39053599-inf-cont-in-icu

INFECTION INFECTION CONTROL IN ICUCONTROL IN ICU

Dr. Dilan Dr. Dilan RanasingheRanasingheMO ( Cardiothoracic MO ( Cardiothoracic Anaesthesia)Anaesthesia)

Why is it Important?Why is it Important?1.1. ICU account for ICU account for ≤≤ 10% of total Hosp. beds. 10% of total Hosp. beds.

2.2. ICU population uses a significant percentage of total ICU population uses a significant percentage of total hospital health care resources.hospital health care resources.

3.3. Incidence of Nosocomial infections in ICUs is 5-10 times Incidence of Nosocomial infections in ICUs is 5-10 times higher than Gen. wds.higher than Gen. wds.

> 20% of all Nosocomial infections.> 20% of all Nosocomial infections.1.1. Nosocomial infections areNosocomial infections are

1.1. Resistant to commonly used Ab.Resistant to commonly used Ab.

2.2. Multidrugs resistant.Multidrugs resistant.

2.2. ↑ ↑ Morbidity, Mortality, ICU stay, Cost.Morbidity, Mortality, ICU stay, Cost.

NOSOCOMIAL INFECTIONSNOSOCOMIAL INFECTIONS(Hospital Associated Infections)(Hospital Associated Infections)

An infection acquired in a patient An infection acquired in a patient in a hospital or other healthcare in a hospital or other healthcare

facility in whom it was not facility in whom it was not present or incubating at the time present or incubating at the time

of admission.of admission.

Why Nosocomial infections Why Nosocomial infections are common in ICU?are common in ICU?

1.1. The normal host defense mechanisms of these critically The normal host defense mechanisms of these critically ill ICU pts are oftenill ICU pts are often

1.1. DisruptedDisrupted by devices (Central lines/U. cath./ETT) by devices (Central lines/U. cath./ETT)2.2. ImpairedImpaired by - Underlying Disease by - Underlying Disease - Result of medical intervention. (H - Result of medical intervention. (H 22 blockers) blockers)

1.1. Urgent & Frequent nature of pt’s needs.Urgent & Frequent nature of pt’s needs. Infection control practices compromised.Infection control practices compromised.

2.2. Multiple Health care teams.Multiple Health care teams.1.1. Different Different responsibilitiesresponsibilities..2.2. Different Different level of traininglevel of training..3.3. Limited Limited timetime..

3.3. External infection control threats.External infection control threats.Can alter the Can alter the endemic floraendemic flora in ICU in ICU

INFECTION CONTROLINFECTION CONTROL

Studies shows Nosocomical infections are Studies shows Nosocomical infections are preventable between 30 – 80% by preventable between 30 – 80% by

proper pt care practices.proper pt care practices.

DefinitionDefinition (Hospital Infection Control Manual – 2005) (Hospital Infection Control Manual – 2005)

SERIES OF SERIES OF PROCEDURESPROCEDURES AND AND GUIDELINESGUIDELINES TO PREVENT TO PREVENT HOSPITAL ASSOCIATED HOSPITAL ASSOCIATED

(NOSOCOMIAL) INFECTIONS.(NOSOCOMIAL) INFECTIONS.

Effective programs are usually base on cooperation of Effective programs are usually base on cooperation of many different Health Care Teamsmany different Health Care Teams..

Infection Control Measures Infection Control Measures in ICUin ICU

1.1. Design & layout of ICU.Design & layout of ICU.

2.2. Hand washing and aseptic precautions.Hand washing and aseptic precautions.

3.3. Environment cleaning.Environment cleaning.

4.4. Cleaning; Disinfection and Sterilization of Cleaning; Disinfection and Sterilization of Equipments / Furniture.Equipments / Furniture.

5.5. Unit discipline.Unit discipline.

6.6. Waste disposal.Waste disposal.

Design & layout of ICU.Design & layout of ICU.

General RequirementsGeneral Requirements Quick and unimpaired access to patients.Quick and unimpaired access to patients. Source isolation, protective isolation or both.Source isolation, protective isolation or both. Facilities for hand washing and drying available at each Facilities for hand washing and drying available at each

bed.bed.

