Archive | May 2017

Case 7: Paediatric Issues in Infection Control (practice/redo)

You were informed by one of the patient service managers that one of her staff (a 26 year-old female) has just been diagnosed by her family practitioner as having chicken pox. She works on the general paediatric ward and her last day of work was three days ago, the same day the rash developed. The nurse had worked with three patients in adjacent rooms for five days prior to her last day of work, although she had been giving break relief to other nurses throughout that period. The unit has twelve patients on the one wing. The children range from age 2 to 13.

Case Seven Questions:

1.What precautions should be taken, if any, to protect patients on the ward? Would you recommend prophylactic therapy for any of the patients? Justify your response.

Precautions for patients:

  • Varicella zoster can be transmitted through air or contact from persons (Lautenbach, p. 301) Therefore all patients with symptoms should be placed on airborne and contact precautions.
  • Patients who have contracted varicella zoster should remain on precautions until lesions have dried and crusted to prevent hospital exposures (Lautenbach, p. 301).
  • Non-immune exposed patients should be placed on airborne precautions for the period from day 10 through day 21 after their exposure or through day 28 if the patient is immunocompromised or has received Varicella zoster immunoglobulin
  • Varicella zoster is rarely spread through air from individuals with localized herpes zoster so patients, visitors and healthcare workers with this disease entity do not need to be restricted so long as their lesions are covered (Lautenbach, p. 301)

Prophylactic therapy:

  • Patients and staff who are non-immune should receive the varicella zoster vaccine as it results in milder outbreak and is cost effective for the hospital given costs associated with secondary cases (Lautenbach, p301)
  • All patients on the unit are a high risk for complications therefore if they can safely receive varicella vaccine, and it is within 3 to 5 days after exposure, give the vaccine (BCCDC, 2004)
  •  For immunocompormized patients give Varicella zoster immune globulin (VZIG) given within 96 hours of exposure (BCCDC, 2004)

2. What, if any, infection control measures should be considered for the hospital workers.

  • non-immune workers could be incubating the infection and could spread it to others
  • all healthcare workers who might have been exposed should not work in patient care capacity during the incubation period (Lautenbach, p. 301)
  • staff members who develop varicella zoster must not work until all lesions have crusted over(Lautenbach, p. 301)
  • non-immunized exposed staff should be considered potentially infectious 8 to 21 days following exposure (28 days if VZIG was given (BCCDC, 2004)

  • Staff who are pregnant or have immunocompromizing conditions such as corticosteroid treatments should receive VZIG  (BCCDC, 2004).
  • immunization status of current staff should be known or sought (BCCDC, 2004)

  • Lab results for Serology for VZV IgG should be determined for non-immune staff before immunization (i.e.unknown or no history of chickenpox) (BCCDC, 2004).

  • staff who are immunized are considered to be immune (4 weeks after the second dose) and no special precautions need to be taken if they are exposure

  • If susceptible staff is not eligible for immunization, or if serology results can not be promptly obtained, refer to a physician for clinical management, which may include prophylaxis with antiviral and VZIG if the HCW is at high risk for complications of varicella disease.

  • susceptible non-immunized HCW/students from work from days 8 through days 21 post-exposure. Extend the exclusion to 28 days, if VZIG is given.

3. What are the tests available to confirm a diagnosis of chicken pox? Is laboratory confirmation always necessary – why or why not?

Laboratory confirmation from Isolation of varicella virus from an appropriate clinical specimen or significant rise in serum varicella IgG antibody level by any standard serologic assay (BCCDC, 2004).

Laboratory confirmation not always necessary in cases where clinical illness arises in an epidemiologically linked person where the link individual has lab confirmed chicken pox.

4. How effective is Varicella zoster vaccination in children? In adults? What are the potential complications?

  • In immunocompetent children 12 months to 12 years of age, a single univalent varicella vaccine dose results in a seroconversion rate of 98% at 4 to 6 weeks after vaccination, with antibodies persisting in 98% at 5 years and 96% at 7 years after vaccination.
  • A second dose of a univalent varicella vaccine in children produces an improved immunologic response that is correlated with improved protection (Government of Canada, 2016).
  • In immunocompetent adults and adolescents 13 years of age and older, 2 vaccine doses administered 4 to 8 weeks apart result in seroconversion rates of 99% at 4 to 6 weeks after the second dose, with persistence of antibodies 5 years later in 97% of vaccine recipients(Government of Canada, 2016).

