The chain of infection is broken by disrupting the continuous chain from source to host, thus prevent- ing transmission of infectious microorganisms.
Transmission is prevented by practicing appropriate hand hygiene, using PPE, and using the set of prac- tices known as Standard Precautions. In addition, patients at risk for spreading or contracting infections may be isolated. OSHA requires all facilities to have an exposure control plan (ECP) that describes all these elements for preventing spread of infection.
ECPs include the following elements to ensure com- pliance with OSHA standards:
• Determination of employee exposure
• Implementation of various exposure controls such as Universal Precautions; engineering and work practice controls (i.e., handwashing, PPE, use of safety needles); and housekeeping
• Hepatitis B vaccine
• Postexposure evaluation and follow-up
• Communication of hazards to employees and training
• Record keeping
• Procedures for evaluating circumstances sur- rounding an exposure incident
FIGURE 4-2 A health care worker wearing a respirator.
Hand Hygiene
Hand hygiene is the most important and effective means of preventing the spread of infection and antibiotic-resistant microorganisms. Hand hygiene includes (1) washing your hands with plain or antimi- crobial soap and water and (2) rubbing your hands with an alcohol-based hand agent. In some institu- tions, an alcohol-based agent may be preferred, but CLSI guidelines indicate that it should not be used as a substitute for hand washing.
While performing your duties, your hands con- tinually come in contact with patients and with po- tentially contaminated material and microorgan- isms. Wearing gloves reduces but does not eliminate the chance of your hands carrying infectious agents.
Performing appropriate hand hygiene significantly reduces the likelihood of passing potentially infec- tious agents on to yourself or other people.
You should perform hand hygiene at the follow- ing times:
• Before and after patient contact
• Before donning and after removing gloves
• Before performing procedures
• After removing PPE
• After touching contaminated equipment
• Before going to break and after returning from break
• Before leaving the laboratory at the end of your shift
You should clean your hands when you enter a patient’s room, even if you just cleaned them in the last patient’s room, because it gives the patient confidence that you are doing all you can to pre- vent health care–associated infection. Always wash your hands when entering the patient’s room in front of the patient even though you have washed them or sanitized several times between patients.
Hand hygiene sanitizes your hands by removing or killing most of the organisms present. In this way, the sanitizer acts as an antiseptic. An antiseptic is an agent used to clean living tissue, preventing sepsis, or infection.
Procedure 4-1 illustrates proper handwashing technique. To sanitize your hands with waterless alcohol-based antiseptic hand rub, apply the product to the palm of one hand, making sure to pump enough of the product to cover all the surfaces of your hands and fingers. Rub your hands together, covering all surfaces of your hands and fingers, until your hands are dry.
Personal Protective Equipment
Personal protective equipment (PPE) consists of barriers and respirators used alone or in combina- tion to protect skin, mucous membranes, and cloth- ing from contact with infectious agents. PPE in- cludes fluid-resistant gowns, aprons, masks and respirators, face shields, goggles, shoe covers, and gloves. The types of PPE you use depend on the tasks or procedures being performed, the amount of fluids you are working with, and the potential for exposure to these fluids.
Fluid-resistant gowns provide full-body cover- age and prevent body fluids or spills from passing through and contacting the skin or clothing. The cuffs are designed to close tightly around the wrists and are covered by the gloves for further protection.
Alternatively, a cloth gown may be worn to prevent contamination of skin and clothing with transmis- sible infectious microorganisms when protection from fluid penetration is not necessary.
Face protection is worn to protect mucous mem- branes of the eyes, mouth, and nose from splashes or sprays of blood and body fluids (including excre- tions and secretions). Face protection includes gog- gles and a mask or chin-length face shield.
Face shields can prevent droplets or spatters from contacting nonintact skin of the face. In some models, the shield can be flipped up out of the way, if necessary. Masks cover the mouth and nose to protect mucous membranes from large droplets of respiratory secretions from a coughing patient and from splashes of blood or body fluids generated dur- ing certain procedures (Figure 4-3).
Goggles and a mask or face shield must be worn during procedures that may generate splashes of blood or body fluid excretions or secretions.
Masks can also worn by health care workers to prevent transmission of infectious microorganisms to patients (e.g., lung transplant or bone marrow transplant patients). Masks are secured to the head either with elastic loops or with two cloth straps for tying behind the head. They also have a metal band at the nose to seal the mask over the bridge of the nose.
CLINICAL TIP
Perform hand hygiene upon entering and before exiting a patient’s room and before donning and after removing gloves.
FLASH FORWARD
You will learn more about antiseptics and disinfectants in Chapter 8.
PROCEDURE 4-1
Hand-Washing Technique
1. Wet your hands.
Remove any rings you are wearing, and wet your hands with warm water.
