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Presenter Ms.Daisy V.T.
5TH Batch Student

Guided by

Dr. Sreedevi T R
Asso. Professor Govt. College of nursing Kottayam.

Healthcare-associated infections (HAIs) are a major cause of morbidity and mortality around the world. According to CDC the increase in invasive procedures and a growing resistance to antibiotics have fuelled a rise in the rate of HAI by 36% over the past 20 years. Overall 1.4 million people worldwide are suffering from nosocomial infections and in India alone, the infection rate is at over 25 per cent,. report by the INICC (the International
Nosocomial Infection Control Consortium )

The importance of healthcare-associated infections as a cause of preventable illness and death- A serious global public health issue and a national priority.

is the responsibility of every health Care personnel

The invasion of the body by pathogenic or potentially pathogenic organisms and their subsequent multiplication in the body (Medical dictionary)

The lodgement and multiplication of parasite in or on the tissues of a host. ( Anathanarayanan, 2008)

Types of infection
Primary infection- initial infection with a parasite in the host Reinfection- is subsequent infections by the same parasite in the host Secondary infection- a new parasite causes an infection in a host whose resistance has been lowered by an already existing infectious disease. Cross infection-a new infection is estabilshed from another host or external source in a patient already suffering from a disease Nosocomial infection-cross infection occurring in hospitals(from Greek word Nosocomion, hospital)

Hospital acquired infection(HAI)

HAI also called nosocomial infection is defined as an infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission It also includes infections acquired in the hospital but appearing after discharge, and occupational related infections among staff of the facility(WHO 2002)

Historical Perspective


Ignaz Semmelweis (1818-1865), the father of infection control demonstrated through experiments that hand-washing could prevent infections.(Concept of nosocomial infection was born) 1950s Infection Control as an organized and recognized discipline was born. Post World War II hospital-based outbreaks of infection caused by Staphylococcus Aureus, mostly in newborn nurseries, Outbreaks demanded an organized response for investigation and control.

Indian context HAIs has received the attention of the Govt. of india and the Rao committee,(1968) and the Sharad kumar committee (1976) were set up to investigate the problem of hospital acquired infections in depth. The World Health Organization First Global Patient Safety Challenge, Clean Care is Safer Care, pledged to tackle the problem of health care-associated infection was launched in 2005 . India is the first country of the South East Asian Region to inaugurate the "Clean Care is Safer Care" initiative and sign a pledge to address health care-associated infections.


The Problem

1.7 million HAIs in hospitalsunknown burden in other healthcare settings 99,000 deaths per year $28-33 billion in added healthcare costs Implementing what we know for prevention can lead to up to a 70% or more reduction in HAIs The Centers for Disease Control and Prevention estimatesten billion dollars in additional hospital costs annually as a direct result of healthcare-associated infections. (AHRQS fact sheet 2002)

HAI Prevention

Healthy People 2020 Phase II New Topic Areas

Access to Health Services Adolescent Health Childrens Health Genomics Global Health Older Adults Healthcare-Associated Infections

Quality of Life Social Determinants of Health Blood Disorders and Blood Safety Healthy Places Preparedness

Nosocomial infection control interventions, although not an explicit target of the United Nations Millennium Development Goals, help support Goal 6 (Combat HIV/AIDS, malaria and other diseases)

As healthcare professionals, it is important to understand two things about infection: infection

1.the various ways infection can be transmitted 2. the ways the infection chain can be broken

The Chain of Infection

1 Causative Agent--any disease-causing microorganism (pathogen)

Bacteria Viruses Fungi Parasites

In adult studies, E. coli, S. aureus and Enterococcus faecalis were the three most common pathogens causing HAIs in adult patients. In pediatric studies, Coagulase negative S. aureus (20%26%), Pseudomonas aeruginosa (5%20%), S. aureus (11-15%), Candida species (4%9%) and viruses, mostly rotavirus and respiratory syncytial virus (22%23% ) were predominant pathogens causing HAIs.

Characteristics of causative agents

Infective dose Pathogenicity Virulence Invasiveness

Viability Antigenic Variation Host Specificity Resistance

2 - Reservoir --the organism in which the

infectious microbes grows or multiplies

Patients and Healthcare

Workers Environment- Patient Care Equipment, Environmental Surfaces and Food Animals Insects Rodents Shell Fish

3. Portal of Exit
The route by which the infectious agent leaves the reservoir


By means of blood, excretions, secretions or droplets from broken skin( puncture, cut, surgical site, weeping wound) Respiratory tract Genitourinary tract Gastrointestinal tract

4 Mode of Transmission

The mechanism for transfer of an infectious agent from the reservoir to a susceptible host.