Potential Complications:

  • injection site pain
  • swelling and redness in 10% to 20% of recipients
  • A low-grade fever has been documented in 10% to 15% of vaccine recipients.
  • A varicella-like rash occurs at the injection site or is generalized in 3% to 5% of vaccine recipients after the first dose.
  • The rash usually appears within 5 to 26 days after immunization.
  • As varicella-like rashes that occur within the first 2 weeks after immunization may be caused by wild-type virus (varicella virus circulating in the community), health care providers should obtain specimens from the vaccine recipient to determine whether or not the rash is due to a natural varicella infection or to the vaccine-derived strain (Government of Canada, 2016).

5. This nurse, as the case turns out, is pregnant and delivers the day following her visit to her family practitioner. The baby is admitted to the neonatal intensive care unit. What measures should be taken?

References:

  1. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.
  2.  BCCDC. 2004. Communicable disease control Varicella zoster.  http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/Epid_GF_VaricellaZoster_July04.pdf
  3. Government of Canada. 2016. Canadian Immunization guide. https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-4-active-vaccines/page-24-varicella-chickenpox-vaccine.html#p4c23a4

Case 6: Infection control in institutional contruction and design (practice/redo)

You have identified a burn patient (60% burns) in the ICU with serial blood and tissue cultures positive for Aspergillus fumigatus. Upon reviewing the patient in ICU and inspecting the area, you notice a bulging ceiling tile in the corridor adjacent to his room. You are told that the tile has been like this for one week now. Maintenance is called and the ceiling tile is removed, at which point you notice greenish discoloration of the inner surface of the tile and evidence of water leakage from the pipe above. The air intake into the patient’s room runs above the discoloured ceiling tile.
Case Six Questions:
1. What special precautions should have been taken for this burn patient upon his admission to the unit?

The patient has burns to 60% of his body and is therefore at very high risk of infections.

Precautions for the patient upon admission to the unit:

  • physical isolation in a private room
  • gloves and gowns during patient contact
  • full body wound assessment
  • appropriate empirical antimicrobial therapy
  • laboratory surveillance cultures
  • routine microbial burn wound cultures (Coban, 2012)
  • patient should have been moved or air intake sealed off when discoloured ceiling tile noted near the air intake to his room

“During, maintenance, renovation and contruction, bacterial or fungal microorganisms in the dust and dirt can contaminate air handling or water systems wich can transmit these organisms to susceptible persons” (Lautenbach, p. 394).
2. If you had been asked to perform an infection control risk assessment prior to tile removal and plumbing remediation, what risk would you assign and why?

Type construction activity: Type C (working on ducts, removing ceiling tiles) (LAUTENBACH, P. 446).

Patient risk group: high risk, immunocompromized, burn patient (Lautenbach, p. 447).

Class of precautions: III/IV due to highest risk and type C (Lautnbach, p. 447).
3. What precautions should the maintenance workers take when they remove and dispose of the affected materials? Is this considered biohazardous material?

Precautions to be taken:

Seeing as we designated the risk class III/IV above, class 4 precations should be used for the most encomapssing precations for all involved.

Class IV precautions to be taken during the contruction project according to Lautenback, p. 448 are as follows:

  • Isolate HVAC systems in the work area to prevent air duct contamination
  • Implement barrier cube method or barrier sealing off of work area out of sheetrock, plywood, or plastic (Lautenback, p. 448)
  • maintain negative air pressure within work site
  • use HEPA equipped air filitration units (lautenback, p. 448)
  • seal off holes, pipes, conduits, punctures
  • construct anteroom: 1. all personel to be HEPA vaccummed before leaving the work site or 2. workers change out of paper coveralls each time they exit the work site (Lautenback, p. 448)
  • all personel to wear shoe covers  that are changed prior to exiting the work site
  • contain contruction waste: transport in tightly covered containers with added cover over transport receptacle or cart (Lautenbach, p. 448).

