INFECTION CONTROL

PROTOCOLS IN I.C.U.

MODERATOR: PRESENTER:
Ms. Ujjwal Dahiya Ms. Sonu Yadav
Lecturer M.Sc. Nursing
CON, AIIMS First Year
 Objectives
• To understand basic infection control (IC) concepts
• Causes of Healthcare associated infections (HAI)
• Epidemiology of healthcare associated infections.
• Need of an infection control protocol.
• Organization and functions of infection control
committee.
• Strategies to prevent HAI.
• Transmission-based precautions.
• Strategies to prevent VAP, CRBSI, and UTIs in ICU
patients.
• Role of organizational and administrative measures in
infection control in ICU.
• Use of antimicrobial agents and monitoring.
 Why Infection Control?
 Hospital acquired infections are a common problem—
prevalence about 9% (according to WHO, 2010)

 Hospital acquired infections contribute to AMR

Overuse of antimicrobials (development)
Poor infection control practices (spread)
 Infection Control (contd..)
 Hospital-acquired infections increase the cost of health
care
 World Bank studies have shown that two-thirds of
developing countries spend more than 50% of their
health care budgets on hospitals

 Effective IC programs are beneficial

They decrease spread of nosocomial infections,
morbidity, mortality, and health care costs
 Development of AMR
 Poor or absent IC practices, especially in intensive care
units, results in cross-transmission of antibiotic-resistant
bacteria.

 Resistant bacteria prompts even greater antibiotic use by

physicians.

 Perception of knowledge by physicians of poor

sterilization, disinfection, or patient care practices
prompts increased antibiotic use (e.g., broad spectrum
and prolonged surgical prophylaxis in an effort to prevent
infections).
 Epidemiology of Healthcare
Associated Infections
Most common sites for nosocomial infections
 Surgical incisions (7%)
 Urinary tract (i.e., catheter-related) (15%)
 Lower respiratory tract (12%)
 Bloodstream (i.e., catheter-related) (28%)
 Epidemiology of Healthcare
associated Infections (contd..)
Common microorganisms
 Aerobic gram-positive cocci (Staphylococcus
aureas [MRSA], enterococci [vancomycin-
resistant]),
 Aerobic gram-negative bacilli (Escherichia coli, P.
aeruginosa, Enterobacter spp., and Klebsiella
pneumoniae)
 Epidemiology of HAI (contd..)

Nosocomial transmission of community acquired,

multidrug-resistant organisms
 M. tuberculosis
 Salmonella spp.
 Shigella spp.
 V. cholerae
 Causes of HAI
 Lack of training in basic IC

 Lack of an IC infrastructure and poor IC practices

(procedures)

 Inadequate facilities and techniques for hand

hygiene

 Lack of isolation precautions and procedures

 Causes of HAI (contd..)
Use of advanced and complex treatments without
adequate training and supporting infrastructure,
 Invasive devices and procedures
 Complex surgical procedures
 Interventional obstetric practices
 Intravenous catheters, fluids, and medications
 Urinary catheters
 Mechanical ventilators
 Causes of HAI (contd..)

• Inadequate sterilization and disinfection practices

and inadequate cleaning of hospital
Infection Control Committee
1. Membership—
• Doctor
• General physician
• Infectious disease specialist
• Surgeon
• Clinical microbiologist
• Infection control nurse
 Infection Control Committee

Membership (contd..)
 Representatives from other relevant departments
 Laboratory
 Housekeeping
 Pharmacy and central supply
 Administration
 Infection Control Committee
2. Functions—
 Addressing food handling, laundry handling, cleaning
procedures, visitation policies, and direct patient
care practices
 Obtaining and managing critical bacteriological data
and information, including surveillance data
 Infection Control Committee
Functions (contd..)
 Developing and recommending policies and
procedures pertaining to infection control
 Recognizing and investigating outbreaks of infections
in the hospital and community
 Intervening directly to prevent infections
 Educating and training health care workers, patients,
and nonmedical caregivers
First principle of infection prevention
35-50% of all HAI are associated with only 5 patient
Care practices:
• Use and care of urinary catheters
• Use and care of vascular access lines
• Therapy and support of pulmonary functions
• Surveillance of surgical procedures
• Hand hygiene and standard precautions
 Strategies to Reduce HAI
1. Hand hygiene:
To ensure appropriate hand washing techniques—
 Provide sinks, clean water, and soap at convenient
locations
 Where sinks, clean water, and hand washing supplies are
unavailable, use alcohol-based products which are
inexpensive, produced locally, convenient, and effective
for hand hygiene.
 Monitor compliance
 Use gloves
Observe hand hygiene:
• When
• How
2. Isolation and Standard Precautions:

 Whenever possible, avoid over-crowding.

• Assess the need for isolation.
• Identify the type of isolation needed:
– Protective isolation for neutropenic or other
immunocompromised patients to reduce the
chances of acquiring opportunistic infections
– Source isolation of colonized or infected patients
to minimize potential transmission to other
patients or staff.
Isolation rooms should have:
• tight-fitting doors,

• glass partitions for observation and

• both negative-pressure (for source isolation) and

positive-pressure (for protective isolation)
ventilations.
 Standard precaution steps
• Hand washing

• Personal protective equipment

• Decontamination

• Waste disposal
 Isolation and Standard Precautions (contd.)

