Infection Prevention and Control, and Specific Infections

Handling Equipment, Linen, and Clothing

• Handle equipment in a way that prevents:
  • Skin/mucous membrane contact.
  • Contamination of clothing.
  • Transfer of disease to other residents or areas.
• Do not reuse equipment until it has been properly cleaned and reprocessed.
• Dispose of single-use equipment properly. Disposable items are discarded after one use (e.g., razors, thermometers).
• Clean and disinfect:
  • All environmental surfaces.
  • Beds, bedrails, and bedside equipment.
  • Frequently touched surfaces (doorknobs, call lights, handles).
• Handle, transport, and process soiled linens and clothing to prevent:
  • Skin and mucous membrane exposure.
  • Contamination of clothing (hold linen away from uniform).
  • Transfer of disease (do not shake linen; fold/roll so dirtiest area is inside; do not put soiled linen on the floor).
• Bag soiled linen at the point of origin.
• Sort soiled linen away from resident care areas.
• Place wet linen in leakproof bags.

Cleaning Spills

• Spills, especially involving blood or body fluids, pose a serious risk of infection and falls.
• Clean spills immediately using the proper solution and equipment.

Guidelines: Cleaning Spills Involving Blood, Body Fluids, or Glass

• Apply gloves before starting; industrial-strength gloves may be best.
• Absorb the spill with the facility's designated product (e.g., an absorbing powder).
• Scoop up the absorbed spill and dispose of it in a designated container.
• Apply the proper disinfectant to the spill area and let it stand wet for at least 10 minutes.
• Do not pick up broken glass with your hands; use a dustpan and broom or other tools.
• Waste containing broken glass, blood, or body fluids should be properly bagged, potentially in a special biohazard waste bag, following facility policy.
• The CDC recommends absorbing and removing fluid first, as disinfectant may be neutralized upon contact with the spilled fluid.

Transmission-Based Precautions

• A second level of precautions beyond Standard Precautions, used when caring for persons infected or suspected of being infected with a disease. These are always listed in the resident's care plan and on the nursing assistant's assignment sheet.
• Used in addition to Standard Precautions.
• Three categories:
  • Airborne Precautions
  • Droplet Precautions
  • Contact Precautions
• The category used depends on the disease and how it spreads.
• May be used in combination for diseases with multiple routes of transmission.

Conditions Requiring Transmission-Based Precautions

• Multidrug-resistant organisms (MDROs) (resistant to one or more antimicrobial agents):
  • Methicillin-resistant Staphylococcus aureus (MRSA)
  • Vancomycin-resistant enterococcus (VRE)
• Clostridium difficile (C. diff or C. difficile)
• Scabies (a skin disease that causes itching)
• Lice
• Influenza (during an outbreak)

Airborne Precautions

• Used for diseases transmitted through the air after being expelled. Pathogens are small and can remain floating for some time.
• Nursing assistants may need to wear special masks (N95 or HEPA) to avoid infection.
• Airborne diseases include tuberculosis, measles, and chickenpox.

Droplet Precautions

• Used for diseases spread by droplets in the air. Droplets typically do not travel more than three feet (CDC recommends six feet for influenza).
• Spread through coughing, sneezing, laughing, talking, or suctioning.
• Include wearing a face mask during care procedures and restricting visits from uninfected people.
• Residents should wear masks when being moved from room to room, if able to do so.
• Nursing assistants should cover their noses and mouths with a tissue when sneezing or coughing, and ask others to do the same. Used tissues should be disposed of in the nearest waste container, not placed in a pocket for later use.
• If a tissue is not available, NAs should cough or sneeze into their upper sleeve or elbow, not their hands, and wash their hands immediately afterward.
• An example of a droplet disease is mumps.

Respiratory Hygiene/Cough Etiquette

• CDC measures to prevent transmission of all respiratory infections in healthcare settings; part of Standard Precautions:
  1. Post visual alerts at entrances instructing patients and visitors to inform staff of respiratory infection symptoms and to practice respiratory hygiene/cough etiquette.
  2. All individuals with signs and symptoms of a respiratory infection must:
     • Cover their noses/mouths with a tissue when coughing or sneezing.
     • Dispose of used tissues in the nearest waste container.
     • Perform hand hygiene after contact with respiratory secretions and contaminated objects.
     • Healthcare facilities must make tissues, no-touch receptacles, hand rub dispensers, and handwashing supplies available to staff, patients, and visitors.
  3. Offer masks to anyone who is coughing and encourage coughing people to sit at least three feet away from others in waiting areas during times of increased respiratory infections.
  4. Advise healthcare personnel to observe Droplet Precautions (in addition to Standard Precautions) when examining a patient with symptoms of a respiratory infection, particularly if fever is present.

