INFECTION CONTROL
Homes, as
well as hospitals, have got to maintain strict practices if infection of the
patient or the caregivers is to be avoided. This brief presentation cannot cover
all important aspects of infection control, but it should help you understand
the major issues.
The
basic elements of infection are viruses, bacteria, and fungi (yeast, etc.). Viruses are not quite alive, but they
capture the mechanisms of a cell to enable themselves to be replicated, often
damaging the host; flu and HIV viruses are familiar. Bacteria are
single-celled organisms that can replicate on their own but use the host to
enhance their growth; gastro-intestinal ailments and skin wound infections are
typically due to bacteria. Fungi are single-celled or multi-celled
organisms that, like bacteria, feed off the host; they spread by producing
spores; “yeast” infections are due to fungi.
A systematic approach to infection
control looks at the following items:
Sources: Infected people
are the major hazard. Post notices that people with colds should not come
in the house or the room. That includes nurses, unless they are wearing
respiratory equipment, not just masks, but equipment that completely filters
what they exhale (e.g., through a HEPA filter, a High-Efficiency
Particulate Air filter, an “absolute filter” 99.9+% efficient). Face masks
allow leakage around the edges in contact with the skin and are usually made of
low-efficiency filter material. They do prevent spit from speaking or coughing
from becoming airborne. Unfortunately, the patient may come home from the
hospital with an infection (“nosocomial” or “iatrogenic”), perhaps “colonized,”
quite possibly a danger to the staff and family.
Transmission: Coughing,
talking, sneezing, as well as shedding from exposed skin, make the organisms
airborne, allowing them to travel to the patient, unless the patient is
breathing air which is filtered by an absolute filter. Direct surface contact occurs when the
patient is touched by someone who is contaminated. Indirect surface contact occurs
when a contaminated person touches a surface that is subsequently touched by
the patient or by someone who touches the patient. Instruments brought
into contact with the patient can carry infectious agents (“germs”), which are
particularly dangerous when the skin is broken, or the probe goes inside the
body. Food and drink and medicines can bring dangerous biological
agents, as well, although the stomach is not sterile, and its acidity generally
handles the destruction of most organisms without allowing illness.
Barriers: For airborne
transmission, one can try to direct clean air toward the patient and
against the flow of contaminated air; pharmaceutical and microelectronics
manufacturing cleanrooms are kept at higher pressures than their
environments, and the pressure in a ventilator mask can be set so as not to
become a slight vacuum when the patient inhales, so that it is always at a
“positive pressure” with respect to the air in the room. Contact
transmission from caregivers and others is reduced using disposable
gloves, which themselves must be kept clean or replaced frequently.
Sometimes, a second pair is worn over the first, so that a change can be made
readily when the outer pair become contaminated. Caregivers and visitors should
wash their hands thoroughly before and after coming in contact with the
patient, preferably with an antibacterial soap. Ideally, objects brought into
contact with the patient would be clean and sterile, but in practice those
objects making external contact are cleaned and disinfected (e.g.,
with alcohol/water or vinegar/water solutions), rather than sterilized (e.g.,
with bleach or iodine solutions or submersion in boiling water), which is appropriate
for internal contact or contact with broken skin. Wounds and sores are protected with
antibiotic ointments or petroleum jelly and with impermeable coverings such
as bandages, except where exposure to the air through a gauze dressing is
prescribed instead.
Removal: Although little can be
done to remove airborne agents once inhaled, those that settle on the skin
can be removed with washing and disinfecting or even using sterilizing
solutions. Where cuts are involved, the value of sterility may be offset by
the possible chemical harshness of a sterilizing agent, leading to the use
instead of various “antibacterial” solutions that include soap and
anti-microbial chemicals, or simply soap, or an alcohol/water solution and
rubbing with the fabric containing it. Harmful chemicals that are ingested are
sometimes removed by encouraging vomiting, using an emetic liquid, but one
rarely knows that a liquid with dangerous germs has recently been ingested.
