Azharuddin
Department of Surgery, Zainoel Abidin Hospital/Faculty of Medicine Syiah Kuala University, Banda Aceh
2011
Objectives Define Infection Control and Aseptic Technique Discuss the 3 elements of transmission of infections List the 5 means of transmission of infectious microorganisms Describe the five modes of transmission of infectious
microorganisms Define isolation and discuss isolation precautions List and describe the five crucial areas, according to the C.D.C.,
for maintaining isolation precautions and their implementations Describe Standard precautions, including who is responsible for
implementation, when to implement, and methods of implementation
Demonstrate proper procedure for donning a sterile gown Demonstrate proper procedure for removal of contaminated
gloves Recognize when the guidelines for a sterile field are violated and
how to act appropriately Describe the purposes, types, materials, and methods of wound
dressings
Definitions Infection Control
Program of disease surveillance, designed to investigate, prevent, and control the spread of infections and their causative microorganisms
Aseptic Techniques Are the methods and procedures used to
create and maintain a sterile field
Infection Control
Prevention of disease in hospitals is a major concern
Transmission of infection requires three elements A source of infecting microorganisms A susceptible host A means of transmission for the
microorganism
Sources of Infection Humans Sources
Include patients personnel Visitors
Can be Carrying an acute disease In the incubation period of a disease Colonized by an infectious agent Chronic carriers of an infectious agent
Other Sources
Pt’s own Endogenous Flora (internal microbes useful to the body)
Contaminated Objects Equipment Medications
Susceptible Host Resistance among persons to pathogenic microorganisms
varies greatly Person may,
Be immune Resistant to colonization Become asymptomatic carriers May develop clinical disease
Host factors may include, but not be limited to: Age Underlying diseases Certain treatments with immunodepressive agents
Antimicrobials Corticosteroids
Irradiation Breaks in the first line of defense mechanisms caused by
Surgical operations Anesthesia Indwelling catheters
Means of transmission
Microorganisms are transmitted in hospitals by several routes
The same microorganism may be transmitted by more than one route
The five main routes of transmission are Contact Droplet Airborne Common vehicle Vectorborne
Contact Transmission
The most important and frequent mode of infection transmission
Divided into two subgroups Direct contact transmission
Direct body to surface contact Physical transfer of microorganisms between a susceptible
host and an infected or colonized person
Indirect contact transmission Contact of a susceptible host with a contaminated
intermediate object, usually inanimate
Droplet Transmission Droplets are generated from a source person by:
Coughing Sneezing Talking Performance of certain procedures
Suctioning Wound care
Transmission occurs when droplets containing microorganisms generated from the infected person are propelled a short distance through the air and deposited on a host’s conjunctivae, nasal mucosa or mouth
Droplets do not stay suspended in air
Airborne Transmission
Occurs by two modes of dissemination Airborne droplet nuclei
Are evaporated droplets containing the infectious agent
Remain suspended in air for long periods of time
Dust particles containing the infectious agent Dispersed widely by air currents Inhaled by a susceptible host
Common Vehicle Transmission
Applies to microorganisms transmitted by contaminated items such as: Food Water Medications Devices Equipments
Vectorborne Transmission
Occurs when vectors transmit microorganisms
Vectors are vermin such as: Mosquitos Flies Rats
This method is of less significance in hospitals
Isolation One means of infection control is isolation Isolation is the separation and placement of
patients in environments that reduce the potential for transmission of infectious microorganisms
When a patient is placed in isolation: Signage is posted outside the patient’s room
indicating specifically required isolation practices A request is posted for visitors to see the
patient’s nurse prior to entering the patient’s room
Isolation Precautions There are two levels of isolation precautions
Standard precautions Designed for the care of all patients in hospitals
regardless of diagnosis or suspected infection status Is the primary strategy for successful nosocomial
infection control
Transmission precautions Based on the concept of avoiding infection by limiting the
potential for transmission of microorganisms Are designed only for the care of specified patients who
are known or suspected to be infected by epidemiologically important pathogens
Standard Precautions
Apply to All patients receiving care in hospitals regardless of
diagnosis or presumed infection status Blood All body fluids, secretions, and excretions except
sweat Non-intact skin Mucous membranes
Are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals
Transmission Based Precautions Designed for patients documented or suspected
to be infected with highly transmissible pathogens for which additional precautions, beyond standard precautions, are needed
There are three types of transmission based precautions Airborne Droplet Contact
Are used in addition to standard precautions
can be used in any combination
C.D.C.
The C.D.C. stands for Center for Disease Control
It is the hospital responsible for developing and issuing guidelines for aseptic techniques and isolation systems.
C.D.C. The C.D.C.
Recommends isolation procedures based on 7 categories Strict isolation Respiratory isolation Protective isolation Enteric precautions Wound and skin precautions Discharge precautions Blood precautions
Requires that guidelines Have a basis that is epidemiologically sound Emphasize the importance of all body fluids, secretions and excretions
of nosocomial pathogens Contain precautions for infections transmitted by airborne, droplet, and
contact routes of transmission Be simple to understand and use Use terms to avoid confusion with existing systems
CDC Cont’d The C.D.C. deemed five
areas crucial to maintaining isolation precautions in hospitals Administrative controls Standard precautions Airborne precautions Droplet precautions Contact precautions
Administrative Controls
Include Education
Developing systems to ensure that patients, personnel and visitors are educated about the use of precautions and their responsibility to adhere to them
Adherence to precaution Periodic evaluation of adherence to precautions Use of findings to direct improvements
Standard Precautions Include:
Handwashing Gloves Mask and eye protection Gown Patient care equipment Environmental control Linen Occupational health and
bloodborne pathogens
Handwashing
Hands should be washed: Immediately after touching,
Blood Body fluids Secretions Excretions Contaminated items
Immediately after gloves are removed Between tasks and procedures on the same patient
Plain soap should be used Procedures
Should last a minimum of 15 seconds Involves vigorous rubbing together of all surfaces of lathered
hands Followed by rinsing under a stream of water
In the case of specific circumstances such as control of outbreak or hyperendemic infections, an antimicrobial agent may be used
Gloves
Clean gloves should be worn when: Touching
Blood Body fluids Secretion Excretions Contaminated items Mucous membranes Non-intact skin
Gloves should be changed in between tasks and procedures on the same patient
Gloves should be removed promptly after use
Gloving Procedures Glove pack is opened Sterile wrapping containing gloves should be opened on a sterile
surface with cuffs toward person gloving Sterile portion of a glove pack is opened by grasping the folds of the
paper enclosing the gloves Grasp the left glove with your right hand by its cuff on the non-
sterile portion and work your left hand into it. Once left is in place, place the first two or three fingers of the left
hand inside the sterile side of the cuff of the other glove He lift the right glove using the fingers inside the cuff only Then work the right hand into the glove pulling the sleeve over the
gown Now place the right fingers on the inside of the left glove cuff and
pull that over the gown Once gloved both hands must remain above waist level
Removal of Gloves
One hand grasps the cuff of the other glove The glove that is grasped is turned inside out as it is
removed The glove that is removed is compacted into the other
glove The thumb of the ungloved hand is hooked inside the
remaining glove The remaining glove is pulled towards the fingers while
being turned inside out Both gloves are removed with contaminated sides
inward Do not snap the gloves Dispose the gloves in the appropriate container
Mask and Eye Protection
Are worn to protect mucous membranes of the eyes, nose & mouth of health care providers
Should be worn when performing procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions
Gown
A clean sterile gown can protect the skin and prevent soiling of clothing of health care workers
Should be worn when performing procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions
Should be removed promptly after procedure
Gowning Procedures
Open sterile pack Grasp gown with hands above waist at
all times Shake open gown so it unfolds Locate the neck and armholes of the
gown Without touching the outside, work
both arms into the sleeves Have a nurse or other personnel tie the
gown at the back and neck
Patient Care & Equipment
Used patient care equipment that is soiled in blood, body fluids, secretions or excretions should be handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms
Ensure that equipment is not used for another patient until it is cleaned appropriately
Ensure that single use items are discarded properly
Environmental Control & Linen Ensure that hospital protocols are in place
regarding routine care, cleaning, disinfection of environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces
Handle, transport, and process linen soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures and contamination of clothing
Occupational Health & Bloodborne Pathogens Disposable syringes and needles, scalpel blades and
other sharp items should be Handled with care Disposed of in proper puncture proof containers.
Never Recap used needles Manipulate them using both hands Direct the point of a used needle toward any part of
the body Remove needles from disposable syringes by hand Bend, break, or manipulate used needles by hand
Mouthpieces, resuscitation bags & other devices should be used as an alternative to mouth to mouth rescusitation
Airborne Precautions
Respiratory Protection Such as an, N95 respirator, should be
worn when entering room
Patient Transport Movement should be limited to essential
purposes Surgical Mask should be worn by the
patient
Droplet Precautions
Mask Should be worn when working within
three feet of the patient or upon entering room
Patient Transport Should be limited to essential purposes
only Patient must wear a surgical mask
Contact Precautions
Gloves Should be used as outlined under standard
precautions Must be changed constantly during the course of
patient care Must be removed before leaving patient’s room
Handwashing Must use an antimicrobial agent
Gown Must be removed before leaving room
Patient transport Should be limited to essential purposes only
Patient Care Equipment Use of this equipment should be limited to a single
patient only
Sterile Field Another aseptic technique is to provide
and maintain a sterile field.
A sterile field is most commonly required in an operating room
There are 8 requirements for providing and maintaining a sterile field.
Requirement 1
All items used within the boundary of a sterile field must be sterile
Single use items are preferred
Packages are considered sterile only when Initial packaging was performed properly Package was stored in a proper manner Package was not mishandled during distribution Shelf life data has not been exceeded
Requirement 2
Once a package is opened, the edges are not considered sterile
Care in opening sterile packages is required to avoid having edges touch the contents of the package, or having the edges touch the gloved hands or sterile gown
Requirement 3
Once donned properly, sterile gowns are considered sterile in the front from the shoulder level to table top level, including the sleeves
Hands should be held above table top level, in front of body during and after scrubbing, gowning & gloving
Requirement 4
Only the top surface of a table is considered sterile
Any surface above the level of the instrument table, or above waist level, whichever is higher, is a sterile surface as long as it is draped properly
Undraped or improperly draped surfaces, or surfaces below the top level of the instrument table or waist, are considered unsterile
Requirement 5
Only sterile items and personnel in sterile attire may enter the field or touch items in a sterile area.
Forceps can be used to transfer items into a sterile area, but are considered contaminated after one use.
Requirement 6
Activity in a sterile area cannot be allowed to render the area unsterile.
Movement within the sterile area must be measured and careful to avoid contact between sterile and unsterile surfaces.
Any contamination of a sterile area must be pointed out immediately by any personnel present for the protection of the patient
Requirement 7
Penetration of a sterile barrier is considered to cause contamination of a sterile field.
Penetration can be via Liquid (most likely) Airflow
Requirement 8
Sterile areas and fields should be prepared as close to the time of use as feasible
They should not be left unattended Where there is doubt about the
sterile quality of an area, a field, or an item, it should be considered unsterile.
Wound Dressings Two factors may dictate the type of
dressing applied or the method of application of a wound dressing The location of the wound The underlying pathologic conditions
No dressing should ever be applied that impedes circulation
When non institutional care is appropriate, a patient or patient’s family must be instructed carefully in proper wound care
Purpose of Wound Dressings The purposes of wound dressings are
to Protect physically the site of injury Prevent contamination of a wound Prevent transmission of infection from a
wound Promote healing
Evaluation of the Wound
Documentation of wound characteristics is necessary for: Appropriate selection of dressing materials and protective
agents Monitoring progress in wound healing
Evaluation of the wound is necessary to determine: Cause Location Area Depth Whether the wound is wet or dry Whether wound is infected
Source of infection Mechanism of infection Microorganism of infections
Wounds can be measured with a ruler Wounds can be documented by photograph.
Types of Dressings
Five methods of dressing applications for wound management are Dry to dry
Application of a dry absorbent or non absorbent dressing to cover the wound
Damp to damp Application of a gauze pad moistened with saline
solution Damp to dry
Application of a moistened dressing that is allowed to dry before removal
Occlusive dressing Applied to provide a semipermeable barrier to air and
moisture penetration Rigid dressing
Provides physical protection to a wound and the adjacent area
Materials/Application Choice of materials for, and method of
application of dressing depends on: Cause of the wound Whether wound is clean or infected If infected, what microorganism caused the
infection The type of dressing The type, if any, of microbial agent to be
applied The site, area & depth of wound Whether a trained professional, the patient, or
the patient's family will be responsible for monitoring and changing the dressing
Types of Materials
The most basic dressing is a Band Aid Telfa pads are best for small wounds Gauze is the most common material used or
dressings Topical antimicrobial agents may be applied
under the gauze portion of the dressing Compression wraps are applied to control edema
in a limb segment or to provide support to a join Edges of lacerations can be approximated using
Steri Strips Tape used to secure an adhesive can be cloth
adhesive or paper tape
Preparation of a Dressing
Supplies must be easily accessible during procedure Sterile fields, when required, must be prepared
appropriately Use appropriate application of aseptic techniques Tape needs to be prepared before starting the application of
a dressing If tape is applied circumferentially on a limb segment, the
ends should not overlap The size of the dressing should cover the wound site In no case should adhesive portion of a dressing come in
contact with a wound
Packing a Wound
Wound may be packed with gauze depending on the depth
Ensure that deeper layers of a wound heal before surface layers
Once packed, cover the wound and packing with additional dressing that is secured with a tape
Applying a Gauze Wrap
Lay portion of gauze roll against limb segment with the still rolled gauze away from the limb
Wrap gauze in a spiral wrap which means in a continuous spiral manner around the limb segment
Angle the roll of the gauze slightly to accommodate for sloping contour and to avoid creating a tourniquet
Unroll the gauze around the limb segment with each successive wrap overlapping the previous wrap by half
Secure the wrap with tape When removing carefully use bandage scissors to cut gauze
Applying a Compression Wrap Involves applying pressure when
wrapping The pressure should be more distal
than proximal Compression wraps may be applied as:
Spiral wraps Figure eight wraps
Same as spiral wrap except the direction of the wrap changes each time the wrap completes one loop of a figure eight
Summary Infection Control and Aseptic
techniques are programs and procedures put in place to limit or prevent the spread of infectious microorganisms
Transmission of infection requires three elements, a source of infecting
microorganisms, a susceptible host and a means of transmission for the microorganism
The five modes of transmission of infections are contact, droplet, airborne, common vehicle and vectorborne
Summary....
Isolation is the separation and placement of patients in environments that reduce the potential for transmission of infectious microorganisms
There are two tiers of isolation precautions: standard precautions and transmission based precautions
The five crucial areas for maintaining isolation precautions are administrative controls, standard precautions, airborne precautions, droplet precautions and contact precautions
Summary....
Standard precautions include proper handwashing, gloving, face & eye protection, gowning, managing of patient care equipment, environmental control, linen care, observance of procedures regarding occupational health & bloodborne pathogens
Maintenance of a sterile field is usually applied for surgical procedures
Summary..... There are 8 requirements of maintaining
a sterile field they are proper handling of opened packages, proper gowning, table sterility, only sterile items can enter field, activity cannot be allowed to render area unsterile, penetration of sterile barriers are considered contamination and sterile fields should be prepared as close to procedure time as possible
Wound care is designed to protect and prevent infection of wound and involves proper evaluation, type of, preparation and application of dressing
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