Contact Precautions

• Used when there is a risk of spreading or contracting a microorganism by touching an infected object or person.
• Transmission can occur with skin-to-skin contact during transfers or bathing.
• Examples: conjunctivitis (pink eye) and Clostridium difficile infection.
• Include wearing PPE and resident isolation.
• Require washing hands with antimicrobial soap and not touching infected surfaces with ungloved hands or uninfected surfaces with contaminated gloves.
• Residents who need Transmission-Based Precautions are often referred to as being in isolation.
• A sign should be on the door indicating Isolation or Contact Precautions and alerting people to see the nurse before entering the room.

Guidelines: Isolation

• Transmission-Based Precautions are always used in addition to Standard Precautions.
• Nurses will set up the isolation unit. Supplies (gloves, masks, gowns or aprons, goggles, face shields, respirator masks) are kept in a special room, within the resident's room, or on an isolation cart outside the room.
• Nursing assistants will be told the proper PPE to wear and how to put it on and remove it safely. Remove PPE and place it in the appropriate container before exiting a resident's room. PPE cannot be worn outside the resident's room. Perform hand hygiene following removal of PPE and again after exiting the resident's room. There may be an alcohol-based hand rub dispenser mounted on the wall inside the room as you exit.
• Do not share equipment between residents. Use disposable supplies whenever possible and discard them in the resident's room before leaving. Use dedicated equipment (only for use by one resident) when disposable is not an option. Do not contaminate reusable equipment by setting it on furniture or counters in the resident's room. Dispose of dedicated equipment properly when the resident is discharged or no longer needs the additional precautions or cleaned and disinfected after use, if required.
• Wear the proper PPE, if indicated, when serving food and drink to residents in isolation. Do not leave uneaten food uncovered in the resident's room. When the meal is completed, remove the meal tray and take it to the designated area, or put it back on the food cart. The dietary staff will handle all soiled trays with gloves, and the tray and dinnerware will be cleaned and sanitized.
• Follow Standard Precautions when dealing with body waste removal. Wear gloves when touching or handling waste. Wear gowns and goggles when indicated. The waste must be disposed of in a manner to minimize splashing and spraying.
• Follow proper PPE guidelines when collecting a specimen from a resident in isolation. Place the specimen in the appropriate container without contaminating the outside of the container. Properly remove PPE and dispose of it in the room. Perform hand hygiene before leaving the room and take the specimen to the nurse.
• Residents need compassion. Reassure residents that it is the disease, not the person, that is being isolated. Explain what steps are being taken. Relay any requests outside your scope of practice to the nurse.

Residents' Rights: Isolation

• Residents' basic needs remain the same while in isolation. NAs should not avoid a resident in isolation, rush through care tasks, or make the resident feel that he or she should be avoided. Being professional, caring, and competent may help lessen a resident's worries or concerns and feelings about being isolated. If an NA has questions about the care he is providing, he should talk to the charge nurse.

Bloodborne Pathogens

• Microorganisms found in human blood that can cause infection and disease in humans. May also be found in body fluids, draining wounds, and mucous membranes.
• Can be transmitted by infected blood entering the bloodstream, or if infected semen or vaginal secretions contact mucous membranes.
• Other transmission methods include:
  • Sexual contact (vaginal, anal, oral).
  • Using a needle to inject drugs and sharing needles.
  • Infected mothers transmitting to babies in the womb or at birth.
• In health care, contact with infected blood or body fluids is the most common way to be infected.
• Standard Precautions, handwashing, isolation, and using PPE prevent transmission.
• Employers are required by law to help prevent exposure.
• NAs can safely touch, hug, and spend time talking with residents who have a bloodborne disease, but should never isolate residents emotionally because they have a bloodborne disease.

