Universal Precautions

righteouschangeDéveloppement de logiciels

14 déc. 2013 (il y a 3 années et 10 mois)

106 vue(s)

A Health Professions Module

Dr.
Ignaz

Semmelweis, a Hungarian physician, delivered babies
in the Vienna General Hospital.


Nearly 20% of the mothers under the doctors’ care in that ward
died following childbirth.


Dr. Semmelweis instituted a practice which reduced that
mortality rate to 1.3%.


You take this practice for granted now, but the medical
community dismissed his results.
What practice do you think
Dr. Semmelweis attempted to introduce to medicine?

Hand washing!

Dr. Semmelweis made his discovery in
1847. At that time there was no germ
theory to support his findings. Despite a
lifetime of attempting to promote
simple hand washing, his notion was
rejected & ridiculed.


Not living to see his work appreciated,
Dr. Semmelweis eventually had a
nervous breakdown & died in an insane
asylum.

There are no other illustrations in
this presentation, so enjoy this one
retrieved on 12/01/09 from
http://clendening.kumc.edu/dc/pc/s
emmelweis01.jpg
.

Procedures for this module & objectives

This section covers
:



Your task to complete this requirement


Student objectives for module

Your task is fairly simple:



Read through this presentation


Take the automated quiz on this same D2L site.


Present proof of passing the quiz (80% or better)
to your department chair.


Note that throughout the presentation there are
Read More
notations in green
which allow you to click a link for additional online information.


You may come upon medical terms that are unfamiliar to you. Please consult an
online or hard copy medical dictionary for clarification.

At the conclusion of this module, you should be able to:



List some of the most high profile healthcare
-
associated infections (HAI).


Identify the means by which communicable diseases are transmitted.


Describe the role of the CDC & OSHA in the prevention of HAI transmission.


State the purpose of “universal” or “standard precautions.”


List some worksite procedures relevant to exposure control.


Identify the components of universal/standard precautions including:


TB tests & immunizations for yourself


Hand hygiene


Use of protective barriers


Proper disposal of “sharps” (any device used to puncture or cut, such as needles &
scapels
)


Identify when Transmission
-
Based Precautions apply


Locate a source of precautions for specific conditions





Putting the term in context

This section covers
:



Prevalence of healthcare
-
associated infections (HAI)


Other terms for HAI


Examples of HAI


Transmission of HAI


Government agencies & their roles in minimizing transmission of HAI


CDC & recommended practices


OSHA & regulation of practices


Terminology review of this section


The Centers for Disease Control and Prevention (CDC) provides
a vast amount of information concerning Healthcare
-
Associated Infections.
(
http://www.cdc.gov/ncidod/dhqp/hai.html
)
The CDC estimates these account for 1.7 million infections &
99,000 associated deaths each year in American hospitals.
Of these infections:



32% are urinary tract infections


22% are surgical site infections


15% are lung infections (pneumonia)


14% are bloodstream infections

What would a medical term be without a Greek
derivation?
Healthcare
-
Associated Infections (HAI)
are also known as
Hospital
-
Acquired Infections

and
as
Nosocomial Infections
(from the Greek words for
disease

&
to take care of
).


Those in the profession will know what you’re talking
about no matter which term you use, but if you
need to sound impressive,
nosocomial

wins hands
down. Those should be washed hands.


Bloodborne pathogens (including HIV/AIDS,
Hepatitis B & C)


MRSA (Methicillin
-
Resistant
Staphylococcus Aureus
)


Pneumonia


Influenza


Norovirus


Varicella (chickenpox), mumps,
Clostridium difficile
(C. diff)
, TB, & a host of others.

If you would like to see a more complete list, visit the
CDC at
http://www.cdc.gov/ncidod/dhqp/id.html
.


