Download MBBS Pediatric PPT 4 Infection Control Neonatal Transport Modified Lecture Notes

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NEONATOLOGY

INFECTION CONTROL IN NICU-LEARNING

OBJECTIVES

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Improved hand hygiene compliance

Barrier precautions/ Barrier nursing

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Reduction of environmental contamination

Antibiotic restriction policies
HAND HYGIENE IN HEALTHCARE

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SETTINGS: AN OVERVIEW

. Background
. Definitions
. Indications

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. Selection of Agents
. Techniques

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

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vol. 51, no. RR-16.

SO WHY ALL THE FUSS ABOUT HAND

HYGIENE?

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Most common mode of transmission

of pathogens is via hands!

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............and the reason for
.Infections acquired in healthcare
.Spread of antimicrobial resistance
EVIDENCE OF RELATIONSHIP BETWEEN HAND

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HYGIENE &

HEALTHCARE-ASSOCIATED INFECTIONS

. Substantial evidence:

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hand hygiene reduces the incidence of infections

. More recent studies: rates lower when antiseptic

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handwashing was performed

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.

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DEFINITIONS

Hand hygiene

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Performing handwashing, antiseptic handwash, alcohol-based

handrub, surgical hand hygiene/antisepsis

Handwashing

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Washing hands with plain soap and water

Antiseptic handwash

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Washing hands with water and soap or other detergents containing

an antiseptic agent

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

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vol. 51, no. RR-16.
DEFINITIONS

Alcohol-based handrub

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Rubbing hands with an alcohol-containing preparation

Surgical hand hygiene/antisepsis

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Handwashing or using an alcohol-based handrub before

operations by surgical personnel

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

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vol. 51, no. RR-16.

Procedural Handwashing
Procedural Handwashing

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Why hand washing?

Simply put...hand hygiene saves lives!
Hand washing is one of the "most important

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means of preventing the spread of infection

CDC Guidelines
FLORA ON HANDS

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Coagulase-negative staphylococci

Staph aureus

Pseudomonas aeruginosa

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Entercococci

Candida spp

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COLONIZED OR INFECTED:

WHAT IS THE DIFFERENCE?

People who carry bacteria without evidence of

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infection (fever, increased white blood cell count) are

colonized

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If an infection develops, it is usually from bacteria that

colonize patients

Bacteria that colonize patients can be transmitted

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from one patient to another by the hands of

healthcare workers

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~ Bacteria can be transmitted even if the

patient is not infected ~
The Iceberg

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Effect

Infected

Colonized

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The Inanimate Environment Can

Facilitate Transmission

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~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a

VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

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HAND WASHING...

Hand washing is the no.1 prevention against spread of

ifetio,isideadoutside

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the hospital settig...Itis

the cornerstone of infection control practice and

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education for anyone who works in health care

Summit Medical Center, Oakland, California

Hand washing can the first line of defense against many

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ifetiousdiseases...theAMAurges otoly

professionals but public also to adopt hand washing as
an important personal priority.

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American Medical Association House of Delegates Resolution

409

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DURATION FOR DIFFERENT TYPES OF HANDWASHING

Two minutes

before entering the unit

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before performing any procedure
after handling any infected baby or secretions

15 seconds

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before and after touching every baby
after touching unsterile surfaces and fomites

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

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vol. 51, no. RR-16.
TYPE OF HAND HYGIENE

. When hands are visibly dirty, contaminated, or

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soiled,

wash

with

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non-antimicrobial

or

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antimicrobial soap and water. Thereafter, use an

alcohol-based handrub

. If hands are not visibly soiled, use an alcohol-

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based handrub for routinely decontaminating

hands.

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Handwash followed by hand rub theoretically superior!

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.

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SELECTION OF HAND HYGIENE AGENTS: FACTORS TO

CONSIDER

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Efficacy of antiseptic agent

Acceptance of product by healthcare

personnel

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Characteristics of product

Skin irritation and dryness

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Accessibility of product

Dispenser systems

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

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vol. 51, no. RR-16.
EFFICACY OF HAND HYGIENE

PREPARATIONS IN KILLING

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BACTERIA

Good

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Better

Best

Plain Soap

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Antimicrobial

Alcohol-based

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soap

handrub

Plain soap is

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just not enough

Ability of Hand Hygiene Agents to

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Reduce Ba

Ti c

me te

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Afte r

r ia

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Di

si o

n n

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fecti Ha

on

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nds

%

log

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0 60

180 minutes

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99.9 3.0

99.0 2.0

Alcohol-based handrub

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(70% Isopropanol)

90.0 1.0

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Antimicrobial soap

(4% Chlorhexidine)

0.0 0.0

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Plain soap

Baseline

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Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
Effect of Alcohol-Based Handrubs on

Skin

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Condition

Self-reported skin score Epidermal water content

Dry

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Healthy

6

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27

5

25

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4

23

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3

21

2

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19

1

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17

0

15

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Healthy

Dry

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Baseline

2 weeks

Baseline

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2 weeks

Alcohol rub Soap and water

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Alcohol rub

Soap and water

~ Alcohol-based handrub is less damaging to the skin ~

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Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.

