Infection Control Protocols

• Infection control is the discipline concerned with preventing nosocomial or

healthcare associated infection. Critical care areas are Intensive Care Unit,
Neonatal Intensive Care Unit, Surgical Intensive Care Unit and Operation
Theatres.
• Possible Nosocomial Pathogens are MRSA, Klebscilla species, [Link],
Enterococci, Pseudomonas species and Candida species. Sources of Infection
can be IV lines, Catheters, ventilators, Air conditioning ducts Health care
personnel, Visitors and Staff.
• Strict infection control is vital and cannot be stressed too much. During the
SARS epidemic a nurse was stationed at the entrance of the ICU to ensure
that everyone entering and leaving the ICU complied with infection control
procedures. Enforcement was strict. Inadequate training and inadequate
understanding of infection control measures are associated with increased risk
of infection.
• Nosocomial infections are one of the most common complications that occur
in ICU patients. Prevention and containment of nosocomial infection is a
fundamental principle of effective medical practice. The critically ill patient is
highly vulnerable to nosocomial infection, which results in significant
morbidity, prolonged length of hospital stay, increased cost and attributable
mortality. It is the responsibility of every member of the health care team to
ensure compliance with Hospital and Unit infection control policies. This may
include reminding senior colleagues or visiting teams to conform to basic
issues such as hand-washing or additional precautions.

Hand Washing:
• Frequent hand washing (before and after attending to a patient) is the most
important factor in preventing infections. Hand-hygiene remains the only
established method of effective infection control and must be strictly
performed by all members of the health care team.

Protective Barriers:
• There is little evidence that wearing gloves is more important than hand
washing in the ICU. Disposable gloves must be worn for all contact with
patient's bodily fluids, dressings and wounds. Gloves must be disposed of
within the patient cubicle on leaving. Aseptic technique is to be used for all
patients undergoing major invasive procedures.

Invasive Devices:
• Critically ill patients frequently require multiple catheters, which alter normal
defence mechanisms by creating new portals for microbes to enter. Infection
rates vary among ICUs based on central-line-days and the type of device.
Total parenteral nutrition and lipid emulsions are frequently administered and
are excellent media for the growth of pathogenic microbes.

Emergence of Microorganisms Resistant to Antibiotic Agents:

• Patients in the ICU are often receiving high doses of various antibiotics, are
close to each other, and are being cared for by busy physicians and nurses.
All these factors create an ideal environment for developing and transmitting
resistant organisms. Specific types of antibiotic-resistant microorganisms vary
with the type of unit, patient population, procedures and associated
equipment, and antibiotic usage.

Mechanical Measures:
• There should be enough space between beds for staff to reach patients and
equipment easily. Separate patient rooms should be provided in order to
prevent contamination. In order to facilitate hand washing by the staff, sinks
should be installed in convenient places. Sinks for disinfection should be in
separate places.
• Hand washing is the single most important infection-prevention intervention,
but even ICU compliance is suboptimal. This is partly due to the inadequate
number of basins, their inaccessible locations, or poor IC design. Where ICU
design precludes ideal sink placement, consideration should be given to
providing alcohol-based hand rubs at each patient location.
• Every ICU should have one or more isolation room with a separate hall for
hand washing, especially if the ICU is in a large, open space. The ICU should
have separate spaces for storage, waste products, and disinfection. All bodily
fluids should be considered contaminated; tests and measurements involving
them should be performed only in specified areas.

Medical Devices:
• Medical technology seems to make constant progress, and new diagnostic
and therapeutic devices are often used in the ICU. Mechanical ventilation is
the most common cause of admission to the ICU. Mechanical ventilation
bypasses the respiratory tract's host defences. Contaminated equipment and
solutions provide a mechanism for the transfer of microorganisms to a
susceptible patient.
• Interventions to decrease the risk of infection include preventing aspiration,
preserving gastric acidity; adhering strictly to the proper cleaning,
reprocessing, and circuit-change protocols for ventilation equipment;
protecting staff and patients by using appropriate isolation precautions and
personal protective equipment; and monitoring respiratory tract infections due
to ventilator usage.

