Download Routine Practices and Additional Precautions

ANNAPOLIS VALLEY DISTRICT HEALTH AUTHORITY
Policy/Procedure
TITLE:
Routine Practices &
Additional
Precautions
Date Effective: December 17, 2013
Applies To:
NUMBER: 282.006
Page
(1 of 10)
All Clinical Areas
All Non-Clinical Areas
POLICY
1.
AVH requires the use of Routine Practices as a minimal level of care that will be
applied to all patients, regardless of disease status. Routine Practices include
protocols that are initiated when there is potential exposure to blood and/or body
fluid, including secretions, excretions or contact with non-intact skin or mucous
membrane.
2.
Strict adherence to Routine Practices will be used in the care of patients with
seriously impaired resistance, including Additional Precautions when indicated.
Terms such as reverse isolation or protective precautions are no longer used for
the management of these patients.
3.
Additional Precautions (Transmission-based Precautions) will be implemented
when there is a known or suspected pathogen that is transmitted by either
contact, droplet, airborne, or a combination of any of these routes of
transmission.
DEFINITIONS
Contact Transmission includes direct contact and indirect contact.
Direct Contact:
Occurs when transfer of micro-organisms results from direct physical contact between
an infected or colonized individual and a susceptible host (body surface to body
surface).
Indirect contact: involves passive transfer of microorganisms to a susceptible host by
way of unwashed hands, contaminated instruments or other inanimate objects in the
patient’s immediate environment.
Airborne Transmission: refers to the spread of micro-organisms being sprayed when
coughing or in dust particles containing skin squames and other debris that remain
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Routine Practices & Additional Precautions
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suspended in the air for long periods. Such micro-organisms are widely dispersed by air
currents and inhaled by susceptible hosts who may be some distance away from the
source patient, even in different rooms or hospital wards.
Droplet Transmission: refers to large droplets, generated from the respiratory tract of
the source patient during coughing or sneezing, or during procedures such as
suctioning or bronchoscopy. These droplets are propelled a short distance, less than
two metres through the air and deposited on the nasal or oral mucosa of the new host.
Large droplets do not remain suspended in air therefore special ventilation is not
required.
Protective Environment or Precautions:(formerly known as Reverse Isolation) was
a common type of isolation designed to prevent contact between potentially pathogenic
microorganisms and persons with seriously impaired resistance. Measures included the
use of gowns, masks and gloves by all of those who entered the patient room. The
Centers for Diseases Control and Prevention (CDC) deleted this category in 1983.
Current literature and guidelines conclude that there is insufficient evidence to support
the use of a protective environment. Recommendations for the care of the highly
immune compromised patient stresses the use of routine practices, including hand
hygiene, and additional precautions when indicated. It is also critical that health care
providers and others who are acutely ill with a communicable infection do not enter the
room of highly immune compromised patients. Recent CDC guidelines have redefined
the term “protective environment” to include engineering designs such as high efficiency
particulate air (HEPA) filtration of incoming air, directional air flow with positive room air
relative to the corridor, and ventilation requirements of more than 12 air exchanges per
hour. This environment is now recommended for allogeneic hematopoietic stem cell
transplant patients and is designed to minimize fungal spore counts in the air to reduce
the risk of invasive environmental fungal infection.
PRACTICE GUIDELINES
1.0 Routine Practices Protocol: Routine practices are achieved through various
means and require decision-making that is dependent on the following:
 Degree of contact
 Degree of contamination
 Environmental conditions
 Patient’s level of understanding/co-operation
 Amount of aerosol/splash generation
 Procedural difficulty and experience level of the provider of care.
1.1 Hand Hygiene:
 Hand hygiene is required before and immediately after patient care, after
handling of potentially contaminated equipment/surfaces, and immediately
after glove removal.
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Routine Practices & Additional Precautions
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Wash hands 10-15 seconds with antimicrobial soap and water, or use a
hospital approved alcohol-based/antiseptic hand rub.
1.2 Personal Protective Equipment (PPE):
Refer to Appendix A for pictorial diagram for donning and removing of PPE.
1.3 Indications for Gloves:
Clean, non-sterile gloves are worn for:
 Any potential exposure to blood, body fluids, secretions or excretions (except
for sweat), non-intact skin, or mucous membranes.
 Handling items that are visibly soiled with blood, body fluids, secretions or
excretions.
