Infection Prevention and Control

Description: “Infection Prevention and Control” contains guidance relating to implications for the infrastructure of infection, prevention and control for norms and standards for all categories of healthcare facilities. It is to be read in conjunction with the full norms and standards suite and covers policy and service context (Part A). IPC principles (Part B), definitions of terms (Part C) and references (Part D). Reference: CSIR 59C1119 E:09 Authors: IUSS Norms and Standards Task Team E:09 Stakeholders: Endorsements: The article is endorsed by the CSIR. Endorsements pending: Submitted to the IUSS Norms and Standards Working Group for endorsement. Supersedes: N/A

Context

Healthcare facilities frequently become focal points for the transmission of communicable diseases because they bring infectious and susceptible individuals together. International research suggests that about 10% of hospital admissions result in healthcare-associated infections, which were neither present nor incubating at the time of admission. A surveillance study in developing countries conducted by the International Nosocomial Infection Control Consortium (INICC) between 2003 and 2008 revealed an unadjusted excess mortality rate from device-related infection at between 23% and 29% (Rosenthal et al., 2010).

Healthcare workers are at higher exposure to infection risk through, for example, occupationally acquired tuberculosis (TB) and needle-stick injuries when compared to the background population. In South Africa, there is a scarcity of data on the prevalence of healthcare-associated infection, but general studies show that these figures are higher in developing countries (Rosenthal et al., 2010).

The discipline of infection prevention and control (IPC) has several implications for the design and engineering of the built environment. These implications affect the enabling of standard precautions and infection control practices (such as the provision of hand basins etc.) and air quality control (for airborne infection), cohort arrangements (spatial separations) and material selection and detailing.

In healthcare facilities, IPC has been recognised as a healthcare priority and is described in subsection 2.6 of the National core standards for health establishments in South Africa (South Africa, 2011).

IPC practices must be tailored to the individual facility and should be determined upfront during the design development process while being proactively addressed using an evidence-based body of knowledge. Late or retrospective consideration of IPC may result in less effective solutions, increased exposure to risk, and additional expense.

The objective of this document is to provide guidance related to the following:

• Facilities, equipment and procedures to address standard precautions and transmission-based measures • Curtailing cross-infection to all building users, including healthcare workers, patients and visitors • Infection control practices in special situations

This document is intended for use by persons compiling clinical briefs for building projects, for built environment professionals and for authors of infection control policies at the facility. The importance of proactive collaboration between the infection control teams, the built environment professionals and clinical service planners in developing the facility design brief and commissioning plans cannot be over-stressed. If the infection control team is not proactively involved in the earliest facility planning stages, a critical opportunity to add value will be lost.

Principles of healthcare-associated infection

Chain of infection

Infection is the result of contact between a viable infectious agent and a susceptible host under a suitable environment. The ability of the infectious agent to infect the host is dependent on the following characteristics of the agent:

• Viability • Virulence • Pathogenicity • Dose • Infectivity

A chain of infection involves a series of essential interdependent elements that must be in place for any transmission and infection to occur. Breaking this chain of infection at any point is generally the most effective method for preventing healthcare-associated infections

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  Chain of Infection

The infectious agent is the pathogen that causes disease.
A reservoir is a place where the agent can survive, for example, infected hosts or contaminated equipment.
Portal of exit is the path by which the agent leaves the reservoir, for example, gastrointestinal tract, respiratory tract.
Portal of entry is the path by which the agent enters the host, for example, gastrointestinal tract, respiratory tract and skin/mucous membranes.
Mode of transmission is the method by which the agent travels between the portals of exit and entry.

Modes of transmission

Contact transmission

Contact transmission is the most frequent form of transmission of healthcare-associated infection internationally. It can be divided into three groups, namely direct contact transmission, indirect contact transmission and droplet spread.

Direct contact transmission occurs when the physical transmission of pathogens is transferred when direct surface-of-body to surface-of-body contact occurs between a susceptible host and an infected person. This can happen when a nurse handles a patient in the course of her duties or even through patient-to-patient contact.

Indirect contact transmission is similar to direct contact transmission with the additional involvement of an intermediate object. Such an object could include medical equipment or building elements.

Droplet transmission occurs when droplets are generated and ejected from an infected host through talking, sneezing or coughing. When these droplets have sufficient size and mass, they retain their ability to carry viable pathogens to a susceptible host, but the mass of these particles normally limits the distance they can travel to less than approximately 1 m. When these droplets settle on a suitable site on a susceptible host, the host can be infected. Certain pathogens are limited to this type of transmission, as they do not remain viable on smaller particles such as droplet nuclei.

