pathogen or infectious agent: a biological, physical, or chemical entity capable of causing disease, such as bacteria, viruses, fungi, protozoa, helminths, or prions

portal of entry: the means by which an infectious agent enters the susceptible host

portal of exit: the route by which an infectious agent exits the reservoir

PPE: specialized clothing or equipment worn by an employee for protection against a hazard

reservoir: a place in which an infectious agent can survive but may or may not multiply or cause disease (HCWs may be reservoirs for nosocomial organisms)

single-use medication vial: a bottle of liquid medication that is given to a patient through a needle and syringe. Single-use vials contain only one dose of medication and should only be used once for one patient, using a new sterile needle and a new sterile syringe

standard precautions: 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

sterilization: the use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores

susceptible host: 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: any mechanism by which a pathogen is spread by a source or reservoir to a person

work practice controls: controls that reduce the likelihood of exposure to bloodborne pathogens by altering the manner in which a task is performed (prohibiting recapping of needles by a two-handed technique) (New York State Department of Health [NYSDOH] & State Education Department [NYSED], 2018)

NYS Infection Control Standards: Background and Current Policies

Infection control is the primary responsibility of all HCWs. For nurses, this responsibility incorporates daily interactions with patients, coworkers, equipment, and the health care environment. In August 1992, legislation was passed requiring HCWs in New York (NY) 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. NYS specifies this responsibility in the Rules of the Board of Regents, Part 29.2 (a) (13) and Title 10, Part 92 of the Official Compilation of Codes, Rules, and Regulations of NY. To become licensed, and every four years after that, nurses must complete coursework 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 NYSDOH and NYSED. It is the HCW's professional responsibility to adhere to infection control standards to prevent disease transmission from HCW to a patient, patient to HCW, and patient to patient, focusing on averting the transmission of HIV, HBV, and HCV and sepsis prevention. This includes the monitoring and overseeing 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 bidirectional 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 HCW exposure. Compliance requires participating in 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 HCWs, patients, and the public. A lack of compliance could also lead to professional misconduct penalties for the HCW, including disciplinary action, revocation of license, and professional liability. Concerned colleagues or members of the public can file a complaint about a nurse's conduct (or other HCWs, other than physicians) with the Professional Misconduct Enforcement Department of the Office of the Professions within NYSED. This can be done by emailing [email protected] or via the complaint form on their website (https://www.op.nysed.gov/enforcement/professional-misconduct-enforcement) (NYS, 1993; NYSDOH & NYSED, 2018; NYSED, n.d.).

Communicable Disease

According to the Centers for Disease Control and Prevention (CDC, 2012, 2023a), 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 (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, and 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. Because HCWs 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 health care agencies. There are vaccines available to prevent several of these diseases (measles, mumps, rubella [MMR], varicella, HBV, and influenza), so it remains imperative that HCWs 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. HCWs 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. Baseline screening for TB is still required for most HCWs, along with a full history and physical for symptoms of any communicable disease that should be investigated further (fever, cough, vomiting, diarrhea, rash, vesicular lesions, draining wounds). The underlying condition may then require treatment and the HCW should limit contact with patients or furlough until no longer infectious. Fit testing should be done to assess which N95 respirator forms a tight seal on the HCW's face for use in the workplace. HCWs 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. Other effective infection prevention strategies include education regarding exposure risk (especially to HIV, HBV, and HCV) as well as standard and universal precautions (hand hygiene, proper use of PPE, and sharps safety). Testing for bloodborne pathogens in HCWs in NYS is voluntary, with protections in place against disclosure of test results or discrimination (CDC; 2022c; Edemekong & Huang, 2022; NYSDOH & NYSED, 2018). HCWs were subjected to daily temperature screenings and symptom checklists before starting their daily shifts throughout the COVID-19 pandemic. As the pandemic has slowed, HCWs are now encouraged to vaccinate themselves regularly and utilize appropriate source control measures (masking) when symptomatic, immediately following an exposure to COVID-19, when working in high-risk areas, when working with high-risk populations, or when working in an area/facility/region experiencing an outbreak (CDC, 2023d). Because 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 Nursing CE course library for modules such as 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 pathogens (infectious agents) 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 micro-organisms inhabit the human body (externally [skin] and internally [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 are the components of the immune system that fight infection and other illnesses. There are two primary immune responses: innate and adaptive immunity (Longo, 2019; McCance & Heuther, 2024).

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 mucous membranes), mechanical barriers (coughing and sneezing), chemical barriers (tears and sweat), inflammatory responses, complement activation, and the production of natural killer 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, 2024).

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, 2024).

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, 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 the activity of other immune effector cells. 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, 2024).

Overview of the Infectious Process

Transmission of infection in health care 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 HCWs with the opportunity to disrupt the cycle and prevent infection (Ignatavicius et al., 2024).

Figure 1

Chain of Infection

The infectious agent (also known as the causative agent) is the pathogen capable of producing infection, and each agent has varying pathogenicity (the ability to cause illness). Virulence is related to the frequency in which a pathogen causes disease (the degree of communicability or infectivity) and its ability to invade and damage the host; virulence designates disease severity. Prompt identification of infection and treatment is essential to mitigate the clinical course and 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 (soil, water, medical equipment) or animate (humans, animals, insects). Other examples of reservoirs are a person with an active infection and a carrier (an asymptomatic individual who harbors an infectious agent without active illness). 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, and excretions, and most commonly occur via the respiratory, gastrointestinal (GI), reproductive, and urinary tracts (CDC, 2016a, 2023d; Ignatavicius et al., 2024).

Modes of transmission are the means through which the infectious agent spreads from the reservoir to the susceptible host. There are four primary modes of transmission: direct contact, indirect contact, droplet, and airborne spread. Direct contact denotes physical contact between the source and the host, such as directly from skin to skin or from mucous membrane to mucous 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 (think 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 health care setting and includes HCW to coworkers and HCW to patients. 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 arthropods (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/micrometer) 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/micrometer). These agents remain suspended in the air for an 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 micro-organism 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, 2016a, 2023a; Ignatavicius et al., 2024).

The portal of entry is the route through which the infectious agent enters the susceptible host. Portals of entry include the mucous membranes; broken skin (percutaneous injury, invasive device, or surgical incision); and the respiratory, GI, and reproductive/genitourinary 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. Infectious agent factors include pathogenicity/virulence, the size of the exposure (inoculum), the route of exposure, and the duration of exposure. Environmental factors that affect susceptibility to infection include contamination of the environment or equipment. 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, flow of urine, normal flora, and the immune system response when these barriers are breached (inflammatory response, humoral immunity, cell-mediated immunity, immune memory). Protecting the skin (natural barrier) and the immune system (innate and adaptive) integrity supports a host's natural defenses against communicable diseases (Ignatavicius et al., 2024; McCance & Heuther, 2024).

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 diminishing 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 (diabetes mellitus [DM], heart disease, chronic kidney disease [CKD]), immunosuppression (cancer, long-term corticosteroid therapy), skin breakdown (burns, lacerations), nutrition (malnutrition, dehydration), environmental and lifestyle factors (tobacco use, alcohol consumption, inhalation of toxic chemicals via workplace exposures), and medical interventions (surgery, radiation therapy) (CDC, 2016a; Ignatavicius et al., 2024). Immunocompromised patients, such as those with cancer undergoing cytotoxic treatments (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 (100.4° F, 38° C), which is the most common indicator of infection in an immunocompromised patient. HCWs 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 Nursing CE Course.

