INFECTION CONTROL IN ICU

Dr. Dilan Ranasinghe

MO ( Cardiothoracic Anaesthesia)

Why is it Important?
1. 2. 3.

ICU account for 10% of total Hosp. beds. ICU population uses a significant percentage of total hospital health care resources. Incidence of Nosocomial infections in ICUs is 5-10 times higher than Gen. wds.

> 20% of all Nosocomial infections.

1.

2.

Nosocomial infections are 1. Resistant to commonly used Ab. 2. Multidrugs resistant. Morbidity, Mortality, ICU stay, Cost.

NOSOCOMIAL INFECTIONS
(Hospital Associated Infections)

An infection acquired in a patient in a hospital or other healthcare facility in whom it was not present or incubating at the time of admission.

Why Nosocomial infections are common in ICU?

1.

The normal host defense mechanisms of these critically ill ICU pts are often
1. 2.

Disrupted by devices (Central lines/U. cath./ETT) Impaired by - Underlying Disease - Result of medical intervention. (H 2 blockers)

1. 2.

Urgent & Frequent nature of pts needs. Infection control practices compromised. Multiple Health care teams.
1. 2. 3.

Different responsibilities. Different level of training. Limited time.

3.

External infection control threats.

Can alter the endemic flora in ICU

INFECTION CONTROL
Studies shows Nosocomical infections are preventable between 30 80% by proper pt care practices. Definition (Hospital Infection Control Manual 2005) SERIES OF PROCEDURES AND GUIDELINES TO PREVENT HOSPITAL ASSOCIATED (NOSOCOMIAL) INFECTIONS.
Effective programs are usually base on cooperation of many different Health Care Teams.

Infection Control Measures in ICU

1. 2. 3. 4.

5. 6.

Design & layout of ICU. Hand washing and aseptic precautions. Environment cleaning. Cleaning; Disinfection and Sterilization of Equipments / Furniture. Unit discipline. Waste disposal.

Design & layout of ICU.

General Requirements

Quick and unimpaired access to patients. Source isolation, protective isolation or both. Facilities for hand washing and drying available at each bed. An 8 bed unit, with 2 divisions Each having 3 beds and isolation room (single bed) Adequate space between beds (3m between bed centers) Mechanical ventilation is desirable. Turnover of air (10/20 air changes/hr) keep airborne bact.

Isolation

Space

Ventilation

Hand washing and aseptic precautions

Microbiology of Skin

The finger nail area is associated with a major portion of the Hand Flora. The subungual are (under the finger nails) often harbour high No. of Micro-organisms.

Which may serve as a source of continuous shedding

The Microbial flora of the Skin consist of

1. 2.

Resident (Colonizing) micro-organisms. Transient (Contaminating) micro-organisms.

Hand washing and aseptic precautions

The Resident microbial flora

Survive and multiply in the skin.

Caugulase negative Staphylococci. Corynebacterium spp. (diptheroids/coryneforms) Acinetobactor spp. Occasionally Enterobacteriaceae spp.

Usually not implicated in Nosocomial infections Can cause minor skin infections Some can cause infections

After invasive procedures Sever immunocompromised Implantable device (Heart valve, Art. HJ)

Hand washing and aseptic precautions

The transient microbial flora

Recent contaminant of the hands acquired from

Colonized / infected pt. Contaminated environment / equipment

These are not constantly isolated from most HCW But more frequently implicate as the source of HAIs Most common are

Gram negative Coliforms (40% - HAI)

E. coli, Enterobacter, Klebsiella

Staphylococcus aureus

Hand washing
Hand washing with plain soap is effective in removing most of transient microbial flora
The component of good hand washing
Using an adequate amount of soap/antiseptic agent Rubbing the hands together 15 sec

To create some friction

Rinsing under running water. Pat dry hands with paper towel or single use clothe towel ? Air dryers Good/ Bad

Hand washing
Purpose of hand washing

To Remove
Soil Organic material

From the hand

Transient micro-organisms

Soap or Antiseptic Agents

Gen. wds Not significant Critical care unit May significant

Possibility of Ab resistant organisms Heavy contamination with organic mater

Hand washing
Soap

Liquid soap is better than bar soap If only bar soap is available

Provide as small pieces just adequate for the day Place on a rack no water is retained

Antiseptic Products
2 - 4% Chlorhexidine gluconate (Good residual activity) 7.5% Povidone iodine

Antiseptic hand cleansers are designed to

Rapidly wash off the majority of the transient flora

by their mechanical detergent effects

Exert an additional sustained antimicrobial activity on the resident hand flora.