Much of the driving force for the recommendations &
regulations regarding HAI has stemmed from
concern over these three diseases (though they
certainly aren’t the only infections with the
potential to circulate in healthcare settings):



HIV/AIDS


Hepatitis B virus (HBV)


Hepatitis C virus (HCV)

Communicable diseases, that is those diseases which are
transmitted to a recipient from a host, make their “leap”
through one or more of the following pathways:



Direct physical contact


including touching & sexual means


Indirect contact
via an inanimate object (
fomite
)


Vector



recipient is bitten by an insect or animal (the vector)


Fecal
-
oral



from contaminated food or drink


Droplet



expelled through coughing, sneezing, talking


Airborne



pathogen hitches a ride on dust or evaporated droplets


Note that bloodborne pathogens (those in blood or other bodily
fluids) may be transmitted by sexual or direct contact or through
fomites (e.g., surgical instruments or dried blood on an object)

Norovirus has made the headlines several times for sickening
passengers on cruise ships, kids at school, and residents of
nursing homes. Take a guess at the means of transmission
for this highly contagious disease. Go on…guess:




A. Direct contact



B. Indirect contact



C. Vector



D. Fecal
-
oral



E. Droplet



F. Airborne



It’s almost hard to be wrong. The
answers

are:





A. Direct contact



B. Indirect contact



C. Vector



D. Fecal
-
oral



E. Droplet



F. Airborne


The point is that there can be and often are several routes of
transmission which means that
you must be exceptionally
aware of your surroundings and practices
.

The answer is ultimately you, but there are a couple of federal agencies
deeply committed to setting standards & regulating healthcare practice
for the safety of your patients & you.


The
Centers for Disease Control & Prevention
(CDC, if your memory is
short) has this mission statement (retrieved 12/1/09 from
http://www.cdc.gov/about/
):






To collaborate to create the expertise, information, and tools that
people and communities need to protect their health


through health
promotion, prevention of disease, injury and disability, and preparedness
for new health threats.”

In the 1983 the CDC authored the
Guidelines for Isolation Precautions
in Hospitals
. Later in the decade, and particularly in response to
the HIV/AIDS epidemic, “
universal precautions
” were instigated
to prevent the spread of pathogens responsible for diseases such
as HIV/AIDS, HBV & HCV transmitted in blood, other bodily fluids
containing visible blood, semen, & vaginal secretions.


The precautions also apply to tissues, cerebrospinal, synovial, pleural,
peritoneal, pericardial, and amniotic fluids. Saliva is included if
visibly contaminated with blood.


Read more at:
http://www.cdc.gov/ncidod/dhqp/bp_universal_precautions.html
.

The more recent CDC recommendations for hospitals are called the

standard precautions
.” To quote directly from page 66 of


2007 Guideline for Isolation Precautions: Preventing Transmission
of Infectious Agents in Healthcare Settings,
(
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf

, retrieved
12/1/09)


“Standard Precautions

combine the major features of Universal
Precautions (UP) and Body Substance Isolation (BSI)* and are based
on the principle that all blood, body fluids, secretions, excretions
except sweat,
nonintact

skin, and mucous membranes may contain
transmissible infectious agents. Standard Precautions include a
group of infection prevention practices that apply to all patients,
regardless of suspected or confirmed infection status, in any setting
in which healthcare is delivered.”


* Defined in the Review of Terms slides at the end of this section.

It’s one thing to receive good advice but quite another to be required
to adopt it. Do you think that everyone started wearing seat belts
when they first came out? Hmm? (Quick quiz: Which state does
not have a seat belt law for adults? Hint: The official state motto is
“Live free or die.” How interesting.)


The
Occupational Safety & Health Administration
(OSHA) is all
about regulating (issuing rules & enforcing them) standards of
occupational health including those related to injuries, fatalities, &
illnesses. It is an agency of the U.S. Department of Labor. If you
don’t think they mean business, you ought to take even a brief
look at their website:
http://www.osha.gov/index.html
. Please do.



Bloodborne Pathogens Standard

29 CFR 1910.1030


Does that not sound like a government decree?


OSHA initially issued 1910.1030 in 1991 and updated it
in 2001. With this, “universal precautions” became
not just a recommendation but an enforceable set
of regulations concerning infection control &
bloodborne pathogens in particular.

The following sources would be interesting to those who want
to learn more about how isolation & precaution practices
entered into the realm of healthcare:



“Standard Precautions”
by
Bjerke
, N. B.
(
http://www.infectioncontroltoday.com/articles/281bpract.html
) is a
thorough & well
-
written history reaching back from the 19
th

century to
the present.



This table from the American Dental Association summarizes the
development of isolation precautions:
http://jada.ada.org/cgi/content/full/134/5/569/T2
)


Agencies

CDC

Centers for Disease Control & Prevention


government agency
providing information & recommendations on a wide array of topics
related to health.

