Download IC-210-001 Infection Prevention and Control Routine Practices and

IC-210-001 Routine Practices
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SOUTH SHORE DISTRICT HEALTH AUTHORITY
TITLE: Infection Prevention and Control:
Routine Practices and Additional Precautions
NUMBER: IC-210-001
Effective Date: March 2012
Page 1 of 14
Applies To: all staff, physicians, volunteers, students
TABEL OF CONTENTS
PAGE
Purpose ……………………………………………………………………………….
Policy ………………………………………………………………………………….
Routine Practices Protocol ………………………………………………………….
Hand Hygiene ……………………………………………………………………....
Personal Protective Equipment (PPE) …………………………………………….
Indications for Gloves …………………………………………………………….
Indications for Masks, Eye Protection, and Face Shields ………………………
Indications for Gowns …………………………………………………………….
Sharps Handling …………………………………………………………………..
Patient Care Equipment ………………………………………………………….
Environmental Cleaning ………………………………………………………….
Miscellaneous
Accommodations/Patient Rooms ………………………………………………..
Laundry ……………………………………………………………………………
Food Services ……………………………………………………………………..
Waste Management ……………………………………………………………….
Transmission-Bases Precautions (Isolation) Protocol …………………………
Contact Precautions ………………………………………………………………….
Droplet Precautions ………………………………………………………………….
Airborne Precautions ………………………………………………………………..
References …………………………………………………………………………...
Appendix A…………………………………………………………………………….
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RELATED DOCUMENTS:
IC-210-006 Reprocessing of Patient Care Equipment,
AD-110-225 Safer Needles
IC-210-004 Antibiotic Resistant Organism (ARO) Policy,
IC-210-007 Visitor Restrictions during an Outbreak.
OH-250-010 Immunization
IC-210-002 Hand Hygiene Policy
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic version prior to use.
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IC-210-001 Routine Practices
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PURPOSE
To protect patients and staff from risk of transmission of epidemiologically significant
organisms.
POLICY
1. Routine Practices is the level of care that will be applied to all patients, regardless of
disease status, when there is the potential for or actual exposure to any blood and/or body
fluids, secretions, and excretions (except for sweat), mucous membranes, or non-intact
skin.
2. Transmission-based Precautions, in addition to Routine Practices, will be implemented
whenever there is a known or suspected pathogen that is transmitted by either contact,
droplet, or airborne (or a combination of any of these routes of transmission).
ROUTINE PRACTICES PROTOCOL
The key to Routine Practices is to be continuously assessing through a “Risk Assessment”
the risk of transmission of microorganisms before any interaction with patients.
“Risk Assessment” must be done before each interaction with a patient or their
environment. This determines which interventions are required to prevent transmission during
the interaction. A patient’s status can change very quickly, so can the need for precautions.
A “Risk Assessment” requires decision-making that is dependent on the following:
•
•
•
•
•
•
Degree of contact
Degree of contamination
Environmental conditions
Patient’s level of understanding/cooperation
Amount of aerosol/splash generation
Procedural difficulty and experience level of the provider of care
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should be checked against the electronic version prior to use.
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Hand Hygiene
South Shore Health has adopted the recommended “four moments of hand hygiene”
patient safety practice from Safer Healthcare Now and the Canadian Patient Safety Institute
encouraging SSH staff to deliver the safest care possible through optimal hand hygiene
practices.
Hand hygiene is required:
1. Before initial patient or patients direct environmental contact
2. Before aseptic procedure
3. After body fluid exposure risk
4. After contact with the patient or patients direct environment
Wash hands 10-15 seconds with antimicrobial soap and water, or use a hospital approved
alcohol-based/antiseptic hand rub.
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Personal Protective Equipment (PPE)
•
Refer to Appendix A for step by step instructions for donning and removing of PPE.
Indications for Gloves
•
Clean, non-sterile gloves are worn for:
- Any potential exposure to blood, body fluids, secretions or excretions (except for
sweat), non-intact skin, or mucous membranes.
