UMDNJ-UNIVERSITY HOSPITAL

INFECTION CONTROL

SELF-STUDY MODULE

Revised January, 2001

Please contact the Infection Control Department if you have any questions related to the information contained in this module.

General office number: 2-5790/2-6332 (6 a.m. – 4:30 p.m.)

INFECTION CONTROL PROFESSIONALS

Ø Beverly Collins, RN, MS, CIC - Hospital Epidemiologist
Pager: (973) 312-4822 (24 hours/day)

Ø Cynthia Blackmon, RN, BSN - Infection Control Practitioner

Pager: (973) 312-5546 - During work hours: 6 a.m. - 1:45 p.m.

Ø Wilfredo Cruz, CIC - Infection Control Practitioner - Pager: (973) 312-4201

During work hours: 3:300 p.m.-7:30 p.m. Mon, Tues, Thurs, Friday and
Saturday 8 a.m-12:45 p.m.

UMDNJ-UNIVERSITY HOSPITAL

INFECTION CONTROL

Self Study Module

Purpose:

This module is designed to provide employees with education on accepted infection control practices and the infection control policies in place at University Hospital, including the bloodborne pathogens exposure control plan and tuberculosis control.

This module is to be used for annual update training and by an Infection Control Practitioner during new employee orientation. It is not to be used by new employees in lieu of attending the Infection Control portion of new employee orientation.

Objectives:

After completing the Infection Control self-study module, you will be able to:

· Describe how infections spread

· Explain Standard Precautions

· Name common infections transmitted by blood and other body fluids

· List types of protective work practices

· Explain and list the types of Personal Protective Equipment use at University Hospital

· Explain the steps involved in exposure reporting and follow up

· Name other types of precautions apart form Standard Precautions

· Explain how tuberculosis (TB) is transmitted

· Describe TB symptoms

· Explain the difference between TB infection and TB disease

· Describe protective steps used against TB exposure

· Describe TB skin test (TST) and where the TST is done.

GENERAL INFECTION CONTROL PRACTICES

Because of viruses such as HIV and the new drug-resistant super bacteria, such as MRSA and VRE, the risk of acquiring an infection in healthcare facilities has increased in recent years for both patients and staff. As a healthcare worker, you must recognize that these threats underscore the fundamental truth that using proper infection control practices is one of your most important job responsibilities.

Infection control practices are easy to ignore because they can be so elementary. Researchers at one hospital found that only 48 percent of staff in the intensive care units washed their hands before examining patients even though they knew they were being watched as part of a research project.

You must take time and make the effort required to consistently adhere to infection control procedures – because these procedures are crucial for protecting your patients and yourself from infection.

I. How Infection Spreads

For infection to spread, three elements are required:

q A source of infectious microorganisms (germs)

q A susceptible host

q A means of transmission for the microorganism.

A. Sources

Unfortunately, healthcare facilities have several sources of infectious microorganisms including:

q People

q Contaminated objects

People, including patients, staff members and visitors, can harbor a variety of infectious microorganisms such as bacteria, viruses, parasites, yeasts and fungi.

Although invisible, these microorganisms may be present in blood and other body fluids and secretions such as saliva, sputum, nasal and vaginal discharge, and wound drainage. They are also present in excrement and are often on the skin’s surface, especially the hands. A person doesn’t have to look or feel sick to be a source of infection. Patients can even infect themselves when microorganisms within their body multiply out of control.

Contaminated objects can also be sources of infection. Some objects especially prone to contamination include floors, bedpans, trash cans, medical equipment, invasive medical devices and dirty laundry.

B. Host

To become a host, a person must be susceptible to the infectious organism. A person exposed to an infectious organism will not necessarily become a host because some people are immune to or able to resist the infection. Unfortunately, healthcare facilities have many different kind of patients that can become hosts. People particularly susceptible to infection include:

q Elderly patients

q Newborns

q Persons with weak or undeveloped immune systems

q Persons with cancer, multiple health problems or chronic diseases that require steroid therapy

q Patients with surgical incisions, catheters, breathing tubes and other medically induced pathways into the body that can allow infections to enter.

The longer a patient is in the hospital, the greater is his or her chance of acquiring an infection.

