BRIEF SUMMARY OF

CONCEPTS IN
INFECTION PREVENTION
AND CONTROL
AISA JENSEN LEE, RN

Objectives
At the end of the lecture, the participants
will be able to:
Define the burden of disease of healthcare
associated infection
Identify the strategies to combat healthcare
associated infection
Hand hygiene
Cleaning and Disinfection

WHAT IS PATIENT SAFETY?

The prevention of healthcare errors, and
the protection of patients from harm
caused by healthcare errors
A new healthcare discipline that
emphasizes the reporting, analysis and
prevention of medical error that often lead
to adverse healthcare events

Question?
Can omission of hand hygiene cause an
adverse event?

What is an adverse event?

harm or injury caused by the management of
the patients disease or condition by health
care professionals rather than by the
underlying disease or condition itself

Yes
Hospitals
Can
Make YOU
Sick!

Joint Commission International Patient

Safety Goals

Identify Patients Correctly

Improve Effective Communication
Improve the Safety of (High-Alert) Medications
Eliminate Wrong-site, Wrong-patient, Wrongprocedure Surgery
Reduce the Risk of HealthCare-Associated
Infections
Reduce the Risk of Patient Harm from Falls

Question?
What is a healthcare associated infection?
What are its implications in a healthcare
institution?

What are HCAIs?

Nosocomial or Hospital-acquired infections

Affect patients in hospital or healthcare facility
Not present or incubating at time of admission
Includes infections that appear after discharge
Includes occupational infections among staff

Burden of Healthcare-associated
Infections (HCAIs)
HCAIs are most frequent adverse events in
healthcare delivery
7-10/100 hospitalized patients will acquire at
least one HCAI
Burden of HCAI is higher in middle and low
income countries
1/3 of operated patients in low income
countries will develop SSI
WHO Fact Sheet

Burden of Healthcare-associated
Infections (HCAIs)
30% of ICU patients in high income countries will
develop at least one HCAI
ICU infections are 2-3 times higher in low to
middle income countries, with device-related
infections 13 times higher
Newborns in developing countries have 3-20 times
higher HCAI rate than high income countries
WHO Fact Sheet

Impact of HCAIs

Prolonged hospital stay

Long-term disability
Increased resistance to antimicrobials
Massive additional financial burden for families,
hospitals and health systems
37,000 annual deaths in Europe
90,000 annual deaths in USA
WHO Fact Sheet

Risk Factors for HCAIs?

Prolonged and inappropriate use of invasive
devices and antibiotics
High risk and sophisticated procedures
Immunosuppression and co-morbidities
Insufficient application of standard and
isolation precautions

HCAIs in Limited Resource

Settings
inadequate environmental hygienic
conditions and waste disposal;
poor infrastructure;
insufficient equipment;
understaffing;
overcrowding;
poor knowledge and application of basic
infection control measures;

Solutions for Problem of HCAI

Identify local determinants of HCAI burden
Improve reporting and surveillance systems
Ensure minimum facility requirements and
dedicated resources for HCAI surveillance
Ensure that core components for infection
control are in place
Implement standard precautions esp. best
hand hygiene practices at bedside

System Changes in MDH

Training and Education

Evaluation and Feedback

Reminders in the Workplace

Institutional Safety Climate

Hand Hygiene Audit

The observation method involves directly
watching hand hygiene behavior and
allows the researcher or investigator to
proactively record hand hygiene
opportunities (based on the indications)
and the action of hand hygiene.
It is the gold standard for measuring
compliance (WHO guidelines)

The golden rules for hand

hygiene
Hand hygiene must be performed exactly where you are delivering
health care to patients (at the point-of-care)
During health care delivery, there are 5 moments (indications) when it is
essential that you perform hand hygiene ("My 5 Moments for Hand
Hygiene" approach)
To clean your hands, you should prefer handrubbing with an alcoholbased formulation, if available. Why? Because it makes hand hygiene
possible right at the point-of-care, it is faster, more effective, and better
tolerated.
You should wash your hands with soap and water when visibly soiled
You must perform hand hygiene using the appropriate technique and
time duration