Disposal of material: Aspergillus is not a biohazard because it is readily found in the hospital environment (dust, dirt, construction debris). Aspergillus is not harmful to healthy people therefore can be disposed of without biohazard precautions(Lautenbach, 441).

4. How should air flow be designed in intensive care areas such as burn units and ICUs?

  • patient rooms should have 6 air changes per hour (Lautenbach, p. 451).
  • 2/6 of the air exchanges per hour must be outdoor exchanges
  • rooms where high risk procedures are performed such as bronchoscopies, should have negative pressure with respect to adjacent areas (Lautenbach, p.451)
  • these high risk ventiliation procedure rooms should have flexible ventilation where pressure can be changed from neutral to negative (Lautenbach, p. 451).
  • If a room with special ventiliation is renovated, air exchanges and air pressure should be measured following the renovation
  • exterior air intakes should be place minimum 8m upwind of exhaust outlets
  • the bottom of such air intakes should be minimum 2m above ground or 1m above roof level
  • air intakes should be located away from cooling towers, trash compactors, loading docks, heliports, biological safety exhaust hoods, sterilizers, aerators, and incinerators (Lautenbach, p. 451).

5. Guidelines exist for new construction and renovations in hospitals. Give examples of these and explain how they differ from construction regulations.

References:

1. Coban, Y. K. (2012). Infection control in severely burned patients. World Journal of Critical Care Medicine, 1(4), 94–101. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3953869/

2. Lautenbach, E., Woeltje, K., and Malani, P. 2010. Practical HealthcareEpidemiology, 3rd ed.

Case 5: blood borne infections (practice/redo)

While replacing a central venous line on a 29 year-old intravenous drug user, the resident receives a sharps injury from the syringe used for the local anaesthetic. The injury, which bleeds freely, is on his left index finger. The resident notes that there was visible blood in the syringe.
Case Five Questions:

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1. What are the immediate preventive measures the resident should take and to what organisms has the resident potentially been exposed?

The resident has potentially been exposed to:  Hep A,B,C, HIV (Lautenbach, p. 322).

Immediate preventative measures:

  • Save the syringe to send to the lab for testing.
  • The resident should continue to allow the wound to bleed freely
  • not promote bleeding by squeezing the wound as it may damage the tissues and increase uptake of any pathogen(s) (BCCDC, 2016).
  • Wash the area well with soap and water (BCCDC, 2016)
  • Notify the hospital’s occupational medical service (Lautenbach, p.322) and file incident report.

4 Key measures:

1. Assessment of the risk of exposure

2. Laboratory testing on the exposed person and the source person

3. Administration of PEP treatment when appropriate to prevent the development of infection

4. Counseling the exposed person to address anxiety, ensure follow-up testing and modify behavior to prevent transmission to contacts (BCCDC, 2016).

The resident should undergo a risk assessment at the hospital ER or occupational health department which includes the following:

  • HBV vaccine history or HBV immune status
  • Personal risks for HCV and/or HIV
  • Obtain verbal informed consent for testing for HBsAg, Anti-HBs, Anti-HBc Total, Anti- HCV and HIV.
  • Also obtain consent for disclosure of their results to their Worksite occupational health department and WorkSafeBC
  • Follow-up the resident’s family physician.
  • Inform HIV testing will be done either Nominally – in which the test is conducted and reported using the client’s full name, address and contact information; or Non-nominally – in which the test is conducted using initials as per agency standards
  • Positive HIV results will be reported to the Medical Health Officer using the nominal or non-nominal identifiers. Non-nominal HIV reporting is identified through checking a tick box on the laboratory requisition form.
  • Test results for HBV and HCV, if positive, will be reported to the person’s testing physician and public health for follow-up.

2. What post-injury preventive measures should be undertaken and under whose direction? What long-term follow-up should the resident receive?

Post injury prevention for each top blood borne disease listed belowe under the hospital’s occupational medical service (Lautenbach, p.322)

HBV measures:

  • If the resident  has not been immunized against HBV they should be given 0.06ml/kg of hepatitis B immune globulin IM. The first dose should be administered within 24hrs post-exposure.
  • The first dose of HBV vaccine should be adminstered at the same time (Lautenbach, p. 323).
  • An additional vaccine dose should be given 1 month later
  • An additional vaccine dose should be given 6 months later
  • a baseline level of HB antibody should be deterined pre-treatment, if the result is positive for HBV no further treatment is required.
  • if the resident was previously vaccinated, a baseline anti-HB should be determined (Lautenbach, p. 323).