TIME SPENT CLEANSING HANDS:

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ONE NURSE PER 8 HOUR SHIFT

. Hand washing with soap and water: 56 minutes

? Based on seven (60 second) handwashing episodes per hour

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. Alcohol-based handrub: 18 minutes

? Based on seven (20 second) handrub episodes per hour

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~ Alcohol-based handrubs reduce time needed

for hand disinfection ~

Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.

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RECOMMENDED HAND HYGIENE

TECHNIQUE

Handrubs

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Apply to palm of one hand, rub hands together

covering al surfaces until dry

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Volume: based on manufacturer

Handwashing

Wet hands with water, apply soap, rub hands

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together for at least 15 seconds

Rinse and dry with disposable towel

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.

REASONS FOR NONCOMPLIANCE

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. Handwashing agents cause irritation and dryness

. Sinks are inconveniently located/lack of sinks

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. Lack of soap and paper towels

. Too busy/insufficient time

. Understaffing/overcrowding

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. Patient needs take priority

Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.
GLOVING

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Wear gloves when contact with blood or other

potentially infectious materials is possible

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Remove gloves after caring for a patient

Do not wear the same pair of gloves for the care of

more than one patient

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Do not wash gloves

Remember the glove is for the patient also !!!

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.

EDUCATION/MOTIVATION PROGRAMS

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Monitor healthcare workers (HCWs) adherence with

recommended hand hygiene practices and give

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feedback

Implement a multidisciplinary program to improve

adherence to recommended practices

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Encourage patients and their families to remind HCWs

to practice hand hygiene

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.
ADMINISTRATIVE MEASURES TO

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IMPROVE HAND HYGIENE

Make improved hand hygiene an institutional

priority

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provide appropriate administrative support and

financial resources

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Place alcohol-based handrubs at entrance to

patient room, or at bedside

Provide HCWs with pocket-sized containers

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.

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PERFORMANCE INDICATORS

Monitor and record adherence to hand

Provide feedback to healthcare workers about their

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performance

Monitor the volume of alcohol-based handrub used

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per 1,000 patient days

Monitor adherence to policies on wearing artificial

nails

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;

vol. 51, no. RR-16.
SUMMARY

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ALCOHOL-BASED HANDRUBS:

WHAT BENEFITS DO THEY PROVIDE?

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Require less time

More effective for standard handwashing than

soap

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More accessible than sinks

Reduce bacterial counts on hands

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Improve skin condition

BARRIER NURSING
CHAIN OF INFECTION

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The interaction between

all the six elements of

the chain determine

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whether an infection wil

result

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INFECTION CONTROL

Sources of microorganisms can include:

Patients

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Health care workers
Visitors

These sources can include:

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Persons with acute illness or infection
Those who are carriers, and
Those who are colonized with microorganisms (harbor the

organism without showing any apparent illness)

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Inanimate objects such as furniture and medical

equipment can also be sources of microorganisms.
OBJECTIVE ? BARRIER NURSING

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The main aim is to create a barrier to

the passage of infectious pathogenic
organisms between the contagious patient

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and other patients and staff in the hospital

WHAT DOES IT CONTAIN?

Ensure that patient care items, bedside equipment, and

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frequently touched surfaces receive daily cleaning

USE DEDICATED

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Thermometer
B/P cuff
Stethoscope
Oxygen source & tubing
Suction tubings

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Antibiotics & other medications
Resuscitation kit
Baby tray

They must be cleaned daily

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BARRIER NURSING CONTD...

BN reduces but does not completely eliminate the

possibility of infection

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BN is only effective if used correctly and at all times

where contact may occur

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The use of Barrier Nursing does not replace basic

hygiene measures such as hand-washing, it is still very

essential to prevent transmission.

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GOOD NICU PRACTICES

PREVENT ENTRY OF MICROBES INTO NICU

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PREVENT PROLIFERATION OF MICROBES

PREVENT SPREAD OF MICROBES

PRACTICES ? PROTECTS NEWBORN FROM DEVELOPING

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INFECTION
PREVENT ENTRY OF MICROBES

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MAINTAINING A CLEAN ENVIRONMENT OUTSIDE NNN--

LABOUR ROOM

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BUFFER ZONE



ENTRY RESTRICTIONS?

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FAMILY MEMBERS

ENTRY OF INFECTED BABIES

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PERSONNEL OF NURSERY

PERSONNEL OF ALLIED SERVICES

HAND WASHING ?SINGLE MOST IMPORTANT INTERVENTION

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GOWNS / MASKS /SLIIPERS

AIR CHANGES

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12 AIR CHANGES /HOURS

0.5 BACTERRIAL FILTER

-

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PREVENT PROLIFERATION OF MICROBES IN

NNN

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EQUIPMENT DISINFECTION

GOOD HOUSE KEEPING--

FLOORS

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WALLS

FANS

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REFRIGERATOR

SINKS

BUCKETS

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PREVENTION OF SPREAD OF MICROBES

BETWEEN BABIES

PREVENT OVER CROWDING--4-6 FEET SPACE

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STAFFING PATTERN--

1 :1

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MULTI DRUG RESISTANT ORGANISM

1:2

SUSPECTED SEPSIS,SEPSIS WITH ORGANISMS

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SUSCEPTIBLE TO WIDE RANGE OF DRUGS.

