1. Newborn Week 2013
Quality issues and Accreditation of
newborn healthcare delivery systems

2. Dr L S Deshmukh
MD,DNB,DM(Neonatology)
Professor,
In charge (Neonatology)
GMC, Aurangabad

3. Introduction
Nosocomial infections :
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*
*
*
In hospital acquired
Higher mortality rate
Longer hospitalization
Increased cost

4. NICU ATTACK

5. Sources of nosocomial infection
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Personnel
Other sources
Fomites – equipments
Environment
Invasive procedures

6. Risk factors for nosocomial
infections
 Intravenous catheters and other invasive
procedures
 Ventilation / suctioning
 Medications
 Overcrowding
 Understaffing
 Prolonged hospital stay
 Contaminated enteral feed
 Health care workers
 Colonization by pathogenic organisms
 Other neonates with infection

7. Nosocomial infections
HCWs get their hands contaminated during

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Taking a patient‟s blood
Examination / Recording TPR / BP
Assisting patients for mobility
Inserting Catheters / Invasive devices
contact with a patient‟s clothes / bed linen
Performing procedures
Wound-dressing
Inanimate objects - bed rails / bedside tables
/ I.V. pumps

8. sepsis – Disaster
Weeks of hard work
+
Sleepless nights
+
Carefully calibrated fluids
+
Meticulous titrated ventilator settings
Inadequate asepsis
=
Nothing (Zero)
Nosocomial infections ~ nightmare

9. Asepsis - Definition
Absence of germs / pathogens
Two types of techniques :
- Medical (Clean)
- Surgical (Sterile)

10. Definition of Terms
Hand hygiene – A general term that
applies to either handwashing, antiseptic
hand wash, antiseptic hand rub, or
surgical hand antisepsis.
Hand washing – Washing hands with
plain soap and water.
Plain soap – Refers to detergents that
do not contain antimicrobial agents or
contain low concentrations.
Antimicrobial soap – Soap containing an
antiseptic agent.

11. Definition of Terms
 Antiseptic agents – Antimicrobial
substances that are applied to the skin to
reduce the number of microbial flora. e.g.
alcohols, chlorhexidine, iodine etc.
 Antiseptic hand wash – Washing hands with
water and soap containing an antiseptic
agent.
 Alcohol-based hand rub – An alcoholcontaining preparation designed for
application to the hands for reducing the
number of viable micro-organisms on the
hands.

12. Five parts of asepsis
Practices that prevent entry of microbes
into the nursery environment
II. Practices that prevent proliferation of
microbes in nursery.
III. Practices that prevent spread of
microbes between babies.
IV. Practices that protect that newborn
from developing infections.
V. Practices that enable better asepsis &
administration.
I.

13. Fight against Macro-organisms

14. Fight against Micro-organisms

15. I- Practices that prevent entry of
microbes into the nursery environment
 Maintain a clean environment outside the
nursery.
 Entry restrictions
 Hand washing
- Single most important intervention
 Gowns/masks/slippers
 Air changes :
- 12 air changes
- 0.5 µ bacterial filters
- ? Roll of exhaust fans
Contd….

16. I- Practices that prevent entry of
microbes in to the nursery environment
Entry restrictions
- Only Mothers Allowed
- No Entry of infected infants
Regulated entry
- Personnel of nursery
- Personnel of allied services

17. II – Practices that prevent proliferation
of microbes in nursery
Good house – keeping practices
- Floors
- Refrigerators
- Bins

18. II – Practices that prevent
proliferation of microbes in nursery
Decontamination of equipments : Imp
- Incubators & open care systems
- Ventilators (change tubing daily)
- Resuscitation bags & kits
(have sufficient Nos.)
- Laryngoscopes
- Disposable Procedure sets
(LP /Taps/ ExTx)
Develop “ Disposable Culture”

19. III – Practices that prevent spread
of microbes between babies
 In addition to Hand washing & “Disposable culture“
 Prevention of overcrowding
- At least 4-6 ft. space in between
- Avoid overcrowding
 Adequate Staffing :
- Tertiary care, 1:1 ratio
- 1:2 for cohorted babies
- 1:3 for noninfectious, treated babies.
- 1:4 for stable babies
 Prohibit stock solutions
 Fomites – Files/stethoscope/Exam.tools/pens/cups/
telephone
 Laminar flow – for mixing / reconst. Drugs / TPN

20. IV – Practices that protect
newborn from developing infections
Breast milk
Involvement of mother
Early discharge
Eye and cord care
Skin care
( position / probes / emollients )
* Handling IV fluids & drugs
*
*
*
*
*
Contd…

21. IV – Practices that protect
newborn from developing infections
* Handling invasive lines & tubes
- Peripheral IV lines
(Change every 72 hrs.)
- Central lines (surgical scrub must)
* Do not keep, if not necessary
- Peripheral IV lines a minute more
- IV infusion for an hour more
- Central line a day more

23. IV – Practices that protect newborn
from developing infections
 Minimize handling & breach of barriers
- Noninvasive monitoring
- Clubbing together rounds
 Aseptic precautions during procedures
- Universal precautions
- IV lines ( assess frequently)
- Endotracheal intubation & suctioning
- Chest tube insertion/LP/Ex transfusion.
- Central lines insertions ( maintain sanctity)

24. Iatrogensis

25. V – Practices that enable better
asepsis
 Environmental surveillance
- At least every month.
 Record of positive cultures
- Analyze data regularly
- Develop antibiotic policy
 Motivating staff- Most Important
- Sweeper to consultant / In-charge
- Regular meetings