2. Apply soap.
Soap should be applied from an easily accessible container.
3. Scrub vigorously.
The friction of rubbing hands together loosens debris and creates a lather to wash away surface material. Rub palms, backs of hands, between fingers, and under nails for at least 15 seconds.
4. Rinse your hands.
While rinsing your hands, be sure to hold them in a downward position. This allows water and lather to run into the sink instead of back on clean hands.
PROCEDURE 4-1—cont’d
Hand-Washing Technique
Respirators are designed to prevent inhalation of airborne microorganisms. These masks fit tightly and have filters whose efficiency capability is set by OSHA and must be certified by the National Institute for Occupational Safety and Health (NIOSH). Such masks are known as N95 masks or
N95 respirators, meaning they filter out a minimum of 95% of airborne particles if they are worn cor- rectly. Before you wear a respirator, you must re- ceive medical clearance and be fit-checked to the specific respirator. You must check the fit each time you wear the respirator by checking for leaks on both inhalation and exhalation.
Gloves are made of a variety of materials (e.g., vinyl, nitrile, latex) and come in a variety of sizes.
Latex used to be the most common material for gloves, but because of the increase in latex allergies, most health care facilities are phasing out their use of latex gloves and replacing them with gloves made of either vinyl or nitrile. Gloves provide a protective barrier against blood and other body fluids and from contamination of hands with microorganisms. They are designed to fit tightly over the hand and fingers to allow precision work. Gloves are not meant to be washed. If they become soiled or come in contact with potentially infectious material, dispose of them and put on a new pair. Never cut the finger tip off a glove to allow for a better feel on a patient’s vein.
Also, you must not use a hand lotion that has protein in it, because this may break down the glove mate- rial. Instead, use a nonprotein-based hand lotion.
5. Dry your hands.
Use a paper towel, being careful not to touch the paper towel dispenser as you are obtain- ing the towel. Dry your hands thoroughly.
Hands should be dried by blotting with the towel, not by rubbing.
6. Turn off the faucet.
Use a new, dry paper towel to turn off the fau- cet. (The faucet is considered contaminated, whereas your hands are now considered clean.) When finished, throw the paper towel in the waste container.
FIGURE 4-3 Health care worker wearing gown, goggles, and gloves.
Shoe covers can protect your shoes and feet from spills of biohazardous materials or chemicals. Shoes that are not protected by shoe covers and that cannot be appropriately disinfected may need to be dis- posed of after a spill.
Putting on and Removing Personal Protective Equipment
The order in which you don and remove your PPE is chosen to ensure that you do not contaminate your skin or clothing with infectious agents. Proce- dures for putting on and removing PPE are illus- trated in Procedures 4-2 and 4-3.
Standard Precautions
Standard Precautions refer to infection control measures that use barrier protection and work prac- tice controls to prevent contact between skin or mucous membranes and blood, other body fluids, and tissues from all people. Standard Precautions are based on the difficulty of identifying all indi- viduals who are infected or harboring infectious agents with whom the health care worker may come in contact. Standard Precautions should be the minimum level of precautions applied when coming in contact with all patients. Guidelines for Standard Precautions were published by the Centers for Dis- ease Control and Prevention (CDC) in 1996 and include the following:
• Hand hygiene. Disinfect hands whether or not gloves are worn. Use an alcohol-based hand agent unless hands are visibly contaminated, in which case, use soap and water.
• Gloves. Wear gloves when collecting or handling blood, body fluids, tissue samples, secretions, excretions, and items contaminated with blood or body fluids. Remove gloves promptly after use and disinfect your hands.
• Gowns. Wear fluid-resistant gowns when there is a likelihood of contamination of your clothing or skin with blood or body fluids.
• Face protection. Wear appropriate protection (mask and goggles or chin-length face shield)
when there is a danger of spray, spatter, or aero- sol formation.
• Sharps disposal. Dispose of all needles and other sharps in a puncture-proof container after engag- ing the safety device. Do not recap the needle.
• Respiratory hygiene and cough etiquette. This component of Standard Precautions was added in 2003 in response to the severe acute respiratory syndrome (SARS) outbreak. These infection con- trol measures are aimed at preventing transmis- sion of respiratory infections. These measures apply to patients, their families and friends, and any person with signs of a cold and respiratory infection. The precautions include posting signs to instruct people who are coughing to cover mouth and nose with tissues, dispose of used tis- sues in the trash, and perform hand hygiene after contact with respiratory secretions. There should also be a supply of tissues and alcohol-based hand agents available for these patients, and people who are coughing should be asked to wear a surgical mask and separate themselves from other patients in the waiting room if possible.