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3

Risk management in IPC

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Risk assessment in IPC

3-1 What is risk assessment in IPC?

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.

3-2 What are the key steps in performing a risk assessment in IPC?

The following steps can be applied in RA for IPC:

1. Identify a problem, hazard or threat

For example, a high rate of needlestick injuries (NSI) among staff

2. Evaluate the problem (to establish the size and context of the problem)

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).

3. Identify infection risks (use a structured approach)

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.

4. Assess the likelihood of occurrence and consequences of infection

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.

5. Determine and implement priority interventions to manage the risk

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.

6. Continually monitor the risk and evaluate the success of your interventions

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

Figure 3-1: Risk assessment in IPC

3-3 When should risk assessment in IPC be performed?

Risk assessment should be performed when:

3-4 Who should perform risk assessment in IPC?

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.

3-5 How is risk categorised in IPC?

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 in IPC

3-6 What is Risk management in IPC?

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.

3-7 What is the purpose of performing risk management in IPC?

There are many reasons for performing RM in healthcare including:

3-8 Which elements are needed for successful risk management in IPC?

The following key elements will help to produce successful RM projects:

Standard and transmission-based precautions

3-9 Which IPC programmes exist to reduce risk of HAI?

There are several IPC programmes and interventions designed to reduce the risk of infection transmission in healthcare including:

3-10 What are standard precautions?

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:

Table 3-1: Further details on standard precautions

Standard precaution Chapter
Hand hygiene 4
Personal protective equipment 3
Safe injection practice and sharps management 3
Waste management 6
Patient placement (isolation) 5
Cough etiquette (respiratory hygiene) 8
Linen handling and segregation 5
Occupational health 1
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

Figure 3-2: Standard precautions

3-11 What are transmission-based 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.

Table 3-2: Transmission-based precautions for the three major routes of transmission (adapted from S Mehtar: Understanding Infection Prevention and Control, Juta, 2010.)

Precaution type Contact Droplet Airborne
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)
  • Contact precautions signage on door/bed
  • alcohol handrub
  • non-sterile gloves
  • disposable aprons
  • dedicated equipment or adequate cleaning of shared equipment.
  • Droplet precautions signage on door/bed
  • alcohol handrub
  • non-sterile gloves and apron only if indicated for a procedure
  • surgical mask and eye protection when within 1 metre of patient.
  • Airborne precautions signage on closed door
  • alcohol handrub
  • non-sterile gloves and apron for intubation, suctioning, bronchoscopy
  • N95 respirators for staff, patient to wear surgical mask when staff are in the room.
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.

3-12 What are procedure-based precautions?

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

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

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

Figure 3-5: Airborne precautions (Adapted from Infection Prevention and Control Manual, Tygerberg Academic Hospital, Cape Town, South Africa, 2012)

Use of personal protective equipment

3-13 What is personal protective equipment?

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.

3-14 When is personal protective equipment required?

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.

Table 3-3: Appropriate use of personal protective equipment (PPE) for common procedures (Adapted from Z cards, S. Mehtar, 2010)

Procedure Hand hygiene Gloves Aprons Masks Eye covers
IV cannulation      
Wound dressing Aseptic technique      
Insertion of NG tube      
Insertion of airway  
Dental procedures Coats ✓ (High-speed drills)
Suturing ✓ Sterile  
Central line insertion ✓ Sterile ✓ Sterile gown
Urinary catheter insertion ✓ Sterile    
Fibre-optic procedures
Delivery (labour) ✓ Sterile gown
Surgery (clean and dirty) ✓ Sterile ✓ Sterile gown
Lumbar puncture ✓ Sterile ✓ Sterile gown  

3-15 When is personal protective equipment not required?

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.

3-16 Where should personal protective equipment be available?

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.

3-17 What should be considered when purchasing personal protective equipment?

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).

3-18 How should IPC be involved in personal protective equipment procurement?

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.

Injection safety and re-use prevention devices

3-19 What is injection safety?

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.

3-20 What is an unsafe injection?

An unsafe injection can include any of the following practices:

3-21 Which diseases are transmitted by unsafe injections?

The major infection risks from unsafe injections include:

3-22 How large is the problem of unsafe injection practices?

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.

3-23 Which global programmes target the issue of injection safety?

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.

3-24 What are ‘safety-engineered’ and ‘re-use prevention’ devices?

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.

3-25 What types of safety-engineered and re-use prevention (RUP) devices are available?

Examples of safety-engineered devices for needlestick injury prevention include:

Examples of RUP devices include:

Care bundles

3-26 What is a care bundle?

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.

3-27 What is the purpose of care bundles?

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.

3-28 Who should be involved in care bundle programmes?

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.