Major Bloodborne Diseases

1. Acquired Immune Deficiency Syndrome (AIDS):
   • Caused by HIV (human immunodeficiency virus).
   • HIV weakens the immune system, leading to AIDS in some individuals.
   • People with AIDS lose all ability to fight infection and can die from illnesses a healthy body could handle.
2. Viral Hepatitis Family:
   • Inflammation of the liver caused by certain viruses, alcohol abuse, medications, and trauma.
   • Can cause permanent liver damage.
   • Common types: A, B, and C.
     • Hepatitis A (HAV): Spread via fecal-oral contamination.
     • Hepatitis B (HBV): Bloodborne disease spread through sexual contact, sharing infected needles, and from mother to baby during delivery. Can survive outside the body for at least seven days and cause infection during that time. Employers must offer nursing assistants a free vaccine to protect them from hepatitis B, usually given as a series of three shots. Symptoms of HBV may include:
       • Loss of appetite
       • Diarrhea and vomiting
       • Fatigue
       • Jaundice (yellowing of the skin, eyes, and mucous membranes)
       • Pain in muscles, joints, and stomach
       • Long-term illness can lead to cirrhosis, liver cancer, death.
     • Hepatitis C (HCV): Transmitted through blood or body fluids and possibly sexual intercourse. Can lead to cirrhosis, liver cancer, and death. No vaccine available.
     • Hepatitis D (HDV): Transmitted by blood. Only found in people who carry HBV.
     • Hepatitis E (HEV): Transmitted by the fecal-oral route, usually through contaminated water. Rare in the United States, more common in other parts of the world.

OSHA's Bloodborne Pathogens Standard

• Requires healthcare facilities to protect employees from bloodborne health hazards.
• Employers must follow rules to reduce or eliminate the risk of exposure to infectious diseases and guides employers and employees through the steps to follow if exposed to infectious material.
• Significant exposures include:
  • Exposure by injection (needle stick).
  • Mucous membrane contact.
  • Cut from an object containing a potentially infectious body fluid (includes human bites).
  • Having non-intact skin (OSHA includes acne).

Employer Guidelines

• Written exposure control plan: Designed to eliminate or reduce employee exposure to infectious material. Includes medical treatment and plans to prevent any similar exposures. Accessible to all employees, and they must receive training on the plan.
• Provide proper personal protective equipment (PPE) at no cost, available in appropriate sizes and readily accessible.
• Provide biohazard containers for disposal of sharps and other infectious waste. Containers must be puncture-resistant, labeled or color-coded, and leakproof.
• Provide a free hepatitis B vaccine to all employees after hire.
• Warning labels must be affixed to waste containers and refrigerators and freezers that contain blood or any other potentially infectious material.
• Keep a log of injuries from contaminated sharps, protecting the confidentiality of the injured employee. Employers are also required to select safer needle devices and to involve employees in choosing these devices.
• Provide training for employees to explain the Bloodborne Pathogens Standard and its contents.
• When an employee is exposed to blood or other potentially infectious material, an incident report or a special exposure report form must be completed. Tests and follow-up care may be needed. The employer will take steps to help keep the employee from becoming sick. Steps will also be taken to help keep similar incidents from occurring again.
• Nursing assistants must report any potential exposures immediately.

Tuberculosis (TB)

• A highly contagious lung disease caused by a bacterium carried on mucous droplets suspended in the air. An airborne disease.
• Infected person releases mucous droplets when talking, coughing, breathing, singing, laughing, or sneezing.
• Symptoms: coughing, trouble breathing, fever, weight loss, and fatigue.
• If left untreated, TB may cause death.

Two Types of TB

• Latent TB Infection: Carries the disease but does not show symptoms and cannot infect others.
• TB Disease: Shows symptoms of the disease and can spread TB to others.

Signs and Symptoms of TB Disease

• Fatigue
• Loss of appetite
• Weight loss
• Slight fever and chills
• Night sweats
• Prolonged coughing
• Coughing up blood
• Chest pain
• Shortness of breath
• Trouble breathing

Guidelines for Tuberculosis

• Follow Standard Precautions and Airborne Precautions.
• Wear PPE as instructed. Special masks (N95, high efficiency particulate air (HEPA)) must be used. You must be fit-tested and trained on how to use the masks.
• Use special care when handling sputum or phlegm (thick mucus from the respiratory passage).
• Residents with TB will be placed in a special airborne infection isolation room (AIIR). Other names for the isolation room may be Negative Air Pressure Room or Acid-Fast Bacillus (AFB) isolation room. Do not open or close the door quickly. The door should remain closed as much as possible.
• Follow isolation procedures for airborne diseases if directed.
• Help the resident remember to take all medication prescribed.
• Multidrug-resistant TB (MDR-TB) is a type of TB that can develop when a person with TB disease does not take all the prescribed medication. Surgery may be the only option for treatment.

