UNIT-8

INFECTION CONTROL IN CLINICAL SETTING

INFECTION

Nature of Chain of Types of Methods of

infection Infection infection transmission

 Nature of infection
 Chain of Infection
 Types of infection
 Methods of transmission

Introduction:

The word "infection" is different from "disease," although the two terms
sometimes are confused. Disease is a general word that describes any abnormality of the
human body or something that interferes with the normal, healthy functioning of the body.

Infection is a term that refers specifically to any abnormal condition caused by a

microbe such as a bacterium, virus or parasite causing interference to some aspect of its
function. An infestation is similar to an infection. It refers to any abnormal condition caused
by an organism larger than a microbe, such as an insect, louse or worm. The phrase
"infectious diseases" is used to refer to both infections and infestations, regardless of the
severity of the condition.
Definition:

Infection is the invasion of body tissues by disease-causing agents, their

multiplication and the reaction of host tissues to the infectious agents and the toxins they
produce.

Infection is the invasion of a susceptible host by pathogens resulting in a disease.

Infection results only if the pathogens invade the host. multiply and alert normal
tissue function.
If the infectious disease is transmitted from one person to another it is called
contagious or communicable disease

CHAIN OF INFECTION

A communicable disease is caused by the transmission of a specific infectious agent

or its toxins from an infected person or animal to a susceptible host. The transmission takes
place either directly or indirectly through intermediate hosts, fomites or vectors. The disease
results from the interaction between the agent and susceptible host. Knowledge of each
component of chain of infection is helpful to understand the natural history of communicable
disease for effective control and intervention.

There are six links in the chain of infection:

 The etiologic agent or micro-organism

 Reservoir (source)
 Portal of exit
 Method of transmission (mode)
 Portal of entry into a host
 Susceptibility of the host
a. Etiologic Agent / Infectious agent

A parasite is an organism that lives in a host and obtains its nourishment from it. The
capability of organisms to produce infectious process depends on many factors such as:

 Number of organisms present,

 The virulence and potency of the organisms (pathogenicity)
 The ability of the organisms to enter into the body.
 The susceptibility of the host and ability of the organisms to live in the host's body.

b. Reservoir / Source

 The reservoir must have certain characteristics such as availability of food, water and
oxygen to grow. Some organisms live in the absence of O, (anaerobic).
 Insects, birds, and other animals are common reservoirs of infection.
  The culex mosquito carries the filarial parasite Food, water, milk, and feces also can
be reservoirs.

c. Portal of Exit from Reservoir:

Before an infection can establish itself in a host, the micro-organisms must have the
reservoir, if the reservoir is within a human. The micro-organisms have a number of exits,
depending on the site of reservoir.

RESERVOIR PORTALS OF EXIT

Respiratory Tract Sputum, exhaling air, through nose/mouth via sneezing,
coughing, breathing or talking, endotracheal tubes or
tracheostomies
Gastro Intestinal Tract Saliva, vomitus, gastric aspirants, anus/ostomies, feces, drainage
Tubes
Urinary Tract Urine, Urethral meatus and Urinary diversion ostomies, sexual
contact, semen
Reproductive Tract Vagina, child birth, sexual contact
Blood Blood and blood product transfusion, contaminated needles,
wounds.

d. Methods of Transmission:

After micro-organism leaves a source or a reservoir, it requires means of transmission

to reach another person or host through a receptive portal of entry.

Direct Vehicle Borne

TRANSMISSION
METHODS OF

Transmission Transmission

Indirect
Transmission
Vector Borne
Airborne Transmission
Transmission
Direct Transmission:

 Direct transmission involves direct transfer of micro-organisms from person to person

through touching, biting, kissing or sexual intercourse.
 Droplet spread is also a form of direct contact but can occur only if the source and the
host are within 3 feet of each other. Sneezing, coughing, spitting, singing or talking
can project droplet spray into conjunctiva, or in to mucous membranes of the eye,
nose, or mouth of another person.

Indirect Transmission:

 Indirect transmission may be either vehicle-borne or vector borne.

Vehicle-borne transmission:

 A vehicle is any substance that serves as an intermediate means to transport and

introduce an infectious agent into a susceptible host through a suitable portal of entry.
 Fomites (inanimate material or objects) such as handkerchiefs, toys, soiled clothes,
cooking or eating utensils, surgical instruments or dressing can act as vehicle.
 E.g. Intravenous needle can be a vehicle for transmission of Micro-organisms from
the reservoir to the host. Water, milk, food, serum, and plasma are other vehicles. Eg.
Water may become contaminated by a food handler who transports the hepatitis 'A'
virus through the food and is then ingested by a susceptible host.

Vector-borne transmission:

 A vector can be an animal or flying or crawling insect that serves as an intermediate

means to transport the infectious agent Transmission may occur by the introduction of
salivary fluids during biting or by depositing feces or other materials on the skin
through the bite, wound or a traumatized skin area.

Air Borne-transmission:

 Air borne transmission occurs when droplet nuclei (residue of evaporated droplets
that may remain in the air for long periods of time) emitted by an infected host (eg.
One with tuberculosis) or dust particles containing the infectious agent (eg.
Clostridium spores from the soil) are transmitted by air currents to a suitable portal of
entry, usually the respiratory tract of another person.
e. Portal of Entry to the Susceptible Host:

 Before a person can become infected, micro-organism must enter the body. The skin
is the barrier to infectious agents however any break in the skin can readily serve as a
portal of entry Micro-organisms can enter the body through the same routes they use
to leave the body such as respiratory tract, urinary tract etc

f. Susceptible Host:

 A susceptible host is any person who is at risk for infection.

 Compromised hosts are persons "at increased risk" individuals who for one or more
reasons are more likely than others to acquire an infection.
 Impairment of the body's natural defences and a number of other factors can affect
susceptibility to infection.

TYPES OF INFECTION
Various types of infection are mentioned below
I. Primary infection: results directly from a specific pathogen e.g. Streptococcal throat
infection
Secondary infection: results indirectly due to another pathogen e.g. AIDS
Super infection: secondary infection that occurs during antibiotic therapy for a primary
infection
II. Acute infection: for a short duration but severe

Chronic infection: persisting over a long time

III. Endogenous infection: type of infection that originates from within the body

Exogenous infection: type of infection that originates from outside the body

IV. Symptomatic infection: organisms cause clinically detectable reactions

Inapparent/Subclinical infection: organisms not only multiply but also cause a

measurable reaction that is not clinically detectable

Latent infection: persisting in tissues for long periods in most of which there are no
symptoms

V. Localised infection: restricted to a limited region/area or to one or more regions

Systemic infection spreads throughout the systems of the body.

 The main characteristic of such an infection is that it affects the bloodstream of an
individual, with the result that the symptoms spread to the whole of the body.

