Infection Control Training for New York State Healthcare Professionals
CONTACT HOURS: 4
Copyright © 2020 Wild Iris Medical Education, Inc. All Rights Reserved.
LEARNING OUTCOME AND OBJECTIVES: Upon completion of this course, you will have increased your knowledge of current, evidence-based information on preventing and controlling the spread of infection. Specific learning objectives include:
- Discuss New York State’s requirements for infection control.
- Summarize the principles and practices of infection prevention and control.
- Describe the modes and mechanisms of the transmission of pathogenic organisms, including the chain of infection.
- Discuss engineering and work practice controls designed to reduce patient and healthcare worker exposure to infectious materials.
- Identify barriers and personal protective equipment for protection from exposure to potentially infectious material.
- Describe the principles and practices for cleaning, disinfection, and sterilization in the healthcare environment.
- Identify occupational health strategies for preventing the transmission of bloodborne and other pathogens to and from healthcare workers.
- Recognize suspected sepsis and methods to prevent it.
TABLE OF CONTENTS
- The Need for Infection Prevention and Control Practices
- Infection Control Principles and Practices
- Modes and Mechanisms of Pathogen Transmission: The Chain of Infection
- Methods for Preventing the Spread of Pathogens in Healthcare Settings
- Engineering and Work Practice Controls
- Barriers and Personal Protective Equipment
- A Safe Environment: Cleaning, Disinfecting, and Sterilizing
- Infectious Disease and Occupational Health Strategies
- Sepsis
- Conclusion
- Resources
- References
THE NEED FOR INFECTION PREVENTION AND CONTROL PRACTICES
Infection control was born in the mid 1800s when Ignaz Semmelweis, a Hungarian obstetrician, demonstrated that handwashing could prevent infection. Semmelweis was director of two obstetrical clinics, one staffed by medical students, the other by midwives. Disturbed by the fact that the maternal mortality rate from postpartum fever in the clinic staffed with medical students was almost six times greater than in the clinic staffed by midwives, he set about analyzing the difference and found that medical students often performed autopsies prior to assisting with deliveries without washing their hands.
Semmelweis came to the conclusion that the medical students performing autopsies (which midwives did not do) were carrying some invisible poisonous material on their hands to the women they were assisting in the delivery room, and he instituted a policy requiring medical students to wash their hands in a solution of chlorinated lime prior to assisting in any obstetrical procedure. As a result of this practice, the mortality rate dropped nearly 90% in the medical students’ clinic, and in a period of two months, the death rate dropped to zero (Zoltán, 2020).
Later in that same century, Florence Nightingale described the relationship between the diseases that were killing her patients during the Crimean war and the conditions in which they were cared for. Nightingale instituted ways to improve overall hygiene and prevent contamination that led to reductions in infections and mortality. Her greatest influence has been on hospital infection control, and many modern healthcare practices (e.g., isolation, ventilation, routine cleaning, medical and human waste disposal) are attributed to her (Nightingale, 2017).
Today, we know about pathogenic microorganisms and how they are transmitted, and we have a great deal of knowledge of the principles of infection control. Despite these advances, preventable infections continue to occur. Why, on any given day, does 1 in 31 patients in United States hospitals have at least one healthcare-associated infection? Why, on average, do healthcare providers clean their hands less than half as often as they should, despite it being known that hand hygiene is the most effective way to prevent healthcare-acquired infections (CDC, 2020a)?
These questions indicate that infection control is not just a matter of knowing what is effective but that there is a strong behavioral element involved in the process of carrying out infection control practices. Both factors must be addressed if the absence of healthcare-acquired infections is the goal. To accomplish this, each healthcare worker should have the necessary knowledge, skills, and abilities to implement effective infection control practices, which then may influence their perceptions and provide motivation to change behavior.
TERMINOLOGY
- Healthcare-associated infection (HAI)
- A healthcare-associated infection is an infection acquired while receiving healthcare in any setting (e.g., hospital, long-term care facility, outpatient clinic, ambulatory setting, home care). These infections occur in patients who do not have infections and are not incubating an infection at the time of entry into the healthcare system but acquire them while receiving treatment for other conditions. Healthcare workers also can be the recipients of HAIs. Other common terms for HAIs are nosocomial (originating in a hospital) and iatrogenic (caused by medical treatment).
