Part 1 of 3

The goal of Part 1 is to present modes of disease transmission and effective strategies for prevention and to inform nurses that failure to adhere to standards could lead to disciplinary action.

Part 1 in this series focuses on the first two of six elements that make up this required course work. These elements are 1) professional responsibility; 2) modes and mechanisms of transmission of pathogenic organisms; 3) engineering and work practice controls; 4) selection and use of barriers and/or personal protective equipment; 5) infection control principles and practices for cleaning, disinfection, and sterilization; and 6) prevention and control of infectious and communicable diseases in healthcare workers.

The Buck Stops Here

Let’s say that you work in a clinic. A patient calls with complaints of a rash. She mentions that her nephew had chicken pox two weeks ago. She arrives an hour later and makes herself comfortable in the waiting room with other patients. Are you guilty of “failure to anticipate a potentially infectious condition and take appropriate action”? Now, put yourself in the hospital setting. You take report on an ED transfer who has had night sweats and a cough. You walk into his room without a respirator mask. Is it just “oops,” or are you guilty of the same infraction? Consider a home care nurse who spills a urine specimen and wipes it up with a paper towel. Is this unprofessional conduct? According to the law, you bet it is.

As you can see, the potential for transmission of pathogens is present no matter where you practice nursing. Each of these examples was potentially avoidable had the nurses anticipated the possibility of a diagnosis, identified potential infectious conditions and chosen appropriate barrier devices, and used the safest work practices possible to protect themselves and their patients from infection. The NY State Health Code now places responsibility on the nurse to recognize the possibility of the spread of communicable disease and to take measures to prevent such spread.

To ensure public safety, NY State has passed legislation that requires nurses and other licensed healthcare workers to complete course work in infection control and barrier precautions. The intent of this legislation is to promote use of safe work practices and engineering controls to reduce the opportunity for patient and employee exposure.

In addition to this continuing education, nurses are responsible for monitoring the performance of all personnel, licensed or not, under their control regarding infection control techniques. Failure to adhere to these principles is considered unprofessional conduct and could subject the nurse to disciplinary action, revocation of license, and/or professional liability. The mechanism for reporting unprofessional conduct includes contacting the State Department of Health so that its staff can investigate complaints.

The NY State Education Department rules of the Board of Regents Section 29.2(a)(13) and Part 92 of Title 10 of the Official Compilation of Codes, Rules, and Regulations of New York clearly delineate unprofessional conduct in the area of infection control. Not only are there professional consequences, but also failure to adhere to infection control standards puts you and your patients at risk for adverse health outcomes. Read on to learn how to avoid these dire hazards.

A Chain of Events

An infectious disease cannot spread from one person to another unless there is an intact chain of transmission that includes 1) the infectious agent, 2) a reservoir, 3) an exit from the reservoir, 4) an environment conducive to transmission of the infectious agent, 5) an entry into a new host, and 6) a susceptible new host. You can prevent the spread of disease by breaking any link in the chain.

A chain of infection begins with the pathogen or infectious agent. Bacteria such as Staphylococcus aureus, viruses including herpes simplex, fungi like Candida albicans, and parasites such as Cryptosporidium are all potential culprits. The reservoir – or source of the infectious agent – is any person, animal, plant, or substance in which an infectious agent normally lives and multiplies. A reservoir can be inanimate. For example, Salmonella, a common cause of food poisoning, is found in improperly prepared egg products or poultry. In this case, the processed food is considered the inanimate reservoir.

A “common vehicle” is the term used to describe contaminated material that serves as a means by which an infectious agent can be transported. Take, for example, outdated, multidose containers of medication or diluent. These vials can get contaminated and become a breeding ground. Also, be wary that a person may actually be a carrier of an infectious agent and pass it along unknowingly.

Next in the chain of events come the portals of exit – sneezing, draining lesions, and blood and body fluids are all means by which a pathogen escapes. To infect another person, however, there must be a portal of entry: gastrointestinal (GI) tract, skin, placenta, genitourinary (GU) system, respiratory tract, mucous membranes, a percutaneous injury, invasive procedures, or vascular access, to name a few.

Pathogens can be transmitted by direct or indirect contact. Agents can be spread by droplet and become airborne, such as in the case of tuberculosis or measles. Transmission can even occur with the help of a vector. Such is the case when mosquitoes transmit malaria to humans. And last, the chain is complete when there is a susceptible host — a person lacking resistance to the offending agent.

Improving the Odds

Factors intrinsic to the susceptible host influence the outcome of exposure to pathogens. Advanced age at one end of the spectrum and prematurity at the other end can affect the competence of organ systems to resist infection. Chronic diseases also impair host defenses.

A number of natural barriers serve to protect the body from invasion by microorganisms. Intact skin, tears, cough and gag reflexes, respiratory cilia, and gastric acidity function as impediments to the influx of bacteria that would colonize or invade deeper tissues. Anesthesia, intubation, surgery, and medication often inhibit – at least briefly – these functions.

