standard
precautions
INTRODUCTION
Healthcare associated
infection (HAI) is considered to be the most frequent adverse event in the
health care delivery system. Prevention of HAI is a major challenge to all
concerned because of increased morbidity and mortality of patients associated
with it. It increases the cost of treatment, prolongs hospital stay, and
utilizes the resources that could be used elsewhere in the health care.
The
important risk factors for the acquisition of infection are invasive procedures
which include operative surgery, intravascular and urinary catheterization and
mechanical ventilation. Many infections are endogenous and are not necessarily
preventable. Nevertheless, these infections can be kept to a minimum by good
infection control practices. Cross infection can be considerably reduced by a
few basic measures, for example hand hygiene or disinfection correctly
performed at the right time.
HAI
is a localized or systemic condition resulting from an adverse reaction to the
presence of an infectious agent(s) or its toxin(s) with evidence that it was
neither present nor incubating at the time of admission to the healthcare
facility. HAI are caused by infectious agents from endogenous or exogenous
sources. Endogenous sources are body sites, such as the skin, nose, mouth,
gastro intestinal tract or vagina that are normally inhabited by
microorganisms. Exogenous sources are those external to the patient, such as
health personnel, visitors, patient care equipment,
medical devices, and the health care environment. Patients entering a health
care setting are at risk for acquiring infections because of lowered resistance
to infectious microorganisms, increased exposure to numbers and types of
disease-causing organisms and invasive procedures. The number of workers caring
for patients, the type and number of invasive procedures and the length of
hospitalization all influence the chance of infection.
The
nurse is responsible for teaching patients about infection, its mode of
transmission, reasons for susceptibility, and measures for infection control.
The nurse's knowledge of infection process, application of infection control
principles, and use of common sense help protect patients from infection. All
those who come in contact with patients must practice infection control
techniques to avoid spreading them to patients.
The cycle of
contagion begins when a disease causing agent or
pathogen enters a susceptible person and makes him a host. This pathogen
starts multiplying in the host without injuring him which is called
colonization. When the pathogen attacks host tissues, it initiates the symptoms
of infection. Infections are spread by contact, droplet, airborne, vector, etc.
The main cause of spread of infection in hospital is often the persons caring
for affected individuals. Health care providers become either contaminated or
colonized while caring for the patients and unknowingly carry the pathogen from
one patient to another.
Standard precautions
Standard precautions
are a set of practices intended to reduce risk for transmission of pathogens
from recognized and unrecognized sources. These precautions apply to blood,
other body fluids containing visible blood, semen, and vaginal secretions, and
body fluids like cerebrospinal, synovial, pleural, peritoneal, pericardial, and
amniotic fluids. It does not apply to feces, nasal secretions, sputum, sweat,
tears, urine, saliva and vomitus unless they contain visible blood. The salient
features of standard precautions are hand hygiene, use of personal protective
equipment, decontamination of patient care devices, safe injection practices, safe handling and
disposal of sharps, safe handling of clinical waste, decontamination of
environment, safe handling of soiled
linen, management of blood/body fluid spillage and post exposure prophylaxis.
1. Hand hygiene
Hand carriage of
bacteria is an important route of transmission of HAI. Hand hygiene is proved
to be the single most effective means for prevention of cross infection in
health care facilities. In order to give due importance to hand hygiene, World
Health Organization (WHO) selected the theme, ‘clean hands save lives',
for its first global patient safety challenge in the year 2004.
Resident
flora of skin includes coagulase negative staphylo-coccus, diphtheroids,
coliforms, etc. Usually this group of organisms does not implicate nosocomial
infection. But when the patient is severely immunocompromised or has an
implant, these can cause infection. Resident flora is not easily removed by
hand washing.
Transient
microbial flora represents recent contaminants of the hands acquired from
colonized or infected patients, from contaminated environment, or equipment.
They are readily transferred from hands of health care workers to the patients.
However, they are easily removed by hand washing.