IsolationIsolation An 8 bed unit, with 2 divisions An 8 bed unit, with 2 divisions Each having 3 beds and isolation room (single bed)Each having 3 beds and isolation room (single bed)

SpaceSpace Adequate space between beds (3m between bed centers)Adequate space between beds (3m between bed centers)

VentilationVentilation Mechanical ventilation is desirable.Mechanical ventilation is desirable. Turnover of air (10/20 air changes/hr) Turnover of air (10/20 air changes/hr)

keep airborne bact. keep airborne bact. ↓↓

Hand washing and aseptic precautionsHand washing and aseptic precautions

Microbiology of SkinMicrobiology of Skin The The finger nail areafinger nail area is associated with a is associated with a

major portion of the major portion of the Hand Flora.Hand Flora. The subungual are (under the finger nails) The subungual are (under the finger nails)

often harbour high No. of Micro-organisms.often harbour high No. of Micro-organisms. Which may serve as a source of continuous Which may serve as a source of continuous

sheddingshedding

The Microbial flora of the Skin consist ofThe Microbial flora of the Skin consist of1.1. ResidentResident (Colonizing) micro-organisms. (Colonizing) micro-organisms.

2.2. TransientTransient (Contaminating) micro-organisms. (Contaminating) micro-organisms.


The Resident microbial floraThe Resident microbial flora Survive and multiply in the skin.Survive and multiply in the skin.

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

Usually not implicated in Nosocomial Usually not implicated in Nosocomial infectionsinfections

Can cause minor skin infectionsCan cause minor skin infections Some can cause infectionsSome can cause infections

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


The transient microbial floraThe transient microbial flora Recent contaminantRecent contaminant of the hands acquired from of the hands acquired from

Colonized / infected pt.Colonized / infected pt. Contaminated environment / equipmentContaminated environment / equipment

These are not constantly isolated from most These are not constantly isolated from most HCWHCW

But But more frequently implicatemore frequently implicate as the source of as the source of HAIsHAIs

Most common areMost common are Gram negative Coliforms (Gram negative Coliforms (40% - HAI40% - HAI))

E. coli, Enterobacter, KlebsiellaE. coli, Enterobacter, Klebsiella

Staphylococcus aureusStaphylococcus aureus

Hand washingHand washing

“ “ Hand washing with plain soap is Hand washing with plain soap is effective in removing most of effective in removing most of

transient microbial flora”transient microbial flora”

The component of good hand washingThe component of good hand washing Using an Using an adequate amountadequate amount of soap/antiseptic agent of soap/antiseptic agent Rubbing the hands together Rubbing the hands together →→ 15 sec 15 sec

To To create some frictioncreate some friction

Rinsing under Rinsing under running waterrunning water.. Pat dry handsPat dry hands with paper towel or single use clothe with paper towel or single use clothe

toweltowel ? Air dryers Good/ Bad? Air dryers Good/ Bad


Purpose of hand washingPurpose of hand washing To RemoveTo Remove

SoilSoil Organic material Organic material From the handFrom the hand

Transient micro-organismsTransient micro-organisms

Soap Soap oror Antiseptic Agents Antiseptic Agents Gen. wds – Not significantGen. wds – Not significant Critical care unit – May significantCritical care unit – May significant

Possibility of Ab resistant organismsPossibility of Ab resistant organisms Heavy contamination with organic materHeavy contamination with organic mater

Hand washingHand washingSoapSoap

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

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

Antiseptic ProductsAntiseptic Products2 - 4% Chlorhexidine gluconate2 - 4% Chlorhexidine gluconate (Good residual activity) (Good residual activity)

7.5% Povidone iodine7.5% Povidone iodine

Antiseptic hand cleansers are designed toAntiseptic hand cleansers are designed to Rapidly wash off the majority of the Rapidly wash off the majority of the transient floratransient flora

by their mechanical detergent effects by their mechanical detergent effects

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


Waterless Hand rubsWaterless Hand rubs Several studies have demonstrated superior efficacy over Several studies have demonstrated superior efficacy over

soap/Chlorhexidine hand wash. soap/Chlorhexidine hand wash.

0.0

1.0

2.0

3.0 0 60

180 minutes

0.0

90.0

99.0

99.9log%

Bac

ter i

al R

ed

uc

tio

n

Alcohol-based handrub(70% Isopropanol)

Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

Hand washingHand washingWaterless Hand rubsWaterless Hand rubs

AdvantagesAdvantages1.1. Have Have immediateimmediate & & sustainsustain antimicrobial performance antimicrobial performance2.2. No wash basin is necessaryNo wash basin is necessary

Can be conveniently available near every pt.Can be conveniently available near every pt.

1.1. More practical and time saving. More practical and time saving. →→ 15 sec. 15 sec.

DisadvantagesDisadvantages1.1. Effects on the userEffects on the user

1.1. May cause drying of the skin May cause drying of the skin →→ Addition of emollients Addition of emollients2.2. Odour may be irritantOdour may be irritant

2.2. Efficacy Efficacy ↓↓ by dilution with water by dilution with water Use with dry handsUse with dry hands

1.1. Activity may Activity may ↓ ↓ when use with soiled hands. Eg bloodwhen use with soiled hands. Eg blood Always wash with soap/antiseptic to clean the visible Always wash with soap/antiseptic to clean the visible

contaminantcontaminant


Recommendations on Hand WashingHands must be washed

1. Between direct contact with individual patients2. Before performing invasive procedures3. Before preparing, handling, serving or eating

food, and before feeding a patient4. When hands are visibly soiled5. After situations or procedures in which microbial

or blood contamination of hands is likely6. Before wearing and after removing gloves7. After personal body functions, such as using the

toilet or blowing one’s nose.

Aseptic precautionsAseptic precautions

DEVICE RELATED NOSOCOMIAL INFECTIONDEVICE RELATED NOSOCOMIAL INFECTIONIs an infection in a patient with a deviceIs an infection in a patient with a device

1.1. Central lineCentral line

2.2. VentilatorVentilator

3.3. Indwelling urinary catheterIndwelling urinary catheter that was in use within the 48-hour period that was in use within the 48-hour period

before onset of infection.before onset of infection. If the interval since discontinuation of the If the interval since discontinuation of the

device is longer than 48 hours, there device is longer than 48 hours, there must be compelling evidence that must be compelling evidence that infection was associated with device use.infection was associated with device use.

Environment cleaningEnvironment cleaningFloorsFloors Mop with GPD twice dayMop with GPD twice day

Use 0.1% Hypochlorite if there is an Use 0.1% Hypochlorite if there is an outbreak of sepsis.outbreak of sepsis.

MopsMops Use separate mops for different cubicles.Use separate mops for different cubicles.

Dry the mops in sun light.Dry the mops in sun light.

Store them upside down.Store them upside down.

Wash mops in 0.1% Hypochlorite weekly.Wash mops in 0.1% Hypochlorite weekly.

WallsWalls Damp dust with GPD once weekly.Damp dust with GPD once weekly.

Horizontal Horizontal SurfacesSurfaces

Damp dust with GPD daily and between Damp dust with GPD daily and between patients.patients.

Dry with clean dry cloth.Dry with clean dry cloth. GDPGDP :- General Purpose Detergents :- General Purpose Detergents

Environment cleaningEnvironment cleaning

Sink / taps / Sink / taps /

door handlesdoor handles

Wash twice a day with GPD.Wash twice a day with GPD.

Bath roomsBath rooms Wash twice daily with GPD, including door Wash twice daily with GPD, including door knobs and taps.knobs and taps.

TelephoneTelephone Wipe daily with 70% alcohol.Wipe daily with 70% alcohol.

Cleaning of Cleaning of SpillagesSpillages

Blood & Body fluidsBlood & Body fluids

Wear heavy duty glovesWear heavy duty gloves

Soak up fluid using absorbent. (wadding, gauze, Soak up fluid using absorbent. (wadding, gauze, paper towels)paper towels)

Pour 1% Hypochlorite solution till it is well Pour 1% Hypochlorite solution till it is well soaked.. Leave >10min.soaked.. Leave >10min.

Discard absorbent as clinical waste.Discard absorbent as clinical waste.

Clean area with detergent & water & dry.Clean area with detergent & water & dry.

Discard gloves as clinical waste.Discard gloves as clinical waste.

Wash hands.Wash hands.

Low risk body fluid (Faeces, Vomitus, Urine)Low risk body fluid (Faeces, Vomitus, Urine)

Wear gloves.Wear gloves.

Soak up fluid using absorbent material.Soak up fluid using absorbent material.

Clean area with detergent & water & dry.Clean area with detergent & water & dry.

Discard gloves as clinical waste.Discard gloves as clinical waste.

Wash hands.Wash hands.

Cleaning, Disinfection and Sterilization of Cleaning, Disinfection and Sterilization of Equipments / Furniture.Equipments / Furniture.

