Infection Prevention (Chapter 24)


Learning Objectives

After completion of this chapter the participant should be able to:

This chapter includes sectiond on:
handwashing
patient isolation
cleaning solutions and
reprocessing single-use devices


Introduction

Introduction of essential devices to newborn care units is critical to improving newborn survival. However, devices can increase hospital acquired infections if adequate disinfection and cleaning measures are not put into place.

This module focuses on infection control measures associated specifically with the essential devices, staff and visitors. A comprehensive discussion of infection prevention and control measures for a newborn care unit is beyond the scope of this document. Please refer to local and WHO guidelines for more detailed practice guidance.

Ward Infection Prevention

Hospitals, wards, equipment and staff are all sources of infection for a baby. These infections are called Hospital Acquired Infections (HAI).

HAIs are often caused by bacteria that are resistant to commonly available antibiotics - multidrug resistant bacteria - and are difficult to treat or eradicate from the nursery. Meticulous care is required to prevent infections from spreading from one baby to another in the ward. The prevention and control of all infections include:

Water, Sanitation and Hygiene (WASH) are key elements in preventing and controlling infections.1

Infections are a major cause of morbidity and increased mortality. They often result in prolonged hospital stays and increased costs to the family. Sick and small neonates are at higher risk than other patients of acquiring HAIs due to the number of devices they may come into contact with in neonatal units. Lowering rates of HAIs means less use of antibiotics and ultimately fewer infections with multidrug resistant bacteria which are very difficult to treat in newborns.

While there are a number of critical elements associated with infection prevention and control in newborn units that will be discussed here, the two most important forms of infection control are always hand washing and health screening.

HANDWASHING

Hand hygiene is the single most important measure to reduce transmitting infections between people and from one site to another on the same patient. All guardians, health care workers (HCWs), or visitors should be taught thorough handwashing (using the WHO technique).

Hand washing or sanitising should be the last thing you do before touching a patient and the first thing you do after completing tasks on a patient

GLOVES

Gloves are worn to protect both HCWs and patients by reducing the spread of infection from bacteria on the hands. Gloves do not change the need to wash or sanitise one’s hands between patient interactions. Gloves should be worn only when necessary and disposed of immediately after use, such as when:

Repeat hand washing or sanitising promptly after removing gloves.


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DRESS CODE

All hospital staff (including HCWs, maintenance and cleaning staff) should wear clean clothes with bare arms below the elbow when entering the neonatal ward. Department policy should be followed; this usually includes that no jewellery (apart from plain wedding bands) is worn, and that nails are kept short, natural, and unvarnished.

Gowns are not a standard precaution for HCWs or families in most neonatal units; if gowns are used, they should not be shared or reused until re-washed.

HEALTH SCREENING

Any HCW or guardian with an acute or transmissible infection should not be on the ward to minimise the spread of infection. Mothers or guardians who have an acute illness should be isolated with their infants, if possible. Any guardian who has an acute respiratory illness should wear a mask and be especially careful about hand washing.

Environment

PATIENT ISOLATION

Departmental isolation policies should cohort at-risk patients with similar infections in an isolation area within the nursery (e.g., babies with multi-drug resistant infections, highly contagious infections, babies born before arrival with signs of infection or any patients with airborne infections). Strict hand hygiene measures should be followed on entry and exit from this area. If equipment is used in any areas where patients are isolated, it should not be returned to the main neonatal care ward until it has been thoroughly cleaned and disinfected according to ward protocol.

Patients should not share cots or radiant warmers. If circumstances mandate that such a practice is unavoidable, cohorting patients with similar illnesses is preferred.

EQUIPMENT CLEANING

All neonatal medical equipment (suctions, CPAP, vital sign monitors, radiant warmers, etc.) should be cleaned regularly in accordance with the training modules and equipment manuals. WHO recommends 0.5% dilution of chlorine as the standard disinfectant for materials and surfaces contaminated by blood or body fluids.2 For metal and rubber surfaces which may be corroded by chlorine, 70% alcohol is also commonly utilised for low level disinfection. Table 3.1 below provides more information on low-level disinfectants appropriate for neonatal wards.3 Cleaning should be carried out when the equipment power source is switched off and it is unplugged. Care must be taken not to let water or other liquid enter internal to a device. Diluted disinfectants have various lifespans; ward guidelines should include accurate lifespans and dilution schedules for those in standard of practice.

TABLE 3.1 CLEANING SOLUTIONS

Disinfectant
Common Name
Recommended Use User & Equipment
Precautions
Sodium Hypochlorite,
0.5% or 1%

liquid bleach

General disinfectant

Kills bacteria, fungi, mycobacteria, spores & viruses

Not affected by hard water (e.g., high mineral content water)

Use 0.5% concentration for disinfection of surfaces & equipment contaminated with blood and body fluids

Use in well-ventilated area

Respiratory irritant (can cause breathing problems)

Appropriate PPE required while handling & using because it can cause skin irritation and burns

Should not be mixed with strong acids or ammonia to avoid release of chlorine gas

Alcohol, 70%

isopropyl, ethyl alcohol, surgical spirit

Use on smooth surfaces, table tops, aprons & other small surfaces on which bleach cannot be used (e.g., metal, rubber)

Can be used for surfaces including rubber stoppers on medication vials Does not leave residue

Use in well ventilated area and avoid inhalation

Keep away from active heat sources, electrical equipment, flames, hot surfaces. Alcohol must always completely dry on equipment prior to use as otherwise it could result in fire.

