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Infection prevention and control core practices: A roadmap for nursing practice
BY RUTH M. CARRICO, PhD, DNP, FSHEA, CIC; HUDSON GARRETT, PhD, MPH, FNP-BC; DAWN BALCOM, DNP, APRN; AND JANET BURTON GLOWICZ, PhD, RN, MPH, CIC, FAPIC
FOR THE SIXTEENTH year in a row, nurses have been recognized as the most trust-ed profession in the United
States.1 The value of ethics and in-tegrity continue to be recognized and appreciated by those we serve—our patients and their fami-lies. It’s our responsibility to provide and perform care that adheres to best practice evidence consistently and reliably. One area where care must consistently align with best practice is infection prevention and control. This article discusses guide-lines and best practices promoted by the Nursing Infection Control Edu-cation Network and the CDC Healthcare Infection Control Prac-tices Advisory Committee to im-prove antibiotic stewardship, reduce microbial transmission, and prevent
the spread of infection in any healthcare setting.
Increased resistance The CDC continues to stress the ur-gent issue of increasing microbial resistance to the few remaining drugs available to treat them.2 It recently joined forces with the American Nurses Association (ANA) to bring awareness to this issue through an approach that prevents inappropriate antibiotic use and stresses infection prevention. By preventing infection, the use of antibiotics may be unnec-essary thereby reducing opportuni-ties for the development of drug resistance.
A partnership between the CDC, ANA, and 20 professional nursing organizations has resulted in the Nursing Infection Control Education
Network.3 Its goal is to improve adherence to infection pre vention practices through enhanced infection prevention and control training. Suc-cess involves using core practices that prevent movement of microor-ganisms between patients, healthcare providers, and the environment to avert transmission of microorganisms and ultimately prevent infection.
Nursing implications In 2014, members of the CDC Healthcare Infection Control Prac-tices Advisory Committee began summarizing the core practices iden-tified as critical for the prevention of infection associated with healthcare. These practices, described in 16 cur-rent CDC guidelines, are relevant to care provided by healthcare providers in any healthcare setting. Following
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extensive review, the Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings was published in 2017.4 It’s orga-nized into eight distinct, yet inter-related, infection prevention and control domains (see Categories of core practices).4 The first four relate to the organizational infrastructure needed to sustain successful implementation of the core practices. These underly-ing elements include: 1. leadership support 2. education and training of healthcare personnel on infection prevention 3. patient, family, and caregiver education 4. performance monitoring and feedback.
Action-oriented core practices that are applicable to nurses and all health-care providers in all settings include: 5. standard precautions 6. transmission-based precautions 7. use of temporary invasive medical devices 8. occupational health.
Each of these domains is described below with specific implications for nursing practice.
Core practices Leadership support. Senior nursing leaders, along with other organization leaders, must ensure that the health-care organization provides sufficient resources to enable frontline personnel to consistently adhere to infection pre-vention practices. They should also ensure that personnel charged with implementing an infection prevention program are appropriately educated with infection prevention–specific education. These individuals need the support of leaders to empower them with the authority that ensures the program’s effectiveness.5-16
Leadership doesn’t come only from the executive level; it should be evident in the practice of all nurses and demonstrated through the care they provide. Nurses must be em-powered to act and respond to the
needs of patients and lead change among coworkers and other team members. It’s the nurse’s responsibil-ity to include leadership development in his or her individual performance development plan and take steps to achieve that goal.5-16
Education and training of health-care personnel on infection preven-tion. Assessment of areas of practice where performance doesn’t meet expectations should be targeted for improvement and then be part of every nurse’s professional develop-ment plan. The nurse must have knowledge regarding specific practice issues, but more important, the nurse must be able to apply that knowl-edge, think critically to address both the expected and unexpected, and perform with consistent practice ex-cellence regardless of where care is delivered.5-8,10-12,14-17 Competence is defined as the ability to apply knowl-edge in practice, and specific compe-tencies focusing on hospital-based healthcare workers have been pro-posed and can be used to form a basis for a facility education and training program emphasizing infection prevention.18
Patient, family, and caregiver education. Preventing infection re-quires engagement of patients, their families, and caregivers, as well as other healthcare providers. Patients must be empowered and enabled to perform self-care in a way that mini-mizes preventable harm. Often they rely on family members and others for assistance. Patient and caregiver engagement includes sharing infor-mation, assessing their ability to per-form desired tasks, ensuring they have the ability to perform those tasks, evaluating that performance, and providing feedback regarding improvement. Information and train-ing methods must recognize language and health literacy capabilities and barriers.
