infection control.pptx

infection control in ICCU

1. COLLEGE OF NURSING MADRAS MEDICAL COLLEGE, CHENNAI-03 MEDICAL SURGICAL NURSING-II infection control, standard safety measures BY EDWIN JOSE.L MSC(N) II YEAR, COLLEGE OF NURSING, MADRAS MEDICAL COLLEGE, CHENNAI

2. INTRODUCTION Critically ill patients are susceptible to a multitude of complications related to both the severity of underlying illness and the need for intensive care therapies. Contemporary cardiac ICUs (CICUs) have an increasing prevalence of non-cardiovascular comorbidities and multisystem organ dysfunction. Thus, it stands to reason that patients admitted to contemporary CICUs will be susceptible to similar preventable complications associated with both their multisystem critical illness and the resources required to treat their complex conditions. As a result, there may be opportunities to improve CICU outcomes through the implementation of evidence-based preventive practices. 

3. Definition-ICCU ICCU (Intensive Coronary Care Unit) is a unit which focused on intensive treatment for heart issues such as coronary heart disease, heart attack, cardiac arrest, heart failure, etc. The intensive cardiac care unit (ICCU) of the hospital has always been where the most vulnerable patients are kept, so they can be closely monitored and treated, often with a one-to-one ratio of nurse to patient, for the most scrupulous of care. Even with great advances in medical technology, these patients continue to be at the greatest risk for infections that are often avoidable by taking a few simple precautions. Healthcare workers treating these patients literally hold life and death in their hands.

4. Infection control- definition Infection prevention and control (IPC) is a practical, evidence-based approach which prevents patients and health workers from being harmed by avoidable infection and as a result of antimicrobial resistance. - - World Health Organization

5. Basic principles of infection control Healthcare-associated infections (HAIs), also known as nosocomial infections, are infections acquired following admission to a healthcare facility that weren't present before admission. The CDC estimates that 1 in 20 patients will develop an HAI. These infections are contracted by an estimated 1.7 million patients annually and responsible for approx. 99,000 deaths each year. All patients are susceptible to HAIs because of potential exposure to microorganisms while in the healthcare setting. because of frequent contact with patients who harbor microorganisms, nurses have a higher occupational exposure than other healthcare professionals. As nurses, we can serve as leaders in preventing HAIs by modeling behaviors to prevent transmission of microorganisms between patients, including proper use of PPE, following agency policies, and understanding the vulnerability of the patients.

6. Chain of infection

7. Infection Control Basics - CDC There are 2 tiers of recommended precautions to prevent the spread of infections in healthcare settings: Standard Precautions Transmission-Based Precautions.

8. Standard Precautions Standard Precautions are used for all patient care and protects healthcare providers from infection and prevent the spread of infection from patient to patient. Standard precautions apply to blood and body fluids, secretions and excretions (except sweat), nonintact skin, and mucous membranes These includes Hand hygiene Use of personal protective devices Respiratory hygiene/cough etiquette Appropriate patient placement Proper handling and cleaning and disinfectant of patient care instruments and devices Handling textiles and laundry carefully safe injection practice

9. Hand hygiene Hand hygiene is the number one weapon in preventing the spread of microorganisms and includes alcohol-based hand rubs and hand washing with soap and water. Alcohol-based hand rubs containing 60% to 95% alcohol are the preferred method for decontaminating hands, except when hands are visibly soiled or when a patient has infectious diarrhea.  C. difficile and norovirus aren't affected by alcohol-based hand rubs; soap and water should be used in suspected or confirmed cases of infectious diarrhea.

10. Moments of handwashing

11. Hand washing

12. Use of personal protective devices PPE includes gloves, gowns, masks, respirators, and eyewear that create barriers to protect skin, clothing, mucous membranes, and the respiratory tract from infectious organisms. The item selected depends on the infectious agent, the type of interaction, and the method of microorganism transmission

13. Respiratory hygiene/cough etiquette Patients with signs and symptoms of a respiratory infection should be taught to cover their mouth and nose with a tissue when coughing or sneezing and dispose of the tissue in the nearest trash container as soon as possible. These patients should perform hand hygiene with alcohol-based rubs, soap and water, or an antiseptic hand wash after being exposed to respiratory secretions or contaminated materials or objects. Healthcare facilities should ensure adequate and readily accessible supplies of tissues and hand hygiene stations. Visual alerts should be posted in facility entrances to remind patients and visitors to inform healthcare professionals of respiratory signs and symptoms. Patients with respiratory symptoms should be masked to contain respiratory secretions.

