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INFECTION PREVENTION AND CONTROL MANUAL September 1, 2011 VIHA Infection Prevention and Control Manual, September 1, 2011 TABLE OF CONTENTS (Click here to see recent changes/additions) PART 1: INTRODUCTION ................................................................................ 15 1. Purpose ...................................................................................................................... 15 2. Scope of the Document .............................................................................................. 15 3. Guiding Principles ....................................................................................................... 15 PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD .................... 16 1. The Chain of Infection................................................................................................. 16 Figure 1: Chain of Infection ................................................................................. 16 A. Causative Agents ............................................................................................... 17 B. Reservoirs .......................................................................................................... 18 Table 1: Human Reservoirs and Transmission of Infectious Agents .............. 19 C. Portal of Exit ....................................................................................................... 19 D. Transmission ...................................................................................................... 20 1. Contact Transmission ............................................................................................. 20 2. Droplet Transmission .............................................................................................. 20 3. Airborne Transmission ............................................................................................ 20 4. Common Vehicle Transmission ............................................................................... 21 5. Vector Borne Transmission ..................................................................................... 21 E. Portal of Entry ..................................................................................................... 21 F. Susceptible Host................................................................................................. 22 PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND PRECAUTIONS................................................................................................. 25 1. ROUTINE PRACTICES .............................................................................................. 25 A. Risk Assessment ................................................................................................ 25 1. Admission ............................................................................................................... 26 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 2 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Ongoing .................................................................................................................. 26 Figure 2: Risk Assessment Decision Tree - Acute Care ................................... 27 B. Risk Reduction ................................................................................................... 28 1. Hand Hygiene ......................................................................................................... 28 Indications for Hand Hygiene .................................................................................. 28 Figure 3: The Four Moments of Hand Hygiene ................................................... 29 Nail and Skin Care .................................................................................................. 30 Type of Cleansing Agent ......................................................................................... 30 Alcohol Based Hand Rub ........................................................................................ 30 Soap and Water ...................................................................................................... 31 Handwashing Technique......................................................................................... 31 Table 2: Levels of Hand Disinfection .................................................................. 32 Hand Hygiene Procedure ........................................................................................ 32 Alcohol based hand rub technique .......................................................................... 32 Soap and Water hand washing technique ............................................................... 32 Surgical asepsis (scrub) technique with an alcohol based hand rub ........................ 33 Surgical asepsis technique with a medicated soap ................................................. 33 2. Respiratory Hygiene/Cough Etiquette ..................................................................... 34 3. Patient Placement ................................................................................................... 35 4. Personal Protective Equipment ............................................................................... 35 Gloves .................................................................................................................... 35 Table 3: Examples of Tasks that Require the Wearing of Gloves .................... 36 Table 4: Glove Use in Patient Care ...................................................................... 37 Figure 4: Choosing the Correct Glove ................................................................ 38 Gowns/Aprons ........................................................................................................ 39 Masks, Visors and Protective Eyewear ................................................................... 40 5. Hair/Jewelry/Uniforms ............................................................................................. 41 Hair ......................................................................................................................... 41 Jewelry ................................................................................................................... 41 Footwear ................................................................................................................. 41 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 3 VIHA Infection Prevention and Control Manual, September 1, 2011 Dress Code for Staff Who Do Not Wear a Uniform, Including Medical Staff ............ 41 Dress Code for Staff Wearing a Uniform ................................................................. 41 6. Safe Handling of Sharps ......................................................................................... 42 7. Decontamination ..................................................................................................... 43 Cleaning.................................................................................................................. 43 Table 5: Reprocessing Decision Chart ............................................................... 43 Disinfection ............................................................................................................. 45 Table 6: Classes of Organisms in Order of Susceptibility to Disinfectants ... 46 Table 7: Disinfection Requirements for Equipment .......................................... 47 Table 8: Advantages and Disadvantages of Major Chemical Disinfectants ... 47 Sterilization ............................................................................................................. 49 Storage ................................................................................................................... 50 Event Related Sterility ............................................................................................. 50 8. Housekeeping ......................................................................................................... 51 9. Laundry ................................................................................................................... 51 Soiled Linen ............................................................................................................ 51 Laundering on the Units .......................................................................................... 52 Clean Linen ............................................................................................................. 52 Handling Soiled Linen contaminated with Hazardous Materials .............................. 53 10. Waste ..................................................................................................................... 54 Biohazardous Waste ............................................................................................... 55 Spillage of Blood or Body Fluids ............................................................................. 55 Waste Containers ................................................................................................... 56 11. Managing Dishes, Glasses, Cups and Eating Utensils ............................................ 56 Managing Tray Delivery – Procedures Specific to Additional Precautions ............... 57 12. Healthy Workplace .................................................................................................. 59 13. Recreational Reading Material and Games ............................................................. 59 C. Education............................................................................................................ 60 2. ADDITIONAL PRECAUTIONS ................................................................................... 61 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 4 VIHA Infection Prevention and Control Manual, September 1, 2011 A. Contact Precautions ........................................................................................... 61 1. Purpose .................................................................................................................. 61 2. Requirements – Signage and Placement ................................................................ 62 3. Contact Precautions – Staff, Patients/Residents, Visitors ........................................ 63 B. Droplet Precautions ............................................................................................ 64 1. Purpose .................................................................................................................. 64 2. Requirements – Signage and Placement ................................................................ 64 3. Droplet Precautions – Staff, Patients/Residents, Visitors ........................................ 64 C. Airborne Precautions .......................................................................................... 65 1. Purpose .................................................................................................................. 65 2. Requirements – Signage and Placement ................................................................ 66 3. Airborne Precautions – Staff, Patients/Residents, Visitors ...................................... 66 4. Actions when Negative Pressure Room Not Available or Malfunctions ................... 68 D. SUMMARY OF PRECAUTIONS ........................................................................ 69 Table 9: Precautions Table .................................................................................. 69 E. Protective (Reverse) Precautions ....................................................................... 70 Procedure ............................................................................................................... 70 F. Management of Cases on Additional Precautions in Diagnostic Areas .............. 71 Figure 5: Management of Infected Patients/Residents on Precautions in Diagnostic Areas .................................................................................................... 72 G. Discontinuing Additional Precautions ................................................................. 73 Table 10: Procedure for Discontinuing Additional Precautions ...................... 73 PART 4: HOUSEKEEPING............................................................................... 74 1. Clean Environment ..................................................................................................... 74 A. ROUTINE CLEANING ........................................................................................ 76 1. DAILY CLEAN......................................................................................................... 76 2. DISCHARGE CLEAN .............................................................................................. 79 3. ROUTINE PLUS DISCHARGE CLEAN ................................................................... 80 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 5 VIHA Infection Prevention and Control Manual, September 1, 2011 B. ENHANCED CLEANING .................................................................................... 81 1. DAILY CLEAN......................................................................................................... 81 2. DISCHARGE CLEAN .............................................................................................. 82 C. TWO STEP CLEANING ..................................................................................... 84 1. TWICE DAILY CLEAN ............................................................................................ 84 2. DISCHARGE CLEAN .............................................................................................. 85 D. SEPARATION OF CLEAN AND SOILED EQUIPMENT ..................................... 86 Table 11: Summary of Cleaning Requirements ................................................. 88 2. Housekeeping Cleaning Terminology ......................................................................... 89 3. Bed Bug Infestation .................................................................................................... 90 Summary of Bed Bug Information ........................................................................... 90 Signs of Infestation ................................................................................................. 90 Key Procedures ...................................................................................................... 90 PART 5: ANTIBIOTIC RESISTANT ORGANISMS............................................ 92 1. Introduction ................................................................................................................. 92 2. Definitions ................................................................................................................... 92 Colonization ............................................................................................................ 92 Infection .................................................................................................................. 92 3. Acute Care Screening Protocol .................................................................................. 92 Figure 6: Patient Record Disease Alert Field ..................................................... 93 Table 12: List of Organisms with Corresponding Precautions and Other Considerations ....................................................................................................... 94 4. ARO Screening and Collecting Swabs ....................................................................... 95 Table 13: Screening and Specimen Collection .................................................. 95 5. Overview of Antibiotic Resistant Organisms ............................................................... 95 A. Methicillin-Resistant Staphylococcus aureus (MRSA) ........................................ 96 B. Vancomycin-Resistant Enterococci (VRE) ......................................................... 96 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 6 VIHA Infection Prevention and Control Manual, September 1, 2011 C. Extended Spectrum Beta-Lactamase (ESBL) Organisms .................................. 97 6. ARO Room Placement ............................................................................................... 98 Figure 7: ARO Room Placement .......................................................................... 98 Special Considerations in Bed Placement for VRE .................................................... 99 7. Key Management Issues ............................................................................................ 99 Table 14: Key Management Issues for MRSA and ESBL ................................... 99 PART 6: OUTBREAK MANAGEMENT ........................................................... 105 1. Introduction ............................................................................................................... 105 2. General Guidelines for Outbreak Management ........................................................ 106 A. Reporting a Suspected Outbreak ..................................................................... 106 Table 15: Contact List .......................................................................................... 106 1. Initial Infection Prevention and Control Precautions .............................................. 106 Figure 8: Suspected Respiratory Infection or Gastroenteritis Outbreak Algorithm .............................................................................................................. 108 2. Confirming an Outbreak ........................................................................................ 109 3. Outbreak Management ......................................................................................... 109 4. Compiling a Post-Outbreak Investigation Summary .............................................. 109 B. Influenza-Like Illness (ILI) Outbreaks ............................................................... 109 1. Introduction ........................................................................................................... 109 2. Confirming an ILI Outbreak ................................................................................... 110 Table 16: Common Differences between Influenza and Common Cold Symptoms ............................................................................................................. 110 Table 17: Respiratory Infections ........................................................................ 111 Table 18: Case Definition for ILI and an ILI Outbreak ..................................... 113 3. ILI Outbreak Management .................................................................................... 113 Practices and Precautions .................................................................................... 113 Room/Unit Closures .............................................................................................. 114 Patient Line Listings .............................................................................................. 114 Staff Line Listings.................................................................................................. 114 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 7 VIHA Infection Prevention and Control Manual, September 1, 2011 Lost Bed Days....................................................................................................... 115 Restrictions on Patient Activities ........................................................................... 115 Working Restrictions for Asymptomatic Healthcare Workers ................................. 115 Working Restrictions for Symptomatic Healthcare Workers................................... 116 Students................................................................................................................ 116 Visitors/ Volunteers ............................................................................................... 117 Meals .................................................................................................................... 117 Pets ...................................................................................................................... 117 Housekeeping ....................................................................................................... 117 Linen ..................................................................................................................... 117 Collection and Transportation of Nasopharyngeal Swabs ..................................... 118 Prophylaxis for Laboratory Confirmed Influenza .................................................... 120 C. Gastrointestinal Illness (GI) Outbreaks ............................................................. 120 1. Introduction ........................................................................................................... 120 2. Confirming a GI Outbreak ..................................................................................... 120 Table 19: Common Bacterial and Viral Causes of Gastroenteritis ................ 121 Table 20: Gastrointestinal Illness Case Definition .......................................... 122 3. GI Outbreak Management ..................................................................................... 122 Practices and Precautions .................................................................................... 123 Room/Unit Closures .............................................................................................. 123 Patient Line Listings .............................................................................................. 123 Staff Line Listings.................................................................................................. 124 Lost Bed Days....................................................................................................... 124 Restrictions on Patient Activities ........................................................................... 125 Working Restrictions for Staff ................................................................................ 125 Students................................................................................................................ 125 Visitors/ Volunteers ............................................................................................... 126 Meals .................................................................................................................... 126 Pets ...................................................................................................................... 126 Housekeeping ....................................................................................................... 126 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 8 VIHA Infection Prevention and Control Manual, September 1, 2011 Linen ..................................................................................................................... 126 Collection and Transportation of Stool Specimens ................................................ 127 Obtaining An Outbreak Number ............................................................................ 127 How To Collect A Stool Specimen......................................................................... 127 Figure 9: Requisition Form for GI Testing ........................................................ 128 D. Outbreaks Caused by Other Organisms ........................................................... 129 1. Clostridium Difficile Outbreak ................................................................................ 129 Confirming a CDI Outbreak ................................................................................... 129 Laboratory samples .............................................................................................. 129 2. Work Restrictions .................................................................................................. 130 Practices and Precautions .................................................................................... 130 3. Scabies ................................................................................................................. 130 Definitions ............................................................................................................. 130 Specific Interventions ............................................................................................ 131 Validation .............................................................................................................. 131 Laboratory Samples .............................................................................................. 131 Control Measures.................................................................................................. 131 Symptomatic Patients/Residents – Treatment ....................................................... 132 Asymptomatic Patients/Residents – Prophylaxis ................................................... 132 Symptomatic Staff – Treatment ............................................................................. 132 Environment .......................................................................................................... 132 Asymptomatic Staff, Volunteers and Physicians – Prophylaxis ............................. 133 Environmental Cleaning ........................................................................................ 133 Scabies Outbreak Conclusion ............................................................................... 133 PART 7: DEPARTMENTAL GUIDELINES ...................................................... 134 1. Inpatient Mother and Baby........................................................................................ 134 A. Routine Practices ............................................................................................. 134 B. Additional Precautions ...................................................................................... 134 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 9 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 21: Common Conditions and Precautions Needed ............................... 134 C. Herpes .............................................................................................................. 135 Figure 10: Precautions Required When Caring for Mother with Non-Genital Herpes ................................................................................................................... 135 Figure 11: Precautions Required When Caring for Mother with Genital Herpes ................................................................................................................... 135 1. Staff Precautions................................................................................................... 135 D. Antibiotic Resistant Organisms ......................................................................... 136 E. Outbreaks ......................................................................................................... 136 2. Neonatal Intensive Care and Special Care Baby Units ............................................ 137 A. Routine Practices ............................................................................................. 137 B. Visitors .............................................................................................................. 137 C. Additional Precautions ...................................................................................... 137 1. Contact Precautions .............................................................................................. 138 2. Droplet Precautions .............................................................................................. 138 3. Airborne Precautions............................................................................................. 138 Table 22: Common Conditions and Precautions Needed ............................... 139 D. Antibiotic Resistant Organisms ......................................................................... 139 E. Outbreaks ......................................................................................................... 140 3. Pediatrics .................................................................................................................. 140 A. Routine Practices ............................................................................................. 140 B. Additional Precautions ...................................................................................... 140 1. Contact Precautions .............................................................................................. 141 2. Droplet Precautions .............................................................................................. 141 3. Airborne Precautions............................................................................................. 142 C. Communicability Periods .................................................................................. 142 D. Antibiotic Resistant Organisms ......................................................................... 143 E. Outbreaks ......................................................................................................... 143 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 10 VIHA Infection Prevention and Control Manual, September 1, 2011 4. Infection Prevention and Control Practices for Surgical Service Areas .................... 144 A. Rationale .......................................................................................................... 144 B. Principles .......................................................................................................... 144 Figure 12: Surgical Booking Procedure ........................................................... 146 Table 23: Assessment for Increased Risk of Communicable Disease Transmission ........................................................................................................ 147 C. Procedure Pre-Operatively ............................................................................... 148 1. Cases Without Identified Need for Additional Precautions ..................................... 148 2. Cases Known to be Colonized with an ARO Without Evidence of Infection ........... 149 3. Cases Where Patient has Evidence of Infection: Contact or Droplet Precautions . 149 Figure 13: Surgical Housekeeping Algorithm .................................................. 151 D. Procedure in the Operating Room .................................................................... 151 1. Routine Practices .................................................................................................. 151 2. Patient Known to be Colonized with an ARO Without Evidence of Infection .......... 154 3. Cases with Infection – Contact and Droplet Precautions ....................................... 155 4. Cases with Infection – Airborne Precautions ......................................................... 156 E. Procedure in the Post-Anaesthetic Area ........................................................... 156 1. Routine Practices .................................................................................................. 156 2. Patient Known to be Colonized with an ARO Without Evidence of Infection .......... 157 3. Cases with Infection – Contact and Droplet Precautions ....................................... 157 4. Cases with Infection – Airborne Precautions ......................................................... 158 5. Burn Unit Recommendations .................................................................................... 159 Unit Isolation ......................................................................................................... 159 Patient Room ........................................................................................................ 159 Isolation Protocols................................................................................................. 160 Visitors .................................................................................................................. 160 Equipment and PPE .............................................................................................. 161 6. Renal Dialysis Department ....................................................................................... 161 A. Introduction ....................................................................................................... 161 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 11 VIHA Infection Prevention and Control Manual, September 1, 2011 B. Policy ................................................................................................................ 161 1. Guidelines for Patient Care ................................................................................... 161 Medication Administration ..................................................................................... 162 Environment and Supplies .................................................................................... 162 Patient Food and Snacks ...................................................................................... 162 Waste ................................................................................................................... 163 Equipment............................................................................................................. 163 Education .............................................................................................................. 163 2. Guidelines for Care of Vascular Access ................................................................ 163 Aseptic Procedure................................................................................................. 164 Skin Antisepsis – Fistulas, Grafts and Catheters ................................................... 164 Catheter Site Dressing Regime ............................................................................. 164 3. Surveillance .......................................................................................................... 165 ARO Screening for Renal Dialysis Patients/Residents .......................................... 165 Screening Requirements for Patients/Residents Not Known to be ARO Positive .. 165 Incoming Visiting Patients/Residents (Travelers) .................................................. 166 Outgoing Traveling Patients/Residents ................................................................. 166 Monitoring ARO Status for Patients/Residents Known to be MRSA or VRE Positive166 MRSA ................................................................................................................... 166 VRE ...................................................................................................................... 167 Consult with Infection Prevention and Control ....................................................... 167 4. Acute Care Patients Receiving Dialysis ................................................................ 167 5. Residential Care Residents Receiving Dialysis ..................................................... 167 6. Routine Surveillance, Evaluation and Management of Communicable Diseases .. 167 7. Guidelines for Patients/Residents Requiring Additional Precautions ..................... 168 Patient Placement for Dialysis ............................................................................... 168 Visitors .................................................................................................................. 168 8. Guidelines for Outbreak Management ................................................................... 168 9. Guidelines for Cleaning and Disinfection ............................................................... 169 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 12 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 24: Disinfection Procedures Recommended for Commonly Used Items or Surfaces in Hemodialysis Units .......................................................... 169 Care and Maintenance of the Dialysis System ...................................................... 170 Water Treatment for Dialysis ................................................................................. 170 10. Guidelines for Peritoneal Dialysis .......................................................................... 170 7. Respiratory Department Guidelines .......................................................................... 173 A. Introduction ....................................................................................................... 173 B. Equipment ........................................................................................................ 173 C. Disposable Equipment ...................................................................................... 173 D. Respiratory Patients/Residents Requiring Additional Precautions .................... 173 1. Guidelines for Ventilator Associated Pneumonia (VAP) ........................................ 174 Definition ............................................................................................................... 174 VAP Prevention Strategies .................................................................................... 174 Surveillance .......................................................................................................... 174 Cross Contamination............................................................................................. 174 Airway Management ............................................................................................. 175 Gastric Reflux Prevention ..................................................................................... 175 Equipment............................................................................................................. 175 Oral Care .............................................................................................................. 175 PART 8: Specific Procedural Recommendations ............................................ 176 1. Asepsis ..................................................................................................................... 176 Microorganisms Live In and On Our Bodies .......................................................... 176 The Seven Keys of Asepsis .................................................................................. 176 Know what is clean ............................................................................................... 176 Know what is contaminated................................................................................... 177 Know what is sterile .............................................................................................. 177 Keep clean, contaminated and sterile items separated ......................................... 177 Keep sterile sites sterile ........................................................................................ 177 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 13 VIHA Infection Prevention and Control Manual, September 1, 2011 Resolve contamination immediately ...................................................................... 177 Train yourself to realize when you have broken technique .................................... 177 Table 25: Approved Antiseptic Agents and Procedures ................................. 178 2. Environment and Furniture in Patient Care Areas .................................................... 180 A. Furniture ........................................................................................................... 180 General ................................................................................................................. 180 Risk Levels ........................................................................................................... 180 Fabric .................................................................................................................... 180 Other Materials ..................................................................................................... 180 B. Fixtures and Fittings ......................................................................................... 181 General ................................................................................................................. 181 Curtains and blinds ............................................................................................... 181 Fittings .................................................................................................................. 181 Vanity tops ............................................................................................................ 181 Handrails and Other Hardware .............................................................................. 182 Ceilings ................................................................................................................. 182 Walls ..................................................................................................................... 182 Floors .................................................................................................................... 182 Posted Signage and Other Posted Materials ......................................................... 182 APPENDICES ................................................................................................. 184 APPENDIX A: Type and Duration of Additional Precautions Where Recommended for Selected Infections and Conditions ............................................................................... 184 APPENDIX B: Glossary of Terms .................................................................................. 208 APPENDIX C: Specific Cleaning Instructions ................................................................ 216 A. Procedure for Cleaning Agitator Tubs/Hydrotherapy Tanks ............................. 216 B. Procedure for Cleaning Fans ............................................................................ 216 C. Procedure for Cleaning Commodes ................................................................. 217 D. Procedure for Cleaning Suction Regulators...................................................... 217 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 14 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 1: INTRODUCTION 1. Purpose This manual has been prepared to assist the healthcare giver by providing a succinct and current guide to infection prevention and control strategies in various healthcare settings. The principles and guidelines set out in the Manual are based on national and international published best practices, which have been modified to reflect the specific needs of VIHA. The manual will be updated from time to time as best practices evolve, and the most current edition will be posted on the VIHA website. 2. Scope of the Document This document covers VIHA Acute, Residential care, Home and Community Care and other community settings. The implementation of routine practices applies to all programs and departments. 3. Guiding Principles Infection prevention and control strategies are designed to protect patients/residents, healthcare providers and the community. Healthcare associated infections (HCAI) cause significant morbidity and mortality, and at least 30% are preventable by correctly following infection prevention and control principles (Haley et al, 1984). A systematic approach to infection prevention and control requires each healthcare provider to play a vital role in protecting everyone who makes use of the healthcare system in all of its may forms; pre-hospital settings, hospitals, clinics, offices, home care and community programs. Healthcare providers must follow infection prevention and control principles at all times, and use critical thinking, risk assesment and problem solving in managing clinical situations. Reference: Ontario Ministry of Health and Residential care Infection Prevention and Control Core Competencies Program, 2005 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 15 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 2: UNDERSTANDING HOW INFECTIONS ARE SPREAD 1. The Chain of Infection The spread of infection is best described as a chain with six links: 1. a pathogen or causative (infectious) agent 2. a reservoir 3. a portal of exit from the reservoir 4. a mode of transmission 5. a portal of entry into the host 6. a susceptible host Figure 1: Chain of Infection Infectious Agents Susceptible Host Reservoirs Portal of Entry Portal of Exit Mode of Transmission An infection can be prevented by breaking any link in the chain of infection. Infection prevention and control measures are designed to break the links and thereby prevent new infection. The chain of infection is the foundation of infection prevention and control. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 16 VIHA Infection Prevention and Control Manual, September 1, 2011 A. Causative Agents Bacteria, viruses, fungi and protozoa (microorganisms) are very common in the environment. Most of these microorganisms cause people no harm, and can in fact be beneficial. Creating an environment with no organisms is not a realistic goal. Bacteria are single celled organisms, some of which can cause disease. We all live with numerous bacteria, referred to as our ―normal flora‖ or ―resident bacteria‖, which usually do not cause disease unless their balance is disturbed. Most bacteria require an infectious dose to cause disease; that is, it usually takes thousands to cause disease, not just one or two. Bacteria vary in infectivity (how easy they are to catch) and virulence (the level of danger from the infection they cause). Viruses are intracellular pathogens, either DNA or RNA, meaning they can only reproduce inside a living cell. Viruses such as HIV and Hepatitis B and C have the ability to enter and survive in the body for years before symptoms of disease occur. Other viruses, such as the influenza viruses, quickly announce their presence through characteristic symptoms. Fungi are prevalent throughout the world, but only a few cause diseases in humans, most of which predominately affect the skin, nails and subcutaneous tissue. A common yeast, Candida albicans, is normal human flora that can cause chronic or severe infections. Fungal infections can be life threatening in critically ill patients/residents. Fungi such as Pneumocystis carinii can be life threatening in persons with HIV/AIDS. Prions are a form of infectious protein believed to be the cause of Creutzfeldt Jakob disease (CJD). Protozoa are single or multi-celled microorganisms that are larger than bacteria. Examples of disease causing protozoa include Amoebas and Giardia, which cause diarrhea, and Plasmodium species, the cause of malaria. They may be transmitted via direct or indirect contact or the bite from an arthropod vector. Parasites are larger organisms that can infect or infest people. Infestation with arthropods, such as lice and scabies, occurs by direct contact with the arthropod or its eggs. Heminths include roundworms, tapeworms and flukes. They infect humans principally through ingestion of fertilized eggs or when the larvae penetrate the skin or mucous membranes. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 17 VIHA Infection Prevention and Control Manual, September 1, 2011 Causative organisms can be eliminated by several methods, including: Sterilizing surgical instruments and anything that comes into contact with sterile spaces of the body Using good food safety methods Providing safe drinking water Vaccinating people so they do not become reservoirs of illness Treating people who are ill Following good hand hygiene practices B. Reservoirs Microorganisms require water to grow and reproduce, so reservoirs are often moist areas. Sometimes a reservoir includes our own normal flora as a contaminant, such as at a sink faucet. In some cases the environment can serve as the reservoir. For example, water supplies may become contaminated by Legionella species. Inadequate air exchange can allow pathogens such as Mycobacterium tuberculosis and Aspergillus to contaminate air supplies. Environmental contamination by pathogens such as Staphylococcus aureus and Enterococcus species also commonly occur in bathrooms and/or on equipment. Appropriate infection prevention and control measures and engineering controls can prevent these reservoirs. Common reservoirs in healthcare facilities include: Ill people Well people. Our normal flora includes bacteria that can be pathogenic if in the wrong part of the body Food; raw meat may harbor pathogens Water from fish tanks or flower vases may contain pathogens, which can cause harm especially for compromised patients/residents Actions we take to eliminate reservoirs include: Treating people who are ill Vaccination Safe handling and disposal of body fluids appropriately Handling food safely Monitoring for water contamination, and restricting flowers in sensitive areas of the hospital Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 18 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 1: Human Reservoirs and Transmission of Infectious Agents Reservoir Transmission vehicle Infectious agent Blood Blood, needle stick, other contaminated equipment, splashes Hepatitis B and C HIV Staphylococcus aureus Staphylococcus epidermidis Skin and Soft Tissue Drainage from a wound or incision Staphylococcus aureus Coliforms Pseudomonas Reproductive tract and genitalia Urine, semen, vaginal secretions Neisseria gonorrhoeae Treponema pallidum Herpes simplex virus Hepatitis B Respiratory tract Droplets from sneezing or coughing Influenza viruses Group A streptococcus Staphylococcus aureus Tuberculosis Gastrointestinal tract Vomitus, feces, bile, saliva Hepatitis A Shigella Salmonella Norovirus Rotavirus Urinary tract Urine Escherichia coli Enterococci Pseudomonas Note: This list is not exhaustive. Reference: Public Health Agency of Canada. (1999) Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Health Care. (currently under revision) C. Portal of Exit The portal of exit is the way in which the causative agent gets out of the reservoir, and it is the link of the chain that we can do the least about. Any break in the skin, including natural anatomical openings and draining lesions, may be the portal of exit from a person; any bodily fluid may carry microorganisms out of the body. Some potent germs live on the patient/resident‘s skin, and thus can easily exit their reservoir. Actions we take to reduce risk from portals of exit include: Covering coughs and sneezes with appropriate measures (e.g. coughing into the elbow) Handling body wearing appropriate personal protective equipment (gloves and gowns) then performing correct hand hygiene Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 19 VIHA Infection Prevention and Control Manual, September 1, 2011 Cover draining wounds covered with an appropriate dressing Health care workers refraining from work when exudative (wet) lesions or weeping dermatitis are present D. Transmission This is the weakest link in the chain of infection. Most efforts to prevent the spread of infection are aimed at eliminating the mode of transmission. Microorganisms are transmitted in healthcare settings by several routes, and the same microorganisms may be transmitted by more than one route. There are five main routes of transmission; contact, droplet, airborne, common vehicle and vector borne. For the purpose of this manual, common vehicle and vector borne will be discussed only briefly, as neither play a significant role in HCAI. 1. Contact Transmission Direct contact transmission is the most important and frequent mode of transmission of HCAI, and is divided into direct and indirect contact transmission. Indirect contact transmission usually involves contact between a susceptible host and a contaminated inanimate object, such as equipment, instruments or environmental surfaces. This is often the result of contaminated hands touching an object or environment. For example, activity staff who use a ball to pass from resident to resident. 2. Droplet Transmission Theoretically, droplet transmission is a form of contact transmission. However, the mechanism of transfer of the pathogen to the host is quite distinct from either direct or indirect contact transmission. Droplets are generated from the source person primarily during coughing, sneezing and talking, and during the performance of certain procedures such as suctioning and administering nebulized medications. Transmission occurs when large droplets containing microorganisms generated from the infected person are propelled a short distance through the air (usually less than one metre) and deposited on the host‘s conjunctivae, nasal mucosa or mouth. Because droplets do not remain suspended in the air, special air handling and ventilation are not required to prevent droplet transmission; that is, droplet transmission must not be confused with airborne transmission. Droplets can also contaminate the surrounding environment and lead to indirect contact transmission. 3. Airborne Transmission Airborne transmission occurs by dissemination of either airborne droplet nuclei; small particle residue (five microns or smaller in size) of evaporated droplets containing microorganisms or dust particles containing the infectious agent (e.g. dust created by rotary powered foot care tools). Microorganisms carried in this manner remain suspended in the air for long periods of Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 20 VIHA Infection Prevention and Control Manual, September 1, 2011 time and can be dispersed widely by air currents. These may be inhaled by a susceptible host within the same room, or over a longer distance from the source patient/resident, depending on environmental factors. Environmental controls are important – special air handling and ventilation help reduce airborne transmission. 4. Common Vehicle Transmission Common vehicle transmission applies to microorganisms transmitted by contaminated items such as food, water and medications, to multiple hosts, and can cause explosive outbreaks. Control is through using appropriate standards for handling food and water, preparing medications and appropriate hand washing. 