Hands
must be decontaminated immediately before each and every episode of direct
patient contact and after any activity that could potentially result in hands
becoming contaminated. It can be accomplished by routine hand washing (with or
without antiseptic agent) or by antiseptic hand rub and surgical hand scrub
using an antiseptic agent. It decreases microbial count on the hand and makes
them cleaner and safer "instruments" of patient care. Mechanical
cleansing of hand uses friction which is an abrasive action. Chemical cleansing
utilizes antimicrobial chemical agents. To promote hand hygiene world wide, WHO
introduced 5 moments of hand hygiene in 2009
Hands
should be washed using soap or an antimicrobial agent at entry to patient care
units, when hands are visibly dirty, or contaminated with blood or body fluids,
before any invasive procedure, after handling clinical waste, after removing
gloves (moisture and warmth associated with the use of gloves gives an
ideal environment for bacterial growth), and before leaving patient care unit.
Method of hand hygiene
It is acceptable to use anti microbial hand-rubs to
decontaminate the hands, provided hands are visibly clean and the task that is
going to be performed is non- invasive. Hygienic hand rub consists of rubbing hands with 2-3 ml of alcohol based chlorhexidine
gluconate. It is a substitute for hand washing in certain occasions. Pour the
agent on the hands and follow the seven steps of hand rubbing. There is automatic dispenser connected to the bottle. The amount it dispenses
at a single press is 2-3ml. After rubbing, it doesn't require further washing
in water. To promote effective hand hygiene, all patient care units are
provided with alcohol based hand rub at the point of care.
How to handrub?
When washing with soap and water, wet hands first with
water, apply soap to both hands and rub hands vigorously for at least 10-15
seconds, covering all surfaces of hands and fingers. Keep hands lower than elbows so that dripping occurs from
finger tips. Rinse hands under running water, dry thoroughly with a clean single
use towel or air dry. Multiple use cloth towels are not recommended .
There
are three types of hand washing:
a) Social hand-washing
It is an inherent
part of personal hygiene, which should be performed before and after routine
patient care or therapies and after contact with a source that is likely to be
contaminated with harmful microorganisms. Soap and water wash is equally
effective as using an antimicrobial agent. The procedure requires 10 to 15
seconds and includes a vigorous brief rubbing together of lathered hands
followed by rinsing under running water.
b) Procedural hand washing
Certain tasks on
patient require more than routine soap and water hand washing. In such
conditions, anti microbial agents may be used for hand washing. Decontamination
of hands could also be achieved by rubbing with alcohol based hand rubs after
an ordinary soap and water wash. This is applicable before and between caring
of high risk patients; before an invasive procedure; upon leaving an isolation
room; before and during care of severely immunocompromised patients; before and
after contact with any type of wound or dressing; after contact with blood and
body fluids. Procedural hand wash requires 30 seconds. Once the hands are wet
with water, apply an anti microbial agent. Rub hands together with vigorous
friction and cleanse all areas of the hand and wrist. Keep hands lower than the
elbows so that dripping of water occurs from fingertips. Rinse hands thoroughly
under running water. Dry hand thoroughly using a clean towel or by air.
c) Surgical hand scrub
The surgical scrub is
a prolonged hand washing activity that usually employs a brush or sponge along
with an anti microbial detergent in order to ensure maximum reduction and
suppression of resident skin flora. Surgical scrubbing, which requires 3-5
minutes, removes soil and micro organisms by the physical process of rubbing,
washing and rinsing. It also inactivates or inhibits microbial growth through
the use of chemical agents. The purpose of the scrub is to reduce the risk of
microbial contamination of the operative wound. Resident skin flora flourishes
in the warm, dark, moist environment of the gloved hand. Therefore, properly
rubbed skin minimizes the possibility of wound contamination during the
procedure which may lead to surgical site infection. However, surgical scrub
using a hard brush and heavy friction leads to skin irritation, rapid microbial
re-growth and, in some cases negates the original effect of the skin scrubbing.
