*4.4.3. Personal Protective Equipment (PPE)*

the hands of HCW. The transient flora colonizes the superficial layer of skin and are removed by hand hygiene. The pathogens like MRSA, VRE, Multidrug resistant Gram negative bacilli, Candida species causing HAI colonize hands of HCW during patient care simply while taking blood pressure or taking temperature etc. or from environment like the uniform, patient's locker, bed rail, bed linens, furnitures etc. The organisms like Staphylococcus aureus, MRSA,

Hand hygiene includes washing hands with soap and water, antimicrobial soap, antiseptic agents, alcohol – based hand rub or surgical hand scrub. Hepatitis C virus (HCV), Rhinovi‐

If hands of HCWs are visibly dirty or contaminated with proteinaceous material, blood or other body fluids of patients, the hands are to be washed with soap and water. An alcohol based hand rub must be used by HCWs when hands are not visibly soiled such as before having any direct contact with patients including taking pulse or blood pressure or lifting a patient, before donning sterile gloves and also after removing gloves, after contact with inanimate objects in patient's immediate environment or if moving from a contaminated body site to a clean body

The maximum incidence of hand contaminations are reported from critical care areas. Hence, to prevent cross transmission, motivation, training, availability of alcohol based hand rubs and repeated reminders are required for HCWs. In most Health care set up, actually following the hand hygiene practice is below 40% where it is indicated [54]. The most important cause for poor hand hygiene compliance is lack of knowledge of guidelines of protocols on hand hygiene, lack of institution priority, lack of role model among the colleagues or superiors

The HCWs are to be specifically explained that wearing gloves does not replace hand hygiene and contamination may occur while removing the gloves. Actually, hand hygiene should be

Selection of hand hygiene products and its easy availability is one the most important step to promote hand hygiene practices during patient care. The new CDC guidelines does not suggest any specific spectrum for a hand hygiene agent and any health care set up can select an agent depending on cost spectrum and the common causative organisms of HAI [56]. Hand hygiene agent used for post contamination must be bactericidal, fungicidal (yeast), virucidal. The agent having activity against unenveloped viruses should be used in peadiatrics (rotavirus) or in oncology units (parvovirus) etc. The agent with mycobactericidal activity should be used in tuberculosis and chest wards, fungicidal activity (moulds) in organ transplant units or AIDS patients are to be considered. Preoperative hand hygiene agent should at least contain bactericidal and fungicidal (yeasts) to reduce the risk of SSIs. Any hand hygiene agent should not cause skin irritation and should dry on its own. WHO advocates to follow formula for

**Formulation I** contains ethanol 80% v/v, glycerol 1.45% v/v and hydrogen peroxide 0.125% v/v. **Formulation II** contains isopropyl alcohol 75% v/v, glycerol 1.45% v/v and hydrogen peroxide

ruses, Adenoviruses and Rotavirus nucleic acid can be found on hands of HCW [52].

VRE can survive for months on inanimate objects.

(specially clinicians), lack of HCWs etc [55].

a habit of HCW while giving patient care.

resource poor settings [57].

0.125% v/v.

site of the patient etc.

14 Infection Control

PPE includes gloves, protective eye wear (goggles), masks, cap, apron, gown, shoe covers etc. PPE should be used when there is a chance to have contact with patient's blood, body fluids, excretion or secretion while giving patient care by – HCWs, support staffs including attend‐ ants, sweeper, laundry staffs, laboratory staffs and family members. Masks alongwith goggles or a face shield may be used for complete protection of the face [58]. PPE should be chosen according to the risk of exposure and always where contact with blood and body fluid may occur. HCWs may be well trained when and how to use PPE and should be explained properly that use of PPE does not replace hand hygiene. Disposable PPEs e.g. gloves, masks, protective eyewear, gowns should never be reused. PPEs should always be changed between patients. All HCWs should follow hand hygiene after removal of PPE. Single use PPE must be discarded or reusable PPE may be put in a bin to send it to laundry and then for sterilization.