In this case, the pathogen is distributed throughout the body, rather than being
concentrated in one area. Bacterial toxin is the major reason that leads to systemic infection

VI. Opportunistic infection: caused by a normally harmless bacteria that become

pathogenic upon favourable changes in their environment e.g. E coli causes urinary infection
(E. coli is normally found in GIT)

Iatrogenic infection: caused as a result of health care

VII. Pyogenic infection: resulting in pus formation.

Abscess: A localized infection with a collection of pus surrounded by an inflamed area.
STAGES OF INFECTION
The course of infection has the following stages
Incubation period

Prodromal stage

Illness stage

Convalescence stage

Stage Description
Incubation period Interval between entrance of pathogen into the body and appearance of
first symptoms e.g. incubation period of Chicken pox is 2 to 3 weeks
 and that of Covid-19 is 4days to14 days

Prodromal Stage Interval from the onset of non-specific signs and symptoms (malaise,
low grade fever, Fatigue) to more specific symptoms. Micro-organism
grows and multiplies and patient is more capable of spreading disease
to others.

Illness Stage Period when the patient manifests signs and symptoms specific to the
type of infection E.g. Chicken pox manifested by vesicles.

Convalescence stage Internal between the disappearances of acute symptoms of an infection

to the complete recovery. It makes take several days to months.

FACTORS INCREASING SUSCEPTIBILITY TO INFECTION

Individuals differ in their susceptibility to infections A more than normal tendency to
contract an infection or other disease is called susceptibility. Multiple innate factors (e.g. age,
nutritional status, genetics, immune competency), pre-existing chronic diseases and external
variables (e.g. concurrent drug therapy) influence the overall susceptibility of a person
exposed to a virus.

There are various factors that increase susceptibility to infection:

Age:

 Throughout the life span, susceptibility to infection changes.

 Newborn infant has immature defences against infection as he is born with only the
antibodies provided by the mother.
 The infant's immune system is incapable of producing the necessary immunoglobulin
and WBCs to adequately fight against infection.
 The young or middle age adults have adequate defences against infection.

Nutritional Status:

 A reduction in the intake of protein and other nutrients such as carbohydrates. fats and
vitamins reduce body's defences against infection and it impairs wound healing

Stress:
  The body responds to emotional or physical stress by the general adaptation syndrome
Adrenocorticotrophic hormone (ACTH) acts on adrenal gland to secrete a hormone
cortisone which acts to increase serum glucose levels and decrease anti-inflammatory
response.
 If stress increases, increased cortisone levels result in decreased resistance to
infection

Disease process:

 Patients with diseases of the immune system are at particular risk for infection e.g.
Leukaemia. AIDS, lymphoma, and Aplastic anaemia

Medical Therapy:

 The immune system attacks foreign bodies to prevent infections from spreading. A
weak immune system causes increased susceptibility to disease.
 Some drugs and medical therapies compromise immunity to infection e.g. immune
suppressant drugs Imuran.
 The nurse assesses the patient's history to determine whether he takes medications at
home that increase susceptibility to infection

Other factors include:

 Broken skin or mucus membrane- Intact skin acts as a mechanical barrier to prevent
organisms from getting into the body tissues.
 Traumatized tissues
 Decreased ciliary action. Mucous membranes can filter microorganisms out before
they get into the body
 Altered peristalsis
 Obstructed urine outflow
 Change in pH of Secretions.
 Reduced haemoglobin level
 Suppression of white blood corpuscles
 It may be drug related or disease related WBC ingests microorganisms by
phagocytosis and thereby reduce infection
 Thinner dermal and epidermal layers of skin decreases sweat and skin elasticity (in
older adults)
  Circulatory or heart disorders like congestive heart disease, calcified heart valves in
lower extremities.
 Dehydration, loss of saliva production
 Loss of ability to secrete Hydrochloric Acid in the stomach. HCI destroys organisms
in the stomach
 Increased colonization of oropharynx, decreased macrophages function, decreased
cough reflex

BODY DEFENSES AGAINST INFECTION

The micro-organisms are present everywhere from bacteria to viruses to fungi. Most
of them are perfectly harmless, but there are some that can harm the body. And it's because of
these pathogenic organisms our bodies have a sophisticated set of defence systems both
inside and outside.

Immunity is the ability of an organism to resist disease, produced in response to

natural exposure or inoculation (active immunity) or by the injection of antiserum or the
transfer of antibodies from a mother to her baby via the placenta or breast milk (passive
immunity)

External Défense Systems:

 The first line of defence includes physical and chemical barriers that are always ready
and prepared to defend the body from infection. These include skin, tears, mucus,
cilia, Hydrochloric Acid in the stomach, urine flow and white blood cells called
Neutrophils.
 Pathogenic micro-organisms must cross this first line of defence. If this defence is
broken, the second line of defence within the body is activated

Skin

 The skin is the largest organ of the body.

 It acts as a barrier between pathogens and body. The skin forms a waterproof
mechanical barrier.
 Micro-organisms that live all over the skin can't get through the skin unless it is
broken.

Tears, mucus and saliva

  The eyes, nose and mouth are entry points for pathogens The tears, mucus and
saliva contain an enzyme that breaks down the cell wall of many bacteria.
 Those that are not killed immediately are trapped in mucus and swallowed.
 There are special cells that line and protect the nose, throat and other passages
within the body.
 The inner lining of gut and lungs also produce mucus to trap invading pathogen

Cilia

 The cilia (very fine hairs) lining the respiratory tract move mucus and trapped
particles away from the lungs. Particles may be bacteria or material such as dust or
smoke.

Hydrochloric Acid in the stomach

 It kills bacteria and parasites that have been swallowed.

Urine flow

 The urine flow flushes out pathogens from the bladder area.

Commensal (beneficial) bacteria

 Commensal microbes are essential to human health. These bacteria are present on the
skin, in the mouth and in the gut and they stop other harmful bacteria from taking
over.
 Commensal microbes stimulate the gastrointestinal epithelium to produce
antimicrobial peptides (AMPs) that act as a first line of defence against invading
pathogenic bacteria.

Neutrophils

 These are white blood cells that can find, kill and ingest pathogens seeking an
entrance into the body (phagocytosis).

Internal Defence Systems

 Internal defence systems act when the external defences fail.

 This could be a virus or bacteria. Once it reaches this stage, it's called an antigen.
 When antigens multiply, body reacts to it.
 The entire internal defence system is called the immune system,
  White blood cells fight against dangerous organisms.
 White blood cells sense infections and move to attack the organisms.
 They ingest and kill the bacteria and they produce antibodies to shut down bacteria
and viruses.

Immune system

 The immune system is a defence system comprising of many biological structures and
processes within an organism that protects against diseases.
 To function properly, an immune system must detect pathogens. Acquired immunity
creates immunological memory after an initial exposure to a specific pathogen.
 It leads to an enhanced response to same pathogen on subsequent exposure.
 This process of acquired immunity is the basis for vaccination.

Immunodeficiency may be due to:

 Genetic disease such as severe combined immunodeficiency

 Acquired conditions such as HIV/AIDS
 Use of immunosuppressive medications.

Autoimmunity

 results from a hyperactive immune system attacking normal tissues as if they were
foreign organisms
 Pollution

Parasites Fungi

IMMUNE
SYSTEM

Viruses Taxins

Bacteria

 Common autoimmune diseases include Hashimoto's Thyroiditis, Rheumatoid

Arthritis, Diabetes mellitus type 1, and Systemic Lupus Erythematosus (SLE).