- Healthcare worker (HCW)
- Any person who has contact with patients, body fluids, or supplies used for patient care as part of their job. This includes physicians, nurses, occupational therapists, and physical therapists as well as administrative, environmental hygiene, and laboratory staff in medical facilities. HCWs also include interns, volunteers, and paid workers/employees who are involved in any aspect of healthcare in any setting. All healthcare workers should be trained in basic infection prevention and control regardless of whether they deliver direct or indirect care to patients.
- Outbreak
- An outbreak is a sudden increase in the occurrence of a particular disease in a particular place and time. An epidemic is an outbreak in which a disease is actively spreading over a wide geographic area and affecting a high proportion of the population. A pandemic is an epidemic that has spread to multiple countries or regions of the world.
- Surveillance
- Surveillance is the continuous, systematic collection, analysis, and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. It can serve as an early warning system for impending public health emergencies, document the impact of an intervention, or track progress toward specific goals.
(WHO, 2020a)
Healthcare-Associated Infections (HAIs)
The CDC (2019a) reports that on any given day approximately 1 in 31 hospital patients has at least one healthcare-associated infection.
COMMON TYPES OF HAIs
More than 80% of HAIs are caused by four types of infection, including:
- Catheter-associated urinary tract infections (CAUTIs). These infections involve any part of the urinary system, including urethra, bladder, ureters, and kidney, and result from incorrect insertion, failure to maintain asepsis, and leaving a catheter in place for too long.
- Surgical site infections (SSIs). These can involve the skin, tissues and organs under the skin, or implants such as material inserted or grafted into the body (e.g., prosthetic joints).
- Central line–associated bloodstream infections (CLABSIs). These are bloodstream infections unrelated to an infection at another site that develops within 48 hours of central line placement. Of all HAIs, these are associated with increased care costs and mortality.
- Ventilator-associated events (VAEs) or pneumonias (VAPs). These events or pneumonias are caused by a wide variety of pathogens, can be polymicrobial, and can be due to multidrug-resistant organisms.
The impact of HAIs infections may be greater when they are due to drug-resistant organisms, which include:
- Methicillin-resistant Staphylococcus aureus (MRSA). This type of bacteria is resistant to many antibiotics.
- Clostridioides difficile (C. difficile) (formerly known as Clostridium difficile). When antibiotics are taken, “good” bacteria are destroyed for several months, during which time infection with C. difficile bacteria can cause life-threatening diarrhea.
- Carbapenem-resistant Enterobacteriaceae (CRE). This family of organisms, which includes Escherichia coli (E. Coli) and Klebsiella pneumoniae, has a high level of antibiotic resistance.
The United States has made significant progress toward the collective goal of eliminating HAIs and is safer now than it was in years past. Nationally, among acute care hospitals there has been an 8%–12% decrease in CAUTIs, CLABSIs, and hospital-onset MRSA infections since 2015 (CDC, 2020b).
HAIs IN OUTPATIENT SETTINGS
Increasingly, healthcare delivery, including complex procedures, is being shifted to outpatient (ambulatory) settings. These settings often have limited capacity for oversight and infection control compared to hospital-based settings. Because patients with HAIs, including those caused by antibiotic-resistant organisms, often move between various types of healthcare facilities, prevention efforts must expand across the continuum of care.
Examples of outpatient settings include:
- Medical group practices
- Clinics at hospitals or other facilities
- Surgery centers
- Imaging centers
- Mental health centers
- Lab centers
- Physical therapy and rehabilitation facilities
- Chemotherapy and radiation therapy centers
- Dialysis centers
- Birthing centers
- Hospice homes
- Home care
Surveillance for infection in outpatient or ambulatory settings is inherently difficult, as detecting infections among outpatients typically requires retrospective reviews of medical records and/or prospective audits. However, intelligent information technology may serve as a meaningful tool. Such automated systems can be used to perform prospective surveillance for infections following outpatient procedures, such as a reference database designed to document surgical site infections in ambulatory surgery and linking institutional databases to detect bloodstream infections (Anderson & Kanafani, 2020).
