≥92% of participants will know basic infection control procedures and techniques.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥92% of participants will know basic infection control procedures and techniques.
After completing this course, the learner will be able to:
Infection control is vital in controlling the transmission and spread of disease-causing pathogens in healthcare facilities. New York state requires registered nurses and other healthcare professionals practicing in the state to complete infection control training and understand and practice the proper infection control procedures. In addition, New York state requires registered nurses and other healthcare professionals to be educated about sepsis, signs and symptoms, risk factors, and treatment.
A registered nurse is starting an IV line. The first attempt is unsuccessful, and as the IV catheter is removed, the stylet punctures the nurse’s forefinger. Blood was visible on the stylet before the puncture occurred. The nurse was wearing gloves. The stylet punctured the tip of the finger, and it did not enter a large vein.
After discarding the IV catheter and placing a dressing over the insertion site, the nurse washes the area with soap and water, covers it with an adhesive bandage, and immediately goes to the hospital’s emergency department. The time from the injury until he arrived in the ED was approximately 15 minutes.
A rapid human immunodeficiency virus (HIV) test is done, and testing for Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) is done, as well. The nurse is 33 years old; he has no past medical history, does not take any prescription medications, and has no risk factors for HBV, HCV, or HIV. He has been fully vaccinated against HBV.
The patient is a 65-year-old male who has been admitted for the treatment of heart failure. He does not have any factors that would now, or would have in the past, increase his risk of being infected with HBV, HCV, or HIV. The patient agrees to be tested for HBV and HCV but refuses to be tested for HIV.
The nurse’s rapid HIV test is negative, his HBV and HCV test are negative, and his HBSAb titer is ≥ 10 mlU/ml. The patient’s HBV and HCV tests are negative.
The ED physician summarizes the situation for the nurse.
Healthcare professionals should adhere to scientifically accepted standards for infection control to prevent disease transmission between patients and healthcare professionals. Healthcare professionals are also responsible for monitoring the infection control practices of subordinates.
Healthcare professionals practicing in New York state must complete an infection control education program during their professional training and every four years after that (NY State Department of Health, September 2019).
A recently passed public health law stipulates that on or before July 1, 2018, “ every physician, physician assistant and specialist assistant practicing in the state shall, on or before July first, nineteen hundred ninety-four and every four years after that, complete course work or training, appropriate to the professional's practice, approved by the department regarding infection control, which shall include sepsis, and barrier precautions, including engineering and work practice controls, following regulatory standards promulgated by the department in consultation with the department of education, to prevent the transmission of HIV, HBV, HCV and sepsis in the course of professional practice. Such coursework or training must also be completed by every medical student, medical resident, and physician assistant student in the state as part of the orientation programs conducted by medical schools, medical residency programs, and physician assistant programs.” (NY State Department of Health, September 2019). In October 2017, legislation was passed requiring the inclusion of sepsis awareness and education into the training curriculum (NY State Department of Health, September 2019).
Section 239 of the New York State Public Health Law - Course Work or Training in Infection Control Practices, informally called the Infection Control and Barrier Precaution law, applies to these professions:
Evidence of completion of the training must be submitted to the State Department of Health or the State Education Department. Physicians, registered physician assistants, and specialist assistants “hired by or granted professional privileges at a hospital or healthcare facility must document to that organization the completion of the approved course work at the time of hiring or when professional privileges are granted or renewed” (NY State Department of Health and State Education Department, 2018a). Healthcare professionals can be exempt from taking an infection control course in certain circumstances. Examples include an infectious disease specialist who has received equivalent training, healthcare professionals who are not actively practicing in New York, and anyone who does not provide direct patient care or oversee individuals or programs where others are responsible for providing patient care or reprocessing patient care equipment (NY State Department of Health, September 2019).
“All licensed healthcare facilities are responsible for monitoring and enforcing the proper use of infection control practices and Standard Precautions. Failure to comply can result in citations, potential fines, and other disciplinary action against the facility. Licensed healthcare professionals who fail to use appropriate infection control techniques may be charged with professional misconduct and disciplinary action.
Patient or employee complaints about lax infection control practices in private offices will cause an investigation by the Department of Health or Education. Substantiated lapses may result in charges of professional misconduct against licensed healthcare professionals who were directly involved, aware of the violations, or responsible for ensuring staff education and compliance” (New York State Education Department, 2011).
Healthcare professionals in New York state must understand and use these infection control techniques (New York State Education Department, 2011):
A chain of events and circumstances is required for infection to occur. These include:
Pathogenic organisms include bacteria, rickettsia, viruses, protozoa, fungi, or parasites. The characteristics of microorganisms that can cause infection and disease are:
The organism and its reservoir are the sources of infection. The organism must have the means to exit the reservoir. In an infected host, organisms exit through the respiratory tract, gastrointestinal tract, genitourinary tract, sexual transmission, or drainage from a wound. A transmission route is necessary to connect the source of infection to its new host.
Direct contact: Person-to-person contact. It can be skin-to-skin contact, sexual contact, and/or contact with infected body fluids like blood, respiratory secretions, or other infected body fluids.
Indirect contact: Usually contact with a harmless inanimate object. The infected inanimate object is called a fomite. Fomites can survive on objects and surfaces for a long time and be a potential source of infection for weeks and months, e.g., fomites containing norovirus and Clostridium difficile (C. difficile).
Droplet contact: It is a form of direct and indirect contact transmission. Large respiratory droplets carrying pathogens are expelled from the respiratory tract by coughing, sneezing, or talking. Droplets move through the air, but because of their size and the limited time they are airborne, they do not travel far and quickly settle on environmental surfaces. Contact with the contaminated surface, e.g., hand contact, and then contact of the hand to a mucous membrane spreads the pathogen from the surface to a host, meaning that
Droplet contact is how the influenza virus is spread. Droplet contact and transmission can also occur if someone is very close to an infected person who is coughing and/or sneezing, and the infected droplets inoculate mucous membranes of the eyes, nose, and/or mouth.
The following table outlines the organism, mode of transmission, and incubation period for the most common microorganisms and parasites.
|Disease/Condition||Organism||Mode of Transmission||Incubation Period|
|Acquired immunodeficiency syndrome (AIDS)||Human immunodeficiency virus||Median of 10 years (Fauci et al., 2022)|
|Amebiasis||Entamoeba histolytica||2-4 weeks, occasionally longer (CDC, 2021h)|
|Chancroid||Haemophilus ducreyi||1-2 weeks (Lautensch-lager & Brockmeyer, 2019)|
|Chickenpox||Varicella-zoster||10-21 days (CDC, 2021b)|
|Cholera||Vibrio cholerae||A few hours-5 days (CDC, 2022a)|
|Creutzfeldt-Jacob disease||Prion protein||16 months to 30 years (Jankovska et al., 2021)|
|C. gatti, 2 weeks to 3 years. (CDC, 2020a)|
C. neoformans, unknown
|Cryptosporidiosis||Cryptosporidium species||2-10 days, an average of 7 days (CDC, 2019d)|
|Cytomegalovirus (CMV)||Cytomegalovirus||Highly variable|
For newborns, the onset is often delayed for months or years (CDC, 2020c; Karamch-andani et al., 2022; Tissera et al., 2022)
|Diarrheal diseases||Campylobacter species||2 to 5 days CDC, 2021a)|
|Clostridium difficile||Variable, it may be up to 12 weeks after exposure to antibiotics (Curry, 2017)|
|Salmonella species||6 hours to 6 days (CDC, 2022o)|
|Shigella species||1-2 days (CDC, 2020j)|
|Yersinia species||4-7 days (CDC, 2019j)|
|Giardiasis||Giardia lamblia||1-3 weeks (CDC, 2021i)|
|Gonorrhea||Neisseria gonorrhoeae||1-14 days (CDC, 2022c)|
|Hand, foot, and mouth disease||Enterovirus genes||Not known, estimates vary widely (Koh et al., 2016, CDC, 2021d)|
|Foodborne hepatitis||Hepatitis A|
|A: 2-6 weeks (CDC, 2020e)|
E: 2-6 weeks (CDC, 2020e)
|Bloodborne hepatitis||Hepatitis B|
|Hepatitis B: 60 to 150 days, average 90 days (CDC, 2022e)|
Hepatitis C: 2 to 26 weeks, average is 2 to 12 weeks (CDC, 2020d)
Hepatitis D: Unclear
|Herpangina||Coxsackie virus||5-7 days (Corsino et al., 2022)|
|Herpes simplex||Human herpes viruses 1 and 2||Average 4 days, range 2-14 days (CDC, 2021c)|
|Histoplasmosis||Histoplasma capsulatum||3-17 days (CDC, 2021f)|
|21-35 days (Brunet et al., 2015)|
|Impetigo||Staphylococcus aureus (most common), Strepto-coccus pyogenes||10 days (CDC, 2022g)|
|Influenza||Influenza virus A, B, or C||1- 4 days (Budd et al., 2017)|
|Legionnaires’ disease||Legionella pneumophila||Commonly 5-6 days, range 2-14 days, occasionally longer (CDC, 2021f)|
|Listeriosis||Listeria monocytogenes||Usually within 2 weeks of ingesting con-taminated food (CDC, 2022j). Median gestational age for fetal listeriosis has been reported to be 31 weeks (Ke et al., 2022)|
|Lyme disease||Borrelia burgdorferi |
|3-30 days (CDC, 2020f)|
|Lymphogranuloma venereum (LGV)||Chlamydia trachomatis||1-2 weeks (Ciccarese et al., 2021)|
|7-30 days (CDC, 2022k)|
|Measles||Measles virus||11-12 days (Gastanaduy et al., 2019)|
|Meningococcal disease: meningitis and septicemia||Neisseria meningitidis||1-10 days, usually 3-4 days (Mbaeyi et al., 2021)|
|Mononucleosis||Epstein Barr virus||4-6 weeks (Cohen, 2014)|
|Mycobacterial diseases (non-tuberculosis) Mycobacterium species||Mycobacterium avium|
pulmonary tract infections
|Mycoplasma pneumoniae||1-4 weeks, shorter and longer incubation periods can occur (CDC, 2018a)|
|Crab louse||Pthirus pubis||2-3 weeks (CDC, 2013)|
|Pinworm||Enterobius vermicularis||1-2 months (CDC, 2013)|
|Pneumocystis pneumonia||Pneumocystis jirovecii||4-8 weeks (Miller et al., 2013)|
|Pneumococcal pneumonia||Streptococcus pneumoniae||1-3 days (CDC, 2022n)|
|Rabies||Rabies virus||Weeks to months (CDC, 2021m)|
|Respiratory syncytial disease||Respiratory syncytial virus||4-6 days average, range of 2 to 8 (American Academy of Pediatrics, 2021)|
|Rocky Mountain Spotted fever||Rickettsia rickettsii||3-12 days (CDC, 2019f)|
|Rotavirus gastroenteritis||Rotavirus||2 days (CDC, 2021n)|
|Rubella||Rubella virus||Average of 17 days, the range is 12-23 days (CDC, 2020i)|
|Scabies||Sarcoptes scabiei||1-4 days if there was a previous exposure, and 4-6 weeks for a first-time exposure (CDC, 2010)|
|Streptococci||Streptococcus group A with about 80 serologically distinct types||Variable, e.g., 2-5 days for group A strep pharyngitis (CDC, 2022d)|
|Syphilis||Treponema pallidum||The average duration is 21 days. The range is 10-90 days (CDC, 2022p)|
|Tetanus||Clostridium tetani||The average duration is 10 days but ranges from 3-21 days (CDC, 2020k). Neonatal tetanus averages 4 days but ranges from 4-14 days (CDC, 2020k)|
|Trichinellosis (Trichinosis)||Trichinella: Many species||1-2 days (CDC, 2020g)|
|Tuberculosis||Mycobacterium tuberculosis||3-8 weeks, 10 weeks for an immune response. A variable amount of weeks to years for symptoms to occur (Gardam & Hota, 2017)|
|Typhoid fever||Salmonella typhi||6-30 days (CDC, 2021p)|
The host must be susceptible to the infection for infection to occur. Factors influencing susceptibility include, but are not limited to:
Pregnant healthcare professionals are not known to be at greater risk of contracting bloodborne infections; however, infectious pathogens can be transmitted to the fetus.