- Handling items that are visibly soiled with blood, body fluids, secretions or
excretions.
- Patients on isolation precautions.
- When handling any chemicals according to WHIMIS recommendations.
- Health care workers with non-intact skin on hands.
•
Change gloves between patients and between activities with the same patient
whereby gloves have been contaminated with blood or body fluids, secretions, or
excretions.
Indications for Masks, Eye Protection, and Face Shields
•
Wear masks, eye protection, or face shields to protect the mucous membranes of the
eyes, nose, and mouth when there is potential for procedures or events to generate
splashes or sprays of blood, body fluids, secretions, or excretions.
•
Wear masks only once and discard immediately if they become moist or damaged.
Avoid touching the mask while it is being worn.
•
Wear NIOSH N95 masks when applying personal protective equipment when dealing
with cases on airborne precautions.
•
Wear eye protection whenever masks are required.
* Eye-glasses are not considered appropriate protection.
Indications for Gowns
•
When there is a need to protect uncovered skin or to prevent soiling clothes during
activities that have the potential to generate splashes or sprays of blood, body fluids,
secretions, or excretions, wear long sleeved gowns or plastic aprons.
•
Put on gowns with the opening at the back with the edges overlapping and tie at the
neck and waist.
•
When removing the gown, undo the ties and remove the gown without touching the
clothing. Turn the gown inside itself, roll it up and place in a laundry hamper or in the
garbage if disposable gowns are used.
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should be checked against the electronic version prior to use.
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Safe Sharps Handling
•
Sharps include any device capable of puncturing skin such as needles, lancets,
intravascular catheters, cannulas, trocars and scalpel blades.
•
Handle used needles and other sharp instruments with care to avoid injuries during
disposal or reprocessing.
•
Immediately dispose of single-use sharp items in a designated hospital sharps
container.
Patient Care Equipment
•
Clean and/or reprocess reusable patient care equipment according to Reprocessing of
Patient Care Equipment Policy IC-210-006
•
All patient care equipment must be thoroughly cleaned and/or disinfected in between
multiple patient uses.
Environmental Cleaning
•
•
Follow established procedures for routine care, cleaning, and appropriate disinfection
of patient furniture and environmental surfaces.
Pay special attention to horizontal and frequently touched surfaces, i.e. bedrails,
doorknobs, etc.
Miscellaneous
Accommodations/Patient Rooms
•
Generally single rooms are not required for routine patient care. However in pediatric
populations, single patient rooms are advantageous due to increased potential or
actuality of communicable disease and the hygienic challenges inherent with this
particular age group.
•
Place patients who visibly soil the environment or whose hygiene cannot be
maintained in single rooms with dedicated toileting facilities. This includes mobile
patients with fecal incontinence, if stools cannot be contained in diapers, and patients
with draining wounds in which dressings are unable to be kept in place.
•
Single rooms are not required for children in diapers unless they have uncontained
diarrhea and cannot be confined to their designated bed space.
Laundry
•
Handle linen with a minimum of agitation and shaking.
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should be checked against the electronic version prior to use.
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•
Roll/fold heavily soiled linen to contain the heaviest soil in the center of the bundle.
Remove large amounts of solid soil prior to folding.
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Use an additional outer bag if linen bag soaks through
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Linen bags should not be overfilled. Tie linen bags securely prior to being transported.
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To provide protection from soiled linen, wear appropriate protective equipment such as
gloves and gowns when handling potentially soiled linen.
Food Services
•
Disposable items are unnecessary. Used dishes, cutlery and trays have not been
associated with the spread of hospital-acquired infection.
•
Return all used trays and contents to Food and Nutrition Services with a minimum of
handling.
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When dismantling trays, wear appropriate clothing, i.e., waterproof gowns and gloves.
Waste Management
•
Potential for exposure to waste still exists and precautions need to be implemented
although waste generated in health care settings has not been shown to be more
hazardous than household waste.
