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Risk assessment (RA) is a process that:
In other words, RA is a detailed examination of potential or existing hazards in healthcare:
Risk assessment is a process that identifies, evaluates and establishes ways to eliminate or control medical hazards.
The following steps can be applied in RA for IPC:
For example, a high rate of needlestick injuries (NSI) among staff
For example, get data on the rate of NSI, the type of NSI, which staff were affected, when, where and how the injuries happened (in theatre, while recapping a needle).
For example, identify all points of risk for NSI, e.g. when taking blood from uncooperative patients; when staff are tired (post-call); no eye protection in casualty, etc.
For example, NSI is a frequent occurrence at your facility and your patient population has a high HIV and hepatitis B prevalence, so consequences of infection would be severe.
For example, priority interventions for your facility: training of all staff in sharps management, sharps containers in all rooms or ensure eye shields available in casualty/obstetrics.
For example, keep records of all NSI before, during and after the interventions, monitor how well the interventions were implemented, improve policies and re-train staff periodically.
Figure 3-1: Risk assessment in IPC
Risk assessment should be performed when:
Ideally RA in IPC is best performed by an experienced IPC practitioner. Input should be gathered from staff in the clinical area concerned (e.g. casualty and theatre staff for needlestick injuries). The IPC practitioner may need assistance from clinicians, laboratory staff or data managers, depending on the location and type of hazard being investigated.
Risk can be categorised as high, medium or low risk depending on the severity of the consequences of any particular hazard. For example, not wearing gloves when obtaining a blood sample would pose a low risk of infection to a healthcare worker. Handling a patient’s central venous catheter without performing hand hygiene would be medium risk. A high risk of infection would arise if a clinician performed an aseptic procedure (e.g. surgery) without performing adequate hand antisepsis.
Risk management (RM) is a structured method to identify, evaluate, avoid or reduce hazards in healthcare. RM assists with prioritising risks and is an essential part of the quality management programme.
Risk management is an essential part of quality management programmes in healthcare.
There are many reasons for performing RM in healthcare including:
The following key elements will help to produce successful RM projects:
There are several IPC programmes and interventions designed to reduce the risk of infection transmission in healthcare including:
Standard precautions (previously called universal precautions) reduce the chance of infection transmission from both known and unknown (unrecognised) sources of infection. They protect healthcare workers, patients and staff from acquiring infection. Standard precautions should be applied to all patients in all circumstances, whether or not they are known to pose an infection risk. All healthcare workers should be trained in the application of standard precautions. Each of the standard precautions are addressed in more detail in the following chapters:
|Personal protective equipment||3|
|Safe injection practice and sharps management||3|
|Patient placement (isolation)||5|
|Cough etiquette (respiratory hygiene)||8|
|Linen handling and segregation||5|
|Decontamination of equipment and the environment||6|
Standard precautions should be applied to all patients in all circumstances, whether or not they are known to pose an infection risk.
Figure 3-2: Standard precautions
Transmission-based precautions (TBP) are interventions put in place to reduce the chance of infection transmission for particular pathogens, e.g. airborne precautions for TB. Remember that TBP are always applied in addition to standard precautions. Bear in mind too that many pathogens have more than one route of transmission, e.g. varicella (chickenpox) will need both airborne and contact precautions. The table below compares and summarises the precautions needed for each of the three major routes of transmission.
