Comprehensive Guide to University Healthcare Precautions and Infection Control

Clinical Precautions and Infection Control Foundations

Precautions in the healthcare setting are designed to protect both the worker and the patient from the transmission of pathogens. These precautions are categorized into two primary types: standard precautions and transmission-based precautions.

• Standard Precautions: Originally known as universal precautions, these are the fundamental practices applied to every patient regardless of their infectious status. This concept assumes that all blood and body fluids (except sweat) are potentially infectious.
• Transmission-Based Precautions: These are implemented when a patient is known or suspected to be infected with specific pathogens. The measures taken are tailored based on the specific pathogen and its mode of transmission (contact, droplet, or airborne).

Standard and Universal Precautions

The concept of universal precautions emerged in the $1970s$ and $1980s$ as a response to the HIV epidemic. Previously, healthcare workers often assumed a patient was not diseased unless a diagnosis was known. In $1996$, the CDC expanded these concepts into standard precautions to include contact with blood, sputum, spit, phlegm, and earwax. Every body fluid except sweat is treated as a potential source of infection.

• Rationale: Treat every patient as if they can infect you, which protects both the practitioner and the patient. This is particularly important when test results are not yet available.
• Minimum Practice: These represent the minimum infection prevention practices applicable to all patient care, regardless of confirmed or suspected status.
• Application Criteria: The degree of protection used depends on the anticipated exposure. For example, if simply looking at a ventilator screen, no PPE may be needed. If touching the patient to listen to breath sounds, gloves are required because of contact with skin and gowns.
• Core Components:
  • Hand hygiene.
  • Use of Personal Protective Equipment (PPE) as appropriate.
  • Sharp safety (needles and scalpels).
  • Environmental cleaning and surface disinfection.
  • Respiratory hygiene/cough etiquette.
  • Appropriate patient placement.

Hand Hygiene: The Primary Step in Infection Control

Hand hygiene is the most critical step in breaking the cycle of infection. It must be performed upon entering and exiting every patient room.

• Methods:
  • Handwashing: Uses soap and water. Soap acts as a surfactant, meaning it does not necessarily kill pathogens on contact but removes them from the skin to be rinsed down the drain.
  • Hand Rubbing: Uses alcohol-based gels or foams. These kill germs directly on the skin but can leave a film after $10$ to $15$ uses, necessitating a traditional soap-and-water wash.
• Effectiveness Factors: Jewelry, long nails, and chipped nail polish can harbor bacteria. Many hospitals, particularly NICUs, ban fake nails or gel polish because chips provide edges where bacteria can reside.
• Timing Recommendations:
  • CDC Guidelines: Perform hand hygiene for $20$ to $30$ seconds.
  • WHO Guidelines: Perform handwashing for $40$ to $60$ seconds.
  • Invasive/NICU settings: May require a three-minute scrub up to the elbows before entering isolates.
• Washing Procedure:
  1. Wet hands with water.
  2. Apply enough soap to cover all surfaces.
  3. Rub palm to palm.
  4. Rub backs of hands and between fingers.
  5. Interlace fingers and rub palms.
  6. Clean thumbs and the webbed space in between.
  7. Rub fingertips in palms (circular motion).
  8. Rinse with water, drying thoroughly with single-use towels.
  9. Use the paper towel to turn off the faucet.
• Rubbing Procedure: Apply a palmful of alcohol product, cover all surfaces, and allow to air dry. The drying process is what kills the pathogens.

Personal Protective Equipment (PPE)

PPE selection is based on the interaction with the patient and the possible modes of transmission. Equipment is provided by the hospital and includes gloves, eye protection, masks, and gowns.

• Donning Sequence (Putting on):
  1. Gown: Secure at the base of the neck and tie so the back is fully covered.
  2. Mask or Respirator: Ensure the mask is anchored high on the head to prevent slipping.
  3. Goggles or Face Shield: Essential for protecting the mucous membranes of the eyes from splatters.
  4. Gloves: The final step. Ensure the glove cuffs cover the wrists of the gown.
• Doffing Sequence (Removing):
  • Preferred Method: Remove gown and gloves together. Pull the gown from the front so it balls up around the gloves, containing the infectious material inside the gown. Then perform hand hygiene.
  • Sequence 2: Remove gown and gloves, then goggles/shield, then mask, followed by hand hygiene.
• Mask Types:
  • Surgical Masks: Thin, paper masks used for standard or droplet precautions. These can use ear loops or ties.
  • N95 Respirator: Blocks approximately $95\%$ of particles that are $0.3$ microns or larger. These require a specific fit test to ensure a tight seal. When breathing, the mask should move in and out with the breath.
  • PAPR (Powered Air Purifier Respirator): Used when N95s cannot achieve a seal, such as with individuals who have extensive facial hair (e.g., large beards). It uses a battery-operated blower and HEPA filters to provide purified air.

