Healthcare facilities — hygiene requirements and operating conditions. Non-specific routes of infection transmission.
MUDr. Marie Kolářová.CSc. Ústav ochrany a podpory zdraví LF MU Spring 2018
Clean Care is Safer Care
□ Safe patient care, including infection prevention, is a priority in all health care settings worldwide. ■
□ A patient safety culture guides the attitudes, norms, and behaviours of individuals and organisations.
□ In a safe culture of care, all staff and leaders assume accountability and responsibility for the well-being of patients.
□Patient safety requires teamwork and collaboration, communication, continual improvement efforts, measurement, understanding the social aspects of behaviour, and techniques such as human factors engineering.
□Recommendations for construction of health care facilities must be based mainly on experience and assessment of infection risks, considering available local resources.
Clean Care is Safer Care
• Patient safety is a global health care challenge. .
•Early pioneers in infection prevention and control (IPC] promoted safe patient care through their work. 1
•Ignaz Semmelweis reduced maternal mortality through! hand hygiene and Florence Nightingale minimised infections in wards during the Crimean war by rigoroud environmental cleanliness.
•Joseph Lister insisted on antisepsis in surgery and reduced surgical site infections.
•Present-day IPC experts regard healthcare-associated infections (HAI) as a critical patient safety issue with complications that are very often preventable.
Chain of infections -
epidemiological specifics and risks in healthcare facilities
THE CAUSATIVE AGENT OF INFECTION (bacteria /MRSA, VRSA, ESBL Clostridium dificille/, viruses, fungi, prions, protozoa)
1. the presence of rezervoir (source) of infection
patients "|   at the ende of incubation period staff     L acute stage students cariers
2. the way of transmission
A/ direct contact - influenza, scabies
B/ indirect contact
- inhalation of droplets containing the infectious agents (TBC, measles, influenza...)
- ingestion of food or water that is contaminated (salmonella, Norwalk virus, VHA....)
- contamination od medical devices, instruments and dressings
3. higher susceptibility of patients
- basic illness
- therapy (ATB, immunosupresive, korticoides)
- surgical operation
- non-physiological inputs (venous catheter, artificial lung ventilation, suction drains)
pacient
risk of prof
n - scabies
Scabies -
as a risk of professional exposure and illness
lateral
0.4 mm in length
Female
Currently, the highest incidence of professional infections among health care professionals is scabies.
Crusted or Norwegian scabies in a patient who has AIDS.
Staphylococcus aureus in a patient who has a Hickman catheter. The extending cellulitis (maximum extent shown by black marker pen line) has responded but the local tunnel infection persists and mandates line removal.
Catheter exit site infection in a patient with central venous catheterization through the jugular vein.
Diffuse skin involvemei with petechial lesions i patient with Staphylococcus aureus bacteremia# endocardi and acute aortic insufficiency.
POTENTIAL ROUTES OF INFECTION
Potential routes of infection
Skin organisms
Endogenous flora
Extrinsic sources (e.g. health care worker, contaminated disinfectant)
Invading wound
Contamination of device prior to insertion
Usually extrinsic; rarely manufacturer
Fibrin sheath, thrombus
Contamination of catheter hub
Extrinsic sources (e.g. health care worker)
Endogenous flora (e.g. from the skin)
Skin
Contaminated infusate
Fluid or medication
Extrinsic sources
Manufacturer
Hematogenous
From distant infection
Intravenous Infusions Sites of Possible Contamination
An acutely infected knee replacement.
The site was washed out but the infection failed to resolve. At re-operation the implant was found to be loose and it needed to be removed. Staphylococcus aureus was grown from deep specimens.
•
Typical X-ray image of infected hip replacement with laconic clarifications and rapid migration
• Díky pečlivé přípravě pacientů, zavedení
super-sterilních sálů a speciálnímu
režimu na nich, díky lepší operační technice a preventivnímu podávání
antibiotik byla incidence hluboké infekce snížena na dnes všeobecně
udávané jedno až dvě procenta.
• MUDr. David Jahoda, doc. MUDr. Pavel Vavřík, CSc, MUDr. Ivan Landor, CSc, I. ortopedická klinika FN Motol a UK i. LF, Praha, foto z archivu autora
Indwelling Catheterisation of Urinary Tract
I a dwelling Catheterisation of Urinary Tract Sites oť Possible Conř^mimition
Caíheter-metal junction
Urine sampling site
Reflux of
rjon Lai mi natec! urine
Bug emptying port
18
Epidemiological specifics and risks in healthcare facilities.