14. Appropriate patient placement Include the potential for transmission of infectious agents in patient-placement decisions. Place patients who pose a risk for transmission to others (e.g., uncontained secretions, excretions or wound drainage; infants with suspected viral respiratory or gastrointestinal infections) in a single-patient room when available patient placement based on the following principles: Route(s) of transmission of the known or suspected infectious agent Risk factors for transmission in the infected patient Risk factors for adverse outcomes resulting from an HAI in other patients in the area or room being considered for patient-placement Availability of single-patient rooms Patient options for room-sharing

15. Spacing between beds In open plan wards, there should be adequate space between each bed to reduce the risk of cross-contamination/infection occurring from direct or indirect contact or droplet transmission. Space between beds should be 1–2 meters. Single rooms Single rooms reduce the risk of transmission of infection from the source patient to others by reducing direct or indirect contact transmission. Single rooms should have: hand-washing facilities ,toilet and bathroom facilities. A room should be cleaned before admitting a patient. There should be a policy for cleaning the room ( i ) after patient discharge (terminal cleaning) and (ii) before admission. All patient-care items used by the previous patient should be removed and replaced with clean items, e.g. bed linen, waterproof covering, oxygen humidifiers, face mask, etc. as per the housekeeping policy.

16. patient care instruments and devices Establish policies and procedures for containing, transporting, and handling patient-care equipment and instruments/devices that may be contaminated with blood or body fluids Remove organic material from critical and semi-critical instrument/devices, using recommended cleaning agents before high level disinfection and sterilization to enable effective disinfection and sterilization processes Wear PPE (e.g., gloves, gown), according to the level of anticipated contamination, when handling patient-care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids

17. Spaulding Classification Scheme Earle H. Spaulding devised a classification scheme for disinfecting and sterilizing patient-care items and equipment (Spaulding, 1968). This classification scheme is based on categorizing patient care equipment Critical items semi-critical items noncritical items

18. Critical items Critical items enter sterile tissue or the vascular system (e.g., needles, indwelling urethral catheters), and carry a high risk for infection if they are contaminated with any microorganism. Therefore, critical items should be sterile because any microbial contamination could transmit infections.

19. semi-critical items Semi-critical items contact mucous membranes or non-intact skin. these items include an oral thermometer and respiratory therapy equipment. Semi-critical devices should be managed the same way regardless of whether the patient is known to be infected with HBV, HCV, HIV, or M. tuberculosis. Some semi-critical items that may come in contact with non-intact skin for a brief period of time (i.e., bed side rails) are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants

20. Noncritical items Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical items can be divided into two categories: Non-critical patient care items may include a blood pressure cuff, laptop computer keyboard, stethoscope, nursing bag taken into the home, pulse oximeter, etc. Virtually no risk has been documented for transmission of infectious agents to patients through non-critical items when they are used as non-critical items and do not contact non-intact skin and/or mucous membranes Non-critical environmental surfaces include the floor, bedside tables, side rails on a hospital bed in the home, television remote, light switches, and the patient’s furniture. Many of these non-critical environmental surfaces are frequently touched by the staff member’s hands and potentially could contribute to secondary transmission by contaminating the home care and hospice staff members’

21. Levels of Disinfection There are three levels of disinfection: High-level disinfection kills all microorganisms except large numbers of bacterial spores; Intermediate-level disinfection kills mycobacteria, vegetative bacteria, most viruses, and most fungi, but does not necessarily kill bacterial spores; and Low-level disinfection kills most vegetative bacteria, some fungi, and some viruses.