One activity central to preventing transmission of infection is hand
hygiene. Teaching patients to cleanse their hands properly and enabling family members to help them perform this task can help pre-vent environmental contamination or movement of microorganisms from the environment to their loved
6-9,11,12,14,15ones. Performance monitoring and
feedback. A primary goal of per-formance evaluation is to enable improvement by identifying areas of strength and weakness. Without objective and informative data, it’s difficult to improve performance in patient care. Nurses must be actively engaged in monitoring their perfor-mance at all levels. Checklists, obser-vations, collaborative rounds, and timely feedback to the care team are examples of activities critical to improvement strategies.5-17,19
Standard precautions. These foundational practices prevent the movement of pathogens during the course of care. Nurses who are using standard precautions appropriately assume that all patients may be in-fected with an organism that could be spread in the healthcare setting. Emphasis on bloodborne pathogens by the Occupational Safety and Health Administration (OSHA) Blood borne Pathogens Standard may result in the belief that standard pre-cautions involve only certain body fluids. In fact, standard precautions involve recognizing that patients and the healthcare environment may be reservoirs of infectious organisms. Implementation of standard precau-tions involves recognition of these risks and the steps needed to pre-vent movement of those organisms. Essential elements of standard precautions include: • hand hygiene • environmental cleaning and disin-fection • injection and medication safety • risk assessment with appropriate use of personal protective equipment (PPE)
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• minimizing potential exposures • reprocessing of reusable medical equipment.20
Microorganisms are present in the patient-care environment, and blood-borne pathogens such as HIV and hepatitis B and C viruses may persist in the blood and body fluids of asymp-tomatic patients. As part of our rou-tine practice, we must have strategies that keep us from coming into un-protected contact with a patient’s body fluids, not just those patients we’ve previously recognized as potentially infectious.21 We want to avoid any opportunity for pathogen movement that may ultimately cause illness in ourselves or transmission to the patient, family, or visitors.
Hand hygiene. Despite the empha-sis on providing care with clean hands, the evidence continues to demonstrate that we think we clean our hands more often than we actu-ally do. Hand hygiene can be per-formed with a soap-and-water hand wash or an alcohol-based hand rub. The CDC and the World Health Or-ganization have published guidelines that define proper hand hygiene.7,22
It’s important to understand who per-forms hand hygiene, when it should be performed, how it should be per-formed, under what conditions, and with which products so that no pa-tient is touched by a nurse or any member of the care team whose hands haven’t been properly cleansed. Nurs-es must be able to recognize risk for cross-contamination, such as when the nurse moves from a dirty or con-taminated patient-care task to a clean patient-care task, and when moving between patient-care touches and touches involving the care environ-ment. Nurses must ensure that no interaction with patients is per-formed by someone whose hands could transmit organisms to them, the equipment used in their care, medication administered to them, or the environment that surrounds them. Protecting patient safety may
require nurses to intervene before other healthcare personnel touch a patient without performing proper hand hygiene or when there’s move-ment between environmental surfaces or objects that may be contaminated, without the necessary performance of hand hygiene.
Environmental cleaning and disinfec-tion. The clinical care environment is a key component in enabling or facili-tating transmission of pathogens. When touched, contaminated envi-ronmental items and surfaces con-taminate the hands of nurses and other healthcare personnel. They can then move microorganisms to pa-tients, other surfaces or items, and other nurses. Surfaces, furniture, and equipment in patient rooms must be regularly cleaned and disinfected us-ing agents approved by the Environ-mental Protection Agency for use in healthcare settings.17 This includes paying attention to all monitoring equipment such as blood glucose monitors; mobile items such as bed-side commodes, wheelchairs, infusion pumps, and computer keyboards; and any other item moved from one pa-tient room or area to another. Nurses must be aware of microorganisms that are particularly challenging with re-spect to environmental contamination (such as Clostridium difficile) and com-municate and work with environmen-tal services personnel to take proper precautions. Further, nursing leader-ship is vital in recognizing risks pres-ent in the clinical care environment that require rapid action and resolu-tion, such as practice deviations asso-ciated with construction barriers or failure to clean and disinfect point-of-care equipment. The network of team members includes many other part-ners beyond environmental services such as clinical engineering, plant operations or facilities management, central sterile processing, and the clinical lab.