Once tissues have been infected, the inflammatory response and humoral and cell-mediated immunities are activated. Conditions such as renal failure, diabetes, and lymphocytic leukemia, as well as medical treatments (e.g., use of steroids, chemotherapy) can impair or suppress these functions.

Virulence of the microorganism can contribute to the morbidity of the susceptible host. Pathogens may secrete exotoxins that have a local or systemic impact. Strains of Pseudomonas that secrete an exotoxin can cause a rapidly progressive necrotizing pneumonia, while certain strains of Staphylococcus secrete a toxin responsible for toxic shock.

The size of inoculum (microorganisms or infectious material) may dictate whether infection occurs. Although a small number of influenza virions or tuberculosis bacilli are sufficient to produce disease in the susceptible host, often a large inoculum is more likely than a small one to produce illness. A classic example is Salmonella, which is unlikely to produce infection when ingested by a healthy host unless many thousands of organisms are present. Similarly, a small inoculum of blood on mucous membranes or broken skin is less likely to result in transmission of an organism like HIV than is a large inoculum. The duration of contact between pathogenic organism and its portal of entry also correlates with the likelihood of subsequent infection. For this reason, contaminated skin and mucous membranes should be promptly washed free of inoculum.

The route of exposure can make a difference in the likelihood of infection or the nature of that infection depending on the pathogen. Deposition of Klebsiella in a surgical wound could result in a wound infection, although ingestion of large numbers of the same organism would not be expected to produce disease. Ingestion of Staphylococcus that had multiplied in improperly stored potato salad might result in gastroenteritis, while growth of the same pathogen in nasal packing could result in toxic shock syndrome.

The Weakest Link

A chain is only as strong as its weakest link. With that in mind, winning the battle means breaking a link in the chain of transmission. Here are some ways that you can dismantle the sequence. Begin by controlling reservoirs.

• Recognize potential reservoirs to minimize later problems. Take, for instance, a ward clerk who has never had varicella. If she develops a febrile illness as her friend's children are recovering from chicken pox, encourage her to stay home until the nature of her illness becomes clear.
• Eliminate pathogenic hazards in the clinical setting. Toss out outdated containers of skin cleansers, disinfectants, and diluents. These may have become contaminated and represent a potential risk to patients and healthcare workers using them.
• Control the route of transmission by becoming familiar with how and when common communicable illnesses present clinically. Keep your index of suspicion keen. And rely on diagnostic measures to determine whether additional steps such as isolation and/or therapeutic intervention are required.
• Be wary about the environment. Dirty storage areas may contaminate supplies, and infectious secretions can contaminate surroundings. Remember that some pathogens survive in dried secretions long enough to infect others coming into contact with them. Carpets might be appropriate in adult waiting and consultative areas where soiling with secretions is improbable. A pediatric waiting area, on the other hand, deserves a more impermeable surface that can be sanitized more effectively. While bookshelves in the secretarial area should be dusted regularly, shelves with patient care materials should be enclosed and regularly cleaned with appropriate detergents.

Next, consider strategies that will interrupt the route of transmission. Generally, this takes the consistent use of simple procedures. Handwashing before and after patient contact is essential. Appropriate use of barriers can also minimize the risk of contamination.

The level of sterilization or disinfection of patient care equipment is generally determined by whether the device comes into contact with intact skin, mucous membranes, or sterile body areas. However, proper management of the patient care environment is trickier and depends on the RN’s ability to anticipate potential pitfalls. Consider the case of a patient on the medical unit with a positive blood culture. The astute nurse performs a prompt initial evaluation, and patient triage will lead to rational patient flow, isolation precautions, or cohorting when necessary. In some situations, transfer of patients is called for.

When it comes to the environment, nurses may have to direct other departments, including housekeeping and engineering, to be sure windows, air conditioners, and air vents are cleaned on a regular basis. Waste management is vital as well. Just as appropriate patient flow is important, the flow of used, potentially contaminated materials and equipment is paramount. Disposable sharp instruments must be placed in puncture-resistant, point-of-use containers. Disposable materials that have been in contact with patients, but which are not visibly contaminated with blood or body substances, should be placed in a covered container lined with an impermeable plastic bag. Visibly soiled material must be discarded in containers dedicated for regulated medical waste and later disposed of in the approved fashion.

Contaminated reusable equipment must be taken to a “dirty” utility area to be washed and disinfected or sterilized. Instruments, especially those contaminated with blood or body substances, should be transported from the point of use to the dirty utility area in a covered container. Clean instruments, equipment, linens, and disposable supplies must not be stored in the dirty utility area, and personnel leaving the dirty utility area must wash their hands. Handwashing must be done in sinks separate and distinct from the sinks used in the reprocessing of contaminated equipment. Dirty linen should always be held away from your uniform so that it does not contaminate clothing. And linen/laundry bins must be located for easy access.

