Certified EKG Technician Exam

This chapter explains how infections spread, how hand hygiene and standard precautions break that spread, when to use contact, droplet and airborne precautions, and the correct order for putting on and taking off personal protective equipment.

An infection can spread only when all six links of the chain of infection are connected. Breaking any one link stops the spread. Health care workers break the chain most often at the mode of transmission link, mainly through hand hygiene and cleaning equipment.

The Six Links of the Chain of Infection

Memory Aid: "All Rabbits Escape Through Every Hole" stands for Agent, Reservoir, Exit, Transmission, Entry, Host.

Many hospital patients are susceptible hosts: older adults, newborns, people with diabetes, cancer patients, and anyone with wounds or IV lines. An infection a patient picks up in a health care setting is called a health care-associated infection (HAI). EKG lead wires, cables and carts move from room to room, so they can carry germs between patients if they are not cleaned.

Hand hygiene is the single most important way to prevent the spread of infection. Perform it:

Before touching a patient

Before a clean procedure, such as applying electrodes to prepared skin

After contact with body fluids or a risk of exposure

After touching a patient

After touching the patient's surroundings (bed rails, tray table, monitor)

Before putting on gloves and right after taking them off

An alcohol-based hand rub is the preferred method when hands are not visibly dirty. Apply enough to cover all surfaces and rub until dry, about 20 to 30 seconds.

Wash with soap and water instead when:

Hands are visibly soiled or contaminated with blood or body fluids

The patient has, or may have, Clostridioides difficile (C. difficile), which forms spores that alcohol does not kill

The patient has norovirus or another illness causing diarrhea or vomiting

Before eating and after using the restroom

Handwashing steps: wet hands with warm water, apply soap, rub all surfaces including between fingers, backs of hands, thumbs and under nails for at least 20 seconds, rinse with fingertips pointing down, dry with a clean paper towel, and use the paper towel to turn off the faucet.

Standard precautions are the basic infection control practices used for every patient, every time, whether or not an infection is known. They are based on the idea that all blood, body fluids (except sweat), nonintact skin and mucous membranes may carry germs. Standard precautions include:

Hand hygiene

Using PPE based on the expected exposure (gloves when touching blood, body fluids, nonintact skin or contaminated items)

Respiratory hygiene and cough etiquette (offer a mask and tissues to a coughing patient)

Safe handling and cleaning of equipment and surfaces

Safe handling of sharps and waste

Safe handling of linens

Transmission-based precautions are added on top of standard precautions when a patient is known or suspected to have certain infections. A sign on the door tells staff which type to use.

Transmission-Based Precautions

For contact precautions, use disposable lead wires or a dedicated machine when the facility provides them. If a shared machine must be used, keep it as clean as possible, use disposable electrodes, and fully disinfect the machine, cables and lead wires before taking them to the next patient. If C. difficile is involved, use the facility's sporicidal (often bleach-based) disinfectant and wash hands with soap and water.

Bedside Scenario: A technician receives an order for a 12-lead EKG on a patient whose door sign shows contact precautions for MRSA. The technician performs hand hygiene, puts on a gown and gloves before entering, performs the EKG with disposable electrodes, removes PPE at the doorway in the correct order, performs hand hygiene, and disinfects the cables and machine before the next patient. This breaks the mode of transmission link.

PPE is clothing and equipment that protects you from contact with infectious materials. It includes gloves, gowns, masks, respirators, goggles and face shields. Choose PPE based on what exposure you expect: gloves for hand contact, a gown if clothing could be soiled, and a mask with eye protection if splashes or sprays are possible.

Donning means putting on PPE. Doffing means taking it off. The order matters because doffing is when most self-contamination happens.

Donning PPE (putting on)

Perform hand hygiene.

Put on the gown and tie it at the neck and waist.

Put on the mask or respirator; fit it to the nose and check the seal if it is an N95.

Put on goggles or a face shield.

Put on gloves last, pulling the cuffs over the gown sleeves.

Doffing PPE (taking off)

Remove gloves first, because they are the most contaminated. Grasp the outside of one glove at the wrist, peel it off, hold it in the gloved hand, slide a clean finger under the second glove and peel it off over the first.

Remove goggles or face shield by the ear pieces or headband.

Remove the gown by untying it and pulling it away from the body, rolling the outside inward.

Remove the mask or respirator by the ties or elastic, without touching the front. Remove an N95 after leaving the room.

Perform hand hygiene right away.

Memory Aid: Donning goes from the body outward to the hands: gown, mask, goggles, gloves. Doffing starts with the dirtiest item: gloves come off first.

Exam Tip: Some facilities remove the gown and gloves together in one motion. If a CET item asks which item is removed first in the standard sequence, the answer is gloves. If it asks which item is put on last, the answer is also gloves.

The chain of infection has six links; breaking any one link, most often by hand hygiene, stops the spread.

Use alcohol-based hand rub unless hands are visibly soiled or the patient has C. difficile or norovirus; then wash with soap and water.

Standard precautions apply to every patient; transmission-based precautions (contact, droplet, airborne) are added for specific infections.

Don PPE in the order gown, mask, goggles, gloves; doff gloves first, then goggles, gown and mask, then hand hygiene.

Gloves never replace hand hygiene.