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https://pixabay.com/en/photos/surgery/

PHC 6517, Module 9: “Patient Care Practices, Part II”

https://en.wikipedia.org/wiki/Bilevel_positive_airway_pressure

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https://en.wikipedia.org/wiki/Hospital-acquired_infection

Guidelines for Preventing Healthcare-Associated Pneumonia, 2003

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Nosocomial Bacterial Pneumonia Prevention

• Staff education

• HCW education

• Nosocomial pneumonias

• Infection control & prevention

• Surveillance

• ICU patients on ventilators

• Causative organisms

• Intrahospital comparisons

• Trends

No Routine Cultures!

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Prevention: General

• Thoroughly clean all equipment & devices to be sterilized or disinfected

• Whenever possible, use steam sterilization (by autoclaving) or high-level disinfection by wet heat pasteurization at >158 F (>70°C) for 30 minutes for reprocessing semi-critical equipment or devices (i.e., items that come into direct or indirect contact with mucous membranes of the lower respiratory tract) not sensitive to heat & moisture

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Examples of Devices

• Laryngoscope blades

• Suction catheters

• Ambu bags

• Mouthpieces & tubing of pulmonary function testing equipment

• Breathing circuits

• Anesthesia devices

• Oral & nasal airways

• Stylets

• Temperature probes

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Examples of Devices

https://commons.wikimedia.org/wiki/

File:Ambu_Bag_valve_mask.jpg

https://commons.wikimedia.org/

wiki/File:Laryngoscope_(1).JPG https://www.flickr.com/photos/nyng/14823823156

https://en.wikipedia.org/wiki/Tracheal_tube

https://en.wikipedia.org/wiki/Oropharyngeal_airway

https://en.wikipedia.org/wiki/Chest_tube

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Examples of Deviceshttps://en.wikipedia.org/

wiki/Tracheal_tube

https://commons.wikimedia.org/wiki/File:Concentric_nebulizer.JPG

https://en.wikipedia.

org/wiki/Spirometry

https://en.wikipedia.org/

wiki/Medical_ventilator

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Prevention: General

• After disinfection, proceed with appropriate rinsing, drying, & packaging, taking care not to contaminate the disinfected items in the process

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Breathing circuit-tubing condensate

• Decontaminate hands with soap & water (if hands are visibly soiled) or with an alcohol-based hand rub after performing the procedure or handling the fluid

©DJH2015

Note condensate collecting in tubing

https://upload.wikimedia.org/wikipedia/commo

ns/3/3e/Premature_infant_with_ventilator.jpg

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Sterilize Ambu Bags between Patients

https://upload.wikimedia.org/wikipedia/commons/thumb/7/7f/Am

bu_Bag_valve_mask.jpg/1024px-Ambu_Bag_valve_mask.jpg

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Pneumococcal Vaccination

• Administer 23-valent pneumococcal polysaccharide vaccine

• Vaccinate patients over 65 yrs & <65 in high-risk groups

https://upload.wikimedia.org/wikipedia/commons/thu

mb/1/10/Pneumovax.jpg/220px-Pneumovax.jpg

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Legionnaires Disease Prevention & Control

• Nebulization– Use sterile H2O to fill

reservoirs

– Avoid large volume air humidifiers unless sterilization is possible (II)

https://en.wikipedia.org/wiki/Nebulizer

https://commons.wikimedia.org/wiki/File:Concentric_nebulizer.JPG

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Use only sterile (not distilled, nonsterile) water or other sterile fluids to fill

reservoirs of devices used for nebulization

Fill with

sterile

water/fluids

https://commons.wikimedia.org/wiki/File:Concentric_nebulizer.JPG

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Legionnaires Disease Prevention & Control

• Maintain high index of suspicion for diagnosis of healthcare-associated Legionnaires disease & perform laboratory diagnostic tests (both culture of appropriate respiratory specimen & the urine antigen test) for legionellosis on suspected cases, especially in patients who are at high risk for acquiring the disease (e.g., patients who are immunosuppressed, including HSCT or solid-organ--transplant recipients; patients receiving systemic steroids; patients aged >65 years; or patients who have chronic underlying disease such as diabetes mellitus, congestive heart failure, & COPD).

Legionella_pneumophila

https://upload.wikimedia.org/wikipedia/commons/a/ab/Legionella_pneumophila_(SEM).jpg

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Breathing Circuits with Humidifiers

• Do not change routinely, on basis of duration of use, the breathing circuit (i.e., ventilator tubing & exhalation valve & attached humidifier) in use on an individual patient

• Change the circuit when it is visibly soiled or mechanically malfunctioning

https://upload.wikimedia.org/wikipedia/commons/b/b5/Ventilators.jpg

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Breathing Circuit Changes

DO NOT CHANGE

on routine basis-

only when

visibly soiled

or when

malfunctioning

https://upload.wikimedia.org/wikipedia/commons/3/3e/Premature_infant_with_ventilator.jpg

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Don’t routinely sterilize internal machinery of anesthesia equipment (II)

https://en.wikipedia.org/wiki/Anaesthetic_machine

https://upload.wikimedia.org/wikipedia/

en/d/d3/Vevo_Anesthesia_System.PNG

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Small-volume medication nebulizers: in-line & hand-held

• Use only sterile fluid for nebulization, & dispense the fluid into the nebulizer aseptically

https://en.wikipedia.org/wiki/Nebulizer

https://upload.wikimedia.org/wikipedia/commons/1/15/Sterile_distilled_water_01.JPG

sterile

distilled water

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GlovingChange gloves & decontaminate hands as described previously between contacts with different patients:

• after handling respiratory secretions objects contaminated with secretions from one patient & before contact with another patient, object, or environmental surface;

• between contacts with a contaminated body site & the respiratory tract of, or respiratory device on, the same patient

https://upload.wikimedia.org/wikipedia/commons/8/8d/Disposable_nitrile_glove.jpg

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Influenza Prevention & Control

• Vaccinate high-risk patient groups

• Vaccinate healthcare workers

• Use amantadine for outbreak control

• Administer amantadine to patients acutely ill with influenza within 48 hours of illness onset

• DC amantadine or rimantadine when influenza A is not lab confirmed

https://upload.wikimedia.org/wikipedia/commons/f/f6/Fluzone_vaccine_extracting.jpg

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RSV InfectionPrevention & Control

• Interrupt transmission with:

–Hand hygiene

–Gloves

https://commons.wikimedia.org/wiki/File:Hand_Sanitizer.JPG

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RSV InfectionPrevention & Control

• During RSV season

– attempt prompt diagnosis

– use rapid diagnostic techniques

– RSV

– influenza

– parainfluenza

https://pixabay.com/en/doctor-patient-hospital-child-899037/

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Pulmonary Aspergillosis Prevention & Control

• When planning construction, demolition, & renovation activities in & around the facility, assess whether patients at high-risk for aspergillosis are likely to be exposed to high ambient-air spore counts of Aspergillus spp. from construction, demolition, & renovation sites, & if so, develop a plan to prevent such exposures.

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Pulmonary Aspergillosis Prevention & Control

• Maintain high index of suspicion for healthcare-associated pulmonary aspergillosis in severely immunocompromised patients

https://commons.wikimedia.org/wiki/File:Birmingh

am_Super_Hospital_under_construction.jpg

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Miscellaneous

• Prevent aspiration

• Prevent gastric colonization

• Use Standard Precautions

• No routine administration of antibiotics

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Guideline for the Prevention of Surgical Site Infection (SSI), 1999

https://commons.wikimedia.org/wiki/File:

Flickr_-_Official_U.S._Navy_Imagery_-

_Doctors_perform_surgery_together..jpg

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Preoperative

Patient preparation– Treat infections remote

to surgical site & postpone elective surgery

– No unnecessary hair removal

– If necessary, remove hair immediately before with clippers

https://en.wikipedia.org/wiki/Razorhttps://commons.wikimedia.org/wiki/File:PB070062_chousei.jpg

Surgical clipper looks somewhat

like an electric razor

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• Shaving damages skin

• Clippers cause less skin damage & should be used immediately before surgery

https://en.wikipedia.org/wiki/Hair

This is a no

shaving

zone.

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Antimicrobial Prophylaxis

– Only as indicated & recommended

– Administer IV timed to therapeutic level at time of incision until closure

– Before elective colorectal surgery, use enemas & cathartics to mechanically prepare the colon & non-absorbable oral antimicrobials the day before surgery

– For high-risk C-sections, give right after cord clamped

https://commons.wikimedia.org/wiki/File:Mechanical_egg_timer.jpg

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Asepsis & Sterile Technique

– Adhere to asepsis principles when placing central venous catheters, placing spinal or epidural anesthesia catheters or when dispensing/ administering I.V. drugs

https://www.youtube.com/watch?v=rkm7DgrXCnw

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Placing Epidural Anesthesia Catheters

https://de.wikipedia.org/wiki/Spinalan%C3%A4sthesiehttps://en.wikipedia.org/wiki/Epidural_administration

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Dispensing/Administering I.V. Drugs

https://upload.wikimedia.org/wikipedia/commons/0/0d/ICU_IV_1.jpg

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SSI Patient Risk Factors

• Age

• Nutritional status

• Diabetes

• Smoking

• Obesity

• Coexisting infections

• Colonization

• Altered Immunity

• Length of preop stay

©DJH2015

https://www.flickr.com/photos/myfuturedotcom/6052491503

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SSI Operation Risk Factors• Duration of surgical

scrub

• Skin antisepsis

• Preop shaving/skin preparation

• Operation duration

• Antimicrobial prophylaxis

• O.R. ventilation

• Instrument sterilization

• Foreign matter in site

• Surgical drains

• Surgical technique

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NNIS Risk Index

• Surgical site wound classification of contaminated/dirty/infected

• ASA score rated by anesthesiologist at 3 or <

• Procedure time

• Patient scores 1 pt. for each variable (risk range 0-3)

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Risk Score –NNIS Data

http://wwwnc.cdc.gov/eid/art

icle/7/1/70-0057-f2

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Surgical Wound Classification

• Class I/Clean IE: elective, primarily closed

• Class II/Clean IE: GU in absence of culture & urine

• Class III/Contaminated IE: open, fresh, traumatic wounds

• Class IV/Dirty/Infected IE: traumatic wound with fecal contamination or foreign body

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Criteria for Defining a Surgical Site Infection

• Superficial incisional SSI– involves only skin or subcutaneous tissue of

incision

• Deep incisional SSI– involves deep soft tissue (e.g., fascial

& muscle layers) of the incision

• Organ/pace SSI– involves any part of anatomy, other than incision,

opened or manipulated during surgery

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Preventing HAIs• In 2011, estimated 721,800 total HAIs

• Preventable adverse events such as these are responsible for 44,000 to 98,000 deaths annually at a cost of $5.7-6.8 billion

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Conclusion• Infection preventionists can significantly

impact the occurrence of healthcare-associated infections through:

–HCW education & training

– Surveillance

–Development/implementation of preventative policies & procedures based on current guidelines