INFECTION PREVENTION AND CONTROL

FY 2008 - Denver Medical Center

The key element for every Infection Prevention and Control Program is
[**effective**]{.underline} **HAND HYGIENE** because contaminated hands
of health care workers are by far the greatest source for transmission
of healthcare--associated infections (HAIs).

  --------------------- ---------------------------------------------------
  This picture          ![](media/image1.png){width="4.210416666666666in"
  describes the         height="2.8743055555555554in"}
  elements necessary    
  for an infection to   
  be spread. The focus  
  of hand hygiene is to 
  break the chain at    
  the transmission      
  point.                

  --------------------- ---------------------------------------------------

In January 2005, **VHA DIRECTIVE 2005-002, "REQUIRED HAND HYGIENE
PRACTICES"** was released. This directive establishes the basic
requirements for hand hygiene practices in VHA facilities including:

-   **Reinforcing the VA's commitment to hand hygiene as an infection
    prevention and control tool**

-   **Stipulating where, when, and with what products hands will be
    cleaned**

-   **Stipulating appropriate use of gloves as protective barriers**

-   **Prohibiting wearing of artificial fingernails for all personnel
    who provide direct, hands-on care to patients**

-   **Establishing responsibilities for procurement and distribution of
    hand hygiene products**

-   **Requiring education of all VA employees**

**What hand hygiene products are used at the ECHCS?**

-   Antimicrobial soap and/or alcohol-based hand rubs in all clinical
    settings (includes inpatient and outpatient areas).

-   Hand lotion that is compatible with both the antimicrobial soap and
    alcohol-based hand rubs.

When should hands be cleaned?

+----------------------------------+-----------------------------------+
| -   Before and after patient     | -   Before eating, applying lip   |
|     contact or contact with      |     balm, or cosmetics            |
|     their immediate environment  |                                   |
|                                  | -   After using the restroom      |
| -   Before inserting any         |                                   |
|     invasive device              | -   Anytime hands become soiled   |
|                                  |     or have contact with body     |
| -   After removing gloves        |     fluids or non-intact skin     |
+----------------------------------+-----------------------------------+

How does hand hygiene work?

+-------------------------------+--------------------------------------+
| **Soap (includes              | **Alcohol gels and foams**           |
| antimicrobial soap) and       |                                      |
| water**:                      | -   These products work by actually  |
|                               |     killing germs on your hands      |
| -   Wet hands with warm water |                                      |
|                               | -   For an alcohol product to work,  |
| -   Apply soap                |     your hands must be free of gross |
|                               |     soiling (i.e. visible dirt)      |
| -   Rub hands together        |                                      |
|                               | -   Squirt gel/foam into the palm of |
| -   Pay close attention to    |     your hand and rub onto all       |
|     the spaces between the    |     surfaces of both hands,          |
|     fingers and area around   |     including between fingers, and   |
|     nails.                    |     allow product to dry.            |
|                               |                                      |
| -   Rinse thoroughly          | -   **[Alcohol can be                |
|     (retained soap can cause  |     flammable]{.underline} so        |
|     skin irritation).         |     alcohol-containing gels/foams    |
|                               |     must be allowed to dry           |
| -   Dry with paper towel and  |     completely before doing          |
|     use the towel to turn off |     activities that may generate     |
|     the faucet.               |     sparks.**                        |
|                               |                                      |
| -   If desired, apply a       | -   **Alcohol products [SHOULD       |
|     compatible lotion to      |     NOT]{.underline} be used when a  |
|     prevent dryness.          |     patient has *C. difficile*       |
|                               |     diarrhea (alcohol will not kill  |
|                               |     *C. diff* spores).**             |
+-------------------------------+--------------------------------------+

**JCAHO and Hand Hygiene:**

> **Expiration date**
>
> o Hand Hygiene products **[DO]{.underline} have an expiration date!**
>
> o The expiration date is located on bag inside the dispensers as well
> as the box the bag comes in. For the pocket size bottles, it is on the
> bottom of the bottle.
>
> o Hand Hygiene products should not be used after the expiration date!
>
> **Observations during surveys**
>
> o JCAHO has placed a high value on hand hygiene because of its proven
> value in improving patient outcomes.
>
> o During surveys they will be watching to see if employees wash their
> hands when appropriate.
>
> o If they observe **3 incidents** where staff did not wash their hands
> it will be a **type 1 recommendation**.