Sharps Safety and Disposal

Sharps including needles and scalpels require extreme caution to prevent accidental sticks, which could lead to chemo-prophylaxis treatments and hospital reporting.

• Rules for Needles: Never recap a needle using two hands. If recapping is necessary, use a one-handed scoop technique on a flat surface.
• Safety Devices: Utilize needle guards, blunt tip needles, and flip-over orange guards. Do not use your finger to flip the safety guard; use a surface.
• Disposal: Place sharps into dedicated puncture-resistant containers. Containers should be replaced when they are approximately $3/4$ full. Never reach into a sharps container to retrieve a specimen or needle.

Transmission-Based Precautions: Contact, Droplet, and Airborne

These precautions are added to standard precautions based on specific diagnoses.

• Contact Precautions: For organisms spread by direct or indirect contact (e.g., MRSA). Requirements include gown and gloves for all interactions. Dedicated disposable equipment (like stethoscopes) is preferred. If using a personal stethoscope, it must be cleaned with bleach or a sporicidal, and a glove can be placed over the bell for extra protection.
• Contact Precautions Plus: Specifically for C. Diff (Clostridioides difficile). Pathogens are not killed by alcohol. Practitioners must wash hands with soap and water ONLY (no foam) and surfaces must be cleaned with bleach.
• Droplet Precautions: For pathogens $> $5$ microns that drop within $3$ to $5$ feet (e.g., Influenza, Pertussis/Whooping Cough, COVID). Requirements include a surgical mask and eye protection. Patients being transported must wear a surgical mask.
• Airborne Precautions: For pathogens $< $5$ microns that remain suspended in the air (e.g., Tuberculosis/TB, Measles, Smallpox, Ebola). Requirements include a fit-tested N95 mask and a negative pressure room.
• Negative Pressure Rooms: These rooms have $6$ to $12$ air changes per hour. Air is pulled into the room/antechamber, passed through HEPA filters, and exhausted outside the hospital to prevent pathogens from riding the wind into hallways.

Specialized Environments and Specimen Handling

• Protective Environment (Neutropenic Precautions): Used for immunocompromised patients, such as oncology and transplant patients. The goal is to minimize fungal and spore counts. No fresh flowers or fruit are allowed. Staff with minor illnesses (e.g., $99$ degree fever) should avoid these assignments or wear a mask at all times.
• Specimen Handling: All specimens (sputum, blood, ABGs) must be labeled with the patient's name, ID number, date of birth, date, time, and collection location. Samples should be placed in biohazard bags if the patient is on isolation. Gloves may be worn to transport the specimen but must be removed before touching shared hospital equipment or charting.

Healthcare Surveillance

Hospitals monitor the acquisition of infections to improve quality and comply with public health reporting (CDC, Louisiana Department of Health).

• Monitoring Targets:
  • HAI: Healthcare Acquired/Associated Infections.
  • CLABSI: Central Line Associated Bloodstream Infections.
  • CAUTI: Catheter Associated Urinary Tract Infections.
  • VAP: Ventilator Associated Pneumonia (occurring $24$ to $48$ hours post-intubation).
  • VAE: Ventilator Associated Events.
• Case Study: Approximately $15$ years ago, LSU Health identified an unusual bacterial infection through surveillance. The CDC traced the outbreak to tainted alcohol swabs from a specific factory, which led to a national recall.

Questions & Discussion

Q: What is a specific example of patient placement for a suspected infection vs. a routine trauma?A: A trauma patient with broken bones goes into a standard room. However, a patient presenting with weight loss, night sweats, and a cough is a suspected Tuberculosis (TB) case. That patient is immediately placed in a negative pressure room until TB is ruled out.

Q: Why don't we use butterflies for ABGs?A: While butterflies can be used in the brachial artery, we typically use specific syringes and needle sizes for arterial blood gas sampling due to the requirements of the tests we perform.

Q: What are the treatments for C. Diff?A: It is a bad bug that causes extreme diarrhea and kills gut flora. One treatment is a fecal transplant, where healthy stool is transplanted into the patient to restore good bacteria.

Q: What is the rule for shoe covers (booties) during doffing?A: If wearing booties, they should be removed while wearing gloves, as the floor is highly contaminated. They can be held inside the gloves when removing the gown to keep the waste contained.

Q: Can you talk about glove etiquette outside of the room?A: You should never walk in the hallway with gloves on unless transporting a specimen. Change gloves as often as needed within the room, but never chart with soiled gloves.