Signs and Symptoms of Infection:

 The signs and symptoms of infection are local or systemic.

Signs and Symptoms of Local Infection:

 Localized infections are most common in areas of skin break down, such as surgical
and traumatic wounds. pressure ulcers and mouth lesions. Infections may also develop
locally in cavities beneath skin e.g. Abscess

Signs and symptoms include:

 Redness, swelling (edema), pain, tenderness, inflammation. drainage from open

lesions or wounds.
 Restriction of body movement may also be present if the infected area is large
enough.

Signs and Symptoms of Systemic infections:

 More generalized symptoms may be seen such as fever, fatigue, tachypnoea,

tachycardia, malaise, enlarged swollen tender lymph nodes, anorexia, nausea,
vomiting
Laboratory tests to screen for infection: ESR, complete blood count (CBC): If there is
infection ESR and WBC count will be elevated.

Nursing Diagnosis related to infection

 Risk for infection

 Impaired skin integrity related to altered circulation immobilization/exposure to
irritants
 Impaired oral mucous membrane integrity related to deficient oral hygiene
 Risk for impaired skin integrity as evidenced by decreased mobility.
 Social isolation related to misconceptions about various diseases like STDs etc.
 Body image disturbance related to patient's aversion to open wound

Infection Control Measures

a. Prevent and control infection:

 Maintain general cleanliness of the hospital and ensure good ventilation.

 Daily mopping and sweeping of floors with antiseptic solution must be ensured.
 Practice good house keeping
 Ensure safe water supply and food to patients in a health setting.
 Safe disposal of excreta, urine, sputum, etc...
 Destruction of rodents and insects by using appropriate chemicals is important as they
play a great role in the spread of an infection.
 Ensure routine hygienic measures such as personal hygiene, oral hygiene etc. for the
patients.

b. Break the chain of Infection:

 Control or elimination of infectious agents

 Proper hand washing with soap and water.
 Disinfect the articles used for the patients.
 Sterilization of contaminated objects, sterilization and disinfection are physical
processes, involving the use of heat, radiation, chemical process
 Bathing with soap and water to remove secretion, drainage, perspiration, etc.
 Frequent change of dressing.
 Proper disposal of wastes and contaminated articles.
  Disposal of contaminated needles and syringes in moisture-resistant, puncture-proof
containers.
 Bottled solutions should be placed with tight caps as per instructions.
 Keep drainage tubes and collection bags under the skin surface of surgical wounds to
prevent accumulation of serous fluid
 Empty and dispose of drainage solution bottles according to agency policy.

c. Control of Portals of Exit:

 Practice aseptic precautions.

 Avoid talking directly into another person's face to prevent droplet infections
 Wearing of masks is important once the nurse herself has infection or deals with
patients suffering from infections.
 Careful handling of wastes like urine, feces, emesis and blood is important.
 Disposable gloves should be worn to prevent direct contact with wastes or infected
materials.

d. Control of transmission of Infection:

 Discourage sharing of bedpans, urinals, basins, eating utensils, etc.

 Use individual thermometers for patients.
 Damp dusting should be done to prevent scattering of dust in air
 Protect own clothing from contact with infected materials.

Practise hand-washing technique. This is recommended in the following situations:

 Before contact with patients who are susceptible to infection.

 After caring for any patient.
 Before performing invasive procedures like administration of injections, suction,
catheterization etc
 Before and after handling dressing or touching open wounds
 After handling contaminated equipment
 Between contact with different patients in high-risk units

e. Control of Portals of Entry:

 Maintain the integrity of skin and mucous membranes

 Proper positioning of tubing prevents injuries and skin break down.
  Regular skin care is essential with application of lubricants
 Turning and positioning of debilitated patients will help in preventing skin break
down.
 Ensure personal hygiene of patients regularly
 Dispose of contaminated syringes and needles to prevent accidental injuries to
hospital personnel as well as patients.
 Proper handling of catheters, drainage sets, etc., is essential.
 Care should be taken while collecting and handling specimens.
 Regular wound care is to be instituted properly to prevent infection.

f. Protection of Susceptible Host:

 This involves protecting normal defence mechanism by

 Regular bathing along with adequate lubrication of skin
 Regular oral hygiene
 Maintaining an adequate fluid intake and good nutritional status
 Encouraging deep breathing and coughing exercises

Isolation Practices:

Isolation precautions control the transmission of pathogens by prevention of direct

contact with the infected patient. Barrier nursing or isolation technique is intended to confine
the micro-organisms within a given and recognized area.

NOSOCOMIAL INFECTION
Nosocomial Infections are those infections acquired in the hospital after admission;
other than the health problems he had on admission. Patients in health care settings are at
increased risk for acquiring infections. A hospital is one of the most likely places for
acquiring infection because it harbours a high population of virulent strains of micro-
organisms that may be resistant to antibiotics. Unfortunately, many nosocomial infections are
transmitted by health care workers. Now the term Health Care Associated Infections is being
used for nosocomial infections

Types:
 Latrogenic Exogenous Endogenous
infections infections infections

latrogenic infections: are types of nosocomial infections resulting from diagnostic or

therapeutic procedures, e.g. Urinary tract infection that develops after catheter insertion. The
incidence can be reduced if nurses practice aseptic techniques.

Exogenous infection: arises from micro-organisms external to the individual that do not exist
as normal flora eg. Salmonella, Clostridium Tetani

Endogenous infection: can occur when part of patient's normal flora become altered and an
over growth results.

e.g. infections caused by enterococci, E. coli When sufficient numbers of micro-organisms

normally found in one body cavity or lining are transferred to another body site it results in
endogenous infections e.g. Enterococci infected material, from the hands to the skin is a
common cause of wound infection.

Common Sites for and causes of Nosocomial Infections:

Urinary
system

Surgical
Blood common or
stream sites traumatic
wounds

Respiratory
Tract
Urinary tract
 Following unsterile techniques for urinary catheterization
 Improper specimen collection techniques.
 Open drainage system
 Obstruction in urine drainage
 Urine from drainage tube being allowed to re-enter in to the bladder
 Repeated catheter irrigations
 Improper hand hygiene.

Surgical or Traumatic Wounds:

 Improper skin preparation or failure to clean skin surface properly prior to surgery.
 Failure to use aseptic techniques during dressing changes
 Use of contaminated antiseptic solutions e.g. Savlon solution which was used
previously was found to be contaminated in many health care settings.

Respiratory Tract:

 Contaminated respiratory therapy equipment’s

 Not following proper aseptic technique while suctioning the airway.
 Improper disposal of secretions.