 Implement specific policies and procedures for patients

with communicable diseases:
 Private rooms and wards for patients with specific
diseases
 Visitation policies
 Hand washing and use of gloves
 Gowns, when appropriate
 Masks, eye protection, gowns
 Precautions with sharp instruments and needles
3. Ensuring a Clean Environment:
 Establish policies and procedures to prevent food and
water contamination
 Establish a regular schedule of hospital cleaning with
appropriate disinfectants
 Dispose of medical waste safely
 Needles and syringes should be incinerated
 Other infected waste can be incinerated or autoclaved for
landfill disposal
 Bag and isolate soiled linen from normal hospital traffic
 Cleaning of patient care areas
• High-quality cleaning and disinfection of all patient-
care areas is important, especially surfaces close to
the patient (e.g. bedrails, bedside tables, doorknobs
and equipment)
• Frequency of cleaning should be as follows: Surface
cleaning (walls) twice weekly, floor cleaning 2-3
times/day and terminal cleaning (patient bed area)
after discharge or death.
Bio-Medical waste management

Color Waste Category Treatment

coding options
Yellow Human and animal Incineration/
wastes, Microbial and Deep Burial
Biological wastes and
soiled wastes
(Cat 1,2,3 and 6)
Color Waste Category Treatment
coding options
Blue Waste sharps and solid Autoclave/Microwave
Waste, infected plastics /
( Cat 4 &7) Chemical Treatment
Destruction/Recycling
and Shredding

Black General waste (food waste, Disposal in

garden waste, Discarded secured land
medicines, Cytotoxic drugs, fills
Incineration ash and
chemical waste)
(Cat 5,9 & 10)
Colour coding
 4. Cleaning, Disinfection, and Sterilization of
Instruments and Supplies
 Written policies and procedures are needed
 All objects to be disinfected or sterilized should first
be thoroughly cleaned
 Use stream sterilization whenever possible
 Quality control in reprocessing is essential
 Monitor and record sterilization parameters (i.e.,
time, temperature, pressure)
 Biological indicators should be used to ensure
sterilization
 Sterilized items must be stored in enclosed clean
areas
 Items or devices that are manufactured for single use
should not be reprocessed (e.g., disposable syringes
and needles
 Disinfectants in use at AIIMS
Disinfectant Dilution Contact time Use time

2% Activator + liquid Disinfection: 20- 14-28 days

glutaraldehyde in 5 L jar 30 min
Sterilisation:
10hrs
Glutaraldehyde + Bacillocid : water Disinfection: 24 hrs
formaldehyde 1 : 49 15min
Sterilisation: 5hrs
& 30 min
5% phenol Phenol: water 10-15 min 24 hrs
5: 95

Isopropyl alcohol No dilution 2-5 min 24 hrs

70%
 Disinfectants (contd.)
Disinfectants Dilution Contact time Use span
6% hydrogen No dilution 6-8 min Use immediately
peroxide after preparation

1% sodium 5% : 80ml + 20ml 20-30 min 8 hrs

hypochlorite bleach solution

Calcium 14g/l : visibly soiled 20-30 min 24 hrs

hypochlorite articles
1.4g/l : clean
objects
40% formaldehyde 30 min then open 15- 30 days
the area after 6 hrs
 5. Sterile Invasive Procedures and Intravenous
Medications

 Intravascular devices
 Use only when necessary.
 Prepare and administer IV medicines and fluids in
a sterile manner, in a designated uncontaminated
area, using specially trained staff.
 5. Sterile Invasive Procedures and Intravenous
Medications (contd..)

 Urinary catheters
 Avoid in-dwelling urinary catheters whenever
possible.
 Use closed drainage systems.
 6. Respiratory Therapy

 Mechanical ventilation and respiratory equipment

 Use only when absolutely necessary.
 Use suction catheters only once.
 Ensure that all equipment has ethylene oxide
sterilization or high-level disinfection before use.
 Wean patient early from ventilators.
 Ensure proper handling of inhalation medications and
supplies.
 7. Surgery and Surgical Site Care

 Minimize preoperative stays in the hospital.

 If necessary to shave the planned operative site, use
clippers (not razors) and shave immediately before the
procedure.
 Use antibiotic prophylaxis only when indicated and
according to established protocols.
 Provide sterile instruments in individually wrapped sterile
packages.
 Use an effective antiseptic, such as iodine, to prepare the
incision site.
 Include perioperative scrub with antiseptic scrub for hand
and forearm antisepsis for surgical teams.
Patient at risk of nosocomial infections
• Age more than 70 years
• Shock
• Major trauma
• Acute renal failure
• Coma
• Prior antibiotics
• Mechanical ventilation
• Drugs affecting the immune system (steroids,
chemotherapy)
• Indwelling catheters
• Prolonged ICU stay (>3 days).
Follow transmission-based
precautions
 Airborne precautions
• Disease-causing microorganisms may be suspended in the
air as small particles, aerosols, or dust and remain infective
over time and distance.