Allow to dry completely before using area

Quaternary ammonium compound

listed as % concentration of QUAT
on different cleaning solutions

General disinfectant for surfaces/equipment contaminated with blood & body fluids

Kills bacteria, fungi and some enveloped viruses (HIV)

Has persistent antimicrobial activity when undisturbed

Use in correct dilution and pour only enough for current use

Does not kill spores, TB or non-enveloped viruses

Hard water, cotton/gauze, organic matter reduce its effectiveness

Iodophor

More commonly used as an antiseptic than a disinfectant

Causes damage to silicone catheters

Improved peroxide hydrogen

General disinfectant for surfaces or equipment contaminated with blood & body fluids

Unaffected by organic matter Non-corrosive & safe for workers

Can be expensive, particularly if purchasing large quantities

Phenolic germicidal detergent

Dettol, Triclosan

Should not be used in neonatal wards since affordable, effective alternatives are available

May cause hyperbilirubinemia and/or neurotoxicity in neonates4

Bleach is one of the most common substances used to disinfect medical devices. Diluted bleach solutions have a lifespan of 24 hours and should be prepared daily. Possible products are presented in Table 3.2 with appropriate ratios to dilute to a 5% solution.

TABLE 3.2 BLEACH PREPARATION

Product

% Chlorine Available Diluting to 5% Solution

Sodium Hypochlorite
liquid bleach

5.25 – 6.15%

1-part bleach to 9 parts clean water
RATIO [1 : 9]

Sodium Hypochlorite
liquid bleach

3.5%

1-part bleach to 6 parts clean water
RATIO [1 : 6]

NaDCC (Sodium Dichloroisocyanurate)

Powder

60%

8.5 grams to 1-liter clean water
RATIO [8.5 g : 1 L]

NaDCC, 1.5 g/tablet

tablet

60%

6 tablets to 1-liter clean water
RATIO [6 tablets : 1 L]

ROUTINE CLEANING

All horizontal surfaces, including bedside equipment (bed rails, bedside tables, trolleys, commodes, taps, weighing scales, etc.) are cleaned and disinfected with a hospital-approved detergent OR disinfectant such as 0.5% chlorine or 70% alcohol solution at least daily and whenever visibly soiled.

Between patient admissions, all cots and patient beds should be cleaned thoroughly (including all surfaces of incubators) with a hospital-approved detergent/disinfectant such as 0.5% chlorine or 70% alcohol solution.

Floors, surfaces, and handles in the neonatal unit should be cleaned daily with appropriate solutions and according to departmental policy.

SAFE HANDLING OF SHARPS

To prevent injuries, use extreme caution when handling sharps. This is particularly pertinent whilst drawing blood during glucometer reading.

Place disposable syringes, lancets, needles, and other sharp items promptly in appropriate puncture-resistant containers.

Reprocessing Single-Use Devices

In general, all single use devices should be used as such. However, in resource limited settings consumables meant for one-time use are commonly reused due to cost and supply chain limitations.

Departmental policy for disinfecting and reprocessing single-use-devices must always be strictly followed in order to prevent infection spreading between patients.

When reprocessing single-use devices, it is extremely important that the cleaning process is not delayed following completion of use. There should be a detailed standard of practice as well as oversight processes for ensuring timely and high-quality reprocessing. If equipment is not reprocessed promptly or adequately between patients, it poses a significant infection risk. Please refer to the Reference Manual for Health Care Facilities with Limited Resources Infection Prevention and Control, Module 63 for more detailed guidance on reprocessing of single-use devices.

Respiratory circuits, tubing and equipment are the most commonly reprocessed single-use devices. Syringes, needles, and disposable gloves must never be reprocessed.

Key Facts for Providers:
Infection Prevention
  • Hospitals, wards, equipment, and staff are all sources of infection for a baby, their family and other health worker.
  • Infections are a major cause of morbidity and increased mortality and neonates are at higher risk than other patients of acquiring hospital associated infections (HAI).
  • Control of HAI must include hand hygiene, environmental cleanliness, medical equipment maintenance and cleaning, waste disposal.
  • The two most important forms of infection control are hand washing and health screening.
  • Hand hygiene is the single most important measure to reduce transmitting infections.
  • Health care workers and guardians at risk of transmitting or obtaining infections should not be on the ward.
  • Facility dress code should be adhered to prevent infections.
  • Infection prevention and cleaning protocols must be followed at all times for cleaning of equipment, linen, preparations of feeds and all procedures.
  • Isolation should be available for high risk or infectious patients.

References

  1. Water, sanitation, hygiene and health: a primer for health professionals. Geneva: World Health Organization; 2019 (WHO/CED/PHE/WSH/19.149). Licence: CC BY-NC-SA 3.0 IGO.
  2. World Health Organization, Regional Office for the Western Pacific, World Health Organization & Regional Office for South-East Asia. Practical guidelines for infection control in health care facilities. (World Health Organization, Regional Office for Western Pacific ; World Health Organization, Regional Office for South-East Asia, 2004).
  3. Sharma, G. Infection Prevention and Control at Neonatal Intensive Care Units. 134.
  4. Curless MS, Ruparelia CS, Thompson E, and Trexler PA, eds. 2018. Infection Prevention and Control: Reference Manual for Health Care Facilities with Limited Resources. Jhpiego: Baltimore, MD.