4.1: Infection Control and Standard Precautions

The Chain of Infection

Infection control is one of the most critical responsibilities of a Licensed Nursing Assistant (LNA). Facilities are environments where vulnerable people live closely together, making the spread of pathogens (disease-causing microorganisms) a constant threat. The spread of disease is conceptualized as the Chain of Infection, which consists of six distinct links. For an infection to occur, all six links must be connected. If an LNA can break even one link, the infection cannot spread.

1. Causative Agent (Pathogen): The biological agent that causes disease, such as bacteria, viruses, fungi, or parasites.
2. Reservoir: Where the pathogen lives and grows. This can be a human, an animal, a surface, or even food and water. Warm, dark, and moist environments are ideal for pathogen growth.
3. Portal of Exit: The way the pathogen leaves the reservoir. In humans, this includes respiratory droplets (coughing, sneezing), blood, urine, feces, saliva, or wound drainage.
4. Mode of Transmission: How the pathogen travels from one person to another. This is often the link easiest for LNAs to break. Transmission can be direct (touching an infected person) or indirect (touching a contaminated object like a bedpan or doorknob).
5. Portal of Entry: The way the pathogen enters a new host. Common portals include the respiratory tract, mucous membranes (eyes, nose, mouth), gastrointestinal tract, and broken skin.
6. Susceptible Host: An uninfected person who could get sick. Residents are often highly susceptible due to age, chronic illness, or weakened immune systems.

Your primary job in infection control is to break the chain. Handwashing breaks the mode of transmission. Covering a cough breaks the portal of exit. Bandaging a wound blocks the portal of entry.

Hand Hygiene: The Ultimate Defense

The most effective way to prevent the spread of infection is proper hand hygiene. This is heavily tested on the state exam and evaluated rigorously during the clinical skills test. Hand hygiene includes washing with soap and water or using an alcohol-based hand rub (sanitizer).

When to Wash Your Hands:

• Immediately when arriving at work and before leaving.
• Before and after every resident contact.
• Before and after wearing gloves (gloves are never a substitute for hand hygiene).
• After using the restroom, coughing, sneezing, or blowing your nose.
• Before handling food or feeding a resident.
• After touching any potentially contaminated surface or object.

The Mechanics of Handwashing: The critical element of handwashing is friction. You must scrub all surfaces of your hands, wrists, fingers, and under your nails for at least 20 seconds. Water should be warm, not hot, to prevent skin breakdown. Keep your fingertips pointed down so contaminated water does not run up your arms. Dry your hands with clean paper towels, and use a dry paper towel to turn off the faucet so you do not recontaminate your clean hands.

Soap and Water vs. Hand Sanitizer: Alcohol-based hand rubs are effective for routine hand hygiene when hands are not visibly soiled. However, hand rubs do not kill certain spores, most notably Clostridium difficile (C. diff). When caring for a resident with C. diff, or when hands are visibly dirty, you must use soap and water.

Standard Precautions

Standard Precautions are the basic level of infection control that should be used in the care of all residents all of the time, regardless of their diagnosis or presumed infection status. The core rule of Standard Precautions is to treat all blood, body fluids, non-intact skin, and mucous membranes as if they are infected.

Body fluids include saliva, sputum, urine, feces, semen, vaginal secretions, pus, and vomit. The only body fluid not included in Standard Precautions is sweat. To adhere to Standard Precautions, LNAs must wear gloves when there is a risk of contact with body fluids, wear a gown or mask if splashing is possible, and practice scrupulous hand hygiene.

Transmission-Based Precautions

When a resident has a specific, known, or highly suspected infection, Transmission-Based Precautions are implemented in addition to Standard Precautions. There are three categories based on how the pathogen travels:

1. Contact Precautions: Used when a pathogen is spread by direct or indirect contact. Examples include MRSA, VRE, and C. diff. Requirements typically include wearing a gown and gloves before entering the room and dedicating equipment (like a stethoscope or blood pressure cuff) solely to that resident.

2. Droplet Precautions: Used for diseases spread by large respiratory droplets produced by coughing, sneezing, or talking. These droplets do not travel far (usually no more than three feet). Examples include influenza, COVID-19, and whooping cough. Requirements include wearing a surgical mask upon entering the room. Residents should wear a mask if they must leave their room.

3. Airborne Precautions: Used for diseases transmitted by tiny airborne droplet nuclei that can remain suspended in the air and travel long distances. Examples include tuberculosis (TB), measles, and chickenpox. Residents are placed in an Airborne Infection Isolation Room (AIIR) with negative air pressure. Staff must wear a fit-tested N95 or higher-level respirator.

Donning and Doffing PPE

Personal Protective Equipment (PPE) protects you from exposure to infectious materials. However, if put on (donned) or taken off (doffed) incorrectly, you risk contaminating yourself or the environment. The state exam often tests the exact sequence.

Sequence for Donning (Putting On) PPE: Always perform hand hygiene before donning PPE.

1. Gown: Fully cover your torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in back of neck and waist.
2. Mask or Respirator: Secure ties or elastic bands at middle of head and neck. Fit flexible band to nose bridge. Fit snug to face and below chin.
3. Goggles or Face Shield: Place over face and eyes and adjust to fit.
4. Gloves: Extend to cover wrist of isolation gown. (Mnemonic to remember donning: Gown, Mask, Goggles, Gloves - generally bottom-up in alphabetical order of face wear).

Sequence for Doffing (Taking Off) PPE: The goal of doffing is to avoid touching contaminated areas of the PPE with your bare skin. The front of the gown, outside of gloves, and front of the mask/goggles are considered contaminated.

1. Gloves: Grasp the outside of one glove near the wrist, peel away, rolling it inside out. Slide an ungloved finger under the wrist of the remaining glove and peel it off over the first glove.
2. Goggles or Face Shield: Remove from the back by lifting the headband or ear pieces.
3. Gown: Unfasten ties, pull away from neck and shoulders, touching inside of gown only. Turn gown inside out and roll into a bundle.
4. Mask or Respirator: Grasp bottom ties or elastics, then top ones, and remove without touching the front.
5. Hand Hygiene: Wash hands immediately after removing all PPE. (Note: Some protocols allow removing the gown and gloves together, but the traditional distinct sequence is most tested).

Bloodborne Pathogens and Sharps Safety

Bloodborne pathogens are microorganisms found in human blood that can cause disease, notably Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV). Facilities must follow the OSHA Bloodborne Pathogens Standard to protect staff.

LNAs do not typically give injections, but they may handle contaminated razors or clean up broken glass. All sharps must be disposed of in a puncture-resistant, leak-proof, red biohazard sharps container. Never recap, bend, or break needles. If an exposure incident occurs (such as a needle stick or blood splashing into the eyes), wash the area immediately and report it to the charge nurse. Facilities must offer the Hepatitis B vaccine free of charge to at-risk employees.