Airborne transmission

When particles expelled from an infected host are so tiny that they evaporate leaving a droplet nuclei (<5µm) containing pathogens, these pathogens can be carried about on air currents. These may remain airborne for hours, which allows them to travel long distances from the infectious host. When inhaled, viable organisms embedded in the droplet nuclei may cause infection.

TB is of primary concern in South Africa. Together with HIV/Aids, it is the greatest cause of morbidity in adults. In South Africa, it is also the fourth highest cause of death in infants and has caused an average life expectancy reduction of 10 years within the last 10 years. Drug-resistant strains of TB can also be contracted by inhalation of viable droplet nuclei. These strains are more expensive and difficult to treat than susceptible strains with poorer outcomes. TB is exclusively spread by airborne transmission. Other airborne diseases include chicken pox (varicella) and measles (rubella).

Vector transmission

Vector-borne diseases play a minor role in healthcare-associated infections and require the assistance of vectors such as rats, mosquitos and flies to transmit microorganisms. Transmission can be through simple contact with a contaminated vector or its waste. Vectors can also transmit micro-organisms through actual penetration of the skin or other membranes by bites or burrowing.

Vehicle transmission

Vehicle transmission occurs when pathogens are transmitted by contaminated sources such as food, water, medication or equipment. Vehicle transmission relies on the mechanisms described under contact transmission.

Overview

Infection control practices can be categorised into two categories. The first category is standard precautions, which must be applied at all times. The second category is additional transmission-based controls where, by virtue of particular circumstances, such as patient diagnosis, infectiousness, vulnerability profiles of susceptible individuals or epidemiological factors, additional precautions are indicated.

IPC is practised in a systematic, hierarchical bundle, where combinations of evidenced-based mitigation measures are taken in order to address risk. While the principles may remain the same, the actual mitigation measures would differ between service type and agent risk under consideration.

Standard precautions

Standard precautions include administrative, environmental (engineering) and personal protective controls as described in the elements listed below.

Infection control programme

The facility should develop an IPC policy that is consistent with the national core standards for health establishments in South Africa, as amended (South Africa, 2011). The elements of such a programme should include the following: • A surveillance plan that identifies critical control points, monitoring intervals and acceptance limits • A responsibility matrix that identifies staff, teams, responsibilities, requisite skills, required training and training plans • The identification of available products and services that are essential for maintaining safety and hygiene and determine usage volumes • Associated protocols for surveillance, training, hygiene and safety.

The infection control committee and teams

According to the infection prevention control policy of South Africa, all healthcare facilities should have an IPC focal person. It is recommended that an infection control committee (ICC) be established in each healthcare facility to facilitate multidisciplinary input and provide resources to the infection control team (ICT). The ICC membership should reflect the spectrum of clinical and administrative services being offered at that facility. The committee should ideally include a microbiologist, an infection control nurse and doctor, an occupational health practitioner, representatives from major clinical specialities, and maintenance, administrative and representatives from other departments as deemed necessary. The ICC is responsible for ensuring that the facility has a facility-specific, coherent IPC plan that aligns with the national strategy and that this plan is documented and maintained in the IPC manual.

The ICC should hold regular meetings in which minutes are kept. These minutes should be copied to the facility’s management committee, as well as any departments directly involved in the proceedings and discussions of the meetings.

The ICTs are responsible for the day-to-day running of the IPC programmes and should consist of at least one physician, one microbiologist and one infection control officer. Each facility should have at least one ICT that is accessible for infection control advice on a 24-hour basis. The ICT should meet regularly enough to discuss daily incidents and issues and should have a standing agenda to discuss IPC surveillance, policy and practice, communication and training, and problems. Minutes should be prepared for these meetings and kept on file. The ICT is responsible for updating and maintaining the IPC manual with approval from the ICC.

Hand hygiene

Hand hygiene is a highly effective method for combating direct and indirect contact transmission. Hand hygiene is performed by washing hands with soap and water or by rubbing the hands with an antimicrobial agent. The World Health Organization recommends a 75% volume/volume (v/v) isopropanol or 80% v/v ethanol low-viscosity hand rub (World Health Organization, 2010). The adoption of alternative solutions, such as gels and foams, will require evidence of efficacy or thorough validation.

In facilities where the use of existing hand basins are replaced by alcohol hand rubs, the increased risk of legionella breeding in and spreading from disused hand basins needs to be mitigated.