Respiratory protection : To prevent inhalation of microorganism the respirator with N-95 or higher filtration can be used. These are recommended if exposure to patients with tuberculosis, SARS CO-V, influenza, Swine flu etc occurs or suspected.

In the current CDC guidelines regarding isolation precaution Respiratory Hygiene / Cough Etiquette are recommended for HCWs, patients and their relatives. Spatially separation (>3 foot) should be followed in persons with respiratory infection in common waiting areas of health care set up. To avoid inhalation of droplet nuclei, droplet precautions e.g. wearing mask are to be implemented for HCWs. Masks should never be confused with particulate respirators which are used to prevent inhalation of small particles contaminated with infectious agent.

#### *4.4.4. Safe injection practices*

The recommendations include :


#### *4.4.5. Infection control practices for lumbar puncture procedure [59]*

The health Care Infection Control Practices Advisory Committee (HICPAC) in 2005 recom‐ mended that the HCW placing a catheter or injecting material into the spinal or epidural space must use a facemasks to prevent droplet transmission of oropharyngeal flora.

#### *4.4.6. Patient care equipment*

To prevent patient to patient transmission, instruments must be cleaned and sterilized. All patient care equipment soiled with blood, body fluids, secretions or excretions must be handled with care to prevent exposure to skin and mucous membranes, clothing and envi‐ ronment. All reusable equipments are to be cleaned and sterilized before using for another patient.

pathogens [60]. Environmental surfaces include clinical contact (medical equipment or high touch) surfaces and housekeeping surfaces. CDC defines clinical contact surfaces that can transmit infection by contaminating hands of HCWs and other patients. These surfaces includes light switches, telephones, doorknobs, beddings, X ray machines, edges of privacy

Infection Control Practices in Health Care Set-Up

http://dx.doi.org/10.5772/55029

17

Housekeeping surfaces (wall of the patient room, floors and sinks) are rarely involved in direct spread of infection and same LLDs and ILDs can be used for decontaminating these surfaces.

For further readings of cleaning and disinfection of noncritical, semicritical and critical patient care equipments, clinical contact and housekeeping surfaces guidelines available at www.ne‐

**Endoscopes :** Recently, in many operative and diagnostic procedures Endoscopes are used and hence, effective decontamination is essential for patient's safety [63]. Some endoscopes are available in both flexible and rigid construction. Modern flexible fibre optic scopes (bronchoscopes, cystoscpes, gastroscopes, sigmoidoscopes etc) cannot withstand high temperatures. These are very delicate, having multiple small channels and blind ends. Hence, they are very difficult to clean and decontaminate. Endoscopes and accessories which come in contact with sterile tissue are classified as critical items and sterilization or HLD should be done ideally. Endoscopes and accessories that come in contact with mucous membrane are put into semicritical items and should be treated with HLD after use. Endoscope sterilization or HLD involve the following steps i.e. disassembling the components, cleaning and disinfec‐ tion with HLD, rinsing the endoscope and its channels with sterile water to remove disinfec‐ tant, then flushing the channels with 70-90% ethyl or isopropyl alcohol and drying by forced

A logbook is to be maintained after each use and reprocessing by noting the patient's name, hospital registration number, the clinician who performed the endoscopy and HCW who did reprocessing and serial number of endoscopes etc. If any endoscope is used in a patient who has been subsequently diagnosed with CJD (Cruitzfeild Jacob disease), further follow up

**Ventilators :** Mechanical ventilators are essentially used in Intensive Care Units (ICUs) and are common source of infection. Ventilator associated pneumonia is one of the commonest HAI after catheter associated UTI (CA-UTI). All HCWs must be trained to follow hand hygiene and use PPE while reprocessing ventilators or any other respiration devices. All disposable devices must be discarded. The ventilators should be cleaned to remove organic soil. The

**Suction equipment :** Preferably separate machine should be used for each patient. A fresh catheter must be used for every suction. After use the contents are discarded and bottle should be washed with detergent and water and then dried up. The tubing, lids, non return valve and

circuits and filters should be disposable so that it can be changed between patients.

curtains, walls of the toilets etc. They should be disinfected with LLDs and ILDs.

vadaaware.com/home/GuidelinesEnvInfectControl908.pdf. may be consulted [62].

