Definition of Nosocomial Infections
Question:
Discuss about the Nosocomial Infections and Nursing Practices for Urinary.
Nosocomial infections are acquired from hospitals and is not initially found in the patient at the time of admission. It is acquired during hospital care and the infections usually arises 48 hours after hospital admission. Nosocomial infection is defined based on the infection of specific sites of the body like urinary and pulmonary infections. Nosocomial infections can be either epidemic or endemic. Epidemic infections occur as a result of outbreaks. Nosocomial infections that are endemic are the most common. Nosocomial infections encompasses the infections present in patients receiving treatments in the hospital. Infections acquired by visitors and staff are also considered to be nosocomial infections. Nosocomial infections acquired from intensive care units (ICUs) are classified as primary or secondary endogenous and exogenous infections. The secondary endogenous and the exogenous infections are acquired from ICUs. Types of nosocomial infections include surgical site, blood stream, urinary tract and lower respiratory tract infections (Mayhall 2012).
Infectious agents – bacteria, fungi, viruses. Patients with acquired immunodeficiency disease, diabetes, leukemia, renal failure. Environmental factor – hospital settings. Multidrug resistant bacteria – Staphylococci, Klebsiella and Pseudomonas. Diagnostic techniques – biopsies, catheterization, ventilation.
The conditions that give rise to nosocomial infections include the type of the organism, proximity to infected individuals, transmission of organisms and immune status of the patients. Some highly infectious microorganisms like the multidrug resistant bacteria, seasonal viruses like the influenza virus and Norovirus are most important as they can be easily transmitted from one patient to another. Patients when come in close proximity to other infected patients, healthcare employees, families or any visitors can contract infections from them. Crowded hospitals settings, transfer of patients from one unit to another and increased number of susceptible individuals in one area can help in the occurrence of nosocomial infections. When standard precautionary measures are not followed, it gives rise to nosocomial infections. Viruses are transmitted through the air in the form of aerosols and are inhaled. Moreover, touching of contaminated surfaces can also give rise to the occurrence of such infections. The immune status of the individuals plays an important role in the occurrence of nosocomial infections. Elderly patients or those with chronic diseases that suppresses the immune system are likely to develop the diseases, when they are kept in crowded hospital settings, where they are most likely to acquire the infections (Green 2014).
Causes of Nosocomial Infections
Staphylococcus aureus, Candida albicans, Escherichia coli, Pseudomonas aeruginosa, Clostridium difficile, Influenza virus, Methicillin resistant Staphylococcus aureus (MRSA) (Lobdell, Stamou and Sanchez 2012).
Transmission by direct contact occurs when infected individual handles a susceptible patient. Indirect transmission involves contact of susceptible individuals with contaminated objects. Air borne infections occur when droplets containing pathogenic microorganisms are inhaled. Common vehicle transmission occurs through contaminated food, water, equipment, medication. Vector borne transmission occurs through mosquitoes, flies, rats (Aslanimehr and Amirkamali 2015).
Neutropenia, cellular and humoral immune dysfunction, bone marrow transplantations and surgically implanted devices (Rolston 2015).
Standard precautions are:
- Washing hands.
- No touch technique usage.
- Wearing gloves.
- Washing of hands after removal of gloves.
- Handling of sharps with extreme care.
- Cleaning up of infective spills.
- Sterilization of contaminated equipment, supplies and clothing.
- Appropriate handling of waste.
- Disinfection of soiled clothing by boiling.
- Daily disinfection of medical instruments.
Maintenance of hand hygiene is the most important, simple and less expensive method to reduce the occurrence of nosocomial infections and the subsequent spread of multidrug resistant bacteria. Hand washing eradicates the transmission of multidrug resistant Staphylococcus aureus, that occurs as a result of working in intensive care units and the hands of the healthcare officials are most commonly infected in such situations. Maintenance of hand hygiene also causes significant reductions in outcomes related to infections, even among the critically ill patients, where infection rates are high. Transmission of Klebsiella infections has been found to be reduced as a result of hand washing. Washing hands before and after contact with patients is a simple means of preventing the spread of infections. Adherence to hand hygiene practices reduces the rates of pathogen acquisition on hands and in turn reduces the rates of hospital acquired or nosocomial infections among the hospital residents (Kirkland et al. 2012).