HCV measures:

  • tested to determine their level of aminotransferases (alanine and asparate) (Lautenbach, p. 324)
  • determine HCV antibody level with sensitivity and antibody test at baseline within 15 weeks of exposure
  • monitor for symptoms as acute hepatitis
  • immune serum globulin should not be administered for occupational exposures
  • monitor with HCV RNA polymerase chain reaction tests
  • use immunomodulators to treat (Lautenbach, p. 324)

HIV measures

  • follow antiretroviral regime for post-exposure prophylaxis
  • Serology test at time of exposure
  • follow up testing at 6 weeks, 3 months and 6 months post-exposure (Lautenbach, p.327)
  • 1 year follow up testing post-exposure, varies on institution

3. Discuss the difference between active and passive sharps injury prevention devices. Give examples of each. Give examples of work practice modifications that reduce the risk of exposure to blood-borne pathogens.

Active sharps injury prevention devices:   Active devices require one- or two-handed activation by the healthcare professional after use (Stankovic, 2011). eg needle protection sheiths that need to be pushed over the needle post-use

Passive sharps injury prevention devices: do not require additional steps to initiate the safety mechanism since it activates automatically during device use (Stankovic, 2011). eg. insulin or subcut butterfly sheiths that automatically sheith the lance.

examples of practice modifications that reduce risk of exposure:

  • using needless systems for subcut medication administration
  • standard precautions so that health care workers hands have a barrier between them and open wounds/areas
  • use of face shields to prevent spash/spray exposure.
  • staff educational programs(CDC, 2008, p. 12)
  • avoidance of recapping and safe needle disposal systems (CDC, 2008, p. 12)
  • Using alternate routes for medication delivery and vaccination when available and safe for patient care(CDC, 2008, p. 13)
  • specimen collection systems that consolidate and eliminate unnecessary punctures(CDC, 2008, p. 12)

4. After reading the article on human factors engineering in the link below, please give your own unique examples of how this approach could be used to prevent injuries and enhance task performance. (Human factors engineering article from WHO: http://www.who/int/patientsafety/education/curriculum/who_mc_topic-2.pdf )

Human factors help improve safety in areas such as

  • safe prescribing practices
  • team communication
  • information handover in between healthcare team members (WHO, date unknown)

 

  • “Human factors recognize that the workplace needs to be designed and organized to minimize the likelihood of errors occurring and the impact of errors when they do occur. While we cannot eliminate human fallibility, we can act to moderate and limit the risks.” (WHO, unknown)
  • eg IV umps that require certain rate to function and beep to inform user if air is in the line
  • “The fact that we can misperceive situations despite the best of intentions is one of the main reasons that our decisions and actions can be flawed, resulting in making “silly” mistakes—regardless of experience level, intelligence, motivation or vigilance.” (WHO, unknown)

  • eg routines like OR swab and instrument counts before and after surgery prevent a swab or instrument being left in the patient.

5. Describe the “bundles” or Class A (Strong evidence) recommendations to prevent central line associated infections. (Central line-associated bloodstream infections. http://www.apic.org/Resources/Topic-specific-infection-prevention/Central-line-associated-bloodstream-infections)

 

References:

1. Lautenbach

2. BCCDC. (2016). Blood and Body Fluid Exposure Management. http://www.bccdc.ca/resource-gallery/Documents/Guidelines%20and%20Forms/Guidelines%20and%20Manuals/Epid/CD%20Manual/Chapter%201%20-%20CDC/CPS_CDManual_BBFExpManage.pdf

3. Stankovic, Ana. (2011). Porotection against needlestick injuries: active or passive safety. https://www.mlo-online.com/protection-against-needlestick-injuries-active-or-passive-safety.php

4. CDC. (2008). Workbook for designing, implementing and evaluating a sharps injury prevention program. https://www.cdc.gov/sharpssafety/pdf/sharpsworkbook_2008.pdf

5.WHO.  Human factors engineering. http://www.who/int/patientsafety/education/curriculum/who_mc_topic-2.pdf