Implementation of Good Practices towards Clostridium Difficile Infection - Essay Example

Implementation of Good Practices towards Clostridium Difficile Infection Background Infection control is a continuous process requiring the efforts of patients, healthcare givers and the community (Donskey, 2010). Many of the infectious agents have adapted to life cycles that guarantee their survival despite the many infection control measures in place. Nosocomial infections are increasingly becoming common across different sections of healthcare institutions (Angenent, & Kelley, 2009), (Katzenstein, 2011). Among the common infectious agents causing nosocomial infections is Clostridium difficile, a case that will be used in this analysis. Interventions compliant with the implementation of good practice have been shown to be effective in controlling and preventing infectious diseases (Donskey, 2010). Areas of nursing practise in healthcare setting are among the most commonly affected section owing to the nature of their functions. This topic highlights good practise implementation strategies and their challenges applicable in nursing care setting especially in a medical ward. The paper discusses and avails guidelines on the fundamental principles of infection prevention and control highlighting the importance of issues such as nutrition and hydration, which form the essential components complementing the nursing practice. The main objective involves coming up with a summary of the key elements and rationale for C. difficile infection prevention and related activities. The scope of application includes all nurses, midwives, and health care assistants despite their practice locale. This is because the entire nursing fraternity, midwives, and other healthcare assistants carry by default a role to prevent microbial associated diseases especially hospital acquired infections (Anderson, Mackel & Stoler, 2008). Accordingly, the information within this analysis is useful and at least partially applicable to all stakeholders within the medical field (Donskey, 2010). Current guidelines and standards. Infection prevention is key in saving lives and reducing morbidity in infected individuals. Successful preventive measures requires good practises, which is a set of standard principles in Nursing Practice, enshrined in principle C; which states that, “Nurses and nursing staff manage risks, are vigilant about the risks, and promote safety for everyone in the place they receive care” (Watterson et al., 2012). Good practice is essential in achieving quality in nursing care and clarifying the effectiveness of nursing contributions towards better health care outcomes and patient experiences (Currie et al., 2011). Apart from good practices, healthcare providers need to adhere to standard safety measures, which are guidelines that ensure safety for both staff and clients in a health or social care organization. According to these guidelines individuals diagnosed with C. difficile infections should be isolated and managed in side wards (DH and HPA. 2008). In this side wards, it is mandatory for every person to follow the guidelines in order to ensure safe practice and control of Clostridium difficile infection as well as other infectious agents (DH and HPA. 2008). Eventually, this best practice becomes natural, and the risk of infections minimized (Duckro, 2012). Good practices in care seek to achieve utmost hand sanitation since hand contamination is a common route of pathogen transfer (DH and HPA. 2008). Secondly, developing a culture of using personal protective equipment is recommended to ensure safety precaution and best practices in nursing practice. Personal protective equipment protects both the patient and the caregiver from cross infections that are common with infectious diseases. Sharps are a common in causing accidents that result in a transmission of infection (DH and HPA. 2008). Safety precautions, therefore, promote and foster safe handling and disposal of sharps thus reducing cases of accidents among caregivers (DH and HPA. 2008). These measures also promote safe handling and disposal of clinical waste as a way of reducing nosocomial infections that can be spread through other routes transmission. The other objectives of safety precaution include; proper handling of blood and bodily fluids, decontamination of equipment at all times, retaining and maintaining a clean environment (clinical), appropriate use of indwelling devices among others (Haley et al., 2014). Clostridium Difficile Clostridium difficile also written as C. difficile or C. diff, is a bacterium that is infective for both humans and animals (Asensio & Monge, 2012). The prevalence of C. diff infections is gradually on the rise with increasing morbidity and mortality (Gomez-Simmonds, Kubin, & Yoko, 2014). Cases of C.diff drug resistance have been noted and empirical evidence shows that hospitalized patients are more susceptible than healthy (non-hospitalized) individuals (Landelle et al., 2014), (Struelens, 2009). Patients with mild symptoms of the infection have a better prognosis and may improve quickly with antibiotic medications (DH and HPA. 2008) . However, those with severe symptoms need advanced