C. Transmission

To be transmitted, microorganisms must enter the host’s body. Entrance may be gained through:

q Inhalation

q The mouth, eyes, nose or other opening into the body

q A break in the host’s skin caused by cuts, nicks, skin abrasions or dermatitis

There are five main routes of transmission:

q Contact

q Droplet

q Airborne

q Common vehicle

q Vectorborne.

1. Contact Transmission—the most common route, can be either direct or indirect.

Direct contact transmission—occurs when microorganisms are physically transferred from the source person’s body surface to the host’s body surface. This can happen when a healthcare worker turns or bathes a patient, or performs other patient care activities that required direct personal contact. Direct contact transmission can also occur between two patients.

Indirect contact transmission—is when a source of infection contaminates an intermediate object, which then contacts a susceptible host. This can happen when contaminated gloves are not changed between patients or when a healthcare worker is stuck with a contaminated needle.

2. Droplet Transmission

Occurs when a source person produces tiny droplets containing infectious microorganisms. The droplets may be generated when the source person coughs, sneezes or talks, or during the performance of certain procedures such as bronchoscopy. The infectious droplets are propelled a short distance through the air and land in the host’s eyes, nose or mouth. Droplets do not remain suspended in the air.

3. Airborne Transmission—can occur over greater distances than droplet

transmission. The infectious microorganisms are carried by microscopic droplet nuclei or even dust particles that remain suspended in the air for long periods of time. The microorganisms can then be inhaled by a susceptible host in the same room, or they may be carried by air currents and infect people further away.

4. Common Vehicle Transmission —occurs when microorganisms are transmitted by contaminated items such as food, water, medications and equipment.

5. Vectorborne Transmission—occurs when mosquitoes, flies, rats and other vermin transmit microorganisms.

Common vehicle transmission and vectorborne transmission are both rare in U.S. healthcare facilities.

II. METHODS OF INFECTION CONTROL

According to the Centers for Disease Control, effective infection control programs have two levels: Standard Precautions and Transmission-Based Precautions.

A. Standard Precautions

The Occupational Safety and Health Administration (OSHA) requires that employers protect employees with exposure to blood and body fluids from potential infection by organisms such as HIV, Hepatitis B (HBV), Hepatitis C (HCV) and syphilis, among others. University Hospital has an Exposure Control Plan which outlines the methods that are in place to minimize employee risk. These methods include the use of standard precautions, exposure reporting and follow up and offering of the Hepatitis B vaccine. The Exposure Control Plan is located in the Infection Control Policy and Procedure Manual.

Since there is no quick, surefire method of determining which patients may be carrying an infectious disease, Standard Precautions require that you treat all patients as though they may be infected. Standard Precautions combine the major features of:

q Universal Precautions—which reduce the risk of transmitting bloodborne pathogens.

q Body Substance Isolation—which reduces the risk of transmitting pathogens from moist body substances.

In other words, you must use Standard Precautions every time you anticipate contact with blood, all body fluids, secretions and excretions, nonintact skin and mucous membranes. Standard Precautions cover all healthcare workers whether they give direct patient care or work in support areas, like maintenance and housekeeping.

Standard Precautions outline a system of safeguards to help you protect yourself from infections such as hepatitis B, hepatitis C and HIV, while also protecting your patients from infectious organisms that are often transmitted from patient to patient by healthcare workers. University Hospital has developed policies using Standard Precautions, including:

q Protective work practices

q Use of personal protective equipment

q Protective Housekeeping

q Protection through the hepatitis B vaccination

q Exposure reporting.

B. Protective Work Practices

You can decrease the spread of infection by using common sense and by practicing good hygiene.

1. Wash Your Hands

Handwashing is the single most important precaution for preventing the spread of infection. The sooner you wash infectious material off you hands, the less likely your chance of infection. Handwashing keeps you from transferring contamination from your hands to other areas of your body or other surfaces you may contact later. Hands should be washed for 10-15 seconds.

Always wash your hands:

q After touching blood, all body fluids, secretions and excretions, non-intact skin, mucous membranes and contaminated items – whether or not gloves are worn

q Immediately after gloves are removed and between patient contacts

q Before eating, drinking, smoking, applying makeup, handling contact lenses or using the restroom

q After you eat, smoke, cough, sneeze or use the toilet.

