Control of infection in ophthalmic practice

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Risk reduction principles

People:

• Consider ALL patients and staff a potential infection risk.
• Staff and patients should wash hands with soap before commencing any examination.
• Wash hands with soap before and after every clinical procedure, even if gloves are worn.
• Staff and patients with any broken skin, however small, must wear an occlusive dressing.
• Staff with any known or suspected infection should not have direct patient contact.

Environment:

• Wear heavy duty gloves for any cleaning procedures.
• Clear up any spillages of blood or other body fluids immediately. Cover with bleach and leave for 15 minutes,
  wipe with disposable paper tissue or cloth. Wash the surface with a clean cloth, detergent and water. Burn all cleaning tissue and cloths.
• Burn or bury soiled materials and other waste.
• Soiled linen – soak first, dispose of the water carefully, and boil the linen before (gloved) hand-washing.

Equipment:

• Used needles and other sharps – dispose of immediately into a puncture-resistant container. Make sure plenty are available in all areas where needles are used.
• Never re-sheath a disposable needle! One-third of needle stick injuries are reported to occur during re-sheathing.
• If a needle stick injury occurs – remove the glove and instrument from the surgical field. (See below re: procedure following a needle stick injury).
• Applanation tonometer prisms (tips only), diagnostic contact lenses, A-scan probes, occluders and pin-holes should be wiped with disposable paper tissue after each use. Store in sodium hypochlorite 1%, in a non- metallic pot, for 10 minutes, rinse in sterile water and dry before re-use.
• Slit lamp – chin rest, head rim, handgrips and table top should be washed with detergent and water between each patient examination.

Surgical instruments & decontamination procedures:

• Loaded needle holders – lie point down on trolley and table tops.
• Pass sharp instruments to colleagues with verbal warning and eye contact communication.
• Sharp instruments should not project beyond the surface edge.
• Ensure surgical instruments are thoroughly cleaned before being passed for sterilization or disinfection.
• Choose the appropriate sterilization or disinfection method for the specific instrument.
• Emphasize care of instruments and sterilization and disinfection procedures in training programmes.

Clinical practice & safety issues:

• Critically review work practices regularly.
• Include control of infection policies in training programmes.
• Implement and emphasize strict adherence to universal control of infection policies.
• Teach correct hand-washing technique and display a written procedure in all relevant areas (see below).
• Eye drops and ointments – provide individual containers for each patient.
• Eye dressings – following removal, dispose of immediately, by burning.
• Eye shields – if removed from a knowingly infected patient, never re-use.
• Pathological specimens – dispose of needles and blades used to obtain corneal and conjunctival material into ‘sharps’ container.
• Wear rubber boots to protect feet in the operating theatre. Feet are particularly at risk of injury from puncture wounds caused by dropped instruments. Never allow sandals to be worn in the operating theatre.
• Wear a plastic or rubber apron under sterile gowns if large amounts of blood spillage is expected.
• Wear eye protection and face masks in the operating theatre.
• Wear gloves on both hands for all invasive procedures and when in contact with broken skin, mucous membranes, blood and body fluids.

In the event of a needle stick injury

• Allow the wound to bleed freely for a few minutes.
• Wash with soap and water.
• Cover with a sterile dressing.
• If known, note the details of the person on whom the needle was used and, if possible, check their HIV status.
• Report the incident to the person-in-charge.
• The injured person should be examined by a medical practitioner and referred for treatment if HIV transmission is a confirmed risk.

Hand-washing technique

• Wet hands with clean, preferably running, water.
• Apply soap or cleanser.
• Rub palm to palm.
• Rub back of left hand over right palm.
• Rub back of right hand over left palm.
• Rub backs of fingers on opposing palms with fingers interlocked.
• Rub palm to palm with fingers interlaced.
• Rub around right thumb with left palm.
• Rub around left thumb with right palm.
• Rub around fingers of right hand with palm of left hand.
• Rub around fingers of left hand with palm of right hand.
• Rinse off soap with clean, preferably running water and dry well.

Remember!

Control of infection principles must be applied in each and every situation and not only when infection hosts are known or suspected. The risk of HIV transmission after a single needle stick injury or broken skin or mucous membrane contact with HIV infected blood, is less than 0.5%.

HIV remains the least likely occupational infection to be transmitted but still causes the most anxiety. Health care workers may become complacent about other serious and more likely risks.

The prion diseases, e.g., Creutzfeld Jakob Disease (CJD), are also giving genuine cause for concern. CJD is resistant to most sterilization methods. The only guaranteed measures to prevent CJD cross-infection is the use of sterile, single-use disposable instruments.

REFERENCES / FURTHER READING

• Ocular Infection: Investigation and Treatment in Practice – D Seal, A Bron & J Hay. Martin Dunitz, London
• Ophthalmic Operating Theatre Practice – A Manual for Developing Countries, I Cox & S Stevens, ICEH 2002
• Journal of Community Eye Health – S Stevens, I Cox; Vol.9,36-42 1996 – R Seewoodhary, S Stevens; Vol.12, 25-28 1999 – I Cox, S Stevens; Vol.13, 40-41, 2000
• Occupational Medicine: State of the Art Reviews Vol.4. Special Issue 1989, Philadelphia, Hanley & Belfus, Inc.
• Risks of HIV infection to Patients and Health Care Personnel – P H Gerst, J J Fildes, P G Rosario, J B Schorr; Critical Care Medicine Vol.18, No.12, 1440-48, 1990
• Occupational HIV Infection and Health Care Workers in the Tropics – H Veeken, J Verbeek, H Houweling, F Cobalens; Tropical Doctor Vol.21, 28-31, 1991
• Creutzfeldt Jakob Disease and the Eye – B Weller & J Ironside; Ophthalmic Nursing Journal Vol.6, Issue 1, 2002
• MRSA: An Infection Control Overview – D Rayner; Nursing Standard Vol.17, No.4, 47-54, 2003
• The Epidemiology and Control of Hepatitis C Infection – U Gungabissoon; Nursing Times Vol.99, No.31,24-25, 2003
• Best Infection Control Practices for Intradermal, Subcutaneous and Intramuscular Needle Injections – Y Hutin et al; Bulletin of the WH0 Vol.81, No.7,491-500, 2003
• Handwashing; The Fundamental Infection Control Principle – R Horton; British Journal of Nursing Vol.4. No.16, 926-933, 1995
• Standard Principles for Preventing Hospital Acquired Infections – H Loveday; Nursing Times Vol.97, No.13, 36-39, 2001