The organism must have a portal of entry into the host for infection to occur. Portals of entry are the mucous membranes, non-intact skin, respiratory tract, gastrointestinal tract, genitourinary tracts, or a mechanism of introduction, such as a percutaneous injury or invasive device.
Microorganisms that can cause disease can develop resistance to antibiotics and other drugs used to treat infections caused by these pathogens. Antibiotic-resistant organisms have become an increasingly serious problem. Some of the more common ones are discussed.
Enterobacteriaceae are gram-negative bacilli that are commonly found in the gastrointestinal tract. Common species of this family that cause infections include Enterobacter, Escherichia coli, and Klebsiella. Carbapenem-resistant Enterobacteriaceae (CRE) are resistant to the carbapenem family of antibiotics (doripenem, ertapenem, imipenem, and meropenem). These antibiotics are traditionally used to treat pathogens resistant to broad-spectrum antimicrobials (CDC, 2019c). CRE is spread through contact with infected surfaces, e.g., hands or contaminated medical equipment. Infections with CRE are particularly dangerous: they can spread rapidly, and the mortality rate in hospitalized patients can exceed 50% (CDC, 2019c). CRE infections usually do not occur in healthy people; they are more likely in hospitalized patients with compromised immune systems, mechanically ventilated patients, or those who have received multiple antibiotics. The incidence of CRE infections is increasing. Control and prevention of CRE infections should focus on the following:
Staphylococcus aureus (S. aureus) is transmitted primarily via the hands of healthcare professionals and by direct contact with contaminated equipment and surfaces. Transmission is very efficient, and S. aureus easily colonizes the skin and nares. Once colonized, the person faces the likelihood of infection when invasive procedures are performed.
MRSA colonization is quite common, so every patient must be assumed to have been exposed to or colonized with MRSA/ORSA. In addition, MRSA often contaminates medical equipment such as stethoscopes and environmental surfaces (Bhatta et al., 2022).
The Centers for Disease Control and Prevention (CDC) recommends strict adherence to Standard and Contact Precautions, personal protective equipment (PPE), and appropriate handling of medical devices and laundry if MRSA is of special clinical or epidemiological significance (CDC, 2016b).
Vancomycin is the first-line drug for treating MRSA infections (Cong et al., 2019), but vancomycin-resistant S. aureus has developed (Cong et al., 2019). The susceptibility of S. aureus strains to vancomycin is determined by a minimum inhibitory concentration (MIC) test. The MIC measures the minimum amount of antimicrobial agent that inhibits bacterial growth in a test tube. Staph bacteria are classified as vancomycin susceptible (VSSA), vancomycin-intermediate (VISA), and vancomycin-resistant (VRSA) (Cong et al., 2019).
These infections must be reported to the CDC and the state health department. The following is guidance for patients infected with VISA or VRSA:
Enterococci are gram-positive bacteria. They are a normal part of the gastrointestinal and female genital tract flora (CDC, 2019i). It is a relatively weak pathogen but can produce significant infections if the patient is infected with vancomycin-resistant enterococcus (VRE). Treatment options for these infections are limited. People at risk for VRE infections include:
VRE is transmitted primarily via the hands of healthcare professionals and by direct contact with contaminated equipment and surfaces. Many approaches have been used to control VRE in healthcare settings. The methods used should be tailored to the clinical setting, the specific patient/patients involved, and the epidemiological characteristics of the situation. Contact Precautions and Standard Precautions should be used to prevent transmission of VRE (CDC, 2019i).
The Mycobacterium tuberculosis bacteria cause tuberculosis (TB), one of the oldest recognized infectious diseases. Multidrug-resistant tuberculosis (MDR-TB) is resistant to isoniazid and some second-line drugs. Extensively Drug-Resistant Tuberculosis (XDR-TB) is resistant to isoniazid, rifampin, and fluoroquinolones. XDR-TB is also resistant to at least one of three injectable second-line drugs, such as amikacin, kanamycin, or capreomycin (CDC, 2016a).
Infection control measures should include separating the infected patient/patients, environmental controls, using Standard Precautions, Respiratory Hygiene/Cough Etiquette, Airborne Precautions, and staff use of particulate respirators (CDC, 2020l; CDC, 2019h).
Penicillin-resistant and multidrug-resistant strains of this pathogen have emerged and are widespread in some communities (Ryan, 2022). A vaccine for the most common serotypes of S. pneumoniae is available, but vaccination rates are not optimal (Lu et al., 2021). Contact Precautions, Droplet Precautions, and Respiratory hygiene/Cough Etiquette should be used when caring for patients infected with this pathogen.
Nosocomial drug-resistant A. baumannii infections cause bacteremia, pneumonia, and UTIs (McKay et al., 2022). The morbidity and mortality rates associated with drug-resistant Acinetobacter infections are very high (Kim et al., 2022a), and outbreaks of these infections in healthcare facilities are difficult to control (Lashinsky et al., 2017).
Contact transmission is the primary way Acinetobacter spreads, so Contact Precautions and Standard Precautions, with particular attention to hand washing, are integral to controlling and preventing these infections. Because of the danger of these infections and the difficulty in containing outbreaks, patients who have an infection with drug-resistant Acinetobacter may need to be isolated, or their placement in the facility should be carefully considered.
Policies, protocols, and controls are incorporated into the healthcare work setting to avoid or reduce exposure to potentially infectious materials. Healthcare-associated transmission is the transmission of microorganisms that are likely to occur in a healthcare setting. It can be reduced using engineered controls, safe injection practices, and safe work practices. Engineering controls are equipment, devices, or instruments that remove or isolate a hazard. Safe injection practices are equipment that allows the optimal performance of injections for patients, healthcare providers, and others that reduce exposure to injury or infection (Siegel et al., 2007). Work practice controls change practices and procedures to reduce or eliminate risks.
Standard Precautions are strategies for protecting healthcare professionals, patients, and visitors from the transmission of pathogenic organisms. Standard Precautions also prevent patient-to-patient transmission and staff-to-patient transmission. Standard Precautions assume that all pre-existing patient infections cannot be identified. The primary underpinning of Standard Precautions is that all body fluids and secretions should be considered potentially infectious. Standard Precautions apply to nonintact skin and mucous membranes, blood, and all body fluids, secretions, and excretions, except sweat (in certain circumstances, sweat can be considered infectious). In some cases, such as with specific pathogens like HIV, a patient’s body fluids, like vomit, are only considered a risk for disease transmission if they contain visible blood. Additional precautions are based on highly transmissible or epidemiologically important pathogens.
Respiratory Hygiene/Cough Etiquette is a strategy to reduce the transmission of respiratory infections at the first point of entry into a healthcare setting and when patients, staff, or visitors have signs/symptoms of a respiratory infection.
The effectiveness of Respiratory Hygiene/Cough Etiquette techniques has been questioned (Zayas et al., 2013). However, it is still considered a mandatory part of infection control, and its use among the lay public can be increased through education (Choi & Kim, 2016).
Healthcare personnel should observe Droplet Precautions (these will be discussed later in the module) when caring for patients with signs and symptoms of a respiratory infection and for whom Respiratory Hygiene/Cough Etiquette is needed (CDC, 2009). Healthcare personnel with a respiratory infection are advised to avoid direct patient contact, especially with high-risk patients. If this is not possible, a mask should be worn while providing patient care (Siegel et al., 2007).
