By Gladys Watkins,2014-12-25 15:10
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    Infection Control

    Infection Control

    Goals & Objectives

Course Description

    ―Infection Control‖ is an online continuing education course for physical therapists and physical therapist assistants. This course presents updated information about the management of infectious agents including sections on risks, precautions, transmission, intervention, and prevention.

Course Rationale

    The purpose of this course is to present therapists and assistants with current information about the management of infectious agents. Course participants will use this information to effectively limit exposure and transmission of communicable pathogens among healthcare workers, patients, and other at-risk populations.

Course Goals and Objectives

    Upon completion of this course, the therapist or assistant will be able to:

    1. Differentiate and understand the three different modes of infectious agent transmission

    2. Recognize infectious agents of special interest and understand the pathologies and

    challenges associated with these organisms.

    3. Differentiate between the various categories of precautions, and know when each should

    be applied.

    4. Identify transmission risks associated with different types of healthcare settings.

    5. Identify transmission risks associated with special patient populations.

    6. Recognize administrative measures used to prevent transmission of infectious agents.

    7. Identify the appropriate use and purpose of each of the Personal Protective Equipment


    8. Identify the practices utilized to prevent exposure to bloodborne pathogens.

    9. Identify appropriate environmental measures, strategies and techniques used to prevent

    infectious agent transmission.

    10. Recognize how to manage visitors to control infectious agent transmission.

    11. Identify the precaution practices associated with specific pathogens.

Course Provider Innovative Educational Services

Course Instructor - Michael Niss, DPT

Target Audience - Physical therapists and physical therapist assistants

Course Educational Level - This course is applicable for introductory learners.

Course Prerequisites None

Method of Instruction/Availability Online text-based course available continuously

Criteria for issuance of CE Credits - A score of 70% or greater on the course post-test.

Continuing Education Credits - Five (5) hours of continuing education credit

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


    Infection Control

    Infection Control

    Course Outline


    Course Goals & Objectives 1 begin hour 1 Course Outline 2-3

    Introduction 4

    Transmission of Infectious Agents 4-10

     Transmission Overview 4

     Sources of Infectious Agents 5

     Susceptible Hosts 5

     Modes of Transmission 6-10

     Contact Transmission 6-7

     Droplet Transmission 7-8

     Airborne Transmission 9-10

     Other Sources of Infection 10

     Infectious Agents of Special Infection Control Interest 11-20

     Clostridium difficile 11

     Multidrug-Resistant Organisms (MDROs) 11-12 end hour 1

     Noroviruses 12-14 begin hour 2

     Acinetobacter 14

     Hepatitis A 14-15

     Hepatitis B 15

     Group A Strptococcus 16

     Pseudomonas aeruginosa 16-17

     Respiratory Syncytial Virus (RSV) 17-18

     Hemorrhagic Fever Viruses (HFV) 18-19

     Severe Acute Respiratory Syndrome (SARS) 19-20 Precautions to Prevent Transmission of Infectious Agents 21-27

     Standard Precautions 21-24 end hour 2

     Transmission-Based Precautions 24-27 begin hour 3

     Contact Precautions 24-25

     Droplet Precautions 25

     Airborne Precautions 25-26

     Applications of Precautions 26

     Discontinuation of Precautions 26-27

     Non-Inpatient Settings 27

    Transmission Risks Specific to Type of Healthcare Settings 27-34

     Hospitals 28-30

     Intensive Care Units 28

     Burn Units 28-29

     Pediatrics 29-30

     Non-acute Healthcare Settings 30-33

     Long-term Care 30-31

     Ambulatory Care 31-32

     Home Care 33

     Other Healthcare Delivery Sites 33-34 Transmission Risks of Special Patient Populations 34-35

     Immunocompromised Patients 34

     Cystic Fibrosis Patients 34-35 end hour 3 Therapies Associated with Transmissible Infectious Agents 35-36 begin hour 4

     Gene Therapy 35

     Donation of Human Biological Products 35-36

     Xenotransplantation 36

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


    Infection Control

    Infection Control

    Course Outline (continued)

