September 10, 2010
   
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Keith F. Woeltje, M.D., Ph.D.

Infection Control and Healthcare

 
Table 1.
Times When Medical Staff Should Use Hand Hygiene.
Before:
  • Patient contact
  • Donning gloves when inserting a CVC
  • Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don't require surgery
After:
  • Contact with a patient's skin
  • Contact with body fluids or excretions, non-intact skin, wound dressings
  • Contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient
  • Removing gloves

Standard Precautions
There are a number of precautions that can prevent the spread of infection in healthcare settings.(4) These precautions should be followed at all times for all patients. In addition to good hand hygiene, gloves should be worn whenever there may be contact with any damaged skin or bodily fluid. Protective equipment should be removed and disposed of before leaving the patient's room so that common areas are not inadvertently contaminated.

Transmission-based Precautions
Standard precautions cannot prevent the spread of all pathogens. For certain diseases, additional precautions are necessary. Your individual hospital's Infection Prevention and Control Department should be contacted for specific details. Transmission-based precautions include:

Droplet Precautions
These precautions should be implemented when patients are known or suspected to have an illness spread by large respiratory droplets, such as N. meningitides, the cause of meningococcal meningitis (the most common form of bacterial meningitis), or influenza. Because the infectious particles are not suspended in the air for long periods, special air handling (see below) is not necessary. A surgical mask or isolation mask is considered to be sufficient respiratory protection from these illnesses.

Airborne Precautions
Because the infectious particles in airborne-spread diseases can remain suspended in air for long periods of time and can travel long distances, so-called special air handling is required for patients with these infections. Patients must be isolated in airborne infection isolation rooms (AIIR, or negative-pressure ventilation rooms). Air pressure in these rooms is kept lower than the air pressure in the adjacent hallway. Thus, air comes in from the hallway, moves through the room and then is removed.

For diseases where there is natural or vaccine-acquired immunity (e.g., chicken pox or measles), healthcare workers who are immune do not usually need any additional respiratory precautions to enter the AIIR. Non-immune workers should not enter the room; in an emergency, they could use the procedure for diseases where there is no immunity (see below).

For tuberculosis or other diseases where there is no question of immunity, some form of personal respiratory protection is required. At a minimum, a respirator is recommended for anyone entering the room.

For diseases where there is natural or vaccine-acquired immunity (e.g., chicken pox or measles), healthcare workers who are immune do not usually need any additional respiratory precautions to enter the AIIR.

It is imperative that patients who are even suspected of having TB, chicken pox or measles be placed on airborne precautions promptly. Although this will lead to a certain degree of isolation, that is far preferable to having other patients and healthcare workers infected because isolation seemed like too much trouble.

Contact Precautions
Contact precautions are used with patients infected or colonized with organisms that are spread primarily via the hands of healthcare workers, or via contact with contaminated surfaces (such as,hospital bedrails, blood-pressure cuffs). While many organisms can spread this way, contact precautions are reserved for organisms that are either:
  • Drug resistant: The current rise in methicillin-resistant Staphylococcus aureus (MRSA) is one example
  • Very dangerous in the healthcare setting: An example is chicken pox, which can be dangerous to adults, particularly those with suppressed immune systems.
  • Both: This is the case of Clostridium difficile, an intestinal bacteria that is normally held in check by the healthy bacteria in our digestive tract. It becomes a problem in people taking antibiotics that destroy the body's natural defenses against the bacteria, resulting in severe diarrhea. Because it is brought on by antibiotic use, it is particularly antibiotic resistant. People may pick up the bacteria in the hospital, making them susceptible to diarrhea if they are later put on antibiotics.
Healthcare workers and family members should always wear gowns and gloves before entering the room of a patient on contact precautions. The gown and gloves should be removed immediately prior to the healthcare worker leaving the room, and hand hygiene should be performed upon exiting the room. At least one study has shown that both gown and gloves are superior to gloves alone in preventing the spread of resistant organisms.(5)

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