Selective Digestive Decontamination:

• The purpose of selective digestive decontamination is the prevention of growth
of gram-negative aerobic bacilli and fungi through the use of non-absorbed
antibiotics that protect the internal anaerobic flora.

Reduce number of visitors coming to healthcare settings:

• Visiting hours of hospital or healthcare setting should be less and specified.
Mask for visitors is also needed. Hand shaking, kissing and hugging should
be prohibited & other items for patients should be prohibited. Healthcare staff
from different departments visiting friends should be restricted.

Care of Environment:
• Regular scrubbing and cleaning of surfaces is essential. Proper and
appropriate use of disinfectants is must. Surfaces should be cleaned with
proper chemical. Instruments should be cleaned properly before sterilisation.
Proper care of AC ducts are also to be kept in mind. Proper cleaning of linen
is necessary. Screening of patients and health care providers is necessary for
various nosocomial infections. Identification, isolation and management of
carriers are also required.

Infection Control Policies and Procedures:

• Given the complexity of delivering care to critically ill patients, policies and
procedure are a necessary part of the organisation of any ICU. These policies
ensure that personnel perform certain procedures, such as central venous
catheter insertion and care, in a consistent manner.
• Written ICU policies should incorporate evidence based infection control
practices. For policies to be effective, they should be clear, concise, and
shared with the staff. Policies that are complex or unrealistic either will be
ignored or will result in even wider variation in how care is delivered owing to
individual interpretation.
• Most private and state hospital accreditation programs base their review of
ICUs not only on whether ICUs have required policies but also on whether
they actually follow them. Therefore, it is important that ICU physician and
nursing staff review these policies on a routine basis in consultation with
infection control practitioners or the hospital infection control committee and
revise these policies when needed.

Nursing management of critically ill patients:

• Nursing care for the critically ill patient can be a challenging endeavor. To
provide high quality care, the nurse is challenged to draw from their
knowledge and experiences, remain flexible and be creative. The nurse must
have a sufficient knowledge and skill base and the ability to think critically.
• The knowledge base must encompass basic concepts of anatomy and
physiology as well as a basic understanding of common disease processes,
diagnostic, and therapeutic procedures. The nurse should also be familiar with
potential complications or risk factors associated with these diseases, and
procedures.
• Traditionally, the nurses have been trained in a task-based fashion. It will be
helpful to include a goal-oriented approach for caring for the critically ill
patient.
• Nursing goals should be directed at identifying and working towards desired
out comes, and identifying and minimising patient risk. For example, the
doctor has diagnosed severe dehydration. The goal is to correct fluid volume
deficits. The patient will need to be placed on IV fluids. The patient is now at
risk for the development of: catheter related infection, other catheter related
complications (Phlebitis, Thrombosis etc.) and fluid overload.
• The nurse should be prepared to take action to minimise these risks, recognise
them if they occur and take appropriate action to correct the problem. This
discussion will address various nursing care procedures and include desired
goals or outcomes along with potential risk factors.

Patient Assessment:
• Upon receiving responsibility for the care of a patient the nurse should assess
the patient. The assessment includes becoming familiar with the patient's
history, and performing a physical examination.
• The history may be obtained from the client or may be passed on between
the nurses during rounds. Rounds are an excellent forum for communication.
Information should be provided as to the significant changes in the patient's
status. The nurse should become skilled at performing physical examinations;
it defines the patient's responses to the disease process.
• The physical exam helps establish a baseline for comparison in evaluating
ongoing nursing or medical interventions. At minimum, a temperature, pulse,
and respiration should be checked; in addition mentation should be noted,
chest auscultated and the bladder palpated.
• The patient's hydration status should be determined. A quick assessment
should be made of all catheters. Following the nursing assessment and a
review of the doctor's orders, plans should be formulated for the nursing care
of the patient.

