High Risk Environments

Infection control and prevention is an essential element of patient safety. Infection can cause considerable pain, suffering and potentially death to patients. All those who come into contact with and are in the environment where vulnerable patients are, have a responsibility to modify their behaviour to ensure that transmission of infection is reduced to a minimum.

The environments discussed here relate to surgical intervention, where due to the incision/wound created, patients are especially vulnerable. These are operating rooms and to a lesser extent catheter laboratories and radiology departments.

Reducing Risk to Yourself

Pathogens in hospitals are particularly virulent and may be resistant to treatment. Pathogens may be bacterium, viruses or other microorganisms that cause infection or disease to its host. Your best mechanism for protecting yourself when going into the environment is to be knowledgeable, aware and take the opportunity frequently to wash your hands.

To protect yourself, using personal protective equipment whenever possible. You would not wish to take these microorganisms away from the hospital to your car or to your next appointment.  

Healthcare Associated Infections

Healthcare associated infections (HAIs) are infections that affect patients coming into hospitals which are not present when they are first admitted (or incubating on admission). They are described as one of the most frequent adverse events, affecting seven in developed, and ten of every hundred patients in developing countries. They cause pain and suffering to patients and their families, which may lead to mortality and there are significant costs for healthcare systems. Such infections annually account for 37,000 attributable deaths in Europe, and potentially many more could be included in the data.

The World Health Organization identifies factors which may be the cause of healthcare associated infections. These are:

  • Prolonged and inappropriate use of invasive devices and antibiotics
  • High risk and sophisticate procedures
  • Immuno-suppression and other severe underlying patient conditions
  • Insufficient application of standard and isolation precautions

Surveillance and Monitoring

Public Health England, Health Protection Scotland, Public Health Wales and the Public Health Agency in Northern Ireland are responsible for the monitoring and surveillance of infection rates in each of the devolved nations’ health services.

The objectives of surveillance are to:

  • Monitor the incidence of infection
  • Provide early warning and investigation of problems and subsequent planning and intervention to control
  • Monitor trends, including the detection of outbreaks
  • Gain information on the quality of care
  • Prioritise the allocation of resources

WHO specifies that surveillance contributes to a 25-57% reduction in HAIs.

Preventing Healthcare Associated Infections

Each year, millions of people around the world are affected by healthcare associated infections, this problem tends only to get widespread attention when there is an outbreak, such as Ebola recently suffered in West Africa. WHO remind us all that:

  • HAIs cause unnecessary death
  • HAIs result in a human and economic burden
  • HAIs prolong hospital stays, create long term disability and increase the burden of antimicrobial resistance

Without regular surveillance and feedback to care facilities, and knowing what the burden of infection is locally and nationally, it is impossible to prioritise action.

Surgical Site Infection

Surgical site infection (SSI) is one of the most frequently cited types of hospital associated infections affecting up to 19.6% of all HAIs in Europe in 2011-12. The Center for Disease Control and Prevention and the European Centre for Disease Prevention and Control define SSI as post-operative infection occurring within 30 days of a surgical procedure (or within one year for permanent implants). 

Patients are negatively impacted by longer stays in hospital and possible returns to surgery. There may also be additional pain and discomfort, and a wound that may not heal properly for many months. In this situation, patients find they are physically and sometimes mentally affected, with increased morbidity and possible death. The impact of this on the patient themselves and their families should not be underestimated.

With the current high priority being placed on reducing HAIs and finding new evidence for the reduction of surgical site infections, all surgical team members are expected to adhere to the strict standards which apply. 

Effect on Patients

HAI can affect any part of the body, including skin, surgical wounds (surgical site infection), urinary system (urinary tract infection), lungs (pneumonia or respiratory tract infection), digestive (gastrointestinal) system and the bloodstream (bacteraemia).

Many infections come from the natural flora of the patient's body, which are normally harmless. However, when patients are vulnerable, particularly following the breach of protection afforded by the skin by surgery, infection may cause issues. It has been estimated that patients have an additional 11 days in hospital if they contract an infection.

The main infectious agents which cause HAIs are: 

Staphylococcus aureus
One third of healthy people may be carriers of Staphylococcus aureus – a bacteria that commonly colonises human skin and mucosa – without causing any problems. However, surgery provides a portal for the bacteria to enter the body (the incision site), where it may cause disease. Possible infections which result to exposure may be wound and skin infections, abscesses, infections in the joints and endocarditis as well as pneumonia and bacteraemia. Some of these diseases may be mild, but others prove to be life threatening.  