Hand washing involves vigorous rubbing of lathered hands and rinsing with water. Hand washing results in suspending the microorganisms and carries out mechanical removal by water. Handwashing with products containing antimicrobial agents mechanically removes and inhibits the growth of the microorganisms by use of soaps, which are medicated. This is a chemical removal of microorganisms. It is called hand antisepsis. A hand rub on the other hand is an alcohol based waterless compound that is used to rub on the hands. It is fundamentally different from the hand washing techniques. Approximately 3 ml of alcoholic hand rub is rubbed on the hands for 30 seconds. Microorganisms are killed by the use of such disinfectants and not just physically removed as in the case of hand washing. Microorganisms that do not come in contact with the alcohol will not be killed. These agents cannot carry out removal of organic materials or soils. Some of the hand rubs include isopropanol, chlorhexidine or quaternary ammonium compounds that slows bacterial growth. The objective of using a hand wash or hand rub is to either remove or kill the transient bacteria present in the contaminated hands of healthcare workers, thereby preventing the chances of cross-contamination.
Types of Nosocomial Infections
Protective clothing can be worn when handling body fluids, blood, mucous membranes or contaminated objects.
Face shields, gloves, goggles, gowns, head covers, masks, respirators and shoe covers. Face shields protect from droplets containing infectious agents. Gloves protect from droplet exposure and spread of germs. Goggles protect eyes from infectious aerosols. Gowns protect the skin and clothing. Head covers prevent the transmission of microbes. Masks help to protect the mouth and the nose. Respirators carry out filtration of the airborne contaminants. Shoe covers help to prevent the spread of infections (Labrague, Rosales and Tizon 2012).
Eliminating the use of sharps, use of protection mechanisms, safe practices, proper disposal, usage of personal protective equipment (PPE) and banning recapping (Himmelreich et al. 2013).
In case of sharp injuries, it is necessary to wash hands with soap and water, wash the eyes with tap water or eye wash. Washing of nose and mouth with running water. The water should not be swallowed. Washing cuts with soap and running water without scrubbing the wound. It is necessary to avoid sucking of the wounds. In the absence of soap and water, alcohol based hand rubs can be used. It is necessary to encourage bleeding from the wounds. The wound should be covered with a proper dressing to prevent contamination of the wounded area. It is necessary to ensure that the sharp is disposed off safely. The source of contamination should be recorded. It is also necessary to report such incidents to the supervisors and other medical personnel. It is necessary to visit the hospital emergency department immediately after the injury and check the status of vaccination.
Infectious, pathological, pharmaceutical, cytotoxic, chemical, radioactive wastes, sharps, heavy metal containing wastes (Www.who.int 2017).
Clinical waste is the waste that contains either full or partial contents of human or animal tissues, body fluids or blood, excretory substances, drugs or various pharmaceutical products, dressings or swabs contaminated with infected body fluids, blood and other contaminated fluids. Clinical wastes also include, needles, syringes or other types of sharp instruments, which if not disposed off properly can damage or be hazardous for an individual. Moreover, they can also transmit the infections to the environment or other individuals. Clinical wastes also involve wastes arising from nursing, medical, treatment or research practices (Www.health.nsw.gov.au, 2017). Proper management involves the proper segregation of the wastes and subsequent storage. It is necessary to mange and dispose off the wastes without causing any potential harm. The wastes are classified according to the types and quantity produced and disposed off accordingly. Various colored bins are used for disposal of various types of clinical wastes. Yellow ones for sharps, blue for medicines and other pharmaceutical products, orange for swabs and dressings, purple for cytotoxic wastes, red for anatomical wastes like placenta or body parts, yellow and black bags for wipes, gloves, infected garments, white ones for amalgam wastes or dental moulds and black bags for municipal wastes.
Transmission of Nosocomial Infections
If the nature of a spillage is not known, the fire alarm needs to be set off immediately. It is necessary for the person who raises the alarm to remain at the site and wait for the fire brigade. The individual should provide details about the spillage to the personnels. The staff working directly below the floor, where the spillage has occurred should be informed immediately. It is necessary for the hospital staff to be trained in handling unknown spillages. It is necessary to follow the necessary safety guidelines to manage spillages. It is necessary to use PPEs like masks, gloves, gowns or safety jackets, head and feet masks, so that no spillage comes in contact with the body or clothing. For acid spillages, it is necessary to use laboratory spill kits containing soda ash and P1 mask is to be worn to avoid inhaling the soda ash (Www.ucl.ac.uk, 2017).