Since transmission can only take place when the host is susceptible, vaccination and pre- and postexposure prophylaxis are imperative. Patient or healthcare workers can be made nonsusceptible to certain communicable diseases through immunization. Immunity to rubella and rubeola is required of healthcare workers. Immunization to hepatitis B is strongly recommended, especially for those having regular exposure to blood and tissue. Postexposure prophylaxis should take place immediately should a needlestick occur.

Put the Lid on Transmission

The saying “An ounce of prevention is worth a pound of cure” deserves amplification when it comes to infection control. Handwashing and isolation precaution strategies are mainstays in preventing cross-infection and protecting both patients and healthcare workers; it is the single most important precaution for preventing the spread of infection.

In 2002 the Centers for Disease Control and Prevention (CDC) issued new guidelines for handwashing (Guidelines for Hand Hygiene in Health-Care Settings) which were developed to improve handwashing practices and reduce transmission of pathogenic microorganisms to patients and healthcare personnel.¹ Below is a summary of the routine handwashing and hand antisepsis recommended by the CDC. Surgical hand antisepsis related to operative procedures is not included but is discussed in the guidelines.

Hand washing with either a non-antimicrobial or antimicrobial soap is recommended:

• When hands are visibly dirty or contaminated with proteinaceous material or blood
• Before eating and after using the rest room
• If there is suspected or proven exposure to bacillus anthracis

Hand decontamination using an alcohol-based hand rub is recommended:

• If hands are not visibly soiled
• Before having direct contact with patients
• Before donning sterile gloves for the purpose of inserting an invasive device that doesn’t require a surgical procedure such as inserting a central or peripheral intravascular catheter or indwelling urinary catheter
• After contact with a patient’s intact skin such as following pulse check
• After contact with body fluids, excretions, mucous membranes, nonintact skin and wound dressings if hands are not visibly soiled
• If moving from a contaminated body site to a clean body site during patient care
• After contact with an inanimate object such as medical equipment that is near the patient

Antimicrobial impregnated wipes such as towelettes may be an alternative to handwashing with a non-antimicrobial soap; however, they are not a substitute for alcohol-based rubs or handwashing with an antimicrobial soap.¹ There is strong evidence that artificial nails and jewelry such as rings harbor bacteria and fungi, but whether they cause a greater transmission of pathogens or contribute to healthcare-associated infections is unknown and an area for further research.¹

Effective handwashing technique requires vigorous rubbing of all surfaces of the hands and fingers against each other with water and a cleanser for a period of 15 seconds, followed by thorough rinsing and drying with a disposable towel.¹ Hot water should be avoided because it increases the risk for dermatitis which facilitates pathogen invasion, and multiple-cloth towels for hand drying are not recommended for use in a healthcare setting.¹ Liquid, bar, leaflet or powdered forms of soap are acceptable for handwashing with a non-antimicrobial soap and water¹, however bar soap is susceptible to harboring bacteria. If it is used the bar should be small and a soap rack used to facilitate drainage and drying.¹

To effectively decontaminate hands with an alcohol-based rub it’s recommended that personnel apply the product to the palm of one hand and rub hands together, covering all surfaces of the hands and fingers until the hands are dry.¹

Isolating the Problem

Isolation precautions refer to the procedures that are used in dealing with all patients to prevent inadvertent transmission of microorganisms from patient to caregiver, caregiver to patient, and patient to patient. Current guidelines provide for two tiers of precautions. The first is called Standard Precautions and is the primary strategy for nosocomial infection prevention. The second tier is called Transmission-based Precautions and is an approach directed at interrupting transmission of epidemiologically important pathogens when a specific infective entity is suspected or identified and where additional precautions beyond Standard Precautions are needed.

Standard Precautions are an example of an interactive approach that is applied routinely to all patients. Nothing has to be known about the source patient because the same measures of barrier protection to prevent soiling of skin and mucous membranes are applied equally to all. Barriers appropriate to the activity, such as gloves, protective eye wear, and impermeable gowns, should be used to prevent any and all contact between skin and mucous membranes and blood. Thus, Standard Precautions embody the principles of Universal and Body Substance Precautions, which have been used until recently. Generally, contact with tears and sweat does not require barrier protection.

Transmission-Based Precautions are designed for patients documented or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed. There are three types of Transmission-based Precautions:

Airborne, where highly contagious pathogens may be present and can be spread by airborne droplet nuclei that remain suspended in and can be widely dispersed by air currents over considerable distances. Patients must be placed in a monitored negative pressure room that provides six to 12 air changes per hour. Susceptible individuals should not enter the room if other immune caregivers are available and must use respiratory protection if entry is unavoidable.

