Download CDHA IC 04-010 Airborne Infection Precautions

INFECTION PREVENTION AND CONTROL MANUAL
Policy & Procedure
TITLE:
Airborne Infection Precautions
NUMBER:
IC 04-010
Effective Date:
July 2012
Page
1 of 21
Applies To:
Holders of Infection Prevention and Control Manual
Table of Contents
Policy ………………………………………………………………………………………………………….
Definitions ……………………………………………………………………………………………………
Procedure ……………………………………………………………………………………………………
Notifications …………………………………………………………………………………………
Accommodations/Placement/Signage …………………………………………………………..
Personal Protective Equipment (PPE) …………………………………………………………...
N95 Respirator Use ………………………………………………………………………………..
Gowns/Gloves/Protective Eyewear ………………………………………………………………
Hand Hygiene ………………………………………………………………………………………
Case Management …………………………………………………………………………………
Patient Flow/Transport …………………………………………………………………………….
Patient/Family/Visitor Education ………………………………………………………………….
Management of Visitors ……………………………………………………………………………
Cleaning of the Patient Environment …………………………………………………………….
Linen/Dishes/Waste ………………………………………………………………………
Patient Care Equipment …………………………………………………………………………..
Specimen Collection ……………………………………………………………………………….
Intubated and Ventilated patients ………………………………………………………………..
Operating Room ……………………………………………………………………………………
Duration of precautions ……………………………………………………………………………
Discharge/Transfer (and Terminal Cleaning) …………………………………………………..
Handling of Deceased Bodies ……………………………………………………………………
Modifications to Airborne Precautions in Long Term Care, Ambulatory Care, Home Care ..
References ……………………………………………………………………………………………………
Related Documents ………………………………………………………………………………………….
Appendix A – Conditions, Clinical Presentations and Etiologies Requiring Airborne Infection
Precautions (in addition to routine practices) ……………………………………………………………..
Appendix B – Strategies to Reduce Aerosol Exposure When Performing Aerosol-Generating
Medical Procedures …………………………………………………………………………………………
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Appendix C – Appropriate Respirator Use Key Points ………………………………………………….
Appendix D – Management of Patients Potentially Exposed to Pulmonary Tuberculosis (TB) ……..
Appendix E – Management of Exposed Susceptible Roommates and Other Close Contacts
Varicella and Measles ……………………………………………………………………………………….
Appendix F – Airborne Isolation Prioritization …………………………………………………………….
Appendix G – Negative Pressure Rooms in Capital Health Facilities ………………………………….
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POLICY
1. Every area is to have a system in place to identify patients with known or suspected
airborne spread illness.
2. Fit testing of healthcare providers for N95 particulate respirators is required by law to
ensure the mask model and number that fits the wearer best. Fit testing is the
responsibility of Capital Health’s Safety Programs who may consult Occupational Health
when required.
2.1. Healthcare providers are to only use those N95 respirators for which they have
been fit tested.
2.2. Healthcare providers are to remain clean shaven in the area of the N95 respirator
seal to ensure facial seal.
3. For both staff and patient safety, Capital Health physicians, staff, learners and
volunteers are expected to be up-to-date with all immunizations, if indicated, in order to
decrease the transmission of infections between patients and staff.
3.1. Healthcare providers are expected to be aware of their immune status to measles
and varicella.
3.2. All healthcare providers should be immune to measles and varicella. A healthcare
provider who is not immune should not provide care for a patient with measles,
varicella or zoster or for a susceptible exposed patient who is in the incubation
period.
3.3. Non-immune healthcare providers should not enter the rooms of patients known or
suspected to have measles, varicella (chickenpox), or disseminated zoster, or the
room of a susceptible, exposed patient in the incubation period for these conditions
unless absolutely unavoidable. In such circumstances the susceptible healthcare
provider should wear an N95 respirator, gloves and gown.
4. Airborne Infection Precautions (in addition to Routine Practices) are required for the
conditions, clinical presentations and specific etiologies as outlined in Appendix A.