Planning Patient Care:

• Planning patient care involves developing plans to meet the needs identified
in the assessment phase. Planning helps the nurse become organised, set
priorities, and contemplate actual and potential problems or risk factors! The
nurse should be capable of recognising those risks and have a plan for
dealing with them.
• A part of the planning process includes the development of nursing care
plans. Nursing care plans should include monitoring ins and outs, nutritional
support, meeting comfort needs including assessing for pain. Measures should
be taken to minimise the risk of nosocomial infections.
• Bandage and wound care should be performed. Non-ambulatory patients will
require recumbent patient care. Catheter care will need to be performed.

Implementation Of The Nursing Care Plans:

Monitoring Intake and Output:

• The nursing goal of monitoring "intake and output" is to ensure maintenance
of fluid balance and nutritional intake. "Intake and output " provide valuable
information about fluid balance and nutritional intake. The patient's entire
intake and output is monitored and documented. "Intake and output" are
monitored at regular intervals throughout the day.
• Intake includes all fluids (water, IV fluids including blood products, and liquid
diets).
• Output includes, urine feces, vomiting and third space losses (fluid loss into
body cavities). The total volume of fluids "intake" should be compared to
"output", the two volumes should be just about equal. If "ins" exceeds outs the
patient is at risk for fluid overload. If "output" exceed "input" then the patient
is at risk for dehydration.
• Assessing body weight is another way of determining fluid balance. Acute
changes in body weight are usually a reflection of acute fluid gains or losses.

Nutritional Support:
• The nursing goal is to ensure that the patient is meeting its energy
requirements. There are serious negative consequences of acute malnutrition
including: decreased immune response, loss of function of tissues and organs
and delayed wound healing.
• A patient's history may be helpful in determining if nutritional support is
needed. If it has been three or more days since the patient ate, nutritional
support may be indicated.
• The physical exam might reveal acute loss of Lean Body Mass, fat, muscle
wasting, or edema. Hypoalbuminemia and Lymphopenia may indicate poor
nutritional status.
• Once it is decided to initiate nutritional support the nurse will need to
calculate the patient's energy requirements. Once the daily caloric
requirement (kcal/day) is determined and the diet has been selected, the
volume of food to feed is calculated.

Patient Comfort Needs:

• The nursing goal for meeting the patient's comfort needs depends on what
comfort need the nurse is addressing. Comfort needs includes keeping the
patient clean and dry, seeing to the patients mental well being, assessing the
patient for pain.
• It is important to consider the patient's mental well-being. Prior to treating a
patient (Poking, Sticking and Prodding) take the time to make friends with the
patient; this may set the tone for further encounters with the patient. It is
helpful to talk and pet them when treatments aren't due, so they don't assume
that every time you open the cage door it means poking and prodding.

Nosocomial Infections:
• Nosocomial infections are hospital acquired infections: the patient did not
enter the hospital with the infection. Factors that predispose a patient to a
hospital acquired infection include age (geriatric or neonate),
immunosuppressed patients and long-term hospitalisation. Nosocomial
infections are perhaps more common in large hospitals and referral centres.
Common causes of nosocomial infections include Escherichia coli, Klebsiella,
Salmonella, canine parvovirus and feline Panleukopenia. The nursing goal is
to minimise the risk of nosocomial infections.

Recumbent Patient Care:

• Patients suffering neurological, orthopedic, or traumatic problems can be
recumbent for prolonged periods of time. Care of the recumbent patient can
be very challenging. Primary nursing goals are to minimise or prevent
decubital ulcers and lung atelectasis.
• Decubitus ulcers develop over bony prominences as a result of continuous
pressure and damage to the skin. Other factors that contribute to decubital
ulcer formation include inadequate nutrition, moist skin, decreased sensory
perception, and friction or shearing forces.
• Adequate nutrition is important for maintaining skin integrity. Moistness can
contribute to skin breakdown. Friction and shearing forces may, occur if a
patient is dragged or pulled across a floor leading to disruption in skin
integrity.

