Infection Control Nursing CE Course

>(noo-muh-kock-uhl): pertaining to or caused by pneumococci, organisms of the species Streptococcus pneumoniae (S. pneumoniae), a common cause of pneumonia and other infectious diseases

portal of exit (pôrdl əv eksət): the route by which microorganisms exit the reservoir on their way to a susceptible host

portal of entry (pôrdl əv entrē): the route by which microorganisms enter the host

reservoir (rezərˌvwär): a place in which an infectious agent can survive but may or may not multiply (healthcare workers may be reservoirs for nosocomial organisms)

retrovirus(reh-troe-vie-ruhs): any of a large group of RNA-based viruses that tend to infect immunocompromised individuals, including HIV and many cancer-causing viruses

sepsis(sep-sis): the presence of pathogens or their toxins in the blood or other tissues

standard precautions(stan-durd pree-kaw-shuns): a group of infection prevention and control strategies that combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents

staphylococcus(staff-flow-kock-uuhs): a genus of gram-positive bacteria that are potential pathogens, causing local lesions and serious opportunistic infections

surgical asepsis(surr-jik-kuhl ae-sep-sis): techniques used to destroy all pathogenic organisms, also called sterile technique

susceptible host (suh-sep-tuh-buhl hohst): a person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting infection or disease when exposed to the agent

transmission (trans-mish-uhn): any mechanism by which a pathogen is spread by a source or reservoir to a person

transmission-based precautions(trans-mish-uhn pree-kaw-shuns): measures taken to prevent the spread of diseases from people suspected to be infected or colonized with highly transmissible pathogens that require measures beyond standard precautions to interrupt transmission, specifically, airborne, droplet, and contact precautions

vancomycin-resistant Staphylococcus aureus (VRSA)(van-koh-my-sin ree-zis-tunt staff-flow-kock-uuhs orr-ee-uhs [vurs-uh]): a strain of the bacterium S. aureus that has become resistant to the antibacterial action of the antibiotic vancomycin (Vancocin)

virulence (vir(y)ələns): the ability of a microorganism to cause disease (New York State Department of Health [NYSDOH] and State Education Department [NYSED], 2018; McCance & Heuther, 2019; Potter et al., 2017)

NYS Infection Control Standards: Background and Current Policies

Infection control is the primary responsibility of all healthcare workers. For nurses, this responsibility incorporates daily interactions with patients, coworkers, equipment, and the healthcare environment. In August 1992, legislation was passed requiring healthcare workers in New York to undergo training on infection control and barrier precautions every four years upon renewing their license. In October 2017, Governor Cuomo signed into law Assembly Bill 6053-A, requiring sepsis awareness and education to be incorporated into the training curriculum.  New York State (NYS) specifies this responsibility in the Rules of the Board of Regents, Part 29.2 (a) (13; NYS, 1993) and Title 10, Part 92 of the Official Compilation of Codes, Rules, and Regulations of NY (NYS Education Department [NYSED], 2021). To become licensed, and every four years after that, nurses must complete course work and/or training appropriate to the individual's professional practice regarding infection control. This course provides infection control training per the mandates set forth by the NYS Department of Health (DOH) and NYSED. This training includes preventing disease transmission from healthcare worker to patient, patient to healthcare worker, and patient-to-patient, focusing on averting the transmission of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) and sepsis prevention. It will review the performance monitoring of all personnel for whom the licensee is responsible; adherence to scientifically accepted standards for handwashing; aseptic technique; use of gloves and other barriers for preventing bi-directional contact with blood and body fluids; thorough cleaning followed by sterilization or disinfection of medical devices; disposal of non-reusable materials and equipment; cleaning protocols of patient equipment that are visibly contaminated or subject to touch contamination with blood or body fluids; and injury prevention techniques or engineering controls to reduce the opportunity for patient and healthcare worker exposure. Compliance can be increased with regular and high-quality training to understand how infection control strategies are effective and why they are necessary, such as a multimodal clean hands campaign developed by the World Health Organization (WHO) Your 5 Moments for Hand Hygiene (see Figure 2). Consequences of poor compliance include increased health risks for healthcare workers, patients, and the public, and could also lead to professional misconduct penalties for the healthcare worker, including disciplinary action, revocation of license, and professional liability (NYS, 1993; NYSDOH & NYSED, 2018; NYSED, 2021).

Communicable Disease

According to the Centers for Disease Control and Prevention (CDC, 2012), a communicable disease is an illness caused by an infectious agent or its toxins that can be transmitted through direct or indirect contact with the infectious agent or its products (e.g., contact with contaminated surfaces, bodily fluids, blood products, through the air) from an infected person, animal, or inanimate source to a susceptible host. Common forms of spread include fecal-oral, food, sexual intercourse, contact with contaminated fomites, droplets, or skin.  Measles, mumps, rubella, influenza, salmonella, methicillin-resistant Staphylococcus aureus (MRSA), HIV, hepatitis, tuberculosis (TB), and SARS-CoV-2 (COVID-19) are examples of communicable diseases. Since healthcare workers are at increased risk of acquiring various types of communicable diseases due to workplace exposure, the CDC collects information about the occurrence and transmission of these conditions to generate relevant infection prevention and control guidelines for healthcare agencies. While there are vaccines available to prevent several of these diseases, it remains imperative that healthcare workers stay up-to-date on recommended vaccinations, which are subject to change. As recently experienced with the COVID-19 pandemic, this should include the development of novel vaccines and the evolving recommendations to help control the spread of this and other deadly diseases. Healthcare workers are encouraged to regularly reassess the CDC vaccination guidelines to ensure compliance and safety. Pre-employment and periodic health assessments are core infection prevention and control strategies as they help identify symptoms that require further testing and treatment.  Regular screening for TB is required for healthcare workers with direct patient care contact, including annual FIT testing of N95 respirators to confirm the respirator forms a tight seal on the healthcare worker’s face before it is used in the workplace. Healthcare workers are encouraged to regularly visit the CDC website for the most updated infection control guidelines, as well as a risk assessment tool to help stratify risk and determine the frequency of necessary testing. Other findings in the history and physical that warrant further evaluation and possible restriction from patient care activities include fever, cough, rash, vesicular lesions, draining wounds, vomiting, or diarrhea. In such instances, the healthcare worker should be furloughed until no longer symptomatic (Edemekong & Huang, 2020). Healthcare workers were subjected to daily temperature screenings and symptom checklists before starting their daily shifts throughout the COVID-19 pandemic (CDC, 2021c). Since the purpose of this course is to provide a review of infection prevention and control principles and practices, specific communicable diseases and their clinical manifestations will not be thoroughly reviewed. For detailed information on particular conditions, please refer to the NursingCE course library for modules such as the Tuberculosis, Hospital Acquired Infections, Pneumonia, HIV, Hepatitis, and many others.

Immune System Review

Each person’s immune system serves a primary role in determining their risk for infection, so a foundational understanding of the immune system is necessary to comprehend how infectious agents evade the body’s defense system and induce illness. The immune system is comprised of a collection of cells, tissues, and organs that work together to defend the body against attacks by foreign invaders or pathogens, such as microbes, viruses, bacteria, and parasites. The immune system strives to prevent invasion and protect against illness by seeking out and destroying pathogens. Numerous microorganisms inhabit the human body (externally [skin] and internally [e.g., gut, vagina]) without causing disease, referred to as normal flora or characteristic bacteria. Normal flora functions to maintain homeostasis of various body systems and prevent infection from external agents. The key to a healthy immune system is its ability to distinguish between the body’s own cells (self) and foreign cells (non-self). The cells of the immune system launch an attack whenever they encounter anything that appears foreign. Any substance capable of triggering an immune response is called an antigen. An antigen can be a virus, bacteria, or any infectious organism, and all antigens carry marker molecules that identify them as foreign. White blood cells (WBCs) are the components of the immune system which fight infection and other illnesses. There are two primary immune responses: innate and adaptive immunity (Longo, 2019; McCance & Heuther, 2019).

Also known as natural immunity, innate immunity is present at birth and is the first line of defense against pathogens. Innate immunity is activated immediately and rapidly in response to pathogen invasion and is always present and prepared to attack. It does not generate immunologic memory, meaning it does not remember past predators. The innate immune system responds nonspecifically every time a predator launches an attack. It includes physical barriers (skin and mucus membranes), mechanical barriers (coughing and sneezing), chemical barriers (tears and sweat), inflammatory responses, complement activation, and the production of natural killer (NK) cells (large granular lymphocytes). The presence of redness and swelling surrounding a skin laceration is an example of innate immunity. Lymphocytes deploy to the wound site, infiltrate the area to keep microbes out, and promote healing before infection ensues (McCance & Heuther, 2019).

Adaptive or acquired immunity is the second line of defense and is highly specific, responding individually to each pathogen. This system is activated if an invading pathogen breaches the innate immune mechanisms. Due to adaptation, the acquired immune system responds comparatively slower than the innate immune system. It boasts immunologic memory and specificity as it “remembers” prior antigens and can repeat a specified response. The immune system organs, or lymphoid organs, are positioned strategically throughout the body. They house macrophages and lymphocytes, the two critical mediators of the adaptive immune system. Macrophages engulf and digest germs and dead cells, leaving behind antigens for the body to identify as dangerous, triggering the stimulation of antibodies. There are two main types of lymphocytes: B-lymphocytes (B-cells) and T-lymphocytes (T-cells). B-cells mediate the production of antibodies that attack antigens left behind by the macrophages. B-cells bind directly with unique proteins on the invading antigen's surface and then hand the baton to the T-cells, who have the job of attacking the target (or infected) cells. They lyse the infected cells, provide immunity against most pathogens, and aid in antibody production (Longo, 2019; McCance & Heuther, 2019).

There are three types of adaptive immunity: humoral immunity, cell-mediated immunity, and T-regulatory cells. Humoral immunity is mediated by B-cells and results in the production of immunoglobulins (Ig), otherwise known as antibodies. T-cells and their cytokine products facilitate cell-mediated immunity, which does not involve antibodies. Instead, cell-mediated immunity includes cytotoxic T-cells (usually CD8) and helper T-cells (usually CD4).  T-regulatory cells, also known as suppressor T-cells, display the markers CD4 and CD25 and limit other immune effector cells’ activity. Ultimately, their primary role is to prevent damage to normal tissues and lessen the inflammatory response. Vaccination is an example of acquired immunity (Longo, 2019; McCance & Heuther, 2019).

Overview of the Infectious Process

Transmission of infection in healthcare consists of six major elements linked to each other in a particular order, as displayed in Figure 1. If all of these elements are not present or are not connected in sequence, infection will not develop. An understanding of the chain of infection provides healthcare workers with the opportunity to disrupt the cycle and prevent infection (Ignatavicius et al., 2018). 

The infectious agent (also known as the causative agent) is the pathogen capable of producing infection, and each agent has varying pathogenicity (i.e., the ability to cause illness). Virulence is related to the frequency in which a pathogen causes disease (i.e., the degree of communicability), its ability to invade and damage the host, and designates disease severity. Prompt identification of infection and treatment is essential to mitigate the clinical course, illness severity, and reduce morbidity and mortality. The reservoir is the source of the infectious agents or where they live, grow, and multiply (or reproduce). Some types of infectious agents only survive in the reservoir, and not all multiply there. Reservoirs can be inanimate (e.g., soil, water, medical equipment) or animate (e.g., humans, animals, insects). A person with an active infection and a carrier (an asymptomatic individual who harbors an infectious agent without active illness) are other examples of reservoirs. For example, the high transmissibility of the SARS-CoV-2 virus by asymptomatic carriers served a prominent role in fueling the COVID-19 pandemic, as these individuals were unknowingly spreading the virus to others. The portal of exit is the route through which the infectious agent exits the reservoir on its journey to the susceptible host. Portals of exit include the skin, blood, secretions, excretions, and most commonly occur via the respiratory, gastrointestinal (GI), reproductive, and urinary tracts (CDC, 2016b, 2021c; Ignatavicius et al., 2018).

