I INFECTION CONTROL ^xiv ^69 ^107 ^140

All women’s health care facilities need effective infection control proce­dures to protect patients and staff. The following recommendations—for hand hygiene; cleaning, disinfecting, and sterilizing patient care equipment; isolation and standard precautions; management of occupational expo­sures and of infected health care workers; and cleaning and disinfecting the environment of care—provide an infection control framework for all health care facilities.

Hand Hygiene

Hand antisepsis is the single most important means of reducing health care-associated infections, a concept first introduced by the Hungarian obstetrician Ignaz Semmelweis in 1847. Improved adherence to hand hygiene has been shown to terminate outbreaks of infection in health care facilities, to reduce transmission of antimicrobial-resistant organisms (eg, methicillin-resistant Staphylococcus aureus), and to reduce overall infection rates. It is a key part of patient safety efforts (see also the “Patient Safety” section in Part 1).

The term hand hygiene refers to either hand washing with soap and water or the use of alcohol-based gels or foams that do not require water. The introduction of alcohol-based products has made hand hygiene much easier to perform and less time consuming, which leads to improved com­pliance with guidelines. The widespread placement of gel or foam dispens­ers in all patient care areas has increased compliance. Alcohol-based hand rubs are more effective at killing bacteria and less irritating to the skin than soap and water. Cleansing with soap and water is preferred when hands are visibly dirty or contaminated with organic materials. The Centers for Disease Control and Prevention (CDC) has published guidelines for hand hygiene in health care settings.

Hand hygiene should be practiced immediately before touching a patient, performing an invasive procedure, or manipulating an invasive device; immediately after touching a patient or contaminated items or surfaces; and after removing gloves or touching items or surfaces in the immediate patient care environment, even if the patient was not touched. Clinicians should perform hand hygiene when leaving a patient’s room even if they didn’t touch the patient because bacteria can survive on patient care equipment and surfaces for days.

The use of sterile or nonsterile gloves also is important in preventing serious hospital infections. Important reasons for the routine use of gloves by hospital personnel include the following:

• Providing an effective barrier between contaminated material or contaminated equipment and the caregiver’s hands

• Reducing the likelihood of acquiring an infectious organism from a patient who is already colonized or infected with a known pathogen

• Preventing the transmission of a skin-carried pathogenic organism from hospital staff to patients

The use of gloves does not mean that proper hand hygiene can be omit­ted because there can be defects or tears in gloves and skin can become contaminated when gloves are removed. Studies have demonstrated that organisms, such as methicillin-resistant S aureus, still can be recovered from surgeons’ hands after gloves have been removed. Consequently, routine hand washing before and immediately after the use of gloves is required.

Isolation and Standard Precautions

The CDC’s “Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings in 2007” includes recommenda­tions for preventing transmission of infectious agents across all health care settings. The CDC guidelines are based on the rationale that identification of a pathogen, its source, and the mode of transmission will suggest a logical means to prevent transmission.

The CDC recommends that standard precautions be used consistently for all patients. Because medical history and examination cannot identify reliably all patients infected with human immunodeficiency virus (HIV) or other bloodborne pathogens, the CDC recommends the use of standard precautions for all patients to protect health care workers from infectious body fluids. These recommendations incorporate the prior concept of uni­versal precautions to prevent transmission of bloodborne pathogens and recognize the importance of all body fluids, secretions, and excretions in the transmission of health care-associated infections.

These precautions apply to the following:

• Blood

• All body fluids, secretions, and excretions except sweat, regardless of whether they contain visible blood

• Nonintact skin

• Mucous membranes

Standard precautions include the following techniques:

• Perform hand hygiene after touching blood or body fluids and contaminated items, even when gloves are worn, and between patient contacts.

• Wear gloves when touching blood, body fluids, and contaminated items, and remove them promptly after use, before touching non­contaminated surfaces.

• Wear a mask and eye and face protection during activities that may generate a splash or spray of blood or body fluids to the face.

• Wear a gown during activities that may generate a splash or spray of blood or body fluids to clothing or skin.

• Handle patient care equipment soiled with blood or body fluids so as to prevent contamination of skin, mucous membranes, clothing, and other surfaces. Single-use items should be discarded properly, and reusable equipment must be cleaned and reprocessed appropriately.

• Have written procedures for routine cleaning, care, and disinfection of frequently touched surfaces.

• Have written procedures for handling soiled linen to prevent con­tamination of clean surfaces.