CleaningCleaning Physical removal of dirt.Physical removal of dirt.

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

DisinfectionDisinfection Elimination of nearly all recognized pathogenic Elimination of nearly all recognized pathogenic

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

SterilizationSterilization Complete elimination of all microbial forms including Complete elimination of all microbial forms including

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

Cleaning, Disinfection and SterilizationCleaning, Disinfection and SterilizationFurnitureFurniture

Bed/BedraiBed/Bedrailsls

CupboardsCupboards

Damp dust daily with Damp dust daily with GPDGPD

Clean with Clean with GPD & 0.1% HypochloriteGPD & 0.1% Hypochlorite for for septic pts.septic pts.

MattresseMattressess

Cover with impermeable material.Cover with impermeable material.

Damp dust Damp dust weeklyweekly with with GPDGPD..

Wipe with GPD between patients and dry Wipe with GPD between patients and dry thoroughly.thoroughly.

Replace torn mattresses.Replace torn mattresses.

Clean with Clean with GPD & 0.1 % HypochloriteGPD & 0.1 % Hypochlorite for septic pts.for septic pts.

Other Other FurnitureFurniture

Minimize the No.Minimize the No.

Damp dust weekly with Damp dust weekly with GDPGDP

Use a separate storage area for non-Use a separate storage area for non-essential itemsessential items

Cleaning, Disinfection and Sterilization Cleaning, Disinfection and Sterilization ventilators & accessoriesventilators & accessories

VentilatorsVentilators

Method Method :- :- GPD or 70% alcoholGPD or 70% alcohol Follow manufacturer’s instructions wherever possible.Follow manufacturer’s instructions wherever possible. Wipe clean with GDP or 70% alcohol & dry Wipe clean with GDP or 70% alcohol & dry dailydaily and and between ptsbetween pts.. External filtersExternal filters should be changed between pts. should be changed between pts. Clean Clean internal mechanismsinternal mechanisms including internal filters according to including internal filters according to

manufacture’s instructionmanufacture’s instruction By authorized maintenance staffBy authorized maintenance staff Should have user manual & maintenance records for each vent.Should have user manual & maintenance records for each vent.

Proper decontamination according to the manufacture’s inst. is Proper decontamination according to the manufacture’s inst. is needed after ventilation of pt with needed after ventilation of pt with TuberculosisTuberculosis, , Resistant Gram-neg. organismsResistant Gram-neg. organisms in RT, in RT, MRSAMRSA in RT, Definite in RT, Definite

fungal lung infectionsfungal lung infections, , Lobar and Community acquiredLobar and Community acquired pneumonias. pneumonias.


Ventilator tubingVentilator tubing

MethodMethod :- :- 1.1. SUSU – Ideal – Ideal

2. 2. CSSDCSSD – Clean with GDP & Autoclave – Clean with GDP & Autoclave

3. 3. 2% Gluteraldehyde2% Gluteraldehyde – Immerse 30min & rinse with – Immerse 30min & rinse with sterile water; Store dry & covered.sterile water; Store dry & covered.

4. 4. Peracetic acidPeracetic acid – Immerse 10min & rinse with sterile – Immerse 10min & rinse with sterile water; Store dry & covered.water; Store dry & covered.

Tubes should be dated & changed weekly. Tubes should be dated & changed weekly. Twice a week for long term pts.Twice a week for long term pts.

Change between pts.Change between pts.

CSSDCSSD – Central Sterilization & Supplies Division – Central Sterilization & Supplies DivisionSUSU – Single Use – Single Use


HumidifiersHumidifiersMethodMethod :- 1. :- 1. GPDGPD – – Empty and clean reservoir Empty and clean reservoir

daily with GDPdaily with GDP

Dry thoroughlyDry thoroughly

Refill with sterile waterRefill with sterile water

22. . CSSDCSSD – Autoclave – Autoclave

Use sterilized humidifiers for Use sterilized humidifiers for all pts all pts

3.3. 2% Gluteraldehyde 2% Gluteraldehyde

4.4. Peracetic acid Peracetic acid


Reservoir bagsReservoir bags

MethodMethod :- 1. :- 1. SUSU – Preferred – Preferred

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

3. 3. CSSDCSSD

4. 4. 2% Glutaraldehyde2% Glutaraldehyde

For known or suspected infections such as TBFor known or suspected infections such as TB


Airways (Plastic / Metal)Airways (Plastic / Metal)Method Method :- :- SU / CSSDSU / CSSD

Oxygen masksOxygen masks Clean daily or when soiledClean daily or when soiled Change between pts.Change between pts.