Airborne infections (e.g.Legionella, avian influenza, SARS, tuberculosis)
Water-, food- or handborne infections (e.g. diarrhoea)
Infection of wounds/surgical incisions from contaminated water, medical devices and dressings (e.g. sepsis)
Bloodborne infections due to contaminated needles and syringes, unsafe blood transfusion (e.g. HBV, HCV, HIV)
•Ventilation, air-conditoning (HVAC) and isolation
• Space available per patient
• Spacing of beds
• Use of separate rooms for highly vulnerable or infectious patients
• Use of masks and correct incineration of wastes
• Water supply (quality and access)
• Excreta disposal
• Hygiene facilities
• Food hygiene
• Hand hygiene
• Use of single-use medical devices and dressings
• Pre-disinfection
• Cleaning and sterilization of instruments and dressings
• Good-quality water
•Asepsis in surgical or dressings procedures
• Health-care waste management and use of single-use needles and syringes
Safe blood transfusion
Heat- and cold-related stress and discomfort (e.g. higher fever)
Vector-borne disease transmission
• Heating, ventilation, air-conditioning (HVAC) and insulation
• Control of disease vectors in and around buildings
• Dr/~>+ar>+i/~>n r\f rvo+ian+o
Mikroclimate, clean medical facilities. Monitoring of contamination.
Positive pressure gradient of the air.
ICU
House keeping, linen management,
caring for a bed.....
Non-physiological inputs into the body.
24
1. Causative aqens in blood, derivates from
blood, plasma
VHB, VHC, VHA (short in the blood), HIV, CMV, rarely EBV,
virus of morbilli (viremie), kandidy-kandidémie,
malárie - (Plasmodia can survive in fresh plasma 3-5°C-14 days),
Toxoplasma gondii - (can survive in blood - 56 days)
2. Causative agens in droplets Adenovirus, coronaviruses, enteroviruses, herpes virus,
myxovirus (influenzae), paramyxovirus, RSV,
rhinovirus, Stafylococcus, Streptococcus spp.,
Meningococcus spp., Haemophilus Influenzae, Neisseria
meningitis,
Bordetella pertussis, Bordetella parapertussis, Mycoplasma pneumoniae, Pneumocystis carinii, Kandidy....
3. Causative agents in stool Enteroviry (VHA, poliomyelitis), VHE, Coxsackie viry, Adenoviry, Enterobactericeae (E.coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus spp., Citrobacter, Enterobacter, Serratia apod) Listeria monocytogenes, Clostridium perfringens, Clostridium tetani, Pneumocystis carinii
Causative agens in:
4. URINE
Virus of measles, parotitis, CMV, VHB, papovavirus, Listeria monocytogenes, Candidae
5. LIQUOR
HIV, different causative agents of meningitid
6. Salive
VHB, HIV, CMV, EBV, herpes virus hominis typ 1,2, virus of measles, rubellla
Biological materials -
ihMlflllltttiU'JH
7. TEARS, EYE-SECRET
VHB, HIV, adenoviruses, Enterovirus typ 70, Coxsackie A 24, Staphylococcus aureus, hemophfilus, pneumokoky, moraxely, chlamydie
8. VAGINA AND CERVIX - SECRET
HIV, VHB, rare VHC, herpes virus hominis typ 1,2, Streptococcus agalactiae, Neisseria gonorrhoea, Haemophilus Ducreyi, Treponema pallidum, Trichomonas vaginalis, Chlamydia lymfogranulomatosis, Chlamydia trachomatis 9. EJACULAT VHB, HIV, rare VHC, CMV,
A Culture of Patient Safety
Culture has been defined as the deeply rooted assumptions, values, and norms of an organisation that guide the interactions of the members through attitudes, customs, and behaviours.
• A culture of patient safety involves: ❖leadership,
❖teamwork and collaboration, ❖evidence-based practices, ❖effective communication, ❖human behaviour, ❖learning, ❖measurement, ❖a just culture, ❖systems-thinking, ❖human factors, ❖and zero tolerance.
Each topic can be applied to infection prevention and control (IPC) practice and make an important contribution to reducing infection risk.
Culture of Patient Safety,
rooted assumptions, values, and norms of an organisation, guidelines.
• Health-care settings include hospitals, health centres, clinics, health posts, dental surgeries, general practitioner settings and home-based care are environments with a high prevalence of infectious disease agents.
• Patients, staff, cariers and neighbours of the health-care setting face unacceptable risks of infection if environmental health is inadequate.
• Hospital hygiene deals with the recognition and control, but primarily with the prevention of hospital infections.
• This guidance is based on the best critically appraised evidence currently available.
• Environmental health in health-care settings can significantly decrease the transmission of such Infections.
• Interventions to improve environmental health in health-care settings are intended to reduce the transmission of infections (in health-care settings) and therefore directly reduce the disease burden. They are also targeted at high-risk populations (for example, immunocompromised patients).