Many strains are sensitive to commonly used antibiotics so can be effectively treated. However, there is a large number of bacteria becoming resistant to many of the antibiotics in use - those resistant to antibiotic methicillin are labelled methicillin-resistant Staphylococcus aureus (MRSA) and often require different types of antibiotic for treatment. Some 1-3% of people are colonised with MRSA. In most cases no treatment is necessary and most of the carriers do not know that they have the bacteria.

As the bacteria can cause devastating illness to hospitalised and other vulnerable patients, screening has become more common to reduce the opportunities for transmission.  

Pseudomonas aeruginosa
P. aeruginosa
is one of the more common causes of HAI and is increasingly resistant to many antibiotics. In hospitals the organism contaminates moist/wet reservoirs such as respiratory equipment and indwelling catheters. Infections can occur in almost every body site but are particularly serious in the bloodstream.

It is an opportunistic pathogen that exploits breaks in the host defences to initiate infection. The bacterium almost never infects uncompromised tissues, yet there is hardly any tissue that it cannot infect if tissue defences are compromised. It causes urinary tract infections, respiratory system infections, dermatitis, soft tissue infections, bacteraemia, bone and joint infections, gastrointestinal infections and a variety of systemic infections, particularly in patients with severe burns and in cancer and HIV/AIDS patients who are immuno-suppressed.

P. aeruginosa infection is a serious problem in patients hospitalised with cancer, cystic fibrosis and burns. The case fatality rate in these patients is near to 50%.

Enterococcus faecalis
Enterococci
are bacteria commonly associated with the normal gut flora of animals and humans. The genus Enterococcus includes more than 17 species, although only a few cause clinical infections in humans. They pose a major therapeutic challenge. They are increasingly becoming resistant to a number of specific and multiple antibiotics used in hospitals.

Infections caused include urinary tract infections, endocarditis, bacteraemia, catheter-related infections, wound infections and intra-abdominal and pelvic infections.

Enterococci can survive for long periods on hard surfaces before transmission and initiation of an infection. US data shows that enterococci is one of the three most commonly isolated bacterium. They typically occur in very ill, debilitated patients who have been exposed to broad-spectrum antibiotics. Mortality rates may exceed 50% in patients who are already ill.

Clostridium difficile
C. difficile
infection is usually spread on the hands of healthcare staff and others who come into contact with infected patients or surfaces (ie, floors, bedpans, toilets) contaminated with the bacteria or its spores. Spores are produced when C. difficile bacteria encounter unfavourable conditions, such as being outside the body. They are hardy and can survive on clothes and environmental surfaces for long periods.

C. difficile infection is the most important cause of hospital-acquired diarrhoea. C. difficile is an anaerobic bacterium that is present in the gut of up to 3% of healthy adults and 66% of infants. C. difficile rarely causes problems in children or healthy adults as it is kept in check by the normal bacterial population of the intestine. When certain antibiotics disturb the balance of bacteria in the gut, C. difficile can multiply rapidly and produce toxins which cause illness. It is known to be the cause of considerable morbidity and risk of mortality.

 

Standard Precautions

One of the main controls which help to protect patients and surgical teams is the concept of standard precautions. The World Health Organization specifies that:

“Standard precautions are meant to reduce the risk of transmission of blood-borne and other pathogens from both recognised and unrecognised sources. They are the basic level of infection control precautions which are to be used, as a minimum, in the care of all patients.”

The Chain of Infection

In order for a disease to be transmitted, three elements need to be present:

  • An infectious agent or pathogen (ie, bacteria, a virus, protozoa, a parasite or a fungus).
  • The pathogen (disease-causing microorganism) needs to find a host in which to multiply. The host needs to be susceptible to the infectious agent and may be a plant, animal or human being.
  • The environment must provide the pathogen with what it needs to survive and multiply and be conducive to disease transmission.

The new host can influence the severity of the disease dependent on the strength of its immune system, the reproductive rate of the infectious agent, immunisation and medical treatment. 

The disease process can be interrupted and this is done by breaking the chain of infection.

Interrupting the chain of infection in hospitals is known to be largely achieved by one set of actions, undertaken often by everyone. Hand hygiene is crucial at all stages of visiting a hospital, as many of the common surfaces which you come into contact may be contaminated with multiple resistant bacteria (eg, handrails, elevator buttons, door handles/push.

Break the chain of infection by thorough hand cleansing.

Hand Hygiene

Hand hygiene is one of the most effective means of breaking the chain of infection and is credited with a huge reduction in the prevalence of MRSA in our hospitals.

Hand hygiene stations are often sited at the entrance to wards and departments and are a timely reminder for everyone, that hand hygiene must be a frequent action. If hands are visibly soiled they must be washed with soap and water. If not, they may be rubbed using alcohol gel, which is also frequently available. Both methods should be done according to the prescribed technique and will reduce microbial contamination.   