|Indication||Patients known to be colonised or infected.||Patients with infections spread by large respiratory droplets.||Patients with pathogens spread in small particles (known as aerosols).|
|Area of risk||Pathogens acquired by touching the patient or any surfaces/equipment that the patient has had contact with.||Pathogens (in respiratory droplets) spread less than 1 metre from the patient and settle onto the surrounding surfaces.||Pathogens (aerosols) spread from the patient and may also settle onto surfaces.|
|Example diseases||Diarrhoeal disease; Skin/wound infections, many other bacterial infections and colonising bacteria.||Meningococcal meningitis; Influenza; mumps, Rubella, Diphtheria, other respiratory viruses, e.g. adenovirus, RSV, rhinovirus, and many others.||Tuberculosis; Measles; Chickenpox (varicella) – note also requires contact precautions.|
|Risk-prone procedures||Wound dressings, vaginal or rectal exams, contact with body fluids||Insertion and suctioning of endotracheal tubes, nasogastric tubes, bronchoscopy.||Insertion and suctioning of endotracheal tubes, bronchoscopy, sputum production. Consider obtaining sputum samples outdoors if possible.|
|Patient placement||Ideally single room, but cohort isolation* or ward placement if no options.||Ideally single room with en-suite bathroom or *cohort isolation. If not available, place on ward near open window with curtains closed around bed||Do not admit unless clinically indicated. Single room with door closed at all times. Cohort isolation if no single rooms. Preferably en suite|
|Equipment and Personal Protective Equipment (PPE)||
|Waste||Put in clinical (infectious) waste box.||Put in clinical (infectious) waste box||Put in clinical (infectious) waste box.|
|Ventilation||No special requirements||No special requirements.||Negative pressure ventilation with 6–12 air changes per hour.If negative pressure is not possible, explore all options to increase air exchange naturally, directing air flow away from other patients and staff.|
|Environment||Dedicated cleaning equipment or clean room last. Terminal cleaning indicated on patient discharge||Dedicated cleaning equipment or clean room last. Terminal cleaning indicated on patient discharge.||Dedicated cleaning equipment or clean room last. Terminal cleaning indicated on patient discharge|
|Discontinue precautions||Only if patient is proven to be clear of colonisation or infection, ideally only once patient is discharged.||When patient's symptoms have resolved or once patient is discharged||When patient's symptoms have resolved, when they are no longer infectious or once patient is discharged.|
* cohort isolation: placing two or more patients with the same disease (caused by the same micro-organism) together in isolation.
Transmission-based precautions are applied in addition to standard precautions based on a pathogen’s route/s of transmission.
This is the requirement for specific interventions, to reduce risk of infection, during a specified procedure. For example, in order to place a central line in a patient, the healthcare worker should apply hand hygiene, proper skin antisepsis, wear appropriate personal protective equipment, use maximal barrier precautions (drapes), use sterile instruments and perform the entire procedure aseptically.
Figure 3-3: Contact precautions (Adapted from Infection Prevention and Control Manual, Tygerberg Academic Hospital, Cape Town, South Africa, 2012)
Figure 3-4: Droplet precautions (Adapted from Infection Prevention and Control Manual, Tygerberg Academic Hospital, Cape Town, South Africa, 2012)
Figure 3-5: Airborne precautions (Adapted from Infection Prevention and Control Manual, Tygerberg Academic Hospital, Cape Town, South Africa, 2012)
Personal protective equipment (PPE) includes any item designed to protect healthcare workers from exposure to pathogens, e.g. gloves, aprons, face covers. It is important to note that the use of PPE does not replace the need for good IPC practices. For example, wearing gloves instead of washing hands is unacceptable as healthcare workers’ hands may still become contaminated through the gloves.
The use of personal protective equipment (PPE) does not replace the need for good infection control practices.
PPE is required for most clinical procedures and aseptic tasks. PPE is also required for domestic, waste management and sterile services department staff. The figure below indicates which PPE are required for certain commonly performed tasks and procedures.
|Procedure||Hand hygiene||Gloves||Aprons||Masks||Eye covers|
|Wound dressing||✓||Aseptic technique|
|Insertion of NG tube||✓||✓|
|Insertion of airway||✓||✓||✓||✓|
|Dental procedures||✓||✓||Coats||✓||✓ (High-speed drills)|
|Central line insertion||✓||✓ Sterile||✓ Sterile gown||✓||✓|
|Urinary catheter insertion||✓||✓ Sterile||✓|
|Delivery (labour)||✓||✓||✓ Sterile gown||✓||✓|
|Surgery (clean and dirty)||✓||✓ Sterile||✓ Sterile gown||✓||✓|
|Lumbar puncture||✓||✓ Sterile||✓ Sterile gown||✓|
No protective equipment is needed for routine patient care (e.g. turning, feeding or washing a patient), unless the patient is nursed under transmission-based precautions.
PPE should be easily available in all clinical areas. They should be located close to the point-of-care to encourage high rates of staff compliance. If certain items of PPE, e.g. N95 respirators are locked away or not easily accessible, staff will not make the effort to use them. Alternatively, if an item of PPE is in short supply, staff will re-use single-use items, e.g. plastic aprons, which increases the risk of infection transmission.
