INFECTION CONTROL – where does one begin

In order to understand `Infection Control’ it is imperative for one to understand the primary chain of infection. For infection to get transmitted in any hospital environment, there are three rudiments that play the primary role: the microorganisms that cause the effect and their source, a vulnerable host and a means of transmission for the bacteria and viruses. A common example would be a healthcare provider who does not wash his hands well before attending to a patient.

Healthcare providers and attendants in hospitals are the commonest human sources of microorganisms. Then there are patients themselves and visitors, who may be have just contracted or already suffer from a disease, or those who are considered to be chronic carriers of an infectious agent. Finally there are contaminated inanimate objects that one may come in contact with. The entire matter is complex as sometimes patients become populated when they are admitted to the hospital; the organism is then endogenous and they become infected with this new organism they pick up.?

Certain individuals are almost immune to infection or have good resistance to infectious bacteria whilst there are others who are asymptomatic carriers. Considering this spectrum of host response and resistivity, factors that promote or belay infectivity are age, prevailing diseases, treatments with antimicrobials or other immunosuppressive agents, irradiation, and breakdown in the defense mechanisms caused by surgery, anesthesia, invasive catheters that may cause the infection and other such innumerable sources.?

It may be less likely to recognize subclinical cases and carriers as opposed to acute clinical cases as the former may not be ill or may appear to maintain normal activities.?

In view of this, hospitals should ensure protection of its healthcare personnel as well as its patients. A good precautionary measure is for hospitals to make it mandatory for healthcare workers with a cold or flu to abstain from work till they are fully recovered.

Some of the common routes of transmission of bacteria are: contact, droplet and airborne, these being most critical to nosocomial infections.?

Often in an ICU, healthcare workers are moving around from patient to patient where for instance in one a tracheostomy is done, in another a wound site needs to be attended to or in yet another a catheter needs to be inserted. The attending healthcare worker may not have the time or the inclination to wash his /her hands after attending to each patient. This in itself can be the cause for infection in the patients. Another example could be a healthcare worker with a cold and without adequate protection, working in an operation theatre, where with each sneeze, sniffle or cough he could be releasing droplets, which could infect the open, incised area of the patient.?

In case of droplet transmission, infectious droplets are generated during coughing, sneezing, talking and through procedures such as bronchoscopy and suctioning.?

Eventually the airborne kind of transmission could be through dust particles containing bacteria or airborne droplet nuclei containing microorganisms that are in the air for long durations of time and which could spread the infection.?

Since clinics and hospitals are the primary places where most ill people go first, these service providers have the first opportunity to recognize and initiate a response against an impending infection and prevent it from spreading. In most well managed hospitals it is for the physicians and experts dealing with infection control to provide immediate containment and precautionary activity required for a suspected biological agent.?

The infection control practitioners assist with the detection and investigation of trends of disease symptoms and unexplained deaths that could be associated with a biological agent. They also monitor possible indicators that could lead to a bacterial outbreak. A constant communication is maintained with the admissions, nursing supervisors, laboratory, emergency and ambulatory care, to review the spectrum of patients, their symptoms and the requisite healthcare being provided. Patients suspected to be infectious agents are adequately isolated. This also applies to patients suffering from a rare disease or syndrome of uncertain etiology that could be a potential transmission agent. It is further essential to report all such cases to the concerned healthcare departments. The infection control practitioners also have to notify all concerned about the exposure the particular institution housing an infected patient has had, or whether a community has been exposed to the biological event and the measures to be taken thereof.

The policies and plans set forth by the infection control practitioners should educate and guide healthcare staff in the containment and exposure prevention of the infectious agent. There should be a preparedness to identify and manage untoward incidences of infection. Containment of the advancement of the communicable disease is of prime importance. The infection control practitioner should advocate and enforce minimum movement of the patient through the facility and implement appropriate isolation until further investigations. Once the biological cause is identified or ruled out through specific lab tests and patient symptoms, further line of action can be instituted. It is also essential to keep the number of staff attending the infected patient to a minimum with an effort to try and accomplish maximum tasks when they come in contact with that patient. However, the healthcare workers should be well protected at all times and made to take utmost care so as not to contract the infection themselves.?

