Nosocomial Infection ----Prevention and control

Wang kefang （王克芳）kefangwang@126.com

你知道吗？ 从 2008 年起， 10 月 15 日是个 ____ 日吗 ?

10 月 15 日是“国际洗手日” 2005 年世界卫生组织提出， 2008 年正式设

立

　　　　　　　　　　　　　　＿＿ 2008 年 10 月 15 日的＜健康报＞

Clean Hands are

Safer Hands

SAVE LIVES: Clean Your Hands

3 Hand Hygiene

何谓手卫生 (hand hygiene)?

A general term referring to any action of hand cleansing ， including handwashing, antiseptic handrubbing and surgical hand antisepsis

--WHO hand hygiene guideline

洗手（ hand washing） 用普通肥皂 / 液和流动水洗手 , 去除手部皮肤

污垢、碎屑和部分致病菌的过程。卫生手消毒 (antiseptic handrubbing)

指用速干消毒剂擦搓手的过程。

外科手消毒 (Surgical hand antisepsis)

外科手术前医护人员用肥皂 / 液和流动水洗手，再用手消毒剂清除或杀灭暂住菌和减少常居菌的过程。

Today’s topics

Why is hand hygiene important for health care workers(HCWs)?

When should hand hygiene be performed?

How to perform hand hygiene?

After petting a dog or cat

42%(16%)

Before handling Or eating food

77%(14%)

After coughing or sneezing

32%(23%)

After using the Bathroom in

your home

83%(10%)

After changing a diaper

73%(4%)

After handling Money

21%(18%)

After using a public restroom

91%(6%)

Hand Washing HabitsHow often do you wash your hands ……(Americans,2005 )

Always wash my hands

(Usually wash my hands)

– Total Sample –

Why is hand hygiene important?

Germs are present on patient skin and surfaces in the patient surroundings

1

23/4/21 9

人体不同部位皮肤细菌量

头皮： 1 x 106 CFUs/cm2

腋窝： 5 x 105 CFUs/cm2

腹部： 4 x 104 CFUs/cm2

前臂： 1 x 104 CFUs/cm2

HCW的手： 3.9 x 104 ～ 4.6 x 106 CFUs/cm2

13-25%

40%

30-39%

腋下

手、手腕

腹股沟

Percent of Patients with MRSA

（耐甲氧西林金黄色葡萄球菌）

Why is hand hygiene important?

By direct and indirect contact, patient germs contaminate health-care workers' hands

Germs survive and multiply on health-care workers' hands

2

某位护士的手印培养 24小时后

23/4/21 13

手部皮肤细菌类型

暂住菌 原皮肤不存在，主要通过接触而附在皮肤上，

处于皮肤表面或角质下表皮细胞上 常住菌

寄宿于皮肤毛囊和皮脂腺开口处，种类、数量常恒定，多无致病性，占总菌量 10 ～ 20%

由于常居皮肤深层，肥皂搓刷不易将它们去除干净，需要用化学消毒剂才能将其杀死或抑制

Defective hand cleansing results in hands remaining contaminated

Why is hand hygiene important?

3

Maternal Mortality Rates

0

2

4

6

8

10

12

14

16

18

1841 1842 1843 1844 1845 1846 1847 1848 1849 1850

First

Second

Semmelweis IP, 1861

Intervention May 15, 1847

Per

cen

tag

e

Hand Hygiene: Not a New Concept

Impact of hand hygiene promotion

Year Hospital setting

Increase of hand hygiene compliance Reduction of HCAI rates Follow-up Reference

1989 Adult ICU 14% to 73% (before pt contact)

HCAI rates: 33% to 10% 6 years Conly et al

2000 Hospital-wide 48% to 66% HCAI prevalence: 16.9% to 9.5% 8 years Pittet et al

2004 NICU 43% to 80% HCAI incidence: 15.1 to 10.7/1000 patient-days 2 years Won et al

2005 Adult ICUs 23.1% to 64.5% HCAI incidence: 47.5 to 27.9/1000 patient-days 21 months Rosenthal et al

2005 Hospital-wide 62% to 81% Significant reduction in rotavirus infections 4 years Zerr et al

2007 Neonatal unit 42% to 55% HCAI incidence: overall 11 to 8.2 i/1000 patient-days in very low birth weight neonates from 15.5 to 8.8 /i1000 patient-days

27 months Pessoa-Silva et al

2007 Neurosurgery NA SSI rates: 8.3% to 3.8% 2 years Thu et al

2008 1) 6 pilot health-care facilities2) all public health-care facilities

1) 21% to 48%2) 20% to 53%

MRSA bacteraemia: 1)0.05 to 0.02/100 patient-discharges per month; 2)0.03 to 0.01/100 patient-discharges per month

1) 2 years2) 1 year

Grayson et al

2008 NICU NA HCAI incidence: 4.1 to 1.2/1000 patient-days 18 months Capretti et al

Evidences…Hand hygiene is the single most effective measure to reduce HCAIs

Protect the patient ， and Protect yourself

When should hand hygiene be performed?

Your 5 Moments for Hand Hygiene

Use What to Perform Hand hygiene

Plain soap 普通肥皂 / 皂液Antimicrobial soap 抗菌肥皂 / 皂液Alcohol-based handrub 酒精擦手液

Ability of Hand Hygiene Agents to Reduce Bacteria on Hands

0.0

1.0

2.0

3.0 0 60 180 minutes

0.0

90.0

99.0

99.9log%

Bac

teri

al R

edu

ctio

n

Alcohol-based handrub(70% Isopropanol)

Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

1×101×104-54-5

个个 /g/g1×106-7

个 /g

污染程度 细菌数 / 克肥皂 医院数 构成比

极严重 >100万 34 54.0％

严重 11-100万 9 14.3％

中度 1.1－ 10万 4 6.3％

轻微 ≤ 1 万 16 25.4％

×

Solid Soap Contamination of 63 Hospitals

消毒液浸泡：错误的手消毒方法

Adoption of alcohol-based handrub is the gold standard in all other clinical situations

Handwashing with soap and water when hands are visibly dirty or following visible exposure to body fluids

How to perform hand hygiene?

如何进行手卫生？

Right palm over left dorsum with interlaced fingers and vice versa

Palm to palm Palm to palm fingers interlaced

Six Steps

Hand Hygiene

Rotational rubbing of left thumb clasped in right palm and vice versa

Backs of fingers to

opposing palms with

fingers interlocked

Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa

Handwashing

Rub hands together for at least 15 seconds

40-60秒

40-60秒

handrubbing

20-30秒

20-30秒

To clean your hands, you should prefer handrubbing with an alcohol-based formulation, if available. Requires less time

Acts faster

More effective

Better tolerated

More accessible

Handwashing40-60 seconds

Handrubbing 20–30 seconds

Scenario 6a 6b Scenario 7a 7b Scenario 8a 8b

Hand Hygiene Scenarios

Contents Concepts

Principals of

Aseptic Technique

Aseptic

Techniques

教学目标 解释术语：无菌区、非无菌区

、无菌物品 掌握无菌技术的原则 熟练掌握无菌技术的基本操作

4Aseptic Technique

Concepts

Aseptic technique the practices which prevent microorganisms

invading human beings, sterile objects and areas from being contaminated during medical procedures and nursing interventions.

Aseptic TechniqueAseptic Technique

Principals of Aseptic Technique

Environment requirement

Staff preparation

Distinguish different areas

Item management

Aseptic concept during procedures

Aseptic TechniqueAseptic Technique

Environment requirement

The environment should be clean, spacious, and disinfected routinely.

The Operating table is clean, dry, and flat and the layout is rational

stop cleaning the surroundings 30 minutes before the procedures, and minimize moving to prevent dust from floating.

Aseptic TechniqueAseptic Technique

Staff

Wear mask and cap, trim fingernails and perform hand hygiene before aseptic procedures.

Wear sterile gown and sterile gloves if necessary.

Aseptic TechniqueAseptic Technique

Distinguish different areas

Aseptic TechniqueAseptic Technique

Aseptic area refers to the sterile area which has not been

contaminated.

Non-aseptic area is a non-sterilized area or an area having been

sterilized but being contaminated again.

Aseptic supply is an aseptic item physically or chemically

sterilized.

Item management

Place aseptic supplies and non-aseptic supplies separately and have distinct label.

Keep aseptic supply in sterile package or container.

Label sterile packages with name, expiration date accurately and store them according to expiration date.

Valid time

A set of aseptic supply is only for a client to use once.

Aseptic TechniqueAseptic Technique

7 days (May 1 to October 1)

14 days (October 1 to the next May 1)

Aseptic supply is an aseptic item physically or chemically sterilized.