OSHA

Occupational Safety & Health Administration

-

government agency
that implements & enforces regulations concerning safety in the
workplace.

This & the following couple of slides have a review of terms to set the stage for
laying out what it actually means to practice universal precautions. If you would like
to delve into the OSHA Standard 1910.1030 for a complete glossary and enumerated
subparagraphs from here to eternity, you will find them at
http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS
&p_id=10051
. Put your feet up; it’s a long read.

Practice of Infection Control

Universal
Precautions

Initially

a term describing the CDC recommendations for limiting
the spread of bloodborne pathogens & later adopted by OSHA as
a label for their approach to infection control.

Body

Substance
Isolation (BSI)

A more inclusive practice of isolation focused on the isolation of
all moist and potentially infectious body substances (blood,
feces, urine, sputum, saliva, wound drainage, and other body
fluids) from all patients, regardless of their presumed infection
status.

(
Retrieved 12/1/09 from
http://wonder.cdc.gov/wonder/prevguid/p0000419/p0000419.asp#head002006000000000
)

Standard
Precautions

The updated recommendations

from the CDC which combine
features of Universal Precautions & Body Substance Isolation.
Read more at:
http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html
.

Infectious

Materials

Bloodborne
pathogens

“Bloodborne pathogens are pathogenic microorganisms that are
present in human blood and can cause disease in humans.”
(
http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html
, retrieved 12/1/09)

OPIM

OSHA term = “other potentially

infectious materials”, including :
(
http://www.osha.gov/SLTC/etools/hospital/hazards/univprec/univ.html
, retrieved 12/1/09)



The following human body fluids
:
semen, vaginal secretions,
cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid,
amniotic fluid, saliva in dental procedures, any body fluid that is visibly
contaminated with blood, and all body fluids in situations where it is difficult or
impossible to differentiate between body fluids;


Any unfixed tissue or organ
(other than intact skin) from a human (living
or dead); and


HIV
-
containing cell or tissue cultures, organ cultures, and HIV
-

or
HBV
-
containing culture medium or other solutions; and blood,
organs, or other tissues from experimental animals infected with
HIV or HBV.

Taking precautions to protect your patients AND yourself.

In essence, this means preventing disease transmission by
consistently using infection control practices with
all

patients in
all
healthcare settings.


This section covers
:


Administrative considerations


Confidentiality


TB test & vaccinations


Hand hygiene


Protective Barriers


Additional precautions

Whether your employer calls their program
Standard
Precautions
in deference to the CDC or
Universal Precautions
as promoted by OSHA, you should become familiar with
these worksite procedures:



Continuing education regarding precautions


The facility’s written exposure control plan


Post
-
exposure protocols (and be sure to follow these
promptly if exposed!)


Record keeping regarding exposure

It should go without saying (and that is a pun as well as the
truth) that whatever you might learn about a patient’s health
status is private & protected information not to be shared
beyond the circle of those involved in the patient’s care.


The U.S. Department of Health & Human Services would like to
tell you more at their site devoted to health information
privacy, specifically regarding the Health Insurance
Portability & Accountability Act (HIPAA). It is found at:
http://www.hhs.gov/ocr/privacy/



Tuberculin skin test
. (TB is not gone! Almost 13,000 cases
were reported in the U.S. in 2008.)



Read more at:
http://www.cdc.gov/tb/
.



Vaccinations
(
http://www.immunize.org/catg.d/p2017.pdf
)


Influenza


Hepatitis B


Measles, mumps, rubella (MMR)


Varicella (chickenpox)


Tetanus, diphtheria, pertussis (
Tdap

or variants as indicated)


NOTE: Your school program and/or your eventual employer may require more
vaccinations than those listed above. Certainly you will require additional
vaccinations if you work/study abroad or with potential exposure to other
diseases.
(Check out
http://wwwnc.cdc.gov/travel/

if you intend to travel.)

With the ghost of Dr. Semmelweis hovering above you at this moment, the
weight of years of CDC proclamations on your shoulders, & the watchful
eye of OSHA over your shoulder, acknowledge that timely & proper hand
washing is probably the single most effective way to prevent the spread
of infection.


Hand cleansing should be done prior to and after each patient interaction, prior to
and after each procedure. (You would also faithfully cleanse your hands prior to
preparing food & eating, after blowing your nose in a tissue, going to the
bathroom, etc., wouldn’t you? Of course you would.)