    Prevention of Transmission of Infectious Agents 36-57

     Administrative Measures 36-39

     Infection Control Professionals 36-37

     Safety Culture and Organizational Characteristics 38

     Adherence to Recommended Guidelines 38-39

     Surveillance for Healthcare-Associated Infections (HAIs) 39-40

     Education of HCWs, Patients, and Families 40-41

     Hand Hygiene 41-42

     Personal Protective Equipment (PPE) 42-47

     Gloves 42-43

     Isolation Gowns 44

     Face Protection 44-46

     Respiratory Protection 46-47 end hour 4

     Practices to Prevent Exposure to Bloodborne Pathogens 47-49 begin hour 5

     Prevention of Sharps-Related Injuries 47-48

     Prevention of Mucous Membrane Contact 48

     Precautions During Aerosol-Generating Procedures 48-49

     Patient Placement 49-52

     Hospitals and Long-Term Care Settings 49-50

     Ambulatory Settings 50-51

     Home Care 51-52

     Transport of Patients 52

     Environmental Measures 52-55

     Patient Care Equipment 53-54

     Textiles and Laundry 54

     Solid Waste 55

     Dishware and Eating Utensils 55

     Adjunctive Measures 55-56

     Chemoprophylaxis 55-56

     Immunoprophylaxis 56

     Management of Visitors 57

     Visitors as Sources of Infection 57

     Use of Barrier Precautions by Visitors 57 Precautions for Selected Infections and Conditions 58-63 References 64

    Post-Test 65-66 end hour 5

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


    Infection Control


    Healthcare-associated infection (HAI) in the hospital is among the most common adverse events in healthcare. CDC estimates there are approximately 1.7 million healthcare-associated infections in U.S. hospitals and 99,000 associated deaths each year. There are approximately 4.5 infections per 100 hospital admissions, 9.3 infections per 1000 patient days in Intensive Care Units (ICUs), and 2 surgical site infections per 100 operations. These estimates are based on best available data, but some infections are known to be underreported, so the actual number of healthcare-associated infections may be higher.

    Estimates of the economic impact of healthcare-associated infections vary because of differences in how the data are defined and analyzed. Data from published studies indicate the estimated cost of healthcare-associated infection ranges from $10,500 per case for bloodstream, urinary tract, and pneumonia infections to $111,000 per case for antibiotic-resistant bloodstream infection in transplant patients.

    Healthcare-associated infections are defined as infections affecting patients who receive either medical or surgical treatments. The procedures and devices used to treat patients can also place them at increased risk for healthcare-associated infections. A patient's skin, the natural protection against bacteria entering the blood, is continually compromised by the insertion of needles and tubes to deliver life saving medicine. Microbial pathogens can be transmitted through tubes and devices that are going into patients, providing a pathway into the blood stream and lungs. Because of the number of procedures and the seriousness of patient conditions, patients treated in the ICU have the highest risk of healthcare-associated infections.

    The frequency of healthcare-associated infections varies by body site. In the United States from, the most frequent healthcare-associated infections reported to the National Nosocomial Infections Surveillance (NNIS) system, overall, were urinary tract infections (34%), followed by surgical site infections (17%), bloodstream infections (14%), and pneumonia (13%).

    Transmission of Infectious Agents

Transmission Overview

    Transmission of infectious agents within a healthcare setting requires three elements: a source (or reservoir) of infectious agents, a susceptible host with a portal of entry receptive to the agent, and a mode of transmission for the agent.

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


    Infection Control

Sources of Infectious Agents

Infectious agents transmitted during healthcare derive primarily from human

    sources but inanimate environmental sources also are implicated in transmission.

    Human reservoirs include patients, healthcare personnel, and household members and other visitors. Such source individuals may have active infections, may be in the asymptomatic and/or incubation period of an infectious disease, or may be transiently or chronically colonized with pathogenic microorganisms, particularly in the respiratory and gastrointestinal tracts. The endogenous flora of patients (e.g., bacteria residing in the respiratory or gastrointestinal tract) also are the source of HAIs.