**What about wearing gloves?**

-   Wear gloves for any anticipated contact with blood, other
    potentially infectious materials, mucous membranes, and non-intact
    skin.

-   Do not wear the same pair of gloves for the care of more than 1
    patient.

-   Do not wash gloves between uses with different patients.

-   **Clean your hands with either an alcohol-based hand rub or
    antimicrobial soap after removal of gloves.**

**What about fingernails?**

-   Natural nails will be clean, neat, and trimmed to ¼ inch or less

-   Nail polish is acceptable so long as it is intact and not chipped or
    worn.

-   Artificial nails (including acrylic overlays, gels, silk wraps, or
    nail jewelry) are prohibited for direct patient-care providers (EVEN
    occasional direct patient care).

######### ISOLATION PRECAUTIONS USED AT THE ECHCS

The VA Eastern Colorado Health Care System uses a type of precaution
system known as **STANDARD PRECAUTIONS.**

In this system, caregivers should consider **ALL** patients potentially
infectious regardless of their diagnosis or presumed infection status.
**STANDARD PRECAUTIONS** incorporates the use of protective barriers for
**ALL** contact with: blood, non-intact skin, all secretions, all body
fluids, mucous membranes, and all excretions (except sweat).

In addition to **STANDARD PRECAUTIONS**, it is recognized that
additional precautions may be needed to interrupt transmission in
patients documented or suspected to be infected with highly
transmissible or epidemiologically important pathogens. When such
patients are identified, it is important to alert caregivers and
intensify standard precautions.

**When STANDARD PRECAUTIONS are intensified, one of the three following
categories will be advised:**

# 

# CONTACT PRECAUTIONS: 

+------------------------+---------------------------------------------+
| ![](med                | -   **Gloves** [mandatory]{.underline} to   |
| ia/image2.jpeg){width= |     enter room -- includes visitors         |
| "2.4541666666666666in" |                                             |
| height="               | ```{=html}                                  |
| 3.1756944444444444in"} | <!-- -->                                    |
|                        | ```                                         |
|                        | -   **Gowns** [mandatory]{.underline} to    |
|                        |     enter room -- includes visitors         |
|                        |                                             |
|                        | Example: **MRSA (methicillin resistant      |
|                        | *Staph aureus*)**                           |
|                        |                                             |
|                        | > **C. difficile**                          |
|                        | >                                           |
|                        | > **VRE**                                   |
|                        | >                                           |
|                        | > **Pan resistant gram negative organisms** |
|                        |                                             |
|                        | Staff often enter the room of an isolation  |
|                        | patient with the intention of only speaking |
|                        | with the patient but, because isolation     |
|                        | frequently results in decreased             |
|                        | interactions, the patient immediately       |
|                        | requests that the caregiver 'hand me        |
|                        | something', 'pull the bedside rail          |
|                        | up/down', 'check my IV', etc. This results  |
|                        | in the caregiver TOUCHING the environment   |
|                        | of the isolation patient, which can contain |
|                        | large numbers of organisms. Caregivers can  |
|                        | pick up these organisms on their            |
|                        | hands/clothing and carry them to another    |
|                        | patient. The **[mandatory use of gloves and |
|                        | gown to enter the room]{.underline}** and   |
|                        | good hand hygiene can prevent the transfer  |
|                        | of epidemiologically important organisms to |
|                        | others.                                     |
+------------------------+---------------------------------------------+