Use hand lotion after washing hands to prevent drying and chapping. However, in some situations, lotions may promoted the growth of harmful microorganisms. Petroleum-based lubricants may deteriorate latex gloves and some tubing. Be sure to wash your hands thoroughly before you apply lotion. Never top-off lotion or soap containers because this can promote the growth of harmful bacteria. Clean containers before refilling or use disposables.

2. Practice Good Hygiene

q Minimize splashing, spraying or spattering when performing procedures involving blood or other potentially infectious materials

q Do not eat, drink, smoke, apply cosmetics or lip balms, or handle contact lenses where there is a reasonable chance you might be exposed to blood or body fluids

q Do not keep food and drink in places where blood or other potentially infectious materials are present. (See attached OSHA Standards Interpretation and Compliance letter located after (page 8) in this module).

3. Handle Sharps With Care

Be careful to prevent injuries from needles and other sharp instruments when using them, cleaning them or disposing of them.

q Never bend, recap or break needles after use

q Dispose of contaminated sharps in appropriate puncture-resistant containers immediately after use.

q Always activate safety mechanism on sharp devices after use and before discarding.

4. Personal Protective Equipment

When worn properly, personal protective equipment (PPE) protects you from infectious hazards. PPE includes gloves, fluid-resistant gowns or aprons, faceshields, protective eyewear and masks, resuscitation bags or other ventilation devices.

PPE must be appropriate for the task you are doing. You should wear as much or as little PPE needed to keep blood or other potentially infectious materials from getting on your clothing, skin or mucous membranes.

For example: If you anticipate skin exposure only to your hands, you only need to wear gloves.

Types of PPE:

a. Gloves

Gloves are the most common type of PPE: You should use disposable gloves for medical procedures and heavy duty utility gloves for some housekeeping activities.

q Before putting on gloves, wash your hands thoroughly. Cover any hand cuts with bandages in case a glove leaks or tears.

q Use disposable gloves only once on a single patient—and then discard.

q Remove disposable gloves as soon as possible if they are contaminated, torn, punctured or damaged in any way, and then discard. Never wash or decontaminate them for reuse.

q Utility gloves may be cleaned or decontaminated for reuse only if they are not damaged. It damaged in any way—throw them out.

q Be careful when removing contaminated gloves, to not touch the outside of the glove. Always wash your hands after removing gloves. No glove offers 100 percent effective protection.

If you have dermatitis that is caused or aggravated by wearing gloves, or if you are allergic to disposable gloves, you should wear cotton glove liners, powderless gloves or hypoallergenic gloves – consult your manager or supervisor.

b. Face Protection

Fluid resistant masks and eye protection (splash guards or goggles) are to be worn if splashing to the face, mouth or nose is likely.

N95 Respirators are required for protection against tuberculosis

c. Fluid-Resistant Gowns

q Are to be worn if splashing or soiling of clothing is likely

q Remove clothing as soon as possible if soiled with blood or body fluids

d. Protection During Resuscitation

Since a patient may expel saliva, blood or other fluids which could contain infectious materials, avoid unprotected mouth-to-mouth resuscitation. Instead, use mechanical emergency respiratory devices and pocket masks designed to isolate you from contact with potentially infectious substances.

5. General Rules For PPE Use

q Always inspect your protective equipment before, during and after use

q Clean and maintain PPE properly

q Repair or discard any equipment that is flawed or damaged

q Replace PPE as soon as possible if it becomes penetrated by blood or other potentially infectious materials

q Always remove PPE before leaving the work area and place it in a designated receptacle for disposal, laundering or processing

q Remove PPE carefully to avoid contamination of clothing and skin.

q Remove PPE in the proper order i.e. gloves before other PPE. Wash hands after PPE removed.

University Hospital also provides equipment necessary to eliminate infectious hazards at their source, such as authoclaves, sharps disposal containers and needles with safety mechanisms attached.

C. Protective Housekeeping

Good housekeeping protects everyone and is everyone’s responsibility. Carefully follow University Hospital’s policies and procedures regarding housekeeping.

Follow these general rules:

- Handle used patient care equipment soiled with blood or other potentially infectious materials with care. Do not let the equipment touch your skin, mucous membrane, clothing, other patients or items in the environment.