Blood Stream:
 Contamination of 1.V fluids
 Addition of connecting tube to IV system.
 Improper care of needle insertion site.
 Contaminated needles or catheters.
 Failure to change IV access site when inflammation first appears.
 Improper technique during administration of multiple blood products.
Prevention
Nosocomial infections can be prevented if all members of health care team take
special care/precautions
It includes:
 Meticulous hand washing before and after attending each patient
 Follow strict aseptic techniques while doing invasive procedures
 Follow medical and surgical
 Proper sterilization of instruments and disinfection of limen, utensils, floor etc.
 Proper waste management-collection and disposal
  Follow universal precautions while handling blood and blood products
 Avoid recapping of needles
 Proper handling, cleansing of linen contaminated with blood, secretions, urine and
excreta.
 Isolate patients with conditions which spread through air provide separate room
 Avoid sharing of instruments
 Safe food and water supply as many diseases spread through food and water
 Practice cohorting i.e. In case the space is inadequate, the patients with same type of
conditions can be put together in a room.
 Limit visitors in hospitals especially for postoperative and immune compromised
patients.
 Avoid overcrowding of patients. Beds should be at least 1-2 meters apart.
 Provide single room especially for patients with communicable diseases.
 Take precautions to prevent airborne diseases such as covering mouth and nose while
coughing. sneezing, laughing etc.
 Patient should be worn mask while transferring or contracting with others.,

ASEPSIS
INTRODUCTION
Asepsis is the state of being free from disease-causing micro-organisms such as
pathogenic bacteria, viruses, pathogenic fungi, and parasites. The term often refers to those
practices used to promote or induce asepsis in an operative field of surgery or medicine to
prevent infection.

Asepsis is a state of freedom from pathogenic microorganisms like bacteria, fungi,

and viruses

Concept of asepsis:

 The nurse's efforts to minimize the onset and spread of infection are based on the
principles of aseptic technique.
  Aseptic technique is an effort to keep the patient free from exposure to infection-
causing pathogens. In medical settings, care providers use a number of procedures to
create and maintain asepsis for patient safety.

Definition:

Aseptic technique is the effort taken to keep the patient as free from hospital micro-
organisms as possible (Crow 1989).

It is a method used to prevent contamination of wounds and other susceptible sites by

organisms that could cause infection.

Aseptic technique means using practices and procedures to prevent contamination

from pathogens. It involves applying the strictest rules to minimize the risk of infection

Types of aseptic technique:

There are two types of asepsis:

Medical Surgical
asepsis asepsis
Medical or Clean Asepsis reduces the number of organisms and prevents their spread by
following certain principles and procedures to prevent infection and control its spread.

Surgical or Sterile Asepsis or Sterile Technique:

It includes procedures used to eliminate micro-organisms from an area and is

practiced by health team members in Operation Theatre, labour and delivery area, major
diagnostic areas and treatment areas.

Medical Asepsis

Basic medical aseptic techniques are focused on breaking the chain to prevent spread
of infection
  During daily routine care, the nurse uses basic medical aseptic techniques to break the
infection chain. Examples of medical asepsis are changing patient's bed linen daily,
hand washing, barrier techniques and routine environmental cleaning.
 Follow isolation technique as required.
 Patients with high susceptibility to infection require special precautions to prevent
exposure to pathogens.
 In medical asepsis, an area or object is considered contaminated only if it is suspected
of containing pathogen (e.g. used bedpan, the floor and a wet piece of gauze).

The basic principles of medical asepsis:

 Cleanse hands frequently following CDC's Hand Hygiene Guidelines

 Clean the least soiled items/area first then the more soiled ones
 Move equipment away from you when sweeping. dusting, or scrubbing articles.
 Avoid having the patient cough, sneeze, or breathe directly on others
 Do not place soiled bed linens or other items on the floor
 Keep soiled items and equipment from touching the clothing of health care personnel.
 Dispose soiled or used items directly into the appropriate containers.
 Pour liquids that are to be discarded, directly into the drain
 Avoid leaning against sinks, supplies and equipment
 Avoid touching your eyes, face and mouth while on duty
 Use practices of personal grooming that help prevent spreading micro-organisms
 Follow your facility's guidelines for isolation and barrier techniques
 All body fluids from any patient is considered contaminated
 The healthcare team and the environment can be a source of contamination for the
patient.
 Isolate the disease not the patient. Medical aseptic practices are involved in all nursing
activities because micro-organisms are always present in the environment
 Micro-organisms are present everywhere in the air, in the water, in food and on
clothes
 Not all micro-organisms are harmful. Some are useful. eg making medications such as
penicillin

Essential components of maintaining medical asepsis include:

 Hand washing
  Utilizing gloves, gown and mask as indicated
 Cleaning/disinfection of equipment
 Handling linens in ways that prevent germs from spreading

Surgical asepsis

Surgical asepsis refers to the highest level of aseptic technique and requires that all areas be
kept as free as possible of micro-organisms

 Sterilization is the process of destroying all micro-organisms both pathogenic and

non-pathogenic including their spores
 These techniques can be practiced by nurses in the OR (surgical incision) or at the
bedside (e.g. inserting IV or urinary catheter and reapplying sterile dressings) where
sterile instruments and supplies are used.
 In surgical asepsis, an area or object may be considered contaminated if touched by
an object that is not sterile (e.g. a tear in a surgical glove during a procedure, a sterile
instrument placed on an unsterile surface).
 The nurse working with a sterile field or with sterile equipment must understand that
the slightest break in technique results in contamination.
 Nurse in an operating room follows a series of steps to maintain sterile techniques,
including applying a mask, protective eyewear and a cap; performing surgical hand
washing, and applying sterile gown and gloves.
 Effectiveness of aseptic practices depends on the nurse's conscientiousness and
consistency in using effective aseptic techniques.

Basic principles of surgical asepsis include:

 Only a sterile object can touch another sterile object

 After hand washing hold the hands above the elbow level; the hands should never be
lowered below the chest level.
 Avoid spilling any solution on a cloth or paper used as a field for sterile set up.
 Avoid talking, coughing, sneezing, and reaching over a sterile field or object. Hold
sterile objects above the waist level.
 All items brought into contact with broken skin or used to penetrate the skin in order
to inject substances into the body or to enter normal sterile body cavities should be
sterile
 Use dry, sterile forceps when necessary
  Consider the edge of a sterile field to be contaminated
 Consider an object contaminated if you have any doubt as to its sterility
 Find remedy for contamination immediately
 The surgical scrub must be done meticulously
 The OT team should not be a source of contamination- no infection, proper apparel,
no jewellery, no long nails or nail polish
 The patient should not be a source of contamination
 The OT technique of the surgeon is of utmost importance
 Recognize potential environmental contamination
 Gowns are considered sterile in front from chest level to the operative level
 Sterile persons should keep hands at or above the waist level
 Contamination occurs when sterile gown and drapes are permeated
 Tables are sterile only at the operative level
 All items used within the sterile field must be sterile
 Unsterile personnel should stay beyond one foot of the sterile field Sterile persons
should touch only sterile items or sterile areas.
 When contamination occurs, take care of it immediately
 Break in technique is pointed out and action is taken P to change situation
 Prevent excessive air currents around the sterile areas. (Moving fast, flapping of the
cloths and drapes)
 Keep the sterile field dry
 Hold the transfer forceps pointing downwards.
 Each sterile supply should be clearly labelled.
 Do not return the unused sterile objects to the container once they are taken out.