Contact (Direct and Indirect) Airborne Vector-Borne Common Vehicle


DIRECT: immediate transmission Actual physical contact between source and patient

INDIRECT CONTACT: Patient to contaminated indirect object Droplets spread

AIRBORNE Organisms contained within droplet nuclei or dust particles (i.e. droplet nuclei of tuberculosis) Suspended in air for extended periods, may be spread through ventilation systems

Mechanical transfer of microbes on external appendages (feet of flies) Harbored by vector, but no biological interaction between vector and agent (yellow fever virus) (i.e.


Respiratory Tract Genitourinary Tract Gastrointestinal Tract Broken skin/Mucous Membrane Blood stream

The route by which an infectious agent enters the susceptible host


6 - The Susceptible Host

The organism that accepts the pathogen. The support of pathogen life & its reproduction depend on the degree of the hosts resistance.

Organisms with strong immune systems are better able to fend off pathogens.

Organisms with weakened immune systems are more vulnerable to the support & reproduction of pathogens.

Common HAIs
Nosocomial Pneumonia Surgical site infections Catheter associated urinary tract infections, Catheter associated blood stream infections.
Other nosocomial infections Skin and soft tissue infections: open sores (ulcers, burns and bedsores) and Gastroenteritis

Impact of nosocomial infections

functional disability and emotional stress of the patient Increased morbidity and mortality longer hospital stays, utilize more healthcare resources HAIs contribute to increased healthcare costs,

INFECTION CONTROL-(BREAKING THE CHAIN OF INFECTION) Infection control is the discipline concerned with preventing nosocomial or healthcareassociated infection.



(Adapted from CDC/WHO guidelines on INFECTION CONTROL,2009)

1.Hand washing
2. Standard Precautions in Hospitals 3. Transmission based Precautions in Hospitals 4. Prevention of Ventilator-Associated Pneumonia 5. Prevention of Surgical Site Infections 6. Prevention of Bloodstream Infections 7. Prevention of Catheter- Associated Urinary Tract Infections 8. Infection Prevention and Control Programs in Hospital Settings. 9. Surveillance and reporting of HAI

2. Hand Hygiene
Most nosocomial infections are thought to be transmitted by the hands of health care workers CDC estimate that one third of all hospital-acquired infections are caused by a lack of adherence to established infection control practices, such as hand hygiene. CDC recommends hand hygiene (i.e., hand washing with soap and water or use of a waterless, alcoholbased hand rub. as the single most effective method of preventing the spread of healthcare-associated infections

Research EvidenceSustained hand hygiene promotion in NICU in Geneva resulted in a 60% reduction in bacterimia among VLBW babies (Borghesi A, 2008) Larson and colleagues (2000) documented that the prevalence of nosocomial infections decreased as HCWs compliance with recommended hand hygiene measures improved.

New CDC/WHO guideline recommendation for hand hygiene in health care settings
Current guidelines recommend the use of alcohol based hand rub formulations as the new standard of care. They are not a substitute for hand washing if hands are soiled. Wash hand with soap and water whenever the hand are visibly soiled or contaminated with blood or body fluids. Recommended before entering the unit & before any Procedure Alcohol hand-rubs are appropriate for rapid hand decontamination between patient contacts.
(WHO Guidelines on Hand Hygiene in Health Care, 2009)


Wash hands for 2 complete minutes before entering the unit & before any Procedure Wash hands for at least 20 seconds before and after touching each patient

Research Evidence
The choice of the best method of hand hygiene is still a matter of debate

Larson et al. found no statistically significant difference in mean microbial counts on nurses hands after traditional hand washing or alcohol-based disinfection On the other hand Girou et al. observed an 83% reduction in bacterial contamination of the hands after use of alcohol based disinfectant compared with 58%reduction after handwashing with antiseptic soap

Saramma et al evaluated the effect of alcohol based hand rub before and after patient contact on SSI after elective neurosurgical procedures. Result did not show a significant reduction in SSI compared with the control group. Study concludes with the possibility is that both the strategies are of equal efficacy for prevention of SSI
(Saramma et al. alcohol based hand rub and surgical site infection. Neurology india.Jan-feb 2011. 59(1).12-17)

Adherence with hand washing

Studies repeatedly documented that the compliance with recommended hand washing practices is unacceptably low, estimated to be <50%. Evidence based remedial measures include Implementation of multifaceted interventional behavioral hand hygiene program. Implementation of hand washing training program for HCW. Continuous monitoring and performance feedback. Increase supplies necessary for hand washing Institutional support. (Pittet D, 2003) (Khaled M, 2008)

3.Standard precautions

hand washing and antisepsis use of personal equipment protective

STANDARD PRECAUTIONSApplied for all patients at all times regardless of their known or presumed infectious status

appropriate handling of patient care equipment and soiled linen prevention of needle stick/sharp injuries environmental cleaning and spills-management appropriate hospital waste management.