MethodsMethods :- 1. :- 1. GPD+70% AlcoholGPD+70% Alcohol Clean with GPD and wipe with 70% alcoholClean with GPD and wipe with 70% alcohol

2. 2. 1% Hypochlorite1% Hypochlorite Use in with/suspected TBUse in with/suspected TB Immerse for 30min & rinse with waterImmerse for 30min & rinse with water


LaryngoscopesLaryngoscopes

MethodMethod :- 1. :- 1. CSSDCSSD →→ Ideal method Ideal method

2.2. GPD+70% Alcohol GPD+70% Alcohol →→Alternate Alternate methodmethod

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

Endotrachial tubesEndotrachial tubes

MethodMethod :- :- SUSU


NebulizersNebulizers MasksMasks

Change daily / When soiledChange daily / When soiled Change between pts.Change between pts.

MethodMethod :- 1. :- 1. GPD+70% AlcoholGPD+70% Alcohol 2. 2. 1% Hypochlorite1% Hypochlorite

Pts with/suspected TBPts with/suspected TB

TubingTubing MethodMethod :- 1. :- 1. SUSU 2. 2. GPD+1% HypochloriteGPD+1% Hypochlorite

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

with water.with water.


Suction apparatusSuction apparatus Suction cathetersSuction catheters

MethodsMethods :- :- SUSU

Suction tubingSuction tubingMethodsMethods :- :- SUSU

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

MethodsMethods :-1. :-1. CSSDCSSD →→ If autoclavable send to CSSD after washing with GPDIf autoclavable send to CSSD after washing with GPD

2. 2. 1% Hypochlorite1% Hypochlorite →→ Non-autoclavable ones, washed Non-autoclavable ones, washed

with GPD and immersed for 30minwith GPD and immersed for 30min

3. 3. 2% Gluteraldehyde2% Gluteraldehyde →→ M Metal lids immersed for 30 min.etal lids immersed for 30 min.


Infusion pumpsInfusion pumps

MethodMethod :- :- GPDGPD →→ Wipe daily Wipe daily Ensure surfaces completely free of infusion Ensure surfaces completely free of infusion

residualsresiduals

Infusion standsInfusion stands

MethodMethod :- :- GPDGPD Wash when soiled and on completion of patient Wash when soiled and on completion of patient

useuse


Arterial linesArterial linesMethodMethod :- SU - pre sterilized items :- SU - pre sterilized items

Change all lines every 48hrsChange all lines every 48hrs

BP cuffsBP cuffs →→ One per ptOne per ptMethod :- GPD Method :- GPD → → Wash and dry between pts Wash and dry between pts

ECG monitorsECG monitorsMethodMethod :- External :- External →→ Damp dust daily and between Damp dust daily and between

PtsPts Control panels Control panels →→ GPD/Alcohol wipe GPD/Alcohol wipe

at the beginning of a shiftat the beginning of a shift

StethoscopesStethoscopes →→ One per ptOne per ptMethodMethod :- Alcohol wipes :- Alcohol wipes

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

Unit disciplineUnit disciplineAim is to achieve protective isolation of the ptAim is to achieve protective isolation of the pt

1.1. Staff handling pts. must wash hands thoroughly Staff handling pts. must wash hands thoroughly before & after attending on pt.before & after attending on pt.

2.2. Staff coming in from other areas of hospital Staff coming in from other areas of hospital 1.1. should wear gowns should wear gowns

only if they examine or make contact with the pt.only if they examine or make contact with the pt.

1.1. Staff and visitors Staff and visitors with obvious infectionwith obvious infection should not should not enter.enter.

2.2. Visitors and staff Visitors and staff should not touch anythingshould not touch anything unless unless it is absolutely essential to do so.it is absolutely essential to do so.

Waste disposalWaste disposalWHO recommendationsWHO recommendations

BlackBlack – Non infectious / Non Hazardous – Non infectious / Non Hazardous YellowYellow – Infectious waste – Infectious waste Sharp binSharp bin

Effluents Untreated effluent should be discharged to

1. Sanitary sewerage system to treatment plant 2. 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 Prevention is primaryprimary

Thank You.Thank You.

39053599-inf-cont-in-icu

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