3-29 What types of care bundles exist?

The following bundles are commonly used in a variety of healthcare settings:

Device-associated bundles:

3-30 What is included in the central line-associated bloodstream infection (CLABSI) bundle?

The elements of the CLABSI bundle include:

  1. Hand hygiene (during insertion and maintenance of the catheter)
  2. Maximal barrier precautions upon insertion (the person inserting the catheter should wear a sterile gown, sterile gloves, hair cover and surgical mask with the patient covered with sterile drapes)
  3. Optimal insertion site selection (the subclavian vein is the preferred insertion site, followed by jugular vein, with the inguinal vein being least preferred because of microbial contamination of the surrounding skin)
  4. Skin preparation with alcohol in 2% chlorhexidine gluconate (preferred over povidone iodine)
  5. Daily review of line necessity (remove any line that is no longer needed)
  6. Line maintenance (wear gloves when handling the line, swab the hubs with alcohol before accessing, change dressings as needed, change administration sets every 96 hours).

3-31 What is included in the ventilator-associated event (VAE) bundle?

The elements of the VAE bundle include:

  1. Elevation of head of bed by 30–45 degrees (to reduce the risk of aspiration of secretions)
  2. Periodic sedation vacations (stop sedatives intermittently to assess if the patient is ready for extubation)
  3. Daily assessment of readiness to extubate
  4. Peptic ulcer disease prophylaxis (not required in paediatrics)
  5. Deep venous thrombosis prophylaxis (not required in paediatrics).

3-32 What is included in the catheter-associated urinary tract infection (CA-UTI) bundle?

The elements of the CA-UTI bundle include:

  1. Avoid unnecessary urinary catheters
  2. Insert urinary catheters using aseptic technique
  3. Maintain urinary catheters based on recommended guidelines
  4. Review urinary catheter necessity daily and remove as soon as possible.

Other important aspects of urinary catheter management (not part of the bundle) include:

3-33 What is included in the surgical site infection (SSI) bundle?

The elements of the SSI bundle include:

  1. Antibiotic prophylaxis (administered in the hour before the first skin incision is made)
  2. Skin preparation (ideally with alcohol in 2% chlorhexidine gluconate, preferred over povidone iodine)
  3. Maintenance of postoperative normothermia (normal body temperature) and glucose control
  4. Maintenance of normovolemia (normal hydration status).

Other important aspects in prevention of SSI (not part of the bundle) include:

3-34 How is the bundle compliance rate measured?

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

3-35 What is the effect of bundle compliance on infection rates?

As the bundle compliance rate increases, the healthcare-associated infection rate (for the specific infection event being monitored) should decrease.

Table 3-4: Example of bundle compliance (adapted from the Institute for Healthcare Improvement (IHI))

  March 2013 April 2013 May 2013 June 2014
UTI bundle compliance (%) 30 23 68 88
CA-UTI rate 11.4 13.8 9.6 5.1

3-36 How are infection rates calculated for each care bundle?

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

3-37 How successful are care bundles in reducing healthcare-associated infection rates?

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.

3-38 What challenges may be encountered when implementing care bundles?

Implementing a care bundle is not an easy task and requires a team effort. Common challenges to programme implementation and sustainability are:

Case study 1

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.

1. Which type of precautions should be adopted in patients with rotavirus gastroenteritis?

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.

2. Which standard precautions should be implemented to prevent the rapid spread of infection in the paediatric ward?

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.

3. What are the key elements of contact precautions for such cases?

Case study 2

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.

1. Why is it essential to know the patient’s HIV- and hepatitis status?

The contaminated syringe might transmit blood-borne viruses including hepatitis B, C and HIV.

2. What precautions should the nurse have taken to avoid this incident?

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.

3. What are the prerequisites to make the healthcare workplace safer?

  1. Plan for safe handling and disposal before beginning any procedure using needles
  2. Modify the work practices that pose a needlestick injury hazard
  3. Promote safety awareness in the work environment.

4. What precautions should be adopted to avoid contamination of multi-dose vials?

Case study 3

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.

1. Which factors influence the risk of surgical site infection?

2. What can the healthcare workers do to reduce the risk of surgical site infection?

Comply with good surgical practice:

3. What additional precautions should be taken to prevent surgical site infection?

4. What practices and policies should be followed to prevent surgical site infection?

Case study 4

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.

1. What could his healthcare workers have implemented to prevent the urinary tract infection?

The catheter-associated urinary tract infection (CA-UTI) care bundle should have been implemented to reduce the risk of catheter-related infections.

2. What elements are included in the CA-UTI bundle?

3. What other factors are important for preventing CA-UTI?

4. Who is responsible for implementing the care bundles?

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.