Droplet, where pathogens are transmitted by droplets generated by coughing, sneezing, and talking. These droplets settle out of the air quickly and propagate no more than two or three feet from the source patient. Segregation from others is desirable but less critical than with airborne precautions. Masks are necessary only when working within three feet of the patient. Special ventilation is not necessary.

Contact, for patients known or thought to be infected or colonized with epidemiologically important microorganisms that can be transmitted by direct or indirect contact. Examples include herpes simplex, scabies, and Clostridium difficile. Wear gloves for contact with patients and immediate surroundings (gloves do not have to be sterile unless a specific procedure requires sterility). Wear a gown if your clothing will have substantial contact with the patient.

Gloves are always discarded as the wearer leaves the patient environment, and hands need to be washed immediately. Similarly, gowns should be discarded in appropriate receptacles.

Part 2 of 3

The goal of Part 2 is to understand the hierarchy and application of preventive strategies, including engineering controls, work practice controls, barriers, and personal protective equipment.

Risky Business

Just walk into a hospital and you become a potential target. Virtually anyone who works in a healthcare setting is at risk for exposure to pathogens. You don’t have to be a physician to be at risk during surgery. Similarly, you need not be an RN to come in contact with infectious material. Direct providers, assistants, ancillary personnel, and patients are all in a potentially perilous situation. And let’s not forget the volunteers and medical and nursing students who are also surrounded by these hazards.

When we left off in Part 1 of this series, our focus was professional responsibility pertaining to infection control and modes and mechanics of disease transmission. Now we’ll consider the interaction between properly designed equipment, devices, and instruments that remove or isolate hazards (engineering controls) and procedures designed to reduce or eliminate exposure to infection (work practice controls).

These concepts have evolved primarily for control of exposure to bloodborne pathogens, such as hepatitis B and HIV, where exposure is percutaneous and mucous membrane/nonintact skin; and to tuberculosis (TB) where transmission occurs via the respiratory tract (airborne). Percutaneous exposure is the result of injury through the skin, while mucous membrane/nonintact skin exposure comes in the form of direct contact or splashes/sprays with blood or body fluid. Parenteral exposure may occur with injection of infectious material, infusion of contaminated blood products, and transplantation of contaminated tissues or organs.

Don’t Get Stuck

Certainly there are situations that place healthcare workers at greater risk of exposure to potentially infectious materials. Take, for example, percutaneous injury. This type of exposure is most likely to occur during the use of sharps, especially when work practices fail to address obvious risk: any use of exposed needles, recapping used needles, manipulation of used needles or other sharps by hand, removal of scalpel blades, blind suturing, use of fingers and hands in the vicinity of or to oppose a suture needle, passing of needles or sharps from one to another, failing to account for sharps used in a procedure, and disposal of used sharps. Blind manual exploration of body sites containing bone, tooth, or metal fragments is similarly hazardous.

We can all appreciate the gravity of risk when injuries occur in an operative site, both to the patient and the healthcare worker. But it’s not only in the operating room where we need to concern ourselves with percutaneous injury. Consider, also, that sharps lost or left unaccounted for during a procedure are a serious risk for anyone in the vicinity, even hours later. And no one would take lightly getting stuck because a sharp instrument was left concealed in a dressing or drape. Personnel at all levels are at risk when a needle or scalpel blade has been disposed of improperly with other trash.

Engineering Controls

Sharps-related injuries can be reduced or eliminated through a combination of engineering controls that will eliminate or isolate the hazard. While the best option is to avoid the use of needles altogether, consider a needleless delivery system for IV administration of medication, fluids, and nutrition. With such a system, withdrawal of blood specimens and piggybacks can be achieved using blunt connectors instead of needles.

Where the use of needles is necessary, continuously shield the needle from accidental contact or cover the needle immediately after use. As for disassembly of sharps, such as scalpels, follow a protocol where a clamp or other device secures the blade so that it can’t slip and cause a cut.

Equipment that can cause splattering, such as centrifuges, should be designed with covered, sealable blood-tube carriers and locking lids. Biological safety hoods should be available and used for the transfer of potentially contaminated material, such as blood specimens. Puncture-resistant containers that seal closed must be used for transfer of such specimens.

Work Practice Controls

When you alter the manner in which a task is performed to eliminate the likelihood of exposure, you are using a work practice control. Such is the case with recapping needles. Although recapping of needles is strongly discouraged, there are settings where it is done. Here, use a one-handed “scoop” technique – insert the needle into the cap while it rests in a cup, in a test-tube rack, or on a stable surface. This procedure eliminates a two-handed recapping situation, which poses a substantial risk of injury from the needle puncturing the hand holding the cap.

As for suturing, be on your guard. Suturing must not be done against an opposing finger, and techniques must be designed to minimize blind suturing where the operator or assistant’s hand may be in the vicinity of the needle. Similarly, passage of sharps from one to another requires the use of a designated safe zone so that accidental punctures don’t occur.