Needlestick and sharps injuries are a common occurrence in healthcare. The CDC estimates that 385,000 sharps injuries occur yearly (Treviño & Arenas, 2020). These injuries are a potential cause for transmission of and infection with the hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), and more than 20 other pathogens (CDC/NORA, 2019). HBV, HCV, and HIV infections are very serious and potentially life-threatening but also preventable. Literature reviews and individual studies have shown that nurses are especially at risk for needlestick injuries compared to other healthcare workers. However, housekeepers, physicians, laboratory staff, and other people who work in healthcare are also at risk for needlestick injuries (Alfulayw et al., 2021).
One serious blood-borne infection can cost more than a million dollars for medications, follow-up laboratory testing, clinical evaluation, lost wages, and disability payments. The human costs after exposure are considerable. Needlestick injuries themselves, even if they do not result in an infection, can be an emotionally upsetting experience, causing anxiety, depression, and PTSD (Hambridge et al., 2022).
Percutaneous injuries can be avoided by eliminating the unnecessary use of needles, using devices with safety features, and promoting education and safe work practices for handling needles and related systems. Since 1993, safety-engineered sharps devices have increased while conventional sharps devices have decreased. Vigorous efforts to prevent needlestick and sharps injuries (e.g., the Needlestick Prevention and Safety Act of 2000) increased awareness of and use of safe injection practices. Improved equipment can help decrease the occurrence of these injuries (Dulon et al., 2020; Ottino et al., 2019).
Several sources have identified the desirable characteristics of needle and sharp safety devices. These characteristics include the following (NIOSH, 2000):
Although these characteristics are desirable, some are not feasible, applicable, or available for certain healthcare situations. For example, needles will always be necessary when alternatives for skin penetration are unavailable. Also, a safety feature that requires activation by the user might be preferable to one that is passive in some cases. Each device must be considered based on its merit and ability to reduce workplace injuries. The desirable characteristics listed here should serve only as a guideline for device design and selection (OSHA, 2011):
Safe injection practice in hospitals is well established. However, needlesticks and sharp injuries continue to occur frequently; they are often not reported, and failure to use safe injection practices has led to several serious outbreaks of HBV and HCV infection (Dolan et al., 2016). Dolan et al. (2016) wrote: “More than 50 outbreaks of viral and bacterial infections occurred in the United States during 1998-2014 because of these unsafe medical practices. These outbreaks resulted in the transmission of HBV, HCV, and bacterial pathogens to more than 700 patients. The unsafe practices used in these outbreaks can be categorized as syringe reuse between patients during parenteral medication administration to multiple patients, contamination of medication vials or intravenous bags after having been accessed with a used syringe or needle, failure to follow basic injection safety practices when preparing and administering parenteral medications to multiple patients, and inappropriate use and maintenance of finger stick devices and glucometer equipment.”
The following are examples of safe injection practices recommended by the CDC and other professional organizations. These apply to the use of needles, cannulas that replace needles, and, where applicable, intravenous delivery systems (CDC, 2011; OSHA, 2011).
Handwashing is one of the most effective methods for preventing patient-to-patient, patient-to-staff, and staff-to-patient transmission of microorganisms. It is one of the foundations of infection control (Mo et al., 2022).
Hands should be washed with soap and water, or an alcohol-based hand rub should be used in these situations:
Improved adherence to hand hygiene, i.e., hand washing or alcohol-based hand rubs, has been shown to terminate outbreaks in healthcare facilities, reduce transmission of antimicrobial-resistant organisms (e.g., MRSA), and reduce overall infection rates (WHO, 2009).
However, despite unequivocal evidence of the effectiveness of hand hygiene and mandatory hand hygiene education, healthcare professionals’ compliance with hand hygiene protocols is often very low, at times < 40% (Eichel et al., 2022). There are many reasons why healthcare professionals are non-compliant with hand hygiene protocols, such as perceived lack of time, perceived inconvenience, high workload, and poor staffing (Scheithauer et al., 2017). Interventions for improving compliance with hand hygiene protocol can increase compliance. The CDC and the World Health Organization (WHO) have published advice and guidelines for improving hand hygiene compliance. As part of these recommendations, the CDC is asking healthcare facilities to develop and implement a system for measuring improvements in adherence to hand hygiene recommendations. Some of the suggested performance indicators include:
Alcohol-based hand cleaners have become integral to infection control because they address some obstacles healthcare professionals face when taking care of patients and frequently washing their hands (CDC, 2017c). Alcohol-based hand rubs are very effective, in most cases as effective as soap and water. They significantly reduce the number of microorganisms on the skin, take less time to use than soap and water, and cause less skin irritation than soap and water. When using an alcohol-based hand rub, apply the product to the palm of one hand and rub your hands together, covering all surfaces of the hands and fingers until the hands are dry, approximately 20 seconds (CDC, 2021e). Note that the volume needed to reduce the number of bacteria on the hands varies by product, and it’s necessary to use the appropriate volume for each specific product to ensure effectiveness (Wilkinson et al., 2017).
The use of hand hygiene does not eliminate the need for gloves; the use of gloves is covered in the next section of the module.
Healthcare personnel should avoid wearing artificial nails and keep natural nails less than one-quarter of an inch long if they care for patients at high risk of infections, e.g., patients in intensive care units or transplant units.
When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and, therefore, usage include its smell, consistency, color, and drying effect on hands.
Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings, and the CDC and other experts recommend its use in these situations.
PPE provides a physical barrier between the patient and the healthcare professional.
Face shields, gowns, goggles, hair covers, masks, and shoe covers should be used if there is a risk for splash contact from blood or other potentially infectious body fluids/secretions to the eyes, mouth, mucous membranes, nose, or skin. Masks and respirators are used in certain situations to protect healthcare personnel, patients, and the public.
Gloves should be used in these situations (Siegel et al., 2007).
Double gloving is often used during surgical procedures. Still, there is no information about the protective effect of this technique during routine patient care, and in those situations, single gloving is generally considered adequate. Latex, nitrile, and vinyl gloves are available. Studies have shown that vinyl gloves are more likely to fail during patient care situations, and latex gloves are superior in terms of bacterial passage if the glove is perforated (Bardorf et al., 2016).
Proper use of gloves (CDC, 2021e):
Masks - often called surgical masks - are single-use items. Surgical masks can protect healthcare workers. Mask use is part of Standard Precautions (when appropriate), Droplet Precautions, and Respiratory Hygiene/Cough Etiquette. Their use and the conditions for which they should be used are mandated by OSHA (OSHA, 2011). Masks should be used in these situations (OSHA, 2011):
Standard Precautions and OSHA Blood-borne Pathogen Standards say that face shields, goggles, or other types of eye and face protection should be used if there is a risk of contact with blood and potentially infectious body fluids/secretions. These devices have been shown to protect healthcare workers against infectious pathogens (Siegel et al., 2007). The choice of which type of protection to use, e.g., goggles versus face shield, is determined by the clinical situation; there are no direct comparisons of one type of eye/face protective device with others (Verbeek et al., 2016). Personal eyeglasses and contact lenses are not considered adequate protective equipment and should not be used as a substitute for face shields, goggles, etc. (Siegel et al., 2007).
Gowns are worn to prevent contamination of clothing and protect the healthcare professional’s skin from blood and body fluid exposure. Impermeable gowns, leg coverings, boots, or shoe covers provide additional protection when large quantities of blood or body fluids may be splashed. The isolation gowns are part of Standard Precautions and Transmission Precautions, which are mandated by the OSHA Bloodborne Pathogens Standard (Siegel et al., 2007; OSHA, 2011). Isolation gowns are intended “to protect the arms and exposed body areas and prevent contamination of clothing with blood, body fluids, and other potentially infectious material” (Siegel et al., 2007). Gowns are sometimes referred to as surgical, isolation, or protective gowns. They are disposable, single-use items made of materials that prevent blood movement and other potentially infectious body fluids/secretions through the gown and onto the user’s skin. Different types of gowns offer differing levels of protection (FDA, 2022).
Isolation gowns should provide full coverage of the arms, the front of the torso, and from the neck to the middle of the thighs, and they should always be used with gloves and other PPE if needed (Siegel et al., 2007). Evidence for the effectiveness of gowns in preventing the transmission of infectious material has been described as mixed (Schirmer et al., 2020; Kilinc Balci, 2016). Laboratory jackets or coats are not an acceptable substitute for an isolation gown.
When removing PPE, it is important only to touch areas of the PPE that are not contaminated or potentially contaminated, e.g., the front of the gown would be considered potentially contaminated, and the ties in the back of the gown would not. Removing PPE in the proper sequence is important; improper removal of PPE and self-contamination is a significant risk for infection (Verbeek et al., 2016).
Transmission-Based Precautions are the infection control techniques and procedures that are used “. . . for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to prevent transmission effectively. Since the infecting agent is usually unknown at admission, Transmission-Based Precautions are used. Transmission-Based Precautions are used according to the symptoms and etiology. Precautions are then modified when the pathogen is identified, or an infectious cause is ruled out” (Siegel et al., 2007). Transmission Precautions are used in addition to Standard Precautions, and Standard Precautions are used in all patient care situations (Siegel et al., 2007).
|Chickenpox (varicella)||Until lesions are crusted, and no new lesions appear.|
|Herpes zoster (disseminated)||Duration of illness.|
|Herpes zoster (localized in an immunocompromised patient)||Duration of illness.|
|Measles (rubeola)||4 days after the onset of the rash or the duration of illness in people who are immunocompromised.|
|Smallpox||Duration of illness.|
|Tuberculosis (pulmonary or laryngeal, confirmed or suspected)||Depending upon clinical response, the patient must be on effective therapy, improve clinically (decreased cough and fever and improved findings on chest radiograph), and have three consecutive negative sputum smears collected on different days, or TB must be ruled out.|
Severe acute respiratory syndrome (SARS) requires Airborne Transmission Precautions. These should be used for the duration of the illness plus 10 days, providing that the respiratory symptoms are improving or absent (Siegel et al., 2007).