5. Vector Borne Transmission Vector borne transmission occurs when vectors such as mosquitoes, flies, rats and other vermin transmit microorganisms. This route of transmission is of less significance in healthcare facilities in Canada than in other settings. E. Portal of Entry The portal of entry can be thought of as the hole in the skin that allows the germ to get into the body and cause disease. Pathogens cannot cause disease if they cannot get into the body. Examples of portals of entry include: Mouth, nose and eyes Other anatomical openings Skin breaks (cuts, rashes) Surgical wounds Intravenous sites Anatomical openings with tubes in place (these are more susceptible than those without) Needle puncture injuries Actions to protect portals of entry include: Dressings on surgical wounds IV site dressings and care Elimination of tubes as soon as possible Masks, goggles and face shields Keeping unwashed hands and objects away from the mouth (don‘t lick fingers to turn pages) Actions and devices to prevent needle stick injuries Food and water safety Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 21 VIHA Infection Prevention and Control Manual, September 1, 2011 F. Susceptible Host Susceptibility can be reduced in several ways. For some diseases there are effective vaccines. Some diseases produce lasting immunity after illness. People have better resistance to disease when they are well rested, well fed and relatively stress free. People who have a healthy immune system are often able to resist infection, even when bacteria are present. Host factors that influence the outcome of an exposure include the presence or absence of natural barriers, the functional state of the immune system and the presence or absence of an invasive devise. Natural barriers to infection include: Intact skin and mucous membranes Cilia (small, hairlike projections that line the respiratory system) that filter inhaled air and trap microorganisms Lung macrophages – large white blood cells that ingest microorganisms, other cells and foreign particles, in a process called phygocytosis Antibodies (humeral immunity) resulting from immunization or previous disease Acidic environment of the stomach, urine and vaginal secretions Normal flora provides competition to pathogens. An upset to the balance of normal flora can allow pathogens to cause infection, such as when a yeast infection follows a course of antibiotics The immune system is a complex network of cells, tissues and organs that interact to defend the body against infections. Defense mechanisms can be non-specific or specific and include humeral immunity (antibodies that circulate in the blood), cell mediated immunity (white blood cells) and the inflammatory response, which brings an increase in these infection fighting defenses to the site of infection A person with normal immune system function is described as immunocompetent. Someone whose immune system is impaired by illness or age is said to be immunocompromised. The very young and the very old are at risk with a compromised immune system. Infections are a major cause of death among newborns. Although babies receive certain temporary immunities from their mother through the placenta and in breast milk, their immune systems are still developing, making them vulnerable to infection. Examples of susceptible hosts include: People with chronic diseases People with invasive devices or tubes in place (e.g. catheters) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 22 VIHA Infection Prevention and Control Manual, September 1, 2011 Malnourished people The very old and the very young People who are tired or under high stress People with skin breaks such as surgical wounds, IV sites or chronic rash People undergoing steroid therapy or treatment for cancer People with HIV Infection People who are well and healthy. No one is immune to all disease Actions required to minimize risk to susceptible hosts include: Vaccinating people against illnesses to which they may be exposed Preventing new exposure to infection in people who are already ill, are receiving immunocompromising treatment or are infected with HIV Maintaining good nutrition Maintaining good skin condition Covering skin breaks Encouraging rest and balance The nature of healthcare settings makes patients/residents vulnerable to the spread of infections, because it brings together many ill people who are both reservoirs and susceptible hosts. Staff are also both reservoirs and susceptible hosts, so we cannot eliminate those two major links of the chain of infection. This is why we must make such efforts to eliminate the mode of transmission; hand hygiene is still the single most effective way to prevent the spread of infection. The reservoir and the susceptible host may reside in the same person, if the individual‘s normal flora gets into the ―wrong‖ part of the body it may cause infection. Examples of this situation include: Fecal flora in the urinary tract, causing a urinary tract infection (UTI) Oral flora in the lungs, causing aspiration pneumonia Skin flora in an IV site, causing a site infection or a blood stream infection To avoid providing the mode of transmission between different body sites of the same patient/resident, one must change gloves and wash hands when moving from one site to another, from a contaminated area to a cleaner one following the ―Four Moments of Hand Hygiene‖ Preventing the spread of infectious organisms includes: Early identification of the infectious organism Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 23 VIHA Infection Prevention and Control Manual, September 1, 2011 Prompt appropriate precautions put in place for patients/residents Initiation of appropriate treatment Precautions have disadvantages to the facility, patients/residents, personnel and visitors, including the cost of specialized equipment and environmental controls, which inconvenience healthcare workers and force solitude for patients/residents. However, these disadvantages must be weighed against the facilities mission to prevent the spread of infection. Source: Evans, N and McDonald, M. Infection Control Guidelines for Healthcare Professionals. Routine Practices are to be applied at ALL times by ALL staff. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 24 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 3: INFECTION PREVENTION AND CONTROL PRACTICES AND PRECAUTIONS 1. ROUTINE PRACTICES Infection prevention and control measures are designed to break the links in the Chain of Infection and thereby prevent new infection. In healthcare settings, because agent and host factors are more difficult to control, interruption in transfer of microorganisms is directed primarily at transmission. Routine practices play a key role in preventing the transmission of infectious disease. The Public Health Agency of Canada (PHAC) has used the term ―Routine Practices‖ since 1999, for the process of risk assessment and risk reduction strategies. Routine practice, previously known as Standard Precautions, is to be used with all patients/residents at all times. Routine practices supersede, and are more encompassing than, previous Blood Borne Pathogen Precautions or Universal Precautions. Based on the assumption that all blood and certain body fluids (urine, feces, wound drainage, sputum) contain infectious organisms (bacteria, viruses or fungi), routine practices reduce exposure (both volume and frequency) of blood and body fluids to healthcare providers. Furthermore, routine practices reduce the risk of cross infection through the reduction in contamination and transmission of microorganisms. The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with patients/residents. The elements of routine practices are summarized here into three parts: a. Risk Assessment b. Risk Reduction c. Education Modified from: The Canadian Committee on Antibiotic Resistance (2007) Infection Prevention and Control Best Practices for Residential care, Home and Community Care including Health Care Offices and Ambulatory Clinics. A. Risk Assessment Risk assessment is performed principally to rule out the presence of infectious disease, but it is also necessary to ensure that appropriate precautions are initiated for the various procedures. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 25 VIHA Infection Prevention and Control Manual, September 1, 2011 1. Admission Assessment should be standardized during the admission process to include: Recent exposures to infectious diseases such as Chickenpox, Measles or Tuberculosis Recent travel history, particularly travel abroad New or worsening cough, and are unable to follow respiratory/cough etiquette Fever New undiagnosed rash Sudden onset of diarrhea Drainage or leakage not contained in a dressing and/or medical appliance Any risk of colonization and/or infection with an Antibiotic Resistant Organism (ARO). See the ARO Screening Questionnaire (catalogue number 28125) on the Forms Navigation Bar. 2. Ongoing A risk assessment should be completed on an ongoing basis, assessing the following: Is the patient continent? How susceptible is the patient to infection? Is their immune system intact? Does the patient have any invasive devices or open areas? What is the risk of exposure to blood, body fluids, microorganisms, mucous membranes or non-intact skin in the task about to be performed? Does the patient have a new or worsening cough, and are unable to follow respiratory/cough etiquette? Does the patient have a fever? Does the patient have a new undiagnosed rash? Does the patient have sudden onset of diarrhea? Does the patient have any drainage or leakage not contained in a dressing and/or medical appliance? How competent is the healthcare provider in performing the task? How cooperative will the patient be while the task is performed? Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 26 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 2: Risk Assessment Decision Tree - Acute Care Healthcare Worker Approaches Patient Routine Practices are initiated, including assessment for infectious diseases. The Risk Assessment for infectious diseases includes assessing for: Fever/cough with or without a rash Skin/soft tissue infection Diarrhea illness Not Yet Diagnosed (with or without vomiting) NO Infectious Disease Suspected YES Continue Routine Practices Continue Routine Practices and add Additional Precautions Screen for MRSA and ensure swabs are collected if indicated Screen for MRSA and ensure swabs are collected if indicated Ongoing daily assessment for infection Assessment and diagnostic investigations are conducted. Results will aid in decision to continue or stop Additional Precautions If symptoms develop during admission, go to "YES" stream. STOP ADDITIONAL PRECAUTIONS when criteria are met. Perform daily assessments for new infections. This is not a static process. Assessment for infectious disease is ongoing and adjustments to infection control precautions are applied based on new findings. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 27 VIHA Infection Prevention and Control Manual, September 1, 2011 B. Risk Reduction Risk reduction consists of many elements, all aimed at assisting the healthcare provider to minimize his/her exposure to and contamination with microorganisms. The degree to which the elements of risk reduction (e.g. personal protective equipment (PPE), clean environment) are implemented are dependent upon the findings of the Risk Assessment. For example, the choice of PPE and cleaning solutions will be determined by whether a patient presents with undiagnosed diarrhea or not. 1. Hand hygiene 2. Respiratory/cough etiquette 3. Patient placement 4. Personal Protective Equipment 5. Uniform and work clothing 6. Safe handling of sharps 7. Decontamination 8. Housekeeping 9. Laundry 10. Waste 11. Managing dishes/tray delivery 12. Healthy workplace 1. Hand Hygiene Hand hygiene is the single most important procedure for preventing cross infection. Body secretions, excretions, environmental surfaces and hands of all healthcare workers can carry microorganisms (bacteria, viruses and fungi) that are potentially infectious to them and others. Hand washing is known to reduce patient morbidity and mortality from hospital acquired infection. It causes a significant decrease in the carriage of potential pathogens on the hands. Indications for Hand Hygiene The decision to decontaminate hands should be based on an assessment of the risk that microorganisms have been acquired on the hands and transiently carried to another person or location. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 28 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 3: The Four Moments of Hand Hygiene Reference: Government of Ontario (2006) Hand hygiene must be carried out in the following situations: At the beginning of every shift Before contact with any patient In between contact with each and every patient After contact with a patient on Additional Precautions or one who is colonized with microorganisms of special clinical significance, e.g. resistant to a number of antibiotics Before performing mouth care Before and after contact with susceptible sites, e.g. wounds, burns, IV sites Before performing invasive procedures, e.g. where natural defenses against infection are breached After hands have been contaminated, e.g. contact with body fluids, soiled linen, equipment or garbage After gloves have been removed Before handling food or medicines Before handling clean linen After using the toilet or after toileting others Before and after eating Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 29 VIHA Infection Prevention and Control Manual, September 1, 2011 Prior to entering and leaving a nursing station Prior to using computers and other electronic devices Hand hygiene may also be desirable at other times. The Infection Prevention and Control Team may request additional requirements for hand hygiene, e.g. during an outbreak of infection. Nail and Skin Care The nails are the area of greatest contamination. Short nails are easier to clean and are less likely to tear gloves. Please refer to VIHA‘s Policy 15.1 – Hand Hygiene Policy. Nail varnish is prohibited, regardless of colour, for staff with direct patient contact, or who work in areas where direct patient contact takes place Nail extensions/nail art and acrylic nails are prohibited for staff with direct patient contact, or who work in areas where direct patient contact takes place Ensure the skin on your hands does not become dry or damaged. In these conditions the hands show a higher bacterial load, which is more difficult to remove than with healthy, intact skin. Hand lotion may be used to prevent skin damage from frequent hand washing. Note: skin lotions for patient and/or staff use have been reported sources of outbreaks, so pump dispensers are preferable over tubes or jars. If a pump dispenser is not available, individualized containers must be used1 Creams that have been taken into a patient‘s room should be dedicated to that patient and either disposed of or sent home with the patient on discharge Compatibility between lotions and antiseptic products, and lotion‘s potential effect on glove integrity should be checked (i.e. lotions should not be petroleum based). Please check with Infection Prevention and Control or Occupational Health and Safety to ensure lotion is approved for use Type of Cleansing Agent Alcohol Based Hand Rub Indications: Use routinely when hands are not physically soiled 1 Skin lotion and cream containers for patients are classified as single patient use items Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 30 VIHA Infection Prevention and Control Manual, September 1, 2011 Alcohol based hand rubs2 (ABHR) can be used in place of soap and water, except where hands are visibly soiled (e.g. feces, blood, etc.). They are especially useful in situations where hand washing and drying facilities are inadequate or where there is a frequent need for hands to be decontaminated (such as in client‘s homes). Every effort should be made to install these products as close to point of care as possible. Alcohol based surgical scrubs are used in situations where a reduction in the resident microbial flora is considered desirable, such as in an operating theatre or similar department, and before performing an invasive procedure, especially the placement of an indwelling medical device. Reference: WHO, World alliance for Patient Safety (2006) WHO guidelines on hand hygiene in healthcare (advanced draft). April 2006. Report No: WHO/WPI/QPS/05.2 Soap and Water Indications: When hands are physically soiled When hands look or feel dirty Following contact with blood or body fluids Following contact with any patient with diarrhea/vomiting, and their environment, including bathroom facilities In clinical areas, soap is supplied as liquid or foam, in sealed containers, where the dispensing nozzle is integral to the container, and changed when the unit is empty. Soap dispenser pumps are never to be reused, refilled or ―topped up‖ and must be disposed of once empty. It is recommended that hands are washed with soap and water if in contact with spores (e.g. Clostridium difficile), because the physical action of washing, rinsing and drying hands has been proven to be more effective than alcohols, chlorhexidine, iodophors and other antiseptic agents. Handwashing Technique A brief wash will remove the majority of transient microorganisms, but the technique should aim to cover all surfaces of the hands. Where soap or a surgical scrub has been used, hands should be rinsed under running water and thoroughly dried with a disposable towel. The soap and hand towels should be of a quality acceptable to users, so as not to deter hand washing. The skin should be maintained in good condition to discourage the accumulation of bacteria. 2 The optimal concentration of ABHR is 70-90% with added emollients; a minimum of 70% ethanol will protect against Norovirus. If the ABHR is a gel, a minimum of 80% ethanol is recommended. ABHR dispensers should read volume per volume, not weight per volume. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 31 VIHA Infection Prevention and Control Manual, September 1, 2011 Hand hygiene should include the cleaning of arms to the elbow, especially when wearing a sleeveless apron. Table 2: Levels of Hand Disinfection Method Social Hygienic hand disinfection Aseptic (Surgical scrub) Solution Alcohol based hand rub or Soap and Water hand wash (if visibly soiled and/or contact with spores likely) Soap and Water hand wash followed by an alcohol based hand rub A 2 minute antiseptic wash (i.e. chlorhexidine (CHG 4%)) and dry on sterile towels or Soap and water hand wash followed by surgical alcohol based hand rub Task For Routine Practices Prior to invasive procedures performed at unit level Prior to surgical procedures Hand Hygiene Procedure The areas of the hands that are often missed are the wrist creases, thumbs, fingertips, under the fingernails and under jewelry. For this reason, only a plain wedding band with no stones is acceptable (please refer to VIHA‘s Policy 15.1 – Hand Hygiene Policy). Alcohol based hand rub technique Soap and water hand wash must be performed if hands look or feel dirty Apply an application to fill cupped palm of one hand Rub into all surfaces of hands (finger tips and nails, wrists, palms, backs of hands and between fingers) There must be sufficient wetness on all skin surfaces that it takes 15 or more seconds to dry Rub hands together until rub has evaporated prior to gloving or touching the patient Soap and Water hand washing technique Wet your hands up to the wrists ensuring all surfaces of the hands are covered by water Apply the cleanser/soap Smooth it evenly all over your hands, including the thumbs and in between fingers, lather well rubbing vigorously. Place fingertips and nails into the lathered palm and rub. Repeat with opposite hand Rinse off every trace of lather under running water, to prevent skin irritation Dry thoroughly, taking special care between the fingers. More than one paper towel may be necessary Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 32 VIHA Infection Prevention and Control Manual, September 1, 2011 Surgical asepsis (scrub) technique with an alcohol based hand rub Use sufficient product to keep hands and forearms wet with the alcohol based surgical scrub (ABSS) throughout the procedure (usually at least a cupped hand filled with ABSS). Apply ABSS to clean, dry hands and nails: Cup hand and hold 1–2 inches from the nozzle PUMP 1 o Dispense first full pump into the cupped palm of one hand (fill cupped hand) o Dip fingertips of the opposite hand into the ABSS and work in under the nails Wipe the excess solution from the fingertips back onto the palm of the same hand o Spread the remaining amount from the palm from wrist to elbow of the opposite arm, covering all surfaces PUMP 2 o Place another full pump into the opposite, dry palm and repeat the above procedure with the other hand PUMP 3 o Dispense a final full pump into either palm and reapply to all aspects of both hands up to the wrist o Proceed to the operating room suite holding hands above elbows After applying ABSS allow hands and forearms to dry thoroughly before donning sterile gloves and gown. Surgical asepsis technique with a medicated soap Wash hands and arms up to elbows with a non-medicated soap before entering the Operating Room area or if hands are visibly soiled Start timing o Scrub each side of each finger, between the fingers and the back and front of the hands for 2 minutes o Scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water running from the elbows, and prevents bacteria laden soap and water from contaminating the hands o Wash each side of the arm from wrist to elbow for 1 minute o Repeat this process on the other hand and arm, keeping the hands above the elbows at all times. If the hand touches anything except the brush at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 33 VIHA Infection Prevention and Control Manual, September 1, 2011 o Rinse hands and arms by passing them through the water in one direction only; from fingertips to elbow o Proceed to the operating room suite, holding hands above elbows At all times during the scrub procedure, care should be taken not to splash water onto surgical attire Once in the operating room suite, hands and arms should be dried using a sterile towel before putting on gown and gloves. Aseptic technique must be maintained at all times 2. Respiratory Hygiene/Cough Etiquette The transmission of SARS-CoV in emergency departments by patients and their family members during the widespread SARS outbreaks in 2003 highlighted the need for vigilance and prompt implementation of infection prevention and control measures at the first point of encounter within a healthcare setting. Respiratory hygiene/cough etiquette is targeted at patients/residents and accompanying family members and friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness, including cough, congestion, rhinorrhea or increased production of respiratory secretions when entering a healthcare facility. The elements of respiratory hygiene/cough etiquette include: Education of healthcare facility staff, patients/residents and visitors Posted signs, in languages appropriate to the population being served, with instructions to patients/residents and visitors Source control measures (e.g. covering the mouth and nose with a tissue when coughing and prompt disposal of used tissues, using surgical masks on the coughing person when tolerated and appropriate) Hand hygiene after contact with respiratory secretions Spatial separation, ideally more than 6 feet between persons with respiratory infection in common areas, when possible It should be noted that although fever will be present in many respiratory infections, patients/residents who are very old or very young and patients/residents with pertussis and mild upper respiratory tract infections are often afebrile. Therefore, the absence of fever does not always exclude respiratory infections. Patients/residents who have asthma, allergic rhinitis or chronic obstructive lung disease also may be coughing and sneezing. While these patients/residents often are not infectious, cough etiquette measures are prudent. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 34 VIHA Infection Prevention and Control Manual, September 1, 2011 Healthcare personnel are advised to observe droplet precautions and hand hygiene when examining and caring for patients/residents with signs and symptoms of respiratory infection. Healthcare personnel who have a respiratory infection are advised to avoid direct patient contact, especially with high risk patients/residents. If this is not possible, then a mask should be worn while providing patient care. Modified from: Siegel, J.D., Rhinehart, E., Jackson, M. Chiarello, L. and the Healthcare Infection Control Practices Advisory Committee (2007) Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. June 2007 3. Patient Placement A further aspect of routine practices is the decision making process for patient placement. Options include single patient rooms, two patient rooms and multi-bedded rooms/bays. Single room accommodation is always the preferred option. However, most facilities have limited resources in this area, and competing considerations when determining the appropriate placement of patients/residents. Single patient rooms are always preferred when there is a concern about the transmission of an infectious agent. In situations that require prioritization of such accommodation, it is prudent to prioritize these rooms for patients/residents who pose a high cross infection risk to other patients/residents, particularly for those who are at increased risk of an adverse outcome from the acquisition of an infection. Occasionally, due to the number of patients/residents who are colonized or infected with the same organism, cohorting the group of patients/residents in the same area may be an option (see ARO Room Placement). 4. Personal Protective Equipment Personal protective equipment (PPE) is used for two reasons: To protect staff from blood or body fluid contamination To reduce the risk of cross infection through the reduction in contamination and transferring of microorganisms to other patients/residents, staff, visitors and the environment Gloves The hands of clinical staff are the most likely means of transmission of healthcare associated infection. Through hand washing and the appropriate use of gloves the risk of cross infection is minimized. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 35 VIHA Infection Prevention and Control Manual, September 1, 2011 There are a number of materials used in the manufacture of gloves, including latex, nitrile and vinyl (PVC). The choice of material will depend on the type of task being performed, contact with chemicals and the risks associated with latex sensitization. The use of vinyl gloves is not recommended for prolonged tasks that require manual dexterity or when contact with blood or body fluids is anticipated. The purpose of wearing gloves is to either prevent the hands becoming contaminated with dirt or microorganisms, or to prevent the transfer of organisms already present on the skin or the hands. It is essential to ensure that hands are washed before putting on gloves and following the removal of gloves. Table 3: Examples of Tasks that Require the Wearing of Gloves Gloves must be worn: When touching mucous membrane When changing a dressing, or having contact with non-intact skin When changing diapers or adult briefs When performing personal hygiene for clients When performing mouth care When indicated for Additional Precautions Gloves should not be worn: When there is no risk of exposure/ splash/ contact with blood, body fluids and non-intact skin When assisting or feeding a patient For social touch When pushing a wheelchair When delivering meals, mail, clean linen For providing care to clients with intact skin, e.g. taking temperature Staff must ensure that the appropriate type of glove is selected for particular procedures with the purpose to ensure safety and protection for staff and patients/residents. When considering the nature of the task, the need for sterile or non-sterile gloves should be assessed. Sterile gloves are worn to protect the patient during aseptic invasive procedures. Non-sterile gloves, latex or latex alternative (e.g. nitrile) are worn to protect the healthcare worker where direct exposure to blood or body fluids and other microorganisms is anticipated. Storage of disposable gloves: it is important to store latex and nitrile gloves separately at all times. This will include, and not be exclusive to, the clean utility room and within all clinical area where the gloves are available for use. Although latex gloves are low protein, there is still a risk of transfer of this protein to nitrile gloves. Nitrile gloves are recommended as an alternative product to latex in the presence of allergy. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 36 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 4: Glove Use in Patient Care Types Specifications Latex Material Level of protection Allergen content Strength and durability Puncture resistant Fit and comfort Chemical resistance Nitrile Material Level of protection Allergen content Strength and durability Puncture resistant Fit and comfort Chemical resistance Vinyl (PVC) Material Level of protection Allergen content Strength and durability Puncture resistant Fit and comfort Chemical resistance Advantages Disadvantages Recommended use Storage Natural rubber Long standing barrier qualities Powder free are lower in allergens Very strong and durable Has re-seal qualities Provides excellent comfort and fit Good protection from most caustics and detergents Synthetic rubber Excellent physical properties and dexterity Contains no latex protein Very strong and durable Excellent puncture resistance Good fit due to high elasticity Excellent resistance Poor against oils, greases and organics Not recommended for individuals who have allergic reactions or sensitivity to latex Most common glove type for a sterile glove and for significant exposures to blood and blood contaminated body fluids Recommended for weak acids, weak bases, alcohols, water solutions DO NOT STORE near Nitrile gloves Not recommended for aromatic solvents, many ketones, esters, many chlorinated solvents DO NOT STORE near Latex gloves Polyvinyl chloride Good level of protection, but based on the quality of the manufacturer Punctures easily when stressed Rigid – non elastic Medium chemical resistance Not recommended for aliphatic, aromatic and chlorinated solvents, aldehydes, keytones Quality varies with manufacturers Used as a general purpose glove when additional strength and dexterity are required Recommended for oils, greases, acids, caustics, aliphatic solvents Alternative to latex for those with a latex allergy for tasks where exposure to blood and body fluids is likely Most common type of general purpose glove for procedures of short duration and minimal exposure to blood and body fluids Recommended for strong acids, bases, salts, other water solutions, and alcohols Adapted from: Sunnybrook Hospital (Toronto) June 2008 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 37 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 4: Choosing the Correct Glove Examination Glove Latex / latex alternative (e.g. nitrile) Vinyl (PVC) Polyethylene/ Polythene Only used in catering Sterile Non-Sterile Non-Sterile All aseptic procedures with potential exposure to blood or body fluids. Sterile pharmaceutical preparations. Non-aseptic procedures with a high risk of exposure to blood or body fluids. Procedures involving sharps Handling cytotoxic material Handling chemicals and disinfectants Tasks which are short and nonmanipulative Tasks which will not pull or twist the glove Tasks where contact with blood or body fluids is unlikely For cleaning tasks Note: when handling chemicals and liquids, follow the manufacturer‘s guidelines on glove selection. Non-disposable household gloves are worn for tasks other than direct patient care (e.g. laundry, or for all work requiring chemicals, cleaners and disinfectants). Where the use of non-disposable household gloves is required, the: Employee‘s department will provide them Department is responsible for maintaining written protocols on the use of gloves and ensuring that employees are aware of and comply with these protocols Gloves must meet WorkSafe BC standards for the task Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 38 VIHA Infection Prevention and Control Manual, September 1, 2011 o Non-disposable gloves must be designated to the individual worker, and must be inspected by the worker daily to ensure that the gloves have no holes or tears in them. If gloves are damaged, they must be discarded and replaced o They must be dried and stored in a clean, dry area o Disposable gloves must not be used as a liner o If disposable gloves are used, then they must be changed regularly to ensure integrity and cleanliness o Regardless of type of glove, they must be washed between clean and dirty tasks and whenever the floor bucket disinfectant solution is changed. Gowns/Aprons Disposable gowns and/or plastic aprons should be worn when there is a risk that clothing may become exposed to blood, body fluids and excretions, with the exception of sweat, or when close contact may lead to contamination by microbes from the patient, materials or equipment. Long sleeved impermeable gowns should be worn where there is a risk of contamination or splashing of blood, body fluids, secretions or excretions, onto the skin or clothing of the healthcare worker. Gowns and aprons are worn as single use items, and must be disposed of after one procedure or episode of patient care. Hand hygiene following apron use must include cleaning of exposed arms to the elbows. Scrubs or laboratory style coats/jackets worn over clothing are not considered to be PPE and must not be worn in place of a disposable gown. Their long sleeves also inhibit correct hand hygiene, and can be a source of contamination. Cloth gowns do not provide the required protection and should not be used. Gowns/aprons must be worn when the caregiver‘s clothing is likely to become contaminated with blood, feces, urine or any other secretions They must be worn when the uniform is likely to become contaminated by microorganisms, e.g. during bed making They must be worn when giving direct patient care Gowns/aprons must only be worn for the duration of the task and disposed of as waste Personal Protective Equipment should be changed following procedures, between patients/residents, and if they become heavily contaminated or torn/split during a procedure Hand hygiene must be performed when the gown or apron is removed Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 39 VIHA Infection Prevention and Control Manual, September 1, 2011 Hand hygiene must include cleaning of exposed arms to elbows if using an apron Masks, Visors and Protective Eyewear The mucous membranes of the mouth, nose and eyes are susceptible areas for infectious agents. Therefore, the use of masks, visors or protective eyewear and full-face shields are important parts of routine practices. Some masks are supplied with the additional protection of a visor. Masks with the additional protection of a visor are single use and must be disposed of when a period of care has finished. Some visors are also supplied as single use, and as such must not be decontaminated. However, reusable visors and goggles can be decontaminated using a Hydrogen peroxide solution, or ready to use Hydrogen Peroxide 0.5% wipe. Masks are worn: By healthcare personnel when engaged in procedures requiring sterile technique to protect patients/residents from exposure to infectious agents carried in the healthcare worker‘s mouth or nose By coughing/sneezing patients/residents to limit potential dissemination of infectious respiratory secretions from the patient to others By healthcare personnel when engaged in aerosol generating procedures with a patient with a droplet infection, e.g. open suctioning, nebulized medication, bronchoscopy A fit tested3 N95 mask is to be worn: During the care of patients/residents who are diagnosed or suspected as having an airborne infection (e.g. Pulmonary Tuberculosis) N95 masks must be used during the entire period of infectiousness (consult with Infection Prevention and Control) A single-use N95 mask must only be worn once Masks and eye protection or a visor are worn: By healthcare personnel to protect them from contact with infectious material from patients/residents, e.g. respiratory secretions and sprays of blood or body fluids, consistent with Routine Practices and Droplet Precautions. Please refer to Donning & Doffing PPE posters 3 Fit tests are performed by Employee Occupational Health & Safety. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 40 VIHA Infection Prevention and Control Manual, September 1, 2011 5. Hair/Jewelry/Uniforms Hair Hair should be clean, neat and tidy Hair fastenings should be minimal Long hair should be tied up off the collar when working in the clinical setting Jewelry Rings with stone settings must not be worn in clinical situations, as they compromise hand hygiene. One plain wedding band is acceptable Wrist watches, bracelets, bangles or other wrist adornments must be removed when caring for patients/residents (exception: Medical Alert Bracelets) as they inhibit correct hand hygiene. Please refer to VIHA‘s Policy 15.1 - Hand Hygiene Policy for more information Footwear Suede or fabric shoes are not acceptable as these cannot be shoe polished or machine washed Dress Code for Staff Who Do Not Wear a Uniform, Including Medical Staff Long sleeves (i.e. scrubs, tee shirts or white coats with long sleeves) should not be worn in the clinical setting and when assessing patients/residents due to the increased potential of the cuffs coming into contact with patients/residents and becoming contaminated4 Ties and lanyards (e.g. hanging nametags) should be tucked in prior to taking part in clinical procedures Dress Code for Staff Wearing a Uniform Sleeves should end above the elbow. Long sleeves (white coats with long sleeves) should not be worn in the clinical setting and when assessing patients/residents due to the increased potential of the cuffs coming into contact with patients/residents and becoming contaminated 5 4 If these requirements cannot be met for religious reasons, alternative options will be determined through discussion with Infection Prevention and Control and area Manager. 5 If these requirements cannot be met for religious reasons, alternative options will be determined through discussion with Infection Prevention and Control and area Manager. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 41 VIHA Infection Prevention and Control Manual, September 1, 2011 Material should be such that it may be laundered on a HOT WASH (above 65 degrees C) to ensure adequate decontamination. A clean uniform must be worn every shift/ working day Sweaters or jackets should not be worn over the uniform, as they are likely to become contaminated with microorganisms Uniform should be changed as soon as possible after finishing work Uniforms should not be worn when visiting public areas such as stores References: Department of Health 2007 UNIFORMS AND WORKWEAR An evidence base for developing local policy Halls, F. et al 1984 ‗A question of uniform‘. NURSING TIMES Vol 87: No50, pp 53-54 6. Safe Handling of Sharps The term ―sharps‖ includes items such as needles, scalpels, scissors, broken glass and other items that may cause laceration or puncture to the skin. Sharps are responsible for a significant number of injuries to staff each year. Safe management of sharps can help to reduce the risk of injury, and therefore the acquisition of infections such as blood borne viruses by both staff and patients/residents. A high proportion of sharps injuries occur during disposal and waste collection. Many sharps hazards have been removed through the introduction of safety engineered sharps. Nonetheless, the prevention of sharps injuries is an essential part of routine practices, including handling and disposing of sharps in a manner that will prevent injury to the user and others. IV tubing should not be cut for disposal, as this will create a sharp end and risk aerosolising the contents. It is the responsibility of the user to ensure the safe disposal of a sharp. Sharps disposal containers must be readily available in all areas Sharps must be discarded immediately after use, directly into a disposal container at the point of use Sharps must not be recapped after use, prior to disposal directly into a disposal container Never bend or break needles after use Do not disassemble needles from syringes or other devices; always dispose of as a single unit IV tubing should be placed directly into a sharps disposal container without cutting it Scalpel blades must be removed using forceps Never fill a sharps disposal container more that ¾ full Never leave a sharp protruding from the sharps disposal container Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 42 VIHA Infection Prevention and Control Manual, September 1, 2011 7. Decontamination Transmission of infectious agents can occur during casual contact from inanimate object to clean surfaces. Micro-organisms can survive on surfaces for long periods. All items of reusable equipment and furnishing in healthcare settings must be cleaned and disinfected/sterilized according to the manufacturer‘s instructions between patient use (e.g. stretchers, BP cuffs, etc). Items that cannot be appropriately decontaminated must not be purchased. Discuss possible new equipment with IPC Practitioner prior to purchasing it in order to assess its suitability for the clinical area with regard to decontamination. Cleaning Definition: cleaning is the physical removal of dirt and organic matter. Cleaning removes up to 80% of microorganisms and is an essential part of infection prevention and control. Organic matter can inactivate certain disinfectants, and therefore must precede disinfection and sterilization. It is important to ensure that multi-use equipment is cleaned properly between patients/residents. Equipment that is classified as critical or semi-critical must be disinfected at the appropriate level following each use (See Disinfection Requirements for Equipment). Non-porous non-critical and other items, for example scales or stethoscopes, can be easily cleaned with an intermediate or low-level disinfectant (see Reprocessing Decision Chart Table below and Classes of Organisms in Order of Susceptibility). Non-critical and other items made of fabric material should be cleaned when visibly soiled and following exposure to blood or body fluids. These items should also have an established routine cleaning with an intermediate or low-level disinfectant. Items such as blood pressure cuffs, which come into contact with the patient, should be wiped between patients/residents using a disinfectant wipe. Patients/residents on additional precautions require dedicated equipment wherever possible. If this is not possible, all equipment must be thoroughly decontaminated following each use, regardless of its classification. If equipment/device cannot be immediately disinfected, all soil must be immediately removed from the device. Table 5: Reprocessing Decision Chart Process Cleaning Some items may require Item All reusable equipment Examples All equipment requires cleaning after use and before further disinfection processes are initiated Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Products and methods Physical removal of soil, dust, or foreign material. Chemical, thermal, or mechanical aids may be used. Page 43 VIHA Infection Prevention and Control Manual, September 1, 2011 Process low level disinfection Cleaning followed by intermediate level disinfection Item Examples Specific environmental surfaces that are touched by personnel during procedures involving parenteral or mucous membrane contact (e.g. dental lamps) Bedpans, urinals, commodes Stethoscopes Blood pressure cuffs Ear specula Hemodialysis surfaces in contact with dialysate Products and methods Soap and water Enzymatic agents Quaternary ammonium compounds Some iodophors (e.g. 3% hydrogen peroxide) Some Semi-critical items After large environmental blood spills Alcohols or spills of microbial cultures in the Hypochlorite solutions laboratory Iodophors Glass or electronic thermometers Hydrotherapy tanks for patients/residents whose skin is not intact Cleaning Semi-critical Items intended for sterilization in the Flexible endoscopes, followed by items plasma or EO sterilizers must be laryngoscopes, respiratory high level meticulously cleaned prior to therapy equipment disinfection sterilizing. Nebulizer cups Anaesthesia equipment Pasteurization Nasal specula 2% gluteraldehyde Tonometer food plate 6% hydrogen peroxide Ear syringe nozzles Peracetic acid Vaginal specula Chlorine or chlorine compounds Vaginal probes used in sonographic scanning Pessary and diaphragm fitting rings Cervical caps Breast pump accessories Cleaning Critical items All items coming into contact with Glass or electronic thermometers followed by Steam under pressure sterile tissue sterilization Dry heat Surgical instruments All instruments used for foot care Ethylene oxide gas 2% glutaraldehyde All implantable devices 6-25% hydrogen peroxide Cardiac and urinary catheters peracetic acid All intravascular devices chlorine dioxide Biopsy forceps or biopsy 6-8% formaldehyde equipment associated with endoscopy equipment Bronchoscopes, arthroscopes, laparoscopes Cystoscopes Transfer forceps High speed dental hand pieces Adapted from: Health Canada, CCDR Hand Washing, Cleaning, Disinfection and Sterilization in Health Care, December 1998, Volume 24S8 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 44 VIHA Infection Prevention and Control Manual, September 1, 2011 Disinfection Definition: Removal and destruction of most pathogens (or disease-causing organisms) by the use of friction (cleaning) and a use of a disinfectant. Usually disinfectants are ―cidal‖ in that they kill the susceptible potential pathogenic agents. Generally, disinfectants used throughout VIHA both clean and disinfect. The selection of a disinfectant should be based on the function the disinfectant is expected to perform, not necessarily on a sales pitch or on what has always been used. Ideally, a disinfectant should be broad spectrum (eliminates bacteria, viruses, protozoa, fungi and spores). The Table on Classes of Organisms in Order of Susceptibility to Disinfectant – outlines the classes of organisms and what is required in the way of disinfectants to eliminate them. Disinfectants are necessary in healthcare settings to kill potentially infectious microorganisms, but may be harmful to staff/patients/residents/public if used inappropriately. All disinfectants used in VIHA facilities are to be approved for use in healthcare facilities and possess a drug identification number from the Health Protection Branch of Health Canada Disinfectants should be compatible with the equipment/device to be disinfected The use of the device should be considered when deciding the type of disinfectant to use Personal and environmental safety should also be considered when selecting a disinfectant The manufacturer‘s instructions for use and storage must be followed Disinfectants should also be: Non-irritating Non-toxic Non-corrosive Inexpensive Selection decisions should include effectiveness against the potential pathogenic agent, safety to people, impact on equipment, the environment, and expense. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 45 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 6: Classes of Organisms in Order of Susceptibility to Disinfectants Organism Type Hardiest Organisms Bacteria with Spores (B. subtitles, C. tetani, C. difficile, C. botulinum, B. anthracis) Level of Disinfectant Chemical Sterilant Protozoa with Cysts Giardia lablia, Cryptosporidium parvum) Mycobacteria (M. tuberculosis, M. avium-intracellulare, M. abscessus) Non-Enveloped Viruses (Coxsackievirus, poliovirus, rhinovirus, Norwalk-like Virus, hepatitis A virus) Fungi Candida species, Cryptococcus species, Aspergillus species, Dermatophytes) High Level Intermediate Level Vegetative Bacteria (Staphylococcus aureus, Salmonella typhi, Pseudomonas aeruginosa, coliforms) Most Susceptible Organisms Enveloped Viruses (Herpes simplex, varicella-zoster virus, cytomegalovirus, measles virus, mumps virus, rubella virus, influenza A and B virus, respiratory syncytial virus, hepatitis B & C viruses, hantavirus and human immunodeficiency virus) Low Level The effectiveness of a disinfectant depends on many factors. These include: Type of contaminating microorganism. Each disinfectant has unique antimicrobial attributes Degree of contamination. This determines the quality, efficacy and time of exposure of the disinfectant required Amount of protein based material present. High protein based materials absorb and neutralize some chemical disinfectants Presence of organic matter and other compounds such as soaps may neutralize disinfectants Chemical nature of disinfectant. It is important to understand the mode of action in order to select the appropriate disinfectant Concentration and quantity of disinfectant. It is important to choose the proper concentration and quantity of disinfectant that is best suited to each situation Contact time and temperature. Sufficient time and appropriate temperature must be allowed for action of the disinfectant and may depend on the degree of contamination and organic matter load Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 46 VIHA Infection Prevention and Control Manual, September 1, 2011 Residual activity and effects on fabric and metal should be considered for specific situations Application temperature, pH and interactions with other compounds must be considered Source: BCCDC Laboratory Services, A Guide to Selection and Use of Disinfectants, 2003 Table 7: Disinfection Requirements for Equipment Category Critical Items that come in contact with the blood stream or sterile body tissues Semi Critical Items that come in contact with mucous membranes or non-intact skin Non-Critical Items that come in contact with intact skin Items that do not come in contact with the patient‘s skin Level of Disinfection Sterilization Examples Surgical instruments Acupuncture needles Foot care instruments High Level Disinfection Internal scopes High Level Disinfection Intermediate Level Disinfection Intermediate Level Disinfection Low Level Disinfection Contact lenses Reusable Peek Flow Meters Mouthpieces Thermometers Ear syringe nozzles Examination tables Stethoscope Blood pressure cuff Skin probes Furnishings Dishes Scales The advantages and disadvantages of the various chemical disinfectants are highlighted below. Table 8: Advantages and Disadvantages of Major Chemical Disinfectants Disinfectant Level of Uses Advantages Disadvantages Disinfection Manufacturers‘ Recommendations for Concentration and Exposure Time must always be followed Alcohols IntermeExternal surfaces · Fast acting · Flammable – keep away from (70% Isopropyl – diate of patient · No residue sources of ignition undiluted) assessment · Non staining · Dilution with water will diminish equipment, e.g. concentration and efficacy O2 saturation · Inactivated by organic material monitors, finger · May harden rubber or cause clips, deterioration of glues thermometers, · Use in the OR near cautery is stethoscopes discouraged; can be on anesthetic carts or wall mounts Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 47 VIHA Infection Prevention and Control Manual, September 1, 2011 Disinfectant Level of Uses Advantages Disadvantages Disinfection Manufacturers‘ Recommendations for Concentration and Exposure Time must always be followed 6 Chlorines IntermeDisinfect · Low cost · Corrosive to metals Household bleach diate hydrotherapy · Fast acting · Inactivated by organic material, (5% Sodium tanks, dialysis · Readily e.g. blood, feces Hypochlorite) equipment, available in non· Irritant to skin and mucous mixed at a ratio of cardiopulmonary hospital settings membranes 1 part bleach to 9 training · Have sporicidal · Use in well-ventilated areas parts water, for a manikins, properties · Unstable when diluted and total of 10 parts) environmental exposed to light (must be kept in surfaces, and an opaque container) glucometers. · For effective use, the following must be considered: Effective Appropriate dilution; disinfectant Stability/shelf life prior to following blood dilution; spills. Stability/shelf life of product after dilution · Follow manufacturer‘s instructions for duration of shelf life, both before and after reconstitution · Tablets and mixed solutions remain stable < 24 hours after reconstitution · Bottles of bleach normally remain stable < 30 days after opening if in an opaque container. Household bleach (5% Sodium Hypochlorite) mixed at a ratio of 1 part bleach to 499 parts water, for a total of 500 parts) (1 cup per laundry tub) (100 ppm) 6 For cleaning of personal laundry Also available in tablet and granule form. Follow manufacturer‘s instructions for proper dilution. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 48 VIHA Infection Prevention and Control Manual, September 1, 2011 Disinfectant Level of Uses Advantages Disadvantages Disinfection Manufacturers‘ Recommendations for Concentration and Exposure Time must always be followed Hydrogen Low Equipment used · Available to use · Can be corrosive to aluminum, peroxide for home in ready-to-use copper, brass or zinc 3% concentrate healthcare, wipes · Cannot be used on anesthetic diluted at a ratio patient · Strong oxidant hosing of 1 part assessment and with good · Limited sporicidal activity Hydrogen care at the cleaning · Wet contact time must be more Peroxide to 16 bedside and properties than 5 minutes parts water for other treatment · Fast acting patient care settings. · Bactericidal in surfaces. less than 1 minute · Viricidal in less than 5 minutes · Environmentally friendly Hydrogen peroxide 3% concentrate diluted at a ratio of 1 part Hydrogen Peroxide to 64 parts water for floors Quaternary ammonium compounds (Usually diluted at 1 part quaternary ammonia to 256 parts water) Cleans floors, walls and furnishings. Low Routinely used in facilities for environmental cleaning in patient care areas (e.g. floors, walls and furnishings). · Inexpensive · Generally nonirritating to hands in diluted form · Contain cleaning properties · Mildly corrosive · Limited use as disinfectant because narrow microbiocidal spectrum · Non-sporicidal Modified from: Health Canada. Canadian Communicable Disease Report, Dec 1998, Vol. 24S. Sterilization The highest level of asepsis is defined by the removal of all microorganisms. It is achieved by autoclaving or by another sterilization process. Items must be thoroughly cleaned before sterilization can occur. For information on sterilization techniques used in your facility contact your local Central Sterilizing/Processing department. (Reprocessing Policy Manual) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 49 VIHA Infection Prevention and Control Manual, September 1, 2011 Storage Storage of Contaminated Equipment Storage of contaminated equipment is to be held in a designated area/container Gross soil must be removed before storage prior to cleaning The storage area must be physically separated (by walls where possible) from a clean area, and be cleaned daily Hand hygiene must be performed before leaving the ―dirty‖ area Once items are cleaned, they should be labeled as such, and moved to a clean storage area Storage of Clean/Sterilized Equipment Areas designated for clean equipment should have a sign displayed identifying the area, and/or cleaned equipment should be labeled as clean Shelf life is event related, not always time related. Sterilized equipment/devices are no longer considered sterile if there is a disruption in the integrity of the packaging (e.g. packaging tear, the packaging becomes wet, or the item is dropped) Items purchased as sterile must be used before the expiration date. If the expiration date has passed, the item must be discarded The areas in which medical devices are stored or handled should be used for storage only, protected from vermin, moisture and the entry of dust from adjacent areas and ventilation systems. There must be sufficient storage space to prevent damage to the packages Sterile items should be stored in an area with limited traffic and a door Sterile medical devices should be stored at least: 25 cm from the floor 45 cm from the ceiling 5 cm from the wall Cardboard boxes must not be used for storage All storage should be above floor level to allow appropriate cleaning Storage must be away from a sink area, to prevent contamination from splashing Event Related Sterility Devices that are received sterile must be maintained sterile until used or until the expiration date has passed, and they are discarded Shelf life of sterile items is event related. Event related factors that may cause contamination and decrease shelf life are: Method and frequency of handling (e.g. dropping a sterile item on the floor renders it contaminated) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 50 VIHA Infection Prevention and Control Manual, September 1, 2011 Method and conditions of storage, such as location (e.g. shelves located below knee level are considered at risk for contamination and are not appropriate for storage of sterile items) Space (e.g. sterile items stored beside a sink are at risk for splashing with water which compromises the integrity of packaging) Temperature, humidity and exposure to moisture, dirt, dust or vermin All sterile items must be checked for sterility before use. The date of expiration relates to product ingredients and stability. For packaged items, check to ensure the integrity of the package is intact and the sterile indicator is white with black stripes All cleaned and disinfected/sterilized devices must be covered and protected from moisture and dust during transport 8. Housekeeping The environment acts as a suitable reservoir for many microorganisms, and therefore the provision of a clean environment for patient care is an integral part of infection prevention and control. (Housekeeping Section) 9. Laundry All laundry is treated the same regardless whether a patient is on routine or additional precautions. Soiled linen shall be handled and transported in a manner in which contaminants are confined and contained. Clean linen that has been dropped on the floor is considered soiled. Soiled Linen Using the guidelines of routine practices, soiled or used linens generated from all sources are considered to be contaminated. Soiled linen from all patients/residents or areas will be handled in the same manner: Wear non-sterile gloves and disposable gown or apron Position hamper/tote/laundry bag in room (i.e. locate centrally in room and open lid) or as close to the room entrance as possible Ensure that linen is free of biomedical waste, sharps, instruments, and patient‘s personal belongings Roll linen carefully into itself. Avoid shaking or fluffing Dispose of into linen tote/hamper Remove PPE and perform appropriate hand hygiene Dirty linen is not to be placed on the bedside tables, floor or in the sink Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 51 VIHA Infection Prevention and Control Manual, September 1, 2011 Soiled linen is to be handled as little as possible: Following removal from the patient bed space, linen must be immediately placed into a hamper/tote/laundry bag To prevent staff injuries, the soiled linen hamper/tote/laundry bags should not be overfilled. Close when ⅔ full Linen that is heavily soiled, saturated or dripping should be placed in a leak proof clear plastic bag and then placed inside the regular hamper/ tote/ laundry bag The laundry hamper/tote/bags, particularly the large laundry bins should be stored in a predetermined dirty area that is at least one meter from any clean items and at least one meter from any fire equipment Mattresses and pillows that are covered with impervious plastic do not have to be sent to the Regional Laundry for cleaning and disinfecting as they can be effectively cleaned on-site using an appropriate disinfectant (see the Reprocessing Decision Chart). Mattresses and pillows must also be monitored for wear points, and replaced as necessary. Remove PPE after handling soiled linen and perform hand hygiene before handling clean linen Laundering on the Units Laundering on units is not advocated in acute care setting. However, in some areas such as residential care settings it may be necessary. In these cases, the following is recommended: The outside of the machines (i.e. washer and dryer) should be cleaned with disinfectant prior to each use If hot-water laundry cycles are used, wash with detergent in water of at least 71o C (at least 160o F) for a cycle of 25 minutes or more Once washed, items should be dried quickly in a dryer (i.e. not air dried) The laundry area should be in a dedicated space and must not be located in the same area as a dishwasher or fridge (used for food) Clean Linen Soiled linen must never come into contact with clean linen. Perform hand hygiene prior to removing clean linen from central supply area or from carts. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 52 VIHA Infection Prevention and Control Manual, September 1, 2011 Clean linen should be unpacked on return from the laundry and stored in a designated area within each department The linen room should have a door, which should be kept closed. If this is not possible then the linen cart covers should remain closed around the linen racks when not being accessed Clean linen must be stored at least one meter away from any ―dirty area/items‖ or fire equipment Clean linen must be stored at least one meter from any dirty items Clean linen is to be handled as little as possible Linen which is removed from the clean supply area/cart is not to be returned to that cart The clean supply cart should only be stocked with one day‘s supply, which should be used before restocking the cart Linen carts are to be dedicated for linen only. The clean linen carts are not to contain other supplies Staff involved in the handling of linen shall ensure that there is no cross contamination of clean and soiled linens during transportation and storage. Handling Soiled Linen contaminated with Hazardous Materials When hazardous materials are used, stored or disposed of, written safe work procedures must be developed and implemented for preparation, administration and waste handling. Departments intending to return soiled linens that are contaminated with hazardous materials must ensure that there is no potential risk to staff or patients/residents. Hazardous materials include, but are not limited to: Chemicals that are a risk due to being toxic, poisonous, carcinogenic, noxious, flammable, combustible, corrosive or reactive with other chemicals. Radioactive substances that are present on soiled linen will be decontaminated at the site at which the patient resides. Linen contaminated by radioactive substances will not be sent to the Laundry until it is decontaminated by removing the radioactive nuclide contaminants or setting it aside for the appropriate time (i.e. ten half lives). Chemotherapy drugs (i.e. Antineoplastics). Any contaminated linen identified by the user site as not able to be safely laundered will be disposed of by the original hospital. For replacement purposes, the originating hospital will Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 53 VIHA Infection Prevention and Control Manual, September 1, 2011 inform the Regional Laundry of the disposal of its linen. If disposal of linen products contaminated by hazardous material is inevitable, the user hospital will consider the use of either disposable products or specific ―discard linen‖ which are linens that are usable but near the end of their life cycle. Note: Items of linen from patients/residents with unusual infections (e.g. Anthrax, Lassa Fever) should not be disposed of without consulting either the Medical Microbiologist in the first instance or the Infection Control Practitioner. Reference: Fraser Health Authority, Acute Care Infection Prevention and Control Manual, 2008 10. Waste VIHA is committed to the safety of the general public, patients/residents and staff. This is of the utmost importance and, therefore, procedures will be adopted whereby any risks associated with waste disposal will be minimized. The object of this section is to provide guidelines and give procedures for the safe disposal of hospital waste. All garbage must be placed in leak proof bags and closed securely before removal from patient‘s room. When garbage bags are ⅔ full it should be secured and removed. All housekeeping staff will wear personal protective clothing when handling clinical waste. This clothing in normal circumstances will take the form of their general uniform, disposable apron and protective gloves. All staff who need to move bags of waste by hand should: Ensure the bags are effectively sealed and are intact Handle bags by the neck only Know the procedure in case of accidental spillage Waste items such as used bandages, briefs and garbage are not to be placed on the bedside tables, floor or in the sink Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 54 VIHA Infection Prevention and Control Manual, September 1, 2011 Yellow Bag Clinical / Biohazardous Waste Black Bag Domestic/ General Waste Containers of blood or other blood saturated body fluids. Disposable containers which are not emptied prior to disposal, should be securely taped shut and tubing clamped Secretions or exudates whose contents cannot be hygienically emptied into toilet (e.g. Hemovac, sputum vial) Transfusion lines or bags containing blood All body tissue – including ‗Exempt body tissue‘ derived from the operating room Items saturated and dripping with blood and body fluids Microbiology cultures Waste derived from the clinical and non clinical areas which is not mentioned above and is not heavily contaminated with blood or body fluids Urinary drainage bags and catheters Feces Office waste Kitchen waste For chemotherapy disposal, see appropriate reference. Biohazardous Waste Biohazardous waste bags should only be filled to ⅔ full, as overfilling will prevent bags from being tied securely The containers for removal of biohazardous waste should be easily recognized, leak proof, and have a durable fitted lid. They must be sealed prior to transport and stored in areas unavailable to untrained staff, patients/residents or the public. Gloves and disposable apron should be worn when handling biohazardous waste. Hands should be decontaminated appropriately following removal of gloves Goggles or face shields should be worn when disposing of body fluids if there is a possibility of splash exposure to eyes or mucous membranes. NOTE: Final disposal of Biohazardous waste will be either by incineration or by autoclaving followed by landfill disposal. Spillage of Blood or Body Fluids (Body Fluids, Secretions and Excretions) Wear gloves and disposable apron Gross soil must be removed prior to cleaning and disinfecting Use paper towels for small spills, mop for large spills Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 55 VIHA Infection Prevention and Control Manual, September 1, 2011 Clean the area Disinfect with approved hospital disinfectant or a fresh solution of household bleach (one part 5% bleach added to 9 parts water). Used paper towels, gloves and apron should be placed in Biohazardous Waste bag Mop heads should be placed in leak proof laundry bags Bucket contents should be poured down the hopper, and the bucket rinsed and wiped with the chlorine solution Hands must be washed at the end of the procedure Waste Containers Only impervious waste containers dedicated for the transporting of clinical waste should be used to minimize the potential for spillage and subsequent contamination of work place areas. Garbage bins used in all non-office environments should all have lids that ideally open with a foot-operated mechanism. Waste trolleys must be such that they can be easily cleaned and drained, do not offer harbourage to insects, and particles of waste do not become lodged in their fabric. The waste must be easily loaded, secured and unloaded. Clinical waste must not be transported in any other type of trolley. Biohazardous waste, sharps and general waste must never be mixed. 11. Managing Dishes, Glasses, Cups and Eating Utensils Dishes/utensils are managed in the same manner, regardless whether a patient is on routine or additional precautions. Food Service workers must wash hands before leaving the kitchen and upon returning to the kitchen, after both delivery and pick-up of trolleys Food Service workers must decontaminate hands using an ABHR or wash hands upon entry and exit of each unit and as needed before handling the next tray in the event the patient‘s personal effects were touched to allow placement of the tray on the over bed table. Gloves are not required in the delivery of trays For removal of trays, Food Service Workers must decontaminate hands upon entry to each unit and before putting on gloves. Trays are picked up from the over bed tables and returned to the trolley. Gloves are removed upon completion of tray pick-up, discarded appropriately, and hands decontaminated before leaving the unit. Carts must be covered prior to leaving the unit All trays and wares are washed, rinsed and sanitized in the kitchen area in accordance with standard dishwashing procedures Trolleys are washed, rinsed and sanitized by Food Services personnel between each meal period, and allowed to air dry before reuse Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 56 VIHA Infection Prevention and Control Manual, September 1, 2011 Trolleys left on the unit for late trays are to be washed, rinsed and sanitized when taken to the food services area, and at a minimum on a weekly basis Note: Food Service Workers will not pick up any trays that contain bodily fluids or sharps. They will bring this to the attention of the nursing staff. Routine Practices Tray Delivery Tray Pick-up Wash hands prior to tray delivery. Disposable gloves not required. Wear disposable gloves. Unit Staff Over bed table must be free of equipment and debris. No preparations required. Food Service Worker Food Service worker does not clear over bed table. Place the tray on the over bed table following standard tray delivery procedures. With gloved hands, pick-up the tray and return it to the tray cart. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or alcohol based hand rub applied before leaving the unit. Managing Tray Delivery – Procedures Specific to Additional Precautions The automated decontamination washing process effectively deals with all microorganisms. Disposable dishes and utensils will not be used. Food Services personnel wear aprons and gloves to strip all trays as all patient trays are considered contaminated Food trays must never be bagged. On the rare occasion that a patient vomits onto the tray, nursing staff (using droplet precautions) rinse off the vomit prior to returning the tray to the kitchen for disinfection Note: Food Service Workers will not pick up any trays that contain bodily fluids or sharps. They will bring this to the attention of the nursing staff. Contact Precautions (Yellow Sign) Unit Staff Food Service Worker Tray Delivery Wash hands prior to tray delivery. Disposable gloves not required Over bed table must be free of equipment and debris. Food Service worker does not clear over bed table. Place the tray on the over bed table following standard tray delivery procedures. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Tray Pick-up Wear disposable gloves No preparations required. With gloved hands, pick-up the tray and return it to the tray cart. Remove gloves, wash hands or use ABHR and put on clean gloves prior to collecting any other trays. Page 57 VIHA Infection Prevention and Control Manual, September 1, 2011 Contact Precautions (Yellow Sign) AND SIGN FOR 2 STEP CLEANING Unit Staff Food Service Worker Droplet Precautions (Green Sign) Unit Staff Food Service Worker Tray Delivery Tray Pick-up Wash hands prior to tray delivery. Wear disposable gloves Disposable gloves not required Note: Food Service Personnel will not deliver/collect trays for anyone with gastro-intestinal symptoms. Over bed table must be free of equipment and debris. Tray is taken directly from the trolley and delivered by nursing staff to patients/residents with gastro-intestinal symptoms. Nursing staff return the tray to the trolley for anyone with gastrointestinal symptoms. Ensure the trolley is left uncovered. Trolley is brought to the unit. Trays for patients/residents with gastrointestinal illness (designated by 2 step cleaning sign) are left on the trolley and unit staff are notified. Trays are delivered to patients/residents on routine practices or contact precautions. Trays are not removed from patient rooms for anyone with gastrointestinal illness. With gloved hands, collect trays from patients/residents‘ on routine practices or contact precautions. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or ABHR applied before leaving the unit. Tray Delivery Tray Pick-up Wash hands prior to tray delivery. Disposable gloves not required Over bed table must be free of debris. Tray is taken directly from the trolley and delivered by nursing staff to patients/residents on droplet precautions. Wear disposable gloves Trolley is brought to the unit. Trays for patients/residents on droplet precautions are left on the trolley and unit staff are notified. Trays are delivered to patients/residents on routine practices or contact precautions. Trays are not removed from patient rooms for anyone on droplet precautions. With gloved hands, collect trays from patients/residents‘ on routine practices or contact precautions. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or ABHR applied before leaving the unit. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Nursing staff return the tray to the trolley for anyone on droplet precautions. Ensure the trolley is left uncovered. Page 58 VIHA Infection Prevention and Control Manual, September 1, 2011 Airborne Precautions (Blue Sign) Unit Staff Food Service Worker Tray Delivery Wash hands prior to tray delivery. Disposable gloves not required Over bed table must be free of debris. Tray is taken directly from the trolley and delivered by nursing staff to patients/residents on airborne precautions. Do Not Enter the room. Trays for anyone on airborne precautions are left on the trolley and the unit staff notified. Trays are delivered to patients/residents on routine practices or contact precautions. Tray Pick-up Wear disposable gloves Nursing staff return the tray to the trolley for anyone on airborne precautions. Ensure the trolley is left uncovered. Trays are not removed from patient rooms for anyone on airborne precautions. With gloved hands, collect trays from patients/residents‘ on routine practices or contact precautions. Gloves are removed upon completion of tray pick-up, discarded, and hands washed or ABHR applied before leaving the unit. 12. Healthy Workplace While the focus of the Infection Prevention and Control program is on protection of the patient, Occupational Health & Safety‘s mandate is to protect the health and safety of VIHA staff. Employee Health Advisors provide occupational health nursing services to staff through prevention and health promotion activities. They maintain close communication and collaboration with Infection Prevention and Control. Information on the Occupational Health & Safety program can be found at: http://www.viha.ca/occupational_health. 13. Recreational Reading Material and Games For normal operations outside of an outbreak situation: Magazines, book and puzzles in optimal condition may be placed in waiting areas and patient lounges for everyone‘s enjoyment. If magazines/books/puzzles are torn, soiled or wet they must be removed and discarded. For operations during an outbreak situation: Magazines/books/puzzles/clutter will be removed from waiting rooms and patient lounges, in order to ensure required additional cleaning can be achieved. The Infection Prevention & Control Program will provide direction for the removal of magazines/books/puzzles/clutter from waiting rooms and patient lounges, during these times. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 59 VIHA Infection Prevention and Control Manual, September 1, 2011 C. Education The final, and it could be argued the most important, element of routine practices is Education. The ongoing acquisition of knowledge related to what are the best infection prevention and control strategies and the communication of that knowledge to fellow professionals, patients/residents and visitors, followed by the demonstration of these skills in day to day practice, and are the keystones to ensuring the ongoing safety of VIHA patients/residents and staff. The following are ways in which education can be used to break the chain of transmission. Understanding infection prevention and control practices. Understand and demonstrate work practices that reduce the risk of infection (e.g. hand hygiene, proper use of PPE, be immunized, and do not come to work with a communicable disease). Who provides infection prevention and control expertise to your setting? Who would you call for help? (See list of VIHA Infection Control Practitioners on the Contact Us navigation bar.) Educate patients/residents/families about hygiene and infection prevention strategies such as hand hygiene. Know where to find in your facility (or who to ask for) standardized education materials on infection reduction strategies such as hand hygiene, respiratory etiquette, and influenza vaccination Be able to identify unusual clusters or illnesses (e.g. respiratory, gastrointestinal, skin); and be aware of person, time, place tracking; and report to the appropriate person Infection prevention and control health promotion Attend in-services and read scientific literature on infection prevention and control Provide leadership and act as a role model to other healthcare providers, patients/residents and visitors with regard to infection prevention and control principles (e.g. communicate new/current material to other health professionals and patients/residents/families) Demonstrate work practices that reduce the risk of infection (e.g. use hand hygiene, use proper equipment, be immunized, and do not come to work with a communicable disease) Modified from: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, June 2007 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 60 VIHA Infection Prevention and Control Manual, September 1, 2011 2. ADDITIONAL PRECAUTIONS Additional Precautions are required when routine practices are not sufficient to prevent transmission of certain microorganisms. 7 For example, additional precautions are warranted for: Diseases, either suspected or confirmed, during the infectious state Situations in which contamination of the patient‘s environment is likely (e.g. a patient with diarrhea that cannot be contained) Patients/residents infected (and/or colonized in acute care) with certain organisms of interest that may be transmitted easily by direct or indirect contact with the patient (intact skin, wounds, or coughing) or with their environment Reference: Public Health Agency Canada (1999) Infection Control Guidelines; routine practices and additional precautions for preventing transmission of infection in healthcare. Health Canada. A. Contact Precautions 1. Purpose Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient‘s environment, e.g. scabies, antibiotic resistant bacteria (MRSA, ESBL). The application of contact precautions for patients/residents infected or colonized with Antibiotic Resistant Organisms. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission of microorganisms. The specific agents and circumstances for which contact precautions are indicated are found in Appendix A. 7 It is important to be sensitive to the effect that Additional Precautions have on patients and others. Patients can feel stigmatized by all the paraphernalia (e.g. gowns, masks, etc) and other patients/visitors may be concerned about their own personal safety. It is best to advise all concerned that the interventions are taken to protect everyone – patients, staff and the public alike. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 61 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Requirements – Signage and Placement Contact precautions signage must be posted on the door and by patient‘s bed in multibed rooms. (See Contact Precautions poster, Catalogue # 0040506, on the Precaution Signs navigation bar on the Infection Prevention and Control website) A single-patient room is preferred for patients/residents who require contact precautions The door may be left open When a single-patient room is not available, consultation with the Infection Control Practitioner is recommended to assess the various risks associated with other patient placement options (e.g. cohorting, keeping the patient with an existing roommate) In multi-patient rooms, at least two meters (6 feet or more) spatial separation between bed and curtain is advised to reduce the opportunities for inadvertent sharing of items between the infected/colonized patient and other patients/residents Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 62 VIHA Infection Prevention and Control Manual, September 1, 2011 3. Contact Precautions – Staff, Patients/Residents, Visitors Staff Patients/Residents Visitors Routine practices to be followed at all times Patients/residents leaving room for tests/mobilization/ rehabilitation will do so with permission of healthcare provider Hand hygiene will be performed upon entering/leaving the facility and the patient‘s room Healthcare personnel will wear appropriate PPE for all interactions that may involve contact with the patient/patient environment Patients/residents will perform hand hygiene upon exiting and re-entering unit/room Visitors/relatives will wear appropriate PPE when providing care or very close patient contact, as directed by responsible nurse PPE will be changed following procedures, between patients/residents or when heavily contaminated/torn/split during a procedure Patients/residents will wear a clean nightgown/house coat or clothes Visitors will not visit multiple patients/residents/rooms during a visit Ensure single use and dedicated patient equipment for the duration of precautions -i.e. dedicated commode Patients/residents‘ wounds will be covered with a fresh dressing Visitors must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom Shared equipment will be decontaminated appropriately prior to removal from precaution room and before further use All dedicated equipment will be decontaminated appropriately on discharge of patient / discontinuation of precautions and prior to removing from patient room Diagnostic procedures will not be postponed, inform receiving department of necessary precautions on the requisition or advising by telephone. Attempt should be made to book infectious cases at the end of the day Linen and garbage will be placed in regular bags and closed securely prior to removal from room Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 63 VIHA Infection Prevention and Control Manual, September 1, 2011 B. Droplet Precautions 1. Purpose Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet route means spread by large particle droplets when patients/residents cough, sneeze or talk (i.e. within a radius of two meters, or 6 feet). Because these pathogens do not remain suspended over long distances in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission. Infectious agents for which droplet precautions are indicated are listed in Appendix A and include B. pertussis, influenza virus, adenovirus, rhinovirus, N. meningitidis, and Group A streptococcus (prior to and for the first 24 hours of antimicrobial therapy). 2. Requirements – Signage and Placement Droplet Precautions sign must be posted on the door and next to patient‘s bed in multi-bed rooms. (See Droplet Precautions poster, Catalogue #0040508, on the Precaution Signs navigation bar on the Infection Prevention and Control website.) During periods of high census, patients/residents on droplet precautions might be placed in a two or four-bed room. A green Droplet Precaution sign will be posted outside the room as well as on the curtain of the affected patient within that room. Single Room: the doors to single rooms can be kept open When a single-patient room is not available, consultation with infection prevention and control personnel is recommended to assess the various risks associated with other patient placement options (e.g. cohorting patients/residents with the same infection, keeping the patient with an existing roommate) Spatial separation of at least two meters (6 feet or more) from patient to curtain and drawing the curtain between patient beds is especially important for patients/residents in multi-bed rooms with infections transmitted by the droplet route 3. Droplet Precautions – Staff, Patients/Residents, Visitors Staff Routine practices to be followed at all times. Gown, gloves and a surgical grade mask (120 mmHg) with visor will be worn within 2 metres (6 feet) of the patient. Particularly important when care promotes respiratory secretions, e.g. nebulisers, suctioning Patients/Residents Patients/residents leaving room for tests/mobilization/ rehabilitation will do so with permission of healthcare provider Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Visitors Hand hygiene will be performed upon entering/leaving the facility and the patient‘s room Page 64 VIHA Infection Prevention and Control Manual, September 1, 2011 Staff Patients/Residents Visitors PPE will be changed following procedures, between patients/residents or when heavily contaminated/torn/split during a procedure Will wear a surgical grade mask (120 mmHg) without visor with ear loop design, fitted to the face Visitors/relatives who are providing care or very close patient contact within 2 metres (6 feet), will wear a surgical grade mask (120 mmHg) with ear loop design and attached visor. Additional appropriate PPE will be worn when directed by responsible nurse Ensure single use and dedicated patient equipment for the duration of precautions i.e. dedicated commode Patients/residents will perform hand hygiene upon exiting and re-entering unit/room Visitors will not visit multiple patients/residents/rooms during a visit Shared equipment will be decontaminated appropriately prior to removal from precaution room and before further use Patients/residents will wear a clean nightgown/house coat or clothes Visitors must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom All dedicated equipment will be decontaminated appropriately on discharge of patient / discontinuation of precautions and prior to removing from patient room Patients/residents‘ wounds will be covered with a fresh dressing Diagnostic procedures will not be postponed, inform receiving department of necessary precautions on the requisition or advising by telephone. Attempt should be made to book infectious cases at the end of the day Linen and garbage will be placed in regular bags and closed securely prior to removal from room C. Airborne Precautions 1. Purpose Airborne Precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g. measles virus, varicella zoster virus [chickenpox], pulmonary tuberculosis, smallpox and possibly SARS-CoV). See Appendix A for detailed list. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 65 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Requirements – Signage and Placement Airborne Precautions sign should be posted on the door indicating N95 mask and other appropriate precautions. (See Airborne Precautions poster, Catalogue #0040504, on the Precaution Signs navigation bar on the Infection Prevention and Control website.) The preferred placement for patients/residents who require Airborne Precautions is in a Negative Pressure Room. A Negative Pressure Room is a single-patient room that is equipped with special air handling and ventilation capacity. Negative Pressure Rooms have: Monitored negative pressure relative to the surrounding area 12 air exchanges per hour for new construction and renovation and 6 air exchanges per hour for existing facilities Please access the Infection Prevention and Control internal web site for a list of Negative Pressure Rooms throughout VIHA In settings where airborne precautions cannot be implemented due to limited engineering resources (e.g. Residential Facilities): Place the patient in a private room Keep the door to the room closed Have the patient wear a surgical grade mask (if possible) Staff and visitors must wear an N95 mask when in patient room Arrange for transfer of patient to a facility with a Negative Pressure Room. Contact Infection Prevention and Control. (See list of Infection Control Practitioners on the Contact Us navigation bar on the Infection Prevention and Control website) NOTE: Facilities Maintenance and Operations Department must be contacted when a Negative Pressure Room is required to verify that the room is monitored and airflow remains negative to surrounding areas. 3. Airborne Precautions – Staff, Patients/Residents, Visitors Staff Routine practices to be followed at all times. All staff entering patient‘s room, escorting , treating or examining the patient must wear a high efficiency N95 mask – the type and size for which they have been fit tested Patients/Residents Patients/residents must remain in the room unless medical condition warrants urgent/emergent procedure /intervention. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Visitors Hand hygiene will be performed upon entering/leaving the facility and the patient‘s room Page 66 VIHA Infection Prevention and Control Manual, September 1, 2011 Staff Patients/Residents Visitors Wherever possible, non immune health care workers should not care for patients/residents with vaccine preventable airborne diseases If the patient is required to leave the room for diagnostic procedures, patient will wear a surgical grade (120 mmHg) fluid resistant mask (without visor), fitted to the face – if their respiratory status permits Visitors/relatives will wear appropriate PPE when providing care or very close patient contact, as directed by responsible nurse. All visitors, whether or not providing care, must wear a surgical grade (120 mmHg) fluid resistant mask (without visor) The doors to the room must be kept closed Patients/residents on airborne precautions are not permitted to go outside for a cigarette – alternative nicotine source ordered by MRP Instructions on application of surgical grade (120 mmHg) fluid resistant mask (without visor) must be provided and use encouraged Following a risk assessment, routine practices may dictate the use of gloves and gown during the episode of care Patients/residents will perform hand hygiene upon exiting and re-entering unit/room Visitors will not visit multiple patients/residents/rooms during a visit PPE will be changed following procedures, between patients/residents or when heavily contaminated/torn/split during a procedure Visitors must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom Ensure single use and dedicated patient equipment for the duration of precautions i.e. dedicated commode. Individual sharps container must be in the room/ante room. Limit equipment and personal items. Used equipment is placed in Central Sterilizing/Processing bin. Items must be cleaned prior to placing in the bin Shared equipment will be decontaminated appropriately prior to removal from precaution room and before further use All dedicated equipment will be decontaminated appropriately on discharge of patient / discontinuation of precautions and prior to removing from patient room Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 67 VIHA Infection Prevention and Control Manual, September 1, 2011 Staff Patients/Residents Visitors Diagnostic procedures will not be postponed, inform receiving department of necessary precautions on the requisition or advising by telephone. Attempt should be made to book infectious cases at the end of the day Linen will be placed in regular bags and closed securely prior to removal from room Garbage will be placed in regular bags and closed securely prior to removal from room. Use of biomedical waste bags is not necessary Dietary staff do not deliver or remove food trays for rooms with patients/residents on airborne precautions. Regular dishes are to be used 4. Actions when Negative Pressure Room Not Available or Malfunctions The following steps should be followed if a facility does not have a Negative Pressure room: Consult with Infection Prevention and Control to determine risk Place patient in private room Keep windows and door to room closed, even if the patient is not in the room Turn off bathroom fan Have patient wear surgical grade mask if possible when healthcare staff and/or visitors are in the room Staff and visitors must wear surgical grade (120 mmHg) fluid resistant mask (without visor) when in patient room Arrange for transfer to facility with Negative Pressure Room The following steps should be followed when the Negative Pressure Room monitoring system indicates a failure with the system: Check that windows and doors are closed. Contact Facilities Maintenance and Operations (FMO) immediately. If FMO determines the problem cannot be fixed, follow the above policy for a facility with no Negative Pressure Room Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 68 VIHA Infection Prevention and Control Manual, September 1, 2011 Note: FMO must post, or have available, a record of inspection and maintenance verifying the efficient operation of these negative air pressure room technologies. A regular schedule of inspections of such rooms must be established and maintained. There should be daily monitoring of negative pressure by nursing staff when room is in use. D. SUMMARY OF PRECAUTIONS Table 9: Precautions Table Contact Droplet Airborne MRSA, Clostridium difficile , lice, scabies N. menigitidis, Mumps, Pertussis, Norovirus, vomiting, Influenza, invasive Group A streptococcus Pulmonary Tuberculosis, Measles, Chickenpox, disseminated Zoster Syndromic Precautions Draining wound, diarrhea NYD, infestation Toxic Shock, 2 or more of the following: Stiff neck Fever Headache Malaise Acute cough Fever, weight loss+ cough, high TB risk, disseminated rash + fever Private Room Preferred Preferred. If in multi-bed room draw curtains YES Negative Pressure Room NO NO YES Gown + Gloves Gown + Gloves + Surgical grade (120 mmHg) fluid resistant mask with face shield Gown + Gloves + 8 N95 mask Gown + Gloves 9 if providing direct care Surgical grade (120 mmHg) fluid resistant mask with attached face shield (gown + gloves if providing 2 direct care ) Surgical grade (120 mmHg) fluid resistant mask (gown + gloves if providing 2 direct care ) Organism Based Precautions (not complete list) Staff Personal Protective Equipment Visitor Personal Protective Equipment 8 9 * Fit tested Direct care = hands on care (i.e. bathing, dressing changes, toileting) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 69 VIHA Infection Prevention and Control Manual, September 1, 2011 Contact Transporting patient (need for Surgical grade 120 mmHg fluid resistant mask) Patient – NO Staff - NO Droplet Airborne Patient – YES (if condition Patient – YES (if condition Staff – allows) YES (with attached face shield) allows) Staff – NO (must wear N951) 10 Routine Plus 2 Step for C. Difficile and 11 Diarrhea NYD Routine Plus CDH, NRGH and PCC at RJH only: CDH, NRGH and PCC at RJH only: CDH, NRGH and PCC at RJH only: Precaution Clean Precaution Clean Precaution Clean * 3 Routine Plus 3 Cleaning E. Protective (Reverse) Precautions Patients/residents with a suppressed or deficient immune system may be at increased risk of acquiring infection during hospitalization. Gowns, gloves and masks are not routinely required. Instrumentation (e.g. catheters and other devices) is to be used only when essential. The physician decides whether or not the patient requires Protective Precautions. Variables the physician may consider are: Severity of immune system depression Length of time patient has been neutropenic Absolute neutrophil count of 0.5 x 109/1 or less (Neutropenia) Procedure Routine practices are to be followed at all time including strict hand washing prior to all patient contact Place in a single room (preferably a Positive Pressure Room if available). Keep door closed. Place sign on door to notify other staff Limit raw vegetables and fruit. Fresh flowers are not allowed in the room 10 Routine daily cleaning using Quaternary ammonia 1:256 (VirEx). Curtains changed on discharge/discontinuation of precautions 11 Accelerated hydrogen peroxide 1:16 (VirOx), area cleaned twice in 24 hours during patients stay, and twice in a row on patient discharge – where ―2 Step Post-it Note‖ posted by nursing staff 5 Precaution Clean using Accelerated Hydrogen Peroxide 1:16 (VirOx). Curtains changed on discharge/discontinuation of precautions Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 70 VIHA Infection Prevention and Control Manual, September 1, 2011 Offer bottled/filtered water and commercially prepared single serving fruit juices Staff aware of incubating or having infection must not care for these patients/residents Visitors with any signs and symptoms of infection should be encouraged to avoid patient contact F. Management of Cases on Additional Precautions in Diagnostic Areas Medical intervention and investigation should not be delayed because a patient requires additional precautions (however, if the test or treatment can be provided in the patient room this should be the first consideration). Use PPE and precautions as indicated on the Additional Precautions sign on the door of the patient‘s room Porters must comply with precautions noted on signage, and must be instructed to remove attire and wash hands upon completion of transport. All equipment used must be appropriately cleaned following transport Charts should not be left on patient‘s bed or given to patient to hold. If no other option is available, charts can be housed in a disposable bag or pillowcase for transport purposes For actively infected patients/residents (if unsure consult with Infection Prevention and Control), follow these procedures: The patient should be taken directly to the procedure room and not left in the corridor For non-urgent cases, book as the last case of the day; this facilitates cleaning of equipment Limit the number of moves and exposure to surfaces whenever possible Remove as much equipment as possible from the room Close all cupboard doors to protect equipment from exposure Use sheets to cover any equipment that cannot be encased or removed Should staff require equipment from a cupboard or from under a cover while performing diagnostic tests on infectious patients/residents, ensure that staff remove gloves and wash hands prior to obtaining this equipment. It is important that contamination of other packages does not occur, as many organisms can survive in the environment for long periods Upon completion of the procedure the patient should be returned to the unit as quickly as possible Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 71 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 5: Management of Infected Patients/Residents on Precautions in Diagnostic Areas Is patient on Additional Precautions? Use Routine Practices for all care. Routine Cleaning NO YES Can test/procedure be done in patient's room? Apply Precautions as identified on signage. Clean equipment post procedure. YES NO Is patient having an invasive interventional procedure? (i.e. Imaging) Protocol B YES NO What Personal Protective Equipment is required? Gloves and Gown Gloves, Gown and Mask Can patient wear a mask? NO Protocol B YES PROTOCOL B: Protocol A Protocol A PROTOCOL A: Minimize patient and staff contact with equipment. Clean patient and staff contact areas post-procedure. Prepare environment:; Schedule as last case Close cupboard doors Move unnecessary equipment as far from patient as possible and cover with a sheet Prepare tray/equipment Use clean circulator only to access supplies TerminalClean post procedure all contact surfaces. (Closed cupboards which were not entered and covered/untouched equipment do not require cleaning.) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 72 VIHA Infection Prevention and Control Manual, September 1, 2011 G. Discontinuing Additional Precautions The table below outlines the criteria for discontinuing the use of additional infection control precautions without prior consultation with an Infection Control Practitioner. Please notify your Infection Control Practitioner when this occurs. Table 10: Procedure for Discontinuing Additional Precautions Routine Practices are used at all times. Additional precautions are in effect when symptoms of infection are present or when concerning infectious diseases are diagnosed. Additional Precautions may ONLY be discontinued when the following criteria are met: Notify your IPC Practitioner when this occurs PRECAUTIONS REASON ARO positive C.difficile positive Contact Precautions* Droplet Precautions* Airborne Precautions* CRITERIA ONLY when authorized by Infection Prevention & Control 48 hours without diarrhea and formed/normalized stools are documented Diarrhea NYD (no vomiting) Stools formed/normalized x 48 hours and Negative C.difficile toxin Skin/soft tissue infection or cellulitis Wound culture results are not MRSA and ARO culture results are negative and Antibiotics given for 24 hours or more and Clinical improvement observed New or worsening cough Responding to antibiotics given for 24 hours or more OR 5 days since start of symptoms when a viral infection is suspected (labs, physical findings) AND Culture of sputum or blood is negative for MRSA AND Negative viral swab for influenza Suspected MRSA with cough Known MRSA with cough Fever with rash NYD, suspect Meningitis Diarrhea NYD with vomiting Meets criteria in box above and Negative ARO cultures Suspected pulmonary TB Concentrated AFB smears negative x 3 Diagnosed pulmonary TB ONLY when authorized by Infection Prevention & Control Chickenpox Widespread Varicella Zoster (Shingles) Cough is resolved but must continue with Contact Precautions Antibiotics given for 24 hours or more and Clinical improvement observed. No diarrhea or vomiting x 48 hours All skin lesions crusted Until lesions can be covered with dressings or are crusted over * Immediately have the room “discharge” cleaned following VIHA Guidelines, Facility specific, even if the patient is not being discharged from the Unit/Facility However, your Practitioner, in consultation with the Infection Prevention & Control Physician, may determine that precautions can be removed earlier for some situations (e.g. C.difficile). Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 73 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 4: HOUSEKEEPING 1. Clean Environment [NOTE: This includes direction relating to current housekeeping service levels only.] PRINCIPLES: As a guiding principle, all healthcare workers share the role of maintaining a clean environment. GUIDELINES: Patient rooms, equipment used in the assessment and care of patients/residents, diagnostic treatment and service delivery areas are to be cleaned and disinfected according to the Infection Prevention and Control (IPC) standards described in this document. Environmental Support Services within the VIHA are to establish and maintain a clean, sanitary, and aesthetically pleasing environment for patients/residents, staff and visitors. The IPC Program will assist by advising on appropriate types of disinfectants for daily routine use; advise on disinfectants for specific situations e.g. outbreaks of epidemiologically significant organisms and when certain difficult to eradicate organisms are present in the environment. When purchasing new patient care equipment, consideration by the Program area must be given to: (1) how easily it can be cleaned/disinfected and (2) determination of who will have responsibility for cleaning it. 1. Quality Auditing In addition to the audits done by Housekeeping Services and Environmental Support Services, the IPC team or designates may from time to time conduct independent audits of the environment, to determine adherence to quality management. Environmental cultures to investigate outbreaks will be at the discretion of Infection Prevention & Control. 2. Evaluating Products Evaluation of new products will be done in cooperation and consultation with Environmental Support Services, Infection Prevention and Control, and Purchasing. Approved disinfecting solutions and applications are listed in Section 3. Exceptions are described under Enhanced Cleaning. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 74 VIHA Infection Prevention and Control Manual, September 1, 2011 The accelerated hydrogen peroxide cleaning and germicidal/disinfectant agent12 is the recommended product for routine housekeeping work. In sites where accelerated hydrogen peroxide is not used routinely, quaternary ammonium compounds are used. The information in this box applies to Cowichan District Hospital, Nanaimo Regional General Hospital and from March 13, 2011 for the Patient Care Centre at Royal Jubilee Hospital CDH, NRGH and PCC at RJH staff are advised that two cleaning processes are now being performed throughout these sites: Routine Cleaning – all daily cleaning in all areas except the operating department, which will remain unchanged (refer to Section A). Precautions Cleaning – single-step cleaning both daily, on discharge of the rooms or bed spaces of patients/residents, or discontinuation of patients/residents on additional infection prevention and control precautions. The procedure described for cleaning in the Enhanced Discharge Clean will be followed (refer to Section B). Cleaning products also have been changed, with a primary focus on removing dirt and soiling which can harbor microorganisms. Disinfection is targeted at areas with precautions. Routine Cleaning – neutral detergent (e.g. Stride) for cleaning the environment and all equipment and furnishings within the environment. Precautions Cleaning - accelerated hydrogen peroxide (e.g. Virox) for cleaning rooms/bed spaces of patients/residents on precautions, and all furnishings and equipment used by those patients/residents (single step). *Please Note: Section 1D – Separation of Clean and Soiled Equipment and Section 3 – Bed Bug Infestation still applies to these sites 12 Use of accelerated hydrogen peroxide has been implemented in some hospitals, approval for its expanded use is being considered. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 75 VIHA Infection Prevention and Control Manual, September 1, 2011 A. ROUTINE CLEANING 1. DAILY CLEAN Nursing Responsibilities: Routine practices are used at all times when handling soiled items. Hand hygiene is performed upon completion of the task Patient care items to manage toileting and personal hygiene (bedpans, urinals, commode pots and washbasins) are emptied and disinfected following use. When done manually, the receptacles are to be emptied, washed or rinsed and then surface wiped with the approved ready to use disinfectant wipe. When automated washer disinfector/hoppers are installed in care areas, items placed in these are cleaned using a sanitation cycle. DEKO Loading and Instructions The items removed from the machine can be used for any patient All receptacles containing body fluids that are not disposable by design (e.g. glass suction canisters), are to be emptied and rinsed with cold water prior to transport to CPS for terminal cleaning and disinfection Patient care items (bedpans, urinals, washbasins) no longer required for care or upon discharge of the patient, are rinsed to remove any visible debris and placed into the designated CPS bin for pick up Equipment for care and assessment e.g. NIBP mobile cart, thermometers, Use regular facility germicidal/disinfectant solution. Applicable to all rooms, including those on Additional Precautions, unless otherwise specified (see Enhanced and Two-Step Cleaning). Staff must wear appropriate Personal Protective Equipment (PPE). Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 76 VIHA Infection Prevention and Control Manual, September 1, 2011 Gloves, that meet WorkSafe BC standards for the task, are to be used for all work requiring chemicals, cleaners, and disinfectants. Household non-disposable gloves are preferred for ongoing use by housekeeping staff. They must be designated to the individual worker, and must be inspected by the worker daily to ensure that the gloves have no holes or tears in them. If gloves are damaged they must be discarded and replaced. They must be dried and stored in a clean dry area. If disposable gloves are used, then they must be changed regularly to ensure integrity and cleanliness. Regardless of the type of glove, they must be washed between dirty tasks and whenever the floor bucket disinfectant solution is changed Floor bucket germicidal/disinfectant solutions are freshly prepared and frequently changed at a minimum after every two large rooms (4-bed rooms) or three small rooms (2-bed or private rooms) As a general principle, high items are cleaned first, using a top-to-bottom approach All cleaning equipment is disinfected at the end of each cleaning shift The mop bucket and double bucket are to be washed and rinsed before refilling Used mop heads are returned to the designated pick up area for transport to the laundry Clean rags and a fresh bucket of germicidal/disinfectant solution will be used for each room to perform contact surface sanitizing. Cleaning rags are to be used only once -- DO NOT re-dip into solution. If flip top bottle of germicidal/disinfectant solution is used instead of bucket, cleaning rag must be saturated. Used cleaning rags are returned to the laundry area in accordance with internal housekeeping procedure The germicidal/disinfectant solution is to be applied to horizontal hand contact surfaces leaving the surfaces wet so that the drying time of that surface is 3 to 5 minutes (or in accordance with manufacturer‘s recommendations to assure the killing of micro organisms) Dry dusting is to be avoided in clinical patient care areas. The approved germicidal/disinfectant must be applied to an approved dust rag or mop, which is then used to remove dust from horizontal surfaces, thus reducing the risk of dispersing dust and micro organisms into the environment Soap and alcohol based hand rub dispensers on wall-mounted and floor model kiosks will be monitored daily. These dispensers include those found at elevators, public entry points, bathrooms, and point of care. When these are empty, the dispenser will be replenished with soap/ new alcohol product. Clean/wipe the outside of the dispenser after refilling Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 77 VIHA Infection Prevention and Control Manual, September 1, 2011 b) Specific The following environmental surfaces and equipment/furniture will be cleaned and disinfected daily. Examples of items have been identified, but this is not an allinclusive list: Central & POD Nursing Stations: Horizontal and contact surfaces, telephones and receivers, hand hygiene sinks including taps and faucets, alcohol based hand rub dispensers and kiosks Floors: To be dust mopped followed by wet mopping with disinfectant solution. (Exception – see Enhanced Cleaning if patients/residents on Additional Precautions) Furniture & Equipment: Horizontal and contact surfaces of over bed tables, bedside tables, the bed rails, handles and control panels, bedside chairs, telephone Bedside equipment including: commode, wheelchair, Geri chair, lifting devices and IV poles, etc Sinks & Bathrooms: Entire sink is thoroughly cleaned, all surfaces and fixtures, counter top, entire toilet is thoroughly cleaned: seat (top and bottom), inside bowl, outside base, walls around sink and toilet, door knobs, light switches, soap and paper towel dispenser. All fixtures, such as handles, call bells and strings, etc. are cleaned. All tubs and showers are thoroughly cleaned Service/Utility Rooms: Soiled and clean service rooms shall be cleaned and disinfected. Sinks and hoppers will be cleaned and disinfected in a similar fashion to patient toilets. Washer disinfectors shall be surface cleaned Garbage Cans: Garbage cans are emptied when full and at minimum once daily, and cleaned/ disinfected inside and out at a minimum of once per week or when visibly soiled Laundry Receptacles: Laundry receptacles are cleaned/disinfected inside and out each day following removal of the bag liner or removal of the laundry bags Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 78 VIHA Infection Prevention and Control Manual, September 1, 2011 Bed Cubicle: Bedside curtains are changed if visibly soiled 2. DISCHARGE CLEAN Nursing Responsibilities Nurses remove all patient belongings. Patient care items such as wound care products, pericare products, creams, etc are sent home with the patient or discarded. Medical equipment including used suction bottles and apparatus will be dismantled and removed from room. Housekeeping Responsibilities Use regular facility germicidal/disinfectant solution. Applicable to all rooms unless otherwise specified, (see Enhanced and Two-Step Cleaning). For rooms on Additional Precautions, bedside curtains are removed and laundered. Staff must wear appropriate PPE. The housekeeping staff removes all linen from the bed or stored in the bed space. All surfaces in the bed space/room as described under Routine Daily Cleaning are cleaned and disinfected. In addition, the following will be cleaned and disinfected: All surfaces of the bed including bed frame, headboard, footboard, light above bed, pull cords, call bells, mattress, pillows, etc The interior of bedside tables, over bed tables and closets Any patient care equipment used by the patient that remains at the bedside, e.g. Geri chair, commode chair, IV pole or pump Television, TV remote, and telephone Wall surfaces at the head of the bed including the medical gas flow meters and suction apparatus holders when disposable and not sent to CPS. When suction bottles and apparatus have not been used, the exterior of these will be disinfected Bedside curtains are changed if visibly soiled Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 79 VIHA Infection Prevention and Control Manual, September 1, 2011 Upon completion of cleaning, gloves are removed, hands washed, bed is made and necessary supplies are replenished. 