Barrier Nursing:

The nursing technique by which a patient with an infectious disease is prevented from
infecting other people is called barrier nursing. Hand hygiene is the simplest, most effective
measure for infection control.

HAND HYGIENE

Hand Washing
 Hand washing also known as hand hygiene, is the act of cleaning one's hands with
soap (or equivalent materials) and water to remove viruses/ bacteria/germs/microorganisms,
dirt, grease, or other harmful and unwanted substances from the hands.

It refers to the practices used to prevent and control the spread of pathogenic
organisms. It protects the patient and his environment from the transmission of disease
producing organisms (prevention of cross infection). The infection can be transferred reduces
the number of bacteria.

Principles underlying Hand Washing are:

 Hand washing involves both mechanical and chemical action.

 The running water and friction used in cleaning are the mechanical actions of
cleaning.
 The soap will emulsify the fat and lower the surface tension of water and it facilitates
the removal of micro-organisms, dirt and oils.
 Hands can easily become contaminated with disease causing organisms.
 Staff members can infect themselves when their hands are contaminated and also
spread infections to co-workers and other patients by touching them or sharing objects
with contaminated hands, as they touch patients, instruments. blood and body fluids.

Purpose of Hand Washing:

 For aesthetic sense.

 To cleanse the hands
 To minimize microbial content of the hands.
 To prevent cross infection from patients to patients. to self, other health personnel and
vice versa.
 To reduce the risk of cross infection before and after any nursing procedures.

When to wash hands?

 After contacting patients, direct or indirect contact with blood and body fluids.
 Before eating food, after visiting the toilets, touching patients and before going from
one patient to another

Equipment/Articles:

 Soap in a soap dish

  Running Water
 Nail Brush (optional)
 Towel
 A sink with elbow control is essential

Surgical Asepsis:

Surgical hand washing refers to the procedure performed for the maximum
elimination of bacteria from the hands and to decrease and suppress the growth of skin
microbes in case of glove tear.

The steps for surgical hand washing are as follows:

1. Apply solution:

Apply approximately 5ml of appropriate solution from the dispenser, using one
downward stroke. Work the solution into the hands, encompassing all areas of the hands and
arms up to just below the elbows.

2. Palm and back of hand:

Place the right palm over the back of the left hand and vice versa, interlacing fingers.
3. Palm to palm:

Rub palm to palm, interlacing fingers.

4. Rubbing fingers:

Rotate and rub backwards and forwards with clasped fingers of the right hand into the
left palm and vice versa.

5. Rubbing thumbs:

Rotationally rub the right thumb clasped in the left hand and vice versa.
6. Fingertips on palms:

Run fingertips on the palms of both hands.

7. Rotating action down arms:

Continue with a rotating action down opposing arms, working to just below the
elbows.

8. Rinse and repeat:

 Rinse and repeat steps 1-7, keeping hands raised above the elbows at all times. This
wash should cover two-thirds of the forearms. Local policy may dictate repeating these steps
a third time, but only up to the wrists.

9. Rinse and dry:

Rinse hands under running water, moving from the clean to dirty area. Turn off the tap
using elbows if necessary. Open a gown pack onto a squared-off surface and take a hand
towel. Dry hands first by placing the opposite hand behind the towel and blotting the skin,
then using a corkscrew motion to dry from hand to elbow. Discard the towel and repeat with a
second towel for the other hand and forearm

Hand Washing - Medical Asepsis:

  Nails should be cut short, as long nails will give roof to the dirt and micro-organisms
 Remove jewels as micro-organisms are present on the jewels and under the rings.
Removal facilitates proper cleaning of hands and arms.
 Open the tap Wet the hands and forearms. Always hold the hands below the elbow
level as hands are considered to be more contaminated than the elbows, hence the
water should flow from the area of least contamination (elbows) to the area of more
contamination (hands).
 Warm water removes less of the protective oil of the skin than the hot water.
 Rinse and apply soap (or) detergent
 Follow steps 1-7 as in surgical hand washing, but keep hands below elbow level.
 Rinse hands under running water. Rinse the soap before it is returned to the soap dish.

Wearing Sterile Gloves

Steps

1. Open the glove pack. With the left hand, grab the right glove by the folded back cuff

2. Slip your right hand into the glove while keeping the fingers and glove pointed downwards

[Link] the second glove with the gloved hand by sliding the finger tips under the cuff of the
second glove

4. Slide the ungloved hand into the glove. Wiggle the fingers into the correct holes until the
gloves fit comfortably.

PERSONAL PROTECTIVE EQUIPMENT(PPE)

 Personal protective equipment, commonly referred to as "PPE", is an equipment worn
to minimize exposure to hazards that cause serious workplace injuries and illnesses. These
injuries and illnesses may result from contact with chemical, radiological, physical, electrical,
mechanical, or other workplace hazards Personal protective equipment may include items
such as gloves, safety glasses and shoes, earplugs or muffs, hard hats, respirators, vests
and full body suits

All personal protective equipment should be safely designed and constructed, and
should be maintained in a clean and reliable fashion. It should fit comfortably, encouraging
worker use. If the personal protective equipment does not fit properly, it can make the
difference between being safely covered or dangerously exposed Employers are required to
ensure its proper use by training the workers

Due to the Covid 19 pandemic the use of PPE became worldwide and known to the
general public

Personal protective equipment are specialized clothing or equipment worn by an employee

for protection against infectious materials (Occupational Safety and Health Administration-
OSHA)

Regulations and Recommendations for PPE:

 OSHA issues workplace health and safety regulations regarding PPE, employers
must:
 Provide appropriate PPE for employees
 Ensure that PPE is disposed or reusable PPE is cleaned, laundered, repaired and
stored after use
 OSHA also specifies circumstances for which PPE is indicated eg. Covid pandemic
 CDC recommends when, what and how to use PPE

Types of PPE used in healthcare settings:

 Glove protect hands

 Gowns/aprons
 protect skin and/or clothing
 Masks and respirators protect mouth/nose when fully covered.
 Respirators protect respiratory tract from airborne infectious agents
 Goggles protect eyes. Personal glasses are not substitutes for goggles.
  Face shields-protect face, mouth

Factors Influencing PPE Selection

 Type of exposure anticipated

e.g. Splash/spray versus touch

 During delivery a splash of amniotic fluid can be expected likewise during surgery
spray of blood /discharges may occur.
 Durability and appropriateness for the task

Sequence for donning personal protective equipment

Goggles
Gown or face
shield

Mask or
Gloves
respirator

 Gown first
 Mask or respirator
 Goggles or face shield
 Gloves

PPE use in healthcare settings: How to Safely Don, Use, and Remove PPE:

 Don before contact with the patient, generally before entering the room
 Use carefully don't spread contamination
  Remove and discard carefully, either at the doorway or immediately outside patient
room; remove respirator outside room
 Immediately perform hand hygiene.

GOWN

 Select appropriate type and size

 Opening should be at the back
 Secure at neck and waist
 If gown is too small, use two gowns
 One gown with ties in front and the other with ties at the back.

