E1661 v 3 INFECTION PREVENTION GUIDELINES for Health Care Facilities in Ethiopia Ministry of Health I i I Ii I INFECTION PREVENTION GUIDELINES for Healthcare Facilities in Ethiopia Ministry of Health Disease Prevention and ControlDepartment FEBRUARY 2005 FORWARD In Ethiopia, efforts to improve the healthcare provided to its citizens are increasing in all aspects of health from family planning services to the provision of antiretroviral medication for HIV positive peoples. Foremost amonig the initiatives currently underway, the protection of patients and healtlhcare workers formi infectionis inside the hospital has been given particular- attention by the Federal Ministr-y of Health. Indeed, the Ministry is scaling-up its activities related infection prevention and will use all opportunities to strengthen ongoing activities. As in many of its program, the M inistry w ill u tilize a vailable e vidence t o e stablish optimal infection prevention practices in healtlh facilities. In hospital and clinical setting, a higlh proportioni of patients are infected with bacteria and viruses, which cause a continued threat to the healtlh of clients and increase cost to the patient as well as the healthcare system. In addition, without adequate infection prevention practices like proper use of gloves or proper hand washing, healthcare workers are at increased risk of acquiring infection, most commonly HIV/AIDS, Hepatitis A and C, as well as other common bacterial and viral infections. Healthcare workers at risk include all staff of at the facility includillng nurses, doctors, laboratory techlnicianis, waste maniagement staffiand laundry staff In the resour-ce constrained settings like many hospitals sin Ethiopia, it is difficult to control the infection rates of patienits acquiring hospital acquil-ed infections and exposul-e of the healthcare workers to suchI infections. Materials, manpower, trainings, policies and -uidelines are needed to promote infection prevention practices. Infection Prevention in hospitals and other- healthcare settings is a hospital-wide and nation-wide campaign. It involves every aspect of patient care, food preparationi, laundry services and hospital wvaste management. Thoughl it requires commiitmltenit and a large amount of materials to implement, outlined in this -uidelines are many \Xass to imp-ox e infectioll prevention practices in these resource constrained settings. Thlis .lVuuionucii Guiidelinie oni Infection Prevention is intenided to act as a resource for healthcare professionials for the guidance on infection prevention practices. The Guideline is developed based on in-countrV experience and internationally acclaimed and standard recommelndations suchl as those of thle T.S. Centers for Disease Control and Prevention recommendations released in 1996. It is icared tovards using innoovative methods tested and used in all parts of the xvorld to reduce the overhead cost of an Infection Prevention )rogram. It is believed that healtlhcar-e w%orkers. pro-ramn manauers and all other stakeholder wvill use this Guideline effectively to prevent infectionis from occutriino at healtlh facilities. I wish to extend nm sincerest thank for all institutiolns that have contrlibuted to the effort of developing- the Guidelinie. Dr. Alemayehu Seifu Disease Prevention and Control Department InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia iii ACKNOWLEDGMENTS The National Infection Prevention Guidelines for Healthcare Facilities in Ethiopia was made possible through the unreserved commitment of professionals and institutions listed below: Dr. Afework Kassa, Federal Ministry of Health, Chair Ato Abebe ShumLle, Federal Ministry of Health, Memiiber Professor Sileshi Lulseged, US Centers for Disease Control and Prevention in Ethiopia and Addis Ababa University Faculty, Menmber Dr. Fahimi Mohammed, John Snow International in Ethiopia, Participanlt Dr. Chandrakant Ruparelia, JHPIEGO, an affiliate of Johns Hopkins University, Secretarl Dr. Mohamminied Ali, US Centers for Disease Control and Prevention in Ethiopia, Co-Secretarv The Ministry of Health acknowledges and expresses its deep appreciation for their contributions. The Ministry of Health also wishes to acknowledge the contributionis of Regional Health Bureaus, various healthcare facilities, healtlhcare piroviders and partner- organizations who assisted in the developmenit of these Infectioni Preventioni Guidelinies. The Ministry of Health graciously acknowledges the commitment, techillcal support and expertise of JHPIEGO, an affiliate of Johns Hopkins University, who made the development of these Infection Prevention Guidelines possible. The Ministry of Health would also like to specially thank the US Centers for Disease Control and Prevention in Ethiopia for the techlical support and finanicial assistance provided in the preparation and printing of these Infection Prevention Guidelines. iv Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia TABLE OF CONTENTS Forward im Acknowledgements iv List of Figures and Tables vi List of Acronymiis Vil CHAPTERS 1. Infection Prevention Principles 1-1 2. Hand Hygiene 2-1 3. Gloves 3-1 4. Personal Protective Equipment and Drapes 4-1 5. Surgical Antisepsis 5-1 6. Safe Practices in the Operating Room 6-1 7. Safe and Appropriate Use of Injections 7-1 8. Waste Management 8-1 9. Instrument Processing 9-1 10. Processing Linen 10-1 11. Traffic Flow and Activity Pattern 11-1 12. Housekeeping 12-1 13. Clinical Laboratory Services 13-1 14. Blood Bank and Transfusion Services 14-1 15. Isolation Precaution Guidelines for Healthcare Facilities 15-1 16. Preventing Nosocomial Infections 16-1 17. Preventing Infectious Diarrhea and Managing Food and Water Services 17-1 18. Preventing Nosocomial Pneumonia 18-1 19. Management of Infection Prevention Programs 19-1 20. Infection Monitoring (Surveillance) Activities 20-1 Glossary Glossary-I InfectionPrevention Guidelinesfor Healthcare Facilitiesin Ethiopia v LIST OF FIGURES AND TABLES Tabl^ ' -i Glove Requirements for Common Medical and Surgical Procedures 3-2 Table 3-2 Glove \Wearing Guidelinies 3-3 Figure 3-1 Cuttilng the Foul- Fingers Off a Glove 3-4 Figure 3-2 Putting Surgical Gloves on Both Hands 3-5 Table 4-1 Holw Personal Protective Equipmenit Blocks thle Spread of Microorgalnismlis 4-1 Table 4-2 Types of Personal Protective Equipnmenit 4-2 Table 5-1 Antiseptic Solutions: Microbiologic Activities and Potential Uses 5-3 Table 6-1 Classification and Inidicationis for PEP 6--2 Table 6-2 Risk Categories and ARV Prophylaxis 6-3 Figure 8-1 Slimple Inciinerator uising Local Materials 8-4 Figure 8-2 Stationary Incinierator 8-4 Figure 8-3 Blirial Site f-or- Waste Disposal 8-5 Figure 9-1 Key Steps in Processilng2 Contaminiiated Instl-ulimenits, Gloves and Othier Itemils 9-1 Table 9-1 Effectiveness of Methods for Processing InstrumiLenits 9-4 Fil-ure 9-2 Example of a HLD Steamer 9- 1() Table 9-2 Prepar-iing and Ulsing Chemilcal Disinfectants 9-12 Table 9-3 Guidelines lor Processinlg Instr-uIments, SuL-gical Gloves, and Other-Itemiis 9-1 3 Table 15-1 Clinical Syndr-omiies or Conditionis to Be Considered for "Empiric L!se" of Transimiissioni-Based Precautionis 1-4 Table 15-2 SuLmmary olfTypes of Precautions and Patients Requirin,g the Precautions 15-5 Table 20-1 Measur-es Identified as Effective in Investi,ating Outbreaks '-l-3 Ethiopia vli Infection Prevention Guidelines for Healthcare Facilitiesin LIST OF ACRONYMS AIDS Acquired Immune Deficiency Syndrome ARV Antiretroviral BSL Biosafety level CDC Centers for Disease Control and Prevention HBV Hepatitis B virus HCV Hepatitis C virus HIV Human Immunodeficiencv Virus HLD High level disinfection IAIS Intra-Amniotic Infection Syndrome IP Infection prevention 1ID Intrauterine device MOH Ministry of Health PEP Post-exposure prophylaxis PMTCT Prevention of Mother-to-Child Transmission PPE Personal protective equipment ppm parts per-million QUAT Quatemiiary ammonium compound SS] Surgical site infection SUD Single-use device TST Time, Steam, Temperature WHO World Health Organizatioln Infection PreventionGuidelines for HealthcareFacilities inEthiopia vii CHAPTER 1 INFECTION PREVENTION PRINCIPLES The IP practices described in these guidelines are intenided for use in all types of medical and healthcare facilities-from large urban hospitals to small rural clinics. They are designed to minimize costs and the need for expensive and often fragile equipment while at the same time assuring a high degree of safety. Objectives: Infectioni Prevention in healtlhcare facilities has two prim1ary objectives: * To prevent infections when providing any type of service that involves noninvasive as wvell as invasive procedures (e.g., injectionis, intravascular infusions, uriniary catheterization, Wound management, fUD insertion, surgical procedures). * To minimize the risk of transmitting serious infections such as HIV, and Hepatitis B and C not only among clients but also to service providers, including cleanilng and housekeeping personinel. The principles of infectioni prevention described below are based on the guidelines issued by Centers for Disease Control and Prevention, Atlanta, Georgia in 1996 and are equally applicable in Ethiopia. The guidelines involve a two level approach: * Standard Precautions, which apply to all clients and patients attending healthcare facilities, and * Transmissioni-Based Precautionis, which apply to hospitalized patienits and also noni-lhospitalized patients wlhere route of transmissioni is clearlv k-nown. PRINCIPLES OF INFECTION PREVENTION The recommended IP practices are based on the following principles: * Consider every person potentially infectious and susceptible to infectiol. * Washingl halnds before and after any procedure is the most practical procedure for preventing cross-conitaminlation (person-person). * Wearing gloves before touching anything potentially infectious and wet-broken sknll, IllUCOUS membrane, blood, body fluids, secretions or excretion or soiled instrument and other itenis--or before performing invasive procedures. * Using physical barriers including personal protective e quipment, if splashes o r spills o f a ny blood, body fluids, secretions or excretions are anticipated. * Using antiseptic agents for cleansing the skin or mucous membrane pnror to surgery, cleanillg wounds, or doing hanidrubs or surgical handscrub. * Ulsing safe work practices, such as not recapping or bending needles, safely passing sharp instruments, and disposing or sharps in puncture resistanit containers. * Processing instruments and other items that come in contact with blood, body fluids, secretions and excretions (decontamination, cleaning, and sterilization or high-level disinfection). InfectionPrevention Guidelines for Healthcare Facilities in Ethiopia 1-1 * Routinely cleaning and disinfecting equipment and furniture in patient care areas. * Disposing contaminated materials and contaminated waste properly. * Isolating patients only if secretions or excretions cannot be contained. Proper infection prevention practices are fundamental to quality of care, and essential to protect healthcare workers, patients, and communities. Particularly in a country such as Ethiopia, where the prevalence of serious infectious diseases such as Hepatitis B and HIV is so high, and preventive interventions for both these diseases are minimal, failure to follow proper infection prevention practices puts healthcare workers, patients and the communities at tremendous risk. Good infection prevention practices include: * Washing hands before and after contact with every client, even ifgloves are worn * Wearing gloves and using appropriate personal protective equipment when contact with any mucous membranies, blood, body fluids, secretions and excretions is anticipated * Proper handling of sharps-especially hypodem-ic needles, scalpels etc.-to protect healtlhcare workers, cleaners and the community * Proper handling of specimens (blood, tissue, excretions and secretions) * Decontaminating all instruments and surfaces, that have come in contact with body fluids or mucous membranes, for 10 minutes in a 0.5% chlorine solution * Thorough washilng and rinsing or instruments and items or surfaces to remove any caked blood or residual tissue before sterilization or high-level disinfection * Properly sterilizing or, when sterilization is not possible,carrying out high-level disinfection of instruments * Proper storing and handling of processed instruments * Managing traffic flow, and activity pattern in wards, procedure areas and operating theatel- * Minimizing preoperative stay in the healthcare facility * Following proper isolation precautions for highly infectious patients if secretions or excretions cannot otherwise be contained * Managing safe and proper disposal ofwastes * Reporting accidental exposure to blood and body fluids including needle stick injuries and proper management of accidental injuries * Providing continuous supportive supervision and monitoring of infection prevention practices and infection rates Proper infection prevention practices break the disease transmission cycle. This is achieved by: * Reducing the number of infection causing microorganisms present (e.g., simple handwashing, cleaning of instruments); * Killing or inactivating infection causing microorganisms (e.g., handwashing with a waterless alcohol preparation, decontamination); 1-2 InfectionPrevention Guidelinesfor Healthcare Facilitiesin Ethiopia * Creating barriers to prevent infectious agents from spreading (e.g., wearing protective equipment); gloves or personal or * Reducing or eliminating risky practices (e.g., using hands-free technique, gloves and using disposable syringes etc.). The decisions regarding selecting an infection prevention practice sterilization or process of medical to use (e.g., instrument versus high-level disinfection, when caring of gloves for the patients and other items) will be based on three categories of potential proposed by Spaulding infection in 1968. risk as The Spaulding categories are summarize below: * Critical: These items and practices affect normally sterile tissues represent or the blood the highest system and level of infection risk. Failure to provide management appropriate, of sterile high-level or, where disinfected items, is most likely to result in infections senous. that are most * Semi-critical: These items and practices are second in importance membranes and affect and small mucous areas of nonintact skin. Management needs are knowledge considerable and skills and require in: * Handling many invasive devices (e.g., gastrointestinal endoscopes * Perfonming and vaginal specula), decontamination, cleaning and high-level disinfection, and * Gloving for personnel who touch mucous membranes and nonintact skin. * Noncritical: Management of items and practices that involve lowest level intact skin and represent of risk. Some the are more important than others. Poor management items such as overuse of non-critical of examination gloves often consumes providing a major only limited share of resources benefits. while There is no indication for using gloves if bare hands blood or are not likely body fluids to come in (except sweat). contact with any The healthcare team should make decisions regarding the infection items to prevention be used based practices on the Spaulding and classification given above. REFERENCES Lynch P et al. 1997. Infection Prevention with Limited Resources. ETNA Communications: Chicago. Spaulding EH. 1968. Chemical disinfection of medical Preservation. and surgical Lawrence materials, CA et al in Disinfection, (eds). Lea & Febiger: Sterilization Philadelphia, and pp 437-446. Garner JS and The Hospital Infection Control Practices precautions Advisory Committee in hospitals. (HICPAC). Infect Control 1996. Guideline Hosp Epidemiol for isolation 17(1): 53-80 and Am J Infect Control24(1):4-52. Infection Prevention Guidelines for Healthcare Facilities in Ethiopia 1-3 i I I i ii i i CHAPTER 2 HAND HYGIENE Hand hygiene is the single most important infection prevention procedure. Proper hand hygiene and the use of protective gloves, whether in the operating room for surgery or in housekeeping for handling contaminated materials, are key components in minimizing the spread of disease and in maintaining an infection-free environment. Appropriate hand hygiene must be carried out: * Before examining (coming in direct contact with) a client/patient * Before putting on sterile or high-level disinfected surgical gloves, or examination gloves * After anv situation in which hands may be contaminated, such as: Handling contaminated objects, including used instruments * Touching mucous membranes, blood, body fluids, secretions or excretions (except sweat) * After removing gloves HAND HYGIENE TECHNIQUES Routine Handwashing The purpose of handwashing is to mechanically remove soil and debris from skin and reduce the number of transient microorganisms. Handwashing with plain soap and cleanl water is as effective in cleaning hands and removing transient microorganisms as washing with antimicrobial soaps and causes less skin irritation. For appropriate handwashing: * Thoroughly wet hands. * Apply a handwashing agent (plain soap or detergent). * Vigorously rub all areas of hands and fingers for 10-15 seconds, paying close attention to fingernails, and areas between the fingers. * Rinse hands thoroughly with clean running water from a tap or a bucket. * Dry hands w ith p ersonal dry clean towel, paper towel or air dry (Using shared towel is not recommended as they quickly become contaminated). Natural or chemncally treated and filteredwater that Issafe to drinkand use for other purposes (11and'ashirlg medical instrument and cleaning). Clean water has zero level of microorganisms including bacteria, parasites, has low turbidity VIRuses and and has minimum level of disinfectants, disinfectant by-products materiials. and orgaric Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia 2-1 * If using personal towel, it should be washed every day. * Use paper towel or towel used for drying hands when turning offwater. Note: * Ifbar soap is used, provide small bars and soap racks, which drain. water; even with E* Use running water and avoid dipping hands into a basin containing standing addition of an antiseptic agent because microorganisms can survive and multiply in these solutions. * A bucket with tap or a bucket with a pitcher can be used if running water is not available fi-om the tap. * Ifliquid soap is being used, do not add soap to partially empty liquid soap dispenser. * Liquid soap dispenser should be washed and dried before refilling it. Hand Antisepsis The purpose of hand antisepsis is to remove soil and debris and reduce both transient and resident flora on the hands. * The technique for hand antisepsis is similar to handwashing except that it involves use of soap containing an antimicrobial agent instead ofplain soap or detergent. Hand antisepsis should be done before: * Examining or caring for highly susceptible patients (e.g., premature infants, elderly patients or those with advanced AIDS, etc.), * Performing an invasive procedure such as placement of an intravascular device, and * Leaving the room of patients on Contact Precautions (e.g., Hepatitis A or E), or who have drug resistant infections (e.g., Methicillin-resistant S. aureus). Antiseptic Handrub The purpose of antiseptic handrub is to inhibit or kill transient and resident flora. Use of a waterless, alcohol-based handnib product is more effective in killing transient and resident flora than antimicrobial handwashing agents or plain soap and water. Antiseptic handrub is quicker and easier to perform, and gives a greater initial reduction in hand flora. These handrubs also contain a small amount of an emollient such as glycerin, propylene glycol or sorbitol that protects and softens skin. 2-2 Infection Prevention Guidelines forHealthcare Facilities in Ethiopia A nonirritating, antiseptic handrub can be made by adding either glycerinea, proplyene glycol or sorbitol to alcohol (2 mL in 100 mL of 60-90% ethyl or isopropyl alcohol solution) (Larson 1990; Pierce 1990). Use 5 mL (about one teaspoonful) for each application and continue rubbing the solution over the hands until they are dry (15-30 seconds). a Glycerine isoftensold in cosmetic departmentsbecause it isused as a hand softener. To be effective, an adequate amount (5 ml) of antiseptic handrub solution should be used. For appropriate handrub: * Apply enough alcohol-based handrub to cover the entire surface of hands and fingers. * Rub the solutions vigorously into hands, especially between the fingers and under the nails until dry. * Do not rinse hands after applying handrub. Since alcohol based handrubs do not remove soil or organic materials, if hands are visibly soiled or contaminated with blood or body fluids, handwashing with soap and water should be done first. In addition, to reduce the "build up" of emollients on hands after repeated use of alcohol- based handrubs, washing hands with soap and water every 5-10 applications is recommended. Surgical Handscrub The purpose of surgical handscrub is to remove soil, debris, transient organisms and resident flora to reduce prior to performing any surgical procedure and for the whole duration of procedure. the The goal is to prevent wound contamination by microorganisms from the hands and armns of the surgeon and assistants. Appropriate surgical handscrub involve following steps: 1. Remove rings, watches and bracelets. 2. Thoroughly wash hands, especially between fingers, and forearms up to the elbows withl soap and water. 3. Clean nails with a nail cleaner (tooth prick or any other pointed instrument). 4. Rinse thoroughly with clean, running water. 5. Apply an antiseptic agent (e.g., 2-4% chlorohexidine). 6. Vigorously rub all surfaces of hands, fingers and forearms for at least 2 minutes. 7. Rinse hands and arms thoroughly, holding hands higher than the elbows (If available, use cooled, filtered and boiled water). 8. Keep hands up and away from the body. 9. Do not touch any surface or article and dry hands and forearms with a clean, dry towel or air dry. 10. Put sterile or high-level disinfected surgical gloves on both hands. Infection Prevention Guidelines for Healthcare FacilitiesinEthiopia 2-3 Alternatively, handwashing with plain soap and water followed by use of a waterless, alcohol- based handrub containing chlorhexidine has been shown to yield significantly greater reduction in microbial counts on hands, improve skin health and reduce time and saves resources (Larson et al 2001). The steps of performing this simpler and shorter surgical handscrub technique are: * Remove rings, watches and bracelets. * Thoroughly wash hands and forearms to the elbows with soap and water. * Clean nails with a nail cleaner (tooth prick or any other pointed instrument). * Rinse with clean running water and dry thoroughly with a clean, dry towel or air dry. * Apply 5 ml of a waterless, alcohol-based handrub to hands, fingers, and forearms and rub until dry; repeat applications and rubbing 2 more times for a total of at least 2 minutes, using a total of about 15 ml of the handrub. * Keep hands up and away from the body; do not touch any surface or article prior to putting sterile or high-level disinfected surgicalgloves on both hands. |Remember: Even where there is no running water, hand washing is possible and is required. If there is not running water, consider using a: * A bucket with a tap * A pitcher or ajug to pour water over hands with the help of an assistant * Waterless alcohol-based solution Drying Hands Avoid using common towels. Shared towels may harbor microorganisms and contaminate hands even after proper handwashing or handrub. * Use a waterless alcohol-based preparation. * Air dry hands. * Carry and use a small, personal towel that is replaced or cleaned daily or when wet or visibly soiled. Other Considerations * Follow the guidelines for using gloves with hand hygiene guidelines. * To minimize contact dermatitis related to frequent handwashing (>30 times per shift) due to the use of harsh detergents and frequent exposures to antiseptic agents, healthcare workers may use hand lotions, creams and moisturizing skin care products. Such products can help prevent and treat contact dermatitis. Such products should be water based and without fragrance. 2-4 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia * Cuticles, hands, and forearmns should be free from lesions (dennatitis or eczema) and skin breaks. Cuts and abrasions should be covered with waterproof dressings. If covering them in this way is not possible, surgical staff with skin lesions should not operate until the lesions are healed. * Research has shown that the area around the base of nails contains the highest microbial count on the hand (McGinley, Larson and Leydon 1988). Several recent studies have shown that long nails may serve as a reservoir for gram-negative bacilli, yeast and other pathogens. Moreover, long nails, either natural or artificial, tend to puncture gloves more easily. GUIDELINES FOR IMPROVING HANDWASHING COMPLIANCE BY THE STAFF Though handwashing has been considered as one of the most important measures for reducing transmission of microorganisms and preventing infection for more than 150 years, compliance to handwashing has been a challenge faced by every healthcare facility. Although it is difficult to change behavior of the staff towards handwashing, there are certain steps that increase the chances of success. These includes but are not limited to: * Widely disseminating current guidelines for hand hygiene practices and the evidence supporting their effectiveness in preventing diseases and the need for health workers to adhere to the guidelines/practices. * Involving hospital administrators in promoting and enforcing the guidelines by convincing them of the cost benefits of handwashing and other hand hygiene practices. * Using successfil educational methods including role modeling, mentoring, monitoring, and positive feedback. X Using performance improvement approaches targeted to all healthcare staff, not just physicians and nurses, to promote compliance. * Considering the needs of staff for convenient and effective options for hand hygiene that make compliance easier. * Making available alternative options like waterless alcohol-based handrubs. This has shown to improve the compliance with the handwashing. REFERENCES Boyce JM and D Pittet. 2002. Guidelines for hand hygiene in healthcare settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHSA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 23(Suppl): S3-S40. Available at: http://www.cdc.gov/handhygiene Centers for Disease Control and Prevention (CDC). 1989. Guidelines for prevention of transmission of human immunodeficiency virus and hepatitis virus to healthcare and public-safety workers. MMWR 38(S-6): 5-6. Deshmukh N, JW Kramer and SI Kjellberg.1996. A comparison of 5-minute povidone-iodine scrub and a 1-minute povidone-iodine scrub followed by alcohol foam. Mil Med 163(3): 145-147. Kikuchi-Numagami K et al. 1999. Irritancy ofscrubbing up for surgery with or without a brush.Acta Derm Venereol 79(3): 230-232. Larson E et al. 2000. An organizational climate intervention associated with increased handwashing and decreased nosocomial infections. Behav Med 26(1): 14-22. Infection Prevention Guidelines forHealthcare Facilities in Ethiopia 2-5 Larson E et al. 2001. Comparison of different regimens for surgical hand preparation. AORN J 73(2): 412-432. Pereira LJ, GM Lee and KJ Wade. 1990. The effect of surgical handwashing routines on the microbial counts of operating room nurses. Am J Infect Control 18(6): 354-364. Pereira LJ, GM Lee and KJ Wade. 1997. An evaluation of five protocols for surgical handwashing in relation to skin condition and microbial counts. J Hosp Infect 36(1): 49-65. Pittet D et al. 2000. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 356(9238): 1307-1312. 2-6 Infection Prevention Guidelines for Healthcare Facilities in Ethiopia CHAPTER 3 GLOVES Hand hygiene, coupled with the use of protective gloves, is a key component in minimizing the spread of disease and maintaining an infection-free environment. In addition, understanding when sterile or high-level disinfected gloves are required and, equally important, when they are not, can reduce costs while maintaining safety for both patients and staff. TYPES OF GLOVES AVAILABLE IN ETHIOPIA * Sterile ofhigh-leveldisinfected surgical glove * Clean Examination gloves * Utility gloves Wear gloves: * When there is a reasonable chance of hands coming in contact with blood or other body fluids, mucous membranes or nonintact skin; * Before performing invasive medical procedures (e.g., inserting vascular devices such as peripheral venous lines); or * Before handling contaminated waste items or touch contaminated surfaces. GENERAL PRINCIPLES FOR GLOVES USE * All staff should wear appropriate gloves prior to contact with blood, body fluids, secretions or excretions from any client/patient. * A separate pair of gloves must be used for each client to avoid cross-contamination. * Wearing gloves does not replace the need for handwashing. WHAT TYPE OF GLOVES TO USE * Disposable clean examination gloves are preferred (High-level disinfected reusable gloves are acceptable) when there is contact with mucous membrane and nonintact skin (e.g., performing medical examinations and procedures such as pelvic examination). * Sterile surgical gloves should be used when performing surgical procedures. * High-level disinfected surgical gloves are t he o nly a cceptable a Iternative i f s teriles urgical gloves are not available, when performing surgical procedures. InfectionPreventionGuidelines for HealthcareFacilities in Ethiopia 3-1 * Clean, heavy duty household (utility) gloves should be used for cleaning instruments, equipment, contaminated surfaces, and while handling or disposing of contaminated waste. Double g loving u sing e ither n ew examination gloves or reprocessed surgical gloves provide some protection in case utility gloves are not available. Table 3-1 provides guidelines on gloves use for common medical and surgical procedures. Table 3-1. Glove Requirements for Common Medical and Surgical Procedures TASK ORTAKORATIIYARE GLOVES PREFERRED ACCEPTABLE ACTIVITY NEEDED? GLOVESa GLOVES Blood pressure check No Temperature check No Injection No Blood drawing Yes Examb HLD Surgicald IV insertion and removal Yes Examb HLD Surgicald Pelvic examination (not for woman in labor) Yes Exam HLD Sur-gicald IUD insertion (loaded in sterile package and Yes Exam HLD Surgicald inserted using no-touch technique) IUD removal (using no-touch technique) Yes Exam HLD Surgicald Manual vacuum aspiration (using no-touch Yes Exam HLD Surgicald technique) Norplant implants insertion and removal Yes Sterile Surgicalc HLD Surgicald Vaginal delivery Yes Sterile Surgical' HLD Surgical j Cesarean section or laparotomy Yes Sterile Surgicalc HLD Surgicald Vasectomy or laparoscopy Yes Sterile Surgical' HLD Surgicald Handling and cleaning instruments Yes Utility Exam or- HLD SurgicalId Handling contaminated waste Yes Utility Exam or HLD Surgicald Cleaning blood or body fluid spills Yes Utility Exam or | HLD Surgical a Although sterile gloves may be used for any surgical procedure, they are not always required. In some cases, examination or HLD surgical gloves are equally safe and less expensive. b This includes new, "never" used individual or bulk-packaged examination gloves (as long as boxes aie stored properly). When sterilization equipment (autoclave) is not available, high-level disinfection is the only acceptable alternative. d Reprocessed surgical gloves. Adaptedfron: Tietjen, Cromun, and McIntosh 1992. 