Susceptible Hosts

    Infection is the result of a complex interrelationship between a potential host and an infectious agent. Most of the factors that influence infection and the occurrence and severity of disease are related to the host. However, characteristics of the host-agent interaction as it relates to pathogenicity, virulence and antigenicity are also important, as are the infectious dose, mechanisms of disease production and route of exposure. There is a spectrum of possible outcomes following exposure to an infectious agent. Some persons exposed to pathogenic microorganisms never develop symptomatic disease while others become severely ill and even die. Some individuals are prone to becoming transiently or permanently colonized but remain asymptomatic. Still others progress from colonization to symptomatic disease either immediately following exposure, or after a period of asymptomatic colonization. The immune state at the time of exposure to an infectious agent, interaction between pathogens, and virulence factors intrinsic to the agent are important predictors of an individuals’ outcome. Host factors such as extremes of age and underlying

    disease, human immunodeficiency virus/acquired immune deficiency syndrome, malignancy, and transplants can increase susceptibility to infection as do a

    variety of medications that alter the normal flora (e.g., antimicrobial agents, gastric acid suppressants, corticosteroids, antirejection drugs, antineoplastic agents, and immunosuppressive drugs). Surgical procedures and radiation therapy impair defenses of the skin and other involved organ systems. Indwelling devices such as urinary catheters, endotracheal tubes, central venous and arterial catheters and synthetic implants facilitate development of HAIs by allowing potential pathogens to bypass local defenses that would ordinarily impede their invasion and by providing surfaces for development of biofilms that may facilitate adherence of microorganisms and protect from antimicrobial activity. Some infections associated with invasive procedures result from transmission within the healthcare facility; others arise from the patient’s endogenous flora.

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


    Infection Control

    Modes of Transmission

    Several classes of pathogens can cause infection, including bacteria, viruses, fungi, parasites, and prions. The modes of transmission vary by type of organism and some infectious agents may be transmitted by more than one route: some are transmitted primarily by direct or indirect contact, (e.g., Herpes simplex virus

    [HSV], respiratory syncytial virus, Staphylococcus aureus), others by the droplet,

    (e.g., influenza virus, B. pertussis) or airborne routes (e.g., M. tuberculosis).

    Other infectious agents, such as bloodborne viruses (e.g., hepatitis B and C viruses [HBV, HCV] and HIV are transmitted rarely in healthcare settings, via percutaneous or mucous membrane exposure. Importantly, not all infectious agents are transmitted from person to person. The three principal routes of transmission are summarized below.

Contact Transmission

    The most common mode of transmission, contact transmission is divided into two subgroups: direct contact and indirect contact.

Direct Contact Transmission - Direct transmission occurs when

    microorganisms are transferred from one infected person to another person without a contaminated intermediate object or person. Opportunities for direct contact transmission between patients and healthcare personnel include:

    ; blood or other blood-containing body fluids from a patient directly

     enters a caregiver’s body through contact with a mucous

     membrane or breaks (i.e., cuts, abrasions) in the skin.

    ; mites from a scabies-infested patient are transferred to the skin of a

     caregiver while he/she is having direct ungloved contact with the

     patient’s skin.

    ; a healthcare provider develops herpetic whitlow on a finger after

     contact with HSV when providing oral care to a patient without

     using gloves or HSV is transmitted to a patient from a herpetic

     whitlow on an ungloved hand of a healthcare worker (HCW).

Indirect Contact Transmission - Indirect transmission involves the transfer of

    an infectious agent through a contaminated intermediate object or person. In the absence of a point-source outbreak, it is difficult to determine how indirect transmission occurs. However, extensive evidence suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission. Examples of opportunities for indirect contact transmission include:

     Hands of healthcare personnel may transmit pathogens after touching an

     infected or colonized body site on one patient or a contaminated

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    Infection Control

     inanimate object, if hand hygiene is not performed before touching

     another patient.

     Patient-care devices (e.g., electronic thermometers, glucose

     monitoring devices) may transmit pathogens if devices contaminated

     with blood or body fluids are shared between patients without cleaning

     and disinfecting between patients.

     Shared toys may become a vehicle for transmitting respiratory viruses

     (e.g., respiratory syncytial virus) or pathogenic bacteria (e.g.,

     Pseudomonas aeruginosa) among pediatric patients.