Aseptic technique and preventive practices

Refers to practices to reduce the risk of post procedure infections in patientsmeasures to decrease the likelihood of micro organisms entering the body during procedures.

Maintaining clean sterile field during procedures Use of sterile instruments and other items for procedures Preparation of the patients for clinical procedures Use of barriers ( gown mask etc.)

Personal protective equipment

Use PPE when contamination or splashing with blood or body fluids is anticipated Disposable gloves Plastic aprons Face masks Safety glasses, goggles, Head protection Foot protection Fluid repellent gowns (May, 2000)

Appropriate handling of patient care equipment

Infections from used instruments and other items pose infection threats to patients and health care workers. Removal of microorganism from a contaminated object is an essential part of infection control

Decontamination Cleaning Sterilization/ high level disinfection Storage

Linen handling and disposal

Gloves and apron - handling contaminated linen Appropriate laundry bags Avoid contamination of clean linen


correct disposal in a puncture resistant container avoid re-capping the needle Do not bend, break or cut the needle before the disposal. Avoid mixing sharps with other wastes discard syringes as single unit avoid over-filling sharps container

Hospital waste management

It is an important part of infection control in health care facilities. It includes segregation, collection. Transportation and disposal. Hospital waste includes 75-90%non- hazardous( general) waste- do not infect them!!! 10-25% hazardous waste- take care of them. Follow hospital guidelines based on govt. of IndiaBiomedical waste management guidelines-1998.

4.Additional (transmissionbased) precautions

Additional (transmission-based) precautions are taken while ensuring standard precautions are maintained. Additional precautions include: Airborne precautions; Droplet precautions; and Contact precautions.

Airborne precautions
Implement standard precautions. Place patient in a single room with negative airflow pressure. Keep doors closed. Anyone who enters the room must wear a special, high filtration, particulate respirator (e.g. N 95) mask. Make the patient to wear a surgical mask while going out of the room.

Droplet precautions
Implement standard precautions. Place patient in a single room (or in a room with another patient infected by the same pathogen). Wear a surgical mask when working within 1-2 meters of the patient. Place a surgical mask on the patient if transport is necessary. Special air handling and ventilation are not required to prevent droplet transmission of infection.

Contact precautions
Implement standard precautions. Place patient in a single room (or in a room with another patient infected by the same pathogen). Wear clean, non-sterile gloves when entering the room. Wear a clean, non-sterile gown when entering the room if substantial contact with the patient, environmental surfaces or items in the patients room is anticipated. Use precautions to minimize the risk of transmission if transport of the patient from the room is required.

Infection control related to common hospital acquired infections


Nosocomial Pneumonia Surgical site infections Catheter associated urinary tract infections, Catheter associated blood stream infections

Prevention of Ventilator Associated Pneumonia

Age appropriate comprehensive mouth care. Daily assessment for extubation readiness.

Intubation and reintubation should be avoided Prevent ventilator circuit condensation Keep the patient in semi recumbent position (3045) for adults and 1530 degree for children to prevent aspiration, especially when receiving enteral feeding. Suction above and below the cuff before lowering the patients head less than to 30% to prevent micro aspiration. The endotracheal tube should be of proper size to prevent leakage of bacterial pathogens around the cuff into the lower respiratory tract.

7.Prevention of Surgical Site Infections

identify and treat all infections remote to the surgical site before elective operation Do not remove hair preoperatively hair may be clipped short if it interferes the procedure. Use an appropriate antiseptic agent for skin preparation. Keep preoperative hospital stay as short as possible Anti microbial prophylaxis Intra operative Ventilation Maintain positive-pressure ventilation in the operating room. Maintain a minimum of 15 air changes per hour, of which at least 3 should be fresh air. Cleaning and disinfection of environmental surfaces

Air and environment Laminar airflow-design to move particle free air( ultra lean air).

Operating room equipment and furniture should be cleaned with germicidal agent at the end of each surgical procedure.

Lidwell et al. compared the effect of ultraclean air alone, antimicrobial prophylaxis alone and combination of both in prosthesis replacement. Results shown antimirobials more effective than ultra clean air. (J Hosp Infect, 1988)

Unexpectedly in one analysis which controlled for many patients OR ventilation with laminar airflow showed no benefit on SSI. ( Brandt C Ann Surg. 2008Nov, 248(5). 695-700.) Without surgical antimicrobial prophylaxis, glove perforation increases the risk of SSI (Heidi M et al. Arhives of surgery. June 2009,
144(6). 553.)

