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Transcript
Transmission Based Precautions Policies (TBP) – Information on Droplet/Contact/Airborne Precautions Date of issue: April 2009 Date of re-issue: April 2010 1) Who should use Transmission Based Precautions policies? The policies can be used by for example, infection control teams, health and social care managers, nurses, doctors, or other health and social care providers. They should be read in conjunction with the associated literature reviews. The policies can be used as a ‘check’ to ensure relevant policies are in place, to ensure content in local policies is current and comprehensive, to inform the basis of local policy development or used in their entirety. 2) What are the objectives of these policies? It is intended that these policies will provide a common, consistent approach to infection prevention and control, prevent duplication of effort and therefore reduce time spent on policy development. They intend to provide evidence based guidance where possible (a standardised scientific methodology has been applied to literature reviewing and critiquing of the evidence base to inform the policies). 3) What are Transmission Based Precautions? Transmission Based Precautions, in addition to Standard Infection Control Precautions (SICPs), are a set of measures that should be implemented when patients/clients are either suspected or known to be infected with a specific infectious agent, when aiming to prevent and control spread, particularly in relation to Healthcare Associated Infections (HAI). Transmission Based Precautions are categorised according to the route of transmission of the infectious agent such as droplet, contact and/or airborne. 4) Why are Transmission Based Precautions necessary? They are necessary because transmission of specific infectious agents will not be prevented by SICPs alone e.g. Mycobacterium tuberculosis. SICPs are the minimum set of measures to be applied at all times within a health and social care setting or where health and social care is being provided. SICPs should be applied for both recognised and unrecognised sources of infection and are intended to protect the patient/client, health and social care worker and any visitors/carers. SICPs must underpin all health and social care activities and should be applied at all times, when exposure to blood, other body fluids secretions or excretions (except sweat) non intact skin or mucous membranes may occur. SICPs also apply to equipment or items in the patient/client environment that may have become contaminated. Transmission Based Precautions (TBP) – Information on Droplet/Contact/Airborne Precautions HPS ICT 2009 Page 1 of 102 5) When should Transmission Based Precautions be applied? Transmission Based Precautions are required in all health and social care settings when a patient/client is known or suspected to be infected/colonised with an infectious agent or an epidemiologically important organism that can be spread by the droplet, contact and/or airborne route. This includes precautions to be taken with those; with active infections, who are incubating infectious disease, who are asymptomatic but suspected to be infectious and those who are colonised with pathogenic microorganisms. Examples of these infectious agents include those of HAI concern such as MRSA and Clostridium difficile that may spread and cause harm to others while care is being delivered. 6) How do the elements of Transmission Based Precautions relate to Standard Infection Control Precautions? The nine elements of SICPs must underpin all health and social care activities. It is therefore assumed, for the purpose of the Transmission Based Precautions policies, that all SICPs are being adhered to and they are therefore not specifically addressed within the documents. More information on SICPs is available from: http//www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx 7) Is there specific concern around multi-drug resistant organisms (MDROs) The need for droplet, contact and/or airborne precautions will vary depending on the patient/client, the setting, and the organism (Refer to Appendix 1). For example highly dependant in-patient areas such as intensive care require different considerations than areas such as mental health settings, however further advice may be required from local Infection Control/Health Protection Teams. Within non acute settings such as care homes, community clinics, during home care, individual risk assessments are required to determine for example, the use of shared facilities such as toilets, based on the patient/clients symptoms, other individuals in the same setting and the availability of hand hygiene facilities, etc. Advice from local Infection Control/Health Protection Teams may be required in the case of MDROs to facilitate risk assessments and provide appropriate individual guidance based on the principles described in the policies. The information within the policies applies to all organisms transmitted via all routes whether MDRO or not. Specific points of note related to MDROs include: Droplet Additional face protection including masks may be required when caring for patients/clients with MDROs when performing certain healthcare activities, even if not routinely advocated for droplet precautions, e.g. during aerosol-generating procedures. Contact Surgical masks are not recommended for the routine care of patients/clients with MDROs cared for under contact precautions such as MRSA. Face protection including surgical masks however are recommended for use with patient/clients with MDROs when performing certain Transmission Based Precautions (TBP) – Information on Droplet/Contact/Airborne Precautions, HPS ICT 2009 Page 2 of 102 healthcare activities which for example may result in splashing to the face e.g. wound irrigation and intubation, in conjunction with recommendations for eye/face protection as per SICPs. Airborne The importance of respiratory masks (FFP3) when caring for patients/clients with MDRO. 7) How long should Transmission Based Precautions remain in place? The duration of Transmission Based Precautions for specific infectious agents spread by droplet, contact and airborne is listed within Appendix 1. However, this list is not exhaustive and is for guidance only. Transmission Based Precautions may require to be lengthened, for example for immunocompromised patients due to the risk of prolonged shedding of organisms. This decision should be based on the individual’s situation, symptoms and treatment and be guided by the physician/clinician in conjunction with the local Infection Control/Health Protection Team. 8) What terms were previously used to describe aspects of Transmission Based Precautions in practice? The terms that were previously used include; barrier nursing, enteric precautions, isolation nursing and source isolation. Transmission Based Precautions incorporate all the measures that have previously been recommended under these terms. Some infectious agents are spread by more than one route, such as both droplet and contact in the case of influenza, therefore these policies should not be considered in isolation. Policies and literature reviews for Transmission Based Precautions can be found at http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx. Transmission Based Precautions (TBP) – Information on Droplet/Contact/Airborne Precautions, HPS ICT 2009 Page 3 of 102 Droplet Precautions Policy and Procedure (an element of Transmission Based Precautions) Date of issue: April 2009 Date of re-issue: April 2012 Introduction What are droplet precautions? Droplet* precautions are a set of infection control measures (to be used in addition to Standard Infection Control Precautions* (SICPs)), which are designed specifically to prevent and control the transmission of infectious agents* spread by droplets to patients/clients and health and social care workers during provision of care. These precautions include: isolation, use of personal protective equipment (PPE), hand hygiene, care of equipment and environment including decontamination, safe handling of linen and waste. Why are droplet precautions important within health and social care settings? It is important to prevent infectious agents that could be present in, for example, the respiratory tract of individuals being transmitted via droplets to others and resulting in healthcare associated infection*. When are droplet precautions required? The need for droplet precautions will vary depending on the patient/client, the setting, the infectious agent (Refer to Appendix 1) and the procedures/activities being undertaken. For example highly dependent in-patient areas such as intensive care require different considerations than areas such as mental health settings. Further advice may be required from local Infection Control/Health Protection Teams. Within non acute settings, such as care homes, community clinics or during home care, individual risk assessments are required. Droplet precautions are required in all health and social care settings when a patient/client is known or suspected to be infected*/colonised* with an infectious agent or an epidemiological important organism* that can be spread by droplets. They include precautions to be taken with those; with active infections, who are incubating infectious disease, who are asymptomatic but suspected to be infectious and those whose respiratory tract is colonised with pathogenic microorganisms*. * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 4 of 102 How do you decide which precautions are required? Not all elements may be required for every patient/client or situation. The use of risk assessment should be applied when assessing the requirement for precautions and further specialist advice should be sought from local Infection Control/Health Protection Teams as required. This policy describes the key precautions to be considered when delivering care to those with infections spread by droplets. Examples of infections spread by droplets and of Healthcare Associated Infection (HAI) concern • Group A streptococcal disease • Meningococcal disease (meningitis/septicaemia) • Influenza • Others causing concern identified locally including those resistant to antibiotics Remember other infections are spread via droplet, airborne and contact (see full list in Appendix 1, this list is not exhaustive and some infectious agents are spread by more than one route) This policy does not give specific guidance for outbreak situations or extremely rare infectious conditions which will require additional critical infection control measures * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 5 of 102 Contents This policy contains information on: Page Underpinning responsibilities for droplet precautions ...................................................... 7 Rationale for droplet precautions ..................................................................................... 10 Patient/client placement (e.g. use of single rooms/isolation) ........................................... 11 Duration of droplet precautions........................................................................................ 13 Patient/client transfers ..................................................................................................... 13 Respiratory hygiene/cough etiquette ............................................................................... 13 Personal Protective Equipment (PPE) ............................................................................. 14 Masks and other face protection...................................................................................... 14 Gloves and aprons........................................................................................................... 14 General good practice points ........................................................................................... 14 Hand hygiene................................................................................................................... 15 Management of care equipment and control of the environment ..................................... 15 Safe management of linen ............................................................................................... 16 Safe disposal of waste ..................................................................................................... 16 Occupational exposure management .............................................................................. 17 Glossary........................................................................................................................... 18 Appendix 1 – Infectious agents – Clinical infections or diseases warranting Transmission Based Precautions in addition to Standard Infection Control Precautions...................................................................................................................... 21 Appendix 2 – Hierarchy of placement for those known or suspected to have an infection spread by infectious droplets ............................................................................. 34 Appendix 3 – Putting on and removing PPE .................................................................... 35 Appendix 4 – Summary of precautions to minimise the spread of diseased caused by infectious droplets............................................................................................................ 36 For further background information, see associated literature review on the elements of droplet precautions * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 6 of 102 What are the underpinning responsibilities for droplet precautions? NHS Boards must: • Ensure systems and resources are in place to facilitate implementation of the policy Managers must: • Ensure that all staff have had instruction/education on the principles of droplet precautions, Standard Infection Control Precautions and risk assessment • Ensure that adequate resources are in place to allow for the recommended infection control measures to be implemented • Ensure areas participate in surveillance and audit programmes at a national and/or local level where required. This will help support the implementation of precautions at the most appropriate times • Undertake a risk assessment to optimise patient/client and staff safety, consulting expert infection control guidance as required • Support staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission* • Ensure any staff with health concerns or who may have become ill due to occupational exposure are referred to the relevant agency e.g., General Practitioner or Occupational Health • Ensure that estates/facilities management provide a safe environment to allow infection* prevention and control precautions to be applied. All staff – (providing direct care in a health or social care setting including patient’s/clients’ own homes) must: • Apply Standard Infection Control Precautions and the measures described in this policy • Ensure all other staff/agencies apply the principles of Standard Infection Control Precautions and the measures described in this policy • Undertake risk assessments when assessing the requirement for droplet precautions • Document when droplet precautions according to the policy cannot be implemented for clinical or other relevant reasons • Provide information on the precautions being taken. This should be communicated to all staff, the patients/clients, and visitors without breaching confidentiality • Offer reassurance to patients/clients and visitors/carers regarding the need for droplet precautions • Advise the patient/client, carers or visitors of any infection prevention and control requirements such as hand hygiene and respiratory hygiene/cough etiquette • Ensure occupational immunisations are up to date (if applicable) • Report to line managers any deficits in; knowledge in relation to droplet precautions/Standard Infection Control Precautions, facilities/equipment or incidents that may have resulted in cross transmission • Attend any mandatory or update infection control education sessions * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 7 of 102 • Report any illness that may be as a result of occupational exposure to their line manager and Occupational Health Department (if applicable) • Not provide direct patient/client care while infectious e.g. suffering diarrhoea and vomiting, as this could cause harm to the patient/client/others. If in any doubt consult with your manager, General Practitioner, Occupational Health Department or the local Infection Control/Health Protection Team • Support other staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission • Ensure staff with health concerns or who have become ill due to occupational exposure are referred to the relevant agency e.g., General Practitioner or Occupational Health • Ensure that estates/facilities management provide a safe environment to allow infection* prevention and control precautions to be applied. Staff with infection control/health protection responsibilities must: • Provide education for staff and management on this policy • Act as a resource for guidance and support when droplet precautions are required • Provide expert advice on the points below and/or seek additional expert advice from infection control specialists on these matters where required; o Provide expert advice for incidents involving epidemiologically important organisms (and outbreaks/incidents) o Provide advice on individual risk assessments, for example a placement* decision Visitors should be advised: • To contact the person in charge before visiting if they are unsure of the infectious status of the person they are visiting • Of appropriate hand hygiene to be carried out before and after visiting as well as other relevant infection prevention and control measures • Of appropriate respiratory hygiene/cough etiquette which should be adhered to • Of the Chief Medical Officer 5 top tips for all patients, staff and visitors. See http://www.scotland.gov.uk/Publications/2004/08/hai Incident reporting: • Any incidents where failures in adopting droplet precautions have occurred and/or incidents which have resulted in cross transmission should be documented and reported as per local incident reporting procedures. * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 8 of 102 Communication and general good practice: • Effective communication between all members of the health and social care team is imperative for the management of infectious agents • Those who are unwell with respiratory symptoms should be advised not to attend non-urgent appointments or visit other settings where infections might spread to those who are vulnerable • Means of communication to alert staff that droplet precautions need to be in place, for example signage that does not breach confidentiality Everyone has an important part to play in improving patient/client safety. Undertaking Transmission Based Precautions is an essential element to ensure everyone’s safety. * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 9 of 102 What is the rationale for droplet precautions? • Droplet precautions are required to prevent the transmission of infectious agents via droplets and to minimise healthcare associated infection (HAI). It is essential to apply the relevant infection control precautions during any health and social activity. Due to the distance that droplets can travel from infected respiratory tracts, which depends on a number of factors including their speed, size, density and a number of additional environmental factors such as temperature, humidity etc., the precautions described are pivotal. Droplet transmission is defined as the transfer of large droplets (>5µm) from the respiratory tract of an infected individual directly onto a mucosal surface or conjunctivae of another individual. Due to the comparative large size of the particles it is accepted that droplets when dispelled only travel relatively short distances through the air, e.g. less than 3 feet (1 metre). The activity, which resulted in the droplet expulsion from the respiratory tract, affects this distance of spread and therefore has to be considered when precautions are being taken • Infected individuals can cause respiratory droplets to be expelled as a result of a number of human activities such as coughing, sneezing and even talking. They can also be a risk during certain healthcare procedures such as endotracheal intubation and suctioning • Droplets are transmitted over short distances and this has been historically defined as less than 3 feet (1 metre) from the patient. This distance has been used as a measure and prevention measures based on this have been shown to be effective NB. Certain respiratory infections spread by droplets, such as SARS, require additional infection control measures. Refer to the literature reviews for additional information sources, seek advice from local Infection Control/Health Protection Teams and in addition, for guidance on Pandemic Influenza see http://www.hps.scot.nhs.uk/resp/guidelines.aspx Remember Transmission Based/additional precautions are always applied in addition to Standard Infection Control Precautions * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 10 of 102 Where should those requiring droplet precautions be cared for? • This requires risk assessment in order to determine the most appropriate placement for patients/clients. This will depend on: • The infectious agent (refer to Appendix 1) • The patient/client and their overall condition e.g. a productive cough • The area where the patient/client is being cared for. This includes the potential for adverse outcomes in others (e.g. consider risks to immunocompromised* patients, those with invasive devices) and the availability of single rooms • The procedure/activities being undertaken • Timeliness of assessment and placement is essential. Additional support may be required if this is problematic and, for example, greater than one hour has elapsed Acute settings • Patients with known/suspected infections requiring droplet precautions should be placed in single rooms with en suite facilities as soon as possible. The door should be kept closed • Certain conditions require the patient to be placed in monitored specialised isolation rooms* as soon as is practical, e.g. SARS. Seek advice from local Infection Control/Health Protection Teams • If rooms are unavailable then transfer to another unit/hospital with suitable facilities should be considered (providing the patient/client is medically stable). A risk assessment by clinicians and managers supported by local Infection Control/Health Protection Teams will help determine when an alternative setting or a transfer is possible • During transfer the patient should wear a surgical mask* and be instructed on the principles of respiratory hygiene/cough etiquette if their condition allows and is practical • If there are no en suite single rooms available then placement decisions should be subject to local risk assessment supported by a member of the local Infection Control/Health Protection Team and might include: • Placement in a single room with no en suite but hand washing facilities with the door being kept closed. The patient should be instructed on the principles of respiratory hygiene/cough etiquette. The room should be suitably ventilated (via an open window if possible) to allow the change of air. The patient should wear a surgical mask where possible when having close contact* with others • Cohorting - where cohorting is the only option this should be considered based on placing those with the same known/suspected infection in the same designated area. This approach is particularly relevant when there are increased numbers of cases e.g. influenza • If cohorting those with the same infection is not possible avoid placing the infected patient with those who are immunocompromised or within long stay facilities such as care homes. Local Infection Control/Health Protection Teams should be consulted for advice on individual risk assessments * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 11 of 102 • Cohorted patients should be at least 3 feet (1 metre) from each other (this should also be considered for patients within for example out-patient/other departments if these visits are essential) • Separation by using a single room without any facilities or in a cubicle* can be used if other options are unavailable. Doors should be kept closed • The use of closed bed screens/curtains should be considered as a final option only and separation of at least 3 feet (1 metre) should be maintained. Particular attention must be given to decontamination of curtains during these times to prevent further spread of infectious agents via this route • The decision to cohort or use rooms/cubicles without facilities will depend on a number of factors. Advice should be sought from local Infection Control/Health Protection Teams Non acute settings (such as care home facilities/community settings) • Where optimum facilities as described are not available and transfer to an acute setting is awaited or not an option: • Separation of patients/clients should still be attempted, as has been described • All other precaution measures as described in this policy should be adhered to, whatever facilities are available, wherever care is being provided • In GP surgeries, for example, where infectious droplets are known/suspected, the person may be requested to wear a surgical mask (dependent on risk assessment/infection suspected) and placed in a single/private consulting room (if practical). The door should be kept closed. The patient/client should be instructed on the principles of respiratory hygiene/cough etiquette. The room should be suitably ventilated (via an open window if possible) to allow the change of air. Surgical masks being worn should be changed when heavily contaminated and/or wet with breath moisture or if damaged/torn • Individual risk assessments based on potential infection risks to other patients/clients as well as individual care needs should take place with additional expert input where required Additional points • During placement or transfers, contact with any immunocompromised patients/clients should be avoided • Patient/clients requiring droplet precautions within acute and/or non acute long stay/community settings should not be transferred unnecessarily to other areas unless essential due to medical reasons • Information on the precautions being applied should be communicated to all staff providing care and the patient/client and visitors without breaching confidentiality • All of the other precaution measures described in this policy should be adhered to as well as ensuring appropriate placement of patients/clients and ensuring all elements of Standard Infection Control Precautions are applied Also see Appendix 2 ‘A Hierarchy for placement of those known or suspected to have an infection spread by infectious droplets’ * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 12 of 102 NB. This policy does not give specific guidance for outbreak situations. Local policies should be referred to or advice sought from local Infection Control/Health Protection Teams How long should droplet precautions remain in place? • Droplet precautions/placement should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent (Refer to Appendix 1 for infectious agents). Contact local Infection Control/Health Protection Teams for further advice What if a patient/client has to be transferred within acute or non acute settings? • It is recommended that patients/clients requiring droplet precautions within acute or non acute settings are not transferred unless there is a necessary requirement (e.g. medical reasons or for placement in an appropriate single room) • The transferring area should give guidance to transport staff and to the receiving area on the droplet precautions required for the individual patient/client • The patient/client should be instructed on respiratory hygiene/cough etiquette and requested to wear a surgical mask if possible. Surgical masks should be changed when heavily contaminated and when wet with breath moisture or if damaged and torn. • PPE may be required for transfers depending on the contact that will be made with the patient/client during that time. Hand hygiene following contact and/or transfer is also important. (See What Personal Protective Equipment (PPE) should be considered for droplet precautions and when should it be worn?). Additionally consider: • An individual risk assessment if the patient/client cannot wear a mask e.g. confused, disturbed or with respiratory distress and unable to tolerate a mask. This should include the known or suspected infectious agent, the contact that will be made, and the need for transfer staff to wear masks. Local Infection Control/Health Protection Teams should be consulted for advice. Routine wearing of masks by transport staff is not normally required • Equipment/linen used for the transfer must be subject to decontamination (See Why are management of care equipment and control of the environment additional considerations for droplet precautions and Why is safe management of linen an additional consideration for droplet precautions?) What are respiratory hygiene/cough etiquette precautions? • Cover nose and mouth with disposable single-use tissues when sneezing, coughing, wiping and blowing nose • Dispose of used tissues into the nearest waste bin • Wash hands after coughing, sneezing, using tissues, or after any contact with respiratory secretions and contaminated objects * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 13 of 102 • Keep hands away from the mucous membranes of the eyes and nose. Certain patients/clients (e.g. the elderly, children) may need assistance with containment of respiratory secretions; those who are immobile will need a receptacle (e.g. a plastic bag) readily at hand for the immediate disposal of used tissues and offered hand hygiene facilities • Instruct all affected patients/clients and any visitors or carers on the steps described What Personal Protective Equipment (PPE) should be considered for droplet precautions and when should it be worn? Masks and other face protection: • A surgical mask is one of the key precautions to be considered when providing care in close contact. It should be put on before care is provided, i.e. on entry into a room or cohort area • The use of these masks can apply to the infectious agents featured in Appendix 1 that are spread via infectious droplets • Masks are not expected to be routinely worn, for example when the health/social care worker has known or proven immunity or close contact care is not being provided. In other seasonal situations, for example, when there are increased numbers of influenza or RSV cases, routine wearing of masks may not be realistic. Seek advice from local Infection Control/Health Protection Teams • Respiratory masks (FFP3)* are not generally expected to be worn for droplet precautions. These masks would only be required when delivering care to those with infections of additional epidemiological significance and/or transmissible by the airborne route (more information can be found in the HPS Airborne Precautions Policy and Procedure http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx) and depending on the activity being undertaken. Advice should be sought from local Infection Control/Health Protection Teams • Face/eye protection is required if there is a risk of mucosal splashing to the eyes as a result of coughing/sneezing • Where masks are not worn all other precautions as described should still be adhered to Gloves and aprons: • Disposable gloves and plastic aprons should be put on before and worn during care activities and where there will be contact with the patient/client or their immediate environment • The use of a disposable fluid repellent gown may be more appropriate in order to gain fuller body protection from specific infectious agents. Advice should be sought from local Infection Control/Health Protection Teams General good practice points: • Supplies of PPE should be available at the single room/cohort area • Aprons (or disposable fluid repellent gowns), masks and gloves should be put on before undertaking care activities * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 14 of 102 • Those entering rooms/areas should not be wearing any outer coats • Keep hands away from face and PPE being worn • PPE should be removed immediately upon leaving the room/area and hand hygiene performed • PPE must be changed and hand hygiene performed between different procedures/care activities on the same patient/client. This is particularly important for gloves as they will become contaminated following one procedure and could lead to cross transmission of infectious agents even in the same patient • PPE must be changed and hand hygiene performed between every patient/client, including others being cared for under droplet precautions within the same area • Surgical masks being worn should be changed when heavily contaminated or wet with breath moisture or if damaged/torn • Gloves should be changed if torn or heavily contaminated • Putting on and removal of PPE should be performed as in Appendix 3 • Safe disposal of PPE is essential immediately following removal Hand Hygiene • Hand hygiene is essential (refer to the HPS Model Infection Control Policy on Hand Hygiene http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx which includes the ‘Your 5 moments for hand hygiene’ and other times when hand hygiene must be performed) Why are management of care equipment and control of the environment additional considerations for droplet precautions? • Care equipment and the environment must be given additional consideration in order to prevent the spread of infectious droplets/respiratory secretions that may be contaminating items: • The patient’s/client’s environment should be cleaned at least daily or when visibly contaminated. Particular attention should be paid to frequently touched and horizontal surfaces surrounding the patient/client (e.g. bed tables, door handles, etc) • Refer to http://www.scotland.gov.uk/Publications/2004/05/19319/36643 for more information on cleaning specifications and HPS Model Infection Control Policy on Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx • An increase in cleaning frequency should be considered particularly if patients/clients are producing copious amounts of respiratory secretions • Equipment should be allocated to individuals being cared for under droplet precautions, e.g. thermometers • Equipment should not be shared with others, where this is unavoidable equipment must be decontaminated following manufacturer’s guidance/local instruction prior to * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 15 of 102 use on others (also refer to HPS Model Infection Control Policy on Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx) • Items of equipment and the environment should be intact. Items that are not intact should be reported and replaced to prevent unnecessary harbouring of infectious agents • The environment should be clutter free to allow for ease of cleaning • Where possible use single use/single patient use equipment and dispose of it after use • Equipment such as mops/buckets used for cleaning in-patient areas (hospital) should be colour coded as stated in the NHSScotland Colour Coding for Hospital Cleaning Materials and Equipment (HFS, 2008). In isolation or dedicated single rooms/areas these should be yellow in colour and should not be used in other rooms/areas. These items should also be clean, fit for purpose and decontaminated or disposed of as appropriate following use. Cleaning equipment should not be left in a patient’s/client’s room between use, unless there is a dedicated storage area • Within NHSScotland premises, the NHSScotland Cleaning Specifications should be complied with. • The NHSScotland Cleaning Specification and Colour Coding of Hospital Cleaning Materials is not applicable in care homes and other community settings however the principles of this policy should be applied. • Terminal cleaning* of equipment and the environment is essential before others are cared for in that area (refer to HPS Model Infection Control Policies on Control of the Environment Policy and Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx It is important that all items are decontaminated (e.g. curtains, bed frames, etc)) • PPE should be worn while undertaking decontamination of equipment/the environment, i.e. gloves and plastic apron • Hand hygiene should always be performed after undertaking decontamination of equipment/the environment Why is safe management of linen an additional consideration for droplet precautions? NHSScotland settings • Linen that could be contaminated with infectious droplets must be managed safely in order to avoid cross transmission of infectious agents. This should be bagged as infected linen within the Healthcare Setting. • Ensure safe handling of linen, i.e. wear PPE and wash hands on removal • Place contaminated linen into an alginate bag at the point of removal. Do not carry linen • Place alginate bags into appropriately colour coded linen bag • Communicate with others who may handle the infected linen to ensure they take precautions * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 16 of 102 Care Home settings • In care home settings the principles of this policy should be applied when dealing with linen that could be contaminated with infectious droplets. This would include bagging infected linen directly into water soluble/alginate bags providing that industrial washing machines are in use. If domestic washing machines are in use or if home laundering is undertaken refer to HPS Washing Clothes at Home leaflet http://www.documents.hps.scot.nhs.uk/hai/infectioncontrol/publications/washing-clothes-home.pdf • See HPS Model Infection Control Policy on Safe Management of Linen http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx) for more information on care of other linen such as people’s own clothing and seek further advice on this from local Infection Control/Health Protection Teams Why is safe disposal of waste an additional consideration for droplet precautions? • Waste that could be contaminated with infectious droplets must be managed safely in order to avoid cross transmission of infectious agents via this route: • Ensure safe handling of waste, i.e. wear PPE and wash hands on removal • Bag waste generated as a result of care activities as per national/local policy for healthcare waste (See HPS Model Infection Control Policy, Safe Disposal of Waste http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx for more information on healthcare waste) Why is occupational exposure management an additional consideration for droplet precautions? • Occupational exposure management is essential for the protection of all health and social care workers and relevant immunisation is an essential consideration when caring for those with diseases spread by infectious droplets: • Ensure occupational immunisations (if required) are up to date, e.g. influenza • Report and manage occupational exposure incidents immediately, including any mucosal splashes. Also refer to Appendix 4 for summary of precautions to minimise the spread of infections transmitted by infectious droplets * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 17 of 102 Glossary Aerosol-generating procedures associated with pathogen transmission - Procedures that have been reported to be aerosol-generating and associated with a documented increased risk of pathogen transmission. These include intubation and related procedures, cardiopulmonary resuscitation, bronchoscopy, autopsy and surgery where high-speed devices (e.g. saw) are used Close Contact - Within 3 feet (1 metre) of the patient/client and/or while performing care activities Colonised - This is when a microorganism establishes itself in a particular body site or the environment without producing disease or causing harm Cubicle - A room/space which is not fully enclosed but is cordoned off by partitions, e.g. the 'walls' of the enclosed space provide a degree privacy for the patient/client but do not completely shut the area off from the outside as they are not continuous from floor to ceiling Cross Transmission – The transmission of an infectious agent from one individual to another via a direct or indirect exposure Droplet - Droplets are particles propelled by coughing and sneezing and during the performance of some procedures. They are generally regarded to be larger than 5 μm in diameter although there is no consensus on size. Droplets can be deposited on the conjunctiva or mucous membranes of the nose, mouth or respiratory tract and the environment. However because of their relatively large size, generally droplets travel only short distances (typically less than 3 feet (1 metre)) before falling Epidemiologically important organism – This encompasses a growing list of pathogenic organisms, which have been identified based on published reports of clusters (>2 patients) within healthcare settings where additional monitoring/precautions are required to control them. Another feature of epidemiologically important organisms is that a number are resistant to antibiotics e.g. MRSA, VRE etc FFP3 respirator mask – FFP stands for ‘filter face piece’. The 3 means high protection that provides protection against small particles in the respirable size range (≤5 µm in size). FFP3 facemasks if worn correctly protect the wearer from inhalation of infectious respiratory droplet nuclei through and around the facemask. FFP3 facemasks conform to the European Standard EN149 2001 (Box CE marked). Fit testing must be carried out prior to providing any care where this type of masks may require to be worn. Fit checking must be carried out each time before entering the isolation room. Further information can be found at: Fit testing - http://www.hse.gov.uk/pubns/fittesting.pdf Fit checking http://www.documents.hps.scot.nhs.uk/respiratory/general/fitcheckmasks.pdf Both these links are contained within HPS FFP3 frequently asked questions: http://www.documents.hps.scot.nhs.uk/hai/infection-control/faqs/ffp3-faqs.pdf * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 18 of 102 Healthcare Associated Infection (HAI) – Infections that are not present at the time the individual’s care commences, but which arise afterward Immunocompromised patient/individual - Patients who have congenital primary immune deficiencies or acquired disease (e.g. treatment-induced immune deficiencies) are at increased risk for numerous types of infections while receiving healthcare and may be located throughout the healthcare facility. The specific defects of the immune system determine the types of infections that are most likely to be acquired (e.g., viral infections are associated with T-cell defects and fungal and bacterial infections occur in patients who are neutropenic). As a general group, immunocompromised patients can be cared for in the same environment as other patients; however, it is always advisable to minimise exposure to other patients with transmissible infections such as influenza and other respiratory viruses. The use of more intense chemotherapy regimens for treatment of childhood leukaemia may be associated with prolonged periods of neutropenia and suppression of other components of the immune system, extending the period of infection risk and raising the concern that additional precautions may be indicated for select groups. With the application of newer and more intense immunosuppressive therapies for a variety of medical conditions (e.g., rheumatologic disease, inflammatory bowel disease), immunosuppressed patients are likely to be more widely distributed throughout a healthcare facility rather than localised to single patient units (e.g. haematology-oncology) Immunodeficient - Lacking immunity and so susceptible to infection. Infection - Is the deposition and multiplication of bacteria and other microorganisms in tissues or on surfaces of the body with an associated host reaction, causing harm or clinical disease Infectious agent - Any organism, such as a pathogenic virus, parasite, or bacterium, that is capable of invading body tissues, multiplying, and causing disease Multidrug-Resistant Organisms (MDROs) – Microorganisms – predominantly bacteria – that are resistant to more than one class of microbial agents Negative pressure isolation room (with anteroom) – These rooms maintain a negative pressure, i.e. the airflow is from the outside adjacent space (e.g. corridors) into the room and then is exhausted to the outside (the anteroom, which is the area with a door to/from the outside corridor and another door giving access to the patient area, must never have both these doors open at the same time). These rooms require strict airflow monitoring Non-enveloped virus - a virus lacking an outer lipoprotein bilayer Pathogenic microorganisms - This is the ability of the species or strain of the microorganism to cause disease. This depends on a number of factors including the number of microorganism, the host defence, treatment etc Placement - This refers to the need for a single room or isolation room, as well as the application of other infection control measures that will minimise the spread of infection by contact, droplet or airborne routes. This provides a physical separation between patients/clients. Refer to Appendix 2 * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 19 of 102 Prolonged shedding – An increased duration of the dissemination of pathogenic microorganisms, commonly associated with immunocompromised individuals, leading to prolonged infectivity Small particles in the respirable size range (≤5 µm) - These aerosolised small particles can retain their infectivity and remain suspended in air over a long period of time, after expulsion through coughing, talking, etc., allowing them to enter the respiratory tract of others including those not within close contact or even the same area as the infected individual. This includes what are sometimes referred to as respiratory droplet nuclei, which are particles that slightly different as they can arise from desiccation of suspended droplets associated with airborne transmission Specialised Isolation Room - This is an enhanced single room with en suite facilities and ventilated lobby (isolation suite). An enhanced single room with a positive pressure ventilated entry lobby and en suite facilities with extract ventilation provides both source and protective isolation. The positive pressure lobby ensures that air from the corridor does not enter the isolation room, and that air from the room does not escape into the corridor. This simple design enables the suite to be used for either source or protective isolation without the need for switchable ventilation or special training for staff. It also provides safe isolation/segregation for patients whose condition is unknown. These rooms require strict airflow monitoring Standard Infection Control Precautions (SICPs) - These are the minimum precautions necessary to reduce the risk of transmission of microorganisms from both recognised and unrecognised sources of infectious agents that may be present in blood, other body fluids, secretions, excretions, non intact skin and mucous membranes. These must be used by ALL health and social care workers in ALL situations involving the care of patients/clients in order to prevent spread of infectious agents to other non intact skin and/or mucous membranes (this includes sharp injuries). They should also be applied when dealing with the immediate patient/client environment which might be contaminated with blood, other body fluids, etc. There are nine elements to SICPs and they are essential in preventing and controlling HAI. These are available on http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx Surgical mask - This is a disposable fluid repellent mask that offers protection from splashes to mucous membranes of the mouth and from infectious droplets Terminal cleaning - This is environmental cleaning after discharge or transfer of an infected/colonised patient/client. The timing of the terminal clean should be discussed with Infection Control/Health Protection Staff as this can vary according to the organism. Follow the procedures recommended in http://www.scotland.gov.uk/Publications/2004/05/19319/36643 * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 20 of 102 Appendix 1 - Infectious agents – Clinical Infections or diseases warranting Transmission Based Precautions in addition to Standard Infection Control Precautions Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) This document does not include exclusion criteria, give full public health guidance, occupational health or disease management. Refer to local NHS Boards for additional information Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Abscess Draining, major Contact 48 hours following antibiotics (depending on the organism) or until drainage stops or can be contained within a dressing Nil Adenovirus (Respiratory infection in paediatrics) Contact/Droplet Requirements of precautions may be extended due to prolonged shedding* of virus, generally until 48 hours following cessation of symptoms Nil Bronchiolitis Contact/Droplet Infectious agents causing this condition will vary Includes Adenovirus, Parainfluenza and Influenza Precautions usually 5-8 days Nil (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 21 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Clostridium difficile or Clostridium difficile associated disease (CDAD) Contact Precautions remain until patient is 48 hours symptom free Mandatory Surveillance Programme exists for this organism in Scotland http://www.hps.scot.nhs.uk/surveillance/ SystemsDetail.aspx?id=277 Infection can incubate for up to 12 weeks following antibiotic therapy If possible discontinue the offending antibiotic therapy Specimens are not required for clearance however 25% of cases suffer recurrence of symptoms Conjunctivitis (acute viral/haemorrhagic) Contact Adenovirus – most common lasts 7-15 days. Enterovirus lasts up to 12 days Highly contagious outbreaks in eye clinics, paediatrics, neonatal and long term care Nil Diarrhoea with a suspected infectious cause Contact Varies depending on the organism seek local guidance from local Infection Control/Health Protection team Many enteric pathogens are notfiable diseases consult local Health Protection Team Diphtheria – Cutaneous Contact Until 2 negative cultures taken 24 hours apart Notifiable Disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 22 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Diphtheria – Pharyngeal toxigenic strains (Cornynebacterium diphtheriae) Droplet/Contact Until negative Notifiable Disease Epiglottitis due to (Haemophilus influenzae type b) Droplet/Contact Patient considered negative when two cultures (Nasal Pharyngeal Aspirate) are taken 24 hours apart Until 24 hours into the course of corrective antibiotic therapy Most common in children 2 months – 5 years Hepatitis, viral Type A&E Contact Herpes simplex (Herpesvirus hominis) • Anogenital Herpesviral Infection • Neonatal Contact For duration of hospital stay – Hep A For duration of hospital illness – Hep E Specifically for nappy wearing infants/incontinent adults Can infect oral mucosa (HSV1) or genital tract (HSV 2). Primary and recurrent infections can occur and duration of precautions will vary but usually until lesions or cold sores disappear Local Health Protection Teams should be informed of cases Notifiable disease Risk to exposed infants delivered vaginally or by C- section and if mother has active infection and membranes have been ruptured for more than 4-6 hours (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 23 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Herpes zoster (varicella-zoster) (Shingles) Contact/Airborne – disseminated disease Infectious until vesicles are dry usually 5-7 days this may be extended for immunocompromised individuals Susceptible health/social care workers should not give direct care if immune caregivers are available Disseminated disease may require an increase in the duration of the precautions Immune caregivers no additional precautions, non immune may require surgical mask in disseminated disease Human metapneumovirus Contact See section on RSV Virus closely related to RSV Impetigo Contact Nil Influenza (seasonal) Droplet/Contact Until 48 hours following corrective antibiotic therapy 5 days except in immunocompromised persons Influenza (pandemic) Droplet/Contact 5 days from onset of symptoms Use of vaccine or antiviral drugs may be considered Avoid placing infected individuals with immunocompromised patients See link to HPS respiratory web pages http://www.hps.scot.nhs.uk/resp/guideli nes.aspx (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 24 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Lice 1. Head 2. Body 3. Pubic Contact Investigation of close contacts is required Measles (rubeola) Airborne 1. Infectious until completion of treatment and/or removal of live lice/eggs 2. Infectious until 24 hours following treatment with an effective insecticide 3. Infectious until completion of treatment and/or removal of live lice/eggs Precautions remain until 4 days after onset of rash. For immunocompromised individuals this is increased for the duration of illness Notifiable disease Susceptible health/social care workers should not enter the room if immune care givers are available. Exposed susceptible care givers may require post exposure vaccine (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 25 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Meningitis – meningococcal Neisseria meningitidis Droplet/Contact Until 24 hours into the course of corrective antibiotic therapy Notifiable disease Post exposure chemoprophylaxis based on local risk assessments for exposed HCW as per Infection Control Team / Health Protection Team advice Meningitis (other causes) Contact Precaution duration depends on the causative organism Household contacts are given prophylactic antibiotics to eliminate carriage and prevent clinical illness, based on local Health Protection Teams advice Enterovirus most common cause and symptoms generally do not exceed 10 days. However aetiology can be due to a variety of viruses and bacteria Airborne precautions may be required in cases of suspected/known Mycobacterium tuberculosis presenting with Meningitis (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 26 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Monkeypox Contact/Airborne Duration of precautions can vary always seek advice from local Infection Control/Health Protection Teams Inform local Health Protection Teams Transmission in hospital unlikely. Mumps (infectious parotitis) Droplet/Contact Until approximately 9 days following appearance of Notifiable Disease symptoms in hospital. Some evidence that this can be reduced to 5 days in community settings for Non immune HCW should not provide previously healthy individuals direct care Multidrug-resistant organisms (MDROs) infection or colonisation (e.g. MRSA, VRE, VISA/VRSA, ESBLs, resistant Streptococcus pneumoniae, Multi drug resistant Mycobacterium tuberculosis Contact/Airborne/ Droplet depending on the infectious agent MDROs will be judged by local or national recommendations depending on the clinical and epidemiological significance. Nil (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 27 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Mycobacterium tuberculosis – Extrapulmonary Contact Risk assessment required Precautions to remain until drainage stops or patient has three negative cultures from exudate Notifiable disease Mycobacterium tuberculosis Pulmonary or laryngeal disease – confirmed Mycobacterium tuberculosis Pulmonary or laryngeal disease – suspected Airborne Airborne Airborne precautions are only required if any aerosol-generating procedures* are being undertaken e.g. suctioning risk assessment in conjunction with the local Infection Control Team Discontinue precautions only when patient is on effective therapy, condition is improving and has 3 negative sputum smears for acid fast bacilli (AFB) collected on 3 consecutive days Discontinue precautions only when the likelihood of infectious TB is deemed negligible and either there is an alternative diagnosis or the 3 sputum smears are negative for AFB. Specimen should be collected 8-24 hours apart at one should be early morning Notifiable disease MDR TB cases always seek guidance when suspected/confirmed cases further information http://www.hps.scot.nhs.uk/resp/guideli nes.aspx There are some exceptions to precaution requirements and local Infection Control/Health Protection/ TB teams must be consulted Notifiable disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 28 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Mycoplasma – atypical pneumonia Droplet/Contact Nil Norovirus Contact/Airborne Precautions remain for duration of hospital stay or when symptoms resolve. Patients can be infectious for up to 13 weeks Patients/clients are infectious until 48 hours following last episode of diarrhoea and/or vomiting Parainfluenza virus infection Contact Precautions remain for duration of active disease usually 5 days following onset of symptoms, however this can vary depending on the organism Nil Parvovirus B19 – slapped cheek syndrome (Erythema infectiosum – Erythrovirus B19) Droplet Non-infectious when the rash appears. If the patient has a chronic disease or is immunocompromised maintain precautions for the duration of illness or whilst patient is hospitalised A common childhood infection lasting 23 days followed by the rash on the cheeks. In adults can be associated with athralgia PlagueYersinia pestis- Droplet/Contact Until 48 hours of the course of antibiotic therapy have been completed Common cause of hospital and long term care setting outbreaks Advice should be sought from an Infection Control/Disease/ Public Health Physician or Consultant Microbiologist when this disease is identified or suspected in pregnancy Notifiable disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 29 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Pneumonia Adenovirus Droplet/Contact Ensure applied for duration of illness Outbreaks reported in paediatric settings Pressure sores (Infected – Major) Contact Precautions should remain unless infectious wound can be occluded or contained within a drainage system Consider precautions for other conditions e.g. leg ulcers Rubella (German Measles) Droplet/Contact Until 7 days after onset of rash Notifiable disease Susceptible HCW should not provide direct clinical care Particularly affects young children, infants and immunosuppressed patients. Highly transmissible in paediatrics Prolonged shedding may occur in immunodeficient* or immunocompromised children Respiratory syncytial virus (RSV) Droplet/ Contact Duration of symptoms (whilst in acute care setting specifically) Rotavirus Contact/Droplet Until 48 hours symptom free. A negative sample is not usually required. Precautions may increase depending on individual situations Scabies Contact Patient/Client infectious until completion of the first insecticide application Consider close/household contacts Severe acute respiratory syndrome (SARSCoV) Droplet/Airborne/ Contact Duration of illness and 10 days following resolution of pyrexia providing no respiratory symptoms Not currently notifiable but ALWAYS notify specialist Infection Control/Health Protection Team (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 30 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Smallpox Contact/Airborne Continue precautions until all scabs have crusted and separated (3-4 weeks) Notifiable disease Currently eradicated Non immune healthcare workers should not provide care Staphylococcal disease (skin, wound, burn – major) Contact Infectious unless wound can be occluded or contained within a drainage system or until 48 hours of corrective antibiotic therapy Nil Streptococcus disease Group A (Streptococcus pyogenes) • Erysipelas – contact • Tonsillitis – droplet • Scarlet fever – droplet • Necrotising fasciitis – contact • Puerperal fever – contact Droplet/Contact Until 24 hours of the course of corrective antibiotic therapy or if present in a wound if this is occluded/ contained Erysipelas, Scarlet fever & Puerperal fever are notifiable diseases Contact precautions particularly important if lesions present (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 31 of 102 Disease/condition/syndrome or Causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Varicella (Chickenpox) Airborne/Contact Until all lesions are dry and crusted Susceptible health/social care workers (e.g. those who are pregnant or immunocompromised) should not enter the room if immune care givers are available In immunocompromised individuals with varicella pneumonia prolonged precautions may be required Pre + post exposure prophylaxis guidance is available http://www.dh.gov.uk/en/Publichealth/ Healthprotection/Immunisation/Green book/DH_4097254 Whooping cough – Bordetella pertussis Droplet/Contact Until 5 days of the commencement of antibiotic therapy If untreated patient infectious for up to 3 weeks Notifiable disease Post exposure prophylaxis for household contacts and in rare circumstances may be indicated for HCWs following prolonged exposure to respiratory secretions (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 32 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Vaccination site infection Contact Until drainage stops from site or if area can be occluded/contained Nil Viral Haemorrhagic Fevers e.g. • Lassa • Ebola • Marburg • Crimean-Congo fever virus Droplet/Contact Duration of illness. Patient highly infectious in the final stages of illness Notifiable Disease ALWAYS seek specialist infection control advice if suspected (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 33 of 102 Appendix 2 A hierarchy for placement of those known or suspected to have an infection spread by infectious droplets Refer to the full droplet precautions policy for further details1 A risk assessment process should be applied2 Be alert to potential cases/symptoms Early recognition is important Diagnosis/suspicion of need for droplet precautions Examples of infections spread by droplets and of HAI concern •Group A streptococcal disease •Meningococcal disease (meningitis/septicaemia) •Influenza •Other infections causing concern – identified locally Isolate all cases as follows in descending order, depending on available facilities: Timeliness of placement is essential – additional support may be required if >1 hr has elapsed. Single room with hand washing facilities and en suite toilet Single room with hand washing facilities only Cohorting: Sharing a room with 1 or more of those with known/suspected same infection (each placed > 3 feet (1 metre) apart) Don’t delay action but seek expert infection control advice to inform risk assessments and subsequent actions. Cohorts Avoid cohorting in long term care facilities and do not include immunocompromised individuals in cohort areas If not available: Separation of at least 3 feet (1 metre) from any adjacent persons by use of; single room with no facilities, cubicle, use of closed bed curtains Infection Control Droplet Precautions Precautions are essential in order to limit the possibility of infection spreading Key Practice Points • Ensure all isolation/cohort areas are supplied with surgical masks, gloves/gowns, aprons and hand hygiene supplies • Teach and reinforce respiratory hygiene/cough etiquette with all individuals • Ensure ongoing and terminal cleaning of isolation areas • Avoid transfer of isolated/cohorted individuals unless clinically essential • Keep in mind that infectious droplets can also be spread via contact • Only discontinue placement/precautions on cessation of symptoms/clearance of specimens/completion of treatment and/or on the advice of specialists in infection control Note 1. Consult the full policy for more detail and for a full list of organisms/diseases requiring precautions. Some infectious agents may require care in specialist isolation rooms 2. Decisions made regarding placement will depend on the many factors including the infectious agent and number of cases. Refer to full policy and local Infection Control/Health Protection Team NB. This hierarchy may not apply to those being cared for in their own homes * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 34 of 102 Appendix 3 – Putting on and removing PPE * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 35 of 102 Appendix 4 * denotes glossary Model Infection Control Policies (Droplet Precautions), HPS ICT 2009 Page 36 of 102 Contact Precautions Policy and Procedure (an element of Transmission Based Precautions) Date of issue: April 2008 Date of re-issue: April 2011 Introduction What are contact precautions? Contact precautions are a set of infection control measures (to be used in addition to Standard Infection Control Precautions* (SICPs)) which are designed specifically to prevent and control the transmission of infectious agents* spread by direct and indirect contact to patients/clients and health and social care workers during provision of care These precautions include: isolation, hand hygiene, use of personal protective equipment (PPE), care of equipment and environment including decontamination, safe handling of linen and waste Why are contact precautions important within health and social care settings? It is important to prevent infectious agents that could be present on for example a patient’s/client’s skin/mucous membranes or immediate environment, being transmitted via contact to others and resulting in Healthcare Associated Infection (HAI)*. This is the most common mode of transmission of infectious agents in care settings and therefore it is essential that all healthcare and social care workers understand how to prevent spread via this route When are contact precautions required? The need for contact precautions will vary depending on the patient/client, the setting, and the infectious agent (Refer to Appendix 1) and the procedures/activities being undertaken. For example highly dependent in-patient areas such as intensive care require different considerations than areas such as mental health settings. Further advice may be required from local Infection Control/Health Protection Teams Within non acute settings, such as care homes, community clinics or during home care, individual risk assessments are required Contact precautions are required in all health and social care settings when a patient/client is known or suspected to be infected*/colonised* with certain infectious agents or epidemiologically important organism* that can be spread by contact They include precautions to be taken with those; with active infections, who are incubating infectious disease, who are asymptomatic but suspected to be infectious and those who are colonised with pathogenic microorganisms* * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 37 of 102- How do you decide which precautions are required? Not all elements may be required for every patient/client or situation. The use of risk assessment should be applied when assessing the requirement for precautions and further specialist advice should be sought from local Infection Control/Health Protection Teams as required This policy describes the key precautions to be considered when delivering care to those with infections spread by contact Examples of infections spread by contact and of Healthcare Associated Infection (HAI) concern • Antibiotic resistant bacteria e.g. Meticillin resistant Staphylococcus aureus (MRSA), Glycopeptide resistant enterococci (GRE) & multi-resistant Gram negative bacilli • Clostridium difficile infection/Clostridium difficile Associated Disease (CDAD) • Norovirus • Others causing concern identified locally including those resistant to antibiotics Remember other infections are spread via contact, droplets* and airborne e.g. influenza, RSV (see full list in Appendix 1, this list is not exhaustive and some infectious agents are spread by more than one route) This policy does not give specific guidance for outbreak situations or extremely rare infectious conditions which will require additional critical infection control measures * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 38 of 102- Contents This policy contains information on: page Underpinning responsibilities for contact precautions....................................................... 42 Rationale for contact precautions .................................................................................... 43 Patient/client placement (e.g. use of single rooms/isolation) ........................................... 44 Duration of contact precautions ....................................................................................... 45 Patient/client transfers ..................................................................................................... 46 Personal Protective Equipment (PPE) ............................................................................. 46 Gloves and aprons........................................................................................................... 46 Face protection ................................................................................................................ 46 General good practice points ........................................................................................... 46 Hand hygiene................................................................................................................... 47 Management of care equipment and control of the environment ..................................... 48 Specific considerations for Clostridium difficile/certain other organisms .......................... 49 Safe management of linen ............................................................................................... 49 Safe disposal of waste ..................................................................................................... 50 Glossary........................................................................................................................... 51 Appendix 1 – Infectious agents – Clinical infections or diseases warranting Transmission Based Precautions in addition to Standard Infection Control Precautions ....................... 54 Appendix 2 – Hierarchy of placement for those known or suspected to have an infection spread by contact ............................................................................................................ 66 Appendix 3 – Putting on and removing PPE .................................................................... 67 Appendix 4 – Summary of precautions to minimise the spread of diseased caused by contact ............................................................................................................................. 68 * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 39 of 102- What are the underpinning responsibilities for contact precautions? NHS Boards must: • Ensure systems and resources are in place to facilitate implementation of the policy Managers must: • Ensure that all staff have had instruction/education on the principles of contact precautions, Standard Infection Control Precautions and risk assessment • Ensure that adequate resources are in place to allow for the recommended infection control measures to be implemented • Ensure areas participate in surveillance and audit programmes at a national and/or local level where required, for example Clostridium difficile Associated disease (CDAD) mandatory surveillance. This will help support the implementation of precautions at the most appropriate times • Undertake risk assessments to optimise patient/client and staff safety, consulting expert infection control guidance as required • Support staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission* • Ensure any staff with health concerns or who have become ill due to occupational exposure are referred to the relevant agency e.g. General Practitioner or Occupational Health • Ensure that estates/facilities management provide a safe environment to allow infection* prevention and control precautions to be applied All staff (providing direct care in a health or social care setting including patient’s/clients’ own homes) must: • Apply Standard Infection Control Precautions and the measures described in this policy • Ensure all other staff/agencies apply the principles of Standard Infection Control Precautions and the measures described in this policy • Undertake risk assessments when assessing the requirement for contact precautions • Document when contact precautions according to the policy cannot be implemented for clinical or other relevant reasons • Provide information on the precautions being taken. This should be communicated to all staff, the patient/client, and visitors without breaching confidentiality • Offer reassurance to patients/clients and visitors/carers regarding the need for contact precautions • Advise the patient/client, carers or visitors of any infection control requirements such as hand hygiene and respiratory hygiene/cough etiquette • Ensure occupational immunisations are up to date (if applicable) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 40 of 102- • Report to line managers any deficits in; knowledge in relation to contact precautions/Standard Infection Control Precautions, facilities/equipment or incidents that may have resulted in cross transmission • • Attend any mandatory or update infection control education sessions • Not provide direct patient/client care while infectious e.g suffering diarrhoea and vomiting, as this could cause harm to the patient/client/others. If in any doubt consult with your manager, General Practitioner, Occupational Health Department or the local Infection Control/Health Protection Team • Support other staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission • Ensure any staff with health concerns or who have become ill due to occupational exposure are referred to the relevant agency e.g. General Practitioner or Occupational Health • Ensure that estates/facilities management provide a safe environment to allow infection* prevention and control precautions to be applied. Report any illness that may be as a result of occupational exposure to their line manger and Occupational Health Department (if applicable) Staff with infection control/ health protection responsibilities must: • • • Provide education for staff and management on this policy Act as a resource for guidance and support when contact precautions are required Provide expert advice on the points below and/or seek additional expert advice from infection control specialists on these matters where required; • Provide expert advice for incidents involving epidemiologically important organisms (and outbreaks/incidents) • Provide advice on individual risk assessments, for example a placement* decision Visitors should be advised: • To contact the person in charge before visiting if they are unsure of the infectious status of the person they are visiting • Of appropriate hand hygiene procedures to be carried out before and after visiting as well as other relevant infection prevention and control measures • • Of appropriate respiratory hygiene/cough etiquette which should be adhered to Of the Chief Medical Officer 5 top tips for all patients, staff and visitors. See http://www.scotland.gov.uk/Publications/2004/08/hai Incident reporting: • Any incidents where failures in adopting contact precautions have occurred and/or incidents which have resulted in cross transmission should be documented and reported as per local incident reporting procedures * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 41 of 102- Communication and general good practice: • Effective communication between all members of the health and social care team is imperative for the management of infectious agents • Those who are unwell with respiratory symptoms should be advised not to attend non-urgent appointments or visit other settings where infections might spread to those who are vulnerable • Means of communication to alert staff to contact precautions need to be in place, for example signage that does not breach confidentiality Everyone has an important part to play in improving patient/client safety. Undertaking Transmission Based Precautions is an essential element to ensure everyone’s safety. * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 42 of 102- What is the rationale for contact precautions? • Contact precautions are required to prevent the transmission of infectious agents via direct and indirect contact and to minimise Healthcare Associated Infection (HAI). Due to the nature of contact transmission the precautions described are pivotal and should be applied during any health and social care activity, even those not normally associated with additional infection control precautions. This includes activities such as feeding, playing or close contact* care when a patient/client has an infectious agent • Direct contact transmission is when an infectious agent is transferred directly from one person to another, i.e. through direct body contact without involvement of inanimate objects or other people, e.g. skin to skin contact when scabies is present or transfer of an infectious agent from an open wound of an infected individual to the mucous membranes or skin break in another susceptible individual • Indirect contact transmission is when an infectious agent is transferred to an individual from an object and/or another person. This can occur in a number of ways and varies depending on the nature of the infectious agent. An example of a mode of indirect transmission includes via the hands of health and social care workers after contact with an infected or colonised patient’s/client’s environment, patient/client care equipment or surgical instruments, which have been inadequately decontaminated. It can also include contact with other items within the care environment that are contaminated, e.g. toys in paediatric settings NB. Certain infections spread by contact, require additional infection control measures. Refer to the literature reviews for additional information sources, seek advice from local Infection Control/Health Protection Teams Remember Transmission Based/additional precautions are always applied in addition to Standard Infection Control Precautions * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 43 of 102- Where should those requiring contact precautions be cared for? • This requires risk assessment in order to determine the most appropriate placement for patients/clients. This will depend on: • • • The infectious agent (Refer to Appendix 1) • The procedure/activities being undertaken The patient/client and their overall condition e.g a productive cough The area where the patient/client is being cared for. This includes the potential for adverse outcomes in others (e.g. consider risks to immunocompromised patients*, those with invasive devices, etc) and the availability of single rooms* • Timeliness of assessment and placement is essential. Additional support may be required if this is problematic and, for example, greater than one hour has elapsed Acute Settings • When appropriate, single rooms with hand washing facilities and en suite toilet are preferred for patients with known/suspected infections requiring contact precautions. The requirement to keep the door closed will depend on risk assessment but is considered good practice • If a single en suite room is required (identified by risk assessment) and these rooms are unavailable then transfer to another unit/hospital with suitable facilities should be considered (providing the patient/client is medically stable). A risk assessment by local Infection Control Teams in conjunction with clinicians and managers will help determine when an alternative setting or a transfer is possible • If placement in a room with facilities or a transfer is not appropriate or possible, placement decisions should be subject to local risk assessment (Support from a member of the local Infection Control/Health Protection Teams should be sought where required). Placement might include: • • In a single room with no en suite facilities but hand washing facilities • If cohorting those with the same infection is not possible avoid placing the infected patients with those who are immunocompromised* or within long stay facilities such as care homes. Local Infection Control, or Health Protection Teams should be consulted for advice on individual risk assessments • For best practice cohorted patients should be at least 3 feet (1 metre) from each other (this should also be considered for patients within for example outpatient/other departments if these visits are essential) • Separation by using a single room without any facilities or placement in a cubicle* can be used if other options are unavailable. • The use of closed bed screens/curtains where practicable should be considered as a final option only, with separation of at least 3 feet (1 metre) maintained. Cohorting – where cohorting is the only option this should be considered based on placing those with the same known/suspected infection in the same designated area. This approach is particularly relevant when there are increased numbers of cases e.g. of MRSA * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 44 of 102- Particular attention must be given to decontamination of curtains during these times to prevent further spread of infectious agents via this route • The decision to either cohort or use rooms/cubicles without facilities will depend on a number of factors. Advice should be sought from local Infection Control/Health Protection Teams • Dedicated equipment should be allocated to individuals being cared for under contact precautions, e.g. thermometers, etc. Non acute settings (such as care home facilities/community settings) • The principles described should be applied however, where optimum facilities as described are not available and transfer is awaited or not an option: • Separation of patients/clients should still be attempted as has been described, for example following risk assessment when norovirus is present • All other precaution measures as described in this policy should be adhered to, whatever facilities are available, wherever care is being provided • Individual risk assessments based on potential infection risks to other patients/clients as well as individual care needs should take place with additional expert input where required Additional points • During placement or transfers, contact with any immunocompromised patients/clients should be avoided • Patients/clients requiring contact precautions within acute and/or non acute long stay/community settings should not be transferred unnecessarily to other areas unless essential due to medical reasons • Information on the precautions being applied should be communicated to all staff providing care and the patient/client and visitors without breaching confidentiality • All of the other precaution measures described in this policy should be adhered to as well as ensuring appropriate placement of patients/clients and ensuring all elements of Standard Infection Control Precautions are applied Also see Appendix 2 ‘A hierarchy for placement of those known or suspected to have an infection spread by contact’ NB. This policy does not give specific guidance for outbreak situations. Local policies should be referred to or advice sought from local Infection Control/Health Protection Teams How long should contact precautions remain in place? • Contact precautions/placement should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent (Refer to Appendix 1 for infectious agents). Contact local Infection Control or Health Protection Teams for further advice * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 45 of 102 What if a patient/client within acute or non acute settings has to be transferred? • It is recommended that patients/clients requiring contact precautions within acute or non acute settings are not transferred unless there is a necessary requirement (e.g. medical reasons or for placement in an appropriate single room) • The transferring area should give guidance to transport staff and to the receiving area on the contact precautions required for the individual patient/client • PPE may be required for transfers depending on the contact that will be made with the patient/client during that time. Hand hygiene following contact and/or transfer is also important (See What additional Personal Protective Equipment (PPE) should be considered for contact precautions?) • If a wound dressing or drainage system is applied to the area of infection/colonisation and this can fully contain leaking body fluids this should be done if possible prior to transfer • Equipment/linen used for the transfer must be subject to decontamination (See Why is the management of care equipment and control of the environment an additional consideration for contact precautions and Why is safe management of linen an additional consideration for contact precautions?) What Personal Protective Equipment (PPE) should be considered for contact precautions and when should it be worn? Gloves and aprons: • Disposable gloves and plastic aprons should be put on before and worn during care activities and where there will be contact with the patient/client or their immediate environment • The use of a disposable fluid repellent gown may be more appropriate in order to gain fuller body protection including for the arms, from specific infectious agents. Advice should be sought from local Infection Control/Health Protection Teams Face protection: • Face/eye protection including masks and goggles may be required if there is a risk of mucosal splashing to the mouth or eyes General good practice points: • Supplies of PPE should be available at the single room/cohort area • Aprons (disposable fluid repellent gowns) and gloves should be put on before undertaking care activities • Those entering rooms/areas should not be wearing any outer coats • Keep hands away from face and PPE being worn * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 46 of 102 • PPE should be removed immediately upon leaving the room/area and hand hygiene performed • PPE must be changed and hand hygiene performed between different procedures/care activities on the same patient/client. This is particularly important for gloves as they will become contaminated following one procedure and could lead to cross transmission of infectious agents even in the same patient • PPE must be changed and hand hygiene performed between contact with every patient/client, including others being cared for under contact precautions within the same area • Gloves should be changed if torn or heavily contaminated • Putting on and removal of PPE should be performed as in Appendix 3 • Safe disposal of PPE is essential immediately following removal Hand Hygiene • Hand hygiene is essential particularly for contact precautions (refer to the HPS Model Infection Control Policy on Hand Hygiene http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx which includes the ‘Your 5 moments for hand hygiene’ and other times when hand hygiene must be performed) • For specific infectious agents such as Clostridium difficile infection or if organic matter such as faeces is present the use of alcohol hand rub for hand hygiene is insufficient and hands must be washed with soap and water * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 47 of 102- Why are management of care equipment and control of the environment additional considerations for contact precautions? • Care equipment and the environment must be given additional consideration in order to prevent the spread of infectious agents that may be contaminating items: • The patient’s/client’s environment should be cleaned at least daily or when visibly contaminated. Particular attention should be paid to frequently touched and horizontal surfaces surrounding the patient/client (e.g. bed tables, door handles, etc) • Refer to http://www.scotland.gov.uk/Publications/2004/05/19319/36643 for more information on cleaning specifications and HPS Model Infection Control Policy on Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx • An increase in cleaning frequency must be considered particularly if patients/clients are suffering for example from vomiting and/or diarrhoea • Equipment should be allocated to individuals being cared for under contact precautions, e.g. thermometers, commodes • Equipment should not be shared with others, where this is unavoidable equipment must be decontaminated following manufacturer’s guidance/local instruction prior to use on others (also refer to HPS Model Infection Control Policy on Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx) • Items of equipment and the environment should be intact. Items that are not intact should be reported and replaced to prevent unnecessary harbouring of infectious agents • • The environment should be clutter free to allow for ease of cleaning • Equipment such as mops/buckets used for cleaning in-patient areas (hospital) should be colour coded as stated in the NHSScotland Colour Coding for Hospital Cleaning Materials and Equipment (HFS, 2008). In isolation or dedicated single rooms/areas these should be yellow in colour and should not be used in other rooms/areas. These items should be clean, fit for purpose and decontaminated or disposed of as appropriate following use. Cleaning equipment should not be left in a patient’s/client’s room/area between use unless there is a dedicated storage area • Within NHSScotland premises, the NHSScotland Cleaning Specifications should be complied with • The NHSScotland Cleaning Specification and Colour Coding of Hospital Cleaning Materials is not applicable in care homes and other community settings however the principles of this policy should be applied • Terminal cleaning* of equipment and the environment is essential before others are cared for in that area (refer to HPS Model Infection Control Policies on Control of the Environment Policy and Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx). It is important that all items are decontaminated (e.g. curtains, bed frames etc.) Where possible use single use/single patient use equipment and dispose of it after use * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 48 of 102- • PPE should be worn while undertaking decontamination of equipment/the environment, i.e. gloves and plastic apron • Hand hygiene should always be performed after undertaking decontamination of equipment/the environment • There is insufficient evidence to advocate routine widespread use of disinfectants for the care environment. Advice should be sought from local Infection Control/Health Protection teams What are the specific considerations for Clostridium difficile (and certain other organisms) when considering care of equipment and control of the environment? • When dealing with known or suspected Clostridium difficile Associated Disease (CDAD), gastrointestinal viruses such as norovirus or other non-enveloped viruses* then equipment and the immediate environment where the patient/client is being cared for must be thoroughly cleaned and disinfected with a solution containing 1000ppm available chlorine-based solution • All surfaces are important however specific attention should be paid to toilets/commodes Why is the safe management of linen an additional consideration for contact precautions? NHSScotland settings • Linen that could be contaminated must be managed safely in order to avoid cross transmission of infectious agents. This should be bagged as infected linen within the Healthcare Setting: • • Ensure safe handling of linen, i.e. wear PPE and wash hands on removal • • Place alginate bags into appropriately colour coded linen bag Place contaminated linen into an alginate bag at the point of removal. Do not carry linen Communicate with others who may handle the infected linen to ensure they take precautions • See HPS Model Infection Control Policy on Safe Management of Linen http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx for more information on care of other linen such as peoples own clothing and seek further advice on this from local Infection Control/Health Protection Teams Care Home Settings • In care home settings the principles of this policy should be applied when dealing with linen that could be contaminated with infectious agents. This would include bagging infected linen directly into water soluble/alginate bags providing that industrial washing machines are in use. If domestic washing machines are in use or if home laundering is undertaken refer to HPS Washing Clothes at Home Leaflet * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 49 of 102- http://www.documents.hps.scot.nhs.uk/hai/infectioncontrol/publications/washing-clothes-home.pdf Why is the safe disposal of waste an additional consideration for contact precautions? • Waste that could be contaminated must be managed safely in order to avoid cross transmission of infectious agents via this route: • • Ensure safe handling of waste, i.e. wear PPE and wash hands on removal Bag waste generated as a result of care activities as per national/local policy for healthcare waste (see HPS Model Infection Control Policy on Safe Disposal of Waste http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx for more information on healthcare waste) Also refer to Appendix 4 for a summary of precautions to minimise the spread of infections caused by contact * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 50 of 102- Glossary Aerosol-generating procedures associated with pathogen transmission - Procedures that have been reported to be aerosol-generating and associated with a documented increased risk of pathogen transmission. These include intubation and related procedures, cardiopulmonary resuscitation, bronchoscopy, autopsy and surgery where high-speed devices (e.g. saw) are used Close Contact - Within 3 feet (1 metre) of the patient/client and/or while performing care activities Colonised - This is when a microorganism establishes itself in a particular body site or the environment without producing disease or causing harm Cubicle - A room/space which is not fully enclosed but is cordoned off by partitions, e.g. the 'walls' of the enclosed space provide a degree privacy for the patient/client but do not completely shut the area off from the outside as they are not continuous from floor to ceiling Cross Transmission - The transmission of an infectious agent from one individual to another via a direct or indirect exposure Droplet - Droplets are particles propelled by coughing and sneezing and during the performance of some procedures. They are generally regarded to be larger than 5μm in diameter although there is no consensus on size. Droplets can be deposited on the conjunctiva or mucous membranes of the nose, mouth or respiratory tract and the environment. However because of their relatively large size, generally droplets travel only short distances (typically less than 3 feet (1 metre)) before falling Epidemiologically important organism - This encompasses a growing list of pathogenic organisms, which have been identified based on published reports of clusters (>2 patients) within healthcare settings where additional monitoring/precautions are required to control them. Another feature of epidemiologically important organisms is that a number are resistant to antibiotics e.g. MRSA, VRE etc FFP3 respirator mask – FFP stands for ‘filter face piece. The 3 means high protection that provides protection against small particles in the respirable size range (≤5 µm in size). FFP3 facemasks if worn correctly, protect the wearer from inhalation of infectious respiratory droplet nuclei through and around the facemask. FFP3 facemasks conform to the European Standard EN149 2001 (Box CE marked). (Fit testing must be carried out prior to providing any care where this type of masks may require to be worn. Fit checking must be carried out each time before entering the isolation room). Further information can be found at: Fit testing - http://www.hse.gov.uk/pubns/fittesting.pdf Fit checking http://www.documents.hps.scot.nhs.uk/respiratory/general/fitcheckmasks.pdf Both these links are contained within HPS FFP3 frequently asked questions: http://www.documents.hps.scot.nhs.uk/hai/infection-control/faqs/ffp3-faqs.pdf Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 51 of 102 Healthcare Associated Infection (HAI) – Infections that are not present at the time the individual’s care commences, but which arise afterward Immunocompromised patient/individual - Patients who have congenital primary immune deficiencies or acquired disease (eg. treatment-induced immune deficiencies) are at increased risk for numerous types of infections while receiving healthcare and may be located throughout the healthcare facility. The specific defects of the immune system determine the types of infections that are most likely to be acquired (e.g., viral infections are associated with T-cell defects and fungal and bacterial infections occur in patients who are neutropenic). As a general group, immunocompromised patients can be cared for in the same environment as other patients; however, it is always advisable to minimise exposure to other patients with transmissible infections such as influenza and other respiratory viruses. The use of more intense chemotherapy regimens for treatment of childhood leukaemia may be associated with prolonged periods of neutropenia and suppression of other components of the immune system, extending the period of infection risk and raising the concern that additional precautions may be indicated for select groups. With the application of newer and more intense immunosuppressive therapies for a variety of medical conditions (e.g., rheumatologic disease, inflammatory bowel disease), immunosuppressed patients are likely to be more widely distributed throughout a healthcare facility rather than localised to single patient units (e.g. haematology-oncology) Immunodeficient - Lacking immunity and so susceptible to infection Infection - Is the deposition and multiplication of bacteria and other microorganisms in tissues or on surfaces of the body with an associated host reaction, causing harm or clinical disease Infectious agent - Any organism, such as a pathogenic virus, parasite, or bacterium, that is capable of invading body tissues, multiplying, and causing disease Multidrug-Resistant Organisms (MDROs) – Microorganisms – predominantly bacteria – that are resistant to more than one class of microbial agents Negative pressure isolation room (with anteroom) – These rooms maintain a negative pressure, i.e. the airflow is from the outside adjacent space (e.g. corridors) into the room and then is exhausted to the outside (the anteroom, which is the area with a door to/from the outside corridor and another door giving access to the patient area, must never have both these doors open at the same time). These rooms require strict airflow monitoring Non-enveloped virus - a virus lacking an outer lipoprotein bilayer Pathogenic microorganisms - This is the ability of the species or strain of the microorganism to cause disease. This depends on a number of factors including the number of microorganism, the host defence, treatment etc Placement – This refers to the need for a single room or isolation room, as well as the application of other infection control measures that will minimise the spread of infection by contact, droplet or airborne routes. This provides a physical separation between patients/clients. Refer to Appendix 2. Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 52 of 102 Prolonged shedding - An increased duration of the dissemination of pathogenic microorganisms, commonly associated with immunocompromised individuals, leading to prolonged infectivity Small particles in the respirable size range (≤5 µm) - These aerosolised small particles can retain their infectivity and remain suspended in air over a long period of time, after expulsion through coughing, talking, etc., allowing them to enter the respiratory tract of others including those not within close contact or even the same area as the infected individual. These are sometimes referred to as respiratory droplet nuclei. This includes what are sometimes referred to as respiratory droplet nuclei, which are particles that slightly different as they can arise from desiccation of suspended droplets associated with airborne transmission Specialised Isolation Room - This is an enhanced single room with en suite facilities and ventilated lobby (isolation suite). An enhanced single room with a positive pressure ventilated entry lobby and en suite facilities with extract ventilation provides both source and protective isolation. The positive pressure lobby ensures that air from the corridor does not enter the isolation room, and that air from the room does not escape into the corridor. This simple design enables the suite to be used for either source or protective isolation without the need for switchable ventilation or special training for staff. It also provides safe isolation/segregation for patients whose condition is unknown. These rooms require strict airflow monitoring Standard Infection Control Precautions (SICPs) - These are the minimum precautions necessary to reduce the risk of transmission of microorganisms from both recognised and unrecognised sources of infectious agents that may be present in blood, other body fluids, secretions, excretions, non intact skin and mucous membranes. These must be used by ALL health and social care workers in ALL situations involving the care of patients/clients in order to prevent spread of infectious agents to other non intact skin and/or mucous membranes (this includes sharp injuries). They should also be applied when dealing with the immediate patient/client environment which might be contaminated with blood, other body fluids, etc. There are nine elements to SICPs and they are essential in preventing and controlling HAI. These are available on http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx Surgical mask - This is a disposable fluid repellent mask that offers protection from splashes to mucous membranes of the mouth and from infectious droplets Terminal cleaning - This is environmental cleaning after discharge or transfer of an infected/colonised patient/client. The timing of the terminal clean should be discussed with Infection Control/Health Protection Staff as this can vary according to the organism. Follow the procedures recommended in http://www.scotland.gov.uk/Publications/2004/05/19319/36643 Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 53 of 102 Appendix 1 - Infectious agents – Clinical Infections or diseases warranting Transmission Based Precautions in addition to Standard Infection Control Precautions Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) This document does not include exclusion criteria, give full public health guidance, occupational health or disease management. Refer to local NHS Boards for additional information Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Abscess Draining, major Contact 48 hours following antibiotics (depending on the organism) or until drainage stops or can be contained within a dressing Nil Adenovirus (Respiratory infection in paediatrics) Contact/Droplet Requirements of precautions may be extended due to prolonged shedding of virus, generally until 48 hours following cessation of symptoms Nil Bronchiolitis Contact/Droplet Infectious agents causing this condition will vary Includes Adenovirus, Parainfluenza and Influenza Precautions usually 5-8 days Nil (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 54 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Clostridium difficile or Clostridium difficile associated disease (CDAD) Contact Precautions remain until patient is 48 hours symptom free Mandatory Surveillance Programme exists for this organism in Scotland http://www.hps.scot.nhs.uk/surveillance/ SystemsDetail.aspx?id=277 Infection can incubate for up to 12 weeks following antibiotic therapy If possible discontinue the offending antibiotic therapy Specimens are not required for clearance however 25% of cases suffer recurrence of symptoms Conjunctivitis (acute viral/haemorrhagic) Contact Adenovirus – most common lasts 7-15 days. Enterovirus lasts up to 12 days Highly contagious outbreaks in eye clinics, paediatrics, neonatal and long term care Nil Diarrhoea with a suspected infectious cause Contact Varies depending on the organism seek local guidance from local Infection Control/Health Protection team Many enteric pathogens are notfiable diseases consult local Health ProtectionTeam Diphtheria – Cutaneous Contact Until 2 negative cultures taken 24 hours apart Notifiable Disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 55 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Diphtheria – Pharyngeal toxigenic strains (Cornynebacterium diphtheriae) Droplet/Contact Until negative Notifiable Disease Epiglottitis due to (Haemophilus influenzae type b) Droplet/Contact Patient considered negative when two cultures (Nasal Pharyngeal Aspirate) are taken 24 hours apart Until 24 hours into the course of corrective antibiotic therapy Most common in children 2 months – 5 years Hepatitis, viral Type A&E Contact Herpes simplex (Herpesvirus hominis) • Anogenital Herpesviral Infection • Neonatal Contact For duration of hospital stay – Hep A For duration of hospital illness – Hep E Specifically for nappy wearing infants/incontinent adults Can infect oral mucosa (HSV1) or genital tract (HSV 2). Primary and recurrent infections can occur and duration of precautions will vary but usually until lesions or cold sores disappear Local Health Protection Teams should be informed of cases Notifiable disease Risk to exposed infants delivered vaginally or by C- section and if mother has active infection and membranes have been ruptured for more than 4-6 hours (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 56 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Herpes zoster (varicella-zoster) (Shingles) Contact/Airborne – disseminated disease Infectious until vesicles are dry usually 5-7 days this may be extended for immunocompromised individuals Susceptible health/social care workers should not give direct care if immune caregivers are available Disseminated disease may require an increase in the duration of the precautions Immune caregivers no additional precautions, non immune may require surgical mask in disseminated disease Human metapneumovirus Contact See section on RSV Virus closely related to RSV Impetigo Contact Nil Influenza (seasonal) Droplet/Contact Until 48 hours following corrective antibiotic therapy 5 days except in immunocompromised persons Use of vaccine or antiviral drugs may be considered Avoid placing infected individuals with immunocompromised patients Influenza (pandemic) Droplet/Contact 5 days from onset of symptoms See link to HPS web respiratory pages http://www.hps.scot.nhs.uk/resp/guideli nes.aspx (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 57 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Lice 4. Head 5. Body 6. Pubic Contact Investigation of close contacts is required Measles (rubeola) Airborne 4. Infectious until completion of treatment and/or removal of live lice/eggs 5. Infectious until 24 hours following treatment with an effective insecticide 6. Infectious until completion of treatment and/or removal of live lice/eggs Precautions remain until 4 days after onset of rash. For immunocompromised individuals this is increased for the duration of illness Notifiable disease Susceptible health/social care workers should not enter the room if immune care givers are available Exposed susceptible care givers may require post exposure vaccine (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 58 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Meningitis – meningococcal Neisseria meningitidis Droplet/Contact Until 24 hours into the course of corrective antibiotic therapy Notifiable disease Post exposure chemoprophylaxis based on local risk assessments for exposed HCW as per Infection Control Team / Health Protection Team advice Household contacts are given prophylactic antibiotics to eliminate carriage and prevent clinical illness, based on local Health Protection Teams advice Meningitis (other causes) Contact Precaution duration depends on the causative organism Enterovirus most common cause and symptoms generally do not exceed 10 days. However aetiology can be due to a variety of viruses and bacteria Airborne precautions may be required in cases of suspected/known Mycobacterium tuberculosis presenting with Meningitis (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 59 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Monkeypox Contact/Airborne Duration of precautions can vary always seek advice from local Infection Control/Health Protection Teams Inform local Health Protection Teams Transmission in hospital unlikely Mumps (infectious parotitis) Droplet/Contact Until approximately 9 days following appearance of Notifiable Disease symptoms in hospital. Some evidence that this can be reduced to 5 days in community settings for Non immune HCW should not provide previously healthy individuals direct care Multidrug-resistant organisms (MDROs) infection or colonisation (e.g. MRSA, VRE, VISA/VRSA, ESBLs, resistant Streptococcus pneumoniae, Multi drug resistant Mycobacterium tuberculosis Contact/Airborne/ Droplet depending on the infectious agent MDROs will be judged by local or national recommendations depending on the clinical and epidemiological significance Nil (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 60 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Mycobacterium tuberculosis – Extrapulmonary Contact Risk assessment required Precautions to remain until drainage stops or patient has three negative cultures from exudate Notifiable disease Mycobacterium tuberculosis Pulmonary or laryngeal disease – confirmed Mycobacterium tuberculosis Pulmonary or laryngeal disease – suspected Airborne Airborne Airborne precautions are only required if any aerosol-generating procedures* are being undertaken e.g. suctioning risk assessment in conjunction with the local Infection Control Team Discontinue precautions only when patient is on effective therapy, condition is improving and has 3 negative sputum smears for acid fast bacilli (AFB) collected on 3 consecutive days Discontinue precautions only when the likelihood of infectious TB is deemed negligible and either there is an alternative diagnosis or the 3 sputum smears are negative for AFB. Specimen should be collected 8-24 hours apart at one should be early morning Notifiable disease MDR TB cases always seek guidance when suspected/confirmed cases further information http://www.hps.scot.nhs.uk/resp/guideli nes.aspx There are some exceptions to precaution requirements and local Infection Control/Health Protection/ TB teams must be consulted Notifiable disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 61 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Mycoplasma – atypical pneumonia Droplet/Contact Nil Norovirus Contact/Airborne Precautions remain for duration of hospital stay or when symptoms resolve. Patients can be infectious for up to 13 weeks Patients/clients are infectious until 48 hours following last episode of diarrhoea and/or vomiting Parainfluenza virus infection Contact Precautions remain for duration of active disease usually 5 days following onset of symptoms, however this can vary depending on the organism Nil Parvovirus B19 – slapped cheek syndrome (Erythema infectiosum – Erythrovirus B19) Droplet Non-infectious when the rash appears. If the patient has a chronic disease or is immunocomprised maintain precautions for the duration of illness or whilst patient is hospitalised A common childhood infection lasting 23 days followed by the rash on the cheeks. In adults can be associated with athralgia PlagueYersinia pestis- Droplet/Contact Until 48 hours of the course of antibiotic therapy have been completed Common cause of hospital and long term care setting outbreaks Advice should be sought from an Infection Control/Disease/ Public Health Physician or Consultant Microbiologist when this disease is identified or suspected in pregnancy Notifiable disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 62 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Pneumonia Adenovirus Droplet/Contact Ensure applied for duration of illness Outbreaks reported in paediatric settings Pressure sores (Infected – Major) Contact Precautions should remain unless infectious wound can be occluded or contained within a drainage system Consider precautions for other conditions e.g. leg ulcers Rubella (German Measles) Droplet/Contact Until 7 days after onset of rash Notifiable disease Susceptible HCW should not provide direct clinical care Respiratory syncytial virus (RSV) Droplet/ Contact Duration of symptoms (whilst in acute care setting specifically) Rotavirus Contact/Droplet Until 48 hours symptom free. A negative sample is not usually required. Precautions may increase depending on individual situations Scabies Contact Severe acute respiratory syndrome (SARSCoV) Droplet/Airborne/ Contact Patient/Client infectious until completion of the first insecticide application Duration of illness and 10 days following resolution of pyrexia providing no respiratory symptoms Particularly affects young children, infants and immunosuppressed patients. Highly transmissible in paediatric units Prolonged shedding may occur in immunodeficient* or immunocompromised children Consider close/household contacts Not currently notifiable but ALWAYS notify specialist Infection Control/Health Protection Team. (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 63 of 102 Disease/condition/syndrome or Causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Smallpox Contact/Airborne Continue precautions until all scabs have crusted and separated (3-4 weeks) Notifiable disease Currently eradicated Non immune healthcare workers should not provide care Staphylococcal disease (skin, wound, burn – major) Contact Infectious unless wound can be occluded or contained within a drainage system or until 48 hours of corrective antibiotic therapy Nil Streptococcus disease Group A (Streptococcus pyogenes) • Erysipelas – contact • Tonsillitis – droplet • Scarlet fever – droplet • Necrotising fasciitis – contact • Puerperal fever – contact Droplet/Contact Until 24 hours of the course of corrective antibiotic therapy or if present in a wound if this is occluded/ contained Erysipelas, Scarlet fever & Puerperal fever are notifiable diseases Contact precautions particularly important if lesions present (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 64 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Varicella (Chickenpox) Airborne/Contact Until all lesions are dry and crusted Susceptible health/social care workers (e.g. those who are pregnant or immunocompromised) should not enter the room if immune care givers are available In immunocompromised individuals with varicella pneumonia prolonged precautions may be required Whooping cough – Bordetella pertussis Droplet/Contact Until 5 days of the commencement of antibiotic therapy If untreated patient infectious for up to 3 weeks Vaccination site infection Contact Viral Haemorrhagic Fevers e.g. • Lassa • Ebola • Marburg • Crimean-Congo fever virus Droplet/Contact Until drainage stops from site or if area can be occluded/contained Duration of illness. Patient highly infectious in the final stages of illness Pre + post exposure prophylaxis guidance is available http://www.dh.gov.uk/en/Publichealth/ Healthprotection/Immunisation/Green book/DH_4097254 Notifiable disease Post exposure prophylaxis for household contacts and in rare circumstances may be indicated for HCWs following prolonged exposure to respiratory secretions Nil Notifiable Disease ALWAYS seek specialist infection control advice if suspected (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 65 of 102 Appendix 2 Appendix 2 A hierarchy for placement of those known or suspected to have an infection spread by contact Refer to the full contact precautions policy for further details1 A risk assessment process should be applied3 Be alert to potential cases/symptoms Early recognition is important Diagnosis/suspicion of need for contact precautions Isolate all cases as follows in descending order, depending on available facilities Single room with hand washing facilities and en suite toilet Single room with hand washing facilities only Cohorting: Sharing a room with 1 or more patients with known/suspected same infection Examples of infections spread by contact and of HAI concern •Antibiotic resistant bacteria e.g. Meticillin Resistant Staphylococcus aureus (MRSA), Glycopeptide resistant enterococci (GRE) & multi-resistant Gram negative bacilli •Clostridium difficile infection • Norovirus •Other infections causing concern – identified locally2 Timeliness of placement is essential – additional support may be required if >1 hr has elapsed. Don’t delay action but seek expert infection control advice to inform risk assessments and subsequent actions. Cohorts Avoid cohorting in long term care facilities and do not include immunocompromised individuals in cohort areas If not available Separation of at least 3 feet from any adjacent persons by use of; single room with no facilities, cubicle, use of closed bed curtains3 Infection Control Contact Precautions Precautions are essential in order to limit the possibility of infection spreading Key Practice Points •Ensure all isolation/cohort areas are supplied with gloves/gowns, aprons and hand hygiene supplies •Remember to encourage/facilitate patient hygiene, particularly hand hygiene •Ensure ongoing and terminal cleaning of isolation areas (consult local IC/HP4 Team on specific infections with regards to the need for environmental disinfectants e.g. Chlorine based products for C. difficile or norovirus) •Avoid transfer of isolated/cohorted individuals unless clinically essential •Only discontinue placement/precautions on cessation of symptoms/clearance of specimens/completion of treatment and/or on the advice of specialists in infection control 1. Consult the full policy for more detail and for a full list of organisms/diseases requiring precautions – some may require specialist units 2. Remember other infections are spread via droplets and contact, e.g. influenza, RSV 3. Decisions made regarding placement will depend on many factors including the infectious agent and number of cases. Refer to local Infection Control/Health Protection Team 4. Infection Control/Health Protection Team NB. This hierarchy may not apply to those being cared for in their own home. * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 66 of 102 Appendix 3 – Putting on and removing PPE * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 67 of 102 Appendix 4 * denotes glossary Model Infection Control Policies (Contact Precautions), HPS ICT 2008 page 68 of 102 Airborne Precautions Policy and Procedure (an element of Transmission Based Precautions) Date of issue: April 2008 Date of re-issue: April 2011 Introduction What are airborne precautions? Airborne precautions are a set of infection control measures (to be used in addition to Standard Infection Control Precautions (SICPs*)), which are designed specifically to prevent and control the transmission of infectious agents* spread by small particles in the respirable size range (≤5μm)* to patients/clients and health and social care workers during provision of care Airborne precautions include: isolation, use of personal protective equipment (PPE), hand hygiene, care of equipment and environment including decontamination, safe management of linen and waste Why are airborne precautions important within health and social care settings? It is important to prevent infectious agents that could be present in, for example, the respiratory tract of individuals, being transmitted by the airborne route to others resulting in healthcare associated infection* When are airborne precautions required? The need for airborne precautions will vary depending on the patient/client, the setting, and the infectious agent (Refer to Appendix 1) and the procedures/activities being undertaken. For example highly dependent in-patient areas such as intensive care require different considerations than areas such as mental health settings. Further advice may be required from local Infection Control/Health Protection Teams Within non acute settings, such as care homes, community clinics or during home care, individual risk assessments are required Airborne precautions are required in all health and social care settings when a patient/client is known or suspected to be infected*/colonised* with an infectious agent or an epidemiologically important organism* that can be spread by the airborne route This includes precautions to be taken with those; with active infections, who are incubating infectious disease, who are asymptomatic but suspected to be infectious and those who are colonised with pathogenic microorganisms* * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 69 of 102 How do you decide which precautions are required? Not all elements may be required for every patient or situation. The use of risk assessment should be applied when assessing the requirement for precautions and further specialist advice should be sought from local Infection Control/Health Protection Teams as required This policy describes the key precautions to be considered when delivering care to those with infections spread by airborne small particles in the respirable size range (≤5μm) Examples of infections spread by the airborne route and of Healthcare Associated Infection (HAI) concern • Acute respiratory Mycobacterium tuberculosis • Chickenpox (varicella) • Measles • Other infections causing concern – identified locally Remember other infections are spread via airborne, droplet* and contact (see full list of infection agents spread by the airborne route in Appendix 1, this list is not exhaustive and some infectious agents are spread by more than one route). For example the potential for airborne transmission of norovirus should be considered. However this policy does not give specific guidance for outbreak situations Some infections spread by the airborne route are extremely rare but are critical to control. These include viral haemorrhagic fevers and the now eradicated smallpox and would be cared for in specialised infectious disease units, the guidance in this policy does not cover these situations * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 70 of 102 Contents This policy contains information on: page Underpinning responsibilities for airborne precautions .....................................................72 Rationale for airborne precautions................................................................................... 75 Patient/client placement (e.g. use of single rooms/isolation) ........................................... 76 Duration of airborne precautions...................................................................................... 78 Patient/client transfers ..................................................................................................... 78 Respiratory hygiene/cough etiquette ............................................................................... 79 Personal Protective Equipment (PPE) ............................................................................. 79 Masks and other face protection...................................................................................... 79 Gloves and aprons........................................................................................................... 80 General good practice points ........................................................................................... 80 Hand hygiene................................................................................................................... 81 Management of care equipment and control of the environment ..................................... 81 Safe management of linen ............................................................................................... 82 Safe disposal of waste ..................................................................................................... 83 Occupational exposure management .............................................................................. 83 Glossary........................................................................................................................... 84 Appendix 1 – Infectious agents – Clinical infections or diseases warranting Transmission Based Precautions in addition to Standard Infection Control Precautions ....................... 87 Appendix 2 – Hierarchy of placement for those known or suspected to have an infection spread by airborne route.................................................................................................100 Appendix 3 – Putting on and removing PPE ...................................................................101 Appendix 4 – Summary of precautions to minimise the spread of diseased caused by the airborne route ...........................................................................................................102 * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 71 of 102 What are the underpinning responsibilities for airborne precautions? NHS Boards must: • Ensure systems and resources are in place to facilitate implementation of the policy Managers must: • Ensure that all staff have had instruction/education on the principles of airborne precautions, Standard Infection Control Precautions and risk assessment • Ensure that adequate resources are in place to allow for the recommended infection control measures such as airborne precautions to be implemented • Ensure areas participate in surveillance programmes at a national and/or local level where required. This will help support the implementation of precautions at the most appropriate times • Undertake a risk assessment to optimise patient/client and staff safety, consulting expert infection control guidance as required • Support staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission* • Ensure any staff with health concerns or who may have become ill due to occupational exposure are referred to the relevant agency e.g., General Practitioner or Occupational Health • Ensure that estates/facilities management provide a safe environment to allow infection* prevention and control precautions to be applied All staff (providing direct care in a health or social care setting including patients/clients own homes) must: • Apply Standard Infection Control Precautions and the measures described in this policy • Ensure all other staff/agencies apply the principles of Standard Infection Control Precautions and the measures described in this policy • Undertake risk assessments when assessing the requirement for airborne precautions • Document when airborne precautions according to the policy cannot be implemented for clinical or other relevant reasons • Provide information on the precautions being taken. This should be communicated to all staff, the patients/clients, and visitors without breaching confidentiality • Offer reassurance to patients/clients and visitors/carers regarding the need for airborne precautions • Advise the patient/client, carers or visitors of any infection prevention and control requirements such as hand hygiene and respiratory hygiene/cough etiquette • Ensure occupational immunisations are up to date (if applicable) • Report to line managers any deficits in; knowledge in relation to airborne precautions/Standard Infection Control Precautions, facilities/equipment or incidents that may have resulted in cross transmission * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 72 of 102 • • Attend any mandatory or update infection control education sessions • Not provide direct patient/client care while infectious e.g. suffering diarrhoea and vomiting, as this could cause harm to the patient/client/others. If in any doubt consult with your manager, General Practitioner, Occupational Health Department or the local Infection Control/Health Protection Team • Support other staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission • Ensure staff with health concerns or who have become ill due to occupational exposure are referred to the relevant agency e.g., General Practitioner or Occupational Health • Ensure that estates/facilities management provide a safe environment to allow infection prevention and control precautions to be applied Report any illness that may be as a result of occupational exposure to their line manager and the Occupational Health Department (if applicable) Staff with infection control/ health protection responsibilities must: • • Provide education for staff and management on this policy • Provide expert advice on the points below and/or seek additional expert advice from infection control specialists on these matters where required: o Provide expert advice for incidents involving epidemiologically important organisms (and outbreaks/incidents) o Provide advice on individual risk assessments, for example a placement* decision Act as a resource for guidance and support when airborne precautions are required Visitors should be advised: • To contact the person in charge before visiting if they are unsure of the infectious status of the person they are visiting • Of appropriate hand hygiene procedures to be carried out before and after visiting as well as other relevant infection control measures • • Of appropriate respiratory hygiene/cough etiquette which should be adhered to Of the Chief Medical Officer 5 top tips for all patients, staff and visitors http://www.scotland.gov.uk/Publications/2004/08/hai Incident reporting: • Any incidents, where failures in adopting airborne precautions have occurred and/or incidents which have resulted in cross transmission, should be documented and reported as per local incident reporting procedures * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 73 of 102 Communication and general good practice: • Effective communication between all members of the health and social care team is imperative for the management of infectious agents • Those who are unwell with respiratory symptoms should be advised not to attend non-urgent appointments or visit other settings where infections might spread to those others who are vulnerable • Means of communication to alert staff to airborne precautions need to be in place, for example signage that does not breach confidentiality Everyone has an important part to play in improving patient/client safety. Undertaking Transmission Based Precautions is an essential element to ensure everyone’s safety. * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 74 of 102 What is the rationale for airborne precautions? • Airborne precautions are required to prevent the transmission of infectious agents via small particles within the respirable size range (≤5μm) and to minimise healthcare associated infection (HAI). It is essential to apply the relevant infection control precautions during any relevant health and social activity. Due to the fact that these are small particles that remain infectious over time and distance and are able to enter the respiratory tracts of individuals without necessarily having close contact* (or being in the same room), the precautions described are pivotal. An activity which results in the expulsion of small particles within the respiratory size range has to be considered when precautions are being taken • Infected individuals can cause respiratory droplets to be expelled as a result of a number of human activities such as coughing, sneezing and even talking. There can also be a risk during certain healthcare procedures such as endotracheal intubation and suctioning NB. Certain respiratory infections require additional infection control measures. Refer to the literature reviews for additional information sources, seek advice from local Infection Control/Health Protection Teams and in addition, for guidance on Pandemic Influenza see http://www.hps.scot.nhs.uk/resp/guidelines.aspx Remember Transmission Based/additional precautions are always applied in addition to Standard Infection Control Precautions * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 75 of 102 Where should those requiring airborne precautions be cared for? • This requires risk assessment in order to determine the most appropriate placement for patients/clients. This will depend on: • • • The infectious agent (Refer to Appendix 1) • The procedure/activities being undertaken The patient/client and their overall condition e.g. a productive cough The area where the patient/client is being cared for. This includes the potential for adverse outcomes in others (e.g. consider risks to immunocompromised* patients, those with invasive devices, etc) and the availability of single rooms • Timeliness of assessment and placement is essential. Additional support may be required if this is problematic and, for example, greater than one hour has elapsed Acute settings • Patients with certain known/suspected infections requiring airborne precautions should be placed in a specialised isolation room or negative pressure isolation room (with anteroom)* with hand washing and en suite facilities, as soon as possible. The door to these rooms must be kept closed • If rooms are unavailable then transfer to another unit/hospital with suitable facilities should be considered (providing the patient/client is medically stable). A risk assessment by local Infection Control/Health Protection Teams in conjunction with clinicians and managers will help determine when an alternative setting or a transfer is possible • During transfer the patient/client should wear a surgical mask* and be instructed on the principles of respiratory hygiene/cough etiquette if their condition allows and is practical • Surgical masks being worn should be changed when heavily contaminated and/or wet with breath moisture or if damaged/torn • Patients/clients should not be asked to wear FFP3* masks. This is for a variety of reasons but mainly due to the nature of the mask which filters inhaled and not exhaled air • If there are no specialised isolation rooms available then placement decisions should be subject to local risk assessment with support from a member of the local Infection Control/Health Protection Team and might include: • • Placement in a single room with en suite facilities. The door should be kept closed • Cohorting is not routinely recommended for those with infections spread by the airborne route. Contact local Infection Control or Health Protection Teams for further information Placement in a single room (or cubicle*) with no en suite facilities. The door should be kept closed. The room should be suitably ventilated if possible (via an open window if possible) to allow the change of air. The patient should wear a surgical mask where possible when having close contact* with others * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 76 of 102 • The patient/client should be instructed on the principles of respiratory hygiene/cough etiquette Non acute settings (such as care home facilities/community settings) • Where optimum facilities as described are not available and transfer to an acute setting is awaited or not an option: • • Separation of patients/clients should still be attempted, as has been described • In GP surgeries, for example, where an infection spread by the airborne route is suspected, the person may be requested to wear a surgical mask (dependent on risk assessment/infection suspected) and placed in a single/private consulting room (if practical). The door should be kept closed. The patient/client should be instructed on the principles of respiratory hygiene/cough etiquette. The room should be suitably ventilated (via an open window if possible) to allow the change of air. Patients/clients should not be asked to wear FFP3 masks. Surgical masks being worn should be changed when heavily contaminated and/or wet with breath moisture or if damaged/torn All other precaution measures as described in this policy must be adhered to, wherever care is being provided • Individual risk assessments based on potential infection risks to other patients/clients as well as individual care needs should take place with additional expert input where required Additional points • It is essential that specialised isolation rooms are monitored to ensure strict airflow in compliance with engineering standards • During placement or transfers contact with any immunocompromised patients/clients should be avoided • Patients/clients requiring airborne precautions within acute and/or non acute long stay/community settings should not be transferred unnecessarily to other areas unless essential due to medical reasons • Information on the precautions being applied should be communicated to all staff providing care and the patient/client and visitors without breaching confidentiality • All of the other precaution measures described in this policy should be adhered to as well as ensuring appropriate placement of patients/clients and ensuring all elements of Standard Infection Control Precautions are applied Also see Appendix 2 ‘A Hierarchy for Placement Of Those Known Or Suspected To Have An Infection Spread By The Airborne Route’ NB. This policy does not give specific guidance for outbreak situations. In addition not all infectious agents will require the level of placement described above as per specialised isolation rooms. Local policies should be referred to or advice sought from local Infection Control/Health protection Teams * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 77 of 102 How long should airborne precautions remain in place? • Airborne precautions/placement should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent (Refer to Appendix 1 for infectious agents). Contact local Infection Control or Health Protection Teams for further advice What if a patient/client has to be transferred within acute or non acute long stay/community settings? • It is recommended that patients/clients requiring airborne precautions within acute or non acute settings, whether in a specialised isolation room or not, are not transferred unless there is a necessary requirement (e.g. medical reasons), or for placement in an appropriate single room • The transferring area should give guidance to transport staff and to the receiving area on the airborne precautions requirement for the individual patient/client. Additional communications are also important if the individual patient/client is infected/colonised with any multi drug resistant organism e.g. Multi Drug Resistant TB • The patient/client should be instructed on respiratory hygiene/cough etiquette and requested to wear a surgical mask (not an FFP3 mask) if possible. Surgical masks should be changed when heavily contaminated and/or wet with breath moisture and if damaged/torn • PPE may be required for transfers depending on the contact that will be made with the patient/client during that time. Hand hygiene following contact and/or transfer is also important. (See What additional Personal Protective Equipment (PPE) should be considered for contact precautions?). Additionally consider: • An individual risk assessment if the patient/client cannot wear a mask e.g. confused, disturbed or with respiratory distress and unable to tolerate a mask. This should include the known or suspected infectious agent, contact that will be made, and the need for transfer staff to wear masks. Local Infection Control/Health Protection Teams should be consulted for advice • If the patient/client has a skin lesion associated with their respiratory infection e.g. Mycobacterium tuberculosis, then the lesions should be covered by a wound dressing or if necessary a drainage system prior to transfer. If skin lesions from Chickenpox cannot be covered, e.g. due to their number and location, then it is especially important that the correct PPE is worn, i.e. gloves/aprons and that staff in direct contact are immune. Local Infection Control/Health Protection Teams should be consulted for further advice • Equipment/linen used for the transfer must be subject to decontamination (See Why is the management of care equipment and control of the environment an additional consideration for contact precautions? and Why is safe management of linen an additional consideration for contact precautions?) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 78 of 102 What are respiratory hygiene/cough etiquette precautions? • Cover nose and mouth with disposable single-use tissues when sneezing, coughing, wiping and blowing noses • Dispose of used tissues in the nearest waste bin • Wash hands after coughing, sneezing, using tissues, or after contact with respiratory secretions and contaminated objects • Keep hands away from the mucous membranes of the eyes and nose. Certain patient/clients (e.g. the elderly, children) may need assistance with containment of respiratory secretions; those who are immobile will need a receptacle (e.g. a plastic bag) readily at hand for the immediate disposal of used tissues and should be offered hand hygiene facilities • Instruct all affected patient/clients and any visitors or carers on the steps described What additional Personal Protective Equipment (PPE) should be considered for airborne precautions? Masks and other face protection: • Respiratory masks, i.e. FFP3 masks (not surgical masks) are designed to prevent inhalation of infectious airborne particles and subsequent access to the mucous membranes of the respiratory tract of an individual. This is one of the key precautions to be considered when delivering care to those with infections transmissible by the airborne route • The use of these masks applies to care of those with active respiratory Mycobacterium tuberculosis (TB). It also applies when extrapulmonary TB and/or infectious TB lesions are present and aerosol-generating procedures* are being undertaken (for advice on when FFP3 masks are no longer required contact local Infection Control or Health Protection Teams. Further TB specific guidance should also be sought http://www.hps.scot.nhs.uk/resp/guidelines.aspx • The FFP3 mask (conforms to EN1492001) must be: • fit tested - the efficiency of the masks depends on them being a tight fit to the wearer’s face. This procedure must be undertaken by a trained professional. Refer to the following guidance for more detail http://www.hse.gov.uk/pubns/fittesting.pdf • fit checked – each time a FFP3 mask has been put on it should be fit checked before entering the patient area. Refer to the following guidance for more detail http://www.hse.gov.uk/pubns/fittesting.pdf • • put on before entry into the specialised isolation rooms changed if you feel you cannot breath with it on or it is damaged or torn (you should leave the area immediately and only then remove and dispose of the mask). Further information on FFP3 masks can be found at http://www.documents.hps.scot.nhs.uk/hai/infection-control/faqs/ffp3faqs.pdf * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 79 of 102 • FFP3 masks are not expected to be routinely worn when caring for those patients/clients with Chickenpox, Measles, disseminated herpes zoster (disseminated varicella zoster/shingles). This is due to the fact that once the skin lesions are evident and the infectious agent is known to be present communicability through the airborne route is less significant. This is also the case because it is expected that most health and social care workers have immunity through vaccination/exposure to Chickenpox/Measles • Patients/clients should not be asked to wear FFP3 masks for a variety of reasons but mainly due to the nature of the mask which filters inhaled and not exhaled air ● The use of surgical masks in other situations where respiratory secretions may spread by the airborne route should be considered along with the use of face protection following Standard Infection Control Precautions ● Surgical masks being worn should be changed when heavily contaminated or wet with breath moisture or if damaged/torn • Other face protection, for example eye protection provided by goggles or visors, may be required if there is a risk of mucosal splashing to the face as a result of, for example, coughing, sneezing or aerosol-generating procedures Gloves and aprons: • Disposable gloves and plastic aprons should be put on before and worn during care activities and where there will be contact with the patient/client or their immediate environment • The use of a disposable fluid repellent gown may be more appropriate in order to gain fuller body protection from specific infectious agents. Advice should be sought from local Infection Control/Health Protection Teams General good practice points • Supplies of PPE should be available at the entrance to the isolation room/lobby • Aprons (or disposable fluid repellent gowns), masks and gloves should be put on before undertaking care activities • Those entering rooms/areas should not be wearing any outer coats • Keep hands away from face and PPE being worn • PPE should be removed immediately upon leaving the room/area and hand hygiene performed • PPE must be changed and hand hygiene performed between different procedures/care activities on the same patient/client. This is particularly important for gloves as they will become contaminated following one procedure and could lead to cross transmission of infectious agents even in the same patient • PPE must be changed and hand hygiene performed between every patient/client • Putting on and removal of PPE on entering and leaving the isolation room/lobby should be performed as in Appendix 3. For those individuals not requiring a specialised isolation room with a lobby then staff must dispose of their PPE inside the single room or immediately on leaving • Safe disposal of PPE is essential immediately following removal * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 80 of 102 Hand Hygiene • Hand hygiene is essential (refer to the HPS Model Infection Control Policy on Hand Hygiene http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx which includes the ‘Your 5 moments for hand hygiene’ and other times when hand hygiene must be performed) Why are management of care equipment and control of the environment additional considerations for airborne precautions? • Care equipment and the environment must be given additional consideration in order to prevent the spread of respiratory secretions that may be contaminating items: • The patient’s/client’s environment should be cleaned at least daily or when visibly contaminated. Particular attention should be paid to frequently touched and horizontal surfaces surrounding the patient/client (e.g. bed tables, door handles, etc) • Refer to http://www.scotland.gov.uk/Publications/2004/05/19319/36643 for more information on cleaning specifications and HPS Model Infection Control Policy on Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx • An increase in cleaning frequency should be considered particularly if patients/clients are producing copious amounts of respiratory secretions • Equipment should be allocated to individuals being cared for under airborne precautions, e.g. thermometers • Equipment should not be shared with others, where this is unavoidable equipment must be decontaminated following manufacturer’s guidance/local instruction prior to use on others (also refer to HPS Model Infection Control Policy on Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx) • Items of equipment and the environment should be intact. Items that are not intact should be reported and replaced to prevent unnecessary harbouring of infectious agents • • The environment should be clutter free to allow for ease of cleaning Where possible use single use/single patient use equipment and dispose of it after use Equipment such as mops/buckets used for cleaning in-patient areas (hospital) should be colour coded as stated in the NHSScotland Colour Coding for Hospital Cleaning Materials and Equipment (HFS, 2008). In isolation or dedicated single rooms/areas these should be yellow in colour and should not be used in other rooms/areas. These items should also be clean, fit for purpose and decontaminated or disposed of as appropriate following use. Cleaning equipment should not be left in a patient’s/client’s room between use unless there is a dedicated storage area Within NHSScotland premises, the NHSScotland Cleaning Specifications should be complied with • • * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 81 of 102 • • The NHSScotland Cleaning Specification and Colour Coding of Hospital Cleaning Materials is not applicable in care homes and other community settings however the principles of this policy should be applied Terminal cleaning* of equipment and the environment is essential before others are cared for in that area (refer to HPS Model Infection Control Policies on Control of the Environment Policy and Management of Care Equipment http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx). It is important that all items are decontaminated (e.g. curtains, bed frames, etc) • PPE should be worn while undertaking decontamination of equipment/the environment, i.e. gloves and plastic apron • Hand hygiene should always be performed after undertaking decontamination of equipment/the environment Why is safe management of linen an additional consideration for airborne precautions? NHSScotland settings • Linen that could be contaminated with respiratory secretions must be managed safely in order to avoid cross transmission of infectious agents. This should be bagged as infected linen within the Healthcare Setting: • • Ensure safe handling of linen, i.e. wear PPE and wash hands on removal • • Place alginate bags into appropriately colour coded linen bag Place contaminated linen into an alginate bag at the point of removal. Do not carry linen Communicate with others who may handle the infected linen to ensure they take precautions • See HPS Model Infection Control Policy on Safe Management of Linen http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx for more information on care of other linen such as people’s own clothing and seek further advice on this from local Infection Control/Health Protection Teams Care Home settings • In care home settings the principles of this policy should be applied when dealing with linen that could be contaminated with infectious droplets. This would include bagging infected linen directly into water soluble/alginate bags providing that industrial washing machines are in use. If domestic washing machines are in use or if home laundering is undertaken refer to HPS Washing Clothes at Home leaflet. http://www.documents.hps.scot.nhs.uk/hai/infectioncontrol/publications/washing-clothes-home.pdf * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 82 of 102 Why is safe disposal of waste an additional consideration for airborne precautions? • Waste that could be contaminated with small particles in the respirable size range must be managed safely in order to avoid cross transmission of infectious agents via this route: • • Ensure safe handling of waste, i.e. wear PPE and wash hands on removal Bag waste generated as a result of care activities as per national/local policy for healthcare waste (See HPS Model Infection Control Policy, Safe Disposal of Waste http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx for more information on healthcare waste) Why is occupational exposure management an additional consideration for airborne precautions? • Occupational exposure management is essential for the protection of all health and social care workers and relevant immunisation is an essential consideration when caring for those individuals with diseases spread by the airborne route: • • Ensure occupational immunisations (if required) are up to date, e.g. VZV Report and manage occupational exposure incidents immediately, including any splashes to the eye • Non immune health/social care workers and those who are pregnant should not provide close care* for individuals with some specific infectious agents transmitted via the airborne route e.g. Chickenpox and Measles. Advice should be sought from Occupational Health or General Practitioners for immunisation, exclusion advice or post exposure guidance. Refer to the following link for information on specific diseases http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbo ok/DH_40972 Also refer to Appendix 4 for summary of precautions to minimise the spread of infections transmitted by the airborne route * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 83 of 102 Glossary Aerosol-generating procedures associated with pathogen transmission - Procedures that have been reported to be aerosol-generating and associated with a documented increased risk of pathogen transmission. These include intubation and related procedures, cardiopulmonary resuscitation, bronchoscopy, autopsy and surgery where high-speed devices (e.g. saw) are used Close Contact - Within 3 feet (1 metre) of the patient/client and/or while performing care activities Colonised - This is when a microorganism establishes itself in a particular body site or the environment without producing disease or causing harm Cubicle - A room/space which is not fully enclosed but is cordoned off by partitions, e.g. the 'walls' of the enclosed space provide a degree of privacy for the patient/client but do not completely shut the area off from the outside as they are not continuous from floor to ceiling Cross Transmission - The transmission of an infectious agent from one individual to another via a direct or indirect exposure Droplet - Droplets are particles propelled by coughing and sneezing and during the performance of some procedures. They are generally regarded to be larger than 5μm in diameter although there is no consensus on size. Droplets can be deposited on the conjunctiva or mucous membranes of the nose, mouth or respiratory tract and the environment. However because of their relatively large size, generally droplets travel only short distances (typically less than 3 feet (1 metre)) before falling Epidemiologically important organism – This encompasses a growing list of pathogenic organisms, which have been identified based on published reports of clusters (>2 patients) within healthcare settings where additional monitoring/precautions are required to control them. Another feature of epidemiologically important organisms is that a number are resistant to antibiotics e.g. MRSA, VRE etc FFP3 respirator mask - FFP stands for ‘filter face piece’. The 3 means high protection that provides protection against small particles in the respirable size range (≤5 µm in size). FFP3 facemasks if worn correctly, protect the wearer from inhalation of infectious respiratory droplets through and around the facemask. FFP3 facemasks conform to the European Standard EN149 2001 (Box CE marked). Fit testing must be carried out prior to providing any care where this type of masks may require to be worn. Fit checking must be carried out each time before entering the isolation room. Further information can be found at: Fit testing - http://www.hse.gov.uk/pubns/fittesting.pdf Fit checking http://www.documents.hps.scot.nhs.uk/respiratory/general/fitcheckmasks.pdf Both these links are contained within our FFP3 frequently asked questions pdf http://www.documents.hps.scot.nhs.uk/hai/infection-control/faqs/ffp3-faqs.pdf * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 84 of 102 Healthcare Associated Infection (HAI) - Infections that are not present at the time the individual’s care commences, but which arise afterwards Immunocompromised patient/individual - Patients who have congenital primary immune deficiencies or acquired disease (eg. treatment-induced immune deficiencies) are at increased risk for numerous types of infections while receiving healthcare and may be located throughout the healthcare facility. The specific defects of the immune system determine the types of infections that are most likely to be acquired (e.g., viral infections are associated with T-cell defects and fungal and bacterial infections occur in patients who are neutropenic). As a general group, immunocompromised patients can be cared for in the same environment as other patients; however, it is always advisable to minimise exposure to other patients with transmissible infections such as influenza and other respiratory viruses. The use of more intense chemotherapy regimens for treatment of childhood leukaemia may be associated with prolonged periods of neutropenia and suppression of other components of the immune system, extending the period of infection risk and raising the concern that additional precautions may be indicated for select groups. With the application of newer and more intense immunosuppressive therapies for a variety of medical conditions (e.g., rheumatologic disease, inflammatory bowel disease), immunosuppressed patients are likely to be more widely distributed throughout a healthcare facility rather than localised to single patient units (e.g. haematology-oncology) Immunodeficient - Lacking immunity and so susceptible to infection Infection - Is the deposition and multiplication of bacteria and other microorganisms in tissues or on surfaces of the body with an associated host reaction, causing harm or clinical disease Infectious agent - Any organism, such as a pathogenic virus, parasite, or bacterium, that is capable of invading body tissues, multiplying, and causing disease Multidrug-Resistant Organisms (MDROs) - Microorganisms – predominantly bacteria – that are resistant to more than one class of microbial agents Negative pressure isolation room (with anteroom) - These rooms maintain a negative pressure, i.e. the airflow is from the outside adjacent space (e.g. corridors) into the room and then is exhausted to the outside (the anteroom, which is the area with a door to/from the outside corridor and another door giving access to the patient area, must never have both these doors open at the same time). These rooms require strict airflow monitoring Non-enveloped virus - A virus lacking an outer lipoprotein bilayer Pathogenic microorganisms - This is the ability of the species or strain of the microorganism to cause disease. This depends on a number of factors including the number of microorganism, the host defence, treatment etc Placement - This refers to the need for a single room or isolation room, as well as the application of other infection control measures that will minimise the spread of infection by contact, droplet or airborne routes. This provides a physical separation between patients/clients. Refer to Appendix 2 Prolonged shedding – An increased duration of the dissemination of pathogenic organisms, commonly associated with immunocompromised individuals, leading to prolonged infectivity * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 85 of 102 Small particles in the respirable size range (≤5 µm) - These aerosolised small particles can retain their infectivity and remain suspended in air over a long period of time, after expulsion through coughing, talking, etc., allowing them to enter the respiratory tract of others including those not within close contact or even the same area as the infected individual. This includes what are sometimes referred to as respiratory droplet nuclei which are particles that can arise from desiccation of suspended droplets associated with airborne transmission Specialised Isolation Room - This is an enhanced single room with en suite facilities and ventilated lobby (isolation suite). An enhanced single room with a positive pressure ventilated entry lobby and en suite facilities with extract ventilation provides both source and protective isolation. The positive pressure lobby ensures that air from the corridor does not enter the isolation room, and that air from the room does not escape into the corridor. This simple design enables the suite to be used for either source or protective isolation without the need for switchable ventilation or special training for staff. It also provides safe isolation/segregation for patients whose condition is unknown. These rooms require strict airflow monitoring Standard Infection Control Precautions (SICPs) - These are the minimum precautions necessary to reduce the risk of transmission of microorganisms from both recognised and unrecognised sources of infectious agents that may be present in blood, other body fluids, secretions, excretions, non intact skin and mucous membranes. They must be used by ALL health and social care workers in ALL situations involving the care of patients/clients in order to prevent spread of infectious agents to other non intact skin and/or mucous membranes (this includes sharp injuries). They should be applied when dealing with the immediate patient/client environment which might be contaminated with blood, other body fluids, etc. There are nine elements to SICPs and they are essential in preventing and controlling HAI. These are available on http://www.hps.scot.nhs.uk/haiic/ic/modelinfectioncontrolpolicies.aspx Surgical mask - This is a disposable fluid repellent mask that offers protection from splashes to mucous membranes of the mouth and from infectious droplets Terminal cleaning - This is environmental cleaning after discharge or transfer of an infected/colonised patient/client. The timing of the terminal clean should be discussed with Infection Control/Health Protection Staff as this can vary according to the organism. Follow the procedures recommended in http://www.scotland.gov.uk/Publications/2004/05/19319/36643. * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 86 of 102 Appendix 1 - Infectious agents – Clinical Infections or diseases warranting Transmission Based Precautions in addition to Standard Infection Control Precautions Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) This document does not include exclusion criteria, give full public health guidance, occupational health or disease management. Refer to local NHS Boards for additional information Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Abscess Draining, major Contact 48 hours following antibiotics (depending on the organism) or until drainage stops or can be contained within a dressing Nil Adenovirus (Respiratory infection in paediatrics) Contact/Droplet Requirements of precautions may be extended due to prolonged shedding* of virus, generally until 48 hours following cessation of symptoms Nil Bronchiolitis Contact/Droplet Infectious agents causing this condition will vary Includes Adenovirus, Parainfluenza and Influenza Precautions usually 5-8 days Nil (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 87 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Clostridium difficile or Clostridium difficile associated disease (CDAD) Contact Precautions remain until patient is 48 hours symptom free Mandatory Surveillance Programme exists for this organism in Scotland http://www.hps.scot.nhs.uk/surveillance/ SystemsDetail.aspx?id=277 Infection can incubate for up to 12 weeks following antibiotic therapy If possible discontinue the offending antibiotic therapy Specimens are not required for clearance however 25% of cases suffer recurrence of symptoms Conjunctivitis (acute viral/haemorrhagic) Contact Adenovirus – most common lasts 7-15 days. Enterovirus lasts up to 12 days Highly contagious outbreaks in eye clinics, paediatrics, neonatal and long term care Nil Diarrhoea with a suspected infectious cause Contact Varies depending on the organism seek local guidance from local Infection Control/Health Protection team Many enteric pathogens are notfiable diseases consult local Health ProtectionTeam Diphtheria – Cutaneous Contact Until 2 negative cultures taken 24 hours apart Notifiable Disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 88 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Diphtheria – Pharyngeal toxigenic strains (Cornynebacterium diphtheriae) Droplet/Contact Until negative Notifiable Disease Epiglottitis due to (Haemophilus influenzae type b) Droplet/Contact Patient considered negative when two cultures (Nasal Pharyngeal Aspirate) are taken 24 hours apart Until 24 hours into the course of corrective antibiotic therapy Most common in children 2 months – 5 years Hepatitis, viral Type A&E Contact Herpes simplex (Herpesvirus hominis) • Anogenital Herpesviral Infection • Neonatal Contact For duration of hospital stay – Hep A For duration of hospital illness – Hep E Specifically for nappy wearing infants / incontinent adults Can infect oral mucosa (HSV1) or genital tract (HSV 2). Primary and recurrent infections can occur and duration of precautions will vary but usually until lesions or cold sores disappear Local Health Protection Teams should be informed of cases Notifiable disease Risk to exposed infants delivered vaginally or by C- section and if mother has active infection and membranes have been ruptured for more than 4-6 hours (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 89 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Herpes zoster (varicella-zoster) (Shingles) Contact/Airborne – disseminated disease Infectious until vesicles are dry usually 5-7 days this may be extended for immunocompromised individuals Susceptible health/social care workers should not give direct care if immune caregivers are available Disseminated disease may require an increase in the duration of the precautions Immune caregivers no additional precautions, non immune may require surgical mask in disseminated disease Human metapneumovirus Contact See section on RSV Virus closely related to RSV Impetigo Contact Nil Influenza (seasonal) Droplet/Contact Until 48 hours following corrective antibiotic therapy 5 days except in immunocompromised persons Influenza (pandemic) Droplet/Contact 5 days from onset of symptoms Use of vaccine or antiviral drugs may be considered Avoid placing infected individuals with immunocompromised patients See link to HPS respiratory web pages http://www.hps.scot.nhs.uk/resp/guideli nes.aspx (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 90 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Lice 1. Head 2. Body 3. Pubic Contact 1. Investigation of close contacts is required Measles (rubeola) Airborne Infectious until completion of treatment and/or removal of live lice/eggs 2. Infectious until 24 hours following treatment with an effective insecticide 3. Infectious until completion of treatment and/or removal of live lice/eggs Precautions remain until 4 days after onset of rash. For immunocompromised individuals this is increased for the duration of illness Notifiable disease Susceptible health/social care workers should not enter the room if immune care givers are available Exposed susceptible care givers may require post exposure vaccine (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 91 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Meningitis – meningococcal Neisseria meningitidis Droplet/Contact Until 24 hours into the course of corrective antibiotic therapy Notifiable disease Post exposure chemoprophylaxis based on local risk assessments for exposed HCW as per Infection Control Team / Health Protection Team advice Meningitis (other causes) Contact Precaution duration depends on the causative organism Household contacts are given prophylactic antibiotics to eliminate carriage and prevent clinical illness, based on local Health Protection Teams advice Enterovirus most common cause and symptoms generally do not exceed 10 days. However aetiology can be due to a variety of viruses and bacteria Airborne precautions may be required in cases of suspected/known Mycobacterium tuberculosis presenting with Meningitis (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 92 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Monkeypox Contact/Airborne Duration of precautions can vary always seek advice from local Infection Control/Health Protection Teams Inform local Health Protection Teams Transmission in hospital unlikely Mumps (infectious parotitis) Droplet/Contact Until approximately 9 days following appearance of Notifiable Disease symptoms in hospital. Some evidence that this can be reduced to 5 days in community settings for Non immune HCW should not provide previously healthy individuals direct care Multidrug-resistant organisms (MDROs) infection or colonisation (e.g. MRSA, VRE, VISA/VRSA, ESBLs, resistant Streptococcus pneumoniae, Multi drug resistant Mycobacterium tuberculosis Contact/Airborne/ Droplet depending on the infectious agent MDROs will be judged by local or national recommendations depending on the clinical and epidemiological significance. Nil (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 93 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Mycobacterium tuberculosis – Extrapulmonary Contact Risk assessment required Precautions to remain until drainage stops or patient has three negative cultures from exudate Notifiable disease Mycobacterium tuberculosis Pulmonary or laryngeal disease – confirmed Mycobacterium tuberculosis Pulmonary or laryngeal disease – suspected Airborne Airborne Airborne precautions are only required if any aerosol-generating procedures are being undertaken e.g. suctioning risk assessment in conjunction with the local Infection Control Team Discontinue precautions only when patient is on effective therapy, condition is improving and has 3 negative sputum smears for acid fast bacilli (AFB) collected on 3 consecutive days Discontinue precautions only when the likelihood of infectious TB is deemed negligible and either there is an alternative diagnosis or the 3 sputum smears are negative for AFB. Specimen should be collected 8-24 hours apart at one should be early morning Notifiable disease MDR TB cases always seek guidance when suspected/confirmed cases further information http://www.hps.scot.nhs.uk/resp/guideli nes.aspx There are some exceptions to precaution requirements and local Infection Control/Health Protection/ TB teams must be consulted Notifiable disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 94 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Mycoplasma – atypical pneumonia Droplet/Contact Nil Norovirus Contact/Airborne Precautions remain for duration of hospital stay or when symptoms resolve. Patients can be infectious for up to 13 weeks Patients/clients are infectious until 48 hours following last episode of diarrhoea and/or vomiting Parainfluenza virus infection Contact Precautions remain for duration of active disease usually 5 days following onset of symptoms, however this can vary depending on the organism Nil Parvovirus B19 – slapped cheek syndrome (Erythema infectiosum – Erythrovirus B19) Droplet Non-infectious when the rash appears. If the patient has a chronic disease or is immunocompromised maintain precautions for the duration of illness or whilst patient is hospitalised A common childhood infection lasting 23 days followed by the rash on the cheeks. In adults can be associated with athralgia PlagueYersinia pestis- Droplet/Contact Until 48 hours of the course of antibiotic therapy have been completed Common cause of hospital and long term care setting outbreaks Advice should be sought from an Infection Control/Disease/ Public Health Physician or Consultant Microbiologist when this disease is identified or suspected in pregnancy Notifiable disease (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 95 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Pneumonia Adenovirus Droplet/Contact Ensure applied for duration of illness Outbreaks reported in paediatric settings Pressure sores (Infected – Major) Contact Consider precautions for other conditions e.g. leg ulcers Rubella (German Measles) Droplet/Contact Precautions should remain unless infectious wound can be occluded or contained within a drainage system Until 7 days after onset of rash Notifiable disease Susceptible HCW should not provide direct clinical care Particularly affects young children, infants and immunosuppressed patients. Highly transmissible in paediatrics Prolonged shedding may occur in immunodeficient* or immunocompromised children Respiratory syncytial virus (RSV) Droplet/ Contact Duration of symptoms (whilst in acute care setting specifically) Rotavirus Contact/Droplet Until 48 hours symptom free. A negative sample is not usually required. Precautions may increase depending on individual situations Scabies Contact Patient/Client infectious until completion of the first insecticide application Consider close/household contacts Severe acute respiratory syndrome (SARSCoV) Droplet/Airborne/ Contact Duration of illness and 10 days following resolution of pyrexia providing no respiratory symptoms Not currently notifiable but ALWAYS notify specialist Infection Control/Health Protection Team (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 96 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Smallpox Contact/Airborne Continue precautions until all scabs have crusted and separated (3-4 weeks) Notifiable disease Currently eradicated Non immune healthcare workers should not provide care Staphylococcal disease (skin, wound, burn – major) Contact Streptococcus disease Group A (Streptococcus pyogenes) • Erysipelas – contact • Tonsillitis – droplet • Scarlet fever – droplet • Necrotising fasciitis – contact • Puerperal fever – contact Droplet/Contact Infectious unless wound can be occluded or contained within a drainage system or until 48 hours of corrective antibiotic therapy Until 24 hours of the course of corrective antibiotic therapy or if present in a wound if this is occluded/ contained Nil Erysipelas, Scarlet fever & Puerperal fever are notifiable diseases Contact precautions particularly important if lesions present (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 97 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration of requirements of precautions Additional remarks Varicella (Chickenpox) Airborne/Contact Until all lesions are dry and crusted Susceptible health/social care workers (e.g. those who are pregnant or immunocompromised) should not enter the room if immune care givers are available In immunocompromised individuals with varicella pneumonia prolonged precautions may be required Whooping cough – Bordetella pertussis Droplet/Contact Until 5 days of the commencement of antibiotic therapy If untreated patient infectious for up to 3 weeks Pre + post exposure prophylaxis guidance is available http://www.dh.gov.uk/en/Publichealth/ Healthprotection/Immunisation/Green book/DH_4097254 Notifiable disease Post exposure prophylaxis for household contacts and in rare circumstances may be indicated for HCWs following prolonged exposure to respiratory secretions (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 98 of 102 Disease/condition/syndrome or causative organism Type of precautions Additional information on duration and requirements of precautions Additional remarks Vaccination site infection Contact Until drainage stops from site or if area can be occluded/contained Nil Viral Haemorrhagic Fevers e.g. • Lassa • Ebola • Marburg • Crimean-Congo fever virus Droplet/Contact Duration of illness. Patient highly infectious in the final stages of illness Notifiable Disease ALWAYS seek specialist infection control advice if suspected (Precautions should remain until the cessation of symptoms, clearance of specimens and/or completion of effective treatment or according to the specific advice relevant to the infectious agent. Contact local Infection Control/Health Protection Teams for further advice.) Refer to the full Transmission Based Precautions Policies and also Appendix 2 (A hierarchy for placement of those known or suspected to have an infection) * denotes glossary Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 99 of 102 Appendix 2 A hierarchy for placement of those known or suspected to have an infection spread by the airborne route Refer to the full airborne precautions policy for further details1 A risk assessment process should be applied5 Be alert to potential cases/symptoms Early recognition is important Diagnosis/suspicion of need for airborne precautions Example infections spread by airborne route and of HAI concern • Active respiratory Mycobacterium tuberculosis (TB) • Chickenpox (varicella) • Measles • Other infections causing concern – identified locally Isolate all cases as follows in descending order, depending on available facilities: 1 Monitored specialised isolation room2 or negative pressure isolation room (with anteroom)3 Timeliness of placement is essential – additional support may be required if >1 hr has elapsed. Don’t delay action but seek expert infection control advice to inform risk assessments and subsequent actions. If not available: Single room with en suite facilities Separation from any adjacent persons by use of; single room or cubicle4 Infection Control Airborne Precautions Precautions are essential in order to limit the possibility of infection spreading Key Practice Points •Ensure all isolation areas are supplied with gloves/gowns, aprons, masks, respirators & hand hygiene supplies •Teach and reinforce respiratory hygiene/cough etiquette with all individuals •Ensure ongoing and terminal cleaning of isolation areas •Avoid unnecessary transfer of isolated individuals unless clinically essential (transfer may be essential for care to be provided in a suitable isolation facility) •Keep in mind that airborne infections may also be spread via contact •Only discontinue placement/precautions on cessation of symptoms/clearance of specimens/completion of treatment and/or on the advice of specialists in infection control •Where the facilities described are not available all other precaution measures in the full airborne policy should still be adhered to 1. 2. 3. 4. 5. Consult the full policy for more detail and for a full list of organisms/diseases requiring precautions – some may require specialist units/mandatory controlled airflow These rooms are not commonly available but are recommended wherever possible Different designs of negative pressure isolation rooms will allow negative pressure to be maintained with or without an anteroom infection control or estates/facilities staff should be consulted. Cohorting (sharing a room with others with known/suspected same infection) is not considered appropriate for airborne infections – if you consider that there is no other option take the advice of specialists in infection control Decisions made regarding placement will depend on many factoring including the infectious agents and number of cases. Refer to full policy and local Infection Control/Health Protection Team Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 100 of 102 Appendix 3 – Putting on and removing PPE Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 101 of 102 Appendix 4 Model Infection Control Policies (Airborne Precautions), HPS ICT 2008 page 102 of 102