Vaccination

Vaccination of HCWs 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 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 faster, 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. Messenger RNA (mRNA) vaccines contain the blueprint for producing antigens (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 U.S. (CDC, 2023i; McCance & Heuther, 2024; U.S. Department of Health and Human Services [HHS], 2022; WHO, 2020).

Table 1

Major Types of Vaccines

(CDC, 2023i; HHS, 2022; WHO, 2020)

Health Care-Associated Infections

HAIs, also known as nosocomial infections, are infections developed in a health care setting while an individual is receiving care for another condition. This terminology does not imply that an infection was solely caused by the health care services rendered, only that it occurred while receiving health care. HAIs can develop in any health care facility, including hospitals, ambulatory clinics, surgical centers, inpatient rehabilitation facilities, and LTC 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 HCWs, fellow patients, medical equipment (blood pressure cuffs, urine collection devices), and the environment (contaminated surfaces, toilets, sinks, doorknobs). According to the CDC (2022a), 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 health care 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 health care facilities and monitors these rates over time (CDC, 2024).

The risk for HAIs depends on multiple influences, such as the infection control practices of the health care facility, the prevalence of pathogens within the community and/or setting and individual patient factors (compromised immune system, increased length of stay, and comorbidities such as heart disease, chronic obstructive pulmonary disease, DM) (CDC, 2021b, 2016a). According to the WHO (2022), approximately 7% of patients in an acute care hospital in high-income countries will acquire at least one HAI during their stay; in low- and middle-income countries, this prevalence increases to 15%. 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 of cases are preventable when HCWs utilize appropriate infection prevention strategies outlined by the CDC (2021b, 2016a). These strategies include basic infection control measures, such as early identification of communicable diseases, isolation of infected (or exposed) individuals, and appropriate treatment of those infected (NYSDOH & NYSED, 2018; Sikora & Zahra, 2023)

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. Most are caused by enterococcus, Staphylococcus aureus, pseudomonas, proteus, klebsiella, and candida. CAUTIs can occur from unsterile catheterizations, repeated catheterizations, and improper management of the drainage system. The most critical risk factor for developing CAUTIs is the prolonged use of a urinary catheter. According to the CDC, 15% to 25% 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 IV antibiotics within the last 90 days is a primary risk factor for developing AR to multiple drugs (CDC, 2015b, 2021b, 2024; Monegro et al., 2023).

Surgical Site Infections (SSIs)

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 (DM, co-existing infections), obesity, malnutrition, and surgical factors (length of the procedure, surgical technique, skin asepsis, and antimicrobial prophylaxis) (Monegro et al., 2023). According to the CDC NHSN (2024), SSIs account for 20% of all HAIs and are the costliest type of HAI, with an estimated annual cost of $3.3 billion and an average of 9.7 additional inpatient days.

Central Line-Associated Bloodstream Infections (CLABSIs) 

CLABSIs 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. These infections develop within 48 hr of central line placement. Central lines provide direct access to the major venous blood supply and remain in situ for long periods. Because 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, 2017a; Haddadin et al., 2022). According to the CDC NHSN (2024), there was a 46% decrease in CLABSIs across U.S. hospitals between 2008 and 2013; however, more than 30,000 CLABSIs still occur in intensive care units (ICUs) and acute care facilities each year. The estimated cost of CLABSIs is around $46,000 per infection (Haddadin et al., 2022).

Hospital-Acquired Pneumonia (HAP) and Ventilator-Associated Pneumonia (VAP)

HAP, or non-ventilator-associated pneumonia event in the NHSN (2024), refers to a lung infection (pneumonia) that occurs 48 hr 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 hr 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 U.S. 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% and increases health care costs by about $40,000. Reducing the exposure to risk factors 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 (early exercise and mobilization) (Monegro et al., 2023; Papazian et al., 2020).

Clostridioides difficile 

Clostridioides difficile (C. diff) is responsible for a spectrum of C. diff infections (CDIs), 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 of starting antibiotics but may occur as early as the first day or as late as 2 months. 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, nonsteroidal anti-inflammatory drug use, and some medical comorbidities. According to the CDC (2019a, 2022a), the overall incidence of CDIs in the U.S. in 2021 was 110.2 cases per 100,000 persons, and about half of those were health care-associated.

Multidrug-Resistant Organisms (MDROs)

MDROs are defined as micro-organisms (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, E. coli, and Klebsiella pneumoniae). MDROs have increased in prevalence over the last few decades. Although transmission most frequently occurs in acute care settings, the emergence and transmission of AR bacteria occur in all health care organizations. 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 are associated with increased length of stay, higher costs, and mortality. The severity and extent of illness caused by MDROs vary by the population and setting; therefore, prevention and control strategies must be designed for the specific requirements of each population, setting, 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 (CDC, 2017b).

Table 2

MDRO Prevention and Control

(CDC, 2017b)

Best Practices for Patient Safety and Infection Control

In 2000, the Institute of Medicine (IOM), now called the National Academy of Medicine, released its 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 influential study ignited a focus on medical practices, spawning new policies and procedures and setting performance standards and expectations for patient safety and quality improvement. 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 health care (IOM U.S. Committee on Quality of Health Care in America, 2000). In response, The Joint Commission (TJC) generated standards requiring health care 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 2024 NPSG for infection control is outlined in Table 3. Infection control programs within health care organizations are coordinated and implemented by HCWs trained in infection control practices and are designed to reduce the risk of HAIs (TJC, 2024). Hospitals execute infection tracking and surveillance systems alongside evidence-based infection control practices to 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 lowering 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 2019, NYS mandated that hospitals specifically report on several SSIs, CLABSIs, CDIs, and carbapenem-resistant enterobacteriaceae (NYSDOH, 2021a).

Table 3

2024 NPSG.07.01.01

(TJC, 2024)

Universal Versus Standard Precautions

Protecting HCWs from infectious disease exposures in the workplace began with Universal Precautions (UP), introduced by the CDC in the 1980s to protect workers from exposure to HIV and similar bloodborne pathogens found in blood and some body fluids (semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, and amniotic fluid). Standard precautions were introduced in 1996 by the CDC to expand UP to include additional body fluids (urine, feces, nasal secretions, sputum, vomit, breast milk, and saliva). The concept in both UP and standard precautions is that these precautions should be instituted and followed on every patient, regardless of infection status. Standard precautions include hand hygiene, the use of appropriate PPE, safe injection practices, and the proper management of contaminated equipment/environment. By contrast, transmission precautions (contact, airborne, and droplet) are designed for patients with specific infections based on transmission information for that particular infectious agent (Occupational Safety and Health Administration [OSHA], n.d.-d).

Standard Precautions

There are two primary tiers of HICPAC/CDC precautions to prevent the transmission of infectious agents: standard precautions and transmission-based precautions (CDC, 2023a). 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 health care settings. Standard precautions are applied to the care of all patients in health care settings (regardless of the suspected or confirmed presence of an infectious agent). 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, eye protection, or face shield; respiratory hygiene/cough etiquette; and safe injection practices. The use of facemasks during spinal/epidural access procedures is included in 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 2013, the CDC recommended that respiratory hygiene/cough etiquette be incorporated as a component of standard precautions. These should be instituted in the health care 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, 2023a).

Respiratory hygiene/cough etiquette applies to anyone entering a health care 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.