ACCREDITATION FOR AMBULATORY HEALTHCARE FACILITIES
The Centers for Medicare and Medicaid Services has granted several organizations, along with itself, the authority to determine whether or not ambulatory healthcare facilities are in compliance with Medicare’s conditions for coverage and provide accreditation for them. While there is no federal requirement for accreditation, some states and private payers require it. Organizations granted authority to accredit include:
- Accreditation Association for Ambulatory Health Care
- Accreditation Commission for Health Care, Inc.
- American Osteopathic Association/Healthcare Facilities Accreditation Program
- Center for Improvement in Healthcare Quality
- Community Health Accreditation Partner
- DNV GL-Healthcare
- National Dialysis Accreditation Commission
- The Compliance Team
- The Joint Commission
(CMS, 2020)
HAIs IN LONG-TERM CARE FACILITIES
Long-term care settings include nursing homes, skilled nursing facilities, and assisted living facilities. Over 4 million Americans are admitted to or live in nursing homes and skilled nursing facilities each year, and nearly 1 million live in assisted living facilities. While reporting is limited, the CDC (2020c) provides the following data about infections in these facilities:
- 1 to 3 million serious infections occur each year.
- Infections include urinary tract infections, diarrheal diseases, antibiotic-resistant staph infections, and many others.
- Infections are a major cause of hospitalization and death.
As many as 380,000 people die of infections in long-term care facilities every year.
Development of Infection Control and Prevention Standards and Guidelines
Standards and guidelines are designed to proactively prevent the spread of infection in healthcare settings. The development of these standards and guidelines came about through the collaborative efforts of the Centers for Disease Control and Prevention, the Joint Commission, the World Health Organization, and the Occupational Safety and Health Administration.
Significant infection control challenges include:
- SARS-CoV-2 (COVID-19)
- SARS-CoV (severe acute respiratory syndrome)
- HIV infection
- Lyme disease
- Escherichia coli
- West Nile virus
- Zika virus
- Candida auris
Reemerging infectious diseases include:
- Tuberculosis
- Pertussis
- Influenza
- Pneumococcal disease
(Johns Hopkins, 2020)
New York State Infection Control Requirements
Title 10, part 92, chapter 785, of the Official Compilation of Codes, Rules, and Regulations of New York established a requirement that certain healthcare professionals licensed in New York State must receive approved training in infection control and barrier precautions every four years unless otherwise exempted.
NEW YORK STATE PROFESSIONS REQUIRING INFECTION CONTROL TRAINING
- Dental hygienists
- Dentists
- Licensed Practical Nurses
- Registered Professional Nurses
- Optometrists
- Physicians
- Physician assistants
- Physician assistant students
- Podiatrists
- Specialist assistants
- Medical residents
- Medical students
The goal of New York State’s mandate is to:
- Assure that licensed, registered, or certified health professionals understand how bloodborne pathogens may be transmitted in the work environment from patient to healthcare worker, healthcare worker to patient, and patient to patient
- Apply current scientifically accepted infection prevention and control principles as appropriate for the specific work environment
- Minimize opportunity for transmission of pathogens to patients and healthcare workers
- Familiarize professionals with the law requiring this training and the professional misconduct charges that may result from failure to comply with the law
CORE ELEMENTS OF NEW YORK STATE INFECTION CONTROL TRAINING
Element I
Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor the performance of those ancillary personnel for whom the professional is responsible
Element II
Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention and control
Element III
Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings
Element IV
Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with potentially infectious material
Element V
Creation and maintenance of a safe environment for patient care in all healthcare settings through application of infection control principles and practices for cleaning, disinfection, and sterilization
Element VI
Prevention and control of infectious or communicable diseases in healthcare workers
Element VII
Sepsis awareness and education
(NYSDOH, 2018)
This course explores each of the seven elements in detail, covering the basic principles of infection control and evidence-based infection control practices.