CPNE: Infection Control Study Module

CPNE
®
Infection Control
Study Module
Effective November 2013
Contents
Infection Control Practices/Asepsis Practices. . . . . 3
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Medical Asepsis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Infection Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Standard Precautions (Tier 1). . . . . . . . . . . . . . . . . . . . . . . 4
Infection Control Methods . . . . . . . . . . . . . . . . . . . . . . . . . 5
Hand Hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Techniques for Hand Hygiene Utilizing
Alcohol-Based Products.. . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Personal Protective Equipment (PPE) . . . . . . . . . . . . . . . . . 6
Transmission Based Precautions (Tier 2) . . . . . . . . . . . . . . . . 8
Immunizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
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Infection Control Practices/Asepsis Practices
3
Infection Control Practices/Asepsis Practices
Purpose
The purpose of this module is to educate the learner in the application of the basic principles
of infection control and asepsis. The guidelines in this module were developed in accordance
with recommendations published by the Centers for Disease Control and Prevention (CDC)
and Healthcare Infection Control Practices Advisory Committee (HICPAC) which are
followed nationwide to control and prevent the transmission of infection.
Introduction
Administrators in health care facilities are required to ensure that health care providers know
and consistently apply the principles of Standard Precautions for all patient care activities.
This mandate includes Excelsior College nursing students who are providing care while taking
the Clinical Performance in Nursing Examination (CPNE®).
After reviewing and studying this content, you should be ready to apply the practices listed
below. Please contact the Excelsior College Nursing Faculty if you have any questions at
888-647-2388. This module provides information about the following practices: Standard
Precautions.
Transmission-based precautions (Droplet, Airborne, and Contact)
Hand hygiene practices
Use of Personal Protective Equipment (PPE)
When you feel confident in your ability to perform the expected Infection Control and
Asepsis practices, you should electronically acknowledge this in the Clinical Performance
in Nursing Examination application. Your acknowledgement signifies that you will apply
the needed Infection Control practices during the CPNE®.
Overview
The Centers for Disease Control and Prevention estimates that there are approximately
1.7 million new cases of infections acquired by patients during their stay in hospitals every
year. “Approximately 99,000 of these cases result in death (although there may be other
factors besides infection), making health care-associated infections (HAIs) one of the top ten
causes of death in the United States. From a business perspective, this translates into a cost
of approximately $4.5–$6.5 billion a year for hospitals to combat these infections” (The Joint
Commission, 2013). Healthcare-associated infections (HAI) are defined by the World Health
Organization as those that develop after 48 hours of hospitalization at a health care facility
that were not present or incubating at the time of admission (Kelley & Monson, 2012).
There are two tiers of precautions: standard and transmission based. Standard Precautions are
used to reduce the risk of transmission of blood, body fluids, secretions, and excretions (except
sweat) to non-intact skin and mucous membranes. The second type, transmission based, is
used in addition to Standard Precautions when there is the possibility of infections being
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Infection Control Practices/Asepsis Practices
spread by droplet, airborne, or contact transmission. It is further recommended that PPE
(personal protective equipment) be used for this type of precaution (Taylor, LeMone, Lillis,
& Lynn, 2011).
It is the responsibility of the Registered Nurse to provide a biologically safe environment for
patients and care providers. To do so, the RN must maintain the principles of asepsis to guide
all nursing actions. Asepsis includes all activities to prevent infections or to break the chain of
infection. There are two categories of asepsis: medical asepsis and surgical asepsis. “Medical
asepsis, often called clean technique, includes procedures and practices that decrease the
number and transfer of pathogens. Surgical asepsis or sterile technique involves practices used
to render and keep objects and areas free from microorganisms” (Taylor et al., 2011, p. 661).
For the purposes of this module, we will focus on medical asepsis.
Medical Asepsis
Nursing actions include:
Practice good hand hygiene techniques.
Prevent all soiled items, including equipment and other used articles,
from touching clothing.
Items should be carried away from the body.
Avoid placing soiled bed linens or any other items on the floor.
Avoid having patients cough, sneeze, or breathe directly on others.
Be sure to provide patients with disposable tissues, and instruct them
to cover their nose and mouth to prevent spread of airborne droplets.
Infection Control
Standard Precautions (Tier 1)
Standard Precautions include a group of prevention practices that apply to all patients in
any health care setting regardless of diagnosis or possible infection status. The intent of
these precautions is to reduce the risk of transmission of both recognized and unrecognized
sources of infection (Siegel, Rhinehart, Jackson, & Chiarello, 2007). Compliance with
Standard Precautions is mandated and closely regulated by Occupational Safety and Health
Administration (OSHA).