- Clean reusable equipment appropriately before using it for the care of another patient. Single-use items must be discarded.

- Do not let sharps container overfill – call Environmental Services (2.5400) to remove containers when they are 2/3 full.

- To prevent contamination, handle soiled linen as little as possible and with minimum agitation. Without sorting or rinsing, place soiled linen in leakproof bags in the area where it was used. Do not place linen on the floor, furniture, windowsill, etc.

- Keep clean linen carts covered when not in use.

- Transport specimens in closed containers. Wear gloves and handle the containers carefully.

- Shake down waste containers and carry waste bags by the top, away from your body.

- Promptly contact Environmental Services to clean major blood and body fluid spills.

D. Regulated Medical Waste

9 All items contaminated with blood or body fluids are characterized as regulated medical waste

and are to be disposed of in red bags.

9 Waste from patients on isolation must also be deposited into red bags.

Note: Items that are not contaminated with blood or body fluids are to be disposed of in clear bags.

Contamination of body or clothing with blood and body fluid is likely. In the event that clothing should become contaminated, it should be removed promptly. REMEMBER: Hepatitis B virus can become active again even after existing dry on surfaces for between seven to thirty days.

9 Sharp objects are to be disposed of into sharp containers.

COMMON BLOODBORNE PATHOGENS

HUMAN IMMUNODEFICIENCY VIRUS (HIV) the virus that causes AIDS.

is transmitted by:

9 Sexual contact with an infected partner

9 Sharing needles with an infected person

9 Perinatally from mother to baby

9 Occupationally through mucous membrane (eye, nose, mouth) splashes, cuts, needlestick and contamination of nonintact skin (burns, acne lesions, wounds, etc).

2. HEPATITIS B (HBV) is transmitted by:

q Sexual contact with an infected partner

q Sharing needles with an infected person

q Perinatally from mother to baby

q Occupationally through mucous membrane (eyes, nose, mouth) splashes, cuts, needlestick and contamination of nonintact skin (burns, acne lesions, wounds, etc).

3. HEPATITIS C (HCV) is transmitted via:

q Sexual contact with a infected partner

Nonsexual household contact

Needle sharing

q Blood transfusion (now very rare)

q Perinatally

q Occupational exposure as described above

OTHER TYPES OF PRECAUTIONS

To prevent the spread of certain highly infectious or drug-resistant organisms, a second level of precautions, Transmission-Based Precautions, must be used in addition to Standard Precautions. Categories of Transmission-Based Precautions include:

q Airborne ( TB, measles, chickenpox, rubella etc.)

q Droplet (RSV, Meningitis etc.)

q Contact (MRSA, VRE, C.difficile, Rotavirus, Hepatitis A etc.)

Sometimes several of these special categories are combined or one category is individualized to meet the needs of the particular patient.

Depending upon the particular category, Transmission-Based Precautions may involve some of the following special infection control measures:

q Placing the patient in a private room or cohorting patients by grouping those who are actively infected with the same microorganisms

q Keeping the patient’s room door closed

q Wearing masks when entering the patient’s room

q Moving the patient from the room only for essential purposes

q Having the patient wear a mask outside the room

q Wearing gloves when entering the patient’s room

q Placing patients with infectious TB in rooms with proper ventilation, such as negative air-pressure rooms, and requiring anyone enter these rooms to wear appropriate respiratory protection.

TUBERCULOSIS

1) What Is Tuberculosis?

Tuberculosis (TB) is a disease that is spread from person to person through the air. TB usually affects the lungs. The germs get into the air when a person with TB of the lung or larynx coughs, sneezes, laughs, or sings. TB can also affect other parts of the body such as the brain, kidney or spine.

2) What Are the Symptoms of Tuberculosis?

q General symptoms may include feelings of weakness, weight loss, fever, loss of appetite, chills and/or night sweats.

q Symptoms of TB of the lungs (pulmonary TB) may included:

Cough, chest pain, fatigue, night sweats, weight loss and fever and blood in the sputum

(hemoptysis).

Other symptoms depend on the particular part of the body that is affected.