• Education of HCWs, staff, visitors, and patients, including information posted at points of entry with instructions provided in plain language(s) for patients and caregivers
• Source control (covering the mouth and nose during coughing and sneezing with disposable facial tissues to contain respiratory secretions, with prompt disposal into a hands-free receptacle and wearing a surgical mask when coughing to minimize contamination of the surrounding environment if tolerated)
• 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, 2023a)

Hand Hygiene

Figure 2

Your 5 Moments for Hand Hygiene 

(WHO, 2009)

Proper hand hygiene is the single most effective risk reduction strategy to prevent HAIs. It is a key component of standard precautions and a highly effective work practice control to limit HCW exposure and risk. 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 (use of an antimicrobial or plain soap and water) as well as alcohol-based products such as gels, foams, and rinses (CDC, 2021a). 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 (C. diff, Bacillus anthracis) 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, 2020a, 2021a, 2022c).

As outlined in the CDC hand hygiene guidelines, HCWs should use an alcohol-based hand rub in the following clinical situations.

• Immediately before direct contact with a patient (such as touching)
• Before performing an aseptic task (such as placing an indwelling device) or handling invasive medical devices (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 their immediate environment (bed linens, surfaces, IV poles)
• After contact with blood, body fluids, or contaminated surfaces
• Immediately after removing gloves (CDC, 2020a, 2021a, 2022c)

HCWs should wash their 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 (B. anthracis, C. diff) (CDC, 2020a, 2021a)

HCWs 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 hygiene prevents the transmission of micro-organisms 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 body sites. Approved hand lotions and creams should be used to prevent and decrease dryness from repeated cleaning. Artificial nails are known to harbor micro-organisms and should, therefore, be avoided when directly caring for patients in high-risk settings (ICUs, operating rooms). Fingernails should be trimmed to one-quarter of an inch. Rings may facilitate the growth of micro-organisms, but further studies are needed to determine if HCWs wearing rings equates to an increased risk for infection spread (CDC, 2020a, 2021a).

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, using the disposable towel to turn off the faucet prevents recontamination of the hands. A step-by-step depiction of this process is displayed in the image sequence below, Figure 3 (CDC, 2021a).

Figure 3

Hand Hygiene: Soap and Water 

Turn on the water and adjust it to a comfortable, warm temperature. Hot water may worsen dry skin and should be avoided.

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

Apply 3 to 5 mL of soap (per manufacturer) 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 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, 2020a).

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

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 health care settings, PPE such as gloves, masks, eyewear, and/or gowns are considered a component of standard precautions. They are necessary for specific clinical situations to prevent the transmission of infectious materials by contact with patients and their blood, body fluids, secretions, or excretions (CDC, 2022c, 2023e; OSHA, n.d.-c).

Gloves. Disposable gloves (see Figure 5) are a primary line of defense in protecting HCWs and patients. They are made from various polymers, such as latex (natural rubber), butyl, nitrile, polyvinyl chloride (vinyl), and neoprene. Disposable medical gloves are available in powdered or non-powdered forms. Nonsterile and sterile gloves are used by HCWs 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. Unfortunately, they can cause allergic reactions in those with latex allergies. Butyl is a synthetic rubber that protects well against peroxide, rocket fuel, corrosive acids, strong bases, alcohols, and ketones. They resist oxidation and abrasion. They do not work well with aliphatic and aromatic hydrocarbons or halogenated solvents. Nitrile gloves are made of synthetic material, mold to the hand, and are stretchy and durable. Nitrile gloves are preferred for tasks that require a high degree of dexterity and protection against chemicals (hazardous drugs such as chemotherapeutic agents) but should not be used with strong oxidizing agents, aromatic solvents, ketones, and acetates. Vinyl gloves are made of synthetic materials, are less stretchy, and do not mold to the hand as well. These are acceptable when the risk of exposure to pathogens is low and a high degree of dexterity is unnecessary (OSHA, 2023).

Figure 5

Gloves

(National Cancer Institute, 2009)

HCWs must wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Gloves should be applied before touching mucous membranes (oral, nasal, genital area), non-intact skin (wounds, surgical incisions, lacerations), and when inserting indwelling or invasive devices (urinary and IV catheters). Glove selection includes the appropriate type of glove (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 micro-organisms (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 micro-organisms to other patients and environments. Sterile gloves should be used when following the principles of surgical asepsis for keeping an area/object free of all micro-organisms. Thorough handwashing must be performed before donning sterile gloves and after discarding the gloves (Potter et al., 2023). 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, slip the ungloved fingers into the glove, and pull tight.

Pull gloves to the wrists of both hands.

To remove: Grasp the cuff of one glove using the opposite gloved hand.

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

Grasp the second glove on the inside of the cuff and pull it inside out using the first hand.

Dispose of the gloves.

Perform hand hygiene.

(Original ATI Images, 2018)

Masks. Face masks 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 (such as during intraperitoneal chemotherapy administration). There are various types of medical-grade face masks 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., 2023).

Figure 7

Masks

(Original ATI images, 2018)

Procedure masks are flat/pleated and affixed 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 face masks 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 HCW from sprays/splashes and prevent any pathogens from the wearer's nose/mouth from potentially spreading to and infecting the patient or operative site (Potter et al., 2023). The image series below (Figure 8) demonstrates step-by-step instructions on the proper application of a surgical mask.

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 snugly 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 HCW'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 HCW. 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 micrometer-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 (see Figure 10). Some of these options also have the advantage of providing face and eye protection in one unit and reducing the risk of self-contamination. Respirators are intended for protection against solids; they are highly durable devices with a soft and comfortable inner surface, adjustable nosepiece, and secure head straps to provide a proper fit (CDC, 2019e, 2022c, 2023e; Potter et al., 2023).

Figure 9

N95 Mask

(Original ATI Image, 2018)

Figure 10 

Types of Respirators

(CDC, 2019d)

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

 

Figure 11

Understanding the Differences Between Masks

 

 

 

(CDC, 2019e)

 

 

HCWs 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 (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 (an assessment of the adequacy of respirator fit by numerically measuring the amount of leakage into the respirator) (CDC, 2022b). Figure 12 demonstrates the process of quantitative fit testing.

Figure 12

Respirator Fit Testing

(CDC, 2018)

 

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 10 or more lb or 4.5 kg), dental changes, facial scarring, or other physical changes that could alter the fit of the respirator. 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 an HCW dons a respirator before entering a patient's room. The respirator should extend beneath the chin, and both the mouth and nose should be protected (CDC, 2020b, 2022b).

Eye and Face 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 adequate 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, 2023a; Potter et al., 2023).

Figure 13

Goggles

(ATI Original Image, 2018)

 

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., 2023).

Figure 14

Applying and Disposing of Eye Protection

(ATI Original Images, 2018)

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); face shields that extend from the HCW's chin to the crown reduce the risk of splash and spray particles. Splashes around the side/edge of the shield can be avoided with a shield that wraps around the sides of the HCW's face (CDC, 2023a).

Figure 15

Face Shield

(ATI Original Image, 2018)

 

Gowns. A clean, nonsterile (isolation) 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. They are always needed when caring for patients on contact precautions and should always be worn with gloves. Select a gown that is appropriate for the activity and the amount of fluid likely to be encountered during a particular activity. Gowns are tested and determined to be either fluid-resistant or impervious, and most are disposable. A properly sized gown should cover the HCW's arms and anterior body surface from the neck to the mid-thigh. Gowns should be removed prior to exiting the patient care area by turning the outer (contaminated) portion of the gown inside out and rolling it into a bundle, avoiding contamination of clothing or skin. A soiled gown should be removed as soon as possible, followed by hand hygiene to avoid transferring micro-organisms to other patients or environments. The Figure 16 image series provides a step-by-step demonstration of applying and disposing of gowns (CDC, 2023a).