Respirators are required to be worn by healthcare personnel if Airborne Precautions are in place or during certain procedures, such as endotracheal intubation in which aerosols are formed (Siegel et al., 2007). A powered air-purifying respirator (PAPR) may be needed in high-risk situations.
An N95 respirator is recommended if Airborne Precautions are required (Siegel et al., 2007). These respirators will block at least 95% of infectious particles 0.3 microns or larger. The N95 is a single-user, disposable item that must be properly fitted to be effective (CDC, 2021o). Fit testing should be done when first using an N95, and after the correct size and model have been chosen, the user should perform a user seal check each time the N95 is used (Siegel et al., 2007).
The N95 respirator is a disposable device, and it is intended to be used once and then discarded (CDC, 2021o). However, according to the CDC, N95 respirators can be used more than once and for an extended period.
“Practices allowing extended use of N95 respirators as respiratory protection, when acceptable, can also be considered. The professionals who manage the institution's respiratory protection program should decide to implement policies that permit extended use of N95 respirators, in consultation with their occupational health and infection control departments, with input from the state/local public health departments. Extended use refers to wearing the same N95 respirator for repeated close-contact encounters with several patients without removing the respirator between patient encounters (CDC, 2022f). Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires a respirator, are placed together (e.g., housed in the same hospital unit, such as a COVID-19 unit). It can also be considered for the care of patients with tuberculosis, varicella, measles, and other infectious diseases where the use of an N95 respirator or higher respirator is recommended” (CDC, 2021o).
Airborne Precautions also require using an airborne infection isolation room (AIIR) with specially engineered airflow and ventilation systems, e.g., a specially ventilated room with at least 12 air changes per hour, negative air pressure relative to the hallway, and outside exhaust or HEPA-filtered recirculation. The door to the room must be kept closed, and the negative air pressure should be monitored (Siegel et al., 2007).
When the patient in airborne precautions must be moved or transported, the patient should wear a surgical mask from when they leave the isolation room until they return.
COVID-19 is primarily transmitted by contact with or inhalation of infected respiratory droplets (Fox-Lewis et al., 2022). Infected respiratory droplets are relatively large and do not travel far from the source (i.e., the infected person), usually < 6 feet (Fox-Lewis et al., 2022), and transmission of COVID-19 by this route requires very close contact with an infected person. However, there is evidence that aerosols can transmit COVID-19 (Fox-Lewis et al., 2022; Andrés et al., 2022). Aerosols are respiratory particles smaller than droplets; they travel further than respiratory droplets and can remain suspended in the air for a long time. There have been many cases in which airborne transmission of COVID-19 has likely occurred (Fox-Lewis et al., Andrés et al., 2022).
The CDC recommends using Standard Precautions when caring for confirmed or suspected cases of COVID-19.
|Invasive Haemophilus influenzae type b disease, including meningitis, pneumonia, and sepsis||Until 24 hours after initiation of effective therapy.|
|Invasive Neisseria meningitis disease, including meningitis, pneumonia, epiglottis, and sepsis||Until 24 hours after initiation of effective therapy.|
|Diphtheria (pharyngeal)||Until antibiotic therapy has finished and two cultures that were done at least 24 hours apart are negative.|
|Mycoplasma pneumoniae infection||Duration of illness.|
|Pneumonic plague||Until 48 hours after effective therapy has been started.|
|Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children, streptococcal pneumonia||Until 24 hours after initiation of effective therapy.|
|Adenovirus pneumonia||Duration of illness. In immunocompromised hosts, the duration of Droplet and Contact Precautions is extended due to the prolonged shedding of the virus.|
|Influenza||For seasonal influenza, 5 days from onset of symptoms, and in immunocompromised patients, for the duration of the illness. For pandemic influenza, 5 days from the onset of symptoms.|
|Mumps||Until 9 days after the initiation of effective therapy.|
|Parvovirus B19||Maintain precautions for the duration of hospitalization when chronic disease occurs in an immunocompromised patient. For patients with a transient aplastic or red-cell crisis, maintain precautions for 7 days. The duration of precautions for immunosuppressed patients with persistently positive PCR is not defined, but transmission has occurred.|
|Rubella (German measles)||Until 7 days after the onset of rash.|
|Meningococcal disease, including meningitis, pneumonia, and sepsis||Until 24 hours after initiation of effective therapy.|
|Viral hemorrhagic fevers||Duration of illness.|
|Pertussis||Until five days after initiation of effective therapy|
Droplet Precautions require a private room, but no special ventilation is necessary, and the door may remain open. Masks should be worn if working within three feet of the patient. If transported, the patient should be masked and observe Respiratory Hygiene/Cough Etiquette.
Diseases requiring Contact Precautions are listed below (Siegel et al., 2007).
|Infection or colonization with multidrug-resistant bacteria||Until completion of antibiotics and culture is negative.|
|Clostridium difficile enteric infection||Duration of illness.|
|Gastroenteritis- multiple different organisms, e.g., E. coli, Shigella, in diapered or incontinent patient||Duration of illness.|
|Hepatitis A, in diapered or incontinent patient||Maintain Contact Precautions in infants and children <3 years of age for the duration of hospitalization; children 3-14 yrs. of age for 2 weeks after onset of symptoms; >14 yrs. of age for 1 week after onset of symptoms.|
|Rotavirus infection in diapered or incontinent patient||Duration of illness.|
|Respiratory syncytial virus infection in infants and young children||Duration of illness.|
|Parainfluenza virus infection, respiratory, in infants or young children||Duration of illness.|
|Enteroviral infection in diapered or incontinent patient||Duration of illness.|
|Scabies||Until 24 hours after initiation of effective therapy.|
|Diphtheria (cutaneous)||Until completion of antimicrobial treatment and two cultures taken 24 hours apart are negative.|
|Herpes simplex virus infection (neonatal or mucocutaneous)||Until lesions are dry and crusted. Asymptomatic, exposed infants with a mother who has active infection and membranes have been ruptured for more than 4 to 6 hours- infant surface cultures obtained at 24-36 hrs. of age must be negative at 48 hours.|
|Herpes zoster (varicella-zoster, shingles)||Duration of the illness.|
|Impetigo||Until 24 hours after initiation of effective therapy.|
|Major abscesses, cellulitis, decubiti, or wound infections||Duration of the illness.|
|Rubella, congenital syndrome||Place the infant on precautions during any admission until 1 year of age, unless nasopharyngeal and urine cultures are negative for virus after age 3 months.|
|Staphylococcal furunculosis in infants and young children||Duration of illness.|
|Acute viral (acute hemorrhagic) conjunctivitis||Duration of illness.|
|Viral hemorrhagic infections (Ebola, Lassa, Marburg)||Duration of illness.|
|Zoster (chickenpox, disseminated zoster, or localized zoster in immunodeficient patient)||Until all lesions are crusted, requires airborne precautions.|
|Smallpox||Duration of illness, requires airborne precautions.|
|Bronchiolitis||Duration of illness.|
|Human metapneumovirus||Duration of illness.|
|Monkeypox||Until lesions are crusted. Airborne Precautions should be used until monkeypox is confirmed and smallpox is excluded.|
|Parvovirus B19||Maintain precautions for the duration of hospitalization when chronic disease occurs in an immunodeficient patient. For patients with a transient aplastic or red-cell crisis, maintain precautions for 7 days.|
|Pneumonia, adenovirus||Duration of illness.|
|Poliomyelitis||Duration of illness.|
|Respiratory infectious disease, acute, infants and young children||Duration of illness.|
|Ritter’s disease (Staphylococcal scalded skin syndrome)||Duration of illness.|
|Severe acute respiratory syndrome (SARS)||Duration of illness. Airborne Precautions and Droplet Precautions.|
|Tuberculosis/extrapulmonary draining lesion||Discontinue precautions only when a patient improves clinically, drainage has ceased, or there are three consecutive negative cultures of continued drainage. Examine for evidence of active pulmonary tuberculosis.|
If Contact Precautions are indicated, the patient should be in a private room. Standard Precautions should be used, and a gown and gloves should be worn if contact with the patient or environmental surfaces is likely to be contacted.
Conditions/Diseases that may require neutropenic precautions:
Immunization is one method to reduce the transmission of communicable diseases. The following are recommendations for immunization based on age and exposure risk. Specifics and schedules for high-risk populations and catch-up immunizations are available from the CDC. Immunization schedules for adults are available from the CDC.
These recommendations for the immunization of healthcare personnel are from the CDC (CDC, 2016b):
Although the environment is a reservoir for various microorganisms, it is rarely implicated in disease transmission except in the immunocompromised population. Applying infection-control strategies effectively prevents opportunistic, environmentally-related infections in immunocompromised populations (Wingard, 2022).
Definitions (Rutala & Weber, 2019)
Infection control strategies include:
General engineering and environmental control principles will be discussed; more information will be provided as specific clinical situations are covered.
Basic education has been briefly discussed in previous sections of the module, and its application to other parts of the infection control process will be covered below. The CDC and OSHA recommend that the healthcare facility or employer inform the staff of potential risks for exposure to infectious materials. The facility should also provide them with the education and equipment they need to prevent contamination of medical equipment and the environment and protect themselves and patients against contamination and infections.