•
Package hospital-produced waste properly to protect the health care worker, patients
and visitors from potential exposure and to facilitate the proper handling, storage,
treatment and /or disposal of the waste.
•
Select appropriate packaging for the type of waste being contained to maintain
integrity during the collection, transport and storage process.
•
Whereas the potential exists for exposure to infectious waste, health care workers
need to protect themselves. Personal protective equipment such as gloves and gowns
should be worn.
This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and
should be checked against the electronic version prior to use.
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TRANSMISSION-BASED PRECAUTIONS (ISOLATION) PROTOCOL
There are three main categories of transmission-based precautions:
contact
droplet
airborne
These transmission-based precautions can be used individually or in combination i.e.
droplet/contact depending on the type of organism, disease entity, or type of patient.
•
Information on transmission-based precautions can be found on the Infection
Prevention and Control intranet site main page and in the “yellow pages” of the
Infection Control Manual located in the shift supervisor’s office at SSRH or the ER at
QGH and FMH. After identifying the organism, symptom, or disease requiring isolation,
determine from the table, the necessary transmission-based precaution requirements.
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Appropriate signage must be posted on the door of an isolation room indicating type of
isolation and necessary transmission-based precaution requirements. Notation should
be made on the patient’s Kardex. Specific transmission-based precaution signs with
pictograms should be posted on the doors to illustrate appropriate precautions and
ensure illiteracy challenges are addressed.
•
Discontinuation of transmission-based precautions must be in accordance with the
“yellow pages” or in consultation with Infection Prevention and Control.
Discontinuation of isolation for Antibiotic Resistant Organisms must be under
the sole direction of Infection Prevention and Control.
•
Notification of transmission-based precautions must be communicated to receiving
unit/department, facility, funeral home or transporting body (i.e. EHS) or MDR if
appropriate.
•
Emergency evacuation: safe and timely evacuation takes priority over the need to
ensure transmission-based precautions are maintained. If time and circumstance
permits, the patient should be properly prepared before leaving their room i.e. wearing
a surgical mask if on airborne precautions. Precautions are to be fully re-instituted as
soon as possible after the emergency situation has been stabilized or given the “all
clear”.
•
Post-mortem care: transmission-based precautions should continue to be applied
during post-mortem care. The exception would be when patients are on airborne
precautions, unless there is the potential for aerosolization of respiratory fluids.
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CONTACT PRECAUTIONS
Accommodation
1) Single room preferable and should have toilet and hand washing facilities. Door may
remain open as long as isolation signage is visible.
2) If unable to assign single room:
•
a spatial separation of at least 1 meter must be maintained between infected
patient and other patients and their visitors
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Prioritize patients with a condition which puts them at high risk of transmission of
microorganisms (e.g. draining wound, cognitive impairment) for a private room
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Roommates should be selected for their ability and that of their visitors to comply
with precautions.
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Roommates should not be at high risk of serious disease if transmission occurs.
•
If possible close privacy curtain between patients to deter direct contact between
patients and visitors
•
Do not share the bathroom. Dedicate commode (to be emptied in dirty utility) and
wash basin to one patient and bathroom to the other.
•
Patients known to be colonized or infected with the same organism may be
grouped together unless acquisition of different strains is a concern i.e. Antibiotic
Resistant Organisms. This should be done in consultation with Infection Prevention
and Control.
Hand Hygiene
1) Hand hygiene must be performed using alcohol hand rub or antibacterial soap and
water before donning gloves on room entry.
2) Hand hygiene with alcohol based hand rub or antimicrobial soap and water before
leaving the room and after removal of gown & gloves. When there is visible soiling,
hands must be washed with soap and water before using alcohol-based hand rub.
3) Hands must be washed with soap and water after caring for patients with known or
suspected Clostirium difficle or norovirus like illness. If a dedicated hand washing sink
is not immediately available (do not use patients bathroom sink) use the alcohol-based
hand rub before leaving the room and proceed to an area where hand hygiene can be
performed with soap and water.