During Procedures Keep the body away from the aseptic area during

procedures. Face sterile area during procedures. Use sterile transfer forceps to fetch sterile items Keep hands and arms above the waist level.

Aseptic TechniqueAseptic Technique

During Procedures Keep the body away from the aseptic area during

procedures. Face sterile area during procedures. Use sterile transfer forceps to fetch sterile items Keep hands and arms above the waist level.

Keep non-aseptic supplies away from aseptic supplies. Once taken out of the container, aseptic supplies can not be put back even not be used.

No one should talk, laugh, cough or sneeze over a sterile field.

When in doubt about the sterility of a package, or consider it contaminated, then re-sterilize the items.

Aseptic TechniqueAseptic Technique

Aseptic Techniques

Apply Sterile Transfer Forceps

Apply Sterile Container

Use Sterile Package

Prepare Sterile Treatment Tray

Pour Sterile Solution

Don and Remove Sterile Gloves

Aseptic TechniqueAseptic Technique

Do you know how to protect yourself and others from infection?

Do you know what to do if you come in contact with blood?

Isolation

Concepts

Isolation

Using a variety of methods, techniques, and measures to prevent pathogens transmission from patients and carriers.

采用各种方法、技术，防止病原体从患者及携带者传播给他人的措施。

IsolationIsolation 卫生部医院隔离技术规范 2009

Concepts

Clean area the area not contaminated by pathogens such as treatment room, Nutrition pantry and pharmacy.

Potentially-contaminated area the area that is potentially contaminated by pathogens like office, laboratory and disinfection room.

Contaminated area the area contaminated by pathogens which is in contact with

clients directly and indirectly such as ward, clients’ restroom and bathroom.

IsolationIsolation

在标准预防 (Standard Precautions) 的基础上，结合疾病的传播途径制定相应的隔离预防措施 (Transmission-

based precautions) 。 隔离病室应有隔离标志，并限制人员的出入。

传染病 / 可疑传染病患者应安置在单人隔离房间。 受条件限制的医院，同种病原体感染的患者可安置

于一室 建筑布局合理，符合有关规定。

Airborne Precautions

Droplet Precautions

Contact Precautions

Isolation Principle

卫生部医院隔离技术规范 2009

----标准预防（ Standard  Precautions）

----基于传播途径的隔离 （ Transmission-based precautions）

Isolation measures

A quick recap

how isolation precautions evolved

over time

1970Isolation Techniques, 1st edtn.

-Introduced seven isolation precaution categories: Strict, Respiratory, Protective, Enteric, Wound and Skin, Discharge, and Blood- No user decision-making required- Simplicity a strength; over isolation prescribed for some infections

1975 Isolation Techniques, 2nd edtn.

Same conceptual framework as 1st edition

1983 CDC Guideline for Isolation Precautionsin Hospitals

-Provided two systems for isolation: category-specific and disease specific- Protective Isolation eliminated; Blood Precautions expanded to include Body Fluids-Categories included Strict, Contact, Respiratory, Enteric, Drainage/Secretion, Blood and Body Fluids- Emphasized decision-making by users

HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS

HISTORY OF GUIDELINES FOR ISOLATION PRECAUTIONS IN HOSPITALS contd--

1985-1988

Universal precautions

Developed in response to HIV/AIDS epidemic- Blood and Body Fluid precautions to all patients, regardless of infection status- Did not apply to feaces, nasal secretions, sputum, sweat, tears, urine, or vomitus unless contaminated by visible blood- Added personal protective equipment to protect HCWs from mucous membrane exposures- Handwashing recommended immediately after glove removal- Added specific recommendations for handling needles and other sharp devices;

1987 Body substance isolation

- Emphasized avoiding contact with all moist and potentially infectious body substances except sweat even if blood not present- Shared some features with Universal Precautions- Weak on infections transmitted by large droplets or by contact with dry surfaces- Did not emphasize need for special ventilation to contain airborne infections- Handwashing after glove removal not specified in the absence of visible soiling

1996 Guideline for Isolation Precautions inHospitals

- Melded major features of Universal Precautions and Body Substance Isolation into Standard Precautions to be used with all patients at all times-Included three transmission-based precaution categories: contact, droplet & airborne- Listed clinical syndromes that should dictate use of empiric isolation until an etiological diagnosis

WHAT ARE STANDARD PRECAUTIONS? Standard Precautions include a group of infection

prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered

---- America CDC in 1996 and updated in 2007

(Siegal JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory

Committee, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, 2007)

All healthcare workers MUST..... Assume that every person is potentially

infected or colonized with an organism that could be transmitted in the healthcare setting.