• Isolate with negative-pressure ventilation.

• Respiratory protection must be employed when entering

the isolation room.

• Use the disposable N-95 respirator mask, which fits tightly

around the nose and mouth to protect against both large
and small droplets.
 Contact precautions
• Infections can be spread by usual direct or indirect
contact with an infected person, the surfaces or
patient care items in the room.
• Isolation is required.
• Non-critical patient-care equipment should
preferably be of single use.
• Limit transport of the patient.
 Droplet precautions
• Microorganisms are also transmitted by droplets
(large particles >5 μm in size) generated during
coughing, sneezing and talking, or a short-distance
travelling
• Isolation is required
• Respiratory protection must be employed when
entering the isolation room or within 6-10 ft of the
patient.
 Specific strategies focused on
prevention of specific nosocomial
infections
 Strategies to reduce VAP
• Avoid intubation whenever possible
• Consider noninvasive ventilation whenever possible
• Keep head elevated at 30-45° in the semi-recumbent
body position
• Daily oral care with chlorhexidine solution of
strength 0.12%
• Daily sedation vacation if feasible and assessment of
readiness to extubate
• Avoid reintubation whenever possible
 Strategies to reduce CRBSI
• Use maximal sterile barrier precautions and a sterile full-
body drape while inserting CVCs, peripherally inserted
central catheters, or guide wire exchange
• Appropriate skin preparation
• Use ultrasound-guided insertion
• Prefer the upper extremity for catheter insertion. Avoid
femoral route for central venous cannulation
• Use either sterile gauze or sterile, transparent, semi
permeable dressing to cover the catheter site.
• Evaluate the catheter insertion site daily and check if a
transparent dressing is present and palpate through the
dressing for any tenderness
• Insertion date should be put on all vascular access devices
Strategies to reduce CRBSI (contd.)
• Closed catheter access systems should be preferred to open
systems
• Clean injection ports with an appropriate antiseptic
(chlorhexidine, povidone-iodine, or 70% alcohol), accessing
the port only with sterile devices. Cap stopcocks when not
in use
• Assess the need for the intravascular catheter daily and
remove when not required
• Replace administration sets, including secondary sets and
add-on devices, every day in patients receiving blood,
blood products, or fat emulsions
• Replace disposable or reusable transducers at 96-h
intervals.
 Strategies to reduce UTI
• Insert catheters only for appropriate indications.
• Follow aseptic insertion of the urinary catheter.
• Maintain a closed drainage system.
• Maintain unobstructed urine flow.
• The urinary bag should never have floor contact.
• Remove the catheter when it is no longer needed.
 Organizational and administrative
measures
• Work with hospital administration for better patient to nurse
ratio in the ICU
• Policies for controlling traffic flow to and from the unit to
reduce sources of contamination from visitors, staff and
equipment
• Waste and sharp disposal policy
• Education and training for ICU staff about prevention of
nosocomial infections
• ICU protocols for prevention of nosocomial infections .
• Audit and surveillance of infections and infection control
practices.
• Infection control team (multidisciplinary approach).
• Antibiotic stewardship.
• Vaccination of health care personnel .
 Employee Health and Training
Program
 Treat work-related illnesses
 Provide vaccinations to decrease infections
 Routine vaccinations (e.g., diphtheria, tetanus, polio,
measles, mumps, rubella, varicella, hepatitis A and B,
BCG)
 Vaccinations during epidemics (e.g., meningitis,
typhoid, influenza)
 Train health workers in—
 Appropriate sterile techniques
 Infection control procedures
 Use of barrier precautions (e.g., gloves) for certain
procedures
 Antimicrobial Use and Monitoring
(DTC and Infection Control Committee Collaboration)

 Establish protocols recommending use of the most

cost-effective agents when treatment is indicated
 Therapeutic guidelines
 Prophylactic guidelines
 Guidelines for surgical prophylaxis
Antimicrobial use and monitoring
• Implement interventions to improve antimicrobials
use
 Measure antimicrobial use to identify misuse
 Indicator studies in primary health care
 Drug use evaluations (DUEs) in hospitals
 Summary
 IC procedures are vital to preventing nosocomial
infections and for controlling hospital costs.
 Simple, inexpensive strategies can prevent many
infections.
 DTC can support many IC activities.
 Hand washing and use of appropriate antiseptics and
disinfectants
 Monitoring IV and injection preparation and
administration
 DTC should actively promote better use of antimicrobials.
 Guidelines for treatment and surgical prophylaxis
 Selection of appropriate antimicrobials for the
formulary
 Antimicrobial use reviews
 Summary (contd.)
 Infection Control Committees or programs, when
functioning effectively, will
 Reduce the spread of infectious diseases
 Decrease morbidity and mortality due to
nosocomial infections
 Maintain employee health and morale
 Decrease the incidence of AMR
 Decrease health care costs
 References
• Infection control manual, AIIMS.
• www.ncbi.nlm.nih.gov
• www.ijccm.gov
• www.wpro.who.int
• www.aun.edu
• www.cdc.gov
• www.cdc.hicpac.gov