Infection Control

Online Course #9008 or #5008 - 10 Contact Hours
Author: Patti V. Hoffman, RN, BS, MPH
©2008 National Center of Continuing Education, Inc.

For your convenience, this course has been divided into 3 sections:
Below is Part 3 of 3.
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Infection Control Practices in Non-Hospital Settings

Long Term Care
On any given day in the United States, more patients are in long-term care settings than are in acute care facilities. Most long-term care is provided in nursing homes to elderly patients, but some facilities provide psychiatric as well as medical care, to the young as well as to the old. Residents of long term care facilities present with a range of functional disability and disease, and infections are common. The most frequent endemic infections are respiratory tract, urinary tract, skin and soft tissue, and gastrointestinal tract, primarily manifesting as diarrhea. Common causes of gastrointestinal outbreaks are E. coli and salmonella, as well as the small round enteric viruses. The most frequent infections involve the urinary tract, and prevalence rates range from 25% to 50% even though most patients are asymptomatic. Respiratory tract infections may include sinusitis, pharyngitis, bronchitis, and pneumonia; the latter is the only infection in the long-term care setting that is often fatal. Outbreaks of respiratory infection caused by influenza A are common. Skin and soft tissue infections include decubitus ulcers and infected vascular and diabetic foot ulcers; non-bacterial causes of skin infection include candidiasis and herpes zoster. Scabies is often present and difficult to contain.
Nursing home residents seem particularly at risk for colonization with antimicrobial drug-resistant organisms, although the colonization usually occurs in a visit to an acute care setting. Some long-term facilities have reported colonization rates with MRSA as high as 30%.
Infection control can be quite problematic in long-term settings for a variety of reasons. Residents of these facilities are often highly functionally impaired; they may be incontinent, immobile, and confused or demented. The worse their functional status, the greater the likelihood of infection or colonization with resistant organisms. Since in most cases the functional impairment has led to admission to the care facility and is in most instances unmodifiable, it may be unrealistic to believe that endemic infections can be prevented among these residents to a significant degree. A series of clinical studies has demonstrated the limited effectiveness of a variety of infection control approaches in long term facilities, including vitamin supplementation, routine vs prn percutaneous feeding tube changes, clean vs sterile intermittent catheterization technique, and aggressive treatment to eradicate MRSA colonization. Further evaluation of the effectiveness of specific interventions is needed.
Another compounding circumstance is the increasing admission to long term care of patients with invasive devices. Appropriate treatment and infection control guidelines need to be developed in each facility for those patients with chronic tracheostomies and respiratory care needs, central lines, and percutaneous feeding tubes, among others.

Home Care
Provision of home care services has also expanded exponentially in the last decade, due to efforts to decrease hospital lengths of stay and shift care to ambulatory settings. Today there are approximately 10,000 agencies that provide home care. Most patients are elderly, with chronic conditions that require skilled care. However, a substantial proportion of home care patients are younger and may include postoperative patients, postpartum mothers and their babies, and patients with acute medical conditions such as diabetes and recent strokes. Services provided may include infusion therapy, tracheostomy care and ventilator support, dialysis, and other invasive procedures.
Limited data are available on the incidence of home-acquired infections and analysis of risk factors, so development of infection control programs specific to the home environment is difficult. Although the home care patient may have less clinical acuity in terms of the degree or intensity of care needed, and less exposure to nosocomial pathogens, there may be other substantial risk factors to be considered. The home care patient may be of advanced age, and may have chronic diseases and reduced immune activity. The care provided by family members is likely to be less structured and controlled, and the environment may be lacking in proper sanitation and ventilation.
Given the relative risks encountered in the home environment and the nature of the interventions, infection control strategies in the home care setting should focus on infusion therapy, urinary tract care, respiratory care, wound care, and enteral therapy. Practices recommended for intravenous therapy in the hospital setting should work well in the home. Procedures for dealing with urinary catheters should, however, be adapted to the specific circumstances of each home patient.
Wound care may be a significant challenge. Home care patients may have a variety of wounds, such as stasis ulcers and pressure sores which are commonly colonized with gram negative flora; this increases the possibility that the patient's new wounds may become infected with his own organisms. Thus, the procedures for wound care in the home should be based on a careful assessment of the real potential for contamination and infection.
Enteral therapy at home presents a risk for gastrointestinal infection. Reduction of this risk may require considerable patient and family teaching with regard to the need for refrigeration of the feeding and scrupulous cleaning of all items used in its preparation, but sterilization of appliances and kitchen tools is probably not necessary.
Standard precautions should always be followed, just as with hospital-based patients. The use of gloves and gowns in the home care setting, however, is more likely to be for the protection of the nurse rather than the patient, and mask use may be limited to those patients with pulmonary tuberculosis.
A home care nurse who is treating a patient with multidrug-resistant organisms should be alert to the need for use of appropriate barriers. Reusable equipment should be dedicated to the use of that particular patient and left in the home. The nurse should plan to see the patient as the last appointment of the day, or at least after seeing patients at increased risk, such as those receiving wound care. Further study is needed to identify significant risks and appropriate risk reduction strategies for use in the home care setting.