These practices include:
Performing hand hygiene
Use of personal protective equipment
(gowns, mask, gloves, and eye protection/ face shield)
Avoidance of recapping needles
Proper handling of used patient-care equipment
Maintaining a clean environment
Reviewing patient’s room assignments to prevent infecting other patients
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Using puncture proof containers for sharps
Providing immunizations (Taylor et al., 2011)
Infection Control Methods
Several infection control methods are used to decrease the risk of transmission of
microorganisms in hospitals. These include:
Hand Hygiene
Hand hygiene is the most effective way to help prevent the spread of infectious agents
(Taylor et al., 2011).
According to the CDC, hand hygiene refers to hand washing with plain soap and water, use
of antiseptic hand rubs including alcohol-based products, or surgical antisepsis (CDC, 2011).
Wearing gloves is not enough to prevent the transmission of pathogens in health care settings
(CDC, 2012).
Recommendations for hand washing with soap and water include:
When hands are visibly soiled
Before eating
After using restrooms
Prior to and after contact with each patient
Before putting on sterile gloves
Before performing any invasive procedures such as
placement of a peripheral vascular catheter
After accidental contact with body fluids or excretions,
mucous membranes, non-intact skin, and wound dressing
When moving from a contaminated body site to a clean body site
during patient care
After contact with inanimate object within the immediate vicinity
of the patient (including medical equipment)
After removing gloves
If hands are not visibly soiled, the use of an alcohol based antiseptic agent may be utilized for
routine hand decontamination in all other clinical situations.
Gloves should always be worn when there is contact with blood, infectious material, mucous
membranes, and non-intact skin. Additionally, natural nails should be kept to less than ¼ inch
long and artificial fingernails or extenders must not be worn when having direct patient contact
(Siegel et al., 2007).
Handwashing Technique. To properly wash hands:
Stand in front of sink and do not allow clothing to come in contact with sink
Remove jewelry
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Infection Control Practices/Asepsis Practices
Turn on water and adjust temperature and force
Wet hands and wrists, keeping hands lower than elbows
so water flows toward the fingertips
Apply soap; lather covering all areas of hands with soap
Firmly rub hands in circular motion, wash the palms and back of hands, each finger
and the area between fingers, the wrist, and the forearm
Wash at least 1 inch above the area of contamination or at least one inch above the
wrist if hands are not visibly soiled
Continue this friction motion for at least 15 seconds
If necessary, use fingernails of opposite hand or orange stick to clean under fingernails.
Rinse thoroughly with water flowing toward fingertips
Pat hands dry with paper towel, beginning with the fingers and moving upward to
toward the forearms. Use another clean paper towel to turn off faucet (Taylor et al.,
2011).
Techniques for Hand Hygiene Utilizing Alcohol-Based Products
To properly cleanse hands utilizing an alcohol based product, follow these steps
(Taylor et al., 2011).
Apply approximately 1–3 ml. of the product to the palm of one hand
Rub hands together covering all surfaces, including between fingers and under nails
Continue rubbing together until hands are completely dry
Many hospitals have adopted the practice of only using soap and water hand washing in the
presence of C. difficile. The CDC has not formally issued a recommendation on this practice.
(Taylor et al., 2011).
Personal Protective Equipment (PPE)
PPE is used to prevent the transmission of infection during patient care for all patients
regardless of known or unknown infectious status. Several types of PPE are:
Gloves
Gloves provide a protective barrier when contact with a potentially infected substance is
possible.
Change gloves as needed when providing care or performing different procedures for
the same patient.
Wear gloves for any care that may involve contact with patient’s blood, body fluids,
secretions, excretions, non-intact skin, and mucous membranes.
Wear gloves for all vascular access procedures such as finger sticks, changing IV dressings, removing IV lines, and administering IV push medication.
Wearing gloves does not replace the need for hand-washing. Gloves may have small
defects or may become torn during use.
Hands can become contaminated during removal of gloves. Remove gloves promptly
after use and wash hands immediately (Siegel et al., 2007).
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Masks, Eye Protection and/or a Face Shield
These are used to protect the mucous membranes of the eyes, nose, and mouth during
procedures and patient care activities that are likely to generate splashes or sprays of blood,
body fluids, secretions, or excretions (Taylor et al., 2011).
