Managing Infection Control

Why This Skill Exists

Healthcare-associated infections (HAIs) affect approximately 1 in 31 hospital patients on any given day (CDC, 2023). The Joint Commission NPSG.07.01.01 requires compliance with hand hygiene guidelines based on CDC/WHO recommendations. CMS Conditions of Participation (§482.42) mandate an active infection prevention and control program. HAIs — including CLABSI, CAUTI, SSI, VAP, and C. difficile — are among the most preventable causes of patient harm, and CMS no longer reimburses for treatment of certain HAIs classified as Never Events. NDNQI tracks HAI rates as nursing-sensitive quality indicators. State mandatory reporting laws require disclosure of specified HAI data. This skill structures the nursing role in infection prevention: standard precautions, transmission-based precautions, surveillance, and documentation per current CDC/HICPAC guidelines.

Checkpoint A — Intake Verification

Required Patient Information

[ ] Infection status: known active infections, colonization status (e.g., MRSA, VRE, CRE, C. difficile)
[ ] Culture results (pending and finalized)
[ ] Current antimicrobial therapy with start dates and planned duration
[ ] Immunocompromised status (neutropenia, transplant, chemotherapy, HIV/AIDS)
[ ] Vaccination status relevant to exposure (influenza, COVID-19, hepatitis B)
[ ] Travel history or epidemiological risk factors for emerging pathogens
[ ] Surgical history within 30 days (SSI surveillance window)

Required Institutional Resources

[ ] Infection prevention and control policy manual
[ ] Current CDC/HICPAC transmission-based precaution guidelines
[ ] Facility antibiogram (for empiric therapy decision support)
[ ] Isolation signage and PPE supply status
[ ] Hand hygiene product availability (alcohol-based hand rub, soap/water)

Step 1 — Implement Standard Precautions

Standard precautions apply to ALL patient encounters regardless of suspected or confirmed infection status:

Hand hygiene per WHO Five Moments:
- Before touching a patient
- Before clean/aseptic procedures
- After body fluid exposure risk
- After touching a patient
- After touching patient surroundings
PPE selection based on anticipated exposure:
- Gloves: contact with blood, body fluids, mucous membranes, non-intact skin, contaminated items
- Gown: anticipated contact with blood/body fluids or contaminated surfaces; during care activities likely to generate splashes
- Mask + eye protection: procedures and care activities likely to generate splashes or sprays of blood, body fluids, secretions, excretions
Respiratory hygiene / cough etiquette: mask symptomatic patients in common areas; provide tissues and hand hygiene
Sharps safety: use safety-engineered devices; never recap needles; dispose immediately in puncture-resistant container at point of use
Safe injection practices: one needle, one syringe, one patient; single-dose vials preferred; multi-dose vials dated when opened and discarded per manufacturer instructions
Environmental cleaning: patient care equipment cleaned and disinfected between patients per institutional policy; high-touch surfaces cleaned per schedule

Step 2 — Implement Transmission-Based Precautions

When standard precautions alone are insufficient, add transmission-based precautions per CDC/HICPAC:

Contact Precautions

Indications: MRSA, VRE, CRE, C. difficile, scabies, wound infections with uncontained drainage, RSV, rotavirus
Requirements: Private room (or cohort); gown and gloves for all room entry; dedicated patient care equipment; enhanced environmental cleaning
C. difficile specific: soap and water for hand hygiene (alcohol-based hand rub does not kill C. difficile spores); bleach-based environmental disinfection

Droplet Precautions

Indications: Influenza, pertussis, meningococcal disease, group A streptococcal pharyngitis/pneumonia, rhinovirus, adenovirus
Requirements: Private room (or cohort with ≥ 3 feet separation); surgical mask within 6 feet of patient; patient wears mask during transport

Airborne Precautions

Indications: Tuberculosis (pulmonary/laryngeal), measles, varicella (chickenpox/disseminated zoster), COVID-19 (per institutional policy), smallpox
Requirements: Airborne infection isolation room (AIIR) with negative pressure and ≥ 6 air changes per hour (existing) or ≥ 12 (new construction); N95 respirator (fit-tested) or PAPR for all room entry; door closed at all times; patient wears surgical mask during transport

Protective Environment (Reverse Isolation)

Indications: Allogeneic hematopoietic stem cell transplant patients, severely neutropenic patients (ANC < 500)
Requirements: Positive pressure room with ≥ 12 air changes per hour; HEPA filtration; restricted visitors; no fresh flowers, plants, or uncooked fruits/vegetables

Step 3 — Manage Invasive Device-Related Infection Prevention Bundles

Central Line-Associated Bloodstream Infection (CLABSI) Prevention Bundle

Hand hygiene before line access
Scrub the hub with alcohol for ≥ 15 seconds before each access; allow to dry
Daily assessment of line necessity — remove lines that are no longer clinically indicated
Dressing integrity assessment each shift; change transparent dressings every 7 days, gauze every 2 days, and immediately if soiled or loosened
Daily chlorhexidine bathing per institutional protocol

Catheter-Associated Urinary Tract Infection (CAUTI) Prevention Bundle

Avoid unnecessary catheterization; use nurse-driven catheter removal protocol
Daily assessment of continued catheter necessity
Maintain closed drainage system — never disconnect tubing
Keep drainage bag below bladder level; do not allow it to contact the floor
Perform perineal hygiene per institutional protocol
Secure catheter to prevent traction and urethral trauma