5. To reduce the transmission of disease, healthcare providers are to provide the
appropriate education on Airborne Precautions to patients, their visitors, families and
caretakers. (Refer to Procedure # 10)
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DEFINITIONS:
Aerosol - Generating
Medical Procedures
(AGMP):
Any procedure carried out on a patient that can induce the
production of aerosols of various sizes, including droplet
nuclei. Examples:
 bronchoscopy procedure
 non-invasive positive pressure ventilation (BIPAP,
CPAP)
 endotrachial intubation
 respiratory/airway suctioning
 high-frequency oscillatory ventilation
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



tracheostomy care
chest physiotherapy
aerosolized or nebulized medication administration
diagnostic sputum induction
Airborne Infection
Isolation Room:
Negative pressure room
Airborne Transmission:
The dissemination of microorganisms by aerosolization
during coughing, sneezing, or during procedures such as
suctioning or bronchoscopy. Microorganisms are contained
in droplet nuclei (the small airborne particles, less than 5
microns, that result from evaporation of large droplets), or in
dust particles containing skin squames and other debris that
remain suspended in the air for long periods of time.
Microorganisms are widely dispersed by air currents and
inhaled by susceptible hosts who may be some distance
away from the source patient, even in different rooms or
hospital wards.
N-95 Particulate
Respirator:
Respiratory protective device that filters inspired air of
particles greater than or equal to 1 micron in size with a filter
efficiency of greater than 95%, and provides a tight facial
seal.
Negative Pressure:
The volume of air exhausted from the room is greater than
the volume being drawn in. The air pressure in the room is
less than that of surrounding areas. Therefore, air is drawn
into the room and does not escape into the hallway or
adjacent areas. With negative pressure, air should be
exhausted directly to the outside. Negative pressure is
created in order to contain contaminated airborne particles.
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PROCEDURE
1. Implement Airborne Infection Precautions based on presenting signs and symptoms; do
not wait for etiology to be confirmed.
2. Implement Routine Practices and Contact Precautions, when indicated, in conjunction
with Airborne Infection Precautions.
3. Document the initiation and removal of Airborne Infection Precautions in the health
record.
4. Notifications
4.1. Notify Infection Prevention and Control (IPAC) (or – after hours – the on-call
Administrator for the facility) when initiating Airborne Infection Precautions.
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5. Accommodation/Placement/Signage
5.1. Place patients known or suspected to have an airborne infection directly into an
airborne infection isolation room (negative pressure room) with the door closed.(See
Appendix G for a list of negative pressure rooms.)
Exception – Operating Room (Refer to Operating Room Procedures – page 9)
5.1.1. Recover patients in PACU in an airborne infection isolation room.
5.1.2. Arrange for dialysis patients to receive dialysis at the bedside in an airborne
infection isolation room.
5.1.3. Arrange for patients with suspect/confirmed pulmonary/laryngeal tuberculosis
who require bronchoscopy to have the procedure done (and recovered) in an
airborne infection isolation room (see Appendix B for more detail).
5.2. Have the pressure differentials checked prior to placing a patient requiring Airborne
Precautions in an airborne infection isolation room using visual indicators (smoke
tubes or flutter strips) and daily when the room is being used for negative pressure
airborne isolation.
5.2.1. Initiate this monitoring with a request to the facility’s Engineering Services.
5.2.2. Engineering Services submits a daily report of readings to the Infection
Prevention and Control department (or – after hours – the on-call
Administrator for the facility) for each negative pressure room in use for
Airborne Infection Precautions.
5.3. If an airborne infection isolation room is unavailable;
5.3.1. place the patient in a single room,
5.3.2. ensure the patient keeps the mask on,
5.3.3. keep the door closed and,
5.3.4. arrange for transfer of the patient to a facility with an available airborne
infection isolation room as soon as medically stable for transport.
5.4. Multi-bed rooms - Patients known to be infected with the same virus (measles or
varicella) may share a room.
Exception: Do not have patients with tuberculosis share rooms as strains and
levels of infectivity may be different.
5.5. Keep doors and windows to airborne infection isolation rooms closed.
5.6. Place the patient in a single room (negative pressure room) with a private
bathroom.
5.7. Keep doors and windows closed at all times.
5.8. Place an Airborne Precautions sign on the closed door.
5.9. Place an Airborne Precautions sign on the front of the health record.
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Airborne Infection Precautions IC 04-010
5.10.
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Put Contact Precautions signage in place as required.
6. Personal Protective Equipment (PPE)
6.1.
Provide a supply of PPE for Airborne Infection Precautions outside the room.
N95 Respirator Use
6.2.
Wear an N95 respirator when:
6.2.1. caring for a patient with suspect or confirmed respiratory tuberculosis.