MASK

Wearing Mask

 Hold mask by top two strings. Tie those two strings at the top and back of the head
with ties above the ears
 Tie two lower ties snugly around the neck with the mask well under the chin.
 Ensure that the mask covers the mouth and the nose adequately
 If glasses are worn, fit the upper edge of the mask under the glasses
 Avoid unnecessary talking and, if possible, sneezing or coughing
 While removing a mask with strings, first untie the lower strings of the mask.
 Discard a disposable mask in the waste container.

Particulate Respirator

Don a Particulate Respirator

 Select a fit tested respirator

 Place over nose, mouth and chin
 Fit flexible nose piece over Nose Bridge
 Secure on head with elastic
 Adjust to fit
 Perform a fit check

Inhale - respirator should collapse

Exhale check for leakage around

Eye and Face Protection:

Don Eye and Face Protection:

 Position goggles over eyes and secure to the head using the car pieces or headband
 Position face shield over face and secure on brow with headband
 Adjust to fit comfortably.
GLOVES

Don Gloves:

 Don gloves last

 Select correct type and size
 Insert hands into gloves
 Extend gloves over isolation gown cuffs

Do's and Don'ts of Glove Use:

 Work from "clean to dirty"

 Limit opportunities for "touch contamination" -protect yourself, others, and the
environment
 Don't touch your face or adjust PPE with contaminated gloves
 Don't touch environmental surfaces except as necessary during patient care
 Discard in appropriate receptacle
 Never wash or reuse disposable gloves

Safe Use of PPE:

 Keep gloved hands away from face

 Avoid touching or adjusting other PPE
  Remove gloves if they become torn, should perform hand hygiene before donning
new gloves
 Limit surfaces and items touched

Sequence for removing PPE:

Goggles
Gloves or Face
Shield

Gown Mask or
respirator

 Gloves
 Goggles or Face Shield
 Gown
 Mask or respirator

Removal of gloves:

 Grasp outside edge near wrist

 Peel away from hand, turning glove inside-out
 Hold in opposite
 Slide ungloved finger under the wrist of the remaining glove
 Peel off from inside, creating a bag for both gloves
 Discard.
Removing Goggles or Face Shield:

 Grasp car or head pieces with ungloved hands

 Lift away from face
 Place in designated receptacle for reprocessing or disposal

Removing Isolation Gown:

 Unfasten ties
 Peel gown away from neck and shoulder
 Turn contaminated outside toward the inside
  Fold or roll into a bundle
 Discard

Removing a mask:

 Untie the bottom, then top tie

 Remove from face
 Discard
Removing a Particulate Respirator:

 Lift the bottom elastic over your head first

 Then lift off the top elastic
 Discard

Hand hygiene:

o Perform hand hygiene immediately after removing PPE

-If hands become visibly contaminated during PPE removal, wash hands before continuing to
remove PPE

o Wash hands with soap and water or use an alcohol-based hand rub

-PPE is available to protect you from exposure to infectious agents in the healthcare
workplace

-Know what type of PPE is necessary for the duties you perform and use it correctly.

Transportation of Infected Patients

A patient is considered as infectious when he is a source of infection to others (from

the infection which the patient is suffering from). Standard precautions are to be followed
while transporting the patient in order to protect highly susceptible groups such as nurses,
doctors workers, patient's attendants etc.

Isolation precautions help to control the transmission of pathogens by preventing the

direct or indirect contact with the infected patient. The isolation techniques are followed to
confine the micro-organisms within a given and recognized area.

Following measures are to be taken while transporting infected patients:

 Follow hospital policy to transport the infected patients

 Plan the transportation welt ahead so that patient can be shifted safely with minimal
contamination to others
 Select timing and route which reduce exposure through droplet infection and direct
contact to maximum people.
 Follow all standard precautions while transporting
 The personnel involved in transportation should have personal protective devices to
protect them from contracting infection
  Have the patient worn mask in case the infection spreads through droplets
 As soon as the patient is shifted out of a room. thorough cleansing and disinfection of
the articles, equipment, room and environment including the sink, toilet and bathroom
should be done
 Keep the patient covered
 Get ready the receiving area with separate linen. articles and equipment for the
patient.
 Have facilities to keep the patient's utilities separately
 All personnel attending the patient should follow strict hand washing after coming in
contact with the patient.
 Use mask, gown and gloves while attending the patient
 Take measures to disinfect and discard patient's bodily fluids-saliva, sputum, stools,
urne, pus. swabs etc
 Concurrent and terminal disinfection should be done
 Educate the patient and his attendants regarding the isolation techniques to be
followed

STANDARD PRECAUTIONS

Standard infection control precautions (SICPs) are the minimum infection prevention
practices that apply to all patient care, regardless of whether infection is known to he present
of not. This helps to prevent the spread of infection and ensure the safety of patients,
healthcare workers and visitors

Standard Precautions are used for all patient care. They're based on a risk assessment
and make use of common-sense practices and personal protective equipment use that protect
healthcare providers from infection and prevent the spread of infection from patient to
patient.

Standard precautions are meant to reduce the risk of transmission of blood borne and
other pathogens from both recognized and unrecognized sources. They are the basic level of
infection control precautions which are to be used, as a minimum, in the care of all patients

Standard Precautions and transmission based precautions

 Contact Precautions
  Airborne Precautions
 Droplet Precautions
 Respiratory hygiene cough etiquette
 Safe injection practices
 Blood isolation
 Enteric isolation

Contact Precautions:

 Clean, non-sterile gloves are usually adequate for routine care of the patients
 Use gloves before providing care to patient
 Change gloves after contact with infective material.
 After providing care, remove gloves and wash hands
 Follow proper use of protective gown in case of direct contact with patient with
communicable diseases. Observe hand hygiene
 Limit the movement or transport of the patient from the room
 Make sure that any infected or colonized areas are covered
 Ensure that patient care items, bedside
 Inte, to Infection Control in Clinical Setting (Asepsis)
 frequently touched surfaces receive cleaning at least two times daily. Keep toilet items
separate for each patient.

Airborne Precautions:

 Used to prevent or reduce the transmission of micro-organisms that is airborne in

small droplet nuclei or dust particles containing the infectious agent.
 Place the patient in private room with 6-12 air changes/per hour.
 Use respiratory protection methods.
 at Limit movement and transport of the patient.
 Use a mask on the patient if they need to be moved
 Keep patient's room door closed.

Droplet Precautions:

 Used to reduce the risk of transmission of micro-organisms transmitted by large

particle droplets
  Droplets usually travel 3 feet or less within the air and thus special air handling is not
required, however newer recommendations suggest a distance of 6 feet be used for
safety.
 Place the patient in a private room
 Use respiratory protection methods such as use of a mask when entering in to the
room.
 Limit movement and transport of the patient
 Use a mask on the patient if they need to be moved and follow respiratory
hygiene/cough etiquette
 Keep patient at least 3 feet apart from visitors

Respiratory Hygiene/Cough Etiquette

 Teach patients and visitors to cover their mouth/nose while coughing and sneezing
 Follow proper disposal of used materials after coughing and sneezing
 Use surgical masks for patients having cough
 Provide alcohol-based hand-rubbing dispensers and supplies for hand hygiene and
educate patients and staff in their use
 Encourage hand hygiene after coughing or sneezing.
 Separate persons with cough and infectious diseases at least 3 feet away from others
 to Infection Control in Clinical Setting (Asepsis)
 Instruct patients and care providers not to touch eyes, nose, or mouth.
 Health care workers should use standard precautions with all patients.