Modes of transmission are the means through which the infectious agent spreads from the reservoir to the susceptible host. There are three primary modes of transmission: direct contact, indirect contact, and airborne spread. Direct contact denotes physical contact between the source and the host, such as directly from skin to skin or from mucus membrane to mucus membrane; commonly referred to as person-to-person transmission. Direct contact is the most common way for an infection to spread from one person to another (e.g., the “common cold”). Kissing, touching, biting, and sexual intercourse are primary examples of direct contact. Poor hand hygiene is a chief mechanism of transferring microbes in the healthcare setting and includes healthcare worker to coworker and healthcare worker to patient. Indirect contact requires a vehicle or vector to transmit the infectious agent and includes modalities such as passive transfer and droplet spread. Indirect contact transmission may occur via equipment in the environment, such as stethoscopes, blood pressure cuffs, and bedside commodes. Vehicles that spread infectious agents include handkerchiefs, toys, utensils, surgical equipment, water, food, serum, and blood. Examples of disease-causing agents found in water include Giardia lamblia, Vibrio cholerae, Shigella, Escherichia coli (E. coli), and hepatitis A. Vector transmission occurs when blood-feeding anthropods (e.g., mosquitoes, ticks, fleas) infect humans. Examples of vector-borne diseases include the West Nile Virus, malaria, Dengue fever, and Lyme disease. Indirect contact transmission also includes contact with infected secretions or droplets. Droplets are produced by talking, coughing, sneezing, or spitting and can travel short distances. Infected droplets (larger than 5 microns/µm) may transmit disease when the source and host are in relatively close proximity (about 3 feet). Susceptible hosts can become infected when the droplets deposit on their oral, nasal, or conjunctival membranes. Influenza is the most common example of an infectious agent that spreads via droplet transmission. Airborne transmission is the spread of infectious agents by dust particles or tiny droplets (less than 5 microns/µm). These agents remain suspended in the air for a more extended time and travel more than 3 feet before entering the susceptible host through a portal of entry (typically the respiratory system). TB, caused by the microorganism Mycobacterium tuberculosis, is the most common example of an illness acquired via airborne transmission. TB infection occurs when a person inhales the TB bacteria released from an infected person; the mycobacteria are transmitted from the airways into the lung tissue (CDC, 2016b; Ignatavicius et al., 2018).

Portal of entry is the route through which the infectious agent enters the susceptible host. Portals of entry include the mucus membranes, broken skin, and the respiratory, GI, and reproductive systems. Infectious agents frequently enter the host by the same route they exited the reservoir. A susceptible host is a person or animal that does not possess sufficient resistance to the infectious agent to prevent them from contracting the infection when exposed. Exposure to an infectious agent does not always lead to an acute illness. Several host factors influence a person’s susceptibility and the severity of illness. Host defenses provide the body with an effective system for protecting against pathogen invasion. These include natural barriers such as intact skin, respiratory cilia, gastric acid and motility, tears, normal flora, and the immune system response when these barriers are breached (e.g., inflammatory response, humoral immunity, cell-mediated immunity, immune memory; Ignatavicius et al., 2018; McCance & Heuther, 2019).

Any breach or impairment in the immune defense increases the risk of host infection. Congenital and acquired health problems can result in a compromised immune system, making the host more susceptible to infection and diminish the body’s ability to combat agents that have gained entry. Host factors that influence the development of infection include age (infants and older adults), chronic illnesses (e.g., diabetes mellitus [DM], heart disease, chronic kidney disease [CKD]), immunosuppression (e.g., cancer, long-term corticosteroid therapy), skin breakdown (e.g., burns, lacerations), nutrition (e.g., malnutrition, dehydration), environmental and lifestyle factors (e.g., tobacco use, alcohol consumption, inhalation of toxic chemicals via workplace exposures), and medical interventions (e.g., surgery, radiation therapy; CDC, 2016b; Ignatavicius et al., 2018). Immunocompromised patients, such as those with cancer undergoing cytotoxic treatments (e.g., chemotherapy, radiation therapy), autoimmune conditions, transplant recipients, and HIV/AIDS, are at heightened risk for acquiring an infection and enduring a more severe clinical course. Due to the impaired functioning of the body’s innate defense system, these patients are particularly vulnerable to infection. They often present with more subtle signs of infection, such as a low-grade fever (e.g., 100.4 °F), which is the most common indicator of infection in an immunocompromised patient. Healthcare workers must exercise extreme caution and hypervigilance when caring for this patient population. Careful monitoring and thorough assessment are critical to preventing complications, as an infection can be fatal (Nettina, 2019).

For more information on infection control when caring for immunocompromised patients, refer to the Oncology Nursing Part 2: Chemotherapy and Oncologic Emergencies Nursing CE Course.

Vaccination

Vaccination of healthcare workers and the public is one of the most prominent and compelling infection prevention and control strategies. The safest and most effective way to develop immunity and fight against a potential illness before it becomes dangerous is accomplished through vaccination. Vaccines work by impersonating the infectious agent, stimulating the immune system to generate antibodies against it without inducing the disease. If the pathogen subsequently attempts to invade the body, the body responds quickly, producing additional antibodies to combat the infection and thwart illness. The most common types of vaccines contain a minuscule, weakened, or inactivated fragment of the organism. This tiny quantity is enough for the body to learn how to build the specific antibody in the event of an encounter with the actual antigen later. Novel vaccines contain the blueprint for producing antigens (e.g., Pfizer-BioNTech COVID-19 vaccine) rather than the antigen itself. Regardless of whether the vaccine comprises the antigen itself or the blueprint, the recipient does not acquire the illness from the vaccine. Some vaccines require multiple doses, given weeks or months apart, to produce the desired immunity, such as long-lasting antibodies and durable memory cells. Table 1 provides a comparison of the major types of vaccines used throughout the US (CDC, 2018; McCance & Heuther, 2019; US Department of Health and Human Services [HHS], 2021; WHO, 2020d).

Healthcare-Associated Infections (HAIs)

HAIs, also known as nosocomial infections, are infections developed in a healthcare setting while receiving care for another condition. This terminology does not imply that an infection was solely caused by the healthcare services rendered, only that it occurred while receiving healthcare. HAIs can develop in any healthcare facility, including hospitals, ambulatory clinics, surgical centers, inpatient rehabilitation facilities, and long-term care settings. HAIs can be endogenous (develop from the patient’s flora) or exogenous (originate outside the patient’s body). Reservoirs known for causing exogenous HAIs include the hands of healthcare workers, patients, equipment (e.g., blood pressure cuffs, urine collection devices), and the environment (e.g., contaminated surfaces, toilets, sinks, doorknobs). In the US, HAIs occur in about 2 million inpatients annually, leading to more than 75,000 deaths each year. According to the CDC (2021a), on any given day, approximately 1 in 31 hospitalized patients and 1 in 43 skilled nursing facility (SNF) residents have at least one HAI. HAIs are associated with high morbidity and mortality, as they have devastating impacts, including prolonged hospitalization, increased suffering, lost productivity, and substantial costs to the healthcare system and society. HAIs are monitored closely by agencies such as the CDC’s National Healthcare Safety Network (NHSN), the most widely used HAI tracking system. The NHSN collects data to identify problematic areas and standardize infection rates to measure, track, and evaluate HAI prevention modalities. The NHSN allows for a more accurate and direct comparison of infection rates between healthcare facilities and monitors these rates over time (CDC NHSN, 2021). The risk for HAIs depends on multiple influences, such as the infection control practices of the healthcare facility, the prevalence of pathogens within the community and/or setting, and individual patient factors (e.g., compromised immune system, increased length of stay, and comorbidities such as heart disease, chronic obstructive pulmonary disease [COPD], DM, etc.). Across healthcare settings, the risk for HAIs is highest among patients admitted to intensive care units (ICUs; CDC, 2016a, 2016b).  According to the WHO (n.d.), in high-income countries, approximately 30% of patients in the ICU are affected by at least one HAI; in low- and middle-income countries, the prevalence increases at least 2 to 3 fold. In a study involving 231,459 patients across 947 hospitals, 19.5% of patients admitted to the ICU had at least one HAI (Stiller et al., 2016). The most common HAIs are described below, and while not representative of all HAIs, they are among the most common and are associated with severe complications. The majority are preventable when healthcare workers utilize appropriate infection prevention strategies outlined by the CDC (2016a, 2016b).  

Catheter-associated Urinary Tract Infections (CAUTIs) 

A urinary tract infection (UTI) involves any part of the urinary system, including the urethra, bladder, ureters, and kidney. According to the WHO (n.d.), UTI is the most frequent HAI in high-income countries, and approximately 75% are associated with a urinary catheter. CAUTIs can occur from unsterile catheterizations, repeated catheterizations, and improper management of the drainage system. The most critical risk factor for developing CAUTI is the prolonged use of a urinary catheter (CDC, 2015b; Monegro et al., 2020). According to the CDC NHSN (2021), 12% to 16% of hospitalized adults will have an indwelling urinary catheter at some point during their hospitalization.  Each day the indwelling urinary catheter remains in place, the patient has a 3% to 7% increased risk of acquiring a CAUTI. Best practice guidelines reinforce the importance of removing these devices as soon as they are no longer needed. Some pathogens can form durable biofilms around the catheters or produce enzymes that inactivate antimicrobial agents, making it harder to treat them and increasing the risk for antimicrobial-resistant (AR) bacteria. Research demonstrates that AR bacteria cause a growing percentage of HAIs and may lead to sepsis or death. Administration of intravenous (IV) antibiotics within the last 90 days is a primary risk factor for developing AR to multiple drugs (CDC, 2015b, 2016a; CDC NHSN, 2021; Monegro et al., 2020).

Surgical Site Infection (SSI) 

SSIs occur when bacteria enter the body at a surgical incision site, and symptoms may include fever, pain, redness, and drainage. SSIs can develop from a breach in sterile technique, improper skin preparation, contamination during dressing changes, or contaminated antiseptic solution. Risk factors include age, medical comorbidities (e.g., DM, co-existing infections), obesity, malnutrition, and surgical factors (e.g., length of the procedure, surgical technique, skin asepsis, and antimicrobial prophylaxis). SSIs are most common following colon surgery, coronary artery bypass graft, hip replacement, and hysterectomy procedures (Monegro et al., 2020). According to the CDC NHSN (2021), SSIs carry a 3% mortality rate, are the costliest type of HAI, with an estimated annual cost of $3.3 billion US dollars and 1 million additional inpatient days per year. 

Central Line-associated Bloodstream Infections (CLABSI) 

CLABIs are serious and potentially fatal bloodstream infections that can occur from a breach in sterile technique during the insertion procedure, improper or inadequate care or management of the line, and during medication administration. Central lines provide direct access to the major venous blood supply and remain in situ for long periods. Since the catheter provides a portal of entry and a direct pathway to the venous system, an infectious agent can quickly spread throughout the bloodstream, generating critical and systemic illness. Bloodstream infections can induce hemodynamic changes, leading to organ dysfunction, sepsis, shock, and death (CDC, 2017; Haddadin et al., 2020). According to the CDC NHSN (2021), there has been a 46% decrease in CLABSIs across US hospitals between 2008 and 2013; however, more than 30,000 CLABSIs still occur in ICU and acute care facilities each year.  The estimated cost of CLABSIs is around $46,000 per infection and carries a mortality rate of up to 25% (Haddadin et al., 2020; Kornbau et al., 2015).

Hospital-acquired Pneumonia (HAP) and Ventilator-associated Pneumonia (VAP)

HAP, or non-ventilator-associated pneumonia event (PNEU) in the NHSH (2021), refers to a lung infection (pneumonia) that occurs 48 hours or more after admission to the hospital and did not appear to be present or developing at the time of admission. A specific type of HAP is VAP, which denotes pneumonia that develops more than 48 hours after endotracheal intubation. Ventilators provide a direct connection between the environment and the patient’s lower respiratory passageways. Infectious organisms enter through the tube, invade the ordinarily sterile lower respiratory tract, colonize the lungs, and overwhelm the host’s defense system. VAP can develop from poor technique while suctioning the airway, using contaminated respiratory equipment, or ineffective hand hygiene. According to Papazian and colleagues (2020), the primary route for bacterial invasion occurs from aspiration of oropharyngeal secretions contaminated by endogenous flora around the endotracheal tube cuff. VAP is one of the most frequent ICU-acquired infections, although incidence rates vary from 5 to 40% depending on the setting and diagnostic criteria. In a 2015 survey of 427 HAIs identified in US acute care hospitals, pneumonia was the most common, with VAP accounting for 32% of infections (Magill et al., 2018).  VAP carries an estimated mortality rate of approximately 10%, extends the length of stay by 7 days, and increases healthcare costs by about $40,000. Reducing the exposure to risk factors for VAP is the most efficient way to prevent VAP, including avoiding intubation and using noninvasive ventilation whenever possible, minimizing sedation, and maintaining and improving physical conditioning (e.g., early exercise and mobilization; Monegro et al., 2020; Papazian et al., 2020; Timsit et al., 2017).

Clostridioides difficile (C. difficile) 

C. difficile (C. diff) is responsible for a spectrum of C. diff infections (CDI), including uncomplicated diarrhea, pseudomembranous colitis, and toxic megacolon (life-threatening inflammation of the colon that can lead to sepsis and death). CDI most commonly occurs following antibiotic use; clinical manifestations typically develop within 10 days after starting antibiotics but may occur as early as the first day or as late as 2 months later (Mayo Clinic, 2020). Other well-known risk factors include a prior diagnosis of CDI, older age (65+ years), admission to a hospital or SNF, immunosuppression, gastric acid suppressants, and some medical comorbidities. According to the CDC (2019b, 2021a), approximately 500,000 CDIs occur in the US each year, and about 1 in 6 patients who develop a CDI will get it again in the subsequent 2-8 weeks.