3) How am I protected against TB Exposure?

q Patients with confirmed or suspected TB are placed on Airborne Disease Isolation in a specially designed negative pressure room in which air flows in one direction from the hallway into the patient’s room. This prevents TB-contaminated air from going back into the hallway and exposing staff, patients and visitors to TB. For negative pressure to be effective, both the door to the anteroom and the door to the patient’s room must remain shut. If doors are left open, negative pressure is “broken” and contaminated air flows into the hallway.

q Employees must put on the N95 respirator with which they were fit-tested before going into the room of a patient on Airborne Disease Isolation.

q Patients on Airborne Disease Isolation must wear a surgical mask when being transported out of their rooms.

q Visitors must also wear a mask when going into Airborne Disease Isolation rooms. Staff must provided education to visitors and patients as needed.

q Health care workers can protect themselves from exposure to TB by following UH Infection Control Policy #841-200-025: “Guidelines for Preventing the Transmission of Tuberculosis in University Hospital and its Ambulatory Care Facilities.”

4) No One Gets TB anymore, Do They?

Yes! About 8 million new cases occur each year in the world. More that 22,000 cases are reported each year in the United States. There are also an estimated 10 to 15 million people in the United States who are infected with the TB germ and have the potential of developing TB disease in the future.

5) Who Gets TB?

Anyone can get TB, but some people are at higher risk. Those at higher risk include:

q People who share the same breathing space (such as family members, friends, co-workers) with someone who has TB disease

q People living in proverty

q Homeless people (including persons living in homeless shelters)

q Foreign born persons from countries where there are high rates of tuberculosis

q Nursing home residents

q Persons in prison

q Alcoholics and intravenous drug users (IVDU’s)

q People with medical conditions such as diabetes, certain types of cancers, and malnourishment (underweight persons)

q Person with HIV infection

q Healthcare workers

6) How Can I Tell If I Have TB?

First, get a TB skin test. If it is positive, you will probably be given other tests to see if you have TB infection or TB disease. Signs and symptoms of active TB may include persistent cough for more than three weeks, fatigue, night sweats, fever and weight loss.

6) What Is The Different Between TB Infection and Infectious TB Disease?

A. TB Infection

People with TB infection carry the germ that causes TB. They are not sick because the TB germ lies inactive in the body. These persons are not infectious and cannot spread the germ to others. However, they may develop active TB disease in the future, especially if they are in one of the high risk groups listed under “Who Gets TB?”. Medicine is often prescribed to prevent these persons from developing TB diseases.

B. TB Disease

People with infectious TB disease are sick from germs that are active in their bodies. They usually have one of more of the symptoms of TB listed in “How can I tell if I have TB?”. These persons are often capable of passing the infection to others. Permanent body damage and death (rare) can result from this disease. Medicines which can cure TB are prescribed for persons with infectious TB disease.

7) Where can I Get a TB Skin Test?

The Occupational Medicine Service (OMS) will test University Hospital employees.

All employees of University Hospital who are negative for TB infection must be skin tested for TB every year. Some employees (such as EMS, ER and Respiratory Therapy employees) may be tested more often depending on the number of TB patients they care for. Records of skin-testing results, evaluations and treatments must be maintained for the duration of employment.

If you have any questions about your TB skin test, call Occupational Medicine Service at 2-2900.

8) How Is the Skin Test Given?

A small needle is used to put some testing material, called tuberculin or PPD, under the skin. This is usually done on the inside of the forearm. The person getting the test must return to the OMS in 48 to 72 hours to see if there is a negative reaction to the test. If there is a positive reaction, the size of the reaction is measured.

9) What If the Skin Test Is Negative?

A negative test usually means that the person is not infected. However, the test may be falsely negative in a person who has been recently infected. It usually takes 2 to 10 weeks after exposure to a person with TB disease for the skin test to react positively. The test may also be falsely negative if the person’s immune system is not working properly.

10) What If the Skin Test Is Positive?

A positive reaction usually means that the person has been infected with the TB germ. It does not necessarily mean that the person has infectious TB disease. Other tests, such as x-rays or sputum samples, are needed to see if the person is infectious. You may need to take medication.

11) What If I Have Infectious TB Disease?

If you have infectious TB, you will not be permitted to return to work until you are no longer infectious. All TB follow-up care is provided, free of charge, at the National Tuberculosis Center’s Lattimore Clinic. All TB follow-up care is confidential. However, your family and friends may be contacted to seek evaluation if it is determined that you have infectious TB.