The My 5 Moments for Hand

Hygiene approach

The geographical conceptualization

of the transmission risk
HEALTH-CARE AREA
PATIENT ZONE

Critical site
with body fluid
exposure risk

Critical site with

infectious risk
for the patient

Things that can be observed in

Observational Hand Hygiene Audit
The quality and thoroughness of hand
hygiene
The accessibility and use of products and
gloves
The discipline of health care workers
(HCWs) performing hand hygiene
Creates opportunity to provide HCWs with
timely feedback.

Strengths:
Count both opportunities for hand hygiene and
the action of hand hygiene
Determine who performed hand hygiene and the
quality of the act
It can provide quantitative and qualitative
information about why and when hand hygiene
failures occur.
Able to differentiate the types of hcws and
patients or family members.

Limitations:
Laborious and costly
Requires uniformity in the selection and training
of observers and in the recording of data.
Possibility of inaccuracy in getting the "true
picture" due to Hawthrone effect.
Captures only a small sample of all opportunities
for performing hand hygiene.
May compromise the patients privacy.

Selection of Opportunities

5 Moments of
Hand Hygiene

 Literatures show that:

Hand Hygiene adherence is usually worse
before patient care than after patient care
High intensity of patient care has been
associated with lower hand hygiene
adherence in a multivariate analysis
Greater number of hand hygiene opportunities
and higher patient to staff ratios widens the
denominator, thus may project poorer
compliance

Selection of Respondents

Physicians
Nurses
Pastoral Care Personnel
Technicians
Physical Therapists
Environmental Services Workers
Dietitians
Phlebotomists
Radiology Technicians

Conducting Observations
Dealing with Double Counting
It is essential that observers be able to
determine what qualifies (what should be
counted) as an opportunity or an action.
Opportunities and actions must be
operationally defined to ensure an accurate
tally.

 Double Counting is an issue when a HCW

appropriately performs hand hygiene after
contact with one patient and then goes directly
to another patient to provide care without again
performing hand hygiene.
Technically, the HCW has not performed hand
hygiene before contact with the second patient
and also not performed hand hygiene after
patient contact on the previous patient.

Determining Frequency of
Observation
Dependent on the reasons for monitoring and resources.

Daily
Weekly
Monthly
Quarterly

Should be more frequent during outbreaks

It is important to monitor during a variety of weekday,
weekends and holiday shifts in order to get a complete
picture.
It can be done in proportion.
Night time and weekend monitoring need fewer observation
due to lesser opportunities for hand hygiene

Determining the Accurate Number

of Obervations
WHO Manual for Observers recommends
observing a minimum of 200 opportunities
during each measurement period.
Sampling size can counted to yield valid findings
in larger population.
Researchers have pointed out that the number
of observations conducted is often too low when
compared to the number of opportunities for
hand hygiene
This is a limitation of the observation method.

Structuring and Scheduling

Observations
Priority areas are based on:
Outbreak areas
Surveillance data

Cleaning and Disinfection

Strategies for cleaning and disinfecting
surfaces in patient-care areas take into
account
a) potential for direct patient contact
b) degree and frequency of hand contact
c) potential contamination of the surface with
body substances or environmental sources
of microorganisms (e.g., soil, dust, and
water).

Cleaning
Cleaning is the removal of visible soil
(e.g., organic and inorganic material) from
objects and surfaces and normally is
accomplished manually or mechanically
using water with detergents or enzymatic
products.

Question?
Is thorough cleaning is essential before
high-level disinfection and sterilization?

Answer
Yes, because inorganic and organic
materials that remain on the surfaces of
instruments interfere with the
effectiveness of these processes.

Decontamination
Decontamination removes pathogenic
microorganisms from objects so they are
safe to handle, use, or discard.