Injection and medication safety. Nu-merous outbreaks of infection have
Categories of core practices4
1. Leadership support
2. Education and training of healthcare personnel on infection prevention
3. Patient, family, and caregiver education
4. Performance monitoring and feedback
5. Standard precautions
6. Transmission-based precautions
7. Use of temporary invasive medical devices
8. Occupational health
been identified in United States health-care facilities related to unsafe injection practices such as reuse of syringes, sharing of insulin pens and blood glu-cose monitoring equipment, reuse of medication vials, and administration of contaminated diluted or compounded medication.23-27 The concept of one needle, one syringe, only one time, has been a focus of large-scale CDC educa-tion campaigns and alerts. Because nurses have a major role in medication administration, they must be compe-tent in all aspects of its preparation, handling, and administration as well as in the safe management of all sup-plies and equipment used for injection or puncture. They must also be able to identify care situations that pose risks, such as inappropriate medication compounding by others, failure to use protective equipment during high-risk injections, and workarounds or “infec-tion control hacks” that may seem to make sense or save time but deviate from best practice. For those interested in an audit tool that can help assess existing safe injection practice, a free app called Safe Injection Practices is available for download from the Apple App Store.
Risk assessment with appropriate use of PPE. Standard precautions require personnel to consider the type of activity in which they’ll use the
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appropriate type and level of PPE to prevent exposure to microorganisms, use that PPE correctly, remove it in a way that prevents self-contamination, and dispose of it in appropriate waste receptacles. The use of PPE must not be restricted to patients with known pathogens. Donning of gowns, gloves, masks, and eye protection may be warranted when extubating patients because exposure to res-piratory secretions may occur as the patient coughs upon removal of the device.
Using PPE as a barrier between the nurse and the patient or the contami-nated environment is addressed in regulatory standards by OSHA as well as CDC recommendations.11,20 When done correctly, these actions protect the nurse wearing the item, the pa-tient who may be inadvertently con-taminated if the nurse didn’t use PPE correctly, the environment, and other coworkers or visitors. Being familiar with the performance standards of various pieces of PPE, as outlined in the Association for the Advancement of Medical Instrumentation (AAMI) standards, and recognizing the label-ing of the various levels of PPE as described in the AAMI standards should be part of the knowledge set of all nurses.28
Minimizing potential exposures. Be-sides the selection and use of PPE, additional actions such as the use of respiratory hygiene, cough etiquette, and hand hygiene should be part of routine practice during all patient-care interactions.5,11,15 The CDC has outlined respiratory hygiene and cough etiquette actions that contain respiratory secretions. These include using masks and tissue to contain secretions, preventing hand contami-nation during a cough by teaching all individuals to cough into their elbow region instead of hands, ensuring im-mediate access to products that can be used to cleanse hands, and provid-ing instructional signage that targets healthcare personnel, patients, and
Nurses who are using standard precautions appropriately assume
that all patients may be infected with an organism
that could be spread in the healthcare setting.
visitors.11 An additional practice that can minimize transmission is early recognition of signs and symptoms of infection such as fever and/or cough, then use of early segregation practices such as isolation or cohorting. Early integration of these practices in triage areas as well as entry points into the healthcare facility or setting should be part of business as usual.
Reprocessing of reusable medical equipment. An example involving re-usable medical equipment familiar to nurses is ensuring that any equip-ment no longer needed by a patient is quickly removed from the patient-care area, sequestered in preparation for reprocessing, and sent for decon-tamination, cleaning, and disinfection before reuse. This principle is also applied in medication rooms where
soiled items are never permitted to enter. Specific actions nurses must take that recognize the risks associ-ated with shared equipment include: • rapid removal of items from the patient-care environment when no longer necessary • sequestering used equipment so it can’t inadvertently be used by another patient until it’s been decontaminated, cleaned, and disinfected • promptly cleaning and disinfecting equipment before reuse by another patient.
Mobile patient-care equipment such as blood glucose monitors must be promptly cleaned and disinfected between uses and care should be tak-en to minimize contamination if the equipment must be taken into the patient room.
Transmission-based precautions. Standard precautions should be the foundation for patient interactions because they provide a basis for safe care that protects patients and health-care personnel by assuming that ev-ery patient and patient encounter may provide an infection transmis-sion opportunity. Transmission-based precautions are used when an organ-ism has been identified or suspected and there’s reasonable knowledge as to how the organism may be spread during the course of care. Transmission-based precautions include the selec-tion, use, and disposal of PPE, use of segregation practices including pa-tient placement and isolation, and use of sound and practical policies and procedures. The role of the nurse extends into role modeling, monitor-ing practice of others, identifying bar-riers to appropriate use of isolation and protective equipment, and edu-cating others in a way that corrects errors in practice and reinforces safety. Nurses must be aware of the isolation precautions used within settings where they practice so they can adhere to those precautions and assist others to do the same. Further, nurses must continually be aware of barriers to
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implementation of protective strate-gies (such as interruption in access to supplies, changes in the physical environment, lack of access to sinks, and lack of resources) so those barri-ers can be addressed.10,11
Use of temporary invasive medi-cal devices for clinical management. The presence of an invasive device represents risk to the patient and eval-uating the need for each individual device should be part of regular nurs-ing assessment. Any invasive device should carry a diagnostic or treat-ment benefit that exceeds its risk. For example, an indwelling urinary cath-eter may be necessary for monitoring intake and output during an acute phase of care, but once that phase has passed, the patient should be as-sessed to determine if that device is still needed and, if not, promptly removed.12 Daily, or even more fre-quent, assessment for need can pre-vent a device from being left in for use as a care convenience (such as an indwelling urinary catheter used for patients with urinary incontinence or an arterial line used for blood draws) or even forgotten. Development, im-plementation, and evaluation of the impact of nurse-driven protocols that can facilitate assessment of need and device removal may help prevent an avoidable infection.
Occupational health. The CDC has clearly articulated the list of vaccine-preventable diseases for which health-care personnel should be immune (including rubeola, mumps, rubella, hepatitis B, and varicella). The CDC also emphasizes the need for pertussis prevention (Tdap) and annual influ-enza vaccination.29 Other vaccines may also be appropriate, such as meningococcal vaccine, for those working in lab settings or other envi-ronments with recognized exposure risks. OSHA has mandated that healthcare personnel be given the opportunity to be vaccinated against hepatitis B at no cost.20 A recent Call to Action published by the National
Foundation for Infectious Diseases (NFID) highlighted the importance of collaborative efforts in improving healthcare personnel immunization rates.30 Organizations such as the Im-munization Action Coalition, as well as NFID, have developed resources to assist with immunization effort im-provements and are readily available at no cost.31 Both the CDC and OSHA address the need for testing for infection with Mycobacterium tuberculosis at an interval consistent with job risk.9
Presenteeism, or coming to work when ill, represents a risk to patients and others, and should not occur. Some specific health conditions that should cause nurses to question their ability to provide safe care includes presence of fever with or without cough, vomiting or diarrhea, rash or skin lesions, and draining wounds or skin eruptions.5
Follow the roadmap to prevent infection Some nurses may be tempted to discount CDC guidelines thinking they’re geared primarily toward acute care settings. In reality, the guidelines focus on development of infection based upon risk and are applicable to every healthcare set-ting. The basic messages in these guidelines include performance of hand hygiene, early and rapid re-moval of invasive devices once no longer necessary, engagement of family members and caregivers, and training of healthcare provid-ers. It’s the responsibility of indi-vidual healthcare professionals to use the elements of basic infection prevention practice and develop a personal competency evaluation and a related professional develop-ment plan.
The first and best step involves a personal decision and acceptance of professional responsibility. The road-map for improved infection preven-tion practice begins with you. ■
REFERENCES
1. Brenan M. Nurses keep healthy lead as most honest, ethical profession. Gallup. 2017. http:// news.gallup.com/poll/224639/nurses-keep-healthy-lead-honest-ethical-profession.aspx.
2. Centers for Disease Control and Prevention. Antibiotic prescribing and use in hospitals and long-term care. 2018. www.cdc.gov/getsmart/healthcare.
3. American Nurses Association. Nursing Infection Control Education network. 2017. www.nursingworld.org/MainMenuCategories/ WorkplaceSafety/Healthy-Work-Environment/ InfectionPreventionControlEducation.
4. Centers for Disease Control and Prevention. Core infection prevention and control practices for safe healthcare delivery in all settings: recommendations of the Healthcare Infection Control Practices Advisory Committee. 2017. www.cdc.gov/hicpac/pdf/core-practices.pdf.
5. Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN, Deitchmann SD. Guideline for infection control in healthcare personnel, 1998. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1998; 19(6):407-463.
6. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250-278.
7. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, et al. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/ SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(12 suppl):S3-S40.
8. Sehulster L, Chinn RY, CDC, HICPAC. Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep. 2003;52(RR-10):1-42.
9. Jensen PA, Lambert LA, Iademarco MF, Ridzon R, CDC. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1-141.
10. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control. 2007;35(10 suppl 2):S165-S193.
11. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: preventing transmission of infectious agents in health care settings. Am J Infect Control. 2007; 35(10 suppl 2):S65-S164.
12. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA, Healthcare Infection Control Practices Advisory Committee. Guideline for prevention of catheter-associated urinary tract infections 2009. Infect Control Hosp Epidemiol. 2010;31(4):319-326.