Hand washing
Waterless Hand rubs

Several studies have demonstrated superior efficacy over soap/Chlorhexidine hand wash. Time After Disinfection log 0 6 180 minutes 3.0 0 2.0 Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Baseline Plain soap

% 99.9

Bacterial Reduction

99.0

90.0

1.0

0.0

0.0

Hand washing
Waterless Hand rubs

Advantages
1. 2.

Have immediate & sustain antimicrobial performance No wash basin is necessary

Can be conveniently available near every pt.

1.

More practical and time saving. 15 sec.

Disadvantages
1.

Effects on the user

1. 2.

May cause drying of the skin Addition of emollients Odour may be irritant Use with dry hands

2.

Efficacy by dilution with water Activity may when use with soiled hands. Eg blood

1.

Always wash with soap/antiseptic to clean the visible contaminant

Hand washing
Recommendations on Hand Washing
Hands must be washed 1. Between direct contact with individual patients 2. Before performing invasive procedures 3. Before preparing, handling, serving or eating food, and before feeding a patient 4. When hands are visibly soiled 5. After situations or procedures in which microbial or blood contamination of hands is likely 6. Before wearing and after removing gloves 7. After personal body functions, such as using the toilet or blowing ones nose.

Hand washing

Aseptic precautions
DEVICE RELATED NOSOCOMIAL INFECTION

Is an infection in a patient with a device

1. 2. 3.

Central line Ventilator Indwelling urinary catheter

that was in use within the 48-hour period before onset of infection. If the interval since discontinuation of the device is longer than 48 hours, there must be compelling evidence that infection was associated with device use.

Environment cleaning
Floors
Mop with GPD twice day Use 0.1% Hypochlorite if there is an outbreak of sepsis. Use separate mops for different cubicles. Dry the mops in sun light. Store them upside down. Wash mops in 0.1% Hypochlorite weekly. Damp dust with GPD once weekly. Damp dust with GPD daily and between patients. Dry with clean dry cloth.

Mops

Walls Horizontal Surfaces

GDP :- General Purpose Detergents

Environment cleaning
Wash twice a day with GPD.

Sink / taps / door handles Bath rooms

Wash twice daily with GPD, including door knobs and taps. Wipe daily with 70% alcohol.

Telephone

Cleaning of Blood & Body fluids Spillages Wear heavy duty gloves
Soak up fluid using absorbent. (wadding, gauze, paper towels) Pour 1% Hypochlorite solution till it is well soaked.. Leave >10min. Discard absorbent as clinical waste. Clean area with detergent & water & dry. Discard gloves as clinical waste. Wash hands. Low risk body fluid (Faeces, Vomitus, Urine) Wear gloves. Soak up fluid using absorbent material. Clean area with detergent & water & dry. Discard gloves as clinical waste. Wash hands.

Cleaning, Disinfection and Sterilization of Equipments / Furniture.

Cleaning

Physical removal of dirt.

Removes many micro-organisms. Should also be done prior to sterilization & disinfection. Difficult to quantify other than visually.

Disinfection

Elimination of nearly all recognized pathogenic organisms.

Not necessarily all micro-organisms. Liquid chemical (detergent/antiseptic), UV light, Boiling water..

Sterilization

Complete elimination of all microbial forms including spores.

Moist heat, Dry heat, Ethylene Oxide gas, Liquid chemicals, Irradiation.

Cleaning, Disinfection and Sterilization

Furniture

Bed/Bedrai Damp dust daily with GPD ls Clean with GPD & 0.1% Hypochlorite for Cupboards septic pts.

Mattresse Cover with impermeable material. Damp dust weekly with GPD. s
Wipe with GPD between patients and dry thoroughly. Replace torn mattresses. Clean with GPD & 0.1 % Hypochlorite for septic pts. Minimize the No. Other Furniture Damp dust weekly with GDP

Cleaning, Disinfection and Sterilization ventilators & accessories

Ventilators

Method :- GPD or 70% alcohol

Follow manufacturers instructions wherever possible. Wipe clean with GDP or 70% alcohol & dry daily and between pts. External filters should be changed between pts. Clean internal mechanisms including internal filters according to manufactures instruction

By authorized maintenance staff Should have user manual & maintenance records for each vent.

Proper decontamination according to the manufactures inst. is needed after ventilation of pt with

Tuberculosis, Resistant Gram-neg. organisms in RT, MRSA in RT, Definite fungal lung infections, Lobar and Community acquired pneumonias.