Multidrug-Resistant Organisms (MDROs)

MDROs are defined as microorganisms (primarily bacteria) that are resistant to one or more classes of antimicrobial agents and include MRSA, vancomycin-resistant Enterococcus (VRE), and other gram-negative bacilli (such as those producing extended-spectrum beta-lactamases [ESBLs], E. coli, and Klebsiella pneumoniae [K. pneumoniae]). MDROs have increased in prevalence over the last few decades. Although transmission most frequently occurs in acute care facilities, all healthcare settings are affected by the emergence and transmission of AR bacteria. Therefore, MDROs have important implications for patient safety, infection control, and the proper selection of antibiotics. Options for managing MDRO infections are limited as these infections are harder to eradicate and associated with increased length of stay, higher costs, and mortality (CDC, 2021a). The severity and extent of illness caused by MDROs vary by the population and setting; therefore, prevention and control strategies must be tailored to the specific needs of each population and facility. In response, the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC) developed guidelines for the control and management of MDROs in 2006. Last updated in 2017, the guidelines outline the epidemiology of emerging MDROs, focusing on evidence-based prevention and treatment strategies. Prevention of AR bacteria depends on appropriate clinical practices that should be incorporated into all routine patient care. The core HICPAC prevention categories are listed in Table 2 (HICPAC, 2017).

Preventing HAIs: Best Practices for Patient Safety and Infection Control

In 2000, the Institute of Medicine (IOM), now called the National Academy of Medicine (NAM), released their landmark report, To Err Is Human. The report called to light the astronomical data surrounding medical errors in acute care hospitals, citing nearly 98,000 hospitalized patient deaths due to preventable medical errors annually. This momentous study ignited a focus on medical practices, spawning new policies and procedures and setting performance standards and expectations for patient safety and quality improvement (IOM US Committee on Quality of Health Care in America, 2000). In addition, the report identified several factors that contributed to patient harm and drew attention from national agencies to examine strategies to deliver safe, effective, and quality healthcare. In response, The Joint Commission (TJC) generated standards requiring healthcare organizations to create a culture of safety. In 2002, TJC published its first set of National Patient Safety Goals (NPSGs), requiring organizations to focus on priority safety practices regarding patient care. The NPSGs are updated annually, and the 2021 NPSG for infection control is outlined in Table 3. Infection control programs within healthcare organizations are coordinated and implemented by healthcare professionals trained in infection control practices and are designed to reduce the risk of HAIs (TJC, 2021). Hospitals execute infection tracking and surveillance systems, alongside evidence-based infection control practices, reduce the rates of HAIs, improve patient safety, and reduce morbidity and mortality. Moreover, many professional licensing boards, including NYS, have taken proactive roles in reducing the risk for HAIs by requiring licensees to complete continuing education about infection control as a condition of license renewal. Under NYS Public Health Law 2819, NYS acute care hospitals have been required to report HAIs since 2007. As of 2018, NYS updated the law mandating hospitals to specifically report SSIs, CLABSIs, and CDIs (New York State DOH, 2018, 2019).Healthcare Worker Protection

According to the CDC (2014), protecting healthcare workers from infectious disease exposures in the workplace involves four primary components:

• training and administrative controls (e.g., infection control policies and procedures)
• engineering controls (e.g., negative pressure rooms for patients with airborne diseases such as TB)
• workplace safety practice controls (e.g., work practice controls such as not recapping)
• personal protective equipment (PPE), including healthcare worker training on how to identify the proper PPE based on the clinical situation, how to correctly put on (don), wear, remove (doff), and appropriately dispose of PPE (CDC, 2014)

Hand Hygiene

Figure 2

Proper hand hygiene is the single most effective risk reduction strategy to prevent HAIs. Performing hand hygiene in the presence of the patient and family promotes trust and models good behavior for others. The term “hand hygiene” refers to both handwashing with an antimicrobial or plain soap and water as well as alcohol-based products such as gels, foams, and rinses (CDC, 2021b). Alcohol-based products contain an emollient that does not require the use of water. According to the CDC, in the absence of visibly soiled hands or when contamination from spore-forming organisms (e.g., C. diff) is unlikely, approved alcohol-based products for hand disinfection are preferred over antimicrobial or plain soap and water because of their superior microbicidal activity, reduced drying of the skin, and convenience in the absence of a sink (CDC, 2020b, 2021b). 

As outlined in the CDC hand hygiene guidelines, healthcare workers should use an alcohol-based hand rub in the following clinical situations:

• immediately before direct contact with a patient (e.g., touching)
• before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices (e.g., IV site, urinary catheter)
• before transitioning care from a soiled body site to a clean body site on the same patient
• after touching a patient or the patient’s immediate environment (e.g., the bed linens, surfaces, IV pole)
• after contact with blood, body fluids, or contaminated surfaces
• immediately after removing gloves (CDC, 2020b, 2021b)

Healthcare workers should wash hands with soap and water instead of using an alcohol-based hand rub in the following clinical scenarios:

• when hands are visibly soiled
• after caring for a patient with known or suspected infectious diarrhea
• after known or suspected exposure to spores (e.g., B. anthracis, C. diff; CDC, 2020b, 2021b)

Healthcare workers are advised to inspect their hands for breaks, cuts, or lacerations in the skin or cuticles before the start of each workday. These open areas provide a portal of entry for organisms. If any breaks in skin integrity are identified, a dressing should be applied before caring for patients. As outlined above, hand prevents the transmission of microorganisms between patients and environments. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination between different body sites. Artificial nails are advised against since they are known to harbor microorganisms. Fingernails should be trimmed to one-quarter of an inch, and rings avoided if possible. If the areas beneath the fingernails are soiled, they should be cleaned with an orangewood stick, if available (CDC, 2020b, 2021b).

Soap and Water 

To clean the hands using soap and water, wet them with water, apply the amount of soup product recommended by the manufacturer, and rub the hands together vigorously for at least 15 to 20 seconds, covering all surfaces of the hands and fingers. Next, the hands should be rinsed with water and dried with a disposable towel. Finally, the CDC recommends using a disposable towel to turn off the faucet to prevent recontamination of hands. A step-by-step depiction of this process is displayed in the below Figure 3 image sequence (CDC, 2020b).

Figure 3

Hand Hygiene: Soap & Water

Turn on the water and adjust it to a comfortable, warm temperature.

Wet the hands, keeping the hands lower than the elbows.

Apply 3 to 5 mL of soap to the hands, coating all surfaces.

Rub the hands vigorously together, working up a lather, for at least 15 seconds.

Rinse thoroughly, pointing the fingers down to allow water to run off the hands.

Dry the hands from the fingers to the wrist.

Turn off the water with a clean paper towel.

(Original ATI Images, 2018)

Alcohol-Based Hand Sanitizer

To properly use an alcohol-based hand sanitizer, the product should be applied to the hands, covering all surfaces, and rubbed together until the hands feel dry. This process should take approximately 20 seconds and is displayed step-by-step in the Figure 4 image series (CDC, 2020b).

Figure 4

Hand Hygiene: Alcohol-Based Rub

Apply 3 to 5 mL (per manufacturer) of antiseptic gel to the palm of one hand.

Rub the hands together, coating all surfaces, and rub vigorously until the gel disappears and the hands are dry. 

(Original ATI Images, 2018)

PPE

The Occupational Safety and Health Administration (OSHA) defines PPE as specialized gear worn by an employee to protect against infectious materials and minimize exposure to hazards that can cause serious illness. In healthcare settings, PPE such as gloves, masks, eyewear, and/or gowns are necessary for specific clinical situations to prevent the transmission of infectious materials by contact with patients, their blood, body fluids, secretions, or excretions (CDC, 2014; OSHA, n.d.-c).

Gloves

Disposable gloves (see Figure 5) are a primary line of defense in protecting healthcare workers and patients. They are made from various polymers such as latex, nitrile rubber, polyvinyl chloride, and neoprene. Disposable medical gloves are available in powdered or non-powdered forms. Nonsterile and sterile gloves are used by healthcare workers depending on the type of patient care activity. Latex gloves are made of natural rubber and typically offer the most comfort, flexibility, fit, and tactile sensitivity. Nitrile gloves are made of synthetic material, mold to the hand, are stretchy, and durable. Nitrile gloves are preferred for tasks that require a high degree of dexterity and protect against chemicals (e.g., hazardous drugs such as chemotherapeutic agents). Vinyl gloves are made of synthetic materials, are less stretchy, and do not mold as well to the hand. Vinyl gloves are acceptable when the risk of exposure to pathogens is low and a high degree of dexterity is unnecessary (Avacare Medical, 2016).

Figure 5

Gloves

(AnsellProtects, 2018)

Healthcare workers must wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Gloves should be applied before touching mucous membranes (e.g., oral, nasal, genital area), non-intact skin (e.g., wounds, surgical incisions, lacerations), and when inserting indwelling or invasive devices (e.g., urinary and IV catheters). Glove selection includes the appropriate type of glove (e.g., sterile or nonsterile) and size. The glove should fit comfortably, be changed if it tears, and must not be washed or reused. The use of gloves does not eliminate the need to follow the CDC guidelines for hand hygiene outlined above. Likewise, performing hand hygiene does not eliminate the need to wear gloves. Gloves should be applied in the appropriate sequence (see donning PPE) and changed between tasks and procedures on the same patient after contact with materials containing a high concentration of microorganisms. Similarly, gloves should be changed before transitioning care from a soiled body site to a clean body site on the same patient. Gloves must be removed in the appropriate sequence (see doffing PPE) and discarded in the proper trash can immediately after use, before touching non-contaminated items and environmental surfaces, and before going to another patient.  Hand hygiene should be performed directly after disposing of the gloves to avoid cross-contamination or transferring microorganisms to other patients and environments. When following the principles of surgical asepsis for keeping an area/object free of all microorganisms, sterile gloves should be used. Thorough handwashing must be performed before donning sterile gloves and after discarding the gloves (Potter et al., 2017). The Figure 6 image series demonstrates the procedure for the proper application of nonsterile gloves.

Figure 6

Applying Nonsterile Gloves

Perform hand hygiene until the product disappears and the hands are dry.

Select the appropriate size glove.

Holding the glove at the opening, slip the fingers into the glove and pull tight.

With the gloved hand, hold the second glove at the opening and slip the ungloved fingers into the glove and pull tight.

Pull gloves to the wrists of both hands.

Remove the gloves by grasping the cuff of the other gloved hand.

Avoiding skin contact, roll the glove inside out and place it in the palm of the gloved hand.

Grasp the glove on the inside of the cuff and pull it inside out.

Dispose of the gloves.

Perform hand hygiene.

(Original ATI Images, 2018)

Masks

Facemasks provide barriers to infectious materials and are often used with other PPE such as gowns and gloves. When worn appropriately, masks and eye protection safeguard the mouth, nose, and eyes during procedures where there is a potential for droplets or splashing of blood, body fluids, or hazardous agents (e.g., during intraperitoneal chemotherapy administration).  There are various types of medical-grade facemasks available, with a few examples displayed in Figure 7. Each mask has specific indications based on the clinical circumstances and anticipated exposure of the patient care activity (Potter et al., 2017).

Figure 7

Masks

(Original ATI images, 2018)

Procedure masks are flat/pleated and affix to the head with ear loops. They are used for any nonsterile procedure. There are two basic types of surgical masks. One type is secured to the head with two ties, conforms to the face with the aid of a flexible adjustment for the bridge of the nose, and can be flat/pleated or duck-billed in shape. The second type of surgical mask is pre-molded with a flexible adjustment for the bridge of the nose and two elastic loops, one for each ear, or a single elastic band. All facemasks have some degree of fluid resistance, but those approved as surgical masks must meet specific standards for protection from penetration of blood and body fluids. Surgical masks protect the healthcare worker from sprays/splashes and prevent any pathogens from the wearer’s nose/mouth from potentially spreading to and infecting the patient or operative site. The below image series (Figure 8) demonstrate step-by-step instructions on the proper application of a surgical mask (Potter et al., 2017).  

Figure 8

Applying a Surgical Mask

Both have a flexible nose piece that is adjusted by pinching at the bridge of the nose. 

Place and hold the mask over the nose, mouth, and chin while stretching the band over the ear or tying the ties behind the head and the neck base.

Adjust the mask to ensure it fits snug against the face and is without gaps. The mask should not be touched or readjusted during use.

After properly removing and disposing of gloves, carefully remove the elastic from the ear or untie the mask from the back of the head, bottom tie first.

Dispose of the mask.

Perform hand hygiene.

(Original ATI Images, 2018)

Respirators

Respirators, commonly referred to as N95 respirators, or high-efficiency particulate air (HEPA) masks, cover the nose and mouth. These are used to reduce the healthcare worker's risk of inhaling hazardous airborne particles, gases, or vapors. Respirators are reserved for case-specific aerosolizing procedures where airborne particulates create a high risk of infection for the healthcare worker. OSHA standards require that National Institute for Occupational Safety and Health (NIOSH)-approved N95 filtering facepiece respirators or higher are used when in contact with patients with suspected or confirmed airborne-transmitted diseases, such as TB or COVID-19. In addition, these masks must meet requirements to minimally filter 95% of 0.3 µm-size particles. Most N95 and HEPA respirators are single-use disposable options (see Figure 9), which tend to be lighter and less cumbersome for the wearer. Reusable options are also available, including elastomeric respirators and powered air-purifying respirators (PAPR; see Figure 10). Some of these options have the advantage of also providing face and eye protection in one unit, as well as reducing the risk of self-contamination. Respirators are intended for protection against solids; they are highly durable devices, have a soft and comfortable inner surface, adjustable nosepiece, and secure head straps to provide a proper fit (CDC, 2014, 2020d; Potter et al., 2017).