13. Centers for Disease Control and Prevention. Guidance for control of infections with carbapenem-resistant or carbapenemase-producing Enterobacteriaceae in acute care facilities. MMWR Morb Mortal Wkly Rep. 2009;58(10):256-260.
14. Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention. Updated norovirus outbreak management and disease prevention guidelines. MMWR Recomm Rep. 2011;60(RR-3):1-18.
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15. O’Grady NP, Alexander M, Burns LA, et al. Guidelines for the prevention of intravascular catheter-related infections. Am J Infect Control. 2011;39(4 suppl 1):S1-S34.
16. Centers for Disease Control and Prevention. Guide to infection prevention for outpatient settings: minimum expectations for safe care. 2015. www.cdc.gov/infectioncontrol/pdf/outpatient/ guide.pdf.
17. Rutala WA, Weber DJ, Healthcare Infection Control Practices Advisory Committee. Guideline for disinfection and sterilization in healthcare facilities, 2008. www.cdc.gov/hicpac/pdf/ guidelines/disinfection_nov_2008.pdf.
18. Carrico RM, Rebmann T, English JF, Mackey J, Cronin SN. Infection prevention and control competencies for hospital-based health care personnel. Am J Infect Control. 2008;36(10):691-701.
19. Tablan OC, Anderson LJ, Besser R, et al. Guidelines for preventing health-care-associated pneumonia, 2003: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee. MMWR Recomm Rep. 2004;53(RR-3):1-36.
20. U.S. Department of Labor, Occupational Safety and Health Administration. Bloodborne pathogens. 1992. www.osha.gov/pls/oshaweb/owadisp.show_ document?p_id=10051&p_table=STANDARDS.
21. Chughtai AA, Barnes M, Macintyre CR. Persistence of Ebola virus in various body fluids during convalescence: evidence and implications for disease transmission and control. Epidemiol Infect. 2016;144(8):1652-1660.
22. World Health Organization. WHO Guidelines on Hand Hygiene in Healthcare: First Global Patient Safety Challenge: Clean Care Is Safer Care. Geneva, Switzerland: World Health Organization; 2009.
23. Fischer GE, Schaefer MK, Labus BJ, et al. Hepatitis C virus infections from unsafe injection practices at an endoscopy clinic in Las Vegas, Nevada, 2007-2008. Clin Infect Dis. 2010;51(3):267-273.
24. Thompson ND, Perz JF, Moorman AC, Holmberg SD. Nonhospital health care-associated hepatitis B and C virus transmission: United States, 1998-2008. Ann Intern Med. 2009;150(1): 33-39.
25. Grohskopf LA, Roth VR, Feikin DR, et al. Serratia liquefaciens bloodstream infections from contamination of epoetin alfa at a hemodialysis center. N Engl J Med. 2001;344(20):1491-1497.
26. Vasquez AM, Lake J, Ngai S, et al. Notes from the field: fungal bloodstream infections associated with a compounded intravenous medication at an outpatient oncology clinic—New York City, 2016. MMWR Morb Mortal Wkly Rep. 2016;65(45): 1274-1275.
27. Ross K, Mehr J, Carothers B, et al. Outbreak of septic arthritis associated with intra-articular injections at an outpatient practice—New Jersey, 2017. MMWR Morb Mortal Wkly Rep. 2017;66(29):777-779.
28. ANSI/AAMI:PB70:2012. Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Health Care Facilities. Arlington VA: Association for the Advancement of Medical Instrumentation; 2012.
29. Centers for Disease Control and Prevention. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(RR-7):1-45.
30. National Foundation for Infectious Diseases. Call to action: improving healthcare personnel immunization rates. 2018. www.nfid.org/hcp-immunization.
31. Immunization Action Coalition. 2018. www. immunize.org.
At the University of Louisville Global Health Center, Division of Infectious Diseases, University of Louis-ville School of Medicine in Kentucky, Ruth M. Carrico is an associate professor and family NP; Hudson Garrett is a family NP and an assistant professor of medicine; and Dawn Balcom is a family NP and clini-cal lead in the Global Health Program. Janet Burton Glowicz is a health research analyst at the CDC’s Division of Healthcare Quality Promotion, Prevention and Response Branch, and a contractor at Northrop Grumman Corporation, both in Atlanta, Ga.
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Use of trade names is for identification only and does not imply endorsement by the Public Health Service or by the U.S. Depart-ment of Health and Human Services.
The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.
DOI-10.1097/01.NURSE.0000541385.06363.73
> For more than 64 additional continuing education articles related to infection topics, go to NursingCenter.com/CE.
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