# AIRBORNE PRECAUTIONS:

+-------------------------+--------------------------------------------+
| ![](m                   | \- Negative airflow room                   |
| edia/image3.jpeg){width |                                            |
| ="2.5319444444444446in" | \- Door closed                             |
| height=                 |                                            |
| "3.2756944444444445in"} | \- **Mask** mandatory**\*\***              |
|                         |                                            |
|                         | Example: **TB**                            |
|                         |                                            |
|                         | # SARS                                     |
|                         |                                            |
|                         | **Varicella (including disseminated        |
|                         | zoster**                                   |
|                         |                                            |
|                         | # Measles                                  |
|                         |                                            |
|                         | Transmission occurs by dissemination of    |
|                         | either droplet nuclei (small particle      |
|                         | residue of evaporated droplets containing  |
|                         | microorganisms that remain suspended in    |
|                         | the air for long periods of time) or dust  |
|                         | particles containing the infectious agent. |
|                         |                                            |
|                         | **\*\***Special masks are required by OSHA |
|                         | and require fit testing by a qualified     |
|                         | industrial hygiene employee. If you have   |
|                         | not been fit tested for the N-95 (orange   |
|                         | duckbill) mask, use a hooded respirator    |
|                         | called a PAPR. PAPRs do not require fit    |
|                         | testing. Both the N95 and the PAPR require |
|                         | a medical clearance. Please contact your   |
|                         | supervisor to arrange fit testing or       |
|                         | obtain a PAPR.                             |
+-------------------------+--------------------------------------------+

> **DROPLET PRECAUTIONS**

+-------------------------+--------------------------------------------+
| ![](m                   | **- Private room (negative airflow NOT     |
| edia/image4.jpeg){width | necessary)**                               |
| ="2.5243055555555554in" |                                            |
| height=                 | **- Mask** mandatory                       |
| "3.2756944444444445in"} |                                            |
|                         | Example: **Influenza**                     |
|                         |                                            |
|                         | ##### Neisseria meningitidis meningitis    |
|                         |                                            |
|                         | #### **Pertussis**                         |
|                         |                                            |
|                         | Droplets are large particles generated     |
|                         | primarily during coughing, sneezing, and   |
|                         | talking. These large droplets usually      |
|                         | travel from 3-5 feet from the source.      |
|                         | Transmission occurs when droplets          |
|                         | containing microorganisms generated from   |
|                         | the infected person are propelled a short  |
|                         | distance through the air and deposited on  |
|                         | the host's conjunctivae (eyes), nasal      |
|                         | mucosa (nose), or mouth. Because droplets  |
|                         | do not stay suspended in the air, special  |
|                         | air handling and ventilation are not       |
|                         | required.                                  |
+-------------------------+--------------------------------------------+

### PROPER USE OF ISOLATION PRECAUTION PERSONAL PROTECTIVE EQUIPMENT (PPE)

+-------------------------------+--------------------------------------+
| **GOWNS**                     | GOWNS are worn to prevent            |
|                               | contamination of clothing and skin   |
| ![](media/                    | when in contact with the patient and |
| image5.jpeg){width="1.3875in" | his environment (especially the      |
| h                             | bed). They should be removed and     |
| eight="1.7493055555555554in"} | discarded prior to leaving the       |
| ![](media/image6.jpeg)        | patient's room.                      |
| {width="1.4034722222222222in" |                                      |
| height="1.78125in"}           | Isolation Gowns are **[SINGLE        |
|                               | USE]{.underline}** disposable items. |
|                               |                                      |
|                               | [**DO NOT**]{.underline} re-use      |
|                               | gowns.                               |
|                               |                                      |
|                               | When isolation or Standard           |
|                               | Precautions requires multiple PPE,   |
|                               | gowns should always be put on FIRST  |
|                               | and tied securely in the back with   |
|                               | clean hands.                         |
+-------------------------------+--------------------------------------+
| **MASK**                      | MASKS are worn for several reasons:  |
|                               |                                      |
| ![](media/image7.jpeg         | 1.  To prevent spread of diseases    |
| ){width="2.066666666666667in" |     spread by the respiratory route  |
| height="2.183333333333333in"} |     (e.g. TB).                       |
|                               |                                      |
|                               | 2.  To prevent spread of diseases    |
|                               |     spread by the droplet route      |
|                               |     (e.g. influenza).                |
|                               |                                      |
|                               | 3.  To prevent contamination of the  |
|                               |     nose and mouth from splashes or  |
|                               |     sprays of body fluids while      |
|                               |     performing patient care          |
|                               |     activities.                      |
|                               |                                      |
|                               | 4.  To prevent inadvertent contact   |
|                               |     of the nose and mouth from       |
|                               |     contaminated hands.              |
|                               |                                      |
|                               | N-95 masks should always be worn     |
|                               | with **[one strap low near the       |
|                               | neckline]{.underline}** and **[one   |
|                               | high on the head]{.underline}** as   |
|                               | demonstrated by the arrows here.     |
|                               |                                      |
|                               | When isolation or Standard           |
|                               | Precautions requires multiple PPE,   |
|                               | mask should be put on                |
|                               | **[SECOND]{.underline}** (after the  |
|                               | gown and before gloves).             |
+-------------------------------+--------------------------------------+