Cleaning, disinfection, and sterilization are essential for infection control and maintaining a safe environment. These processes can be used singly or in combination. They are done using different tools and techniques, producing different results. In simple terms, sterilization is intended to kill all microorganisms, disinfection will kill/remove most microorganisms, and cleaning will physically remove surface contamination and debris.
Except in rare and special instances, items that do not ordinarily touch the patient or touch only intact skin are not involved in disease transmission and generally do not necessitate disinfection between uses on different patients. These items include crutches, bed boards, blood pressure cuffs, and other medical accessories. Consequently, depending on the particular equipment or item, washing with a detergent or using a low-level disinfectant may be sufficient when decontamination is needed. If non-critical items are grossly soiled with blood or other body fluids, a higher level of disinfection is required (Rutala & Weber, 2019).
Cleaning removes visible and surface contamination from an object; that is its primary purpose, and cleaning can be completed mechanically or with cleaners. Cleaning can also help disinfect, but the two processes are different. Cleaning is not intended to kill bacteria or other microorganisms. Disinfection is destroying pathogenic organisms; disinfection cannot and does not eliminate all organisms.
The following information is from the CDC Guideline for Sterilization and Disinfection in Healthcare facilities (Rutala & Weber, 2019).
Sterilize critical medical and surgical devices and instruments that typically enter sterile tissue, the vascular system, or a sterile body fluid flow (e.g., blood) before using them on/for a patient (Rutala & Weber, 2019). Provide, at a minimum, high-level disinfection for semi-critical patient-care equipment (e.g., gastrointestinal endoscopes, endotracheal tubes, anesthesia breathing circuits, and respiratory therapy equipment) that touches either mucous membranes or nonintact skin (Rutala & Weber, 2019).
Perform low-level disinfection for non-critical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin (Rutala & Weber, 2016).
Do not perform disinfectant fogging for routine purposes in patient-care areas.
The manufacturer should be contacted for questions about disinfectants. A source of information about low-level or intermediate-level disinfectants is the Antimicrobial Program Branch, Environmental Protection Agency (EPA), Selected EPA-Registered Disinfectants (EPA) (703) 308-6411, online link.
Endoscopes are fragile, expensive, difficult to clean, much used, and susceptible to contamination (Rutala & Weber, 2019). There are millions of endoscopic procedures done each year, and iatrogenic infections caused by contamination of endoscopes are rare (Calderwood et al., 2018; Rutala & Weber, 2019). However, endoscopes have been linked to more infectious outbreaks than any other reusable medical device, and failure to properly clean and disinfect endoscopes is a primary reason these outbreaks happen (Rutala & Weber, 2019). In addition, studies have shown that even cleaned and processed endoscopes are often contaminated (Goyal et al., 2022).
The recommendations for the disinfection and sterilization of endoscopes listed below are from the CDC (Rutala & Weber, 2019). The American Society for Gastrointestinal Endoscopy, multi- medical societies, and the Society of Gastroenterology has also published guidelines for cleaning endoscopes (Calderwood et al., 2018). Test each flexible endoscope for leaks as part of each reprocessing cycle to detect damaged endoscopes. Remove any instrument that fails the leak test from clinical use and repair this instrument.
Store endoscopes in a manner that will protect them from damage or contamination.
Other medical devices in contact with mucous membranes are considered to be semi-critical. They include but are not limited to, rectal and vaginal probes, flexible cystoscopes, tonometers, and ultrasound probes used for various procedures. The risk of contracting an infectious disease from one of these devices is minimal but not impossible Contamination with microorganisms such as cytomegalovirus, human papillomavirus, hepatitis C, herpes simplex, Klebsiella, and Pseudomonas have been found on these devices, even after cleaning and disinfection (Leroy, 2013).
Disinfection strategies vary widely for these semi-critical items/devices. The FDA requests that manufacturers provide at least one validated cleaning and disinfection/sterilization protocol in labeling their devices. The CDC guidelines are listed below; disinfection and sterilization with different hydrogen peroxide or ultraviolet light are also being evaluated for sterilizing these devices.
Steam is the preferred method for sterilizing critical medical and surgical instruments that are not damaged by heat, steam, pressure, or moisture.
Flash sterilization is acceptable for processing cleaned patient-care items that cannot be packaged, sterilized, and stored before use. It is also used when there is insufficient time to sterilize an item using the preferred package method. Still, flash sterilization should not be used for convenience, as an alternative to purchasing additional instrument sets, or to save time. Because of the potential for serious infections, flash sterilization is not recommended for implantable devices (i.e., devices placed into a surgically or naturally formed human body cavity). However, flash sterilization may be unavoidable for some devices like orthopedic screws and plates. Suppose flash sterilization of an implantable device is unavoidable. In that case, recordkeeping (i.e., load identification, patient’s name/hospital identifier, and biological indicator result) is essential for epidemiological tracking (e.g., of surgical site infection, tracing results of biological indicators to patients who received the item to document sterility), and to assess the reliability of the sterilization process.
The time and temperature used for flash sterilization vary, depending on the type of sterilizer and the type of item, i.e., porous vs. non-porous items. Example: A non-porous item like a metal instrument with no lumens would be flash sterilized at 132°C/270°F for 3 minutes.
Steam sterilization – sterilization by moist heat under pressure - is the most widely used and dependable form (Rutala & Weber, 2019). Moist heat destroys microorganisms through the irreversible coagulation and denaturation of enzymes and structural proteins. The process is nontoxic, inexpensive, rapidly microbicidal, sporicidal, and rapidly heats and penetrates fabrics (Rutala & Weber, 2019).
The basic principle of steam sterilization in an autoclave is to expose each item to direct steam contact at the required temperature and pressure for the specified time; the four parameters of steam sterilization are steam, pressure, temperature, and time. The two common steam-sterilizing temperatures are 121°C (250°F) and 132°C (270°F). These temperatures (and other high temperatures) must be maintained for the minimal time to kill microorganisms. Recognized minimum exposure periods for sterilization of wrapped healthcare supplies are 30 minutes at 121°C (250°F) in a gravity displacement sterilizer or 4 minutes at 132°C (270°C) in a pre-vacuum sterilizer.
Steam sterilization should be used whenever possible on all critical and semi-critical items that are heat and moisture-resistant, even when it is not essential for preventing pathogen transmission. Steam sterilizers also are used in healthcare facilities to decontaminate microbiological waste and sharps containers.
The Joint Commission (TJC) has recommendations for the immediate use of steam sterilization (IUSS). (TJC, 2017).
The FDA considers hospitals or third-party reprocessors to be manufacturers and regulated similarly. Therefore, a reused single-use device will have to comply with the same regulatory requirements of the device when it was originally manufactured (Rutala & Weber, 2019).
are designed to remove soil and contaminants by cleaning and inactivating microorganisms by disinfection or sterilization. Reprocessing reusable devices should follow this three-step process (FDA, 2015).
Disinfectants used in healthcare facilities can be contaminated with disease-causing microorganisms, and hospital-acquired infections caused by contaminated disinfectants have been documented (Häfliger et al., 2020). These measures should be used to reduce the occurrence of contaminated disinfectants (Rutala & Weber, 2019):
The home environment should be as safe as hospitals or ambulatory care. Epidemics should not be a problem, and cross-infection should be rare. Healthcare providers are responsible for providing family members with information about home infection-control procedures, including hand hygiene, proper cleaning and disinfecting equipment, and safe storage of cleaned and disinfected devices.
Construction activities in or near healthcare facilities increase disease risks for airborne and waterborne diseases.
The purpose of heating, ventilation, and air conditioning (HVAC) systems in healthcare facilities is to:
Decreased performance of healthcare facility HVAC systems, filter inefficiencies, improper installation, and poor maintenance can contribute to the spread of healthcare-related airborne infections. The CDC has further recommendations for HVAC systems in healthcare facilities that should be reviewed (Sehulster & Chinn, 2003).
Dentists and dental office personnel are exposed to blood, body fluids, and aerosols, and the exposure can be by direct contact, indirect contact, or inhalation. Transmission of infectious agents from staff to patient or patient to staff is rare in dental settings, but it has occurred (CDC, 2016c).
Infection control in dental settings is identical to infection control in other healthcare settings, and the basic principles outlined here should be observed (Rutala & Weber, 2019).
Administrative measures: A written infection control and infection prevention policy must be in place, there should be at least one person responsible for coordinating/overseeing the policy, and there should be a plan for handling exposures.
Infection control and infection prevention training: Training/education in infection control and infection prevention must be completed during the hiring period. It should also be performed annually, when employees are learning or performing new procedures, and according to local, state, and federal regulations.
Dental personnel safety: This would include (but is not limited to) proper immunizations, OSHA-approved training in the OSHA Bloodborne Pathogens Standards, knowing the proper post-exposure protocol, and rules/policies for dental personnel and patients who have a potentially infectious illness. There are specific recommendations regarding the influenza virus (Sebastiani et al., 2017):
Sterilization and disinfection: Policies and procedures for sterilization and disinfection must be in place and easily accessed, dental staff must be trained in these policies and procedures, and the appropriate equipment necessary for sterilization and disinfection must be available. Dental equipment, like medical equipment, should be divided into critical, semi-critical, and non-critical, and these classifications should be used as a guideline for choosing sterilization and disinfection techniques. Specific recommendations for dental setting sterilization and disinfection include the following (CDC, 2016c):
Cleaning to remove debris and organic contamination from instruments should always occur before disinfection or sterilization. If blood, saliva, and other contamination are not removed, these materials can shield microorganisms and potentially compromise the disinfection or sterilization process. Automated cleaning equipment (e.g., ultrasonic cleaner, washer-disinfector) should remove debris, improve cleaning effectiveness, and decrease worker exposure to blood. After cleaning, dried instruments should be inspected, wrapped, packaged, or placed into container systems before heat sterilization. Packages should be labeled to show the sterilizer used, the cycle or load number, the date of sterilization, and, if applicable, the expiration date. Information like this can help retrieve processed items if an instrument processing/sterilization fails.