Catheters:
• The nurse is charged with the care of a variety of types of catheters. In
general, the nursing goals for catheters include: minimising the risk of
infection, insuring functionality, and prevention of complications, which are
specific to the type of catheter in use. It is important to be familiar with the
mechanism of catheter related infections. Sources of infection include: care
giver hands, migration of organism along the catheter (internal and external),
and contaminated disinfectants.

Intravenous Catheters:
• IV catheter care should be performed every 48 hours or often as needed
basis. The catheter dressing should be removed and the site inspected. You
should look for signs of Phlebitis, Infection, and or Thrombosis.
• Signs of phlebitis may include Erythema, Swelling, Tenderness upon
palpation, and an apparent increase in skin temperature over the vein. The
signs of infection are phlebitis and a Purulent discharge.
• Signs of thrombosis include a vein that stands up without being held off and a
thick cord like feeling to the vein. When signs of phlebitis or thrombosis are
apparent, the catheter should be removed and a new one placed at a
different site.
• While flushing the catheter with Heparinised saline, the insertion site should
be observed for leaking of fluid at the insertion site and pain upon injection.
• If either one is observed, the catheter should be removed and replaced with a
new one. If any portion of the catheter is exposed, it should be noted. If the
catheter site looks good then the site should be cleaned with an Iodophor or
Chlorhexidine solution.
• When the catheter site is dry, apply a small amount of Betadine or antibiotic
ointment to a sterile gauze pad and cover the insertion site. Then re-bandage
the catheter. Traditionally it has been recommended not to leave a catheter in
place any longer than 72 hours.
• It has been shown that the likelihood of complications increases the longer
catheters is left in place. It has been experienced that as long as routine
catheter care is performed, and the catheter removed when problems are first
noticed, one can often exceed the 72 hour rule.
• IV catheters should be observed several times a day. If the catheter bandage
is found to be wet, then the reason should be identified and the bandage
should be changed.

Urinary Catheter Care:

• Urinary catheter care is performed every 8 hours. It entails cleaning the
Prepuce or Vulva and its surrounding area with Betadine scrub and water
rinse. The urinary catheter itself should be kept clean especially in the female
patient where the vulva is in close proximity to the rectum.
• The urinary catheter should be attached to a collection system. By
maintaining a closed collection system you decrease the chance of a urinary
tract infection (UTI).
• Do not disconnect the urinary catheter from the collection system. Drain the
system every 2-4 hours rather than hourly. Urinary collection bags may be
obtained commercially or you can use an empty sterile IV bag.

Chest Drain / Gastrostomy Tube Care:

• The procedure for chest drain and gastrostory tube care is much like IV
catheter care. The bandage is removed and the insertion site is inspected
every 24 hours. The site is cleaned and re-bandaged.

Bandage / Incision or Wound Care:

• Bandages are placed to protect Lacerations and surgical incisions and
provide minimal support. They should remain dry and clean. The technician
should look for signs that an appendage bandage is too tight or is irritating to
the patient.
• The bandage should be free of abnormal odours. The skin above the
bandage should be checked for local irritation. The bandage should be
evaluated if the patient is licking or chewing the bandage.
• A patient's surgical incision should be evaluated several times a day. A
surgical incision may be expected to produce mild redness and swelling with
no drainage from the incision site.
• Extensive surgical manipulation, Infectious Contamination, or Self-mutilation
(licking, scratching) cause swelling, redness, bruising, drainage. Localized
swelling, which is fluid filled, may be due to a Seroma (serum pocket) or
hematoma (hemorrhage) formation.
• Swelling that occurs several days postoperatively and is hot to the touch, may
be due to an abscess or cellulitis.