Surgical Site Infection (SSI) Prevention

Pre-operative: appropriate antibiotic prophylaxis within 60 minutes of incision (per SCIP measures)
Intra-operative: maintain normothermia, glucose control
Post-operative: maintain sterile technique for dressing changes; monitor incision for signs of infection (redness, warmth, swelling, purulent drainage)

Ventilator-Associated Pneumonia (VAP) Prevention Bundle

Elevate HOB 30–45 degrees
Daily sedation vacation and assessment of readiness to extubate
Peptic ulcer prophylaxis per order
DVT prophylaxis per order
Oral care with chlorhexidine per institutional protocol and current evidence

Step 4 — Conduct Infection Surveillance

Monitor for signs and symptoms of infection: fever, elevated WBC, new-onset tachycardia, wound changes, altered mental status in elderly
Report suspected HAIs to the infection preventionist per institutional policy
Collect surveillance cultures per order and protocol (blood cultures: two sets from two sites; urine culture: clean-catch or from catheter port, never from drainage bag)
Track device days: central line days, catheter days, ventilator days — the denominator for HAI rate calculations
Document compliance with prevention bundle elements per shift
Report notifiable diseases to the infection preventionist for state and local health department reporting per jurisdictional requirements

Step 5 — Manage Exposure Events

Needlestick/sharp injury: Wash with soap and water immediately; report to employee health; source patient testing per protocol; initiate post-exposure prophylaxis evaluation within 2 hours for HIV exposure
Blood/body fluid splash to mucous membranes: Irrigate thoroughly; report per institutional protocol
Patient exposure to communicable disease: Identify all exposed patients and staff; implement appropriate precautions; notify infection preventionist
Outbreak recognition: Two or more epidemiologically linked cases of the same organism require investigation; report to infection preventionist immediately

Step 6 — Document Infection Control Activities

Isolation precautions: type, indication, date initiated, signage placed, PPE compliance
Hand hygiene: document compliance observations per institutional monitoring program
Bundle compliance: daily documentation of each bundle element (CLABSI, CAUTI, VAP)
Culture results: time obtained, pending vs. final results, antimicrobial adjustments
Exposure events: nature of exposure, immediate actions, reporting completed, follow-up plan
Patient education: infection prevention education provided (hand hygiene, wound care, antibiotic stewardship)

Checkpoint B — Infection Control Compliance Review

Shift-Level Verification

[ ] Isolation precautions correctly implemented with appropriate signage and PPE availability
[ ] Hand hygiene performed per WHO Five Moments (minimum compliance benchmark: ≥ 90%)
[ ] All invasive device prevention bundles documented with compliance status
[ ] Device necessity reviewed for all central lines, urinary catheters, and ventilators
[ ] Environmental cleaning schedule adhered to; high-touch surfaces cleaned per protocol
[ ] Patient and family educated on isolation precautions and hand hygiene

Surveillance Check

[ ] Cultures collected per order with proper technique
[ ] Antimicrobial therapy reviewed: appropriate drug, dose, duration, de-escalation when culture results available
[ ] Suspected HAIs reported to infection preventionist
[ ] Notifiable conditions identified and reporting initiated

Quality Audit

[ ] Hand hygiene compliance meets or exceeds institutional benchmark (Joint Commission expects action plan if < 90%)
[ ] Transmission-based precautions match current CDC/HICPAC guidelines for identified organisms
[ ] CLABSI, CAUTI, SSI, and VAP prevention bundles documented with ≥ 95% compliance
[ ] Device days accurately tracked for NDNQI and CMS reporting
[ ] HAI rates trended against NHSN benchmarks; SIR (Standardized Infection Ratio) < 1.0 targeted
[ ] Antibiotic stewardship documentation supports appropriate use (right drug, right dose, right duration)
[ ] Exposure events managed per OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030)
[ ] Staff fit-testing for N95 respirators current per OSHA (29 CFR 1910.134)
[ ] Compliant with Joint Commission NPSG.07.01.01 and CMS CoP §482.42
[ ] Infection control data supports hospital participation in CMS Hospital-Acquired Condition Reduction Program

Guidelines

CDC/HICPAC: Guidelines for Isolation Precautions (2007, updated 2019) — standard and transmission-based precautions
Joint Commission NPSG.07.01.01: Comply with hand hygiene guidelines; goal ≥ 90% compliance
CMS CoP §482.42: Hospitals must have an active infection prevention and control program with surveillance, prevention, and reporting
OSHA Bloodborne Pathogens Standard: 29 CFR 1910.1030 — employer responsibilities for exposure prevention and post-exposure management
NDNQI: HAI rates (CLABSI, CAUTI, VAP) are nursing-sensitive quality indicators submitted quarterly
NHSN: National Healthcare Safety Network — standardized HAI surveillance definitions and benchmarking
CMS HAC Reduction Program: Hospitals in the bottom quartile for HAI performance face payment reduction; CLABSI, CAUTI, MRSA bacteremia, and C. difficile are scored
Antibiotic stewardship: Joint Commission requires antimicrobial stewardship programs per MM.09.01.01; nursing role includes questioning inappropriate antibiotic orders and monitoring for adverse effects
Scope of practice: All nursing personnel implement standard precautions; RN directs transmission-based precaution implementation and conducts surveillance assessment; infection preventionist provides expert consultation