Download ACPHD CRE Packet - Alameda County Public Health Department

ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY
PUBLIC HEALTH DEPARTMENT
Alex Briscoe, Director
Muntu Davis, MD, MPH, Director, Health Officer
Division of Communicable Disease Control and Prevention
1000 Broadway, Ste 500
Oakland, CA 94607
Tel (510) 267-3250
Fax (510) 268-2111
Erica Pan, MD, MPH, Director & Deputy Health Officer
Sandra Huang, MD, TB Controller & CD Controller
Caring for Patients with
Carbapenem-resistant Enterobacteriaceae (CRE)
Recommendations for Long-Term Care Facilities (LTCFs)
COVER SHEET
Date:
To:
From:
Fax:
Email:
[Sender is exempt from requiring authorization per HIPAA [citation 164.512 (b)]
Thank you for reporting the CRE case(s) at your facility. A Public Health Nurse will be in contact with
you for further guidance. Please begin reviewing this packet, which includes the following
documents and guidelines:
Recommendations Checklist (enclosed)
General Principles of Infection Prevention and Control (enclosed)
Environmental Checklist for Monitoring Terminal Cleaning (enclosed)
CRE Toolkit (attached)
Inter-facility Transfer Form (attached) with Clinical Assessment Tool (enclosed)
Under the direction of the Alameda County Health Officer, the recommendations provided are in
supplementation to the California State Department of Public Health’s recommendations.
CONFIDENTIAL INFORMATION
The attached material is intended for the use of the individual or organization to whom it is addressed, and may contain information
that is confidential, privileged and exempt from disclosure under applicable law. If you are not the intended recipient, you are notified
that any use, distribution or copying of this document is strictly prohibited. In the event that you receive this communication in error,
please notify us immediately. Thank you.
Note: Privacy Rule (HIPAA) permits covered entities to disclose PHI without authorization to public health authorities or other entities
who are legally authorized to receive such reports for the purpose of preventing or controlling disease. This includes the reporting of
disease, conducting public surveillance, investigations, or interventions.
Alameda County Public Health Department
Communicable Disease Control and Prevention Communicable Disease Unit
1000 Broadway, Suite 500, Oakland, CA 94607
Phone: (510) 267-3250 Fax: (510) 268-2111
Patient Information
Name:
DOB:
Address:
Next of kin:
Relationship:
Address:
Phone:
Phone:
Comments:
Discharge Facility
Name of facility:
Complete address:
Admit date:
Discharge date:
Infection control contact:
Phone:
Fax:
Email:
Director of Nursing:
Phone:
Fax:
Email:
Comments:
Receiving Facility
Name of facility:
Complete address:
Infection control contact:
Phone:
Fax:
Email:
Admit date:
Director of Nursing:
Phone:
Fax:
Email:
Comments:
CRE Definition, for reporting purposes
 Any Klebsiella spp., E. coli, or Enterobacter spp. resistant to any of the carbapenems (meropenem,
imipenem, doripenem and ertapenem) OR
 Any Klebsiella spp., E. coli, or Enterobacter spp. with demonstrated production of a carbapenemase
(i.e., KPC, NDM, VIM, IMP, OXA-48) by a recognized test (e.g., PCR, metallo-β-lactamase test, modifiedHodge test, Carba-NP)
Resources
 ACPHD Health Alerts/Advisories (including CRE) http://www.acphd.org/health-alerts.aspx
 2012 CRE Toolkit (CDC) http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
 California Department of Public Health (CDPH) Healthcare Associated Infections (HAI) Program
http://www.cdph.ca.gov/programs/hai/Pages/default.aspx
Recommendations Checklist
Recommendations are subject to change and are only advised as of date recommended
Date
Recommendation
Infection Control
Place CRE infected and colonized patients in private rooms with contact precautions
Encourage treating clinicians to limit antibiotic exposure and use of invasive devices
Educate affected staff, visitors, and patients about CRE
Carbapenem-resistant Enterobacteriaceae in Healthcare Settings
http://www.cdc.gov/HAI/organisms/cre/index.html
Hand Hygiene
Wash Hands thoroughly or use alcohol based hand sanitizers
 Before entering patient room (even if gloves are used)
 After removing gloves and exiting the patient room
More information and guidance available at http://www.cdc.gov/handhygiene/
Personal Protective Equipment (PPE)
To be used by all staff and visitors entering the patient’s room
All PPE should be available outside the patient’s door and donned before entering room
All PPE should be properly doffed (removed) while inside the patient’s room and placed in a garbage
can that should be positioned near the doorway inside the patient’s room
Gown, gloves
mask, eye protection or face shield if indicated, such as potential body fluid splash or respiratory
droplet exposure – as per standard precautions
Healthcare Equipment
Dedicated equipment for CRE patient as much as possible – blood pressure cuff, pulse oximeter,
thermometer, stethoscope
Non-dedicated equipment must be disinfected before leaving the patient’s room
Environmental Cleaning
Provide in-service/education to Environmental services staff and Patient care staff to reinforce
cleaning/disinfecting policy/procedures
Ensure all patient care staff are educated regarding the appropriate cleaning of critical equipment
used for patients
Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008
http://www.cdc.gov/hicpac/Disinfection_Sterilization/3_4surfaceDisinfection.html
Select the appropriate cleaning/disinfecting product based on manufacturer’s specifications
Ensure daily environmental cleaning of high touch surfaces including but not limited to bedrails, door
knobs, light switches, bedside tables, call lights, bathroom faucet handle, toilet flush handle, phones,
elevator buttons
Monitor effective cleaning of environment using observation or florescent staining/bioluminescence if
available
Patient’s room must be terminally cleaned upon patient discharge
(Please refer to attachment- CDC Environmental Checklist for Monitoring Terminal Cleaning)
Linens and Clothing
All linen and clothing of known CRE patients must be collected and washed separately
Wear PPE, sort and bag at point of contact and agitate minimally
Laundry equipment must be maintained to prevent microbial contamination
New laundry technologies allow linen washing without requirements for hot water and chlorine
o Hot water 160°F x 25 min
o Cold water 71-77°F with 125 ppm chlorine bleach rinse or equivalent detergent (not
required to have stated anti-microbial)
Admission Screening
Consider testing for CRE colonization on admission for patients with CRE risk factors
(e.g. admission from LTAC hospitals, open wounds, presence of indwelling devices, multiple comorbidities, high antimicrobial usage
Isolate and implement pre-emptive standard and contact precautions until admission screening
cultures return negative
If unable to place patient in private room, patient may cohort only with a patient with similar risk
factors (as mentioned above).
Notify ACD Unit by phone at (510) 267-3250 within 1 business day of any new CRE identification,
according to CRE definition. Fax lab report to ACD Unit at (510) 268-2111
Exposed Contact Screening
Identify patients who shared a room or bathroom with a known CRE patient
Identify patients who shared healthcare personnel with a CRE patient, before contact precautions
were implemented
Consider performing surveillance screening cultures on patients identified as exposed
Notify ACD Unit by phone at (510) 267-3250 within 1 business day of any new CRE identification,
according to CRE definition. Fax lab report to ACD Unit at (510) 268-2111
Specimen Collection Instructions
Consult with your facility’s clinical laboratory
Pre-moisten a sterile culture swab in bacterial culture media in the accompanying culturette tube
Insert moistened tip of swab into the anal canal and turn 2-3 times
Replace swab in culturette tube and secure top
Make sure to note type of culture as “screening”
If specimen is not plated for testing within 4 hours, swab may be stored at 4°C for up to 3 days
Notify ACD Unit by phone at (510) 267-3250 within 1 business day of any new CRE identification,