Dialysis Units
The number of patients with end-stage renal disease treated by maintenance hemodialysis in the United States has increased sharply during the past 30 years. In an environment where multiple patients receive dialysis concurrently, repeated opportunities exist for person-to-person transmission of infectious agents, directly or indirectly, via contaminated devices, equipment and supplies; environmental surfaces; or hands of personnel. The CDC has developed the following recommendations to minimize the spread of disease in these settings:

• Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station; remove gloves and wash hands between patients or stations.
• Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
  • Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth-covered blood pressure cuffs) should be dedicated for use only on a single patient.
  • Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
• When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station.
• Do not use common medication carts to deliver medications to patients. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. If trays are used to deliver medications to individual patients, they must be cleaned between patients.
• Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled.
• Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machine's pressure monitors. Change filters/protectors between patient treatments, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients.
• Clean and disinfect the dialysis station (chairs, beds, tables, machines, etc.) between patients.
  • Give special attention to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients' blood.
  • Discard all fluid and clean and disinfect all surfaces and containers associated with the prime waste (including buckets attached to the machines).
• For dialyzers and blood tubing that will be reprocessed, cap dialyzer ports and clamp tubing. Place all used dialyzers and tubing in leak-proof containers for transport from station to reprocessing or disposal area.

All dialysis patients should undergo routine testing for Hepatitis B (HBV) and Hepatitis C (HCV) infections, according to the following schedule:

Schedule for Routine Testing for HBV and HCV Infections

Patient Status

Anti-HBs and anti-HBc positive

All patients should be vaccinated against Hepatitis B. Each patient should then be tested for anti-HBs one to two months after the last dose. If anti-HBs is <10 mIU/mL, consider patient susceptible, revaccinate with an additional three doses, and retest for anti-HBs. If anti-HBs is >10 mIU/mL, consider the patient immune, and retest annually. If anti-HBs declines to <10 mIU/mL at any time, give the patient a booster dose of vaccine and continue to retest annually.
HBsAg-positive patients should be treated according to the unit's infection control practices for all patients. In addition, these patients should be dialyzed in a separate room using separate machines, equipment, instruments, and supplies. Staff members caring for HBsAg-positive patients should not care for HBV susceptible patients at the same time (e.g., during the same shift or during patient change-over).

Precautions in the Dental Setting
The dental caregiver has unique requirements and should place special emphasis on the following precautions to prevent exposure to bloodborne pathogens in institutional and non-institutional dental settings.

1. In addition to wearing gloves for contact with the oral mucous membranes of all dental patients, all dental caregivers should wear surgical masks and protective eyewear or chin-length plastic shields during dental procedures in which splashing or spattering of blood, saliva, or gingival fluids is likely. Rubber dams, high-speed evacuation, and proper patient positioning should be utilized to minimize generation of droplets and spatter.
2. Dental handpieces should be sterilized after each use with patients because blood, saliva or gingival fluid may be aspirated into the handpiece or waterline. If handpieces cannot be sterilized, they should be flushed for at least 20-30 seconds to discharge water and air from the lines. The outside surface of the handpiece should be cleaned and wiped with a suitable chemical germicide and rinsed. Handpieces should be flushed at the beginning of each working day and after use with each patient. Handpieces that cannot be sterilized should be replaced or retrofitted with heat stable components to permit sterilization as soon as feasible. As with other equipment, the manufacturer's instructions should always be followed. The dental caregiver should follow the same precautions for other reusable intraoral instruments attached to, but removable from the dental unit air or water lines such as ultrasonic scalers and air/water syringes.
3. All blood and saliva should be thoroughly and carefully cleaned from material that has been used in the mouth (impression materials, bite registration, etc.), especially before polishing and grinding intraoral devices. All contaminated materials, impressions, and intraoral devices should be cleaned and disinfected prior to being handled in the dental laboratory and before they are placed in the patient's mouth. Dental workers should consult with manufacturers to determine the appropriate disinfectant for each material used.
4. All dental equipment and surfaces that are difficult to disinfect (e.g., light handles or x-ray unit heads) and that may become contaminated should be wrapped with impervious-backed paper, aluminum foil, or clear plastic wrap. The coverings should be removed and discarded, and clean coverings should be put in place after use with each patient.