Multidrug-Resistant Organisms (MDROs)

• Microorganisms, mostly bacteria, that are resistant to one or more antimicrobial agents commonly used for treatment. MDROs are increasing and is a serious problem.

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• Antibiotic-resistant infection often acquired in healthcare facilities (HA-MRSA).
• Community-associated MRSA (CA-MRSA) occurs in people not recently admitted to healthcare facilities and with no past diagnosis of MRSA. Often manifests as skin infections.
• Almost always spread by direct physical contact with infected people or indirect contact by touching contaminated equipment or supplies.
• Prevention: Good hygiene and handwashing with soap and warm water, is the single most important measure to control the spread of MRSA. Follow Standard Precautions, along with Transmission-Based Precautions, as ordered. Keep cuts and abrasions clean and covered until healed. Avoid contact with other people's wounds or material that is contaminated from wounds.

Vancomycin-Resistant Enterococcus (VRE)

• Enterococci are bacteria that live in the digestive and genital tracts. They normally do not cause problems in healthy people.
• Vancomycin-resistant enterococci are bacteria that have developed resistance to antibiotics as a result of being exposed to vancomycin.
• Spread through direct and indirect contact.
• Symptoms: fever, fatigue, chills, and drainage.
• Often difficult to treat and may require the use of several medications.
• VRE infections can cause life-threatening infections in those with compromised immune systems.
• Prevention: Proper hand hygiene, wear PPE as directed. Follow Standard Precautions, along with Transmission-Based Precautions, as ordered. Items may need to be disinfected, and that information should be listed in the care plan.

Clostridium Difficile (C. Diff or C. Difficile)

• A spore-forming bacterium which can be part of the normal intestinal flora. When the normal intestinal flora is altered, C. difficile can flourish in the intestinal tract.
• Produces a toxin that causes a watery diarrhea.
• Enemas, nasogastric tube insertion, and GI tract surgery increase a person's risk of developing the disease.
• The elderly are at a higher risk of getting C. difficile infection.
• The overuse of antibiotics may also alter the normal intestinal flora and increase the risk of developing C. difficile.
• Can also cause colitis, a more serious intestinal condition.
• Spores can be carried on the hands of people who have direct contact with infected residents or with environmental surfaces contaminated with C. difficile.
• Alcohol-based hand sanitizers are not considered effective on C. difficile. Soap and water must be used each time hand hygiene is performed.
• Symptoms: frequent, foul-smelling, watery stools. Other symptoms include diarrhea that contains blood and mucus, nausea, lack of appetite, and abdominal cramps.
• Prevention: Handwashing with soap and water, handling contaminated wastes properly, cleaning surfaces with an appropriate disinfectant (such as bleach), and limiting the use of antibiotics.

Employer and Employee Responsibilities for Infection Prevention

• State and federal government agencies have guidelines and laws concerning infection prevention.
• OSHA requires employers to provide for the safety of their employees through rules and suggested guidelines.
• The CDC issues guidelines for healthcare workers to follow on the job.
• Facilities consider these rules very carefully when writing their policies and procedures.

Employer Responsibilities

• Establish infection prevention procedures and an exposure control plan to protect workers.
• Provide continuing in-service education on infection prevention, including education on bloodborne and airborne pathogens and updates on any new safety standards.
• Have written procedures to follow should an exposure occur, including medical treatment and plans to prevent similar exposures.
• Provide personal protective equipment (PPE) for employees to use and teach them when and how to properly use it.
• Provide free hepatitis B vaccinations for all employees.

Employee Responsibilities

• Follow Standard Precautions.
• Follow all of the facility's policies and procedures.
• Follow care plans and assignments.
• Use provided personal protective equipment as indicated or as appropriate.
• Take advantage of the free hepatitis B vaccination.
• Immediately report any exposure to infection.
• Participate in annual education programs covering the prevention of infection.