     Instruments that are inadequately cleaned between patients before

     disinfection or sterilization (e.g., endoscopes or surgical instruments) or

     that have manufacturing defects that interfere with the

     effectiveness of reprocessing may transmit bacterial and viral

     pathogens. Clothing, uniforms, laboratory coats, or isolation gowns used

     as personal protective equipment (PPE), may become contaminated with

     potential pathogens after care of a patient colonized or infected with an

     infectious agent, (e.g., MRSA , VRE, and C. difficile. Although

     contaminated clothing has not been implicated directly in transmission, the

     potential exists for soiled garments to transfer infectious agents to

     successive patients.

Droplet Transmission

    Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. However, in contrast to contact transmission, respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks, or during procedures such as suctioning, endotracheal intubation, cough induction by chest physical therapy and cardiopulmonary

    resuscitation. Evidence for droplet transmission comes from epidemiological studies of disease outbreaks, experimental studies and from information on aerosol dynamics. Nasal mucosa, conjunctivae and less frequently the mouth, are susceptible portals of entry for respiratory viruses. The maximum distance for droplet transmission is currently unresolved, although pathogens transmitted by the droplet route have not been transmitted through the air over long distances, in contrast to the airborne pathogens discussed below. Historically, the area of defined risk has been a distance of <3 feet around the patient. Using this distance for donning masks has been effective in preventing transmission of infectious agents via the droplet route. However, experimental studies with smallpox and investigations during the global SARS outbreaks of 2003 suggest

    that droplets from patients with these two infections could reach persons located

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    Infection Control

    6 feet or more from their source. It is likely that the distance droplets travel depends on the velocity and mechanism by which respiratory droplets are propelled from the source, the density of respiratory secretions, environmental factors such as temperature and humidity, and the ability of the pathogen to maintain infectivity over that distance. Thus, a distance of <3 feet around the patient is best viewed as an example of what is meant by ―a short distance from

    a patient‖ and should not be used as the sole criterion for deciding when a mask

    should be donned to protect from droplet exposure. Based on these considerations, it may be prudent to don a mask when within 6 to 10 feet of the patient or upon entry into the patient’s room, especially when exposure to

    emerging or highly virulent pathogens is likely. More studies are needed to improve understanding of droplet transmission under various circumstances.

    Droplet size is another variable under discussion. Droplets traditionally have been defined as being >5 μm in size. Droplet nuclei, particles arising from

    desiccation of suspended droplets, have been associated with airborne transmission and defined as <5 μm in size, a reflection of the pathogenesis of

    pulmonary tuberculosis which is not generalizeable to other organisms.

    Observations of particle dynamics have demonstrated that a range of droplet sizes, including those with diameters of 30μm or greater, can remain suspended

    in the air. The behavior of droplets and droplet nuclei affect recommendations for preventing transmission. Whereas fine airborne particles containing pathogens that are able to remain infective may transmit infections over long distances, requiring AIIR to prevent its dissemination within a facility; organisms transmitted by the droplet route do not remain infective over long distances, and therefore do not require special air handling and ventilation.

    Examples of infectious agents that are transmitted via the droplet route include Bordetella pertussis, influenza virus, adenovirus, rhinovirus, Mycoplasma

    pneumoniae, SARS-associated coronavirus (SARS-CoV), group A streptococcus, and Neisseria meningitidis. Although respiratory syncytial virus may be

    transmitted by the droplet route, direct contact with infected respiratory secretions is the most important determinant of transmission and consistent adherence to Standard plus Contact Precautions prevents transmission in healthcare settings.

    Rarely, pathogens that are not transmitted routinely by the droplet route are dispersed into the air over short distances. For example, although S. aureus is

    transmitted most frequently by the contact route, viral upper respiratory tract infection has been associated with increased dispersal of S. aureus from the

    nose into the air for a distance of 4 feet under both outbreak and experimental conditions.