22. Handling textiles and laundry carefully Handle used textiles and fabrics with minimum agitation to avoid contamination of air, surfaces and persons If laundry chutes are used, ensure that they are properly designed, maintained, and used in a manner to minimize dispersion of aerosols from contaminated laundry

23. safe injection practice To promote injection safety, gloves should be worn when administering injections. Puncture-proof disposal systems are recommended to dispose of uncapped needles and sharps. Never recap needles following administration of medication to reduce the risk of being stuck with an unclean needle. engage a needle safety device immediately after performing an injection.

24. Environmental cleaning Establish policies and procedures for routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling. Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient (e.g., bed rails, over bed tables) and frequently-touched surfaces in the patient care environment (e.g., door knobs, surfaces in and surrounding toilets in patients’ rooms) frequently In facilities that provide health care to pediatric patients or have waiting areas with child play toys (e.g., obstetric/gynecology offices and clinics), establish policies and procedures for cleaning and disinfecting toys at regular intervals

25. Use the following principles in developing this policy and procedures: Select play toys that can be easily cleaned and disinfected Do not permit use of stuffed furry toys if they will be shared Clean and disinfect large stationary toys (e.g., climbing equipment) at least weekly and whenever visibly soiled If toys are likely to be mouthed, rinse with water after disinfection; alternatively wash in a dishwasher When a toy requires cleaning and disinfection, do so immediately or store in a designated labeled container separate from toys that are clean and ready for use

26. 3 Bucket System Clean Solution Bucket – Add/Mix your cleaning solution to the first, clean bucket. Saturate your mop in the solution. Waste Bucket – Wring excess cleaning solution from your mop into the second bucket – the waste bucket. Mop – Apply the solution to the surface, using your preferred method of mopping, or you can find our mopping technique guide. Waste Bucket – Wring the waste water into the waste bucket for the second time. Rinse Bucket – Rinse your mop in the third bucket, filled with rinsing solution. Waste Bucket – Wring excess rinsing solution into waste bucket, then repeat the process until your surfaces are sparkling!

27. Blood and body substance spill management Use PPE (gloves, face masks and fluid-resistant gowns) for cleaning blood spills. Wear protective shoe covers/ boots when cleaning large spills x For decontamination of small spills (<10ml), if sodium hypochlorite solution is selected, use a 1:100 dilution (525–615 ppm of available chlorine). If spills involve larger amounts of blood, or involve a spill of microbiology cultures in the laboratory, a 1:10 dilution of hypochlorite solution for first application (before cleaning) reduces the risk of infection during cleaning. After the first application, remove the visible organic matter with absorbent material (e.g. disposable paper towels), discard into leak-proof, labelled bag/ container and then dispose of as per waste management guidelines.

28. Transmission-based precautions Use transmission-based precautions in addition to standard precautions when the standard precautions aren't enough to protect from communicable disease transmission. There are three types of transmission-based precautions: Contact precautions Droplet precautions Airborne precautions

29. Contact precautions Contact precautions are used in addition to standard precautions when caring for patients with known or suspected diseases that are spread by direct or indirect contact. Contact precautions include gloving and gowning when in contact with the patient, objects, and surfaces within the patient's environment. All reusable items should be cleaned and disinfected according to organizational policy, and disposable items should be thrown away immediately after being used.

30. Droplet precautions   Droplet precautions require the use of a surgical mask in addition to standard precautions when within 3 ft of a patient known to have or suspected of having a disease spread by droplets. These include influenza, pertussis, and meningococcal disease. Healthcare personnel should observe droplet precautions when examining a patient with respiratory symptoms, especially if the patient has a fever. These precautions should remain in effect until it's determined that the symptoms aren't caused by an infection that requires droplet precautions.

31. Airborne precautions   Airborne precautions are used in addition to standard precautions when in contact with patients with known or suspected diseases spread by fine particles transmitted by air currents, such as tuberculosis, measles, and severe acute respiratory syndrome. wear a National Institute for Occupational Safety and Health certified, fit-tested N-95 respirator just before entry into an area shared with a patient suspected or known to have one of these diseases. Because there are several sizes of N-95 respirator, healthcare personnel must be fit tested according to organizational policy or at least every 2 years to be sure using the correct size. If eye protection is needed, wear goggles or a face shield during all contact with the patient, not just predict splashes or sprays.