Figure 16

Applying and Disposing of Gowns

Donning and Doffing PPE. The exclusion (or hot) zone is defined as a patient care area with actual or potential contamination. The contamination reduction (or warm) zone is the transition space between the exclusion and support zones. This is designated as the space of entry/exit of the exclusion zone. The support (or cold) zone is considered free from contamination. It may be used for planning and staging. PPE should not be worn in any non-clinical areas of the facility (bathrooms, break rooms, locker rooms). Hand hygiene is performed prior to and following PPE application/removal using soap/water. To effectively reduce the spread of micro-organisms, 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. PPE should always be disposed of in the properly designated containers (CDC, 2022c, 2023a).

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 it 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, n.d., 2023a).

Figure 17

Sequence for Donning PPE

 

(CDC, n.d.)

 

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/anteroom before exiting. The exception is a respirator mask, which should be removed outside the room after closing the door.
2. Remove the gloves first (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 ungloved fingers under the glove cuff, pulling it off, and pulling it inside out.
3. Remove eyewear; remember that the front/outside of eyewear is contaminated. Lift from the back without touching the front. If reusable, place them in the designated receptacle for reprocessing or dispose of them in a waste container if single-use.
4. Remove the gown by untying the ties (neck, then waist), taking care to avoid touching the contaminated (front and sleeves) surfaces of the gown, and rolling the gown inside out; place in a dirty linen container.
5. Remove the mask by handling only the back 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 immediately. If the hands become visibly soiled during the removal of the PPE, perform hand hygiene before proceeding (CDC, n.d., 2023a).

 

 

Figure 18

Sequence for Doffing PPE - Example 1

 

(CDC, n.d.)

 

 

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 it away from your body so that the ties break, touching the outside of the gown only with gloved hands, folding and rolling the 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 them in the designated receptacle for reprocessing or dispose of them 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, n.d., 2023a).

Transmission-based precautions are the second tier of infection control and are intended for use alongside the 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, 2023a):

• 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 (the placement of patients infected with the same organism in the same room, based on organizational needs).

Cohorting was implemented during the COVID-19 pandemic. Consultation with a member of the infection control committee is recommended before deciding to cohort patients. HCWs should be aware of the potential adverse effects of isolation precautions (mood disturbances, perception of stigma, less contact with clinical staff, more preventable adverse events) in an effort to reduce their impact and enhance patient/family acceptance and adherence (CDC, 2023a).

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 HCWs. Examples of infections in which contact precautions are instituted include MDROs (VRE, MRSA), C. diff, respiratory syncytial virus, impetigo, head lice, acute viral conjunctivitis, norovirus, rotavirus, disseminated herpes zoster, and the herpes simplex virus (if neonatal, disseminated or primary mucocutaneous). 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. The CDC's 2007 guideline for isolation precautions for preventing the transmission of infectious agents in health care settings was last updated in 2023. According to the guideline, the following fundamental principles apply to all patients on contact precautions (CDC, 2016b, 2023a):

• Appropriate patient placement
  • If possible, patients on contact precautions should be placed in a private room with a private bathroom to prevent cross-contamination. In addition, the CDC offers specific recommendations based on the health care facility as follows:
    • Acute care facilities/hospitals: Single patient room placement is advised if available.
    • LTC and residential settings (SNFs, rehabilitation centers): Room placement decision-making should be based on balancing the risks to other residents.
    • Ambulatory settings (clinics, urgent care, private offices): Patients should be placed in an exam room or separate section as soon as possible.
• Appropriate PPE
  • Contact precautions require HCWs 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 discarded before exiting the patient room.
• Limit the transport and movement of patients outside of their designated rooms 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 (such as 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 (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, rhinovirus, Hib or Neisseria meningitidis meningococcal disease, mumps (parotitis), or mycoplasma/Hib/meningococcal/group A streptococcus/adenovirus pneumonia (CDC, 2016b, 2023a). According to the CDC's isolation precautions guideline, the following fundamental principles apply to all patients on droplet precautions (CDC, 2016b, 2023a):

• Put a mask on the patient for source control.
• Appropriate patient placement:
  • As with contact precautions, private rooms are preferred for patients on droplet precautions to prevent cross-contamination. The CDC offers more specific recommendations based on the health care facility as follows.
    • Acute care facilities/hospitals: If single rooms are unavailable, consult with infection control personnel for alternative patient placement options.
    • 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 HCWs to wear a surgical mask when within 3 feet of the patient. A mask should be donned before entering the patient's room.
• Limit the transport and movement of patients outside of their designated rooms 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 zoster, smallpox, possibly severe acute respiratory syndrome, and disseminated herpes zoster (or localized in immunocompromised patients). According to the CDC's isolation precautions guideline, the following fundamental principles apply to all patients on airborne precautions (CDC, 2016b, 2023a).

• 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 the absence of proper engineering controls, the patient should be masked and placed in a private room with the door closed.
• Whenever possible, susceptible HCWs (pregnant women, unvaccinated workers) should be restricted from entering the room of patients with known or suspected measles, chickenpox, disseminated zoster, or smallpox.
• Appropriate PPE
  • Airborne precautions require HCWs 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 rooms 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, HCWs 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 (varicella, measles, or smallpox).

Although the evidence suggests that masks are likely adequate to protect HCWs against measles and varicella zoster, for consistency and simplicity, many facilities require the use of respirators for entry into all AIIRs, regardless of the specific infectious agent. Respirators are also currently recommended to be worn during the performance of aerosol-generating procedures (intubation, bronchoscopy, suctioning) on patients with SARS-CoV –2 infection, avian influenza, and pandemic influenza.

Protective Environment (PE)

In addition to transmission-based precautions, a PE is another type of precaution HCWs may encounter. A PE is designed to safeguard patients at high risk for infection due to an immunocompromised state (hematopoietic stem cell transplant recipients). Sometimes referred to as neutropenic or protective precautions, a PE reduces the risk of environmental fungal infections. These patients require a private room with positive airflow and HEPA filtration for incoming air, without carpeting or soft upholstered furniture. In addition, these patients should only be transported out of their rooms for medically necessary purposes. They should wear a mask when outside of their room (N95 respirator during periods of construction within the facility). Fresh flowers and potted plants are typically not permitted inside PE 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 micro-organisms 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. While injuries from needles and other sharp devices used in health care 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 (CDC, 2023b; OSHA, n.d.-a).

Table 4

Overview of HIV, HBV, and HCV 

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 be percutaneous (such as through needlesticks or punctures from other sharp instruments contaminated with an infected patient's blood), mucous membrane/non-intact skin (blood or body fluid in direct contact with the eye, nose, mouth, or skin via splash/spray, or indirectly via contaminated hands), or parenteral (contaminated medication or blood product or via sharing blood monitoring devices). The most common scenario in the health care 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 in the absence of visible blood, and microbes may be present without clouding or other indicators of contamination. Exposures may lead to notification and testing of thousands of potentially exposed patients and HCWs, bloodborne disease transmission, disciplinary action, license revocation, and legal action (CDC, 2023b; NYSDOH & NYSED, 2018; OSHA, n.d.-a).