3-2 Infection Prevention Guidelinesfor Healthcare Facilitiesin Ethiopia REMOVING AND DISCARDING OR REPROCESSING GLOVES * If gloves are to be discarded, briefly inmmerse them in 0.5% chlorine solution, remove and dispose in a container for contaminated waste. * If gloves are to be processed and reused, remove gloves by inverting them and soak the gloves in the 0.5% chlorine solution for 10 minutes before cleaning and processing them WEARING GLOVES General guidelines for wearing gloves are given in Table 3-2. Table 3-2. Glove Wearing Guidelines PROCEDURES TYPE OF GLOVES COMMENTS Any time there may be contact I. Examination gloves 1. Single use disposable gloves with mucous membranes and (recommended) broken or non-intact skin 2. Sterilized or high-level 2. High-level disinfected reusable disinfected surgical gloves surgical gloves are acceptable if (acceptable) disposable examination gloves are not available All procedures involving contact I. Sterile surgical gloves 1. Single use disposable sterile with any tissue underneath the skin (recommended) surgical gloves For example starting an IV line, 2. Sterilized reusable surgical 2. Sterilized reusable surgical handling contaminated waste or gloves (acceptable) gloves are acceptable if touchinig contaminated surfaces disposable sterile surgical gloves are not available 3. High-level disinfected reusable 3. When sterilization equipment is . surgical gloves (acceptable only not available, high-level if there are no sterile gloves) disinfection is the only acceptable alternative Handling and cleaning used 1. Heavy duty household (utility) 1. Heavy duty utility gloves: instruments gloves (recommended) These are reusable, but must be decontaminated and cleaned Cleaning contaminated suirfaces betwveen use Handling or disposing or disposing or contaminated waste 2. Double gloving with reprocessed 2. When utility gloves are not surgical or new examination available, double gloving with gloves are acceptable reprocessed surgical gloves or new examination gloves provide some protection Gloves are not required if there is not contact with mucous membranes, blood, body fluids, secretions, or excretions (e.g., checking blood pressures, temperature check, or giving IM injections) NO GLOVES REQUIRED Gloves should not be worn when it is not required, to ensure availability when needed (i.e., use sterile gloves for necessary purpose only-they are expensive irrespective of who is paying for it) InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 3-3 When to Double Glove * The procedure involves coming in contact with large amounts of blood or other body fluids. * Orthopedic procedures in which sharps bone fragments, wire sutures and other sharps are likely to be encountered. * Surgical gloves are reused. * Surgical procedures lasting more than 30 minutes. Whether or not the surgeon, assistant or nurse should double glove should be considered carefully, especially where gloves are reused and in areas where the risk of contracting blood borne pathogens, such as HIV, is high (>5% prevalence). When to Use Elbow Length Gloves Elbow length gloves should be used during vaginal deliveries and cesarean sections when the chance of coming in contact with blood is 25% and 35% respectively. Elbow length gloves are also recommended while performing procedures like manual removal of placenta and any other procedure where there is a contact with large volume ofblood or body fluids. When r eadymade elbow Iength g loves a re n ot a vailable, a n e ffective alternative (as described below) can be easily made from previously used surgical latex gloves that have been decontaminated, cleaned and dried, and either sterilized of high-level disinfected. 1. Cut the four fingers completely off each glove just below where all the firigers join the gloves (see Figure 3-1). Figure 3-1. Cutting the Four Fingers Off a Glove ,,,<,,- 2. Sterilize or HLD 2-3 pairs of cut-off (fingerless) gloves according to the recommended process for each method and store the gloves after final processing in a sterile or high-level disinfected container until needed How to Use * Perfomi surgical handscrub. * Put fingerless sterile or HLD gloves and pull up to the forearms. 3-4 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia * Put intact sterile or HLD surgical gloves on both hands so that the distal end of the fingerless gloves is completely covered (see Figure 3-2). Figure 3-2. Putting Surgical Gloves on Both Hands --- ,,, \ - - - -L 't SOME DOS AND DON'TS ABOUT GLOVES * Do wear the correct size gloves, particularly the surgical gloves. A poorly fitting glove can limit your ability to perform the task and may get damaged easily * Do change surgical gloves penrodically (every 45 minutes) dunrng long cases as the protective effect of latex gloves decreases with time and inapparent tears may occur * Do keep fingernails trimmed moderately short (less than 3 mm beyond the finger tip) to reduce the risk of tears * Do pull gloves up over cuffs of gown (ifworn) to protect the wrists * Do use water-soluble hand lotions and moisturizers often to prevent hands from drying, and cracking due to frequent handwashing and gloving * Don't use oil-based hand lotions or creams, because they will damage latex rubber surgical and examination gloves * Don't use latex gloves ifyou have allergy to latex * Don't store gloves in areas where there are extremes of temperature (e.g., direct sunlight, near the heater, air conditioner, ultraviolet light, and X-ray machine). These conditions may damage the gloves (cause breakdown of the material they are made of), thus reducing their effectiveness as a barrier * Don't reprocess gloves that are cracked or have detectable holes/tears * Don't reprocess examination gloves for reuse InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 3-5 REFERENCES Centers for Disease Control (CDC). 1987. Recommendations for prevention of HIV transmission in healthcare settings. MMWR 36(Suppl 2): 1S-1 8S. National Institute for Occupational Safety and Health, Department of Health and Human Services (NIOSH). 1997. NIOSH Alert: Preventing Allergic Reaction to Nature Rubber Latex in the Workplace. No. 97: 135. 3-6 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia CHAPTER 4 PERSONAL PROTECTIVE EQUIPMENT AND DRAPES Protective barriers and clothing, now commonly referred to as personal protective equipment (PPE), have been used for many years to protect clients from microorganisms present on medical staff and others working in the healthcare setting. More recently, with the enmergence of HIV/AIDS and HBV/HCV and resurgence of tuberculosis in many countries including Ethiopia, PPE now become important for protecting the healthcare providers as well. Table 4-1 describes how personal protective equipment blocks the spread of microorganisms. This will help health workers and healthcare facility make decisions about using personal protective equipment. PERSONAL PROTECTIVE EQUIPMENT Table 4-1. How Personal Protective Equipment Blocks the Spread of Microorganisms WHERE BARRIERS TO STOP THE WHO THE MICROORGANISMS HOW MICROORGANISMS SPREAD OF BARRERS ARE FOUND ARE SPREAD MICROORGANISMS PROTECTS Healthcare Staff Hair and scalp Shedding skin or hair Cap Patient Nose and mouth Coughing, talking Mask (water resistant) Patient Body and skin Shedding skin or hair Scrubsuit, covergowns Patient Hands Touchinlg Gloves, handwashing or Patient waterless antiseptic Patient Mucous membranes and Touching Gloves I Patient and staff nonintact skin Blood and body fluids Splashing or spraying Gloves, eyewear, mask, Staff drapes, and apron Touching (contact) Instrument processing Patient Accidental exposure with Protective footwear. Staff contaminated needles and decontamination and scalpel blades disposal; use of a Safe or Neutral Zone during surgery Infectious waste Utility gloves, plastic bags Staff and proper disposal Unprepaied skini Touching Skin preparation, drapes, Patient gloves Clinic or hospital Touching Gloves, handwashing Staff and their environrnent Dressing families Infection Prevention Guidelinesfor Healthcare Facilitiesin Ethiopia 4-1 Table 4-2. Types of Personal Protective Equipment TYPE OF PPE MUST BE USED FOR PRIMARILY PROTECTS Caps, Gowns/Scrub Suits, Invasive procedures where tissue beneath the skin is Service provider and Masks, Aprons, Drapes exposed client Closed boots or shoes (open Situation involving sharp instruments or where spillage Service provider sandals are not acceptable) or infectious agents is likely Goggles or glasses, Masks, Situation where splashing or blood, body fluids, Service provider Apron, or Mackintosh secretions or excretions is likely Mackintosh or Apron Situation where splashing or spillage of blood, body Service provider fluids, secretions or excretions is likely Masks Situation which call for airborne or droplet transrmission Service providers and precautions client Sterile Drapes Major or rninor surgical procedures Client Caps are used to keep the hair and scalp covered so that flakes of skin and hair are not shed into the wound during surgery. Caps should be large enough to cover all hair. Eyewear protects staff in the event of an accidental splash of blood or other body fluid by covering the eyes. Eyewear includes clear plastic goggles, safety goggles, and face shields. Prescription glasses are also acceptable. Masks and eyewear should be worn when performing any task where an accidental splash into the face could occur. If faceshields are not available, goggles or glasses and mask can be used together. Footwear is worn to protect feet from injury by sharp or heavy items or fluids that may accidentally fall or drip on them. For this reason, sandals, "thongs" or shoes made of soft materials are not acceptable. Rubber boots or leather shoes are acceptable, but they must be kept clean and free of contamination from blood or other body fluid spills. Shoe covers are unnecessary if clean, sturdy shoes are available for dedicated use only in the surgical area. Gloves protect hands from infectious materials and protect patients from microorganism on staff members' hands. They must be worn anytime there is a possibility of contact with potentially infectious materials or when handling contaminated waste or cleaning or disinfecting instruments. Gloves should be changed between each client contact to avoid cross contamination. Gloves should not be worn for non-critical procedures such as bed making, however, handling visibly soiled linen requires utility gloves. Mackintosh or plastic apron is used to protect clothing or surfaces from contamination. Aprons made of rubber or plastic provide a waterproof barrier along the front of the healthcare worker's body and should also be worn during procedures where there is a likelihood of splashes or spillage ofblood, body fluids, secretions or excretions (e.g., when conducting deliveries). Masks should be large enough to cover nose, lower face, jaw and all facial hair. They are worn in an attempt to contain moisture droplets expelled as health workers o r s urgical s taff s peak, cough or sneeze, as well as to prevent accidental splashes of blood or other contaminated body fluids from e ntering t he h ealth workers' n ose o r m outh. U nless t he m asks a re m ade o f fluid- resistant materials, however, they are not effective in preventing either very well. 4-2 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia Scrubsuits or covergowns are worn over, or instead of, routine clothes. A be cut so low as to V-neck shirt slide off must not the wearers' shoulders or expose men's chest hair. Surgical gowns were first used to protect patients from microorganisms and arms present on of the healthcare the abdomen staff during surgery. Lightweight cloth gowns, Ethiopia, generally however, available offer little in protection. Under the circumstances, before putting either wear a plastic on the surgical apron gowns or, if large spills occur, take possible shower or after completing bathe as soon as the surgery or the procedure. Drapes There are four types of drapes: towel drapes, drapes or lap sheets, site drapes, drapes. and pack wrapper Sterile drapes made of cloth can be placed around a prepared area. Cloth surgical incision drapes allow to create a work moisture to soak through and can help to spread even after organisms surgical from skin, cleansing with an antiseptic agent, into the incision. hands nor sterile or Thus, neither gloved high-level disinfected instruments and other items should they are in place. Using touch drapes once towel drapes to create a work area around the of skin that incision limits needs to the amount be cleaned and it reminds the surgical team not to touch the other areas. USING DRAPES FOR SURGICAL PROCEDURE * All drapes should be applied around a completely dry, widely prepared skin. * If sterile drapes are used, sterile or HLD surgical gloves should be drapes. worn when placing the * Drapes should be handled as little aspossible and should never be shaken or flapped. * Always hold drapes above the area to be draped, and discard the drape if it falls below this area For minor surgical procedure: * Use a site drape if the open skin required around the incision is not bigger than five cm. * Place the hole in the drape over the prepped incision site and do not the skin. move it once it has touched * If site being draped is not sterile, put on a sterile or HLD gloves patient to after placing avoid contaminating the drape on the the gloves. For major surgical procedure: * Use large drapes or lapsheets to cover patient's body. These because they drapes do not need will not be to be sterile near the incision site. They should be clean and dry. * After preparing the skin place the steriletowel drapes to square off the incision site. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 4-3 * Begin by placing the drape on the area closest to you. Once in place, the drape should never be moved closer to the incision. It can, however, be pulled away from it. * Use nQn-perforating towel clips to secure the corners of the towel drapes. During Procedure * Do not use the patient's body or the draped area for placing instruments. * Keep all instruments on the instrument stand covered with a sterile towel or drape. Remember: Once a sterile drape touches the patient's skin itis no longer sterile. REFERENCES Chen CC and KWelleke. 1992. Aerosol penetration through surgical masks. Am J Infect Control 20(4): 177-184. Gershon R and B Zirkin. 1995. Behavioral factors in safety training, in Laboratory Safety, Principles and Practices, 2nd ed. Flemming DO et al (eds). AMS Press: Washington, DC, pp 269-277. Gershon R and D Vlahov. 1992. Assessing and reducing HIV risk to the critical care nurse. Critical Care Nursing Currents 3: (No 3). Larson EL et al. 1995. APIC Guidelines for Infection Control Practice. Guidelines for handwashing and hand antisepsis in healthcare settings. Am J Infect Control 23(4):251-269. Mitchell NJ. 1991. Surgical facemasks in modern operating rooms-a costly and unnecessary ritual? J Hosp Infect 18(3): 239-242. 4-4 InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia CHAPTER 5 SURGICAL ANTISEPSIS Postoperative wound infection remains a leading cause of nosocomial infections, developing especially countries including in Ethiopia. A vast majority of postoperative wound infections incisional or superficial are caused by microorganisms normally found on the patient's mucous membranes skin or from adjacent to the surgical site, and less often from other sites the assistants. and surgeon or Preoperative surgical antisepsis consists of three processes: * Hand hygiene * Gloving of the surgical team * Applying antiseptic agent to the surgical site Handhygiene and use of gloves has been discussed earlier. This chapter will skin and mucous focus on preparing membrane prior to procedures. Although skin cannot be sterilized, applying an antiseptic solution minimizes microorganisms the number of around the surgical site that may contaminate the surgical infection. wound and cause GENERAL PRINCIPLES * If visibly soiled, clean any injection site, operative site, or external genitalia with before applying soap and water any antiseptic. * No skin preparation is required prior to giving intramuscular, subcutaneous injections unless or intradennal the injection site is visibly soiled. * Surgical sites should be prepared with an appropriate antiseptic solutions, motion starting using a circular from the center and working outward. * The vagina and cervix should be prepared using a speculum by applying antiseptic solution an appropnate 2-3 times prior to inserting anything into the cervical os. * Never use alcohol containing antiseptic to prepare mucous membrane (e.g., vagina and cervix) * Always allow the antiseptic enough time to dry. * Do not allow the antiseptic to pool underneath the patient's body; this can irritatethe skin. * Do not shave surgical sites as shaving increases the likelihood of infection. * Do not remove hair from surgical sites at all unless absolutely necessary. removed, trim If hair must be the hair close to the skin surface immediately before surgery, being careful nick or injure not to the skin. * Always ask patient about allergic reactions before selecting an antiseptic solution. InfectionPrevention Guidelines for Healthcare Facilities inEthiopia 5-1 Select an antiseptic solution from the following recommended products: * Alcohol based solutions of iodine and chlorhexidine * Alcohols (60-90% ethyl, isopropyl or "methylated spirits") * Chlorhexidine gluconate (2-4%) * Chlorhexidine gluconate and cetrimide, various concentration at least 2% (e.g., Savlon®) * Iodine (3%) aqueous iodine and alcohol containing products * lodophors (7.5-10%), various other concentrations (e.g., Betadine) * Chloroxylenol (Para-chloro-metaxylenol or PCMX) (0.5-3.75%), various other concentrations (e.g., Dettol®) DO NOT dilute Savione or Dettol® available in the market. Product that should not be used as antiseptic: * Hexachlorophene * Benzalkonium Chloride * Mercury Laurel or other Mercury Containing Compounds STORING AND DISPENSING ANTISEPTIC * Pour the antiseptic into a small, reusable container for daily use * Label the container correctly * Do not store gauze or cotton wool in antiseptic because this promotes contamination * Do not refill antiseptic dispenser before washing and cleaning once it is near empty or empty. * Wash reusable antiseptic containers thoroughly with soap and clean water, rinse with boiled water ifavailable and drip dry before refilling * Label reusable antiseptic containers with the date each time they are washed, dried and refilled * Concentrated antiseptic solutions should be stored in a cool, dark area. Never store them in direct sunlight or in excessive heat. Always follow the manufacturer's instructions for diluting an antiseptic solution. 5-2 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia Table 5-1. Antiseptic Solutions: Microbiologic Activities and Potential Uses ACTIVITY AGAINST BACTERIA RELATIVE AFFECTED USES Most SE OF BYGROUP BY Comments etchyls or isopropyl)d God God Noe FatMoeat es Yso memranses ono guoodfru hsia ethyl or isopropyl) membranes; not good for physical cleaning ofskin, no persistent activity Chlorhexidine' (2-4%) Good Good Fair Good Fair None Inter- Slight Yes Yes Has good persistent effect; (Hibitane, Hibiscrub) mediate Toxicity to ears and eyes Iodine Preparation (3%) Good Good Good Good Good Poor Fast Marked No Yes Not for use on mucous membranes (Water or alcohol or open wounds; Can burn skin so based) remove after several minutes lodophors (7.5-10%) Good Good Good Good Good None Inter- Moderate Yes Yes Can be used on mucous (BetadineJ) mediate membranes. Wait for 2 minutes after applying Para-chloro- Fair Good Poor Fair Poor Unknown Slow Minimal No Yes Penetrates the skin and shouldnot metaxynelol (PCMX) be used on newborns (0.5-4%) Triclosan (0.2-2%) Good Good Fair Good Poor Unknown Inter- Minimal Yes No Acceptability on hands varies mediate Note: Savlon, which contains chlorhexidine, is not listed becauseconcentration of chlorhexidine vary from country to country from less than 1% to 4%. Some of these agents, suchas iodine or chlorhexidine, are combined with alcohol to form tinctures and are available in the combinedformulations. Adapted,from: Larson 1988; Olmsted 1996. 5-3 Infection Prevention Guidelines for Healthcare Facilities in Ethiopia REFERENCES Hutin Y et al. 2001. Best infection control practices for intradermal, subcutaneous and intramuscular needle injeGtions. World Health Organization (WHO), Safe Injection Global Network: Geneva. Nichols RL. 1991. Surgical wound infection. Am J Med 91 (Suppl 3B): 54S-64S. Spaulding EH (ed). 1968. Chemical disinfection of medical and surgical materials, in Disinfection, Sterilization and Preservation. Lawrence CA et al (eds). Lea & Febiger: Philadelphia, pp 437-446. 5-4 Infection Prevention Guidelines for Healthcare Facilities in Ethiopia CHAPTER 6 SAFE PRACTICES IN THE OPERATING ROOM The operating room has special characteristics that increase the chance of accidents. The staff often uses and passes sharp instruments without looking at the instrument or letting the other person know what they are doing. The workspace is confined and ability to see what is going on in the operative field for some members of the team may be poor. There is moreover, the need for speed and the added stress of anxiety, fatigue, frustration and even anger. Finally, in many instances the exposure to blood often occurs without the person's knowledge, usually not until the gloves are removed. The fact that fingers are frequently the site of minor scratches and cuts further increases the risk of infection with blood borne pathogens. To avoid all injuries that could result from handling sharp instruments and objects (e.g., hypodermic needles, wire sutures, skin hooks and towel clips, sharp-toothed tenaculi and scalpel blades): * Use a small Mayo forceps (not fingers) when holding the scalpel blade, putting it on or taking it off or loading the suture needle. * Always use tissue forceps (not fingers) to hold tissue when using a scalpel or sutunrng. * Use a "hands free" technique to pass or transfer sharps by establishing a Safe or Neutral Zone in the operative field. * Always remove sharps from the field immediately after use and put in a sharp container. * Make sure that sharps containers are replaced when they are only three-quarters full and place containers as close and conveniently as possible to where sharps are being used. THE "HANDS FREE" TECHNIQUE FOR PASSING SURGICAL INSTRUMENTS 1. Place a sterile or high-level disinfected kidney basin, or other suitable small container, on the operative field between assistants and the surgeon. The container is designated as the Safe or Neutral Zone in which sharps are placed before and immediately after use. 2. Alert the surgeon when a sharp instrument is being transferred. Say "sharp" and then pass the instrument. 3. To avoid dulling scalpel b lades, u se a p lastic c ontainer or p lace a sterile c loth in a m etal container. DESIGNING SAFER OPERATIONS * Have a brief preoperative discussion of how sharps will be handled during the procedures by all team members and needs of the surgeon during surgery. * Review how to make each step in the operation safe. Infection Prevention Guidelines for Healthcare Facilities in Ethiopia 6-1 * Avoid using straight suture needles; use curved needles instead. * If available, use blunt needles for suturing soft tissues. Post Exposure Prophylaxis Guidelines The Disease Prevention and Control Department of the Ministry of Health in collaboration with HIV/AIDS Prevention and Control Office (HAPCO) and Drug Administration and Control Authority published the Guidelines for Use of Antiretroviral Drugs in Ethiopia, in 2003. According to these guidelines proper infection prevention practices, which include appropriate following of standards precautions, is the most effective way of protecting healthcare providers from accidental transmission of HIV and other blood borne pathogens. The priority, therefore, must be to train all healthcare personnel in prevention methods and to provide them with necessary safe materials and personal protective equipment. Components of post-exposure management include crisis management, risk assessment, laboratory assessment ofsource, post-exposure prophylaxis, and followup care. Testing Testing source: Rapid test is done, following the national testing protocol, after pretest counseling and consent has been given by the source. Posttest counseling is provided once the results are available. Testing healthcare provider: HIV serology should be performed at the time of injury, and repeated at 6 weeks, 3 months, and 6 months. The healthcare worker should be advised to practice safe sex or abstain until serology is negative at 6 months post exposure. WHO classification and indications for PEP i s r ecommended for E thiopia. T his c lassification assumes that serological status of the source patient is known. Table 6-1. Classification and Indications for PEP TYPE OF EXPOSURE SOURCE PATIENT HIV POSITIVE Symptomatic and/or high viral load Asymptomatic and/or low viral load Massive Recoimmended Recoimmended Intennediate Recommended Possible Minimal Possible Possible (but to be discussed) Timing of initiation of treatment: To be effective the time of administering the prophylaxis should be as short as possible (within 1-2 hours, post exposure). However, the maximum delay in initiation of treatment, which would block infection, is not known in humans. Prophylaxis is sometimes given empirically up to 2 weeks in the case of severe exposure when the delay has been unavoidable. Therapeutic regimen: The therapeutic regimen may be decided on, drugs previously taken by the source patient, known or possibie cross resistance of drugs taken by the source patient, seriousness of the exposure and availability of the various ARVs. 6-2 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia The use of ZDV, as monotherapy for PEP, no longer appears justified in countnres where it has been used in patients for 10 years. Therefore, ZDV monotherapy for PEP is valid option in developing countries where ARVs are not available widely. Post-HIV Exposure Prophylaxis Table 6-2. Risk Categories andARV Prophylaxis RISK CATEGORY ARV PROPHYLAXIS DURATION Low Risk ZDV 300 mg bid + 3TC 150 mg bid OR Combivir I tab bid 28 days High Risk ZDV 300 mg bid + 3TC 150 mg bid + IDV 800 mg tid OR 28 days Combivir I tab bid + IDV 800 mg tid Low risk exposure: * Exposure to a small volume of blood or blood contaminated fluids from asymptomatic HIV positive patients * Following an injury with a solid needle * Any superficial injury or mucocuteneous exposure High-risk exposure: * Exposure to a large volume of blood or potentially infectious fluids or blood contaminated fluid from a patient with clinical AIDS or early seroconversion phase ofHIV * Injury with a hollow needle and/or deep and extensive injuries When source virus likely to be resistant to or healthcare provider is intolerant of basic regimen, ddl 200 mg bid + d4T 40 mg bid, d4T 40 mg bid + 3TC 150 mg bid, ZDV 300 mg bid + ddl 200 mg bid. For high-risk exposure to HIV positive source or when source virus is resistant, basic regimen plus Protease Inhibitor, Dual PI, NNRTI or third NRTI (Abacavir) may be added. As the risk of transmission is low and there is no evidence that 3-drugs regimen is better than 2-drug regimen. 3-drug regimen is associated with more toxicity and decreased adherence. Essential Steps to Follow When Post-Exposure ProphylaxisisAvailable * Identification of the accident: The accidental exposure to blood must be recognized as such by the health worker. This requires training of all healthcare providers at risk. * Foresee/prepare arrangements: These should function 24 hours a day. Anyone exposed should be able to receive confidential counseling and treatment in the hours following the accident. * Identify resource persons among the health facility personnel to help the exposed person to take the necessary steps and take care of him/her. * Identify a prescriber to evaluate the risk, decide on treatment to be offered and follow up the patient. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 6-3 * Initial serology: The healthcare worker who has been accidentally exposed should have HIV pretest counseling and a reference serology within eight days of the accident to check for prior infection. All those initially testing negative should have follow up serology. * Serological followup: counseling and testing should be offered at three and six months after the accident. * Provision of treatment: The treatment, which will comprise of 1 or a combination of 2 to 3 ARVs must be available at all times, must not be out of stock or out o f d ate and m ust be prescribed by a professional. Serology testing of the source patient: when the serological status of the source patient is not known, this person must be informed about the accident in order to obtain consent to test for HIV. Confidentiality of the result must be maintained at all times. If he/she refuses to test for HIV or consent is not possible, prophylaxis should be considered if there are indications of possible infection. REFERENCES Davis MS. 2001 a. A dvanced P recautions f or T oday's O R: The O peratingR oom P rofessional's H andbook f or t he Prevention of Sharps Injuries and Bloodborne Exposures, 2nd ed. Sweinbinder Publications LLC: Atlanta. Fox V. 1992. Passing surgical instruments, sharps without injury. AORN J 55(1): 264. Guidelines for Use of AntiretroviralDrugs in Ethiopia, Ministry of Health,Disease Prevention and Control Department in Collaboration with HIV/AIDS Prevention and Control Office (HAPCO) and Drug Administration and Control Authority (DACA) Addis Ababa, Feb. 2003. 6-4 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia CHAPTER 7 SAFE AND APPROPRIATE USE OF INJECTIONS The World Health Organization (WHO) estimates that at least 50 percent of all injections are unsafe-posing serious health risks to recipients, health workers, and the public. In many developing countries injection overuse and unsafe practices account for a substantial proportion of new infections with Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Viruses (HIV).In the year 2000 only, WHO has estimated, injections with contaminated needles or syringes caused: 21 million new infections with hepatitis B, two million with hepatitis C and 260,000 new infection of HIV. Hence, eliminating unnecessary injections is the highest priority to prevent injection-associated infections. When injections are medically indicated they should be administered safely. Best injection practices for intradermal, subcutaneous or intramuscular injections include: the use of sterile injection equipment, the prevention of contamiiination of injection equipment and medication, the prevention of needle- stick injuries to the provider and the prevention of access to used needles to the community. WHAT IS SAFE INJECTION? A safe injection is an injection practice that does not harm the recipient, does not expose the provider to any avoidable risk, and does not result in any waste that is dangerous for other people. BEST PRACTICES WHILE USING NEEDLES AND SYRINGES These best practices are measures that have been determined through scientific evidences or expert consensus to most effectively protect patients, providers and communities. These are divided in to four major areas of intervention: 1. Use Sterile Injection Equipment * Use a single use syringe and needle for each injection (Auto-disable syringes are mandatory for all immunization injections. For curative and other types of injection, syringes with reuse prevention d evices and syringes with safety features are recommended. Where these are not available, standard disposable syringes can be used.) * Ensure that the syringe and needle are sealed and inspect packaging for breaches i n b arrier integnty. * If single use syringes and needles are unavailable, use equipment designed for steam sterilization. The quality of sterilization process must be confirmed using time, steam, temperature (TST) spot indicators. * Reconstitute each unit of medication separately using single use synrnge and needle or stenle equipment. InfectionPrevention Guidelines for HealthcareFacilities in Ethiopia 7-1 2. Prevent Contamination of Injection Equipment and Medication * Prepare each injection in a clean designated area, where blood or body fluid contamination is unlikely. * Use single dose vials rather than multi-dose vials. * If multi-dose vials must be used, always pierce the septum with a sterile needle. Avoid leaving the needle in place in the stopper of the vial. * Select pop-open ampoules rather than ampoules that require use of a metal file to open. * If you are using an anmpoule that requires a metal file to open, protectfingers with a clean barrier (e.g., small gauze pad) when opening the ampoule. * Inspect for and discard medications with visible contamination or breaches of integrity (e.g., cracks, leaks). * Follow product-specific recommendation for use, storage and handling. * Swabbing of a new vial tops or ampoules with an antiseptic or disinfect is unnecessary. If swabbing with an antiseptic is selected for use, use a clean, single use swab and maintain product specific recommendation contact time. Do not use cotton balls stored wet in a multi-use container. * Skin preparation before injection. Wash skin that is visibly soiled or dirty with soap and water. If swabbing witlh an antiseptic is selected for use, use a clean, single use swab and maintain product specific recommendation contact time. Do not use cotton balls stored wet in a multi-use container. * Discard a needle that has touched any non-sterile surface. 