3. ROUTINE PLUS DISCHARGE CLEAN For those bed space/room where the patient was discharged/transferred while still on additional precautions the bedside curtains must be changed and the walls washed Upon completion of cleaning, gloves are removed, hands washed, bed is made and necessary supplies are replenished. SCHEDULED AND CYCLED CLEANING & DISINFECTION: Cleaning and disinfection of the following items not captured during routine daily or discharge cleaning will be managed on a cycled basis and following additional written policies. Care & Assessment Equipment: Contact surfaces of equipment used in the care and assessment of the patient including fixed ceiling lift control devices, infection prevention and control barrier supply carts, intravenous and nutrition administration pumps In some areas, an arrangement has been made with Central Processing and Sterilization departments to clean pumps such as gastric, IVAC, nutrition administration, continuous pumps; crash cart and defibrillator, emergency cart, and continuous renal replacement therapy (CRRT) machines. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 80 VIHA Infection Prevention and Control Manual, September 1, 2011 B. ENHANCED CLEANING 1. DAILY CLEAN Use accelerated hydrogen peroxide germicidal solution, mixed at a 1:16 ratio for all contact surfaces including wall at head of bed; and mixed to a 1:64 ratio for floors and other walls. Applies to rooms with VRE positive and exposed patients. Applies when outbreak of any organism is declared, unless otherwise specified (see TwoStep Cleaning). Cleaning checklist is used, signed off, and submitted to housekeeping supervisor. Housekeeping Checklist Staff must wear appropriate PPE. In addition to the Routine Daily Clean procedures, specific enhanced cleaning techniques and procedures are followed. Nursing Responsibilities Nursing will identify the need for enhanced daily clean in accordance with IPC guidelines (i.e., signage at the door). Post the green “enhanced” post-it note. Housekeeping Responsibilities The housekeeping cart containing all the necessary cleaning supplies and equipment is placed outside the door. Freshly prepared germicidal/disinfectant solution, plenty of cleaning rags, paper supplies, garbage bags, soap, sharps container and housekeeping keys are placed in an easily accessible place on the cart. Instructions for entry precautions outlined on the Infection Prevention and Control Precautions sign on the door must be followed before entering room. Proceed to gown, fasten gown ties at back, making sure gown edges overlap to cover uniform completely; wear cap and mask if required. Put on disposable gloves and pull up over cuffs of gown. An Infection Prevention and Control Barrier Supply Cart or alternative may be located in the hall outside the room All patient contact items are thoroughly cleaned using the enhanced cleaning technique. Cloths will be pre-soaked in accelerated hydrogen peroxide based solution and kept in a bag until used. A fresh cleaning rag is used for each item cleaned (1 for the sink, 1 for the chair, etc.). Each used rag is discarded into a garbage bag and when room is completely cleaned, the bag of cleaning rags is removed from room to be laundered Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 81 VIHA Infection Prevention and Control Manual, September 1, 2011 Note: The germicidal/disinfecting agent (mixed at a 1:16 ratio) is applied heavily enough to assure a 5-minute contact/drying time, or consistent with manufacturer‘s instructions. Wet mop floor with germicidal/disinfectant solution. Upon completion, mop handle is wiped before it is placed back in the wet mop bucket. DO NOT DUST MOP ROOM Upon completion of cleaning, prepare to exit room. Remove gloves by pulling inside out; do not touch the outside of the gloves, if possible. Discard into garbage. Perform hand hygiene. Pull off gown by pulling free and holding upper ties and inside surfaces. Pull sleeves inside out when pulling arms out. Roll gown up with inside surface facing out and place in garbage or if reusable gown, in linen hamper/tote by door. Garbage must be contained in tied off bag before leaving room13. Wash hands before leaving room. Please see also Donning and Doffing Garbage is transported to designated pick up area. Return to housekeeping room with cart, thoroughly clean and decontaminate housekeeping equipment. Remove mop head and place in black garbage bag for laundering, transport to designated pick up area. Use germicidal/disinfectant solution to thoroughly clean all equipment used – mop handle, bucket, wringer, double bucket, keys, etc Thoroughly wash hands and forearms using soap and water or use an alcohol based hand rub product, in nearest utility room 2. DISCHARGE CLEAN Use accelerated hydrogen peroxide germicidal solution, mixed at a 1:16 ratio for all contact surfaces including wall at head of bed; and mixed to a 1:64 ratio for floors and other walls. Applies to rooms with VRE positive and exposed patients. Applies when outbreak of any organism is declared, unless otherwise specified (see TwoStep Cleaning). Cleaning checklist is used, signed off, and submitted to housekeeping supervisor. Housekeeping Checklist Staff must wear appropriate PPE. This type of cleaning is done when a patient has been found to have a microorganism capable of living long periods in the environment and presents risk of infection in patients/residents admitted to the room at a later time e.g. VRE. It is either done on 13 In most cases this will be regular waste and not biohazardous waste. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 82 VIHA Infection Prevention and Control Manual, September 1, 2011 transfer/discharge of the patient with the infection or when the patient is no longer exhibiting symptoms of the infection. All steps identified in Routine Discharge Cleaning are followed. In addition, cleaning of the room and equipment/furniture includes vertical surfaces and fixtures, window treatments and bedside curtains. Window curtains are changed, and window blinds are surface wiped/disinfected. Hydrogen peroxide disinfectant solution is used with attention to detailed cleaning of difficult to clean surfaces e.g. call bell buttons, medical gas controls, bedside commodes, bed controls, etc. Nursing Responsibilities Nursing will identify the need for enhanced daily clean in accordance with IPC guidelines (i.e., signage at the door). Post the green “enhanced” post-it note. The Infection Prevention and Control Precautions sign must remain posted until the cleaning is done. All patient belongings are removed from the room Open, unused medical supplies are to remain in the room to be discarded Medical and patient equipment will be managed in the same manner as described in Routine Discharge Cleaning Housekeeping Responsibilities The procedures described for cleaning in the Routine Discharge Clean and Enhanced Daily Clean will be followed. In addition, the following procedures are also performed during an Enhanced Discharge Clean: Housekeeping Checklist Take minimal supplies into the room with precautions. All exposed unused supplies are discarded into the garbage: toilet paper, bar soap, gloves, bags, etc. If sharps container is full, remove it, wipe with disinfectant and place in designated area. If not full, wipe exterior with disinfectant All patient contact items are thoroughly cleaned: furniture, fixtures, sinks, call bell cords, door knobs, exterior surfaces of soap and paper towel containers, etc Change the cubical curtains and window drapes. If roller or venetian blinds, wipe with disinfectant. Wash the ledges, over bed lights; wash the windows, window ledges, walls; wash the bed (including frame and mattress); wash the radiators, cubical curtain rails, shelves; wash the inside and outside of waste baskets Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 83 VIHA Infection Prevention and Control Manual, September 1, 2011 Entire bathroom, tub and shower are thoroughly cleaned. Shower curtain is removed for laundering Wet mop floors of patient room and bathroom. Upon completion, mop handle is wiped before it is placed back in the wet mop bucket. DO NOT DUST MOP ROOM Once cleaning and sanitizing is complete; barrier clothing is removed and hand hygiene performed Bed is made and necessary supplies are replenished: toilet paper, paper towels, soap. Housekeeping staff replaces the cubicle, shower and window curtains Infection Prevention and Control Precaution sign is disinfected and removed from the door. If sign is located in a Plexiglas Holder, the holder is disinfected and the sign is flipped over so the back side showing hand hygiene is now visible. The Housekeeping Checklist and any other ―Requires Cleaning‖ sign that has been used is removed, initialed and submitted to the Housekeeping Supervisor Housekeeping staff is to thoroughly clean and sanitize their equipment Hands and forearms are washed with soap and water or with the alcohol based hand rub product C. TWO STEP CLEANING 1. TWICE DAILY CLEAN This is a process that includes: Cleaning as set out for Enhanced Daily Clean completed twice during the day Use accelerated hydrogen peroxide germicidal solution, mixed at a 1:16 ratio for all contact surfaces including wall at head of bed; and mixed to a 1:64 ratio for floors and other walls Applies to rooms where patients have GI illness symptoms or confirmed Norovirus, Clostridium difficile, Rotavirus, etc Staff must wear appropriate Personal Protective Equipment (PPE) In accordance with the Infection Prevention and Control Manual, Two Step Daily Clean may be requested when the patient has an organism known to be resistant to standard disinfectants. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 84 VIHA Infection Prevention and Control Manual, September 1, 2011 Nursing Responsibilities Nursing must place the appropriate Infection Prevention and Control sign on the door and inform housekeeping staff of the need for Two Step Daily Clean in accordance with IPC guidelines. Post the orange “2-step” post-it note. Housekeeping Responsibilities The procedures described for cleaning in the Enhanced Daily Clean will be followed, but completed on two separate occasions during the day. 2. DISCHARGE CLEAN This is a 2 step process that includes: Cleaning as set out for Enhanced Discharge Clean Once surfaces are dry, cleaning is repeated Use accelerated hydrogen peroxide germicidal solution, mixed at a 1:16 ratio for all contact surfaces including wall at head of bed; and mixed to a 1:64 ratio for floors and other walls Cleaning checklist is used, signed off, and submitted to housekeeping supervisor. Housekeeping Checklist Applies to rooms where patients have GI illness symptoms or confirmed Norovirus, Clostridium difficile, Rotavirus, etc. Staff must wear appropriate Personal Protective Equipment (PPE). In accordance with the Infection Prevention and Control Manual, Two Step Daily Clean may be requested when the patient has an organism known to be resistant to standard disinfectants. Nursing Responsibilities Nursing must place the appropriate Infection Prevention and Control sign on the door and inform housekeeping staff of the need for Two Step Discharge Clean in accordance with IPC guidelines. Post the orange “2-step” post-it note. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 85 VIHA Infection Prevention and Control Manual, September 1, 2011 The responsibilities described for cleaning in the Enhanced Discharge Clean will be followed. Housekeeping Responsibilities The procedures described for cleaning in the Enhanced Discharge Clean will be followed, and repeated a second time when the surfaces are dry. . D. SEPARATION OF CLEAN AND SOILED EQUIPMENT Clean and soiled equipment will be stored/held within separate designated areas on all units. Areas will be identified using clear signage, for example: Clean commodes only (Return all other equipment to designated area) Clean equipment only Soiled equipment only Clean and soiled areas should be at least 2 metres (6 feet apart) Once a piece of equipment has been cleaned using the appropriate method, a pink laminated ―Clean‘ tag will be attached. The tag will be removed prior to use of the equipment. The tag will be cleaned appropriately prior to it being stored ready for further use. Examples of equipment needing to be tagged following cleaning: Commode chairs Intravenous poles Intravenous pumps Wheelchairs Walkers Patient chairs Once a piece of medical equipment is no longer needed by the patient, or a patient is discharged/ discontinuation of precautions, the piece of medical equipment will remain within the patient room/bed space and be removed following the appropriate cleaning process or, if necessary, removed for cleaning in the Dirty Utility Room. If the equipment was in a room Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 86 VIHA Infection Prevention and Control Manual, September 1, 2011 where patients/residents were on precautions, it must remain there until appropriately cleaned. The equipment will be tagged ‗clean‘ and stored in the appropriate designated area. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 87 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 11: Summary of Cleaning Requirements Cleaning Requirements – Please refer to more complete information in the Guidelines DISCHARGE CLEAN TYPE ROOM TYPE 14 Chemical R H Regular rooms X 15 C Items E W X X Room/bedspace with additional precautions (i.e., MRSA) X X ROOM TYPE Bedside drapes if soiled Chemical R H C Items E W X X X X Chemical R H X C X Items E W X Bedside drapes if soiled X X Specifics Chemical R H X S Bedside drapes if soiled 1. Diarrhea (unusual for patient) 2. GI organisms (i.e., c-diff, Norovirus, etc.) Suspected or Confirmed 3. GI Outbreak Second Time Chemical R H X C X Items E W * X S X X X * X X C X R Chemical H B C Items E W Other (unusual or emerging) Suspected / Confirmed / Outbreak Specifics Bedside drapes if soiled; * walls if soiled X X X Bedside drapes Items E W X X Specifics S X Bedside drapes & curtains Chemical R H X C X Items E W X X X X X Specifics S X Bedside drapes & curtains X DISCHARGE CLEAN TYPE Specifics S R Chemical H B C At discretion and direction of IPC Practitioners R = Regular Germicidal Solution H = Accelerated Hydrogen Peroxide C = Contact Items (tables, rails, handles, switches, etc) E = Entire Room (total clean – walls, etc. included) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Bedside drapes if soiled TWO STEP DISCHARGE CLEAN DISCHARGE CLEAN TYPE ROOM TYPE X ENHANCED DISCHARGE CLEAN DISCHARGE CLEAN TYPE ROOM TYPE Specifics S DISCHARGE CLEAN TYPE ENHANCED DAILY CLEAN 1. An Outbreak (other than those described under two-step) 2. VRE -Suspected or Confirmed 15 Specifics S DISCHARGE CLEAN TYPE ROOM TYPE 14 DISCHARGE CLEAN TYPE Items E W Specifics S At discretion and direction of IPC Practitioners W = Washroom (all items) Page 88 S = Special Requirement (list in ‗Specifics‘ box) VIHA Infection Prevention and Control Manual, September 1, 2011 2. Housekeeping Cleaning Terminology Level of Cleaning Type of Clean Cleaning chemicals to be used ROUTINE ENHANCED 2-STEP VIHA approved Quaternary Ammonium (e.g. VirEX 2) diluted 1:256 for contact surfaces; OR Hydrogen Peroxide (e.g. VirOX 5, Accel) diluted 1:16 for contact surfaces or 1:64 for floors. VIHA approved Hydrogen Peroxide (e.g. VirOX 5, Accel) product VIHA approved Hydrogen Peroxide (e.g. VirOX 5, Accel) product Diluted 1:16 for contact surfaces or 1: 64 for floors Diluted 1:16 for contact surfaces or 1: 64 for floors Nursing responsible for identifying level of cleaning required (e.g. MRSA, ESBL) Nursing responsible for identifying level of cleaning required (e.g. VRE) Nursing responsible for identifying level of cleaning required (e.g. GI illness) DAILY When No Precaution Sign Posted Follow Routine Housekeeping cleaning procedure; refer to housekeeping checklist. Clean all contact surfaces. Replace curtains if visibly soiled *. PPE as per routine practice ** Precaution Sign & no Cleaning Notice Posted Follow Routine Housekeeping cleaning procedure; refer to housekeeping checklist. Clean all contact surfaces. Replace curtains if visibly soiled *. Use PPE (Gown, Gloves, Mask as indicated on sign) ** Precaution Sign & Enhanced Cleaning Notice Posted Follow Routine Housekeeping cleaning procedure using hydrogen peroxide solution; refer to housekeeping checklist. Clean all contact surfaces; and spot clean walls Replace curtains if visibly soiled * Use PPE (Gown, Gloves, Mask as indicated on sign) ** Precaution Sign & 2-Step Cleaning Notice Cleaning occurs twice each day: o first clean in the morning o second clean in the afternoon Follow Routine Housekeeping cleaning procedure using hydrogen peroxide solution; refer to housekeeping checklist. Clean all contact and vertical surfaces. Replace curtains if visibly soiled *. Follow and complete housekeeping checklist and give signed checklist to supervisor. Use PPE (Gown, Gloves, Mask as indicated on sign) ** DISCHARGE(formally known as “Terminal”) Discharge or transfer of a patient from a bed Precautions have been discontinued by Infection Prevention and Control – identified as Routine Plus discharge clean When No Precaution Sign Posted Routine discharge cleaning procedure; use housekeeping checklist Clean all contact and horizontal surfaces. Replace curtains if visibly soiled and at least once a month * PPE as per routine practice ** Precaution Sign & Enhanced Cleaning Notice Posted Routine discharge cleaning procedure using hydrogen peroxide; use housekeeping checklist Clean all contact, horizontal and vertical surfaces. Replace privacy curtains, including window curtains within the bed space/room * Use PPE (Gown, Gloves, Mask as indicated on sign) ** Precaution Sign & 2-Step Cleaning Notice 2-Step Cleaning Required o Step 1. Clean with hydrogen peroxide solution to remove organic debris. Allow to dry. o Step 2. Disinfect – Wipe surface with cloth saturated with hydrogen peroxide solution. The surface or item is to remain wet for 5 minutes, then wipe or air dry. Follow Enhanced discharge cleaning procedure using hydrogen peroxide; use the 2-step cleaning process above; Clean all contact, horizontal and vertical surfaces. Replace privacy curtains, including window curtains within the bed space/room * Follow and complete housekeeping checklist and give signed checklist to supervisor. Use PPE (Gown, glove, Mask as indicated on sign) ** Precaution Sign & no Cleaning Notice Posted – identified as Routine Plus discharge clean Routine discharge cleaning procedure, use housekeeping checklist Clean all contact , horizontal and vertical surfaces Replace privacy curtains, including window curtains within the bed space/room * Use PPE (Gown, Gloves, Mask as indicated on sign) ** * Bathroom cubicle curtains must be changed if visibly soiled and at least weekly, and daily for patients/residents with diarrhea, c.difficile or norovirus. ** Hand hygiene is to be performed between each patient environment and each time before gloves are put on and again after gloves are removed. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 89 VIHA Infection Prevention and Control Manual, September 1, 2011 3. Bed Bug Infestation If a bed bug infestation is suspected, contact the Housekeeping Supervisor through the call centre. Summary of Bed Bug Information Biological Information: Primarily active at night and hide during the day Take advantage of small cracks and crevices/depressions Require blood meal for development Have sucking not chewing mouthparts (important for containing insect) Egg to adult generally 45-55 days Female produces between 200 to 500 eggs during lifetime Typical life span between 6 to 12 months Grow by shedding exoskeleton Extreme heat (approx 45oC or cold is lethal – heat is more effective) Generally not considered to vector disease (yet do harbour pathogens) Are not good climbers on smooth surfaces Reported - adults can live roughly 1½ years without a blood meal. Signs of Infestation Insect (up to ¼ inch – typically reddish-brown/yellow – may be white) Fecal smears (digested blood) or spots on bedding/bed Bite marks – typically raised welt with crust appearance (some no reaction) Eggs – tiny in clusters – small, light coloured Shed skeletons Sweet/musty odour with severe infestation levels Key Procedures Important - obtain a specimen if possible Treat area as if contaminated - assume contamination exists even if unsure Contain patient possessions and infested items in sealed plastic Never move any items from infested area without properly sealing in plastic (or similar material) Always label infested items and ensure separation from uninfested items Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 90 VIHA Infection Prevention and Control Manual, September 1, 2011 Wash and Dry washable items using high temperature Non-washable items can be dry cleaned Ensure clean laundry and uninfested materials are not stored or transported with infested materials where cross contamination can occur There should be two distinct and separate protocols for handling dirty, possibly contaminated laundry and other items. This will reduce the possibility of cross-contamination Vacuum beds and mattresses and surrounding area Develop handling protocol - minimize contact or potential contact between patient possession, clean/dirty laundry and potentially infested items Steam cleaning can potentially be used Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 91 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 5: ANTIBIOTIC RESISTANT ORGANISMS 1. Introduction Antibiotic resistant organisms (AROs), also known as multi-drug resistant organisms (MDROs), are defined as microorganisms that are resistant to one or more classes of antimicrobial agents. Although the names of certain AROs describe resistance to only one agent these pathogens are frequently resistant to a number of antimicrobial agents. Examples of resistant bacteria are: Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Bacteria containing Extended Spectrum Beta-Lactamase (ESBL) Or any bacteria resistant to usual antibiotic therapy, such as Burkholderia cepacia. 2. Definitions Colonization Colonization is the presence, growth and multiplication of the organism in one or more body sites without observable clinical symptoms. Infection Infection occurs when microorganisms invade a body site, multiplying in tissue and causing clinical manifestations of local or systemic inflammation e.g. fever, redness, heat, swelling, pain. 3. Acute Care Screening Protocol All patients/residents admitted to acute care hospitals will be screened using the ARO Screening Questionnaire. Persons identified as having risk factors for MRSA acquisition will be swabbed for MRSA. Based on your assessment, perform actions as required — collect cultures and implement additional precautions where appropriate. Note: Notify Infection Prevention and Control of all patients/residents placed on additional precautions. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 92 VIHA Infection Prevention and Control Manual, September 1, 2011 Check the Patient Record disease alert field. This will be blank unless the patient has previously been positive for an ARO. Figure 6: Patient Record Disease Alert Field Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 93 VIHA Infection Prevention and Control Manual, September 1, 2011 If an ARO alert is present, the type of resistant organism will be identified according to the following codes: As soon as initial nursing risk assessment is complete, nursing staff can place patients/residents on appropriate precautions (no need to wait for physician’s directive). Table 12: List of Organisms with Corresponding Precautions and Other Considerations Code Name of Organism MRSA Methicillin Resistant Staphylococcus aureus VRE Vancomycin Resistant Enterococcus ESBL Extended Spectrum Beta Lactamase BCEP Burkholderia cepacia KPC Klebsiella pneumoniae carbapenemases MRAB Multi Drug Resistant Acinetobacter baumannii Multi Drug Resistant Pseudomonas aeruginosa MRPA MRSP Multi Drug Resistant Pneumococcus MRTB Multi Drug Resistant Tuberculosis VRSA Vancomycin Resistant Staphylococcus aureus New organism not listed above Unusual combination of AROs listed above Other – ARO Multiple AROs Precautions and Other Considerations in acute care16 Contact Precautions Routine Plus Cleaning (bedside curtains changed on discharge) Contact Precautions according to VIHA‘s Policy 15.3 Management of Patients with VRE (Acute and Residential) Contact Precautions Routine Plus Cleaning Cystic fibrosis patients/residents are placed on Contact Precautions, in a Private Room, do not cohort with another diagnosed cystic fibrosis patient Routine Plus Cleaning Contact or Droplet Precautions dependent on location of organism Routine Plus Cleaning Contact Precautions Routine Plus Cleaning Contact or Droplet Precautions dependent on location of organism Routine Plus Cleaning Droplet Precautions Preferably Private Room Routine Plus Cleaning Airborne Precautions Negative Pressure Room Routine Cleaning Contact Precautions Enhanced Cleaning Discuss with IPC practitioner Dependent on Organisms involved 16 Precautions are based on the acute care setting. In other settings, routine practices are generally sufficient, unless identified differently by the IPC Practitioner. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 94 VIHA Infection Prevention and Control Manual, September 1, 2011 4. ARO Screening and Collecting Swabs Table 13: Screening and Specimen Collection Encounter Admission to acute care Screening Questionnaire YES ARO Screening Cultures If positive response to screening questionnaire Staff responsible for obtaining cultures If admitted via ER/ED – RN If direct admit – MRN MRSA VRE ESBL Nares Groin Wound Sputum if productive cough NO Urine, Rectum Wound, stoma, device Admission to Residential Care NO If known MRSA positive, swab taken 30 days after admission Receiving RN/LPN Nares Groin Wound Sputum if productive cough NO NO Admission, discharge from ICU or InPatient Renal NO All admissions and discharges NICU and Paeds ICU: only transfers from another hospital (within or external to VIHA), and discharge from unit MRN Nares Groin Wound Sputum if productive cough Rectum Wound NO Transfer between VIHA hospitals or other hospitals NO All admissions who have been transferred from another hospital (within or external to VIHA) MRN Nares Groin Wound Sputum if productive cough NO NO * Hospice, End of Life, and stand-alone Palliative Care Units – contact IPC practitioner for direction. 5. Overview of Antibiotic Resistant Organisms In most instances, infections due to AROs have clinical manifestations that are similar or the same as infections caused by susceptible pathogens. However, options for treating patients/residents with these infections are often extremely limited due to their multiple resistances to antibiotics. The result is that infections due to AROs often cause increased morbidity and mortality, as well as increased length of hospital stay and costs. The following factors contribute to emergence of resistance in this setting: intensive, prolonged use of broad spectrum antibiotics high intensity of medical care provided in the close physical confines of a hospital a more vulnerable population, especially patients/residents suffering chronic illness, those critically ill, those with invasive devices in place, those requiring intensive medical or surgical care Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 95 VIHA Infection Prevention and Control Manual, September 1, 2011 A. Methicillin-Resistant Staphylococcus aureus (MRSA) Staphylococcus aureus (S. aureus) is a common cause of infection in hospital and the community, causing a spectrum of problems from minor skin and wound infections, to serious deep infections such as osteomyelitis and blood stream infection, which may be associated with significant morbidity and mortality. Staphylococcus aureus can survive on the skin, particularly the anterior nares, skin folds, hairline, perineum and umbilicus, without causing infection. This is known as colonization. Methicillin-Resistant Staphylococcus aureus (MRSA) are strains of S. aureus that are resistant to antibiotics such as cloxacillin and cephalosporins. Cloxacillin is considered to be identical to Methicillin (the drug used by the laboratory to detect resistance). MRSA are cross-resistant to all cephalosporins, imipenem, meropenem, aminoglycosides, erythromycin and quinolones, and they may also be resistant to many other antibiotics. Certain strains of community-acquired MRSA can cause much more serious infections (eg. Necrotizing pneumonia) than typical MSSA, in part due to a number of toxins of virulence factors, including Panton Valentine Leukocidin (PVL) toxin. In community settings the prevalence is unknown; however the following represent high-risk groups: injection drug users dialysis or chemotherapy patients/residents individuals living in Residential Care Facility persons living on the street or using shelters individuals in correctional facilities individuals taking frequent and/or prolonged courses of broad spectrum antibiotics chronically ill persons will a skin infection that was difficult to treat individuals discharged from healthcare facilities that were in hospital for a period longer than 48 hours individuals who have had a medical procedure in a medical clinic or who have been hospitalized anywhere outside of Canada B. Vancomycin-Resistant Enterococci (VRE) Enterococci are part of the normal flora of the gastrointestinal tract. They are organisms of low virulence but can cause infections such as urinary tract infection, bacteraemia and endocarditis, particularly in debilitated patients/residents. Acquired resistance to Vancomycin has emerged in enterococci. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 96 VIHA Infection Prevention and Control Manual, September 1, 2011 Most enterococcal infections arise from the patient‘s endogenous flora, but cross infection between hospital patients/residents does occur. Contact transmission, either directly from person to person or indirectly via contaminated inanimate objects such as commodes or bedpans, plays an important role in mode of transmission. C. Extended Spectrum Beta-Lactamase (ESBL) Organisms Extended Spectrum Beta-Lactamase is a bacterial enzyme with the ability to break down (inactivate) a wide variety of antibiotics, including penicillins and all first, second and thirdgeneration cephalosporins. When present, this enzyme results in the bacteria being resistant to antibiotic therapy. ESBL enzymes are most commonly found in two bacteria – Escherichia coli (otherwise known as E. coli) and Klebsiella pneumoniae, but can also be found in bacteria such as Salmonella, Proteus, Morganella, Enterobacter, Citrobacter, Serratia, and Pseudomonas. In many cases, ESBL bacteria can colonize the gut and other body sites without producing disease. Significant infections include urinary tract infections and surgical wound infections. Patients/residents whose gastrointestinal flora has been altered by previous antibiotic treatment are predisposed to acquiring these pathogens. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 97 VIHA Infection Prevention and Control Manual, September 1, 2011 6. ARO Room Placement Figure 7: ARO Room Placement Room Placement for a Patient Positive for an Antibiotic Resistant Organism Colonized Patient Infected Patient Single Room Available? Single Room Available? *YES NO NO Place in Single Room YES Place in Double Room. Prepare to manage personal space. *YES Place in Single Room Double Room Available? Double Room Available? YES Place in Double Room. Prepare to manage personal space. NO Place in multi-bed room. Prepare to manage personal space. NO Consult with Infection Prevention & Control Place in multi-bed room. Confine patient to bed space with curtains drawn. Consult with Infection Prevention & Control when available *If more than one patient with same ARO on ward, it may be preferable to cohort in a semi-private or multi-bed room as appropriate Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 98 VIHA Infection Prevention and Control Manual, September 1, 2011 Due to the limited number of single rooms available, where patients/residents must be placed in a double or multi-bedded room, priority for the single room assignment should be as follows (in priority order): 1. 2. 3. 4. 5. 6. Clostridium difficile infection Diarrhea cause not yet diagnosed MRSA infection Patient colonized with multiple AROs MRSA Colonization Infection from other source Special Considerations in Bed Placement for VRE In some instances, VRE infected or colonized patients/residents will need VRE management (i.e. patients/residents in a designated renal unit, an adult Intensive Care Units or pediatric or neonatal Intensive Care Unit). In these instances, please refer to VIHA‘s Policy 15.3 Management of Patients with VRE (Acute and Residential) for bed placement procedures. 7. Key Management Issues Table 14: Key Management Issues for MRSA and ESBL Presentation ARO status Reservoirs MRSA – Methicillin Resistant Staphylococcus aureus Infection or colonization of any body site; most often skin and wound infections ESBL – Extended Spectrum Beta Lactamase A variety of gram negative bacteria, most commonly Escherichia coli and Klebsiella species have acquired ESBL. Usually found in lower gastrointestinal tract, also in urine and moist wounds. A patient is colonized with MRSA when culture report is positive for Staph. Aureus resistant to cloxacillin with no clinical symptoms or infection. A patient is colonized with ESBL when a culture report is positive for Extended Spectrum Beta Lactamase with no clinical symptoms or infection Notice of previous colonization within a VIHA facility will be recorded in: The Health Record encounters and/or Powerchart The Admission Record which shows ―ALERT‖ for ARO status Notice of previous colonization within a VIHA facility will be recorded in: The Health Record encounters and/or Powerchart The Admission Record which shows ―ALERT‖ for ARO status Contaminated environmental surfaces (floors, bed linens, over bed tables and blood pressure cuffs) may also serve as a reservoir. Contaminated environmental surfaces such as floors, bed linens, over bed tables and blood pressure cuffs may also serve as a reservoir. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 99 VIHA Infection Prevention and Control Manual, September 1, 2011 Mode of Transmission MRSA – Methicillin Resistant Staphylococcus aureus Therefore, routine disinfection of the environmental surfaces is necessary to reduce the potential bacterial load. ESBL – Extended Spectrum Beta Lactamase Therefore, routine disinfection of the environmental surfaces is necessary to reduce the potential bacterial load. Direct and indirect contact (see Part 2: Transmission) Direct and indirect contact (see Part 2: Transmission) The primary mechanism for transmission of MRSA from one patient to another is via hands that have become transiently colonized either after direct contact with colonized or infected patients/residents while performing care, when removing gloves or when touching contaminated surfaces. ESBL producing bacteria are spread through feces and secretions (i.e. wound drainage, sputum and urine) by direct contact with an infected person. It can spread from patient to patient on the hands of healthcare workers or via contaminated devices. Colonized or infected patients/residents with large open, poorly healing wounds, urinary incontinence with infected urine or extensive desquamating skin conditions are more likely to disperse large numbers of organisms into the environment. Droplet transmission is possible with patients/residents who have a productive cough and are MRSA colonized within their nares/respiratory system. Period of Incubation Likelihood of Transmission Precautions for ARO Colonized & Infected Patients/ Residents Variable Variable The likelihood of transmission increases in patients/residents with: Draining wounds or open skin lesions Poor respiratory hygiene and coughing Fecal or urinary incontinence, diarrhea, ileostomy or colostomy, poor hygiene Invasive devices in place Requiring intensive contact care, i.e. post CVA, dementia, post major surgery, Intensive Care treatment Requiring mobility assistance, i.e. paraplegic, amputee Infection due to greater number of organisms present The likelihood of transmission increases in patients/residents with: Urinary catheter Diarrhea Poor hygiene Fecal or urinary incontinence, ileostomy or colostomy Requires intensive contact care, i.e. post CVA, dementia, post major surgery, Intensive Care treatment Infection due to greater number of organisms present Routine practices are to be applied at all times. All patients/residents admitted to acute care will be screened using the ARO Screening Questionnaire. All patients/residents identified ‗At Risk‘ will be swabbed for MRSA Routine practices are to be applied at all times. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Once colonization is confirmed: The infection prevention and control measures to prevent the spread of ESBL are the same, whether the patient is Page 100 VIHA Infection Prevention and Control Manual, September 1, 2011 MRSA – Methicillin Resistant Staphylococcus aureus Swab sites for MRSA will include Nares Groin (creases at junction of torso with the legs, on either side of pubic area) Open wound(s) All patients/residents admitted to an intensive care unit or designated inpatient renal unit will be swabbed at specific time frames – please refer to page 2 of VIHA‘s Policy 15.2 Management of Patients with MRSA (Acute Care) Screening/swabbing for MRSA is not required for residents being admitted to or transferred from acute care to Residential care. Residents – previously identified as MRSA positive – will be swabbed one month after admission/transfer The infection prevention and control measures to prevent the spread of MRSA are the same, whether the patient is colonized or infected with MRSA Notify the Infection Control Practitioner and ensure patient entered onto Precautions log for unit. In acute and residential care, post Contact Precautions sign Ensure ongoing communication of the patient‘s status with other relevant healthcare workers (e.g. diagnostics, housekeeping etc). Place the patient in an appropriate room (see patient placement). In acute and residential care, contact precautions must be put in place including donning a gown/apron and gloves for all contact with the patient and their physical environment. Ensure contact Precautions sign is posted Droplet precautions should be put in place if the patient has a cough with or without productive sputum Provide the patient with dedicated toilet/commode facilities. Encourage the patient with meticulous hand hygiene, particularly on leaving the room and after toilet etc. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. ESBL – Extended Spectrum Beta Lactamase colonized or infected with ESBL In acute care, post Contact Precautions sign. In continuing care, apply contact precautions for all close personal care Notify the Infection Control Practitioner. Ensure ongoing communication of the patient‘s status with other relevant healthcare workers (e.g. diagnostics, housekeeping etc). Place the patient in an appropriate room (see patient placement). Provide the patient with dedicated toilet/commode facilities. Encourage the patient with meticulous hand hygiene, particularly on leaving the room and after toileting etc. Page 101 VIHA Infection Prevention and Control Manual, September 1, 2011 MRSA – Methicillin Resistant Staphylococcus aureus Staff Must: Wear gloves and gown/apron for close personal contact (remember bare below the elbow when wearing an apron) ESBL – Extended Spectrum Beta Lactamase Staff must: Wear gloves for all casual contact Wear gloves and gown/apron for close personal contact (remember bare below the elbow when wearing an apron). Visitors must: Visitors must speak with the patient‘s primary nurse before visiting patient so that proper precautions techniques and procedures can be discussed. Visitors must: Provided visitors of patients/residents with ESBL are healthy, there is no restriction on visiting, and it carries no risk. Visitors are required to adhere to contact precautions and wear protective clothing when providing patient care. Scrupulous hand hygiene practices must be followed. If visitors are not providing care, they are not required to wear protective clothing, BUT scrupulous hand hygiene practices must still be followed whenever they leave the room. Patients/Residents must: Wear clean dressing gown/clothing when exiting the room Wear shoes or slippers; no bare feet Have a clean dry dressing covering any skin/soft tissue infections 17 Acute Care Patients : Mobilization and rehabilitation should be restricted to those prescribed activities that are essential to patient care Are encouraged not to visit any common areas on the unit or other patients‘ rooms Visitors are required to adhere to contact precautions and wear protective clothing when providing patient care. Scrupulous hand hygiene practices must be followed. If visitors are not providing care, they are not required to wear protective clothing, BUT scrupulous hand hygiene practices must still be followed whenever they leave the room. Patients/Residents must: Wear clean dressing gown/clothing when exiting the room Wear shoes or slippers; no bare feet Have a clean dry dressing covering any skin/soft tissue infections Acute Care Patients: Mobilization and rehabilitation should be restricted to those prescribed activities that are essential to patient care Are encouraged not to visit any common areas on the unit or other patients‘ rooms Residential care patients The resident can leave their room for all activities, but is to be excluded from food preparation activities 17 It must be remembered that a residential care facility is a resident‘s home and infection control precautions must be balance with promoting an optimal, healthy lifestyle for the residents, particularly in view of the fact that colonization or infection with AROs may persist indefinitely or may periodically re-emerge, despite treatment or attempts at decolonization. Epidemiological studies indicate that ―Routine Practices‖ and the appropriate Additional Precautions when providing close personal care in residential care facilities minimize the risk of potential ARO transmission. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 102 VIHA Infection Prevention and Control Manual, September 1, 2011 Decolonization MRSA – Methicillin Resistant Staphylococcus aureus All patients/residents found to be MRSA positive will be considered for topical decolonization treatment, in an attempt to eradicate MRSA and reduce the risk of subsequent infection. ESBL – Extended Spectrum Beta Lactamase There is no decolonization therapy for ESBL. For patients/residents infected with ESBL, treatment is limited. For Acute Care Facilities, please refer to VIHA‘s Policy 15.2 - Management of Patients with MRSA (Acute Care) For Residential Care Facilities, please refer to VIHA‘s Policy 15.4 - Management of Residents with MRSA (Residential Care) Treatment For infected patients/residents, treatment is determined by the Most Responsible Physician. Please refer to the Antimicrobial Prescribing Guide for Adult Patients: System Wide Initiative (SWI) booklet for more detail Treatment and repeat cultures should be ordered by the Most Responsible Physician in consultation with the Medical Microbiologist or Infection Prevention and Control Physician. Discontinuation of Additional Precautions For colonized patients/residents, wait 7 days post completion of any antibiotic treatment (topical, oral or injectable) or following decolonization. Separate swabs from nares, groin and any other sites previously found to be positive Two negative sets of swabs 7 days apart (the first swabs must be negative before doing the second set). Please refer to VIHA‘s Policy 15.2 Management of Patients with MRSA (Acute Care) and Policy 15.4 Management of Residents with MRSA (Residential Care) for further information If first swab is positive, consider decolonization if not already done so, wait 7 days before doing another swab Notify the Infection Control Practitioner if the swabs have been done and are negative Wait 30 days post completion of any antibiotic treatment (topical, oral or injectable). Separate swabs from rectum and any other sites previously found to be positive Urine specimen, specifying an ESBL screen Two negative sets of results 30 days apart (the first swabs/specimens must be negative before doing the second set) If first swab/ specimen is positive, wait 30 days before doing another swab Notify the Infection Control Practitioner if the swabs/ specimens have been done and are negative For infected patients/residents, wait 30 days post completion of any antibiotic treatment (topical, oral or injectible) prior to initial set of swabs being taken. Then follow the above steps Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 103 VIHA Infection Prevention and Control Manual, September 1, 2011 Discharge or Transfer Environmental Management MRSA – Methicillin Resistant Staphylococcus aureus The Most Responsible Physician to discharge the patient home as early as their physical condition permits The receiving facility or home care must be notified prior to transfer for patients/residents colonized or infected with MRSA. The Most Responsible Nurse must record status on the Home Care Transfer Form If cultures remain positive on discharge, decolonization may be continued following consultation with MRP ESBL – Extended Spectrum Beta Lactamase The Most Responsible Physician to discharge the patient home as early as their physical condition permits The receiving facility or home care must be notified prior to transfer for patients/residents colonized or infected with ESBL. The Most Responsible Nurse must record status on the Home Care Transfer Form Laundry Waste Cleaning Laundry Waste Cleaning Patient Care Equipment – once patient has been discharged or precautions have been discontinued, precaution signage will remain in place and all patient equipment will remain in the room. Equipment will only leave the room once housekeeping has disinfected it appropriately. Patient Care Equipment – once patient has been discharged or precautions have been discontinued, precaution signage will remain in place and all patient equipment will remain in the room. Equipment will only leave the room once housekeeping has disinfected it appropriately. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 104 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 6: OUTBREAK MANAGEMENT VIHA’s Infection Prevention and Control Program would like to thank Capital Health Region in Alberta, Canada for generously sharing their Outbreak Prevention, Control and Management in Acute Care Facilities document with us. The shared materials greatly assisted us in our development of this section of our manual. 1. Introduction Early recognition of unusual clusters of illness and swift actions in response to these episodes are essential for effective management of outbreaks. It is vital that all healthcare workers collaborate to facilitate prompt identification, reporting, specimen collection, and implementation of appropriate infection prevention and control measures to help minimize the impact of an outbreak. Early recognition of suspected outbreaks is important. Patients/residents and staff should be assessed on an ongoing basis for signs/symptoms of an infectious disease (see algorithm). An outbreak may be declared anytime that the number of individuals presenting with similar signs/symptoms exceeds the normal expected number of cases. Contact your Outbreak Lead any time you are suspicious that an outbreak may be occurring within your unit. The majority of outbreaks that occur are either respiratory or gastrointestinal. The following case definitions were developed to assist in the early identification of ―unusual clusters‖ of influenza-like (ILI) or gastrointestinal (GI) illness and/or outbreaks. The purpose of this section of the manual is to provide current best practice/evidence-based guidelines to assist staff with outbreak prevention, control, and management of outbreaks. The information is divided into four sections: Section A – General guidelines for management of any suspected outbreak activity. Subsequently, these basic recommendations may be enhanced or modified depending on identification of the causative agent. Section B – Specific recommendations for the prevention, control, and management of influenza outbreaks. Section C – Specific recommendations for the prevention, control, and management of outbreaks of gastrointestinal illness. Section D – Specific recommendations for the prevention, control and management of Clostridium difficile (CDI) and Scabies outbreaks. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 105 VIHA Infection Prevention and Control Manual, September 1, 2011 2. General Guidelines for Outbreak Management A. Reporting a Suspected Outbreak Prompt reporting permits early identification and interventions to interrupt transmission, reducing morbidity and mortality. Report any suspicion of an outbreak to the necessary authority as soon as possible. The table below identifies whom to contact for your area. Table 15: Contact List Infection Prevention and Control Contact VIHA Infection Prevention and Control VIHA Infection Prevention and Control Physician VIHA Amalgamated LTCF (Owned/Operated) VIHA Infection Prevention and Control VIHA Infection Prevention and Control Physician VIHA Affiliated LTCF, Private LTCF, and Community Public Health: CD Nurses (ILI); CD Environmental Health Officers (NLI) Public Health Medical Health Officers (MHO) Type of Facility VIHA Acute Care Medical Physician Contact After hours contact Medical Microbiologist on-call – covers all medical microbiology calls and any URGENT infection prevention and control issues that cannot wait until the IPC practitioner is available. (Paged through the RJH switchboard (250-370-8000). Weekends/Stat Holidays – IPCP On-Call from 0930-1730 hours, for all acute care hospitals, St. Joseph‘s Acute and Residential, and all VIHA-owned residential facilities. Contact via your manager-on-call who has the number for the IPCP on-call. Medical Health Officer on-call – Covers all questions from affiliated continuing care facilities. (MHO Numbers) 1. Initial Infection Prevention and Control Precautions Routine practices are to be used at all times with all patients/residents. In addition, based on the type of outbreak, appropriate Additional Precautions will need to be implemented as soon as possible. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 106 VIHA Infection Prevention and Control Manual, September 1, 2011 It is essential to NOT wait until the causative agent is identified before implementing Additional Precautions. Initiate appropriate additional precautions as soon as a patient presents with symptoms. The appropriate type of precautions (e.g. contact and/or droplet) must be determined by the presenting symptoms and the procedure being undertaken (e.g. mask with visor for any cough inducing procedure for suspected ILI). Precaution signs should be posted on the entrance to each affected room and elsewhere as directed by your Outbreak Lead. The Suspected Respiratory Infection or Gastroenteritis Outbreak algorithm provides guidance as to what initial infection prevention and control precautions are required in the event of any ILI/GI outbreak. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 107 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 8: Suspected Respiratory Infection or Gastroenteritis Outbreak Algorithm Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 108 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Confirming an Outbreak The Infection Control Practitioner, in consultation with the Infection Prevention and Control Physician and/or the Infection Prevention and Control Manager, will review the data and confirm that an outbreak is occurring. The IPCP will notify other areas of the organization that the unit/facility is on Outbreak Status (i.e. sending out a memo and/or in the case of Residential Facilities, posting on Healthspace). 3. Outbreak Management In the event of an outbreak in a VIHA facility, Infection Prevention and Control will work collaboratively with the outbreak team to investigate, identify, and plan the management of the outbreak. 