Cleaning, Disinfection and Sterilization ventilators & accessories

Ventilator tubing Method :- 1. SU Ideal

2. CSSD Clean with GDP & Autoclave 3. 2% Gluteraldehyde Immerse 30min & rinse with
sterile water; Store dry & covered.

4. Peracetic acid Immerse 10min & rinse with sterile

water; Store dry & covered.

Tubes should be dated & changed weekly.

Twice a week for long term pts.

Change between pts.

CSSD Central Sterilization & Supplies Division SU Single Use

Cleaning, Disinfection and Sterilization ventilators & accessories

Humidifiers Method :- 1. GPD Empty and clean reservoir

daily with GDP Dry thoroughly Refill with sterile water

2. CSSD Autoclave
all pts Use sterilized humidifiers for

3. 2% Gluteraldehyde 4. Peracetic acid

Cleaning, Disinfection and Sterilization ventilators & accessories

Reservoir bags Method :- 1. SU Preferred 2. GPD

Partially filling the bag with water and GPD. Shaking the bag and then rinsing withy sterile water. Outer surface is washed with GPD & water and dried

3. CSSD 4. 2% Glutaraldehyde
For known or suspected infections such as TB

Cleaning, Disinfection and Sterilization ventilators & accessories

Airways (Plastic / Metal) Method :- SU / CSSD Oxygen masks

Clean daily or when soiled Change between pts.

Methods :- 1. GPD+70% Alcohol

Clean with GPD and wipe with 70% alcohol

2. 1% Hypochlorite
Use in with/suspected TB Immerse for 30min & rinse with water

Cleaning, Disinfection and Sterilization ventilators & accessories

Laryngoscopes Method :- 1. CSSD Ideal method 2. GPD+70% Alcohol Alternate method

Wash blade with GPD & wipe with 70% Alcohol Wipe hand piece with 70% Alcohol. Store dry.

Endotrachial tubes Method :- SU

Cleaning, Disinfection and Sterilization ventilators & accessories

Nebulizers

Masks
Change daily / When soiled Change between pts.

Method :- 1. GPD+70% Alcohol 2. 1% Hypochlorite

Pts with/suspected TB

Tubing Method :- 1. SU 2. GPD+1% Hypochlorite

Flush with GPD & aspirate 1% Hypochlorite into tube. Immerse in 1% Hypochlorite for 30 min & rinse well with water.

Suction apparatus Suction catheters

Methods :- SU

Cleaning, Disinfection and Sterilization ventilators & accessories

Suction tubing Bottles/Jars

Methods :- SU

Empty when 2/3 full or daily whichever is more frequent.

Methods :-1. CSSD If autoclavable send to CSSD after washing with GPD 2. 1% Hypochlorite Non-autoclavable ones, washed
with GPD and immersed for 30min

3. 2% Gluteraldehyde Metal lids immersed for 30 min.

Cleaning, Disinfection and Sterilization ventilators & accessories

Infusion pumps Method :- GPD Wipe daily

Ensure surfaces completely free of infusion residuals

Infusion stands Method :- GPD

Wash when soiled and on completion of patient use

Cleaning, Disinfection and Sterilization ventilators & accessories Arterial lines

Method :- SU - pre sterilized items

Change all lines every 48hrs

BP cuffs One per pt ECG monitors

Method :- GPD Wash and dry between pts Method :- External Damp dust daily and between Pts Control panels GPD/Alcohol wipe
at the beginning of a shift

Stethoscopes One per pt

Method :- Alcohol wipes

Clean daily and between pts Should not be taken from pt to pt without cleaning

Unit discipline
Aim is to achieve protective isolation of the pt
1.

2.

Staff handling pts. must wash hands thoroughly before & after attending on pt. Staff coming in from other areas of hospital
1.

should wear gowns

only if they examine or make contact with the pt.

1.

2.

Staff and visitors with obvious infection should not enter. Visitors and staff should not touch anything unless it is absolutely essential to do so.

Waste disposal
WHO recommendations

Black Non infectious / Non Hazardous Yellow Infectious waste Sharp bin

Effluents Untreated effluent should be discharged to

1. 2.

Sanitary sewerage system to treatment plant Closed drainage system

Dedicated sink/commode for this purpose If there is no closed drainage system decontaminate before discharge into the drainage system.

with equal volume of 1% Hypochlorite TB 5% Lysol overnight

Prevention is primary
Thank You.