Figure 9

N95 Mask

Figure 10

Types of Respirators

Figure 11 is an infographic adapted from the CDC’s National Personal Protective Technology Laboratory (NPPTL, 2019) displaying the fundamental differences between three major types of masks used in healthcare settings: surgical mask, N95 respirator, and a half facepiece respirator/HEPA mask.

Fit Testing 

Healthcare workers must be fit-tested before using an N95/HEPA mask. Fit testing assesses the fit of a specific respirator model and size to the wearer’s face and includes qualitative fit testing (QLFT; a pass/fail test to assess the adequacy of respirator fit that relies on the individual’s response to the test agent), and quantitative fit testing (QNFT; an assessment of the adequacy of respirator fit by numerically measuring the amount of leakage into the respirator). Figure 12 demonstrates the process of fit testing, with qualitative displayed on the left side of the image and quantitative on the right side (NIOSH, 2015b). 

OSHA requires employers to provide a sufficient number of models and sizes of respirators so that employees can be provided with a respirator that is comfortable and fits appropriately. Further, employees are only allowed to use the make, model, style, and size of respirators that have been successfully fit tested. Fit testing is required for all users of respirators with tight-fitting facepieces, including filtering facepiece respirators. The fit test ensures that, when appropriately donned, the selected brand and size of the respirator fits adequately to protect the wearer from excessive inward leakage of contaminant through the face seal. The fit test must be repeated annually and whenever there are any changes in the employee’s physical condition, such as weight gain or loss (typically ten or more lbs.), dental changes, facial scarring, or other physical changes that could alter the fit of the respirator (NIOSH, 2015b).  If the respirator has a nosepiece, it should be fitted to the nose with both hands (not one hand) to ensure it is not bent or tented. The respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). A user seal check should be performed every time a healthcare worker dons a respirator before entering a patient's room. The respirator should be extended beneath the chin, and both the mouth and nose should be protected (CDC, 2014, 2020d).

Face and Eye Protection

Goggles/glasses, face shields, and full-face respirators provide a barrier to infectious substances and are typically used in conjunction with other PPE such as gloves, gowns, and masks. The type of face and eye protection depends on the specific work conditions and potential for exposure. Knowledge and awareness of the potential exposure based on the clinical circumstances are essential to make an informed decision about the appropriate face and eye protection. Eyeglasses prescribed for vision correction and contact lenses are not considered eye protection. It is crucial to evaluate the combination of PPE recommended for the specific clinical situation for the most effective protection. For example, some masks may not fit properly with various goggles or shields. Similarly, a full-face respirator may provide adequate protection without additional PPE. Goggles are available with direct or indirect venting. Direct-vented goggles can potentially allow the penetration of splashes and are not as reliable as indirect-vented goggles. As shown in Figure 13, goggles must fit securely to provide adequate protection from splashes, sprays, and respiratory droplets (CDC, 2014, 2019a; Potter et al., 2017).

Safety glasses are excellent for providing impact protection, but they do not adequately protect against splash, spray, and respiratory droplets. Thus, they are not typically used for infection control purposes. For proper application and removal of eye protection, refer to the Figure 14 image series (Potter et al., 2017).

Face shields are sometimes used as an alternative to safety glasses/goggles. Since the face shield covers a larger surface area than glasses/goggles, it protects additional facial areas (see Figure 15); however, it does not fit tightly against the face, rendering the healthcare worker more vulnerable to splash and spray particles that can easily penetrate beneath the shield. Therefore, face shields are typically used in combination with other forms of protection and should not be considered the best defense when used alone (Potter et al., 2017).

Gowns

A clean, nonsterile gown is adequate for protecting skin and preventing soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Most patient interactions do not require a gown, but they are always needed when caring for patients on contact precautions. Select a gown that is appropriate for the activity and amount of fluid likely to be encountered. Remove a soiled gown as soon as possible and perform hand hygiene to avoid transferring microorganisms to other patients or environments. Gowns are tested and determined to be either fluid-resistant or impervious, and most are disposable. The Figure 16 image series provides a step-by-step demonstration of applying and disposing of gowns (Potter et al., 2017).

Figure 16

Applying and Disposing Gowns

Select the appropriate type and size of the gown.

Donning and Doffing PPE

To effectively reduce the spread of microorganisms, adhering to the proper sequence of donning and doffing PPE is vital. The CDC's recommendations for both tasks are listed below, followed by a graphic example of each. Since more than one method may be acceptable, learners are reminded to consult the training and practices as outlined by their institution’s policies and procedures (CDC, 2014, 2020d).

Donning PPE (see Figure 17)

1. Gather the appropriate PPE to don based on the patient's clinical situation, anticipated risk of exposure, and evidence-based infection control standards. 
2. Perform hand hygiene immediately before donning equipment.
3. Put on the gown by placing the arms into the sleeves, then tie the gown at the neck, overlap the gown in the back, and tie at the waist.
4. Put on the face mask by placing it over the nose and tying strings at the back of the head. If glasses are worn, set the rim of the face mask under the glasses to prevent the glasses from fogging.
5. Put on eyewear/goggles/face shield
   1. When wearing an N95 respirator, select the proper eye protection to ensure that the respirator does not interfere with the proper fit and positioning of the eye protection. Likewise, ensure the eye protection does not affect the fit or seal of the respirator.
6. Apply gloves and pull the cuff of the gloves over the gown sleeve; gloves should cover the wrist of the gown (CDC, 2014, 2020d).

Doffing PPE (see Figures 18 and 19)

Removing equipment when using reusable/washable gown (Figure 18):

1. Remove all PPE at the doorway of the room before exiting.  The exception is a respirator mask which should be removed outside the room after closing the door. 
2. Remove the gloves first since they are the most soiled piece of equipment. Remove the first glove by pinching it at the cuff and invert the glove as it is removed. Then, remove the second glove by sliding fingers under the cuff, pulling it off, and pulling it inside out. 
3. Remove eyewear; remember the outside of eyewear is contaminated. Lift from the back without touching the front. If reusable, place in the designated receptacle for reprocessing, or dispose of in a waste container if single-use.
4. Remove the gown by untying the ties, taking care to avoid touching the soiled surface of the gown, and rolling the gown inside out—place in a dirty linen container.
5. Remove the mask by handling only the ties/elastic. The front of the mask is contaminated. The bottom ties should be undone first to prevent the mask from falling onto the front of the uniform.  If using a respirator mask, remove it after leaving the room. 
6. Perform hand hygiene.  If the hands become visibly soiled during the removal of the PPE, perform hand hygiene before proceeding (CDC, 2014, 2020d).

Removing equipment when using a disposable/breakaway gown (Figure 19):

1. Remove all PPE at the doorway of the room before exiting.  The exception is a respirator mask which should be removed outside the room after closing the door. 
2. Grasp the gown in front and pull away from your body so that the ties break, touching outside of gown only with gloved hands, folding and rolling gown inside-out into a bundle
3. Peel your gloves off simultaneously as you remove the gown at the sleeves/wrists, only touching the inside of the gloves and gown with your bare hands. Place both into the proper waste container.
4. Remove eyewear; remember the outside of eyewear is contaminated. Lift from the back without touching the front. If reusable, place in the designated receptacle for reprocessing, or dispose of in a waste container if single-use.
5. Remove the mask by handling only the ties/elastic. The front of the mask is contaminated. The bottom ties should be undone first to prevent the mask from falling onto the front of the uniform.  If using a respirator mask, remove it after leaving the room. 
6. Perform hand hygiene.  If the hands become visibly soiled during the removal of the PPE, perform hand hygiene before proceeding (CDC, 2014, 2020d).

Standard and Transmission-Based Precautions

There are two primary tiers of CDC precautions to prevent the transmission of infectious agents: standard precautions and transmission-based precautions (CDC, 2014).

Standard Precautions

Standard precautions are the basis of infection control practices and are of utmost importance to prevent the transmission of infectious agents and communicable diseases in healthcare settings. Standard precautions are applied to the care of all patients in healthcare settings (regardless of suspected or confirmed presence of an infectious agent) and are the first line of defense to break the chain of infection and protect healthcare workers and patients. Standard precautions are premised on the concept that every patient’s blood or body fluids are potentially contaminated with infectious agents. Standard precautions are employed with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes. Providing care using standard precautions includes hand hygiene, gloves, gown, facemask, face shield; respiratory hygiene/cough etiquette; and safe injection practices. The use of facemasks during spinal/epidural access procedures is included within the definition of standard precautions.  The selection of PPE depends upon anticipated blood, body fluid, or splash exposure. The efficacy of standard precautions relies on how well individuals and institutions adhere to the recommended guidelines. In addition to hand hygiene practices, standard precautions include selecting and using proper PPE based on the level of anticipated contact with the patient and the potential for exposure to infectious material. In 2013, the CDC recommended that respiratory hygiene/cough etiquette be incorporated into infection control as a component of standard precautions. These should be instituted in the healthcare setting at the first point of contact with a potentially infected person to prevent the transmission of all respiratory infections. The recommended practices have a robust evidence base (CDC, 2014; Siegel et al., 2019). 

Respiratory hygiene/cough etiquette applies to anyone entering a healthcare setting (patients, visitors, and staff) with signs or symptoms of illness (cough, congestion, rhinorrhea, or increased production of respiratory secretions). The components of respiratory hygiene/cough etiquette include the following:

• covering the mouth and nose during coughing and sneezing
• using disposable facial tissues to contain respiratory secretions, with prompt disposal into a hands-free receptacle
• wearing a surgical mask when coughing to minimize contamination of the surrounding environment
• turning the head when coughing and staying at least 3 feet away from others, especially in common waiting areas
• washing hands with soap and water or alcohol-based hand rub after contact with respiratory secretions (CDC, 2014; Siegel et al., 2019).

Further, healthcare workers are encouraged to post educational signs in languages appropriate to the population(s) treated; this can help reinforce and communicate these instructions to patients, family, and visitors (CDC, 2014; Siegel et al., 2019).

Transmission-Based Precautions

Transmission-based precautions are the second tier of infection control and are intended for use alongside standard precautions described above. Transmission-based precautions are reserved for patients suspected of being infected or colonized with specific infectious agents that require additional precautions to prevent transmission. Also referred to as isolation precautions, transmission-based precautions are based on the infectious organism’s mode of transmission. Corresponding to the primary modes of transmission discussed earlier, the major categories of transmission-based protection include contact, droplet, and airborne precautions. These are used for patients with highly transmissible pathogens when the route of transmission is not entirely interrupted by standard precautions. Regardless of the specific type of transmission-based precautions required, the following principles should be routinely adhered to (CDC, 2019a; Siegel et al., 2019):

• thoroughly perform hand hygiene before entering and leaving the room of a patient in isolation
• properly dispose of contaminated supplies and equipment according to agency policy
• apply knowledge of the mode of infection transmission when using PPE
• protect all persons from exposure during the transport of an infected patient outside of the isolation room
• single private rooms are preferred when available, but cohorting may be implemented during outbreaks of infections (i.e., the placement of patients infected with the same organism in the same room, based on organizational needs) 

Cohorting was implemented during the recent COVID-19 pandemic. Consultation with a member of the infection control committee is recommended before deciding to cohort patients (CDC, 2019a; Siegel et al., 2019).

Contact Precautions

Contact precautions are used when a disease is transmitted via direct contact, contaminated body fluids, or indirectly through contaminated instruments, equipment, or the hands of healthcare workers. Examples of infections in which contact precautions are instituted include VRE, MRSA, C. diff, respiratory syncytial virus (RSV), norovirus, rotavirus, and the herpes simplex virus. Contact precautions may also apply in the presence of excessive wound infection/drainage, fecal incontinence, or other discharges from the body that suggest an increased potential for extensive environmental contamination and risk of transmission (CDC, 2014, 2016c; Siegel et al., 2019). The CDC’s 2007 guideline for isolation precautions for preventing the transmission of infectious agents in healthcare settings was last updated in 2019. According to the guideline, the following fundamental principles apply to all patients on contact precautions (CDC, 2019a):

• Appropriate patient placement
  • If possible, it is recommended that patients on contact precautions are placed in a private room with a private bathroom to prevent cross-contamination. In addition, the CDC offers specific recommendations based on the healthcare facility as follows: 
    • Acute care facilities/hospitals: single patient room placement is advised if available 
    • Long-term care (LTC) and residential settings (e.g., SNFs, rehabilitation centers): room placement decision-making should be based on balancing the risks to other residents. 
    • Ambulatory settings (e.g., clinics, urgent care, private offices): patients should be placed in an exam room or separate section as soon as possible.
• Appropriate PPE
  • Contract precautions require healthcare workers to wear nonsterile gloves and gowns during all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. PPE should be donned upon room entry and properly discarding before exiting the patient room.
• Limit the transport and movement of patients outside of their designated room to medically necessary purposes only. When transporting a patient on contact precautions outside their room is required, the following principles apply:
  • cover the infected or colonized areas of the patient’s body
  • remove and dispose of all contaminated PPE and perform hand hygiene before transporting patients
  • don clean PPE to care for the patient at the transport location
• Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs) whenever possible. If the shared use of medical equipment is unavoidable, follow the institution’s disinfection policies to ensure it is decontaminated effectively.
• Prioritize the cleaning and disinfection of patients' rooms on contact precautions ensuring rooms are frequently cleaned and disinfected (e.g., at minimum once daily and before use by another patient).