The Five Moments of Hand Hygiene
Described by the World Health Organization, hand hygiene should be undertaken:

  • Before touching a patient
  • Before clean/aseptic procedure
  • After body fluid exposure risk
  • After touching a patient
  • After touching patient surroundings

In your own interest, if you have any kind of upper respiratory tract infection, you should wash your hands frequently to reduce the likelihood of passing it on to vulnerable patients.

Transmission Types

Direct
Close association - not necessarily through physical contact - is the means of direct transmission of a disease.  

Transmission may occur through droplet transfer, by a cough or a sneeze of an infected person. Microorganisms are propelled to the host’s conjunctivae, nasal mucosa or mouth. The source and susceptible host need to be one metre or less from each other for transmission to occur.

Airborne transmissions can be carried on air currents that are inhaled by a potential host, either in the same room or over a longer distance from the source. Microorganisms transmitted this way include rubella, varicella and mycobacterium tuberculosis. Control of such transmissions can be extremely challenging. 

A portal of exit enables pathogens to leave an infected host and pass them (ie, via body fluids, blood or airborne droplets via sneezes or coughs).

They can be accepted through a portal of entry into the new host (ie, penetration, inhalation or ingestion).

Indirect
Indirect transmission requires a “vector” or carrier – an organism, which could be a biting insect or tick. The carrier passes the disease or parasite from one animal or plant to another.

The disease may be transmitted indirectly through contaminated items (ie, surgical instruments, blood and intravenous solutions).   

Standard precautions will assist you in protecting yourself from transmission of disease by the use of risk assessment and barrier protections, such as gloves, masks and eye protection.

Clothing and Drapes

One of the many ways that the patient may be protected from infectious agents in the hospital, especially when undergoing surgery, is for the team around them to be dressed in clothing which is only worn for the duration of surgery or a surgical list, before it is laundered at high temperatures.

When you attend surgery, you will change into a scrub suit (also known as blues or greens) and out of them at the end of the attendance. If you have been wet or splashed with blood during surgery, you should change immediately. 

The procedure of covering a patient and surrounding areas with a sterile barrier to create and maintain a sterile field during a surgical procedure is called draping.

The purpose of draping is to eliminate the passage of microorganisms between non-sterile and sterile areas. They are generally disposable but may also be of an enhanced textile type which reduces contamination of the wound site but may also be able to be laundered.

In addition to special clothing, you may be offered other protective equipment suitable for the environment, such as eye protection. It is best to take advantage of it although you may note a curious complacency amongst the staff to use it. You should ignore that and protect yourself.

You will also be protecting your shoes from becoming splashed by using your own clogs or those from the hospital. Many companies will allow you to be reimbursed for purchase of your own clogs. These should be kept in your car in a cloth bag and wiped clean between uses.

Personal Protective Equipment

Ensuring that you are safe in high risk environments means understanding the elements of protective equipment which is available for you to use, in a variety of risky situations.

You will need to make a personal risk assessment. Review what you know about the procedure ahead of you – is there a particular risk of splash of blood or body fluid? Do you know that the surgeon is likely to want you to approach the operating table to show you the anatomy? If you are in ICU or a catheter lab are you protected from the risk of infection from the patient or from x-ray? The type of PPE will vary according to the risk assessment you make.  

You may never know whether the assessment you made was correct; but if you have ensured your own safety and reduced the opportunities for transmission of microorganisms to you and your family, then it has been worthwhile.  

Personal Protective Equipment

PPE available for selection:

Gloves
You should not need to wear gloves for many of your hospital activities. On the occasions when it may be relevant, you should find unsterile gloves for your size when:

  • A piece of your kit is being taken back to the company without having been decontaminated
  • Explanted material is handed to you straight from the patient
  • Engineers may need to fix a piece of equipment which has not been able to be cleaned before it is transported back to base

Don’t forget to wash your hands after removal of the gloves.

Eye protection and masks
It is recommended that you wear a surgical mask if you assess that you are going to have your face close to the surgical wound. Surgical facemasks protect you from splash and also the patient’s wound from your respiratory droplets. Facemasks also provide some degree of protection from inhalation of surgical smoke which is carcinogenic. Drills and saws used in open surgery and orthopaedics create minute splashes of blood and tissue which spread in the air. Eye protection and facemasks will protect you from this.

Some masks contain an integral and attached visor but many do not. You should look for alternative eye protection in the form of goggles or other face visors. 