 Health care workers with non-intact skin on hands.
 Change gloves between patients and between activities with the same patient
whereby gloves have been contaminated with blood or body fluids,
secretions, or excretions.
1.4 Indications for Masks, Eye Protection, and Face Shields:
 Wear masks, eye protection, or face shields to protect the mucous
membranes of the eyes, nose, and mouth when there is potential for
procedures or events to generate splashes or sprays of blood, body fluids,
secretions, or excretions.
 Wear masks only once and discard immediately if they become moist or
damaged. Avoid touching the mask while it is being worn.
 Wear NIOSH N95 masks for airborne precautions.
 Wear surgical/procedural mask for droplet precautions.
1.5 Indications for Gowns:
 When there is a need to protect uncovered skin or to prevent soiling clothes
during activities that have the potential to generate splashes or sprays of
blood, body fluids, secretions, or excretions, wear long sleeved gowns or
plastic aprons.
 Put on gowns with the opening at the back with the edges overlapping and tie
at the neck and waist.
 When removing the gown, undo the ties and remove the gown without
touching the clothing. Turn the gown inside itself, roll it up and place in a
laundry hamper or in the garbage if disposable gowns are used.
1.6 Safe Sharps Handling:
 Sharps include any device capable of puncturing skin, insertion in
extravenous bags, such as needles, lancets, intravascular catheters,
cannulas, trocars and scalpel blades.
 Handle used needles and other sharp instruments with care to avoid injuries
during disposal or reprocessing.
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Immediately dispose of single-use sharp items in a designated hospital
sharps container.
1.7 Patient Care Equipment:
 Clean and/or reprocess reusable patient care equipment according to
 Reprocessing of Patient Care Equipment Policy 282.008.
 All patient care equipment must be thoroughly cleaned and/or disinfected in
between multiple patient use.
1.8 Environmental Cleaning:
 Follow established procedures for routine care, cleaning, and appropriate
disinfection of patient furniture and environmental surfaces.
 Pay special attention to horizontal and frequently touched surfaces, i.e.
bedrails, doorknobs, etc.
1.9 Accommodations/Patient Rooms:
 Place patients who visibly soil the environment or whose hygiene cannot be
maintained in single rooms with dedicated toileting facilities. This includes
mobile patients with fecal incontinence, if stools cannot be contained in
diapers, and patients with draining wounds in which dressings are unable to
be kept in place.
 Single rooms are not required for children in diapers unless they have
uncontained diarrhea and cannot be confined to their designated bed space.
1.10
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1.11
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Laundry:
Remove large amounts of solid soil prior to folding.
Roll/fold heavily soiled linen to contain the heaviest soil in the center of the
bundle.
Use an additional outer bag if linen bag soaks through
Linen bags should not be overfilled. Tie linen bags securely prior to being
transported.
To provide protection from soiled linen, wear appropriate protective
equipment such as gloves and gowns when handling potentially soiled linen.
Food Services:
Disposable items are unnecessary. Used dishes, cutlery and trays have not
been associated with the spread of hospital-acquired infection.
Food & Nutrition Services will deliver and pick up trays to all isolation rooms
within AVH with the exception of those on airborne precautions (see
appendix).
Return all used trays and contents to Food and Nutrition with a minimum of
handling. Used trays can be left on bottom shelf of dietary cart in patient
kitchen.
When dismantling trays, wear appropriate clothing, i.e., waterproof gowns and
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Routine Practices & Additional Precautions
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gloves.
1.12
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Waste Management:
Potential for exposure to waste still exists and precautions need to be
implemented.
Package hospital-produced waste properly to protect the health care worker,
patients and visitors from potential exposure and to facilitate the proper
handling, storage, treatment and /or disposal of the waste.
Select appropriate packaging for the type of waste being contained to
maintain integrity during the collection, transport and storage process.
Whereas the potential exists for exposure to infectious waste, health care
workers need to protect themselves. Personal protective equipment such as
gloves and gowns should be worn.
2.0 ADDITIONAL PRECAUTIONS (TRANSMISSION-BASED PRECAUTIONS):
 There are three main categories of isolation precautions—contact, droplet and
airborne pictograms There are three main categories of transmission based
precautions – contact, droplet and airborne. These precautions can be used
individually or in combination i.e. droplet/contact depending on the type of
organism, disease entity, or type of patient.
 Information on transmission-based precautions can be found in the “yellow
pages” of the Infection Control Manual entitled Tables of Symptoms/Disease
Organism/Diagnosis. After identifying the organism, symptom, or disease
requiring isolation, determine from the table, the necessary transmission based
precaution requirements.
 Appropriate signage must be posted on the door of an isolation room indicating
type of isolation and necessary transmission-based precaution requirements.
Notation should be made on the patient’s Kardex. Discontinuation of isolation
precautions must be in accordance with the “yellow pages” or in consultation with
Infection Prevention & Control.
 Notification of isolation precautions must be communicated to healthcare workers
providing care or service, and upon transfer of patient to receiving
unit/department, facility, funeral home or Emergency Health Services (EHS).
 In an emergency situation, safe and timely evacuation takes priority over the
need to ensure precautions are maintained.
 Isolation precautions should continue to be applied during post-mortem care. The
exception would be when patients are on airborne precautions, unless there is
the potential for aerosolization of respiratory fluids.
3.0 CONTACT PRECAUTIONS
3.1 Accommodation:
 Single room preferable and should have toilet and hand washing facilities.
Door may remain open as long as isolation signage is visible.
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If unable to assign single room:
o A spatial separation of at least 1 metre must be maintained between
infected patient and other patients and their visitors.
o Roommates should be selected for their ability and that of their visitors to
comply with precautions.
o Roommates should not be at high risk of serious disease if transmission
occurs.
o Patients known to be infected with the same organism may be grouped
together unless acquisition of different strains is a concern i.e. Antibiotic
Resistant Organisms.
3.2 Gloves:
 Should be worn on room entry.
 Should be removed before leaving patient’s room or bed space.
3.3 Gowns:
 Should be worn if clothing or forearms will have direct contact with the patient,
frequently touched environmental surfaces or objects, and there is increased
risk of environmental contamination due to incontinence, draining wounds, etc.
 Should be removed before leaving patient’s room or bed space.
3.4 Masks:
 Masks are not routinely required.
3.5 Hand Hygiene:
 Wash hands with Antimicrobial soap and water or alcohol-based hand rinse
before leaving the room and after removal of gown & gloves. When there is
visible soiling, hands must be washed with soap and water before using
alcohol-based hand rinse.
 After hand hygiene, take care not to contaminate hands before leaving the
room.
3.6 Equipment and Environment:
 Dedicated patient care equipment i.e. thermometers, blood pressure cuffs,
stethoscopes, etc.
 Equipment must be thoroughly cleaned and disinfected before reuse on
another patient.
 Disposable supplies in the room should be kept to a minimum and must be
discarded once the patient is discharged from the room i.e. soaps, Kleenex,
toilet paper, toothettes, incontinent pads, etc
3.7 Patient Transport:
 Patient should leave room for essential purposes only.
 Precautions must be maintained during transport.
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Receiving departments and facilities, and transporting personnel (porters, EHS
must be notified of precautions prior to transport.
3.8 Visitors:
 Should be kept to a minimum. In the event of an outbreak, refer to policy,
Visitor Restrictions During an Outbreak 282.001.
 Visitors should talk to a nurse before entering the room and be instructed on
appropriate use of PPE and transmission-based precautions.
 The risk to the health of the visitor should be evaluated prior to admittance to
room.
4.0 DROPLET PRECAUTIONS
4.1 Accommodations:
 Single room preferable and should have toilet and hand washing facilities.
Door may remain open as long as isolation signage is visible.
 If unable to assign single room:
o A spatial separation of at least two metres (6 feet) must be maintained
between infected patient and other patients and their visitors.
o Roommates should be selected for their ability and that of their visitors to
comply with precautions.
o Roommates should not be at high risk of serious disease if transmission
occurs.
4.2 Masks:
 A surgical procedure mask is to be worn if within two metres (6 feet) of the
patient.
 A mask is not required for mumps or rubella if immunity is confirmed.
4.3 Eye Protection:
Should be worn for care of children with symptoms of acute respiratory infection if
within one metre of coughing patient or if performing procedures that may induce
coughing.
 Should be worn for other infections transmitted by large droplet as per Routine
Practices.
4.4 Patient Transport:
 Patient should leave room for essential purposes only;
 Precautions must be maintained during transport. Patient should wear a
surgical mask and wash hands for transport.
 Receiving departments and facilities, and transporting personnel (porters,
EHS) must be notified of precautions prior to transport.
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4.5 Visitors:
 Should be kept to a minimum. In the event of an outbreak, refer to policy
282.001, Visitor Restrictions During an Outbreak.
 Visitors should talk to a nurse before entering the room and be instructed on
appropriate use of PPE and transmission-based precautions.
 In the case of patients with acute viral respiratory infection, masks are not
mandatory for those persons for whom wearing a mask for a prolonged period
of time may be impractical. The risk to the health of the visitor should be
evaluated prior to admittance to room.
5.0 AIRBORNE PRECAUTIONS
5.1 Accommodations:
 Single room.
 Negative pressure in relation to surrounding areas.
 A minimum of 6-9 air exchanges per hour.
 Air discharged outside the building and away from intake ducts, or through a
high-efficiency filter if re-circulated.
 Door kept closed whether or not patient is in the room.
 After discharge door kept closed until sufficient time has elapsed to allow
removal of airborne organisms.
 Patient confined to room.
 Room should have own toilet, hand washing and bathing facilities.
5.2 Special considerations for accommodation:
 If unable to obtain an appropriately ventilated room, consideration should be
given to transferring patients with infectious forms of tuberculosis to an
institution with such accommodation. Plans should be coordinated in advance
with other institution.
 For measles or varicella, in the event that a negative pressure room is
unavailable and where transfer is not a feasible option, consideration for using
a single room with door closed is acceptable, given that most individuals are
immune and post exposure prophylaxis is possible. Such patients should be
accommodated on wards where there are no susceptible,
immunocompromised patients. Whereas the number of negative pressure
rooms is limited, priority for use of such rooms should be set according to the
impact of potential airborne transmission. (i.e. infectious tuberculosis, measles,
varicella, disseminated zoster, extensive localized zoster). Consultation must
occur with Infection Prevention and Control.
5.3 Personnel and Visitors:
 All health care personnel must have documented immunity to measles
according to Immunization Policy. Personnel and visitors susceptible to
measles should not enter the room of a patient with measles.
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Varicella-susceptible personnel and visitors should not enter the room of a
patient with varicella or disseminated zoster unless exceptional circumstances
make this mandatory.
5.4 Masks:
 Special masks: high-efficiency particulate respirator (N95) masks should be
available (in all sizes and styles that have been utilized in the district fit-testing
process) for all personnel who enter the room of a patient with infectious
tuberculosis, or for non-immune persons who absolutely must enter the room
of a patient with varicella, disseminated zoster or measles.
5.5 Patient Transport:
 Patient should be out of the room for essential procedures only.
 Patient should wear surgical (procedure) mask during transport (Page 8 of 8
282.006).
 Personnel in area to which patient is to be transported should be aware of
precautions to follow.
 Infection Prevention and Control should be consulted prior to any transport.
 Health care worker transporting the patient should wear an N95 respirator.
5.6 Visitors:
 Visitors should talk with a nurse before entering the room and, if indicated,
should be instructed in the appropriate use of a mask and other precautions.
The number of visitors should be restricted.
 In the event of an outbreak, refer to policy, Visitor Restrictions During an
outbreak – 282.001.
REFERENCES
APIC Text of Infection Control and Epidemiology (2000). Infectious Waste
Management. 74(1-7).
Health Canada. (1998). Hand Washing, Cleaning, Disinfection and Sterilization in
Health Care. Canada Communicable Disease Report, 24(Supp 8): i-xi, 1-57.
Health Canada. (1999). Routine Practices and Additional Precautions for Preventing the
Transmission of Infection in Health Care. Canada Communicable Disease Report.
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Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.
Routine Practices & Additional Precautions
Page 10 of 10
Ontario Agency for Health Protection and Promotion. (November 2012). Routine
Practices and Additional Precautions In All Health Care Settings, 3rd edition. Provincial
Infectious Diseases Advisory Committee.
Risi, George F. Chapter 15, The Immunocompromised Host – Preventing Infection in
the Immunocompromised Host. APIC Text Online. 2012. Available at
http://text.apic.org/account/login Accessed January 22, 2013.
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. Available at
http://www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf Accessed January 28, 2013.
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