• Take care to prevent injuries when using sharp instruments. Never recap used needles; instead, place used disposable syringes, needles, scalpel blades, and other sharps in puncture-resistant, disposable containers located as close as practical to the area where the items are normally used. Evaluate and use, as appropriate, devices to pre­vent exposures, such as blunt-tip suture needles, safety scalpels, self-sheathing needles, and needle-holding devices. (The U.S. Food and Drug Administration, the CDC’s National Institute for Occupational Safety and Health, and the Occupational Safety and Health Administration strongly encourage health care providers in surgical settings to use blunt-tip suture needles as an alternative to standard suture needles, when clinically appropriate, to reduce the risk of needlestick injury and subsequent pathogen transmission to surgical personnel.) Use a no-touch method to pass sharp instru­ments between individuals.

• Have mouthpieces readily available to use as an alternative to mouth-to-mouth resuscitation.

• Follow respiratory hygiene and cough etiquette.

• Adhere to safe injection practices.

• Wear a mask for insertion of catheters or injection of material into spinal or epidural spaces via lumbar puncture procedures (eg, myelogram or spinal or epidural anesthesia).

Postexposure Testing and Prophylaxis

If one is inadvertently exposed to the blood of a patient, immediate atten­tion is required, specifically the following: wash needlestick injuries and cuts with soap and water; flush splashes to the nose, mouth, or skin with water; and irrigate eyes with clean water, saline, or sterile irrigants. Using antiseptics or squeezing the wound has not been shown to reduce the risk of transmission of a bloodborne pathogen. Additionally, the use of caustic agents such as bleach is not recommended.

Public Health Service guidelines for the management of occupational exposures to HIV, including recommendations for postexposure prophy­laxis, are available (see Resources).

The CDC advises that if a health care worker is exposed to blood or body fluids that might result in hepatitis B virus (HBV) transmission, the recommended postexposure management strategy depends on the health care worker’s HBV vaccination status and HBV antibody levels and on the source patient’s hepatitis B surface antigen status (see Bibliography). After an occupational exposure, such as a needlestick injury, the health care worker, as well as the patient, should be tested for the antibody to hepatitis C virus (HCV). Postexposure prophylaxis for HCV is not effective and is not recommended. However, early antiviral therapy may be effective in reduc­ing the risk of progression to chronic HCV infection.

Management of Infected Health Care Workers

The risk of transmission of bloodborne infectious agents from infected health care workers to patients must be considered, although the rate is exceedingly low. Clinicians infected with a bloodborne virus must make a decision as to which procedures they can continue to perform safely. This decision will depend on the category of clinical activity and the circulat­ing viral burden. The physician’s level of expertise and his or her medical condition, including mental status, are other factors to be considered. The Society for Healthcare Epidemiology of America (SHEA) and the CDC rec­ommend that the decision be made in consultation with an expert review panel, although the CDC indicates that oversight by an expert review panel is not needed for clinicians infected with HBV who do not perform exposure-prone procedures.

The SHEA and the CDC have categorized obstetric-gynecologic proce­dures according to the level of risk of bloodborne pathogen transmission. Some aspects of obstetrics and gynecology do not involve measurable risk of transmission of infection. For example, routine vaginal examinations carry negligible risk of bloodborne virus transmission. Hysterectomies carry a definite risk of bloodborne virus transmission. There is some dis­agreement between the SHEA and CDC guidelines. The SHEA guidelines, unlike those from the CDC, include a category of intermediate risk. In the SHEA guidelines, bloodborne virus transmission is deemed theoretically possible but unlikely for minor gynecologic procedures (such as insertion and removal of contraceptive devices).

In addition to the type of procedure, the restriction of clinical practice also depends on the type of virus and the circulating viral burden. High- viral load concentrations have been associated with an increased risk of transmission, but guidelines vary as to the viral burden that would trigger the need for expert review panel oversight or practice limitation.

Cleaning and Disinfecting Patient Care Equipment

To reduce the risk of disease transmission in the health care environment, it is imperative that all facilities follow established infection-control practices in cleaning, disinfecting, and sterilizing patient care equipment. Health care workers should be aware that practices regarding the selection and use of sterilization methods and disinfectants continue to evolve, with new recommendations coming forth as new products and information become available. The CDC and the Association for Professionals in Infection Control and Epidemiology provide recommendations for the preferred methods for disinfection and sterilization of patient care equipment in the health care environment (see Bibliography). The American Institute of Ultrasound in Medicine has published guidelines for cleaning and prepar­ing endocavitary ultrasound transducers between patients (see Box 2-2).

