LONG-TERM OUTCOMES OF ICU PATIENTS
IV. INFECTION CONTROL AND THE ICU
A. Background: As noted above, hospital-acquired infection (HAI) is a potentially
preventable, serious complication in ICU patients. These are associated with statistically significant worsening of important ICU quality measures, including morbidity, mortality, length of stay, and costs of care. An important element of delivering quality care is prevention of these infections and further transmission.
B. Transmission. Transmission of infection requires three elements: a source or reservoir of infectious agents, a susceptible host with a portal of entry the infectious agent can access, and a mode of transmission for the agent. Patients admitted to the ICU are at particular
risk for the acquisition of new infections while in the hospital. Critical illness itself increases susceptibility to new infections due to “immune paralysis” secondary to
lymphocyte depletion and down-regulation of adaptive immunity. Additionally, many ICU patients have underlying risk factors for infection, such as extremes of age, diabetes, malignancy, and drug-induced immunosuppression. Medications delivered in the ICU such as antibiotics, gastric acid suppressants, and corticosteroids alter the patient’s normal microbial flora and responses to microbes. Lastly, many devices used to monitor or treat patients breach the natural barriers to infection, including skin and mucosal surfaces, creating ports of entry for infectious agents. The source of the infectious agent transmission is usually other people (health care workers, other patients, visitors, etc.).
Health care providers are regularly exposed to multiple sources of infection; hence, strict hygiene is paramount, as described below. Physical elements of the hospital environment may also participate in the transmission of infections and are minimized by contemporary methods of room cleaning and disinfection.
C. Standard Precautions
1. Background. Standard infectious precautions should be used with all patient
interactions. They are based on the principle that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain transmissible infectious agents.
2. Standard precautions include the following:
a. Hand hygiene: Use of alcohol-based products or washing with soap or water after any contact with body fluids, after removing gloves, and between all patient contacts (that is, before entering and upon exiting each patient’s room).
b. Personal protective equipment (PPE)
1. Nonsterile gloves: When touching body fluids, any mucous membrane, or nonintact skin
2. Nonsterile gown: Wear a single-use impermeable gown during procedures and during any patient interaction in which clothing or exposed skin may contact patient body fluids, mucous membranes, or nonintact skin.
3. Mask, eye protection (goggles), or face shield: Wear during procedures and patient care activities that may generate a splash or spray of blood, body fluid, secretion, or excretion.
3. Environmental surfaces and devices: Soiled patient care equipment is handled with gloves or other PPE until appropriately discarded or cleaned, followed by hand hygiene. Environmental surfaces are routinely cleaned and disinfected. Laundry and textiles are handled to prevent transmission of infection.
4. Sharps injury prevention
a. Background: Injuries from needles and other sharps have been associated with the transmission of HBV, HCV, and HIV to health care providers. Direct costs associated with sharp injuries range from $71 to $5,000 per incident. Six devices cause nearly 80% of injuries: disposable syringes, suture needles, winged steel needles, scalpel blades, IV catheter stylets, and phlebotomy needles. In one study, 56% of sharp injuries occur with hollow bore needles, which are associated with the highest likelihood of HIV transmission to health care workers. Safe handling of these devices is an essential element of standard
precautions. Hospital sharp injury prevention programs typically include a well- defined process for reporting sharps injuries as well as providing evaluation and potential infection prophylaxis for health care workers following a sharp injury.
Education and intervention should be targeted to areas with prior incidents as well as those at high risk (e.g., emergency and operating rooms).
b. Injury prevention strategies
1. Use needleless systems and devices when able.
2. Use needles and sharps engineered with safety devices.
3. During procedures,
a. the user of the sharp should be in control of its location and ensure that others are aware a sharp is in use
b. use instruments, not fingers, to grasp needles, retract tissues, and load/unload needles and scalpels
c. do not directly pass sharps to another person; instead pass through a preidentified neutral zone
4. Avoid recapping needles and if necessary do so using a one-handed technique.
5. Avoid leaving sharps with sharp end exposed.
c. Ensure all sharps are appropriately disposed of immediately in designated and marked disposal containers.
D. Transmission-Based Precautions: These precautions are utilized when a specific infectious etiology is known or suspected. They are based on how that microorganism may be transmitted. They are used, singly or in combination, in addition to standard precautions.
1. Contact transmission and precautions:
a. Contact transmission can be separated into two types:
1. Direct contract transmission occurs when microorganisms are transferred from one infected person to another, without an intermediate object or person. It includes passage of infectious agents through blood or body fluid that contacts mucous membranes or nonintact skin or transfer from skin to skin.
2. Indirect contact transmission involves transfer of an infectious agent using another person or object as an intermediary. It includes transfer by
nondisinfected hands of health care professionals, common patient care devices or toys, or improperly sterilized surgical equipment.
b. Contact precautions are utilized with a variety of conditions that are usually spread via direct contact transmission. These include infectious agents such as MRSA, RSV, parainfluenza, lice, rotavirus, vancomycin-resistant enterococcus and Clostridium difficile. They are also utilized with wound drainage or other excessive amounts of body fluid.
c. Health care professionals should wear gown and gloves with all interactions with patients on contact precautions to prevent exposure from patients or their environment.
d. Patients should be placed in single rooms or cohorted with other patients infected with the same microorganism.
2. Droplet transmission and precautions. Microorganisms that are transferred by droplet transmission travel in droplets directly from the infected person’s respiratory tract to another person’s susceptible mucosal surfaces over short distances (approx. 3 ft). They may also be transferred by contact transmission.
a. Infectious agents transmitted by droplet include Bordatella pertussis, influenza virus, adenovirus, rhinovirus, Mycoplasma pneumonia, group A strep, and Neisseria meningitidis.
b. Health care professionals should wear a mask, usually in addition to contact precaution gear, when interacting with patients on droplet precautions.
c. Patients should be placed in private rooms and wear masks when outside the room.
3. Airborne transmission and precautions: Airborne transmission occurs by airborne droplet nuclei and small particles that remain infective over time and distance. They may traverse large distances and infect people who have not been in the same room with the patient.
a. Infectious agents transmitted by the airborne route include Mycobacterium tuberculosis, Varicella zoster, and rubeola.
b. Health care professionals should wear an N95 mask or respirator during all interactions with the patient.
c. The patient should be placed in a private isolation room with special ventilator capacity (“negative pressure room”) that allows 12 air exchanges per hour. The patient should wear a mask whenever out of the isolation room.
E. Infection Control Surveillance Programs
1. It is essential for ICUs to have real-time tracking of hospital-acquired infections to prevent further morbidity and mortality. A close working relationship with the hospital’s infection control staff is very helpful.
2. Weekly or monthly reports should be displayed for staff to promote accountability and a culture of safety. Practices adopted from industry such as prominent displays of
“weeks from last infection,” for example, are effective and increasingly popular.
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I. INTRODUCTION
In caring for critically ill patients, it is inevitable that ethical issues will arise. Patients often have complex medical conditions, multiple providers, and uncertain prognosis or treatment plans. This can lead to conflict and moral distress among patients, family, health care
providers, and support staff. We describe a proactive approach to ethical issues in the ICU.
Adoption and adaptation of these measures may help minimize conflict and moral distress.
Key ethical concepts and practical guidelines are provided in order to optimize care in a variety of circumstances in which ethical tensions may arise because of conflicts over values or decision-making authority. It is hoped that you will build trust and connect with your patients and their families through empathy, seeking to understand them, confronting (rather than avoiding) problems, managing expectations well, and providing optimal clinical care.