3.Prevent Injuries to the Provider Before administering an injection or any skin piercing procedure ensure that the following precautions are observed depending on the types of procedure being done. * Anticipate and take measures to prevent sudden patient movement during and after injection. * Avoid recapping and other hand manipulation of needles. If recapping is necessary, use a single-handedscoop technique. * All used syringes and needles or any other sharps should be discarded at the point of use in an enclosed sharps container that is puncture and leak proof and that is sealed before completely full. * Disposable gloves are indicated only ifexcessive bleeding anticipated. 3. Prevent Access to Used Needles and Syringes * Seal sharp containers for transport to a secure area in preparation for disposal. After closing and sealing sharps containers, never open, empty or reuse or sell them. * Manage/dispose sharps waste in an efficient, safe and environment-friendly way to protect people from voluntary or accidental exposure to used injection equipment. 7-2 InfectionPrevention Guidelines for Healthcare Facilities in Ethiopia SHARP CONTAINERS DO'S AND DON'TS * Do put sharps containers as close to the point of use as possible and practical, ideally within arm's reach. Also, they should be easy to see, recognize and use. * Do attach containers to walls or other surfaces ifat all possible. * Do mark them clearly so that people will not unknowingly use them as a garbage container for discarding or other items. * Do place them at a convenient height so staff can use and replace them easily. * Do mark the fill line atthe three quarters full level. * Don't shake a container to settle its contents and make room for more sharps. * Don't place containers in high traffic areas (corridors outside patient rooms or procedure rooms) where people could bump into them or be stuck by someone carying sharps to be disposed of * Don't place containers on the floor or anywhere they could be knocked over or easily reached by a child. * Don't place containers near light switches, overhead fans or thermostat controls where people might accidentally put their hand into them. PREPARING SHARPS FROM LOCALLY AVAILABLE MATERIALS Several infection preventions programs in developing countries use locally available materials prepare, s imple, to e ffective, a nd i nexpensive sharp c ontainers. T he h ealth w orkers and program managers are encouraged to use innovative approaches to develop sharps containers from readily available "throw away" items, such as metal food containers made of aluminum, plastics (e.g. tin or heavy cooking oil bottles and cans), heavy-duty cardboard boxes and even the used plastic drinking water bottles with caps. Although some are safer than other, they all provide sustainable a no-cost, source of disposable sharps container for use in small clinics, polyclinicsand district- level hospitals with limited budgets. Remember: * Use those objects which are puncture resistant * Identify where to put a hole on the container for dropping the used sharps * Cleary name the container, "SHARPS" * Mark a 3/4level line. * Appropriately seal and dispose of container as per the waste disposal guidelines. STANDARDS FOR ADMINISTERING INJECTIONS * Prepare a well-laid up tray, include emergency drugs for management of possible drug reaction. * Wash hands with soap and water. Alcohol could be used as a secondary step afler soap water except and for EPI injections. * Drip dry. You can use small paper towels or any single use towels. Infection Prevention Guidelines for Healthcare Facilities inEthiopia 7-3 * Check for the integrity of the vial/ampoule for the following: expiry dates, breach, leaks, particles or any contamination. * Make sure that the right drug, right dose and route are used for the right patient or client. * For medications that need to be reconstituted (powder forms) it should be done according to the manufacturer's instruction, using the correct diluents. * Draw the right dose as prescribed, including expelling the air * Ensure aseptic technique while giving the injection * Administer the drug at the correct site * Dispose the used syringes and needles immediately into the sharp's container. (Never give used syringes and needles to patients or clients to carry home even if they came with the equiplllellt). * A patient should be kept for at least 5 minutes after the injection has been given and be observed for any possible adverse effects or events. * Thank the patient or the client. * Record the date and time of injection administered. Special Note: * All patients undergoing an injection should be educated/counseled before injection is given e.g., type of drug, side effects, possible adverse effects/events following the administration of the injection and total number of doses to be given by injection. * Self-injecting patients such as diabetic patients should be properly informiied about their medications and how to ensure safety of injection. In case a patient needs to take the injection equipmenit homiie, he should be counseled on storage, disposal and sterility of their drugs and equipment. REFERENCES Simonsen L et al. 1999. Unsafe Injections in the developing world and transmission ofblood borne pathogens: A review. Bulletin World Health Organization77(10): 789-800. WHO/BCT/03.01: Managing Injection Safety, 14 March 2003. 7-4 InfectionPrevention GuidelinesforHealthcare Facilities in Ethiopia CHAPTER 8 WASTE MANAGEMENT The purpose of waste management is to: * Protect people who handle waste items from accidental injury, * Prevent the spread of infection to healthcare workers who handle the waste, * Prevent the spread of infection to the local community, and * Safely dispose of hazardous materials. Waste must be properly handled within the clinic setting, even before it is taken for incineration, burial or other disposal, to protect clients,staff, and the community. Waste from healthcare facilities may be non-contaminated or contaminated (studies in other countries h ave shown t hat a pproximately 8 5% o ft he waste generated in the hospitals is non- contaminated) Non-contaminated wastes pose n o i nfectious risk t o p ersons w ho h andle t hem. Examples of non-contaminated waste include paper, trash, boxes, bottles and plastic containers, which contain products delivered to the clinic. Contaminated waste potentially infectious or toxic, if not disposed of properly. Contaminated waste include, blood, body fluids, secretions and excretions and items that have come in contact with them, such as sharps and used dressings, as well as medicines, medical supplies or other chemicals that may be toxic. * Contaminated and non-contaminated wastes should be separated at origin, to reduce the volume of contaminated waste and minimize the cost to the institution for more expensive procedures required for managing and disposing of contaminated waste properly. * When possible, use separate containers for combustible and non-combustible waste. * Never sort through contaminated wastes (e.g., do not try to separate non-contaminated waste from contaminated wastes, or combustible from non-combustible, after they have been combined). STEPS OF WASTE MANAGEMENT * Segregation * Collection * Transportation * Disposal Infection Prevention Guidelinesfor Healthcare FacilitiesinEthiopia 8-1 How to Dispose of Sharps and Sharp Containers * Use puncture-resistant sharps containers and work practices that minimize the unnecessary handling or sharps. * Wlhen container is three-quarterfull, remove from the procedure area for disposal. * Dispose of the sharps and sharp containers by burning, burying or encapsulating. * Always put on a heavy duty gloves when handling sharps containers. Encapsulation is recommended as one of the alternative way to safely dispose of sharps, wlhen burriln, or burying is not possible. For encapsulation sharps are collected in punlcture-resistant and leakproof containers. When container is three-quarter full, a material such as cement, plastic foam or clay is poured into the container until completely filled. After the material has hardenied, the container is sealed and buried. It is possible to encapsulate chemicals or pharmaceutical waste together with sharps. How to Dispose of Liquid Waste Liquid contaminated waste requires special handling, because it may pose an infectious risk to healthcare worker who handle the waste. * Wear P PE including utility gloves, protective eyewear and plastic apron when handling anud transporting liquid waste. * Pour waste down a utility sink drain or a flushable toilet and rinse with water. Avoid splashing. * If no sewage system available, dispose of liquid in a deep, covered hole, not into open drains. * Decontamiiinate containers by placing them in a 0.5% chlorinie solution before washilng themii. * Remove utility gloves, wash and dry hands or use antiseptic handrub as described in the guidelines. How to Dispose of Solid Waste Dispose of contaminated wastes separately from non-contaminated waste, because contamiiinated wastes needs special handling as follows: * Wear heavy duty or utility gloves when handling and transporting solid wastes. * Dispose of solid wastes by placing them in a plastic or galvanized metal container with a tight fitting cover. * Collect the waste containers on a regular basis and transport the burnable ones to the incinierator or area for burning. * Remove gloves and wash and dry hands or use an antiseptic handrub. Contaminated wastes should be disposed of during or immediately following a procedure. using non-corrosive leakproof containers with lids. There should be a sufficient number of waste containers, in convenient locations, to minimize carryinm contaminated wvastes from place to place. 8-2 Infection Prevention Guidelinesfor Healthcare Facilitiesin Ethiopia Non-contaminated wastes should be managed at health facility disposal level or thirough system. municipal How to Dispose of Hazardous Waste All hazardous waste material-chemical, pharmaceutical should be and one containing incinerated or buried heavy metals- if the quantity is very small. should be The large quantity sent back to the original of such materials supplier. Special situations * If a patient or family member wants to take home the placenta place them or body in a plastic parts for bag and bunral, first then into a rigid container for transport. * Blood and other cultures and stocks of infectious agents from sterilized laboratory by steaml sterilization work shlould be at the earliest, prior to disposal,if possible. Final Disposal of Wastes Open site of waste shoLt?d be avoided because they: * Pose infection risks and fire hazards * Produce foul odor * Attract insects * Are unsightly Incineration is controlled burning of solid, liquid or gaseous gases and combustible residues wastes containing to produce little or no burnable material. * Incineration provides highi temperatures and destroys microorganisms; methlod for and therefore, disposal of contaminated is the best wastes; incineration also reduces the bulk burLied. of wastes to be * Simple incinerators can be built from locally-available materials-bricks, fuel or oildrLmns, etc. concrete as shown blocks, used in Figure 8-1. * Pressurized gas containers (aerosol cans), large amounts of reactive and photographic chemical or radiographic waste, silver salts wastes, plastic containing polyvinyl sets or disposable chloride syringes), (blood bags, IN' and waste with high mercury or cadmium thermometers, content, used battenres such as broken and lead-lined wooden panels should not be incinerated. Infection Prevention Guidelines for Healthcare Facilities in Ethiopia 8-3 Figure 8-1. Simple Incinerator using Local Materials 50 cm USED FUEL DRUM (20 inches) Funnel-shaped opening Brick or Stone Supporl 20mm (0.5 inch) iron bars IL EE passed through holes in dnun. EARTH BASE Hole spacing spprox. 5 cm (2 inches). -0jm m (12inches) Brick or stone support arranged to create draught Figure 8-2. Stationary Incinerator s t:A w-w Li ' , - Source: Juncker et al 1994. Burial Only contaminated and hazardous waste needs to be buried. For effective and safe burial: * Access to the disposal site should be restricted. * The burial site should be lined with a material of low permeability, ifpossible. * Select site at least 50 meters away from any water source to prevent contamination ofthe water table. * The site should have proper drainage, be located downhill from any wells, free of standing water and not in an area that floods. How to Make and Use a Small Burial Site for Waste Disposal * Find an appropriate location as mentioned above. * Dig a pit 1meter square and 2 meter deep. The bottom ofthe pit should be 2 meters above water level. * Dispose of the contaminated waste in the pit and cover the waste with 10-15 cm of soil each day. The final layer of dirt should be 50-60 cm and compacted to prevent odors and attractions of insects, and to keep animals from digging up the buried waste. * Depending on volume such a pit should last for 30-60 days. 8-4 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia Figure 8-3. Burial Site for Waste Disposal ProuthlesccUTr IctICearound Shcd ,Ioire mesh cnhedded she pit in toptel dI - - z-~--------------. , Garbage When heconItiLS Larnh mormd arc to keep / 50(-6(0cm(20-31,inches) surtace waler out .- ofthe pit beIn.vthesurThce.till - the holew)th sail - I 0-1I i.m 14-X.sIh) r Waste Disposal Tips * Use heavy duty utility gloves and appropriate p ersonal protective equipment wastes. when h andling * Decontaminate and clean gloves between use. * Handle wastes carefully to avoid spills or splashes. * Always wash hands after removing gloves and handling contaminated wastes. * Avoid transferring contaminated waste from one container to another. * Incineration is the preferred method for waste disposal, as the heat destroy will generally infectious be sufficient microorganisms to and will also prevent scavenging items. and reuse of discarded * If incineration is not possible, then careful burial is the next best alternative. * Dispose of used toxic chemicals or medicine containers properly: * Rinse glass containers thoroughly with water; glass containers detergent, may be washed rinsed, dried with and reuses * For plastic containers that contained toxic substances such as glutaraldehyde, times with waster and rinse three dispose by incineration and/or burial; these containers for sharp disposal containers, may be used but do not reuse them for any other purpose * Equipment that is used to hold and transport wastes must not be used the clinic for any other or healthcare purpose in facility, and contaminated waste containers should be labeled clearly. * Contaminated waste containers should be cleaned each time contaminated they are emptied ones when and non- they are visibly soiled. REFERENCES Centers for Disease Control (CDC). 1985. Recommendations T-lymphotropic for preventing virus type transmission III/lymphadenopathy-associated of infection with human virus in the workplace. MMWR 34(45): 681-686; 691-695. Rutala WA. 1993. Disinfection, sterilization and waste 2nd ed. disposal, Wenzel RD in Prevention (ed). Williams and Control & Wilkins: of Nosocomial Baltimore, Infections, MD. South East Asia Regional Office (SEARO), World Health Facilities. Organization. SEARO: New Delhi, 1988. A Manual pp 72-8 on Infection Control in Health World Health Organization (WHO). 1999. Safe Management of Wastes from Healthcare Activities. WHO:Geneva. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 8-5 I ii i I i 0 CHAPTER 9 INSTRUMENT PROCESSING In working to create an infection-free environment, it is important that the rationale for each of the recommended infection prevention processes. and their limitations, be clearly understood by clinic staff at alllevels-from healthcare providers to cleaning and maintenance. Figure 9-1. Key Steps in Processing Contaminated Instruments, Gloves and Other Items DECONTAMINATION Soak in0.5%o chlorinesolution for 10 minutes CLEANING Wearing gloves and appropriatepersonal protective equipment, thoroughly wash and rinse toremove all blood and tissue from instruments STERILIZATION HIGH-LEVEL DISINFECTION Chemical Boil or Steam Gluteraldelhvde 2°o 10 hrs Completely covered timmilersed), atrolling Formialdehyde 8% 24 hrs boil, with a lidon, for 20 min Autoclave Chemical 106k Pa (1 lb in) pressLure 12I"C(2500F) Gluteraldeh%de 2%20 immn Unwrapped 20 miii WVrapped 30 mnii| Formaldehyde 8% 20 min Clliorine 0.1%O(prepared using boiled ,sater) I Dry Heat 20 inin. 170" C for 60 mn Cool and Use Immediately OR Store Properly DECONTAMINATION Decontamination is the first step in handling used instrumenits and gloves. Immediately after use. all instumments should be placed in an approved disinfectant such as 0.5% chiorine solution for i 0 minutes to inactivate most organisms, including HBV and HIV (ARON i 990: ASHCSP 1986). Infection Prevention Guidelines for Healthcare Facilities inEthiopia 9-1 For achieving satisfactory decontamination: * Make fresh solution every morning, or more often ifthe solution becomes cloudy. * Use plastic, non-corrosive container for decontamination. This prevents, sharp instruments from getting dull due to contact with metal containers. It also prevents instruments from getting rusted due to chemical reaction (electrolysis) that can occur between two different metals when placed in water. * Do not soak metal instruments in water for more than one hour, even if they are electroplated, to prevent rusting. * Do not mix chlorine solutions with either formaldehyde or with ammonia-based solutions as toxic gas may be produced. Decontaminating Hypodermic Needles, Syringes, and Large Surfaces * Hypodermic needles and syringes that are to be disposed of should be decontaminated and placed in a puncture-resistant sharp container * Large surfaces, such as pelvic examination or operating tables, or tables for delivery, that may have come in contact with blood and body fluid should be decontaminated using 0.5%chlorine solution. Decontaminating Used Instruments and Other Items 1. Keep surgical or examination gloves after completing the procedure. 2. Place all instruments in 0.5% chlorine solution for 10 minutes immediately after completing the procedure. 3. Decontaminate any surface contaminated during the procedure by wiping them with a cloth soaked in 0.5% chlorine solution. 4. Immerse gloved hands in 0.5% chlorine solution. 5. Remove gloves by turning inside out. If disposing of gloves, place them in a leak proof containing or heavy-duty plastic container. 6. If reusing gloves, soak in 0.5% chlorine solution for 10 minutes for decontamination. 7. Remove instruments from 0.5% chlorine solution after 10 minutes and immediately rinse them with cool water to remove residual chlorine before being thoroughly cleaned. 8. Two buckets can be used in the procedure areas or operating rooms, one filled with 0.5% chlorine solution and one with water, so instruments can be placed in the water after 10 minutes to help prevent corrosion. Remember: Leaving instruments in plain water for more than one hour can lead to rusting. 9-2 InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia Steps for Making a 0.5% Chlorine Solution for Decontamination A 0.5% chlorine solution (Barkina) can be made from readily available liquid or powder chlorine. Liquid chlorine is available under different brand names in different concentration for example "Ghion" available in Ethiopia contains 5% chlorine. Manufacturers of, widely used brand Sedex, contains 5% chlorine. Formula for Making a Dilute Solution from Concentrated Solutions * Determine the concentration (% concentration) of the chlorine solution * Deternine the desired concentration (% dilution) * Check concentration (%concentrate) of the chlorine product you are using. * Deter-mine total parts water needed using Table 10-1 or the following formula: Totail Parts(TP) water KO = Concentrate 'S,Diliute * Mix I part concentrated bleach with the totalparts water required. Example: Make a dilute solution (0.5%) from 5% concentrated r5.0%01 solution STEP 1: Calculate TP water: -1=10 - I = 9 LO.5 %0] STEP 2: Take I part concentrated solution and add to 9 parts wvater. Once instruments and other items have been decontaminated, they can safely be further processed. This consists ofcleaning and finally either high-level disinfection of sterilization. CLEANING After decontamination of soiled instruments or gloves in 0.5% chlorine solution for 10 minutes, they must be cleaned to remove organic materials or chemical residue. Using liquid soap, if available, is preferable. Liquid soap removes grease, oil, and other foreign matters in solution so that they can be removed easily by the cleaning process. Abrasive cleaners used for household cleaning, including steel wool, should be avoided as they can result in scratches on the instruments which can be a potential site for harboring microorganisms. Table 9-1 shows the effectiveness of methods for processing instruments. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 9-3 Table 9-1. Effectiveness of Methodsfor Processing Instruments METHOD EFFECTIVENESS END POINT (kill or remove microorganisms)ENPOT Kills HBV and HIV and most 10 minute soak Decontamination microorganisms Cleaning (water only) Up to 50% Until visibly clean Cleaning (soap and rinsing with Up to 80% Until visibly clean water) High-Level Disinfection 95% (does not inactivate some Boiling, steaming or chemnical for endospores) 20 minutes Sterilization 100% High-pressure steam, dry heat or chemical for recommended time Cleaning Tips * Wear gloves while cleaning instruments and equipment. (Thick household or utility gloves work well.) Iftorn or damaged, they should be discarded; otherwise they should be cleaned and left to dry at the end of the day for use the following day. * Wear protective eyewear (plastic visors, face shields, goggles or glasses, protective shoes) and a plastic apron, if available, while cleaning instruments and equipment to minimize the ri§k of splashing contaminated fluids into the eyes and onto the body. * To prevent splashing keep the items being washed under the surface ofthe water. * Instruments should be washed with a soft brush in soapy water. Particular attention should be paid to instruments with teeth, joints, or screws where organic material can collect. After cleaning, instruments should be thoroughly rinsed with clean water to remove soap residue that can interfere with chemical disinfectants used for HLD or sterilization. Remember: The items that cannot be cleaned thoroughly should not be reused and discarded. STERILIZATION Sterilization should be used for instruments, surgical gloves and other items that come in direct contact with the blood stream or normally sterile tissues. Sterilization can be achieved by physical agents such as high-pressure steam (autoclaving), dry heat, or chemical sterilants such as gluteraldehyde or formaldehyde. Instructions for Sterilization by Autoclaving I. Do not put plastic or rubber instruments or equipment in the autoclave unless the manufacturer's instructions say it is safe, as they will melt. Where electricity is a problem, instruments can be sterilized in a nonelectric steam sterilizer using kerosene or other fuel as a heat source. 9-4 Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia 2. Make sure that instruments and items to be sterilized have been decontaminated, cleaned and dried. All jointed instruments should be in the opened or unlocked positions, while instruments composed of more than one part or sliding parts should be disassembled. 3. Instruments should not be held tightly together by rubber bands or any other means that will prevent steam contact with all surfaces. 4. Wrap the sharp edges and needle points in a gauze before sterilizing to help prevent dulling of sharp instruments. Repair or replace instruments as needed 5. Do not allow to boil dry. Steam should always be escaping from the pressure valve. 6. If using a pressure cooker or kerosene-powered gravity displacement steam sterilizer, bring the water to a boil and let steam escape from the pressure valve; then turn down heat, but keep steam coming out ofthe pressure valve. 7. Sterilize at 121°C (250°F) for 30 minutes for wrapped items, 20 minutes for unwrapped items; time with a clock. Start counting time after the pressure has reached 15 Lbs/in2 or 106 kPa. 8. Wait 20-30 minutes (or until the pressure gauge reads zero) to permit the sterilizer to cool sufficiently. Then open the lid or door to allow steam to escape. 9. Allow instrument packs to dry completely before removal, which may take up to 30 minutes. (Wet packs act like a wick drawing in bacteria, viruses and fungi from the environment) Wrapped instrument packs are considered unacceptable if there are water droplets or visible moisture on the outer surfaces of the packages when they are removed from the steam sterilizer chamber. If using rigid containers, close the lids tightly. 10. To prevent condensation, when removing the packs from the chamber, place sterile traysand packs on a surface padded with paper or fabric. 11. After sterilizing, items wrapped in cloth or paper are considered sterile as long as the pack remains clean, dry and intact. Unwrapped items must be used immediately or stored in covered sterile containers. 12. Do not store trays or packs until they reach room temperature. This usually takes about an hour. 13. Maintain a steam sterilizer log including, heat begun, correct temperature and pressure achieved, heat turned down, and heat turned off. 14. Each load should be monitored with mechanical (time, temperature and pressure) and chemical (internal and external chemical test strips) indicators. 15. Autoclave should be tested daily with an air-removal test to ensure proper air removal. Infection PreventionGuidelines for HealthcareFacilities in Ethiopia 9-5 Guidelines for Operating and Maintaining Autoclave Machines Instruction for operation and routine maintenance of autoclave machines should be included in the basic training of healthcare staff. An autoclave machine will reliably sterilize items only when kept in good working condition and operated correctly. Steam Contact To ensure proper steam contact: * Decontaminate, clean and dry objects being sterilized as per guidelines. * Keep instruments opened, and unlocked. * Do not stack the instruments. * Do not wrap the packages too tightly. * Do not arrange the packs in the sterilizer too close to each other. * Position the containers in a way that air can easily be displaced and steam can have enough contact with all surfaces. * Ensure that the small drain strainer at the bottom ofthe sterilizer is not clogged. This may result in trapping air inside the sterilizer. * Follow the manufacturer's manual for maintenance of the sterilizer. In some cases, however, a weekly flush of hot liquid soap through the exhaust line will keep it cleaned out. * Appropnrate Temperature (121 °C all throughout the process), Timing (20 minutes for unwrapped and 30 minutes for wrapped), and adequate Moisture (100% moisture in the steam) should be ensured during any autoclaving cycle. * To ensure correct operation, when available, consult specific operating instructions from the manual supplied by the manufacturer. Sterilization by Dry Heat When available, dry heat is a practical way to sterilize needles and other sharp instruments. Dry-heat sterilization can be achieved with a simple oven as long as a thermometer is used to verify the temperature inside the oven. InstructionsforUsing Dry Heat for Sterilization 1. Use dry heat only for items that can withstand a temperature of 170'C/340'F (Perkins 1983). 2. Decontaminate, clean, and dry all instruments and other items to be sterilized. 3. If desired, wrap instruments in aluminum foil or place in a metal container with a tight- fitting, closed lid. Wrapping helps prevent recontamination prior to use. Hypodermic or suture needles should be placed in glass tubes with cotton stoppers. When using dry heat to sterilize items wrapped in cloth, be sure that temperature does not exceed 170°C/340°F. Needles and other instruments with cutting edges should be sterilized at lower temperatures (1600C [3200F]), because higher temperatures can destroy the sharpness of cutting edges. 9-6 InfectionPrevention GuidelinesforHealthcare FacilitiesinEthiopia 4. Place loose instruments in metal containers or on trays in the oven and heat to the desired temperature. 5. After the desired temperature is reached, begin timing. The following temperature/time is recommended (APIC 2002): * 170°C (3400F) 60 minutes * 160°C (320°F) 120 minutes * 1500C (3000F) 150 minutes * 140°C (285°F) 180 minutes * 121C (250°F) overnight 6. Depending upon the temperature selected, the total cycle time (preheating, sterilization time and cool down) will range from 2.5 hours at 170°C to more than 8 hours at 121°C. 7. After cooling, remove packs and/or metal containers and store in a cool dry area. Loose items should be removed with sterile forceps and used immediately or placed in a sterile container with a tight-fitting lid. Chemical Sterilization * Chemical sterilization is an alternative to high-pressure steam or dry-heat sterilization is chemical sterilization often called "cold sterilization". It is useful for those items, which would get damaged by high-pressure steam or dry heat. They can be sterilized using chemicals such as Gluteraldehyde and formaldehydes. Because glutaraldehyde works best at room temperature, chemical sterilization cannot be assured in cold environments (temperatures less than 20°C/68°F), even with prolonged soaking. Formaldehyde should never be mixed with chlorine or chlorinated water because a dangerous gas (bis-chloromethyle-ether) is produced. Instructionsfor Chemical Sterilization 1. Decontaminate, clean and dry all instruments and other items to be sterilized using chemical. 2. Completely submerge items in a clean container filled with the chemical solution and place the lid on the container. 