The OSHA Bloodborne Pathogens Standard has been in place since 1991 to protect health care 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 (Needlestick Safety and Prevention Act, 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 health care setting with details on employee protection measures. This should include engineering and work practice controls, PPE, employee education, surveillance, vaccination campaigns, and other strategies as needed. NIOSH created the CDC's Stop Sticks campaign, but it is currently maintained by the NORA (CDC, 2019c). The campaign aims to raise awareness among HCWs about their risk of workplace exposure to bloodborne pathogens from needlesticks and sharps-related injuries (see Figure 20). Educating HCWs is the first step in prevention. In addition, maintaining up-to-date vaccination offers vital immunity against possible exposure to HBV. According to WHO (2023a), the HBV vaccination series provides nearly 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 HCWs is more significant than in previous years due to co-infections with multiple bloodborne diseases, emerging MDROs, and comorbidities associated with DM (CDC, 2019c). Sometimes, sharps can be avoided or substituted in medical practice to reduce risk to HCWs. For example, needle-free medication delivery systems and blunt surgical suture needles can be used to reduce the risk of a sharps injury. Elimination and substitution are considered the most effective control strategies to reduce risk in the workplace (CDC, 2022c, 2023b).

Figure 20

Stop Sticks Campaign: Prevention

 

 

 

(CDC, 2013)

 

Engineering Controls

When hazards cannot be avoided, engineering controls use technology to remove or isolate the associated hazard. Engineering controls, such as AIIR and sharps containers for the disposal and transport of needles and other sharp objects, reduce the likelihood of bloodborne pathogen exposure. Engineering controls should minimize exposure by providing equipment with passive safety features that offer continuous protection. Examples of engineering controls to prevent needlestick and other sharps-related hazards in health care settings include retracting needles, sliding needle sheaths, hinged needle covers, puncture-resistant sharps containers, and splatter shields on medical equipment associated with risk-prone procedures (such as locking centrifuge lids). Sharps disposal containers should be constructed of puncture-resistant plastic (or metal) with a lid that allows sharps to be placed inside, but not removed, and not large enough for a hand to be placed inside the container. These containers should be positioned in areas where they are most needed and emptied regularly. Ideally, engineering controls should be integrated (versus accessory devices), and safety features should never be circumvented. Appropriate HCW training and maintenance of this equipment is essential, and unsafe/traditional equipment should be eliminated when possible (CDC, 2023a, 2023b; Needlestick Safety and Prevention Act, 2000; NYSDOH & NYSED, 2018; OSHA, n.d.-a).

Work Practice (Administrative) Controls

Work practice controls are plans, policies, and procedures designed to reduce the risk of bloodborne pathogen exposure by altering how a task is performed. Work practice controls include prohibiting the recapping of needles by a two-handed technique, not bending or breaking needles before disposal, proper handling of blood and body fluids, and the protection and separation of work surfaces and equipment to prevent contamination. The employer is responsible for developing a written and explicit Exposure Control Plan to reduce exposure to risk. This plan should be created with input from staff at risk of exposure, updated at least annually, and contain schedules, methods, and procedures related to reducing exposure risk. It should also contain an exposure determination outlining the job titles and classifications (along with specific tasks and procedures) that are at risk of exposure (CDC, 2022c, 2023b; NYSDOH & NYSED, 2018; OSHA, n.d.-a).

Biohazard waste (blood and body fluids) should be clearly labeled and safely disposed of, and procedures for cleaning spills of blood and body fluids should be outlined, including initial removal of bulk material and then use of an appropriate disinfectant. Sharps containers should be monitored and emptied regularly to prevent becoming overfilled. Barriers should be placed to prevent instruments from becoming contaminated when work surfaces are in direct proximity to patient procedure treatment areas. When suturing or disassembling sharps, HCWs are encouraged to use forceps or suture holders (not fingers). Contaminated sharps should be disposed of as soon as possible in designated sharps containers and passed by use of designated "safe zones." Work practice controls should also include protocols that identify a sequence of actions to follow if an exposure does occur. While proper use of PPE and hand hygiene are considered components of standard precautions, the training and education of HCWs on their appropriate use and disposal, selection, and availability of the PPE equipment/handwashing supplies is considered a work practice control. Because administrative controls require a change in behavior, they are considered less effective than engineering controls, which are passive (CDC, 2022c, 2023b; NYSDOH & NYSED, 2018; OSHA, n.d.-a).

Training and education regarding potential hazards are considered work practice controls. High-risk behaviors should be identified so they may be avoided. HCWs should avoid holding tissue with fingers, recapping needles (especially with two hands), and 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. HCWs should never leave exposed sharps on patient procedure/treatment work surfaces. Contaminated sharps should not be manipulated by hand (removing scalpel blades from holders or removing needles from syringes). High-risk practices that may lead to direct mucous membrane exposure include contact with contaminated hands or open skin lesions/dermatitis and inadvertent splashes/sprays of blood or body fluids. Parenteral exposures may occur due to sharing of blood monitoring devices (glucometers, lancets, hemoglobinometers) or infusion of contaminated medication/fluids/blood products (CDC, 2022c, 2023b; NYSDOH & NYSED, 2018; OSHA, n.d.-a).

Surveillance of injuries/illnesses related to exposure is also considered a work practice control. This should include identification of who is at risk (laboratory personnel, nurses, physicians), what devices cause more exposure incidents (devices with hollow bores carry a higher risk of disease transmission, while "butterfly"-type IV catheters and recoil devices cause more injuries), areas or settings where exposures tend to occur, and which circumstances tend to result in injury. This surveillance should also include the adherence to and success of established post-exposure prophylaxis protocols (NYSDOH & NYSED, 2018).

Safe Injection Practices

According to OSHA and the CDC (2023a), safe injection practices require HCWs to follow a series of specific recommendations. The following recommendations apply to the use of needles, cannulas that replace needles, and IV delivery systems (CDC, 2023a, section IV.H. and I.; NYSDOH & NYSED, 2018):

• Maintain aseptic technique to avoid contamination of sterile injection equipment, such as sterile, single-use, disposable needles and syringes for each injection given and single-dose vials (preferred).
• A designated "clean" medication area should be set aside for the sole purpose of drawing up all medications, and hand hygiene should be performed before handling medications.
• Do not administer medication from a syringe or IV bag to multiple patients, even if the needle or cannula on the syringe is changed or administered into the IV tubing. Instead, use a new sterile syringe and needle for each medication, each time, for every patient. Never leave a needle or other device ("spikes") inserted into a medication vial septum or IV bag/bottle for multiple uses. This is a direct route for micro-organisms to enter the vial and contaminate the fluid.
• 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 (such as a rubber septum) should be disinfected using alcohol before drawing up medication and only accessed with a new sterile needle. Multidose vials should be assigned to a single patient if possible. 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 when expired or if sterility is compromised/questioned.
• All infusion components (infusion and administration sets, such as IV bags, tubing, and connectors) are a single interconnected unit and should be considered directly or indirectly in contact with blood/body fluids. They should be used for one patient only and then disposed of appropriately. 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. A lack of visible blood or signs of contamination in a syringe, tubing, medication vial, or other device does not mean it is free of infectious agents.
• 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 (during myelograms, lumbar puncture, and spinal or epidural anesthesia).

When caring for patients with DM, peripheral capillary blood monitoring devices intended for use with a single patient should not be shared. Ideally, lancets should be single-use instruments that automatically retract after puncture for maximum safety; these should never be reused for multiple patients. Patients who self-inject medications at home should be instructed on how to dispose of used needles safely. Community services, such as drop-off collection sites, syringe exchange programs, and special waste pickup services, are available to assist patients with used needle disposal. Patients should be referred to the EPA and their local department of health websites for more information (EPA, 2004; OSHA, 2008). 