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


    Infection Control

    Airborne Transmission

    Airborne transmission occurs by dissemination of either airborne droplet nuclei or small particles in the respirable size range containing infectious agents that remain infective over time and distance (e.g., spores of Aspergillus spp, and

    Mycobacterium tuberculosis). Microorganisms carried in this manner may be

    dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face-to-face contact with (or been in the same room with) the infectious individual. Preventing the spread of pathogens that are transmitted by the airborne route requires the use of special air handling and ventilation systems (e.g., AIIRs) to contain and then safely remove the infectious agent. Infectious agents to which this applies include Mycobacterium tuberculosis,

    rubeola virus (measles), and varicella-zoster virus (chickenpox). In addition, it is speculated that variola virus (smallpox) may be transmitted over long distances through the air under unusual circumstances and AIIRs are recommended for this agent as well; however, droplet and contact routes are the more frequent routes of transmission for smallpox. In addition to AIIRs, respiratory protection with NIOSH certified N95 or higher level respirator is recommended for healthcare personnel entering the AIIR to prevent acquisition of airborne infectious agents such as M. tuberculosis.

    For certain other respiratory infectious agents, such as influenza and rhinovirus, and even some gastrointestinal viruses (e.g., norovirus and rotavirus) there is some evidence that the pathogen may be transmitted via small-particle aerosols, under natural and experimental conditions. Such transmission has occurred over distances longer than 3 feet but within a defined airspace (e.g., patient room), suggesting that it is unlikely that these agents remain viable on air currents that travel long distances. AIIRs are not required routinely to prevent transmission of these agents. Additional issues concerning examples of small particle aerosol transmission of agents that are most frequently transmitted by the droplet route are discussed below.

Airborne Transmission From Patients - The emergence of SARS in 2002, the

    importation of monkeypox into the United States in 2003, and the emergence of avian influenza present challenges to the assignment of isolation categories because of conflicting information and uncertainty about possible routes of transmission. Although SARS-CoV is transmitted primarily by contact and/or droplet routes, airborne transmission over a limited distance (e.g. within a room), has been suggested, though not proven. This is true of other infectious agents such as influenza virus and noroviruses. Influenza viruses are transmitted primarily by close contact with respiratory droplets and acquisition by healthcare personnel has been prevented by Droplet Precautions, even when positive pressure rooms were used in one center. Observations of a protective effect of UV lights in preventing influenza among patients with tuberculosis during the influenza pandemic of 1957-’58 have been used to suggest airborne


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    Infection Control

    In contrast to the strict interpretation of an airborne route for transmission (i.e., long distances beyond the patient room environment), short distance transmission by small particle aerosols generated under specific circumstances (e.g., during endotracheal intubation) to persons in the immediate area near the patient has been demonstrated. Also, aerosolized particles <100 μm can remain

    suspended in air when room air current velocities exceed the terminal settling velocities of the particle. SARS-CoV transmission has been associated with endotracheal intubation, noninvasive positive pressure ventilation, and cardiopulmonary resuscitation. Although the most frequent routes of transmission of noroviruses are contact and food and waterborne routes, several reports suggest that noroviruses may be transmitted through aerosolization of infectious particles from vomitus or fecal material. It is hypothesized that the aerosolized particles are inhaled and subsequently swallowed.

    Concerns about unknown or possible routes of transmission of agents associated with severe disease and no known treatment often result in more extreme prevention strategies than may be necessary; therefore, recommended precautions could change as the epidemiology of an emerging infection is defined and controversial issues are resolved.

Airborne Transmission from the Environment - Some airborne infectious

    agents are derived from the environment and do not usually involve person-to-person transmission. For example, anthrax spores present in a finely milled powdered preparation can be aerosolized from contaminated environmental surfaces and inhaled into the respiratory tract. Spores of environmental fungi (e.g., Aspergillus spp.) are ubiquitous in the environment and may cause disease in immunocompromised patients who inhale aerosolized (e.g., via construction dust) spores. As a rule, neither of these organisms is subsequently transmitted from infected patients.

    Environmental sources of respiratory pathogens (eg. Legionella) transmitted to humans through a common aerosol source is distinct from direct patient-to-patient transmission.

Other Sources of Infection

    Transmission of infection from sources other than infectious individuals include those associated with common environmental sources or vehicles (e.g.

    contaminated food, water, or medications (e.g. intravenous fluids). Although Aspergillus spp. have been recovered from hospital water systems, the role of water as a reservoir for immunosuppressed patients remains uncertain. Vectorborne transmission of infectious agents from mosquitoes, flies, rats, and other vermin also can occur in healthcare settings.

    Innovative Educational Services

    To take the post-test for CE credits, go to: WWW.CHEAPCEUS.COM


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