Droplet Precautions

Droplet precautions are used when a disease is transmitted by large droplets expelled into the air and are recommended for patients with known or suspected infections with pathogens generated by coughing, sneezing, or talking. Examples of patients who require droplet precautions include those who have influenza, pertussis, meningococcal disease, or Mycoplasma pneumonia (CDC, 2016c; Siegel et al., 2019). According to the CDC’s isolation precautions guideline, the following fundamental principles apply to all patients on droplet precautions (CDC, 2019a):

• Put a mask on the patient for source control.
• Appropriate patient placement:
  • As with contact precautions, it is also recommended that patients on droplet precautions are placed in a private room with a private bathroom to prevent cross-contamination. The CDC offers more specific recommendations based on the healthcare facility as follows: 
    • Acute care facilities/hospitals: if single rooms are unavailable, utilize the recommendations for alternative patient placement considerations in the Guideline for Isolation Precautions.
    • LTC and other residential settings: decisions regarding patient placement should be made on an individual basis regarding infection risks to other residents in the room and available alternatives. 
    • Ambulatory settings: place patients in an exam room or cubicle as soon as possible and instruct patients to follow all the respiratory hygiene/cough etiquette standards described in the previous section.
• Appropriate PPE
  • Droplet precautions require healthcare workers to wear a surgical mask when within 3 feet of the patient. A mask should be donned before entering the patient room. 
• Limit the transport and movement of patients outside of their designated room to medically necessary purposes only. When transporting a patient on droplet precautions outside their room, the following principles apply:
  • Put a surgical mask on the patient
  • Instruct the patient to comply with respiratory hygiene/cough etiquette standards. 

Airborne Precautions

Airborne precautions are used when a disease is transmitted by smaller droplets and are indicated for patients with known or suspected infectious pathogens spread via the airborne route. Examples of diagnoses that require airborne precautions include TB, measles, varicella, severe acute respiratory syndrome, and disseminated herpes zoster (Siegel et al., 2019). According to the CDC’s isolation precautions guideline, the following fundamental principles apply to all patients on airborne precautions (CDC, 2019a):

• Put a mask on the patient for source control.
• Appropriate patient placement
  • If possible, the patient should be placed in a private airborne infection isolation room (AIIR) equipped with negative pressure airflow. This airflow filters air through a HEPA filter and then directs the air outside the facility. In settings where airborne precautions cannot be implemented due to the absence of proper engineering controls, the patient should be masked and placed in a private room with the door closed. This recommendation will decrease the likelihood of airborne transmission until the patient is transferred to a facility with an AIIR or discharged.
• Whenever possible, susceptible healthcare workers (e.g., pregnant women, unvaccinated workers) should be restricted from entering the room of patients with known or suspected airborne illnesses, especially measles, chickenpox, disseminated zoster, or smallpox. 
• Appropriate PPE
  • Airborne precautions require healthcare workers to apply a fit-tested NIOSH-approved N95 respirator (or higher-level respirator) before entering the patient’s room.
• Limit the transport and movement of patients outside of their designated room to medically necessary purposes only. When transporting a patient on airborne precautions is required, the following principles apply:
  • Place a surgical mask on the patient.
  • Instruct patients to comply with respiratory hygiene/cough etiquette standards.
  • Of note, healthcare workers transporting patients on airborne precautions do not need to wear a mask or respirator during transport if the patient is wearing a mask and infectious skin lesions are covered.
• Susceptible persons should receive appropriate immunization as soon as possible following unprotected contact with vaccine-preventable airborne conditions (e.g., varicella, measles, or smallpox).

Recommendations for TB screening and Post-Exposure Management. As of December 16, 2020, the NYSDOH is updating the requirements for baseline and annual TB assessments of healthcare personnel in certain regulated facilities in response to the recent systematic review performed by the CDC (Sosa et al., 2019) that found a low percentage of healthcare workers have a positive TB test at baseline and upon serial testing. Updated recommendations for screening and testing of healthcare workers include the following:

• Baseline (preplacement) screening and testing
  • TB screening of all healthcare workers, including a symptom evaluation and test (interferon-gamma release assay [IGRA] or tuberculin skin test [TST]) for those without documented prior TB disease or latent tuberculosis infection (LTBI) 
  • Individual TB risk assessment 
• Post-exposure screening and testing
  • Symptom evaluation for all healthcare workers when exposure is recognized. For those with a negative baseline TB test and no prior TB disease or LTBI, perform a test (IGRA or TST) when the exposure is identified. If that test is negative, another test should be performed 8 to 10 weeks after the last exposure.
• Evaluation and treatment of positive test results
  • Treatment is encouraged for all healthcare workers with untreated LTBI unless medically contraindicated.

 Following exposure to TB, an active pulmonary TB infection is treated with combined anti-TB therapies for 6 to 9 months. The first-line anti-TB agents include isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA). Typically, healthcare workers can return to work after symptoms have resolved and three sputum smears are negative for acid-fast bacilli (AFB; CDC, 2016d). If a healthcare worker does not demonstrate active disease but develops a newly positive TST, NYS policy recommends treatment with isoniazid (INH) for 6 to 9 months to prevent active TB from developing. Workplace exposure to other infectious diseases should be handled on a case-by-case basis with the occupational health provider. For example, a susceptible (non-immune) healthcare worker exposed to chickenpox is usually furloughed from work beginning the 10th day through the 21st day following the exposure (i.e., the incubation period for chickenpox). Healthcare workers should consult current federal, state, and local requirements for post-exposure evaluation and management of all airborne and droplet transmitted conditions. NYS and CDC-mandated reporting require healthcare workers to report any suspected or confirmed TB case to the DOH or designed official within 24 hours. In addition, healthcare workers should contact the NYSDOH Bureau of Communicable Disease Control at (518) 473-4439 or (866) 881-2809 after hours. Additional NYS post-exposure guidelines can be found on the DOH website (CDC, 2012; NYSDOH, n.d.-a).

Protective Environment

In addition to transmission-based precautions, a protective environment is another type of precaution healthcare workers may encounter. A protective environment is designed to safeguard patients at high risk for infection due to an immunocompromised state (e.g., severe burns, myeloablative [high-dose] chemotherapy, organ or bone marrow transplant recipients). Sometimes referred to as neutropenic or protective precautions, a protective environment reduces the risk of environmental fungal infections. These patients require a private room with positive airflow and HEPA filtration for incoming air, and healthcare workers should wear masks when caring for them. In addition, these patients should only be transported out of their rooms for medically necessary purposes and should wear a mask when outside of their room. In severely immunocompromised patients, fresh flowers and potted plants are not permitted inside their rooms, and dietary restrictions may also apply, such as avoiding raw fish or fresh fruits and vegetables (Nettina, 2019). 

Preventing Bloodborne Pathogen Transmission

Bloodborne pathogens are infectious microorganisms in human blood that can be transmitted to other humans and cause illness. Occupational exposure to bloodborne pathogens from needlesticks and other sharps-related injuries is a serious yet preventable problem. Still, an estimated 385,000 needlesticks and other sharps-related injuries are sustained by hospital-based healthcare workers each year, averaging 1,000 sharps injuries per day (NIOSH, 2016a; OSHA, n.d.-a). According to the National Occupational Research Agenda (NORA, 2019), 53% of needlestick Injuries affect nurses. While injuries from needles and other sharp devices used in healthcare and laboratory settings are associated with transmitting several pathogens, HIV, HBV, and HCV are the most commonly transmitted during patient care; see Table 4 for a brief overview of these bloodborne pathogens (NIOSH, 2016a; OSHA, n.d.-a).

For a bloodborne pathogen to be transmitted, the bodily fluids of an infected person must enter into the bloodstream of another person. Occupational exposures can occur through needlesticks or punctures from other sharp instruments contaminated with an infected patient’s blood (including blood-contaminated saliva) or through contact of the eye, nose, mouth, or skin with a patient’s blood. Exposure can be percutaneous (handling contaminated needles/sharps), mucous membrane/non-intact skin (blood or body fluid exposure via direct contact, contaminated hands, or splash/spray), or parenteral (administering contaminated medication or blood product or via sharing blood monitoring devices). The most common cause of transmission in the healthcare setting is when an infected person’s blood enters another person’s bloodstream through an open wound. Bloodborne pathogens can be present in sufficient quantities to produce infection without visible blood. Poor adherence to safety measures can lead to notification and testing of thousands of potentially exposed patients and healthcare workers, bloodborne disease transmission, disciplinary action, license revocation, and legal action (NIOSH, 2016a; OSHA, n.d.-a).

The OSHA Bloodborne Pathogens Standard has been in place since 1991 to protect healthcare personnel from occupational exposure to blood and other potentially infectious materials. In 2000, the Needlestick Safety and Prevention Act became public law and was enforced to help prevent bloodborne pathogen injuries. The act revised the bloodborne pathogens standard, in effect under the OSHA Act of 1970, to include safer medical devices and updated engineering controls to eliminate or minimize occupational exposure to bloodborne pathogens through needlestick and other percutaneous injuries. The act is premised on the concept that safer devices lead to a safer working environment (H.R.5178 - 106^th Congress, 2000). According to OSHA (n.d.-a), to eliminate the hazards of occupational exposure to bloodborne pathogens, an employer must implement an exposure control plan for the healthcare setting with details on employee protection measures. The CDC’s Stop Sticks campaign was created by NIOSH but is currently maintained by the NORA (2019). The campaign aims to raise awareness among healthcare workers about their risk of workplace exposure to bloodborne pathogens from needlesticks and sharps-related injuries (see Figure 20). Educating healthcare workers is the first step in prevention. In addition, maintaining up-to-date vaccination offers vital immunity against possible exposure to HBV. According to WHO (2020a), the HBV vaccination series provides 98 to 100% protection against HBV. The use of standard precautions, engineering controls generating safer medical devices, and PPE has led to a decline in the frequency of bloodborne exposures. However, the risk of occupational exposure to healthcare workers is more significant than in previous years due to the rising aging populations accessing healthcare with HIV, HBV, HCV, co-infections with multiple bloodborne diseases, and emerging MDROs (NORA, 2019). 

Figure 20

Stop Sticks Campaign: Prevention

(NCRA, 2013)

Engineering Controls

Engineering controls, such as sharps containers for the disposal and transport of needles and other sharp objects, combined with workplace regulations, such as prohibiting the recapping of needles by a two-handed technique, reduce the likelihood of bloodborne pathogen exposure. Engineering controls minimize exposure by providing equipment that contains passive safety features and offers continuous protection. Examples of engineering controls to prevent needlestick and other sharps-related hazards in healthcare settings include self-sheathing needles, puncture-resistant sharps containers, and splatter shields on medical equipment associated with risk-prone procedures. Appropriate healthcare worker training on the use of this equipment is essential, and these safety features should never be circumvented (CDC, 2011, 2019a; H.R.5178 - 106^th Congress, 2000; NIOSH, 2015a).

Work Practice (Administrative) Controls 

Work practice controls aim to reduce the risk of bloodborne pathogen exposure to healthcare workers by altering how the task is performed or isolating the workplace's bloodborne pathogen hazard. Work practice controls include proper hand hygiene; handling, disposing, and cleaning of blood and body fluids; selection and use of PPE; protection and separation of work surfaces and equipment to prevent contamination; and safe handling of sharps. When suturing, healthcare workers are encouraged to use forceps or suture holders, avoid holding tissue with fingers, and avoid performing procedures where there is poor visualization (blind suturing). They are also advised to avoid using the non-dominant hand opposing or next to the sharp and avoid performing procedures where bone spicules or metal fragments are produced. Healthcare workers should never leave exposed sharps on patient procedure/treatment work surfaces; these should be disposed of as soon as possible in designated sharps containers (CDC, 2011, 2019a; NIOSH, 2016b).