or combined (using 2-3 antibiotics) antibiotic treatment (Gomez-Simmonds, Kubin, & Yoko, 2014) Risks Factors Every employee working in the health department has a key responsibility to ensure the prevention and control of infections in work places as well as in the community. This responsibility covers all health and social care organizations, regardless of the patient setting or care provider. Good health practice is geared towards prevention and management of infections caused by pathogens such as C. diff while ensuring patient and provider safety (Madan et al., 2014). There are many attributions to infection or diseases, for example, different microorganisms such as bacteria, fungi, viruses, and prions cause a myriad of infections and diseases (Beltrami, 2010). Some of the diseases caused by these pathogens include; urinary tract, wounds, respiratory, blood, bone and skin infections (Beltrami, 2010). To say that not all infections are transmissible will be in order, nonetheless, the majority of them such as influenza, clostridium difficile and norovirus can be transmitted from one person to another hence end up causing transmissible infections (Artel, 2011). Health and social care facilities especially medical wards generate a challenging environment in the hemispheres of infection control due to the operations undertaken on a daily basis (Juneau et al., 2013). In such environments, cross infections and the transfer of microorganisms to and from patient, equipment and staff is highly probable. It is a safety precaution to be vigilant and extra careful at all times when working in these environments due to the risks involved. Pressure associated with opportunist pathogens and the intensity and complexity of health care environments increase the vulnerability of these areas (Angenent & Kelly, 2009). Measures such as making sure that the clinics, health centres, and social care facilities remain clean, and washing hands regularly, ensuring knowledge and skills for promotion of a clean environment contribute greatly in minimizing the risk of cross infection in these surroundings (DH and HPA. 2008). Clinical Features and Diagnosis Clostridium difficile belongs to a family of other pathogens that cause tetanus and botulism (Neuberger, Saadi, Shetern, & Schwartz, 2013). The C. difficile bacterium has two forms in its natural history. The first is the active infectious form that cannot survive in the environment (outside a host) for prolonged periods (Neuberger, Saadi, Shetern, & Schwartz, 2013). The other form is inactive and it is referred to as spore and it can survive in a harsh environment for a long period of time. Spores do not cause infections directly however, when ingested they transform to the active form, which establishes an infection inside the host (Neuberger, Saadi, Shetern, & Schwartz, 2013). These spores can be found nearly everywhere in the environment including medical and general wards. When ingested the spores remain inactive in the gastrointestinal truct until a person takes an antibiotic (Neuberger et al., 2013). The antibiotic disrupts the normal flora of the colon, which is essential in preventing C. difficile colonisation (Neuberger et al., 2013). Normal flora such as E.coli competes with pathogen for attachment surfaces in the gut thereby reducing the chances of it establishing an infection (Neuberger et al., 2013). As a consequence, disrupted normal flora due to broad spectrum antibiotic treatment, which causes C. difficile to transforms into its infectious form and produce toxins that inflame and damage the colon (Donskey, 2010). The inflammation results in a chemotactic migration of white blood cells (WBCs) to the colon as an immunological response to control the spread of the pathogen. WBCs engulf (eat) the pathogenic bacteria in a process known as phagocytosis. In severe cases, the toxins cause necrosis of the cell and tissues on the inner lining of the colon, forming tissue debris (Currie et al., 2011). The tissue debris mixes with white blood cells and gives the appearance of a white, membranous patch covering the inner lining of the colon (Donskey, 2010). This severe form of C. difficile colitis is called pseudo-membranous colitis because the patches appear like membranes (Aiello & Larson, 2010). Another condition caused by Clostridium difficile infection is colitis. In colitis, the pathogen produces endotoxins that damage the lining and integrity of the colon. The symptoms of a mild Clostridium difficile infection include diarrhoea, fever, and abdominal pain (Keessen, Harmanus, Dohmen, Kuijper, & Lipman, 2013). In chronic infection, the pathogen can cause severe complications, such as dehydration, rupture of the colon, and systemic infections (Keessen, Harmanus, Dohmen, Kuijper, & Lipman, 2013). C. difficile colitis has the highest frequency in inpatients, though the number of cases reported in outpatients shows a gradual increase (Keessen, Harmanus, Dohmen, Kuijper, & Lipman, 2013). The control and prevention of C. difficile therefore is a responsibility burden for social care facilities, health organizations and the nursing profession in delivering proper care. The diagnosis of C.diff involves both clinical