The Caregiver and Infection Control

After all of the facts have been presented in any infection control program and after all of the suggestions and requirements for preventing the transmission of disease have been made, there remains one controlling factor. That factor is vital in order for any program, no matter how well planned or presented, to be successful. That factor is YOU, the caregiver. You are the most important part of any infection control program because you are the one who makes it function properly. Without your dedication in application of the program, it is doomed to failure. The foregoing facts and requirements will assist you in assuring that your infection control program is successful.

APPENDIX A

Type and Duration of Precautions Needed for Selected Infections and Conditions

* Type of Precautions: A, Airborne; C, Contact; D, Droplet; S, Standard; when A, C, and D are specified, also use S.
^† Duration of precautions: CN, until off antibiotics and culture-negative; DI, duration of illness (with wound lesions, DI means until they stop draining); U, until time specified in hours (hrs) after initiation of effective therapy; F, see footnote.
^a No dressing or dressing does not contain drainage adequately.
^b Dressing covers and contains drainage adequately.
^c Also see syndromes or conditions listed in Table 5.
^d Install screens in windows and doors in endemic areas.
^e Maintain precautions until all lesions are crusted. The average incubation period for varicella is 10 to 16 days, with a range of 10 to 21 days. After exposure, use varicella zoster immune globulin (VZIG) when appropriate, and discharge susceptible patients if possible. Place exposed susceptible patients on Airborne Precautions beginning 10 days after exposure and continuing until 21 days after last exposure (up to 28 days if VZIG has been given). Susceptible persons should not enter the room of patients on precautions if other immune caregivers are available.
^f Place infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine cultures are negative for virus after age 3 months.
^g Additional special precautions are necessary for handling and decontamination of blood, body fluids and tissues, and contaminated items from patients with confirmed or suspected disease. See latest College of American Pathologists (Northfield, Illinois) guidelines or other references.
^h Until two cultures taken at least 24 hours apart are negative.
ⁱ Call state health department and CDC for specific advice about management of a suspected case. During the 1995 Ebola outbreak in Zaire, interim recommendations were published.(97) Pending a comprehensive review of the epidemiologic data from the outbreak and evaluation of the interim recommendations, the 1988 guidelines for management of patients with suspected viral hemorrhagic infections (16) will be reviewed and updated if indicated.
^j Use Contact Precautions for diapered or incontinent children <6 years of age for duration of illness.
^k Maintain precautions in infants and children <3 years of age for duration of hospitalization; in children 3 to 14 years of age, until 2 weeks after onset of symptoms; and in others, until 1 week after onset of symptoms.
^l For infants delivered vaginally or by C-section and if mother has active infection and membranes have been ruptured for more than 4 to 6 hours.
^m Persons susceptible to varicella are also at risk for developing varicella when exposed to patients with herpes zoster lesions; therefore, susceptibles should not enter the room if other immune caregivers are available.
ⁿ The "Guideline for Prevention of Nosocomial Pneumonia" (95,96) recommends surveillance, vaccination, antiviral agents, and use of private rooms with negative air pressure as much as feasible for patients for whom influenza is suspected or diagnosed. Many hospitals encounter logistic difficulties and physical plant limitations when admitting multiple patients with suspected influenza during community outbreaks. If sufficient private rooms are unavailable, consider cohorting patients or, at the very least, avoid room sharing with high-risk patients. See "Guideline for Prevention of Nosocomial Pneumonia" (95,96) for additional prevention and control strategies.
^o Patient should be examined for evidence of current (active) pulmonary tuberculosis. If evidence exists, additional precautions are necessary (see tuberculosis).
^p Resistant bacteria judged by the infection control program, based on current state, regional, or national recommendations, to be of special clinical and epidemiologic significance.
^q For 9 days after onset of swelling.
^r Maintain precautions for duration of hospitalization when chronic disease occurs in an immunodeficient patient. For patients with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days.
^s Maintain precautions until 5 days after patient is placed on effective therapy.
^t Avoid cohorting or placement in the same room with a CF patient who is not infected or colonized with B cepacia. Persons with CF who visit or provide care and are not infected or colonized with B cepacia may elect to wear a mask when within 3 ft of a colonized or infected patient.
^u Avoid placement in the same room with an immunocompromised patient.
^v Until 7 days after onset of rash.
^w Discontinue precautions only when TB patient is on effective therapy, is improving clinically, and has three consecutive negative sputum smears collected on different days, or TB is ruled out. Also see CDC "Guidelines for Preventing the Transmission of Tuberculosis in Health-Care Facilities."

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