+------------------------------+---------------------------------------+
| **GLOVES**                   | GLOVES are worn for 3 important       |
|                              | reasons:                              |
| ![](media/image8.jpeg){      |                                       |
| width="2.6166666666666667in" | 1.  To prevent contamination of hands |
| height="1.9625in"}           |     with resistant organisms          |
|                              |                                       |
|                              | 2.  To provide a protective barrier   |
|                              |     and prevent gross contamination   |
|                              |     when touching body fluids, mucous |
|                              |     membranes and non-intact skin.    |
|                              |                                       |
|                              | 3.  To reduce the likelihood that     |
|                              |     organisms present on personnel    |
|                              |     hands will be transmitted to      |
|                              |     patients during patient care.     |
|                              |                                       |
|                              | When isolation or Standard            |
|                              | Precautions require multiple PPE,     |
|                              | gloves should be put on               |
|                              | [**LAST**]{.underline} and should     |
|                              | **[always cover the sleeve            |
|                              | cuff]{.underline}** of the gown. Note |
|                              | how the thumb is used to tuck the     |
|                              | gown under the glove.                 |
+------------------------------+---------------------------------------+

> **How to Remove Isolation Precaution PPE**

+--------------------+----------------+---------------+----------------+
| ### 1.             | ### 2. Re      | ### 3. Remove | ### 4. Cle     |
| With gloves in pla | move gloves wh |  mask, touchi | an your hands. |
| ce pull gown ties  | ile rolling th | ng only the s |                |
| until they break ( | e gown. Avoid  | traps, and di | ![](media      |
| waist first, shoul | contaminating  | spose in wast | /image13.jpeg) |
| der second) and, s | the hands by k | e receptacle. | {width="1.7076 |
| tarting with the s | eeping them on |               | 38888888889in" |
| houlders, pull the |  the clean sid | ![](media/ima | h              |
|  gown away from yo | e of the gown. | ge12.jpeg){wi | eight="2.27708 |
| u rolling it with  |  Dispose of co | dth="1.651388 | 3333333333in"} |
| the contaminated s | ntaminated gow | 8888888888in" |                |
| ide in as you go.  | n and gloves i | hei           |                |
|                    | n wastebasket. | ght="2.042361 |                |
| ![](media/image    |                | 111111111in"} |                |
| 9.jpeg){width="2.1 | ![](media      |               |                |
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| height="2.87       | {width="1.7076 |               |                |
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|                    | h              |               |                |
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|                    | h              |               |                |
|                    | eight="2.22361 |               |                |
|                    | 1111111111in"} |               |                |
+--------------------+----------------+---------------+----------------+

Patients who are in Precautions should leave the room
**[ONLY]{.underline}** for essential medical purposes.

[**ALWAYS**]{.underline} notify the receiving area of the type of
precautions needed.

####### **[Airborne and Droplet Precautions]{.underline}** 

Patient must wear a fresh N95 mask and be instructed NOT to remove the
mask.

######### Contact Precautions

######## All wounds/lesions must be covered with fresh dressings

> If organism is in respiratory secretions, patient must wear a mask

-   Use clean wheelchair or stretcher

-   Drape clean sheet lengthwise across wheelchair or stretcher and have
    patient sit/lay.

-   Wrap sheet around patient mummy style so that all skin surfaces
    except face are covered by clean sheet. Patient does not need to
    wear gown/gloves. The clean sheet should keep the patient from
    contaminating surfaces and other people.

-   Transport personnel should wear PPE as dictated by the precaution,
    i.e., gown and gloves.

-   Follow same procedure for return to the patient's room.