A note on professionalism: Most healthcare facilities have soap & sinks and/or hand
sanitizer lotion in every room & at every station. This is obvious. So, too, should
your practice of hand cleansing be obvious. Let the patient see you enter his/her
domain vigorously cleansing your hands. There’s a story here…

The second year medical student conducted a preliminary evaluation of her patient who was in
for a routine annual physical. She (the medical student) was clearly well
-
versed in the
examination process and took delight in carefully explaining each of the tests she
performed. She chatted amicably throughout, thereby developing a fine patient rapport.


At length the attending physician entered the room (rolling a dab of hand sanitizer around his
fingers) introduced himself to the patient and took his turn at reviewing the records and
confirming the results of the student’s evaluation. Now there is perhaps no way to conduct
the final step of the examination to everyone’s complete satisfaction, but the physician
introduced the digital rectal exam as kindly as any human could, explaining that this was
still an important method of detecting prostate irregularities. (If you cannot now guess the
gender of the patient, perhaps you should review anatomy.)


As he and the medical student prepared for this last step, the medical student brightly chirped:


“I guess I should have washed my hands prior to entering the room.”


This is a regrettable show stopper. The patient, himself a healthcare provider and the author of
this module, did not retrieve his eyebrows from the “oh my!” position for quite some time.

The
“Guideline for Hand Hygiene in Health
-
Care Settings”
CDC document at
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

will answer virtually any question
you might have on the topic. Hand hygiene includes the following practices:



Hand washing with plain soap & water


The choice for visibly dirty hands


Little to no antimicrobial activity



Hand washing with antimicrobial soap (soap with antiseptic agent) & water


See table of antiseptic agents on next slide



Using an antiseptic hand rub


Waterless, typically alcohol
-
based solutions


See table of antiseptic agents on next slide



Not all of these are interchangeable, meaning that there are some situations in
which one method is preferred over the other. An individual must also
consider any history of allergic reaction to various products & the potential
for contact dermatitis resulting from chronic use of a product.

Table excerpted from the CDC’s “Guidelines for Hand Hygiene in Health
-
Care Settings ,” p. 45 retrieved 12/1/09 at
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
.

Clostridium difficile
, a bacterium transmitted by contact with feces (as in: diarrhea) is a major
problem in healthcare institutions particularly affecting older adults & especially those who
have been on a course of antibiotics. (
Read more at the Mayo Clinic site devoted to the
topic:
http://www.mayoclinic.com/health/c
-
difficile/DS00736
).


Here’s a sobering note from the Guidelines for Hand Hygiene in Health
-
Care Settings regarding
C. difficile
(p. 17 at
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

)
:


“None of the agents (including alcohols,
chorhexidine
, hexachlorophene,
iodophors
, PCMX, and
triclosan
) used in antiseptic
handwash

or antiseptic hand
-
rub preparations are reliably
sporicidal

against
Clostridium
…”


As a presumably healthy individual you may not get ill, but you may be a carrier. The CDC
encourages you to:


Wear gloves (this
presumes

you suspect
C. difficile
!)


After removing the gloves, wash your hands with a non
-
antimicrobial or an antimicrobial
soap & water or disinfect with an alcohol
-
based hand
-
rub.


Wash Your Hands: The Right Way

When washing hands with soap and water:



Wet your hands with clean running water and apply soap. Use warm
water if it is available.


Rub hands together to make a lather and scrub all surfaces.


Continue rubbing hands for 15
-
20 seconds. Need a timer? Imagine
singing "Happy Birthday" twice through to a friend.


Rinse hands well under running water.


Dry your hands using a paper towel or air dryer. If possible, use your
paper towel to turn off the faucet.


Always use soap and water if your hands are visibly dirty.


The above is directly from the CDC at
http://www.cdc.gov/Features/HandWashing/

(retrieved 12/1/09
). If you
would like to see pictures of hand washing or review their video, please visit that site.
Noteworthy in the
script for the video is the statement that up to 80% of all infections are transmitted by hand.

Also from the CDC is this regarding the use of hand sanitizers:


When using an alcohol
-
based hand sanitizer:


Apply product to the palm of one hand.


Rub hands together.


Rub the product over all surfaces of hands and fingers until hands are dry.