Postoperative Incision Care Perform hand hygiene before and after dressing changes and any contact with the surgical site. When an incision dressing must be changed, use sterile technique. Educate the patient and family regarding proper incision care, symptoms of SSI, and the need to report such symptoms.

8.Prevention of Bloodstream Infections

Hand hygiene Aseptic technique during catheter insertion and care Catheter insertion Do not routinely use arterial or venous cut down procedures as a method to insert catheters. Catheter-site dressing regimens - Use either sterile gauze or sterile, transparent, semi permeable dressing to cover the catheter site. -Gauze dressings that prevent visualization of the insertion site should be changed routinely every 48 hours on central sites and immediately if the integrity of the dressing is compromised. -Replace catheter-site dressing if the dressing becomes damp, loosened, or visibly soiled.

Catheter removal -Promptly remove any intravascular catheter that is no longer essential. - Do not routinely replace central venous or arterial catheters solely for the purposes of reducing the incidence of infection. - Replace peripheral venous catheters every 7296 hours in adults to prevent phlebitis. - Leave peripheral venous catheters in place in children until IV therapy is completed, unless complications (e.g., phlebitis and infiltration) occur.
A study in the journal Infection Control and Hospital Epidemiology shows that about 24% of patients with catheters will develop catheter related infections, of which 5.2% will become bloodstream infections. Death has been shown to occur in 420% of catheter-related infections.

Prevention of Catheter-Associated Urinary Tract Infections

Burden of CAUTIs Urinary tract infection is the most common hospital acquired infection; 80% of these infections are attributable to an indwelling urethral catheter. Risk factors for development of CAUTI The duration of catheterization- most important risk factor Limiting catheter use and, when a catheter is indicated, minimizing the duration the catheter remains in situ are primary strategies for CAUTI prevention. Ensure aseptic technique during catheter insertion Ensure that trained personnel insert urinary catheters.

Reservoir for transmission The drainage bag of the bacteriuric patient is a reservoir for organisms that may contaminate the environment and be transmitted to other patients. Willson M et al identified the following nursing interventions to reduce the risk of catheter-associated urinary tract infection: staff education, monitoring of catheter use and CAUTI incidence, insertion technique, urethral meatal care, securement, use of a closed drainage system, bladder irrigation, frequency of catheter change, and antiseptic solutions in the drainage bag.
J Wound Ostomy Continence Nurs. 2009 Mar-Apr;36(2):137-54.

1. Infection Prevention and Control Programs in Hospital Settings

A well organized infection control programme can prevent 25-50% HAI
(Hospital infection society of India)

The important components of the infection control programme are

basic measures for infection control. education and training of health care workers; protection of health care workers, e.g. immunization; Surveillance for infections in patients and personnel incident monitoring; outbreak investigation; infection control in specific situations research.

The infection control committee

Representatives of various units within the hospital (medical, nursing, engineering, housekeeping, administrative, pharmacy, sterilizing service and microbiology departments); Development of policies for the prevention and control of infection and to oversee the implementation of the infection control programme develop its own infection control manual/s; and monitor and evaluate the performance of the infection control programme.

Infection control team

Responsible for the day-to-day activities of the infection control programme. support and participate in research and assessment programmes at the national and international levels. carry out the surveillance programme; develop and disseminate infection control policies; monitor and manage critical incidents; coordinate and conduct training activities.

Infection control manual

Hospital-associated infection control 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. Readily available for health care workers, and updated in a timely fashion.

Surveillance and reporting of HAI

Surveillance is the monitoring of infections in the unit by conducting periodic surveys to detect and record methodically all HAIs. Continuous surveillance allows the early identification of outbreaks. A good surveillance practice is an important aspect of infection control.

Nursing implications

Nurses are the key to maintain infection control measures in health care settings

Role of the Infection Control Nurse

Need to have high degree of awareness and knowledge in infection control Research indicates a positive relationship between knowledge and practice. (Viji A et al, 2007) Collect and co ordinate information regarding hospital infections from various clinical departments Conducts in-service education, refresher courses and training programmes on infection control. Continues vigilance, assessment and supervision of clinical performance of various levels of workers. Continues surveillance for HAI. Conducts awareness among the patients and visitors about infection control

Preventing Healthcare-associated Infections the Time is NOW Problem is critical and costly but preventable Interventions can have an immediate national impact Interventions can be cost savings Ongoing efforts are needed to address changes in healthcare

Infection control is not just a matter of following standards and guidelines. It involves improving awareness and changing attitudes and work practices at both the institutional and individual level. It is essential that everyone involved in health care contribute to improving the quality of patient care (NHMRC, 1996).

Thought for infection control

It is not important how much you know but it is most important how much you practice. Caring attitude should be reflected in your work practice, which will reflect your infection control practices.

If you fail to practice infection control, you are failing to care for your patients.

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