12) What If I have Had BCG Vaccine?

UMDNJ-UH does not accept BCG vaccination in accordance with CDC recommendations. All positive skin test reactors will be evaluated.

13) What should I Do If I have TB Infection or Disease?

Get the required follow up tests. Follow your doctor’s advice and take the medicine as prescribed. Today, TB is easily prevented and cured with medication.

14) What Should I Do If I Am HIV Positive?

HIV infected health care workers may have a higher risk of becoming infected with TB in the workplace. Also, persons with HIV may have a more rapid onset of TB disease which may not be detectable by PPD skin testing. If you are HIV positive, discuss your job responsibilities with your health care provide. You may wish to consider voluntary work reassignment.

INFECTION CONTROL EDUCATION POST-TEST

NAME ________________________DEPT./UNIT__________________ DATE ________

_______1. In airborne transmission germs are carried over great distances on dust and can

remain in the air for long periods of time. True/False

_______2. In droplet transmission, germs travel short distances through the air and land in

the host’s eyes, nose or mouth. True/False

_______ 3. Bloodborne pathogens include

a) HIV

b) Hepatitis B

c) Hepatitis C

d) Syphilis

e) All of the above

_______ 4. All of the following are examples of occupational exposure to bloodborne pathogens

EXCEPT

a) A respiratory therapist is splashed with blood in the eye during an arterial puncture.

b) A nurse sustains a needlestick when discarding a needle use to draw blood from a patient.

c) A nursing assistant gets a drop of clear urine on his shoe while emptying urine from a Foley catheter.

d) A surgeon sustains a scalpel cut when making an abdominal incision on a patient.

_______ 5. Standard Precautions mean that blood and body fluid are treated as if potentially

infectious. True/False

_______ 6. Personal Protective Equipment (PPE) includes

a) Latex or vinyl disposable gloves

b) Fluid shield masks

c) Fluid resistant gowns

d) All of the above

_______ 7. Handwashing should be performed by using soap, running water and vigorous friction for

a) 5-7 seconds

b) 10-15 seconds

c) 3-4 seconds

d) Wetting the fingertips under running water for 2 seconds

_______ 8. Handwashing should be performed

a) After soiled gloves are removed

b) After patient contact

c) Before patient contact

d) All of the above

_______ 9. Sharps containers are available for the prompt disposal of all needles and other sharp

objects including broken glass. True/False

_______10. Items contaminated with blood or body fluids are placed into red bags.

True/False

_______11. The OSHA Bloodborne Pathogens Standards prohibit eating and drinking in areas where blood and body fluids are handled because these germs can be introduced into the body by contaminated hands and contaminated beverage containers. True/False

_______12. Items that are not contaminated with blood or body fluids are placed into clear bags.

True/False

_______13. As long as disposable gloves are not broken they could be washed and re-used.

True/False

______ 14. The Exposure Control Plan for Bloodborne Pathogens is located in the Infection Control Policy and Procedure Manual. True/False

______ 15. Contact precautions are used for patients with drug-resistant organisms such as

MRSA and VRE . True/False.

_______16. TB is primarily transmitted by

a) Direct skin-to-skin contact

b) Needlesticks

c) Airborne droplets

d) Blood splashes to the face

_______17. A patient with TB disease is infectious and must be put on Airborne Disease Isolation.

True/False

_______18. A person with TB Infection is not infectious. True/False

_______19. Negative Pressure means

a) Air flows in one direction from the patient's room into the hallway.

b) Air flows in one direction from the hallway into the patient's room.

c) Air flows back and forth from the patient's room into the hallway.

_______20. An N95 respirator must be worn by all staff members going into the room of a patient on Airborne Disease Isolation. True/False

_______21. TB skin testing is done every year for most employees with negative skin tests.

True/False

_______22. Some employees receive skin tests more often than once a year if they care for many TB

patients. True/False

_______ 23. The precaution sign used for Airborne Disease isolation is

a) b) c) d)

_______ 24. Patients on Airborne Disease Isolation must wear a surgical mask when they are

transported out of their rooms. True/False

_______ 25. Symptoms of TB disease include

a) Night sweats

b) Cough

c) Fever

d) Weakness

e) All the above