3. Allow items to soak: * 10 hours in a glutaraldehyde (check specific product instructions), or * at least 24 hours in 8% formaldehyde. 4. Remove objects from the solution with sterile forceps; rinse all surfaces three times in sterile water and air dry. Ideally, three separate (sequential) rinse containers should be used. Monitoring Sterilization Procedures * Biological Indicators are recommended for use at regular intervals. For steam stenrlizers, Bacillus stearothermophilus, weekly and as needed and for dry-heat sterilizers, Bacillus subtilis, weekly and as needed. * Chemical Indicators include tape or labels, which monitor time, temperature and pressure for steam sterilization, and time and temperature for dry-heat sterilization. InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 9-7 * External indicators should be used to verify that items have been exposed to the correct conditions ofthe sterilization process and that the specific pack has been sterilized. * Internal indicators are placed inside a pack or container in the area most difficult for the sterilization agent (steam or heat) to reach (i.e., the middle ofthe linen pack). * Chemical indictors, such as heat sensitive tape or glass vials containing pellets that melt at certain temperatures for a given time, do not guarantee that sterilization has been achieved. They do, however, indicate whether mechanical or procedural problems in the sterilization process have occurred. * Mechanical indicators for sterilization provide a v isible record o f t he t ime, t emperature and pressure for that sterilization cycle. This is usually a printout or graph from the sterilizer, or it can be a log of time, temperature and pressure kept by the person responsible for the sterilization process that day. This is most inexpensive way to make sure that sterilization process was carried out as per the guidelines. STORAGE All sterile items should be stored appropriately to protect them from dust, dirt, and moisture. The storage area should be located next to or connected to where sterilization occurs, in a separate enclosed area with limited access that is used just to store sterile and clean patient care supplies. In smaller clinics, this area may be just a room close to the Central Supplies Department or in the Operating Room. Instructions for Storing Sterile Items I. Keep the storage area clean, dry, dust-free and lint-free. 2. Control temperature and humidity (approximate temperature 240C and relative humidity <70%) when possible. 3. Packs and containers with sterile (or high-level disinfected) items should be stored 20-25 cm off the floor, 45-50 cm from the ceiling and 15-20 cm from an outside wall. 4. Do not use cardboard boxes for storage. Cardboard boxes shed dust and debris and may harbor insects. 5. Date and rotate the supplies (first in/first out). This process serves as a reminder, but does not guarantee sterility of the packs. 6. Distribute sterile and high-level disinfected items from this area. Shelf Life * The shelf life of an item after sterilization is event-related. The item remains sterile until something causes the package or container to become contaminate-time elapsed since sterilization is not the determining factor. * To make sure items remain sterile until you need them, prevent events that can contaminate sterile packs, and protect them by placing them in plastic covers (thick polyethylene bags). 9-8 InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia * Before using any sterile item, look at the package to make sure the wrapper is intact, the seal unbroken and is clean and dry (as well as having not water stains). * If the quality ofwrapping cloth is poor and plastic bags are not available, limiting the shelf life is a reasonable option to ensure the sterilityof the instruments. HIGH-LEVEL DISINFECTION Although sterilization is the safest and most effective method for the final processing of instruments, often sterilization equipment is either not available or not suitable. In these cases, HLD is the only acceptable alternative. How to Prepare a HLD Container * For small containers, boil water in the covered container for 20 minutes, then pour out the water, which can be used for other purposes, replace the cover and allow container to dry. * Alternatively, and for large containers, fill a plastic container with 0.5% chlorine solution and immerse the cover in chlorine solution as well. Soak both for 20 minutes. Rinse the cover and the inside of the container three times with boiled water and allow to air dry. Large metal containers cannot be HLD using chemicals. High-Level Disinfection by Boiling * Although boiling instruments in water for 20 minutes will kill all vegetative forms of bacteria, viruses, yeast and fungi, boiling will not kill all endospores reliably. InstructionsforHLD by Boiling 1. Decontaminate, clean and dry all instruments and items to be high-level disinfected. 2. Completely immerse all items in the water. For plastic items that float on the surface of boiling water, it is not necessary that they be fully covered by the water to achieve HLD if the pot is covered with lid. Make sure all bowls and containers to be boiled are full of water. 3. Close lid over pan and bring water to a gentle, rolling boil. B oiling w ater t oo v igorously wastes fuel, rapidly evaporates the water and may damage delicate instruments or other items. 4. Start timer. In the HLD log, note time on the clock and record the time when rolling boil begins. 5. Boil all items for 20 minutes. 6. After boiling for 20 minutes, remove objects with previously high-level disinfected forceps. Never leave boiled instruments in the water that has stopped boiling. 7. Use instruments and other items immediately or, with high-level disinfected forceps or gloves, place objects in a HLD container with a tight-fitting cover. Once the instruments are dry, if any pooled water remains at the bottom of the container, remove the dry items and place them in another HLD container that is dry and can be tightly covered. InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 9-9 For protecting the life ofinstruments that are frequently boiled: 1. Boil the water for 10 minutes at the beginning of each day before use. 2. Use the same water throughout the day, adding only enough to keep the surface at least I inch above the instruments to be HLD. 3. Drain and clean the boiler or pot at the end of each day to remove lime deposits. High-Level Disinfection by Steaming Steaming surgical gloves has been used as the final step in processing gloves for many years in several countries. The effectiveness of this process has been confinned by research. Any locally available instrumiient for steaming can be used for this purpose. Figure 9-2. Example of a HLD Steamer Lid boiluig water InstructionsforHLD bySteaming 1. Place instruments, plastic MVA cannulae and other items in one of the steamer pans with holes in its bottom. To make removal from the pan easier, do not overfill the pan. 2. Repeat this process until up to three steamer pans have been filled. Stack the filled steamer pans on the top of a bottom pan containing water ior boiling. A second empty pan witlhout whole should be placed on the counter next to the heat source. 3. Place lid on the top pan and bring the water to a full rolling boil. 4. When steam begins to come out between the pans and the lid, start the timer or note the time on the clock and record the time in the HLD log. 5. Steam items for 20 minutes. 6. Remove the top steamer pan and put the lid on the pan that was below it. Gently shake excess water from the pan just removed. 7. Put the pan just removed onto the empty pan. Repeat until all pans are restacked on this empty pan and the top pan is covered with the lid. 9-10 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 8. Allow items to air dry in the steamer pan before using. 9. Using HLD forceps, transfer the dry items to a dry, HLD container with a tight fitting cover. Instruments and other items can also be stored in the stacked and covered steamer pans as long as a bottom pan (one with no holes) is used. HLD using Chemicals Although number of disinfectants is commercially available in most countries including Ethiopia, four d isinfectants-chlorine, g lutaraldehyde, formaldehyde a nd h ydrogen p eroxide- are routinely used for HLD. Key Steps in Chemical HLD I. Decontaminate, clean and dry all instruments. 2. Completely immerse all items in the high-level disinfectant. 3. Soak for 20 minutes (for 0.1% chlorine prepared using boiled water, 2-4% gluteraldehyde, 8% formaldehyde, and 6% hydrogen peroxide). 4. Remove items using HLD or sterile forceps or gloves. 5. Rinse well with boiled and filtered water three times and air dry. 6. Use promptly or store in a dry, HLD container with tight fitting lid. Alcohols and iodophors are disinfectants and not high-level disinfectants and should not be used for HLD purpose. Table 9-2 provides information on preparing and using chemical disinfectants. Note: Chemical disinfectants should be stored in a cool, dark area. The glass containers, used for storing chemicals, should be washed with soap, rinsed, dried and reused. Alternatively, thoroughly rinse g lass c ontainers with water and dispose of by burying. Plastic containers used for toxic substances such as formaldehyde should be rinsed with water and disposed of by burning or burying. They should never be reused. To further prevent them from being reused, put a hole in each container before disposal so that water or other liquids cannlot be carried in it. toilet The used chemicals should be carefully poured down a utility sink drain or into a flushable and rinse or flush with water. Liquid waste can also be poured into a latrine. Avoid splashing. The products-Acridine derivatives, Cetrimide (Cetavlaon), Chlorohexedine gluconate and cetrimide in various concentration (Savlonc'), Chlorinated Lime and boric acid (Eusol R), Chlorxynelol in alcohol (Dettol') and Mercury compounds-should not be used as disinfectants. They are antiseptics, mainly used to clean the skin. InfectionPreventionGuidelines for Healthcare Facilities in Ethiopia 9-11 Table 9-2. Preparing and Using Chemical Disinfectants Disinfectant (common Effective How to Skin Eye Respiratory Leaves Time Time Needed fe2 solution or Concentration Dilute Irritant Irritant Irritant HDDResidue for Sterilization brand)HL CHEMICALS FOR STERILIZATION OR HIGH-LEVEL DISINFECTION Chlorine 0.1% Dilution Yes (with Yes Yes Yes' Yes 20 minutes Do not use Change every 14 days, procedures prolonged sooner if cloudy. vary, contact) Formaldehyde 8% 1part 35-40% Yes Yes Yes No Yes 20 minutes 24 hours Change every 14 days, (35-40%) solution to 4 sooner if cloudy. parts boiled water Glutaraldehyd Varies (2-4%) Add activator Yes Yes Yes No Yes 20 minutes 10 hours for Change every 14-28 e(Cidex®) (vapors) at 25OCd Cidex® days; sooner if cloudy. Hydrogen 6% 1part 30% Yes Yes No Yes No 20 minutes Do not use Change daily; sooner Peroxide solution to 4 if cloudy. (30%) parts boiled water CHEMICALS FOR DISINFECTION (alcohols and iodophors are not high-level disinfectants) Alcohol (ethyl 60-90% Use full Yes (can Yes No No No Do not use Do not use If container (bottle) or isopropyl) strength dry skin) kept closed, use until empty. lodophors (10% Approximately I part 10% No Yes No Yes Yes Do not use Do not use If container (bottle) povidone- 2.5% PVI to 3 parts kept closed, use until iodine) (PVI) water empty. aAll chemical disinfectants are heat and light sensitive and should be stored away from direct sunlightand in a cool place (<40 0C). bSee Tables 10-1 and 10-2 for instructions on preparing chlorine solutions. 'Only corrosive with prolonged (>20 minutes) contact at concentrations >0.5% if not rinsed immediately with boiled water. dDifferent commercial preparations of Cidex and other glutaraldehydes are effective at lower temperatures (20°C) and for longer activated shelf life. Always check manufacturers' instructions. Adaptedffrom: Rutala 1996. 9-12 InfectionPrevention Guidelines forHealthcare Facilities in Ethiopia Table 9-3. Guidelines for Processing Instruments, Surgical Gloves, and Other Items INSTRUMENTS OR DECONTAMINATION CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTIONb OTHER ITEMS ITEMS Ftirststep inhandlingused itemis, i t-iedices Removes allvisible blood bodyfluids and Destroys allmicroorganisms,including Destroys all viuses.bactena,parasites,fungi -isk of HBV HCV and HIV viriuses. dirt. endospores. andsome endospores. Not necessary Airways (plastic) Soak in a 0.5% chlorine solution Wash with soap and water. Rinse Not necessary for 10 minutes prior to cleaning. with clean water, air or towel Rinse and wash immediately. dry. Ambu bags and CPR face masks Wipe exposed surfaces with Wash with soap and water. Rinse Not necessary Not necessary gauze pad soaked in 60B90% with clean water, air or towel dry. alcohol or 0.5% chlorine; rinse immediately. Aprons (heavy plastic or rubber) Wipe with 0.5% chlorine Wash with liquid soap and water. Not necessary Not necessary solution. Rinse with clean wvater. Rinse with clean water, air or Between each procedure or each towel dry at the end of the day or time they are taken off. when visibly soiled. Bed pans, urinals or emesis Not necessary. Using a brush, wash with Not necessary Not necessary basins disinfectant solution (soap and 0.5% chlorine). Rinse with clean water. Blood pressure cuff Ifcontaminated with blood or If soiled, wash with soap and Not necessary Not necessary body fluids, wipe with gauze pad water. Rinse with clean water, air or cloth soaked with 0.5% or towel dry. chlorine solution. Diaphragms or fitting rings (used Soak in 0.5% chlorine solution Wash with soap and water. Rinse Not necessary but can be * Steam or boil for 20 minutes. for sizing with clients) for 10 minutes prior to cleaning. with clean water. Air or towel dry. autoclaved at 121°C (250'F) 106 * Chemically high-level Rinse or wash immediately. kPa (15 lbs/in2) for 20 minutes disinfect by soaking in 8% (unwrapped). fornaldehyde, or a 2-4% glutaraldehyde for 20 minutes. Rinse well in water that has been boiled. Exam or operating room tables or Wipe off with 0.5% chlorine Wash with soap and water if Not necessary Not necessary other large surface areas (carts solution. organic material remains after and stretchers) decontamination. 9-13 InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia Table 9-3. Guidelines for Processing Instruments, Surgical Gloves, and Other Items (continued) INSTRUMENTS OR DECONTAMINATION CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTIONb OTHER ITEMS ITEMS Fir-strisk stepofinHB hanidling utsed iterns; it rediuces Renioi es all visibledirt. blood, bodyfluids and Destroys all microorganisms, including viruses, bactena,parasites.fiingi V,HCV andHIV viruses. endospores. Destroys allandsome endospores Footwear (rubber shoes or boots) Wipe with 0.5% chlorine Wash with liquid soap and water. Not necessary Not necessary solution. Rinse with clean water. Rinse with clean water, air or At the end of the day or when towel dry at the end of the day or visibly soiled. when visibly soiled. Hypodermic needles and syringes While holding needle under the Disassemble, and then wash with Preferable (glass only): Acceptable (glass or plastic): (glass or plastic) surface of 0.5% chlorine soap and water. Rinse with clean * Dry heat for 2 hours after * Steam or boil for 20 minutes. solution, fill assembled needle water, air or towel dry syringes reaching 160°C (320°F) (glass and syringe with solution and (only air dry needles). syringes only), or (Chemical HLD is not soak for 10 minutes prior to * Autoclave at 121 °C (250°F) recommended because chemical cleaning. Rinse by flushing three and 106 kPa (15 lbs/in2) for 20 residue may remain even after times with clean water. minutes (30 minutes if repeated rinsing with boiled wrapped). water. These residues may interfere with the action of drugs being injected.) IUDs and inserters Not appropriate Not appropriate Not recommended. Most IUDs Not recommended (never reuse) and inserters come in sterile packages. Discard if package seal is broken. Between cases, soak for 20 Laparoscopes Wipe exposed surfaces with Disassemble, then using a brush Sterilize daily using chemical gauze pad soaked in 60B90% wash with soap and water. Rinse sterilization. Soak in: minutes in: alcohol; rinse immediately. with clean water, towel dry. * a glutaraldehyde (usually 2%) * a glutaraldehyde (usually for 10 hours, or 2-4%), or * 8% formaldehyde for 24 * 8% formaldehyde, or hours. * 0.1% chlorine solution with Rinse with sterile water or water boiled and filtered (if which has been boiled for 20 necessary) water. minutes three times. Rinse three times with water that has been boiled for 20 minutes. PPE (caps, masks, covergowns)d Not necessary. (Laundry staff Wash with soap and hot water. Not necessary Not necessary should wear plastic aprons, gloves Rinse with clean water, air or and protective foot and eyewear machine dry. Wrap for reuse. wvhen handling soiled linen.) 9-14 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia Table 9-3. Guidelines for Processing Instruments, Surgical Gloves, and Other Items (continued) INSTRUMENTS OR DECONTAMINATION CLEANING STERILIZATIONa OTHER ITEMS ITEMS HIGH-LEVEL DISINFECTIONb Fststep inhandling Misk ofH V HCV'uised itenis; it reduces arnl IXViliruses. Remonves all visibledirt. blood, bodyfluidsand Destroys all rnicroo,ganisms.including endospores. Destroys alland someendospores viuses, bactena parasitefimagi Stethoscopes Wipe with gauze pad soaked in If soiled, wash with soap and Not necessary Not necessary 60-90% alcohol. water. Rinse with clean water, air or towel dry. Storage containers for Soak in 0.5% chlorine solution Wash with soap and water. Rinse * Dry heat for I hour after instruments (metal or Boil container and lid for 20 plastic) for 10 minutes prior to cleaning. with clean water, air or towel reaching 170°C (340°F), or minutes. If container is too large: Rinse or wash immediately.c dry. * Autoclave at 121°C (250°F) * Fill container with 0.5% and 106 kPa (15 lbs/in2 ) for 20 chlorine solution and soak for nminutes (30 minutes if 20 minutes. wrapped). * Rinse with water that has been boiled for 20 minutes and air dry before use. Suction bulbs (rubber) Soak in a 0.5% chlorine solution Wash with soap and water. Rinse Not necessary Not necessary for 10 minutes prior to cleaning. with clean water, air or towel Rinse and wash immediately. dry. Suction cannulae (plastic) for Soak in 0.5% chlorine solution Pass soapy water through Not recommended. (Heat from manual vacuum aspiration Steam or boil for 20 minutes. for 10 minutes prior to cleaning. cannulae three times, removing autoclaving or dry-heat ovens (MNVA) Rinse or wash immediately. all particles. will damage cannulae.) Suction catheters Soak in 0.5% chlorine solution Pass soapy water through Not recommended. (Heat from (nibber or plastic) * Steam or boil for 20 minutes. for 10 minutes prior to cleaning. catheter three times. Rinse three autoclaving or dry-heat ovens (Chemical HLD is not Rinse or wash immediately. times with clean water (inside will damage plastic catheters; recommended because and outside). may remain . rubber catheters can be chemical residue autoclaved.) even after repeated rinsing with boiled water.) Surgical gloves Soak in 0.5% chlorine solution Wash with soap and water. Rinse Ifused for surgery: * Steam for 20 minutes and for 10 minutes prior to cleaning. with clean water and check for * Autoclave at 121 °C (250°F), allow to dry in steamer. Rinse or wash immediately. holes. If to be sterilized, dry and 106 kPa(15 lbs/in2) for 20 inside and out (air or towel dry) minutes. and package. * Do not use for 24B48 hours. 9-15 Infection Prevention Guidelines for Healthcare Facilities in Ethiopia Table 9-3. Guidelines for Processing Instruments, Surgical Gloves, and Other Items (continued) DECONTAMINATION CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTIONb OTHER ITEMS ITEMS Fi-strisk stepofiniiandlingused itets, itreduces Remzoves all visibledirt. blood, bodyfl.uidsand Destroys allmiicroorganisms, incliuding viuses, bacteia.parasitesfungi HBV HCVandHIVvinuses. endospores. Destroysallandsome endospores. Surgical gowns, linen drapes and Not necessary. (Laundry staff Wash with soap and hot water. Autoclave at 120°C/250°F and Not practical wrappers should wear plastic aprons, Rinse with clean water, air or 106 kPa (15 lbs/in2) for 30 gloves and protective foot and machine dry. minutes. eyewear, when handling soiled linen.) Surgical instruments (metal) Soak in 0.5% chlorine solution Using a brush, wash with soap Preferable: Acceptable: for 10 minutes prior to cleaning. and water. Rinse with clean * Dry heat for I hour after * Steam or boil for 20 minutes. Rinse or wash immediately.c water. Ifto be sterilized, air or reaching 170°C (3400F)', or * Chemically high-level towel dry and wrap in packs or * Autoclave at 121 °C (250°F) and disinfect by soaking for 20 individually. 106 kPa (15 lbs/in2) for 20 minutes. Rinse well with minutes (30 minutes if boiled water and air dry before lwrapped). use or storage. For sharp instruments: Dry heat for 2 hours after reaching 160°C (3200F).e Thermometers (glass) Not necessary Wipe with disinfectant solution Not necessary Not necessary (soap and 0.5% chlorine). Rinse with clean water, air or towel dry. Transfer forceps (chittle) and Soak in 0.5% chlorine solution Using a brush, wash with soap Preferable: Acceptable: container (metal) for 10 minutes prior to cleaning. and water. Rinse with clean * Dry heat for I hour after * Steam or boil for 20 minutes. Rinse or wash immediately.c water. Ifto be sterilized, air or reaching 170°C (340°F)', or Chemically high-level (Reprocess per shift or when towel dry. * Autoclave at 121°C (250°F) and disinfect by soaking for 20 contaminated.) 106 kPa (15 lbs/in2 ) for 20 minutes. Rinse well with minutes (30 minutes if boiled water and air dry before wrapped). use. Urinary catheters (rubber and Soak in 0.5% chlorine solution Using a brush, wash with soap Preferable (metal only): Acceptable (rubber or metal): straight metal) for 10 minutes prior to cleaning. and water. Rinse three times with * Dry heat for 2 hours after * Steam or boil for 20 minutes. Rinse or wash immediately.' clean water (inside and outside). reaching 160°C (320°F), or * Autoclave at 121°C (250°F) and 106 kPa (15 lbs/in2) for 20 minutes (30 minutes if wrapped). 9-16 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia Table 9-3. Guidelines for Processing Instruments, Surgical Gloves, and Other Items (continued) INSTRUMENTS OR DECONTAMINATION CLEANING STERILIZATIONa HIGH-LEVEL DISINFECTIONb OTHER ITEMS ITEMS Firstrisk inHB stepof handlingused items, It redtuces Destroys nll niicroorganisnis. including viruses, bactena, parasites,fungi V HCV and HIVviruses Removes all visibledir blood. bodyfluids and t endospores Destroysallandsome endospor-es. Ventilator tubing or circuits Not necessary Using a brush, wash with soap Not possible using an autoclave Acceptable and water. Rinse with clean or dry heat oven. * Steam or boil for 20 minutes. water and air dry. * Air dry before use. or contaminated. aIf unwrapped, use immediately; if wrapped, reprocess if package becomes damaged bIfsterilization (dry-heat or autoclave) is not available, these items can be high-level disinfected either by boiling, steaming or soaking in a chemical disinfectant. "Avoid prolonged exposure (> 20 minutes) to chlorine solution (> 0.5%) to minimize corrosion (rusting) of instruments and deterioration of rubber or cloth products. dPaper or plastic gowns, caps or masks. Place in a plastic bag or leakproof, covered waste container for disposal. Instruments with cutting edges or needles should not be sterilized at temperatures above 160LiC to avoid dulling. 9-17 Infection Prevention Guidelines forHealthcare Facilities in Ethiopia REFERENCES Association for Practitioners inInfection Control (APIC). 2002. APIC Text of Infection Control and Epidemiology on CD-ROM. APIC: Washington, DC. Association of Operating Room Nurses (AORN). 1990. Clinical issues. AORN J 52: 613-615. Gruendemann BJ and SS Mangum. 2001. Ultraviolet irradiation and lights, in Infection Preventionin Surgical Settings. WB Saunders Company: Philadelphia, pp 32-35. Nystrom B. 1981. Disinfection of surgical instruments. J Hosp Infect 2(4): 363-368. Rutala WA. 1996. APIC guidelines for selection and use of disinfectants. Am J Infect Control, 24(4): 313-342. Tietjen LG, W Cronin and N McIntosh. 1992. High-level disinfection, in Infection Prevention Guidelines for Family Planning Programs. Essential Medical Information Systems, Inc.: Durant, OK, pp 74-84. World Health Organization (WHO). 1989. Guidelines on Sterilization and High-Level Disinfection Methods Effective Against Human Immunodeficiency Virus (HIV). AIDS Series 2. WHO: Geneva. 9-18 InJection Preveention GuidelinesforHealthcareFacilitiesin Ethiopia SECTION 10 PROCESSING LINEN Although soiled linen may contain large numbers ofmicroorganisms, there is little risk to health workers during linen processing. When work related infections occur, they often are the due to healthcare workers not using gloves or not washing their hands during or after collecting, transporting and sorting soiled items. No additional precautions are necessary, regardless of the patient's diagnosis, if standard precautions are used in all situations. Principles and key steps in processing linen: * Housekeeping and laundry personnel should wear gloves and other personal protective equipment as indicated when collecting, handling, transporting, sorting and washing soiled linen. * When collecting and transporting soiled linen, handle it as little as possible and with minimum contact to avoid accidental injury and spreading of microorganisms. * Consider all cloth items (e.g., surgical drapes, gowns, wrappers) used during a procedure as infectious. Even ifthere is no visible contamination, the item must be laundered. * Carry soiled linen in covered containers or plastic bags to prevent spills and splashes, and confine the soiled linen to designated areas (interim storage area) until transported to the laundry. * Carefully sort all linen in the laundry area before washing. Remember: Do not presort or wash linen at the point of use. USE OF PERSONAL PROTECTIVE EQUIPMENT Utility gloves, plastic or rubber apron and protective eyewear and closed shoes that protect feet from dropped items and spilled blood and body fluids should always be used when collecting and handling, transporting, sorting, hand washing soiled linen or loading in automnatic washers. Collecting and Transporting Soiled Linen After invasive medical or surgical procedures or when changing linen inpatient rooms: * Collect used linen in cloth or plastic bags or containers with lids. If linen is heavily contaminated with blood or body fluids, carefully roll the contaminated area into the center of the linen and place in a leak proof bag or container with a lid. * Cloth bags are adequate for the majority of the patient care linen. They require the same processing as their contents. Infection Prevention Guidelines for HealthcareFacilities in Ethiopia 10-1 * Handle soiled linen as little as possible and do not shake it. This helps prevent spreading microorganisms to the environment, personnel and other patients. * It is not necessary to double-bag or use additional precautions for used linen from patients in isolation. * Do not sort and wash soiled linens in patient care areas. * Collect and remove soiled linen after each procedure on daily basis or as n eeded including patient rooms. * Transport collected soiled linen in closed leak proof bags, containers with lids or covered carts to the processing area daily or as needed. * Transport soiled linen and clean linen separately. If there are separate carts or containers available for soiled and clean linen, they should be labeled accordingly. If not, thoroughly clean the containers or carts used to transport soiled linen before using them to transport clean linen. Sorting Soiled Linen * The processing area for soiled linen must be separate from other areas such as those used for folding and storing clean linen. * Ensure adequate ventilation and physical barriers between the clean and soiled linen areas * Always wear protective eyewear, utility gloves, appropriate footwear and plastic or rubber apron while handling soiled linen. * Be watchful about scalpels, sharp tipped scissors, hypodermic and suture needles. * Wash hands after removing the gloves. Laundering Linen All linen items including bed sheets, surgical drapes, masks, gowns should be thoroughly washed before reuse. Decontamination of linen prior to washing is not necessary unless linen is heavily soiled and will be hand washed. The workers should not carry wet, soiled linen close to their body even though they are wearing a plastic or rubber apron. The storage time for soiled linen before washing is related to practical issues, such as available space and aesthetics, not to infection prevention practices. Handwashing Linen * Wash heavily soiled linen separately from nonsoiled linen. * Wash the entire item in water with soap to remove all soilage, even if not visible. * Use warm water and add bleach to aid cleaning and bactericidal action. Also add some sour (mild acetic acid) to prevent yellowing of linen, if available. Remember: Presoaking in soap, water and bleach is necessary only for heavily soiled linen. 10-2 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia * Check items for cleanliness. Rewash if it is dirty or stained. * Rinse linen with clean water. Machine Washing linen. * Wash heavily soiled linen separately from nonsoiled machine. * Follow manufacturer's instruction for operating the * Do not overload the machine. * Use hot water, bleach and sour as discussed above. offirst cycle. * Heavily soiled linen may need two cycles if not found visibly clean at the end * Air dry or machine dry before further processing. Drying, Checking And Folding Linen the fabric offthe * Linen can be machine dried or air dried in direct sunlight, ifpossible, keeping ground, away from dust and moisture. either discard or repair * After the linen is dry, check for holes and threadbare areas. If damaged, before reuse. folded. If surgical drapes are to * The linen that is not going to be sterilized should be ironed and be sterilized,do not iron. Ironing dries out the material, making autoclaving more difficult. Storing Transporting and Distributing Clean Linen * Keep clean linen in clean, closed storage area areas * Use physical barriers to separate folding and storage rooms from soiled * Keep shelves clean * Handle stored linen as little as possible * Clean and soiled linen should be transported separately be thoroughly cleaned before using the * Containers or carts used to transport soiled linen should same for transporting clean linen * Clean linen must be wrapped or covered during transport to avoid contamination linen in patient's area * Protect clean linen until it is distributed, do not leave extra * Handle clean linen as little as possible * Avoid shaking clean linen. It releases dust and lint into the room them * Clean soiled mattresses before putting clean linen on Sterilization is a preferred end process for surgical gowns, linen drapes and wrappers. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 10-3 REFERENCES Centers for Disease Control (CDC). 1988. Update: Universal precautions for preventionof transmission of HIV, HBV, and other bloodborne pathogens in health setting. MMWR: 37(24): 377. Economics Report. 1994. In-house laundry/linen reprocessing: Who does it? Health Facilities Management 7(6): 126. Occupational Safety and Health Administration (OSHA), US Department of Labor. 