The ability of a sterilizer to reach the conditions necessary to achieve sterilization should be monitored using a combination of biological, mechanical, and chemical indicators. Biological indicators, or spore tests, are the most accepted method for monitoring the sterilization process because they assess the sterilization process directly by killing known highly resistant microorganisms (e.g., Geobacillus or Bacillus species). A spore test should be used at least weekly to monitor sterilizers. However, mechanical and chemical monitoring should also be performed because spore tests are only performed periodically (e.g., once a week, once a day), and the results are usually not obtained immediately.
Sterile instruments and supplies should be stored in covered or closed cabinets. Wrapped packages of sterilized instruments should be inspected before opening and use to ensure the packaging material has not been compromised (e.g., wet, torn, punctured) during storage. The contents of any compromised packs should be reprocessed (i.e., cleaned, packaged, and heat-sterilized again) before use on a patient.
Sterilization monitoring (e.g., biological, mechanical, chemical monitoring) and equipment maintenance records are important components of a dental infection prevention program. Maintaining accurate records ensures cycle parameters have been met and establishes accountability. In addition, if there is a problem with a sterilizer (e.g., unchanged chemical indicator, positive spore test), documentation helps to determine if an instrument recall is necessary.
Medical waste, including tissues, extracted teeth, dental amalgams, and other materials, should be considered infectious and handled and disposed of properly.
Environmental infection control and prevention (CDC, 2016c): Surfaces that are likely to be contaminated and that patients or staff may have contact with should be regularly cleaned or cleaned using the proper disinfectant. Ordinary surfaces (e.g., walls) can be cleaned with soap and water; high-level disinfectants are not recommended for these surfaces as they can be corrosive and damaging. Spills of contaminated/potentially contaminated material should be correctly and promptly cleaned, and PPE should be used during the cleanup.
Emphasis on cleaning and disinfection should be placed on surfaces most likely to become contaminated with pathogens, including clinical contact surfaces (e.g., frequently touched surfaces such as light handles, bracket trays, switches on dental units, and computer equipment) in the patient-care area. When these surfaces are touched, microorganisms can be transferred to other surfaces, such as instruments.
Clinical contact surfaces should be barrier protected or cleaned and disinfected between patients. EPA-registered hospital disinfectants or detergents/disinfectants labeled for use in health care settings should be used for disinfection. Disinfectant products should not be used as cleaners unless the label indicates the product is suitable for such use. Follow manufacturer recommendations for cleaning and disinfection (e.g., amount, dilution, contact time, safe use, and disposal). Facility policies and procedures should also address prompt and appropriate cleaning and decontamination of spills of blood or other potentially infectious materials. Surfaces like floors, walls, and sinks carry less risk of disease transmission than clinical contact surfaces, and they can be cleaned with soap and water or cleaned and disinfected if visibly contaminated with blood.
Dental unit water quality: Water lines used for dental procedures can develop biofilm and growth of bacteria (CDC, 2021k). Most of the microorganisms typically found in dental unit waterlines have limited pathogenic potential, but Legionella species, Pseudomonas aeruginosa, and non-tuberculous Mycobacterium have been found in these water systems. Dental units must have a water filtration system that allows for ≤ 500 colony-forming units (CFU) per mL of heterotrophic water bacteria (CDC, 2021k). (Note: A heterotrophic organism requires carbon and nitrogen for its metabolic activity).
Key recommendations for maintaining dental water quality are (CDC, 2021k):
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) are common nosocomial infections. HAP is the most common nosocomial infection (Klompas et al., 2022a) and is a significant cause of morbidity and mortality (Ko et al., 2021; Modi & Kovacs, 2020). HAP is defined as new pneumonia that begins > 48 hours after admission in non-intubated patients (Modi & Kovacs, 2020). VAP is defined as new pneumonia that begins > 48 hours after endotracheal intubation (Modi & Kovacs, 2020).
Using these recommendations can prevent VAP (Klompas et al., 2022a).
“Little robust data exist on interventions to prevent HAP. Most studies are nonrandomized, and many do not report the impact on objective outcomes such as length of stay, mortality, or antibiotic
utilization” (Klompas et al., 2022a). Klompas et al. (2022b) made the following recommendations for methods that may help prevent HAP. “Classify potential prevention strategies into (1) practices supported by interventional studies suggesting lower HAP rates, (2) practices with insufficient data of benefit or harm, and (3) practices that are not recommended, with evidence of futility or possible harm.” The care methods listed below are supported by interventional studies that suggest that their use might reduce the risk of HAP (Klompas et al., 2022b), and the risk of harm associated with them is small.
Vaccination is one of the core components for preventing nosocomial infections like HAP and VAP (Klompas, 2022b), such as vaccination against COVID-19 and influenza. Pneumonia is recommended, and “vaccination decreases the likelihood that any given patient or healthcare worker at any given time is a silent carrier and that if they are, that they will transmit SARS-CoV-2 to another patient or provider” (Klompas, 2022b).
Measures that may help prevent aspiration are listed below (Klompas, 2021; Neill & Dean, 2019; AACCN, 2016).
Legionella is a bacterium that causes the pulmonary infection of Legionnaire’s disease (CDC, 2021g).
Legionellosis outbreaks in workplaces are commonly caused by Legionella growth in poorly maintained artificial water systems (CDC, ND). Examples of sources of Legionella-contaminated water systems that can cause Legionnaire’s disease are listed below (CDC, 2021g; OSHA, ND).
Standard Precautions are sufficient infection control techniques when caring for a patient with Legionnaires’ disease (Siegel et al., 2007).
Healthy people do not have a high risk of developing Legionnaire’s disease, and the infection rate after exposure is <5% (CDC, 2021g; OSHA, ND). However, Legionnaire’s disease can be quite severe, and the fatality rate has been reported to be 10% and 25% if the disease is contracted in a hospital (CDC, 2021g). Factors that increase the risk of developing Legionnaires’ disease include (CDC, 2021g):
Testing for Legionnaires’ disease should be done if (CDC, 2021g):
Clinical laboratory testing: Periodically review the availability and clinicians’ use of laboratory diagnostic tests for Legionnaires’ disease. If clinicians do not routinely use the tests on patients diagnosed with or suspected of pneumonia, implement measures to enhance clinicians’ use of the tests.
Water Management for the Prevention of Legionella Contamination:
A water management program identifies conditions that may cause Legionella contamination and intervenes to minimize the growth and spread of Legionella and other waterborne pathogens in building water systems (CDC, 2021g). Seven key activities should be performed in a Legionella water management program (CDC, 2021g):
An effective water management system should (CDC, 2021g):
Routine water sampling to detect Legionella may be appropriate (CDC, 2021g). “The water management program team should regularly monitor water quality parameters, such as disinfectant and temperature levels. By monitoring these parameters, the team can ensure that building water systems are operating to minimize hazardous conditions that could encourage Legionella and other waterborne pathogens to grow. However, it is up to the team to determine how to validate the program's efficacy, based on the environmental assessment and data supporting the overall performance of the water management program” (CDC< 2021h)
Transplant units: In facilities with hematopoietic stem-cell- or solid-organ transplantation programs, periodic culturing for Legionellae in water samples from the transplant unit(s) can be performed as part of a comprehensive strategy to prevent Legionnaires’ disease in transplant recipients.
No recommendation can be made about the optimal methods (i.e., frequency, number of sites) for environmental surveillance cultures in transplant units.
Maintain a high index of suspicion for Legionellosis in transplant patients with healthcare-associated pneumonia even when environmental surveillance cultures do not yield Legionella.
If Legionella spp. is detected in the water of a transplant, remove faucet aerators in areas for severely immunocompromised patients.
Transplant units/positive cultures: If Legionella are detected in the potable water supply of a transplant unit, and until Legionella are no longer detected by culture:
Healthcare facilities that do not house or treat severely immunocompromised patients (e.g., hematopoietic stem cell transplant or solid-organ transplant recipients):
Pertussis is caused by the Bordetella pertussis (B. pertussis) bacterium. The B. pertussis bacterium is transmitted by the deposition of infected nasal, oral, or respiratory secretions on a host’s mucous membranes. The B. pertussis bacterium is highly contagious; secondary attack rates are > 80% in susceptible household contacts. People who are particularly vulnerable to becoming infected with B. pertussis and developing severe symptoms are:
Transmission in healthcare facilities happens when there is close, face-to-face unprotected (unmasked) contact with an infected person, e.g., an unmasked healthcare worker bathing or feeding a patient, administering a bronchodilator, or doing/assisting with intubation.
The incubation period of pertussis is typically 5 to 10 days, but symptoms may begin as late as 3 weeks after exposure.
Use Standard Precautions and Droplet Precautions when caring for someone who has or is suspected of having pertussis. Droplet precautions should be used for 5 days after the initiation of effective treatment; after that time, the patient is no longer contagious (Siegel et al., 2007). Preferably the patient should be in a single room, but cohorting is acceptable (Siegel et al., 2007). Single-patient rooms are preferred. Post-exposure chemoprophylaxis for household contacts and healthcare workers with prolonged exposure to respiratory secretions is recommended (Siegel et al., 2007).
The CDC recommendations for preventing the transmission of B. pertussis in healthcare facilities include:
Diagnosis of pertussis is made based on clinical history and laboratory testing. Although cultures are considered the gold standard for diagnosing pertussis, polymerase chain reaction (PCR) provides sensitive results more rapidly.