32. Safe Disposal of Waste In hospitals there are several different categories of waste ranging from domestic waste (typical everyday waste), contaminated waste (swabs, probe covers, dressings etc.) to high-risk hazardous waste (sharps, medical devices etc.) It is likely that the waste will need to be separated. It is important to follow Biomedical waste management guidelines- 2018 as to the proper separation and treatment of this waste

33. Infections related to ICCU Infections and sepsis are prevalent in CICU populations, both on admission and as acquired complications during hospitalization Patients in the CICU increasingly receive therapies such as invasive medical devices for hemodynamic monitoring, short-term mechanical support, renal replacement therapy, and targeted temperature management (TTM), which are associated with increased risk for health care–associated infections (HAIs) HAIs include catheter-associated urinary tract infection (CAUTI), central line–associated bloodstream infection (CLABSI), ventilator-associated pneumonia (VAP), infection with multidrug resistant (MDR) pathogens, surgical site infections occurring with mechanical circulatory support (MCS).

34. Catheter-Associated Urinary Tract Infection (CAUTI) CAUTIs are a common occurrence in hospitalized patients, with an estimated 1.4 to 1.7 per 1000 catheter days in general ICUs, although data among patients admitted to CICUs are unavailable. The most important risk factor for developing CAUTI is duration of catheterization, with other risk factors including female sex, older age, diabetes mellitus, bacterial colonization of the drainage bag, and errors in catheter care. Limiting the overall use of urinary catheters and the number of urinary catheter days is the most important strategy for preventing CAUTI.

35. Strategies for Prevention of Catheter-Associated Bacteriuria and CAUTI

36. Bundle of care for prevention of CAUTI CAUTI insertion bundle Verification of need prior to insertion Insert urinary catheter using aseptic technique Maintain urinary catheter based on recommended guidelines CAUTI maintenance bundle Daily documented assessment of need Catheter secured – device to secure catheter in place Hand hygiene performed for patient contact Daily meatal hygiene performed with soap and water Drainage bag emptied using a clean container Unobstructed flow maintained

37. central line–associated bloodstream infection (CLABSI), CLABSI is defined by the Centers for Disease Control and Prevention as a laboratory-confirmed bloodstream infection with either a recognized bacterial or fungal pathogen cultured from blood cultures and unrelated to infection at another site or a common commensal organism ( eg , coagulase-negative Staphylococcus) in blood cultures collected on different days/different sites unrelated to infection at another site and associated with of the following signs or symptoms: fever (>38.0°C), chills, or hypotension Risk factors for CLABSI include both host factors ( eg , chronic illness, immunodeficiency, malnutrition, and age) and catheter factors ( eg , duration of catheterization, type of catheter, conditions of insertion, access site care, and skill of catheter inserter).

38. Prevention of CLABSI is multifactorial, but limiting the use of intravascular catheters and the number of intravascular catheter days is the most important strategy to prevent CLABSI. Although routine replacement of central venous catheters (CVCs) is not recommended, regular evaluation for CVC necessity and surveillance for access site infections is good practice. The risk of CLABSI is lowest with subclavian vein followed by internal jugular vein CVC placement. Use of antimicrobial-impregnated catheters or dressings is reasonable if catheter-related infections have not fallen to acceptable levels (which may include zero infections) despite implementation of other preventive measures. Appropriate use of tunneled catheters or peripherally inserted central catheters may reduce the risk of infection when long-term central venous access is required for longer-term medication administration. However, the benefits and risks must be balanced. In particular, to prevent damage to central and peripheral arteries and veins, caution is advised with the use of peripherally inserted central catheters for patients on dialysis or with chronic kidney disease (glomerular filtration rate )

39. Washing hands with soap and water before placement or manipulation Ensuring staff are adequately trained in sterile insertion using full barrier precautions (cap, mask, sterile gown, sterile gloves, and full sterile drape) Using 2% chlorhexidine solution with proper air drying before insertion Avoiding femoral site for catheterization Promptly removing unnecessary catheters Furthermore, a quality improvement approach to CLABSI prevention is recommended, including collecting and monitoring data of CLABSI rates and evaluating each CLABSI for preventable contributing factors.