• Good hospital hygiene is vital to any strategy for preventing HCAIs in hospitals
Hospital hygiene
• Putting policy into practice in this area demands strong links between sectors such as:
• building and construction management, planning, I
• purchasing technology, I
• ventilation and air conditioning I
• hospital water supplies and sanitation, potable water, I
• hand hygiene I
• housekeeping, cleaning and disinfection the general hospital environment,
• linen management, bed care I
• disinfection and sterilization of medical devices I
• catering to patients and staff, prevention of healthcare-associated I foodborne illnesses I
• patient transport and laboratory samples I
• healthcare waste management; proper sorting and minimizing the amount of waste I
•
Health Care Facility Design,
Construction, and Renovation
Recommendations for construction of health care facilities must be based mainly on experience and assessment of infection risks, considering available local resources, as published evidence is scarce. Patients' vulnerability to air and water contaminants while in or near a construction site must be taken into account.
Several factors might influence transmission of infection, some of which are listed below:
^Vulnerability of patients in ICUs, operation theatres, in common wards and in out-patients' clinics where patients are at different stages of susceptibility to infection.
>Numbers and types of rooms
>Number of beds in a room Numbers of patients, staff, and visitors
>Numbers and types of procedures and examinations
>Storage of equipment and textiles
>Available space and adequate equipment
>Floors, finishes, and surfaces
>Water, electricity, and sanitation
>Ventilation and air quality
>Space for handling used and unused medical equipment >Space for handling food, laundry, and waste
Housekeeping
• Contaminated environmental surfaces can lead to an increased risk of transmission of pathogens to patients via the hands of healthcare workers or medical equipment.
• Cleaning with detergent and water always precedes disinfection since I disinfectants are deactivated in the presence of organic matter, chemical I deposits, and dirt.
• Cleaning must focus on high-touch surfaces and other areas that may be heavily contaminated. These areas may vary depending on the type of clinical activity in an area.
Housekeeping
• Environmental cleaning programmes include:
1) setting standards for cleaning,
2) fixing a cleaning routine with checklists that cover all areas,
3) using cleaning products, education, direct supervision, as wel as periodic objective monitoring of the effectiveness of cleaning (if feasible), and
4) providing immediate feedback to cleaning staff.
• There is no consensus on the use of disinfectants for routine cleaning of non-critical surfaces.
• Low-touch surfaces X high-touch surfaces
The management of linen
• In clinical areas, the management of linen has a dual purpose,
namely to keep clean linen clean until it reaches the patient and
to prevent dirty linen from contaminating patients, staff, the envi-ronment, or other linen.
The management of linen
• There must be a clear separation between clean and dirty linen.
There are different types of dirty linen: I
Used linen is linen that has been used in patient care but is not visibly I soiled.
• Soiled linen is visibly contaminated with blood, body fluids, secretions, or excretions, i.e., with a high bio-load of microorganisms.
• Infectious linen is linen that was used in the care of patients on I transmission-based precautions (i.e. patients with communicable disease, colonised, or infected with multi-drug resistant micro-organisms). The contamination may not be visible.
• Infested linen is linen used in the care of patients with parasites, such as lice, fleas, bedbugs, or scabies.
Laundry Cycle
Storage of clean linen
Transportation of clean linen
Use of linen in patient care
\7
Collection of dirty linen
Storage of dirty linen
\7
Transportation of dirty linen
Water Hygiene
• Everyone should have access to water free from pathogenic microbial and chemical contaminants.
• Hospitals often have complex plumbing and ambient-temperature water I treatment systems. Both can be colonised by microorganisms. Efforts are necessary to prevent infectious risks from bacterial contamination and formation of biofilms.
• In health care settings a continuous supply of a great quantity of safe I water is essential.
• Potable water can be rendered microbiologically safe by boiling, filtering, orchlorination.
In health care settings, additional water treatment may be necessary (e.g., deionisation).
• The infection prevention and control team should monitor and assess the risks for contamination of water in their facilities.
• Hospital water supplies from specific areas should be tested regularly to I confirm freedom from contamination
Water Hygiene
• Modes of transmission for waterborne infections
• A). Direct contact [e.g., hydrotherapy]
• B). Ingestion of water [e.g., contaminated ice]
• C). Indirect-contact transmission [e.g., improperly reprocessed medical device]
• D). Inhalation of aerosols dispersed from water sources
Healthcare Waste Management
• Sharps are the most likely health care waste to cause injury and/or exposure. Therefore, at a minimum, a waste management program must focus on sharps handling.
•Proper segregation using available means will reduce the risk of disease transmission and minimise the amount of potentially infectious health care waste generated.
A range of treatment options for waste are available. Consideration should be given to those that reduce the opportunity for exposure and impact on the environment.
• Education and regular reinforcement of practices are the keys to success.
Sorted waste-
????
with syringes and needles (after using)!!!
46
The bag with blood in the transparent sack (must be black and nontransparent and fat (0,2 mm) with symbol „Biological Risk)
Education and training of staff.
• Health-care settings also provide an educational opportunity to promote safe
• environments that are relevant to the population at large, and thereby also contribute to
• safe environments at home and in community settings, such as schools.