The mask should fit closely to your face, including your nose and under your chin with the tapes tied. They should cover your nose and mouth and once on the face should not be touched. When taking off a mask, hold it by the ties, discard it into the waste bin and then wash your hands.

Association for Perioperative Practice standards recommend that a facemask should be changed after every procedure and that masks should never be allowed to hang around the neck or be placed in a pocket for later use.  

There are also plastic aprons, but these are likely to be used only by healthcare staff getting involved in a procedure which may be wet or moist with patient's bodily fluids.

Other Appropriate Attire

All head and facial hair should be covered completely by a head cover/cap – surgical site infections have been traced to organisms isolated from the hair and scalp. Disposable caps are ideal as others have to be laundered at home. 

Headwear should be donned prior to donning the scrub suit. This eliminates the possibility of hair or dandruff being shed onto scrub clothing.

Jewellery should be removed as it has been shown to increase surface bacterial counts when left in situ.

Fingernails should be clean, short and free from nail varnish. False finger nails, including acrylic or gel-coated nails should not be worn. These have been shown to harbour microorganisms such as fungi and Gram-negative bacteria even after hand washing – they can also inhibit hand washing.

“Bare Below the Elbow” Policy

As an adjunct to hand hygiene policies, many NHS trusts have a bare below the elbow policy for all staff and visitors. Being bare below the elbow creates more effective hand hygiene and reduces the risk of cross infection. The policy highlights that infection is more likely to occur directly via hands or indirectly via an environmental source. Hand-mediated transmission is one of the major contributors to the acquisition and spread of infection across hospitals. Ensuring hands are decontaminated effectively using the correct techniques around the hands and wrists is important.

It is not obvious but this policy also indicates short-sleeved shirts to avoid cuffs being the cause of microorganism transmission. In the same way, ties are now less frequently worn by healthcare workers who may lean over patients, potentially contaminating the textile and passing on microorganisms to the next patient.

Blood-Borne Viruses

Blood-borne viruses (BBVs) are viruses that some people carry in their blood and can be spread from one person to another. Those infected with a BBV may show little or no symptoms of serious disease, but other infected people may be severely ill. You can become infected with a virus whether the person who infects you appears to be ill or not – indeed, they may be unaware they are ill as some persistent viral infections do not cause symptoms. An infected person can spread blood-borne viruses from one person to another by various routes and over a prolonged time period.

The most prevalent BBVs are:

  • Human immunodeficiency virus (HIV) – a virus which causes acquired immunodeficiency virus (AIDS), a disease affecting the body's immune system
  • Hepatitis B (HBV) and hepatitis C – BBVs causing hepatitis, a disease affecting the liver

As well as through blood, BBVs can also be found and transmitted through other body fluids, eg:

  • Vaginal secretions
  • Semen
  • Breast milk

Unless contaminated with blood, minimal risk of BBV infection is carried by:

  • Urine
  • Saliva
  • Sweat
  • Tears
  • Sputum
  • Vomit
  • Faeces

The presence of blood in these bodily fluids and materials isn't always obvious, so care should still be taken to avoid infection.

Blood-borne viruses that cause hepatitis include the hepatitis B virus (HBV) and hepatitis C virus (HCV). Other viruses that cause hepatitis (such as hepatitis A and E) are not usually passed on by blood-to-blood contact and hence do not present a significant risk of blood-borne infection.

Many of the medical device companies who expect that as part of your role you will be frequently in a high-risk environment, will enable you to be immunised against hepatitis B.

Blood-Borne Viruses

How blood borne viruses are spread
BBVs are mainly transmitted sexually or by direct exposure to infected blood or other body fluids contaminated with infected blood. In the workplace, direct exposure can happen through accidental contamination by a sharp instrument (ie, a needle or broken glass).

Infected blood may also spread through contamination of open wounds, skin abrasions, skin damaged due to a condition such as eczema, or through splashes to the eyes, nose or mouth.

BBVs are transmitted by blood, or other body fluids containing virus. This happens when the blood or fluids enter into the body of a susceptible person (or new host).

The rate of viral transmission varies depending on how the person has been exposed to the virus (the route of transmission), the type of virus, how much of the virus the carrier has in their body and the immune status of the exposed person.

The more common routes of transmission include:

  • Sexual intercourse (common for HBV, HIV; inefficient for HCV)
  • Sharing injecting equipment
  • Skin puncture by blood-contaminated sharp objects (eg, needles, instruments or glass)
  • Childbirth (ie, the mother infects the child either before or during birth, or through breast-feeding)

There are a great many different guidance documents relating to protection for healthcare workers in specific situations. Some of those are referenced by the Health and Safety Executive.