40. Strategies for Prevention of CLABSI

41. Bundle of care for prevention of CLABSI Insertion bundle Maximal sterile barrier precautions (surgical mask, sterile gloves, cap, sterile gown, and large sterile drape). Skin cleaning with alcohol-based chlorhexidine (rather than iodine). Avoidance of the femoral vein for central venous access in adult patients; use of subclavian rather than jugular veins Dedicated staff for central line insertion and competency training/ assessment. Standardized insertion packs. Availability of insertion guidelines (including indications for central line use) and use of checklists with trained observers. Use of ultrasound guidance for insertion of internal jugular lines

42. Maintenance bundle Daily review of central line necessity Prompt removal of unnecessary lines Disinfection before manipulation of the line Daily chlorhexidine washes (in ICU, patients >2 months) Disinfect catheter hubs, ports, connectors, etc. before using the catheter Change dressings and disinfect site with alcohol-based chlorhexidine every 5–7 days (change earlier if soiled)

43. ventilator-associated pneumonia (VAP), VAP is defined as pneumonia occurring in patients who are endotracheally intubated and mechanically ventilated for >48 hours. Recent data have demonstrated that up to 1 in 5 patients in contemporary CICUs require mechanical ventilation (MV) during hospitalization, with rates increasing over time. Patients who are mechanically ventilated after cardiac arrest, particularly those receiving therapeutic hypothermia, are at a higher risk of developing VAP, likely because of the high prevalence of intra-arrest aspiration noninvasive ventilation modalities can be considered in appropriately selected patients to reduce the duration of endotracheal intubation through either avoidance of initial intubation or facilitation of early extubation .

44. Strategies to Reduce the Incidence of VAP

45. Bundle of care for prevention of VAP Maintenance of in-use respiratory therapy equipment Processing reusable equipment Suctioning of the respiratory tract Elevation of the head of the bed between 30 and 45 degrees Peptic ulcer disease prophylaxis Deep venous thrombosis (DVT) prophylaxis unless contraindicated Daily mouth care with chlorhexidine

46. Infection with multidrug resistant (MDR) pathogens Antibiotic Stewardship and Prevention of Antibiotic Resistance Antibiotic stewardship has been defined as coordinated interventions designed to improve and measure the appropriate use of antibiotic agents, including choice of agent, duration of therapy, dosage, and route of administration. Potential benefits associated with an antibiotic stewardship program include increased microbial susceptibility rates to targeted antibiotics ( ie , reduced prevalence of MDR organisms) and improved patient outcomes, including a reduction in CDI. Despite a dearth of studies examining the outcomes associated with stewardship programs in the CICU setting, implementation of antibiotic stewardship programs in all critical care units has been advocated.

47. surgical site infections occurring with mechanical circulatory support (MCS). In contemporary CICUs, the use of temporary MCS devices is common, ranging from 7% to 10% of admitted patients. The rates of infection vary with duration of use and type of MCS device, with reported incidences ranging from 1% for intra-aortic balloon pumps and Impella to nearly one-third of patients requiring extracorporeal membrane oxygenation (ECMO) support. The duration of MCS has consistently been shown to be a major risk factor for the development of infections and is particularly relevant for contemporary CICUs because the duration of ECMO support has increased over time.

48. Peri-implantation antibiotic prophylaxis may be appropriate for selected patients with temporary MCS devices who are at elevated risk of infection ( ie , patients with a longer anticipated duration of temporary MCS), as is standard for durable MCS device implantation. In addition, it is reasonable to use temporary MCS support for the minimum duration necessary to mitigate the risk of associated infections. Alternative vascular access sites for temporary MCS ( ie , axillary artery) have been reported and could reduce infection rates, but data to support this strategy are limited

49. Standard safety measures

50. Patients safety The first principle of Health Care service is “first to do no harm” (‘Primum non nocere (Latin)’, Hippocrates oath). With advancement of Medical Technology, patient care processes have become more complex. Patient care requires optimum coordination between Healthcare providers (doctors, nurses, technicians, etc ), technology (like CT Scan, MRI, C Arm, etc ), drugs, work-practices, processes, etc. This makes modern hospitals one of the most vulnerable and high risk places, prone for making mistakes that may result in death or serious injuries to patients, whom it is supposed to cure. In India, it is estimated that around 5.2 million injuries occur due to medical errors, resulting in around 3 million preventable deaths every year.