Only good quality PPE should be procured (ideally after consultation with the IPC practitioner). The purchase of low-quality items often ends up costing healthcare facilities more, since several items have to be used for a single task, e.g. gloves that tear easily. A variety of sizes of each type of PPE, e.g. gloves, N95 respirators, will be needed to ensure that all staff can find a product that fits correctly. Consideration must also be made for staff members with latex allergy (powder-free gloves and alternative products, e.g. neoprene or nitrile gloves should be available).
Ideally when new PPE products are introduced, the procurement department should send product samples to the IPC practitioner and clinicians for evaluation. Based on the feedback from IPC and the clinical users, the procurement department should consider all factors (quality, ease of use, availability) and not only cost, before deciding on procurement and tenders. Where items already on tender are found to be defective or of poor quality, the IPC practitioner should report this to procurement and facility management.
Injections are one of the most commonly used methods to deliver preventive or curative therapy, e.g. immunisations, intramuscular antibiotics and for obtaining blood samples for analysis. Injections can be given into several different spaces, e.g. intradermal, intramuscular, intravenous, intrathecal (by lumbar puncture) or into joint spaces. Injection safety is the over-arching term that refers to the prevention of infection transmission through elimination of unsafe injection practices.
Injection safety refers to the prevention of bacterial infection and blood-borne virus transmission through elimination of unsafe injection practices.
An unsafe injection can include any of the following practices:
The major infection risks from unsafe injections include:
The World Health Organization (WHO) estimates that globally up to four injections are administered per person every year. They estimate that up to 70% of injections given in low-income countries are unsafe. This leads to millions of exposures and infections especially with blood-borne viruses annually, most of which are undocumented.
Up to 70% of injections given in low-income countries are unsafe.
The ‘Safe Injection Global Network’ (SIGN) is a WHO-affiliated partnership between multiple stakeholders worldwide that aims to achieve safe and appropriate use of injections. In the United States of America, the Centers for Disease Control (CDC) affiliated programme on injection safety is called ‘The One & Only Campaign’. These campaigns aim to promote the use of needles, syringes, and single-dose medication vials ‘only one time, for one patient’. Both the WHO and CDC have useful educational material and toolkits on injection safety available for download from their websites.
Safety-engineered devices include:
Safety-engineered devices reduce the risk of needlestick injury and re-use prevention devices discourage healthcare workers from recycling needles and syringes.
Examples of safety-engineered devices for needlestick injury prevention include:
Examples of RUP devices include:
Care bundles are a group of interrelated best practices used to prevent device- and procedure-related healthcare-associated infections, e.g. catheter-associated urinary tract and surgical site infections.
There is strong evidence of effectiveness for each element of a care bundle. Each bundle element can individually improve care, but when all elements are applied together, substantially greater reductions in infection rates are achieved. The focus of measurement is the completion of the entire bundle as a single intervention, rather than completion of individual elements, a so-called all-or-nothing approach.
In South Africa, the ‘Best Care Always’ campaign is involved in supporting bundle implementation in both public and private healthcare facilities.
A care bundle is a group of interrelated best practices used to prevent device- and procedure-related healthcare-associated infection.
Care bundles provide a proven method to reduce specific types of healthcare-associated infections. These programmes are very effective in motivating, organising and encouraging communication among clinical teams around a specific problem, e.g. the staff of an intensive care unit or surgical ward.
When implementing a care bundle it is important to involve a multidisciplinary team, e.g. doctors, nursing staff, theatre staff, respiratory therapists (as appropriate to the specific bundle).
All stakeholders have to ‘buy-in’ to the process, as care bundles require the active participation and support of the entire healthcare team. Programmes built on team consensus are much more effective. It is very useful to identify a project champion, a recognised leader/expert who is actively involved in the clinical care of the individual ward or unit.
Implementation of a care bundle requires the active participation of the entire healthcare team on a particular ward or unit.