observations and laboratory test. Laboratory tests such provide confirmatory results by isolating and identifying the pathogen or its toxins. Some of the laboratory tests include isolation of the pathogen in faeces and serological screening for toxoids (DH and HPA. 2008). Treatment for C. difficile infection Doctors prescribe a ten day course of one of the following oral antibiotics. The first line drug is metronidazole (flagyl) and the second line treatment is dificid (fidaxomicin) (Crawford, Huesgen, & Danziger, 2012). A third regiment that is still effective in clearing C. difficile infection is vancomycin (vancocin). Flagyl as a first line drug is expected to show patient improvement within 72 hours of administration. However, the drug may have side effect of diarrhoea, which should not be confused with that caused by the pathogen or its toxins. During treatment other supportive interventions include taking plenty of water and other fluids to replenish the lost fraction. A person can also get intravenous fluid to prevent dehydration (Perez et al., 2013). Therefore, antibiotics are very effective in the treatment and management of C.difficile infections. General principles of infection and control of C. difficile Effective preventive measures of any infectious agent caused disease require a broad understanding of its transmission channels. Majority of the preventive measures target certain stages of its natural history especially those causing transmission. There are a couple of methods through which C. difficile can be transmitted. a). Methods of transmission i). Contact transmission Transmission of C. defficile by contact is one of the commonest route reported in a significant number of studies (Pu et al., 2014). This contact can either be direct or indirect. Direct contact transmission is said to occur when the pathogens responsible for infection development are transferred from one person to another. For example, transmission of the pathogen through contact with body fluids such as patient’s blood through contaminated sharps. On the other hand, indirect conduct transmission occurs when a pathogen affects an individual via an intermediate. The intermediate can be an object or a person. For example, nurses’ hands can transmit infectious pathogens after touching an infected patient with bare hands or protective gear, and touch another individual (through a handshake) without the protective gear or cleaning their hands (Katzenstein, 2011). In this mode both the vegetative and spore forms of C.difficile can be easily transmitted across individuals as previously explained. ii). Droplet transmission Droplet transmission transmits C. difficile pathogens from one person to another through activities such as coughing, sneezing or talking and during the performance of certain procedures. Droplets are small and contain C. difficile pathogenic particles that are larger than five microns in size (Stanley et al., 2013). They transmit infections when they travel directly from the respiratory tract of an infected person to susceptible mucosal surfaces of another person (McManus, 2010). The limitations for this transmission include gravity and distance through, which the particles must travel. However, they are effective in congested population with poor ventilation. The effect of gravity on the particle reduced the distance it can travel. However, such droplets can also be transmitted via indirect method, especially, when they come to contact with mucosal surfaces. iii). Air born transmission Airborne transmission occurs when pathogen particles hang in the air for a longer period. A person creates small particles during talking, breathing, coughing or sneezing (Arlet, 2011). These particles, through evaporation, hang in the air such that if a person is infected, the pathogens will affect other persons. Infections occur during diagnostic sputum induction, bronchoscopy, airway suctioning, end tracheal intubation, positive pressure ventilation through facemasks and high frequency oscillatory ventilation (Keessen et al., 2013). The pathogens hanging in the air can travel long distances due to air current movement, hence, creating a larger contaminated environment. When a person inhales, the air passes through a mucous respiratory tract creating a breeding zone for the pathogen to build a nest. Spores of C. difficile can be easy transmitted by this route since they survive in the environment for long periods. b). Scope of transmission Clostridium difficile infection (CDI) has negatively impacted the health of healthcare providers and patients to a greater over the years (Hutin & Hauri, 2010). As such, the scope of infection for this disease is primarily associated with the use/overuse of certain antibiotics (Hutin & Hauri, 2010). As the medical profession is already well aware of the potential risk that an over-dependence upon antibiotics creates, the added risk for the potential transmission of CDI is a further complication that must be addressed Moreover, from an analysis of the relevant and existing healthcare data, it is clear and apparent that the broad majority of new C. difficile infections take place in managed care facilities; such as hospitals and