4. Compiling a Post-Outbreak Investigation Summary Within VIHA facilities, the Infection Prevention and Control Team will lead the preparation of an outbreak summary once the outbreak is declared over. The Clinical Coordinator, Manager, Team Leader and the Occupational Health & Safety representative are expected to be key contributors to the summary. Once a summary is complete it is reviewed by the Infection Prevention and Control Team and key issues/concerns and/or successes are escalated to the Infection Prevention and Control Quality Committee for its review. B. Influenza-Like Illness (ILI) Outbreaks 1. Introduction Outbreaks of influenza generally occur in Canada between fall and early spring. Influenza viruses cause disease among all age groups. Rates of serious illness and death are highest among persons aged 65 years or older and in persons of any age who have medical conditions that place them at increased risk from complications of influenza. In most local outbreaks, complications and/or deaths related to influenza A occur in the elderly, immunocompromised and pediatric patients/residents. It is recommended that each facility have a process in place to ensure eligible inpatients receive influenza immunization each year. Annual influenza immunization is the primary tool for preventing influenza and its severe complications. According to the Canadian National Advisory Committee on Immunization (NACI) statement on influenza vaccination, all healthcare workers have a duty to promote, implement, and comply with influenza immunization recommendations to decrease the risk of infection and complications in vulnerable populations for which they provide care. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 109 VIHA Infection Prevention and Control Manual, September 1, 2011 NACI considers the provision of influenza immunization for healthcare workers to be an essential component of the standard of care. To prevent transmitting influenza to those at high risk of influenza related complications, all healthcare providers should receive annual influenza immunization, unless contraindicated. Outbreaks of influenza can be propagated when staff immunization rates are low even though immunization rates in patients/residents may be high. The optimal time for delivering organized immunization campaigns for both patients/residents and staff is in the autumn. Effectiveness of the influenza vaccine is dependent on the age and immunocompetence of the person receiving the vaccine and the similarity of the virus strains in the vaccine and those in circulation during the influenza season. Although elderly persons and those with chronic diseases may have a lower immune response to the vaccine than healthy young adults, the vaccine is still very effective in preventing lower respiratory tract infections such as pneumonia and other secondary complications, thereby reducing the risk for hospitalization and death. The influenza virus changes from year to year so the vaccine is adjusted to match with the viruses expected to be circulating during the current influenza season. Each spring the World Health Organization, CDC Atlanta, and the Public Health Canada Agency decide on the three components of the vaccine. For the current influenza vaccine information see the National Advisory Committee on Immunization (NACI) and for FAQs the BC Healthfiles 2. Confirming an ILI Outbreak The following two tables help to differentiate between signs and symptoms of influenza and other respiratory organisms. Table 16: Common Differences between Influenza and Common Cold Symptoms Symptoms/Description Influenza Common Cold Fever Usually high Sometimes Chills, aches, pain Frequent Slight Loss of appetite Sometimes Sometimes Cough Usual Sometimes Sore throat Sometimes Sometimes Sniffles or Sneezes Sometimes Common Involves whole body Often Never Symptoms appear quickly Always More gradual Extreme Tiredness Common Rare Complications Pneumonia - can be life threatening Sinus infection Ear infection Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 110 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 17: Respiratory Infections ORGANISM INFLUENZA TYPE A or B SYMPTOMS MODE OF TRANSMISSION INCUBATION PERIOD PERIOD OF COMMUNICABILITY Sudden onset of respiratory illness with fever and cough and with one or more of the following: sore throat, athralgia (painful joints), myalgia (muscle pain), runny nose, headache, prostration Person to person by droplets or direct contact with articles recently contaminated with respiratory secretions. 1 to 4 days Adults: Usually 24 hours prior to symptoms and up to 4 days after clinical onset Pediatric & Immunocompromised: Usually 24 hours prior to symptoms and up to 7 days after clinical onset Note: Fever may not be prominent in those >65 years or in paediatric populations or those who are immunocompromised In children under 5, gastrointestinal symptoms may also be present RESPIRATORY SYNCYTIAL VIRUS (RSV) Similar to common cold symptoms; usually mild but can be moderate to severe. Severe lower respiratory tract disease can occur in the elderly. RESTRICTIONS Precautions: Droplet Cases should remain on precautions until they are over the acute illness and have been afebrile for 48 hours (minimum of 5 days from onset of acute illness). Unit restrictions for an influenza outbreak remain in place for 6 days after onset of symptoms in the last case. Person to person usually by direct or close contact with contaminated secretions which may involve droplets or fomites. 2 to 8 days, average 4 to 6 days Period of viral shedding is usually from 3 to 8 days but may be longer in pediatric and those who are immunocompromised. Virus may live on environmental surfaces for many hours and for a halfhour or more on hands. Precautions: Adults: Droplet precautions Pediatrics: Droplet precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness. PARAINFLUENZA Type 1, 2, 3 Similar to common cold symptoms. Can also cause serious lower respiratory tract disease with repeat infection (e.g. pneumonia, bronchitis, and bronchiolitis) in the elderly Person to person through direct contact with infected persons or exposure to respiratory secretions on contaminated surfaces or objects. 2 to 6 days Varies with different types. Adults: Droplet precautions Pediatrics: Droplet and contact precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 111 VIHA Infection Prevention and Control Manual, September 1, 2011 ORGANISM ADENOVIRUS SYMPTOMS Similar to common cold symptoms; usually mild but can be moderate to severe. MODE OF TRANSMISSION INCUBATION PERIOD Person to person through direct contact with infected persons or exposure to respiratory secretions on contaminated surfaces or objects. 2 to 14 days PERIOD OF COMMUNICABILITY While symptomatic. RESTRICTIONS Adults: Droplet precautions Pediatrics: Droplet precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness. HUMAN METAPNEUMOVIRUS Similar to common cold symptoms; usually mild but can be moderate to severe. Note: unlike influenza, patients/residents usually maintain a normal appetite. Person to person through direct contact with infected persons or exposure to respiratory secretions on contaminated surfaces or objects. 2 to 8 days While symptomatic Adults: Droplet precautions Pediatrics: Droplet and Contact Precautions while symptomatic In pediatric settings, unit restrictions may be recommended by Infection Prevention and Control. Cases should remain on precautions until they are over the acute illness, for a minimum of 5 days. Reference: John Hopkins University, Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 112 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 18: Case Definition for ILI and an ILI Outbreak Influenza-like Illness (ILI) Case Definition Influenza like illness (ILI) New or worsening cough and Fever more of the following: sore throat athralgia (painful joints) myalgia (muscle pain) runny nose headache prostration 18 and one or *Temp >38 or fever that is abnormal for that individual. Temp <35.6 or >37.4 may be indicative of health conditions or medical therapy such as use of anti-inflammatory medications, or corticosteroids etc. Temp > 38 may not always be present in infected elderly persons. Subjective report of fever may be sufficient in some cases. ILI Outbreak Suspected Within a LTCF, or a geographic area of an acute care setting (e.g. floor, unit), the occurrence of 2 or more symptomatic cases among patients, residents, clients or staff within 1 week. Note: ILI outbreak definition primarily applies to LTCF settings as outbreaks in Acute Care settings may only be identified in long stay units (e.g. psychiatry, rehab, or transitional care units). Symptomatic staff cases must have worked within the facility or area during the 3 days prior to onset of symptoms (i.e. during their incubation period). 3. ILI Outbreak Management All ILI illness is to be treated as if it is Influenza A or B until proven otherwise. Once influenza is ruled out it is quite possible that Infection Prevention and Control will require all the following restrictions to remain in place save for those that are described for unvaccinated staff. Always consult with Infection Prevention and Control to determine what precautions or restrictions are required. Practices and Precautions Routine practices are used for the care of all patients/residents at ALL times. Influenza can be spread by contact and droplet routes, consequently, droplet precautions are required. Droplet precautions include: Thorough hand washing before and after any patient contact Wearing of a gown and gloves Surgical grade mask with attached visor or face shield Appropriate hand washing while removing protective attire. This is important as contamination from used attire may occur during removal 18 Note: BCCDC/BC Facility Influenza Immunization Policy: October 18, 2010 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 113 VIHA Infection Prevention and Control Manual, September 1, 2011 Room/Unit Closures The Infection Prevention and Control Team in collaboration with the Clinical Coordinator/Manager of Patient Care and members of the Outbreak Management Team will determine room and unit closures. Patient Line Listings Infection Prevention and Control requires a daily completion of line listings. It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the line listings are filled out completely at the beginning of each day, and submitted to the Infection Control Practitioner by 1000 hrs, by either fax or email as agreed. Information required includes: Identification of the unit Date of completion Contact person and details Patient information Name Date of birth Room number Symptoms, and onset date Specimens sent Influenza immunization information Line listing paperwork should be kept up to date and be available within the affected area, and faxed/emailed daily to identify any new cases, and current symptom status of all patients/residents affected. The reporting period is 0700 hrs the previous day to 0700 hrs of day of faxing/emailing. If there are no new cases within a 24 hour period, this should be stated on the line listing. Discontinue daily faxing/emailing of line listings only when instructed by the Infection Control Practitioner. Staff Line Listings Occupational Health & Safety requires daily completion of staff line listings. It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure the following information is completed each day, and forwarded to Occupational Health & Safety: Identification of the unit Date of completion Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 114 VIHA Infection Prevention and Control Manual, September 1, 2011 Contact person and details Staff details Full name Telephone number Date last worked Symptoms and onset date Number of shifts missed Specimen information Influenza immunization information. Discontinue daily faxing/emailing of line listings only when instructed by Occupational Health & Safety. Lost Bed Days It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the bed days lost is recorded at the beginning of each period (0700-0700). Restrictions on Patient Activities Patients/residents symptomatic with a respiratory illness should be restricted to their room, on droplet precautions for a minimum of five (5) days after the start of the illness, or until the symptoms are no longer present, whichever time period is longer. All group activities will be cancelled during the course of the outbreak. Patients/residents may be transferred to other healthcare facilities for a higher level of care (e.g. Emergency), should their condition require and with communication with that unit/facility. The transport company and receiving facility must be notified of the precautions required. The patient must wear a mask for transport. The Infection Prevention and Control Team should also be informed of the transfer. Any offsite appointments are discouraged, unless absolutely necessary. Where necessary, the receiving department or facility is to be notified beforehand. The patient must wear a mask, and the transport company and receiving facility must be notified of precautions required. Working Restrictions for Asymptomatic Healthcare Workers Working Restrictions for Asymptomatic Staff, immediately following the identification of the outbreak: Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 115 VIHA Infection Prevention and Control Manual, September 1, 2011 Working on the Outbreak Unit (VIHA policy No. 5.8.6PR, Influenza Prevention Program Procedure) Unvaccinated staff are subject to exclusion from work within the outbreak facility or reassignment until the outbreak is declared over. An exception to exclusion of unvaccinated staff may be made if the unvaccinated staff take antiviral medication as prescribed and the antiviral medication is continued until the outbreak is declared over. These workers must be alert to the signs and symptoms of influenza, particularly in the first two (2) days after starting antiviral prophylaxis, and should be excluded from the patient care environment should they develop symptoms19. During an outbreak of laboratory confirmed influenza20, unvaccinated healthcare workers or those vaccinated within two (2) weeks of the onset of outbreak21 must obtain antiviral medication, if they are to work on the outbreak unit. Working on a Non-Outbreak Unit Asymptomatic healthcare workers, who are not vaccinated for influenza and have worked on an outbreak unit within three (3) days of the outbreak declaration, will be unable to work on another unit/facility for three (3) days after the last shift they worked on that unit. This is to ensure that they remain free from infection following their last exposure. Once the three days has lapsed, and if they remain without symptoms, they may work on a non-outbreak unit or facility. This includes casual staff who work in several areas. Working Restrictions for Symptomatic Healthcare Workers All symptomatic staff (including students and physicians) must remain off work for a minimum of five (5) days after onset of illness or until asymptomatic, whichever is the longer time period. Students Students on healthcare worker programs22 will be permitted to attend outbreak units, if they have previously received instruction on Infection Prevention and Control principles. The students and Educational Facility Instructor must abide by the same requirements for vaccine and/or antiviral medication, and the same work restrictions as those of all other healthcare workers. The Educational Facility Instructor is responsible to provide completed student 19 Unvaccinated staff can use the form letter ―Family Physicians ordering Health Care Worker Anti-viral Medication‖ to obtain prophylactic medication. Note: the cost of antiviral medication is not covered by the employer. 20 If the presentation meets the outbreak definition for ILI then one should assume it is influenza, until proven otherwise by the MHO or IPCT 21 Those considered not protected at the time the outbreak commences. Vaccinated staff should discuss with Occupational Health & Safety about when they can discontinue taking prophylactic medication. 22 This includes all professions of caregivers, including medical students Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 116 VIHA Infection Prevention and Control Manual, September 1, 2011 vaccination lists to Occupational Health & Safety and to ensure student compliance with healthcare worker restrictions. Visitors/ Volunteers Visitation to an outbreak unit should be restricted to 2 visitors per patient at any one time during scheduled visitation hours. Patients/residents should be reviewed and visitors/volunteers determined on an individual basis, considering the needs and medical condition of the patient. Staff must be consistent with their approach to facility visitation throughout the outbreak. Visitors/volunteers choosing to enter the facility must be free of symptoms of illness, and encouraged to be vaccinated. However, it must be noted that maximum protection takes at least 2 weeks from vaccination. Visitor/volunteers must be educated in the correct procedure for hand hygiene and on the correct use of PPE if required. Visitors/volunteers will not visit other patients/residents/patient rooms, must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom. It is important to consider the needs of the patients/residents and possible staffing shortages, and weigh these against the concern about community spread of the disease. Meals Symptomatic patients/residents should dine in their room with tray service and be restricted from the dining room and communal activities involving food preparation. The trays are managed according to direction for individuals on droplet precautions. Pets No pets are allowed on affected units. Housekeeping For ILI, routine cleaning is required. Attention to detail must be given, especially with horizontal surfaces and bedside curtains (which must be changed on discharge of the patient or discontinuation of precautions). Other housekeeping requirements may also be requested. See also the Housekeeping Cleaning Terminology table. Linen No special handling/cleaning of linen is required. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 117 VIHA Infection Prevention and Control Manual, September 1, 2011 Collection and Transportation of Nasopharyngeal Swabs Specimen results directly impact outbreak management strategies for outbreaks of ILI. Take samples from residents who are newly symptomatic (within 72 hours) or as directed. Before performing any nasopharyngeal swab, ensure there are no contraindications (e.g. facial surgery or trauma). Collect a nasopharyngeal swab from newly symptomatic patients/residents, preferably within 24–72 hours of onset of symptoms (see directions below). Specimens must be transported directly to the laboratory as soon as possible. Using established methods for transporting STAT laboratory specimens (i.e. with a cold pack). Return samples to the laboratory, either by courier during regular business hours or by taxi after hours and on weekends. The laboratory covers cost of transportation of specimens back to a VIHA laboratory. They will provide instruction on the process at the time. Purpose: This procedure describes how to collect a nasopharyngeal swab for influenza testing. Collect specimens from patient presenting with Influenza like illness within 72 hours of onset of symptoms Routine diagnostic swabs in transport media are NOT acceptable Calcium alginate swabs used for Bordetella pertussis are NOT acceptable. Residues present in the swabs may inhibit PCR assays Nasopharyngeal swabs are available from the Microbiology Laboratory at RJH, NRGH, CRH, and from the Laboratory at CDH, VGH, SPH, LMH, WCGH, and SJGH Supplies Obtain an ‗Influenza Outbreak kit‘ from the Laboratory Flocked viral swab with Viral transport media (COPAN Red Top) VIHA inpatient Microbiology requisition If not available, use Herpes viral swab with viral transport media (Blue Top) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 118 VIHA Infection Prevention and Control Manual, September 1, 2011 Procedure 1 Explain procedure to the patient. 2 Protect yourself (fluid resistant mask with visor, gloves and disposable gown). 3 If the patient has a lot of mucous, ask them to use a tissue to gently blow their nose prior to specimen collection. · Influenza is found in the cells that line the nasopharynx, not in the mucous 4 With head supported, push the tip of the nose upwards. Insert the swab backwards and downwards to a depth of 2-4 cm into one nostril. Rotate the swab gently for 5-10seconds. 5 Place the swab into the virus transport media, snap off the top of swab, tighten cap securely. 6 Label container with sample type and a minimum of two patient identifiers: First/Last Name, DOB, PHN, or use patient label with bar graph demographics label. 7 Instruct the patient to use a tissue to contain cough and mucous. · Provide hand hygiene for the patient after the procedure References: 1. BCCDC H1N1 Specimen Collection Guidelines. 2. Vancouver Coastal Health, Influenza-like Illness Outbreak – Specimen Collection. Staff will obtain an ‗Influenza outbreak kit‘ from the laboratory which will include appropriate swabs and requisition forms. Please ensure that you include the facility and relevant outbreak unit on the requisition. This will ensure the test is done promptly and correctly reported. Continue collecting specimens from newly symptomatic patients/residents until the laboratory confirms the organism or you are instructed to stop by the Infection Prevention and Control Team, Public Health, Medical Health Officer, Microbiologist or Infectious Disease/Control Physician. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 119 VIHA Infection Prevention and Control Manual, September 1, 2011 Prophylaxis for Laboratory Confirmed Influenza Prophylaxis is the prevention of a disease (in this case influenza) through the use of medication. As the type of anti-viral medication used varies based on the strain of influenza and patterns of organism resistance, it is important that the prophylaxis used is the one recommended by the Medical Health Officer during the current influenza season. Check the protocol to ensure that it contains this year‘s date. Also, as patients/residents‘ kidney function may change, it is important that both the Physician‘s prepared order form and the patient‘s creatinine levels are updated annually. C. Gastrointestinal Illness (GI) Outbreaks 1. Introduction Infectious gastrointestinal (GI) illness or gastroenteritis (―gastro‖) can be associated with a high incidence of morbidity and mortality. Many of these infections are attributable to Norovirus (previously known as Norwalk-like virus). Norovirus is extremely communicable and outbreaks are common. Outbreaks can present in sporadic episodes, or as intensely concentrated events occurring all at once. Attack rates can be quite high (> 50%) in both staff and patients/residents. Symptoms of Gastroenteritis include any combination of nausea, vomiting, diarrhea, and/or abdominal pain, which may be accompanied by myalgia, headache, low-grade fever, and malaise. Although most gastroenteritis cases are mild and self-limiting, serious dehydration and/or aspiration pneumonia secondary to emesis can occur in debilitated individuals. Transmission usually occurs via the fecal/oral or vomitus/oral route, but can also include fomite (objects or environmental surfaces) or droplet spread. 2. Confirming a GI Outbreak Outbreaks of diarrhea in hospitals, nursing homes and NICUs have been associated with a wide variety of organisms including salmonella, shigella, Clostridium difficile, vibrio (cholera), Staphylococcus aureus, cryptosporidium, rotavirus and other enteroviruses. Some of the most common bacterial and viral agents causing infectious diarrhea, their incubation period and most prominent clinical characteristics are listed in the Table below — Common Bacterial and Viral Causes of Gastroenteritis. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 120 VIHA Infection Prevention and Control Manual, September 1, 2011 Table 19: Common Bacterial and Viral Causes of Gastroenteritis Organism name Description Salmonella (salmonellosis) Produces fever, nausea and vomiting followed by diarrhea that frequently contains mucus (whitish and stringy), but rarely blood, in stools. The incubation period is less than 72 hours (3 days) when large doses of organisms are eaten in contaminated food or drinks. Outbreaks among children, however, are commonly the results of contact transmission, and about 50% of exposed infants will develop illness once a case is introduced in a nursery. Adults, on the other hand, usually get salmonellosis from contaminated food, drinks or inadequately cleaned and disinfected medical instruments such as endoscopes. Once several patients/residents or staff are infected, transmission by contact to new susceptibles may be very rapid. Salmonellosis is a common cause of infectious diarrhea, accounting for more than 50% of all diarrhea outbreaks in nursing homes in which the causative agent was identified (Levine et al 1991). Control of outbreaks may be difficult; some nurseries or units have had to restrict new admissions. Safe food handling is essential for prevention, especially raw (uncooked) eggs or egg products (e.g.homemade mayonnaise or tartar sauce). Antibiotic treatment prolongs the time the infected person may carry the organism in her/his GI system, but antibiotic treatment may be necessary for septic or severely ill patients/residents. Shigella (shigellosis) Produces rapid onset of diarrhea, with stools containing mucus and often blood. Infected persons are often more sick than is typical for other infecting agents. The incubation period is 1–6 days, and the usual source is fecal/oral transmission from acutely infected patients/residents. Outbreaks are less common than with salmonella or viral agents, and patients/residents shed the organisms only for a short period after becoming symptomatic. Clostridium difficile (formerly called antibiotic-resistant diarrhea or pseudomembranous colitis) Has increasingly become an important cause of diarrhea. It may be the cause of nearly half of all cases of nosocomial diarrhea in adult hospitalized patients/residents. The diarrhea ranges from mild and self-limiting to severe pseudomembranous colitis, which can be fatal. Because C. difficile is present in the stools of infants and preschool children, colonization without clinical disease apparently occurs. Its presence in the GI tract gradually decreases with age. In addition, C. difficile may become endemic in the nursery and other high-risk units. No nosocomial outbreaks have been associated with food borne transmission, suggesting that contact transmission from contaminated articles or the hands of staff is responsible. For example, one report noted that when culture-negative patients/residents were placed in a hospital room currently or previously occupied by a person with C.difficile diarrhea, they were more likely to develop this type of diarrhea than patients/residents placed in rooms where no patient had had C. difficile diarrhea. This suggests the organism can persist on inanimate articles (e.g. lamps, door handles or bed rails) for some time unless rooms are thoroughly cleaned between patients/residents. Strains that cause acute diarrhea have not been reported to be nosocomially transmitted. Toxic strains have been transmitted in restaurants from contaminated meat that was not cooked sufficiently to kill the organisms and could be a problem in healthcare facilities that prepare their own meals from raw meat. Escherichia coli Vibrio cholerae Subgroups produce acute, severe diarrheal disease characterized by local outbreaks, widespread epidemics and occasional individual outbreaks. Cholera is usually associated with contaminated water sources. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 121 VIHA Infection Prevention and Control Manual, September 1, 2011 Organism name Rotavirus Description Cause sudden onset of vomiting and diarrhea within 48–72 hours (2–3 days) after exposure. Fever and upper respiratory symptoms are present in about half the cases. In addition the virus may be present in the sputum or secretions for several days. This may account for the extremely rapid transmission and seasonal peak in infections during winter. Symptoms subside in a few days, but the stool may contain virus for up to 2 weeks. Rotaviruses are the most common cause of diarrhea in children under five. Because it is highly infectious, during nursery outbreaks nearly all infants will become infected. Like C. difficile, the virus survives well on inanimate surfaces and may become endemic in hospitals. Reference: John Hopkins University, Infection Prevention Guidelines for Healthcare Facilities with Limited Resources Table 20: Gastrointestinal Illness Case Definition Gastrointestinal Illness (GI) Case Definition Norovirus Like Illness: A resident or healthcare worker experiencing sudden unexplained vomiting or diarrhea in the absence of a functional cause. Diarrhea is considered two or more stools greater than the number normally experienced in a day, and in the absence of laxatives 23 or other bowel stimulating products . Diarrhea should be liquid enough to take the shape of the container. GI Outbreak Suspected if: An outbreak should be suspected if the following 25 occurs on a designated geographical unit : The onset among patients/residents and/or staff of 3 or more symptomatic cases of gastroenteritis within a 4 day period. 26 Cases must be confirmed with the Infection Prevention and Control Team. Once they are confirmed and the number of cases within the correct time period validated, an outbreak will be declared and restrictions imposed. Note: To be defined as a case, the person must have been present in the facility during the period of time it takes to incubate the disease. If a staff member has not been in the facility within the past 3 days, even if they have gastro symptoms, they do not qualify as a Norovirus case for the purposes of 24 facility tracking . They may have Norovirus, but it would be considered a ―community‖, not ―workplace‖, associated case. 3. GI Outbreak Management All GI illness is to be treated as if it is Norovirus until proven otherwise. Once Norovirus is ruled out it is quite possible that Infection Prevention and Control may modify some of the 23 Although antibiotics can cause diarrhea also, gastroenteritis should be suspected, especially once antibiotic associated diarrhea is excluded. 24 This person may be the index case or initiator of an outbreak and their information should be communicated to the Infection Prevention and Control/ Public Health Lead and Employee Occupational Health & Safety or staffing person. 25 Outbreak Unit designation varies based on the design and layout of the physical structure. The boundaries of the Outbreak Unit will be established by the Outbreak Lead/Medical Lead in collaboration with the Responsible Physician and the facility administrator. 26 Cases must meet the case definition and then the number of cases must be adequate to meet the outbreak definition. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 122 VIHA Infection Prevention and Control Manual, September 1, 2011 restrictions/precautions in place. Always consult with the Infection Prevention and Control Team to determine what actions are required. Practices and Precautions Routine practices are used for the care of all patients/residents at all times. Norovirus can be spread by contact and droplet routes, consequently Droplet Precautions are required for vomiting and handling body fluids only. Droplet precautions include: Thorough hand washing before and after any patient contact Wearing of a gown and gloves Surgical grade mask with attached visor or face shield Appropriate hand washing while removing protective attire. This is important as contamination from used attire may occur during removal Where there is explosive diarrhea and vomit, the wearing of a fluid repellent gown is required Room/Unit Closures The Infection Prevention and Control Team in collaboration with the Clinical Coordinator/Manager of Patient Care and members of the Outbreak Management Team will determine room and unit closures. Patient Line Listings Infection Prevention and Control requires a daily completion of line listings It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the line listings are filled out completely at the beginning of each day, and submitted to the Infection Control Practitioner by 1000hrs, by either fax or email as agreed. Information required includes: Identification of the unit Date of completion Contact person and details Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 123 VIHA Infection Prevention and Control Manual, September 1, 2011 Patient information Name Date of birth Room number Symptoms, and onset date Specimens sent Line listing paperwork should be kept up to date and be available within the affected area, and faxed/emailed daily to identify any new cases, and current symptom status of all patients/residents affected. The reporting period is 0700 hrs the previous day to 0700 hrs of day of faxing/ emailing. If there are no new cases within a 24 hour period, this should be stated on the line listing. Discontinue daily faxing/emailing of line listings only when instructed by the Infection Control Practitioner. Staff Line Listings Occupational Health & Safety requires daily completion of staff line listings. It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure the following information is completed each day, and forwarded to Occupational Health & Safety: Identification of the unit Date of completion Contact person and details Staff details Full name Telephone number Date last worked Symptoms and onset date Number of shifts missed Specimen information Discontinue daily faxing/emailing of line listings only when instructed by Occupational Health & Safety. Lost Bed Days It is the responsibility of the Clinical Coordinator/Manager of Patient Care (or designate) to ensure that the bed days lost is recorded at the beginning of each period (0700-0700). Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 124 VIHA Infection Prevention and Control Manual, September 1, 2011 Restrictions on Patient Activities Patients/residents symptomatic for a GI illness should remain in their room on droplet precautions for a minimum of 2 days (48 hours) after symptoms have ended, unless going off the unit for tests which are in the interests of the patient‘s well being (however, if the test or treatment can be provided in the room this should be the first consideration). These patients/residents should dine in their room with tray service and not attend communal activities/dining room. If the person shares a room with someone who is not yet symptomatic, a commode or alternate unshared toilet facility should be provided to prevent further crosscontamination. Patients/residents should be reminded about, and assisted with hand washing if necessary. Note: Norovirus can appear to ―relapse‖ frequently, i.e. experience onset of gastroenteritis symptoms after being asymptomatic for 24 – 48 hours. This relapse is likely due to malabsorption following infection, rather than a recurrence or reinfection of Norovirus. These patients/residents should be isolated again until they are symptom free for 48 hours, as cross infection may still occur. The recurrence of symptoms should be noted on the line listing. All group activities will be cancelled during the course of the outbreak. Patients/residents may be transferred to other healthcare facilities for a higher level of care (e.g. Emergency), should their condition require and with communication with that unit/facility. The transport company and receiving facility must be notified of the precautions required. The Infection Prevention and Control Team should also be informed of the transfer. Offsite appointments are discouraged, unless absolutely necessary. Where necessary, the receiving department or facility is to be notified beforehand. The transport company and receiving facility must be notified of precautions required. Working Restrictions for Staff Working Restrictions for Staff, please review the GI/Norovirus Algorithm for Staff on the Infection Prevention and Control internal web site. This algorithm covers information on: Working on the Outbreak Unit Working on a Non-Outbreak Unit Symptomatic Healthcare Workers Students Students of healthcare worker programs27 will be permitted to attend outbreak units, if they have previously received instruction on Infection Prevention and Control practices. The students and Educational Facility Instructor must abide by the same work restrictions as those of all other healthcare workers set out in the GI/Norovirus Algorithm for Staff. The 27 This includes all professions of caregivers, including medical students Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 125 VIHA Infection Prevention and Control Manual, September 1, 2011 Educational Facility Instructor is responsible for ensuring student compliance with healthcare worker restrictions. Visitors/ Volunteers Visitation to an outbreak unit should be restricted to 2 visitors per patient at any one time, during scheduled visitation hours. Patients/residents should be reviewed and visitors/volunteers determined on an individual basis, considering the needs and medical condition of the patient. Staff must be consistent with their approach to facility visitation throughout the outbreak. Visitors/volunteers choosing to enter the facility must be symptom free of any communicable illness (respiratory illness, diarrhea/vomiting, rash, etc). Visitor/volunteers must be educated in the correct procedure for hand hygiene and on the correct use of PPE if required. Visitors/volunteers will not visit other patients/residents/patient rooms, must not visit public areas within the facility (unit kitchen, cafeteria, shops/kiosks in main entrance etc.) and SHALL NOT use the patient/resident bathroom. It is important to consider the needs of the patients/residents and possible staffing shortages, and weigh these against the concern about community spread of the disease. Meals Symptomatic patients/residents should dine in their room with tray service and be restricted from the dining room and communal activities involving food preparation. The trays are managed according to direction for individuals on droplet precautions. Pets No pets are allowed on affected units. Housekeeping During a GI outbreak, units must be cleaned using the twice daily clean, and two step discharge clean. Attention during cleaning must be given to frequent-touch areas, specifically horizontal surfaces and bathrooms. See Housekeeping Cleaning Terminology. A thorough clean of the unit following a GI outbreak should not begin until 4 days (96 hours) following the cessation of symptoms. Linen No special handling/cleaning of linen is required. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 126 VIHA Infection Prevention and Control Manual, September 1, 2011 Collection and Transportation of Stool Specimens Management strategies for outbreaks of gastrointestinal illness are not dependent on laboratory confirmation. However, it is valuable to collect stool specimens from cases during outbreaks to try to identify the etiology, if possible. As directed by Outbreak Lead/Medical Lead, collect stool specimens from patients/residents that are acutely ill with GI symptoms, preferably within 24-48 hours of onset of symptoms. Collect one stool specimen from up to 6 symptomatic patients/residents. This number of specimens is usually sufficient to determine the etiology of the outbreak. Specimens must be transported to the laboratory as soon as possible using established methods for transporting STAT laboratory specimens. Obtaining An Outbreak Number A unique outbreak identifier number is assigned to each specific GI outbreak. Contact the Infection Prevention and Control Team to get your number. How To Collect A Stool Specimen Gather supplies including a dry specimen container and a clean tongue depressor or plastic spoon Pre-label specimen container accurately including patient information and date of collection Ensure Outbreak Number is on the requisition Perform hand hygiene and don appropriate PPE Scoop the specimen into the container with a disposable tongue depressor or plastic spoon Fill the container with stool up to one third or approximately one-tablespoon full Keep the outside of the container clean, screw the lid tightly onto the plastic container If possible, have a second person waiting outside the room holding open a biohazard bag to drop the specimen container into. Have the second person seal the bag Remove PPE appropriately and perform hand hygiene Send the specimen and the requisition to the laboratory in a biohazard bag marked ―STAT‖ Note: only stool specimens will be tested. Emesis is no longer acceptable as a suitable specimen for confirmation of GI. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 127 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 9: Requisition Form for GI Testing Under examination required, check Other, and write ―Norovirus PCR‖ One BCCDC virus isolation requisition must be completed for each specimen. Also include: Facility From Outbreak Unit_________(state Unit) Patient identifiers Facility contact person This will ensure the test is done promptly and correctly reported. Continue collecting specimens from newly symptomatic patients/residents until the laboratory confirms the organism or you are instructed to stop by the Infection Prevention and Control Team/Public Health, Medical Health Officer, Microbiologist or Infectious Disease/Control Physician. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 128 VIHA Infection Prevention and Control Manual, September 1, 2011 D. Outbreaks Caused by Other Organisms 1. Clostridium Difficile Outbreak Clostridium difficile illness (CDI) should be considered when a patient experiences sudden unexplained diarrhea in the absence of a functional cause. The case definition for CDI is: Acute onset of diarrhea (3 or more loose stools within a 24 hr period) without another etiology (diarrhea should be liquid enough to take the shape of the container). And one or more of the following Laboratory confirmation (positive toxin), or Diagnosis of typical pseudo-membranes on sigmoidoscopy or colonoscopy or histological/pathological diagnosis of CDI, or Diagnosis of toxic megacolon. It is assumed that any stool sent to the laboratory for CDI testing is from a patient that has had at least 3 episodes of loose stools in a 24 hour period. It is accepted that the surveillance protocol may overestimate the number of cases as some patients/residents may have had only one or two loose stools prior to a specimen being collected. Confirming a CDI Outbreak The outbreak definition for CDI is: 3 or more cases who meet the above case definition within a defined geographical area and are found to be hospital acquired on the same unit (i.e. does not include community acquired cases or those readmitted or transferred from a different unit). The Infection Prevention and Control Team will review and validate that an outbreak exists. Laboratory samples Stool that is liquid enough to assume the shape of the container is the acceptable specimen and must be specifically requisitioned for CDI testing. If the results of the test are ―Antigen Positive‖ and ―Toxin Negative‖ and symptoms persist, another specimen should be sent for CDI testing. Send repeat samples only on patients/residents that meet the definition of relapse or reinfection (based on a symptom-free interval). Relapse or reinfection is defined as a reoccurrence of symptoms within 30 days of a previous diagnosed cases of CDI. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 129 VIHA Infection Prevention and Control Manual, September 1, 2011 Testing for cure is not required. 2. Work Restrictions There are no staff work restrictions associated with a CDI outbreak. Practices and Precautions Contact precautions in private room or cohorting with other confirmed cases Emphasize the importance of hand washing for patients/residents, staff and visitors. ABHRs are less effective for killing C. difficile spores; hand washing must be encouraged using a neutral soap and water Twice daily cleaning and 2 step discharge cleans are required in any rooms with affected patients/residents. Attention is required especially to frequent touch areas and bathrooms/toilet facilities 3. Scabies Definitions Clinical features of infestation skin penetration visible as papules or vesicles burrows formed by mites under the skin are visible as linear tracts lesions are seen most frequently in inter-digital spaces, anterior surfaces of wrists and ankles, axillae, folds of skin, breasts, genitalia, belt-line and abdomen. Infants may have lesions of the head, neck, palms and soles of the feet itching does not always occur with a primary infestation, but when it does it is most intense at night itching may continue for approximately 6 weeks after treatment. This does not mean treatment was not successful Suspected case Patient has the above clinical features of scabies infestation Clinically diagnosed case Patient has the above clinical features of scabies but skin scraping does not positively confirm the presence of scabies Confirmed case Patient with skin scraping showing mites, eggs or fecal pellets, or a written opinion by a dermatologist based on signs and symptoms Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 130 VIHA Infection Prevention and Control Manual, September 1, 2011 Close contact Unprotected, prolonged, direct contact with skin, clothing or linens of a person with untreated scabies Crusted (Norwegian) scabies Is usually seen in immunocompromised people, this form of scabies is characterized by widespread, extensive crusting and scaling of the skin. Rash may be present and on any area of the body and thousands of mites may be present This form of scabies is highly contagious An outbreak is considered when: Two or more patients/residents diagnosed with scabies on one unit within a 2-week period or One patient plus one or more staff members on one unit are diagnosed with scabies within a 2-week period Specific Interventions Validation The Infection Prevention and Control Team will validate an outbreak and its extent. This may involve consultation with a dermatologist to attempt to confirm the diagnosis by obtaining skin scrapings Assessment of all current patients/residents, staff, volunteers and students on the unit for symptoms must be carried out prior to administration of treatment or prophylaxis of cases or contacts. All patients/residents cared for on the unit and staff assigned on the unit in the previous 6 weeks will be tracked and contacted Administration will be informed of a suspected outbreak by the Infection Prevention and Control team Laboratory Samples Skin scrapings are obtained by a person trained in collection of the specimen using a kit requested from the Microbiology Laboratory Control Measures Upon validation of an outbreak, the unit will be closed to admissions and transfers. Discharged patients/residents should be assessed for symptoms and advised of the need for treatment or prophylaxis Only patients/residents who have symptoms or have positive skin scrapings need to be placed on contact precautions until 24 hours after initiation of treatment. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 131 VIHA Infection Prevention and Control Manual, September 1, 2011 Patients/residents with Crusted Scabies remain on precautions until symptoms have abated Treatment of symptomatic cases and prophylaxis of all contacts (including asymptomatic patients/residents, healthcare workers, volunteers and visitors) must take place within the same 24-hour period Symptomatic Patients/Residents – Treatment Staff, using contact precautions and working in teams, will bathe and dry patients/residents, clip the patients/residents‘ fingernails, and clean under their nails. Examine the scalp for crusted lesions in confirmed cases. Apply medication as ordered and according to the drug information insert. Simultaneously the patient bed must be stripped, cleaned and remade and clothing is bagged In accordance with contact precautions, staff must wear long sleeved gowns and gloves, which are changed between patients/residents Follow-up baths to remove medication are done at either 8 or 12 hours after treatment, dependent on the treatment used. Bed is again stripped and remade Asymptomatic Patients/Residents – Prophylaxis Prophylaxis of asymptomatic patients/residents is limited to the involved unit. These patients/residents receive one application of medication and follow-up bath. Linens and clothing are changed per routine Symptomatic Staff – Treatment Every employee case must be reported to Occupational Health & Safety, who can facilitate dermatology consultation and staff case management. Staff and students who have worked on this unit over the previous 6 weeks must be contacted and assessed Staff diagnosed with scabies are relieved of direct patient contact until 24 hours after initiation of treatment Household, sexual and other close contacts (skin to skin contact or sharing clothes or bed linens) of a staff case should receive treatment (if symptomatic) or prophylaxis during the same 24-hour period as the staff treatment Pet prophylaxis is not needed, as animal scabies is a different species Environment All linen, towels and clothing used in the previous 4 days should be washed in hot water (60ºC) and heat dried. Items that cannot be washed in hot water should be stored in a plastic bag for at least 7 days before washing and reusing Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 132 VIHA Infection Prevention and Control Manual, September 1, 2011 There is no need for special treatment of furniture, mattresses or rugs. General cleaning and thorough vacuuming is recommended Asymptomatic Staff, Volunteers and Physicians – Prophylaxis For staff – apply the medication, and then bath or shower at either 8 or 12 hours, dependent on the treatment used later as per the medication package information insert For volunteers/physicians, need for prophylaxis treatment is determined on the amount of direct contact that the person has with the patient and environment No special handling of clothing or linens is needed Family members of asymptomatic staff do not require prophylaxis Note: If pregnant, or for children under 2 years of age, consult physician prior to treatment Environmental Cleaning Special attention should be paid to the items with which infested patients/residents have had direct skin contact in the previous four days. These include clothing, wheelchair cushions, shoes, slippers, coats, lap blankets, etc. Items that cannot be washed in hot water (60ºC) or sent to laundry are placed in a sealed plastic bag for 7 days or dry-cleaned. General cleaning and thorough vacuuming of furniture is recommended. Scabies Outbreak Conclusion The unit may be reopened to admissions and transfers when all patients/residents involved have received treatment or prophylaxis and follow-up baths. Symptomatic patients/residents may still be cared for in isolation. Monitoring continues for at least 6 weeks following last exposure for development of new cases. Reference: Scabies Control Guidelines circular #2005: 02, BC Centre for Disease Control February 2005. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 133 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 7: DEPARTMENTAL GUIDELINES 1. Inpatient Mother and Baby A. Routine Practices Routine practices are to be used with all patients/residents at all times. The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with the patient. The elements of routine practices are: Risk Assessment Risk Reduction Education Hand hygiene is the single most effective method of reducing cross infection. The healthcare setting provides an ideal opportunity to educate parents on the importance, methods and situations for hand hygiene. B. Additional Precautions Additional precautions are required when routine practices are not sufficient to prevent the transmission of certain microorganisms. It may be necessary to isolate both mother and baby into a single room. Where this is not possible, additional precautions can be implemented in a multi-patient room. However, in this situation it is important to limit the movement of the mother around the room/unit. Table 21: Common Conditions and Precautions Needed Note: This list is not exhaustive, but includes conditions of particular importance to this area (see also Appendix A) CONDITION Ophthalmia neonatorum PRECAUTIONS / PRACTICES Contact Precautions Pustules/cellulitis Toxoplasma, Rubella, Cytomegalovirus and Herpes Virus (TORCH) Syndrome Varicella Herpes (Non-Genital and Genital) Routine Practices Droplet Precautions Airborne Precautions See algorithm below COMMENTS Until 24 hours of effective antibiotic therapy No precautions necessary by the parents Between 10–21 days 28 28 Neonates born to mothers with active Varicella should be placed on airborne precautions until 21 days of age (or 28 days if VZIG is given). If a mother develops chicken pox from 5 days before to 3 days after delivery, consult the physician regarding the possible administration of VZIG to the neonate. Neonates (up to 2 months of age) of antibody positive mothers, who are exposed to varicella do not require isolation. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 134 VIHA Infection Prevention and Control Manual, September 1, 2011 C. Herpes Figure 10: Precautions Required When Caring for Mother with Non-Genital Herpes Mother with Non-Genital Herpes Lesions dry / crusted Lesions open / weeping ROUTINE PRACTICES Good personal hygiene? NO YES CONTACT PRECAUTIONS Single room isolation Instruction regarding hygiene measures NO Can lesions be covered with dressing or mask? YES ROUTINE PRACTICES Reinforce need to cover lesions Figure 11: Precautions Required When Caring for Mother with Genital Herpes Mother with Genital Herpes No open lesions; No recent positive culture Lesions present; or recent positive for HSV ROUTINE PRACTICES CONTACT PRECAUTIONS Single room isolation 1. Staff Precautions Staff must be free from any transmissible infection. This includes dermatitis, which can be colonized with microorganisms, and skin cells are readily shed. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 135 VIHA Infection Prevention and Control Manual, September 1, 2011 Staff with herpes lesions must not work while they are in the early stages of disease (wet blistered lesions). Lesions must be dry and scabbed, and preferably covered with a dressing prior to returning to work. Information relating to staff immunization can be obtained from Occupational Health & Safety. Any further advice should be sought from Occupational Health & Safety. D. Antibiotic Resistant Organisms AROs are defined as microorganisms that are resistant to one or more classes of antimicrobial agents. a. Methicillin Resistant Staphylococcus aureus (MRSA) b. Vancomycin Resistant Enterococci (VRE) c. Bacteria containing Extended Spectrum Beta Lactamase (ESBL) All admissions to the maternity unit must be screened for AROs by completing the ARO Screening Questionnaire. It is the responsibility of the nurse/midwife completing this questionnaire to collect the swabs as required. If swabs are required from the mother, a vaginal swab for MRSA is also required. The vagina is a significant site as a source of transmission to the newborn. In the instance that a parent or family member living in the home is identified as having an ARO, there is a significant risk that the baby will become colonized during their hospitalization. For this reason, the baby should also be treated as if positive, and appropriate additional precautions put in place. E. Outbreaks The Infection Prevention and Control Team will investigate all outbreaks in close liaison with the Clinical coordinator/Clinical Nurse Leader/Unit Manager (Outbreak Team). In order to bring control, and reduce/prevent further cross infection, it is essential to alert the Infection Prevention and Control Team as soon as there is any suspicion there could be an outbreak. An outbreak is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is greater than would normally be expected. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 136 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Neonatal Intensive Care and Special Care Baby Units A. Routine Practices Due to the vulnerability and increased invasive procedures required, the neonate is at great risk from acquiring an infection. Routine practices are to be used with all patients/residents at all times The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with the patient. The elements of routine practices are: Risk Assessment Risk Reduction Education Hand hygiene is the single most effective method of reducing cross infection. Parents must be taught and encouraged to perform hand hygiene before any contact with their baby. B. Visitors Parents, visitors or staff believed to be incubating or infectious with a communicable illness must be restricted from visiting the nursery. Staff should contact Occupational Health & Safety for further information and advice Parents, visitors or staff with open skin lesions should be assessed and counseled prior to having contact with the neonate. Staff should contact Occupational Health & Safety for further information and advice Mothers believed to be incubating or infectious with a communicable illness should be assessed by the physician to confirm prior exposure and advice on where visitation may occur All visitors must be discouraged from visiting other parents at their baby‘s cot or incubator at any time C. Additional Precautions Additional precautions are required when routine practices are not sufficient to prevent the transmission of certain microorganisms. It may be necessary to isolate the neonate into a single room. Where this is not possible, additional precautions can be implemented in a multi-patient room with the use of an incubator. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 137 VIHA Infection Prevention and Control Manual, September 1, 2011 It is usually not necessary for parents to wear gloves for contact with their baby, but hand hygiene must precede and follow any contact with the baby. A long sleeved gown should be worn when additional precautions are required, to prevent contamination of their clothing and therefore transmission to the environment. 1. Contact Precautions Contact precautions are implemented for pathogenic organisms, which are principally spread through direct (hands) or indirect (equipment, environmental) contact. Label the cot, incubator or room with the yellow precautions sign Gloves and gown are worn for all contact with the neonate and their physical environment Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the neonate. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning Terminology 2. Droplet Precautions Droplet precautions are implemented for pathogenic organisms, which are transmitted by aerosol of respiratory secretions, emesis or diarrhea, through forceful expulsion of these body fluids. Label the cot, incubator or room with the green precautions sign Gloves and gown are worn for all contact with the neonate and their physical environment. A mask with visor may be necessary, particularly if the neonate is not in an incubator Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the neonate. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning Terminology 3. Airborne Precautions Airborne precautions are implemented for pathogenic organisms, which are transmitted by way of the respiratory tract. The neonate is cared for in an isolation room with negative pressure ventilation. The Infection Prevention and Control Team should be consulted, and will advise where a negative pressure room is unavailable Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 138 VIHA Infection Prevention and Control Manual, September 1, 2011 Label the room with the blue precautions sign All staff are directed to wear an appropriate mask if susceptible to the confirmed or suspected infection Doors to the room must remain closed Table 22: Common Conditions and Precautions Needed Note: This list is not exhaustive, but includes conditions of particular importance to this area (see Appendix A) CONDITION Ophthalmia neonatorum PRECAUTIONS/ PRACTICES Contact Precautions Pustules/cellulitis TORCH Syndrome Routine Practices Droplet Precautions Varicella Airborne precautions D. COMMENTS Until 24 hours of effective antibiotic therapy No precautions necessary by the parents Between 10-21 days29 Antibiotic Resistant Organisms AROs are defined as microorganisms that are resistant to one or more classes of antimicrobial agents Examples of Antibiotic Resistant Organisms include: Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Bacteria containing Extended Spectrum Beta Lactamase (ESBL) All admissions to the Neonatal/Special Care Baby Unit must be screened for AROs by completing the Neonatal ARO Screening Questionnaire. It is the responsibility of the nurse/midwife completing this questionnaire to collect the swabs as required. ESBL is very rare in neonates and therefore screening swabs for these organisms are not required from the neonate. In the instance that a parent or family member living in the home are identified as having an ARO, there is a significant risk that the baby will become colonized during hospitalization. For this reason, the baby should also be treated as if positive and appropriate additional precautions put in place. 29 Neonates born to mothers with active Varicella should be placed on airborne precautions until 21 days of age (or 28 if VZIG is given). If a mother develops chicken pox from 5 days before to 3 days after deliver, consult the physician regarding the possible administration of VZIG to the neonate. Neonates (up to 2 months of age) of antibody positive mothers, who are exposed to varicella do not require isolation. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 139 VIHA Infection Prevention and Control Manual, September 1, 2011 The parents of the baby being isolated for TORCH syndrome or hepatitis are not required to wear protective clothing for handling their child, as they have already been exposed and are therefore either immune or infected. It is still important for parents to wash their hands following contact to reduce the risk of further contamination of the environment through contact. E. Outbreaks The Infection Prevention and Control Team will investigate all outbreaks in close liaison with the Clinical coordinator/Clinical Nurse Leader/Unit Manager (Outbreak Team). In order to bring control, and reduce/prevent further cross infection, it is essential to alert the Infection Prevention and Control Team as soon as there is any suspicion there could be an outbreak. An outbreak is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is greater than would normally be expected. 3. Pediatrics A. Routine Practices Due to the vulnerability and increased invasive procedures required, children are at great risk from acquiring an infection. Routine practices are to be used with all patients/residents at all times. The key to implementing routine practices is to assess the risk of transmission of microorganisms before any interaction with the patient. The elements of Routine Practices are: Risk Assessment Risk Reduction Education Hand hygiene is the single most effective method of reducing cross infection. The healthcare setting provides an ideal opportunity to educate children and their parents/visitors on the importance, methods and situations for hand hygiene. B. Additional Precautions Additional precautions are required when routine practices are not sufficient to prevent the transmission of certain microorganisms. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 140 VIHA Infection Prevention and Control Manual, September 1, 2011 The implementation of additional precautions into pediatric units and departments presents some unique challenges. Unfortunately, it is very difficult to set specific rules as precautions taken often depend upon the age and developmental stage of the child. Young children have a limited understanding of infection prevention and control, because it is difficult for them to comprehend cause and effect relationships between germs and illness. These children require greater restrictions on their activities, as they cannot be relied upon to practice routine infection prevention and control practices, such as cough etiquette or hand hygiene after using the bathroom. It is essential to communicate honestly and openly with parents, to harness their cooperation and support in limiting the child‘s activities. Older children understand causality better, and can be provided with factual information. However, compliance with infection prevention and control principles can still be problematic, and often requires great skill to encourage the child. Communication and education of family members and visitors is essential to ensure compliance with routine practices and any additional precautions implemented. Decisions to isolate and add precautions must be fully explained to the family, with the underlying rationale for doing so. 1. Contact Precautions Contact precautions are implemented for pathogenic organisms, which are principally spread through direct (hands) or indirect (equipment, environmental) contact. Where possible isolate the child in a single room, or cohort with other children with the same infectious illness. Where this is not possible: Precautions should be put in place in a multi-bedded room and the Infection Control Practitioner informed Label the room with the yellow precautions sign Gloves and gown are worn for all contact with the child and their physical environment Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the child. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning Terminology 2. Droplet Precautions Droplet precautions are implemented for pathogenic organisms, which are transmitted by aerosol of respiratory secretions, emesis or diarrhea, through forceful expulsion of these body fluids. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 141 VIHA Infection Prevention and Control Manual, September 1, 2011 Where possible isolate the child in a single room, or cohort with other children with the same infectious illness. Where this is not possible, precautions should be put in place in a multi-bedded room and the Infection Control Practitioner informed Label the room with the green precautions sign A mask with visor may be necessary Ensure the isolation cart is positioned appropriately for easy access to protective clothing and other equipment, but not in a position where it will become contaminated Dedicate equipment to the child. Where equipment cannot be dedicated, it must be thoroughly decontaminated after use Notify housekeeping as special cleaning will be required. See Housekeeping Cleaning Terminology 3. Airborne Precautions Airborne precautions are implemented for pathogenic organisms, which are transmitted by way of the respiratory tract. The child is cared for in an isolation room with negative pressure ventilation. The Infection Prevention and Control Team should be consulted, and will advise where a negative pressure room is unavailable Label the room with the blue precautions sign All staff are directed to wear an appropriate mask if susceptible to the confirmed or suspected infection Doors to the room must remain closed C. Communicability Periods Note: this list is not exhaustive, but includes conditions of particular importance to this area (See Appendix A) Susceptible Contacts of From – (days after first contact) To – (days after last definitive contact) Chickenpox 10 days 21 days (28 days if VZIG given) Diphtheria 2 days 14 days if no culture or until bacteriology confirms absence of carrage Mumps 12 days 25 days Polio 0 days When stools negative Streptococcal Pharyngitis 1 day 1 day (treated) 3 days (untreated) Rubella (German Measles) Rubeola (Measles) Tuberculosis (pulmonary) 14 days 23 days 7 days 18 days 4 weeks Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Until bacteriology confirms absence of infection Page 142 VIHA Infection Prevention and Control Manual, September 1, 2011 Pertussis (Whooping Cough) 5 days 14 days after last exposure or until cases and contacts have received a minimum of 14 days course of appropriate antibiotics Precautions are not required before and after the above established incubation periods. During the presumed infectious period, elective admission should be avoided. Patients/residents admitted during these times shall be treated with appropriate precautions. D. Antibiotic Resistant Organisms AROs are defined as microorganisms that are resistant to one or more classes of antimicrobial agents. Examples of Antibiotic Resistant Organisms include: Methicillin Resistant Staphylococcus aureus (MRSA) Vancomycin Resistant Enterococci (VRE) Bacteria containing Extended Spectrum Beta Lactamase (ESBL) All admissions to the Paediatric unit must be screened for AROs by completing the ARO screening questionnaire. It is the responsibility of the nurse completing this questionnaire to collect the swabs as required. In the instance that a parent or family member living in the home are identified as having an ARO, there is a significant risk that the baby will become colonized during hospitalization. For this reason, the child should also be treated as if positive and appropriate additional precautions put in place. In the instance that a parent (mother, father or mother‘s partner) is identified as having an ARO, there is a significant risk that the child will become colonized during hospitalization. For this reason, the child should also be treated as if positive and appropriate additional precautions put in place. E. Outbreaks The Infection Prevention and Control Team will coordinate all outbreaks in close liaison with the Clinical coordinator/Clinical Nurse Leader/Unit Manager. In order to bring control, and reduce/prevent further cross infection, it is essential to alert the Infection Prevention and Control Team as soon as there is any suspicion there could be an outbreak. An outbreak is defined as the occurrence of two or more related cases of the same infection, or where the number of infections is greater than would normally be expected. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 143 VIHA Infection Prevention and Control Manual, September 1, 2011 4. Infection Prevention and Control Practices for Surgical Service Areas A. Rationale Surgical procedures are associated with risk of introducing infection to the patient as a result of disruption of normal host barriers. Hence, use of appropriate sterile technique by all personnel is necessary to reduce the risk of introducing infection to the patient. However, given the invasive nature of operative procedures, there is also significant risk of exposure and contamination of healthcare staff and the environment in surgical care areas by blood, body fluids and tissue (including airborne skin and other epithelial cells colonized with microbes) from patients/residents undergoing surgery. Consequently, strict adherence to infection prevention and control practices is necessary to protect staff and other patients/residents. This includes following strict aseptic technique, the appropriate use of PPE, as well as thorough cleaning and disinfection of the surgical environment (from preanaesthetic to operative to post-anaesthetic areas) between patients/residents. The basic standard of infection prevention and control and housekeeping practices should be sufficient in most cases to prevent the transmission of infection. This is particularly relevant for antibiotic resistant organisms (AROs), since a patient‘s colonization status may not be known at the time of their surgical procedure. Patients/residents who require additional precautions in the operating room are those who have clinical signs and symptoms consistent with infection with a communicable pathogen, whether directly related to the nature of the surgical procedure or not (e.g. a patient with diarrhea undergoing pacemaker implantation), or who are known to be colonized with a pathogen that represents an increased risk of transmission (e.g. AROs). B. Principles Routine practices are exercised by all staff at all times. Additional precautions will be dictated by prior knowledge of ARO colonization status and patient assessment of risk for transmission of communicable disease (evidence of infection, whether directly related to the surgical procedure or not). Only anaesthetic/OR equipment and supplies needed for the surgical procedure are to be brought into the operating suite. Equipment that cannot be removed should be located as far from the procedure table as possible. If within a one metre distance, they should be draped to protect them from splashes. The drape is removed and replaced during post-case cleaning. Personal items (e.g. computers, brief cases, backpacks, etc.) are not to be brought into the operating suite. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 144 VIHA Infection Prevention and Control Manual, September 1, 2011 Use of appropriate barrier precautions by staff at all times is essential to protect staff and reduce risk of communicable disease transmission. Patient isolation is generally unnecessary and potentially detrimental to patient care. Cleaning and disinfection must be performed for all cases sufficient to eradicate most pathogens (including AROs) from the surgical environment and must be performed between each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all surgical care areas. This will likely have significant potential impact on flow through the operating rooms. Enhanced cleaning (for VRE) or Two-Step cleaning (for diarrheal illnesses) using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring Additional Precautions, on the recommendation of Infection Prevention and Control. See Housekeeping Cleaning Terminology Where feasible, cases involving patients/residents who require additional precautions should be booked at the end of the slate. If the case cannot be delayed, thorough cleaning and disinfection of the surgical care areas must be assured between cases. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 145 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 12: Surgical Booking Procedure Booking Request No Infection ARO- or unknown No Infection ARO+ Infection ARO+ or ARO- Airborne Infection Only ARO+ or ARO- Airborne AND other infection Book for Routine Discharge Cleaning Book for Routine Discharge Cleaning Book for Routine Discharge Cleaning + Walls Book Negative Pressure Room & Routine Discharge Cleaning Book Negative Pressure Room & Routine Discharge Cleaning + Walls Patient Reassessment for Communicable Disease (Infection) Risk (Pre-admit Clinic, Anesthesiologist, Surgeon, Admitting Nurse) No Infection No Infection Infection Contact Precautions - Gloves - casual contact - Gowns - close contact - Hand hygiene after any contact Droplet Precautions - Gloves & gown for all contact - Mask with shield if within 3 feet - Hand hygiene after any contact Airborne Precautions - N95 Mask - Negative pressure room *TB/Chickenpox ARO+ or ARO- *TB/Chickenpox & other infection Routine Practices Contact Precautions Contact / Droplet Precautions Airborne Precautions plus Contact Precautions (if required) Airborne AND Contact / Droplet Precautions Routine Discharge Cleaning Routine Discharge Cleaning Routine Discharge Cleaning + Walls Routine Discharge Cleaning Routine Discharge Cleaning + Walls Airborne AND Contact / Droplet Precautions: - N95 Mask - Negative air room - Gloves & gown for all contact - Shield or protective eye wear within 3 feet - Hand hygiene after any contact *Most common airborne organisms. Schedule case at end of day or allow an extra 10 minutes for cleaning. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 146 VIHA Infection Prevention and Control Manual, September 1, 2011 When a surgical booking is made, increased risk of communicable disease transmission should be identified by the booking surgeon (i.e. infection, see the following Table: Assessment for Increased Risk of Communicable Disease Transmission). Table 23: Assessment for Increased Risk of Communicable Disease Transmission Determine from the booking surgeon (at time of booking) and patient and/or unit staff (hospitalized patient) if the patient has: TB or Chicken Pox • Airborne Precautions Fever & Cough • Droplet Precautions Skin Infection, open wound, boil or abscess • Contact Precautions Diarrhea in the past 2 days • Contact Precautions No risk factors for communicable disease transmission • Routine Practices If on contact precautions, determine from the patient and/or unit staff if the patient has: C.difficile VRE Note: If there is a Norovirus outbreak in the facility/unit from which the patient is coming, check with Unit Manager/Infection Control Practitioner. Cases where there is NO known colonization with an ARO and no identified increased risk of communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased Risk of Communicable Disease Transmission) may be booked at ANY TIME with direction for Routine Discharge Cleaning. See Housekeeping Cleaning Terminology Cases where there is known colonization with an ARO but no identified increased risk of communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased Risk of Communicable Disease Transmission) may be booked at any time with direction for Routine Discharge cleaning. See Housekeeping Cleaning Terminology. OR/PAR staff to use Contact Precautions. If there is identified increased risk of communicable disease transmission (i.e. infection, see Table 21: Assessment for Increased Risk of Communicable Disease Transmission), determine if the infection is known or thought due to tuberculosis (TB) or chickenpox. If so, book as an Airborne case at any time in a negative pressure OR suite, with direction for Routine Discharge Cleaning. See Housekeeping Cleaning Terminology. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 147 VIHA Infection Prevention and Control Manual, September 1, 2011 If there is an infection other than TB or chickenpox, the case may be booked as a contact or droplet case at any time with direction for Routine Discharge Cleaning with the addition of wall surfaces. Additional time for such cleaning to be done (add an approximate additional 10 minutes) should be added. Cases with infections where two-step cleaning is required (i.e. Norovirus, clostridium difficile, etc.), should be booked at the end of the slate if possible. Where feasible, it should be recommended that ALL patients/residents have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated to be feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended. C. Procedure Pre-Operatively See also Assessment for Increased Risk of Communicable Disease Transmission 1. Cases Without Identified Need for Additional Precautions The patient should have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated to be feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended. All slated Same Day Admit or Daycare patients check in and are prepared in the normal fashion, including hand hygiene on arrival. They should be instructed on admission on hand hygiene and instructed to clean toilet surfaces after personal use with accelerated hydrogen peroxide wipes. For non-elective cases, if possible, the patient should be instructed to wash hands or use ABHR on arrival to the preoperative area. Patients/residents should be assessed for presence of increased risk of communicable disease transmission (i.e. infection; see Assessment for Increased Risk of Communicable Disease Transmission). If present, follow the appropriate algorithm (see Surgery Booking Request) The need for additional precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Routine practices are to be used by all personnel unless otherwise indicated. Cleaning/disinfection of environmental surfaces in all pre-operative care areas contaminated or potentially contaminated by the patient should be performed prior to next patient use. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 148 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Cases Known to be Colonized with an ARO Without Evidence of Infection See Assessment for Increased Risk of Communicable Disease Transmission. The patient should have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated for nonelective cases. Chlorhexidine (4%) is the antiseptic agent recommended. All slated Same Day Admit or Daycare patients check in and are prepared in the normal fashion, including hand hygiene on arrival. They should be instructed on admission on hand hygiene and instructed to clean toilet surfaces after personal use with accelerated hydrogen peroxide wipes. For non-elective cases, if possible, the patient should be instructed to wash hands or use ABHR on arrival to the preoperative area. Patients/residents should be treated with contact precautions when close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic areas. The need for contact precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). The patient chart will be transported in a pillowcase. When removed from the pillowcase, the chart should be placed on a clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Patients/residents should be assessed for presence of increased risk of communicable disease transmission (i.e. infection; see Assessment for Increased Risk of Communicable Disease Transmission). If present, follow the appropriate algorithm (see Surgery Booking Request); this may require additional precautions. The need for additional precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Cleaning/disinfection of environmental surfaces in all pre-operative care areas contaminated or potentially contaminated by the patient should be performed prior to next patient use. 3. Cases Where Patient has Evidence of Infection: Contact or Droplet Precautions See Assessment for Increased Risk of Communicable Disease Transmission. The patient should have a preoperative bath or shower with antiseptic soap the night before and the morning of surgery. This is mandatory for elective cases, but not anticipated to be feasible for non-elective cases. Chlorhexidine (4%) is the antiseptic agent recommended. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 149 VIHA Infection Prevention and Control Manual, September 1, 2011 Patients/residents known to have an infection or who are already under additional precautions should be transferred under contact or droplet precautions directly into the OR or to the OR holding area (not the pre-operative area) on their bed or stretcher. Cleaning of that environment may be necessary if there is obvious contamination. If the patient is in the Emergency Department (ED) and transfer on the ED stretcher is not feasible, if possible, the patient should be transported on a stretcher from the post-anaesthetic area, brought from the post-anaesthetic area to ED by the porter. The patient chart will be transported in a pillowcase. When removed from the pillowcase, the chart should be placed on a clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Patients/residents should continue to be treated with contact or droplet precautions when close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic areas). The need for and type of contact or droplet precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Patients/residents should be assessed for presence of increased risk of communicable disease transmission (i.e. infection) other than that already identified prior to admission to the surgical care area; see Assessment for Increased Risk of Communicable Disease Transmission. If present, follow the appropriate algorithm (see Surgery Booking Request). The need for additional precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Cleaning of environmental surfaces in all pre-operative care areas contaminated or potentially contaminated by the patient should be performed prior to next patient use. Where additional precautions are required, Enhanced cleaning or Two-Step cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring Additional Precautions, on the recommendation of Infection Prevention and Control (see the Surgical Housekeeping algorithm and Housekeeping Cleaning Terminology.) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 150 VIHA Infection Prevention and Control Manual, September 1, 2011 Figure 13: Surgical Housekeeping Algorithm No Infection ARO+ or ARO- Cases requiring Airborne Precautions Infection Requiring Contact Precautions Cases requiring Droplet Precautions Routine Discharge Cleaning with *H2O2 1:16 or QAC Routine Discharge Cleaning with *H2O2 1:16 or QAC All horizontal and contact surfaces (both sides) in pre-anesthetic area, OR & postoperative area All horizontal and contact surfaces (both sides) in pre-anesthetic area, OR & postoperative area Cleaning of walls if visibly soiled (OR) Cleaning of walls (OR) Cleaning of head space walls and Change bedside drapes when visibly soiled (PAR) Cleaning of head space walls and Change bedside drapes after patient (PAR) Two-Step Cleaning for - C.difficile - Norovirus - Diarrhea *H2O2=Acclerated Hydrogen Peroxide - Preferred cleaning solution and must be used for VRE. QAC=Quaternary Ammonium Compound D. Procedure in the Operating Room 1. Routine Practices Routine practices are to be used by all personnel. All personnel entering and remaining in the OR are to perform hand hygiene (at a minimum) prior to entering the suite. Hand hygiene must be used before and after contact with the Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 151 VIHA Infection Prevention and Control Manual, September 1, 2011 patients/residents or their environment. Hand hygiene product should be available at point-ofuse for this purpose. All personnel in the OR must wear a fluid-resistant mask within one metre of any potential splash/splatter risk. A mask with face shield must be worn when there is risk of splash with blood or body substances, contaminating mucous membranes, during surgery, placement of venous lines and intubation. Gloves must also be worn at all times where there is risk of contact with blood or body substances (e.g. during intubation). Disposable gloves must be available at point-of-use for this purpose. Shoe covers or footwear dedicated to the surgical care area must be worn at all times and removed prior to leaving the surgical care area followed immediately by hand hygiene. Only anaesthetic/OR equipment and supplies needed for the surgical procedure are to be brought into the operating suite. Equipment that cannot be removed should be located as far from the procedure table as possible. If within a one metre distance, they should be draped to protect them from splashes. The drape is removed and replaced during post-case cleaning. Personal items (i.e. computers, brief cases, backpacks, etc.) are not to be brought into the operating suite. Hand hygiene must be performed before removal of any supply from a drawer or cupboard during surgery. Any supply removed from a drawer or cupboard during surgery is considered contaminated following the surgical procedure. Such unused supplies must be . The patient chart should be placed on a clean surface away from patient contact surfaces (such as the bed). Hand hygiene should be performed before and after handling the chart. Where possible, program the telephone for auto-answer to permit hands-free handling of incoming calls. Gloves should always be removed and hand hygiene performed prior to handling the phone. Remove patient set pans and return them to the Sterile Core (or equivalent) prior to patient arrival. The scrub nurse will contain all instruments, suction bottles and used anaesthetic equipment in the case cart, where case carts are used. The case cart door will remain open until housekeeping closes it prior to its removal for decontamination. Alternatively, where case carts are not available, one or (preferably) two tables well removed from the operative site will be designated for holding and keeping separate sterile and contaminated instruments respectively; these will be covered with a drape at the end of the case. At the end of the case, the cleaners/nurse will remove the cart or table(s) to be delivered to CSD for cleaning/disinfection and the cleaners will perform cleaning of the room. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 152 VIHA Infection Prevention and Control Manual, September 1, 2011 All equipment brought into the room during a case, such as the C-arm, must remain in the room until cleaned/disinfected by the cleaners. Additional needed supplies should be passed directly to OR staff by Sterile Core (or equivalent) personnel from the Sterile Core. Where required, radiology aprons should be worn by scrubbed personnel under sterile gowns for the entire case. Radiology aprons must be handled following hand hygiene. All doors to the OR must be kept closed throughout surgeries. Entry to the OR suite during surgery is strongly discouraged. Appropriate signage on the door (―No Entry‖) should support this. OR staff should not generally enter the Sterile Core. Where necessary OR staff should enter the Sterile Core directly from the OR, not from the outside corridor. All unused sterile equipment must be returned to the Sterile Core or CSD. Cleaning and disinfection must be performed for all cases sufficient to eradicate most pathogens (including AROs) from the surgical environment and must be performed between each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all surgical care areas since it meets this standard. Enhanced cleaning or Two-Step cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring Additional Precautions, on the recommendation of Infection Prevention and Control (see the Surgical Housekeeping Algorithm and the Housekeeping Cleaning Terminology.) Routine discharge cleaning practices will include cleaning of all horizontal (both sides) and contact surfaces within the room that have been touched by the patient, surgeon, assistants, and anesthetist, and includes the anesthetic cart, monitors and leads, dust covers on keyboards and on equipment, as well as operating lights and switches. In addition, the floor must be wet mopped. The walls are wiped when visibly soiled. Cleaning of the walls is done daily, preferably at the end of the slate. For any patient with increased risk of communicable disease transmission (i.e. infection, see Assessment for Increased Risk of Communicable Disease Transmission and the Surgical Housekeeping Algorithm), cleaning of the walls is done in conjunction with the Routine Discharge Cleaning. See Housekeeping Cleaning Terminology. The room may be used again as soon as the indicated type of cleaning is complete. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 153 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Patient Known to be Colonized with an ARO Without Evidence of Infection See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents should be treated with contact precautions when close personal care is being provided (from pre-anaesthetic to operative to post-anaesthetic areas. The need for Contact Precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Appropriate signage should be placed on all doors to the OR. In addition to routine dress code outlined above (see Page 152), the anaesthetist and circulating nurse must wear shoe covers dedicated for the particular case. Other personal barrier equipment/ clothing should be used as outlined under contact precautions. The patient chart may be brought into the room and placed on a designated clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. Both the circulating nurse and anesthetist may do charting on this surface, as long as gloves that have touched the patient are removed before doing so and after hand hygiene. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Gloves are always to be removed after activities where patient contact has occurred (e.g. IV starts, intubations) before contact with clean items/areas. Hand hygiene must be performed before and after glove use. The patient bed or stretcher is to be taken out of the room and covered with a sheet. The appropriate Additional Precautions sign is to be placed on top of the bed. At the end of the case, the sheet should be removed from the bed and placed in the OR linen hamper. If the bed or stretcher needs to be exchanged, housekeeping staff should be notified accordingly and the bed should be stripped in the hall and cleaned (+/- Two-step cleaning as warranted) before being put back into circulation. See Housekeeping Cleaning Terminology. Following the surgical procedure, the circulating nurse and/or anaesthetist and/or porter will remove or exchange shoe covers and contaminated gloves and discard them before leaving the OR. Hand hygiene with ABHR is to be done immediately following removal of contaminated barrier clothing. Clean gloves must be worn for transport of the patient. Pressing elevator buttons while wearing gloves for patient transport is acceptable, as there is very low likelihood of contamination of the elevator button. Garbage and linen may be collected as routine, unless alternative methods are requested by Infection Prevention and Control. However, there should be no recycling performed. The OR may be used for the next patient once Routine cleaning is completed. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 154 VIHA Infection Prevention and Control Manual, September 1, 2011 3. Cases with Infection – Contact and Droplet Precautions See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents should be treated with appropriate contact or droplet precautions as warranted at all times while in the surgical care areas (from pre-anaesthetic to operative to post-anaesthetic areas). The need for contact or droplet precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Appropriate signage should be placed on all doors to the OR. In addition to routine dress code outlined above (see Page 152), the anaesthetist and circulating nurse must wear shoe covers dedicated for the particular case. Other personal barrier equipment/clothing should be used according to contact/droplet precautions. The patient chart may be brought into the room and placed on a designated clean surface away from patient contact surfaces (such as the bed and any over bed table, etc.). Hand hygiene should be performed before and after handling the chart. Charting may be done on this surface by both the circulating nurse and anaesthetist, as long as gloves that have touched the patient are removed before doing so and after hand hygiene. The chart may be returned to the same pillowcase used for transport, as long as the inside of the pillowcase has not been contaminated. Gloves are always to be removed after activities where patient contact has occurred (e.g. IV starts, intubations) before contact with clean items/areas. Hand hygiene must be performed before and after glove use. The patient bed or stretcher is to be taken out of the room and covered with a sheet. The appropriate additional precautions sign is to be placed on top of the bed. At the end of the case, the sheet should be removed from the bed and placed in the OR linen hamper. If the bed or stretcher needs to be exchanged, housekeeping staff should be notified accordingly and the bed should be stripped in the hall and cleaned (+/- Two-step cleaning as warranted – see Housekeeping Cleaning Terminology) before being put back into circulation. Following the surgical procedure, the circulating nurse and/or anaesthetist and/or porter will remove or exchange shoe covers and contaminated gloves and discard them before leaving the OR. Hand washing or hand hygiene with ABHR is to be done immediately following removal of contaminated barrier clothing. Clean gloves must be donned for transport of the patient. Pressing elevator buttons, while wearing gloves for patient transport is acceptable, as there is very low likelihood of contamination of the elevator button. Garbage and linen may be collected as per routine, unless alternative methods are requested by Infection Prevention and Control. However, there should be no recycling performed. The OR may be used for the next patient once Routine Discharge Cleaning including the walls is completed. This will include ―Routine Discharge Cleaning‖ as outlined above, as well Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 155 VIHA Infection Prevention and Control Manual, September 1, 2011 as cleaning of the walls. Enhanced cleaning or Two-Step cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring additional precautions, on the recommendation of Infection Prevention and Control. (See the Surgical Housekeeping Algorithm and Housekeeping Cleaning Terminology.) 4. Cases with Infection – Airborne Precautions See Assessment for Increased Risk of Communicable Disease Transmission. Procedures for patients/residents requiring airborne precautions should only be performed if negative air pressure can be assured within the OR relative to the hallway and adjacent rooms. Appropriate signage should be placed on the OR door. In addition to routine dress code outlined above (see Page 152), all personnel in the OR must wear an N95 mask (for which staff have been fit tested) at all times; see airborne precautions. Additional precautions are necessary only if warranted. Routine practices (including housekeeping) should be followed otherwise; see the Surgery Booking Request Algorithm and the Surgical Housekeeping Algorithm. E. Procedure in the Post-Anaesthetic Area 1. Routine Practices Routine practices are to be used by all personnel at all times. A minimal amount of supplies should be stored in the patient stretcher area. Cleaning and disinfection must be performed for all cases sufficient to eradicate most pathogens (including AROs) from the surgical environment and must be performed between each case. Accelerated hydrogen peroxide (1:16) is the agent advocated for cleaning of all surgical care areas since it meets this standard. Routine discharge cleaning practices after discharge of patient from PAR will include cleaning of all horizontal and contact surfaces within the stretcher area that may have been touched by the patient and staff, and includes counters, stretcher, monitors, IV poles, keyboard, etc. In addition, the floor must be wet mopped. Headspace wall is wiped and bedside curtains changed when visibly soiled; see the Surgical Housekeeping algorithm. Cleaning of the headspace wall is done at minimum daily, preferably at the end of the slate. Cleaning of the stretcher area for patients/residents on additional precautions will include the above. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 156 VIHA Infection Prevention and Control Manual, September 1, 2011 Routine discharge cleaning as well as the headspace wall, see the Surgical Housekeeping algorithm. The stretcher area may be used again as soon as the appropriate type of cleaning is complete. 2. Patient Known to be Colonized with an ARO Without Evidence of Infection See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents should be treated with contact precautions when close personal care is being provided (from pre-anesthetic to operative to post-anesthetic areas). The need for contact precautions must be clearly communicated to other staff in the surgical care areas (OR and post-anaesthetic area). Patients/residents requiring additional precautions generally do not require placement in an isolation room in the post-anesthetic area, but can be managed within the general postanesthetic area, as long as dedicated toileting facility is provided (e.g. dedicated commode) and there is acceptable physical separation from adjacent stretchers (at least two metres/6 feet). Patients/residents on contact precautions requiring nebulized therapy, non-invasive ventilation or who have had a tracheostomy performed (not ventilated) are placed on droplet precautions with a curtain around the stretcher; see Assessment for Increased Risk of Communicable Disease Transmission. Appropriate signage should be placed at the foot of the bed or on the curtain around the stretcher. Appropriate infection prevention and control barriers must be used for direct patient care; see Assessment for Increased Risk of Communicable Disease Transmission. The post-anaesthetic bay may be used for the next patient once routine discharge cleaning is completed; see Surgical Housekeeping algorithm. Bedside curtains are changed if visibly soiled. Enhanced cleaning or Two-Step cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents requiring additional precautions, on the recommendation of Infection Prevention and Control. (See Surgical Housekeeping algorithm and Housekeeping Cleaning Terminology. 3. Cases with Infection – Contact and Droplet Precautions See Assessment for Increased Risk of Communicable Disease Transmission. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 157 VIHA Infection Prevention and Control Manual, September 1, 2011 Patients/residents requiring additional precautions generally do not require placement in an isolation room in the post-anesthetic area, but can be managed within the general postanesthetic area, as long as dedicated toileting facility is provided (e.g. dedicated commode) and there is acceptable physical separation from adjacent stretchers (at least two metres/6 feet). Patients/residents on droplet precautions should be managed with additional physical barrier of drawn curtains between patient bays. Patients/residents on contact/droplet precautions requiring nebulized therapy, non-invasive ventilation or who have had a tracheostomy performed (not ventilated) must be placed under droplet precautions with the bedside curtain drawn around the stretcher. Appropriate signage should be placed at the foot of the bed or on the bedside curtain. Appropriate infection prevention and control barriers must be used for direct patient care; see contact/droplet precautions. The post-anesthetic bay may be used for the next patient once routine discharge cleaning, including head space walls is completed; see Surgical Housekeeping algorithm. Where patients/residents have been on droplet precautions, curtains should be changed between patients/residents; see Surgical Housekeeping algorithm. Enhanced cleaning or Two-Step cleaning using accelerated hydrogen peroxide may be necessary in particular instances for patients/residents additional precautions, on the recommendation of Infection Prevention and Control. (See Surgical Housekeeping algorithm and Housekeeping Cleaning Terminology.) 4. Cases with Infection – Airborne Precautions See Assessment for Increased Risk of Communicable Disease Transmission. Patients/residents requiring airborne precautions should be transferred to the postanaesthetic area wearing a surgical grade mask. Patients/residents requiring airborne precautions should be recovered ONLY in a private room in which negative air pressure can be assured within the room relative to the general post-anesthetic area and adjacent rooms. Appropriate signage should be placed on the isolation room door. Any person entering the isolation room must wear an N95 mask (which staff must be fit tested for) at all times. Additional precautions are necessary only if warranted; see airborne precautions. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 158 VIHA Infection Prevention and Control Manual, September 1, 2011 The post-anaesthetic bay may be used for the next patient once routine cleaning is completed; see the Surgical Housekeeping algorithm. 5. Burn Unit Recommendations Infection prevention and control begins at the time the patient is admitted to the hospital and continues until the patient‘s graft sites have healed. Because of the nature of the burn wound (loss of preventive covering of the skin) the burned patient is more susceptible to invasive bacterial infection. The patient is ―autocontaminated‖ prior to arrival at the hospital by the bacteria that survive in the hair follicles and sweat glands beneath the burned tissues, and by the dirt from the burned clothing or accident environment. In addition, the burn wound provides the media necessary for bacterial growth; food, warmth and moisture. Eliminating reservoirs of infection begins with the patient and we must rely on aseptic technique as a factor in controlling the infection inherent in the patient. All patients/residents in the Burn Unit, Intensive and Intermediate, will be isolated. Unit Isolation Unit doors must be kept closed to maintain positive pressure when there are patients/residents within the unit being treated for burns. All disciplines (including medical staff and hospital services) must ensure they perform thorough hand hygiene upon entering and exiting this unit. It is acceptable to use ABHR or soap and water. Nursing must ensure a clean, freshly laundered uniform is worn at the start of each shift. Patient Room Each patient‘s room is a separate isolation unit. Before entering: Appropriate and thorough hand hygiene must be carried out before entering and upon leaving room. Hand hygiene stations are provided for this purpose directly outside each individual room. PPE will be donned prior to entry of the patient‘s room. This includes isolation gowns, caps, gloves and all other appropriate protective attire that may be necessary (masks, face shield etc). Upon exiting the patient‘s room, all PPE must be discarded in the appropriate receptacles contained within the room and new attire donned if re-entering. Housekeeping, food service employees and all other auxiliary staff must check with nursing staff for direction prior to entering the patient‘s room. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 159 VIHA Infection Prevention and Control Manual, September 1, 2011 Isolation Protocols Isolation protocols must be instituted for all patients/residents treated for burns: Private room must be used Doors must be kept closed Individual gown technique is imperative for all persons entering room Surgical masks must be worn by all persons entering patient rooms Hands must be washed as per policy by all personnel before entering, after leaving and as otherwise indicated during patient care Gloves – must be put on routinely by all personnel before entering and kept on until discarded in a receptacle before leaving the room Attire must be discarded in appropriate receptacle, then hands must be washed upon leaving room Visitors Visitors entering the Unit: Cap to be worn over hair Clean, disposable protective gowns to be worn Surgical mask to be worn When leaving Unit, visitors will be instructed to discard all attire in laundry/garbage hampers provided in the patient‘s room and wash hands Visitors will be restricted to two persons per patient at a time Visitors will be restricted to immediate family only (any deviation from this must be approved by the person in charge) Visitors will NOT be allowed to visit during treatment hours If children are to visit, parents must be informed of all necessary precautions required and ensure adherence to unit policy for both patient and visitor safety Personal items such as bedding, clothing or any items made of fabric that cannot be decontaminated appropriately are not permitted in the acute private rooms. Advice may be obtained from Infection Prevention and Control for any questions Real plants or flower arrangements are not permitted on the unit Visitors must be instructed not to sit on patient‘s bed Pets are not permitted on the unit at any time Note: All Visitors must be made aware of the implications of visiting a patient treated for burns and the importance of basic precautions and hand hygiene, especially when it is a new burn and when not covered with a dressing. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 160 VIHA Infection Prevention and Control Manual, September 1, 2011 Equipment and PPE Other aspects of isolation within unit: Sterile gloves are worn for contact with the burn wound Protective gowns must be worn during wound care and hydrotherapy All outside equipment will be cleaned with a disinfecting solution prior to being brought into the unit. If the equipment is to be used for more than one patient, it must be disinfected after each patient use Items from Pharmacy, Central Sterilizing/Processing, Stores and Linen will be considered clean and may be taken directly into unit 6. Renal Dialysis Department A. Introduction There is a high risk of infection from blood borne viruses and transmission of infectious organisms in the dialysis setting from contaminated environmental surfaces and equipment, inappropriate healthcare worker technique and person-to-person transmission. Stringent infection prevention and control principles and procedures must be followed to decrease these risks and ensure a safe level of care. B. Policy Basic infection prevention and control principles must be met at all times to prevent transmission of infectious disease and to ensure protection of patients/residents and staff in the dialysis environment. 1. Guidelines for Patient Care Ensure all staff are knowledgeable and well-trained and will adhere to the principles of infection prevention and control, including implementation of routine practices Use routine practices for all patients/residents Maintain strict aseptic technique during all dialysis procedures Implement routine monitoring and follow-up for signs and symptoms of any adverse reaction, including local and systemic infection from vascular access or contamination during dialysis Advise patients/residents and visitors to complete hand hygiene prior to entering the dialysis treatment station and on exit from the unit once dialysis is complete; ensure pamphlets and adequate hand hygiene education are provided Ensure appropriate signage with step by step instructions for hand hygiene are visible and ABHR is available on entry and throughout the unit Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 161 VIHA Infection Prevention and Control Manual, September 1, 2011 Healthcare workers must follow established guidelines for hand hygiene techniques and procedures Meticulous aseptic technique is critical to prevent vascular access site contamination Hand hygiene must be performed before and after palpating a vascular access site, before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of the insertion site should not be performed after the application of antiseptic, unless aseptic technique is maintained. Medication Administration Common medication carts must not be used for medication. If trays are used to pass medications, they must be cleaned in between patients/residents Multiple dose medication vials must not be used between patients/residents. When they are used, prepare individual patient doses in a clean area away from dialysis stations and deliver separately to each patient Medications should be mixed and stored in a designated, separate area, separate from any contaminated/used supplies or equipment IV medication or dilution vials labeled for single use should not be punctured more than once. Once a needle has entered this type of vial, the sterility of the product can no longer be guaranteed. Do not pool residual medication from multiple vials Environment and Supplies Cleaning and disinfection procedures must meet hospital requirements, including the use of hospital approved disinfectants and cleaning solutions. Refer to the cleaning section of the infection prevention and control manual for approved disinfectants Blood spills must be managed appropriately following established VIHA Renal guidelines Clean non-sterile gloves and waste containers should be placed near each dialysis station Sufficient number of sinks with warm water and soap, and ABHR for when hands are not visibly soiled must be available Supply carts should not contain both clean supplies and blood-contaminated items and should not be moved from within one patient space to another or stored in patient care areas Supplies and equipment labeled ‗single use only‘ must be dedicated for single patient use. In instances where equipment is intended for multiple use, disinfection of items must be performed between patients/residents There must be a separate storage area for patient‘s articles Patient Food and Snacks Snacks supplied by the dialysis unit should be pre-wrapped only Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 162 VIHA Infection Prevention and Control Manual, September 1, 2011 Dialysis chairs should be draped for patients/residents given foods that may spill on the chair/bed. Drapes must be changed in between each patient. If a drape is not available, thorough cleaning of the chair must be performed to remove all remnants of food prior to the next patient‘s use Patients/residents should be instructed to perform hand hygiene prior to eating Waste Discard all fluids and disinfect all surfaces and containers associated with prime waste Waste generated from a hemodialysis facility should be considered potentially infectious and handled according to local and provincial regulations governing medical waste disposal All disposable items containing fluids or biohazardous material should be placed in thick, leak resistant bags and stored in appropriately constructed and labeled receptacles Equipment Non-disposable items that cannot be cleaned and disinfected (e.g. adhesive tape, cloth covered BP cuffs etc), must be dedicated whenever possible for use on a single patient only. If common use equipment cannot be dedicated, ensure adequate cleaning and disinfection between patients/residents There must be strict adherence to policy and procedures for the use, disinfection and maintenance of hemodialysis machines and all dialysis related equipment Manufacturer‘s recommendations must be followed Refer to VIHA Reprocessing policy for decontamination of critical, semi-critical and non critical equipment. Items taken into a dialysis station, including those placed on top of dialysis machines, should either be disposed of, dedicated for single patient use only, or cleaned and disinfected before the next patient use or returning to storage. Education Regular updated education must be provided to patients/residents and their families, clarifying their role in health maintenance and the prevention of dialysis-related complications and infections. 