1991. Occupational exposure to bloodborne pathogens: Final rule. Fed Regist 56(235): 64004-64182. 10-4 Infection Prevention Guidelines for Healthcare Facilities in Ethiopia CHAPTER 11 TRAFFIC FLOW AND ACTIVITY PATTERN Microbial contamination is minimized by reducing the number of people permitted into an area and by defining the activities that take place there. The traffic flow should be limited in procedure areas, surgical units, and work areas (where instruments are processed. These include dirty and clean areas where soiled instruments, equipments and other items are first cleaned and then processed and stored.). It is important to direct activity patterns and traffic flow in above-mentioned areas to keep contaminated areas separate from areas where procedures take place. The space, equipment, and need for a well defined traffic flow and activity pattern become progressively more complex as the type of surgical procedure changes from general surgery and obstetric to open heart surgery. The space requirements for these facilities are: * Changing room and scrub area for clinic staff * Preoperative area where clients are examined and evaluated prior to surgery * Operating room * Recovery area for patient observation after surgery (may be combined with the preoperative area) * Processing area for cleaning and sterilizing or high-level disinfecting instruments and other items * Space for storing sterile packs and/or high-level disinfected containers of instruments and other items The recommended infection prevention practices for minimizing microbial contamination of specific areas in healthcare facilities are briefly described below. PROCEDURE AREA * Limit traffic to authorized staff and patients at all times. * Permit only the p atient and s taff p erforming and a ssisting w ith p rocedures i n t he p rocedure room. The number of trainees should be kept to minimum possible. * Patients can wear their own clean clothing, if not so, healthcare facility may provide cloths. However, for the patients undergoing major surgical procedures, healthcare facility should provide hospital clothes. * Staff should wear attire and personal protective equipment according to the procedure performed. * Have a covered container filled with a 0.5% solution for immediate decontamination of instrument and other items once they are no longer needed. InfectionPrevention Guidelines for Healthcare Facilities in Ethiopia 11-1 * Have a leakproof, covered waste container for disposal of contaminated waste items. * Have a puncture-resistant container for safe disposal of sharps at point ofuse. * Have storage space in procedure rooms for clean, high-level disinfected and sterile supplies. SURGICAL UNIT The surgical unit is divided into four designated areas, unrestricted area (a point through which staff, patients and materials enter the surgical unit), transition zone (where staff put on surgical attire), semi restricted area (a peripheral area of surgical unit and includes preoperative and recovery rooms, storage space for sterile and HLD items, and corridors leading to the restricted area) and restricted area (consists of the operating room and scnrb sinks). Environmental controls and use of surgical attire increase as one moves from unrestricted to restricted area. Staff with respiratory or skin infection and uncovered open sores should not be allowed to work in the surgical unit. Unrestricted area needs no special traffic flow, whereas transition zone should allow only the authorized staff (Staff who perforn or assist procedures in the procedure rooms). Displaying a signboard in local language limiting the entry of unauthorized persons may work in some facilities. SEMIRESTRICTED AREA * Limit traffic to authorized staff and patients at all times * Have a work area for processing of clean instruments * Have storage space for clean and sterile or HLD supplies with enclosed shelves * Have door limiting access to the restricted area of the surgical units * Staff who work in this area should wear surgical attire and a cap RESTRICTED AREA * Limit traffic to authorized staff (staff who perform and assist procedures) and patients at all times * Keep the door closed at all times, except during movement of staff, patients, supplies and equipment * Scrubbed staff must wear full surgical attire and cover head and facial hair with a cap and mask * Staff should wear clean, closed shoes * Masks are required when sterile supplies are opened and scrubbed staff are operating * Patients entering the surgical unit should wear clean gowns or be covered with clean linen, and have hair covered 11-2 InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia OPERATING ROOMS flies. * Enclose the operating room to minimize dust and eliminate that be located areas of the hospital or healthcare facility * The operating room should away from are heavily traveled by staff and patients. Before Surgery for immediate container with 0.5% chlorine solution * Place a clean, covered filled decontamination ofused instruments covered waste container for contaminated waste items * Place a plasticbag or leakproof, at the point of use but c ontainer for the s afe disposal o f sharps * Place a p uncture-resistant without contaminating the sterile field waste container linen away from sterile items. * Place leakproof, covered for soiled the traffic and ring stand side by side in an area away from * Organize tables, both Mayo walls, cabinets nonsterile surfaces pattern and at least 45 cm from and other and arm board covers on the operating room bed * Place a clean sheet, a lift sheet oxygen and anesthesia equipment * Check and set up suction, the floor that are ready to open on the tables, not on * Place supplies and packages be to be used during the procedure should * Mayo stand and other nonsterile surfaces that are covered with asterile towel or cloth During Surgical Procedures the entering the operating room only to those necessary to perform * Limit the number of staff the procedure Minimize the outside help during procedure and to patients. * Keep doors closed all times movements to a minimum * Keep the number ofpeople and their * Keep talking to a minimum surgical attire-scrub suits, plasticapron, clean cap and mask * Scrubbed staff should wear full shoes, and sterile surgical gloves protective eyewear, clean closed all times arms and hands within the operative field at * Scrubbed staff should keep their mask, and protective wear surgical attire-cap, clean closed shoes, * Nonscrubbed staff should eyewear. room stay atthe periphery of the operating * Nonscrubbed staff should field with a 0.5% contaminated debris in areas outside the surgical * Clean accidental spills or chlorine solution as promptly as possible 11-3 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia After Surgery Surgical procedure staff wearing utility gloves should: * Collect all waste and remove it from the room in closed leakproof container * Close and remove puncture resistant container when they are three quarterfull * Remove covered container with a 0.5% chlorine solution, with instruments and surgical gloves in it, from operating room * Remove soiled linen * Remove waste, soiled linen, soiled i nstruments and equipment, and supplies that h ave b een opened but not used, inan enclosed cart for reprocessing WORK AREA FOR INSTRUMENT PROCESSING Work area consists of four areas-"dirty" receiving/cleanup area, clean work area, the cleaned equipment storage area, and sterile or HLD storage area. Dirty receiving/cleanup area should have: * A receiving counter * Two sinks if possible with a clean water supply, and * A clean equipment counter for drying Clean work area should have: * A large work table * Shelves for holding clean and packaged items, and * A high-pressure autoclave, a dry-heat oven, a steamer or a boiler Clean equipment storage area should have: * Shelves for storing clean equipment, and * An office or desk for record keeping Sterile or HLD Storage Area This area should be separated from the sterilization area. * Limit access to the storage area and/or store items in closed cabinets or shelves * Keep storage area clean, dry, dust-free and lint-free byregular housekeeping * Packs and containers with sterile or HLD should be stored 20-25 cm off the floor, 45-50 cm from the ceiling and 15-20 cm from an outside wall * Do not use cardboard boxes for storage 11-4 InfectionPrevention Guidelines for HealthcareFacilitiesinEthiopia * Date and rotate the supplies that has package to be sure it is notdirty, wet, * Before dispensing any item been stored, check the or damaged disinfected from this area * Dispense sterileand high-level articles as possible * Touch or handle sterile packages as little Sterile or as the of the package is maintained. The p acks w ill remain s terile a s Iong integrity HLD containers will remain so until they are opened. REFERENCES Their Influence and Shelf-Life, Part I.www.cea.purdue.edu/ Belkin NL. 1997a. Textiles of Today: on Sterilization IAHCSMM/25LESSON.HTM. Their Influence and Shelf-Life, Part II. www.cea.purdue.edu/ Belkin NL. 1997b. Textiles of Today: on Sterility IAHCSMM/26LESSON.HTM. 1982. Principles of Disinfection,Preservation and Sterilization. RussellAD, WB Hugo and GA Ayliffe. and Practice England. Blackwell ScientificPublications: Oxford, Control in World Health (WHO) 1988. A Manual on Infection South EastAsia Regional Office (SEARO), Organization HealthFacilities.SEARO: New Delhi, India, pp39-42. 11-5 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia CHAPTER 12 HOUSEKEEPING walls, cleaning and clinics, including the floors, Housekeeping refers to the general ofhospitals other surfaces. ofgeneral housekeeping it to: and certain types of equipment, tables and The purpose that may contact with patients,visitors,staffand * Reduce the number ofmicroorganisms come in the community; and for patients and staff. * Provide a clean and pleasant atmosphere GENERAL PRINCIPLES OF CLEANING remove dirt, debris and * Scrubbing (frictional cleaning) is the best way to physically microorganisms. any disinfection dirt, debrisand other materials * Cleaning is required prior to process because disinfectants. can decrease the effectiveness of many chemical on the basis oftheir safety, and cost. * Cleaning products should be selected use, efficacy, from the areas to the most soiled areas and from * Cleaning should always progress least soiled areas and fall on the floor will be cleaned up high to low areas, so that the dirtiest debris that last. dust, debris and and dusting should be avoided to prevent * Dry sweeping, mopping, surfaces. Airborne fungal into the air and landing on clean microorganisms from getting as they fatal infections in immunosuppressed spores are especially important can cause patients (Arnow et al 1991). (Too much or too should be followed when using disinfectants. * Mixing (diluting) instructions little water may reduce the effectiveness of disinfectants.) b ased on the type o f surface, cleaning * Cleaning methods and written schedules should b e ofthe area. amount and type of soil present, and the purpose Schedules and to maintain a standard of cleanliness. * Routine cleaning is necessary and posted. procedures should be consistent cleaning product, the factors like, intended use, When selecting a disinfectant or other consider efficacy, acceptability, safety and cost. HOW TO PREPARE DISINFECTANT CLEANING SOLUTION They should not solutions are excellent, inexpensive disinfectants. Although chlorine-containing Doing so containing an acid, ammonia or ammonium chloride. be mixed with cleaning solutions that can be toxic. solution is ideal will release chlorine gas and other byproducts 0.5% chlorine 1-2% phenols or 5% carbolic acid can be used as disinfectant for cleaning purpose. Alternatively enough detergent disinfectants will make a mild, for the purpose of cleaning. Adding to these soapy cleaning solution. 12-1 FacilitiesinEthiopia Infection Prevention Guidelines forHealthcare CLEANING METHODS Wet mopping is the most common and preferred method to clean floors. Single, double, or triple-bucket techniques can be used for cleaning the floors. While using single bucket the solutions should be changed when dirty. The double-bucket technique extends the life of the cleaning solution and saves both labor and material costs. Flooding followed by wet mopping is recommended in the surgical suite, if possible. Flooding the floor with disinfectant solution is best done at times when foot traffic is minimal. Dusting is most commonly used for cleaning wall, ceilings, doors, windows, furniture and other environmental surfaces. Wet mopping is best suited for the purpose of removing the dust from any surfaces. Dry dusting should be avoided and dust clothes and mops should never be shaken to avoid the spread of microorganisms Personal protective equipment (PPE) like utility gloves and shoes that protect the feet from accidental injuries, and plastic aprons, mask and protective eyewear should be used at all times during cleaning. GUIDELINES FOR CLEANING SPECIFIC AREAS * Walls, windows, ceilings and doors, including door handles: Sport clean whenever visibly dirty using a wet mop. Routine damp dusting is adequate and no special cleaning is required. * Chairs, lamps, tables, tabletops, beds, handrails, grab bars, lights, tops of the doors and counters: Wet mop with damp cloth using disinfectant cleaning solution. Pay attention to contaminated areas on these surfaces. * Noncritical equipment: Items like stethoscopes and blood pressure cuffs should be wiped with a damp cloth, detergent and water whenever visibly dirty or everyday. It they become soiled with blood of body fluids or the patient under contact precautions, it should be cleaned and disinfected using alcohol before reuse. * Floors: Floors should be cleaned as frequently as needed with a wet mop, detergent and water using double-bucket technique. A disinfectant should be used when contamination is present. * Sinks: Scrub frequently with separate mop, cloth or brush and a disinfectant cleaning solution. * Toilets and latrines: S crub frequently w ith s eparate m op, c loth o r b rush a nd a d isinfectant cleaning solution. * Patient rooms: Clean daily and after patient discharge, using the processes described above. Same cleaning process applies to rooms ofpatients under isolation precautions. Any equipment used for cleaning the rooms of patients under isolation precautions should be disinfected before using in other room. * Procedure room: Wipe horizontal surfaces, equipment, and furniture used for the procedure with a disinfectant cleaning solution after each procedure and whenever visibly soiled. * Curtains: Change and clean curtains according to the routineschedule and when visibly dirty. 12-2 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia after each shift and * Laboratory: Wipe counter tops with a disinfectant cleaning solution below. whenever visibly soiled. Clean blood or other body fluid spills as described Cleaning Spills of Blood and Other Body Fluids immediately: Clean spills ofblood, body fluids and other potentially infectious fluids visible materials using a * For small spills, while wearing utility or examination gloves, remove cloth soaked in 0.5% chlorine solution. chlorine solution, mop up the solution and then clean * For large spills, flood the areawith a 0.5% as usual with detergent and water. Schedule and Procedures for the Operating Room each day, all flat surfaces Do n ot dry m op or sweep the operating room. At the beginning of Total cleaning is not should be wiped with a clean, lint free moist cloth to remove dust and lint. cleaning of the necessary between each case for surgical procedures. Total cleaning or terminal operating room should be done at the end of each day. should be All areas of surgical suite, scrub sinks, scrub or utility areas, hallways and equipment totally cleaned, regardless ofwhether they were used during the last 24 hours. purpose. * Use freshly prepared 0.5% chlorine solution for decontamination waste containers and replace with clean * At the end of each day remove all contaminated containers. Remove soiled linen in closed * Close and remove sharp containers if they are three quarters full. leakproof containers. solution. * Wipe all surfaces from top to bottom using disinfectant cleaning blood or body fluids of thepatients should * Any surfaces that might have come in contact with cleaning solution and let be wiped with 0.5% chlorine solution. Then clean with disinfectant them dry. procedure. Ifwalls and ceilings are deteriorating or damp, cover with lean plastic sheets during to reduce microbial contamination of Fumigation with dilute formaldehyde solution Over and above it is environmental surfaces such as walls, ceilings and floors is not effective. is a safer, time consuming and fumes are toxic. Scrubbing with a disinfectant and cleaning on these surfaces. quicker and more effective way to reduce microbial contamination Between each case: with 0.5% chlonrne * Clean spills with 0.5% cleaning solution, if spills are large flood the area solution. cleaning solution. * Wipe all surfaces and mattress pads with a disinfectant in contact with a patient or body fluids with a * Wipe all the flat surfaces that have come disinfectant cleaning solution. 12-3 InfectionPrevention GuidelinesforHealthcare FacilitiesinEthiopia * Mop the center of operating room surrounding the operating room bed with disinfectant cleaning solution. * Collect and remove all waste from the operating room in closed leakproof containers. * . Close and remove containers from the operating room when they are three quarters full. * Remove covered containers with 0.5% chlorine solution with instruments and replace them with clean container with a fresh 0.5% chlorine solution. X Rernove soiled linen in a leakproof, covered, waste container. CLEANING SOILED AND CONTAMINATED CLEANING EQUIPMENT * Decontaminate cleaning equipment that has been contaminated with blood and body fluids. * Wash cleaning buckets, cloths, brushes and mops with detergent and water daily, or sooner if visibly dirty. * Rinse in clean water. * Dry completely before reuse. REFERENCES Arnow P et al. 1991. Endemic and epidemic aspergillosis associated with in-hospitalreplication of Aspergillus organisms. J Infect Dis 164(5): 998-1002. Centers for Disease Control and Prevention (CDC). 1991. Chlorine gas toxicity from mixture of bleach with other cleaning products. MMWR 40(36): 619-621. Chou T. 2002. Environmental Services, in APIC Text of Infection Control and Epidemiology. Association for Professionals in Infection Control and Epidemiology(APIC): Washington, DC, pp 73-81. 12-4 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia CHAPTER 13 CLINICAL LABORATORY SERVICES fluids is at some risk of Any laboratory worker who handles blood or potentially infected body or research units accidental injury or exposure. The staff working in clinical laboratories risk. isolating or handling pathogenic microorganisms are at the greatest containment and safety Biosafety Level Guidelines: Combination of primary and secondary laboratories and bacteriology research units guidelines designed for use in microbiology risk: functioning at four levels (BSL-1 to BSL-4) ofincreasing safety guidelines and is entirely * BSL-1 is the lowest level of containment and microbiologic for those working based on standard laboratory practices. These guidelines are recommended in healthy with microorganisms, such as Bacillussubtilis, that are not known to cause infections adults. working with agents (e.g.,Salmonella * BSL-2 is generally applied in bacteriology laboratories When standard microbiologic species) associated with human diseases of varying severity. barriers, practices areapplied, the agents may be handled on open benches, especially if primary The use of such as facemasks, gowns and examination gloves, are used when appropriate. biologic safety cabinets (BSCs) and safety centrifuges may be necessary. by the airborne * BSL-3 is aimed at containing hazardous microorganisms primarily transmitted (chicken pox). Laboratory staff route (aerosols and droplets), such as tuberculosis or varicella equipment, including that work in these situations must be trained in the use of appropriate suitable ventilation systems and the use of BSCs. life-threatening diseases that can * BSL-4 is designed for use where agents causing or untreatable fever affect the laboratory worker via the airborne route are present, such as hemorrhagic suits viruses. Trained workers using BSCs or wearing full-body, air-supported positive pressure the facilityitself must be totally must perform all procedures in these laboratories. In addition, ventilation and waste management isolated from other laboratories and have specialized systems. contamination mucous membrane are Inhalation, ingestion, puncture wounds, and of skin and laboratory workers. most common ways infections from pathogenic organisms occur among should be handled Wearing a simple plastic facemask or shield can minimize these risks. Sharps with care and disposed of immediately after use in sharps containers located close to the work area. GENERAL BIOSAFETY AND INFECTION PREVENTION GUIDELINES containing * Wear new examination gloves when handling blood, body fluids and/or specimens pathogenic microorganisms. * Eating, drinking or smoking should not be permitted in the laboratory. or research specimens. * Food should not be stored in refrigeratorsused for clinical devices (e.g.,suction bulbs). * No mouth pipetting is permitted; use proper mechanical 13-1 InfectionPrevention Guidelines forHealthcare Facilities inEthiopia * Do not open centrifuges while still in motion. * Always cover the end of blood collection tubes with a cloth or paper towel, or point them away from anyone's face when opening. * Decontaminate w ork s urfaces d aily o r w hen c ontaminated, s uch as a fter s pills, with a 0.5% chlorine solution. * Wear protective face shields or masks and goggles if splashes and sprays ofblood, body fluids, or fluids containing infectious agents are possible. * Wear heavy-duty or utility gloves when cleaning laboratory glassware. * Use puncture-resistant, leakproof containers for sharps. * Place infectious waste materials in plastic bags or containers. BLOOD DRAWING (PHLEBOTOMY) Blood drawing is considered to be one of the highest risk procedures so far as accidental exposure blood and injuries are concerned (CDC). When collecting a blood specimen be sure to: * Wear examination gloves * Have assistance when patients might be uncooperative * Have assistance for holding children when doing heel sticks REFERENCE Exposure Prevention Information Network (EPINet) Data Reports. 1999. Uniform Needlestickand Sharp Object Injuty Report 21 Hospitals, 1999. International Healthcare Worker Safety Center, Universityof Virginia. Available on: www.med.virgina.edu/epinet/soi99.html 13-2 InfectionPrevention Guidelines for Healthcare FacilitiesinEthiopia CHAPTER 14 BLOOD BANK AND TRANSFUSION SERVICES for process, provide human blood intended Blood bank and transfusion services collect, store and in and, finally, infusion into a patient.Staff working transfusion, perform pre-transfusion testing is also at risk injury or exposure to blood banks and transfusion services of accidental contaminated blood or blood products. Blood bank and transfusion services involve: informed consent * Selecting donors and assuring that they have given donors * Collecting blood from screened antibodies and infectious disease * Testing for blood components, * Storing and transporting blood blood * Pretransfusion testing ofpatient's * Transfusing patients DONOR SELECTION AND INFORMED CONSENT any physical of each donor. (This should include * Complete the medical history and examination infected and or events that put a person at risk of being medical problems, behaviors, to the person receiving the transfusion.) transmitting a serious disease to the of the donation process should be explained * Prior to collection of blood, the elements understand language. potential donor in simple, easy to ml of potential adverse responses to drawing 400-500 * Explain about the risks ofvenipuncture, blood. will be informed will be performed. Ho\w exactly the donor * Explain the laboratory tests that about the test results including any other imedical abnomialities. HCV, test including hemoglobin, or hematorcrit,HIV, HBV, * Perform the routine laboratory syphilis, and malaria. consent be completed for eachdonor. * Complete a written informed form should BLOOD COLLECTION 1. Make sure all items are available: a sufficient amount of . Blood collection set consisting of sterile plastic bag containing to be collected anticoagulant for the quantity of blood * IV tubing and large gauge hypodernic needles * Pair ofsterile or HLD surgical gloves pressure cuff * Clean tourniquet or blood or clean gauze squares or cotton swabs * Antiseptic solution and sterile 14-1 in Ethiopia InfectionPrevention Guidelines for Healthcare Facilities * Surgical tape * Towel to place under patient's hand or forearm * Basin of clean warm water * Soap * Clean dry towel to wash patient's arm if visibly * Plastic soiled bag or leakproof, covered waste container * Puncture-resistant for disposal of contaminated sharps container items 2. Explain the procedure to the donor. 3. Identify the best vein for inserting the IV needle (a prominent, large and firm vein). 4. Put the tourniquet or blood pressure cuff on space to the upper confirmn arm about that the vein is 9 cms above visible the antecubital and then release the toumiquet or cuff. 5. If the venipuncture site is visibly soiled, a clean first wash cloth or if with ask the soap and donor clean water to wash the forearm. and dry with 6. Wash hands and dry with a clean towel or air and rub dry (Alternatively both hands vigorously use alcohol handrub-5 until dry). ml 7. Place the donor's arm on the clean towel and cleanse antiseptic solution. an area U se a about 3 circular cm in diameter m otion o utward with an over the vein. (If from the proposed using povidone needle iodine insertion or other site take full iodophors, effect.) allow 2 minutes for antiseptic to 8. Do not touch the area after applying the antiseptic solution. 9. Put the tourniquet or blood pressure cuff on 60 mm the upper of mercury arm again, while collecting raise the pressure the blood. up to 40- 10. Put sterile or HLD surgical gloves on both hands. I . Insert the hypodermic needle into the vein without tourniquet touching or cuff and then the skin if possible, secure the needle release the by placing collection a short tubing below the piece oftape area cleansed across the blood with antiseptic. 12. When required amount of blood has been obtained, barrel or remove tip of the needle the needle and place without touching it in a puncture the resistantsharps container. 13. Cover the insertion site with a 2x2 gauze square, secure gauze square and apply pressure using 1 or until bleeding 2 pieces of surgical stops and tape. 14. Prior to removing gloves, place any blood-contaminated leakproof, covered waste waste container. items in a plastic bag or 15. Wash hands or use an antiseptic handrub as above. 16. Have patient remain resting on a bed or in the donor chair for several minutes. 17. Provide the donor with something to drink and eat. 14-2 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 18. Tell the donor to drink more fluid during the next 24 hours and avoid alcohol or smoking until more food has been eaten. Ask the donor to lie down if there is dizziness or nauseating sensation. To avoid contamination of collected blood: * Maintain appropriate storage conditions (stored at 1-60C and monitoring temperature every four hours). * Test the blood unit without entering the closed collection system. * Infuse or discard the blood unit within a short period once the closed system has been opened. BLOOD COMPONENT AND INFECTIOUS DISEASE TESTING * ABO blood group and Rh type * Blood from donor with history of transfusions or pregnancy should be tested for unexpected antibodies to red cell antibodies using methods to demonstrate clinically significant antibodies * Human immunodeficiency virus by testing for antibodies to HIV-1 and 2. As per the national policy on H1V/AIDS for Ethiopia, All donated blood shall be screened prior to transfusion. In remote areas where testing facilities are limited, simple and/or rapid HIV tests shall be made available. Blood donors shall be informed about the tests, which w ill b e c arried o ut o n t he donated blood. In case of a donor wanting to know his/her HIV serostatus, he/she shall be referred to the appropriate health facilities for counseling and testing. * Syphilis by screening with Rapid Plasma Reagent (RPR) test * Hepatitis B and Hepatitis C virus by testing for Hepatitis B surface antigen BLOOD STORAGE AND SHORT DISTANCE TRANSPORT * Blood units must be stored in a refrigerator at 1-60C. * There must be a system to monitor temperatures continuously and record them at least every 4 hours. DISCARDING BLOOD THAT HAS BEEN EXPOSED TO HIGHER TEMPERATURES While doing this: * Wear examination or utility gloves and protective eyewear * Pour content down a utility sink drain, onto a flushable toilet or latrine * Place empty blood bags and tubing in a leakproof container * Dispose by burning or burying InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 14-3 PRETRANSFUSION TESTING AND CROSS-MATCHING * Test a sample of recipient blood using the same methods and recommended infection prevention practices used to test donor blood * Repeat testing of the donor blood to confirm the ABO group and Rh * Crossmatch the red cells of selected donor against the serum or plasma of the recipient to be sure there are no ABO and Rh incompatibility. TRANSFUSION OF BLOOD OR BLOOD COMPONENTS Indications for blood transfusion are: * Actively bleeding patients, and * Patients with chronic or symptomatic anemia. The generally accepted hemoglobin level for transfusing patients with acute blood loss it 7gm%, with those patients having a level of 6 gm% almost always requiring transfusion but those with a level of 10 gm% rarely need it. Transfusing Patients Before starting the transfusion: * Explain the procedure to the patient ifhe/she is conscious. * Correctly identify the blood product and the patient: confirm patient's name, check compatibility information attached to the blood bag, and expiry date, check the ABO Rh of the patient on the patient chart, double check blood or type ofblood product with the physician's order, check blood for clots. * Record baseline pulse and blood pressure. * Ask patient or relatives to report chills, headaches, itching or rash immediately. * Once the transfusion has stated, take patient's pulse, blood pressure every 5 minutes for the first 15 minutes and hourly thereafter, observe the patient for flushing, itching, difficulty in breathing, hives (clear fluids filled lesions on the skin) or other rash when checking for the vital signs. Preventing Complicationsand NosocomialInfections To preventing complications and nosocomial infections in patients: * Avoid unnecessary transfusions * Screen donors for serious bloodbome infections (HIV, HBV, HCV, Syphilis) * Collect donor blood aseptically into a closed system to minimize contamination, and accomplish all steps in processing the blood within this closed system 14-4 Infection Prevention Guidelines for HealthcareFacilitiesin Ethiopia * Store blood and blood products at the correct temperature and make sure the unit is within the expiry date * Take all steps to ensure that donor and patient blood are compatible in termns ofABO, Rh and crossmatching * Verify all information matching the blood with the intended recipient * Use aseptic techniques to establish the peripheral IV line for giving the transfusion * Monitor patients vital signs regularly and check for any adverse reactions * Stop transfusion immediately in the event of adverse reactions ProtectingHealthcare Workers Wear gloves while collecting, testing and transfusing blood. Handle the sharps carefully and dispose immediately in puncture resistant container. Wear personal protective equipment at all times. Improving performance and compliance with recommended policies and guidelines can be significantly enhanced if, there is: * A consistent support by hospital administrators to improve the quality of services, * Supervisors regularly provide positive feedback and rewards, and suggestions for improvement, and * Physicians and other senior staff and faculty role model the practices and behaviors by actively supporting the policies and guidelines. REFERENCES American Association of Blood Banks (AABB). 2002. Standards For Blood Banks and Transfusion Services,2151 ed. American Association of Blood Banks: Bethesda, MD. American Society of Anesthesiologists Task Force (ASATF). 1996. Practice guidelinesfor blood component therapy. Anesthesiology 84(3):732-747. Lipscomb J and R Rosenstock. 1997. Healthcare workers: protecting those who protect our health.Infec Control Hosp Epidemiol 18(6):397-399. Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia 14-5 I i iI i I CHAPTER 15 ISOLATION PRECAUTION GUIDELINES FOR HEALTHCARE FACILITIES Although the spread of infectious disease in hospital has been recognized for many years, understanding how to prevent nosocomial infection and implementing policies and practices that are successful have been more difficult. Standard Precautions, which apply to all clients and patients attending healthcare facilities, and Transmission-Based Precautions, which apply primarily to hospitalized patients (Garner and HICPAC 1996). There are three major routes of transmission of infectious diseases, airborne, droplet and contact. TRANSMISSION BASED PRECAUTIONS The isolation precautions guidelines involve a two level approach, first the Standard Precautions, apply to all clients and patients attending healthcare facilities, and the second, Transmission Based Precautions which apply primarily to hospitalized patients. In all situations, whether used alone or in combination, Transmission-Based Precautions must be used in conjunction with the Standard Precautions. Transmission-Based Precautions include air, droplet and contact precautions. Protective isolation of immunocompromised patients, such as those with AIDS, is not effective way to reduce the risk of cross-infection. AIRBORNE PRECAUTIONS The airborne precautions are designed to reduce the nosocomial transmission of particles 5 pim or less in size that can remain in the air for several hours and be widely dispersed. They are effective in preventing infections like Tuberculosis, Chicken pox and measles. They are recommended for patients with either known or suspected infections that could be transmitted by airborne route. The precautions include: * Patient Placement * Private room * Door closed * Room air is exhausted to the outside (Negative air pressure) using fan. * If private room not available, place patients in room with patient having active infection with the same disease, but with no other infection · The staff on duty should check all visitors for susceptibility before allowing them to visit * Respiratory Protection * Wear surgical mask * If chickenpox or measles, no mask needed for immune persons, susceptible persons should not enter the room * Remove mask after leaving the room and place in a plastic bag or waste container with tight-fitting lid and reprocess if to be reused Infection Prevention Guidelinesfor Healthcare Facilitiesin Ethiopia 15-1 * Patient Transport * Limit transport of patient to essential purposesonly * During transport, patient must wear a surgical mask * Notify the area receiving the patient * In areas where TB is prevalent, it is important to have a mechanism to quickly assess patients with suspected TB and put them under the airborne precautions. DROPLET PRECAUTIONS These precautions reduce the risks for nosocomial transmission of pathogens spread wholly or partly by droplets larger than 5 atm in size (e.g., H. influenzae and N. Meningitides, M. pneumoniae, flu, mumps, and rubella viruses). Other conditions include diphtheria, pertussis, pneumonic plague and strep. pharyngitis. The droplet precautions are simpler than airborne precautions as particles remain in the air for a short time and travel only a few feet. * Patient placement * Private room, door may be left open * If private room not available, place patient in room with patient having active infection with the same disease, but with no other infection * If neither option is available, maintain separation of at least 3 feet between patients * Respiratory protection * Wear mask if within 3 feet ofpatient * Patient transport * Limit transport of patient to essential purposes only * During transport, patients must wear surgical mask * Notify area receiving patients CONTACT PRECAUTIONS Contact precautions are indicated for patients infected or colonized with enteric pathogens, herpes simples and hemorrhagic fever viruses and multidrug resistant bacteria. Chicken pox is spread both by the airborne and contact routes at different stages of illness. Contact precautions should be implemented for patient with wet or draining infection that may be contagious (e.g., draining abscesses, herpes zoster, impetigo, conjunctivitis, scabies, lice and wound infection). Use in addition to Standard Precautions for patients known or suspected to be infected or colonized with microorganisms transmitted by direct contact with the patient or indirect contact with environmental surfaces or patient care items. 15-2 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia * Patient placement * Private room; door may be left open * If private room not available, place patient in room with patient having active infection with the same microoroganism, but with no other infections * Gloving * Wear clean, nonsterile examination gloves or reprocessed surgical gloves when entering room * Change gloves after contact with infectious materials * Remove gloves before leaving patient room * Handwashing * Wash hands with antimicrobial agent, or use alcohol handrub, after removing gloves * Do not touch potentially contaminated surfaces or items before leaving the room * Gowns and protective apron * Wear clean, nonsterile gown when entering patient room if patient contact is anticipated or patient is incontinent, has diarrhea, an ileostomy, colostomy or wound drainage not contained by dressing * Remove gown after leaving room. Do not allow clothing to touch potentially contaminated surfaces or items before leaving the room. * Patient Transport * Limit transport of patient to essential purposes only * During transport, ensure precautions are maintained to minimize nrsk of transmission o f organisms * Patient care equipment . Reserve noncritical patient care equipment for use with a single patient if possible, otherwise process as per guidelines * Clean and disinfect any equipment shared among infected and non-infected patients after each use EMPIRIC USE OF TRANSMISSION-BASED PRECAUTIONS * If there is any question of an infectious process in a patient without a known diagnosis, implementing Transmission-Based Precautions should be considered based on the patient's signs and symptoms until a definitive diagnosis is made. * A complete listing of clinical syndromes or conditions warranting the empiric use of Transmission-Based Precautions is presented in Table 15-1. InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 15-3 Table 15-1. Clinical Syndromes or Conditions to Be Considered for "Empiric Use" of Transmission-Based Precautions CLINICAL SYNDROME OR C09DITION2 POTENTIAL EMPIRIC PATHOGENSb PRECAUTIONS Diarrhea Acute diarrhea with a likely infectious cause in an Enteric pathogens' Contact incontinent or diapered patient Diarrhea in an adult with a history of recent antibioticuse Clostridiumdifficile Contact Meningitis Neisseria Droplet meningitidis Rash or exanthems, generalized, etiology unknown PetechialVecchymotic with fever Neisseria Droplet meningitidis Vesicular Varicella Airborne and Contact (chicken pox) Maculopapular with coryza and fever Rubeola (measles) Airbome Respiratory infections Cough/fever/upper lobe pulmonary infiltrate in an HIV- Mycobacterium Airborne negative patient or a patient at low risk for HIV infection tuberculosis Cough/fever/pulmonary infiltrate in any lung location in an Mycobacterium Airborne HIV-infected patient or a patient at high risk for HIV tuberculosis infection Paroxysmal or severe persistent cough during periods of Bordetellapertussis Droplet pertussis activity Respiratory infections, particularly bronchiolitis and croup, Respiratory syncytial Contact in infants and young children or parainfluenza virus Risk of multidrug-resistant microorganismns History of infection or colonization with multidrug-resistant Resistant bacteriad Contact organisms Skin, wound or urinary tract infection in a patient with a Resistant bacteriad Contact recent hospital or nursing home stay in a facility where multidrug-resistant organisms are prevalent Skin or wound infection Staphylococcus Contact aureus, group A streptococcus Patients with the syndromes or conditions listed below may present with atypical signs or symptoms (e.g., pertussis in neonates and adults may not have paroxysmal or severe cough). The clinician's index of suspicion should be guided by the prevalence of specific conditions in the community, as well as clinical judgment. b The organisms listed under the column "Potential Pathogens" are not intended to represent the complete, or even most likely, diagnoses, but rather possible etiologic agents that require additional precautions beyond Standard Precautions until they can be ruled out. These pathogens include enterohemorrhagic Escherichiacoli 01 57:H7, Shigella, hepatitis A and rotavirus. d Resistant bacteria judged by the infection control program, based on current state, regional or national recommendations, to be of special clinical or epidemiological significance. Adaptedfrom: Gamer and HICPAC 1996. 15-4 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia To assist health workers in correctly implementing the appropriate precautions, Table 15-2 provides summary of the types of isolation precautions and the illnesses for which each type of precaution is recommended. Table 15-2. Summary of Types of Precautions and Patients Requiring the Precautions Standard Precautions Use Standard Precautions for the care of allpatients. Airborne Precautions In addition to Standard Precautions, use Airborne Precautions for patients known or suspected illnesses transmitted to have serious by airborne droplet nuclei. Examples of such illnesses include: Measles Varicella (including disseminated zoster)a Tuberculosisb Droplet Precautions In addition to Standard Precautions, use Droplet Precautions for patients known or suspected illnesses transmitted to have serious by large particle droplets. Examples of such illnesses include: Invasive Haemophilusinfluenzae type b disease, including meningitis, pneumonia, epiglottitis and sepsis Invasive Neisseriameningiiidisdisease, including meningitis, pneumonia and sepsis Other serious bacterial respiratory infections spread by droplet transmission, including: Diphtheria (pharyngeal) Mycoplasma pneumonia Pertussis Pneumonic plague Streptococcal (group A) pharyngitis, pneumonia, or scarlet fever in infants and young children Serious viral infections spread by droplet transmission, including: Adenovirusa Influenza Mumps Parvovirus B19 Rubella Contact Precautions In addition to Standard Precautions, use Contact Precautions for patients known or suspected transmitted by to have serious direct patient contact illnesses easily or by contact with items in the patient's environment. Examples of such illnesses include: Gastrointestinal, respiratory, skin or wound infections or colonization with multidrug-resistant infection control bacteria judged program, based by the on current state, regional or national recommendations, epidemiologic significance. to be of special clinical and Enteric infections with a low infectious dose or prolonged environmental survival, including: Clostridium difficile For diapered or incontinent patients: enterohemorrhagic Escherichia coli 01 57:H7, Shigella, Respiratory syncytial hepatitis A or rotavirus virus, parainfluenza virus or enteroviral infections in infants Skin infections and young children that are highly contagious or that may occur on dry skin, including: Diphtheria (cutaneous) Herpes simplex virus (neonatal or mucocutaneous) Impetigo Major (noncontained) abscesses, cellulitis or decubiti Pediculosis Scabies Staphylococcal furunculosis in infants and young children Zoster (disseminated or inthe immunocompromised host)a Viral/hemorrhagic conjunctivitis Viral hemorrhagic infections (Ebola, Lassa, or Marburg) a Certain infections require more than one type of precaution. bSee CDC "Guidelines for Preventing the Transmission of Tuberculosis in Healthcare Facilities." Adaptedfrom: Garner and HICPAC 1996. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 15-5 REFERENCE Ducel G. 1995. Les nouveaux risques infectieux.Futuribles: 203: 5-32. 15-6 Infection Prevention Guidelines forHealthcare Facilities in Ethiopia CHAPTER 16 PREVENTING NOSOCOMIAL INFECTIONS Nosocomial (hospital acquired) infections are widespread. They are important contributors to morbidity and mortality. They will become even more important as public health problems with increasing economic and human impact because of increasing number and over crowding of people, more frequent impaired immunity (age, illness and treatments), new microorganisms and increasing bacterial resistance toantibiotics. The most important nosocomial infections that can be prevented include: * Urinary tract infections, pneumonia and diarrhea * Infections following surgery or invasive medical procedures * Maternal and newborn infections Most of the nosocomial infections mentioned above can be prevented with readily available, relatively inexpensive strategies by: * Adhering to infection preventions practices, especially hand hygiene and wearing gloves as recommended in these guidelines * Paying attention to well-established processes for decontamination and cleaning of soiled instruments and other items, followed by either sterilization or high-leveldisinfection;and * Improving safety in operating rooms and other high-risk areas where the most serious and frequent injuries and exposures to infectious agents occur. Unfortunately, not all nosocomial infections are preventable. For example, some reflect the influence of advanced age, chronic disease such as uncontrolled diabetes, end-stage kidney disease or advanced pulmonary emphysema, sever malnutrition, treatment with certain drugsthat lower immunity, and increasing impact of AIDS. PREVENTING NOSOCOMIAL URINARY TRACT INFECTIONS Placement of an indwelling catheter should be performed only when other methods of emptying the bladder are not effective.The accepted indications for catheterization are: * For short-term management of incontinence or retention not helped by other methods * To measure urine output over several days in criticallyill patients * To instill medications * For treatment of urinary outlet obstruction * For postoperative management of surgical patients with impaired bladder function InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 16-1 Indwelling catheters should not be used for the long-term management of incontinence. Other methods of management of urinary tract problems include: * Intermittent catheterization using a reusable "red rubber" straight catheter * Condom catheter for male patients * Adult diaper pads * Bladder retraining * Use of drugs to stimulate urination (e.g., carbacol) GUIDELINES FOR INFECTION PREVENTION DURING INSERTION, REMOVAL AND/OR REPLACEMENT OF URINARY CATHETER Before inserting a catheter, check to be sure that it is being inserted for the right reason. During Insertion 1. Make sure that all of the items required to perform the procedure are available: * Sterile catheter with close continuous drainage system or HLD or sterile straight catheter and clean unrne collection container HLD or sterile syringe filled with boiled or sterile water for blowing up the balloon of an indwelling catheter · HLD or Sterile surgical gloves, antiseptic solution, sponge forceps with gauze squares or large cotton applicators, single-use packet of lubricant, light source if needed, basin of clean warm water, soap, a face cloth and a clean dry towel, plastic bag or leakproof, covered waste container 2. Prior to starting the procedure have patient wash the urethral area, if that is not possible wash the area with soap and water. 3. Wash hands with soap and clean water and dry with a clean dry towel or air drv (Alternatively, alcohol handrub can be used if hands are not visibly soiled). 4. Put sterile or HLD gloves on both hands. 5. Prep the urethral area two times with an antiseptic solution using either cotton applicators or a sponge forceps with gauze squares. 6. Avoid touching the tip of the catheter during the procedure. 7. Appropriately dispose all the waste materials including the catheter. 8. Ifreusing the catheter, place it in a 0.5% chlorine solution for 10 minutes for decontamination. 9. Remove gloves and dispose appropriately. 10. Wash hands or use an antiseptic handrub as appropriate. 16-2 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia During Removal and/or Replacement 1. Make sure that all items as mentioned above are available. 2. Have the patient wash the urethral area or do it for them wearing a pair of clean examination gloves. 3. Wash hands or use an antiseptic handrub. 4. Put clean examination gloves on both hands. 5. Prep the urethral area two times with an antiseptic solution. 6. If you are replacing the indwelling catheter follow appropriate TP steps as mentioned above under the Insertion Procedure. Tips for Preventing Infections inCatheterized Patients * Remove the catheter as soon as possible. * The catheter collection system should remain closed and not be opened unless absolutely necessary for diagnostic or therapeutic reasons. * Caution the patient against pulling on the catheter. * Urine flow through the catheter should be checked several times a day. * Avoid raising the collection bag above the level ofthe bladder. * If it becomes necessary to raise the bag above the level of the patient's bladder during transfer of the patient to a bed or stretcher, clamp the tubing. * Before the patient stands up, drain all urine from the tubing into the bag. * The urine drainage (collection) bags should be emptied aseptically; touching the tip of the emptying tube to the side of the collection bag or permitting the tip to touch the urine in the vessel should be avoided. Replace bags with new or clean containers when needed. * If the drainage tubing becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the ends of the catheter and tubing with an antiseptic solution before reconnecting them. * Wash the head of the penis and urethral opening (men) or the tissue around the urethral opening (women) after a bowel movement or if the patient is incontinent. * If frequent irrigation is required, the catheter should be changed. There is no evidence that daily perineal care reduces the risk of catheter associated Urinary Tract Infections. What Does Not Work * Continuous irrigation of the bladder with antibiotics does not prevent UTIs and is associated with increased risk of resistant organisms * The role of prophylactic antibiotics has not been established in preventing UTIs among catheterized patients * Applying antiseptic or topical antibiotics to the urethral area does not reduce the risk of catheter associated UTIs Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia 16-3 PREVENTING SURGICAL SITE INFECTIONS (SSIS) To-reduce the risk of nosocomial SSIs, a systematic but realistic approach must be applied with awareness that this risk is influenced by characteristics of the patient, the operation, the healthcare staff and the hospital. The surgical wound classification system includes four categories, clean, clean-contaminated, contaminated and dirty or infected. Reducing the Risk of Surgical Site Infections The risk of surgical site infection can be greatly reduced if each member of the team follow the steps described below, before, during and after surgical procedure. Preoperative 1. Preparation of the patient · Whenever possible, identify and treat all infections remote to the surgical site before an elective operation and postpone elective operations on patients with remote site infections until the infection has resolved. * Do not remove hair preoperatively unless the hair at or around the incision site will interfere with the operation. * If hair is removed, remove immediately before the operation, preferably with a pair of scissors. · Adequately control serum blood glucose levels in all diabetic patients. * Encourage stopping use of tobacco products at least 30 days prior to elective operation. * Do not withlhold any blood products from surgical patients as a mean to prevent SSI. * Instruct patients to shower with soap and water or an antiseptic agent on at least the night before the operation day. * Thoroughly wash and clean at and around the incision site to remove gross contamination before performing antiseptic skin preparation. * Prep the skin using concentric circles moving toward periphery. * Keep preoperative hospital stay as short as possible. 2. Hand/forearm antisepsis for surgical team members * Keep nails short and do not wear artificial nails. * Perform a preoperative surgical scrub for at least 2-5 minutes using an appropriate antiseptic. Scrub up to elbows. Do not use brush for scrubbing. * After performing the surgical scrub, keep hands up and away from the body so that water runs from the tips of the fingers toward the elbows. Dry hands with a sterile towel and put on a sterile gown and gloves. * Clean underneath each fingernail prior to performing first surgical scrub of the day. * Do not wear hand or arm jewelry. 16-4 InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 3. Management of infected or colonized surgical personnel * Surgical personnel with signs and symptoms of a transmissible infectious running nose, fever, malaise) disease (e.g., should promptly report to their supervisors. * Personnel having potentially transmissible infectious conditions (e.g., infected should not skin lesions) be allowed to work in the operating rooms. * Do not routinely exclude surgical personnel who are colonized aureus with organism or Group such as S. A Streptococcus, unless such personnel epidemiologically have been linked to dissemination of the organism in the healthcare setting. 4. Antimicrobial prophylaxis * Administer a prophylactic antimicrobial agent only when indicated, its efficacy and select against most it based on common pathogens causing SSI for a * Administer specific operation. by the IV route the initial dose of antibiotic, timed such concentration that a bactericidal of the drug is established in serum and tissues Maintain when the incision therapeutic is made. levels of the agent in serum and tissues throughout until, at most, the operation a few hours and after the incision is closed in the operating room. * Before elective colorectal operations in addition to above, mechanically by use of enemas prepare the colon and cathartic agent. * For high-risk cesarean section, administer the prophylactic antibiotic immediately umbilical cord is clamped. after the Intraoperative 1. Ventilation in operating room * Let the air enter at the ceiling, and exhaust near the floor. * If available, use positive pressure ventilation in the operating rooms. * Do not use WV (Ultra Violet) radiation in the operating room to prevent * Keep operating SSI. room doors closed except as needed for passage of equipment, and the patient. personnel · Limit number of personnel entering the operating room to necessary personnel. 2. Cleaning and disinfection of environmental surfaces * Use disinfectant to clean the surfaces visibly soiled with blood of body next operations. fluids before the * Do not perform special cleaning or closing of operating rooms after contaminated operations. or dirty * Do not use tacky mats at the entrance to the operating room suite rooms for or individual infection operating prevention. 3. Microbiologic sampling * Do not perform routine environmental sampling of the operating epidemiological room unless investigation. as a part of 4. Sterilization of surgical instruments * Sterilize all surgical instrument according to the guidelines discuss in processing. chapter on instrument InfectionPrevention Guidelines for Healthcare Facilities in Ethiopia 16-5 5. Surgical attire and drapes * Wear mask and cap to fully cover the face and hair before entering the operating room. Wear them throughout the operation. * Do not wear shoe covers to prevent SSIs. * Use surgical gowns and drapes that are effective bamiers. * Change scrub suite that are visibly soiled, contaminated and/or penetrated by blood or other potentially infectious materials. 6. Asepsis and surgical technique * Adhere to principles of asepsis when placing IV device, spinal or epidural anesthesia, or when dispensing and administering IV medication. * Assemble sterile equipment and solutions immediately prior to use. * Handle tissue gently, maintain effective hemostasis, minimize devitalized tissue and foreign bodies and eradicate dead space at the surgical site. * Use delayed primary skin closure or leave an incision open to heal by second intention if the surgeon considers the surgical site to be heavily contaminated. * If drainage is necessary, use a closed suction drain. Place a drain throughi a separate incision distant from the operative incision. Remove drain as soon as possible. Postoperative IncisionCare 1. Protect surgical incision with a sterile dressing for 24 to 48 hours postoperatively and incision that has been closed primarily. 2. Wash hands before and after dressing and any contact with the surgical site. 3. When an incision dressing must be changed, use sterile technique. Healthy tissue growth is damaged when the dry gauze is removed; therefore, moisten the dry gauze with sterile normal saline before removing/changing the dressing. 4. Educate patients and families regarding proper incision care, symptoms of SSI, and the need to report such symptoms. 5. No recommendations to cover an incision closed primarily beyond 48 hours, nor on the appropriate time to shower or bathe with an uncovered incision. Putting topical antibiotic ointment on closed skin incisions does not decrease the risk of SSIs. The guidelines for choosing a prophylactic antibiotic for prevention of wound infection and sepsis in surgical patients and for preventing bacterial endocarditic in patients with previous endocarditis, prosthetic heart valves, and complex congenital heart disease are given on the next page. PREVENTING INFECTIONS RELATED TO USE OF INTRAVASCULAR DEVICES The use of intravascular devices, both venous and arterial, has dramatically increased during the past decade. Because catheters inserted into the venous or arterial bloodstream bypass the nomial skin defense mechanism, these devices provide a way for microorganisms to enter the bloodstreamii 16-6 InfectionPrevention Guidelines for HealthcareFacilitiesin Ethiopia from: the device at the time of insertion, subsequent contamination of the device or attachments or pathogens on the skin surrounding the insertion site. Infection Prevention Practices for Insertion, Maintenance and Removal of Peripheral Venous Lines Nosocomial infection could occur anytime while: * Establishing an fV line * TV Line is in position * Changing the IV solution and changing IV tubing and * Removing TV line * Administering blood or blood products The risk of nosocomial infections can be greatly reduced by using proper infection preventions practices and proper monitoring of patient. These practices include: * Making sure all items required for performing a procedure are available * Preparing skin at the site of venipuncture following the guidelines on preparing the skin * Washing hands with soap and clean water or using alcohol handrub if hands are not visibly soiled * Following aseptic teclnique while handling the infusion set and assembling the parts * Putting on clean examination gloves or reprocessed surgical gloves before puncturing a vein * Properly securing the needle or catheter and covering venipuncture site using clean square gauze and surgical tapes |Note: Applying antimicrobial ointment around the insertion site does not reduce the risk of infection. * Changing dressing every 72 hours or whenever it is wet, soiled or loose * Disposing of all contaminated wastes including gloves following the waste disposal guidelines * Monitoring patient on hourly basis (depending upon patient's condition) to determine her/lhis response to the fluid therapy and checking that, IV line is open and running * Checking every 8-12 hours for phlebitis or evidence of infection * Rotating infusion site every 72-96 hours, when practical * Changing infusion set whenever they are damaged and at 72 hours routinely * Avoiding direct contact with the spikes while changing IV solution * Changing IV tubing every 24 hours if used to administer blood, blood product or lipid emulsion, or 96 hours for other fluids * Avoiding direct contact with any area of the tubing that will come in contact with IV fluid or blood InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 16-7 * Covering the venipuncture site with dry gauze square when site is changed and new line is established * Covering the venipuncture site with dry gauze square or sterile bandage after removing the TV line PREVENTING MATERNAL AND NEWBORN INFECTIONS The following prevention efforts are being recommended to successfully reduce the risk of fetal and newborn infections: * Maternal immunization (Tetanus Toxoid) * Antenatal treatment of maternal syphilis, gonorrhea and Chlamydia infections. * Prophylactic use of postnatal eye drops to prevent chlamydia, gonorrhea and candida eye infections * Prophylactic treatment of pregnant women at risk of group B streptococcal disease and * Maternal and newborn treatment with antiretroviral to prevent mother-to-child transmission of HIV. Infection Prevention Guidelines for Reducing the Risk of Maternal and Newborn Infections Minimizing the Risk ofInfectionduringLabor and Vaginal Delivery Although vaginal deliveries do not require the aseptic conditions of an operating room, a few simple practices can make the procedure safer for the mother, the infant and the healthcare providers. For example keeping hands, perineal area and newborn's umbilical area clean during and following childbirth, and having clean delivery kits help improve the safety of home births for both mother and newborn. Prolonged ruptured membranes, trauma to the birth canal, manual removal of placenta, episiotomy, and midcavity forceps delivery increase the risk of endometritis and UTI. To minimize this risk: * Use a pair of clean examination gloves, or HLD surgical gloves, for each vaginal examination during delivery (Sterile gloves are not necessary for vaginal examination) * Keep number of vaginal examination during labor to minimum possible (15' vaginal examination at admission. Followed by repeat examination every four hours, unless indicated otherwise) * Avoid pushing the tip of the examination finger up against the opening to the cervix until active labor occurs or until the decision has been made to induce labor * Carefully limit cases for student training to those patients in active and progressive labor 16-8 Infection Prevention Guidelines forHealthcare Facilitiesin Ethiopia Vaginal Delivery Steps that can be taken to decrease the risk of maternal infection before and during delivery: Before Delivery 1. Make sure all supplies are available for proper infection prevention: * Examination gloves * HLD or sterile surgical gloves * Elbow-length gloves-readymade or prepared in clinic * PPE-mask, apron, faceshield or goggles * Basin of clean warm water * Soap · Waterless antiseptic handrub * HLD or sterile instruments including sterile cord clamp * Cotton thread * Clean basin for placenta * Clean drape for wrapping the newborn · Sharp container · Leakproof covered waste container * Bucket with 0.5% chlorine solution * Gauze squares * Enough quantity of disposable syringes and needles 2. Make sure all instruments required for assisting conducting delivery are available (sterile delivery set, episiotomy set, and necessary medications) 3. With examination gloves on wash the perineal area of the woman with soap and clean water. Use a downward and backward motion when washing the perineal area so that fecal organisms will not be introduced into the vagina. Clean the anal area last and place the washcloth or towel in a plastic container. 4. Do not shave the perineal hair. If required trim them using a pair of scissors. 5. Immerse both gloved hands in 0.5% chlorine solution, remove gloves by inverting and place them in the plastic bad or a leakproof covered container. 6. Thoroughly wash hand with soap and water and dry using towel or air dry. 7. Apply 5 ml of the antiseptic handrub to hand and forearms and rub vigorously until dry. Repeat application 2 more times or at least for 2 minutes. 8. Put HLD or sterile surgical gloves on both hands. 9. Wear protective equipment including plastic apron and face shield (or a mask and goggles and plastic shoes). During Delivery * For resuscitation of the newborn, use mechanical suction ifavailable. Formouth suction, place a trap in the line. * If manual removal of the placenta is required, use elbow length gloves or fingerless surgical gloves. Infection Prevention Guidelines forHealthcare Facilitiesin Ethiopia 16-9 After Delivery I. Before removing the gloves, put the placenta in the clean basin and place all waste items in the plastic bag or leakproof, covered waste container 2. If an episiotomy was done or there were vaginal or perineal tears requiring surgical repair, place sharps in the puncture-resistant sharp container, dispose of single use hypodermic needle and syringes by flushing three times with 0.5% chlorine solution before putting in a puncture-resistant container. If, reusing, fill syringes with needle attached with 0.5% chlorine solution and soak for 10 minutes. 3. Immerse both gloved hands in a 0.5% chlorine solution; remove by inverting, and place in the plastic bag or leakproof, covered waste container for discarding. If reusing, place them in a 0.5% chlorine solution for 10 minutes. 4. Wash hands or use an antiseptic handrub. Infection Prevention Guidelines for Minimizing the Risk of Infection during Cesarean Section * The surgical team should use proper personal protective equipment. * Double gloving should be used as per the national guidelines. * Appropriate antibiotic prophylaxis should be given IV after the cord is clamped it the risk of infection is high. * With prolonged ruptured membranes or with documented chorioamnionitis, avoid spillage of amniotic fluid into the abdominal cavity, place folded, moistened sterile laparotomy pads on either sides of the uterus to catch as much contaminated fluid as possible, If large amounts of meconium or amniotic fluid spills into the abdominal cavity, remove the laparotomy pads and lavage the cavity with sterile isotonic saline solution. Do not explore the peritoneal cavity unless absolutely necessary, and then only after closure of the uterine incision and surgical gloves have been changed. * If the cervix is closed and membranes were not ruptured prior to the surgery, dilate the cervix through the vagina sufficiently to permit the outflow of blood and fluid after delivering the baby and placenta, insert gloved finger into the cervix only once to dilate it, do not go back and forth or remove the hand from the pelvis and then put the finger back into cervix, when dilatation is completed, remove the gloves and put on a new pair of sterile or HLD surgical gloves. * The health worker receiving the infant should wash hands and put on clean examination gloves before handling the baby. * The baby should be placed on a clean towel after being passed off to the health worker canrng for the infant. * To minimize the postoperative wound infection, patients should not be shaved prior to surgery, make skin incision with a scalpel rather than cautery, after the fascia is closed, irrigate the wound with sterile isotonic saline and then blot it dry, do not place drains in the subcutaneous layer, close the skin edges using a subcuticular technique and apply a sterile dressing and care for the wound as described elsewhere in these guidelines. 16-10 InfectionPrevention Guidelines for Healthcare Facilities in Ethiopia Postpartum Care of the Woman * Wear examination or utility gloves when handling perineal pads, touching lochia or touching the episiotomy. * Teach the woman how to wash the perineal area with clean warm water after changing a pad or having bowel movement. * If the woman is breastfeeding, teach her how to care for her breasts and nipples to avoid infection. Also teach woman how to put baby to the breasts. * After cesarean delivery, to avoid pulmonary problems during the immediate postoperative period and for the next few days, use anti pain medicine cautiously, encourage woman to move about in bed and take deep breaths frequently, and get her out of bed and walking within the first 12 hours. * If indwelling catheter was inserted, check to be sure urine is flowing and the unrne collection system is intact, follow the "Tips for Preventing Infections" as described under prevention of urinary tract infections and remove catheter as soon as possible (within 24 hours). Care of the Newborn * Wash hands before holding or caring for the infant. * Wear gloves and plastic apron when handling the newborn until blood, meconium or amniotic fluid has been removed from the infant's skin. * Carefully remove blood and other body fluid using a cotton cloth, not gauze, soaked in warm water followed by drying the skin. * Bathing or washinlg the newkborn should be delayed until the baby's temperature is stabilized. The buttocks and perineal areas are the most important to keep clean. They should be washed after changing diapper using a cotton clothe soaked in warm soapy water, and then carefully dried. * Wash hands, or use an antiseptic handrub, before and after cord care. * Keep cord stump clean and dry. * Do not cover the cord stump with a dressing or bandage. * Fold the diaper below the cord stump. * If the cord stump gets soiled or dirty, gently was it with warm (preferably boiled) clean soapy water, and rinse with warm (preferably boiled) clean water. Preventing Specific Infection ofFetus and Newborn * Group B Streptococcal Septicemia: Providing prophylactic antibiotics against Group B Streptococcal Septicemia to women having any one of the risk factors including, group B streptococci bacteriuria during pregnancy, previously delivered infant infected wvith group B streptococcal infection, preterm birth, rupture of membranes (>18 hours) and clinically evident chorioamnionitis with maternal temperature greater than 38°C or pnror infected clild, Prophylactic antibiotics should be given as soon as labor starts or a risk factor is identified. Recommnended treatments include Penicillin G 5 million units IV loading dose followved by 2.5 million units every four hours until delivery. Alternative regimens include, Ampicillin 2 g I! InfectionPrevention Guidelines forHealthcare Facilitiesin Ethiopia 16-11 loading does and then 1 g IV every 4 hours until delivery or Erythromycin 500 mg. IV every six hours until delivery. * Chlamydial Infection: In absence of antenatal testing for mothers, prophylactic eye drops is the only preventive measure to prevent chlamydial conjunctivitis. However, it will not prevent pneumonia which is mild and easily and inexpensively treated following standard precautions and appropriate transmission based precautions * Gonorrheal Infection: Prevention during pregnancy includes treatment ofinfected women with Erythromycin or other appropriate antibiotics. In the absence of antenatal testing, prophylactic eye drops (tetracycline or erythromycin) is the only preventive measure usually available. Follow the National STI Management Guidelines for managing all STIs including Gonorrhea. * Neonatal Tetanus: Can be prevented by immunizing all women of childbearing age, especially pregnant women (at the minimum two doses oftetanus toxoid prior to delivery 4 weeks apart), improving the quality and availability of maternity care and educating mothers, relatives and birth attendants of the need for cutting the cord with a clean instrument and keeping the cord stump clean and dry. * Syphilis Antenatal: Testing of pregnant women is routinely done in Ethiopia. If the results of serologic tests are positive, woman should receive treatment for syphilis according to the National STI Management Guidelines * Hepatitis B: Ideally all pregnant women should be immunized for Hepatitis B. If HBV is endemic all infants should receive HBV vaccine within 12 hours. * Hepatitis C: There is no vaccine for HCV and so primary prevention, including education combined with behavior change interventions aimed at promoting safe sexual practices, is the only option. * Herpes Simplex Virus: Where possible, pregnant women at term with documented genital lesions and intact membranes should be delivered by cesarean section, however, this may not be possible a t m ost p laces w ith Iimited r esources. S tandard precautions a nd transmission-based precautions should be used to minimize the risk of transmission to other newborn and health workers. Mothers with active lesions should be placed on transmission-based precautions until discharge. Mother should cover nongenital lesions and thoroughly wash and dry her hands before touching the baby. She should cover her upper body with a clean cloth or gown so that the baby does not come in contact with lesions. If the woman has lesions on her lips, or blisters or face, she should not cuddle or kiss her baby until the lesions are healed. Use of a mask is recommended. Breastfeeding can be done provided there are no lesions in the breast area and all skin lesions are covered. Direct contact of a newborn with other family members or friends who have active HSV should be avoided * HIV: Please refer to National PMTCT guidelines published by MOH, Ethiopia for prevention of HIV infection to newborn. * Human P apilloma V irus: Infants born to mothers infected with genital HPV do not need special precautions. Cesarean section may be necessary, however, in women whose genital warts are so extensive that soft tissue stretching of the vulva and perineum may not be sufficient to allow vaginal delivery. * Rubella: Newborns lacking passively acquired maternal antibodies may develop congenital rubella infection if exposed to the virus during pregnancy. Vaccination of all children and nonpregnant women is the most effective method of preventing congenital rubella in infants. 16-12 Infection PreventionGuidelines for Healthcare Facilitiesin Ethiopia Newborns with congenital rubella infection, or those bom to mothers know to have had rubella dunrng pregnancy, should not be kept with other newborns. Pregnant women with active rubella at the time of admission to the hospital should labor and give birth in a separate area. * Vericella (Chicken Pox): Newborns lacking passively acquired matemal antibodies may develop a life-threatening infection if exposed to the virus within the last two weeks of pregnancy or at the time of delivery. The greatest nrsk is ifthe baby is born within 2-5 days after the onset of matemal chicken pox. If available, infants at risk should receive vanrcella immune globulin, 1.25 ml TM. Standard precautions and Transmission-based Precautions should be followed for these newboms. Pregnant women with active venrcella at the time of admission to the hospital should labor and give birth in a separate area. Where possible, care should be provided to the mother only by health workers known to have had varicella or those previously vaccinated. REFERENCES American Academy of Pediatrics (AAP) and American Academy of Obstetricians and Gynecologists (ACOG). 1997. Guidelines for Perinatal Care, 4th ed, revised. AAP: Elk Grove, IL. Association for Professionals in Infection Control and Epidemiology (APIC). 2002. Intravascular device infections, in APIC Text of Infection Control and Epidemiology, revised ed. APIC: Washington, DC, pp 30-1 to 30-8. Burke JP and D Zavasky. 1999. Nosocomial urinary tract infections, in Hospital Epidemiology and Infection Control, 2nd ed. Mayhall CG (ed). Lippincott, Williams and Wilkins: Philadelphia, pp 173-187. Burke JP, RA Larsen and LE Stevens. 1986. Nosocomial bacteriuria-estimating the potential for prevention by closed sterile drainage systems. Infect Control 7(Suppl 2): 96-99 Centers for Disease Control and Prevention (CDC) and Hospital Infection Control Practices Advisory Committee (HICPAC). 1996. Guidelines for prevention of intravascular device-related infections. Infect Control Hosp Epidemiol 17(7): 438-473. (Authors: Pearson ML and HICPAC). Conover W and TR Moore. 1984. Comparison of irrigation and intravenous antibiotic prophylaxis atcesarean section. Obstet Gynecol 63(6): 787-791. Cunningham FG et al. 1983. Perioperative antimicrobials for cesarean delivery: Before or after cord clamping? Obstet Gynecol 62(2): 151-154. Hemsell DL. 1991. Prophylactic antibiotics in gynecologic and obstetric surgery. Rev Infect Dis 13(Suppl 10): S821- S841. Horan TC et al. 1992. CDC definitions of nosocomial surgical site infections, 1992: A modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 13(10): 606-608. Iffy L et al. 1984. Infectioncontrol in obstetrics, in Operative Perinatology: Invasive Obstetric Techniques. Iffy L andC Charles (eds). Macmillan: New York, pp 86-99. Landry K and D Kilpatrick. 1997. Why shave a mother before she gives birth? Matern Child Nurs 2: 189-190. Maki DG. 1992. Infections due to infusion therapy, in Hospital Infections, 3rd ed. JV Bennett and PS Brachman (eds). Little, Brown and Company: Boston, pp 849-898. Maki DG, M Ringer and CJ Alvarado. 1991. Prospective, randomized trial of povidone-iodine, alcohol and chlorhexidine f or p revention o f i nfection a ssociated w ith c entral venous a nd arterial catheters. Lancet 338(8763): 339-343. Mayhall CG. 1992. Diagnosis and management of infections of implantable devices used for prolonged venous access. Curr Clin Top Infect Dis 12: 83-110. Infection Prevention Guidelines forHealthcare Facilitiesin Ethiopia 16-13 The Medical Letter. 2001. Antimicrobial prophylaxis in surgery. The Medical Letter43: 1116-1117. SHEA, APIC, CDC and SIS. 1990. Consensus paper on the surveillance of surgical wound infections. Infect Control Hosp Epidemiol 18(5): 599-605. Warren JW. 2000. Nosocomial urinary tract infections, in Principles and Practices of Infectious Diseases, 5th ed. Mandell JE et al (eds). Churchill Livingstone, Inc.: Philadelphia, pp 328-339. Warren JW et al. 1978. Antibiotic irrigation and catheter-associated urinary tractinfections. N Engl J Med 299(11): 570-573. 16-14 Infection Prevention Guidelines for Healthcare Facilities in Ethiopia CHAPTER 17 PREVENTING INFECTIOUS DIARRHEA AND MANAGING FOOD AND WATER SERVICES Outbreaks of diarrhea in various patient care areas of hospitals have been associated with a wide variety of organisms including salmonella, shigella, C. difficile, cholera, C. ailbictains, Staph. aureuxs, cryptosporidium, rotavirus and other enteroviruses. GUIDELINES FOR REDUCING THE RISK OF NOSOCOMIAL DIARRHEA * Hand cleanliness and gloves: Patients and staff should perform hand hygiene after contact with fecal organisms in bathrooms, on toilet articles such as bedpans, or on patients who have fecal incontinence. Wear new, clean examination gloves before touching mucous membranes of all patients, including infants and children and utility gloves should be worn if activities are likely to involve touching or handling feces. * Environmental contamination and soiled linen: Clean bedpans and bathroom equipment that are regularly handled by patients and staff with a disinfectant daily and whenever they have been used. All soiled articles should be immediately cleaned and disinfected. Guidelines for processing linen should be meticulously followed. * Food services personnel: Food handlers with diarrhea should be immediately removed from handling foods. They should not retum to food handling or work with immunocompromised patients or intensive care or transplant patients until all symptoms are over for 24-48 hours. * Patients with diarrhea: These patients should be managed according to Standard Precautions with Transmission-Based Precautions added if the diagnosis indicates. Infants born to mothers with diarrhea should not enter the regular wards. Rather, rooming-in should be provided for mother and infant, and the mother should be taught good hygiene. * Outbreak management: The successful management of outbreaks of diarrhea related to common source contamination in healthcare facilities usually requires, finding the common source and eliminating it, grouping patients with diarrhea together and not allowing the sharing of equipment or staff with any new or uninfected patients, discharging affected and unaffected patients early if they can be managed at home, making sure that housekeeping is through and frequently performed, and providing separate space and extra staff to care for affected infants in neonatal wards. Managing Food and Water Services Factors that increase risk of nosocomial diarrhea in healthcare facilities include the fact that thev serve food for more hours, serve ill and immunocompromised patients, transporting and distributing food at greater distances, and prepare nasogastric feeding and special diets. In addition, staff often are transient, poorly trained and may have other health problems that can contribute to poor quality food services. InfectionPrevention Guidelines forHealthcare Facilities in Ethiopia 17-1 Food Service Guidelines All activities in the food service department should be monitored regularly to be sure that safety standards are being followed, including: * Holding temperatures should be above 60°C/140°F or below 7°C/450F. Thermometers for food storage should be checked periodically. Warm, perishable foods should be cooled before being stored. * Cooking should be complete. Frozen food items should be thawed before cooking to avoid the presence of cold spots in the interior. * Personal health and hygiene of food service staff are of great importance and should be supervised by a knowledgeable person. Hand hygiene plays cnicial role in preventing nosocomial diarrhea. The staff should report any gastrointestinal problems or skin lesions, especially on hands. They need to know how properly inspect, prepare and store the foods they handle, how to clean and operate equipment they use such as slicers, blenders and dishwashers, ifthey are available and waste management. * Ensure equipment cleaning and disinfection, especially cutting boards used for preparing raw meat, fish or poultry. * Purchase raw food from known vendors that meet local inspection standards, if possible. Foods prepared at homes should not be shared with other hospitalized patients. Preparation of Clean Water Water boiled for 1-5 minutes is considered safe to drink, while water boiled for 20 minutes is high-level disinfected. Alternatively, water can be disinfected and made safe for drinking by adding a small amount of sodium hypochlorite. The formula for preparing 0.001% of chlorine solution is given elsewhere in these guidelines. The preparation of clean water containing up to 0.001% sodium hypochlorite solution is inexpensive, easy to do and often is needed during emergency situation. REFERENCES Levine WC et al. 1991. Foodborne disease outbreaks in nursing homes, 1975-1987. JAMA 266(15): 2105-2109. Lynch P et al. 1997. Preventing nosocomial gastrointestinal infections, in Infection Prevention with Limited Resources. ETNA Communications: Chicago, pp 125-130. McFarland LV et al. 1989. Nosocomial acquisition of Clostridium difficile infection. N Engl J Med 320(4): 204-208. Villarino ME et al. 1992. Foodbourne disease prevention in healthcare facilities, in Hospital Infections, 3rd ed. Bennett JV and PS Bachman (eds). Little, Brown and Company: Boston, pp 345-358. 17-2 InfectionPrevention Guidelines forHealthcare Facilities in Ethiopia CHAPTER 18 PREVENTING NOSOCOMIAL PNEUMONIA GUIDELINES FOR REDUCING THE RISK OF NOSOCOMIAL PNEUMONIA Preoperative Pulmonary Care During preoperative period teach patients about to take deep breaths, moving in the bed, frequent coughing, and early movement-sitting up and walking-to prevent postoperative pulmonary problems. Limited use of narcotic analgesics for a short duration can reduce the risk of nosocomial pneumonia. Preventing Colonization and Infection with New Organisms Using clean gloves (new examination or reprocessed surgical gloves) prior to contact with the mucous membrane or nonintact skin of patients play significant role in preventing colonization with pathogenic organisms. Respiratory Therapy Equipment To minimize cross-contamination when suctioning patients on ventilators: * Wash hands or use an alcohol-based antiseptic handrub before putting on gloves. * Wear c]ean examination gloves, or reused surgical gloves that have been high-level disinfected, and a protective face shield or mask. * Remove gloves immediately after therapy is completed and discard them in a plastic bag or leakproof, covered waste container. * Wash hands or use an alcohol-based antiseptic handrub after removing gloves. Suction catheters should be decontaminated, cleaned and high-level disinfected by boiling or steaming between uses. In addition, use of large containers of saline or other fluids for instillation or rinsing the suction catheter should be avoided. If possible, only small containers of sterile solutions or boiled water, which can be used only once and then replaced, should be used. To reduce the risk of contamination and possible infection from mechanical respirators and other equipment, the following are suggested: * Prevent condensed fluid in the ventilator tubing from refluxing into the patient because it contains large numbers oforganisms. (Any fluid in the tubing should be drained and discarded, taking care not to allow the fluid to drain towards the patient.) * Use only small nebulizer bulbs because nebulizers produce aerosols that can penetrate deep into the lungs. (Contaminated large-volume nebulizers have been associated witlh gram-niegati\e pneumonia and should not be used.) * Contaminated humidifiers for oxygen administration and ventilator humidifiers are unlikely to cause n osocomial p neumonia b ecause they d o n ot g enerate a erosols. T hese h uLrlidifiers can, Infection Prevention Guidelines for HealthcareFacilities in Ethiopia 18-1 however, be a source of cross-contamination, so they should be cleaned and disinfected between patients. * Although ventilator circuits may become contaminated at the patient end by organisms from the respiratory tract, there is little evidence that pneumonia is associated with this contamination. Therefore, it is not necessary to change the circuits. * Breathing circuits should be decontaminated, cleaned and high-level disinfected by steaming or soaking in a chemical high-level disinfectant. * Resuscitation devices, such as Ambu bags, are difficult to decontaminate, clean, high-level disinfect and dry between uses. For example, if not thoroughly disinfected and dried, fluids left inside the bag or face piece can be aerosolized during the next use. To prevent this, a good system for prompt reprocessing and return to use is necessary. Preventing Gastric Reflux Even short-term (a few days) use of nasal feeding tubes increases the risk of aspiration. Feeding small, frequent amounts rather than large amounts may be less risky. Also, raising the head of the bed, so that the patient is more or less in a sitting position, makes reflux less likely. Postoperative Care * Follow proper hand hygiene and gloving procedures. * Ifusing suction catheters, decontaminate, clean and HLD before use. * Use only small nebulizer bulbs and one bulb should not be used for more than one patient. * Limit the use of anti pain medication and nasogastric tubes. * Help patient move out of the bed as soon as possible. * Encourage deep breathing in the immediate postoperative period and for the next few days following surgery. REFERENCES Centers for Diseases Control and Prevention (CDC). 1994. Guidelines for prevention of nosocomial pneumonia. Part 1. Issues on prevention of nosocomial pneumonia. Part 2. Recommendations for prevention of nosocomial pneumonia. Am. J Infect Control 22(4): 247-292. (Authors: Tablan OC et al and HICPAC) Lynch P et al. 1997. Preventing nosocomial pneumonia, in Infection Prevention with Limited Resources. ETNA Communications: Chicago, pp 131-134. Schaefer SD et al. 1996. Respiratory care, in Pocket Guide to Infection Prevention and Safe Practice. Mosby-Year Book, Inc.: St. Louis, MO, pp 363-386. 18-2 InfectionPrevention GuidelinesforHealthcare Facilitiesin Ethiopia CHAPTER 19 MANAGEMENT OF INFECTION PREVENTION PROGRAMS Successful programs for preventing the spread of infectious disease by any route in healthcare facilities are based on understanding the scope of the problem, prioritizing activities and effectively using available resources. Because available resources are invariably limited, careful planning, implementing and monitoring activities on a regular basis, whether in a health post or a busy district/regional hospital, are all essential. It is the responsibility of administrators and health facility managers, working in conjunction with key staff (the nurses, surgeons and cleaning staff) serving on operating room safety or infection prevention committees (if not already establish, form a committee including the staff from regional/zonal/woreda level and assign a focal person), to set standards for performance as per the national guidelines, guide the staff and regularly monitor staff performance and help staff at all levels "buy in" to using common sense when performing their assigned duties, as well as using appropriate personal protective equipment at all times. The main organizing principles for managing an infection prevention program include: * Establishing the r elative importance o f problems using the Spaulding categories of potential infection risk: . Critical . Semicritical * Noncritical * Identifying and analyzing the reasons for poor or incorrect performance * Costing the issues WHO SHOULD BE INVOLVED IN MANAGING THE PROGRAM The working group should include representatives from a variety of patient care areas including surgery, central sterilization department, housekeeping, laboratory, laundry, kitchen, and administration. Basic Guidelines and Activities that Help Managers Implement Successful IP Practices * Use national infection prevention guidelines to handle situations in which patients or staff are exposed to the risk of infection. * Conduct staff orientation before new polici&s, recommendations, or procedures are started and provide followup training when management reinforcement is needed. * Be sure adequate supplies, equipment, and facilities are available before start-up to ensure compliance. InfectionPrevention Guidelines for HealthcareFacilities in Ethiopia 19-1 * Conduct regular reviews to ensure the adequacy of the recommended changes or practices, to solve any new problems, and to address staff concerns. For making management decisions regarding the changes to be made in the current practices, the evidence-based recommendations in these guidelines should be used. STAFF TRAINING Initially, all levels of healthcare workers need to know why infection prevention is important. Key topics to be taught should include: * The disease transmission cycle, routes of infection and how to break the cycle * Use of standard precautions when dealing with all clients/patients, not just those who appear or are known to be infected * Methods of minimizing disease transmission as well as "hands on" demonstrations covering, handwashing and using waterless, alcohol-based antiseptic handrub, cleaning up a blood or body fluid spill, giving an injection and disposing of sharps, learning to suture with blunlt-tipped needles * Instrument processing and waste management To have long-term effects, the initial training should be followed up, and monitoring should be targeted toward identifying and solving specific problems related to introducing the new process or procedure. General reminders regarding the importance of maintaining an infection-free environment for safer delivery of services also should be repeatedly emphasized. Monitoring the Effectiveness of Training Regular monitoring of infection prevention practices and processes is important, not only to assess their effectiveness but also to determine the topics about which staff may need more training or review. To monitor effectiveness: * Spot check how staff are performing any new procedure * Assess whether recommended practices are being followed * Note whether the necessary equipment and supplies are available and being used properly Based on the findings, future topics for training can be identified. MONITORING INFECTION PREVENTION PRACTICES Keeping records of infections that occur in hospitals and clinics is a time-honored way of monitoring the effectiveness of infection prevention practices. In particular, keeping records on postoperative infections can help to identify breaks in recommended infection prevention practices. There should be a staff assigned to keep records or relevant information. 