Therefore, it is advisable to use a soft brush or sponge for hand scrub.
Members
of the surgical team should follow standard procedures for skin and nail care
before hand scrub. Cuts, abrasions, exudative lesions, and subungual spaces
tend to get colonized with the organisms and can endanger the patient by
increasing the risk of infection. Keep nails short, if it extends past the tip
of the fingers; avoid fingernail polish and artificial nail; keep skin and nail
clean and in good condition with cuticles uncut; remove ring, wristwatch and
other wrist ornaments.
Procedure: The
skin of the hands and forearms should be intact, without open lesions or
cracked skin. Remove watch, rings and bracelets if any. Remove debris from
underneath fingernails. Wet the hands and forearms. Apply antiseptic agents
from the dispenser to the hands and perform an initial wash to 2 inches above
the elbows. 1% Triclosam (Gamophen) and 7.5% Povidone Iodine are recommended.
Wet the hands and apply lotion from the dispenser using elbow. Begin the scrub
using a sponge starting from subungual areas spending the majority of the time
on hands (nails, fingertips, and palms). Proceed with scrubbing from the hands
to the arms. Using a clean technique, transfer the sponge to the other hand and
scrub the wrist section of the second arm. After arm, scrub elbows of both
hands and discard sponge. Rinse thoroughly under running water, with the hands
held higher than the elbows and allowing water to flow from the hands to the
elbows.
2. Use of personal protective equipment
Standard precautions
involve the use of personal protective equipment such as gloves, gown, apron,
mask, and protective eyewear, which can reduce the risk of exposure of the
healthcare worker’s skin and/or mucous membranes to potentially infective
materials. Selection of protective equipment should be based on an assessment
of the anticipated risk of transmission of microorganisms to the patient, and
contamination to the healthcare worker by patients’ blood, body fluids,
secretions or excretions.
Gloves must be worn as single-use item and should be
changed between patients. Sterile gloves must be worn for invasive procedures
and contact with sterile sites. Wear clean non sterile gloves when handling
items or surfaces soiled with blood and body fluids and all activities that have been assessed as
carrying a risk of exposure to pathogenic microorganisms (eg. phlebotomy,
touching blood, body fluids, excretions or secretions, mucous membranes,
clinical waste etc). Change gloves between different tasks or treatment on the
same patient as necessary and remove gloves promptly after use. Gloves must be
disposed of as clinical waste and hands decontaminated after the gloves have
been removed.
Wear
other personal protective equipment such as mask, eye protection, face shield,
or fluid-repellant gown during procedures and care activities that are likely
to generate splashes or sprays of blood or body fluids. Use gown to protect
skin and prevent soiling of clothing. Full-body fluid-repellent gowns must be
worn by the personnel in operation theatres, cath labs. CSSD and in all areas
where instrument washing takes place, as there is a risk of extensive splashing
of blood, body fluids, secretions or excretions, onto the skin or clothing of
healthcare workers.
Masks
and protective eyewear or face shields should be worn when the generation of
droplets/ splashing of blood and body fluids into the face and eyes is
anticipated. Personal protective items must be put on immediately before an
episode of patient contact or treatment and removed as soon as the activity is
completed.
3. Reprocessing of patient care equipment and
devices
The method of
decontamination, choice of disinfectant, and level of decontamination is
selected based on anticipated risk of infection, the particular situation
existing in the institute and the latest Centers for Disease Control and
Prevention (CDC) recommendations. The transmission of infection in association
with equipment is recognized as a major problem.
Approximately
250 major cardiovascular and neurosurgical procedures are performed monthly in
the institute, in addition to the minimally invasive vascular, intra cardiac
and intracranial diagnostic and interventional procedures. Different variety of
instruments and devices come into contact with patient's tissue and mucosa
during these interventions where there are chances for introducing organisms.
Any lapse in the process of cleaning, disinfection and sterilization of devices
risks transmission of environmental pathogens to the patient.
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