A healthcare worker vaccinated against pertussis may become infected and develop the disease. Post-exposure prophylaxis with azithromycin, clarithromycin, or erythromycin is recommended. Trimethoprim-sulfamethoxazole is an alternative (Kilgore et al., 2016).
Symptomatic healthcare personnel with known or suspected pertussis should be excluded from working from 21 days from the onset of the cough or until 5 days after the start of effective antimicrobial therapy.
Asymptomatic healthcare personnel exposed to pertussis who receive postexposure prophylaxis do not need work restrictions (Kilgore et al., 2016).
The Advisory Committee on Immunization Practices (ACIP) recommends that healthcare workers receive a single dose of Tdap (CDC, 2020h). After receipt of Tdap, a dose of Td or Tdap is recommended every 10 years (CDC, 2020h). However, the revaccination of healthcare workers should be considered in certain situations, e.g., an increased risk of a suspected or documented case of healthcare-transmitted pertussis.
Vaccinating healthcare personnel with Tdap should not be considered an adequate substitute for infection prevention and control measures and post-exposure prophylaxis. Revaccinated healthcare personnel should still receive post-exposure antimicrobial prophylaxis when applicable.
There is no evidence that in a healthcare facility revaccination prevents pertussis transmission or the development of the disease.
Infants are at the greatest risk for severe or fatal pertussis, so healthcare personnel who work with infants or pregnant women should be prioritized for revaccination.
“Healthcare facilities considering repeat Tdap doses for healthcare personnel are encouraged to consult with their state and local public health departments regarding the use of additional doses of Tdap” (CDC, 2021o).
Pertussis is a reportable disease, and the local or state health department should be notified about all confirmed and suspected cases of pertussis.
Aspergillus is a fungus that is the cause of pulmonary aspergillosis. Aspergillus is ubiquitous in the environment and is transmitted to human hosts by inhalation of infected conidia (CDC, 2022h). Hospital-acquired cases have been reported, sometimes related to construction dust exposure and contaminated medical equipment. The incubation period for aspergillosis is unclear (CDC, 2022h).
Infection with Aspergillus can cause a localized pulmonary infection, especially in patients with pulmonary disease, and immunocompromised people can develop an invasive pulmonary infection. The infection can spread to other organs like the bones, brain, and skin (CDC, 2022h). People who are at risk for a severe, invasive Aspergillus infection include (but are not limited to) those who have:
Aspergillosis is diagnosed by culturing and histopathologic/cytologic examination of fluid and tissue samples (Patterson et al., 2016). Treatment will depend on the patient’s co-morbidities and the type of infection, i.e., localized or invasive.
Standard Precautions are sufficient for infection control (Siegel et al., 2007) unless the patient has a massive soft tissue Aspergillus infection that is copiously draining and requires repeated irrigation; in that situation, use Airborne and Contact Precautions, as well (Siegel et al., 2007).
Hospitalized allogeneic hematopoietic stem cell transplant patients and other patients who are highly immunocompromised should be placed in a protective environment. One should reduce the patient’s exposure to dust and limit exposure to cut flowers or plants (Patterson et al., 2016).
“Leukemia and transplant centers should perform regular surveillance of cases of invasive mold infection. An increase in incidence over baseline or invasive mold infections in patients not at high risk for such infections should prompt evaluation for a hospital source” (Patterson et al., 2016).
The CDC’s recommendations for a protective environment (PE) are listed below (CDC, 2015a).
Surface Cleaning and Disinfection:
Adenoviruses, parainfluenza virus, and respiratory syncytial virus (RSV) are common causes of infections like the common cold, conjunctivitis, gastroenteritis, and pneumonia (Clark et al., 2022; CDC, 2020k; CDC, 2019e; Crowe, 2022). Infections with these viruses can be mild and self-limiting. Still, they can also cause a serious illness, particularly in someone who is immunocompromised, in the elderly, the very young, or in people with certain diseases/medical conditions (Clark et al., 2022; CDC, 2020h; CDC, 2019e).
Adenovirus infections can be especially harmful to people with COPD, HIV, an immunocompromised immune system, and those who have had cardiac surgery or a stem cell transplant (Clark et al., 2022).
Older adults and people with compromised immune systems are susceptible to a severe parainfluenza virus infection (CDC, 2019e).
Infants, children, and adults with certain diseases/medical conditions or in certain age groups are more likely to develop a severe RSV infection and include (CDC, 2019e):
Adenoviruses are transmitted by direct contact with a fomite or an infected person and by inoculation of mucous membranes by infected respiratory droplets (CDC, 2019b).
Human parainfluenza viruses are transmitted directly with infected droplets or when an infected person breathes, coughs, or sneezes, spreading infected droplets. The human parainfluenza viruses may remain infectious in airborne droplets for over an hour and on surfaces for a few hours, depending on environmental conditions (CDC, 2019e).
The respiratory syncytial virus is transmitted by infected secretions of the eyes and nose (CDC, 2020k).
Respiratory syncytial virus
Influenza infections are very common, and every year in the United States, 5% to 20% of the population gets an influenza infection (CDC, 2021l). For most people, influenza infection is mild and self-limiting. Still, influenza can be very severe and occasionally fatal for the elderly, young people, or certain diseases/medical conditions (CDC, 2021j). From 2010 to 2020, there were 12,000 to 52,000 deaths from the flu every year.
Influenza is primarily transmitted by contact with large, infected respiratory droplets that are expelled when an infected person coughs or sneezes (CDC, 2021l). The droplets can inoculate mucous membranes after hand contact with an infected fomite (CDC, 2021l). Because the infected droplets do not remain airborne for long or travel a long distance (≤ 6 feet), direct inoculation requires very close contact with an infected person (CDC, 2021l).
Factors that increase the risk of serious complications for the flu include, but are not limited to (CDC, 2021j)
The CDC’s recommendations for preventing the seasonal flu from occurring in patients and staff of healthcare facilities are discussed below. A healthcare facility is defined as including, but not limited to “. . . acute-care hospitals; long-term care facilities, such as nursing homes and skilled nursing facilities; physicians’ offices; urgent-care centers, outpatient clinics; and home healthcare” (CDC, 2021l). These recommendations are available online.
Vaccination and early treatment with antiviral medications are for people with an increased risk for influenza complications. Staff with a high risk for influenza complications should consult with their provider if they develop signs and symptoms of influenza.
Healthcare personnel who perform patient care are at risk for exposure to potentially dangerous pathogens, and the most common of these are HBV, HCV, and HIV. Fortunately, the transmission of one of these highly virulent microorganisms from patient to provider and the development of infection is usually uncommon. However, occupational exposures to pathogens such as HBV, HCV, and HIV are a common everyday experience in healthcare facilities and during patient care. Nurses and other healthcare professionals must understand the risks of exposure and how to protect themselves.
Blood is the most important transmission source to healthcare professionals. Other body fluids, such as cerebrospinal fluid, synovial fluid, pericardial fluid, pleural fluid, peritoneal fluid, and amniotic fluid, are potentially infectious (Weber, 2020). Semen and vaginal secretions can be a source of sexual transmission of these viruses (Fauci et al., 2022). Other body fluids, e.g., feces, gastric secretions, nasal secretions, saliva, sputum, sweat, tears, and urine, may contain low amounts of HBV, HCV, and HIV. Unless these fluids are visibly contaminated with blood, they are not considered infectious (Fauci et al., 2022; Schillie et al., 2018; Weber et al., 2015).
HIV: The primary risk of HIV transmission in healthcare is exposure to contaminated blood, typically by a needlestick injury. The risk of HIV transmission after percutaneous exposure has been reported to be 0.23% (Shenoy & Weber, 2021). The risk of HIV transmission after mucosal exposure is estimated at 0.09% (Shenoy & Weber, 2021). The risk of HIV transmission after non-intact skin exposure is rare (Fauci et al., 2022) and has been estimated to be < 0.1% (Shenoy & Weber, 2021). Transmission of HIV through intact skin has not been documented (Fauci et al., 2022).
Fauci et al. (2022) wrote: “In the United States, a total of 58 documented cases of occupational HIV transmission to health care workers, and 150 possible transmissions have been reported by the CDC. Since 1999, only one confirmed case (a laboratory technician sustaining a needle puncture while working with a live HIV culture in 2008) has been reported.”
However, as with the risk estimations for HCV exposure, these estimates have been criticized as possibly being too high and based on conditions that do not reflect current exposure circumstances and the availability and effectiveness of post-exposure prophylaxis (Nwaiwu et al., 2017).
Fortunately, the risk of HCV and HIV transmission and infection is very low, and although HBV is highly infectious, hepatitis B vaccination prevents infection after exposure (Schillie et al., 2018).
Any actual, possible, or potential occupational exposure to HBV, HCV, or HIV should be reported to the appropriate in-house person or department (e.g., supervisor, employee health) immediately or as soon as possible. Do not decide that exposure is/is not a risk for HBV, HCV, or HIV transmission. The decision is the responsibility of the person/department that evaluates risks and prescribes treatment. In several investigations of nosocomial HBV outbreaks, most infected healthcare professionals could not recall an overt percutaneous injury. Although in some studies, up to one-third of the infected persons recalled caring for a hepatitis B surface antigen-positive patient. However, HBV and HCV can survive on environmental surfaces for many hours and days (Shenoy & Weber, 2021). Treatment of exposures should focus on wound care, evaluation of the risk, and post-exposure drug prophylaxis (Schillie et al., 2013):
Other helpful resources are:
Monkeypox is a rare viral disease caused by the monkeypox virus. It is endemic in rainforests in Central and West Africa (Siegel et al., 2007), but there have recently been many (relatively so) cases reported in the United States.