Safe Injection Practices

According to OSHA and the CDC (2011, 2019a), safe injection practices require healthcare workers to following a series of specific recommendations. The following recommendations apply to the use of needles, cannulas that replace needles, and IV delivery systems CDC (2011, 2019a):

• Maintain aseptic technique to avoid contamination of sterile injection equipment.
• Employ proper hand hygiene practices before handling all medications.
• Use needleless safety devices whenever possible.
• A designated “clean” medication area should be set aside for the sole purpose of drawing up all medications.
• Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Instead, use a new sterile syringe and needle for each medication, each time, for every patient. Never leave a needle or other device (e.g., “spikes”) inserted into a medication vial septum or IV bag/bottle for multiple uses or administer medication from the same syringe or IV bag to multiple patients.
• Use single-dose vials for parenteral medications and dedicate vials of medication to a single patient whenever possible. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use.
• If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile. Multidose vials should be disinfected using alcohol before drawing up medication and only accessed with a new sterile needle. Do not keep multidose vials in the immediate patient treatment area and store them according to the manufacturer’s recommendations. Multidose vials should be discarded if sterility is compromised or questioned. 
• Expired medications are considered to have compromised sterility and should be disposed of safely.
• All infusion components (infusion and administration sets such as IV bags, tubing, connectors) are a single interconnected unit and should be considered directly or indirectly in contact with blood/body fluids. Therefore, consider a syringe or needle/cannula contaminated once used to enter or connect to a patient’s IV infusion bag or administration set and is for single-use only; this applies to needles/syringes used to access a port along the patient’s tubing line.
• Never leave sharp or used needles in a pocket or on any counter or workspace. Dispose of the sharp device into a puncture-proof, leak-proof sharps disposal container immediately after use. 
• Avoid recapping a needle if possible, but if necessary, use a one-handed technique only.
• Avoid bending or breaking a needle, and never force a needle into a full sharps’ container.
• Regarding special lumbar puncture procedures, a surgical mask should be worn when placing a catheter or injecting material into the spinal canal or subdural space (i.e., during myelograms, lumbar puncture, and spinal or epidural anesthesia).

When caring for diabetic patients, peripheral capillary blood monitoring devices intended for use with a single patient should not be shared. Disposable lancets should never be reused for multiple patients. Ideally, lancets should be single-use and retract after puncture for maximum safety. Patients who self-inject medications at home should be instructed how to dispose of used needles safely. Community services are available to assist patients with used needle disposals, such as drop-off collection sites, syringe exchange programs, and special waste pickup services. Patients should be referred to the US Environmental Protection Agency (EPA) and their local department of health websites for more information (CDC, 2019a; EPA, 2004).

Bloodborne Pathogen Exposure

Following a needlestick or sharps-related exposure, the risk of acquiring an infection varies depending on several factors such as:

• pathogen 
• type and severity of exposure
• amount of blood involved in the exposure
• amount of pathogen in the patient’s blood at the time of exposure

While most exposures do not result in infection, the exposed healthcare worker should be evaluated immediately by a qualified healthcare professional in case treatment is needed. Following exposure to a needlestick, sharps injury, blood or body fluid of a patient, NIOSH (2016a) advises the healthcare worker to immediately following these steps:

• wash the site of the needlestick or cut with soap and water
• flush splashes to the nose, mouth, or skin with water
• irrigate eyes with clean water, saline, or sterile irrigants
• report the incident to a supervisor or the person responsible for managing exposures
• immediately seek medical evaluation from a qualified healthcare provider (NIOSH, 2016a)

Exposure incidents should be reported immediately. Healthcare facilities have a duty to their employees and patients to track, study, and actively prevent these incidents whenever possible by identifying high-risk individuals, procedures, equipment, and patient care areas. An exposure incident warrants prompt evaluation by a licensed medical provider. Occupational health clinicians should obtain a complete medical history, including vaccination history, and perform a comprehensive physical exam and risk assessment. In some cases, post-exposure treatment may be recommended and should begin immediately (NIOSH, 2016a). Occupational health clinicians caring for exposed healthcare workers can call the National Clinician Consultation Center (NCCC) Post-Exposure Prophylaxis Hotline (PEPline) for advice on managing occupational exposures to HIV, HBV, and HCV. The PEPline is available 24 hours/7 days a week at 1-888-448-4911 (NCCC, 2021). In addition, information regarding post-exposure prophylaxis and approaching/informing source patients or healthcare workers should be provided (NIOSH, 2016a).  An overview of the NYS post-exposure evaluation and management guidelines for bloodborne pathogens are listed in Table 5. A detailed account of the guidelines can also be found on the DOH website (NYSDOH and NYSED, 2018).

HIV Post-Exposure Prophylaxis (PEP) 

According to the NYSDOH AIDS Institute (NYSDOH AI, 2020c) guidelines for PEP, ARV therapy effectively prevents HIV infection in an exposed individual when initiated ideally within 2 hours, but no later than 72 hours following the exposure. The rapid and effective response to possible HIV exposure is key to preventing the development of an HIV infection. When ARV is administered within the 72-hour timeframe, it has a rapid onset, elicits antiviral acts on multiple sites in the body, thereby blocking viral replication, containing and preventing the infection. According to the guidelines, ARV medications have minimal adverse effects. These agents are recommended for pregnant women as they have been safely tested. The exception is the small risk of teratogenicity with dolutegravir (DTG) when taken during the first trimester, and contraception should be used while taking this medication. The following are recommended ARV regimens for HIV PEP:

• tenofovir disoproxil fumarate/emtricitabine plus raltegravir (TDF/FTC plus RAL) or
• TDF/FTC plus dolutegravir (TDF/FTC plus DTG)
• lamivudine (3TC; Epivir) may be substituted for FTC in either regimen
• raltegravir (RAL) may be prescribed in the high-dose (HD) formulation, but the HD should not be given to pregnant patients (NYSDOH AI, 2020c)

Following exposure to HIV, the healthcare worker should also be assessed for concurrent exposure to HCV (NYSDOH AI, 2020b, 2020c).

Management of Potential Exposure to HCV

The healthcare worker exposed to HCV should undergo the following baseline blood tests, preferably within 48 hours of the exposure: HCV antibody, HCV RNA, and liver enzyme tests. If HCV is diagnosed, the individual should be referred to a specialist experienced in treating HCV. Occupational health clinicians should not prescribe or administer immunoglobulin or ARV for PEP (NYSDOH AI, 2020b).

Management of Potential Exposure to HBV

Following potential exposure to HBV, the healthcare worker should undergo testing for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs); this applies to patients who are known to be non-immune or whose immunity status is unknown. Non-HBV-immune individuals exposed to HBV in blood or bodily fluid should promptly initiate the HBV vaccine series; it is recommended that the first dose is administered during the initial occupational health evaluation. The decision to start the HBV vaccination series should not be delayed while awaiting testing, and ideally, the vaccine should be administered within 24 hours of exposure. In addition to initiating the HBV vaccine, clinicians should administer prophylactic hepatitis B immune globulin (HBIG) as soon as possible, ideally within 7 days of exposure but not more than 14 days. If the healthcare worker is at high risk of HBV infection, clinicians should proceed as if they are confirmed HBsAg-positive. If the patient is negative, then no further action is necessary. Once the HBV vaccine series has been initiated, the recipient should receive the second and third doses in 1 to 2 months and 6 months, respectively, after the first dose for the standard vaccine; or 1 month later for the recombinant vaccine (NYSDOH AI, 2020a).

In addition, the NYS policy regarding healthcare workers with a bloodborne infection states that bloodborne pathogen infection alone does not justify limiting a healthcare worker's professional duties, and healthcare workers are not required to inform patients or employers that they have a bloodborne pathogen infection. To determine appropriate restrictions, if any, the healthcare worker should be evaluated for job duties/scope of practice, compliance with standard precautions, presence of weeping dermatitis or open wounds, overall health, physical health, and cognitive status. Frequently expert panels, advisory councils, or ethics committees are consulted for assistance with decision-making regarding these complex cases (NYSDOH AI, 2020a, 2020b, 2020c; NYSDOH and NYSED, 2018).

Cleaning, Disinfection, and Sterilization

As part of their infection control standards, healthcare organizations have policies and procedures governing the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces and guidelines for how those processes should be recorded and tracked. Healthcare workers are advised to consult their institution’s infection control policies regularly. According to the NYSDOH and NYSED (2018), there should be physical separation between patient care areas and cleaning/reprocessing zones. NYS environmental control measures to prevent the spread of pathogenic organisms in healthcare settings include the following components:

• cleaning, disinfection, and sterilization of all reusable patient care equipment
• environmental cleaning/housekeeping, including linen and laundry management
• appropriate ventilation
• food services
• waste management (NYSDOH and NYSED, 2018)

Cleaning is the removal of foreign matter from objects. Most, but not all, of the microorganisms are removed. Cleaning involves water, detergent, and scrubbing. Soiled objects must be cleaned before they are disinfected or sterilized. The CDC (2019c) Guideline for Disinfection and Sterilization in Healthcare Facilities offers evidence-based recommendations on the preferred methods for cleaning, disinfecting, and sterilizing patient care medical devices and the healthcare environment. Last updated in 2019, 

adherence to these recommendations (and to the instructions on cleaning product labels) can significantly reduce the risk for infection associated with the use of invasive and noninvasive medical equipment. The CDC (2020a) recommends a basic risk assessment for determining the environmental cleaning method and frequency in healthcare facilities. The frequency, method, and process of cleaning procedures for individual patient care areas should be based on the risk of pathogen transmission. This risk is assessed by considering the following three major components:

• the probability of contamination
• the vulnerability of the patients to infection
• the potential for exposure (i.e., high-touch vs. low-touch surfaces; CDC, 2020a)

These three elements combine to determine low, moderate, or high risk; more frequent and rigorous environmental cleaning processes are required for areas at high risk. A brief overview of the CDC’s low, moderate, and high-risk classification is outlined in Table 6 (CDC, 2019c, 2020a).

 For all environmental cleaning procedures, the CDC (2020a) advises that healthcare workers routinely follow these general cleaning strategies:

• Conduct a visual preliminary site assessment to determine if the patient’s status could pose a challenge to safe cleaning or if there is any need for additional PPE or supplies (e.g., asses for spills of blood or body fluids, if the patient is on transmission-based precautions or if there are any obstacles [e.g., clutter, damage, or broken furniture]).
• Proceed with cleaning from cleaner to dirtier areas to avoid spreading dirt and microorganisms (see Figure 21) and from high to low (or top to bottom). Cleaning from high to low (e.g., cleaning surfaces before floors) prevents dirt and microorganisms from dripping or falling and contaminating already cleaned areas.  
• Clean in a systematic manner, such as clockwise around the patient’s room.

In acute care settings/hospitals, most cleaning, disinfection, and sterilization of patient-care devices are performed via a central processing department. However, healthcare workers must understand their responsibilities with regards to the cleaning of patient-care devices (CDC, 2019c, 2020a):

1. Patient care items should be meticulously cleaned with water and detergent or with water and enzymatic cleaners before high-level disinfection or sterilization procedures.
2. Remove visible residue using appropriate cleaning agents capable of removing organic and inorganic residues.    
3. Clean medical devices as soon as practical after use (e.g., at the point of use) as soiled materials become dried onto the instruments and make the removal process more difficult.
4. Perform manual cleaning using friction for visibly soiled objects (or mechanical cleaning with ultrasonic cleaners, washer-disinfector, washer-sterilizers, if available).
5. Ensure that the detergents or enzymatic cleaners selected are compatible with the metals and other materials used in medical instruments. In addition, confirm that the rinse step is adequate for removing cleaning residues to levels that will not interfere with subsequent disinfection/sterilization processes.
6. Inspect equipment surfaces for breaks in integrity that would impair either cleaning or disinfection/sterilization. Discard or repair equipment that no longer functions as intended or cannot be adequately cleaned, disinfected, or sterilized.

To perform manual cleaning of a soiled object, the following steps are advised (CDC, 2019c, 2020a):

1. Don appropriate PPE, including protective eyewear and utility gloves.
2. Use cold water to rinse the soiled object as hot water will cause the organic material to coagulate, making microorganism removal more difficult.
3. After rinsing, use soap and water to scrub the object and then rinse it again.
4. Apply friction using a brush to remove any remaining grime.
5. Rinse the object and dry it thoroughly.
6. Follow institution or agent policy to clean the sink and the equipment.    

Reusable items can be placed into one of three categories depending on the risk of infection associated with their use. Critical items enter the patient’s body, tissue, or vascular system and pose a high risk of infection, such as surgical instruments and biopsy forceps. Therefore, sterilization is required for critical items. Semi-critical items come in contact with mucous membranes or non-intact skin, such as endoscopes, laryngoscope blades, and vaginal speculums. Semi-critical items require either high-level disinfection or sterilization. Non-critical items come in contact with intact skin and require only low-level disinfection. Examples include stethoscopes, blood pressure cuffs, bedpans, and furniture.  Industry guidelines and equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. The choice of disinfection/sterilization level and method should be based on the intended use and the manufacturer’s recommendations. Written instructions should be available for each instrument, medical device, and equipment reprocessed, including handling and storage after being processed (CDC, 2019c).