Decontamination renders a material or item to be safe to use. The microbial load is reasonably reduced so that it is free from infections that can get transmitted. Antisepsis, disinfection and sterilization are different forms of decontamination. Sterilization means the complete absence of living microorganisms and even viruses. It involves killing of the microorganisms. The methods used in sterilization are heat, hydrogen peroxide gas, plasma, radiation, ozone and ethylene dioxide gas. Disinfection eliminates most but not all pathogens. It reduces the microbial contamination levels. Chemical disinfection are not able to kill bacterial or fungal spores but chemical sterilization can kill spores. Some of the common disinfectants used in the lab are 70% ethanol and 10% bleach. Disinfection can be classified into high, intermediate and low levels based on the types of disinfectants used. Disinfectants are used on inanimate objects or surfaces with the aim to kill most microorganisms except spores (Killeen and McCourt 2012).
Disinfection is defined as a process that kills most but not all microorganisms. It is unable to kill bacterial spores. It destroys and prevents the growth of pathogenic microbes. It is less effective when compared with sterilization, which in turn kills all types of microorganisms. Disinfectants are a type of antimicrobial agents that when applied on inanimate objects kills the microorganisms present on the surface of these objects. Disinfectants kill microorganisms by interfering with the microbial metabolism or destroying the cell wall of bacteria. There are various types of disinfectants like air disinfectants like glycols, alcohols like ethanol, isopropanol, aldehydes like formaldehyde and glutaraldehyde and oxidizing agents like sodium hypochlorite, calcium hypochlorite, chloramines, chloramines T, chlorine dioxide, hydrogen peroxide, hydrogen peroxide vapor, iodine, ozone, peracetic acid, performic acid, among others. Some disinfectants are wide spectrum while others have a smaller spectrum but are generally non toxic, non corrosive and inexpensive (Abreu et al. 2013).
Risk Factors for Developing Nosocomial Infections
Autoclaving, flash, dry and moist heat, radiation.
Microorganisms, particularly bacteria become resistant to antibiotics by the following ways. Development of evolutionary point mutations in target genes can give rise to antibiotic resistance in bacteria. An example is the mutation of the beta-lactamase gene that leads to resistance to beta-lactam antibiotics like penicillin, ampicillin, among others. Acquisition of extrachromosomal elements like plasmids and transposons can give rise to resistance to antibiotics because of the presence of the antibiotic metabolizing genes in either the plasmids or the transposons. Another way is to acquire DNA from exogenous sources like naturally competent bacteria can acquire DNA from the surrounding environment like antibiotic resistance genes. Other antibiotic resistance mechanisms include enzymatic modifications that either modifies or destroys the antibiotic before reaching the desired target. The antibiotic loses its function and activity. Bacteria also show resistance to antibiotics because of their outer membranes that prevents the antibiotic penetration. Alterations of the antibiotic target site can also cause resistance to antibiotics, as the antibiotic is unable to bind to the target. Overuse of antibiotics can also make the microorganisms resistant to antibiotics by promoting genetic alterations, mutagenesis and gene transfers. Antibiotics can also remove the sensitive microorganisms leaving behind the resistant ones to grow (Blair et al. 2015).
Before and after touching patients, before aseptic procedures, after exposure to body fluids, after touching patients.
At the beginning and end of a shift, entering ICUs, entering the patient rooms, before and after patient contact, before wearing gloves, before aseptic procedures, after exposure to blood or body fluids, after handling wastes, after using computers in clinical areas.
The routine hand washing technique includes wetting hands with water and soap. The quantity of the soap should be the size of a coin. This is followed by rubbing of palms to create a rich lather. Next, it is necessary to rub the back of the hands. Next, it is necessary to rub both the hands by interlocking fingers. This helps to remove contaminants present in between fingers. Then it is necessary to rub the back of the fingers and also the tips of the fingers. Fingers and the nails may contain residual contaminants, which can be removed by this procedure. Next, it is necessary to rub the thumbs and the end of the wrists. Finally, it is necessary to rinse both hands properly by keeping the hands under free flowing tap water.
Prevention of Nosocomial Infections
Infectious agents, reservoirs and means of transmission.
“See it, assess it, fix it, evaluate it and review it”.
National Safety and Quality Health Service Standards.
Control measures for sharp disposal involves the use of recapping devices for needles, and use of impermeable containers. The containers should comply with SHARPSAFE type and have a biohazard symbol. For preparing instruments for sterilization, it is necessary to take safety precautions like use of gloves. The instruments should be cleaned prior to sterilization to remove residual matter. Ultrasonic cleaning can be carried out. Instruments of different metals should be separated and wrapped in autoclavable cloths and an indicator should be provided. Contact precautions include wearing gloves and gowns to prevent immediate contact with patient or the surroundings. During cleaning of contaminated work surfaces, it is necessary to wear gloves and masks to prevent contact with hand or to prevent the inhalation of aerosols while cleaning. Control measures for removing wastes involves the use of gloves and gowns, masks. Use of PPEs while handling linen is a must (Chartier 2014).