Safe injection practices:

 Strictly follow proper disposal of syringes and needles in appropriate containers

 Avoid re-sheathing the needles
 Avoid removing needles
 Discard syringes as a single unit
 Avoid over-filling sharps container
 Use masks for insertion of catheters or for injection into spinal or epidural areas.

Blood Isolation

Blood isolation is followed to prevent the transmission of blood borne diseases.

Follow strict universal precautions while handling blood and blood products. Wear gloves
and cover the cuts or abrasions or wound if any, before handling blood. Any objects coming
in contact with blood should be disinfected before reusing them.

Enteric Isolation

This is indicated when the organisms causing the disease are transmitted through
feces e.g. Typhoid fever is transmitted through feco- oral route and salmonella organisms are
present in the feces of patients. Practice thorough hand washing. Use gown and gloves while
caring for the patient.

Reverse Barrier Nursing:

It refers to the precautions taken to prevent the spread of infection from the health
care providers or from the attendants to the patients, e.g. immunocompromised patients are
liable to get infection from health providers or patient's care givers unless precautions are
taken. They should wear gloves, mask and gown to protect the patient.

BIOMEDICAL WASTE MANAGEMENT

Introduction:

The waste produced in the course of health care activities carmes a higher potential
for infection and injury than any type of waste.

Therefore, safe and reliable method for its handling is essential, inappropriate
methods in handling of health cars waste may have serious public health problems and
significant impact on health

Definition

According to bio-medical waste management and handling) rales, 1998 of Indias,

"Biomedical waste ich waste which generated during the diagnosis, treatment or
immunization of human beings or animals or research activities pertaining or in production or
testing of biologicals Between 75 to 90% of waste produced by the health care providers are
al non risk. The remaining health care waste is regarded as hazardous and may cause variety
of health risk

Classification of health care waste:

Waste Category Description and Example

 Pathological waste Human tissues or fluids e.g. Body parts, blood and other body fluids,
fetus.

Sharps Sharp waste e.g. Needles, infusion sets, scalpels, knives, blades,
broken glass

Pharmaceutical waste Waste containing pharmaceutical waste e.g. expired medicines that are
no longer needed, items that are contaminated by or containing
pharmaceuticals (bottles, boxes)

Genotoxic waste Waste substances with genotoxic properties e.g. Cytotoxic drugs often
used in cancer therapy (genotoxic chemicals)

Chemical waste Waste containing chemical substance e.g. Laboratory reagents, film
developer disinfectants that are expired or no longer needed solvents

Wastes with high Batteries, broken thermometers, bleed-pressure gauges

content of heavy metals

Pressurized containers Gas cylinders, gas cartridges as aerosol cans

Radioactive waste Radioactive waste substance e.g. unused liquids from radio therapy or
laboratory research, contaminated glass, waste packages, absorbent
papers urine, excreta from patient treated with sealed sources
Infectious waste Laboratory cultures
Waste from isolation wards
Tissues (Swabs)
Materials or equipment that have been in contact with the infected
patient’s excreta

Health care waste generation:

Health care waste generation differs froth country to country. Within the country the
waste generation depends on the numerous factory such as established waste management
methods, type of health care establishment, hospitals, proportion of reusable items employed
in health care etc.

 80% are of general health-care waste, which can be managed by the normal domestic
and urban waste management system.
  15% are pathological and infectious waste.
 1% of sharp waste
 3% is of chemical and pharmacological waste
 Less than 1% special waste, such as radioactive or cytotoxic waste, pressurized
containers, broken thermometers.

Average composition of hospital waste in India

Material Percentage of weight

Paper 15%

Plastic 10%

Rags 15%

Metal (sharps) 1%

Infectious waste 1.5%

Glass 4.0%

General waste (food waste 53.5%

Sweepings from hospital
premises)
 All individuals exposed to such hazardous health care waste are potentially at risk
which includes those who generate the waste and those who handle the waste.
 The main groups at risk are doctors, nurses, health care auxiliaries and hospital
maintenance personnel. The patient in health-care establishment, visitors to health
care agencies are also at risk.
 Workers in support service such as laundries, waste handling and transportation
section and workers in waste disposal facilities such as landfills or incinerators
including scavengers are at very high risk

HAZARDS OF BIOMEDICAL WASTES

1. Hazards from infectious waste and sharps:

  Pathogens in infectious waste may enter the human body through a puncture,
abrasion or cut in the skin, through mucous membranes, by inhalation or by
ingestion.
 There is a high risk for infections with HIV and hepatitis virus B and C that can be
transmitted through health care waste.

2. Hazards from chemical and pharmaceutical waste:

 Many of the chemicals and pharmaceuticals used in health care settings are toxic,
genotoxic, corrosive, flammable, reactive, explosive or shock sensitive.
 Although present in small quantity they may cause intoxication either by acute or
chronic exposure and injuries including burns.

3. Hazards from genotoxic waste:

 The severity of the hazards for health care personnel depends on the extent and
duration of exposure by inhalation of dust or aerosols, or by absorption through the
skin.

4. Hazards from radioactive waste:

 The type of disease caused by radioactive waste is determined by the type and extent
of exposure.
 It can range from headache, dizziness and vomiting to much more serious problems.
 It as genotoxic, it may also affect the genes.

5. Public Sensitivity:

Apart from health hazards, the general public is very sensitive to visual impact of health care
waste particularly anatomical

Property of waste Possible contents of waste Health hazards

Infectious Infective waste material of Diseases such as Hepatitis
any kind, generated in A, B, C, D, E,
hospitals, blood and blood Gastroenteritis Typhoid
products fever, TB, Postop infections,
AIDS, Skin and Blood
Disorders etc.
 Injurious Sharps - Needles, Knife, Tetanus, AIDS, Hepatitis B,
Blades, Ampules, Glass Septicaemia, Wound
slides, Test Tube, Broken Infections etc.
Glassware and other sharps
Cytotoxic Radioactive materials, Immunosuppression,
strong acids and alkalis, Anaemia,
concentrated phenyl, anti- Thrombocytopenia, Ulcers,
cancer drugs etc. Cancer, Foetal
Abnormalities, Genetic
Disorders etc.

Chemical Laboratory waste, Burns/Scalds, Corrosion,

Chemotherapy waste, gases, Poisoning, skin diseases,
dyes, insecticides, Cancer
Photographic etc. chemicals
etc.

CAUTION:

Among all health care workers nurses spend more time and longer time in the
hospitals. Because of more exposure to hospital waste, they are at risk for infection like HIV
and Hepatitis

Treatment and disposal technologies for health care waste.