The following bundles are commonly used in a variety of healthcare settings:
Catheter-associated urinary tract infection (CA-UTI) bundle. Procedure-associated bundles:
The elements of the CLABSI bundle include:
The elements of the VAE bundle include:
The elements of the CA-UTI bundle include:
Other important aspects of urinary catheter management (not part of the bundle) include:
The elements of the SSI bundle include:
Other important aspects in prevention of SSI (not part of the bundle) include:
Checklists are prepared for each bundle element. A witness verifies that each bundle element was complied with. The checklist is then scored as ‘compliant’ if all bundle elements were implemented or ‘non-compliant’ if any bundle elements were missing. Non-compliance to one element of the bundle means non-compliance to the whole bundle. The calculation of compliance is then performed as:
(Number of checklists that showed full compliance ÷ Total number of checklists) × 100
As the bundle compliance rate increases, the healthcare-associated infection rate (for the specific infection event being monitored) should decrease.
|March 2013||April 2013||May 2013||June 2014|
|UTI bundle compliance (%)||30||23||68||88|
A systematic surveillance system is needed for the specific infection type being targeted, e.g. surveillance for surgical site infections if the SSI bundle is being implemented. This will allow the clinical team to objectively measure the success of bundle implementation.
For device-related infections, a denominator (known as device days) must be counted and used in the calculation formula. The device days are counted as the number of patients with the indwelling device of interest (e.g. central catheters) in place for the period of interest (usually calculated monthly). For surgical site infections, the number of infections is usually divided by the total number of surgeries or type of surgeries during the chosen time period (month).
An example of a calculation of the CA-UTI rate for a Urology Ward in September 2013 follows.
Five patients developed a CA-UTI (physician and/or laboratory confirmed UTI were included in the surveillance programme). A total of 290 urinary catheter days were counted (30 patients had a catheter in for six days each, 20 patients had a catheter in for five days each, one patient had a catheter in for 10 days = 290). The formula to calculate the CA-UTI rate is:
CA-UTI rate = (5 CA-UTI events ÷ 290 urinary catheter days) × 1000 = 17.2 CA-UTI per 1000 catheter days
In both high-income and low-resource settings, there is ample published evidence that properly implemented care bundles are very effective at reducing infection rates. The most common infection across all healthcare settings are CA-UTI, so improvements in this area can result in substantial cost savings for facilities. The infections associated with highest mortality are CLABSI and VAE, so implementation of these bundles, particularly in intensive care settings can improve overall patient outcomes and save costs.
Well-implemented care bundles can reduce infections, mortality and healthcare costs, even in low-resource settings.
Implementing a care bundle is not an easy task and requires a team effort. Common challenges to programme implementation and sustainability are:
A child is admitted to the paediatric ward with gastroenteritis and a diagnosis of rotavirus infection is confirmed on stool analysis. The IPC practitioner is made aware of the situation and she advises the ward staff to follow strict standard and transmission-based precautions.
Patient isolation, standard precautions, contact AND droplet precautions should be implemented for rotavirus gastroenteritis. Rotavirus is one of several communicable diseases that have more than one route of transmission.
Handwashing with soap and water or a sufficient amount of alcohol handrub may be used before and after touching the patient. Personal protective equipment (for contact and droplet transmission) should be worn. Terminal cleaning and disinfection of the environment and equipment will be required.
A nurse giving an injection to an ICU patient from a multi-dose vial is pricked while re-capping the needle. He washes the blood off his hand with soap and running water. He immediately tries to find out the patient’s HIV- and hepatitis B and C status.
The contaminated syringe might transmit blood-borne viruses including hepatitis B, C and HIV.
Used needles should not be re-capped. They should be immediately disposed of in a puncture-proof sharps box located within arm’s reach of the procedure.
An obstetric patient with obstructed labour had to undergo Caesarean section. After three days, a purulent (pussy) discharge was observed at the wound site. Bacteriological culture showed the growth of methicillin-resistant Staphylococcus aureus, which was successfully treated with antibiotics.
Comply with good surgical practice:
A patient admitted in the critical care unit with haemorrhagic stroke needed to have a urinary catheter inserted. After 48 hours he reports symptoms of a urinary tract infection. His doctor sends a urine sample for culture. A pathogen is cultured and the patient’s infection is successfully treated with antibiotics. The patient’s overall condition improves and his urinary catheter is later removed.
The catheter-associated urinary tract infection (CA-UTI) care bundle should have been implemented to reduce the risk of catheter-related infections.
The IPC practitioner together with clinicians should provide education about the benefits of care bundles and the ward staff should ensure implementation and compliance with all bundle elements.