Gowns
Gowns should be worn to protect the skin and to prevent soiling of clothing during procedures
and patient-care activities that are likely to generate splashes or sprays of blood, body fluids,
secretions, and excretions.
The following nursing actions should be taken:
Select a gown that is appropriate for the activity and amount of fluid likely to be
encountered
Remove a soiled gown as promptly as possible
Wash hands to avoid transfer of microorganisms to other patients or environments
(Taylor et al., 2011)
Mouthpieces or other Ventilation Devices
Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouthmouth resuscitation methods (Taylor et al., 2011).
Contaminated Needles and Sharps
Contaminated needles and other contaminated sharps must not be bent,
recapped, or removed.
Place used syringes and needles, scalpel blades, or other sharps in designated puncture–resistant sharps containers (Taylor et al., 2011).
If a designated puncture-resistant sharps container is not readily available,
recapping of the needle may be performed using the one-handed scoop method.
The syringe and needle must be disposed of in a designated puncture-resistant sharps
container as soon as is feasibly possible.
Specimen Handling and Transport
Standard Precautions must be used to obtain, transport and handle all specimens and in
accordance with hospital policy (Taylor et al., 2011).
Contaminated Equipment
Use Personal Protective Equipment (PPE) to handle used equipment that is soiled with blood,
body fluids, secretions, and excretions to prevent:
Exposures to skin and mucous membrane
Contamination of clothing
Transfer of microorganisms to other patients and environments
Nursing actions will ensure that:
Reusable equipment is not used for the care of another patient until it has been appropriately cleaned and reprocessed.
Single-use items are properly discarded (Taylor et al., 2011).
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Infection Control Practices/Asepsis Practices
Contaminated Laundry
Contaminated laundry is placed in a bag and handled in a way that avoids
transfer of microorganisms to other patients, staff, and the environment.
Linen that is wet with blood or body secretions must be placed in a leak proof bag
(Taylor et al., 2011).
Blood/Body Fluid Spills
Always use gloves when cleaning up a blood/body fluid spill.
Follow the hospital’s policy on cleaning up a blood or body fluid spill
(Taylor et al., 2011).
Treatment of Exposure Incidents
Incidents that result in injury or contamination of a care provider must be reported and
treated immediately.
Follow the hospital’s protocols for treating and reporting these incidents.
Every facility is required to have a plan for documenting, tracking and treating these
occurrences (Siegel et al., 2007).
Transmission Based Precautions (Tier 2)
Transmission based precautions are used in addition to Standard Precautions for hospitalized
patients who are suspected to have an infection that can be transmitted by airborne, droplet,
or contact routes. These precautions can be utilized alone or in combination with the others.
Airborne Precautions
Airborne precautions are used for patients who have infections that are spread through the air,
such as tuberculosis, varicella (chicken pox), and measles.
Principles include:
The patient will be in a private room that has monitored negative pressure.
Anyone entering the room must always follow standard precautions and must wear a
fitted N95 respirator (Siegel et al., 2007).
Wear a N95 or higher respirator for potential exposure to infectious agents transmitted
via the airborne route.
N95 respirators/masks should not be shared, because they may become contaminated
with germs that can be spread between people (FDA, 2013).
All health care personnel that use N95 or higher respirators/masks are required to be fit
tested annually according to OSHA requirements (CDC, 2011).
N95 respirators/masks are devices that may help prevent the spread of viruses and bacteria
from one person to another. They are one part of an infection-control strategy that should also
include frequent hand washing and social distancing.
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All persons with signs and symptoms of a respiratory infection are instructed to:
Cover the mouth and nose with a tissue when coughing or sneezing
Dispose of the used tissue in the nearest waste receptacle
Perform hand hygiene after contact with respiratory secretions and contaminated
objects/materials (CDC, 2011)
Droplet Precautions
Droplet precautions are used for patients with an infection spread by large droplets such as
rubella, mumps, diphtheria, and adenovirus in infants and children. This involves contact of
the conjunctivae or the mucous membranes of the nose or mouth of a susceptible person with
large particle droplets containing microorganisms.
Droplets are usually generated through coughing, sneezing, or talking. The patient
should be in a private room.
All staff must wear a mask when working within three feet of the patient.
Masks are not necessary for health care workers transporting such patients as long as
the patient is wearing a mask (Taylor et al., 2011).
Health care personnel observe droplet precautions in addition to Standard Precautions,
when examining and caring for patients with signs and symptoms of a respiratory infection spread by airborne route.