Apply a set of work practices to Blood all body fluids (except sweat) mucous membranes non intact skin.

Standard Precautions

Respiratory hygiene

Linen & laundry

Waste Management

C&D

PPE

Hand hygiene

Patient placement

Key Components of Standard Precautions

Safe injection

Recommendation for all individuals with respiratory symptoms

Cover the nose/mouth when coughing or sneezing

Perform hand hygiene if contact respiratory secretions and contaminated objects

Put on a surgical mask

Respiratory hygiene and cough etiquette

• Use tissue paper to contain respiratory secretions and dispose in the waste receptacle

Standard Precautions

Respiratory hygiene

Linen & laundry

Waste Management

C&D

PPE

Hand hygiene

Patient placement

Key Components of Standard Precautions

Safe injection

Personal Protective Equipment(PPE)

specialized clothing or equipment worn by an employee for protection against infectious materials

PPE Use in Healthcare Settings

Types of PPE Used in Healthcare Settings

Gloves – protect hands

Gowns/aprons – protect skin and/or clothing

Masks and respirators– protect mouth/nose

Goggles – protect eyes

Face shields – protect face, mouth, nose, and eyes

PPE for Standard Precautions: Based on Risk Assessment IF direct contact with blood & body fluids, secretions,

excretions, mucous membranes, non-intact skin Gloves Gown

IF there is the risk of spills onto the body and/or face Gloves Gown Face protection (mask plus eye protection goggle;

face shield)

What Type of PPE Would You Wear?

• Giving a bed bath?• Generally none

• Suctioning oral secretions?• Gloves and

mask/goggles or a face shield – sometimes gown

• Transporting a patient in a wheel chair?

• Generally none

• Taking vital signs?• Generally none

• Drawing blood from a vein?• Gloves

• Responding to an emergency where blood is spurting?

• Gloves, fluid-resistant gown, mask/goggles or a face shield

• Cleaning an incontinent patient with diarrhea?

• Gloves / gown

• Irrigating a wound?• Gloves, gown,

mask/goggles or a face shield

?

Isolation measures

*Transmission-based precautions are often used empirically, according to the clinical syndrome and the likely etiological agent

Infectious Agent

Contact Droplet Airborne

Direct IndirectDroplet Nuclei

Hands

Equipment/Environment

Injection

Insect/Animal

Contact Precautions

经接触传播疾病如肠道感染、多重耐药菌感染、皮肤感染等的患者

在标准预防的基础上，还应采用接触隔离措施

耐 甲 氧 西 林 金 黄 色 葡 萄 球 菌 -

MRSA

耐万古霉素肠球菌 -VRE

产超广谱 β- 内酰胺酶 -ESBLs 细菌多重耐药铜绿假单胞菌 -MDR-PA

-------- 患者的隔离患者的隔离 Limit patient contact with non-infected

persons Place patient in a single room or cohort

with similar patients Limit transportation

Contact Precautions

---- 医务人员的防护 (2-1) Use non-sterile, clean, disposable gloves 接触隔离患者的血液、体液、分泌物、排泄物等物

质时，应戴手套；离开隔离病室前，接触污染物品后应摘除手套，洗手 / 手消毒。手上有伤口时应戴双层手套。

Contact Precautions

---- 医务人员的防护 (2-2) Use non-sterile, clean, disposable, gown,

apron (only if gown is not impermeable) 进入隔离病室，从事可能污染工作服的操作时，

应穿隔离衣；离开病室前，脱下隔离衣，按要求悬挂，每天更换清洗与消毒 ; 或使用一次性隔离衣。接触甲类传染病应按要求穿脱防护服。

Contact Precautions

鼠疫 霍乱 H1NI SARS

病原微生物经悬浮在空气中的微粒 - 气溶胶来传播的疾病如肺结核、水痘等

在标准预防的基础上，还应采用空气隔离措施。

Airborne Precautions

---- 患者的隔离 Use surgical mask or particulate respirator Place the patient in adequately ventilated