Needlestick and Sharps Injuries

There should not be too many opportunities during the course of surgery for you to get a sharps or needlestick injury. However, many healthcare workers do get injured during the course of their work – which means that the risk is inherent in the environment. Most sharps injuries are caused by needles, scalpels or other sharp instruments and are avoidable if everyone practices safely. Clinical staff undertaking blood retrieval or managing tissue in some way (surgeons as well as laboratory staff) are the highest at risk, but ancillary staff managing healthcare waste are also at some considerable risk.

Analysis by the Health Protection Agency of where most injuries occur identify that wards, followed by theatres, then A&E followed by intensive care units. These are all areas of the hospital where medical device reps might be working in support of their product range. When the injuries occur is also interesting – during use as well as the point just before disposal being the highest risk moments.

Reporting Injuries

All hospitals and NHS trusts have reporting procedures should you get injured. Get advice locally so that if you need treatment immediately, this can be undertaken either in A&E or occupational health before you leave the site. You should take a copy of the incident report so that you can copy it to your employer.

Accidental injury by a sharp implement, such as a hollow bore needle contaminated with a blood-borne virus, can lead to the transmission of blood-borne viruses. While the risks of contracting a blood-borne virus are variable, the anxiety of having to go through blood tests and possible treatment can cause a great deal of stress.

If you are off for more than five days with the injury, employers must comply with the requirements of the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) 2013 relating to sharps injuries and report sharps injuries formally to the Health and Safety Executive.

They must do this when the source patient is known to carry a blood-borne virus, is subsequently found to have a blood-borne virus, or the healthcare worker develops a virus following a sharps injury.  

Clean Healthcare Environments

The importance of patients, visitors and staff not transmitting infections by cross-contamination cannot be underestimated. The environment of a hospital needs to be as clean as possible and for all opportunities for reduction of microorganisms to be taken.

There is increasing concern in many hospital areas that cleaning is not done as well as it may be, as it is often a shared task between nurses and cleaners with opportunities for gaps in efficiency.

There are many areas in a hospital which are frequently touched by potentially contaminated hands. These include lift buttons, handrails, door plates and many types of bed and patient furniture. These need to be routinely cleaned, many times a day preferably by the same team each time, who take responsibility and pride in their work.

Cleaning must be undertaken before disinfection because many of the chemicals are not effective in the presence of dirt and organic matter. Some pathogens such as norovirus and C. difficile are not inactivated by commercial disinfectants routinely used in health settings. In situations where contamination with these pathogens is suspected, a bleach/chlorine solution (1:10) is recommended for disinfecting contaminated surfaces and items. Some patient care items may be damaged or destroyed by certain disinfectants due to the aggression of the chemicals.

Waste Management

Hospitals produce vast quantities of waste (ie, pharmaceutical, clinical and cytotoxic) which may be hazardous to the handlers and to the environment and will need to be made safe for disposal.

Clinical waste defined by the 1992 Controlled Waste Regulations may contain:

  • Human or animal tissue
  • Blood or bodily fluids
  • Excretions
  • Drugs or other pharmaceutical products
  • Swabs or dressings
  • Syringes, needles or other sharp instruments which, unless rendered safe, may prove hazardous to any person coming into contact with it

Clinical waste also refers to any other waste arising from medical, nursing, dental, veterinary, pharmaceutical or similar practice, investigation, treatment, teaching or research

Compliance is a matter of law. The correct and proper management of clinical waste is vital for any organisation that produces hazardous waste, due to the strict legislation in place to prevent harm being caused to the environment and human health.

At source, all waste is segregated and made safe before it is contained and transported within the hospital to be moved around the UK to its eventual final disposal site, often by incineration. 

Antimicrobial Resistance

Antimicrobial resistance is rapidly becoming a global problem. Microorganisms multiply and mutate very easily enabling small changes in their genetic make-up to change them fundamentally. If they are exposed to many different antibiotics in acute care facilities, they rapidly change from being effective to being ineffective against common bacteria and viruses. The intensity of antimicrobial use in acute care, together with the highly susceptible patient population creates an ideal environment for the facilitation of emerging and cross transmission of resistant organisms.

Many hospitals are reducing their use of antibiotics until diagnosis of the sensitivity of the microorganisms has been determined. This is believed to be an effective way of protecting antibiotics for use into the future. However, if we should listen to the doom merchants (and there are many) we are fast running out of options and approaching the post-antibiotic era when a small finger cut or minor surgery could be the cause of death. Joint and organ transplants will be impossible.   

It therefore behoves all of us to use the simple methods of interrupting the transmission of infections at all times in hospital, to reduce risks to us all.   

Exam

This ends the course. You can now continue to the exam. 

 

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