19-2 Infection Prevention GuidelinesforHealthcare Facilitiesin Ethiopia For trouble-shooting questions to consider include: * Are recommended infection prevention being followed in the operating rooms? * Is the operative site being cleaned preoperatively, especially when it is visibly soiled? * Is an approved antiseptic at the correct concentration being used to prepare the operative site? * Do any members of the surgical team have long fingemails? * Are surgical gloves being reused? * Are the infections linked to any particular surgical team or person? * Are instruments and equipment being thoroughly cleaned prior to sterilization or high-level disinfection? * Is the sterilizer working correctly? * Is sterilization or high-level disinfection being timed correctly? Ift he answer t o a ny o f t hese q uestions i s "no", further information about the identified areas should be collected and the problems identified before deciding whether training, better equipment or management reinforcement is the corrective action needed. REFERENCES Lynch Pet al. 1997. Infection Preventionwith Limited Resources. ETNA Communications: Chicago, pp 2-9. Seto W H et a 1.1990. Brief report: The utilization of influencing tactics for the implementation policies. Infect Control of infection control Hosp Epidemiol 11(3): 144-150. InfectionPrevention Guidelines for Healthcare Facilitiesin Ethiopia 19-3 i I CHAPTER 20 INFECTION-MONITORING (SURVEILLANCE) ACTIVITIES Efforts to prevent patients from acquiring an infection or bad outcome while in a hospital require that healthcare workers use infection prevention practices of demonstrated value and monitor the care being provided. In the broadest sense, infection-monitoring (surveillance) activities are designed to guide corrective action based on accurate information, or to provide the rationale for not acting when only selective or biased information is available. Poorly designed monitoring activities can, however, waste resources by collecting data that are never used or that fail to provide an accurate picture of what is happening. This occurs most often when surveillance is inconsistent or analysis is incomplete. Although all healthcare facilities should monitor patient care practices to prevent nosocomial (hospital-acquired) infections and minimize the chance of bad outcomes, surveillance is labor- intensive. As a general rule, monitoring by surveillance should be used only if it will provide specific information not available at less cost. Moreover, it should not consume resources that could be better spent elsewhere. For most facilities with limited resources, the priority should be: * Ensure recommended infection prevention practices, such as sterilization, or where appropnrate HLD, of all items that come in contact with normally sterile tissue, are adhered to. * Ensure patient care practices are performed according to the best available evidence (i.e., use standard precautions for all patients). * Monitor compliance with recommended practices for certain high-risk procedures, such as inserting centralvenous catheters. * Work to eliminate unnecessary and unsafe injections. Finally, routine surveillance should not outweigh investigating outbreaks, or providing safe water, food and sanitation within the hospital or healthcare facilities. WHEN TO CONSIDER PERFORMING SURVEILLANCE Surveillance should be done only after recommended steps for preventing nosocomial infections have been taken. Only after successfully implementing and monitoring infection prevention practices as described in these guidelines should the recommendation of surveillance be considered. Casefinding: This could be done by, doing regular clinical review of medical records, talking with patients, discussion with staff, reviewing laboratory findings, and records from the radiology department will provide very useful information in identifying new cases of nosocomial infections. Focusing on specific areas in the hospital (postoperative and postpartum wards, intensive care units for newborn) could be very cost efficient yielding quick results. InfectionPrevention GuidelinesforHealthcare Facilities in Ethiopia 20-1 Detecting and managing outbreaks: Generally an assistance of qualified epidemiologist is required in order to investigate an outbreak of a nosocomial infection. However, in many instances, the cause of the outbreak can be easily identified and can be resolved without complete investigation. COMMON MISTAKES IN OUTBREAK INVESTIGATIONS * There is no clear definition of an outbreak for all disease. * Isolation of an organism rarely explains an outbreak. * The presence of organisms from multiple sites or personnel usually suggest that these sites became colonized from another source and were not the cause of the outbreak. * Negative cultures do not justify concluding that the site was not responsible for the outbreak. * Prevention measures are not implemented imnmediately. * Other similar practices are not evaluated. Table 20-1 describes the measures identified as effective in investigating outbreaks. 20-2 Infection Prevention Guidelines for HealthcareFacilitiesin Ethiopia Table 20-1. Measures Identified as Effective inInvestigating Outbreaks SITE WHERE TO LOOK FOR SOURCE AND/ OR MODE INTERIM MEASURES Common Uncommon Urinary tract * Urinary tract * Inadequately * Re-emphasize infection known aseptic practices instrumentation processed relating to insertion and maintenance of * Cross-contamination instruments urinary catheters, and monitor compliance. via hands of personnel * Contaminated * Institute glove use for any contact with * Poor hand hygiene antiseptic solution urine. (e.g., povidone- * Separate catheterized patients from each iodine) other. * Put on clean gloves just before contact with urinary meatus. * Wash hands, or use an antiseptic handrub, after removal of gloves. Surgical * Organisms acquired * Airborne spread * Re-emphasize known aseptic wounds practices and intraoperatively by * Preoperative surgical technique. contact with contamination * Exclude infected personnel from patient symptomatic or (contaminated care. asymptonatic shedders antiseptic solution) * Separate those at risk from those infected. among staff * Put on sterile or high-level disinfected * Contaminated products gloves just before wound contact. (wound irrigating a JJse sterile fluids for wound caTe. solutions) s . * Wash hands, or use an antiseptic * tchnqueafter Por handrub, srgial and skills ofsurgeon removal of gloves. (hemostasis, glove * Improve skills and techniques of the puncture) surgeon. Lower * Colonization of upper . Airborne spread * Re-emphasize respiratory known aseptic airway with secondary practices and surgical technique. tract aspiration into lung * If respiratory therapy is associated with * Contamination of cases, examine technique used for nebulized solutions or disinfection and deliver-y of therapies (e.g, respiratory therapy multidose vials). equipment surfaces * Separate those at risk from those imfected. * Cross-contanniation * Put on clean gloves just before contact wvith via hands of personnel mucous membranes and suctioniig of patients. * Wash hands, or use an antiseptic handrub. after removal of gloves. Blood * Intravascular, * Inadequately * Re-emphasize known aseptic practices and especially central processed surgical technique. venous catheters instruments * Intravenous catheters should be changed * Contamirnation of * Preoperative every 96 hours. insertion site contamination * Put on sterile or high-level disinfected (contaminated gloves before inserting catheter and wound antiseptic solutions) contact. * Wash hand, or use an antiseptic handr-ub. after removal of gloves. Adaiptedrjiomn:Lynch et al 1997. Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia 20-3 REFERENCE Lynch P et al. 1997. Surveillance, outbreak investigations,and exposures, in Infection Prevention withLimited Resources. ETNA Communications: Chicago, pp 31-48. 20-4 Infection Prevention Guidelines for Healthcare Facilitiesin Ethiopia GLOSSARY Airborne Transfer of particles 5 pim or less in size into the air, either as airborne transmission droplets or dust particles containing the infectious microorganism; can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or suctioning; can remain in the air for up to several hours; and can be spread widely within a room or over longer distances. Special air handling and ventilation are needed to prevent airborne transmission. Animate Property of having life or being alive (e.g., human tissue or organs). Antisepsis Process of reducing the number of microorganisms on skin, mucous membranes or other body tissue by applying an antimicrobial (antiseptic) agent. Antiseptic or Chemicals that are applied to the skin or other living tissue to inhibit or antimicrobial agent kill microorganisms (both transient and resident) thereby reducing the (terms used total bacterial counts. interchangeably) Antiseptic handrub Fast acting antiseptic handrubs that do not require use of water to or waterless, remove transient flora, reduce resident microorganisms and protect the alcohol-based skin. Most contain 60-90% alcohol, an emollient and often an additional antiseptic handrub antiseptic (e.g., 2-4% chlorhexidine gluconate) that has residual action. (terms used interchangeably) Asepsis and aseptic Combination of efforts made to prevent entry of microorganisms into technique any area of the body where they are likely to cause infection. The goal of asepsis is to reduce to a safe level or eliminate the number of microorganisms on both animate (living) surfaces (skin and tissue) and infanimate objects (surgical instruments and other items). Bactericide Agent that kills bacteria. Biosafety level (BSL) Combination of primary and secondary containment and safety guidelines guidelines designed for use in microbiology laboratories and bacteriology research units functioning at four levels (BSL-1 to BSL-4) of increasing risk. Infection Prevention Guidelinesfor HealthcareFacilitiesinEthiopia Glossary-] Biological safety Devices that provide protection for personnel, the agent being processed cabinets (BSCs) and the environment. They range in complexity from level I (general research cabinets for use with low- to moderate-risk microorganisms) to level III (totally enclosed cabinets with gas-tight construction that provide maximum protection to workers and the environment). Clean water Natural or chemically treated and filtered water that is safe to drink and use for other purposes (e.g., handwashing and medical instrument cleaning) because it meets specified public health standards. These standards include: zero levels of microorganisms, such as bacteria (e.g., fecal coliform and Escherichia coli), parasites (e.g., Giardia lamblia) and viruses (e.g., hepatitis A or E); low turbidity (cloudiness due to particulate matter and other contaminants); and minimum levels of disinfectants, disinfectant by-products, inorganic and organic chemicals and radioactive materials. At a minimum clean water should be free of microorganismiis and have low turbidity (is clear, not cloudy). Cleaning Process that physically removes all visible dust, soil, blood or other body fluids from inanimate objects as well as removing sufficient numbers of microorganisms to reduce risks for those who touch the skin or handle the object. Cleaning solution Any combination of soap (or detergent) and water used to wash or wipe down environmental surfaces such as floors, walls, ceilings and furniture. Clinically significant Antibody capable of producing an adverse reaction to transfused blood antibody or blood product obtained from a donor (allogenic antibody) or recipient (autologous antibody). Closed system for System in which the blood is not exposed to air or outside elements obtaining blood during collection, processing-including separation of components (e.g., platelets) if required prior to transfusion-and storage. It is the safest way to collect, process and store blood. Colonization Pathogenic (illness- or disease-causing) organisms are present in a person (i.e., they can be detected by cultures or other tests) but are not causing symptoms or clinical findings (i.e., no cellular changes or damage). Contact time Amount of time a disinfectant is in direct contact with the surface or item to be disinfected. For surface disinfection, this time period is framed by the application to the surface until complete drying has occurred. Glossary-2 Infection PreventionGuidelinesfor HealthcareFacilitiesin Ethiopia Contact Infectious agent (bacteria, virus or parasite) transmitted transmission directly or indirectly from one infected or colonized person to a susceptible host (patient), often on the contaminated hands of a health worker. Contaminated State of having been actually or potentially in contact with microorganisms. As used in healthcare, the term generally refers to the presence of microorganisms that could be capable of producing disease or infection. Corrosion Action of chemical solutions, such as those containing salt (sodium chloride) or commercial bleach (sodium hypochlorite at concentrations above 0.5%), to cause metal instruments to be gradually eaten away (rusted) with prolonged contact (i.e.,more than I hour). Critical medical Devices that penetrate skin or invade normally sterile parts device (or of the body item) (e.g., central venous catheters). These items contact blood and require sterilization. Culture Growth of microorganisms in or on a nutrient medium; to grow microorganisms in or on such a medium. Decontamination Process that makes inanimate objects safer to be handled by staff before cleaning (i.e., inactivates HBV, HCV and HIV and reduces, but does not eliminate, the number of other contaminating microorganisms). Detergents and Cleaning products (bar, liquid, leaflet or powder) that lower surface soaps (terms used tension, thereby helping remove dirt and debris and transient interchangeably) microorganisms from hands. Plain soaps require friction (scrubbing) to mechanically remove microorganisms while antiseptic (antimicrobial) soaps also kill or inhibit growth of most microorganisms. Disinfectant Chemical that destroys or inactivates microorganisms. Disinfectants are classified as low-, intermediate-, or high-level depending on their ability to kill or immobilize some (low- or intermediate-level) or all (high-level) microorganisms (but not all spores). Phenols, chlorine or chlorine- containing compounds and quaternary ammonium compounds (QUATs) are classes of disinfectants frequently used to clean noncritical surfaces such as floors, walls and furniture. Disinfectant Products that are a combination of a detergent (soap) and cleaning solution a chemical disinfectant. Not all detergents and disinfectants are compatible. Several combinations are available commercially or can be prepared, such as alkaline detergents with chlorine compounds, alkaline detergents with QUATs or other nonionic surfactants, and acid detergents with iodophors. Infection Prevention GuidelinesforHealthcareFacilitiesin Ethiopia Glossary-3 Droplet Contact ofthe mucous membranes ofthe nose, mouth or conjunctivae of transmission the eye with infectious particles larger than 5 pm in size and can be produced by coughing, sneezing, talking or procedures such as bronchoscopy or suctioning. Droplet transmission requires close contact between the source and the susceptible person because particles remain airborne briefly and travel only about 3 feet (1 meter) or less. Dry heat Oven that sterilizes metal instruments, glass syringes and bottles and sterilization other items by dry heat. Plastic and rubber items cannot be dry-heat sterilized because temperatures used (160-1 70°C) are too high for these materials. Encapsulation Filling a sharps container that is three-quarters full with cement or clay, which, after hardening, can be disposed of safely in a landfill. Endemic illness Infectious disease, such as cholera or AIDS, which is continuously or disease present at some level (prevalence) in a particular country or region. Endometritis Acute postpartum infection of the lining (endometrium) of the uterus with extension into the smooth muscle wall (myometrium). Clinical features include fever, usually developing on the first or second postpartum day, uterine tenderness, lower abdominal pain, foul-smelling vaginal discharge (lochia) and signs of peritonitis in women who have had a cesarean section. Endospore or spore Relatively water-poor round or elliptical resting cell consisting of (terms used condensed cytoplasm and nucleus surrounded by an impervious cell wall interchangeably) or coat. Spores are relatively resistant to disinfectants and sterilants, specifically the bacillus and clostridium species. Environmental Standards specifying procedures to be followed for the routine care, controls cleaning and disinfection of environmental surfaces, beds, bedrails, bedside equipment and other frequently touched surfaces. Epidemic Rapid spread of an infectious disease, such as cholera, among many individuals in a hospital or community at the same time. Episiotomy Surgical cut made in the perineum (usually at the 6 o'clock position) just prior to delivery. The purpose is to facilitate delivery of the presenting part and minimize the risk of injury to the perineal area. Episiotomies are, however, associated with increased bleeding, may extend resulting in increased tearing (3rd or 4th degree perineal laceration), frequently become infected and, most importantly, usually not necessary. Glossary-4 Infection PreventionGuidelinesfor HealthcareFacilitiesinEthiopia Exposure time Period of time during a sterilization process in which items are exposed to the sterilant at the specified sterilization parameters. In a steam sterilization process, exposure time is the period during which items are exposed to saturated steam at the specified temperature. Handwashing Process of mechanically removing soil and debris from the skin of hands using plain soap and water. Hazard Intrinsic potential property or ability of any agent, equipment, material or process that can cause harm. High-level Process that eliminates all microorganisms except some bacterial disinfection (HLD) endospores from inanimate objects by boiling, steaming or the use of chemical disinfectants. Hospital-acquired Infection that is neither present nor incubating at the time the patient infection or came to the hospital. (Nosocomial refers to the association between care nosocomial (terms and the subsequent onset of infection. It is a time-related criterion that used interchangeably) does not imply a cause and effect relationship.) Incineration Controlled burning of solid, liquid or gaseous combustible (burnable) wastes to produce gases and residues containing little or no burnable material. Infectious Microorganisms capable of producing disease in appropriate hosts. microorganisms Infectious waste The part of medical waste that is capable of causing infectious diseases. Intermediate-level Agent that destroys all vegetative bacteria, including tubercle bacilli, disinfectant lipid and some nonlipid viruses, and fungus spores, but not bacterial spores. Intra-amniotic Acute clinically detectable infection in the uterus and its contents (fetus, infection syndrome placenta and amniotic fluid) during pregnancy. (IAIS) (also referred to as amnionitis or chorioamnionitis) Invasive group B Newborn infection characterized by bacteremia, pneumonia, meningitis streptococcal sepsis and death in up to 25% of infants with the infection. It occurs most commonly following IAIS. Other sites of infection include newborn skin infections (cellulitis) and infections in bones (osteomyelitis). Infection Prevention GuidelinesforHealthcareFacilitiesin Ethiopia Glossary-S Laboratory- Nosocomial infection resulting from the performnance of laboratory acquired infection activitigs by staff, regardless of how it occurred. Linens Cloth items used in healthcare facilities by housekeeping staff (bedding and towels), cleaning staff (cleaning cloths, gowns and caps) and surgical personnel (caps, masks, scrub suits, surgical gowns, drapes and wrappers). Also used by staff working in specialty units such as intensive care (ICUs) and other units performing invasive medical procedures (e.g., anesthesiology, radiology, or cardiology). Low-level Agent that destroys all vegetative bacteria (except tubercle bacilli), lipid disinfectant viruses, some nonlipid viruses, and some fungus, but not bacterial spores. Mechanical Automated devices that monitor the sterilization process (e.g., graphs, indicator gauges, printouts). Microorganisms Causative agents of infection. They include bacteria, viruses, fungi and parasites. For infection prevention purposes, bacteria can be further divided into three categories: vegetative (e.g., staphylococcus), mycobacteria (e.g., tuberculosis) and endospores (e.g., tetanus). Of all the common infectious agents, endospores are the most difficult to kill due to their protective coating. Municipal waste General waste for collection by municipalities (e.g., local city or town authorities) generated mainly by households, commercial activities and street sweeping. Mycobacteria Bacteria with a thick, waxy coat that makes them more resistant to chemical disinfectants than other types of vegetative bacteria. Noncritical medical Devices that normally make contact with the patient's intact skin (e.g., device (or item) blood pressure cuff, oxygen masks). These devices require low- to intermediate-level disinfection, and reuse carries little risk. Nonionic Neutral (neither positively or negatively charged) particle or substance. Nonlipid viruses Viruses consist of a core of nucleic acid is surrounded by a coat of protein. Nonlipid viruses are generally viewed as more resilient to inactivation than lipid viruses. Nonlipid viruses are also referred to as nonenveloped or hydrophilic (water-seeking) viruses. Glossary-6 Infection PreventionGuidelinesfor HealthcareFacilitiesin Ethiopia Nosocomial or Infection that is neither present nor incubating at the time hospital-acquired the patient came to the hospital. (Nosocomial refers to the association infection (terms between care used and the subsequent onset of infection. It is a time-related interchangeably) criterion that does not imply a cause and effect relationship.) Nosocomial diarrhea On at least 2 consecutive days having at least three loose or watery stools with the onset more than 72 hours after admission to the hospital (or more days than the incubation period if the agent is known). Nosocomial infection Infection occurring after birth but excluding those infections in newborns known to have been transmitted across the placenta such as congenital syphilis, cytomegalovirus, rubella, varicella (chicken pox) and the protozoan parasite, Toxoplasmosisgondii. Nosocomial infection Infection that is neither present nor incubating at the time the patient in obstetrical is admitted to the hospital. Most urinary tract infections and endometritis patients are nosocomial even though the causative organism may be endogenous (i.e., present in the maternal lower genital tract prior to delivery). Occupational injury Injury or infection acquired by healthcare staff while performing their or infection normal duties. Operating room Area or space where surgical procedures are performed. Organ/Space SSI Any part of the body other than the incised body wall parts that were opened or handled during an operation. Parts per million Concentrations of trace contaminant gases in the air (or chemicals (ppm) in a liquid) are commonly measured in parts per million (ppm) by volume. To convert percent concentration to ppm and vice versa, use this formula: ppm =percent (%) x 10,000. Personal protective Specialized clothing or equipment (e.g., gloves, face mask equipment or plastic (PPE) apron) worn by an employee for protection against exposure to blood or body fluids or other hazards. Uniforms, pants, and shirts not designed to function as protection against a hazard are not considered to be PPE. Phlebitis Area of swelling, redness, warmth and tenderness of the skin around the site where the intravascular catheter comes out of the skin (the exit site). If phlebitis is associated with other signs of infection, such as fever and pus coming from the exit site, it is classified as a clinical exit site infection. Infection Prevention Guidelinesfor HealthcareFacilitiesinEthiopia Glossary- 7 Protective barrier Physical, mechanical or chemical process that helps prevent the spread of infectious microorganisms from person to person (patient, healthcare client or health worker), and from equipment, instruments and environmental surfaces to people. QUAT Abbreviated form of the term quaternary ammonium compound; a surface-active, water-soluble, low-level disinfecting substance that has four carbon atoms linked to a nitrogen atom through chemical (covalent) bonds. Reprocessing Decontaminating, disassembling (if necessary), cleaning, inspecting, testing, packaging, relabeling, and sterilizing or high-level disinfecting single-use devices (SUDs) after they have been used on a patient for their intended purpose. Reprocessing also is performed on SUDs that were removed from the package (or container) but not used on a patient or whose expiration date has passed. Resident flora Microorganisms that live in the deeper layers of the skin, as well as within hair follicles, and cannot be completely removed. even by vigorous washing and rinsing with plain soap and clean water. Resterilization Repeat application of a terminal process designed to remove or destroy all viable forms of microbial life, including bacterial spores, to an acceptable sterility assurance level. This process is performed on devices whose expiration date has passed or that have been opened and may or may not have been used on a patient. Safe Zone (also Device or designated area of the sterile field in which sharps are placed, Neutral Zone) accessed, returned, and retrieved to avoid hand-to-hand transfer of sharps between personnel. Sanitary landfill Engineered method of disposing of solid waste on land in a manner that protects the environment (e.g., by spreading the waste in thin layers, compacting it to the smallest practical volume and then covering it with soil at the end of each working day). Scavenging Manual sorting of solid waste at landfills and removal of usable material. Segregation Systematic separation ofsolid waste into designated categories. Semicritical medical Devices that come in contact with mucous membranes or nonintact skin device (or item) during use (e.g., endoscopes, respiratory equipment). These devices require high-level disinfection if sterilization is not practical, and reuse carries a greater risk for cross-contamination than noncritical items. Glossary-8 Infection PreventionGuidelinesfor HealthcareFacilitiesin Ethiopia Septic pelvic Thrombosis (blockage) of the deep pelvic veins due to inflammation and thrombophlebitis blood clots. It is uncommon (approximately I in 2000 deliveries). Predisposing factors include cesarean section after long labor (>24 hours), premature rupture of membranes, difficult delivery (forceps or vaginal extraction), anemia and malnutrition. Sharps Suture needles, scalpel blades, scissors, wire sutures, broken glass or any object thatcan cause a puncture or cut. Soaps and Cleaning products (bar, liquid, leaflet or powder) that lower surface detergents (terms tension, thereby helping remove dirt, debris used interchangeably) and transient microorganisms from hands. Plain soaps require friction (scrubbing) to mechanically remove microorganisms while antiseptic (antimicrobial) soaps also kill or inhibit growth of most microorganisms. Soiled or Linen from multiple sources within the hospital or clinic that contaminated has been linen collected and brought to the laundry for processing. All items, regardless of whether or not they are visibly dirty or have been used in a surgical procedure, must be washed and dried. Sorting Process of inspecting and removing foreign, and in some cases dangerous, objects (e.g., sharps or broken glass), from soiled linen before washing. This step is extremely important because soiled linen from the operating room or clinic occasionally contains sharps (e.g., scalpels, sharp-tipped scissors, hypodermic and suture needles and towel clips). Spaulding Strategy for reprocessing contaminated medical devices. The system classification classifies medical devices as critical, semicritical, or noncritical based upon the risk from contamination on a device to patient safety. Spore or endospores Relatively water-poor round or elliptical resting cell consisting (terms used of condensed cytoplasm and nucleus surrounded by an impervious interchangeably) cell wall or coat. Spores are relatively resistant to disinfectants and sterilants, specifically the bacillus and clostridium species. Steam sterilization Sterilization process that uses saturated steam under pressure, for a specified exposure time and at a specific temperature, as the sterilizing agent. Infection Prevention Guidelinesfor HealthcareFacilitiesinEthiopia Glossary-9 Sterilants Chemicals used to destroy all forms of microorganisms, including endospores. Most sterilants are also high-level disinfectants when used for a shorter period of time. Sterilants are only used on inanimate objects (e.g., surgical instruments) that are used in semicritical and critical areas (e.g., surgery). Sterilants are not meant to be used for cleaning environmental surfaces. Sterile or sterility State of being free from all living microorganisms. In practice, usually described as a probability function (e.g., the probability of a microorganism surviving sterilization as being one in a million). Sterilization Process that eliminates all microorganisms (bacteria, viruses, fungi and parasites) including bacterial endospores from inanimate objects by high-pressure steam (autoclave), dry heat (oven), chemical sterilants or radiation. Sterilizer Apparatus used to sterilize medical instruments, surgical gloves, equipment or supplies by direct exposure to the sterilizing agent (autoclave or dry-heat oven). Surfactant Agent that reduces the surface tension of water or the tension at the interface between water and another liquid; a wetting agent found in many sterilants and disinfectants. Surgical asepsis Preparation and maintenance of a reduced (safe) level of microorganisms during an operation by controlling four main sources of infectious organisms: the patient, personnel, equipment and the environment. Surgical site Either an incisional or organ/space infection occurring within 30 days infections (SSI) after an operation or within 1 year if an implant i s p resent. Incisional SSIs are further divided into superficial incisional (only involves skin and subcutaneous tissue) and deep incisional (involves deeper soft tissue, including fascia and muscle layers). Surgical unit Whole surgical area including lockers and dressing rooms, preoperative and recovery rooms, peripheral support areas including storage space for sterile and high-level disinfected items and other consumable supplies, corridors leading to restricted areas, the operating room(s), scrub sink areas and the nursing station. Surveillance Systematic collection of relevant data on patient care, the orderly analysis of the data and the prompt reporting of the data to those who need it. Active surveillance consists of collecting information directly from patients or staff, while passive s urveillance includes examining reports, laboratory infonrmation and data from other sources. Glossary-10 Infection Prevention Guidelinesfor HealthcareFacilitiesin Ethiopia Transfusion service Facility or hospital unit that provides storage, pretransfusion testing and cross-matching, and infusion of blood or blood products to intended patients (recipients). Transient flora Microorganisms acquired through contact with patients, other healthcare workers or contaminated surfaces (e.g., examination tables, floors or toilets) during the course of the normal workday. These organisms live in the upper layers of the skin and are partially removed by washing with plain soap and clean water. Unit of blood Sterile plastic bag in which a fixed volume of blood is collected in a suitable amount-of anticoagulant. Urticarial reaction Allergic reaction consisting of itching (pruritis), hives, skin rash and/or similar allergic condition occurring during or following a transfusion of blood or blood products. Vegetative bacteria Bacteria that are devoid of spores and usually can be readily inactivated by many types of germicides. Visibly soiled hands Hands showing visible dirt or are visibly contaminated with blood or body fluids (urine, feces, sputum or vomit). Waste management All activities, administrative and operational (including transportation activities), involved in the handling, treatment, conditioning, storage and disposal of waste. Waterless, alcohol- Fast acting antiseptic handrubs that do not require use of water to based antiseptic remove transient flora, reduce resident microorganisms and protect the handrub or skin. Most contain 60-90% alcohol, an emollient and often an additional antiseptic handrub antiseptic (e.g.,2-4% chlorhexidine gluconate) that has residual action. (terms used interchangeably) Infection Prevention GuidelinesforHealthcareFacilitiesin Ethiopia Glossary-l I i i i I i iI ~ - .. 0; , K f 80