1:3

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SEPTIC BABIES RECEIVED AB AND PRESENTLY NON ?

INFECTIOUS

1:4

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STABLE BABIES

HAND WASHING

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DISPOSABLE

LAMINAR FLOW

PROHIBITING OF STOCK SOLUTIONS

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FOMITES- UNDERESTIMATED

FILES

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STETHOSCOPES

EXAMINATION TRAY

PENS

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COFFEE/TEA MUGS

TELEPHONES
PROTECT NEW BORNS FROM DEVELOPING INFECTIONS

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BREAST FEEDS/MILK

INVOLVEMENT OF MOTHER

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EARLY DISCHARGE POLICY

CORD CARE

SKIN CARE

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HANDLING OF PARENTERAL FLUID/ DRUGS

HANDLING OF INVASIVES LINES AND TUBES

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PERIPHERAL LINES

CENTRAL LINES

REMOVING LINES

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MINIMIZE HANDLING.

ASEPETIC PRECAUTIONS DURING PROCEDURES

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HAND WASHING BEFORE

INTRAVENOUS LINES

ET SUCTIONING

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ET INSERTION , L P, DVET, CENTRAL LINE INSERTION----

SAME SANCTITY AS SURGICAL PROCEDURE
PRACTICES ENABLE BETTER ADMINISTRATION

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ENVIRONMENT SURVEILLANCE

RECORD OF POSITIVE CULTURE.

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MOTIVATING THE STAFF.

NEONATAL TRANSPORT

INDICATIONS

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BEST transport method: in-utero transport

Monitoring during transportation

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Complications
INDICATIONS

Need for higher care

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Need for high frequency

Need for iNO

Need for ECMO

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Need for hypothermia/whole body cooling/head cooling

Need for cardiac procedure

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Lack of NICU bed/expertee/equipment

PREPARE FOR TRANSPORT

Check ID, compare with mothers folder.

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IV fluids ( Neonatalyte)

History

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Reason for transfer

Escorts?
MONITORING
COMPLICATIONS

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HIGH RISK NEONATE:
COMPLICATIONS DURING TRANSPORT

Hypoxia

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Hypoglycaemia

Hypothermia

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Hyperbilirumenaemia

Hypovolaemia

Heavy sedation

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Infection

HISTORY OF REGIONALIZED TRANSPORT

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Medical transports date back as early as Ceasar

? First transport isolette (1893)

? Newborn inter-hospital transport--9's

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? Chicago Dept. of Health System--9's

? Assisted ventilation on transport--9's France

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? Modern transport--97's Usher, Canada
ROTCH-PUTNAM INCUBATOR(CIRCA 1893)
THE OBSTETRICAL BAG TRANSPORT

INCUBATOR (1922)

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DE LEE & WELDE TRANSPORT

INCUBATORS 9'S)

NOVEL THERAPIES & EQUIPMENT: AVAILABLE DURING

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TRANSPORT

ELBW (surfactant, thermoregulation)

? Inhaled Nitric Oxide

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? ECMO

? Ventilators (HFOV)

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? Brain Cooling

MRI Transport Incubator

? Capnography

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? Wireless internet and more

? Telemedicine (consults, ECHO, U/S)

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? Cong. Heart defects/transport to Cath lab

ECMO: ON TRANSPORT

ECLS started at referring hospital

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? Time is of the essence
? Must weigh benefit vs. risks and costs
? Team to include surgeons, neonatologists,

perfusionists, RRT 's, ECMO nurses

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? Need to be equipped, self-sufficient for 24h
? Cornish (Wilford Hall Air Force Base) first to use
portable ECMO on isolette (1987 & 1991) C-9 aircraft
? Now 16 year military experience (Wilson, Pediatrics,

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2002)

HIGH FREQUENCY VENTILATION DURING TRANSPORT

. To treat severe RDS/ ARDS

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? Minimizes barotrauma
? Uses low TV & high rates
? NICU units NOT portable
? Transport models being developed & tested

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MCQS: INFECTION CONTROL

To perform hand hygiene activity, the minimal time

needed using alcohol based handrub is

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10 Sec

b) 20 Sec

c) 30 sec

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d) 40 sec

To perform hand hygiene activity, the minimal time

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needed using soap and water is

10 Sec

b) 20 Sec

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c) 30 sec

d) 40 sec

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How many moments for hand hygiene exist according

to WHO

a)4

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b) 5 c) 6 d) 7

What is the most frequent source responsible for health

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care-associated infections?
a) The hospital's water syste ) The hospital air

c) Germs already present on or within the patient d)

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The hospital environment

Which of the following require hand hygiene actions

(hand rub/hand washing)?

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Before touching a patient Y / No

Immediately after body fluid exposure

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Yes /

No
After exposure to the immediate surroundings of a

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patient

Ye s / No

Immediately before a clean/aseptic procedure

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Ye s / No

After touching a patient

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Ye s / No