6.2.2. when irrigating tuberculosis sites or wounds (may cause aerosols).
6.2.3. caring for a patient with varicella or measles if (the healthcare provider) is not
immune. Note: This is not recommended; refer to Policy Statement #3.
6.2.4. performing or assisting with Aerosol Generating Medical Procedures (AGMP).
(See Strategies to Reduce Aerosol Generation (Appendix B), on patients with
signs and symptoms of severe acute respiratory syndrome (SARS),
tuberculosis, or other emerging respiratory infections.
6.2.5. caring for a patient with suspect or confirmed viral hemorrhagic fever who has
pneumonia.
6.2.6. caring for a patient with suspect or confirmed monkeypox or smallpox.
Respirator Exception: Only healthcare providers who are known to be immune to
chickenpox (varicella) and measles (rubeola) should enter the rooms of patients with
varicella (chicken pox)/disseminated zoster (shingles) and/or rubeola (measles). No
N95 respirator is required in this case.
6.3.
Change the N95 respirator whenever it is damp or soiled.
Note: N95 respirators are a single use item.
6.4.
When leaving the room, close the door, remove the N95 respirator outside the
room, discard immediately into a dedicated garbage receptacle (yellow bag) and
clean your hands.
Gowns
6.5.
Wear gowns to prevent contamination of clothing as per Routine Practices and a
point of care risk assessment.
Gloves
6.6.
Wear gloves as per Routine Practices for direct contact with all respiratory
secretions or the lesions of varicella zoster.
Note: The use of gloves does not replace hand hygiene.
Protective Eyewear
6.7.
Wear goggles or a face shield if spray, splash or splatter is anticipated, as per
Routine Practices.
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7. Hand Hygiene
7.1. Follow the Four Moments for hand hygiene to prevent the transmission of infection.
7.2. Ensure a supply of alcohol based hand rub is available at the bedside for patient
and visitor use.
7.3. Instruct patient and visitors on the importance of proper hand hygiene techniques.
7.4. Offer patients frequent opportunities to clean their hands, assist with hand hygiene
as necessary.
8. Case Management
For varicella:
8.1. Have the patient remain in the room until all lesions have crusted.
8.2. Advise susceptible staff and visitors not to enter the room.
8.2.1. If exceptional circumstances make this necessary, advise the staff/visitor to
wear an N95 respirator, gown and gloves.
8.3. Advise the patient to be out of the room for medically essential purposes only,
unless it is established that all other patients and all healthcare providers are
immune to varicella.
8.4. When out of the room, have the patient wear a surgical or procedure mask, ensure
skin lesions are covered and bedclothes and bedding (as required) are clean.
For measles:
8.5. Have the patient remain in the room until 4 days after the onset of rash or for
duration of the illness if immunocompromised.
8.6. Advise susceptible staff and visitors not to enter the room.
8.6.1. If exceptional circumstances make this necessary, advise the staff/visitor to
wear an N95 respirator
8.7. Advise the patient to be out of the room for medically essential purposes only,
unless it is established that all other patients and all healthcare providers are
immune to measles.
8.7.1. Have the patient wear a surgical or procedure mask when out of the room.
9. Patient Flow/Transport
The ambulatory freedom of patients on Airborne Infection Precautions is restricted in
order to minimize the potential for transmission of airborne spread illness.
9.1.
9.2.
Instruct patients to leave their room only for medically essential purposes.
Ensure that a healthcare provider accompanies the patient whenever outside the
room.
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Airborne Infection Precautions IC 04-010
9.3.
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Put a surgical mask on the patient (if tolerated) when the patient leaves the room.
(Surgical masks are preferred over procedure masks as they are designed to
prevent respiratory secretions of the wearer from entering the air.) Allow the patient
to remove the mask once in an airborne infection isolation room.
Note: Patients do not wear N95 respirators.
9.3.1. If the patient must be transported and cannot wear a surgical mask, plan the
transport to limit the exposure of other individuals (E.g.: no waiting in the
reception areas.)
9.3.2. Contact Security Services to have an elevator taken out of service for
transport of this patient only.
9.3.3. Cover skin lesions of patients due to varicella or smallpox or nonpulmonary
draining lesions due to M. tuberculosis with a clean sheet.
9.4.
If the patient has proven or suspect tuberculosis, viral hemorrhagic fever,
smallpox or monkeypox, advise the transport staff to wear a N95 respirator during
transport.