51. Physical Safety Safety of engineering and support services Fire Safety Safe Environment in Hospital Safety of Clinical Care

52. Physical Safety This includes safety of health care infrastructure including Designing, planning and maintenance of hospital infrastructure - e.g. Location of critical departments, segregation of general and patients traffic within the hospital, provision of ramps, and annual preventive maintenance of the facility. It also includes the measures taken for making building earthquake resistant especially in earthquake prone area. Safety of electrical installation - secured wiring, adequate earthing, availability of standard and adequate power outlets, display of danger signs and a system of periodic check-up and power audit of electrical installations in the hospital, special areas requiring high power load (ICU, Cardiac care unit, SNCU) are few areas, needing special attention for the safety.

53. Safety of engineering and support services This includes safe installation & operations of hospital equipment, periodic inspections & maintenance, mandatory alternate electric supply, intercom connection, Emergency alarm system for lifts and central oxygen and vacuum supply, regular inspection of water quality as well adequate alternate power backup arrangements especially for critical areas like ICU, SNCU, OT and Labour room

54. Fire Safety This includes availably of fire extinguisher (correct type, adequate in number at correct location, skill to use them), fire exit plan, training and mock drill of staff for using fire fighting equipment and evacuation.

55. Safe Environment in Hospital This includes Proper cleaning and decontamination of patient care and procedure areas like labour table, OT, wards, injection rooms, dressing room, etc. Proper segregation, storage and disposal of biomedical waste as per guidelines (Biomedical Waste Rules ,2016) Ensuring adequate air exchanges especially in high-risk area ICU, SNCU, OT, etc. Proper sewage disposal and prevention of water logging in health care facility Measures for preventing rodents, pest control and stray animals in patient care

56. Safety of Clinical Care Infection Prevention Practices Medication Safety Identification and monitoring of vulnerable and high-risk patients Proper identification of surgical sites and use of surgical safety checklists Monitoring and reporting of adverse events

57. Infection Prevention Practices Ensuring proper hand washing practices among the care providers (provision for hand washing facilities, correct technique (6-steps), and ensuring practices) Proper disinfection/ sterilization of surgical instruments and surfaces Use of personal protection equipment’s like gloves, masks, apron, etc. Periodic immunization and medical check-up of the care providers

58. Medication Safety Proper identification of patient before drug administration Double check of drug and dosages of high alert medicines Maintenance of expiry dates of drugs, Segregation of ‘look alike and sound alike’ drugs (e.g. Digene & Digoxin (for heart), Fortwin & Fortam , Daonil & Dapsonil ) Ensuring that medical orders are written in legible and comprehendible writing

59. Identification and monitoring of vulnerable and high-risk patients old age, children, stupors/ comatose patients, under drugs / sedation, domestic violence victims, etc. Proper identification of surgical sites and use of surgical safety checklists ( WHO check-lists) Monitoring and reporting of adverse events like hospital acquired infections and adverse drug reaction. It helps in taking preventive action (NOT PUNITIVE ACTION)

60. Health workers safety in iccu physical environment  of the ICCU (lighting, conditioning, noise, equipment, work space),  working conditions  (daily workload, working in shifts, standing for long hours, caring for patients with co-morbidities, inadequate income),  psychosocial factors  (dissatisfaction with work, workplace stress, frequently encountered deaths, interaction with families of patients, workplace violence),  ergonomic factors  (repositioning the patients and repeating movements such as pushing, pulling, elevating and bending),  biological factors  (being exposed to infectious organisms during invasive and non-invasive procedures)  chemical factors  (being exposed to antiseptic and disinfectants or inhaling their gases).