*4.4.6.4. Cleaning and decontamination of specific equipment can be discussed as follows*

air. Then the endoscopes are stored by hanging vertically with caps.

investigation must be done.

bottles are autoclaved if required.

#### *4.4.6.1 .High level disinfection (HLD), Intermediate level disinfection (ILD) and Low level disinfection (LLD) [60].*

High level disinfection (HLD) is a process that kills all microorganisms except large numbers of bacterial spores. The Food and Drug Administration definition of HLD is a sterilant used for a shorter contact time to achieve 106 log kill of an Mycobacterium sp. HLD chemicals can also be used for sterilization only with extended exposure time. The examples are glutaralde‐ hyde 2%, Hydrogen peroxide 7.5%, Hydrogen peroxide and peracetic acid 1% / 0.8%, Hypo‐ chlorite and hypochlorus acid i.e. 650-675 ppm and 400-450 ppm respectively etc. HLD can be used for heat – sensitive semi critical patient care equipments e.g. Gastrointestinal endoscopes, bronchoscopes etc.

Intermediate level disinfection (ILD) – ILD is defined as a disinfection procedure that is cidal for Mycobacteria, vegetative bacteria, most viruses and fungi but does not kill bacterial spores. Tuberculocide germicide does not prevent transmission of tuberculosis in health care set – ups. The term tuberculocide is used to denote germicidal potency of disinfectant. The examples of ILD are hypochlorite, alcohols, phenols etc. ILDs are mainly used for soiled noncritical patient care items or surfaces contaminated with visible blood/ body fluids/sputum/faeces/Mycobacteria.

Low level disinfection (LLD) is a process that kills most vegetative bacteria, some fungi and some viruses (lipophilic viruses) etc in ≤ 10 minutes. LLD includes some chlorine based products, phenolics and quaternary ammonium compounds or 70-90% alcohol. LLD is used for non critical patients care items.

#### *4.4.6.2. Critical, semicritical & non critical devices*

The definition of HLD, ILD and LLD correlates well with Spaulding's classification of devices [61]. The Equipment/device is defined as **Critical** if the medical device enter into a normally sterile tissue or vasculature and for reprocessing sterilization is required. The examples are cardiac catheter, needle, surgical instruments, implants etc.

The medical devices are called **Semicritical** if the device can come in contact with mucous membrane or non intact skin. For reprocessing, sterilization is desirable but HLD is acceptable. The examples are respiratory therapy equipment, some endoscopes etc.

The **Noncritical** devices can be defined as devices that come in contact with intact skin, e.g. Blood pressure cuff, Stethoscopes etc and for reprocessing ILD / LLD can be used.

#### *4.4.6.3. Environmental surfaces*

In 1991, CDC has proposed an additional category as 'Environmental surfaces' to Spaulding's classification that do not come in contact with patients but serve as reservoir of resistant pathogens [60]. Environmental surfaces include clinical contact (medical equipment or high touch) surfaces and housekeeping surfaces. CDC defines clinical contact surfaces that can transmit infection by contaminating hands of HCWs and other patients. These surfaces includes light switches, telephones, doorknobs, beddings, X ray machines, edges of privacy curtains, walls of the toilets etc. They should be disinfected with LLDs and ILDs.

Housekeeping surfaces (wall of the patient room, floors and sinks) are rarely involved in direct spread of infection and same LLDs and ILDs can be used for decontaminating these surfaces.

For further readings of cleaning and disinfection of noncritical, semicritical and critical patient care equipments, clinical contact and housekeeping surfaces guidelines available at www.ne‐ vadaaware.com/home/GuidelinesEnvInfectControl908.pdf. may be consulted [62].