nursing homes (Hutin & Hauri, 2010). As such, standard precautions involve work practices that should be applied by all workers, patients and visitors within a health environment or social care facility to prevent these infections. This also ensures effective control of other infections. Taken as the first approach towards good health practices, these standard precautionary measures, attain maximum prevention and control of infections. In general, they are preventive measures implemented to break the spread of infections (Duckro, 2012). c).The risk management basics In the context of this research, the term ‘risk’ means the possibility of contracting C. difficile infections from patients or health care workers from activities emanating from the healthcare environments. On the other hand, risk management includes the interventions preventing and reducing harm arising from C. difficile pathogen causing infections (Duckro, 2012). Three levels for successful approaches to risk management in a health environment exist. The first level is the wide facility level where support for effective risk management is done through organizational risk management policy, staff training, follow-up of outcomes and monitoring and reporting evaluation. The other level is the word or departmental based. Inserting risk management is configured in all policies, in a view, to considering risks in all situations (Calfee, & Farr, 2011). The third is at the individual level, where specific procedures performed by individuals are run through a risk assessment basis and necessary precautionary measures adopted. For instance, providing education sessions on hand hygiene to all parties involved (Duckro, 2012). The standard of risk management outlines several steps or approaches that allow continuous quality improvement on risk management methods. The first step involves establishing context that is identifying the basic parameters that are required to manage risks. The second step is avoiding risks; it entails an establishment of whether there is a risk and if the risk is avoidable in future events (Aiello & Larson, 2010). The next step is identifying potential risks such that all potential risk are addressed during analysis and treatment. The other important step is analyzing the risks such that the source of the risk, impact and likelihood of occurrence are identified. The next step encompasses risk evaluation so that priorities are identified. The last step embraces treating the risk by implementing appropriate management and control options and standards (Bhalla, 2010). Through further examination of Table 2.0, represented within the appendix of this analysis, the reader can come to a more informed understanding with respect to the different levels and potential treatments that CDI should be engaged with; dependent upon t he symptoms and overall level of severity that is engenders (Bhalla, 2010). Good safety practises in nursing care There are a number of good practice recommendations and can ensure effective and efficient management of C. difficile cases. Some of these recommendations are discussed below. I). Hand hygiene The risk involves transmitting C.difficile pathogens through touch (Duckro, 2012). Most of the time, hands harbour microorganisms that cause infections such that touching may bring a shifting effect of pathogens (Moehring et al., 2013). Hands are contaminated especially with respiratory fluid during events like coughing or sneezing. Struelens (2009) outlines that contaminated hands lead to cross-transmission of pathogens in non-outbreak situations. Evidence based research has shown that most health workers, visitors and patients do not decontaminate and clean their hands as often as is required (Juneau et al., 2013). It also shows that the correct techniques are not observed during decontamination processes (Beltrami, 2010).Hand hygiene is mandatory in high dependency (medical wards) according to the current guidelines. The standard procedure for hand hygiene states that hands must be decontaminated through a routine hygiene procedure (Beltrami, 2010). The procedure involves several steps. These steps stipulate that hands must be decontaminated before touching a patient, before a procedure, after performing a procedure or body substance exposure risk, after touching a patient and after touching a patient’s surroundings (Aiello, & Larson, 2010). One of the most effective means of remediating against the potential spread of CDI is to ensure that the best practice of healthcare sanitation is practiced. Although it involves a litany of steps, proper healthcare professional hand sanitation has definitively been proven to have a direct correlation to the overall spread of this disease (Asensio & Monge, 2012). It is also necessary to decontaminate hands after removal of protective gloves (Aiello & Larson, 2010). It is a standard procedure to decontaminate hands after visiting the toilet, touching any equipment in the surroundings, and after hands becoming visibly soiled. Before starting or leaving work, eating or handling food and drinks, using or touching any equipment, the hands are supposed to be decontaminated (Headley, 2012). However, the research points out