Environmental Infection Control

The CDC also has issued guidelines and recommendations for environ­mental infection control in health care facilities. These guidelines include such topics as infection control for ventilation and water systems; use of

Box 2-2. Guidelines for Cleaning and Preparing Endocavitary Ultrasound Transducers Between Patients

1. Remove probe cover and clean probe with running water and a mild, nonabrasive, liquid soap. A brush may be used to clean crevices. Rinse and dry.

2. Disinfect with a sterilant approved by the U.S. Food and Drug Administration[†] that is in accordance with the manufacturer’s instruc­tions concerning compatible disinfecting agents.

3. Cover the probe with a barrier before use. Nonlubricated, nonmedicated condoms are an excellent barrier. Nonlatex barriers should be available for latex-sensitive patients.

4. Wear gloves when performing transvaginal ultrasonographic examina­tions, removing the barrier, and cleaning the probe. dust-control procedures and barriers during construction, repair, renova­tion, and demolition; environmental infection control measures for spe­cial areas with patients at high risk; environmental surface cleaning and disinfection strategies with respect to antibiotic-resistant microorganisms; use of barrier protective coverings for difficult-to-clean equipment, such as computer keyboards; and infection-control procedures for health care laundry (see Resources).

Bibliography

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Association for Professionals in Infection Control and Epidemiology. APIC text of infection control and epidemiology. 3rd ed. Washington, DC: APIC; 2009.

CDC guidance for evaluating health-care personnel for hepatitis B virus protec­tion and for administering postexposure management. National Center for HIV/ AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention. MMWR Recomm Rep 2013;62:1-19. [PubMed] [Full Text]

Food and Drug Administration. FDA-cleared sterilants and high level disinfec­tants with general claims for processing reusable medical and dental devices- March 2009. Silver Spring (MD): FDA; 2009. Available at: http://www.fda.gov/ MedicalDevices/DeviceRegulationandGuidance/ReprocessingofSingle-UseDevices/ ucm133514.htm. Retrieved January 30, 2014.

Henderson DK, Dembry L, Fishman NO, Grady C, Lundstrom T, Palmore TN, et al. SHEA guideline for management of healthcare workers who are infected with hepatitis B virus, hepatitis C virus, and/or human immunodeficiency virus. Society for Healthcare Epidemiology of America. Infect Control Hosp Epidemiol 2010;31:203-32. [PubMed] [Full Text]

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Rutala WA, Weber DJ. Guideline for disinfection and sterilization in healthcare facilities, 2008. Healthcare Infection Control Practices Advisory Committee. Atlanta (GA): Centers for Disease Control and Prevention; 2008. Available at: http://www. cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008.pdf. Retrieved July 16, 2013. Siegel JD, Rinehart E, Jackson M, Chiarello L. 2007 guideline for isolation precau­tions: preventing transmission of infectious agents in healthcare settings. Healthcare Infection Control Practices Advisory Committee. Atlanta (GA): Centers for Disease Control and Prevention; 2007. Available at: http://www.cdc.gov/hicpac/pdf/isola tion/Isolation2007.pdf. Retrieved July 16, 2013.

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Resources

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Centers for Disease Control and Prevention. Exposure to blood: what healthcare personnel need to know. Atlanta (GA): CDC; 2003. Available at: http://www.cdc. gov/HAI/pdfs/bbp/Exp_to_Blood.pdf. Retrieved July 16, 2013.

Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care. Atlanta (GA): CDC; 2011. Available at: http://www.cdc.gov/HAI/pdfs/guidelines/standatds-of-ambulatory- care-7-2011.pdf. Retrieved July 16, 2013.

Centers for Disease Control and Prevention. Hand hygiene in healthcare settings. Available at: http://www.cdc.gov/handhygiene. Retrieved July 16, 2013.

Centers for Disease Control and Prevention. Healthcare-associated infections.

Available at: http://www.cdc.gov/hai. Retrieved July 16, 2013.

Centers for Disease Control and Prevention. Occupational HIV transmission and prevention among health care workers. Atlanta (GA): CDC; 2013. Available at: http://www.cdc.gov/hiv/pdf/risk_occupational_factsheet.pdf. Retrieved September 26, 2013.

Facilities Guidelines Institute. Guidelines for design and construction of health care facilities. 2014 ed. Chicago (IL): American Society for Healthcare Engineering of the American Hospital Association; 2014.

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