9.4.1. For other conditions (i.e., measles, varicella), check whether the transport
staff are immune; if so a N95 respirator is not required.
9.5.
Advise the receiving area that the patient requires Airborne Precautions as per
Transfer of Accountability protocols.
10. Patient/Family/Visitors Education
10.1. Educate patients, their visitors, families and caretakers about the precautions
being used, the duration of the precautions as well as the prevention of
transmission of disease to others.
10.2. Instruct patients with known or suspected airborne infections to wear a surgical
mask and to cover skin lesions with a dry dressing if, for medical reasons, they
have to leave their airborne infection isolation room. (Refer to Procedure #9).
10.3. Instruct visitors to wear the same PPE as healthcare providers unless it is
determined the visitor already has had prolonged exposure to the patient or if
immune to the specific disease/condition for which the patient is on Airborne
Precautions.
10.3.1.
Instruct visitors to perform a fit seal check if wearing an N95 respirator.
11. Management of Visitors
11.1. Ensure that visitors check at the nursing desk prior to visiting.
11.2. Keep visitors to a minimum (limited to members of the person’s household).
Note: For safety reasons, infants, children under 12 years of age, and
immunocompromised persons are not permitted to visit.
(Return to Table of Contents)
For tuberculosis:
11.3. Restrict visitors to immediate family or guardian. Screen close contact visitors
(E.g.: household members, those who routinely have visited the patient’s home)
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Page 9 of 21
for the presence of a cough; refer coughing visitors for tuberculosis assessment
immediately.
11.3.1.
Until assessed, advise the visitor to visit only if it is essential and to
wear a surgical mask while in the facility.
For other airborne infections:
11.4. Instruct visitors to speak with a nurse before entering the patient’s room.
11.5. Restrict visitors of patients on Airborne Precautions from visiting, unless
confirmed to be immune to the specific infection for which the patient is on
Airborne Precautions, unless the visit is essential (E.g.: parent, guardian or
primary caretaker).
11.5.1.
If the visit is essential, advise non-immune visitors to wear appropriate
PPE.
12. Cleaning of the Patient Environment
12.1. Clean as per routine cleaning.
12.2. Change privacy curtains with transfer or discharge.
13. Linen
13.1. Special handling of linen is not indicated.
14. Dishes
14.1. Disposable dishes are not required.
15. Waste
15.1. Follow routine waste handling procedures.
16. Patient Care Equipment
16.1. Where possible, dedicate equipment for use with this patient only or clean
between patients.
16.2. Clean and disinfect all equipment between uses as per Routine Practices.
17. Specimen Collection
Note: With the exception of viral hemorrhagic fever (VHF) (E.g. Ebola, Marburg, Lassa
fever) and smallpox, specimens do not require special labeling.
17.1. Double bag in zip lock bags all specimens that are sent through the pneumatic
tube system.
17.2. Do not send VHF or smallpox specimens through the pneumatic tube system,
arrange hand delivery by Porter Services.
18. Intubated and Ventilated patients:
18.1. Ensure an appropriate bacterial filter is placed on the endotracheal tube to
prevent contamination of the ventilator and the ambient air.
18.2. Perform endotracheal suctioning using a closed suction apparatus.
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Page 10 of 21
19. Operating Room
19.1. Postpone elective procedures until the patient is non-infectious.
19.2. If surgery must be performed, book procedures at the end of the day’s schedule,
if possible.
19.2.1.
19.2.2.
Advise the OR and PACU of the need for Airborne Infection
Precautions as per Transfer of Accountability protocols.
Place a surgical mask on the patient for transport directly to the OR.
Note: Extrapulmonary Tuberculosis: Transmission is unlikely to occur from
individuals with extrapulmonary TB except during procedures that create
aerosolization of particles (such as the irrigation of tuberculosis-infected wounds
or joints). In the case of an aerosol generating procedure, implement Airborne
Precautions.
20. Duration of Precautions
20.1. Always consult the Infection Prevention and Control department before
discontinuing Airborne Infection Precautions.
Note: Duration of precautions varies according to the extent or stage of the
disease and the treatment received.
Tuberculosis
20.2. Place patients with suspected, untreated, or initially treated smear positive or
smear negative pulmonary tuberculosis on Airborne Precautions for at least 14
days of therapy.
Note: Patients with laryngeal, cavitary persistently smear positive or drug
resistant tuberculosis may require longer Airborne Precautions.