Terminologies
Terms with the suffix cide or cidal for killing action also are
commonly used.
For example, a germicide is an agent that can kill
microorganisms, particularly pathogenic organisms (germs).
The term germicide includes both antiseptics and
disinfectants.
Antiseptics are germicides applied to living tissue and skin;
disinfectants are antimicrobials applied only to inanimate
objects.
Virucide, fungicide, bactericide, sporicide, and tuberculocide
can kill the type of microorganism identified by the prefix.

Spauldings Classification

Cleaning of Medical
Equipment
Manufacturers of medical equipment should provide
care and maintenance instructions specific to their
equipment. These instructions should include
information about:
the equipment compatibility with chemical
germicides
whether the equipment is water-resistant or can be
safely immersed for cleaning
how the equipment should be decontaminated if
servicing is required

 In the absence of manufacturers instructions,

non-critical medical equipment (e.g.,
stethoscopes, blood pressure cuffs, dialysis
machines, and equipment knobs and controls)
usually only require cleansing followed by low- to
intermediate-level disinfection, depending on the
nature and degree of contamination
Ethyl alcohol or isopropyl alcohol in
concentrations of 60%90% (v/v)

 Barrier protection of surfaces and

equipment is useful esp. for frequently
touched items
An example of this approach is the use of
plastic wrapping to cover the handle of the
operatory light in dental-care settings
Coverings should be removed and discarded
while the health-care worker is still gloved

Cleaning of the Hospital

Environment
Housekeeping surfaces can be divided into
two groups
minimal hand-contact (e.g., floors, and ceilings)
frequent hand-contact (high touch surfacese.g., doorknobs, bedrails, light switches, wall
areas around the toilet in the patients room,
and the edges of privacy curtains)
This must be cleaned and/or disinfected more
frequently

Ideal Disinfectant
Broad spectrum:
Fast acting:

a wide antimicrobial spectrum

rapid kill

Not affected by
environmental factors:

be active in the presence of organic

matter (e.g., blood, sputum, feces) and
compatible with soaps, detergents, and
other chemicals encountered in use

Nontoxic:

not be harmful to the user or patient

Surface compatibility:

not corrode instruments and metallic

surfaces and not cause the
deterioration of cloth, rubber, plastics,
and other materials

Residual effect on treated

surfaces:
Odorless:
Economical:
Solubility:
Stability:

leave an antimicrobial film

Easy to use with clear label
directions
have a pleasant odor or no
odor
not high in cost
be soluble in water
be stable in concentrate and
use-dilution

Cleaner:

good cleaning properties

Environmentally friendly:

not damage the environment

on disposal

Disinfectants
Sterilants and high-level
disinfectants
1 Formaldehyde
2 Glutaraldehyde
3 Ortho-phthalaldehyde
4 Hydrogen peroxide
5 Peracetic acid
6 Hydrogen peroxide /peracetic
acid combination
Intermediate-level disinfectants
7 Sodium hypochlorite
8 Iodophors
Low-level disinfectants
9 Phenols
10 Quaternary ammonium
compounds

http://www.hospitalmanagem
ent.net/features/featureppcdisinfectants-hai-globaldata/

Hydrogen Peroxide Vaporization

Cleaning and decontamination of the room must be done
prior to HP Vaporization
Evidence suggest helpful in controlling outbreaks when there
is evidence of an environmental reservoir.
Use on hard, non-porous surfaces only
Precise instructions on the use and maintenance of the
device are essential. Follow manufacturers instructions
Elimination of the HP or clearance of the vapor requires, for
some formulations, up to 3-4 hours
Avoid entering the room undergoing HP vaporization if
necessary, use PPE (N95, eye shield) upon entering the
room.

 Useful for environmental cleaning of room:

Long staying patients (> 1 month)
With Multi-drug resistant organisms
During outbreaks
Not for routine disinfection of area