that evidence shows neglect in all these areas in general (Beltrami, 2010). II). Personal protective equipment Transmission of C. difficile pathogens through contact or droplet route creates several risks. Contamination can take place between the workers, patients, environment, and visitors. Transmission occurs through contact with mucous membrane of an infected group patient (Inns, 2013). Personal protective equipment refers to protective barriers used to isolate and contact any elements that may cause infections (Aiello & Larson, 2010). The equipment isolates mucous membrane, airways, skin and clothing from contact with infectious agents. Examples of protective gears used as part of standard precautions include aprons, gowns, gloves, surgical masks, and protective eyewear and face shields. Studies by scholars such as Ramanathan (2014) indicated that most health care employees follow the standard procedures for protection purposes. They are aware that the use of these barriers acts as a protective measure to all persons in these environments (Calfee, 2011). Several factors are considered as guidelines to the protective gear a person will use on different occasions. The first factor is the probability of exposure to blood and body substances. The second factor considers the blood substance involved. The last factor embroils route of transmission of infectious agents (Aiello & Larson, 2010). Evidence points out that not all personal preventive equipment meet therapeutic goods criteria hence putting the staff at risk (Aiello & Larson, 2010). In other instances, workers neglect stipulated manufactures instructions on the use of this equipment. The risk assessment of the situation will guide on how and which protective equipment should be used (Donskey, 2010). III). Handling and disposing of sharps The risks involve exposure of health workers to sharp objects. Sharps puts health workers at risk of injury and the potential exposure to blood borne infectious C. difficile pathogens (Toepfer et al.,2014). Statistics containing evidence based show that injuries occur most often in the following scenarios: (Donskey, 2010) a). During use of a sharp device on a patient (41%); b). After use and before disposal of a sharp device (40%); and c). During or after appropriate or inappropriate disposal of sharp devices (15%) Sharps objects include needles, scalpels, stitch cutters, glass ampoules and all other sharp instruments. The survey shows that accidents are common in health environments showing that many nurses obtain at least one needle stick or other sharp objects injuries (Hutin & Hauri, 2010). Spores of C. difficile can contaminate wounds caused by sharp accidents. IV). Safe handling and disposal of chemical wastes Standards provide that every work place should have a written policy on waste disposal, which provides guidance on all aspects, including special waste, such as pharmaceuticals and cytotoxic waste, segregation of waste and audit trails (Crawford et al., 2012). Mixing immix-able wastes causes an eruption of endogenous reactions that enhance pathogen growth. The pathogens cause infections. Evidence based findings show that many organizations do not take keen consideration of labelling their waste bags (Kundrapu et al., 2014). Some health facilities dispose of sharps with other waste products posing a risk in the collection of waste. Such sharp objects should be placed in containers that could not burst hence containing them in a safe environment (Herwaldt, 2011). Clinical waste is a potential source of infection for C. difficile. V). Routine management of the physical environment Studies suggest by such researchers as Lofgren et al. (2014) indicate that there is evidence based upon the understanding that microorganisms hide extremely well within the health facility environment. Evidence from Lofgren points to the fact that eruptions of the bacteria are suggesting an association between poor environmental hygiene and the transmission of infectious pathogens in health care settings and social care settings. Transmission occurs through direct or indirect contact with contaminated equipment. In other cases, the fixtures and fittings were inappropriate hence acted as agents of pathogen harbour eventually transmitting the pathogens to people who encounter the fixtures. The principle practice of good conduct stipulates that health facilities should be patient friendly and offer a safe environment for care (Struelens, 2009). VI). Reprocessing of reusable instruments and equipment According to Rahimi et al,. (2014) any infectious agent introduced into the body may result in infection. Other studies have shown that not in all health care facilities reusable instruments and equipment are handled in a manner that will prevent patient, healthcare workers and the environmental contact from potential degeneration of infectious materials (McManus, 2010). McManus (2004) also stipulates that single-use medical devices should not be reprocessed as they cannot withstand the processes. Facilities must, therefore, seek licenses in case they want to start reprocessing equipment in order to maintain acceptable standards. All health centres should be open at all times