Disinfection is the removal of nearly all microorganisms and depends on the contact time with the chemicals used. It does not destroy spores. There are three levels of disinfection: low, intermediate, and high, as outlined below (CDC, 2019c):

• Low level (noncritical items) disinfection kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA.
• Intermediate level (some semi-critical and noncritical items) disinfection kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a tuberculocide (i.e., a substance that destroys the TB-causing spore) by the EPA.
• High-level (semi-critical items) disinfection kills all organisms, except high levels of bacterial spores, with a chemical germicide cleared for marketing as a sterilant by the US Food & Drug Administration (FDA). 

Chemical agents such as alcohols, formaldehyde, chlorines, and ammonium are used for high-level disinfection. The CDC recommends high-level disinfection of HBV, HCV, HIV, or TB-contaminated devices. High level-disinfection is also used for medical equipment such as endoscopes. Features to consider when a disinfecting product is selected include immersion versus surface product, organic matter or biofilm, stability of the disinfectant, contact time with components, and financial costs. For processing patient care equipment contaminated with bloodborne pathogens (HIB, HBV, HCV), AR microbes, MDROs, and CDI, the CDC (2019c) advises the use of standard sterilization and disinfection procedures; these are considered adequate to sterilize or disinfect instruments or devices contaminated with blood or other body fluids from persons infected with bloodborne pathogens or emerging pathogens. No changes in these procedures for cleaning, disinfecting, or sterilizing are necessary for removing bloodborne and emerging pathogens other than prions (rare, transmissible neurodegenerative diseases that can affect humans and animals). When bloodborne pathogens other than HBV or HIV are of concern, OSHA continues to require the use of EPA-registered tuberculocidal disinfectants or hypochlorite solution (diluted 1:10 or 1:100 with water). In the presence of large blood spills, a 1:10 final dilution of EPA-registered hypochlorite solution should initially be used to inactivate bloodborne viruses to minimize risk for infection to healthcare personnel from percutaneous injury during cleanup (CDC, 2019c).

Sterilization destroys all microorganisms on the surface or within the device, including viruses and spores, to prevent disease transmission associated with the use of that item. Sterilization requires sufficient exposure time to heat, chemicals, or gases. Moist heat (using an autoclave) is used for items that can tolerate high pressure and a temperature above the boiling point. Most medical and surgical equipment used in healthcare settings is comprised of materials that are heat stable and are intended for heat (or steam) sterilization procedures. Ethylene oxide (ETO) gas destroys microorganisms and spores. ETO gas is very effective for heat-sensitive items but is toxic to humans. In acute care facilities/hospitals, all critical items should undergo sterilization. In most healthcare settings, employees in a central processing unit have advanced education in disinfection and sterilization and provide these services for the facility.  There are biological, process, and physical monitors that allow staff to confirm process completion/successful sterilization. The use of boiling water is appropriate for sterilization in the home setting because it is inexpensive and convenient; however, this technique cannot destroy all bacterial spores and viruses and is therefore not utilized in healthcare settings. Over the last decade, several new, lower-temperature sterilization systems have been developed. They are being used to sterilize medical devices, such as hydrogen peroxide gas plasma, peracetic acid immersion, and ozone. Nurses must understand the core processes and components involved in the sterilization process and clarify the necessary steps to be taken before submission of items for sterilization (i.e., pre-cleaning/soaking of the items; CDC, 2019c).

Special procedures are required for handling brain, spinal, or nerve tissue from patients with known or suspected prion disease (e.g., Creutzfeldt-Jakob disease [CJD]). Consultation with infection control experts before performing procedures on such patients is warranted.  No process is flawless, and there have been cases of disease transmission due to faulty disinfection or sterilization processes. Factors that have contributed to contamination in reported cases of disease transmission include failure to reprocess or dispose of items between patients, inadequate cleaning, inadequate disinfection or sterilization, contamination of disinfectant or rinse solutions, improper packaging, storage and handling, and/or inaccurate record-keeping of reprocessing requirements (CDC, 2019c).

Healthcare workers with primary or supervisory responsibilities for equipment, instruments, or medical device reprocessing (e.g., staff working in the sterile processing department or physician practices where medical equipment is reprocessed on-site [e.g., gynecologic offices]), are responsible for not just understanding the core concepts and principles, but must also help determine appropriate reprocessing practices. Refer to the FDA and NIOSH websites for more information regarding federal regulations. All methods selected should be evaluated for the following:

• efficacy 
• efficiency (time required for reprocessing)
• compatibility with materials: corrosiveness, penetrability, leaching, disintegration, heat tolerance, moisture sensitivity
• toxicities such as occupational health risks, environmental hazards, abatement methods, monitoring exposures, the potential for patient toxicity/allergy
• residual effects including antibacterial residual, patient toxicity/allergy
• ease of use, as well as the need for specialized equipment or training requirements
• stability of the method, including concentration, potency, and the effect of organic material
• odor
• financial cost
• monitoring requirements and frequency (CDC, 2019c, NYSDOH and NYSED, 2018)

Waste Management

Properly disposing of patient-care equipment contaminated with blood, body fluids, secretions, and excretions is essential for preventing the spread of microorganisms to other patients and environments. Contaminated disposable equipment should be discarded in the proper receptacle for biohazardous waste per your facility’s procedural guidelines and not in the regular trash (see Figure 22). Sharp objects, including needles, lancets, should be disposed of in designated sharps containers. Do not use reusable equipment to care for other patients until it has been cleaned and reprocessed appropriately. For example, reusable bedpans and blood pressure cuffs should be disinfected before use on another client.  Dispose of blood, body fluids, suctioned fluids, and excretions by flushing them into the sewage system or per agency protocol. When dumping potentially infectious fluid, healthcare workers are advised to exercise caution to avoid splashing it on their clothing or the surrounding environment. All specimens should be considered potentially infectious and collected in a container that closes securely. Healthcare workers should also exercise caution to avoid contaminating the outside of the container. Most agencies require placing the specimen in a plastic bag labeled "Biohazard" before transporting it (CDC, 2015a).

Safe Sharps Disposal

According to the NYSDOH (n.d.-b), healthcare workers should educate themselves, colleagues, and patients on the safe disposal of used sharps at home. These practices protect family members, pets, and anyone who handles trash and recyclables from illness and injury. Puncture-resistant sharps containers (see Figure 23) can be purchased at local drugstores or pharmacies or are available via syringe exchange programs. A summary of the recommendations are as follows (NYSDOH, n.d.-b):   

• If a puncture-resistant sharps container is unavailable, use a plastic bottle that cannot be broken or punctured (e.g., empty bleach or laundry detergent bottle) and close the screw-on cap tightly. Next, apply tape over the cap and write “contains sharps” on the bottle. Avoid using milk cartons, coffee cans, and glass bottles.
• Put sharps in the puncture-resistant container as soon as they are used.
• Keep the container closed and away from children and pets.
• Bring an appropriate container when traveling.
• Never put used sharps in the trash, flush them down the toilet, or drop them into a sewer.
• Do not bend, clip, or put the cap back on used sharps.
• Do not put sharps containers in with the recyclables. 

In NYS, all hospitals and SNFs are required by law to accept household-generated sharps. NYS also operates designated safe sharps collection and exchange sites (NYSDOH, n.d.-b).

Linens

Soiled linens should be held away from the body to prevent contamination of clothes, as demonstrated in Figure 24. Linens soiled with blood, body fluids, secretions, and excretions should be immediately placed and transported in a leak-resistant bag. Avoid shaking or tossing linens, as this can spread microorganisms to other patients and environments. Also, to prevent transmitting infection, do not place soiled linens on the floor. If clean linens touch the floor or any unclean surface, immediately put them in the dirty linen container (CDC, 2015a, 2019c).

Latex and Latex-Free Equipment

Latex sensitivity and latex allergies are of concern to healthcare workers and patients. According to OSHA (n.d.-b.), approximately 8 to 12% of healthcare workers are latex sensitive with reactions ranging from mild irritation to severe allergic reactions. Healthcare workers and patients with allergies to kiwifruit, papayas, avocados, bananas, potatoes, or tomatoes should be screened cautiously as they are at higher risk for having a sensitivity to latex (Potter et al., 2017). Latex products are manufactured from a milky fluid derived from the rubber tree, Hevea brasiliensis. Several chemicals are added to the liquid during the manufacturing process of commercial latex products. Some proteins in the latex can be irritating, causing mild to severe symptoms. The three most common reactions to latex products include irritant contact dermatitis, allergic contact dermatitis (delayed hypersensitivity), and latex allergy (NIOSH, 2014).

Irritant contact dermatitis. Rubber latex products often cause irritant contact dermatitis. Areas of the skin, usually the hands, become dry, itchy, and irritated. This reaction is caused by skin irritation from gloves and possibly from exposure to other workplace products and chemicals. The reaction can also result from repeated hand washing and drying, incomplete hand drying, use of cleaners and sanitizers, and exposure to powders added to the gloves. Irritant contact dermatitis is not a true allergy (NIOSH, 2014; Potter et al., 2017).

Allergic contact dermatitis. Exposure to chemicals added to latex during harvesting, processing, or manufacturing can lead to allergic contact dermatitis. These chemicals cause skin reactions similar to those caused by poison ivy. The rash usually begins 24 to 48 hours after contact and may progress to oozing skin blisters or spread away from the area of skin touched by the latex (NIOSH, 2014; Potter et al., 2017).

Latex allergy. The most severe reaction to latex is a latex allergy. The protein in rubber can cause an allergic reaction in some people. Also, when healthcare workers change gloves, the protein/powder becomes airborne and could be inhaled into the respiratory tract. Reactions usually begin within minutes of exposure to latex but can occur hours later and produce various symptoms. Mild reactions to latex involve skin redness, hives, and itching. More severe reactions may include symptoms such as rhinitis, sneezing, itchy eyes, scratchy throat, asthma (difficulty breathing, coughing spells, and wheezing), and anaphylactic shock (NIOSH, 2014; Potter et al., 2017).

Powdered latex gloves carry a higher risk for latex reactions because the latex allergen adheres to the powder. The powder is released into the air and then can be inhaled into the lungs. Effective January 18, 2017, the FDA banned the use of powdered surgeon's gloves, powdered patient examination gloves, and absorbable powder for lubricating a surgeon's glove, noting that these items present an unreasonable and substantial risk of illness or injury (Federal Register, 2016). Although most healthcare facilities operate as latex-free environments, healthcare workers should consider the following strategies to prevent latex allergies (NIOSH, 2014; OSHA, n.d.-b; Potter et al., 2017):

• Use non-latex gloves for activities that do not involve exposure to infectious materials (e.g., housekeeping, food preparation).
• Avoid oil-based creams or lotions while using latex gloves which can cause the latex material to break down.
• After wearing gloves, wash hands with mild soap and dry them thoroughly.
• Request reduced-protein, powder-free gloves if the healthcare facility supplies latex gloves.
• Regularly clean all areas commonly contaminated with latex-containing dust.
• Recognize the signs and symptoms of a latex allergy.

Once a healthcare worker or patient has been identified with a latex sensitivity or allergy, the entire healthcare team must be aware to prevent exposure. While some medications may help reduce symptoms, total avoidance of latex is the best treatment available.  Replacing latex-containing gloves and supplies with non-latex items is essential. A latex-free cart supplied with latex-free items should be used for all care to prevent exposing the patient or healthcare worker to latex (NIOSH, 2014; OSHA, n.d.-b; Potter et al., 2017).

Sepsis

Sepsis is a life-threatening medical emergency that requires early recognition and

intervention. It is the systemic manifestation of infection occurring when infectious organisms have entered the bloodstream. Widespread inflammation is triggered, creating systemic inflammatory response syndrome (SIRS). The organisms in the bloodstream will enter other body areas, leading to extensive hormonal, tissue, and vascular changes. If not appropriately treated, sepsis can lead to organ dysfunction; circulatory, cellular, and metabolic dysfunction; and death. Sepsis and septic shock commonly occur in the US and worldwide. According to the CDC (2020c), over 1.7 million Americans develop sepsis each year, and about 270,000 of these patients die. Most sepsis cases are community-acquired; 7 out of 10 patients with sepsis had recently received healthcare services or had chronic conditions requiring frequent medical care (NYSDOH and NYSED, 2018).  Sepsis is the most common cause of admissions to ICUs in the US (Genga & Russell, 2017), and it is the most common cause of death among adults admitted to ICUs (Gauer et al., 2020). According to the CDC (2020c), 1 in 3 patients who die in a hospital will die of sepsis. Although the management of sepsis has improved, the condition’s incidence is increasing as more MDROs emerge. When sepsis is not recognized early and treated, it will progress to severe sepsis. Severe sepsis consists of the features described above plus sepsis-induced organ dysfunction. All tissues are involved, considered hypoxic to some degree, and organ dysfunction ensues. Septic shock is defined as a decrease in blood pressure in a septic patient that further compromises major organ function and does not respond to treatment with adequate fluid replacement (Ignatavicius et al., 2018; NYSDOH and NYSED, 2018).  