4) After hand hygiene, take care not to contaminate hands before leaving the room.
Gloves:
1) should be worn on room entry
2) should be removed before leaving patient’s room or bed space.
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Gowns:
1) should be worn if clothing or forearms will have direct contact with the patient,
frequently touched environmental surfaces or objects, and there is increased risk of
environmental contamination due to incontinence, draining wounds, etc.
2) should be removed before leaving patient’s room or bed space.
Equipment and Environment
1) Dedicated patient care equipment i.e. thermometers, blood pressure cuffs,
stethoscopes, etc. if possible
2) Equipment must be thoroughly cleaned and disinfected before reuse on another
patient.
3) Disposable supplies in the room should be kept to a minimum and must be discarded
once the patient is discharged from the room i.e. soaps, Kleenex, toilet paper,
toothettes, incontinent pads, etc
Patient Transport
1) Patient should leave room for essential purposes only.
2) Patients should be encouraged to perform hand hygiene before leaving their room and
upon returning to their room.
3) Precautions must be maintained during transport
4) Receiving departments and facilities, and transporting personnel (porters, EHS) must
be notified of precautions prior to transport.
Visitors
1) Should be kept to a minimum. In the event of an outbreak, refer to policy IC-200-007,
Visitor Restrictions during an Outbreak.
2) Visitors should talk to a nurse before entering the room and be instructed on
appropriate use of PPE and transmission-based precautions.
3) The risk to the health of the visitor should be evaluated prior to admittance to room.
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DROPLET PRECAUTIONS
Accommodations
1) Single room preferable and should have toilet and hand washing facilities. Door may
remain open as long as isolation signage is visible. Some respiratory etiologies require
two categories of protection (e.g. contact and droplet)
2) If unable to assign single room:
•
a spatial separation of at least 2 meters must be maintained between infected
patient and other patients and their visitors.
•
Roommates should be selected for their ability and that of their visitors to comply
with precautions.
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Instruct patients and visitors on respiratory etiquette
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Keep privacy curtain pulled to further provide spatial separation
•
Roommates should not be at high risk of serious disease if transmission occurs.
Masks
1) A surgical procedure mask is to be worn if within 2 meters of the patient.
2) A mask and eye protection is not required for mumps or rubella if immunity of
healthcare worker is confirmed. If possible, staff not immune to mumps or rubella
should not care for these patients.
Eye Protection
1) Should be worn for care of patients anytime a mask is required. Eye protection must
be large enough to provide full coverage of eyes (3 sided goggles/shields).
Patient Transport
1) Patient should leave room for essential purposes only.
2) Precautions must be maintained during transport. Patient should wear a surgical mask
and wash hands for transport.
3) Receiving departments and facilities, and transporting personnel (porters, EHS) must
be notified of precautions prior to transport.
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should be checked against the electronic version prior to use.
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Visitors
1) Should be kept to a minimum. In the event of an outbreak, refer to policy IC-210-007
Visitor Restrictions during an Outbreak.
2) Visitors should talk to a nurse before entering the room and be instructed on
appropriate use of PPE and transmission-based precautions.
3) In the case of patients with acute viral respiratory infection, masks are not mandatory
for household members who may already have been exposed. This can be assessed
on a case by case basis. The risk to the health of the visitor should be evaluated prior
to admittance to room.
Airborne Precautions
Accommodation
•
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Single room
Negative pressure in relation to surrounding areas
A minimum of 12 air exchanges per hour
Air discharged outside the building and away from intake ducts, or through a highefficiency filter if re-circulated
Door kept closed whether or not patient is in the room
After discharge the door is kept closed until sufficient time has elapsed to allow for the
required air exchanges to remove airborne organisms
Patient confined to room unless medically required (e.g. diagnostic procedure)
Room should have own toilet, hand washing and bathing facilities
Special considerations for accommodation:
•
If unable to obtain an appropriately ventilated room, consideration should be given to
transferring patients with infectious forms of tuberculosis to an institution with such
accommodation. Plans should be coordinated in advance with other institution.