According to the NYSDOH (2019b), HCWs 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 21) can be purchased at local drugstores or pharmacies or are available via syringe exchange programs. A summary of the recommendations is as follows (NYSDOH, 2019b):

• Never put used sharps in the trash; flush them down the toilet or drop them into a sewer.
• Put sharps in the puncture-resistant container as soon as they are used.
• Do not bend, clip, or put the cap back on used sharps.
• If a puncture-resistant sharps container is unavailable, use a plastic bottle that cannot be broken or punctured (such as an 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, or glass bottles.
• Keep the container closed and away from children and pets.
• Bring an appropriate container when traveling.
• 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, 2019b).

Figure 21

Sharps Container 

 

(Original ATI Image, 2018)

 

 

 

Management of Bloodborne Pathogen and Other Exposures

Following exposure to varicella, measles, mumps, rubella, or pertussis, the exposed HCW should be evaluated by a licensed medical provider who is familiar with the current recommendations for post-exposure evaluation and treatment. 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 HCW should be evaluated immediately by a qualified professional in case treatment is needed. Following exposure to a needlestick, sharps injury, or blood or body fluid of a patient, NIOSH (CDC, 2023b) advises the HCW to follow these steps immediately:

• 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 health care provider (CDC, 2023b).

Exposure incidents should be reported immediately. Health care 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. Occupational health clinicians caring for exposed HCWs 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 7 days a week from 11:00 to 20:00 EST at 888-448-4911. In addition, information regarding post-exposure prophylaxis and approaching/informing source patients or HCWs should be provided (CDC, 2023b; NCCC, n.d.). An overview of the NYS evaluation and management following bloodborne pathogen exposure is listed in Table 5. A detailed account of the guidelines can also be found on the DOH website (NYSDOH & NYSED, 2018).

Table 5

NYS Management Following Bloodborne Pathogen Exposure

(NYSDOH & NYSED, 2018)

HIV Post-Exposure Prophylaxis (PEP) 

According to the NYSDOH AIDS Institute (NYSDOH AI, 2023c), an occupational exposure to HIV is defined as:

• Skin broken by a sharp object (including hollow-bore, solid-bore, and cutting needles or broken glassware) that has been in the source's blood vessel or is contaminated with blood, visibly bloody fluid, or other potentially infectious material (percutaneous exposure)
• A bite from a patient with visible bleeding in the mouth that causes bleeding in the exposed individual
  • PEP is not indicated for an exposure to saliva, including from being spat on, in the absence of visible blood
• A splash of blood, visibly bloody fluid, or other potentially infectious material to the mouth, nose, or eyes (mucous membrane exposure)
• A non-intact skin (dermatitis, chapped skin, abrasion, or open wound) exposure to blood, visibly bloody fluid, or other potentially infectious material

If the source's status is unknown, consent for testing should be obtained. This should include HIV antigen/antibody (Ag/Ab+) testing (lab-based or point-of-care) as well as HBV surface antigen (HBsAg) and HCV RNA or Ab+ testing. Some facilities include this consent in their general medical consent forms for all patients to prevent testing delays with this step. Anonymous testing may be completed without source patient consent in certain circumstances (such as the source patient is deceased, unconscious, or otherwise unable to consent, and there is no surrogate immediately available). If those tests are negative, and the source has not had a potential HIV exposure in the last four weeks, then PEP is not indicated. If the test is negative but there is a risk of exposure in the previous four weeks, an HIV RNA assay should be run on the source individual, and PEP treatment should be started until those results are available. If the source is unavailable, refuses testing, cannot consent, or is known to have HIV, a 28-day course of PEP is indicated. ARV therapy effectively prevents HIV infection in an exposed individual when initiated ideally within 2 hr, but no later than 72 hr, 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 and elicits antiviral acts on multiple sites in the body, thereby blocking viral replication to contain and prevent 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: Tivicay) 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 300 mg/emtricitabine 200 mg (/FTC; Truvada) daily plus raltegravir (RAL: Isentress) 400 mg twice a day (TDF/FTC plus RAL) or
• TDF/FTC (Truvada) plus DTG (Tivicay) 50 mg daily (TDF/FTC [Truvada] plus DTG)
• lamivudine 300 mg (Epivir) may be substituted for FTC in either regimen
• RAL may be prescribed in the high-dose (HD) formulation at 1200 mg daily, but the HD should not be given to pregnant patients (NCCC, 2021; NYSDOH AI, 2023c)

Following exposure to HIV, the HCW should also be assessed for concurrent exposure to HCV. Providers in NYS should keep in mind that HIV infection is a reportable condition, and the NYSDOH should be notified of any confirmed diagnosis within 24 hr (NYSDOH AI, 2023b, 2023c).

Management of Potential Exposure to HCV

The risk of transmission with HCV is higher than HIV following occupational exposure (1.8% following a needlestick versus just 0.3% with HIV). The risk of HCV transmission with mucous membrane exposure is negligible unless it is through receptive anal intercourse. A history of sexually transmitted infections, including HIV, increases the risk of HCV and HBV transmission. The HCW exposed to HCV should undergo baseline blood tests (HCV Ab+ and liver function/enzyme tests), preferably within 48 hr of the exposure. If the HCV Ab+ testing is positive, HCV RNA testing should be done for confirmation. If HCV is diagnosed, the individual should be referred to a specialist experienced in treating HCV, as there is no effective prophylaxis for HCV infection. Occupational health clinicians should not prescribe or administer immunoglobulin or ARV for PEP of HCV. As described above, if the source's status is unknown, consent for testing should be obtained. Nucleic acid amplification testing for HCV RNA or HCV Ab+ testing can be done with HCV PCR to confirm if Ab+ testing is positive. If the source is unavailable, refuses testing, or is positive, and the exposed HCW tests are initially negative, the HCW should then undergo follow-up testing with HCV RNA and alanine aminotransferase (ALT) at 4 weeks and Ab+ testing at 12 weeks post-exposure. At week 24, NYSDOH recommends repeat ALT and HCV Ab+ testing with reflex RNA testing if either of the initial tests is abnormal (NCCC, 2021; NYSDOH AI, 2023b).

Management of Potential Exposure to HBV

The risk of transmission with HBV ranges from 1% to 31% depending on the presence of HBV e antigen, the marker of active replication. As mentioned above, if the source's status is unknown, consent for testing should be obtained, and HBsAg testing should be performed. If the HBsAg is negative, the exposed individual does not require further treatment/testing. 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 hr of exposure. Vaccination within 24 hr has been shown to prevent infection in 70% to 90% of exposed individuals. This also applies to exposures where the source is not available, does not consent to testing, or is at increased risk for HBV infection. In addition to initiating the HBV vaccine, clinicians should administer prophylactic hepatitis B immune globulin 0.6 mL/kg as soon as possible (ideally within 7 days and no later than 14 days) if the source has known acute or chronic HBV infection and the exposed HCW is non-immune or their immune status is unknown. Following vaccination, the HCW should undergo testing for HBV surface antibodies  1 to 2 months after the final vaccine dose. Vaccinated HCWs should receive the first dose of the vaccine. At the same time, an Ab+ titer is performed to confirm immunity (unless the immune response has previously been confirmed), while HBsAg results for the source are pending (NCCC, 2021; NYSDOH AI, 2023a).