according to CRE definition. Fax lab report to ACD Unit at (510) 268-2111
Patient Movement
If patient being discharged, call ACD Unit at (510) 267-3250 for further guidance
Considerations for Inter-Facility Movement (e.g. transfers outside the facility)
Notify ACD Unit at (510) 267-3250 before transferring known CRE patient outside of the facility
Use the Inter-Facility Transfer Form and send to transporting agency (include in patient chart),
receiving facility, and ACD Unit fax (510) 268-2111
Notify the transport agency and receiving facility of patient’s isolation status and contact precautions
prior to transport
Ensure wounds, stool, and urine are adequately contained
Have patient wear clean/freshly laundered clothes or a patient gown
Considerations for Intra-Facility Movement (e.g. transfers within the facility)
Patients who are at highest risk for transmission must remain in their room on contact precautions at
all time. Patients at highest risk for transmission may include, but are not limited to, those who are
non-ambulatory, dependent upon HCP for ADLS, vent-dependent, incontinent of bowel or bladder, or
have any wounds or drains.
Ambulatory, non-dependent patients may be allowed out of contact precautions IF the following
criteria are met:
 Patient must be A&O and able to follow directions/instructions, able to maintain hand hygiene,
and continent of bowel and bladder
 Patient must have clean clothes/freshly laundered when leaving the room, a wheelchair that
has been disinfected each time patient is to leave the room, hand hygiene every time before
leaving the room
 PT and OT, as much as possible, should be done in the room with full PPE/contact precautions.
If it is necessary to use the gym, should be the last one to receive service for the day. All
equipment and hard surfaces must be disinfected after the patient receives therapy.
 Any personnel providing services such as toileting, showering or bathing or teaching ADL skills
to the patient must still maintain contact precautions/use full PPE. These activities must take
place in the patient’s room
Staffing
If more than one CRE patient, cohort staff so that the same staff only care for CRE patients
Otherwise, have staff care for the CRE patient after other patients have been seen, as long as this
does not negatively affect the patient’s care
Policy Consideration
Include in policy all surfaces and equipment that can reasonably be expected to be contaminated by
bacteria (high touch surfaces as defined above)
Define responsibility and frequency for cleaning and disinfecting patient care equipment and surfaces.
High touch surfaces should be cleaned at least every shift with 1-2 designated staff
Avoid staff cross-contaminating from CRE unit to non-CRE unit
Cleaned/disinfected items should be labeled (date/time)
Ensure compliance with policy (e.g. competency testing, hand hygiene compliance rates)
Other/Specific recommendations
General Principles of Infection Prevention and Control
For Communicable Disease Investigators
Table of Contents
1.
Introduction
2
2.
Definitions
2
3.
Modes of Disease Transmission
3
4.
Cycle of Disease Transmission
5
5.
Hierarchy of Controls to Prevent Disease Transmission
6
6.
Definitions of Isolation Precautions
a.
Standard
7
b.
Respiratory
7
c.
Contact
9
d.
Combinations of Precautions
10
7.
Hand Hygiene
10
8.
Respiratory Hygiene and Cough Etiquette
14
9.
Personal Protective Equipment (PPE)
14
10.
General Recommendations
11.
a.
Sanitation, Disinfection, and Sterilization
17
b.
Patient Care Equipment
18
c.
Management of Biohazard Waste/Trash
18
d.
Handling of Laundry
19
e.
Handling of Dishes
20
Suggested User References
20
12. Attachments:
Table of Hand Hygiene Products
21
Proper Mixing of Bleach for disinfection
22
How to Don and Doff PPE
23-24
Introduction
Communicable disease investigators have always been faced with a myriad of disease challenges for which they
have to recommend and/or implement containment measures. Outbreaks of new diseases such as Severe Acute
Respiratory Syndrome (SARS), threats of pandemic influenza and bioterrorism, West Nile Virus, and increased
awareness of outbreaks of pertussis and norovirus have fueled a demand for knowledge and competency with
infection control principles. This document, designed as a crash course for communicable disease outbreak
investigators, will present general principles of infection prevention and control, modes of transmission,
precautions, proper use of personal protective equipment, and comments on topics such as sanitation and
disinfection, handling of laundry, and waste management. It is not intended to be all-inclusive. For more detail,
consult with an infection prevention and control specialist, the CDC website, and/or a reference text.
The words “infection prevention and control”, taken literally, are the science, art and practice of preventing
communicable infections or diseases, and/or controlling their further spread. The underlying scientific principles
presented here can be adapted across any setting, and activities optimized according to available resources.
Definitions
Active Disease: Infection with multiplication of organisms, invasion, and clinical symptoms.
Asymptomatic Disease: Infection characterized by multiplication of the organism, no evidence of clinical
disease, but evidence of immune system response. An example is a positive tuberculin skin test result.
Cohorting: Keeping persons infected or colonized with the same organism together, and separate from those
not infected or colonized with that organism. Cohorting staff means that certain staff are designated to work
either with the cohort or with non-cohorted groups. They should not work with both groups during the same
work shift, but if they must, they should work from non-cohorted to cohorted, and then not return to working
w/ the cohorted group during that shift.
Colonization: Multiplication of an organism at a body site(s) without evidence of clinical disease or immune
system response. Examples would be carriage of Neisseria meningitidis in the throat or Staphylococcus aureus
in the anterior nares.
Contact: An individual who may have been exposed to the disease being investigated
Droplet Nuclei: Small particles of dried respiratory secretions. The infectious capacity of droplet nuclei is
dependent upon how long they are suspended in the air, how long they are viable in the environment, how
large the infectious dose of the organism is, organism virulence, and host susceptibility.
Fomites: Surfaces or objects that are contaminated with the infectious agent and are capable of transmitting it.
(singular is ‘fomes’)
Host Susceptibility: Strength of host immune response. Humans can develop immunity via infection with the
organism or via vaccination. Immune response is decreased by weak or non-existent immune function due to
disease (e.g., HIV), or immunosuppression due to chronic diseases, use of steroids, chemotherapy,
transplantation, pregnancy, or lack of an available or appropriate vaccination.
Infection: Successful transfer of a microorganism to a susceptible host with subsequent multiplication,
colonization, and invasion.
Pathogenicity: The ability of an agent to cause disease in a susceptible host. This can be influenced by host
immune factors and size of the dose required to cause infection.
Transmission: Method of transfer of organism to susceptible host.
Virulence: Intrinsic capacity of an agent to cause disease, and severity of the resultant disease – sometimes
measured in case-fatality rate.
Modes of Disease Transmission
1. Respiratory Transmission:
a. Airborne Transmission: When organisms carried on dust particles or droplet nuclei are inhaled by a
susceptible person in the same room or over a longer distance from the infectious source. The
likelihood of disease transmission via the airborne route is dependent upon infectiousness of the
organism, how many microorganisms are expelled into the air, how well the organism survives in the
environment, how long and how close one is to the infectious source, and air flow (how long does the
organism remain suspended in that air space or how fast it is diluted/ dispersed).