These precautions are maintained until it is determined that the cause of the symptoms
is not an infectious agent that requires droplet or airborne precautions.
Health care personnel with a respiratory infection should avoid direct patient contact;
if this is not possible, a face mask should be worn while providing patient care.
Frequent hand hygiene should be reinforced. (CDC, 2011).
Contact Precautions
Contact precautions are used for patients who are infected with a microorganism that
spreads by direct or indirect contact such as Methicillin-resistant Staphylococcus aureus
(MRSA), Vancomycin-resistant Staphylococcus aureus (VRE) and Vancomycin-intermediate
Staphylococcus aureus (VISA) (Taylor et al., 2011). A new organism Carbapenem-resistant
Enterobacteriaceae (CRE) has been identified by the CDC as a growing problem in health care
facilities (CDC, 2012).
Direct contact involves skin to skin contact.
Indirect contact involves the host contaminating an inanimate object in the patient’s
environment.
The patient may be in a private room and gloves as well as a gown should be worn while
providing care (Taylor et al., 2011).
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Immunizations
Health care workers have the potential for exposure to patients and/or to infectious materials
including body substances, contaminated medical supplies and equipment, contaminated
environmental surfaces, or contaminated air (CDC, 2011). Due to patient contact of infective
material from patients, many health care personnel are at risk for exposure to (and possible
transmission of) vaccine-preventable diseases. Health care personnel must be up-to-date with
all recommended vaccinations, including an annual influenza vaccine (CDC, 2011).
The Immunization Action Coalition (2012) recommends that all health care workers be
immunized for:
Hepatitis B
Influenza
Measles/Mumps/Rubella (MMR)
Varicella
Tetanus
Diphtheria
Pertussis
Meningococcal Meningitis
Required immunizations for CPNE® are based on the CDC “Recommended Vaccines for
Healthcare Workers” which can be viewed on the CDC website at www.cdc.gov/vaccines
/adults/rec-vac/hcw.html
Summary
The best assurance for prevention of illness caused by blood borne pathogens is education
related to the mode of transmission, careful practice, the use of Standard Precautions and
adherence to the recommendations of the CDC regarding vaccination.
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References
Centers for Disease Control and Prevention (2012). CRE Toolkit—Guidance for control of
Carbapenem-resistant Enterobacteriaceae (CRE). Retrieved March 11, 2013 from: http://
www.cdc.gov/hai/organisms/cre/cre-toolkit/
Centers for Disease Control and Prevention (2011). Hand hygiene in healthcare settings.
Retrieved Feb. 27, 2013 from: http://www.cdc.gov/handhygiene/
Centers for Disease Control and Prevention (2011). Morbidity and mortality weekly report,
Immunization of health care personnel, from: Recommendations of the Advisory
Committee on Immunization practices. Retrieved Feb.27, 2013 from: http://www.cdc.gov/
mmwr/pdf/rr/rr6007.pdf
Centers for Disease Control and Prevention (2011). National Healthcare Safety Network
(NHSN Reports) Retrieved March 4, 2013 from: http://www.cdc.gov/nhsn/dataStat.html
Food and Drug Administration (2013). In medical devices, masks and N95
respirators. Retrieved March 4, 2013 from: http://www.fda.gov/MedicalDevices/
ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/
PersonalProtectiveEquipment/ucm055977.htm#1
Immunization Action Coalition (2012). Healthcare personnel vaccination recommendations.
Retrieved Feb. 27, 2013 from: http://www.immunize.org/catg.d/p2017.pdf
Kelly, K & Monson, J. (2012). Hospital acquired infections. Surgery Oxford,30.12.,640–644.
Retrieved March 1, 2013 from: http://dx.doi.org.vlib.excelsior.edu/10.1016/j.
mpsur.2012.10.005
Siegel, J., Rhinehart, E., Jackson., Chiarello, L. (2007). Guidelines for isolation precautions:
Preventingtransmission of infectious agents in healthcare settings. Retrieved March 4, 2013
from: http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
Taylor, C., Lillis, C., Lemone, P., & Lynn, P. (2011). Fundamentals of nursing, The art and
science of nursing Care 7th edition pp. 652–682. Philadelphia, PA: Lippincott, Williams &
Wilkins.
The Joint Commission (2013). New tool in the fight against health care–associated infections:
Compendium of strategies to prevent healthcare–associated infections in acute care
hospitals. Retrieved Feb. 28, 2013 from: http://www.jcrinc.com/New-Tool-in-the-FightAgainst-Health-Care-Associated-Infections/
November 2013
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