for internal and external audit to encourage them to comply with the set standards. All the equipment that can be reprocessed should undergo several steps of reprocessing in a systematic order. For instance, majority of these equipments must be disinfected, cleaned, disinfected again and then sterilized. Empirical evidence shows that many health care workers at times do not follow the standard procedure for reprocessing (McManus, 2010). As a consequence, spores of C. Difficile can easily survive in these equipments and result in transmission of the pathogen. Conclusion In general, the paper has addressed recommended ways that promote good practice in the nursing profession. Several factors are involved in forming important aspects of strategies that are reliable in creating a healthy co-existence in a social care and health environment. The first aspect that requires high sensitization is hands hygiene. People should regularly clean their hands in order to minimize pathogen infection effects. After washing, hands should be dried so that the microorganisms do not get moisture necessary for their survival. Healthcare providers are provided with options of using personal protective equipment to curb infections. There are several methods of transmission that key in providing a healthy working environment. These methods include contact transmission, droplet transmission, and airborne transmission among many others. For effective prevention and control of infection transmission, the basic factor identified is hygiene. Good practice is a responsibility bestowed to health workers, patients, and even visitors of health care-centres. They are all responsible for maintaining a healthy environment free from infectious agents such as C. difficile prevention and control of infections Recommendations Hand decontamination should be done before contact with the patient and after any activity that may contaminate the hands. This includes decontamination after removing of gloves. Use of quality methods to disinfect hands such as alcohol, gels and hand rubs are also essential in preventing transmission of diseases. The health facilities should station many washing points so that visitors and patients can wash their hands regularly. Using inappropriate methods for drying hands may increase potentiality for pathogen transfer. For instance, sharing of hand towels should not be recommended. Instead, Quality paper for drying should be stationed at all washing stations to facilitate quality drying. Health workers should ensure that they use personal protective equipment and follow all instructions placed by manufacturers and health standard practices. Use disposable gloves whenever there is an impending contact with body fluids and blood. Proper ways of wearing gowns and aprons should be taught to all health workers to avoid touching them at areas where they are contaminated. Health care facilities should purchase instruments that help in grasping needles, retract tissues and load/unload needles and scalpels to prevent direct contact with them and avoid accidents. This is especially applicable in areas of nursing that involves daily handling of sharp objects such as needles. Appropriate ways of disposing of single-use sharps should be devised in order to avoid accidents should be recommended in all areas of nursing dealing with clinical waste. Labelling of all the waste bins is essential in enhancing waste segregation that minimizes health hazards.References Aiello, E & Larson, L. 2010. What is the evidence for a causal link between hygiene and infections? Lancet Infect Dis 2(2): 103–10. (viewed 10th March 2014) Anderson, L., Mackel, D. C., & Stoler, B. S. 2008. Carpeting in hospitals: an epidemiological evaluation. J Clin Microbiol 15(3): 408–15. (viewed 10th March 2014) Angenent, L. T., & Kelley. S. T. 2009. Molecular identification of potential pathogens in water and air of a hospital therapy pool. Proc Natl Acad Sci U S A 102(13): 4860–65. 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Data extraction table World health organization Guidelines on hand hygiene in health care (2010) United state centers for disease control and prevention Workbook for designing, implementing and evaluating a sharps injury prevention program (2008) Guideline for disinfection and sterilisation in healthcare facilities (2009) Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings (2007) Management of multidrug-resistant organisms in healthcare settings (2010) Guidelines for infection control in the dental setting (2008) Guidelines for environmental infection control in health-care facilities (2009) Source: Table 2.0 Showing a relationship between risks and severity of Infectious borne diseases. Likeli- hood Consequences Negligible Minor Moderate Major Extreme Rare Low low Low Medium Very high Unlikely Low Medium Medium High Very high Possible Low Medium High Very high Very high Likely Medium High Very high Very high Extreme Almost Certain Medium Very high Very high Extreme Extreme Low risk Manage by routine procedures. Medium risk Manage by specific monitor or audit procedures High risk Very high risk Extreme risk This is serious and must be addressed immediately Source: Read More