Obligate – organism must be inhaled; e.g., Mycobacterium tuberculosis
Opportune – organism lands on mucous membrane; e.g., Hantavirus
b. Droplet Transmission: Occurs when there is contact between mucous membranes (nose, mouth or
eyes) of a susceptible person with large particle droplets (larger than 5 microns) containing
microorganisms generated by a person who is infected with or is a clinical carrier of a disease that is
transmitted in that manner. Large particle droplets are expelled into the air when the infected person
coughs, sneezes, talks, sings, or when certain procedures such as suctioning, sputum induction, or
bronchoscopy are performed. Because generated droplets do not remain suspended indefinitely in the
air and travel short distances (3-5 feet from the source), special air handling or ventilation precautions
are not required.
c. Near-aerosol Transmission: Is a cross between airborne and droplet transmission. Pathogen-containing
droplets generated from a contagious source are of varied sizes that do not neatly sort themselves into
which droplet flies what number of feet from the source before falling out of the air. Smaller droplet
nuclei may travel further than 3 feet from the source, leading to potential disease transmission at
further than 3 feet. Examples are SARS and possibly influenza. There is currently a lack of definitive
scientific evidence on how they are most often transmitted.
2. Contact Transmission: Occurs when there is transfer of organisms as a result of physical touch.


Direct – involves skin-to-skin contact with physical transfer of microorganisms from an infected or
colonized person to a susceptible host.
Indirect – involves contact of a susceptible host with a contaminated intermediate host, usually
something inanimate in the environment.
3. Combination Transmission: Some diseases may be transmitted via more than one mode. An example is that
chickenpox is transmitted primarily via the airborne route, but can also be spread by physical contact with
draining skin lesions.
Cycle of Disease Transmission
The cycle of disease transmission requires an infected person, animal, reservoir, or vector, an effective way to
transmit the disease, and a susceptible host. (See Figures 1 and 2.) Interruption of the chain at any point by
application of appropriate infection prevention precautions will stop transmission of disease.
Mode of
Transmission:
(airborne, droplet,
contact)
Susceptible
Transmitter
Host
Figure 1 – Chain of infection for person-to-person disease transmission. Examples of such diseases are
tuberculosis, pertussis, or scabies.
Mode of Transmission
(may include vector or
common vehicle such as
food)
Fomite or Reservoir (such
as a surface or an animal)
Susceptible
Host
(may include animals)
Figure 2 – Chain of transmission for diseases or conditions such as foodborne illnesses, West Nile
Virus, or Hantavirus. Environmental Health rather than infection control would advise for control of vectors.
Hierarchy of Controls to Prevent Disease Transmission
Much illness is spread because susceptible persons do not suspect that they are being exposed to the disease in
question. The most effective prevention against disease transmission is heightened awareness and early
recognition and control of the source of the infection. In order, next steps include administrative controls,
application of engineering controls, the healthcare worker practicing effective habits to protect him/herself, and
as a ‘last resort’, use of personal protective equipment. Examples are as follows:
1. Early Recognition and Control: Refers to rapid identification of a potentially infectious disease by having a
high index of suspicion for that disease in the list of differential diagnoses, and taking immediate steps to
protect against potential transmission. If a patient presented to a healthcare setting with a fever and
generalized rash, possible diagnoses to rule out might be chickenpox or measles. Because chickenpox or
measles are known to be contagious, the healthcare worker should immediately mask the patient if possible
(control airborne spread of virus), and move the patient away from other potentially susceptible persons by
escorting them to an airborne isolation room or to the outside away from other persons.
2. Administrative Controls: Refers to policies and procedures such as pre-employment screening for immunity
via disease history or vaccination. Requirements for measles immunity and 2-step tuberculosis screening
are examples.
3. Engineering Controls: Refers to a mechanical or engineered method of providing protection to the
healthcare worker. An airborne isolation room is one example of an engineering control. A safety syringe is
another example.
4. Safe Work Practice Habits: Refers to practices the healthcare provider can do to minimize exposure to
infections. Examples are hand hygiene before and after patient contact; if the patient is in an isolation
room, keeping the door closed and traffic in and out of the isolation room to a minimum; disinfection of
contaminated equipment after use; and the practice of respiratory hygiene/cough etiquette. Proper
application of preventive precautions as described below is essential.
5.
Personal Protective Equipment: This refers to gowns, gloves, masks, respirators, or eye protection used as
protection against disease transmission, to be worn when one of the above measures is not available,
feasible, or provides insufficient protection for the healthcare worker.
Definitions of Isolation (Preventive) Precautions:
1.
Standard Precautions:
Is the main approach to reducing the risk of transmission of disease, specifically those transmitted via body
substances. Former names included “Universal Precautions” (precautions were to be applied against
bloodborne pathogen-containing fluids from all persons receiving care regardless of diagnosis or presumed
infection status) and “Body Substance Isolation” (precautions were to be taken against any moist body
substance). Standard precautions apply to: 1) blood; 2) all body fluids, secretions and excretions except
sweat, regardless of whether or not they contain visible blood; 3) nonintact skin; and 4) mucous
membranes. Standard Precautions are designed to reduce the risk of transmission of microorganisms from
both recognized and unrecognized sources of infection when providing healthcare. Per the 2007 CDC
Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, this
definition has been expanded to include practices for respiratory hygiene, cough etiquette and injection
safety. These practices include:










Appropriate hand hygiene
Barrier protective equipment such as gloves; mask, eye protection, face shield; gowns (see note
below)
Proper use and handling of patient care equipment
Proper environmental cleaning and disinfection
Proper handling of linen
Adherence to guidelines such as the Bloodborne Pathogens Exposure Control regulations
Proper patient placement (where the potential for disease transmission is minimized)
Respiratory Hygiene/Cough Etiquette
Safe injection practices
Use of masks for insertion of catheters or injection of material into spinal or epidural spaces via
lumbar puncture procedures (e.g., myelogram, spinal or epidural anesthesia).
Of note, while most elements of Standard Precautions were developed for the protection of healthcare
personnel, these new elements of Standard Precautions also focus on the protection of patients.
More detailed information, if not included later in this document, can be found at
http://www.cdc.gov/ncidod/dhqp/gl_isolation_standard.html.
2.
Respiratory Precautions:
a. Airborne Precautions
Are designed to reduce the risk of airborne transmission of infectious agents. Airborne transmission
occurs by dissemination of either airborne droplet nuclei (small-particle [5microns or smaller] residue of
evaporated droplets) or dust particles containing infectious agents that become suspended in the air for
long periods of time.
Special air handling and ventilation are required to decrease the possibility of or prevent airborne
transmission. Such handling can consist of increased ventilation to dilute the air (such as an exhaust fan
or keeping the patient outside), filtration of the air through high efficiency particulate air (HEPA)
filtration or a personal respirator, or the use of ultraviolet germicidal irradiation (UVGI), e.g., sunlight or
a UV lamp. Airborne precautions should be applied to any persons known or suspected of being
infected with epidemiologically important pathogens that can be transmitted via that route. Practices
include:




Placement of the person known or suspected to be infected in a private room with a closed door
that has: 1) monitored negative air pressure in relation to the surrounding areas; 2) 6-12 air changes
per hour (this can be accomplished by adjusting air intake into the room or using a portable HEPA
filtration unit); or by cohorting with another person actively infected with the same disease (consult
with infection control prior to cohorting).
Respiratory protection (N95 respirator, half or full-face respirator, or positive air purifying respirator
[PAPR]) must be worn by the healthcare worker when entering the airborne infection isolation
room.
Limit transport of the infected person to essential purposes only.
If possible, have the patient wear a mask (not respirator) to decrease environmental contamination.
Ensure that the mask does not have an exhalation valve!
More detailed information can be found at
http://www.cdc.gov/ncidod/dhqp/gl_isolation_airborne.html.
b. Droplet Precautions
Are designed to reduce the risk of droplet transmission of infectious diseases. Droplet precautions
should be applied to any person known or suspected to be infected with epidemiologically important
pathogens spread via that route. Practices include:




Placement of the person in a private room. When a private room is not available, cohort the person
in a room with persons who have active infection with the same microorganism. When neither of
the above is achievable, maintain spatial separation of at least 3 feet between the infected person
and other persons or visitors. Special ventilation is not required, and the room door may remain
open.
Wear a surgical (with strings), procedure (with ear loops), or a cone mask when working within 3
feet of the infected person’s head. Per requirements of Standard Precautions, eye protection and a
gown should be worn if splash or spray of respiratory secretions is anticipated.
Limit movement of the person to essential purposes only. The receiving area should be aware of
and affirm the patient’s arrival prior to arrival. If possible, the presence of other persons such as
visitors or other patients should be minimized. This can be sometimes accomplished by scheduling
tests or procedures at the end of a clinic day.
If possible, have the person wear a surgical or procedure mask to decrease environmental
contamination when they are outside of their room.
More detailed information can be found at http://www.cdc.gov/ncidod/dhqp/gl_isolation_droplet.html.
c) Near-aerosol Precautions
Refers to the application of droplet and airborne precautions for distances up to 12-20 feet away from
the potentially or infectious patient, including placement in an airborne infection isolation room and use
of an N-95 respirator or higher level respirator by the healthcare worker. There is no official category of
these precautions at present. Check with the most recent CDC guidelines and any state or local
guidance for more up-to-date guidance on whether to use droplet vs. airborne precautions, particularly
when dealing with new or novel diseases. If the science is unable to rule out a particular mode of
transmission, the health department may elect to be prudent and advise the healthcare worker to use a
higher level of protection when potentially working with a patient with the disease in question, i.e. an
N95 respirator rather than a surgical or procedural mask for a novel respiratory disease. It is always
good practice to mask the ill person (if tolerated) with a surgical or procedure mask to contain droplet
nuclei at the source, thereby minimizing potential environmental contamination.
3. Contact Precautions:
Are designed to reduce the risk of transmission of diseases by various modes of contact.
Control recommendations include:

Placement of the person in a private room. When a private room is not available, cohort the person in a
room with persons who are colonized or have active infection with the same microorganism. When
neither of the above is achievable, maintain spatial separation between the infected person and other