Alcohol
-
based hand sanitizers are NOT effective when hands are visibly
dirty or contaminated with blood or fecal matter as examples. (In these
instances, washing with an antimicrobial soap & water might be
indicated.)


Personal protective equipment (PPE) or personal protective attire
(PPA) are selected and worn based upon the nature of the patient
interaction* and the likely mode of pathogen transmission.** PPE
include:



Gloves


Masks


Gowns & other apparel


Eye, face, mouth, & inhalation protection


*Naturally the CDC has recommendations on when to use PPE. The

Yale
-
New Haven Hospital
(
http://www.med.yale.edu/ynhh/infection/precautions/intro.html
)

offers more on the
use of PPE along with instruction on how to don (put on) the equipment & remove the
equipment. This is presented in the following slides.

**A presentation of Transmission
-
Based Precautions follows the PPE information.

CDC: 2007 Guidelines for Isolation Precautions, p. 134, retrieved 12/1/09
from
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf
.

Gloves are worn to prevent the health care worker's hands from becoming
contaminated with blood or body substances. Gloves should be worn for:



Procedures involving direct contact with the blood and body substances of any patient.


Procedures where contact with blood and body substances might be expected to occur.


Procedures involving direct or potential contact with the mucous membranes of any
patient.


Procedures involving direct or potential contact with the non
-
intact skin of any patient.
Non
-
intact skin is skin that is cut, chapped, abraded, cracked, afflicted with weeping or
exudative

lesions, or is otherwise broken. Touching or handling any instruments,
equipment, or surfaces that have been, or may have been, in contact with blood or body
substances.


In addition, gloves should be worn in providing care to a patient or in managing equipment
when the health care worker has cuts, scratches, or other breaks in the skin on his/her
hands.

Sterile gloves should be used for all sterile procedures and for
activities that involve contact with areas of the body that are
normally sterile.


There should be an adequate supply of clean disposable gloves
on the standard precautions stations or in other locations
that are convenient to each patient's room.


Gloves used in patient's care should be worn only for contact
with the patient. Once used, gloves must be discarded
before leaving the patient's room.

Procedure for donning sterile gloves:

1.
Remove all jewelry, including rings.

2.
Wash hands using an antimicrobial cleansing agent.

3.
Dry hands thoroughly with a paper towel. Use the towel to turn off the faucet.

4.
Remove the packet of gloves from the outer wrapper. Place this packet on a clean, dry,
flat surface.

5.
Unfold the packet as if opening a book. Position the packet so that the cuffed ends of the
gloves are nearest to you.

6.
Grasp the center flaps and open. Both gloves must have folded cuffs. Position the
packaging so that it lies flat.

7.
Use one hand to glove the other. Grasp the edge of the right glove cuff with the fingers of
the left hand, and slip the right hand into this glove. Pull it on by holding onto the cuff,
but
do not

touch the outside of the glove.

8.
Adjust both gloves so they fit properly. Make sure there are no gaps between the
fingertips and the ends of the gloves.

9.
Inspect the gloves for nicks and tears before and during the procedure. Obtain a new pair
of sterile gloves if there is a break in aseptic technique or if a nick or tear occurs.


The three categories of Transmission
-
Based Precautions come into effect when
Standard Precautions are insufficient to interrupt the route(s) of transmission.
(This means that Standard Precautions AND the indicated Transmission
-
Based
Precautions should be in effect.) The categories are:



Contact precautions


Apply when excessive wound drainage, fecal incontinence, or other discharges


Ideally entails single room or spatial arrangements to protect others in shared room


Caregiver wears gown & gloves


Droplet precautions


Apply with respiratory illnesses spread through relatively close approximation to others


Ideally entails single room or spatial arrangements & curtain to protect others in shared room


Caregiver wears mask


Airborne precautions


Apply when infectious agents may be suspended in the air over long distances


Preferred placement for patient in airborne infection isolation room


Caregiver wears mask or respirator as indicated by disease
-
specific recommendations

CDC: 2007 Guidelines for Isolation Precautions, p. 121, retrieved 12/1/09 from
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf
.

The CDC’s 2007 Guidelines for Isolation Precautions contains a 23 page Appendix listing precautions for
selected infections & conditions. A sample of this (retrieved 12/1/09 from page 94 of that document at
http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf
) is displayed below.