Sepsis is also a leading cause of mortality for infants and children. Globally, an estimated 1.2 million cases of childhood sepsis occur each year. Recent research demonstrates that more than 4% of all hospitalized patients less than 18 years and approximately 8% of patients admitted to pediatric ICUs (PICUs) in high-income countries have sepsis. Mortality rates for childhood sepsis range from 4% to 50%, depending on illness severity, risk factors, and geographic location (Weiss et al., 2020). More than 75,000 children develop severe sepsis in the US each year, and an estimated 7,000 of these children die (Sepsis Alliance, 2020). Severe sepsis and septic shock impact approximately 50,000 patients in NY each year. On average, 30% of affected patients died from this syndrome before implementing the NYS Sepsis Care Improvement Initiative. Since early detection of sepsis and timely interventions can significantly improve the chances of survival, the Sepsis Care Improvement Initiative and “Rory’s Regulations” were adopted to help educate healthcare workers. These initiatives promote education and encourage the early recognition and timely treatment of sepsis throughout NYS. By mandating regular and consistent training and requiring hospitals to adopt evidence-based treatment protocols for the recognition and treatment of sepsis, the goal of these regulations is to improve sepsis outcomes statewide (NYDOH, 2019).

In 2013, End Sepsis (formerly called the Rory Staunton Foundation) coordinated efforts for NYS to become the first state to establish a mandate requiring all hospitals to adopt sepsis protocols. Known as “Rory’s Regulations,” every hospital in NYS was required to develop protocols to improve the rapid identification and treatment of sepsis. NYS regulations require hospitals to adopt evidence-based protocols to ensure early diagnosis and treatment of sepsis and healthcare worker training to implement such protocols. To ensure compliance with these regulations, the protocols must be submitted to the NYS DOH for approval and need to include all of the following:

• screening and early recognition of patients with sepsis, severe sepsis, and septic shock
• a process to identify and document individuals appropriate for treatment through explicit sepsis protocols
• guidelines for treatment, including the early delivery of antibiotics
• appropriate training, resources, and equipment for healthcare providers to help quickly identify and treat sepsis in adults and children
• the reporting of all sepsis-related data to the NYS DOH (End Sepsis, n.d.; NYDOH, 2019, 2021)

While anyone with an infection can develop sepsis, there is increased risk for sepsis in specific populations such as the very young (neonates and infants under one year), adults over 65 years, those with chronic conditions (e.g., DM, lung disease, CKD, and cancer), and those with weakened or impaired immune systems (CDC, 2020c). Sepsis starts with an infection—most often pneumonia—that triggers a dysregulated host response. Other infections that commonly lead to sepsis include gastrointestinal, genitourinary, and skin and soft tissue infections, as well as other respiratory infections (Gauer et al., 2020). Organisms that often cause sepsis include gram-negative (K. pneumoniae, Pseudomonas aeruginosa, and E. coli) and gram-positive (S. aureus and S. pneumoniae) bacteria. A sepsis infection progresses to a critical situation over several days. As the infection advances, pathological changes occur faster and become more severe. Clinical manifestations vary based on the type of infection and the patient’s underlying health and comorbidities. The early stage of sepsis has a short duration, and the clinical manifestations can be subtle. As a result, the condition is often missed or misdiagnosed. Signs and symptoms of sepsis can include altered mental status (confusion, disorientation), shortness of breath, tachycardia, tachypnea, fever, chills, clammy or sweaty skin, and severe pain (CDC, 2020c; Ignatavicius et al., 2018). 

For infants and children with sepsis, risk factors for increased mortality include younger ages, complex neurological conditions, infective endocarditis, immunodeficiency, HIV, burns, malignancy, and transplant status. Low-birth-weight neonates are also considered a high-risk population. Neonatal sepsis is classified as early or late. Early neonatal sepsis appears within the first 72 hours after birth, and late neonatal sepsis begins after 72 hours. Early neonatal sepsis is acquired before or during childbirth, so the pathogens are usually obtained from the mother’s genitourinary tract. Late neonatal sepsis occurs most often in infants who remain hospitalized. Risk factors for early neonatal sepsis include maternal Streptococcus agalactiae colonization. Mothers who do not undergo prophylactic antibiotic treatment have a 25-fold higher risk of having a newborn with early neonatal sepsis. Amniotic membrane rupture for over 18 hours and chorioamnionitis are also risk factors for early neonatal sepsis. Late neonatal sepsis more frequently occurs in low-birth-weight infants with long-term hospitalization or in late preterm or full-term infants who require prolonged hospitalization. Clinical signs of early and late neonatal sepsis include apnea, difficulty breathing, cyanosis, fast or slow heart rate, poor perfusion, irritability, lethargy, hypotonia, seizures, vomiting, abdominal distension, food intolerance, gastric residue, hepatomegaly, unexplained jaundice, inability to regulate body temperature, petechiae, or purpura (Markwart et al., 2020; Procianoy & Silveira, 2020).

When sepsis is suspected, diagnostic testing should include laboratory studies such as complete blood count and blood cultures and potentially urine cultures/stool cultures/wound cultures to help identify the primary pathogen. Fluid resuscitation for adults should be at least 30 mL/kg of IV crystalloid fluid (e.g., 0.9% normal saline [NS] or lactated ringers [LR]) within the first 3 hours. IV broad-spectrum antibiotics should be started empirically as soon as possible and then de-escalated as soon as the causative agent and antibiotic susceptibilities are identified. Providers should also know their facility’s existing guidance for diagnosing and managing sepsis. Sepsis can also be prevented with basic infection control techniques described in this course, including hand hygiene and vigilant management of any chronic medical conditions (CDC, 2020c; Gauer et al., 2020; Rhodes et al., 2017). Time is of the essence, especially in high-risk patients; each hour delay in initiating appropriate resuscitation measures or persistence of hemodynamic abnormalities is associated with a clinically significant increased risk of death (Weiss et al., 2020). In adult patients, cardiac output is maintained with a combination of tachycardia and ventricular dilation, and lower systemic vascular resistance is associated with higher mortality rates. At the same time, dysfunction of oxygen extraction impacts oxygenation. Pediatric septic shock is characterized by hypovolemia, and decreased cardiac output is associated with poor outcomes. In addition, oxygen delivery is usually deficient in pediatric patients, not oxygen extraction. For these reasons, early fluid resuscitation is vital in all sepsis patients, especially in pediatric patients (Davis et al., 2017; Weiss et al., 2020).

Patients should be educated about the signs and symptoms of sepsis. High-risk patients should be counseled on symptoms that should prompt notification of the provider. Education should include hand hygiene, chronic disease management, and updated vaccinations, which help prevent sepsis. Patients should seek medical care urgently if they have an infection that is not improving or is getting worse, especially if it is accompanied by a fever, chills, shortness of breath, altered mental status, clammy or sweaty skin, and/or severe pain (CDC, 2020c). Further, the goals of care and prognosis should be discussed with the patient and their family. Patients with sepsis and multiorgan system failure have high mortality rates, and those who survive may have resulting morbidity or poor quality of life. Therefore, the treatment goals for a septic patient in the ICU should be realistic, even though the outcome for these patients may be difficult to predict. End-of-life planning is essential, and palliative care should be discussed early and implemented appropriately, especially if the patient was experiencing declining health before diagnosing sepsis. The goals of care should be established and discussed with the patient and their family as early as possible but no later than 72 hours after ICU admission. Even though patients can experience decreased quality of life, long-term sepsis survivors often report being satisfied with their quality of life and state they would undergo ICU treatment again. In this context, patient-specific conversations and goals of care are necessary (Prescott & Angus, 2018; Rhodes et al., 2017).

For more detailed information on sepsis, refer to the Sepsis for RNs and LPNs, or Sepsis for APRNs NursingCE courses.

Documentation

Documentation is an essential component of patient care. Not only does it provide information about the care provided and the patient’s clinical status, but it also communicates information to other healthcare workers to assure both quality and continuity of care. Additionally, documentation in the medical record is used in legal proceedings for reimbursement, education, research, and quality assurance. Thorough and accurate documentation is considered a professional standard of nursing practice, serving to safeguard patient care, reduce the potential for miscommunication and errors, and promote quality outcomes (Woods, 2019). The American Nurses Association (ANA, 2010) views the nurse as individually responsible and accountable for maintaining professional competence. Documentation is a valuable method for demonstrating that the nurse has applied appropriate nursing knowledge, skills, and clinical judgment according to professional nursing standards (Potter et al., 2017; Woods, 2019). 

Documentation must not only meet professional and employer standards, but it must also meet the criteria required by the legal system. The format used for documentation varies from agency to agency. Healthcare workers have a professional responsibility to demonstrate proficiency with the employer's selected format. Only approved abbreviations should be utilized, and all documentation should be clear, accurate, concise, and legible. When using an electronic health record (EHR), ensure documentation is without spelling errors (Potter et al., 2017; Woods, 2019). 

Maintain privacy and confidentiality of all patient information. Mandatory compliance with the privacy rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was introduced in 2003 to ensure that patient information is kept confidential, to give patients more control over their personal healthcare information, and control who has access to it. HIPAA initially required written consent for the disclosure of all patient information. Since this process leads to delays in providing timely patient care, the act was revised. To date, healthcare workers are required to notify patients of their privacy policy and to make a reasonable effort to obtain written acknowledgment of this notification. All healthcare workers, including students, have a legal and ethical obligation to adhere to the HIPAA regulations. In clinical settings, students should only gather the information from the patient’s medical record that they need to provide safe and efficient care. Any written material students prepare and share, submit, or distribute must exclude the patient’s name, room number, date of birth, medical record number, and other identifiable demographic information. Documentation for infection control should include the following core components as well as any additional information pertinent to the patient’s care:

●    infection control measures used

●    clean or sterile gloves used

●    if the patient has a latex sensitivity or allergy

●    the patient’s response to care

●    any specimens and cultures obtained and sent to the laboratory

●    disposal precautions used

●    type of isolation protocol used (Potter et al., 2017; Woods, 2019)

For more information on this topic, refer to the Nursing Documentation NursingCE course.

Evidence-Based Research on Infection Control

Study 1: Motivating Process Compliance through Individual Electronic Monitoring: An Empirical Examination of Hand Hygiene in Health Care (Staats et al., 2016):

This study investigated the effectiveness of electronic monitoring to increase hand hygiene compliance within the health care setting.  The study used radio frequency identification-based systems on 71 hospital units to monitor for appropriate hand washing.  Initially, there was found to be a significant increase in compliance.  However, over 3.5 years of continued observation, hand hygiene compliance gradually decreased. Furthermore, in areas where the monitoring devices had been discontinued, the follow-up revealed that compliance rates had been reduced to levels below those before the initiation of the study.  The authors concluded that although individual electronic monitoring can dramatically increase hand hygiene compliance, there needs to be sustained organizational commitment for the compliance rates to continue (Staats et al., 2016).

Study 2: Evaluation of Isolation Compliance Using Real-Time Video in Critical Care (Oey et al., 2015):

In two ICU settings, cameras viewed patient rooms and recorded health care professional adherence with recommended PPE based upon CDC precautions to reduce disease-based transmission. Personnel were recorded for one week, 24 hours a day, for compliance with airborne, droplet, and contact precautions.  The interactions were streamed to an independent auditor who monitored for personnel for using an N95 respirator for airborne precautions, a surgical mask for droplet precautions, and a gown plus gloves for contact precautions. There were 16,571 interactions observed of health care professionals with patients in isolation.  The compliance rates for contact, droplet, and airborne Precautions were 10%, 16%, and 11%, respectively.  The overall rate of compliance with CDC PPE recommendations in the ICU was 11%. The authors concluded that compliance with CDC PPE recommendations is low in the acute care setting (Oey et al., 2015).

Frequently Asked Questions in Infection Control

1. Are prescription eyeglasses or contact lenses an acceptable form of eye protection?
   No. Neither eyeglasses nor contact lenses provide enough coverage to prevent infectious disease (splashes) via ocular exposure and transmission.
2. How long can fingernails be?
   Nails should extend no further than ¼ inch past the nail bed, and special care should be taken to clean the underside thoroughly.
3. Are artificial nails acceptable in health care facilities?
   Evidence demonstrates that healthcare workers with artificial nails carry more pathogens on their nails than other healthcare workers. As a result, the effectiveness of hand hygiene is reduced. Therefore, the CDC, TJC, and the American Association of Operating Room Nurses recommend prohibiting artificial nails in healthcare workers.
4. How far can a virus-laden droplet travel and still be a potential source of infection?
   It can travel up to 3 feet in any direction and still be infectious.
5. If without a facial tissue, is it appropriate to “sneeze into your sleeve”?
   Yes, this action reduces the transmission of airborne infections.
6. How long can influenza viruses survive outside a host?
   With moderate humidity, influenza viruses can live 24 to 48 hours on steel and plastic and 8 to 12 hours on cloth and facial tissues at room temperature.
7. How can I protect elderly and immunocompromised patients from HAIs?
   Standard precautions should be used with all patients to prevent the spread of pathogens.

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World Health Organization. (2020c). HIV/AIDS. https://www.who.int/news-room/fact-sheets/detail/hiv-aids

World Health Organization. (2020d). How do vaccines work? https://www.who.int/news-room/feature-stories/detail/how-do-vaccines-work