Hardening the target: To make the patient
less susceptible to infection is a major goal of the maintenance of
general good health, including optimal nutrition and adequate sleep. Viral
infections must be defeated by the patient; vaccinations help prepare
the immune system for this battle. For the elderly, however, flu shots are
often only 50% efficient, and for younger people only somewhat better. We
require our nurses to get vaccinated against the flu, as do the patients and
the family.
Remedy: If the patient becomes
ill, the causal organism is determined, and medicine prescribed, if
available. As noted, little can be done about most viruses once they
are active, except to maintain the patient’s general health. For a urinary
tract infection, a common ailment in chronic illness situations, a urine
sample is taken and tested against available drugs, a “culture and
sensitivity” test, which will indicate to which antibiotics the organism is
“sensitive,” meaning susceptible. Secretions from the lung, sputum, can
be analyzed similarly for the same purpose. An infected wound will be treated
by a broad-spectrum antibiotic cream or ointment, often after receiving wiping
with a disinfectant or a sterilizing agent in a pad. These infections can lead
to more general, systemic, infections which must be caught
immediately (by noting elevated temperature, pulse rate, respiration rate) and
treated with antibiotics, administered orally, by gastric tube, intravenously,
or by intra-muscular injections, as ordered by the doctor.
CONTAMINATION CONTROL
The considerations for contamination
control are like those for infection control, except that it would be
unusual for a contaminating chemical to reach the patient in a dose large
enough to cause illness. Sources need to be identified and eliminated or
minimized. Transmission through the air is prevented using clean air
flowing toward the source rather than from it or using filters, filtered air
supply, and facemasks for the patient and caregivers. Face masks
generally will reduce the inhaled concentration of airborne solids and liquids
(aerosols) but not eliminate them and rarely are they effective on toxic
gases, should any be present.
Spills of liquids and powders
need to be cleaned up carefully and thoroughly. A spill should be absorbed in a
wiper that is then discarded; next, the area is rinsed with clean water, and
that water absorbed, and that wiper discarded, too. Wipe from the cleanest toward
the dirtiest, from the driest toward the wettest. Gloves should be used. Using
a damp wipe on the patient’s skin will transfer some skin oils and salts
from caregiver to patient, unless the wipe is held in a glove. Liquids or
powders spilled onto the floor represent a hazard from reduced traction for
the staff, leading to slips and falls. Even a dry cloth or paper on the floor
can represent a hazard; we lost a nurse for three months after she slipped on a
dryer anti-static sheet in our laundry room. [She should not have dropped it,
should have picked it up, should have not stepped on it, but “should” doesn’t
mean “didn’t.”]
Removal of contaminants from the
patient is normally done with soap and water or alcohol and water, again with a
gloved hand holding a clean, damp wipe. Removal is completed when the surface
is wiped dry.
HIPAA CONTROL
This section alerts you to the risk of
running afoul of the Federal Health Information Portability and Accountability
Act of 1996, HIPAA. Basically, you want to keep medical information
confidential. Grant (2014) describes the mechanisms necessary to achieve
and maintain compliance. He represents a company that offers services of this
kind: The Compliancy Group, LLC. “LLC” for “Limited Liability Corporation”
means they have taken steps to incorporate and limit their liability, just in
case. In case of what? In case someone takes their advice, gets in trouble with
the Feds, and tries to blame Grant and Group. They offer The Guard, to control
the audit process: “regulatory review, risk analysis, risk management, document
management, and incident management.” You can contact them at info@compliancygroup.com.
A homeowner is not likely to need the
Group’s services but is well advised to keep the medical information of the
patient restricted to those with what the government calls “need to know.” The
doctors treating the patient will likely want the protection of signed
acknowledgment of their HIPAA policies, restrictions, and practices designed to
safeguard patient information.
The
seriousness of these HIPAA issues is reflected in the costs of the ebooks on
the topic at Amazon. The first 15 in terms of relevance ranged from $1 to $430,
with half costing $25 or more.
The
manager of nursing care at home should assure that sensitive information is not
stored on computers connected to the Internet and that paper copies be
carefully handled to prevent theft or loss.
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
Our book is available from amazon.com, bn.com, and OutskirtsPress.com: How to Manage Nursing Care at Home
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