## IMPORTANT INFECTION PREVENTION AND CONTROL POINTS TO REMEMBER

### Needle Disposal

> Syringes, needles, and other disposable sharp objects are to be placed
> in heavy plastic sharps disposal containers located in all patient
> care areas. Used needles should not be broken off or recapped before
> disposal. Most needle stick injuries occur during recapping. All areas
> of the hospital have specific designated locations for storage of used
> reusable sharps. Familiarize yourself with these locations
> [before]{.underline} use.
>
> **Cleaning and decontaminating spills of blood:** (For large spills or
> spills you do not feel qualified to clean, activate the SPIL
> protocol). For small spills you feel qualified to clean:

-   Wear eye and face protection if there is anticipated splashing.

-   Wear shoe covers if it is likely that you will contaminate your
    shoes.

-   Put on gloves and cover blood spill with disposable towels. Apply
    hospital-approved germicide (Caviwipes) or 1:10 dilution of bleach
    (Hypewipes or Bleachrite) to towels until saturated. Clean spill and
    dispose of soiled towels in red/biohazard plastic bag.

-   Again, decontaminate surface with a hospital approved germicide or
    1:10 dilution of bleach.

-   Wipe area with clean towels and air dry.

-   Remove contaminated items, shoe coverings, etc. and place in
    red/biohazard plastic bag for disposal in contaminated (red bag)
    trash. Remove gloves last.

-   Wash hands after removing gloves.

**Employee Health**

> Employee health hours are 8:00 - 9:00 AM and 3:00 - 4:00 PM , Monday
> through Thursday. Friday hours are 8:00 -- 9:00 AM only. Employee
> Health services includes emergency diagnosis and first treatment of
> illness during working hours to enable the employee to remain on duty
> through the work shift. Life-threatening emergencies will be handled
> through the Emergency Room. Non-emergent accidents or injuries will be
> handled in Employee Health or, if unavailable, the Emergency Room.
>
> Employee Health offers the following vaccines:

-   **Hepatitis B vaccine** - recommended for employees who are expected
    to have contact with blood or body fluids as a part of their
    assignment. The vaccine is given in 3 doses over a 6-month period.

-   **Influenza vaccine** - Recommended for all ECHCS employees. The
    vaccine is offered yearly in the fall.

-   **Tetanus vaccine** -- when indicated.

All employees are required to complete a 2 step TB skin test prior to
starting work. Annual TB skin testing is not required. However, further
skin testing is required if an employee has been exposed to a person
with active, infectious TB disease.

> **Blood Exposures** - ALL BLOOD EXPOSURES ARE IMPORTANT AND SHOULD BE
> REPORTED!
>
> Blood Exposures include:

-   Parenteral Exposures (blood to blood): Sharps injuries (needle
    stick, scalpel cut, pipette break, etc.) or blood/body fluids in
    fresh open cuts or non-intact skin.

-   Mucous membrane exposure (splashing of body fluids into eyes, nose
    or mouth)

Any blood exposure is important. Detailed instructions on blood exposure
follow-up can be found in the Infection Prevention and Control Manual
located in the computer on the VA Eastern Colorado Health Care System's
Intra-net home page. In the event of a computer outage, a hard copy can
be found in the nursing supervisor's office and the Administrator of the
day (AOD) office.

> Should you experience an unprotected exposure to blood or body fluids
> follow these steps:

1.  Clean/flush the exposed area thoroughly.

2.  Report the incident promptly to your immediate supervisor.

```{=html}
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```
1.  Report to Employee Health ASAP. If Employee Health is closed, report
    to the Emergency Room.

2.  Complete an INCIDENT REPORT via the electronic reporting program
    "ASISTS"

3.  Notify Infection Prevention and Control

For questions related to Infection Prevention and Control contact:

######## Linda B. Laxson, RN, BSN, CIC 303-399-8020 ex 3132; pager 303-609-5460

> Keith Rains, RN, BSN, CIC 303-399-8020 ex 3071; pager 303-609-5461
>
> Karen Guerin, RN 303-399-8020 ex 3065; pager 303-201-2658
>
> Georgiana Inskeep, RN, CIC 719-553-1026 (covers CBOCs and Pueblo NHCU)