61. physical environment   Suitable lighting in the ICU varies as the lighting in the entrance and the waiting area is recommended to be 150 lx, circulation areas to be between 100 and 150 lx, and offices to be 750 lx. A direct interference with vision must be prevented and glare must be minimised . The nurse desks and monitoring areas should be located where light can be received in a 90° angle The ideal temperature for workplaces is recommended as between 19° and 23°C but may vary in different settings The relative humidity is stated as to be maintained between 40 and 70%.

62. working conditions   Studies in the literature show that there is a correlation between increased workload and increased medical errors and hospital infections The working characteristics in the ICU which require long work schedules lead to physical and mental fatigue Increase human resources as per the requirements

63. psychosocial factors   There are various psychosocial risk factors in ICU settings, such as high qualitative and quantitative demands, emotional demands, low job control, role conflicts, ambiguity, mobbing and physical violence, which affect ICU workers’ well-being The ICCU team members may encounter uncertainties, varied situations that require immediate action, high level of knowledge, psychomotor and cognitive skills and competences which may cause fatigue The social hazards in the ICCU setting are usually generated by working long shifts which require working at night and weekends. They may cause isolation from family relationships, social life difficulties, overall disinterest towards others, uncontrolled aggressiveness and difficulty in making decisions regarding personal life

64. ergonomic factors    There are many force and energy requirements for work tasks in the ICCU setting and there must be considerations of biomechanical rules and workplace adjustments to prevent ICCU workers from musculoskeletal disorders. Occupational musculoskeletal disorders not only occur in acute conditions but also may develop on account of cumulative micro traumas usually in relation to lack of  balance  of the body for tissue repair and adaptation to physical stress  In ICCUs where the physical characteristics were not designed properly, healthcare professionals have a higher risk of musculoskeletal injuries due to repeated physical loads during patient care

65. biological factors   Transmission of infectious agents can occur through blood and body fluids on equipment or their droplets’ absorption by skin or mucosa through direct or indirect contact or lung penetration through the air. Intensive care unit work tasks and processes require direct or indirect contact with biological materials that results in illness and disease As in many other healthcare units, ICUs have the highest rate of needle stick injuries in the nursing workforce that can result in transmission of most common blood-borne infections such as Hepatitis B and C, other Hepatitis infections and HIV. Other infections can transmit to ICU workers by spreading through close contact and by droplets, such as tuberculosis and meningococcal meningitis

66. chemical factors   The ICCU workers face chemical hazards such as being exposed to antiseptic and disinfectants or inhaling their gases. During the work tasks and processes in the ICCU settings , ICCU workers can be exposed to surface cleaners, antiseptic solutions and anaesthetic gases such as formaldehyde. The exposure can occur through many routes, which commonly happens by penetration after lung inhalation, absorption by skin or mucosa contact through eyes or nose. They can cause inflammation or irritation on the part where contact occurred. Moreover, it can lead to dermatitis, allergic reactions (i.e. sneezing and rhinitis), asthma and cancer 

67. journal

68. CONCLUSION Critically ill patients in CICU are prone to complications unique to their underlying diseases that may be under-presented in general ICUs. As a nurse ,we are leader in prevention and control of infection through meticulous interventions.

69. bibliography Patterson CE. Basic principles of infection control. Nursing made Incredibly Easy. 2015 May 1;13(3):28-37. Isolation Precautions [Internet]. Cdc.gov. 2020 [cited 2022 May 8]. Available from: https://www.cdc.gov/infectioncontrol/guidelines/isolation/index.html WHO’s Infection prevention & control department [Internet]. Who.int. [cited 2022 May 8]. Available from: https://www.who.int/teams/integrated-health-services/infection-prevention-control Blakeley JO, Evans DG, Adler J, Brackmann D, Chen R, Ferner RE, Hanemann CO, Harris G, Huson SM, Jacob A, Kalamarides M. Consensus recommendations for current treatments and accelerating clinical trials for patients with neurofibromatosis type 2. American journal of medical genetics Part A. 2012 Jan;158(1):24-41.