In addition, the NYS policy regarding HCWs with a bloodborne infection states that bloodborne pathogen infection alone does not justify limiting an HCW's professional duties. HCWs are not required to inform patients or employers that they have a bloodborne pathogen infection. To determine appropriate restrictions, if any, the HCW 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. Standard precautions and infection control education continue to be the recommendations to limit infection transmission (NYSDOH, 2012; NYSDOH AI, 2023a, 2023b, 2023c; NYSDOH & NYSED, 2018).

Recommendations for TB Screening and Post-Exposure Management

As of December 16, 2020, the NYSDOH (2020) updated its requirements for baseline and annual TB assessments of HCWs 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 HCWs have a positive TB test at baseline and upon serial testing. Updated recommendations for screening and testing of HCWs include the following (NYSDOH, 2020).

• Baseline (preplacement) screening and testing
  • TB screening of all HCWs, 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
• Annual TB education
• Post-exposure screening and testing
  • Symptom evaluation for all HCWs is recommended when exposure is recognized. Those with a negative baseline TB test and no prior TB disease or LTBI should be tested (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 HCWs with untreated LTBI unless medically contraindicated.

An active pulmonary TB infection is treated with combined anti-TB therapies for 4 to 9 months. The 4-month regimen for patients 12 years and older includes high-dose rifapentine (RPT), moxifloxacin, isoniazid (INH), and pyrazinamide (PZA). The 6- to 9-month regimen also includes INH and PZA along with rifampin (RIF) and ethambutol. Typically, HCWs can return to work after symptoms have resolved, and three sputum smears are negative for acid-fast bacilli. LTBI (positive TB test results without radiographic findings or symptoms of disease) should be treated using once-weekly INH and RPT for 3 months, daily RIF for 4 months, or daily INH and RIF for 3 months. LTBI is not infectious and does not require the HCW to take a leave of absence from work during their treatment (CDC, 2023h). 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) HCW exposed to chickenpox (varicella) is usually furloughed from work beginning the 10th day through the 21st day following the exposure (the incubation period for chickenpox). HCWs should consult current federal, state, and local requirements for post-exposure evaluation and management of all airborne and droplet-transmitted conditions. NYS and CDC mandate reporting of any suspected or confirmed TB case to the DOH or designated official within 24 hr. In addition, HCWs 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 NYSDOH website (CDC, 2012; NYSDOH, 2019a).

Cleaning, Disinfection, and Sterilization

As part of their infection control standards, health care 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, including how those processes should be recorded and tracked. HCWs 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 health care 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 & NYSED, 2018)

The potential for contamination of equipment/devices can be affected by several factors, such as their construction, use, and environment. The equipment/device may be susceptible to external (presence of hinges or crevices) or internal contamination (presence of lumens, reservoirs). The construction material/composition should also be considered, as certain cleaners and methods for disinfection/sterilization are inappropriate based on the materials used or their design/configuration in a piece of equipment/device. Manufacturer recommendations regarding the compatibility of materials/chemicals, heat and pressure tolerance, and time/temperature for reprocessing should be followed. The potential for contamination is higher for equipment/devices that are frequently contacted (bedrails, door handles, light switches, stethoscopes, reflex hammers) or exposed to body substances (such as oral thermometers) or environmental micro-organisms. Practices should be designed to limit/avoid high-level hand contamination or cross-contamination. Finally, the level of contamination of equipment/devices is affected by the types/number of micro-organisms and any risk of cross-contamination. Frequent contamination or a higher risk of cross-contamination may indicate the need for certain equipment/devices to be cleaned between patient procedures/encounters. If single-use/disposable equipment must be reused due to resource scarcity, the consequences of this decision and methods to mitigate those consequences should be planned and considered ahead of time, along with any federal and state regulations regarding this practice (NYSDOH & NYSED, 2018).

Cleaning is the removal of foreign matter from objects. Most, but not all, of the micro-organisms are removed. Cleaning involves water, detergent, and scrubbing. Soiled objects must be cleaned before they are disinfected or sterilized. The CDC (2019b) Guideline for Disinfection and Sterilization in Health care Facilities offers evidence-based recommendations on the preferred methods for cleaning, disinfecting, and sterilizing patient care medical devices and the health care environment. Adherence to these recommendations, last updated in 2019, and the manufacturer instructions on product labels can significantly reduce the risk of infection associated with the use of invasive and noninvasive medical equipment (CDC, 2019b).

For all environmental cleaning procedures, the CDC (2023c) advises that HCWs 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 (asses for spills of blood or body fluids, if the patient is on transmission-based precautions, or if there are any obstacles [clutter, damage, or broken furniture]).
• Proceed with cleaning from cleaner to dirtier areas to avoid spreading dirt and micro-organisms (see Figure 22) and from high to low (or top to bottom). Cleaning from high to low (such as cleaning surfaces before floors) prevents dirt and micro-organisms from dripping or falling and contaminating already cleaned areas.
• Clean in a systematic manner, such as clockwise around the patient's room.

Figure 22

Cleaning From Cleaner to Dirtier Areas

 

 

(CDC, 2023c)

 

In acute care settings/hospitals, most cleaning, disinfection, and sterilization of patient-care devices are performed via a central processing department. However, HCWs must understand their responsibilities with regard to the cleaning of patient-care devices (pre-cleaning, soaking) prior to submission and how equipment is cleaned/disinfected/sterilized (even if they are not physically performing these tasks). This includes the concepts of standard and universal precautions, the proper use of PPE, and safe handling of medical devices/equipment/instruments (CDC, 2019b):

• Patient care items should be meticulously cleaned with water and detergent or with water and enzymatic cleaners before high-level disinfection or sterilization procedures.
• Remove visible residue using appropriate cleaning agents capable of removing organic and inorganic residues.       
• Clean medical devices as soon as practical after use (at the point of use) as soiled materials become dried onto the instruments and make the removal process more difficult.
• Perform manual cleaning (using friction) or mechanical cleaning (with ultrasonic cleaners, washer-disinfector, washer-sterilizers, if available). Automatic washers must be used in accordance with the manufacturer's recommendations, with expected reprocessing of cleaning equipment and solution changes performed regularly. Disposable cleaning equipment should not be reused.
• 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.
• 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, 2019b):

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 the 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, such as surgical instruments and biopsy forceps, enter the patient’s body, normally sterile tissue or the vascular system, and pose a high risk of infection. This also includes equipment through which sterile body fluids flow (blood). Sterilization is required for critical items before use on each patient. Semi-critical items come in contact with mucous membranes or non-intact skin, such as endoscopes, laryngoscope blades, endotracheal tubes, anesthesia breathing circuits, respiratory therapy equipment, and vaginal speculums. Semi-critical items require at least high-level disinfection (or sterilization). Noncritical items only come in contact with intact skin and require low-level disinfection. Examples include stethoscopes, blood pressure cuffs, bedpans, and furniture/patient care surfaces (bedrails, over-the-bed tables). 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, 2019b; NYSDOH & NYSED, 2018).

Disinfection is the removal of nearly all micro-organisms 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, 2019b):

• 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 (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 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 (2019b) 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 be used initially to inactivate bloodborne viruses to minimize the risk of infection to health care personnel from percutaneous injury during cleanup. Policies/procedures should also outline the tracking and recordkeeping necessary regarding equipment usage and reprocessing and any handling instructions or storage post-disinfection (CDC, 2019b; NYSDOH & NYSED, 2018).