 Incineration

Wet and dry

Microwave
thermal
irradiation
treatment

Chemical Land
disinfection disposal

1. Incineration:

 Incineration is a high temperature, dry oxidation process that reduces organic and
combustible waste to inorganic and incombustible matter which results in very
significant reduction of wastes volume and weight.
 The process is usually selected to treat waste that cannot be recycled, reused or
disposed of in a land fill site.
 Incineration requires no pre-treatment.

Type of Incinerators:

Incinerators can range from very basic combustion unit that operate at much lower
temperature to extremely high temperature operating plants.

The three basic kinds of incineration are:

(a) Double chamber (pyrolytic incinerators)

It is designed to burn infectious health care waste.

(b) Single chamber

Used when double chamber incinerators are not affordable

(c) Rotary kilns.

 It operates at high temperature. It is capable of causing decomposition of genotoxic
substances and heat-resistant chemicals

Types of waste not to be incinerated are:

 Pressurized gas containers

 Large amount of reactive chemical waste.
 Halogenated plastics such as PVC
 Waste with high mercury or cadmium content such as broken thermometers, used
batteries, and lead-lined wooden panels.
 Sealed ampoules or ampoules containing heavy metals.

ii. Microwave Irradiation:

 Most of the Micro-organisms are destroyed by the action of microwave of at a

frequency 2450 MHz, and wave length of 12.24 cm.
 The water contained in the waste is continuously heated in microwave. Infectious
components are destroyed by heat conduction. The efficiency of the microwave is
checked by bacteriological and virological tests.

iii. Land Disposal (Burial):

 The use of a land fill has to be regarded as an acceptable disposal route. There are two
types of land disposal-open dumps and sanitary landfills.
 The health care waste should not be dumped on or around the open dumps. The risk
with this is the animals coming into contact with infectious pathogens.

Sanitary landfills: Sanitary landfills are a method of waste disposal where the waste is
buried either underground or in large piles. This method of waste disposal is controlled and
monitored very closely. A landfill, also called sanitary landfill, is a land disposal site for
waste, which is designed to protect from environmental pollution and health risks. It is not
the same as an open dump.

IV. Chemical disinfection:

 Chemicals are added to wastes to kill or inactivate the pathogens it contains. This
treatment usually results in disinfection rather than sterilization.

Chemical disinfection is most suitable for treating

  Liquid waste such as blood, urine, stools or hospital sewage.
 Solid wastes such as microbiological

V. Wet and dry thermal treatment:

Wet thermal treatment:

 Wet thermal treatment or steam disinfection is done by exposing infectious waste to

high temperature, high pressure steam, and is similar to the autoclave sterilization
process.
 The process is inappropriate for the treatment of anatomical waste, chemical and
pharmaceutical waste.

Dry thermal treatment:

Screw-feed technology:

 This technology is based on non-burn and dry thermal disinfection process in which
the waste is shredded and heated on rotatory or rotating anchor.
 The waste is reduced to 80% in volume 20-35% in weight. It is suitable for infectious
waste and sharps.

VI. Inertization:

 The process of inertization involves mixing waste with cement and other substance
before disposal in order to minimize the risk of toxic substance contained in the waste
migrating into surface water or into ground water."
 National legislation is the basis for improving health care waste disposal practices in

any country.

Bio-Medical Waste Management in India:

 Bio Medical waste management in India (Management and Handling) Rules 1998,
prescribed by ministry of environment and forests, Government of India came into
force on 28th July 1998. This rule applies to those who generate, collect, receive,
store, dispose, treat or handle the biomedical waste in any manner. Wastes are
 differentiated into 10 categories (see below) colour code is assigned for the
segregation of wastes.

Category/option Waste category

Category - 1 Human anatomical waste
Category - 2 Animal waste
Category - 3 Microbiology and biotechnology waste
Category - 4 Sharp waste
Category - 5 Discarded waste, discarded medicines and cytotoxic
waste
Category - 6 Solid waste
Category - 7 Solid waste
Category - 8 Liquid waste
Category - 9 Incineration waste
Category -10 Chemical waste

National guidelines for waste management 2016:

According to National guidelines for waste management 2016, there are only four
categories of wastes and four colour codes. These new guidelines may be followed in the
country in the near future.

Following are the colour codes and categories

1. Yellow: Any wastes that can be incinerated are collected in these bags. It includes
human /animal wastes, soiled wastes, expired/discarded medicines, chemical wastes,
microbiology wastes, gloves etc

2. Red: Waste items that can be recycled are collected in these bags. Examples are soiled
wastes that could be recycled and used, bottles, tubing, catheters, syringes without needles
etc.

3. White: (puncture proof)- e.g. Metal sharps such as needles, scalpels, blades etc

4. Blue: Nonmetal glass wastes (e.g. ampoules) are collected in these bags.

5. There are no black coloured bags.

SAFETY MEASURES

Aims of Safety measures:

 To prevent the transmission of disease from patient to patient, from patient to nurses,
health care workers or and vice versa.
 To prevent injury to nurses while handling the waste
 To prevent general exposure to the harmful toxic effects of the cytotoxic and
genotoxic chemical biomedical waste as much as possible.

Measures of protection:

Following measures may be quite effective if used properly:

(i) Personal protective devices

 Cap/Scarf
 Shield (for working in a radiation prone zone)
 Goggles/plain glass
 Mask
 Apron/gowns (or full sleeve shirt)
 Gloves
 Gumboots.
(ii) General Protective measures:

 All nurses and other hospital employees must be vaccinated against Hepatitis B.
 Take extreme care while handling needles and other sharps, since most sharp injuries
occur between the points of use and disposal.
 Sharps should not be left casually on counter tops, food trays, beds, etc.
 Clipping, bending or breaking the glass and needles with hands must not be practiced
as this can cause accidental injuries.
 Sharps should be segregated at the site of generation and there after placed in
puncture proof containers.
 All disposable items must be dipped in hydrochloride solution for at least half an hour
to ensure that they are disinfected.
 Use protective devises while taking care of patients with infections.
 In operation theatre, goggles/glasses must be worn
 Use bowls to transfer sharp instruments from doctor to nurse or vice versa.

(iii) In case of injury caused by infected sharps:

(a) Special precaution is needed if injury occurs with sharps infected with HIV or hepatitis B
cases.

 Clean the wound immediately with spirit or betadine.

 An injection of TT is advisable
 Pressing of wound may be required to stop bleeding
 Consult the physician as early as possible.

(b) In case infectious solution is spilled on the body.

 Remove the soiled clothes and wash the part thoroughly with the plenty of water.
 Apply non-irritant antiseptic cream on the part.
 In case of spillage in eyes, wash it with water, avoid rubbing.
 Consult the physician.

Post exposure prophylaxis with anti-retroviral combination of 2-3 drugs is advisable to nurses
or care workers within two hours of exposure. Follow the post exposure guidelines of NACO.

(iv) Other measures of safety:

 Nurses need to be well equipped with latest information, skills and practice in
managing and handling the biomedical waste.
 There should be a course on biomedical waste management in all nursing curriculum.
 There should be continuous system of evaluation about the hospital waste
management.
 It is better to use such techniques which can prevent and minimize waste production.