persons or visitors. Special ventilation is not required, and the room door may remain open. Consult
with infection control before cohorting patients.
Hand Hygiene – see Hand Hygiene section
Put on gloves when entering the room if contact with any room surface or occupant is anticipated.
Change gloves after having contact with infective material that may contain high concentrations of the
microorganism, before moving from a ‘dirty’ to a ‘clean’ part of the body, or if the gloves become torn.
Remove gloves upon exit; perform hand hygiene immediately after glove removal and before touching
anything else. Gloves should never be washed and reused.
Wear a gown if contact between the patient or patient’s environment and the healthcare worker’s
clothing is anticipated. Remove the gown prior to leaving that environment and perform hand hygiene.
Advise staff to limit movement of the patient to essential purposes only. If a patient in contact
precautions needs to come out of the room, drainage from infected or colonized wounds should be
contained, outer garments clean, and their hands cleaned prior to leaving the room. The receiving area
should be notified and accept the patient prior to the patient’s arrival.
Dedicate equipment such as blood pressure cuffs and stethoscopes for use on the isolated person only.
If equipment must be used for other persons or patients, it should be disinfected prior to such use.
Large equipment such as x-ray machines and medication carts should be disinfected immediately after
being removed from the room.
During gastroenteritis outbreaks, there should be no sharing of common food in the facility (e.g.,
doughnuts in a break room, applesauce on a medication cart, drinking pitchers, water glasses, etc.)
Advise frequent cleaning and disinfection of commonly touched areas in the person’s environment, such
a door handles, chair armrests, nearby tables, etc. During a facility outbreak, in common areas,
environmental cleaning should be enhanced. This means that hallway railings, door handles, tops of
nurses’ stations, medication carts, etc. should be more frequently cleaned.
More detailed information can be found at http://www.cdc.gov/ncidod/dhqp/gl_isolation_contact.html
4. Combinations of Precautions:
There may be more than one mode of transmission for the disease involved (i.e., chickenpox is transmitted
via inhalation of airborne particles and contact with draining lesions), the mode of transmission may be
unclear because the disease is new or novel (example: Severe Acute Respiratory Syndrome [SARS]), or the
disease may be evolving (example: avian influenza). In such instances, both sets of precautions would be
applied.
The decision of what personal protective equipment (PPE) should be used by the healthcare worker to protect
against disease transmission should be based upon available scientific evidence of the mode of transmission.
When scientific evidence is not available or is unclear, prudence dictates a more conservative approach in the
selection of protective equipment until more is known about the route of transmission of the disease in
question. The Precautionary Principle, which states that “Worker safety relies on the precautionary principle
that reasonable action to reduce risk should not await scientific certainty.”, should be followed.
Hand Hygiene:
Hand hygiene has frequently been cited as the single most important practice to reduce the transmission of
infectious agents in any setting – healthcare, food preparation areas, restaurants, congregate living facilities,
schools, daycare settings or homes – and is thus an essential component of all infection-reduction regimens. In
one study, it was found that hands were the transmission vehicle in ~90% of 81 foodborne illness outbreaks,
that improper handwashing by employees was observed in 73% full-service food establishments , and that
hands were washed significantly less often when gloves were used. In other studies, non-compliance among
healthcare workers was observed to be generally below 50% of hand hygiene opportunities (IHI), and hand
hygiene among school children after use of the bathroom was ~50%. On the positive side, numerous studies
have been conducted in healthcare and other settings which demonstrate decreased infection rates, decreased
school absenteeism, and decreased employee absenteeism with the use of good hand hygiene and infection
prevention practices.
Many factors contribute to poor compliance with hand hygiene, including lack of knowledge of the role of hands
in disease transmission, how hands become contaminated and proper hand hygiene techniques, employee time
constraints, lack of access to hand hygiene products or facilities, or health issues such as contact dermatitis from
frequent handwashing. Program success comes from not only addressing the above issues; commitment from
institutional leadership to create a culture where good hand hygiene is valued is essential.
Hand hygiene can refer to handwashing with plain or antimicrobial soaps and water, use of alcohol-based
products (gels, rinses, foams) that contain an emollient and do not require the use of water, or the use of
antiseptic towelettes. Soaps contain a surfactant (chemical) that lifts dirt so that it can be more easily removed.
Antimicrobial soaps will provide a residual “kill” of bacteria on hands. Alcohol-based products provide rapid kill
of bacteria and some viruses on hands. Recommendations for use of plain or antimicrobial soap and water vs.
an alcohol-based product can be found in the attachment entitled “Hand Hygiene”.
1. When to Perform Hand Hygiene:

Circumstances (not all-encompassing):
o
o
o
o
o
o
o
o
o




upon arrival or departure from work
after using the restroom
before and after eating, smoking or touching face or hair
before donning sterile gloves
before and after contact with a patient
before going from a dirty to clean area on a patient
after touching contaminated objects or equipment
between preparation of raw meats and ready-to-eat foods
after removal of gloves
If hands are visibly soiled or contaminated with body secretions or excretions, wash hands with either
plain or antimicrobial soap and water; if that is not available, use a waterless towelette
In the absence of visible soiling, a waterless hand hygiene product can be used (see exceptions, next
section).
Rings, artificial nails, and long or infected natural nails have been associated with outbreaks of infection
in healthcare facilities.
More information can be found at http://www.cdc.gov/handhygiene/.
2. Procedure for Handwashing (When Using Water)







Wet hands before applying soap so that soap will rinse off more easily. Soap acts by lifting organic
material so that it is more easily rinsed.
Apply soap: use vigorous friction x 15 seconds alternating between the front and back of hands, around
fingers, over thumb, across fingernails (see illustration).
Rinse hands thoroughly.
Dry hands. Less abrasive towels are preferable.
Turn off faucet with paper towel.
Use paper towel to open restroom door to leave.
Hot water may cause increased dermatitis. There is no evidence that water temperature affects
handwashing effectiveness. Water temperature should be comfortable so as to facilitate compliance.
3. Use of Waterless Hand Hygiene Products
Waterless hand products are extremely effective in killing bacteria and many viruses on hands: the alcohol
(isopropyl or ethyl) kills organisms by denaturing protein, thus rapidly destroying their cell wall or covering.
Product effectiveness is dependent upon proper use, i.e., sufficient quantity of product (follow the
manufacturer’s recommendation), use of friction, and contact time (covering all hand surfaces for at least 15
seconds).
Exceptions to the Use of Waterless Hand Hygiene Products: When the contamination is from bacterial
spores (such as Clostridium difficile), there is insufficient contact time for the alcohol to kill the spore.
Viruses such as human rotavirus and norovirus do not have an outer covering or envelope for the alcohol to
break down. When such pathogens may be present, use of handwashing with running water as opposed to
use of a hand hygiene product is preferred, especially if an outbreak is in progress.
4. Hand Lotion
Use of hand lotion is recommended for the following reasons:



Increased glove use causes more hand irritation.
Cracked or dry hands shed more germs.
In terms of compliance, workers with more healthy hands are more likely to wash them.
The lotion should be compatible with latex gloves. A fast way to check this out is to look at the lotion
ingredients: if mineral oil or a form of petroleum is one of the first 3 ingredients, the lotion will cause the
latex to weaken, so should not be used with latex gloves. If after 5-10 minutes, there is still a ‘greasy’
residue on the hands, the lotion probably contains a petroleum-based ingredient.
5. Compliance with Hand Hygiene
Many employees have been educated as to when and how to clean their hands, and can demonstrate
competence when tested. When looking at a facility to assess hand hygiene compliance, also observe and
address ‘systems problems’ such as:






Number and convenience of sinks in relation to the work area.
Sufficient supplies (tepid or warm water, soap, and disposable paper towels, or hand hygiene products).
Evidence (such as consumption of hand hygiene products) that employees are actually using the sink.
Do ‘time pressures’ interfere with compliance?
Do managers and coworkers model and support good hand hygiene practices?
Are there consequences for non-compliance with hand hygiene?
Correction of systems-types of issues can make compliance more convenient and/or easier. Training should be
ongoing and repetitive.
Another approach to achieving compliance with hand hygiene is the concept of “hand awareness” – teach
employees to notice what they actually do/touch with their hands, such as hand-to-face activities, or to notice
what they touch on the way to lunch. Another visualization technique for correct glove use is to ask employees
to imagine that their gloves are coated with ketchup and think about what would become coated with ketchup
from their gloves. With active training and use of visualizations, they will hopefully become more conscientious
about practicing appropriate hand hygiene. Development of hand awareness requires a major behavior change
that occurs over time.
Respiratory Hygiene and Cough Etiquette:
Respiratory hygiene and cough etiquette are the important strategies to contain respiratory microorganisms at
the source and limit their spread from infectious persons. The elements include:

Education of healthcare workers, the infectious person and general public on the importance of
containing respiratory secretions to prevent transmission of disease; and
Post signs in languages appropriate to the population served with instructions for persons with
respiratory symptoms to:

o
o
o
o
Immediately report symptoms of respiratory infection to the person providing the healthcare
intervention;
Use source control measures (e.g., covering the nose/mouth with a tissue when coughing; cough
into their elbow instead of hands; dispose of used tissues appropriately; wear a surgical [with
strings], procedure [with ear loops], or cone mask if tolerated);
Perform hand hygiene measures after contact with respiratory secretions;
In common waiting areas, maintain to the extent possible, a spatial separation (ideally at least 3
feet) between themselves and other persons.
Personal Protective Equipment (PPE):
Refers to the specialized clothing or equipment worn by a person or
employee to provide barrier protection against potentially infectious
persons, materials, or the environment. Selection is based upon the type
of exposure anticipated, durability and appropriateness of the PPE for the
task, and fit. There are three general categories of protective clothing:
gloves, facial protection (including respirators), and gowns. For guidance
on how to put on and take off PPE, see the attachments on pages 23-24.
1. Gloves: are used to protect hands of the healthcare worker from the patient, the patient from what could
be carried on the healthcare worker’s hands, and either from what could be in the environment. An earthy
saying is “If it is wet and you didn’t wet it, wear gloves.” Gloves can be made of various materials – vinyl,
latex, nitrile, or other. They are usually single-use. Gloves should fit over the hands and wrists snugly, and
tightly over the cuffs if worn with a gown. Dos and don’ts of glove use include:
DO






Wear when contact with body secretions is
anticipated.
Put them on immediately before doing a
procedure.
Work from ‘clean to dirty’, whether with the
patient, food, or equipment.
Change them immediately if they tear or
puncture during the procedure.
Remove them immediately after the
procedure; discard in an appropriate
receptacle.
Use hand hygiene immediately upon removal.
DO NOT







Wash or re-use the gloves.
Touch your face or adjust PPE with clean or
contaminated gloves.
Touch environmental surfaces except as
necessary during the patient care.
Wear them between patients.
Use them as an excuse not to clean your
hands.
Wear them for extended periods of time
(studies show that gloves fatigue and become
more porous after 20 minutes).
Use lotions where petroleum or mineral oil is a
major ingredient; these chemicals weaken
latex.
2.
Masks and Respirators:
Masks are made from paper or cloth, and are used as a barrier between the nose and mouth, and large
respiratory droplets. They may tie on (surgical mask), have elastic bands that hook over the ears (procedure
mask), or be a rigid cone that attaches with a single elastic band around the head. For droplet precautions,
a mask that covers the nose and mouth is always to be worn when within 3 feet of the ill person’s head.
Additional eye protection is required by Standard Precautions when procedures are done that are likely to
generate splashing or spraying of body fluids; the type needed is dictated by the type and duration of task.
If respiratory secretions are anticipated to be copious, eye protection (e.g., goggles or a faceshield mask)
should be worn. Correct facial protection should cover the forehead, extend below the chin, and wrap
around the side of the face. Regular eye glasses provide insufficient protection as they may not cover a
large enough area and provide no side protection. Masks can also serve an essential function to protect the
public from the wearer. There, it functions as a barrier – the mask stops respiratory droplets near the point
of origin so that the droplets are less likely to contaminate the environment. Even masks with efficient
filters may not effectively filter small particles because they are not designed to seal tightly to the face.
Masks are single use disposable, and should be changed when damp to maintain their barrier status.
A. Pleated surgical mask
B. Pre-molded surgical mask
C. Procedure mask
Respirators are made of electrostatically charged fibers that trap and help reduce the wearer’s respiratory
exposure to small (< 5 micron) airborne contaminants, thus protecting the wearer from those who are or
might be infected. Types of respirators include disposable N-95s, half or full-face, or positive air purifying
respirators (PAPRs). When the disease requires use of a respirator, the employer must have a respiratory
protection program as specified by OSHA or Cal-OSHA regulations. Per federal and state law, personnel
must receive a medical evaluation, be trained on how to properly wear a respirator, and be fit tested for a
respirator prior to having to wear one. The employee should know how to properly check for face seal
leakage every time they put on a respirator, and how to properly store the respirator between uses.
Examples of disposable filtering facepiece N95 respirators

In addition to filtering facepiece respirators, there are other types of respirators such as elastomeric respirators and
powered air-purifying respirators (PAPRs). PAPRs and some elastomeric respirators also offer eye protection.
Examples of other types of respirators
Elastomeric respirator
with eye protection
Elastomeric respirator
without eye protection
Powered air-purifying
respirator (PAPR)
N-95 respirators are disposable and manufacturers do not recommend re-use. However, should a situation
arise where they become a scarce resource, the Institute of Medicine has issued the following guidance for
re-use by the same provider:
o If splash or splatter is anticipated, the respirator must be protected from splash and dirt (a clear
plastic face shield can be worn over the respirator)
o Structural integrity of the respirator must be maintained (it is not crushed, moist, or soiled)
o It is stored in a clean dry space between uses (such as a drawer or bag with the wearer’s name)
o The wearer should wash hands prior to and after handling the respirator
o The respirator is not too difficult to breathe through.
There are no regulations pertaining to whether non-employees (such as family members and visitors) should
be offered a respirator. Due to potential liability issues, it would be prudent to query the non-employee for
underlying respiratory disease, and teach them how to properly put on and seal-check the respirator prior to
offering them one. Additional information about respirators and respirator use can be found at:



3.
http://www.cdc.gov/niosh/nppti/respirators/respsars.html
http://www.cdc.gov/niosh/99-143.html
http://www.cdc.gov/niosh/topics/respirators
Gowns/Aprons: are used to protect the skin and clothing of the healthcare worker from anticipated contact
with body fluids. They can be made of synthetic material, plastic, or cloth, and have differing degrees of
permeability (how much fluid can pass through the material). Choice of which kind to use should be
dependent upon the task and duration of the task to be performed. For example, if a body fluid is splashed
on a gown, the healthcare worker must be able to remove or change the gown before the fluid soaks
through to clothing or skin; if unable to change the gown in time, a more impermeable gown should be
chosen. A yellow isolation gown may be suitable for contact precautions; a more fluid-resistant gown
should be selected for the Trauma Room or Delivery Room.
General Recommendations
1. Sanitation, Disinfection, and Sterilization:
Sanitation is cleaning. Disinfection means the killing organisms on a surface, excluding bacterial spores.
Sterilization means the complete killing of organisms on a surface, including bacterial spores. In the late
1960s, a gentleman named E. H. Spaulding proposed levels of germicidal cleaning based on the degree of
risk of infection from the surface or piece of equipment. Briefly, non-critical items such as floors,
wheelchairs, blood pressure cuffs, or stethoscopes can be sanitized or cleaned since they would only come
in contact with a person’s intact skin, which is itself an important barrier to infection. Semi-critical items
such respiratory therapy equipment should be disinfected (generally soaked in a liquid until bacteria and
viruses have been killed) because they come in contact with mucous membranes. What Spaulding
considered critical equipment (such as surgical instruments, needles, various catheters or drains) must be
sterile as they will enter a sterile part of the body, and risk of infection from their use would be high.
Knowledge of the application of Spaulding’s levels is most pertinent in an acute care setting. Under those
circumstances, an infection control practitioner, sterilization specialist, or operating room nurse would be
most familiar with the specific situational requirements.
As per the above, disinfection does not kill bacterial spores. An Environmental Protection Agency (EPA)approved disinfectant that is effective against common hospital organisms should be used for disinfection in
healthcare settings. Most disinfectants are inactivated by dirt or vegetative matter. An essential part of
cleaning, therefore, is the removal of physical dirt using soap and friction prior to disinfection. When mixing
the disinfectant solution, it is important to follow the manufacturer’s label instructions: wet the area to be
disinfectant, and let the area sit for 10 minutes. Then wipe off the excess disinfectant. If the solution is
mixed ‘extra-strong’, it will not provide extra disinfection, but will instead be more toxic and expensive.
In a non-healthcare setting, the same principles apply – physical removal of germs is 90% of the process.
Clean the area to reduce the amount of dirt and germs (bioburden), then disinfect the area. The difference
is that the general public does not usually have access to EPA-approved disinfectants. Some products such
as Lysol advertise as a ‘disinfectant’ but have not gone through the stringent EPA approval process, so their
efficiency is not known, and they cannot claim the ‘disinfectant’ label. That does not mean that they will
not work. Disinfection can also be achieved with the use of household bleach diluted in a 1:10 solution.
Recommendations for proper use of bleach follow. Specifics are listed on page 20 “How to Mix Bleach
Solutions”.
 Clean the area needing disinfection.
 Mix a fresh bleach solution daily (unless storing the mixture in an opaque container for < 30 days as
light inactivates chlorine, which provides the disinfection).
 Moisten the area to be disinfected; leave wet for 10 minutes, then wipe dry.
 Either discard the remainder of the bleach at the end of the day, or label it properly, including name,
strength, and date mixed so that it is not mistaken for another solution.
2. Patient Care Equipment:
In healthcare settings under outbreak conditions, when possible, medical care equipment (such as
disposable blood pressure cuffs, stethoscopes, wheelchairs) should be assigned to the individual patient.
The equipment should be thoroughly cleaned prior to use with another patient. Cloth objects should be
washed and dried or disposed of.
When surveying such a setting, look for common equipment – such as scales, wheelchairs, gurneys, shower
chairs, medication carts, etc. that could travel from room to room and contribute to an ongoing outbreak.
Reusable medical equipment should be cleaned and disinfected between patients according to
manufacturer’s instructions. Availability of disinfectant wipes near points of use may enhance compliance
with this requirement.
3. Management of Biohazardous Waste/Trash:
The California OSHA Bloodborne Pathogens Exposure Control Standard (CCR, Section 8) is a regulation that
specifies how biohazardous waste (materials with uncontained blood or other potentially infectious body
fluids) should be contained for disposal – in a red bag or one with a prominent biohazard symbol, nonaccessible to the general public (read: ‘in a locked area’).
The Medical Waste Act dictates how such waste must actually be disposed of. Used microbiology culture
plates and body parts belong in a red biohazard bag. Large volumes of bloody fluid can be flushed down a
sewer line. In deciding how to manage other specified regulated wastes or liquids for disposal, the key word
is ‘uncontained’. This means that if the blood, body fluid, or blood flakes are controlled, they may enter the
regular trash stream. An easy way to quickly tell how the waste should be disposed of is to apply the
principles of “squeeze, flake, or drip” – if one can squeeze blood or bloody fluid out of a dressing, or blood
will flake off, the dressing should go in a red bag. If blood ‘drips’ off an impervious gown or drape, it is not
controlled, and should go in a red bag. If the bag breaks during routine handling and an exposure to blood
or other fluids could result, a red bag (or two) should be used. If, however, there is a spot of blood in a
piece of gauze or cotton ball and an imagined squeeze test would yield nothing, and the gauze can go into
regular trash. Newspaper or other absorbent material can be used to contain excess fluids so that they can
be disposed of in household trash. Persons are advised not to dig around in trash without protective
clothing such as gloves on.
4. Handling of Laundry:
Soiled laundry such as clothing, bedding, and towels, even when contaminated with body secretions, can be
handled safely in the home setting provided certain basic principles are followed.



Soiled laundry should be carried at arms’ length so that it does not touch the clothing of the person
carrying it.
If laundry is soiled, even with large amounts of blood or bloody fluids, that portion of the laundry
can be rolled to the inside of the bundle, and then the bundle placed in a laundry hamper or bag.
The laundry hamper should be near the point of use; i.e., the worker should not have to walk more
than 10-20 feet before being able to place the laundry in a hamper.





Laundry should never be sorted outside of the laundry cleaning area. This includes transferring of
soiled laundry from one bag or hamper to another to ‘fill up’ the bag.
Laundry bags should be changed before they become so overfilled (or tear from excess weight) that
they cannot be closed for transport or moved.
Laundry workers are required to handle all linen as if it were infectious for bloodborne pathogens.
In a home setting, family members should take care not to put soiled laundry up against their
clothing.
Laundry may be washed at a temperature compatible with fabric and detergent, and dried at the
hottest temperature compatible with that fabric.
If there are issues of sharps (used needles or syringes, sharp instruments) in the soiled laundry, the issue of
proper disposal of sharps at the point of generation (where used) needs to be addressed by that institution.
5. Handling of Dishes:
Dishes and eating utensils do not require special handling, but should not be shared between persons unless
cleaned first. They should be run through a dishwasher after use, or washed in hot soapy water and rinsed
thoroughly. The use of disposable eating plates and utensils is a choice of logistics only, not an infection
control issue. Hand hygiene guidelines for food preparation and in relation to eating apply.
Suggested User References:
APIC Text of Infection Control & Epidemiology 2nd Ed. Association for Practitioners in Infection Control &
Epidemiology; ©2005
CDC Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/IDSA Hand Hygiene Task Force. MMWR 2002;51(No. RR16)
CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.
HICPAC Recommendations. [2004, Draft]
Green LR, Selman C. Factors Impacting Food Workers’ and Managers’ Safe Food Practices: A Qualitative Study.
Food Protection Trends, Vol. 25 (12), pp 981-990.
Institute for Healthcare Improvement . How-to Guide: Improving Hand Hygiene. www.IHI.org, 2006
Mayhall CG Ed. Hospital Epidemiology and Infection Control 3rd Ed. Lippincott Williams & Wilkins ©2004,
Philadelphia.
Acknowledgements:
Dr. Jon Rosenberg (Infectious Diseases Branch) and Kathy Harriman, RN, PhD, (Immunization Branch) for
technical assistance
Local Health Departments for offering suggestions to improve the readability and usefulness of this document
HAND HYGIENE
PRODUCT
Water
Plain soap
INDICATION


When hands
soiled/contaminated
If the organism is not killed or
inactivated by waterless hand
sanitizer (e.g. Clostridium
difficile, norovirus)
After:

exposure to blood and body
fluids

coming on duty

use of bathroom

sneezing or blowing nose

prolonged glove use

all direct patient care

a buildup of emollients
Before:

leaving the hospital

eating
Waterless Hand Sanitizer
Alcohol-based foam

Degerming required prior to
invasive procedures or contact
or gel
with highly susceptible clients.

After all direct patient care.

When hands are not visibly
soiled or contaminated.

During disasters or other
situations where plumbing is
interrupted.
Antiseptic towelettes


Water is not available.
Visible soiling on hands.
TECHNIQUE










Approved Lotion
Must use aqueous
(water-based), not
oil-based solutions

Use to improve skin, maintain
skin integrity and increase
moisture content to prevent
drying and cracking of hands.

RATIONALE
Wet hands under a stream of
water.
Apply handwashing agent
(liquid or other).
Vigorously rub together all
surfaces of hands from wrist
to fingertips and around nails
for at least 10 seconds.
Thoroughly rinse hands under
a stream of water.
Pat dry with a towel. DO NOT
friction rub.
Use towel to turn off water
faucet. Do not touch dirty
faucet with clean hands.

Mechanical removal of soiling
via friction and running water.
suspends the flora from the
skin, and allows them to be
rinsed off.
½ - ¾ inch diameter rubbed
thoroughly into hands until
completely absorbed.
Contaminated surfaces will
exist if an insufficient amount
of solution is used, or there is
a failure to cover to cover all
surfaces of the hands.
Requires periodic
handwashing to remove film
buildup.
Open towelette and
vigorously rub hands
thoroughly; dispose.
Use >1 for gross soiling.


Is an adjunct to handwashing.
Provides rapid hand antisepsis
in the absence of visible
soiling.
Is gentler on hands than the
regular use of soap and water.
Apply an approved lotion or
cream as directed on
container after hand hygiene.
Containers must be for
individual use, not refillable.




Is an adjunct to handwashing.
Use of friction to remove soil
is imperative.
Reduces shedding and
transmission of microbes.

Maintains skin barrier

integrity.

Must be latex compatible.

Avoid contamination of the
lotion.
* In general, the decision whether hand hygiene via handwashing, an alcohol-based hand hygiene product, or an antiseptic towelette
should occur is dependent upon the degree of contamination likely to occur with the contact, the intensity of contact with patients or
equipment, and the patient’s susceptibility to infection.
HOW TO MIX BLEACH SOLUTIONS
Bleach Solution #1 (800 ppm)
Bleach Solution #2 (200 ppm)
Use for hard surfaces
Use for mouthed toys, food contact surfaces
Water
1 gallon
(16 cups)
1 quart
(4 cups)
1 pint
(2 cups)
Regular Bleach
5.25%
¼ cup
1 tablespoon
Ultra Bleach
6-6.25%
3 1/3
tablespoons
2 ½ teaspoons
1 ½ teaspoons
1 ¼ teaspoons
Water
1 gallon
(16 cups)
1 quart
(4 cups)
1 pint
(2 cups)
Regular Bleach
5.25%
1 tablespoon
Ultra Bleach
6-6.25%
2 teaspoons
¾ teaspoon
½ teaspoon
3/8 teaspoon
¼ teaspoon
Note:
o Test Bleach Solution #2 with test kits daily (range should be 50-200 ppm). Your local environmental
health agency may be able to tell you where to purchase the test kits. A pool supply store may also sell
them.
o It is recommended to make solutions fresh daily; label with date and contents.
o Clean/scrub items and surfaces before disinfecting.
o Store bleach out of reach of children.
o Date bleach when purchased; do not keep longer than 3 months.
Thanks to the Minnesota Department of Public Health and the Hennepin County Community Health Department.
CDC Environmental Checklist for Monitoring Terminal Cleaning1
Date:
Unit:
Room Number:
Initials of ES staff (optional):2
Person Completing this form
Evaluate the following priority sites for each patient room:
High-touch Room Surfaces3
Cleaned
Not Cleaned
Bed rails / controls
Tray table
IV pole (grab area)
Call box / button
Telephone
Bedside table handle
Chair
Room sink
Room light switch
Room inner door knob
Bathroom inner door knob / plate
Bathroom light switch
Bathroom handrails by toilet
Bathroom sink
Toilet seat
Toilet flush handle
Toilet bedpan cleaner
In Room closet
curtains
Not Present in Room
Evaluate the following additional sites if these equipment are present in the room:
High-touch Room Surfaces3
Cleaned
Not Cleaned
Not Present in Room
IV pump control
Multi-module monitor controls
Multi-module monitor touch screen
Multi-module monitor cables
Ventilator control panel
Mark the monitoring method used:
Direct observation
Fluorescent gel
Swab cultures
ATP system
Agar slide cultures
____________________________
1
Selection of detergents and disinfectants should be according to institutional policies and procedures
Hospitals may choose to include identifiers of individual environmental services staff for feedback purposes.
3
Sites most frequently contaminated and touched by patients and/or healthcare workers
2
Current clinical assessment of known CRE patient
A tool to be used in addendum to the Inter-Facility Transfer Form (CDC)

Medical Diagnosis:
o Acute/Chronic Respiratory conditions
o Other diagnosis


IS patient a Dialysis patient? Yes/No
If Yes
o Frequency of dialysis per week
o Name of facility providing dialysis
o Transport service to dialysis if external facility

Current Functional Assessment of Patient
o Is patient bed bound/wheelchair bound
o Does patient require use of mechanical lift/supportive equipment - Yes/No
o Ambulation(Circle One)
 Completely dependent
 Requires some assistance
 Independent
Communication
o Is patient A&O- Yes/No
o Is patient able to understand verbal content/instructions- Yes/No
o Is patient able to verbalize/express needs/wants- Yes/No
Feeding (circle One)
o PO
o Tube feeding (Nasal, G-tube, GJ-tube, J-tube)
Toileting/Bathing (Circle One)
o Incontinent of urine/stool
o Requires use of urinal, commode/bedpan
o Able to use bathroom independently or w/assistance
Therapeutic services required for patient (circle or list all that apply)
o PT
o OT
o Speech
o Other