Sterilization destroys all micro-organisms 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. 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 health care settings. In acute care facilities/hospitals, all critical items should undergo sterilization. In most health care settings, employees in a central processing unit have advanced education in disinfection and sterilization and provide these services for the facility. 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 health care settings is comprised of materials that are heat-stable and are intended for heat (or steam) sterilization procedures. Ethylene oxide (ETO) gas destroys micro-organisms and spores. While ETO gas is very effective for heat-sensitive items, it is toxic to humans. Industry experts are attempting to develop alternatives to ETO or methods to reduce the gas emissions of ETO use. 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 (pre-cleaning/soaking of the items; CDC, 2019b; FDA, 2019).

There are biological, process, and physical monitors that allow staff to confirm process completion/successful sterilization. Monitoring may occur through biological, process (tape, indicator strips), and/or physical (gauges for temperature or pressure) methods. Policies/procedures should also outline the tracking and recordkeeping necessary regarding equipment sterilization and any handling/packaging instructions or storage post-sterilization (NYSDOH & NYSED, 2018).

While medical instruments/devices/equipment are typically processed according to their recommended use and not based on the patient's diagnosis, special procedures are required for handling brain, spinal, or nerve tissue from patients with known or suspected prion disease (). 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 recordkeeping of reprocessing requirements (CDC, 2019b).

Factors that lead to contamination, such as breaks in protocol, can lead to the compromised integrity of equipment/devices/instruments. Examples 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
• Inadequate/inaccurate recordkeeping of reprocessing requirements (NYSDOH & NYSED, 2018)

HCWs with primary or supervisory responsibilities for equipment, instruments, or medical device reprocessing (staff working in the sterile processing department or physician practices where medical equipment is reprocessed onsite [such as gynecologic offices]) are responsible for not just understanding the core concepts and principles but also must 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) and financial cost
• Compatibility with materials, such as corrosiveness, penetrability, leaching, disintegration, heat tolerance, and moisture sensitivity
• Toxicities such as any occupational health risks, environmental hazards, abatement methods, monitoring exposures, the potential for patient toxicity/allergy, and/or odor
• Residual effects such as antibacterial residual or patient toxicity/allergy
• Ease of use and the need for specialized equipment, additional training, or specific monitoring
• Stability of the necessary supplies, including their concentration, potency, efficacy, and potential effect on organic material (CDC, 2019b, NYSDOH & 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 micro-organisms 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 23). Sharp objects, including needles and 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 being used 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, HCWs should be cautious 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. HCWs should also avoid contaminating the outside of the container. Most agencies require placing the specimen in a plastic bag labeled "Biohazard" before transporting it (CDC, 2015a).

Figure 23            

Waste Receptacles 

 

 

 

(Original ATI Images, 2018)

 

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, tossing, or placing soiled linens on the floor, as this can spread micro-organisms to other patients and environments. If clean linens touch the floor or any unclean surface, immediately put them in the dirty linen container (CDC, 2015a, 2019b).

Figure 24

Soiled Linens

 

 

 

(Original ATI Images, 2018)

Latex and Latex-Free Equipment

Latex sensitivity and latex allergies are of concern to HCWs and patients. According to OSHA, latex sensitivity can present with reactions ranging from mild irritation to severe allergic reactions. HCWs 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. 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 (CDC, 2023f; OSHA, n.d.-b).

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, and the use of cleaners and sanitizers. Irritant contact dermatitis is not a true allergy (CDC, 2023f).

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 hr after contact and may progress to oozing skin blisters or spread away from the area of skin touched by the latex (CDC, 2023f).

Latex Allergy

The most severe reaction to latex is a latex allergy. The protein in rubber can cause an allergic reaction in some people. Reactions usually begin within minutes of exposure to latex but can occur hr 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 (CDC, 2023f).

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 health care facilities operate as latex-free environments, HCWs should consider the following strategies to prevent latex allergies (CDC, 2023f; OSHA, n.d.-b):

• Use non-latex gloves for activities that do not involve exposure to infectious materials (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, hands should be washed with mild soap and dried thoroughly.
• Always use reduced-protein, powder-free gloves.
• Regularly clean all areas commonly contaminated with latex-containing dust.
• Recognize the signs and symptoms of a latex allergy.

Once an HCW or patient has been identified with a latex sensitivity or allergy, the rest of the health care 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 (CDC, 2023f; OSHA, n.d.-b).

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. 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 U.S. and worldwide. According to the CDC (2023g), over 1.7 million Americans develop sepsis in a typical year, and about 350,000 of these patients die. Most sepsis cases are community-acquired; 7 out of 10 patients with sepsis had recently received health care services or had chronic conditions requiring frequent medical care (NYSDOH & NYSED, 2018). Sepsis is a common cause of admission to ICUs, and it is the most common cause of death among adults admitted to ICUs (Gauer et al., 2020). According to the CDC (2023g), 1 in 3 patients who die in a hospital had sepsis while hospitalized. 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., 2024; NYSDOH & 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 old and approximately 8% of patients admitted to pediatric ICUs 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 18 children die from sepsis in the U.S. each day, and it remains the leading cause of death in children globally (Sepsis Alliance, 2023). 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 HCWs. 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 (NYSDOH, 2021b).

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 10 NYCRR §§ 405.2 and 405.4 require hospitals to adopt evidence-based protocols to ensure early diagnosis and treatment of sepsis and HCW training to implement such protocols. To ensure compliance with these regulations, the protocols must be submitted to the NYSDOH 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 HCWs to help quickly identify and treat sepsis in adults and children
• The reporting of all sepsis-related data to the NYSDOH (End Sepsis, n.d.; NYSDOH, 2021b, 2022)

While anyone with an infection can develop sepsis, there is an 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 (DM, lung disease, CKD, and cancer), and those with weakened or impaired immune systems (CDC, 2023g). Sepsis starts with an infection—most often pneumonia—that triggers a dysregulated host response. Other infections that commonly lead to sepsis include GI, genitourinary, skin and soft tissue infections, and 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 Streptococcus 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 during this early stage. 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, 2023g; Ignatavicius et al., 2024).

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 hr after birth, and late neonatal sepsis begins after 72 hr. Early neonatal sepsis is acquired before or during childbirth, so the pathogens are usually obtained from the mother’s genitourinary tract. 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 hr and chorioamnionitis are also risk factors for early neonatal sepsis. Late neonatal sepsis occurs most often in infants who remain hospitalized, such as low-birth-weight infants with long-term hospitalization or 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 (0.9% normal saline or lactated Ringer's) within the first 3 hr. 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, 2023g; Evans et al., 2021; Gauer et al., 2020). 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, not oxygen extraction, is usually deficient in pediatric patients. 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, 2023g). 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 contracting 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 hr 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 (Evans et al., 2021; Prescott & Angus, 2018). 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 HCWs 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., 2023; 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. HCWs 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, ensure that documentation does not contain spelling errors (Potter et al., 2023; 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 health care information, and to 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, HCWs are required to notify patients of their privacy policy and to make a reasonable effort to obtain written acknowledgment of this notification. All HCWs, 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., 2023; Woods, 2019)

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

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 HCWs with artificial nails carry more pathogens on their nails than other HCWs. 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 HCWs.
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 hr on steel and plastic and 8 to 12 hr on cloth and facial tissues at room temperature.
7. How can I protect older adults and immunocompromised patients from HAIs?
   Standard precautions should be used with all patients to prevent the spread of pathogens.

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