26. Hand Hygiene
Historical perspective :
oUse of antiseptics – 19th century
oLiquid chloride solution, 1825
oIgnaz Semmelweis, 1846
Use of chlorine solution –
Decreased mortality
(First evidence)
In 1961, US Public Health services
recommended hand washing for
health personnel

27. Normal Bacterial Skin Flora
» Normal human skin – colonized with
bacteria.
Total bacterial count – 3.9x104 to 4.6x106
Transient Vs Resident flora’
» Transient flora –
Superficial layers
Easily removed with washing
Usually acquired through patient contact /
infected source
Usual cause of nosocomial infection
» Resident flora :
- More deeper
- Not easily removed
- May be pathogenic

29. Purpose of Handwashing
* Removal all dirt and debris
* Reduce cross contamination from microbes
* Interrupt the fecal – oral route of
infection.
* Reduce risk of hands acting as vectors
* Breaks a link in a chain of infections.
* Increase the image of cleanliness of
Health Care Personnel.

30. Indications for hand washing
 Hands are visibly dirty or
contaminated
 Before having direct contact with
patients
 Before donning sterile gloves
 Before doing procedures
 After handling contaminated body
fluids

31. Types of hand wash
Routine / social
Procedural (antiseptic)
Surgical hand scrub
„Time‟ method / „stroke
count‟ method
 Details must be followed
 Recommended time
 First - 2 min, then 30 sec.





32. Hand Rub
Selection of hand hygiene agents
 Must provide efficacious hand
hygiene with low irritancy potential.
 Maximize acceptance by HCWs
 Should not be costly.
 Must have adequate information from
manufacturers.
 Friendly dispenser systems

33. Criteria for selection of disinfectant
 Broad spectrum of action
 Rapid action
 Ability to suppress microbial re-growth
for a prolonged period of time.
 Non-irritating to the skin
 Non allergenic
 Effective after the first use
 Visually and aesthetically acceptable
 Cost effective

34. Types of chemical disinfectants
* Phenolics (environmental disinfectants)
- Black and white fluids
- Active against a wide range of bacteria
- e.g. Cresol & LYSOL
* Chloroxylenols (non irritant)
- e.g. Dettol, Ibcol
- High concentrations are required (2.5 – 5.0%)
* Chlorine releasing agents (Cheap)
- Effective disinfectants
- Rapidly effective against viruses, fungi, bacteria & spores.
- Should be prepared daily
- e.g. Sterite, Chloros, Presept
Contd….

35. Types of chemical disinfectants
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•
•
•
•
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Iodine or Idophors
- For hand disinfection or surgical scrub
- e.g. tincture of iodine, povidone iodine (betadine)
Aldehydes
- e.g. Glutaraldehyde (Cidex), Formaldehyde (Formalin)
- Nondamaging to metal, plastics, or rubber
- Useful for heat sensitive items.
Alcohols
- e.g. ethyl alcohol 70% (ethanol), isopropranol
- Rapid disinfection
- Cheap
Chlorhexidine
- Skin antiseptic, used for procedures
- Costlier
Quaternary ammonium compounds
Hydrogen peroxide and related compounds
Ethylene oxide gas

36. Recommended disinfectants
* A chlorine releasing agent
(virus – contaminated material)
* Phenolic disinfectant (for routine use)
* Hypochlorides and other chlorine releasing
agents (baths, toilets, wash basins)
* Glutaraldehyde – immersible metal objects

38. Performance Indicators for
Hand Hygiene
» Periodically monitor and record
adherence
» Provide feed back
» Monitor the volume of antiseptic use
/ soap / towels
» Monitor adherence to policies
» During outbreaks, total assessment.

39. Risk factors for poor hand
hygiene practices
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Physician status
Higher work load
Handwashing agents cause irritation and dryness

Sinks are inconveniently located/shortage of sinks
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Lack of soap, water and towels
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Often too busy/ insufficient time
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Overcrowding
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Lack of guidelines / protocols
Needs - “ Behavioral Change “

40. Optimal NICU design
 Adequate space (80-100
sq. ft. for Level III)
 Minimum 6 ft. distance
between incubators /
warmers
 Facilities for hand wash
 Foot or elbow operated
taps
 Air circulation facility

41. Fumigation
 No additional benefit, provided
excellent house keeping and asepsis
 Mostly done routinely
 Periodically / following epidemic
 During low occupancy
 Spraying may be used

42. Fumigation

43. Waste Disposal

44. Isolation of neonates
* Open wounds or skin lesions
0r acute gastroenteritis
* Strict hand washing
* Use of individual equipment
* Use of disposable
* Maintain optimum distance

45. Nursery Outbreaks
 Cluster of infection with
same pathogens
 Common source
• Contaminated equipments
(Thermometers,Ventilators,Stetho)
• Environmental reservoirs
• Lapses in hand washing – Most IMP.
“neonatologist‟s nightmare”

46. Nursery Outbreaks Lessons
 Be vigilant to detect an increased
incidence of common organisms
 Adopt a systematic approach
 Be prepared to be surprised

47. Infection control and prevention
“best practices.”
 staffing,
 spacing,
 cohorting,
 auditing cleaning effectiveness,
 auditing hand hygiene,
 frequent microbiologic screening

49. Without commitment
from everybody involved
in care, Infection Control
becomes a “BIG JOKE”

51. CONCLUSIONS
• Hand washing & common sense
are the best disinfectants.
• Mother is the best nurse of the baby.
• Breast milk is the best antidote.
• “MININMAL HANDLING” is the key.
• Conscious, determined efforts & health
education is our moral responsibility.