There will be instances where sharp objects cannot be shielded. Take, for example, the exploration of wounds containing bone, tooth, or metal fragments. Work practice controls include using instruments or special protective gloves – not fingers.

While some of these strategies seem to “go without saying,” they are worth reiterating. Always use care in the handling and disposal of needles and other sharp objects. And remember that small modifications in procedure will reduce risk – using forceps, suture holders, or other instruments for suturing; not holding tissue with fingers; and never leaving sharps on a field are but a few examples.

The Dreaded Splash

The risk of blood or body fluid splashes to mucous membranes or bare skin may occur during any surgical or invasive procedure, such as vascular access, intubation, or suctioning of the pulmonary tree. Wound care also carries a risk of exposure. Similarly, cleaning contaminated work surfaces, equipment, and instruments poses risk for skin or mucous membrane exposure and percutaneous injury.

Routine use of appropriate protective clothing, including gloves, gowns and face shields, is mandatory. Technicians and other ancillary personnel who are involved in maintaining and cleaning equipment and work surfaces are also at risk of exposure from environmental contamination.

Prompt cleanup of spills using a deliberate protocol to suppress splashing and spread of the contaminating material, disinfection of the spill with fresh sodium hypochlorite solution, and removal of the spilled material will minimize the potential exposure to others.

The Air Up There

Airborne transmission poses unique challenges. The use of both engineering and work practice controls for prevention of airborne exposure has evolved to the greatest degree for TB, where the risks increase with inadequate ventilation, prolonged stays in the immediate vicinity of the source patient, inability to control aerosol production from the source patient, and failure to identify cases.

Hospital patient care areas where susceptible patients are seen, whether recognized or not, should have adequate ventilation. Patients known to have infectious respiratory secretions must be placed in negative pressure rooms where there are six or more air exchanges per hour. Ultraviolet lighting designed for these areas may also reduce the number of infectious airborne droplet nuclei. Another alternative, typically used only temporarily, is a demistifier tent where negative pressure within the tent is maintained and the air exchanges are achieved through a HEPA-filtered fan.

When considering the home, office, or clinic environment, instruct patients to cover their mouths with fresh disposable tissues when coughing or sneezing to reduce dispersal of infectious material. The rapid identification of potentially infectious individuals through triage and physical separation of them from other patients and staff will reduce the communicable potential of these patients.

Shielding Yourself and Your Patients

In order to defend yourself against potentially infectious material, you’ll need a variety of barriers and personal protective equipment (PPE). A barrier is a material object designed to physically separate the user from a hazard. PPE is specialized clothing or equipment designed to protect the wearer from a hazard, either toxic or infectious.

PPEs and barriers typically include gloves; protective clothing, such as gowns, aprons and laboratory coats; masks, face shields, and eye protectors; shoe and head covers; and specialized surgical skin coverings and wound dressings.

Before you choose what you’ll need, you must first anticipate the risk. In each situation, ask yourself whether there could be blood or body fluid splash, contact with minimal bleeding or drainage, contact with major bleeding or drainage, or exposure to respiratory droplets. Choosing what to wear is based on your assessment.

Let’s start with gloves. Standard Precautions dictate the use of gloves whenever contact with blood or body fluids is anticipated. Use them whenever touching or examining moist areas of the body, especially wounds and areas of skin that are weeping or draining. Typically, gloves for patient examination are made from latex rubber or vinyl. If either the wearer or the patient is allergic to latex rubber, vinyl gloves should be used.

Sterile gloves must be worn for invasive procedures. In addition to protecting the healthcare worker, gloves are used to prevent drainage or contamination from personnel to patient. Thick utility gloves are called for in the case of environmental cleanup or decontamination procedures. While the wearer won’t have exceptional tactile sensation with these, they are less likely to be punctured or torn than latex or vinyl varieties.

Next, consider whether a gown is necessary. Gowns, aprons, and lab coats offer protection from contamination of skin and clothing by secretions and splattered blood or body fluids. Permeable cloth coats and gowns are suitable for patient contact or laboratory procedures where contamination will probably be light and penetration of the garment by contaminated fluids is unlikely. Fluid-resistant gowns or aprons offer a greater degree of protection if soiling is likely to be heavier. If heavy soiling should occur, the wearer must be able to promptly remove the soiled garment before penetration by contaminated fluid occurs. Impervious gowns and aprons tend to be heavier and more uncomfortable, but offer secure protection from heavy soiling by contaminated fluids as could occur during bloody surgical procedures or autopsies.

Then we have masks. Surgical masks protect the wearer from liquid droplets and fluid splatters. They are typically used during surgery, invasive procedures, intubation, and bronchoscopy for the safety of both patient and healthcare worker.