As one of the measures, an infection disaster management requires that the concerned HVAC staff understand the facility’s air handling systems in order to protect occupants and buildings from airborne hazards. The infection control practitioner is also responsible to assist in implementing an action plan should an airborne illness be experienced or an airborne-transmitted biological agent be released in the building. The plan would have to take into account an aerosolisation of the suspected bacteria and a need for decontamination of any casualties.

For instance, as reported, the last cases of smallpox disease as a result of natural causes were seen in Somalia in 1977, and in 1980. World Health Organization (WHO) declared smallpox eradicated from the earth. In the USA children were not vaccinated after 1972. Whilst immunity to the disease has waned, the disease is contagious after an incubation period. The virus is transmitted through an infected person's saliva and droplets that are aerosolized by coughing or speaking or through direct contact with the infected individual's skin. Today it is even possible for the virus to spread through the circulating HVAC systems in healthcare facilities. To prevent accidents, healthcare providers should wear respiratory protection when entering the patient's room. They should wear clean gloves and gown before entering the patient’s room and making contact with him or his environment. Whilst leaving the patient’s room the gown must be left behind and hands washed with an antimicrobials agent. Based on the nature of the infection it may become necessary to use face shields, masks and eye protectors.

The selection of the protection material can never be over emphasized. One has to take into purview the level of exposure to risk. Often, care of the infected patient may involve exposure to blood, body fluids and other infectious material. The protection material could undergo stress during the course of handling instruments, vascular lines etc., exposing the healthcare provider to high risk. On the other hand administering an injection, routine suctioning, handling food are comparatively low risk tasks. Often double gloving is resorted to (two pairs of gloves are worn, one on top of the other). This is mainly in very high-risk situations or in cases where the type of patient handling may cause chances of violating the high protection barrier.

Selection of medical gloves must be made taking into consideration various qualifying factors. In USA for instance, medical glove manufacturers must meet the FDA performance criteria. Gloves labeled as `powder-free’ must not have more than 2 mg. of particulate per glove. The lowest permissible protein level is not more than 50 micrograms per gram. All medical gloves must be statistically sampled to meet certain approved standards. The tensile strength is another important parameter: it reflects how much force is required to stretch a sample of a glove until it breaks. Then there is the elongation factor, which relates to material stretchiness; a sample with a higher elongation will stretch more before breaking. In case of the thickness norms, FDA requires a minimum of 0.10 mm for surgical gloves and 0.08 mm for examination gloves. As far as the length is concerned the FDA requires a minimum length ranging from 245 to 265 mm (depending on size) for surgical gloves and from 220 to 230 mm (depending on size) for examination gloves. The gloves are also tested for puncture resistance. In this, the test measures the force required to rupture a sample with a steel pin. A bacteriophage penetration resistance test is also of great significance as it measures the effectiveness of the material used in protection by using a surrogate microbe under conditions of continuous contact. Then there is the chemical resistance test to measure the resistance to permeation by various chemical agents

There are some additional, accepted and followed procedures for infection control such as: timely discharge of patients to prevent exposures to biological agents with existing inpatients; cancellation or re-scheduling of surgeries; diagnostic tests; cancellation of clinic appointments and diagnostic tests; using specific routes of admissions; designating specific elevators for patient transport; scheduling appropriate staff for triage and inpatient areas to minimize number of staff coming in direct contact with the infected patient.?????????

Whilst pursuing advancements in modern medical technology, one often tends to overlook the basics. For instance, cleaning the patient's personal space. A telephone can carry up to 100 times more bacteria than a toilet bowl, but that doesn't necessarily mean that the toilet bowl is cleaner. Studies have shown that bacteria easily gather at workplaces. As a result a desk can harbour 400 times more bacteria than the average toilet seat. Keeping this in view one can imagine how many more germs could be hovering around in a hospital filled with sick people. In patient rooms alone every surface is potentially covered with bacteria, which is enough reason to follow the cleaning guidelines to the letter. Other areas that are likely to be overlooked are door handles, IV poles, bed frames, soap dispensers, etc.

One of the primary rules in infection control is `hand washing’. If one reflects at the earliest days in childhood, the oft heard `wash your hands well’ from our parents bring back memories of basic hygiene that they tried to inculcate at home. Today when we practice infection control as healthcare providers, the rationale behind this practice can never be over emphasized.

The hands are the first contact points between healthcare workers and the myriad of patients that they manage and take care of. However, as helpful and indispensable as these hands have been, they have more often than not been the cause of spread of infection. For instance, fingernails have harboured scores of microorganisms and cleaning under the nails daily with a nail file or any other appropriate device is most essential.

The length of the fingernail too is important, although every individual has his / her own interpretation of this. Ideally a fingernail must not extend beyond the fingertip! In the healthcare delivery system since gloves are most commonly used, long nails could create a tear in the gloves and the protection that the former provide would be marred. Moreover, when making physical contact with patients, long nails could cause harm to the patient. Hence it is imperative to have clean, short fingernails that are well manicured (smooth edges) and the surrounding skin intact. The Centres for Disease Control and Prevention had published two years ago a case where there were 16 neonate deaths linked to a nurse with long artificial nails!

Further, artificial nail applications (nail polish etc.) invite microbes and are most likely to pass on the risk of infection. There are some who believe that clear nail polish is safe. But then have the bacteria been notified to stay clear of these!??After all this polish is a foreign body that is most likely to have chemical action when it comes in contact with the various chemicals and solutions that healthcare workers deal with during the course of their work in hospitals. Even when using gloves, there is every likelihood of the polish interacting with the wounds through glove tears. Jewelry is another abode for bacteria as the adornments are difficult to clean and can harm patients even with their sharp edges and inappropriate designs.???????????

Basically hand washing involves cleaning from the fingertips to wrists. However, during procedures such as insertion of Foley catheters, intravascular lines and respiratory tubes, dressing procedures or equivalent levels of patient care, the skin cleansing and disinfecting extends from fingertips to forearms. This reduces the microbial flora of the skin that may be unprotected by personal protective gear beyond gloves and/or over the sterile field. The extra antisepsis effort is reasonable in keeping in view the invasive nature of care and resources available.?

When the question is of surgical intervention, including cardiac catheterisation and some invasive radiographic procedures, washing is even more stringent. The commonly known hand scrub involves a hands free mechanism to initiate the stream of water and the antiseptic liquid soap. The common surgical scrub agents are iodophors, chlorhexidine gluconate, triclosan, and PCMX formulations. The amount to be used is generally specified on the dispenser however, more is not necessarily better or more effective. The area for washing and disinfecting is from fingertips to two inches above the elbow. This process generally takes about two minutes.

Using a good antiseptic has great values. The FDA defines a healthcare antiseptic as a product applied typically to the skin to help prevent infection or cross contamination; being frequently used; reducing the number of transient microorganisms on intact skin; having a broad spectrum and being fast acting and persistent. Not only is cleansing accomplished, skin disinfection occurs, destroying microorganisms.

Alcohol is a quick killer of microbes and in the early 1980s, alcohol liquid products were used specially owing to the lack of hand washing sinks in healthcare areas. These preparations contained ingredients that prevented the skin from drying. However, the American Institute of Architects (AIA) construction guidelines now incorporate more sinks in their designs as the qualities of hand washing have gained greater realization and acceptance. This has led to a decline in the need for alcohol as a cleansing agent. However, in recent times this cleansing media has returned in gel and foam form and is supported by some experts as the most appropriate means of increasing personal compliance in hand hygiene in the healthcare delivery system. No doubt, there are adverse reactions by competitive manufacturers of other cleansing agents. Hence the power of total acceptance of alcohol handrubs is yet to be established. What is accepted is the capability of the alcohol hand rub to kill microbes yet this agent does not posses the cleansing qualities.

In the healthcare delivery activity taking all necessary precautions for infection control in itself is a daunting task than having to cause adversity through preventable occurrences.

Whilst these precautions are minimal, the devices and accompaniments such as the draining sink, warm running water, a liquid non- antimicrobials soap, paper towels, waste basket etc. also need to be paid adequate attention to.

The principles of infection control are fundamental and of prime importance to those who make them viable and effective in daily routines. It is imperative to differentiate between the dirty and the clean to the cleanest and make a concerted effort to aim for the superlative.?

Dhanraj Chandriani

[email protected]

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