room Limit patient movement

Airborne Precautions

---- 医务人员的防护 Use a particulate respirator( 医用防护口

罩 )when entering the patient isolation room；

进行可能产生喷溅的诊疗操作时，应戴防护目镜或防护面罩，穿防护服

当接触患者及其血液、体液、分泌物、排泄物等物质时应戴手套。

Airborne Precautions

接触经飞沫传播的疾病，如百日咳、白喉、流行性感冒、病毒性腮腺炎、流行性脑脊髓膜炎等

在标准预防的基础上，还应采用飞沫隔离措施。

Droplet Precautions

---- 患者的隔离 Use surgical mask ； Limit patient movement 。 Maintain a distance ≥ 1 meter between

infectious patient and others Place patient in a single room or cohort with

similar patients Room ventilation or disinfect

Droplet Precautions

---- 医务人员的防护 Use a mask when < 1 m of patient

进行可能产生喷溅的诊疗操作时，应戴护目镜或防护面罩，穿防护服；

当接触患者及其血液、体液、分泌物、排泄物等物质时应戴手套。

Droplet Precautions

保护性隔离 ----反向隔离（ protective isolation ）

适用范围 抵抗力低下或极易感染的患者，如严重烧伤、早产儿、白血病、脏器移植及免疫缺陷患者等。

保护性隔离措施单间隔离，有条件可放在正压病房注意口腔卫生，采用洗必泰漱口，每天至少 4 次尽量不与其他无关人员接触严格执行手卫生规范正确穿戴口罩、帽子、隔离衣（接触患者面为清洁面）患感染性疾病期间，不得进入隔离室无关人员不得进入隔离室治疗、护理应有计划的集中进行，减少出入室的次数不进入隔离室内探视。必要时应做好手卫生并戴口罩疑患感染时，不得探视不得携带鲜花、宠物入室保证隔离室内压力高于走廊定期对室内环境进行消毒。

患者

工作人员

家属访客

环境管理

Terminal Disinfection

Terminal disinfection of the client

Terminal disinfection of the ward

IsolationIsolation

Terminal disinfection of the client

Transferred to other wards or discharged bathe the clients and wear clean clothes take their personal items with them after

disinfection.

For the dead client clean the body with disinfectant and plug the mouth,

nose, ears, anus with sterile cotton, change wound dressing, envelop the body with disposable linen.

IsolationIsolation

Terminal disinfection of the ward

Close the doors and windows, open bedside table, spread the quilt and place the mattress vertically on the bed, fumigate them with disinfectant or disinfect by ultraviolet light.

Then open the door and windows furniture and floor: rubbing Thermometer: immersion Blood-pressure meter and stethoscope: fumigation Mattress, quilt and pillows: ultraviolet light.

IsolationIsolation

Isolation techniques

Hand hygiene Cap and mask Goggles/Face shieldsGlovesGowns/aprons

Cap

masks

棉纱口罩 (Cotton mask)

一次性外科口罩(disposal surgical mask)

医用防护口罩(particulate respirator)

滤过率 95%---99%滤过率 95%---99%

滤过率 90%滤过率 90%

滤过率取决于纱布厚度6 层 90%8 层 100%

滤过率取决于纱布厚度6 层 90%8 层 100%

N99N95

wash hands: Before Wear a mask after taking off the mask

如何佩戴如何佩戴 N95N95 口罩口罩

１拉松头带。金属软条向上，将手穿过头带 ２戴上口罩，头带分

别置於头顶後及颈後 ３将双手的食指及中

指由中央顶部向两旁同时按压金属软条。 ４检查妥当（密合

性检查）

DON’T

× × ×

× ×

——Face shields

Goggles: 安全的玻璃来防护眼睛

Gowns

– Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated

PPE Use in Healthcare Settings

Gloves Indications for gloving and for glove removal

87

手套的种类

● 　 无菌乳胶手套● 　清洁一次性使用乳胶手套● 　双层手套● 　一次性使用薄膜手套● 　卫生胶手套

手套的使用

≠■ Glove use does not

replace any hand hygiene action

PreventionIs Primary!

Protect patients…protect healthcare personnel…

promote quality healthcare!

教学内容 概述 隔离原则 隔离预防措施 常用隔离技术

教学目标 解释术语：隔离、清洁区、潜在

污染区、污染区、标准预防 掌握隔离的原则与措施 掌握隔离技术的基本操作方法

5 医院隔离预防医院隔离预防

Words:

Hand Hygiene

Handwashing

Alcohol-based handrub

Aseptic Technique

Aseptic area

Aseptic supply

Isolation

Clean area

Contaminated area