For protection from very small (< 5 micron) airborne droplet nuclei that can pass through or around most masks, specifically with patients having or suspected of having pulmonary TB, particulate respirators complying with Occupational Safety and Health Regulations are required. These are tight-fitting masks that do not permit the flow of air around the mask during inhalation and are fitted with HEPA filters capable of removing 0.3 micron particulate matter from the inspired air with 95% efficiency. This type of mask is required when working with patients with TB, changing demistifier tent filters, performing diagnostic sputum inductions or bronchoscopy, or administering some aerosolized medications. Users of these masks must be trained in their fit and use, and their training must be documented.

Face shields, including safety glasses or goggles, will protect the mucous membranes of the eyes, nose, and mouth of the user from splattering of blood or contaminated fluids. Use these during any drilling or other procedure where spraying or splattering of contaminated fluids is possible.

Head covers serve a dual role of protecting your head from sprayed or splattered fluids and also protecting the patient from desquamated cells and hair from the wearer. They are commonly used under the same circumstances as surgical masks.

Shoe covers and other drapes and covering materials for equipment and environmental surfaces protect these items from contamination resulting from spills and splatters of contaminated material, simplifying subsequent decontamination and cleaning.

Special sterile skin and wound coverings or dressings may be applied in the context of surgery to prevent contamination of an adjacent fresh surgical incision or to protect a fresh surgical wound from environmental contamination during the early postoperative hours.

The Choice Is Yours

The use of barriers should safeguard the health of both the healthcare worker and the patient in all settings. To optimally do so, PPE must fit the user properly and be functionally intact. Intactness is ensured by regular inspection to check for holes or puncture sites (gloves, impermeable aprons, or gowns), by not exceeding the device’s useful life (mask not saturated with moisture), and by not attempting to clean or sanitize a single-use implement (latex gloves).

Barriers can and do become contaminated during normal use. They can cause contamination when the wearer subsequently handles unrelated environmental objects (telephones, charts, another patient’s environment), and thus must be removed immediately after the user completes the procedure for which they were worn.

Overuse of barriers and PPE can cause the patient to feel emotionally isolated and healthcare workers to feel inappropriately secure. It also sharply raises the cost of patient care. The indications for PPE and barriers are quite specific. Their use is subject to the same rational patient care principals as any other medical tool.

Part 3 of 3

The goal of Part 3 is to understand how to maintain a safe environment through disinfection and sterilization techniques and to prevent the spread of infectious and communicable diseases.

Congratulations. You’ve made your way through the first two parts of this series. Get ready to see how to create a safe environment for yourself and your patients. But first you’ll need some basic terminology. Cleaning is the removal of foreign material from objects. Decontamination is the process of removing disease-producing microorganisms, rendering objects safe for handling. Disinfection results in the elimination of many pathogenic microorganisms with the exception of bacterial endospores. And sterilization completely destroys all forms of microbial life.

Watchful Is as Watchful Does

Ugh. Who really wants to handle contaminated equipment? After all, materials that have come into direct contact with pathogens can result in outbreaks of infection. These outbreaks can occur as a result of inadequate cleaning, disinfection, or sterilization. The reuse of disposable items has been the culprit in some cases, while failure to reprocess equipment between patients is another serious transgression. But contaminated objects can sometimes slip right past us. Take, for example, unsuspected growth of bacteria in disinfecting solutions, in water supply systems for hemodialysis equipment, in detergent holding tanks for automated endoscope cleaning systems, and in reusable bars of soap.

We must be vigilant in looking for factors that contribute to these slip-ups. Consider the impact of overpacking instrument trays that need to be sterilized or overloading sterilizers that then fail to reach the right temperature or achieve adequate sterilization time.

Let’s consider some of the basics. As the name implies, single-use materials must be disposed of promptly after one use. If they are soiled or have come in direct contact with a contaminated area or if they are considered sharps (whether contaminated or not), they become regulated medical waste and must be placed in an appropriate bag or container labeled "biohazard" and disposed of properly.

Conversely, reusable devices are not tossed. They do need specific handling once contaminated, though. Instruments must be placed in covered containers for transport to a dirty utility area for processing. Once there, you may be accustomed to presoaking some of these items. Keep in mind that while presoaking in sanitizing solution may assist in the subsequent cleaning process, it may cause corrosion to delicate devices.

Thorough internal and external cleaning of instruments and devices having direct contact with patient tissues is the critical first step in the processing of reusable devices. The majority of contaminating microorganisms are mechanically removed during this step. In fact, the detergent itself kills many organisms. Don’t let your guard down yet, though. Inadequate cleaning may impair the utility of the device and will definitely impair the effectiveness of most subsequent disinfecting procedures.

To Sterilize or Not to Sterilize

As with virtually all decisions we make daily, start with an assessment. Think first about the level of antimicrobial activity needed. Floors and walls need just a low-level disinfection, which can be accomplished with an ammonia/detergent combination. When it comes to sterilizing operative instruments, high-level sterilization is required.