Elimination, substitution, engineering controls, administrative controls and PPEs.
Hand washing, wearing gloves, regular disinfection with disinfectants.
Communication techniques include inter-hospital, intra-hospital communication, mobility like the use of radio paging, asynchronous communications like the use of e-mails or voice mails. Inter hospital communications can be carried out by the use of teleconsultation and the use of video links. Mobile staff can be contacted by the use of radio paging. Pagers are ubiquitous for communication between hospital staff. Hospitals have a lot of interruptions that impede necessary work to be carried out. It is necessary for the workers to use e-mails or voice mails to communicate between staff. Telephone calls are a major source of interruption as the staff have to attend the calls when performing some important duty. Patient updates and necessary care information can be provided to the staff through the use of e-mails and voice mails.
It is necessary to train staff and monitor them during implementation of infection control procedures in order to ensure a safe environment for patients and all other individuals working in the hospital. Without proper training, staff can carry out various malpractices that can give rise to various nosocomial infections that can be significantly hazardous for patients, particularly the critically ill ones. Proper training is needed for proper management of spillages and wastes. It is also necessary to carry out regular disinfection of the hospital items. Sterilization needs to be carried out of contaminated clothing, instruments, among others. It is necessary to train the staff about the use and importance of PPEs to prevent damage and spread of infection. Moreover, they should also be given training about the updated safety rules or guidelines of the hospital (Loveday et al. 2014).
Local Ground ambulance, Non emergency air ambulance and non emergency ground ambulance.
Reference List
Abreu, A.C., Tavares, R.R., Borges, A., Mergulhão, F. and Simões, M., 2013. Current and emergent strategies for disinfection of hospital environments. Journal of Antimicrobial Chemotherapy, 68(12), pp.2718-2732.
Aslanimehr, M. and Amirkamali, S., 2015. Hospital aquired infection.
Blair, J.M., Webber, M.A., Baylay, A.J., Ogbolu, D.O. and Piddock, L.J., 2015. Molecular mechanisms of antibiotic resistance. Nature Reviews Microbiology, 13(1), pp.42-51.
Chartier, Y. ed., 2014. Safe management of wastes from health-care activities. World Health Organization.
Green, K.Y., 2014. Norovirus infection in immunocompromised hosts. Clinical Microbiology and Infection, 20(8), pp.717-723.
Himmelreich, H., Rabenau, H.F., Rindermann, M., Stephan, C., Bickel, M., Marzi, I. and Wicker, S., 2013. The management of needlestick injuries. Deutsches Ärzteblatt International, 110(5), p.61.
Killeen, S. and McCourt, M., 2012. Decontamination and sterilization. Surgery (Oxford), 30(12), pp.687-692.
Kirkland, K.B., Homa, K.A., Lasky, R.A., Ptak, J.A., Taylor, E.A. and Splaine, M.E., 2012. Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series. BMJ Qual Saf, pp.qhc-2012.
Labrague, L.J., Rosales, R.A. and Tizon, M.M., 2012. Knowledge and Compliance of Standard Precautions among Student Nurses. International journal of advanced nursing studies, 1(2), pp.84-97.
Lobdell, K.W., Stamou, S. and Sanchez, J.A., 2012. Hospital-acquired infections. Surgical Clinics of North America, 92(1), pp.65-77.
Loveday, H.P., Wilson, J., Pratt, R.J., Golsorkhi, M., Tingle, A., Bak, A., Browne, J., Prieto, J. and Wilcox, M., 2014. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection, 86, pp.S1-S70.
Mayhall, C.G., 2012. Hospital epidemiology and infection control. Lippincott Williams & Wilkins.
Rolston, K.V., 2015. Immunologic Issues. In Advances in Cancer Survivorship Management (pp. 375-384). Springer New York.
Www.health.nsw.gov.au (2017). Clinical waste management. [online] Health.nsw.gov.au. Available at: https://www.health.nsw.gov.au/environment/clinicalwaste/Pages/default.aspx [Accessed 21 Nov. 2017].
Www.ucl.ac.uk (2017). Cite a Website – Cite This For Me. [online] Ucl.ac.uk. Available at: https://www.ucl.ac.uk/medicalschool/msa/safety/docs/spillagemanagement.pdf [Accessed 21 Nov. 2017].
Www.who.int (2017). Health-care waste. [online] World Health Organization. Available at: https://www.who.int/mediacentre/factsheets/fs253/en/ [Accessed 21 Nov. 2017].
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