•
For measles or varicella, in the event that a negative pressure room is unavailable and
where transfer is not a feasible option, consideration for using a single room with door
closed is acceptable, given that most individuals are immune and post exposure
prophylaxis is possible. Such patients should be accommodated on wards where
there are no susceptible, immunocompromised patients.
•
Whereas the number of negative pressure rooms is limited, priority for use of such
rooms should be set according to the impact of potential airborne transmission.
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Consultation must occur with Infection Prevention and Control (i.e., infectious
tuberculosis, measles, varicella, disseminated zoster, extensive localized zoster).
Personnel and visitors
•
All health care personnel must have documented immunity to measles according to
Immunization Policy OH-250-010. Personnel and visitors susceptible to measles
should not enter the room of a patient with measles.
•
Varicella-susceptible personnel and visitors should not enter the room of a patient with
varicella or disseminated zoster unless exceptional circumstances make this
mandatory.
Masks
•
Special masks: high-efficiency particulate respirator (N95) masks should be available
(in all sizes and styles that have been utilized in the district fit-testing process) for all
personnel who enter the room of a patient with infectious tuberculosis, or for nonimmune persons who absolutely must enter the room of a patient with varicella,
disseminated zoster or measles.
Patient Transport
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Patient should be out of the room for essential procedures only
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Patient should wear surgical (procedure) mask during transport
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Personnel in area to which patient is to be transported should be aware of precautions
to follow.
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Infection Prevention and Control should be consulted prior to any transport.
Visitors
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Visitors should talk with a nurse before entering the room and, if indicated, should be
instructed in the appropriate use of a mask and other precautions. The number of
visitors should be restricted.
•
In the event of an outbreak, refer to policy IC-210-007, Visitor Restrictions during an
Outbreak.
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should be checked against the electronic version prior to use.
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REFERENCES
Association for Professionals in Infection Control and Epidemiology, Inc. (2009). APIC text of
infection control and epidemiology. Waste Management 102-1. Washington, DC.
CDC (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious
Agents in Healthcare Settings
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
Provincial Infectious Disease Advisory Committee (2009).Routine Practices and Additional
Precautions in all healthcare settings. Ontario.
Public Health Agency of Canada. ( 2010) Guidance: Infection Prevention and Control
Measures for Healthcare Workers in Acutea Care and Long-term Careb Settings.
http://www.phac-aspc.gc.ca/nois-sinp/guide/ac-sa-eng.php
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Appendix A
STEPS FOR PUTTING ON PERSONAL PROTECTIVE EQUIPMENT (PPE):
1. Perform hand hygiene
2. Put on gown with ties in back. Secure neck and waist ties.
3. Put on mask/respirator. Secure, ties, loops or straps. Mold metal piece to nose,
Perform seal checks if respirator.
4. Put on protective eyewear. Adjust fit. Facial shields should fit over brow.
5. Put on gloves. Gloves should come over gown cuffs.
STEPS FOR REMOVING PERSONAL PROTECTIVE EQUIPMENT (PPE):
1. Untie gown in back-waist ties only
2. Remove gloves- remove gloves using glove to glove/skin to skin technique. Grasp
outer edge near the wrist and peel away rolling the glove inside out. Reach under the
second glove and peel away. Discard immediately.
3. Remove gown- remove gown in a manner that prevents contamination of the clothing
and skin. Starting at the back of the neck pull the tabs and carefully insert hands inside
of the gown rolling the gown away from the body, rolling into a bundle and discard.
4. Hand Hygiene
5. Remove eye protection ( if wearing)- touch the arms of goggles or the headband of the
face shield, pulling away from the face.
6. Remove mask using ties/straps (if wearing)- using ties or straps, bend forward to allow
the mask to fall away from the face. Discard.
7. Hand Hygiene
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