Devices that are likely to come into contact with normally sterile body sites must be sterilized with moist heat (steam) or chemicals (ethylene oxide, hydrogen peroxide). Typically, these methods use chemical or biological indicators to determine whether all microorganisms and spores have been killed.

Instruments used to invade nonsterile body sites (upper respiratory tract, upper and lower GI tracts) or that come in contact with mucous membrane or nonintact skin must undergo high-level disinfection after thorough cleaning, if they cannot be sterilized (sterilization may cause damage to optics or significantly shorten the device’s life span). This process is expected to kill virtually all organisms with the possible exception of bacterial or fungal spores. When it comes to which disinfection agent to choose, the processing temperature, and the soaking time, follow the manufacturer’s recommendations. Of course, freshness of the disinfecting solutions and cleanliness of containers and support equipment are vital to avoid cross-infection and contamination.

When devices come in contact with intact skin, they need to be cleaned with a detergent/antimicrobial solution capable of killing vegetative bacteria, pseudomonas, and viruses, including hepatitis B. Here you can choose solutions of aldehydes, phenolics, or halogens combined with detergent. Again, follow any and all manufacturer’s recommendations, which will minimize corrosion or other damage to materials in the device.

Some equipment manufacturers recommend automated disinfection of some products, such as endoscopes. This technique offers the advantage of consistency and relatively unattended processing and minimizes the need for personnel expertise and time. However, quality control issues arise, such as detecting outdated or contaminated disinfecting solutions, maintaining machinery, and ensuring that items have been disinfected as represented.

Keeping Clean Items Clean

Now your equipment is disinfected. What next? These items must be covered or wrapped and stored in a clean, dry place with the date of reprocessing clearly marked. Look for your written policy that determines rotation of stock, acceptable shelf life, and events that would invalidate the disinfection, such as disruption of or water damage to the wrapping. Prepackaged sterile items should be dealt with in the same way. Periodic culturing of disinfected devices should be done to ensure that the process has been effective and that contamination has not occurred.

All medical and surgical procedures deserve periodic evaluation from the infection control standpoint. You’ve got to ask some questions. Consider the efficacy and appropriateness of disposal of single-use devices and materials. Find out whether reusable devices like blood pressure cuffs, electronic thermometers, and stethoscopes are being reprocessed appropriately. Are environmental surfaces such as examination tables covered and cleaned consistently? Look for ways that cross-contamination could occur.

If disposable equipment or devices are being reused, will reprocessing effectively disinfect without impairing function or reliability? Departure from the manufacturer’s recommendations is not prohibited. However, a protocol must exist governing how preservation of function and verification of disinfection will be monitored. Satisfactory adherence to the protocol is demonstrated via the use of a logbook. Generally speaking, this type of departure from manufacturer’s recommendations is costly and carries a risk of liability.

Caring for the Caregiver

In order to protect healthcare workers from communicable diseases, we have to employ occupational health strategies. As applied to infection control, these are a set of activities intended to assess, prevent, and control transmission. To do so, we rely on pre-employment and periodic health assessments to reveal the presence of infective illness.

Through serologic screening and immunization programs, healthcare workers susceptible to or infected with rubella, rubeola, varicella, hepatitis B, TB, and influenza are identified. Remember that NY State law requires that healthcare workers be immune to rubella and rubeola. This is not true of varicella, hepatitis B, or influenza. But susceptibility to these illnesses has implications with respect to the type of patients that can be assigned to these healthcare workers. Currently, immunization against hepatitis B is strongly recommended, although not mandated. However, the employer must make hepatitis B vaccine available to healthcare workers at no cost. Immunization of personnel with influenza vaccine, while voluntary, appears to provide some protection to patients with respect to influenza infection.

Calling In Sick

Everyone gets sick now and then, and nurses are no exception. In the best interests of everyone, personnel need to be evaluated when they have symptoms of communicable disease, including fever, cough with or without sputum production, exanthemas, vesicles, skin lesions, weeping dermatitis, draining wounds or sores, or diarrhea. Healthcare workers with certain reportable diseases, such as amebiasis, are not permitted to work, despite familiarity with universal precautions and disease-specific precautions, until shown to be free of the infecting organism.

Inevitably, there will be times when personnel are exposed to communicable disease — in or out of the workplace. Following a documented exposure of susceptible healthcare workers to TB, varicella, rubella, rubeola, pertussis, or mumps, an evaluation must be done. Look for sero- or skin test conversion and the development of clinical manifestations of infection and document results. Unless immunity can be demonstrated, exposed workers should not have contact with susceptible patients or coworkers once the disease-specific latent period has elapsed. It may become necessary for the employee to take a furlough until it is clear that he or she is noninfectious. Intervention with vaccination or immune globulin, if possible, is appropriate but not required. Prophylactic use of antibiotics following exposure to meningococcal meningitis, for example, should be described in the personnel policy.