21. Discharge/Transfer (and Terminal Cleaning)
21.1. Keep the Airborne Infection Precautions sign in place following discharge/transfer
of a patient on Airborne Infection Precautions.
21.2. Keep the doors and windows closed.
21.3. *Leave the room empty for at least 2 hours following discharge/transfer before
placing another patient in the room.
*In the Cobequid Emergency department, there are two rooms used for Airborne
Infection Precautions. Due to the air handling specifications at the Cobequid
Community Health Centre, Room 2046 must remain closed for 24 minutes after
patient discharge and Room 2064 for 21 minutes after patient discharge.
*These numbers are derived following the Centres for Disease Control and Prevention (2005).
Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care
Settings.
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Page 11 of 21
21.4. If entering the room during these respective time periods, wear an N95
respirator, (inclusive of Housekeeping staff performing the terminal clean.)
21.5. Contact Infection Prevention and Control for further information/direction.
22. Handling of Deceased Bodies
22.1. Use Routine Practices and a point of care risk assessment.
22.2. Use Airborne Precautions for handling the deceased body of a patient who had
infectious respiratory tuberculosis, measles or varicella until the 2 hour time
frame has elapsed in order to remove airborne contaminants in the patient’s
room.
23. Modifications to Airborne Precautions in Long-Term Care:
Tuberculosis (infectious, respiratory (pulmonary or laryngeal)):
23.1. Determine the tuberculosis infection status of residents in residential facilities at
the time of admission.
23.2. Arrange for immediate transfer to a facility with airborne infection isolation
rooms. Reduce the likelihood of transmission of tuberculosis if transfer is
delayed by:
23.2.1. Placing the patient in a single room with the door closed, preferably
without recirculation of air from the room and as far away from rooms of
other residents as possible (discuss with Engineering Services).
23.2.2. Limiting the number of people entering the room (E.g.: no non-essential
visitors or staff).
Varicella or disseminated varicella zoster or localized varicella zoster that cannot be kept
covered/immunocompromised patient, or measles:
23.3. Determine the immune status (measles, varicella) of residents in residential
facilities at the time of admission and offer immunization, if appropriate.
23.4. Arrange for transfer to a facility with airborne infection isolation rooms. Reduce
the likelihood of transmission if transfer is delayed by:
23.4.1. Placing the resident in a single room with the door closed, preferably
without recirculation of air from the room and as far away from rooms of
other residents as possible (discuss with Engineering Services).
23.4.2. Limiting the number of people entering the room (E.g.: no non-essential
visitors or staff).
Note: If all staff and all other residents in the facility are immune and if nonimmune visitors can be excluded, transfer to a facility with an airborne infection
isolation room may not be essential.
23.4.3. Do not place infectious patients on units where there are susceptible
immunocompromised patients.
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Page 12 of 21
24. Modifications of Airborne Precautions for Ambulatory Care:
24.1. Have a system (e.g., triage, signage) at entry to ambulatory settings or when
making telephone appointments to identify patients with known or suspected
infection that require Airborne Infection Precautions (I.e.: infectious tuberculosis,
measles, varicella or disseminated zoster).
24.1.1.
If feasible, schedule the visit at a time to minimize exposure of other
patients, such as at the end of the day.
24.2. Direct patients with suspected airborne infection to put a mask on upon entry to
the facility.
24.3. Place patients known or suspected to have airborne infection directly into an
airborne infection isolation room (if available).
24.3.1. Place the patient into a single room if an airborne infection isolation room is
unavailable; ensure the patient keeps the surgical mask on and the door
remains closed.
24.3.2. Allow the patient to remove the mask once in an airborne infection isolation
room.
24.4. Follow recommendations for Staff, Patient Flow and Personal Protective
Equipment as per above policy and procedure.
24.5. Upon discharge, allow sufficient time for the air to be free of aerosolized droplet
nuclei before using the room for another patient (tuberculosis) or for a nonimmune
patient (measles or varicella).
Note: Two hours is the Capital Health standard, except in the Cobequid
Emergency department. (See Procedure #21)
25. Modifications of Airborne Precautions for Home Care:
25.1. Develop a system to screen patients and family members prior to home care visits
to identify patients or family members with known or suspected infection that
requires Airborne Infection Precautions (I.e.: infectious tuberculosis, measles,
varicella or disseminated zoster).
25.2. Home care agencies consult with Public Health to determine if the patient is
infectious for respiratory tuberculosis and requires Airborne Infection Precautions.
REFERENCES
The Public Health Agency of Canada. (2010). Routine Practices and Additional Precautions
for Preventing the Transmission of Infection in Health Care.
Centers for Disease Control and Prevention. Guidelines for Preventing the Transmission
of Mycobacterium Tuberculosis in Health-Care Settings, 2005. MMWR 2005; 54 (No. RR17)
Public Health Agency of Canada. Canadian Tuberculosis Standards, 6 th Edition, 2007
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RELATED DOCUMENTS
Policies
IC 02-001
Reporting Notifiable Diseases and Conditions
IC 07-021
HEPA-Care Portable HEPA Filter Unit Model #HC800F
IC 03-002
Outbreak Management
IC 04-002
Routine Practices
IC 04-xxx
Contact Precautions (pending)
Appendices
Appendix A - Conditions, Clinical Presentations and Specific Etiologies Requiring Airborne
Infection Precautions (In Addition To Routine Practices)
Appendix B - Strategies to Reduce Aerosol Exposure When Performing AerosolGenerating Medical Procedures (AGMP)
Appendix C - Appropriate Respirator Use Key Points
Appendix D - Management of Patients Potentially Exposed to Pulmonary Tuberculosis (TB)
Appendix E - Management of Exposed Susceptible Roommates and Other Close Contacts
Varicella and Measles
Appendix F - Airborne Isolation Prioritization
Appendix G - Negative Pressure Rooms in Capital Health Facilities
Brochures
WC-85-1432 Airborne Precautions
Other
Airborne Precautions Door Sign (PrinA844)
Airborne Precautions Chart Cover – (PrinA846)
***
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Page 14 of 21
Appendix A
Conditions, clinical presentations and specific etiologies requiring Airborne
Infection Precautions (in addition to Routine Practices)
Conditions/Clinical Presentation:
Based on Signs and Symptoms
Other Considerations:
Note: Contact Precautions may also be
required.
Suspected infectious respiratory TB (pulmonary or
Local Public Health authorities must be
laryngeal tuberculosis), chronic cough, fever, pulmonary notified of suspect TB cases.
infiltrates in a patient at risk for tuberculosis
Use strategies to reduce aerosol
generation.
Hemorrhagic fever with pneumonia, acquired in
Use Contact Precautions as well.
appropriate endemic or epidemic area
Local Public Health authorities must be
notified of suspect hemorrhagic fever
cases.
Rash (maculopapular), with fever and one of: coryza,
Measles immune health care workers only.
conjunctivitis and cough
Local Public Health authorities must be
notified of suspect measles cases.
Use Contact Precautions as well.
Rash - vesicular, compatible with varicella or
disseminated zoster until these are ruled out
Varicella immune health care workers
only.
Use Contact Precautions as well.
Rash- vesicular/pustular, in appropriate epidemiologic
context until smallpox, disseminated vaccinia and
monkeypox ruled out, if epidemiologically possible
Use Contact Precautions as well.
Local Public Health authorities must be
notified of suspect cases.
Specific Etiology (Microorganism Specific)
Other Considerations:
Note: Contact Precautions may also be
required.
Measles immune health care workers only.
Local Public Health authorities must be
notified.
Use Contact Precautions as well.
Local Public Health authorities must be
notified.
Local Public Health authorities must be
Notified.
Use strategies to reduce aerosol
generation.
Special considerations for paediatrics:
tuberculosis in young children is rarely
contagious. However, family members
may be contagious. Assess visiting family
Measles (rubeola)
Monkeypox
Tuberculosis, infectious forms:
Respiratory (pulmonary or laryngeal)
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for cough.
Non-respiratory tuberculosis, if
procedures that may aerosolize drainage are performed
Routine unless drainage not contained.
Varicella (chickenpox)
Varicella immune health care workers
only.
Use Contact Precautions as well.
Zoster (shingles):
disseminated (normal or immunocompromised host)
extensive, localized zoster that cannot be covered (in
paediatric settings or settings where there are
susceptible immunocompromised patients) localized, in
immunocompromised patient (even if covered)
Varicella immune health care workers
only.
Use Contact Precautions as well.
Lassa, Ebola, Marburg, Crimean-Congo and other viral
hemorrhagic fevers with pneumonia
Use Contact Precautions as well.
Local Public Health authorities must be
notified.
Use Contact Precautions as well.
Local Public Health authorities must be
notified.
Smallpox
Reference: The Public Health Agency of Canada. (2010). Routine Practices and Additional Precautions for Preventing the Transmission of Infection
in Health Care.
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Page 16 of 21
APPENDIX B
Strategies to Reduce Aerosol Exposure When
Performing Aerosol-Generating Medical Procedures (AGMP)
Apply the following strategies to reduce the level of aerosol exposure when performing
AGMP for patients with suspected or confirmed severe acute respiratory syndrome
(SARS), tuberculosis and emerging respiratory infections.
1.
2.
3.
4.
5.
6.
7.
Limit AGMP to those that are medically necessary.
Anticipate and plan for AGMP.
Use appropriate patient sedation.
Limit the number of staff in the room when AGMP are performed.
Perform AGMP in airborne infection isolation rooms whenever feasible.
Maintain negative pressure.
Use single rooms (with the door closed and away from high risk patients if feasible), in
settings where airborne infection isolation rooms are unavailable.
8. Ensure N95 respirators are worn by all staff present in the room during the procedure.
9. Use closed endotracheal suction systems wherever possible.
Note: When responding to a code (cardiac arrest) on a patient with an airborne infection
who is not in an airborne infection isolation room and if transfer to a single room or airborne
infection isolation room is not feasible: pull the privacy curtain and ensure all staff in the
room or within the privacy curtain area are wearing appropriate personal protective
equipment. Remove visitors and other patients (if feasible).
Bronchoscopy in Suspect or Confirmed Pulmonary/Laryngeal TB patients
(In-patients and Outpatients)
1. A patient with a diagnosis of suspected/confirmed pulmonary/laryngeal TB requiring bronchoscopy,
must always be treated and recovered in a negative pressure room and placed on Airborne Infection
Precautions in addition to Routine Practices.
a. The Minor Procedures department (4th floor) at the Halifax Infirmary has 2 negative pressure
rooms equipped for bronchoscopic procedures and recovery.
b. The booking physician notifies the Minor Procedures department of the patient’s status prior to
the patient’s arrival.
c. On arrival at Minor Procedures, place the patient in the negative pressure room immediately.
d. Place Airborne Precaution signs on the door.
e. Have the patient wear a surgical mask when travelling to and from Minor Procedures.
2. The patient must remain in the negative pressure room until coughing has subsided and recovery is
complete.
a. Provide the patient with an adequate supply of tissues and instruct him/her in cough etiquette
and proper disposal of the soiled tissues.
3. Complete cleaning and high level disinfection of the bronchoscope as per the recommended cleaning
and disinfection procedures.
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APPENDIX C
Appropriate Respirator Use Key Points










Only use a respirator for which you have been fit-tested.
Perform hand hygiene prior to putting the respirator on.
Perform a seal (fit) check.
Avoid self-contamination by not touching the respirator on its external surface
during use and disposal.
Remove respirators carefully by the straps.
Do not dangle a respirator around the neck when not in use; do not reuse disposable
respirators.
Change the respirator if it becomes wet or soiled (from the wearer's breathing or
due to an external splash).
Change the respirator if breathing becomes difficult.
Discard the disposable respirator immediately after its use (i.e., dispose of when
removed from the face), into a hands-free waste receptacle and perform hand
hygiene.
In cohort settings respirators may be used for successive patients.
Reference: The Public Health Agency of Canada. (2010). Routine Practices and Additional Precautions for
Preventing the Transmission of Infection in Health Care.
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APPENDIX D
IPAC Department Procedure
Management of Patients Potentially Exposed to Pulmonary Tuberculosis (TB)
If a patient found to have pulmonary or laryngeal TB was not immediately managed with
Airborne Infection Precautions, other patients and staff may have been exposed to TB.
Since TB is spread by the airborne route, significant exposure to staff and patients may
occur and contact lists may be extensive.
STAFF EXPOSURES:
All potential staff exposures are reported to, and managed by, Occupational Health.
PATIENT EXPOSURES:
Inpatient exposures are assessed and followed up by the Infection Control Practitioner
(ICP).
Outpatients are followed up by Public Health.
Factors to be considered include duration of exposure (minutes or hours to days), location
of the patient in relation to others, and the degree of infectivity of the source patient
(symptomatic, coughing or not, wearing a mask or not, number of acid fast bacilli (AFB) in
sputum).
1. Move the source patient and place in an Airborne Infection Isolation room under
Airborne Infection Precautions.
a. Do not admit another patient to the original room/bed for at least two hours
to allow for sufficient air changes. See Procedure #21.3 above regarding
requirements at the CCHC Emergency Department.
2. Determine patient contacts’ names based on location/movement of source patient.
3. Notify Public Health with the names of the source patient and patient contacts.
4. Notify Occupational Health of areas with staff exposures.
5. TB contacts do not require any type of additional precautions (Routine Practices
and room placements are appropriate) unless they have TB themselves.
6. For all in house contacts the ICP will recommend the attending physician order:
a A baseline tuberculin skin test (TST) as soon as possible (within 2 weeks of
last exposure).
b If the baseline TST is positive, this suggests a previous TB exposure. A chest
x-ray should be completed (if not recently done). The patient should be
medically evaluated to determine if treatment of latent TB is warranted.
c If the baseline TST is negative, a repeat TST should be arranged in 8-12
weeks from last exposure. If negative, no further follow up is required.
d If the second TST is positive, a chest X-ray should be done. The patient
should be medically evaluated to determine if chemoprophylaxis is warranted.
Treatment for latent TB is usually recommended by TB converters.
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APPENDIX E
IPAC Department
Management of Exposed Susceptible Roommates and Other Close Contacts
Varicella and Measles
For varicella:
1. Determine the immune status of exposed roommates and other close contacts.
2. Place exposed susceptible contact in single airborne infection isolation room from 7
days after the first possible exposure until 21 days after the last exposure.
3. Refer to the most recent National Advisory Committee on Immunization
recommendations to determine whether varicella-zoster immune globulin is
recommended for exposed susceptible contacts at risk of severe disease, and, if
given, precautions should be extended to 28 days after exposure.
4. Suggest the attending physician offer varicella vaccine to exposed susceptible
individuals within 72 hours after first contact and no contraindications to the vaccine,
and if given, precautions should be extended to 28 days after exposure.
5. Precautions for exposed individuals are to be followed regardless of the
administration of varicella-zoster immune globulin or vaccine.
For measles:
1. Determine the immune status of exposed roommates and other close contacts.
2. Notify Public Health.
3. Suggest the attending physician provide susceptible contacts with prophylaxis i.e.,
measles vaccine or immunoglobulin as per the most recent National Advisory
Committee on Immunization recommendations.
4.
Place exposed susceptible contacts in single airborne infection isolation rooms from
five days after the first possible exposure until 21 days after the last exposure
regardless of post-exposure prophylaxis.
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APPENDIX F
IPAC Department
Airborne Isolation Prioritization
Facilities that do not have appropriately ventilated rooms should transfer patients with
infectious forms of tuberculosis to institutions with such accommodation.
Plans should be coordinated in advance with other institutions.

For measles or varicella, facilities without negative pressure rooms and where
transfer is not a feasible option may consider using a single room with door closed,
given that most individuals are immune and post exposure prophylaxis is possible.
Such patients should be accommodated on wards where there are no susceptible,
immunocompromised patients.

If numbers of negative pressure rooms are limited, priority for use of such rooms
should be set according to the impact of potential airborne transmission in that
specific institution. The priority from highest to lowest is:
1.
2.
3.
4.
5.
infectious tuberculosis
measles
varicella
disseminated zoster
extensive localized zoster.
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APPENDIX G
Negative Pressure Rooms in Capital Health Facilities
Room #
3625
Location
3 IMCU HI
Room #
7334
Location
7.3 HI
3628
3 IMCU HI
7414
7.4 HI
3675
Emergency HI
8114
8.1 HI
3682
Emergency HI
8214
8.2 HI
3615
Emergency HI
8314
8.3 HI
8414
8.4 HI
2057
MSICU VG
2063
MSICU VG
4541
Minor Procedures HI
Minor Procedures
4539
(recovery) HI
4114
4.1 HI
2832
Emergency DGH
4214
4.2 HI
1222
Dialysis DGH
5104
5.1 HI
2046
Cobequid ED
5206
5.2 HI
2064
Cobequid ED
5438
HI Recovery
5614
HI Recovery
6134
6.1 HI
6214
6.2 HI
6863
CCU HI
7114
7.1 HI
7214
7.2 HI
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