Monkeypox is transmitted by direct contact with the monkeypox rash, scabs, or infected body fluids (CDC, 2022l). It can also be transmitted by respiratory secretions if someone has prolonged, face-to-face contact or during intimate physical contact, by touching contaminated items, and vertical transmission from mother to fetus (CDC, 2022l). Airborne transmission does not appear to occur. And monkeypox can be spread from an infected animal to a human by bites, scratches, and eating the meat of an infected animal (CDC, 2022l). It is unknown if monkeypox can be transmitted by semen or vaginal fluids (CDC, 2022l).
Monkeypox is not contagious during the incubation period; it is possibly contagious during the prodromal period and is contagious if a rash is present (CDC, 2022l). When all the scabs have fallen off and new skin has formed, monkeypox is no longer contagious (CDC, 2022l).
Young children (<8 years of age), individuals who are pregnant or immunocompromised, and individuals with a history of atopic dermatitis or eczema may be at an increased risk for severe outcomes from monkeypox disease (CDC, 2022l).
Use Standard Precautions, Airborne Precautions (until monkeypox has been confirmed and smallpox has been ruled out), and Contact Precautions until the lesions have crusted over (Siegel et al., 2007).
A confirmed or suspected monkeypox patient should be in a single room; a special air-handling room is unnecessary (CDC, 2022l).
Staff who enter the room should wear a gown, gloves, N95, and eye protection (CDC, 2022l).
Transporting the patient outside the room should be done only if necessary and unavoidable, and the patient should wear a mask outside the room (CDC, 2022l). Any aerosol-generating procedures should be done in an AIIR.
Waste that has been contaminated with monkeypox should be handled like any other potentially infectious material (CDC, 2022l). No specific cleaning/disinfection procedures are required. Dry dusting, sweeping, or vacuuming should be avoided; wet cleaning is preferred.
Visitors should be limited to persons essential to the patient's well-being (CDC, 2022l).
Healthcare personnel and patients in healthcare facilities exposed to monkeypox should be monitored and receive post-exposure management according to current recommendations (CDC, 2022m).
Vaccines for monkeypox are available. Antiviral treatment can be used for patients with a high risk for severe disease.
Key points from the CDC’s Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic are summarized below. The full text of these recommendations is available online: use this link to access.
The CDC also recommends infection control and transmission prevention in dialysis clinics, dental offices, emergency medical services, long-term care facilities, intermediate care facilities for people with intellectual disabilities, and psychiatric residential facilities. Those recommendations can be viewed using this link.
Sepsis shall mean a proven or suspected infection accompanied by a systemic inflammatory response. Severe sepsis shall mean sepsis plus at least one sign of hypoperfusion or organ dysfunction. For pediatrics, severe sepsis shall mean one of the following: cardiovascular organ dysfunction or acute respiratory distress syndrome (ARDS), or two or more organ dysfunctions. Septic shock shall mean severe sepsis with persistent hypotension or cardiovascular organ dysfunction despite adequate intravenous fluid resuscitation. Septic shock in pediatrics means severe sepsis and cardiovascular dysfunction despite adequate intravenous fluid resuscitation.
The clinical view of sepsis has changed over time, and terms such as systemic inflammatory response syndrome (SIRS), early sepsis, severe sepsis, and septicemia are no longer included in the definition of sepsis.
The pathogenesis of sepsis is very complex, and a full discussion of the process will not be included here. In brief, sepsis begins with an infection and indicates the presence of a microorganism. The normal response to infection is to destroy or contain the microorganisms through the immune response, e.g., the activity of macrophages and the activation and production of inflammatory mediators that direct and control the immune response. In sepsis, however, the inflammatory response is exaggerated and generalized, and healthy tissue and organs, not only those of the initial location of the infection, become damaged and dysfunctional.
A bacterial infection typically causes sepsis. The populations at risk for sepsis include children < 1 year of age, people ≥ 65 years of age, people with chronic conditions like diabetes, lung disease, kidney disease, or cancer, and those with an impaired immune system (New York State, 2018b). An infection often causes sepsis in the lungs, urinary tract, skin, and/or gastrointestinal tract (New York State, 2018b). “Most sepsis cases are community-acquired. Seven in 10 patients with sepsis have recently used healthcare services or had chronic conditions requiring frequent medical care (New York State, 2018b).
Sepsis is a very serious public health problem. The WHO noted that in 2017 there were an estimated 48.9 million cases of sepsis and 11 million sepsis-related deaths worldwide, which accounted for almost 20% of all global deaths (WHO, 2020). The New York State Department of Health (2018a) estimates that severe sepsis and septic shock affect approximately 50,000 patients annually. The mortality rate of sepsis for the fourth quarter of 2018 was 23.5% (New York State Department of Health, 2019).
The New York State Sepsis Improvement Initiative and Rory’s Law
In 2014, New York began to require every hospital in the state that provides care for sepsis patients to develop and implement evidence-based protocols. They are to provide the Department of Health with clinical information that could be used to evaluate the hospital’s performance and to determine the risk-adjusted mortality of patients treated for sepsis at each hospital. These requirements were initiated in response to the death of 12-year-old Rory Staunton. Staunton developed sepsis after suffering an abrasion, and despite being hospitalized, he died five days after the injury. The opinion is that Staunton’s case was mismanaged and that although he had clear clinical and laboratory indications of sepsis, the diagnosis was not made. His parents began a movement for public awareness of sepsis and change in in-hospital care of sepsis, eventually culminating in the passage of the informally known regulations as Rory’s Law.
Each hospital in New York that provides care for patients with sepsis must abide by and follow Sections 405.2 and 405.4 of the New York State Codes, Rules, and Regulations (NYSDH, 2017). Sections 405.2 and 405.4 are outlined below in a (very slightly) abbreviated form; the full texts can be accessed using this link.
The medical staff shall ensure that staff with direct patient care responsibilities and, as appropriate, staff with indirect patient care responsibilities, including, but not limited to, laboratory and pharmacy staff, are periodically trained to implement sepsis protocols. The medical staff shall ensure updated training when the hospital initiates substantive protocol changes.
Hospitals shall submit the required sepsis protocols to the department for review. Hospitals must implement these protocols after receiving a letter from the department indicating that the proposed protocols have been reviewed and are consistent with the established criteria. Hospitals must update protocols based on newly emerging evidence-based standards. Unless the department identifies hospital-specific performance concerns, protocols are to be resubmitted at the department's request, not more frequently than once every two years.
The medical staff shall collect, use, and report quality measures related to recognizing and treating severe sepsis for internal quality improvement and hospital reporting to the department. Such measures shall include, but not be limited to, data to evaluate each hospital’s adherence rate to its sepsis protocols, including adherence to timeframes and implementation of all protocol components for adults and children.
Hospitals shall submit data specified by the department to permit the department to develop risk-adjusted severe sepsis and septic shock mortality rates in consultation with appropriate national, hospital, and expert stakeholders. Such data shall be reported annually or more frequently at the department's request and be subject to audit at the department's discretion.
As sepsis is caused by infection, New York state has infection control education outlined in New York State Law 6505-B and Section 239 of the New York State Public Health Law.
New York State Law 6505-B mandates infection control education for dental hygienists, dentists, licensed practical nurses, optometrists, podiatrists, and registered nurses practicing in the state (NYSDH, 2017).
Section 239 of the New York State Public Health Law states:
Implementation of these measures has been beneficial. The New York State Report on Sepsis Care Improvement Initiative: Hospital Quality Performance (published in 2019) reported that hospitals had improved the initiation of sepsis protocols and the early treatment protocols, and mortality rates have improved. The adult mortality rate decreased to 25.4% from 30.2%; the pediatric mortality rate fluctuated from 6.8% in quarter two of 2014 to 5.3% in quarter one of 2015, to a low of 6.5% in quarter three of 2015 (NYSDH, 2017).
Coordinated efforts to improve sepsis detection and treatment positively impact patient survival. Performance improvement programs like the New York state program improve compliance with sepsis care guidelines and decrease patient mortality (Evans et al., 2021).
Early identification and, thus, early treatment of sepsis is critically important; this point is repeatedly stressed in the medical literature. A 2017 article that used data from 2014 – 2016 and reported to the New York State Department of Health reinforced this as early initiation of antibiotic therapy decreased the mortality rate (Seymour et al., 2017). Many therapies for treating sepsis, particularly antibiotic therapy and fluid resuscitation, are recommended to be given within the first few hours of treatment. Late administration increases mortality risk (Schmidt & Mandel, 2022). Early identification of sepsis involves:
The signs and symptoms of sepsis include, but are not limited to:
Sepsis is characterized by a very high or very low fever, a rapid heart rate, and a general sense of not feeling well, which happen in the context of an infection.
The Sepsis Alliance uses the mnemonic TIME as an educational device to teach people about the signs and symptoms of sepsis (Sepsis Alliance, ND).
Seek medical attention immediately; do not wait. If someone has sepsis, nothing can be done at home to improve the situation, and delaying treatment is dangerous.
Sepsis often begins outside the hospital, but public awareness of sepsis is very low (Jabaley et al., 2018). Early recognition and treatment are critically important, so educating patients, families, caregivers, and the public about sepsis is important.
The lay public will often not have the technical background to understand the complexities of sepsis, but that is not a hindrance to providing them with accurate information that is simple to use and has practical benefits. Any basic educational program about sepsis should include sections on the seriousness of sepsis, causes of sepsis, signs, and symptoms, what to do if you suspect someone has sepsis, and sepsis prevention. The following information provides a framework for such a program.
Healthcare professionals must adhere to scientifically accepted infection control standards and be responsible for monitoring subordinates' infection control practices. Incorporating work practice controls and engineering controls helps avoid or reduce exposure to potentially infectious materials and hazards. Compliance with environmental infection control measures will decrease healthcare-related infections among patients, especially the immunocompromised, and healthcare professionals.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.