As for TB, the so-called Tine test is not considered to be reliable enough and is not recommended for workplace screening. Surveillance for TB exposure is achieved by the periodic intradermal inoculation of 5 units PPD (Mantoux test). The frequency of screening in a health care facility should be based on:

• The profile of TB in the community
• The number of patients with infectious TB to whom the healthcare workers in an area or occupational group may be exposed
• Previous documentation of person-to-person transmission of M. tuberculosis and healthcare workers’ skin test conversions (if any)

Healthcare workers who are potentially at high risk for exposure to TB should be tested every six months; others may be tested annually.²

Generally, ad hoc testing in response to a perceived TB exposure should be avoided and a regular semiannual schedule maintained. Occasionally, infection control or department of health representatives will recommend otherwise when a highly communicable infection is detected. Conversion of skin-test status to TB is relevant for documentation of exposure, initiation of chemoprophylaxis, and surveillance for clinical infection. Diagnosis, and in some instances, merely strong suspicion of a reportable disease (tuberculosis) obligate the treating physician to report the case to the New York State Department of Health for follow-up.

After a Needlestick

The risk to healthcare workers of infection with HIV and hepatitis B and C is explicitly addressed in Occupational Safety and Health Administration and NY State Department of Health regulations. Prevention of hepatitis B is encouraged through serologic testing for susceptibility and use of recombinant hepatitis B vaccine. This vaccine is made by recombinant-DNA technology and is a safe, highly effective vaccine that protects millions of adults and children worldwide. It should be used selectively in susceptible personnel and may be used in concert with hepatitis B hyperimmune globulin prophylactically following parenteral exposure.

Report all needlestick injuries and parenteral exposures to the employer immediately. The injured employee is advised to submit to baseline testing for hepatitis B, hepatitis C, and HIV antibodies. While the source patient is under no obligation, the patient’s physician can request testing of the source patient for these antibodies. The patient must agree with explicit informed consent for HIV antibody testing before that person can be tested.

Guarantee confidentiality to both the patient and healthcare worker with respect to the results of such testing. Additionally, the employee should be advised of the availability of prophylaxis for HIV infection. At present, the Centers for Disease Control and Prevention recommend post-exposure chemoprophylaxis with medications, including protease inhibitors. Exposure to fluids, such as urine, sweat, or saliva, unless visibly contaminated with blood, does not warrant prophylaxis.

In recommending chemoprophylaxis, the degree of risk for contracting an HIV infection should be assessed. The highest risk results from a deeply penetrating puncture wound or laceration where blood from the source patient is deposited in tissues, or the sharp causing the injury is visibly bloody with source patient blood. When the sharp is not visibly soiled with blood, there is an intermediate degree of risk. Contamination of mucous membranes with blood and extended contact of skin with blood from a source patient also pose an intermediate risk of infection. Low risk is involved when there is a superficial injury with little likelihood that the source patient’s blood has contaminated tissues.

When the Employee Is the Source

When a healthcare worker exposes a patient to a bloodborne pathogen, serologic testing (or other testing method such as polymerase chain reaction (PCR) provided a suitable level of reliability can be demonstrated) should be requested of both the worker and patient, with necessary consents, pre- and posttest counseling, and safeguarding of confidentiality. Ethics dictate that patients be advised when exposed to a bloodborne pathogen from a healthcare worker. That patient is entitled to know the nature of the exposure and should have the reason for the exposure explained. Make arrangements for ongoing surveillance of the patient and healthcare worker and for therapeutic intervention if infection is documented. The identity of the source healthcare worker and that person’s serologic status to hepatitis B and C and HIV may not be disclosed without that person’s consent.

Like patients, healthcare workers must consent in writing before HIV antibody testing can be performed, and they may refuse. The results of such testing must be confidential and may not be the basis for a job action, such as termination, demotion, or even promotion. However, the nature of that person’s practice with respect to invasive procedures, the technique for performing them, and the perceived risk to patients may be evaluated in the context of that person’s serologic and health status. Compliance with infection control standards is expected.

The presence of weeping dermatitis or skin lesions that may increase the risk of cross-contamination should influence binding recommendations affecting invasive procedures permitted that worker. Similarly, the worker’s overall health status, immunological well-being and cognitive function affect what duties that person is permitted to perform. Healthcare institutions should assemble an expert panel to evaluate healthcare workers infected with bloodborne pathogens and make binding recommendations with respect to continued ability to work in their usual capacity. Consistent with federal disability statutes, any recommendation should seek to impose the least restrictive alternative. The healthcare worker may seek a second opinion from the department of health. An employer without resource should consult with the department of health with respect to an infected or ill employee.