Clinical hand basins have the following requirements:

• Low-flow aerosolising faucets are not allowed, as these promote the droplet spread of possible waterborne pathogens like legionella. • Elbow-operated taps are preferable over electronically activated taps as the latter presents additional maintenance and reliability issues and unit failure could result in the failure of the hand hygiene programme. • Water stream from faucets should not fall directly into the waste outlet in order to prevent the possible aerosolisation of pathogens residing in the waste outlet. • Hand basins should not include waste overflows, as these provide an additional risk for aerosolisation of pathogens breeding in the waste pipes.

The reader is referred to the IUSS: GNS Building Engineering Services and the IUSS: GNS Generic Room Requirements guidance documents for additional information.

Aseptic techniques

Aseptic techniques can make special demands on facility and space planning. An example of this is the scrub procedure of surgical staff and movement protocol between the scrub room and the operating theatre. In this instance, scrub team clasp their hands and raise their elbows as they move into the theatre to prevent contamination after scrubbing. This action would be hindered by conventional doors, door mechanisms and door sizes. Sliding doors and wider openings need to be considered in this instance.

The reader is referred to the IUSS: GNS Facilities for Surgical Procedures and the IUSS: GNS Generic Room Requirements guidance documents for further information.

Barrier nursing

When nursing care is given to patients who are suffering from highly infectious diseases, are severely immuno-compromised or highly susceptible to infection, barrier nursing techniques are used. Nursing staff use agent-appropriate masks, respirators, gowns and gloves to provide the requisite protection. In addition, barrier nursing may require containment or protective isolation facilities. Barrier nursing can combat contact and airborne transmission. For additional information on the requirements on facilities for barrier nursing and isolation, the reader is referred to the IUSS: GNS Adult Inpatient Services guidance document.

Housekeeping and cleaning

Cleaning, disinfection and sterilisation are central to any successful IPC plan. This holds true for facilities cleaning, hand hygiene and instrument sterilisation.

Environmental surfaces, such as those in patient-rooms and theatres, are classified as ‘non-critical’ according to the Spaulding system, which classifies objects based on their ability to spread infection. This classification is applicable to medical devices but does not imply that these surfaces should not be subject to hygienic design principles and rigorous cleaning, even though they may not require regular disinfection. However, high-touch areas should be identified and these should be decontaminated regularly to prevent contact transmission. These surfaces should be durable and resilient to the available cleaning, disinfection and sterilisation methods and chemicals employed.

The safety and efficacy of disinfectants and detergents must be established before they are adopted for use. Material safety data sheets must be available and reviewed for all cleaning materials. Special precautions and protocols must be adopted, maintained and monitored where required. Appropriate and available disinfectants and detergents should be identified, reviewed, quantified, budgeted for and documented in the IPC manual.

Disposal of waste disinfectants and detergents should be in accordance with the national regulations and the IUSS: GNS Waste Disposal and the IUSS: GNS Decommissioning guidance documents.

Materials and finishes

The primary concern relating to materials and finishes in combating contact transmission is that these should be selected and installed so that they are cleanable, durable, non-particle-liberating and impervious in clinical areas. Material selection for IPC should be limited to settings that warrant it. For example, antimicrobial surfaces can be used on high-touch areas of general patient areas (for example, door handles) and all surfaces in burn units.

For more information on this extensive and complex subject, the reader is referred to the IUSS: GNS Materials and Finishes guidance document.

Waste management

For information on IPC-related topics, such as sharps disposal, spill management, equipment, and material handling and classification, the reader is referred to the IUSS: GNS Waste Disposal and IUS: GNS Decommissioning guidance documents.

Personal protective equipment

The following personal protective equipment (PPE) should be considered with standard precautions against contact and airborne transmission:

• Gloves • Caps • Gowns • Masks • Respirators • Overshoes (critical areas)

In their designs, facility designers should make provision for the secure storage consumables, the appropriate day-to-day access to consumables and their routine disposal and/or decontamination. These items should be identified, reviewed, quantified, budgeted for and documented in the IPC manual.

Zones

Healthcare facilities can consist of zones of varying risk of infection transmission. These areas can be described as non-critical, critical or aseptic. Environmental IPC in these areas may be achieved through the implementation of primary and/or secondary protective barriers.

In order to identify these areas and their associated risks and protocols to staff, patients and visitors, the colour-coding of building elements should be implemented, and clear signage should be included. For areas of exceptional infection risk, access control systems should be implemented.

High-risk areas

Areas presenting a high risk of infection transmission include, but are not limited to the following: