containers.
Keep fly trappers on each bedside of
patient.
Pesticide spray should be used weekly.
Visitors control:
Traffic should be restricted except for doctor,
nurse and supportive staff.
Allow only one attendant (3-4hours).
Keep the doors and windows closed.
Mobile phones should not be allowed inside
the area.
Machines (X-rays, echo machines,
ultrasound machine) from outside shouldbe
cleaned with spirit before theiruse.
 Breaking the chain 3 of
infection:
 Portal of exit:
Practice aseptic precaution.
Avoid talking directly into the client’s mouth to
prevent the droplet infection.
Wearing of mask is compulsory if the nurse is
infected or she is dealing with the patients who
are infected.
Careful handling of waste like urine,faeces,
emesis and blood is important.
Disposable gloves should be worn to prevent
direct contact with wastes or infected materials.
 Breaking the chain 4 of
infection:
Mode of transmission:
 Contact Precautions;
Single patient room.
Staff to perform hand hygiene, put on
gown/apron and gloves prior to entering patient
room and when anticipatingcontact with the
patient or their surroundings is.
Remove gown/apron and gloves and perform
hand hygiene after leavingroom.
Clean and disinfect non-disposable equipment
and items when removedfrom patient room.
 Droplet Precautions;
Single patient room.
Staff to put on surgical mask when entering
room and remove and dispose of maskafter
leaving room and perform hand hygiene.
Instruct patient about respiratoryhygiene
and cough etiquette.
Limit patient movement outside the room to
medically-necessary purposes.
Patient to put on a surgical mask when
leaving room.
 Airborne Precautions;
Single negatively pressured room.
Door to remain closed.
Staff to put on N95/P2 mask when
entering patient room and removeand
dispose of mask and perform hand
hygiene after leaving room.
Instruct patient about respiratory hygiene
and cough etiquette.
Patient to put on surgical mask when
leaving room.
 Breaking the chain 5 of
infection:

 Portal of entry:
Maintain integrity of skin andmucous
membrane.
Prepare position of tubing, etc. may
prevent injuries and skinbreakdown.
Turning and positioning of debilitated
clients.
Ensure the personal hygiene of
client regularly.
Proper disposal of contaminated
syringe and needles.
Proper handling of catheters and
drainage set etc. care should be taken
while collecting and handlingspecimen.
 Breaking the chain 6 of
infection:
 Protecting susceptible host:
Protecting the normal defense mechanism
by,
Regular oral hygiene.
Maintaining adequate intake.
Encouraging deep breathing exercise.
Encouraging proper immunization of
children and adult client.
 Maintaining healing process:
Promotion of intake of well-balanced diet
containing essential protein, vitamins, fats
and carbohydrates.
Institution measures to improve appetite of
patient.
Helping the client toidentify methods to
relieve stress.
What is Infection Control?

Patient to Worker to
Worker
Visitor Worker
Patient
Visitor
Patient
Visitor to
Worker
Visitor
Patient
INFECTION CONTROL

Infection control is the discipline concerned

with preventing nosocomial or healthcare-
associated infection.

It is an essential (though often under-recognized and

under-supported) part of the infrastructure of health care.
Infection control addresses factors related to the spread
of infections within the health-care setting, including
prevention, monitoring/investigation of demonstrated or
suspected spread of infection within a particular health-
care setting, and management (interruption of
outbreaks).
HOSPITAL INFECTION CONTROL
PROGRAMME

The aim of the Hospital Infection Control Program is

dissemination of information, surveillance activities,
investigation, prevention and control of nosocomial
infections in the hospitals.
Nosocomial infections affects approximately 2 million
patients annually in acute care facilities in our
country and their annual patient care costs several
millions of rupees.

Studies shows that nearly one-third of nosocomial

infections can be prevented by a well organised infection
control programme. But only less than 10% are actually
prevented.
To be effective the infections control programme should
include the following.

1.Organised surveillance and control activities

2.One infection control practitioner for every major
Health Facility.
3. A Trained Hospital Epidemiologist
THE IMPORTANT COMPONENTS OF
THE INFECTION CONTROL PROGRAM
ARE:

basic measures for infection control, i.e. standard and

additional precautions;
education and training of health care workers;
protection of health care workers, e.g. immunization;
identification of hazards and minimizing risks;
routine practices essential to infection control such as
aseptic techniques ,
use of single use devices, reprocessing of instruments
and equipment ,
antibiotic usage, management of blood/body
fluid exposure,
handling and use of blood and blood products,
surveillance;
incident monitoring;
outbreak investigation;
infection control in specific situations; and
Research
sound management of medical waste;
1. INFECTION CONTROL
COMMITTEE

2. INFECTION CONTROLTEAM

3. INFECTION CONTROL MANUAL

INFECTION CONTROL
COMMITTEE:-
It is a multidisciplinary committee responsible for
monitoring program policies implementation and
recommend corrective actions.
It includes representatives from different concerned
hospital departments & management. They meet
bimonthly.
It establishes standards for patient care, it reviews and
assesses IC reports and identifies areas of
intervention.
The hospital ICC is charged with the responsibility for
the planning, evaluation of evidenced-based practice and
implementation, prioritization and resource allocation of
all matters relating to infection control.
The ICC must have a reporting relationship directly to
either administration or the medical staff to promote ICP
visibility and effectiveness. The ICC should meet
regularly (monthly) according to local need
INFECTION CONTROL TEAM :-

INFECTION CONTROL INCHARGE

SISTER INCHARGE

INFECTION CONTROL NURSE

TEAM MEMBERS TO BE AUTHORISED:-

Team should have authority to manage an effective

control program.
Team should have a direct reporting with senior
administration.
Infection control team members or are responsible for
day-to-day functions of IC and preparing the yearly
work plan.
They should be expert and creative in their job.
THE ICC HAS THE FOLLOWING TASKS:-

To review and approve the annual plan for infection

control
To review and approve the infection control
policies.
To support the IC team and direct resources to
address problems as identified
To ensure availability of appropriate supplies
To review epidemiological surveillance data and
identify area for intervention.
To assess and promote improved practice at all levels of
the health care facility
To ensure appropriate training in infection control and
safety.
To review risks associated with new technology and new
devices prior to their approval for use.
To review and provide input into an outbreak
investigation
MANAGEMENT OF INFECTION CONTROL
IN A HOSPITAL

Monthly they have one infection control meeting on

3rd Friday/saturday with all committee members
In which they deal with all infection control
prevention measures of hospital
Also they discuss with all department and
infection control nurse about monthly report of
infection control in hospital
Also they have in-service education in hospital for staff,
2 times class lecture for staff and one time class lecture
for infection control nurse.
Also they give education to staff and students at
bedside.
They follow all the protocols like universal precaution,
BMW etc.
THE ROLE OF ICN:-

Identify, investigate and monitor infections, hazardous

practice and procedures
Participate in the preparation of documents relating to
service specifications and quality standards.
Participate in training and educational programs and in
membership of relevant committees where infection
control input is needed
Educate individuals and groups about the risk,
prevention, transmission, and control of infection,
disease-specific care, appropriate precautions, and
appropriate assessments
Investigate, manage and conduct surveillance of
suspected and confirmed outbreaks of infection
Training and education under the supervision of ICO

Increase awareness among patients n visitors about

infection control

Maintain infection control standard and policies.

SURVEILLANCE

PREVENTIVE ACTIVITIE

STAFF TRAINING
SURVEILLANCE:-

DEFINITION:-
It is the outgoing systematic collection,
analysis and interpretation of health data
essential to the planning, implementation and
evaluation of health care practices.
PURPOSE OF SURVEILLANCE

Reduce infection rates within a hospital

Identify outbreak
Convincing medical personnel
Evaluating control measures
SURVEILLANCE ACTIVITIES:-

Operative Procedures
Critical Care Units (MICU, SICU, NICU)
Targeted Surveillance
Outbreak Investigation
AIMING AT PREVENTING SPREAD OF
INFECTION:

Treating all patients in the health care facility with the

same basic level of “standard” precautions involves
work practices that are essential to provide a high
level of protection to patients, health care workers
and visitors.
STANDARD PRECAUTIONS:
These measures must be applied during every patient care,
during exposure to any potentially infected material or
body fluids as blood and others.
Components:
A. Hand washing.
B. Barrier precautions.
C. Sharp disposal.
D. Handling of contaminated material.
HAND WASHING:-

Hand washing is the single most effective precaution for

prevention of infection transmission between patients
and staff.
Hand washing with plain soap is mechanical removal of
soil and transient bacteria (for 10- 15 sec.)
Hand antisepsis is removal & destroys of transient flora
using anti-microbial soap or alcohol based hand rub (for
60 sec.)
BARRIER PRECAUTIONS
A general term referring to any method or device used to reduce c
ontact with potentially infectios body fluids, including.
facial masks, double gloving and fluid-resistant gowns
gloves;
protective eye wear (goggles);
mask;
apron;
gown;
boots/shoe covers; and
Cap/hair cover.
SHARP DISPOSAL
Sharps are objects or devices that have been used in patient care, medical,
research, or industrial laboratories. Sharps can be glass, metal, or plastic with
rigid corners, sharp edges, or protruding pieces that can slice, scrape or pierce
the skin. Sharps may include (but aren’t limited to):

Acupuncture needles
Broken glass or capillary tubes
Blood vials
Scalpel blades
Syringes with and without needles
Suture needles
Trauma scene waste that can cut,slice or pierce
Culture dishes and slides
Tubing with needles
Needles and tubing
ADDITIONAL (TRANSMISSION-BASED)
PRECAUTIONS:-
Additional (transmission-based) precautions are taken
while ensuring standard precautions are maintained.
Additional precautions include:
Airborne precautions;
Droplet precautions; and
Contact precautions.
STAFF TRAINING
Staff health promotion and education:
1. HCW’s are at risk of acquiring infection, they can
also transmit infection to patients and other
employee.
2. Employee health history must be reviewed,
immunizations recommendations to be considered.
3. Release from work if sick, occupation injury
must be notified.
4. Continuous education to improve practice, better
performance of new techniques
Master institutional infection control orientation and in
service education program-for all level staff

Wards/departmental in service training program

Infection control seminar/workshops and symposia

INFECTION CONTROL MANUAL:-

Every Hospital should have a nosocomial infection

prevention manual or a Hospital associated infection
prevention manual containing recommended
instructions and practices for patient care.
The manual should be developed and updated by the
infection control team and reviewed and approved by
the committee.
It must be made readily available for health
care workers, and updated in a timely fashion.
Definition:

A hospital-acquired infection is usually one

that first appears three days after a patient is
admitted to a hospital or other health care
facility. Infections acquired in a hospital are
also called Nosocomial infections.

 For a HAI, the infection must occur:

Up to 48 hours after hospital admission.
Up to 3 days after discharge.
Up to 30 days after an operation.
In a healthcare facility when someone was
admitted for reasons other than the infection.
Sites and cause of HAI:

• CAUTI
• CA-BSI
• VAP
• SSI
 Infection control checklist for NABH
accreditation preparation
Facility and infrastructure for infection
control
a. Appropriate distance must be maintained between adjacent
beds. Various standards such as ASHRAE, JCAHO, BSI
recommends a minimum distance of 8 feet (2.4 meters) to be
maintained between centres of adjacent beds in a multi-bed ward. In
ICU however, the inter-bed distance should be higher, about 10 feet
(3 meters), or an area of at-least 20 square meter per bed.
b. Adequate hand wash basins must be available in wards
and ICUs. Recommended norms are one hand wash basins for
every 6 beds in wards and for every 2 beds in ICU.
C. Isolation rooms must be available, both in wards and
in ICU. These must be of both types, positive and
negative isolation rooms.
D. Adequate and demarcated space should be available
in wards to keep urine, stool samples of patients, their
disposal, washing and storage of contaminated / soiled
linen, place to make disinfectant solution and placement
of bedpans etc.
e. Separate room for storing dirty utility and soiled
linen must be available in all wards. These rooms must
have facility for bed pan sink, Macintosh sink, slop sink
and supply of hot and cold water.
f. Demarcated space for keeping biomedical waste
containers should be available in each ward.
g. The floor and walls, especially in ICU must be easily
cleanable and non-porous.
h. ICU should have defined protective and clean zone.
An air-curtain must be provided at entrance of ICU.
i. ICU should have minimum 15 air changes per hour
(5 fresh + 10 recirculation) as per ASHRAE standards
j. Operation theatre must meet zoning and ventilation
requirements
B. Organization for Infection control
Following HR and organizational structures must be in place for
infection control
a. Infection control officer – He/she could be an infectious
disease specialist or a medical microbiologist, who works as an in-
charge of infection control
b. Infection control nurses (ICN) – These are nurses that are
trained in infection control practices, surveillance and monitoring. 2-
3 ICN is required for a 100 bed hospital. ICN works for
implementation of infection control practices and for data collection
through surveillance
c. Infection control committee for taking decisions on matters
related to infection control
d. Infection control team for implementing infection control
practices and measures across the hospitals
e. Infection control programme: Infection control programme
describes everything that is planned and done to prevent infections
in the hospitals. This programme must be updated once a year
f. Infection control manual – The manual documents infection
control practices for various functions in the hospital
 C. Policies, processes, practices and implementation
Following policies and process must be in place for infection control
a. High risk areas within the hospitals should have been identified
and listed. These are areas which has higher potential of spreading
infection. Such areas include, OT, ICU, post-operative ward, blood
bank, CSSD, post-mortem area etc.
b. High risk procedures that are performed within hospital must
be identified and listed. These are procedures that has higher chance
of causing infection to patients. Such procedures include,
endoscopies, long surgeries, cardiac catheterization, bone marrow
transplants etc.
c. Standard precautions must be followed across the hospital
while providing patient care.
d. Staff must use appropriate hand hygiene guidelines. These
guideline includes, when wash hands, what kind of hand washing is
required in different situations, proper method of hand washing (6
point or 9-point hand wash) and other measures to keep hand
hygienic
e. Hand washing technique must be displayed near every hand
wash basin
f. Personal protective equipment must be available in all patient
care area as per requirements. These include thing like gloves, masks,
aprons etc. The healthcare staff must know when and how to use the
personal protective equipment
g. The policy of “One needle, one syringe, only one time” must be
followed across the hospital. Staff giving injections and infusions must
be trained on best injection practices
h. Barrier nursing practices must be followed for isolation patients
i. Appropriate care bundles must be used for patients on high risk
of acquiring HAI, such as patients on ventilator, urinary catheters,
central line catheter and surgical patients
j. An antibiotic policy must be available and followed for
prescribing antibiotics – Antibiotic policy is a policy document that
guides what kind of antibiotics should be prescribed for different kind
of clinical conditions. The antibiotic policy must be revised from time
to time.
k. A policy should be there for change of linen – The linen must be
changed daily, and whenever it gets soiled. It should also be changed
for every new patient getting admitted.
l. Laundering process must adhere to infection
control measures. These include segregation and
cleaning of soiled linen.
m. Kitchen should be hygienic and sanitized condition.
Health check-ups of food handlers must be done to
identify those who are suffering with communicable
diseases
n. Housekeeping procedures must be defined and
standardized to achieve optimal infection control
o. Procedure for identifying and handling infection
outbreaks must be available
p. Procedures for CSSD activities for preventing
spread of infections must be followed
q. Procedure of segregation and handling of
biomedical waste should be followed, as per regulatory
guidelines
D. Surveillance, monitoring and indicators
a. Surveillance for infection control should be regularly carried
out. The frequency of surveillance in high risk areas should be
higher
b. Surveillance must include both, patient surveillance and
environmental surveillance
c. The data of HAI should be collected through surveillance
d. The data collected through surveillance must be verified
e. During surveillance, monitoring of certain significant type of
infections should be done, such as occurrence of multi-drug
resistant organisms
f. Compliance of hand-hygiene guidelines by healthcare staff
must be monitored
g. Effectiveness of housekeeping services must be monitored
h.
Clinical Quality indicators to determine effectiveness of
infection control measures
i. Catheter-associated urinary tract infection rates
ii. Ventilator associated pneumonia
iii. Catheter linked blood stream infections
iv. Surgical site infections
Others:
Hand Hygiene Compliance rate
Mock Drills (Spill Management etc)
NSI
Ventilator Bundle for prevention of Ventilator
Associated Pneumonia (VAP)
1. Elevation of the head of the bed
2. Daily sedative interruption and daily
assessment of readiness to extubate
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis
5. Daily oral care with chlorhexidine
Central Line Bundle for prevention of catheter
associated blood stream infections (CA – BSI)
1. Hand Hygiene Washing hands or using an
alcohol-based waterless hand cleaner helps to
prevent contamination of central line sites and
bloodstream infections
2. Maximal Barrier Precautions Upon
Insertion
3. Daily Review of Line Necessity with Prompt
Removal of Unnecessary Lines
Urinary Catheter Bundle for prevention of
catheter associated urinary tract
infections(CAUTI)
1. Assessment of the requirement for
continuing catheterization
2. Checking whether the catheter has been
continuously connected to the drainage system
3. Daily meatal hygiene
4. Urobag is regularly emptied in a clean
container
5. Hand hygiene is performed prior to and
after each catheter care procedure
Surgical care bundle for prevention of surgical
site infections (SSI)
1. Prophylactic antibiotic
2. No hair shaving
3. Glucose control (peri-operative) Glucose
must be kept under control limit to prevent SSI
4. Normothermia (except cardiac surgery)
5. Pre-op screening for S. aureus or MRSA –
If found positive the organism must be
decolonized first before operating
[BIO-MEDICAL WASTE MANAGEMENT]
MANAGEMENT OF
BIO MEDICAL
WASTE :-
BIO MEDICAL
WASTES:

SEGREGATE AND
PACK IT RIGHT AT
THE POINT OF
GENERATION
BIO MEDICAL WASTES COLLECTION &TRANSPORT
BIO MEDICAL WASTES COLLECTION &TRANSPORT
THANK YOU

THANKS TO ALL