2. Guidelines for Care of Vascular Access Follow Established Guidelines Provided by the National Kidney Foundation–Kidney Dialysis Outcomes Quality Initiative (NKF - KDOQI) for Selection and Maintenance of Vascular Access for Hemodialysis. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 163 VIHA Infection Prevention and Control Manual, September 1, 2011 Aseptic Procedure Gloves must be changed between patients/residents and hand hygiene performed Care to be taken to avoid touching surfaces with gloved hands that will later be touched with ungloved hands Staff must wear gowns, full face shields, or masks with eye protection to protect themselves and their clothing when performing procedures in which blood or body fluid splatter may occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers and centrifugation of blood) Discard protective equipment in provided waste receptacles and linen hampers nearest the dialysis station Skin Antisepsis – Fistulas, Grafts and Catheters Disinfect clean skin with an approved antiseptic before needle insertion and during dressing changes Approved antiseptics for cleansing fistula, graft, arterial catheters and central venous catheter (CVC) insertion sites include a 2% chlorhexidine gluconate preparation as a first choice 10% Povidone-Iodine solution or 70% alcohol may be used in the case of skin reaction to chlorhexidine. If iodine is used, it must be allowed to dry for at least 2 minutes prior to skin puncture Sodium Hypochlorite solutions may be used as an alternate antiseptic at the discretion of the Infection Prevention and Control Team Any other solution to be used for vascular access site care must be first approved by Infection Prevention and Control Team Catheter Site Dressing Regime A new sterile dressing should be applied with each dialysis treatment A topical antibiotic ointment should be applied at the catheter exit sites whenever possible to help reduce the risk of infection A dry gauze dressing is the recommended choice, and should be applied with each dialysis treatment and replaced when site inspection is required or the dressing becomes loosened or soiled Patients/residents should be instructed to keep the CVC dressing clean and dry, to replace the dressing if it becomes damp, soiled or loosened and to report to their healthcare provider any changes in their catheter site or any new discomfort at the site Occlusive transparent dressings: If a transparent dressing is used, chose a product with a high-moisture vapor transmission rate to prevent increased moisture accumulation under the dressing Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 164 VIHA Infection Prevention and Control Manual, September 1, 2011 (some types of these dressings are associated with an increase in microbial growth under the dressing and thus an increase risk of infection) Follow established BC Renal Agency guidelines for transparent dressing care policy Occlusive dressings are less compatible with the use of antimicrobial ointment at catheter exit sites 3. Surveillance Surveillance of important blood borne viruses and AROs will be performed on a routine basis for monitoring and infection prevention and control purposes. ARO Screening for Renal Dialysis Patients/Residents Prevalence Screening Prevalence screening for AROs are organized by Infection Prevention and Control at regularly scheduled time frames Frequency of screening and information collected is reviewed annually and in consultation with the renal dialysis group to establish if there are indications for further surveillance Prevalence screening may be performed more frequently at the direction of Infection Prevention and Control during times of increased incidence, outbreaks and heightened surveillance, etc. MRSA screening includes: Swabs to be collected prior to commencement of dialysis and then annually on the patient‘s birthday Swab sites include both nares (one swab), rectal swab (one swab), large (draining) wounds. VRE screening Includes: Swabs to be collected prior to commencement of dialysis and then annually on the patient‘s birthday VRE point prevalence (collecting swabs from all patients/residents at a set point in time) will be performed twice yearly VRE swab sites include a rectal swab, ostomy swab (swab should be stool stained; collect both ostomy and rectal swab only if patient continues to pass fluid/stool through rectum) and any large draining wounds. Screening Requirements for Patients/Residents Not Known to be ARO Positive Screening for MRSA/VRE is to be completed: On initial admission to any hemodialysis or peritoneal dialysis facility Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 165 VIHA Infection Prevention and Control Manual, September 1, 2011 Upon returning from travel (within or outside BC, for any period of time) Upon return from admission to an acute care hospital or residential care facility (unless already collected within the last 48 hours) When peritoneal dialysis patients/residents require temporary hemodialysis unless swabbed within the previous 48 hours Incoming Visiting Patients/Residents (Travelers) The patient‘s current ARO status should be received within 2-4 weeks prior to the patient‘s arrival to the dialysis unit. A risk assessment should be made on arrival to the dialysis unit Visiting dialysis patients/residents should be screened for MRSA and VRE upon their initial arrival to the dialysis unit Patients/residents returning from travel outside Canada should be screened with a risk assessment completed to determine if additional precautions are necessary until negative results are available. Outgoing Traveling Patients/Residents For patients/residents traveling outside BC: If requested, current ARO culture results should be provided to the receiving dialysis unit along with the patient‘s clinical information Monitoring ARO Status for Patients/Residents Known to be MRSA or VRE Positive Patients/residents noted to be ARO positive are not routinely screened for the known ARO. However, upon patient or Infection Prevention and Control‘s request, requirements for alert removal and discontinuation of precautions include: all ARO positive patients/residents must have stopped all antibiotics (topical and oral, including decolonization protocol if MRSA positive) at least one week (or one month if infected) prior to collecting swabs MRSA Collect two sets of swabs, at least one week apart Wait at least one week after the last positive culture if the patient was colonized Wait one month from the last positive culture if the patient had an ARO infection If both sets of results are negative and the patient has not been on oral/topical antibiotics contact Infection Prevention and Control for further guidance MRSA decolonization is not routinely performed (clinical indications such as large draining wounds require further assessment), but may be an option for some patients/residents. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 166 VIHA Infection Prevention and Control Manual, September 1, 2011 VRE Collect two sets of swabs, at least one month apart Wait at least one month after the last positive culture If both sets of results are negative and the patient has not been on topical/oral antibiotics contact Infection Prevention and Control for further guidance Consult with Infection Prevention and Control Consult with the Infection Prevention and Control prior to discontinuing precautions for final approval Contact Infection Prevention and Control prior to discontinuing precautions on patients/residents with multi-ARO (e.g. VRE and MRSA) Consult with Infection Prevention and Control for follow up of ESBL 4. Acute Care Patients Receiving Dialysis Patients admitted to acute care hospitals who meet the admission screening questionnaire criteria should have swabs collected Patients admitted to acute care must have a discharge swab collected 5. Residential Care Residents Receiving Dialysis Residents admitted to acute care from a residential care facility and meet the admission screening questionnaire criteria should have swabs collected Note: In instances where Infection Prevention and Control has approved for a patient to personally collect an ARO swab, the patient must be given the appropriate pamphlet with accurate instructions to guide their technique and to ensure VIHA has access to results. Consult with Infection Prevention and Control first. 6. Routine Surveillance, Evaluation and Management of Communicable Diseases Refer to CDC Recommendations: Guidelines for Vaccinating Kidney Dialysis Patients/Residents and Patients/Residents with Chronic Kidney Disease (Recommendations of the Advisory Committee on Immunization Practices –ACIP) for further recommended guidelines for surveillance and patient vaccinations Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 167 VIHA Infection Prevention and Control Manual, September 1, 2011 7. Guidelines for Patients/Residents Requiring Additional Precautions Patients/residents who exhibit the following require additional precautions while receiving treatment at a renal dialysis unit: Known to have a confirmed ARO (MRSA, VRE or ESBL) Confirmed C.difficile Undiagnosed diarrhea Large open draining wounds Productive cough Patient Placement for Dialysis Patients/residents known to be positive with an ARO should be cared for in a private room if available, but may also be cohorted with patients/residents of the same ARO in a shared room or area (complete a risk assessment for signs and symptoms of infection prior to cohorting). The cohorted area is a defined geographical area in the hemodialysis unit with physical separation from other dialysis stations Note: for patients/residents known to be ARO positive, whether or not cohorting is possible, the patient‘s dialysis station must be thoroughly cleaned prior to the next patient‘s treatment Visitors In order to maintain a safe patient environment: Visitors will perform hand hygiene on entry and exit to the dialysis unit. Education and pamphlets must be provided to ensure appropriate technique Visitors should don gowns and gloves when providing direct patient care. Information will be given to visitors on the importance of hand hygiene while in the renal dialysis environment Visitors should not enter other patient‘s dialysis stations and should not be present during times when vascular access is occurring 8. Guidelines for Outbreak Management Patients/residents receiving dialysis who are transferred from an outbreak unit must be placed on the appropriate precautions with the appropriate cleaning provided when the patient has left the station. Patients/residents should be dialyzed in an area separate from others whenever possible. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 168 VIHA Infection Prevention and Control Manual, September 1, 2011 9. Guidelines for Cleaning and Disinfection The following cleaning practices must be met performed between all patients/residents: Clean and disinfect dialysis station (chairs, beds, tables, machines) between each patient with a recommended disinfectant Special attention to be paid to cleaning control panels on the dialysis machines and other surfaces that are frequently touched and potentially contaminated with patients/residents blood Discard all fluids, clean and disinfect all surfaces, tubing and containers associated with the prime waste (including buckets attached to the machines if applicable) Dialysis machines: o Surface must be cleaned between each patient; interior to be cleaned by technician or designated personnel daily or immediately if contaminated, according to the Association for the Advancement of Medical Instrumentation (AAMI), the Canadian Standards Association (CSA) and manufacturer‘s recommendations Curtains should be changed when visibly soiled and routinely on a monthly basis. In areas where patients/residents known to be ARO positive are cohorted change curtains weekly Telephones, keyboards and general office surfaces must be cleaned daily. All keyboards should be covered. Use alcohol swabs or hydrogen peroxide wipes for covered keyboards. Nursing staff/Unit clerks to provide additional cleans throughout the day following use For patients/residents with undiagnosed diarrhea or symptoms of diagnosed Norovirus or C.difficile, a two-step clean is necessary (see Housekeeping Cleaning Terminology.) For patients/residents known to be VRE positive, enhanced cleaning is implemented between patients/residents (see Housekeeping Cleaning Terminology). Table 24: Disinfection Procedures Recommended for Commonly Used Items or Surfaces in Hemodialysis Units Item or Surface Gross blood spills or items contaminated with visible blood Hemodialyzer port caps Water treatment and distribution system Scissors, hemostats, clamps, blood pressure cuffs, stethoscopes Low level Disinfection Intermediate level disinfection 30 X X X X 31 X X 32 30 Careful mechanical cleaning to remove debris should always be done before disinfection. If item is visibly contaminated with blood, use a tuberculocidal disinfectant. 31 Water treatment and distribution systems of dialysis fluid concentrates require more extensive disinfection if significant biofilm is present within the system. 32 If item is visibly contaminated with blood, use a tuberculocidal disinfectant. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 169 VIHA Infection Prevention and Control Manual, September 1, 2011 Environmental surfaces, including exterior surfaces of hemodialysis machines X Adapted from: CDC MMWR Vol 50/No.RR-5, 2001 Care and Maintenance of the Dialysis System AAMI and CSA standards must be followed Manufacturer‘s recommendations must be followed Water Treatment for Dialysis Dialysis units must meet or exceed AAMI and CSA standards for hemodialysis water purity, quality and monitoring Water samples should be collected at the point where water enters the dialysate concentrate proportioning unit Dialysis fluid samples should be taken from the entry or exit point of the dialyzer during or at termination of dialysis If acceptable levels are exceeded, disinfection of the water system must occur and repeat samples taken prior to use Written procedures must be available, outlining all testing policy and procedures, actions performed if contamination levels are exceeded and how documentation and records are maintained 10. Guidelines for Peritoneal Dialysis Infection prevention and control Considerations: Strict use of aseptic technique and sterile dressings are required for the operative wound and exit sites until well healed Perform aseptic manipulation of the sterile disposable lines that deliver dialysis fluid into the peritoneal cavity for peritoneal dialysis and aseptic connection of the tubing to the patients/residents‘ catheter Wear gloves whenever there is any potential contact with dialysis effluent, during exit-site care, and when drawing blood or taking dialysate samples. Wear gloves, gown and face shield when disposing of the effluent Peritoneal effluent should be considered potentially infectious for bloodborne pathogens PD drains must be used for draining peritoneal/dialysate only Patients/residents must be instructed on proper use of these sinks and shown where sinks designated for personal care and hand washing are located. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 170 VIHA Infection Prevention and Control Manual, September 1, 2011 Peritoneal Dialysis sinks: On a weekly basis, peritoneal dialysis sinks will be disinfected using a bleach solution of 100 mL of 5% household bleach diluted in 900 mL of water (for a 1:9 ratio of 1 part bleach to 9 parts water out of a total of 10 parts). Pour the solution down the sink drain, let it sit for 5–10 minutes, and follow with a water flush. Notify maintenance immediately if there is any residue or clogs noted in the drain. Sources: American Institute of Architects. (2006). Renal Dialysis unit (acute and chronic) Guidelines for design and construction of healthcare facilities. (pp.93-96). Washington, DC: American Institute of Architects. Association for Advancement of Medical Instrumentation. (2003). AAMI standards and recommended practices, dialysis. Arlington, VA: American National Standards Institute Association for Professionals in Infection Control and Epidemiology. (2004). Infection control in ambulatory care. (pp.98-107). Washington, DC: Association for Professionals in Infection Control and Epidemiology. Association for Professionals in Infection Control and Epidemiology. (2005). Dialysis. APIC text of infection nd control and epidemiology 2 edition. (pp.1-15). Washington, DC: Association for Professionals in Infection Control and Epidemiology. Bender, F., Bernardini, J., & Piraino, B. (2006) Prevention of infectious complications in peritoneal dialysis: Best demonstrated practices. Kidney International, 70, 44-54. Bianchi, P,. Buoncristiani, E., Buoncristiani, U. (2007). Disinfection by sodium hypochlorite: Dialysis applications. Contributions to Nephrology. 154, 1-6. BC Renal Agency. (2008). Prevention, treatment and monitoring of vascular access related infection in hemodialysis patients: Vascular access guideline Brunch, M. (2007. Toxicity and safety of topical sodium hypochlorite. Contributions to Nephrology, 154, 24-38. Center for Disease Control. (2001). Recommendations for preventing transmission of infections among chronic hemodialysis patients. Morbidity and Mortality Weekly Report. 50 (RR-5), 1-43. Center for Disease Control. (2002). Guidelines for prevention of intravascular catheter related infections, Morbidity and Mortality Weekly Report. 51(RR-10), 1-26. Center for Disease Control. (2003). Guideline for environmental infection control in health care facilities. Center for Disease Control. (2006). Guidelines for vaccinating kidney dialysis patients and patients with chronic kidney disease (summarized from recommendations of the advisory committee on immunization practices). Department of Health. (2002). Good practice guidelines for renal dialysis/transplantation units: Prevention and control of blood borne virus infection. De Vos, J., Elseviers, M., Harrington, M., Zampieron, A., Vlaminck, H., Ormandy, P., et al. (2006). Infection control practice across Europe: Results of the European practice database project. EDTNA/ERCA Journal, 32 (1), 38-41. Health Canada. (1999). Infection control guidelines: Routine practices and additional precautions for preventing the transmission of infection in health care. Canada Communicable Disease Report. Vol. 25S4. Lam, L. D., Newman, A., & CHICA Dialysis Interest Group. (2005). A survey of infection control practices in hemodiaysis units in Canada. Canadian Journal of Infection Control, 20(3), 118-136. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 171 VIHA Infection Prevention and Control Manual, September 1, 2011 Mendoza-Guevara, L., Castro-Vazquez, F., Aquilar-Kitsu, A., Morales-Nava, A., Rodriguez-Leyva, F. SanchezBarbosa, J.L. (2007). Amuchina 10% solution, safe antiseptic for preventing infections of exit-site of Techkhoff catheters, in the pediatric population of a dialysis program. Contributions to Nephrology. 154, 139-144. National Center for Infectious Diseases. (1999). National surveillance of dialysis-associated diseases in the united states. Atlanta, Georgia: Public Health Service, Department of Health and Human Services. National Kidney Foundation. (2006). Clinical practice guidelines for peritoneal dialysis adequacy: Update 2006. National Kidney Foundation. (2006). Kidney dialysis outcomes quality initiative, clinical practice guidelines for vascular access: Update 2006. Peleman, R., Vogelaers, D., & Verschraegen, G. (2000). Changing patterns of antibiotic resistance-update on antibiotic management of the infected vascular access. European Renal Association –European Dialysis and Transplant Association, 15, 1281-1284. Taal, M,. Fluck, R., & McIntyre, W. (2006). Preventing catheter related infections in hemodialysis patients. Current Opinion in Nephrology and Hypertension. 15, 599-602. Vancouver Coastal Hospital Infection Prevention and Control Manual. (2006). Vancouver coastal infection control guidelines for hemodialysis patients with antibiotic resistant organisms (revised December 2005 and January 2006). Zuckerman, M. (2002). Surveillance and control of blood-borne virus infections in haemodialysis units. Journal of Hospital Infection, 50, 1-5. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 172 VIHA Infection Prevention and Control Manual, September 1, 2011 7. Respiratory Department Guidelines A. Introduction Prevention and control of hospital-acquired infections associated with respiratory therapy is dependent upon adequate procedures for maintenance and operation, including the use of strict aseptic technique, routine practices and appropriate reprocessing methods. B. Equipment Microorganisms found in respiratory equipment often come from the patient during breathing or coughing into the system. It is essential that this contamination be destroyed or removed from all reusable apparatus Routine practices must be used for handling all used equipment. All contaminated equipment must be cleaned and decontaminated before attempting sterilization Follow the manufacturers‘ recommendations for disassembling equipment and for cleaning and decontamination The outside surfaces of large pieces of equipment should be cleaned and disinfected after use (e.g. nebulizers, oxygen tents, humidifiers, incubators, compressors etc.). Clean thoroughly using a hospital approved detergent and/or disinfectant that is consistent with manufacturer‘s recommendations Cover and protect all equipment when not in use For guidelines regarding the appropriate care and use of specific respiratory equipment, solutions and products, refer to established VIHA Respiratory Therapy policy and procedure If an outbreak is suspected, notify Infection Prevention and Control. The Infection Control Practitioner will coordinate all swabs collected from equipment for laboratory analysis C. Disposable Equipment A wide variety of disposable equipment is available and should be used whenever possible, especially in the care of patients/residents where there is a risk of contact with potentially infectious body fluids, excretions and secretions Single use items must not be reprocessed, according to VIHA Reprocessing Manual. D. Respiratory Patients/Residents Requiring Additional Precautions A risk assessment must be completed prior to initiating any respiratory procedure to determine which additional precautions are necessary. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 173 VIHA Infection Prevention and Control Manual, September 1, 2011 For all respiratory procedures, such as sputum induction, nasal-pharyngeal washes/specimen collection, use of nebulizers etc, refer to established VIHA Respiratory Therapy policy and procedure. 1. Guidelines for Ventilator Associated Pneumonia (VAP) Definition Ventilator associated pneumonia is defined by CDC as a condition in patients/residents on mechanical ventilation for > 48hrs, who present with fever, cough and new onset of purulent sputum, combined with: Radiologic evidence of a new or progressive pulmonary infiltrate Leukocytosis A suggestive Gram's stain Growth of bacteria in cultures of sputum, tracheal aspirate, pleural fluid, or blood. Reference: CDC Guidelines for Preventing Health-care associated Pneumonia, 2003 VAP Prevention Strategies Surveillance Infection Prevention and Control conducts ongoing surveillance for all new cases of pneumonia, including patients/residents at high risk for healthcare related pneumonia such as those admitted to ICU, mechanically ventilated patients/residents or high risk surgical patients/residents Goals of surveillance: Identify outbreaks early Ensure the appropriate precautions and education are put into place Determine trends and help identify practices that require closer review and education. Cross Contamination Routine Practices must be adhered to at all times, including: Use of gloves before handling respiratory secretions or contaminated objects Appropriate hand hygiene (soap and water or ABHR) before and after any contact with the patient or equipment in the patient‘s environment; before and after contact with mucous membranes or any respiratory secretions Use of gown (impermeable) when contact with respiratory secretions are anticipated Use of mask when contact with respiratory secretions are anticipated and when performing procedures that induce coughing or create aerosol Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 174 VIHA Infection Prevention and Control Manual, September 1, 2011 Airway Management Perform orotracheal rather than nasotracheal intubation, unless contraindicated Ensure secretions are removed from above the cuff prior to deflating the cuff of an ET tube when repositioning or removing Gastric Reflux Prevention Maintain elevation of the head of the bed between 30 – 45 degrees unless contraindicated Ensure routine verification of placement of feeding tube Equipment For maintenance care, ensure there is periodic draining and discarding of any condensate collected in the tubing Ensure condensate is not able to drain toward the patient Oral Care Ensure standard practice for thorough oral care/decontamination is available and utilized Sources: Centre for Disease Control. (2003), Guidelines for environmental infection control in health care facilities. Morbidity and mortality weekly report, 52(RR10), 1-42. Chulay, M. (2005). VAP prevention: The latest guidelines. RN, 68(3), 53-56. Evans, E. (2005). Best-practice protocols: VAP prevention. Nursing Management, 36(12), 10-16. Favero, M.S., Bond, W.W. (1991). Sterilization, disinfection and antisepsis in the hospital manual of clinical microbiology. Washington, DC: American Society for Microbiology. Ohana, S., Denys, P., Guillemot, D., Lortat-jacob, S., Ronco, E., Rottman, M., et al. (2006). Control of an ACC1-producing Klebsiella pneumonia outbreak in a physical medicine and rehabilitation unit. Journal of Hospital Infection, 63, 34-38. O‘Keefe-McCarthy, S. (2006). Evidence-based nursing strategies to prevent ventilator-acquired pneumonia. Canadian Association of Critical Care Nurses, 17(1), 8-11. Powers, J. (2006). Managing VAP effectively to optimize outcomes and costs. Nursing Management Supp, 37, 48b-48f. Vancouver Island Health Authority. (2008). Respiratory therapy policy and procedure. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 175 VIHA Infection Prevention and Control Manual, September 1, 2011 PART 8: Specific Procedural Recommendations 1. Asepsis Aseptic technique can be defined as all the measures we take to purposefully reduce the number of microorganisms to an irreducible number for the purpose of preventing transmission of infection. The strictness (or level) of aseptic technique increases as you perform more invasive procedures. For example, taking a blood pressure requires only clean technique, while procedures that enter a sterile body cavity require sterile technique. Microorganisms Live In and On Our Bodies Transient microorganisms are easily picked up on hands, clothing, inanimate objects, etc., and are easily removed by hand washing and cleaning (physical removal of "germs"), antisepsis and disinfection. Antisepsis (or hand washing and pre-op skin preparation) is the removal of transient microorganisms from the skin with a reduction in the resident flora. Resident or Normal Flora are those microorganisms that are constantly present on our bodies; no amount of scrubbing will totally remove them (the skin cannot be made sterile). These organisms cause "trouble" when introduced into normally sterile areas (like the bladder or bloodstream). Pathogens: Microorganisms that nearly always produce disease. For example: Salmonella and Shigella cause diarrheal illness upon ingestion of enough organisms. Normal flora can become pathogenic when introduced into areas where they don't belong, for example, through insertion of a catheter or through surgery. S. epidermidis, normal flora of the skin, causes most central line infections and hip implant infections. The Seven Keys of Asepsis Know what is clean Know what is contaminated Know what is sterile Keep clean, contaminated and sterile items separated Keep sterile sites sterile Resolve contamination immediately Train yourself to realize when you have broken technique Know what is clean Clean techniques are any procedures that involve contact with intact skin or mucous membranes only. For example, when you are taking blood pressure or temperature, these articles need to be clean only. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 176 VIHA Infection Prevention and Control Manual, September 1, 2011 Know what is contaminated Certain procedures like dressing changes produce contaminated materials. These contaminated materials must be disposed of properly by incineration or autoclave. Touching non-intact skin is a contaminated procedure; wear clean gloves unless a sterile procedure (like a dressing change) is being done. Know what is sterile During certain procedures (for example, the insertion of an IV or urinary catheter), sterile technique must be used. The level of sterile procedures increases with the level of invasiveness. For example, surgical procedures require stricter aseptic technique than starting an IV. Sterile gloves are required for sterile procedures. Keep clean, contaminated and sterile items separated Keep contaminated articles from touching clean or sterile items. Store clean and sterile items separately from contaminated areas or items. Keep sterile items from touching anything but a sterile field or another sterile item. Keep sterile sites sterile Once a tube has been inserted into the body, care must be given to mitigate the travel of microorganisms up the catheter or tube. Give dressing changes or catheter care and replace catheters per your facility's policy and procedure. Resolve contamination immediately If sterile technique cannot be used or is broken (e.g. during an emergency), resolve contamination when it occurs. For example, if an IV is inserted during an emergency, replace the IV as soon as possible after the code is completed. Train yourself to realize when you have broken technique If a technique is broken, remedy the problem if possible. For example, if during the insertion of an IV the catheter is contaminated by touching a non-sterile surface, replace the catheter before insertion. If contamination cannot be resolved, report it to the proper person. For example, if the bowel is nicked during surgery, the case classification will change from clean or clean-contaminated to contaminated and extra care should be given to prevent infection. For details on approved disinfectants and antiseptics for different procedures see the Table below – Approved Antiseptic Agents and Procedures. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 177 VIHA Infection Prevention and Control Manual, September 1, 2011 Reference: Rhodes, M. (2003) The ABCs of Infection Control. Infection control Today Magazine Table 25: Approved Antiseptic Agents and Procedures PURPOSE OF SKIN PREPARATION Patient’s personal hygiene AGENT(S) CONTACT TIME Neutral soap 10-15 seconds Alcohol antisepsis 15 seconds Neutral soap 10-15 seconds Hand antisepsis Alcohol based hand rub Approved alcohol based hand rub 15 seconds Aseptic hand scrub or rub CHG 2% detergent Povidone Iodine 10% Approved alcohol based hand rub 3-5 minutes 3-5 minutes 2-3 minutes Preparation of skin for intramuscular or subcutaneous injections 70% Isopropyl alcohol Until dry Preparation of skin for peripheral venous access CHG 2% with 70% isopropyl (preferred) or 70% Isopropyl alcohol Povidone Iodine 10%, followed by 70% Isopropyl alcohol Until dry Withdrawal of blood for other studies 70% Isopropyl alcohol Until dry Preparation of skin site before insertion of arterial, central, or epidural lines, hemodialysis access or any inserting any scope through the skin Adults: 2% CHG with 70% Isopropyl alcohol Until dry Staff hygiene Social hand wash Preparation of skin for: Withdrawal of blood for culture and sensitivity COMMENTS Hand hygiene to be promoted after toileting and before meals Hand hygiene to be promoted after toileting and before meals Attention to nails. Remove rings and watches. Perform when hands visibly soiled and when managing C.difficile patients/residents. Use as first line or routine approach to hand hygiene. *Do not use if hands visibly soiled or when managing C.difficile. To be performed prior to aseptic procedures. If alcohol based hand rub used, 2-3 liberal applications rubbed all surfaces-hands, wrists, forearms Care not to retouch prepared skin surface For neonates or if allergic to Povidone Iodine: 2% CHG with 70% Isopropyl alcohol Until dry (at least 2 minutes) Neonates: 2% CHG (no alcohol) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Amuchina 10% (Except Plus) for hemodialysis patients/residents with skin allergy or sensitivity Page 178 VIHA Infection Prevention and Control Manual, September 1, 2011 PURPOSE OF SKIN PREPARATION Ongoing care of sites used for line access to a sterile space AGENT(S) CONTACT TIME COMMENTS 2% CHG with 4% alcohol preservative Until dry Care of wounds post surgical or trauma Sterile normal saline Wipe dry with sterile gauze Care of pin sites Sterile normal saline and/or hydrogen peroxide 3%; or Povidone Iodine 10% Until dry Care of decubiti Sterile normal saline or CHG 2% solution or Povidone Iodine 10% Preparation for gynecologic examination None (see comments) Good perineal washing. Colposcopy – Povidone Iodine 10%. Urinary Catheterization/Urology Normal Saline (see comments) Good perineal washing CHG 4% (see comment) Shower night before and morning of surgery with CHG 4%. Rinse well. Open containers to be discarded and replaced after 24 hours Ortho: Cleanse daily and prn with normal saline; gently remove scabbing. Other Specialties: Check with MRP for orders. Saline used if discharge is present Pre-operative skin prep In-house Same day surgical admissions: Patient arrives with: only 1 application of CHG 4% Patient arrives with: no applications of CHG 4% completed; or allergy to CHG 4% 3 minutes CHG 4% (see comment) Coach patient to allow lather to remain on skin for 3 minutes Apply once to surgical area for 3 minutes. Rinse area thoroughly. As per VIHA Nursing Policy & Procedure Manual. PCMX; or Povidone Iodine scrub. Note: Once opened, bottles of sterile normal saline should be dated, and used up or discarded, preferably by the end of each shift and certainly within 24 hours of opening. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 179 VIHA Infection Prevention and Control Manual, September 1, 2011 2. Environment and Furniture in Patient Care Areas A. Furniture General All furniture should be constructed in a way that permits cleaning of all surfaces The size, shape and design of the furniture must allow easy access to cleaning staff Risk Levels Vinyl is required for furnishings in high risk areas High level of risk applies to any area specifically used by patients/residents (i.e. patient rooms, waiting rooms) and any area where a healthcare worker goes after providing direct patient care (e.g. nursing station, staff lounge, report area, conference rooms, offices within patient care areas Durable, cleanable fabrics are appropriate in low risk areas Low level of risk applies to any office areas where staff are not providing direct patient care, or return to after providing direct patient care Fabric Fabric must be impermeable to water, stain resistant and made of a material that does not promote the growth of microorganisms The material should be durable, easily cleaned and withstand cleaning with institutional cleaning/disinfecting solutions. Their selection should be based on an understanding of the principles of decontamination and maintenance requirements (e.g. able to withstand multiple application of diluted disinfectants over time) Limit the amount of pleating in fabric and make sure the seams are sealed There should be limited off-gassing from the fabric Other Materials Plastic laminate furniture offer good designs and realistic wood grain patterns. Another option combines polyurethane sealed woods on vertical surfaces with solid surfacing on horizontal surfaces The purchasing of new wood furniture is not recommended. Existing wood furniture must be assessed regularly to assure that the finish remains sealed (note: wood furniture requires regular maintenance to keep lacquer intact) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 180 VIHA Infection Prevention and Control Manual, September 1, 2011 Note: The above criteria apply to all clinical areas throughout the healthcare system – patient rooms, waiting rooms, unit offices (i.e. social worker, coordinator, manager), nurses‘ station, staff rooms and conference rooms. Fabric, if desired, is acceptable in administrative/executive offices and related meeting areas. B. Fixtures and Fittings General All fixtures and fittings should prevent the collection of dust and growth of mold, mildew and other microorganisms They must be easy to maintain, and have proven durability under actual conditions of use and maintenance in healthcare facilities Curtains and blinds Curtains can easily become contaminated with microorganisms. All curtains must be able to withstand a washing process at disinfection temperatures (71 c for 25 minutes or more), or be able to withstand the washing/drying sanitizing processes that occur in an industrial or institutional setting Venetian horizontal blinds are not recommended as they become dusty and difficult to clean. Certain vertical blinds may be acceptable if design allows appropriate cleaning Blinds need to be of a construction that allows cleaning of all surfaces and functional parts Fittings The use of lamps with fabric shades is not recommended If fabric shades used, the fabric must be removable and be able to withstand washing temperatures of 71 c for 3 minutes or 65 c for 10 minutes It is recommended to avoid lamps that have pull strings for operation, unless it is a material that is easily cleaned and will not rust Ceiling lights and wall mounted fixtures should have lenses and enclosed housings Vanity tops Vanity tops must be constructed of a solid surface material, with integrated bowl and backsplash Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 181 VIHA Infection Prevention and Control Manual, September 1, 2011 Handrails and Other Hardware Stainless steel remains the material of choice for handrails and other hardware, because of its durability and ease of maintenance Wood is acceptable if sealed, but requires ongoing maintenance Ceilings The ceiling must be cleanable and built to prevent the infiltration of dust from the plenum space The ceiling should be made of a material that does not promote the growth of microorganisms Walls Low volatile organic compound (VOC) scrub-able paint must be used If vinyl wall covering is selected, it should have minimal texture to facilitate thorough cleaning All wall coating/covering and adhesives used must have antimicrobial treatments where available Floors Sheet vinyl flooring with welded seams and an integral cove base Carpeting in patient care areas is strongly discouraged Posted Signage and Other Posted Materials Most signage presents a very low risk for transmission of organisms. Determination of whether a sign/poster that is posted should be laminated is based upon the following considerations: Length of time it is likely to be posted Whether the signage is for long term use and is stored between uses Whether the signage would require a wipe down of its surfaces when area is cleaned Risk of contamination based on where it will be posted – low frequency or high frequency touch areas Where it will be used – patient care area, staff rooms, office/business area. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 182 VIHA Infection Prevention and Control Manual, September 1, 2011 When a poster/sign is developed for posting and a decision needs to be made regarding lamination, the following four basic principles should be considered: 1. Laminate the poster/sign if it will be posted for a long-term period (30 days or greater), or stored and re-used (i.e. precaution signs) 2. Don‘t laminate if poster/sign is to be posted for short term (less than 30 days) 3. If not laminated, remove and replace if it becomes dirty, tattered, or torn 4. If the poster/sign is to be posted in a patient or staff bathroom or dirty utility room, it must be laminated regardless of the duration of use Please note: Sheet protectors are not recommended as an alternate to lamination because they cannot be easily cleaned and require tape to seal the top. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 183 VIHA Infection Prevention and Control Manual, September 1, 2011 APPENDICES APPENDIX A: Type and Duration of Additional Precautions Where Recommended for Selected Infections and Conditions Legend: Precautions used in addition to Routine Practices Type of Precautions: A - AIRBORNE C - CONTACT D - DROPLET R - ROUTINE PRACTICES Duration of Precautions: CN DI - Until off antimicrobial treatment and culture negative DE U - Until the environment is completely decontaminated Unknown - Criteria for establishing eradication of pathogen has not bee determined Duration of illness (with wound lesions, DI means until wounds stop draining) Until time specified in hours (hrs) after initiation of effective therapy Adapted from: Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: preventing Transmission of Infectious Agents in Healthcare Settings, June 2007 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 184 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments Draining, major C DI No dressing or containment of drainage; until drainage stops or can be contained by dressing. Draining, minor or limited R Dressing covers and contains drainage. Acquired human immunodeficiency syndrome (HIV) R Post-exposure chemoprophylaxis for some blood and body fluid exposures. Actinomycosis R Not transmitted from person to person. Amebiasis R Person to person transmission is rare. Transmission in settings for the mentally challenged and in a family group has been reported. Use care when handling diapered infants and mentally challenged persons. Anthrax R Infected patients/residents do not generally pose a transmission risk. Cutaneous Anthrax R Transmission through non-intact skin contact with draining lesions possible, therefore use Contact Precautions if large amount of uncontained drainage. Handwashing with soap and water preferable to use of waterless alcohol based antiseptics since alcohol does not have sporicidal activity. Pulmonary Anthrax R Not transmitted from person to person. Environmental Anthrax: aerosolizable spore-containing powder or other substance R Abscess Adenovirus infection (see agentspecific guidance under gastroenteritis, conjunctivitis, pneumonia) DE Until decontamination of environment complete. Wear respirator (N95 mask or PAPRs), protective clothing; decontaminate persons with powder on them. Hand hygiene: Handwashing for 30-60 seconds with soap and water or 2% chlorhexidine gluconate after spore contact (alcohol based hand rubs inactive against spores). Post-exposure prophylaxis following environmental exposure: 60 days of antimicrobials (either doxycycline or ciprofloxacin) and post-exposure Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 185 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments vaccine under IND. Antibiotic-associated colitis (see Clostridium difficile) Antibiotic Resistant Organisms (AROs), infection or colonization (e.g. MRSA, VRE, VISA/VRSA, ESBLs, resistant S. pneumoniae) R/C Arthropod-borne viral encephalitides (eastern, western, Venezuelan equine encephalomyelitis; St. Louis, California encephalitis; West Nile Virus) and viral fevers (dengue, yellow fever, Colorado tick fever) R Not transmitted from person to person except rarely by transfusion, and for West Nile virus by organ transplant, breastmilk or transplacentally. Install screens in windows and doors in endemic areas. Use DEET-containing mosquito repellents and clothing to cover extremities. Ascariasis R Not transmitted from person to person. Aspergillosis R Contact Precautions and Airborne Precautions if massive soft tissue infection with copious drainage and repeated irrigations required. Babesiosis R Not transmitted from person to person except rarely by transfusion. Blastomycosis, North American, cutaneous or pulmonary R Not transmitted from person to person. Botulism R Bronchiolitis (see respiratory infections in infants and young children) C Brucellosis (undulant, Malta, Mediterranean fever) R AROs judged by the Infection Prevention and Control Program, based on local, provincial or national recommendations, to be of clinical and epidemiologic significance. Contact Precautions recommended in settings with evidence of ongoing transmission, acute care settings with increased risk for transmission or wounds that cannot be contained by dressings. Avian influenza (see influenza, avian, below) Not transmitted from person to person. DI Use mask according to Routine Practices. (Droplet precautions if patient coughing). Not transmitted from person to person except rarely via banked spermatozoa and sexual contact. Provide antimicrobial prophylaxis following laboratory exposure and monitor serology. Campylobacter gastroenteritis (see gastroenteritis) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 186 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Candidiasis, all forms including mucocutaneous R Cat-scratch fever (benign inoculation lymphoreticulosis) R Cellulitis R Chancroid (soft chancre) (H.ducreyi) R Chickenpox (see varicella) A Duration Comments Not transmitted from person to person. Transmitted sexually from person to person. Chlamydia trachomatis Conjunctivitis R Genital (lymphogranuloma Venereum) R Pneumonia (infants 3 months of age or less) R R Outbreaks in institutionalized populations reported, rarely. Open drain in place; limited or minor drainage R Contact Precautions if there is copious uncontained drainage. No drain or closed drainage system in place R Chlamydia pneumoniae Cholera (see Gastroenteritis) Closed-cavity infection Clostridium C. botulinum R C. difficile (see Gastroenteritis) C Not transmitted from person to person DI C. perfringens Food poisoning R Not transmitted from person to person. Gas gangrene R Transmission from person to person rare; one outbreak in a surgical setting reported. Use Contact Precautions if wound drainage is extensive. Draining lesions R Not transmitted from person to person. Pneumonia R Not transmitted from person to person. Colorado tick fever R Not transmitted from person to person. Congenital rubella C Coccidioidomycosis (valley fever) Until 1 year of age Routine Practices if nasopharyngeal and urine cultures repeatedly negative after 3 months of age. Conjunctivitis Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 187 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Acute bacterial R Chlamydia R Gonococcal R Acute viral (acute hemorrhagic) C Duration Comments DI Adenovirus most common; Enterovirus 70, Coxsackie virus A24, also associated with community outbreaks. Highly contagious; outbreaks in eye clinics, pediatric and neonatal settings, institutional settings reported. Eye clinics should follow Routine Practices when handling patients/residents with conjunctivitis. Routine use of infection prevention and control measures in the handling of instruments and equipment, and disinfection of eye equipment between patients/residents, will prevent the occurrence of outbreaks in this and other settings. Corona virus associated with SARS (SARS-CoV) (see severe acute respiratory syndrome) Coxsackie virus disease (see enteroviral infection) Creutzfeldt-Jakob disease (CJD, vCJD) R Use disposable instruments or special sterilization/ disinfection for surfaces, objects contaminated with neural tissue if CJD or vCJD suspected and has not been ruled out; No special burial procedures. Croup (see respiratory infections in infants and young children) Crimean-Congo Fever (see Viral Hemorrhagic Fever) R Cryptococcosis R Cryptosporidiosis (see also gastroenteritis) C Cysticercosis R Not transmitted from person to person. Cytomegalovirus infection, including in neonates and immunosuppressed patients/residents. R No additional precautions for pregnant Healthcare Workers (requires saliva contact for transmission). Decubitus ulcer (see pressure ulcer) R Not transmitted from person to person. Dengue fever R Not transmitted from person to person. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Not transmitted from person to person. Page 188 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Comments Type Duration Cutaneous C CN Until 2 cultures taken 24 hrs apart negative Pharyngeal D CN Until on appropriate treatment and 2 cultures taken 24 hrs apart negative. Diarrhea, acute-infective etiology suspected (see gastroenteritis) Diphtheria Ebola virus (see viral hemorrhagic fevers) Echinococcosis (hydatidosis) R Not transmitted from person to person. Echovirus (see enteroviral infection) Encephalitis or encephalomyelitis (see specific etiologic agents) Endometritis (endomyometritis) R Enterobiasis (pinworm disease, oxyuriasis) R Enterococcus species (see multidrugresistant organisms if epidemiologically significant or vancomycin resistant) Enterocolitis, C. difficile (see C. difficile, gastroenteritis) Enteroviral infections (i.e. Group A and B Coxsackie viruses and Echo viruses) (excludes polio virus) R Epiglottitis, due to Haemophilus influenzae type b D Epstein-Barr virus infection, including infectious mononucleosis R Use Contact Precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks. U 24 hrs Erythema Infectiosum (also see Parvovirus B19) See specific disease agents for epiglottitis due to other etiologies) Pregnant staff should not provide care. Escherichia coli gastroenteritis (see gastroenteritis) Food poisoning Botulism R Not transmitted from person to person. C. perfringens or welchii R Not transmitted from person to person. Staphylococcal R Not transmitted from person to person. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 189 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Furunculosis, staphylococcal Infants and young children Duration R C Comments Contact Precautions if drainage not controlled. Follow institutional policies if MRSA. DI R Not transmitted from person to person. C/D Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks for gastroenteritis caused by all of the agents below. Adenovirus R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Campylobacter species R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Cholera (Vibrio cholerae) R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. C. difficile C DI Cryptosporidium species C DI Gangrene (gas gangrene) Gastroenteritis Discontinue antibiotics if possible. Do not share electronic thermometers; ensure consistent environmental cleaning and disinfection. Hypochlorite solutions are required for cleaning for all cases. Handwashing with soap and water preferred because of the absence of sporicidal activity of alcohol in alcohol-based hand rubs. E. coli Enteropathogenic O157:H7 and other shiga toxin-producing strains R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Other species R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional Giardia lamblia Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 190 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Comments Type Duration C/D DI Use Contact Precautions for all infected and exposed cases for the duration of illness and to control institutional outbreaks. Persons who clean areas heavily contaminated with feces or vomitus may benefit from wearing masks since virus can be aerosolized from these body substances; ensure consistent environmental cleaning and disinfection with focus on bathrooms even when apparently unsoiled. Hypochlorite solutions are required for cleaning for all cases. Alcohol is less active, but there is no evidence that alcohol based hand rubs are not effective for hand decontamination. Cohorting of affected patients/residents to separate airspaces and toilet facilities may help interrupt transmission during outbreaks. Rotavirus C DI Ensure consistent environmental cleaning and disinfection and frequent removal of soiled diapers. Prolonged shedding may occur in both immunocompetent and immunocompromised children and the elderly. Salmonella species (including S. typhi) R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Shigella species (Bacillary dysentery) R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. Vibrio parahaemolyticus R Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. C/D Use Contact Precautions for incontinent persons of any age for the duration of illness or to control institutional outbreaks. outbreaks. Noroviruses Viral (if not covered elsewhere) Yersinia enterocolitica R Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Use Contact Precautions for diapered or incontinent persons for the duration Page 191 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments of illness or to control institutional outbreaks. German measles (see rubella; see congenital rubells) Giardiasis (see gastroenteritis) Gonococcal Ophthalmia neonatorum (gonorrheal Ophthalmia, acute conjunctivitis of newborn) R Gonorrhea Granuloma inguinale (Donovanosis, granuloma venereum) R Guillain-Barré syndrome Not an infectious condition. Haemophilus influenzae (see disease-specific recommendations) Hand, foot and mouth disease (see enteroviral infection) Hansen‘s Disease (see Leprosy) Hantavirus pulmonary syndrome R Helicobacter pylori R Not transmitted from person to person Hepatitis, viral Type A R Provide Hepatitis A vaccine postexposure as recommended by Public Health. Incontinent patients/residents with diarrhea C Maintain Contact Precautions in infants and children less than 3 years of age for duration of hospitalization; for children 3 – 14 years of age for 2 weeks after onset of symptoms; more than 14 years of age for 1 week after onset of symptoms. Type B – HbsAg positive; acute or chronic R See specific recommendations for care of patients/residents in hemodialysis centres Type C and other unspecified non-A, non-B R See specific recommendations for care of patients/residents in hemodialysis centres. Type D (seen only with hepatitis B) R Type E R Type G R Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Use Contact Precautions for all symptomatic individuals and incontinent individuals for the duration of illness. Page 192 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments Herpangina (see enteroviral infection) Hookworm R Herpes simplex (Herpesvirus hominis) Encephalitis R Mucocutaneous, disseminated or primary, severe C Until lesions dry and crusted Mucocutaneous, recurrent (skin, oral, genital) C Until lesions dry and crusted Neonatal C Until lesions dry and crusted Disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out A/C DI Susceptible healthcare workers should not enter room if immune caregivers are available; no recommendation for protection of immune healthcare workers; no recommendation for type of protection, i.e. surgical mask or respirator, for susceptible healthcare workers. Localized in patient with intact immune system with lesions that can be contained/ covered. R DI Susceptible healthcare workers should not provide direct patient care when other immune caregivers are available. Also, for asymptomatic, exposed infants delivered vaginally or by CSection and if mother has active infection and membranes have been ruptured for more than 4 to 6 hrs until infant surface cultures obtained at 2436 hrs of age are negative. Herpes zoster (varicella-zoster) (shingles) Histoplasmosis R Not transmitted from person to person. Human immunodeficiency virus (HIV) R Post-exposure chemoprophylaxis for some blood and body fluid exposures. Human metapneumovirus C DI Impetigo C U 24 hrs Note: In this document the term ―patient‖ is inclusive of patient, resident or client. HAI reported, but route of transmission not established. Assumed to be Contact / Droplet transmission as for RSV since the viruses are closely related and have similar clinical manifestations and epidemiology. Wear masks according to Routine Practices. Page 193 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Infectious mononucleosis Duration Comments 5 days except Single patient room when available or cohort; avoid placement with high-risk patients/residents; mask patient when transported out of room; chemoprophylaxis / vaccine to control / prevent outbreaks. Use gown and gloves according to Routine Practices; may be especially important in pediatric settings. Duration of precautions for immuno-compromised patients/residents cannot be defined; prolonged duration of viral shedding (i.e. for several weeks) has been observed; implications for transmission are unknown. R Influenza Human (seasonal influenza) D DI in immunocompromised persons Avian (e.g. H5N1, H7, H9 strains) Pandemic influenza (also a human influenza virus) See www.cdc.gov/flu/avian/professional/infe ct-control.htm for current avian influenza guidance. D 5 days Kawasaki syndrome See http://www.pandemicflu.gov for current pandemic influenza guidance. Not an infectious condition. Lassa fever (see viral hemorrhagic fevers) Legionnaires‘ disease Not transmitted from person to person. Leprosy R Leptospirosis R Not transmitted from person to person. Lice http://www.cdc.gov/ncidod/dpd/parasite s/lice/default.htm Head (Pediculosis) C Body R Transmitted person to person through infested clothing. Wear gown and gloves when removing clothing; bag and wash clothes according to CDC guidance above. Pubic R Transmitted person to person through sexual contact. Listeriosis (listeria monocytogenes) R Person-to-person transmission rare; cross-transmission in neonatal settings and endoscopy. Lyme disease R Not transmitted from person to person. U 4 hrs Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 194 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Lymphocytic choriomeningitis R Lymphogranuloma venereum R Malaria R Duration Comments Not transmitted from person to person. Not transmitted from person to person except through transfusion rarely and through a failure to follow Routine Practices during patient care. Install screens in windows and doors in endemic areas. Use DEET-containing mosquito repellents and clothing to cover extremities. Marburg virus disease (see viral hemorrhagic fevers) Measles (rubeola) A Melioidosis, all forms R Not transmitted from person to person. Aseptic (nonbacterial or viral; also see enteroviral infections) R Contact Precautions for infants and young children. Bacterial, gram-negative enteric, in neonates R Fungal R Haemophilus influenzae, type B, known or suspected D Listeria monocytogenes (See Listeriosis) R Neisseria meningitidis (meningococcal) known or D 4 days after onset of rash; DI in immunocompromised Susceptible healthcare workers should not enter room if immune care providers are available; no recommendation for face protection for immune healthcare worker; no recommendation for type of face protection for susceptible healthcare workers, i.e. mask or respirator. For exposed susceptibles, post-exposure vaccine within 72 hrs or immune globulin within 6 days when available. Place exposed susceptible patients/residents on Airborne Precautions and exclude susceptible healthcare workers from duty from day 5 after first exposure to day 21 after last exposure, regardless of post-exposure vaccine. Meningitis U 24 hrs U 24 hrs Note: In this document the term ―patient‖ is inclusive of patient, resident or client. See meningococcal disease below Page 195 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments suspected Streptococcus pneumoniae R M. tuberculosis R Other diagnosed bacterial R Meningococcal disease: sepsis, pneumonia, meningitis D Molluscum contagiosum R Monkeypox Mucormycosis A/C Concurrent, active pulmonary disease or draining cutaneous lesions may necessitate addition of Contact and/or Airborne Precautions. For children, Airborne Precautions until active tuberculosis ruled out in visiting family members (see tuberculosis below). U 24 hrs Post-exposure chemoprophylaxis and immunoprophylaxis for household contacts, healthcare workers exposed to respiratory secretions. A-Until monkeypox confirmed and smallpox excluded; C-Until lesions crusted See www.cdc.gov/ncidod/monkeypox for most current recommendations. Transmission in hospital settings unlikely. Pre- and post-exposure smallpox vaccine recommended for exposed healthcare workers. R Multidrug-resistant organisms (MDROs) (See Antibiotic Resistant Organisms) Mumps (infectious parotitis) D U 9 days Mycobacteria, non-tuberculosis (atypical) After onset of swelling susceptible healthcare workers should not provide care if immune caregivers are available. Note: Recent assessment of outbreaks in health 18-24 year olds has indicated that salivary viral shedding occurred early in the course of illness and that 5 days of Additional Precautions after onset of parotitis may be appropriate in community settings; however, the implications for healthcare personnel and high-risk patient populations remain to be clarified. Not transmitted from person to person. Pulmonary R Wound R Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 196 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Comments Type Duration Mycoplasma pneumonia D DI Necrotizing enterocolitis R Contact Precautions when cases clustered temporally. Nocardiosis, draining lesions, or other presentations R Not transmitted from person to person. Norovirus (see gastroenteritis) Norwalk agent gastroenteritis (see gastroenteritis) Orf R Parainfluenza virus infection, respiratory in infants and young children C Parvovirus B19 (Erythema Infectiosum) D Pediculosis (lice) C U 24 hrs after treatment Pertussis (whooping cough) D U 5 days Single patient room preferred. Cohorting an option. Post-exposure chemoprophylaxis for household contacts and healthcare workers with prolonged exposure to respiratory secretions. Recommendations for Tdap vaccine in adults (pediatric nurses, doctors) under development. Pinworm infection (Enterobiasis) R DI Viral shedding may be prolonged in immuno-suppressed patients/residents. Maintain precautions for duration of hospitalization when chronic disease occurs in an immuno-compromised patient. For patients/residents with transient aplastic crisis or red-cell crisis, maintain precautions for 7 days. Duration of precautions for immunosuppressed patients/residents with persistently positive PCR not defined, but transmission has occurred. Pregnant staff should not provide care. Plague (Yersinia pestis) Bubonic R Pneumonic D U 48 hrs Antimicrobial prophylaxis for exposed healthcare worker. D/C DI Outbreaks in pediatric and institutional settings reported. In immuno- Pneumonia Adenovirus Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 197 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments compromised hosts, extend duration of Droplet and Contact Precautions due to prolonged shedding of virus. Bacterial not listed elsewhere (including gram-negative bacterial) R B. cepacia in patients/residents with Cystic Fibrosis (CF), including respiratory tract colonization C Avoid exposure to other persons with CF; private room preferred, including clinic visits. Criteria for discontinuing Precautions not established. Use Precautions for duration of hospitalization if other CF patients/residents on the unit. See CF Foundation guideline. B. cepacia in patients/residents without Cystic Fibrosis (see Antibiotic Resistant Organisms) Chlamydia R Fungal R Haemophilus influenzae, type b Adults R Infants and children C U 24 hrs Legionella spp. R Meningococcal D U 24 hrs Mycoplasma (primary atypical pneumonia) D DI Pneumococcal pneumonia R Pneumocystis jiroveci (Pneumocystis carinii) R Staphylococcus aureus R See meningococcal disease above Multidrug resistant bacterial (see Antibiotic Resistant Organisms) Streptococcus, group A Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Use Droplet Precautions if evidence of transmission within a patient care unit or facility. For MRSA, see Antibiotic Resistant Organisms For Invasive Group A Streptococcus, Contact or Droplet Precautions for 24 hrs until appropriate antibiotic treatment given. Includes pneumonia, toxic shock syndrome, necrotizing fasciitis, but not cellulitis. Page 198 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Comments Type Duration Adults D U 24 hrs See streptococcal disease (group A streptococcus) below. Contact Precautions if skin lesions present. Infants and young children D U 24 hrs Contact Precautions if skin lesions present. Varicella-zoster (See Varicellazoster) Viral Adults R Infants and young children (see respiratory infectious disease, acute, or specific viral agent) C DI Major C DI Minor or limited R If dressing covers and contains drainage. Psittacosis (ornithosis) (Chlamydia psittaci) R Not transmitted from person to person. Q fever R Rabies R Person to person transmission rare; transmission via corneal, tissue and organ transplants has been reported. If patient has bitten another individual or saliva has contaminated an open wound or mucous membrane, wash exposed area thoroughly and administer post-exposure prophylaxis. Rat-bite fever (Streptobacillus moniliformis disease, Spirillum minus disease) R Not transmitted from person to person. Relapsing fever R Not transmitted from person to person. Poliomyelitis Pressure ulcer (Decubitus ulcer, pressure sore) infected If no dressing or containment of drainage – until drainage stops or can be contained by dressing. Prion disease (See Creutzfeld-Jacob Disease) Resistant bacterial infection or colonization (see Antibiotic Resistant Organisms) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 199 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments Respiratory infectious disease, acute (if not covered elsewhere) Adults R Infants and young children C DI Respiratory syncytial virus infection, in infants, young children and immuno-compromised adults C DI Reye‘s syndrome R Not an infectious condition. Rheumatic fever R Not an infectious condition. Rhinovirus D Rickettsial fevers, tickborne (Rocky Mountain spotted fever, tickborne typhus fever) R Not transmitted from person to person except through transfusion, rarely. Rickettsialpox (vesicular rickettsiosis) R Not transmitted from person to person. Ringworm (Dermatophytosis, dermatomycosis, tinea) R Rarely, outbreaks have occurred in healthcare settings (e.g. NICU, rehabilitation hospital. Use Contact Precautions for outbreak. Ritter‘s disease (staphylococcal scalded skin syndrome) C Rocky Mountain spotted fever R Roseola infantum (exanthem subitum; caused by HHV-6) R DI DI Wear mask according to Routine Practices. In immuno-compromised patients/residents, extend the duration of Contact Precautions due to prolonged shedding. Droplet most important route of transmission. Outbreaks have occurred in NICUs and LTCFs. Add Contact Precautions if copious moist secretions and close contact likely to occur (e.g. young infants). See staphylococcal disease, scalded skin syndrome below. Not transmitted from person to person except through transfusion, rarely. Rotavirus infection (see gastroenteritis) Rubella (German measles) (also see congenital rubella) D U 7 days after onset of rash Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Susceptible healthcare workers should not enter room if immune caregivers are available. No recommendation for wearing face protection (e.g. a surgical mask) if immune. Pregnant women who are not immune should not care for these patients/residents. Administer vaccine within three days of exposure to non-pregnant susceptible individuals. Place exposed susceptible Page 200 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments patients/residents on Droplet Precautions; exclude susceptible healthcare personnel from duty from day 5 after first exposure to day 21 after last exposure, regardless of postexposure vaccine. Rubeola (see measles) Salmonellosis (see gastroenteritis) Scabies C U 24 hrs following treatment Scalded skin syndrome, staphylococcal C DI Schistosomiasis (bilharziasis) R Severe acute respiratory syndrome (SARS) A/D/C DI plus 10 days after resolution of fever, provided respiratory symptoms are absent or improving See staphylococcal disease, scalded skin syndrome below. Airborne Precautions preferred; Droplet Precautions if Airborne Infection Isolation Room unavailable. N95 or higher respiratory protection; surgical mask if N95 unavailable; eye protection (goggles, face shield); aerosolgenerating procedures and ―super shedders‖ highest risk for transmission via small droplet nuclei and large droplets. Vigilant environmental disinfection. (See www.cdc.gov/ncidod/sars) Shigellosis (see gastroenteritis) Smallpox (variola; see vaccinia for management of vaccinated persons) A/C Sporotrichosis R Spirillum minor disease (rat-bite fever) R DI Until all scabs have crusted and separated (3–4 weeks). Nonvaccinated healthcare workers should not provide care when immune healthcare workers are available; N95 or higher respiratory protection for susceptible and successfully vaccinated individuals; post-exposure vaccine within 4 days of exposure protective. Not transmitted from person to person. Staphylococcal disease (S. aureus) Skin, wound, or burn Major C DI Note: In this document the term ―patient‖ is inclusive of patient, resident or client. No dressing or dressing does not contain drainage adequately. Page 201 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Minor or limited Duration R Comments Dressing covers and contains drainage adequately. Multi-drug resistant (see Antibiotic Resistant Organisms) Pneumonia R Scalded skin syndrome C Toxic shock syndrome R Streptobacillus moniliformis disease (rat-bite fever) R DI Consider healthcare personnel as potential source of nursery, NICU outbreak. Not transmitted from person to person Streptococcal disease (group A streptococcus) Invasive Group A Streptococcus (iGAS) (including pneumonia, toxic shock syndrome, necrotizing fasciitis, but not cellulitis) D U 24 hrs Outbreaks of serious invasive disease have occurred secondary to transmission among patients/residents and healthcare personnel. Contact Precautions for draining wounds as below; follow recommendations for antimicrobial prophylaxis in selected conditions. C/D U 24 hrs No dressing or dressing does not contain drainage adequately Skin, wound, or burn Major Minor or limited R Dressing covers and contains drainage adequately Endometritis (puerperal sepsis) R Pharyngitis in infants and young children D U 24 hrs Pneumonia D U 24 hrs Scarlet fever in infants and young children D U 24 hrs Streptococcal disease (group B streptococcus), neonatal R Streptococcal disease (not group A or B) unless covered elsewhere R Multidrug-resistant (see Antibiotic Resistant Organisms) Strongyloidiasis R Syphilis Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 202 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments Latent (tertiary) and seropositivity without lesions R Skin and mucous membrane, including congenital R Contact Precautions for primary or secondary stage of disease. Hymenolepsis nana R Not transmitted from person to person. Taenia solium (pork) R Not transmitted from person to person. Other R Not transmitted from person to person. Tetanus R Not transmitted from person to person. Tinea (e.g. Dermatophytosis, dermatomycosis, ringworm) R Rare episodes of person-to-person transmission. Toxoplasmosis R Transmission from person to person is rare; vertical transmission from mother to child, transmission through organs and blood transfusion rare. Toxic shock syndrome (staphylococcal disease, streptococcal disease) R Droplet Precautions for the first 24 hrs after implementation of antibiotic therapy if Group A streptococcus is a likely etiology. Trachoma, acute R Tapeworm disease Transmissible spongiform encephalopathy (see CreutzfeldJacob disease, CJD, vCJD) Trench mouth (Vincent‘s angina) R Trichinosis R Trichomoniasis R Trichuriasis (whipworm disease) R Tuberculosis (M. tuberculosis) A/C Discontinue precautions only when patient is improving clinically, and drainage has ceased or there are three consecutive (one week apart) negative cultures of continued drainage. Examine for evidence of active pulmonary tuberculosis. Extrapulmonary, no draining lesion, meningitis R Examine for evidence of pulmonary tuberculosis. For infants and children, use Airborne Precautions until active pulmonary tuberculosis in visiting family members ruled out. Pulmonary or laryngeal disease, confirmed A Discontinue precautions only after consultation with Infection Prevention & Extrapulmonary, draining lesion Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 203 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments Control Practitioner (minimum of 2 weeks on treatment, clinical improvement, and three consecutive sputum smears negative for acid-fast bacilli collected on separate days). Reference BCCDC. Pulmonary or laryngeal disease, suspected A Skin-test positive with no evidence of current active disease R Discontinue precautions only when the likelihood of infectious TB disease is deemed negligible, and either 1) there is another diagnosis that explains the clinical syndrome, or 2) the results of three sputum or BAL smears for AFB are negative. Each of the three specimens should be collected 24 hrs apart, preferably early each morning. Tularemia Draining lesion R Not transmitted from person to person. Pulmonary R Not transmitted from person to person. Rickettsia prowazekii (Epidemic or Louse-borne typhus) R Transmitted from person to person through close personal or clothing contact. Rickettsia typhi R Not transmitted from person to person. Typhoid (Salmonella typhi) fever (see gastroenteritis) Typhus Urinary tract infection (including pyelonephritis), with or without urinary catheter R Vaccinia (vaccination site, adverse events following vaccination) Vaccination site care (including autoinoculated areas) Only vaccinated healthcare workers have contact with active vaccination sites and care for persons with adverse vaccinia events; if unvaccinated, only healthcare workers without contraindications to vaccine may provide care. R Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Vaccination recommended for vaccinators; for newly vaccinated healthcare workers: semi-permeable dressing over gauze until scab separates, with dressing change as fluid accumulates, approx. 3–5 days; Page 204 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments gloves, hand hygiene for dressing change; vaccinated healthcare worker or healthcare worker without contraindication to vaccine for dressing changes. Eczema vaccinatum C Fetal vaccinia C Generalized vaccinia C Progressive vaccinia C Until lesions dry and crusted, scabs separated For contact with virus-containing lesions and exudative material Post vaccinia encephalitis Blepharitis or conjunctivitis R/C Iritis or keratitis R Vaccinia-associated erythema multiforme (Stevens Johnson Syndrome) R Secondary bacterial infection (e.g. S. aureus, group A beta hemolytic streptococcus) R/C Varicella Zoster Use Contact Precautions if there is copious drainage. Not an infectious condition. A/C Follow organism-specific (strep, staph most frequent) recommendations and consider magnitude of drainage. Until lesions dry and crusted Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Susceptible healthcare workers should not enter room if immune caregivers are available; no recommendation for face protection of immune healthcare workers; no recommendation for type of protection, i.e. surgical mask or respirator for susceptible healthcare workers. In immuno-compromised host with varicella pneumonia, prolong duration of precautions for duration of illness. Post-exposure prophylaxis: provide post-exposure vaccine ASAP but within 120 hours; for susceptible exposed persons for whom vaccine is contraindicated (immuno-compromised persons, pregnant women, newborns whose mother‘s varicella onset is 5 days or less before delivery or within 48 hrs after delivery) provide VZIG, when available, within 96 hours; if unavailable, use IVIG; Use Airborne Precautions for exposed susceptible persons and exclude exposed susceptible healthcare workers beginning 8 days after first exposure Page 205 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Duration Comments until 21 days after last exposure or 28 days if received VZIG, regardless of post-exposure vaccination. Variola (see smallpox) Vibrio parahaemolyticus (see gastroenteritis) Vincent‘s angina (trench mouth) R Viral hemorrhagic fevers, due to Lassa, Ebola, Marburg, CrimeanCongo fever viruses A DI Single-patient negative pressure room preferred. Emphasize: 1) use of sharps safety devices and safe work practices; 2) hand hygiene; 3) barrier protection against blood and body fluids upon entry into room (single gloves and fluid-resistant or impermeable gown, face/eye protection with masks, goggles or face shields); and 4) appropriate waste handling. Use N95 or higher respirators when performing aerosol-generating procedures. Largest viral load in final stages of illness when hemorrhage may occur; additional PPE, including double gloves, leg and shoe coverings may be used, especially in resource-limited settings where options for cleaning and laundry are limited. Notify public health officials immediately if Ebola is suspected. No dressing or dressing does not contain drainage adequately. Viral respiratory diseases (not covered elsewhere Adults R Infants and young children (see respiratory infectious disease, acute) Whooping cough (see pertussis) Wound infections Major C DI Minor or limited R DI Yersinia enterocolitica gastroenteritis (see gastroenteritis) Zoster (varicella-zoster) (see herpes zoster) Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 206 VIHA Infection Prevention and Control Manual, September 1, 2011 TYPE AND DURATION OF ROUTINE PRACTICES AND PRECAUTIONS RECOMMENDED FOR SELECTED INFECTIONS AND CONDITIONS Infection/Condition Precautions Type Zygomycosis (phycomycosis, mucormycosis) Duration R Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Comments Not transmitted from person to person. Page 207 VIHA Infection Prevention and Control Manual, September 1, 2011 APPENDIX B: Glossary of Terms Admission Restrictions – any restrictions placed on unit during an outbreak that limits the normal admission pattern (e.g. no off-service admissions to a unit) Aseptic technique. The measures taken to purposefully reduce the number of microorganisms (germs) to an irreducible number for the purpose of preventing transmission of infection. These include handwashing, disinfection and sterilization Antisepsis/Sanitation. This method of infection prevention and control includes using soap and water to wash the hands and body as well as the use of antiseptics such as alcohol, iodine and betadine to clean the skin for medical procedures, as these inhibit the growth of pathogenic microorganisms. This level of asepsis may kill or inhibit some microbes but is generally not effective against spores. American Institute of Architects. A professional organization that develops standards for building ventilation, The ―2001Guidelines for Design and Construction of Hospital and Health Care Facilities‖, the development of which was supported by the AIA, Academy of Architecture for Health, Facilities Guideline Institute, with assistance from the U.S. Department of Health and Human Services and the National Institutes of Health, is the primary source of guidance for creating airborne infection isolation rooms (AIIRs) and protective environments. Ambulatory care settings. Facilities that provide healthcare to patients/residents who do not remain overnight (e.g. hospital-based outpatient clinics, nonhospital-based clinics and physician offices, urgent care centers, surgicenters, free-standing dialysis centers, public health clinics, imaging centers, ambulatory behavioral health and substance abuse clinics, physical therapy and rehabilitation centers, dental practices and outpatient clinics. Antibiotic Resistant organisms (AROs). Also known as multidrug resistant organisms (MDRO). In general, bacteria that are resistant to several classes of antimicrobial agents and usually are resistant to most commercially available antimicrobial agents (e.g. MRSA, VRE, extended spectrum beta-lactamase [ESBL]-producing or intrinsically resistant gram-negative bacilli). Bed closure – a bed space is closed to admissions or transfers in Bioaerosols. An airborne dispersion of particles containing whole or parts of biological entities, such as bacteria, viruses, dust mites, fungal hyphae, or fungal spores. Such aerosols usually consist of a mixture of mono-dispersed and aggregate cells, spores or viruses, carried by other materials, such as respiratory secretions and/or inert particles. Infectious bioaerosols (i.e. those that contain biological agents capable of causing an infectious disease) can be generated from human sources (e.g. expulsion from the respiratory tract during coughing, sneezing, talking or singing; during suctioning or wound irrigation), wet environmental sources (e.g. HVAC and cooling tower water with Legionella) or dry sources Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 208 VIHA Infection Prevention and Control Manual, September 1, 2011 (e.g. construction dust with spores produced by Aspergillus spp.). Bioaerosols include large respiratory droplets and small droplet nuclei (Cole EC. AJIC 1998;26: 453-64). Caregivers. All persons who are not employees of an organization, are not paid, and provide or assist in providing healthcare to a patient (e.g. family member, friend) and acquire technical training as needed based on the tasks that must be performed. Cohorting. In the context of this guideline, this term applies to the practice of grouping patients/residents infected or colonized with the same infectious agent together to confine their care to one area and prevent contact with susceptible patients/residents (cohorting patients/residents). During outbreaks, healthcare personnel may be assigned to a cohort of patients/residents to further limit opportunities for transmission (cohorting staff). Colonization. An individual who has been found to be culture positive at one or more body sites but who has no signs or symptoms of infection. Disinfection: The process of using chemical agents or boiling water to destroy or kill pathogenic microbes. Droplet nuclei. Microscopic particles more than 5 microns in size that are the residue of evaporated droplets and are produced when a person coughs, sneezes, shouts, or sings. These particles can remain suspended in the air for prolonged periods of time and can be carried on normal air currents in a room or beyond, to adjacent spaces or areas receiving exhaust air. Engineering controls. Removal or isolation of a workplace hazard through technology. AIIRs, a Protective Environment, engineered sharps injury prevention devices and sharps containers are examples of engineering controls. Epidemiologically important pathogens. Infectious agents that have one or more of the following characteristics: 1) are readily transmissible; 2) have a proclivity toward causing outbreaks; 3) may be associated with a severe outcome; or 4) are difficult to treat. Examples include Acinetobacter sp., Aspergillus sp., Burkholderia cepacia, Clostridium difficile, Klebsiella or Enterobacter sp., extended-spectrum-beta-lactamase producing gram negative bacilli [ESBLs], methicillin-resistant Staphylococcus aureus [MRSA], Pseudomonas aeruginosa, vancomycin-resistant enterococci [VRE], methicillin resistant Staphylococcus aureus [MRSA], vancomycin resistant Staphylococcus aureus [VRSA] influenza virus, respiratory syncytial virus [RSV], rotavirus, SARS CoV, noroviruses and the hemorrhagic fever viruses). Hand hygiene. A general term that applies to any one of the following: 1) handwashing with plain (nonantimicrobial) soap and water); 2) antiseptic hand rub (waterless antiseptic product, most often alcohol-based, rubbed on all surfaces of hands); or 3) surgical hand antisepsis (antiseptic hand wash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient hand flora and reduce resident hand flora). Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 209 VIHA Infection Prevention and Control Manual, September 1, 2011 Healthcare-associated infection (HAI). An infection that develops in a patient who is cared for in any setting where healthcare is delivered (e.g. acute care hospital, chronic care facility, ambulatory clinic, dialysis center, surgicenter) and is related to receiving healthcare (i.e. was not incubating or present at the time healthcare was provided). In ambulatory and home settings, HAI would apply to any infection that is associated with a medical or surgical intervention within the previous one year. Since the geographic location of infection acquisition is often uncertain, the preferred term is considered to be healthcare-associated rather than healthcare-acquired. Healthcare personnel, healthcare worker (HCW). All paid and unpaid persons who work in a healthcare setting (e.g. any person who has professional or technical training in a healthcare-related field and provides patient care in a healthcare setting or any person who provides services that support the delivery of healthcare such as dietary, housekeeping, engineering, maintenance personnel). Hematopoietic stem cell transplantation (HSCT). Any transplantation of blood or bone marrow-derived hematopoietic stem cells, regardless of donor type (e.g. allogeneic or autologous) or cell source (e.g. bone marrow, peripheral blood, or placental/umbilical cord blood); associated with periods of severe immunosuppression that vary with the source of the cells, the intensity of chemotherapy required, and the presence of graft versus host disease (MMWR 2000; 49: RR-10). High-efficiency particulate air (HEPA) filter. An air filter that removes more than 99.97% of particles more than 0.3 microns (the most penetrating particle size) at a specified flow rate of air. HEPA filters may be integrated into the central air handling systems, installed at the point of use above the ceiling of a room, or used as portable units (MMWR 2003; 52: RR-10). Home care. A wide-range of medical, nursing, rehabilitation, hospice and social services delivered to patients/residents in their place of residence (e.g. private residence, senior living center, assisted living facility). Home health-care services include care provided by home health aides and skilled nurses, respiratory therapists, dieticians, physicians, chaplains, and volunteers; provision of durable medical equipment; home infusion therapy; and physical, speech, and occupational therapy. Immunocompromised patients/residents. Those patients/residents whose immune mechanisms are deficient because of congenital or acquired immunologic disorders (e.g. human immunodeficiency virus [HIV] infection, congenital immune deficiency syndromes), chronic diseases such as diabetes mellitus, cancer, emphysema, or cardiac failure, ICU care, malnutrition, and immunosuppressive therapy of another disease process [e.g. radiation, cytotoxic chemotherapy, anti-graft-rejection medication, corticosteroids, monoclonal antibodies directed against a specific component of the immune system]). The type of infections for which an immunocompromised patient has increased susceptibility is determined by the severity of immunosuppression and the specific component(s) of the immune system that is affected. Patients/residents undergoing allogeneic HSCT and those with chronic graft versus host disease are considered the most vulnerable to HAIs. Immunocompromised states also make it more difficult to diagnose certain infections (e.g. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 210 VIHA Infection Prevention and Control Manual, September 1, 2011 tuberculosis) and are associated with more severe clinical disease states than persons with the same infection and a normal immune system. Infection. The condition when an organism (bacterial, viral, or parasitic) has entered a body site, is multiplying in tissue, is causing the clinical manifestations of disease, such as fever, suppurative wound, or pneumonia, and is documented by positive cultures, such as from blood, sputum, wound or urine cultures Infection Control Practitioner (ICP). A person whose primary training is in either nursing or epidemiology and who has acquired special training in infection prevention and control. Responsibilities may include collection, analysis, and feedback of infection data and trends to healthcare providers; consultation on infection risk assessment, prevention and control strategies; performance of education and training activities; implementation of evidencebased infection prevention and control practices or those mandated by regulatory and licensing agencies; application of epidemiologic principles to improve patient outcomes; participation in planning renovation and construction projects (e.g. to ensure appropriate containment of construction dust); evaluation of new products or procedures on patient outcomes; input into or collaboration with employee health services related to infection prevention; implementation of preparedness plans; communication within the healthcare setting, with local and Provincial health departments, and with the community at large concerning infection prevention and control issues; and participation in research. Certification in infection control (CIC) is available through the Certification Board for Infection Control. Infection prevention and control program. A multidisciplinary program that includes a group of activities to ensure that recommended practices for the prevention of healthcareassociated infections are implemented and followed by Healthcare Workers, making the healthcare setting safe from infection for patients/residents and healthcare personnel. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requires the following five components of an infection prevention and control program for accreditation: 1) surveillance: monitoring patients/residents and healthcare personnel for acquisition of infection and/or colonization; 2) investigation: identification and analysis of infection problems or undesirable trends; 3) prevention: implementation of measures to prevent transmission of infectious agents and to reduce risks for device- and procedure-related infections; 4) control: evaluation and management of outbreaks; and 5) reporting: provision of information to external agencies as required by local and Provincial law and regulation (www.jcaho.org). The infection prevention and control program staff has the ultimate authority to determine infection prevention and control policies for a healthcare organization with the approval of the organization‘s governing body. Long-term care facilities (LTCFs). An array of residential and outpatient facilities designed to meet the bio-psychosocial needs of persons with sustained self-care deficits. These include skilled nursing facilities, chronic disease hospitals, nursing homes, foster and group homes, institutions for the developmentally disabled, residential care facilities, assisted living facilities, retirement homes, adult day healthcare facilities, rehabilitation centers, and longterm psychiatric hospitals. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 211 VIHA Infection Prevention and Control Manual, September 1, 2011 Mask. A term that applies collectively to items used to cover the nose and mouth and includes impermeable procedure masks, surgical masks, and N95 masks (respirators). Negative Pressure Room (NPR). Also known as Airborne infection isolation room (AIIR), a negative pressure room is a single-occupancy patient-care room used to isolate persons with a suspected or confirmed airborne infectious disease. Environmental factors are controlled in NPRs to minimize the transmission of infectious agents that are usually transmitted from person to person by droplet nuclei associated with coughing or aerosolization of contaminated fluids. Negative Pressure Rooms should provide negative pressure in the room (so that air flows under the door gap into the room); and an air flow rate of 6–12 ACH (6 ACH for existing structures, 12 ACH for new construction or renovation); and direct exhaust of air from the room to the outside of the building or recirculation of air through a HEPA filter before returning to circulation (MMWR 2005; 54 [RR-17]). Nosocomial infection. A term that is derived from two Greek words ―nosos‖ (disease) and ―komeion‖ (to take care of) and refers to any infection that develops during or as a result of an admission to an acute care facility (hospital) and was not incubating at the time of admission (signs and symptoms of infection develop after 48 hours of admission). Personal protective equipment (PPE). A variety of barriers used alone or in combination to protect mucous membranes, skin, and clothing from contact with infectious agents. PPE includes gloves, masks, respirators, goggles, face shields, and gowns. Procedure Mask. A covering for the nose and mouth that is intended for use in general patient care situations. These masks generally attach to the face with ear loops rather than ties or elastic. Unlike surgical masks, procedure masks are not regulated by the Food and Drug Administration. Protective Environment. A specialized patient-care area or room (also known as a Positive Pressure Room), usually in a hospital, that has a positive air flow relative to the corridor (i.e., air flows from the room to the outside adjacent space). The combination of high-efficiency particulate air (HEPA) filtration, high numbers (more than 12) of air changes per hour (ACH), and minimal leakage of air into the room creates an environment that can safely accommodate patients/residents with a severely compromised immune system (e.g. those who have received allogeneic hemopoietic stem-cell transplant [HSCT]) and decrease the risk of exposure to spores produced by environmental fungi. Other components include use of scrubbable surfaces instead of materials such as upholstery or carpeting, cleaning to prevent dust accumulation, and prohibition of fresh flowers or potted plants. Residential care setting. A facility in which people live, minimal medical care is delivered, and the psychosocial needs of the residents are provided for. Respirator. A personal protective device or mask worn by healthcare personnel to protect them from inhalation exposure to airborne infectious agents that are more than 5 microns in size. These include infectious droplet nuclei from patients/residents with M. tuberculosis, variola virus [smallpox], SARS-CoV), and dust particles that contain infectious particles, such Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 212 VIHA Infection Prevention and Control Manual, September 1, 2011 as spores of environmental fungi (e.g. Aspergillus sp.). The CDC‘s National Institute for Occupational Safety and Health (NIOSH) certifies respirators used in healthcare settings. The N95 disposable particulate, air purifying, respirator/mask is the type used most commonly by healthcare personnel. Other respirators used include N-99 and N-100 particulate respirators, powered air-purifying respirators (PAPRS) with high efficiency filters; and non-powered full-face piece elastomeric negative pressure respirators. A listing of NIOSH- approved respirators can be found at http://www.cdc.gov/niosh/npptl/topics/respirators. Respirators must be used in conjunction with a complete Respiratory Protection Program, as required by the Occupational Safety and Health Administration (OSHA), that includes fit testing, training, proper selection of respirators, medical clearance and respirator maintenance. Respiratory Hygiene/ Cough Etiquette. A combination of measures designed to minimize the transmission of respiratory pathogens via droplet or airborne routes in healthcare settings and should be practiced by patients/residents, healthcare workers, and visitors. The components of Respiratory Hygiene/Cough Etiquette are 1) covering the mouth and nose during coughing and sneezing, 2) using tissues to contain respiratory secretions with prompt disposal into a no-touch receptacle, 3) offering a surgical mask to persons who are coughing to decrease contamination of the surrounding environment, and 4) turning the head away from others and maintaining spatial separation, ideally more than 6 feet, when coughing. If a tissue is not available, the mouth and nose can be covered by a sleeve. These measures are targeted to all patients/residents with symptoms of respiratory infection and their accompanying family members or friends beginning at the point of initial encounter with a healthcare setting (e.g. reception/triage in emergency departments, ambulatory clinics, healthcare provider offices) (Srinivasin A ICHE 2004; 25: 1020 Routine Practices (previously known as Standard or Universal Precautions). A group of infection prevention practices that apply to all patients/residents, regardless of suspected or confirmed diagnosis or presumed infection status. Routine Practices are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Routine Practices include hand hygiene, and depending on the anticipated exposure, use of gloves, gown, mask, eye protection, or face shield, as well as safe injection practices. Also, equipment or items in the patient environment likely to have been contaminated with infectious blood or body fluids must be handled in a manner to prevent transmission of infectious agents (e.g. wear gloves for handling, contain heavily soiled equipment, properly clean and disinfect or sterilize reusable equipment before use on another patient). The application of Routine Practices during patient care is determined by the nature of the HCW-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some interactions (e.g. performing venipuncture), only gloves may be needed; during other interactions (e.g. intubation), use of gloves, gown, and face shield or mask and goggles is necessary. Education and training on the principles and rationale for recommended practices are critical elements of Routine Practices because they facilitate appropriate decision-making and promote adherence when HCWs are faced with new circumstances. An example of the importance of the use of Routine Practices is intubation, Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 213 VIHA Infection Prevention and Control Manual, September 1, 2011 especially under emergency circumstances when infectious agents may not be suspected, but later are identified (e.g. SARS-CoV, Neisseria meningitides). Routine Practices are also intended to protect patients/residents by ensuring that healthcare personnel do not carry infectious agents to patients/residents on their hands or via equipment used during patient care. Safety culture/climate. The shared perceptions of workers and management regarding the expectations of safety in the work environment. A hospital safety climate includes the following six organizational components: 1) senior management support for safety programs; 2) absence of workplace barriers to safe work practices; 3) cleanliness and orderliness of the worksite; 4) minimal conflict and good communication among staff members; 5) frequent safety related feedback/training by supervisors; and 6) availability of PPE and engineering controls. Source Control. The process of containing an infectious agent either at the portal of exit from the body or within a confined space. The term is applied most frequently to containment of infectious agents transmitted by the respiratory route but could apply to other routes of transmission, (e.g. a draining wound, vesicular or bullous skin lesions). Respiratory Hygiene/Cough Etiquette that encourages individuals to ―cover your cough‖ and/or wear a mask is a source control measure. The use of enclosing devices for local exhaust ventilation (e.g. booths for sputum induction or administration of aerosolized medication) is another example of source control. Sterilization. The only level of asepsis that kills all microbes, including spores, viruses and TB. It includes the use of gas, chemicals, steam under pressure and radiation. Sterilization is used on medical instruments and equipment, surgical dressing, gowns, etc Surgical mask. A device worn over the mouth and nose by operating room personnel during surgical procedures to protect both surgical patients/residents and operating room personnel from transfer of microorganisms and body fluids. Surgical masks also are used to protect healthcare personnel from contact with large infectious droplets (more than 5 microns in size). Surgical masks are evaluated by the FDA using standardized testing procedures for fluid resistance, bacterial filtration efficiency, differential pressure (air exchange), and flammability in order to mitigate the risks to health associated with the use of surgical masks. These specifications apply to any masks that are labelled surgical, laser, isolation, or dental or medical procedure (http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm072549.htm). Surgical masks do not protect against inhalation of smaller particles and should not be confused with particulate respirators/masks that are recommended for protection against selected airborne infectious agents, (e.g. Mycobacterium tuberculosis). Unit closure – a unit or area is closed to admissions and transfers in References: Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 214 VIHA Infection Prevention and Control Manual, September 1, 2011 Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices Advisory Committee, 2007 Guideline for Isolation Precautions: preventing Transmission of Infectious Agents in Healthcare Settings, June 2007 Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 215 VIHA Infection Prevention and Control Manual, September 1, 2011 APPENDIX C: Specific Cleaning Instructions A. Procedure for Cleaning Agitator Tubs/Hydrotherapy Tanks Prior to cleaning an agitator tub it is important to don PPE (Personal Protective Equipment). Nursing Responsibilities (between patient use): drain dirty water close drain and start filling tub when water level, covers half of whirlpool intake, turn on whirlpool pump motor turn water off when water starts to surge out the whirlpool outlet add manufacturer approved disinfectant (MAP) to water in the bottom of tub (follow manufacturers‘ directions on concentration and amount) and let the whirlpool run for one minute wash/scrub the interior of tub with brush/mop and the disinfectant in tub swing chair over tub and clean with disinfectant drain the system shower down interior of tub and chair with clean water and back flush the pump wipe down chair with clean cloth. End of the Day Cleaning (Housekeeping Staff) fill tub with water to point midway between chair and overflow add manufacturers approved cleaning agent at appropriate strength to the water lower chair into water activate whirlpool for 3 – 5 minutes scrub and clean all surfaces of chair(s) rinse the chair thoroughly and drain the tub drain the system shower down interior of tub and chair with clean water and back flush the pump wipe down chair with clean cloth B. Procedure for Cleaning Fans Fans must not be used in Acute Patient Care settings. When fans are used in other settings, they must have a removable fan blade grill cover. When the fan is no longer required, or at a minimum once per month, the grill cover must be removed and the fan blades cleaned with the approved disinfectant wipes. When the grill is replaced, all surfaces of the fan including the base and electrical cord are cleaned and sanitized. A dust cover is placed over the fan head. The fan must be sent to Facilities Maintenance and Operations annually for inspection and maintenance. Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 216 VIHA Infection Prevention and Control Manual, September 1, 2011 C. Procedure for Cleaning Commodes Nursing Responsibilities Contact surfaces of the commode (seat, armrests, and basin) must be cleaned and sanitized following each patient use. The approved disinfectant ready to use wipes must be readily available for this purpose. When a commode dedicated for patient use is no longer required by the patient, housekeeping is notified and a completed ―Housekeeping: cleaning and disinfection required‖ sign is placed on the chair to prevent use by another patient. (A sign is being developed.) Housekeeping Responsibilities Upon notification by nursing staff, the commode will be removed from circulation and taken for cleaning and disinfection. Chairs that are constructed to withstand power washing or automated washing in a machine designed for this purpose may be processed in this manner, where such equipment is available. When manual cleaning is done, all surfaces must be cleaned and then disinfected. NOTE: If the chair is found to be in a state of disrepair or surfaces are cracked, the chair cannot be adequately cleaned. This must be brought to the attention of the nursing manager or leader so that repair or replacement can be facilitated. D. Procedure for Cleaning Suction Regulators Procedure for ensuring safe Infection Prevention and Control practices to ensure appropriate use of wall mounted suction equipment: Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment along with the single-use inner liners, red lids, and sealed suction tubing packages are placed in all patient rooms. If used during the patient‘s admission, the Hard Plastic Reusable Suction Canister with fixed red tubing and wall attachment is taken to the Dirty Utility Room cleaned and returned to the patient bedside. The single-use inner liners, red lids, and suction tubing are removed and discarded upon discharge. A new single-use liner and red lid is placed within the clean hard outer canister and a new sealed suction tubing package is placed at the bedside. Hard Plastic Reusable Suction Canister with fixed red tubing and fixed wall attachment with single-use inner liners and red lids within patient rooms that are not used are surface wiped at discharge. The outside of the sealed suction tubing packaging is surface wiped upon patient discharge. The sealed suction tubing packaging is an indicator that the suction bottle was NOT used. If the Hard Plastic Reusable Suction Canister with fixed red tubing and wall Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 217 VIHA Infection Prevention and Control Manual, September 1, 2011 attachment and the single-use inner liners and red lids are clean and the suction tubing package is open, discard the suction tubing Within the Endoscopy suite, staff will cleans the Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment and discard the single-use inner liners, red lids, and the suction tubing between every patient case. N.B. The Hard Plastic Reusable Suction Canisters with fixed red tubing and fixed wall attachment are manufactured and sold as a reusable item. The Suction Canister inner liners and sealed suction tubing packages are manufactured, sold, and labeled as single-use items (i.e. one patient only). Note: In this document the term ―patient‖ is inclusive of patient, resident or client. Page 218 VIHA Infection Prevention and Control Manual, September 1, 2011 RECENT CHANGES/ADDITIONS September 1 – Updated the ILI Outbreak Suspected Case Definition April 7, 2011 Update to Table 10-Procedure for Discontinuing Additional Precautions (revised since the March 16 update) Added a hyperlink to the Intranet‘s listing of the negative pressure rooms throughout VIHA at the beginning of the Airborne Precautions section Change to the short list of examples mentioned in the introduction to Airborne Precautions Added gown and gloves to the first bullet that touches on the recommend PPE for staff when Droplet Precautions are in place Added the last bullet in the column for visitors when contact, droplet and airborne precautions are in place Substituted many of the points about staff working restrictions during a GI/Norovirus outbreak with a hyperlink to an easy-to-follow algorithm Updated the recommendations for visitors/volunteers during GI Illness Outbreak and during an ILI Outbreak Updated the length of time that housekeeping needs to wait (now 4 days rather than 5 days) after a GI/Norovirus Outbreak before starting their precaution cleaning Changed ―patient‖ to ―patient/resident‖ throughout as this manual is applicable to both Acute and Residential sites April 1, 2011 – the ARO Screening Questionnaire replaces the old MRSA Screening Questionnaire March 14, 2011 – procedures surrounding magazines/books/puzzles February 22, 2011 – addition of Precaution Table February 8, 2011 – updated mask information for patients/residents and visitors when Airborne Precautions are in place February 2, 2011 – additional housekeeping information for CDH, NRHG and the PCC at RJH January 31, 2011 – change to the Nasopharyngeal Swab procedure Note: In this document the term ―patient‖ is inclusive of patient, resident or client. 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